Nursing diagnosis – IMPAIRED WHEELCHAIR MOBILITY

IMPAIRED  WHEELCHAIR  MOBILITY

DEFINITION

Limitation of independent operation of wheelchair within environment

DEFINING CHARACTERISTICS

• Impaired ability to operate a manual or power wheelchair on curbs,

even surfaces, uneven surfaces, and/or an incline or a decline

RELATED FACTORS

• Cognitive impairment

• Environmental constraints

• Deconditioning

• Impaired vision

• Deficient knowledge

• Limited endurance

• Depressed mood

• Musculoskeletal impairment

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Physical regulation

• Pharmacological function

• Neurocognition

EXPECTED OUTCOMES

The patient will

• Have no complications associated with impaired wheelchair mobil-

ity, such as skin breakdown, contractures, venous stasis, thrombus
formation, depression, alteration in health maintenance, and falls.

• Maintain or improve muscle strength and joint ROM.

• Achieve the highest level of independence and safety possible with

regard to wheelchair use.

• Express feelings regarding alteration in ability to use wheelchair.

• Participate in social and occupational activities to the greatest

extent possible.

• Demonstrate understanding of techniques to improve wheelchair

mobility.

SUGGESTED NOC OUTCOMES

Ambulation: Wheelchair; Balance; Mobility Level; Muscle Function

INTERVENTIONS AND RATIONALES

Determine:  Assess wheelchair status: Seat is wide and deep enough

to support thighs, low enough for feet to touch the floor, yet high

enough to allow easy transfer from bed to chair; the back is tall

enough to support upper body; brakes on wheels lock; and seat belt

is present (may attach at waist, hips, or chest). Assessment ensures

chair meets patient’s physical needs (identifies need for modification),

promotes comfort, and prevents injuries (e.g., falls).

Assess patient’s level of strength in arms, and if chair is easy for

patient to operate when weak. This determines the need for a

motorized wheelchair to help maintain mobility and independence.

Identify patient’s level of independence using the functional mobil-

ity scale. Communicate findings to staff to promote continuity of

care and preserve the documented level of independence.

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Monitor and record daily evidence of complications related to

impaired wheelchair mobility. Patients with neuromuscular dysfunc-

tion are at risk for complications.

Assess patient’s skin on return to bed and request a wheelchair

cushion, if necessary, to maintain skin integrity.

Perform:  Perform ROM exercises for affected joints, unless

contraindicated, at least once per shift. Progress from passive to

active ROM as tolerated. This prevents joint contractures and mus-

cle atrophy.

Inform:  Explain to patient location of vulnerable pressure points and

instruct to shift and reposition weight to prevent skin breakdown.

Ensure patient maintains anatomically correct and functional body

positioning to promote comfort.

Demonstrate techniques to promote wheelchair mobility to the

patient and family members and note the date; have them perform a

return demonstration to ensure continuity of care and use of proper

technique.

Attend:  Encourage patient to operate her wheelchair independently

to the limits imposed by her condition to maintain muscle tone,

prevent complications of immobility, and promote independence in

self-care and health maintenance skills.

Encourage attendance at physical therapy sessions and reinforce

prescribed activities on the unit by using equipment, devices, and

techniques used in the therapy session. To maintain continuity of

care and promote patient safety.

Manage:  Refer patient to a physical therapist to enhance wheelchair

mobility and rehabilitation of musculoskeletal deficits.

Help patient identify resources for maintaining highest level of

mobility (e.g., community stroke program, sports associations for

people with disabilities, and the National Multiple Sclerosis Society)

to promote reintegration into the community.

SUGGESTED NIC INTERVENTIONS

Exercise Promotion: Strength Training; Exercise Therapy: Balance;

Exercise Therapy: Muscle Control; Positioning: Wheelchair

Reference

Gavin-Dreschnack, D., et al. (2005, April–June). Wheelchair-related falls: Cur-

rent evidence and directions for improved quality care. Journal of Nursing
Care Quality, 20(2), 119–127.

Nursing diagnosis – IMPAIRED PHYSICAL MOBILITY

IMPAIRED  PHYSICAL  MOBILITY

DEFINITION

Limitation in independent, purposeful physical movement of the

body or of one or more extremities

DEFINING CHARACTERISTICS

• Gait changes, postural instability; difficulty turning

• Limited ROM; ability to perform fine and gross motor skills

• Movement-induced tremor, uncoordinated or jerky movements

• Slowed and/or uncoordinated movements; reaction time.

• Substitution of other behaviors for impaired mobility (for instance,

increased attention to other’s activity and controlling behavior)

RELATED FACTORS

• Activity intolerance

• Decreased endurance; muscle

• Altered cellular metabolism

control, mass or strength

• Body mass index above

• Depressive mood state

75th percentile

• Deficient knowledge about

• Cognitive impairment

value of exercise

• Contractures

• Developmental delay

• Cultural beliefs regarding

• Discomfort

age-appropriate activity

• Disuse

• Deconditioning

• Joint stiffness

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition

EXPECTED OUTCOMES

The patient will

• Maintain muscle strength and joint ROM.

• Be free from complications (e.g., contractures, venous stasis,

thrombus formation, skin breakdown, and hypostatic pneumonia).

• Achieve the highest level of mobility (will transfer independently,

will be wheelchair-independent, or will ambulate with assistive
devices such as walker, cane, and braces).

• Carry out mobility regimen.

• Use resources to help maintain level of functioning.

SUGGESTED NOC OUTCOMES

Ambulation; Ambulation: Wheelchair; Joint Movement: Hip; Joint

Movement: Shoulder; Mobility; Transfer Performance

INTERVENTIONS AND RATIONALES

Determine:  Identify level of functioning using a functional mobility

scale. Communicate patient’s skill level to all staff members to pro-

vide continuity and preserve identified level of independence.

Monitor and record daily any evidence of immobility

complications as they may be more prone to develop complications.

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Perform:  Perform ROM exercises to joints, unless contraindicated, at

least once every shift to prevent joint contractures and muscular

atrophy. Turn and reposition patient every 2 hr. Establish a turning

schedule and post at bedside. Monitor frequency of turning to pre-

vent skin breakdown by relieving pressure. Place joints in functional

position. Use trochanter roll along the thigh, abduct thighs, use

high-top sneakers, and pull a small pillow under patient’s head to

maintain joints in a functional position and prevent musculoskeletal

deformities.

Place items within reach of the unaffected arm if patient has one-

sided weakness or paralysis to promote patient’s independence.

Carry out medical regimen to manage or prevent complications

(e.g., administer prophylactic heparin for venous thrombosis). This

promotes patient’s health and well-being.

Provide progressive mobilization to the limits of patient’s

condition (bed mobility to chair mobility to ambulation) to maintain

muscle tone and prevent complications of immobility.

Inform:  Instruct patient and family members in ROM exercises,

transfers, skin inspection, and mobility regimen to help prepare for

discharge and promote continuity of care. Request return

demonstration to ensure use of proper technique.

Attend:  Help patient use a trapeze and side rails to encourage inde-

pendence in mobility. Instruct him to perform self-care activities to

increase muscle tone.

Encourage physical therapy sessions and support activities on the

unit by using the same equipment and technique. Request written

mobility plans for reference. Ensure all members of the healthcare

team are reinforcing learned skills in the same manner.

Manage:  Refer patient to a physical therapist for development of

mobility regimen to help rehabilitate musculoskeletal deficits.

Assist patient in identifying resources such as American Heart

Association to provide a comprehensive approach to rehabilitation.

SUGGESTED NIC INTERVENTIONS

Exercise Promotion: Strength Training; Exercise Therapy: Joint

Mobility; Exercise Therapy: Muscle Control; Positioning: Wheelchair

Reference

Gillis, A., & MacDonald, B. (2005, June). Deconditioning in the hospitalized

elderly. The Canadian Nurse, 101(6), 16–20.

Nursing diagnosis – IMPAIRED BED MOBILITY

IMPAIRED  BED  MOBILITY

DEFINITION

Limitation of independent movement from one bed position to another

DEFINING CHARACTERISTICS

Impaired ability to perform the following actions while in bed:

• Move from supine to long sitting or long sitting to supine

• Move from supine to prone or prone to supine

• Move from supine to sitting or sitting to supine

• “Scoot” or reposition body

• Turn from side to side

RELATED FACTORS

• Cognitive impairment

• Musculoskeletal and/or

• Deconditioning

neuromuscular impairment

• Deficient knowledge

• Obesity

• Environmental constraints

• Pain

• Insufficient muscle strength

• Sedating medications

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Pharmacological function

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Have no complications associated with impaired bed mobility,

such as altered skin integrity, contractures, venous stasis, thrombus
formation, depression, altered health maintenance, and falls.

• Maintain or improve muscle strength and joint ROM.

• Achieve the highest level of bed mobility possible (independence,

independence with device, verbalization of needs for assistance with
bed mobility, requires assistance of one person or two people).

• Demonstrate ability to use equipment or devices to assist with

moving about in bed safely.

• Adapt to alteration in ability to move about in bed.

• Participate in social, physical, and occupational activities to the

extent possible.

SUGGESTED NOC OUTCOMES

Body Positioning: Self-Initiated; Cognition; Immobility

Consequences: Physiological; Immobility Consequences: Psychocogni-

tive; Joint Movement, Mobility; Neurological Status: Consciousness

INTERVENTIONS AND RATIONALES

Determine:  Identify patient’s level of independence using functional

mobility scale and document findings to provide continuity of care.

Monitor and record daily evidence of complications related to

impaired bed mobility (contractures, venous stasis, skin breakdown,

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thrombus formation, depression, altered health maintenance or self-

care skills, falls). Assess patient’s skin every 2 hr to maintain skin

integrity.

Perform:  Perform ROM exercises to affected joints, unless

contraindicated, at least once per shift. Progress from passive to

active ROM, as tolerated, to prevent joint contractures and muscle

atrophy.

Assist patient in maintaining anatomically correct and functional

body positioning to relieve pressure, thereby preventing skin break-

down and fluid accumulation in dependent extremities. Encourage

repositioning every 2 hr while in bed.

Establish a turning schedule for immobile patient. Encourage pro-

gressive mobility within patient’s limits to maintain muscle tone,

prevent complications, and promote self-care.

If you are uncertain about your ability to move the patient,

request help from colleagues to maintain safety.

Inform:  Instruct patient and family members in techniques to

improve bed mobility and ways to prevent complications to help

prepare the patient and family members for discharge.

Demonstrate patient’s bed mobility regimen and note the date.

Have patient and family members perform a return demonstration

to ensure continuity of care and use of proper technique.

Attend:  Encourage patient to participate in physical and

occupational therapy sessions. Incorporate equipment, devices, and

techniques used by therapists into your care. Request written

instructions from the patient’s therapists to use as a reference to

help ensure continuity of care and reinforce learned skills.

Manage:  Refer patient to a physical therapist to continue improve-

ment in bed mobility and rehabilitate musculoskeletal deficits; and

an occupational therapist to continue to maximize self-care skills.

Assist patient in identifying and contacting resources for social

and spiritual support to promote the patient’s reintegration into the

community and help him maintain psychosocial health.

SUGGESTED NIC INTERVENTIONS

Bed Rest Care; Body Mechanics Promotion; Exercise Promotion:

Strength Training; Exercise Therapy: Joint Mobility; Exercise Ther-

apy: Muscle Control; Positioning

Reference

Lyder, C. H. (2006, August). Assessing risk and preventing pressure ulcers in

patients with cancer. Seminars in Oncology Nursing, 22(3), 178–184.

Nursing diagnosis – IMPAIRED MEMORY

IMPAIRED  MEMORY

DEFINITION

Inability to remember or recall bits of information or behavioral

skills

DEFINING CHARACTERISTICS

• Inability to determine whether a behavior was performed

• Inability to learn new skills or information or to perform

previously learned skills

• Inability to recall factual information and recent or past events

• Incidences of forgetting, including forgetting to perform a behavior

at a scheduled time

RELATED FACTORS

• Anemia

• Fluid and electrolyte

• Decreased cardiac output

imbalance

• Excessive environmental

• Hypoxia

disturbances

• Neurological disturbances

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Neurocognition

• Emotional

• Self-care

• Fluids and electrolytes

EXPECTED OUTCOMES

The patient/family will

• Express feelings about memory impairment.

• Acknowledge need to take measures to cope with memory

impairment.

• Identify coping skills to deal with memory impairment.

• State specific plans to modify lifestyle.

• Establish realistic goals to deal with further memory loss.

SUGGESTED NOC OUTCOMES

Cognition; Cognitive Orientation; Concentration; Memory; Neuro-

logical Status: Consciousness

INTERVENTIONS AND RATIONALES

Determine:  Observe patient’s thought processes during every shift.

Document and report any changes. Changes may indicate progressive

improvement or a decline in patient’s underlying condition.

Perform:  Implement appropriate safety measures to protect patient

from injury. He or she may be unable to provide for his or her own

safety needs.

Call patient by name and tell him or her your name. Provide

background information (place, time, and date) frequently through-

out the day to provide reality orientation. Use a reality orientation

board to visually reinforce reality orientation.

Spend sufficient time with patient to allow her to become comfort-

able discussing memory loss and establish a trusting relationship.

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Be clear, concise, and direct in establishing goals to promote max-

imal use of patient’s remaining cognitive skills. Offer short, simple

explanations to patient each time you carry out any medical or

nursing procedure to avoid confusion.

Label patient’s personal possessions and photos, keeping them in

the same place as much as possible, to reduce confusion and create

a secure environment.

Inform:  Inform patient that you are aware of his or her memory loss

and that you will help him or her cope with his or her condition to

bring the issue into the open and help patient understand that your

goal is to help him or her.

Teach patient ways to cope with memory loss (e.g., using a beeper

to remind her when to eat or take medications; using a pillbox

organized by days of the week; keeping lists in notebooks or a

pocket calendar; having family members or friends remind her of

important tasks). Reminders help limit the amount of information

patient must maintain in her memory.

Help patient and family members establish goals for coping with

memory loss. Discuss with family members the need to maintain the

least restrictive environment possible. Instruct them on how to main-

tain a safe home environment for patient. This helps ensure that

patient’s needs are met and promotes his or her independence.

Demonstrate reorientation techniques to family members and pro-

vide time for supervised return demonstrations to prepare them to

cope with patient with memory impairment.

Attend:  Encourage patient to develop a consistent routine for

performing activities of daily living to enhance his self-esteem and

increase his self-awareness and awareness of his environment.

Encourage patient to interact with others to increase social

involvement, which may decline with memory loss.

Encourage patient to express the feelings associated with impaired

memory to reduce the impact of memory impairment on patient’s

self-image and lessen anxiety.

Manage:  Help family members identify appropriate community sup-

port groups, mental health services, and social service agencies to

assist in coping with the effects of patient’s illness or injury.

SUGGESTED NIC INTERVENTIONS

Anxiety Reduction; Calming Technique; Cerebral Perfusion Promo-

tion; Dementia Management; Fluid and Electrolyte Management;

Memory Training; Neurologic Monitoring; Reality Orientation

Reference

Parahoo, K., et al. (2006, June). Expert nurses’ use of implicit memory in the

care of patients with Alzheimer’s disease. Journal of Advanced Nursing,
54(5), 563–571.

Nursing diagnosis – RISK FOR IMPAIRED LIVER FUNCTION

RISK  FOR  IMPAIRED  LIVER  FUNCTION

DEFINITION

At risk for liver dysfunction

RISK FACTORS

• Hepatotoxic medications (e.g.,

• Viral infection (e.g., hepatitis

acetaminophen, statins)

A, B, or C, Epstein-Barr)

• HIV coinfection

• Chronic biliary obstruction

• Substance abuse (e.g., alcohol,

and infection

cocaine)

• Nutritional deficiencies

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Risk management

• Pharmacological function

• Fluids/electrolytes

EXPECTED OUTCOMES

The patient will

• State effects of environmental and ingested chemicals and

substances on their health and liver function.

• Work with industry managers and with public health officials to

lower or eliminate the presence of environmental chemicals and
substances in their work or living environment.

• Have liver function indicators within normal limits.

• Modify lifestyle and risk behaviors to avoid behaviors leading to

hepatic dysfunction and inflammation.

• Maintain long-term follow-up for chronic illness with healthcare

provider.

• Manage concurrent disease processes that impact hepatic function.

• Optimize nutritional intake for needs.

• Acknowledge the impact of medications on hepatic function.

• Observe measures to avoid the spread of infection to self and to

others.

SUGGESTED NOC OUTCOMES

Health-Promoting Behavior; Risk Control—Alcohol; Risk Control—

Drug Use; Safe Home Environment; Substance Addiction

Consequences

INTERVENTIONS AND RATIONALES

Determine: Assist patient and family to assess workplace and home

environments for potential hepatotoxic substances to increase

patient’s awareness of hazards in the environment and to lower

potential for hepatic injury.

Monitor for clinical manifestations of hepatic inflammation and

dysfunction to notify physician in order to initiate treatment if liver

function is compromised. Clinical manifestations may include

fatigue, depression or mood changes, anorexia, RUQ tenderness,

pruritis, jaundice, bruising, or nontraumatic bleeding.

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Monitor customary clinical laboratory tests to alert the healthcare

provider of the status of the immune/inflammatory response, the

degree of hepatic metabolic dysfunction, and the impact of concur-

rent disorders on liver function. Clinical laboratory tests include

complete blood cell (CBC) count:   lower red blood cell count,

elevated WBC (increased immunocyte and inflammatory responses);

basic metabolic panel—altered electrolyte balance, elevated glucose,

elevated blood urea nitrogen and creatinine level, elevated HbA1c;

hepatic plasma markers: elevated liver enzymes (alanine aminotrans-

ferase, aspartate aminotransferase, and    -glutamyltranspeptidase);

positive immunoassays for pathogen and viral antigens; elevated

ammonia; elevated bilirubin; low coagulation factors; low total

protein/albumin; elevated lipid panel.

Perform: Carry out postprocedure measures, as ordered, to identify

and/or minimize complications.

Inform: Teach patient about the following: perform hand hygiene

before and after personal hygiene and care; cover draining and non-

healing wounds; report to care provider; inform others of infectious

condition so that each observes barrier precautions; adhere to

prescribed plan of care and treatment with immune system modifiers

(antibiotics, antivirals, interferon, others); maintain a balanced nutri-

tional diet intake. These measures minimize patient’s risk for self-

infection and spread of infection and allow the patient to help modify

lifestyle to maintain optimum health level for self and for others.

Along with healthcare team, prepare the patient for and later evaluate

the results of liver biopsy and provide explanation to patient and family.

The patient and family need understanding of purpose for and

implications of results obtained from a liver biopsy. This support and

education helps the patient understand rationale for plan of treatment

and genetic counseling for genetically linked hepatic disorders.

Attend: Provide a nonjudgmental attitude toward patient’s lifestyle

choices to promote feelings of self-worth.

Manage: Refer patient to counseling and therapy to address lifestyle

choices and risk behaviors. Modification of behaviors will provide

risk avoidance for drug and alcohol abuse and exposure to body-

substance pathogen infection.

SUGGESTED NIC INTERVENTIONS

Behavioral Modification; Environment Risk Protection; Infection

Protection; Risk Identification; Risk Identification—Genetic; Self-

Modification Assistance; Sports Injury Prevention; Surveillance

Reference

McCance, K. L., & Huether, S. E. (2006). Pathophysiology: The biologic basis

for disease in adults and children (5th ed., pp. 1413–1428). St. Louis, MO:
Elsevier-Mosby.

Nursing diagnosis – IMPAIRED HOME MAINTENANCE

IMPAIRED  HOME  MAINTENANCE

DEFINITION

Inability to independently maintain a safe growth-promoting imme-

diate environment

DEFINING CHARACTERISTICS

• Difficulty in maintaining home in a comfortable environment

• Outstanding debts or financial crises

• Request for assistance with home maintenance

• Disorderly surroundings

• Unwashed or unavailable cooking equipment, clothes, or linens

• Accumulation of dirt, food wastes, or hygienic wastes

• Offensive odors

• Inappropriate household temperatures

• Lack of necessary equipment or aids

• Presence of vermin or rodents

RELATED FACTORS

• Deficient knowledge

• Impaired functioning

• Disease

• Insufficient finances

• Inadequate support systems

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Communication

• Roles/relationships

• Coping

• Self-perception

• Knowledge

EXPECTED OUTCOMES

The patient and family members will

• Express concern about poor home maintenance.

• Verbalize plans to correct health and safety hazards in home.

• Identify community resources available to help maintain home.

SUGGESTED NOC OUTCOMES

Family Functioning: Role Performance; Self-Care: IADLs

INTERVENTIONS AND RATIONALES

Determine: Assess home environment, financial resources, patient’s

knowledge about self-care; and communication patterns in the fam-

ily. Assessment information will assist in identifying appropriate

interventions.

Perform: List obstacles to effective home maintenance management

with patient and family to develop understanding of potential and

actual health and safety hazards. Begin discussions at patient’s level

of comfort. Adult learners learn best where they have specific needs

to fulfill.

Assist family members to assign daily and weekly responsibility

for home maintenance activities. Having a schedule will promote

consistency in following the plan of care.

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Inform: Teach patient and family the importance of home

maintenance to ensure safety. Provide written materials on environ-

mental aspects of home maintenance.

Teach skills such as setting down and choosing from a list of

options, and assertiveness skills to enhance coping strategies. Help

patient and family develop a program by using relaxation strategies

(i.e., meditation, guided imagery, yoga, exercise) to reduce anxiety.

Attend: Encourage weekly discussions about progress in maintaining

home maintenance schedule to develop family unity and allow mem-

bers to address problems before they become overwhelming.

Manage: Assist family members to contact community agencies that

can assist them in their efforts to improve home maintenance man-

agement, such as self-help groups, cleaning services, and extermina-

tors. Community resources can lessen family’s burden while

members learn to function independently.

SUGGESTED NIC INTERVENTIONS

Active Listening; Coping Enhancement; Counseling; Emotional

Support; Family Integrity Promotion; Family Support; Home

Maintenance Assistance

Reference

Horvath, K. J., et al. (2005, September–October). Caregiver competence to

prevent home injury to the care recipient with dementia. Rehabilitation
Nursing, 30(5), 189–196.

Nursing diagnosis – IMPAIRED GAS EXCHANGE

IMPAIRED  GAS  EXCHANGE

DEFINITION

Excess or deficit in oxygenation and/or carbon dioxide elimination

at the alveolar-capillary membrane

DEFINING CHARACTERISTICS

• Abnormal pH and arterial

• Headache upon awakening

blood gases levels

• Hypoxia and hypoxemia

• Abnormal respiratory rate,

• Increased or decreased carbon

rhythm, and depth

dioxide levels

• Confusion

• Irritability/Restlessness

• Cyanosis

• Nasal flaring

• Diaphoresis

• Pale, dusky skin

• Dyspnea

• Tachycardia

RELATED FACTORS

• Alveolar-capillary membrane changes

• Ventilation–perfusion changes

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition

• Cardiac function

• Respiratory function

EXPECTED OUTCOMES

The patient will

• Carry out ADLs without weakness or fatigue.

• Maintain normal Hb and HCT levels.

• Express feelings of comfort in maintaining air exchange.

• Cough effectively and expectorate sputum.

• Be free from adventitious breath sounds.

• Perform relaxation techniques every 4 hr.

• Use correct bronchial hygiene.

SUGGESTED NOC OUTCOMES

Gas Exchange: Ventilation; Respiratory Statue: Gas Exchange; Vital

Signs

INTERVENTIONS AND RATIONALES

Determine: Monitor respiratory status; rate and depth of breaths;

chest expansion; accessory muscle use; cough and amount and color

of sputum; and auscultation of breath sounds every 4 hr to detect

early signs of respiratory failure.

Monitor vital signs, arterial blood gases, and Hb levels to detect

changes in gas exchange.

Report signs of fluid overload or dehydration immediately. This

can lead to changes in acid-base balance and affect respiratory status.

Perform: Elevate head 30 to facilitate lung expansion and prevent

atalectasis. Assist with ADLs as needed to decrease tissue oxygen.

149
Perform bronchial hygiene as ordered (e.g., coughing, percussing,

postural drainage, and suctioning) to promote drainage and keep

airways clear. Administer bronchodilators, antibiotics, and steroids,

as ordered.

Record intake and output every 8 hr to monitor fluid balance.
Auscultate lungs every 4 hr and report abnormalities to detect

decreased or adventitious breath sounds.

Orient patient to the environment, that is, use of call bell, side

rails, and bed positioning controls. Place side rails up and bed

position down when the patient is in bed. Place personal items

within the patient’s reach. Assist patient when he or she is getting

out of bed in case of dizziness. These measures prevent risk of

falling. Move patient slowly to avoid hypostatic hypotension. Post

a notice where it can be seen that the patient is at risk for falling.

Inform: Teach and demonstrate correct breathing and coughing tech-

niques such as diaphragmatic or abdominal breathing and have

patient return demonstration to ensure patient understands proper

technique and promote effective coughing and deep breathing.

Teach patient correct way of using inhalers. Remind patient about

mouth care after each dose. Failure to clean the mouth after inhal-

ing can cause candidiasis in the throat.

Review all medications with patient and family and list side

effects for each to ensure that the patient recognizes side effects and

reports them to the physician.

Encourage relaxation techniques to reduce oxygen demand.

Attend: Encourage patient to express feelings. Attentive listening

helps build a trusting relationship.

Encourage family members to stay with the patient, especially

during times of anxiety to promote relaxation which reduces oxygen

demand.

Manage: Request for a case manager to make a home visit to help

prepare family for the patient’s return to a safe environment.

Refer patient to community resources and offer written informa-

tion that can be referred to when needed.

SUGGESTED NIC INTERVENTIONS

Acid–Base Management; Airway Management; Airway suctioning;

Anxiety Reduction; Energy Management; Exercise Promotion; Fluid

Management

Reference

Marklew, A. (2006, January–February). Body positioning and its effect on

oxygenation—A literature review. Nursing in Critical Care, 11(1), 16–22.

Nursing diagnosis – IMPAIRED ENVIRONMENTAL INTERPRETATION SYNDROME

IMPAIRED  ENVIRONMENTAL

INTERPRETATION  SYNDROME

DEFINITION

Consistent lack of orientation to person, place, time, or

circumstances over more than 3 to 6 months necessitating a

protective environment

DEFINING CHARACTERISTICS

• Chronic confusion

• Consistent state of disorientation to environment

• Inability to reason, concentrate, or follow simple instructions

• Loss of occupation or social function resulting from memory decline

• Slow response to questions

RELATED FACTORS

• Dementia

• Depression

• Huntington’s disease

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Knowledge

• Communication

• Sensory perception

EXPECTED OUTCOMES

The patient will

• Acknowledge and respond to efforts by others to establish

communication.

• Identify physical changes without making disparaging comments.

• Remain oriented to the environment to the fullest possible extent.

• Remain free from injuries.

The caregiver will

• Describe measures for helping the patient cope with disorientation.

• Demonstrate reorientation techniques.

• Describe ways to make sure that the home is safe for the patient.

• Identify and contact appropriate support services for the patient.

SUGGESTED NOC OUTCOMES

Cognitive Orientation; Concentration; Fall-Prevention Behavior;

Memory; Safe Home Environment

INTERVENTIONS AND RATIONALES

Determine: Assess cultural status, functional ability and coordination,

interaction with others in social settings, and presence of vision or

hearing deficits. Assessment of these factors will help in identifying

appropriate interventions.

Perform: Orient patient to reality, as needed: call patient by name;

tell patient your name; provide day, date, year, and place; place a

photograph or patient’s name on the door; keep all items in the

same place. Consistency and continuity will reduce confusion and

decrease frustration.

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Place patient in a room near the nurse’s station to provide imme-

diate assistance from staff, if needed.

Clear patient’s room of any hazardous materials, and accompany

patient who wanders to prevent injury.

Work with patient and caregivers to establish goals for coping

with disorientation. Practice with coping skills can prevent fear.

When speaking to the patient, face him and maintain eye contact

to foster trust and communication.

Promote independence while performing ADL measures patient is

unable to perform to reduce feelings of dependence.

Inform: Provide written information to caregivers on reorientation

techniques. Demonstrate reorientation techniques to caregiver to

prepare caregiver to cope with the patient when he or she returns

home.

Teach caregivers to assist patient with self-care activities in a way

that maximizes patient’s potential to encourage patient’s independence.

Attend: Be attentive to the patient when you are with him. Be aware

that patient may be sensitive to your unspoken feelings about him in

order to inspire confidence in the caregiver.

Help patient and caregivers cope with feelings associated with the

disease. Understanding promotes affective coping.

Have patient perform ADLs. Begin slowly and increase daily, as

tolerated to assist patient to regain independence and enhance self-

esteem. Provide reassurance and praise for completing simple tasks.

Focus on patient’s strengths.

Involve caregiver and patient in planning and decision making as

a cooperative effort supports patient’s needs.

Encourage patient to engage in social activities with people of

all age groups once a week to help relieve the patient’s sense of

isolation.

Manage: Refer patient to case manager/social worker to ensure

that patient receives longer term assistance to ensure continued

care.

Refer caregiver to a support group. Caregivers need continuous

support from others to cope with the need to provide constant

supervision to the patient.

SUGGESTED NIC INTERVENTIONS

Anxiety Reduction; Behavior Management; Dementia Management;

Emotional Support; Mood Management; Reality Orientation

Reference

Patton, D. (2006). Reality orientation: Its use and effectiveness within older

person health care. Journal of Clinical Nursing, 15(11), 440–449.

Nursing diagnosis – IMPAIRED DENTITION

IMPAIRED  DENTITION

DEFINITION

Disruption in tooth development and eruption patterns or structural

integrity of individual teeth

DEFINING CHARACTERISTICS

• Caries; extractions; evidence of periodontal disease

• Evulsion

• Inability or unwillingness of parents or caregiver to provide child

with dental care; lack of access to dental care

• Lack of knowledge of appropriate dental hygiene practices

• Malocclusion; plaque; toothache

• Loose teeth; premature loss of primary teeth

• Erosion of enamel

RELATED FACTORS

• Barriers to self-care

• Ineffective oral hygiene

• Bruxism

• Nutritional deficits

• Chronic use of coffee, tea, red

• Sensitivity to cold

wine, tobacco

• Sensitivity to heat

• Chronic vomiting

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Knowledge

• Roles/responsibilities

• Nutrition

• Values and beliefs

EXPECTED OUTCOMES

The individual will

• Brush teeth with minimal supervision.

• Demonstrate good brushing technique.

• Not show evidence of dental caries, periodontal disease, or maloc-

clusion.

• Reduce quantity of cariogenic foods in his or her diet.

• Show evidence of good daily oral hygiene.

SUGGESTED NOC OUTCOME

Oral Hygiene; Self-Care: Oral Hygiene

INTERVENTIONS AND RATIONALES

Determine: Assess dental history; primary and secondary tooth devel-

opment; frequency of visits to dentist; frequency of brushing; condi-

tion of the teeth; nutritional status; medications; socioeconomic sta-

tus. Assessment of these factors will help to identify appropriate

interventions.

Perform: Provide tooth brush, toothpaste, and dental floss.

Schedule times for brushing and have patient begin keeping a

record. Keeping a record will promote compliance.

Inform: Teach child principles of good oral hygiene by using teaching

methods appropriate to his age-group to foster compliance.

105
Teach the child and his or her parents or caregiver about the rela-

tionship between diet and dental health. Show the child pictures that

promote good dental health and pictures of foods that lead to den-

tal decay. If the child can read, teach him or her to read labels;

teach him or her to avoid products with excessive sucrose. Sucrose

is a simple sugar that promotes dental decay.

Demonstrate good brushing technique. Stress the importance of

having teeth feel clean rather than the need to follow a specific pro-

cedure.

Attend: Encourage parents to create a pleasant mealtime environment

with nutritious foods made to look appealing to a child so that the

child will learn to recognize nutritious foods.

Give positive reinforcement for good choices. Be supportive to the

parents as they try to help the child modify diet to include more

nutritional foods. It is not easy to teach children to make right food

choices, and parents benefit from encouragement to keep reinforcing

good healthy choices.

Encourage ample fluid intake to keep gums well hydrated.

Adequate fluids promote healthy gums.

Manage: Refer to dentist for assessment of dental health.

Schedule a follow-up appointment with parents to ensure they

have taken child to the dentist.

Where it is indicated, refer to a nutritionist for help in modifying

diet.

SUGGESTED NIC INTERVENTIONS

Oral Health Maintenance; Oral Health Promotion; Teaching:

Individual

Reference

Melvin, C. S. (2006, January–February). A collaborative community based

oral care program for school age children. Clinical Nurse Specialist, 20(1),
18–22.

Nursing diagnosis – IMPAIRED VERBAL COMMUNICATION

IMPAIRED  VERBAL  COMMUNICATION

DEFINITION

Decreased, delayed, or absent ability to receive, process, transmit,

and use a system of symbols

DEFINING CHARACTERISTICS

• Disorientation to person, space,

• Dyspnea

time

• Impaired articulation

• Difficulty comprehending and

• Inability or lack of desire to

maintaining usual communica-
tion pattern

speak
• Inability to speak dominant

• Difficulty expressing thoughts

language

verbally (aphasia, dysphasia,
apraxia, dyslexia)

• Inappropriate verbalizations
• Lack of eye contact or poor

• Difficulty forming words or

selective attention

sentences (aphonia, dyslalia,
dysarthria)

• Stuttering or slurring
• Visual deficit (partial or

• Difficulty using or inability to

total)

use facial expressions or body
language

RELATED FACTORS

• Absence of significant others

• Differences related to develop-

• Altered perceptions

mental age

• Alteration in self-concept, self-

• Environmental barriers

esteem, or central nervous
system

• Lack of information
• Physical barriers (e.g.,

• Anatomical defect (e.g., cleft

tracheostomy, intubation)

palate, alteration of the neuro-
muscular visual system,
phonation apparatus)

• Physiological conditions
• Psychological barriers (e.g.,
psychosis, lack of stimuli)

• Brain tumor

• Side effects of medications

• Cultural differences

• Stress

• Decrease in circulation to

• Weakening of the

brain

musculoskeletal system

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Neurocognition

• Communication

• Respiratory function

EXPECTED OUTCOMES

The patient/family will

• Have needs met by staff members.

• Express satisfaction with level of communication ability.

• Maintain orientation.

• Maintain effective level of communication.

• Answer direct questions correctly.

59

SUGGESTED NOC OUTCOMES

Cognition; Communication; Communication: Expressive; Communi-

cation: Receptive; Information Processing

INTERVENTIONS AND RATIONALES

Determine: Observe patient closely for cues to his or her needs and

desires, such as gestures, pointing to objects, looking at items, and

pantomime to enhance understanding. Avoid continually responding

to gestures if the potential exists to improve speech to encourage

desire to improve.

Monitor and record changes in patient’s speech pattern or level of

orientation. Changes may indicate improvement or deterioration of

condition.

Perform: Speak slowly and distinctly in a normal tone when address-

ing patient, and stand where patient can see and hear you. These

actions promote comprehension.

Reorient the patient to reality: Call patient by name; tell him or

her your name; give him or her the background information (place,

date, and time); use television or radio to augment orientation; use

large calendars and communication boards (including alphabet and

some common words and pictures). These measures develop orienta-

tion skills through repetition and recognition of familiar objects.

Use short, simple phrases and yes-or-no questions when patient is

very frustrated to reduce frustration.

Inform: Instruct family members to use techniques listed above to

ease their frustration in communication with the patient.

Attend: Encourage attempts at communication and provide positive

reinforcement to aid comprehension.

Allow ample time for a response. Don’t answer questions yourself

if patient has ability to respond. This improves patient’s self-concept

and reduces frustration.

Repeat or rephrase questions, if necessary, to improve communication.

Don’t pretend to understand if you don’t, to avoid misunderstanding.

Remove distractions from the environment during attempts at

communication. Reduced distractions improve comprehension.

Manage: Review diagnostic test results to determine improvement or

deterioration of the disease process. Adjust the care plan

accordingly.

SUGGESTED NIC INTERVENTIONS

Active Listening; Communication Enhancement: Hearing Deficit; Com-

munication Enhancement: Speech Deficit; Learning Facilitation; Touch

Reference

Philpin, S. M., et al. (2005, May). Giving people a voice: Reflections on con-

ducting interviews with participants experiencing communication
impairment. Journal of Advanced Nursing, 50(3), 299–306.

Nursing diagnosis – READINESS FOR ENHANCED COMFORT

READINESS  FOR  ENHANCED  COMFORT

DEFINITION

A pattern of ease, relief, and transcendence in physical, psychospiritual

environmental, and/or social dimensions that can be strengthened

DEFINING CHARACTERISTICS

• Expresses desire to enhance comfort

• Expresses desire to enhance feelings of contentment

• Expresses desire to enhance relaxation

• Expresses desire to enhance resolution of complaints

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Communication

• Coping

EXPECTED OUTCOMES

The patient will

• Express positive perception of nursing assistance to perform activi-

ties that promote comfort.

• Experience physical and psychological ease.

• Develop plans to optimize level of comfort.

• Report an increase in relaxation.

SUGGESTED NOC OUTCOMES

Coping Enhancement; Client Satisfaction; Comfort Level; Emotional

support; Environmental Management

INTERVENTIONS AND RATIONALES

Determine: Assess patient’s satisfaction with the amount of assistance

the nurse is presently offering to determine whether the patient per-

ceives self as performing physical, psychosocial, and spiritual activi-

ties as a level that is comfortable for self-changes in status.

Determine what enhancements to care can be made to provide the

patient a greater degree of comfort.

Ask for feedback from the patient at least once a day to evaluate

progress.

Perform: Adjust environmental factors, where possible, to enhance

the patient’s feeling of a safe and comfortable environment.

Assist patient with bathing, feeding, and toileting to ensure that

his or her needs are met.

Turn and reposition patient every 2 hr to promote comfort.

Inform: Teach patient when he or she is ready about his or her dis-

ease. Present only what patient is able and willing to absorb to pre-

vent him or her from becoming overwhelmed.

Avoid insisting that the patient accept information. Readiness is

an important factor in adult education. Provide both patient and

family with written information such as pamphlets and so forth.

57
Teach the patient and family techniques for relaxation such as

guided imagery to promote comfort and reduce anxiety.

Attend: Provide emotional support and encouragement to help

improve ability of patient to cope with the diagnosis.

Involve patient in planning and decision making. Having the abil-

ity to participate will encourage greater compliance with the plan

and enhance comfort.

Encourage patient to communicate with others, asking questions

and clarifying concerns based on readiness. This will enhance the

patient’s learning ability.

Manage: Maintain frequent communication with physicians and

other staff to determine what the patient is being told about his or

her condition.

Collaboration will foster consistency in what the patient is being

told.

Refer patient to a mental health professional/grief counselor if

denial interferes with ability of patient to function within limits.

SUGGESTED NIC INTERVENTIONS

Anxiety Reduction; Calming Techniques; Counseling; Health Educa-

tion; Reality Orientation; Truth Telling

Reference

Telford, K., et al. (2006, August). Acceptance and denial. Implications for

people adapting to chronic illness: Literature review. Journal of Advanced
Nursing, 55(4), 457–464.

Nursing diagnosis – IMPAIRED COMFORT

IMPAIRED COMFORT

DEFINITION

Perceived lack of ease, relief, and transcendence in physical, psycho-

spiritual, environmental, and social dimensions

DEFINING CHARACTERISTICS

• Disturbed sleep pattern, inability to relax, and restlessness

• Insufficient resources (e.g., financial, social support)

• Lack of environmental or situational control

• Lack of privacy

• Noxious environmental stimuli

• Reports being uncomfortable, hot or cold, or hungry

• Reports distressing symptoms, anxiety, crying, irritability, and

moaning

• Reports itching

• Reports lack of contentment in situation

• Treatment-related side effects (e.g., medication, radiation)

ASSESSMENT FOCUS

• Cardiac

• Respiratory

• Muscle tone

• Sleep patterns

• Pain

EXPECTED OUTCOMES

The patient will

• Maintain heart rate, rhythm, and respiration rate within expected

range during rest and activity.

• Maintain muscle mass and strength.

• Report pain using pain scale.

• Report periods of restful sleep.

SUGGESTED NOC OUTCOMES

Comfort Status; Coping; Knowledge Health Promotion; Pain Control

INTERVENTIONS AND RATIONALES

Determine: Monitor pain level using scale 1–10. Using a scale will

allow evaluation of the effectiveness of pain-relieving measures.

Assess vitals signs during times of discomfort, including blood

pressure, heart rate and rhythm, and respirations. Use the patient’s

baseline vital signs to evaluate response to pain and response to

pain-relieving measures.

Assess sleeping patterns in response to discomfort. Interruption of

sleep is common in patients experiencing discomfort.

Perform: Provide a quiet and relaxing atmosphere. Encourage active

exercise to increase feeling of well-being. Provide pain medications

as ordered; evaluate response to evaluate effectiveness of pain-relieving

measures.

Inform: Teach relaxation exercises and techniques to promote

reduced pain levels, sleep, and anxiety. Teach medication administra-

tion and schedule to facilitate pain relief. Teach massage therapy to

caregiver to promote comfort.

Attend: Provide support and encouragement during periods of

discomfort. Include patient in plan of action to promote self-care.

Manage: Refer to pain management clinic if pain cannot be

controlled through relaxation and exercise. Refer to physical thera-

pist to accommodate patient’s level of physical activity. Refer to

massage therapist to promote relaxation. All healthcare professionals

contribute to the overall goal of maintaining comfort.

SUGGESTED NIC INTERVENTIONS

Active Listening; Aromatherapy; Calming Technique; and Coping

Enhancement

Reference

Dowd, T., Kolcaba, K., Fashinpaur, D., Steiner, R., Deck, M., & Daugherty, H.

(2007). Comparison of healing touch and coaching on stress and comfort in
young college students. Holistic Nursing Practice, 21(4), 194–202.