Nursing diagnosis – DEFICIENT KNOWLEDGE

DEFICIENT  KNOWLEDGE  (SPECIFY)

DEFINITION

Absence or deficiency of cognitive information related to a specific

topic

DEFINING CHARACTERISTICS

• Inability to follow through with directions

• Inability to perform well on a test

• Inappropriate or exaggerated behaviors (hysteria, hostility,

agitation, apathy)

• Verbalization of the problem

RELATED FACTORS

• Cognitive limitation

• Lack of recall

• Information misinterpretation

• Unfamiliarity with information

• Lack of exposure

resources

• Lack of interest in learning

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity

• Nutrition

• Communication

• Sleep

• Coping

• Values/beliefs

• Knowledge

EXPECTED OUTCOMES

The patient will

• Communicate desire to understand disease state and need for

treatment.

• Demonstrate ability to perform new health-related procedures.

• Set realistic learning goals within target dates.

• State intention to make needed modifications in lifestyle.

SUGGESTED NOC OUTCOMES

Cognition; Concentration; Information Processing; Knowledge: Dis-

ease Process; Knowledge; Health Behaviors; Knowledge: Health

Resources; Knowledge: Illness Care; Stress Level

INTERVENTIONS AND RATIONALES

Determine: Determine level of knowledge and skills patient already

possesses about his or her health status; motivation to understand

what is needed to improve health status; obstacles to learning; sup-

port systems; usual coping patterns; beliefs about health and treat-

ment of disease; ethnicity; financial resources. Assessment informa-

tion will assist in identifying appropriate interventions.

Perform: Establish an environment of mutual trust and respect to

enhance learning. Consistency between action and words, combined

with the patient’s self-awareness ability to share this awareness with

others, and receptiveness to new experiences form the basis of a

trusting relationship.

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Develop with patient specific learning goals with target dates.

Involving patient in planning meaningful goals encourages

compliance.

Select teaching strategies that will enhance teaching/learning effec-

tiveness, such as discussion, demonstration, role-playing, and visual

materials. Provide all the equipment needed for the patient to learn.

This reduces frustration, aids learning, and minimizes dependence by

promoting self-care.

Inform: Teach those skills that the patient must incorporate into

daily living. Have patient do return demonstration of each skill to

aid in gaining confidence.

When teaching, go slowly and repeat frequently. Offer small

amounts of information and present it in various ways. By building

cognition, patient will be better able to complete self-care measures.

Include family members.
Demonstrate to family members how each self-care measure is

broken down into simple tasks to enhance patient’s success and fos-

ter a sense of control.

Attend: Encourage family members to participate in and have

patience toward learning process (patient may need to repeat new

skills multiple times) to help create a therapeutic environment after

discharge.

Manage: Have patient incorporate learned skills into care while still

in the hospital. This allows practice and time for feedback.

Provide patient and/or family with names and telephone numbers

of resource people or community agencies so that care is continuous

and follow-up is possible after discharge.

If financial hardship interferes with the ability of the family to

provide equipment and supplies, offer a referral to a social worker

to improve the family’s access to financial assistance.

SUGGESTED NIC INTERVENTIONS

Behavior Management; Behavior Modification; Decision-Making

Support; Energy Management; Family Support; Financial Resource

Assistance; Health Education; Healthcare Information Exchange:

Risk Identification; Learning Facilitation; Support System Enhance-

ment; Teaching Procedure/Treatment

Reference

Shen, Q., et al. (2006, May–June). Evaluation of a medication education pro-

gram for elderly hospitalized inpatients. Geriatric Nursing, 27(3), 184–192.

Nursing diagnosis – RISK FOR DEFICIENT FLUID VOLUME

RISK  FOR  DEFICIENT  FLUID  VOLUME

DEFINITION

At risk for experiencing vascular, cellular, or intracellular

dehydration

RISK FACTORS

• Conditions  that  influence  fluid

• Knowledge deficit related to

needs (e.g., hypermetabolic state)

fluid volume

• Excessive loss of fluid from

• Loss of fluid through abnor-

normal routes (e.g., diarrhea)

mal routes (e.g., drainage

• Extremes of age or weight

tube)

• Factors that affect intake or

• Medications that cause fluid

absorption of, or access to,
fluids (e.g., immobility)

loss

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Maintain stable vital signs.

• Have normal skin color.

• Maintain urine output of at least ___ ml/hr.

• Maintain electrolyte values within normal range.

• Maintain intake at _____ ml/24 hr.

• Have an intake equal to or exceeding output.

• Express understanding of need to maintain adequate fluid intake.

• Demonstrate skill in weighing himself or herself accurately and

recording weight.

• Measure and record own intake and output.

• Return to normal, appropriate diet.

SUGGESTED NOC OUTCOMES

Electrolyte & Acid–Base Balance; Fluid Balance; Hydration;

Nutritional Status: Food & Fluid Intake; Risk Detection; Urinary

Elimination

INTERVENTIONS AND RATIONALES

Determine: Monitor and record vital signs every 4 hr. Fever, tachy-

cardia, dyspnea, or hypotension may indicate hypovolemia.

Determine patient’s fluid preferences to enhance intake.
Maintain accurate record of intake and output to aid estimation

of patient’s fluid balance. Measure urine output every hour. Record

and report output of less than ____ ml/hr. Decreased urine output

may indicate reduced fluid volume. Measure and record drainage

from all tubes and catheters to take such losses into account when

replacing fluid.

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When copious drainage appears on dressings, weigh dressings

every 8 hr and record with other output sources. Excessive wound

drainage causes significant fluid imbalances (1 kg dressing equals

about 1 qt [1 L] of fluid).

Test urine specific gravity each shift. Monitor laboratory values

and report abnormal findings to physician. Increased urine specific

gravity may indicate dehydration. Elevated HCT and Hb levels also

indicate dehydration.

Monitor serum electrolyte levels and report abnormalities. Fluid

loss may cause significant electrolyte imbalance.

Obtain and record patient’s weight at same time every day to help

ensure accurate data. Daily weighing helps estimate body fluid status.

Monitor skin turgor each shift to check for dehydration; report

any decrease in turgor. Poor skin turgor is a sign of dehydration.

Examine oral mucous membranes each shift. Dry mucous

membranes are a sign of dehydration.

Perform: Cover wounds to minimize fluid loss and prevent skin

excoriation.

Keep oral fluids at bedside within patient’s reach and encourage

patient to drink. This gives patient some control over fluid intake

and supplements parenteral fluid intake.

Force oral fluids when possible and indicated to enhance replace-

ment of lost fluids. (Bowel sounds should be present and patient

awake before giving oral fluids.)

Administer parenteral fluids, as prescribed, to replace fluid losses.

Maintain parenteral fluids or blood transfusions at prescribed rate to

prevent further fluid loss or overload.

Progress patient to appropriate diet, as prescribed, to help achieve

fluid and electrolyte balance.

Inform: Instruct patient in maintaining appropriate fluid intake,

including recording daily weight, measuring intake and output, and

recognizing signs of dehydration. This encourages patient and care-

giver participation and enhances patient’s sense of control.

SUGGESTED NIC INTERVENTIONS

Acid–Base Management; Fluid Management; Fluid Monitoring;

Hypovolemia Management; Hypovolemia Intravenous Therapy;

Hypovolemia Monitoring; Surveillance

Reference

Mentes, J. (2006, June). Oral hydration in older adults: Greater awareness is

needed in preventing, recognizing, and treating dehydration. American Jour-
nal of Nursing, 106(6), 40–49.

Nursing diagnosis – DEFICIENT FLUID VOLUME

DEFICIENT  FLUID  VOLUME

DEFINITION

Decreased intravascular, interstitial, or intracellular fluid; water loss

alone without change in sodium

DEFINING CHARACTERISTICS

• Changes in mental status

• Decreased pulse volume and pressure, urine output, and venous

filling

• Dry skin and mucous membranes

• Increased body temperature, HCT, pulse rate, and urine concen-

tration

• Low blood pressure

• Poor turgor of skin or tongue

• Sudden weight loss

• Thirst

• Weakness

RELATED FACTORS

• Active fluid volume loss

• Failure of regulatory mechanisms

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Maintain stable vital signs.

• Have normal skin color.

• Have electrolyte levels within normal range.

• Maintain an adequate fluid volume.

• Maintain an adequate urine volume.

• Have normal skin turgor and moist mucous membranes.

• Have a urine specific gravity between 1.005 and 1.010.

• Have normal fluid and blood volume.

• Express understanding of factors that caused fluid volume deficit.

SUGGESTED NOC OUTCOMES

Electrolyte & Acid–Base Balance; Fluid Balance; Hydration; Nutri-

tional Status: Food & Fluid Intake

INTERVENTIONS AND RATIONALES

Determine: Monitor and record vital signs every 2 hr or as often as

necessary until stable. Then monitor and record vital signs every

4 hr. Tachycardia, dyspnea, or hypotension may indicate fluid

volume deficit or electrolyte imbalance.

Measure intake and output every 1–4 hr. Record and report sig-

nificant changes. Include urine, stools, vomitus, wound drainage,

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nasogastric drainage, chest tube drainage, and any other output.

Low urine output and high specific gravity indicate hypovolemia.

Weigh patient daily at same time to give more accurate and con-

sistent data. Weight is a good indicator of fluid status.

Assess skin turgor and oral mucous membranes every 8 hr to

check for dehydration. Give meticulous mouth care every 4 hr to

avoid dehydrating mucous membranes.

Test urine specific gravity every 8 hr. Elevated specific gravity may

indicate dehydration.

Measure abdominal girth every shift to monitor for ascites and

third-space shift. Report changes.

Perform: Cover patient lightly. Avoid overheating to prevent vasodi-

lation, blood pooling in extremities, and reduced circulating blood

volume.

Administer fluids, blood or blood products, or plasma expanders

to replace fluids and whole blood loss and facilitate fluid movement

into intravascular space. Monitor and record effectiveness and any

adverse effects.

Don’t allow patient to sit or stand up quickly as long as circula-

tion is compromised to avoid orthostatic hypotension and possible

syncope.

Administer and monitor medications to prevent further fluid loss.

Inform: Explain reasons for fluid loss, and teach patient how to

monitor fluid volume; for example, by recording daily weight and

measuring intake and output. This encourages patient involvement

in personal care.

SUGGESTED NIC INTERVENTIONS

Acid–Base Management; Electrolyte Monitoring; Fluid Management;

Hypovolemia Management

Reference

Kelley, D. M. (2005, January–March). Hypovolemic shock: An overview. Crit-

ical Care Nursing Quarterly, 28(1), 2–19.

Nursing diagnosis – deficient diversional activity

Deficient Diversional Activity
DEFINITION
Decreased stimulation from (or interest or engagement in)
recreational or leisure activities
DEFINING CHARACTERISTICS
• Usual hobbies are not performed in hospital setting.
• Patient states feelings of boredom or wishing for something to do.
RELATED FACTORS
• Environmental lack of diversional activity
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Cardiac function
• Emotional status
• Neurocognition
EXPECTED OUTCOMES
The patient will
• Express interest in using leisure time meaningfully.
• Express interest and participate in activities that can be provided
(e.g., watch selected television program, listen to radio or music
daily).
• Report satisfaction with use of leisure time.
• Modify environment to provide maximum stimulation (e.g.,
hanging posters or cards and moving bed next to a window).
SUGGESTED NOC OUTCOMES
Leisure Participation; Motivation; Social Involvement
INTERVENTIONS AND RATIONALES
Determine: Assess leisure activity preferences. Identify the type of music
patient prefers; seek help from family and hospital resources to provide
selected music daily that relieves boredom and stimulates interest.
Perform: Provide supplies and set time to indulge in hobby. Obtain
radio, television, or crochet hook and yarn (if desired). Allow
patient to (if TV or radio) select programs. Communicate patient’s
desires to coworkers (e.g., Turn on television set at _____ [time]
to _____ [channel]. Give crochet hook and yarn to patient daily
at _____ [time]). Specifying time for activity indicates its value.
Avoid scheduling activities during leisure time, which is integral
to quality of life.
Ask volunteers (friends, family, or hospital volunteer) to read
newspapers, books, or magazines to patient at specific times.
Personal contact helps alleviate boredom.
Engage patient in conversation while carrying out routine care.
Discuss patient’s favorite topics as much as possible. Conversation
conveys caring and recognition of patient’s worth.
• DEFICIENT DIVERSIONAL ACTIVITY
• Physical status
• Respiratory function
Provide talking books or I-Pod if available. These provide loweffort
sources of enjoyment for bedridden patient.
Obtain an adapter for television to provide captions for hearingimpaired
patient.
Provide plants for the patient to tend to. Caring for live plants
may stimulate interest.
Change scenery when possible; for example, take the patient outside
in a wheelchair to help reduce boredom.
Attend: Encourage discussion of previously enjoyed hobbies,
interests, or skills to direct planning of new activities. Suggest performing
an activity helpful to others or otherwise productive to promote
interest.
Encourage patient’s family or caregiver to bring personal articles
(posters, cards, and pictures) to help make environment more stimulating
(the patient may respond better to objects with personal
meaning).
Manage: Make referral to recreational, occupational, or physical
therapist for consultation on adaptive equipment to carry out
desired activity; arrange for therapy sessions. Adaptive equipment
allows patient to continue enjoying activities or may stimulate interest
in new activities.
SUGGESTED NIC INTERVENTIONS
Activity Therapy; Animal-Assisted Therapy; Art Therapy; Recreation
Therapy
Reference
Wheeler, S. L., & Houston, K. (2005, March–April). The role of diversional
activities in the general medical hospital setting. Holistic Nursing Practice,
19(2), 87–89.