Nursing diagnosis – DYSFUNCTIONAL GASTROINTESTINAL MOTILITY

DYSFUNCTIONAL  GASTROINTESTINAL

MOTILITY

DEFINITION

Increased, decreased, ineffective, or lack of peristaltic activity within

the gastrointestinal system

DEFINING CHARACTERISTICS

• Nausea

• Abdominal pain

• Vomiting

• Absence of flatus

• Abdominal distension

• Hard, dry stool

• Change in bowel sounds

• Difficulty passing stool

(e.g., absent, hypoactive,
hyperactive)

• Diarrhea
• Abdominal cramping

• Increased gastric residual

• Accelerated gastric emptying

RELATED FACTORS

• Anxiety

• Malnutrition

• Surgery

• Food intolerance (e.g., lactose,

• Immobility

gluten)

• Pharmacological agents (e.g.,

• Ingestion of contaminants

narcotics, laxatives, antibiotics,
anesthesia)

(e.g., food, water)
• Enteral feedings

• Aging

• Inactive lifestyle

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Verbalize strategies to promote healthy bowel function.

• Acknowledge the importance of seeking medical help for persistent

alteration in GI motility.

• Not experience any fluid and electrolyte imbalance as a result of

altered motility.

• Understand the need for early ambulation following abdominal

surgery.

SUGGESTED NOC OUTCOMES

Bowel Elimination, Electrolyte and Acid–Base Balance, Gastrointesti-

nal Function

INTERVENTIONS AND RATIONALES

Determine: Assess abdomen including auscultation in all four quad-

rants noting character and frequency to determine increased or

decreased motility.

Assess current manifestations of altered GI motility to help iden-

tify the cause of the alteration and guide development of nursing

interventions.

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Monitor intake and output to identify need for restoration of fluid

balance.

Perform: Collect and evaluate laboratory electrolyte specimens. Some

altered motility states may require electrolyte replacement therapy.

Insert nasogastric tube as prescribed for patients with absent

bowel sounds to relieve the pressures caused by accumulation of air

and fluid.

Inform: Educate patients regarding importance of maintaining diet

high in natural fiber and adequate fluid intake. Fiber increases stool

bulk and softens the stool. Fluid will promote normal bowel elimi-

nation pattern.

Attend: Encourage activities such as walking as tolerated for patients

with decreased GI motility. Increased activity will stimulate peristal-

sis and facilitate elimination.

Manage: Coordinate with dietitian and other healthcare professionals

as needed to meet the unique needs of each individual patient.

SUGGESTED NIC INTERVENTIONS

Fluid/Electrolyte Management; Gastrointestinal Intubation; Tube

Care: Gastrointestinal

Reference

Sabol, V. K., & Carlson, K. K. (2007). Diarrhea: Applying research to bedside

practice. AACN Advanced Critical Care, 18, 32–44.

Nursing diagnosis – DYSFUNCTIONAL FAMILY PROCESSES ALCOHOLISM

DYSFUNCTIONAL  FAMILY  PROCESSES:

ALCOHOLISM

DEFINITION

Psychosocial, spiritual, and physiological functions of the family unit

are chronically disorganized, which leads to conflict, denial of prob-

lems, resistance to change, ineffective problem solving, and a series

of self-perpetuating crises

DEFINING CHARACTERISTICS

• Alcohol abuse; agitation; blaming; broken promises

• Deficient knowledge about alcoholism

• Denial of problems; difficulty with intimate relationships

• Enabling to maintain alcoholic drinking pattern

• Rationalization; moodiness; rejection; tension

• Triangulating family relationships

• Marital problems; ineffective spousal communication

RELATED FACTORS

• Abuse of alcohol

• Family history of alcoholism

• Addictive personality

• Family history of resistance to

• Biochemical influences

treatment

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Communication

• Emotional

• Knowledge

• Coping

• Self-perception

• Values and beliefs

EXPECTED OUTCOMES

Family members will

• Acknowledge there is a problem with alcoholism within the family.

• Sign contracts stating they will not engage in abusive behavior.

• Communicate their needs, using “I” statements.

• Discuss problems in an open, safe environment.

• Acknowledge their strengths and progress in resolving problems.

• State plans to continue to seek counseling and attend appropriate

support group meetings.

SUGGESTED NOC OUTCOMES

Family Coping; Family Functioning; Family Normalization; Role

Performance; Substance Abuse Consequences

INTERVENTIONS AND RATIONALES

Determine: Assess drinking pattern; use of other substances; patterns

of withdrawal; ability of alcoholic member to function in

occupational and familial roles; ability of family members to func-

tion in their roles; family health history; affiliation with a religious

group and religious practices. Assessment factors will assist in identi-

fying appropriate interventions.

Perform: Create an environment in which family members feel free

to express themselves honestly about the present situation to

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decrease their anxiety and help family members develop confidence

in their ability to resolve problems.

Inform alcoholic family member that he will have to acknowledge

his alcoholism before progress can be made in rebuilding family

relations to establish abstinence as a basis for treatment.

Inform: Teach family members to communicate their needs

assertively. Have them practice using “I” statements to express feel-

ings to help them get in touch with their feelings.

Inform patient and family about the symptoms and effects of addic-

tive behaviors on both the patient and the family to help them under-

stand the role they play in both the disease and the recovery process.

Do interactive planning and role-playing with the patient and

family to help them gain the skills needed to effect necessary

changes in communication patterns in the family. Role-playing helps

create a realistic view of the behaviors that reinforce behaviors in

themselves and the patient.

Attend: Encourage family members to acknowledge that alcoholism is

a problem within the family in order to break through family denial.

Ask alcoholic family member to sign a contract stating he will

abstain from alcohol to help him take responsibility for his own

behavior.

Help family members evaluate the consequences of abusive and vio-

lent behavior. Inform them that any suspected abuse will be reported.

Ask family members to sign contracts so they will not continue to

abuse one another to make them take responsibility for their behavior.

Being able to identify strengths provides the confidence the family

needs to continue working toward a positive outcome for both

patient and family.

Assist family members to identify their strengths and talk about

progress they have made in resolving problems associated with alco-

holism or living with a family member who has alcoholism.

Provide additional emotional support to the head of the family

about altered role and additional responsibility to build self-esteem.

Manage: Refer family for continued family therapy so they can con-

tinue the process of restructuring their lives.

Refer patient and family to AA, Alanon, or other appropriate sup-

port group to establish the importance of abstinence.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Family Process Maintenance; Family Support;

Substance Use Prevention; Substance Use Prevention

Reference

Fowler, T. L. (2006, July). Alcohol dependence and depression: Advanced

nursing interventions. Journal of the American Academy of Nurse
Practitioners, 18(7), 303–308.