Impaired ability of an infant to suck or coordinate the suck/swallow

response resulting in inadequate oral nutrition for metabolic needs


• Inability to coordinate sucking, swallowing, and breathing

• Inability to initiate or sustain effective suck


• Anatomic abnormality

• Oral hypersensitivity

• Neurological delay or impair-

• Prematurity


• Prolonged NPO status

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Nutrition

• Growth and development

• Roles/relationships


The neonate will

• Not lose more than 10% of birth weight within first week of life.

• Gain 4–7 oz (113.5–198.5 g) after first week of life.

• Remain hydrated.

• Receive adequate supplemental nutrition until able to suckle suffi-


• Establish effective suck-and-swallow reflexes that allow for

adequate intake of nutrients.

The parents will

• Identify factors that interfere with neonate establishing effective

feeding pattern.

• Express increased confidence in their ability to perform appropri-

ate feeding techniques.


Breast-Feeding Establishment: Infant; Breast-Feeding Maintenance;

Muscle Function; Nutritional Status: Food & Fluid Intake;

Swallowing Status


Determine: Weigh neonate at the same time each day on the same

scale to detect excessive weight loss early.

Continuously assess neonate’s sucking pattern to monitor for inef-

fective patterns.

Assess parents’ knowledge of feeding techniques to help identify

and clear up misconceptions.

Assess parents’ level of anxiety about the neonate’s feeding diffi-

culty. Anxiety may interfere with the parents’ ability to learn new


Monitor neonate for poor skin turgor, dry mucous membranes,

decreased or concentrated urine, and sunken fontanels and eyeballs

to detect possible dehydration and allow for immediate intervention.

Record the number of stools and amount of urine voided each

shift. An altered bowel elimination pattern may indicate decreased

food intake; decreased amounts of concentrated urine may indicate


Assess the need for gavage feeding. The neonate may temporarily

require alternative means of obtaining adequate fluids and calories.

If neonate requires intravenous nourishment, assess the insertion

site, amount infused, and infusion rate every hour to monitor fluid

intake and identify possible complications, such as infiltration and


Perform: Remain with the parents and neonate during the feeding to

identify problem areas and direct interventions.

For bottle-feeding, record the amount ingested at each feeding; for

breast-feeding, record the number of minutes the neonate nurses at

each breast and the amount of any supplement ingested to monitor

for inadequate caloric and fluid intake.

Provide an alternative nipple, such as a preemie nipple. A preemie

nipple has a larger hole and softer texture, which makes it easier for

the neonate to obtain formula.

For breast-feeding, ensure that the neonate’s tongue is properly

positioned under the mother’s nipple to promote adequate sucking.

Alternate oral and gavage feeding to conserve the neonate’s


Inform: Teach parents to place the neonate in the upright position

during feeding to prevent aspiration.

Teach parents to unwrap and position a sleepy neonate before

feeding to ensure that the neonate is awake and alert enough to

suckle sufficiently.

Attend: Provide positive reinforcement for the parents’ efforts to

improve their feeding technique to decrease anxiety and enhance

feelings of success.

Manage: Assess neonate for neurologic deficits or other pathophysio-

logic causes of ineffective sucking to identify the need for referral

for more extensive evaluation.


Attachment Promotion; Breast-Feeding Assistance; Lactation Coun-

seling; Nonnutritive Sucking


Kelly, M. M. (2006, September–October). Primary care issues for the healthy

premature infant. Journal of Pediatric Health Care, 20(5), 293–299.




Inability to identify, manage, and/or seek out help to maintain health


· Demonstrated lack of adaptive behaviors (internal or external

environmental changes)

· Demonstrated lack of knowledge regarding basic health practices

· History of lack of health-seeking behaviors

· Reported or observed impairment of personal support systems

· Reported or observed inability to take responsibility for meeting

basic health practices in any or all functional pattern areas.

· Reported or observed lack of equipment or financial and other



· Cognitive impairment

· Diminished gross motor skills

· Complicated grieving

· Inability to make appropriate

· Deficient communication skills


· Diminished fine motor skills

· Ineffective family coping

ASSESSMENT FOCUS                           (Refer  to  comprehensive  assessment  parameters.)

· Communication

· Knowledge

· Coping

· Risk management

· Healthcare system

· Values and beliefs


The patient will

· Maintain current health status.

· Sustain no harm or injury.

· Verbalize feelings and concerns.

· Explain health maintenance program.

· Identify available health resources.


Coping; Decision Making; Health Beliefs: Perceived Resources;

Health-Promoting Behavior; Social Support; Spiritual Health


Determine: Assess current health status; personal habits such as use

of tobacco, drugs, and alcohol; level of knowledge about disease

process; level of family and community assistance; coping

mechanisms and communication skills (verbal and written); and

degree of motivation to maintain health. Assessment factors will

assist the nurse in establishing interventions for this diagnosis.

Perform: Provide assistance with self-care, as needed. Encourage

increasing levels of independence. The patient should be as

independent in ADLs as possible.


Administer medications as prescribed to ensure continuation of


Adapt environment to that which is best suited to the particular

patient. Reorient the patient as needed. In the disoriented patient,

reorientation should take place frequently to keep the person as

close to knowing person, place, and time as possible.

Provide a consistent caretaker whenever possible to promote sta-

bility for the patient.

Plan a health maintenance program for patient and family members

addressing current disabilities. Provide patient and family with a writ-

ten copy. Giving instructions in writing will reinforce the various

aspects of the program and increase the possibility of compliance.

Inform: Fully describe all aspects of the patient’s care to the family

to elicit cooperation from them in continuing a plan.

Instruct family members how to carry out health maintenance

practices. Demonstrate skills such as bathing, feeding, and reality

orientation; then, have family members return demonstration under

supervision. Involving family members allows them the opportunity

to perform skills and solve problems with support and supervision.

Provide specific instructions on how to maintain a safe

environment for the patient to avoid falls and other types of

accidental injuries.

Teach relaxation techniques (e.g., guided imagery, progressive mus-

cle relaxation, and meditation) that can be done by the patient and

the family to enhance coping ability and restore psychological and

physical equilibrium by decreasing autonomic response to anxiety.

Attend: Encourage patient and family to verbalize feelings and con-

cerns related to health maintenance. This promotes better

understanding and greater ease in managing challenging situations.

Demonstrate willingness to repeat instruction and demonstrate

skills needed to care for the patients until they feel comfortable.

Manage: Refer to social and community resources, such a stroke sup-

port group, and Alzheimer’s family support group. This helps the family

gain support and receive factual information. It provides opportunity to

express feeling in a group where others are experiencing similar issues.

Making referrals is appropriate to mental health professional to

assist with prevention of burnout for the family.


Anticipatory Guidance; Coping Enhancement; Counseling; Discharge

Planning; Health Education; Health System Guidance; Physician

Support; Referral; Support System Enhancement


Cole, C. S., et al. (2006, April). Assessment and discharge planning for the

older hospitalized adults with delirium. Medsurg Nursing, 15(2), 71–76.

Nursing diagnosis – INEFFECTIVE DENIAL



Conscious or unconscious attempt to disavow the knowledge or

meaning of an event to reduce anxiety/fear, but leading to the detri-

ment of health


• Delay in seeking or refusal of medical attention to detriment of


• Displacement of fear about condition’s impact

• Displacement of sources of symptoms to other organs

• Failure to perceive personal relevance or danger of symptoms

• Inability to admit impact of disease on life pattern

• Inappropriate affect

• Minimization of symptoms

• Refusal to admit fear of death or invalidism


• Anxiety

• Lack of control of the situation

• Fear of death

• Overwhelming stress

• Fear of loss of autonomy

• Threat of unpleasant reality

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Coping

• Communication

• Values and beliefs


The patient will

• Describe knowledge and perception of present health problem.

• Describe life pattern and report any changes.

• Express knowledge of stages of grieving.

• Demonstrate behavior associated with the grief process.

• Indicate, either verbally or through behavior, an increased aware-

ness of reality.


Acceptance: Health Status; Anxiety Level; Coping; Fear Self-Control;

Health Beliefs: Perceived Threat; Symptom Control


Determine: Assess patient’s understanding and perception of present

health state, including awareness of diagnosis, and perception of rel-

evance on life pattern and description of symptoms.

Evaluate coping status and mental status, including mood, affect,

memory, and judgment. Assessment of these factors will help iden-

tify appropriate interventions.

Perform: Schedule a specific amount of uninterrupted non-care-

related time each day with the patient to allow patient to express

feelings and concerns.

Assist patient with ADLs as needed to conserve energy and avoid

overexertion. Assist with grooming (e.g., shaving for men, hair and

makeup for women). Offer massage to enhance comfort and

promote relaxation.

Encourage active exercise (e.g., provide a trapeze or other assistive

device if needed). Exercise will promote positive attitude.

Inform: Discuss stages of anticipatory grieving to increase

understanding of what is happening and increase patient’s ability to


Teach patient about diagnosis and treatment as he or she demon-

strates readiness to learn. Provide brochures and simple written

materials to help with the learning process.

Attend: Provide emotional support and encouragement to help

improve patient’s self-concept and motivate the patient to be more

involved in planning care.

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

ity to participate will encourage greater compliance with the plan

for treatment.

Have patient perform self-care activities. Begin slowly and increase

daily, as tolerated. Performing self-care activities will assist patient

to regain independence and enhance self-esteem.

Schedule treatments apart from visiting to allow for periods of


Maintain frequent discussions with physicians and staff to be cer-

tain what patient has been told by other care providers.

Manage: Refer to case manager/social worker for follow up care.

Refer to clergy person for spiritual care if patient expresses interest.


Anxiety Reduction, Behavior Modification; Calming; Counseling;

Decision-Making Support; Truth Telling


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.




Pattern of community activities for adaptation and problem-solving

that is unsatisfactory for meeting the demands or needs of the com-



• Deficits in participation

• Excessive conflicts

• Expressed powerlessness and vulnerability

• Failure of community to meet its own expectations

• High illness rate

• Increased social problems (abuse, divorce, and unemployment)

• Perception of stressors as excessive


• Deficits in community social

• Natural disasters

support services

• Man-made disasters

• Deficits in community social

• Inadequate resources for prob-


lem solving

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Communication

• Risk management

• Coping

• Values and beliefs

• Healthcare system


Community members will

• Express awareness of seriousness of high school adolescent preg-

nancy rate in their community.

• Express need for plan to reduce prevalence of teen pregnancy.

• Develop and implement plan to reduce teen pregnancy.

• Evaluate success of plan in meeting goals and objectives and will

continue to revise it, as necessary.

• Report reduction in rate of teen pregnancy.


Community Competence; Community Health Status


Determine: Assess the following: community demographics; number of

teen pregnancies in the community in the past 2 years; attitudes toward

teen mothers and their infants; availability of programs in the schools

that help teen mothers continue their education; teens’ knowledge about

sex and sexuality; religious attitudes in the community toward sex

and sexuality; influence of religious groups on educators. Assessment

information will be useful in establishing appropriate interventions.

Perform: Collect statistical data from schools to analyze teen

pregnancy rates as a basis for evaluating a pregnancy prevention


program. Plan a teen pregnancy program that can be used in

schools. Include information on risks, problems, and complications

of teen pregnancy. Contact local corporations for financial assistance

in supporting educational programs.

Establish clubs for adolescent girls in the community. These can

be used as a method for educating as well as helping girls establish

healthy relationships.

Establish therapeutic relationships with pregnant adolescents to

build support during this difficult period.

Inform: Provide education on birth-control measures (including absti-

nence from sex) and have this information available at school.

Encourage an information campaign to educate adolescents, parents,

and community members about problems related to teen pregnancy.

Teach parent to observe behavioral cues from child. For example,

the child may become fussy when he is ready for a nap or may pull

his ear if he has an earache to indicate that he has pain. Explain the

range of options for responding to these cues in positive ways. Par-

ents may be unfamiliar with cues from child behavior.

Teach parents to give physical care when the need exists. The

parents may need instruction on the importance and proper way of

providing care. Teach relaxation techniques that can be done by the

parents such as guided imagery, progressive muscle relaxation, and

meditation. These measures restore psychological and physical equi-

librium by decreasing autonomic response to anxiety.

Encourage local youth groups and religious and social

organizations to feature guest speakers on pregnancy prevention at

their meetings. Speakers with expertise in the area of teen pregnancy

are better able to provide information that may help teens make

better choices in sexual behavior.

Attend: Encourage community members to establish school-based

clinics that allow teens access to reproductive-system models, preg-

nancy tests, and nonprescription birth-control measures to support

teens who choose to protect themselves from unwanted pregnancy.

Manage: Develop a referral list for teens that includes resources such as

hospitals with human sexuality courses, charities that provide prenatal

care and childbirth services, women’s clinics, and Planned Parenthood

to compensate for restricted access to information in the schools.


Community Health Development; Health Education; Health Screen-

ing; Program Development


Brindis, C. D. (2006). A public health success: Understanding policy changes

related to teen sexual activity and pregnancy. Annual Review of Public
Health, 27, 277–295.

Nursing diagnosis – INEFFECTIVE COPING



Inability to form a valid appraisal of the stressors, inadequate

choices of practiced responses, and/or inability to use available



• Change in communication patterns

• Decreased use of social support

• Destructive behavior toward self or others

• Difficulty asking for help

• Fatigue

• High illness rate

• Inability to meet basic needs and role expectations

• Statements indicating inability to cope


• High degree of threat

• Inability to conserve adaptive energies

• Inadequate resources available

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Communication

• Coping


The patient will

• Verbalize increased ability to cope.

• Expand support network to meet social and emotional needs.

• Locate and use appropriate resources for help in problem solving.

• Report increased ability to meet demands of daily living.

• Make changes to environment to ensure enhanced coping or move

into long-term care facility, as needed.


Coping; Decision Making; Impulse Self-Control; Information

Processing; Social Interaction Skills


Determine: Monitor physiological responses to increased activity

level, including respirations, heart rate and rhythm, and blood pres-

sure. Vital signs are likely to change as the patient deals with the

frustration from poor coping strategies. Assess understanding of the

current health problem and desire to participate in treatment.

Perform: Listen to the patient. Respond in a matter-of-fact, nonjudg-

mental manner. Judgmental responses will impede the development

of a trusting relationship. Practice guided imagery and deep breath-

ing with the patient to help the patient relax.


Inform: Provide patient with information about relaxation

techniques. These techniques take practice. Information will help the

patient understand the benefit.

Teach patient about her disease process and explain treatments to

allay fear and allow the patient to regain sense of control.

Teach positive coping strategies and have patient role-play them

and give praise for successful modeling. This will help to reinforce

coping behaviors.

Attend: Assist patient to develop short- and long-term goals to

encourage better coping and a roadmap to measure progress.

Provide emotional support and encouragement to help improve

patient’s negative self-concept and motivate the patient to perform

ADLs. Involve patient in planning and decision making. Having the

ability to participate will encourage greater compliance with

treatment plan. Encourage patient to engage in social activities with

people of all age groups. Participation once a week will help relieve

the patient’s sense of isolation.

Manage: Refer patient for professional psychological counseling. For-

mal counseling helps ease the nurse’s frustration, increases objectiv-

ity, and fosters collaborative approach to patient’s care.

Before discharge, refer patient to case manager who can help

patient become involved in informal community programs, such as

volunteer, foster grandparents, or religious groups, to provide peer

and social contact and decrease the patient’s loneliness and isolation.

Refer patient to a support group. In the context of a group, the

patient may develop a more positive view in the present situation.


Coping Enhancement; Decision-Making Support; Emotional Support;

Environmental Management; Impulse Control Training; Support Sys-

tem Enhancement


Popejoy, L. (2005, September). Health-related decision-making by older adults

and their families: How clinicians can help. Journal of Gerontological Nurs-
ing, 31(9), 12–18.

Nursing diagnosis – ineffective breathing pattern

Inspiration and/or expiration that does not provide adequate ventilation
• Accessory muscle use
• Abnormal heart rate response to activity
• Altered respiratory rate or depth or both
• Assumption of 3-point position
• Decreased minute ventilation
• Decreased vital capacity
• Decreased tidal volume
• Dyspnea
• Nasal flaring
• Prolonged expiratory phase
• Pursed lip breathing
• Anxiety
• Body position
• Chest wall deformity
• Musculoskeletal impairment
• Obesity
• Pain
• Respiratory muscle fatigue
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Activity/exercise
• Cardiac function
• Neurologic and mental status
• Respiratory function
The patient will
• Maintain respiratory rate within 5 of baseline.
• Regain arterial blood gases to baseline.
• Express feelings of comfort when breathing.
• Demonstrate diaphragmatic pursed-lipped breathing.
• Achieve maximal lung expansion with adequate ventilation.
• Maintain heart rate, rhythm, and blood pressure within expected
range during periods of activity.
• Demonstrate skill in conserving energy while carrying out ADLs.
Mechanical Ventilation Response: Adult; Respiratory Status: Airway
Patency; Respiratory Status: Gas Exchange; ADLs
Determine: Monitor and record respiratory rate and depth at least
every 4 hr to detect early stages of respiratory failure. Auscultate
breath sounds at least every 4 hr to detect decreased or adventitious
breath sounds. Report changes.
Perform: Administer oxygen, as ordered, to maintain an acceptable
level of oxygen at the tissue level.
Suction airway as needed to maintain patent airways.
Assist patient to Fowler’s position, which will promote expansion
of lungs and provide comfort. Support upper extremities with
pillows, providing a table and cover it with a pillow to lean on.
Turn and reposition patient at least every 2 hr. Establish a turning
schedule for the dependent patient. Post schedule at bedside and
monitor frequency. Turning and repositioning prevent skin
breakdown and improve lung expansion and prevent atelectasis.
Assist patient with ADLs as needed to conserve energy and avoid
Encourage active exercise: Provide a trapeze or other assistive device
whenever possible. Such devices simplify moving and turning for many
patients and allow them to strengthen some upper body muscles.
Inform: Teach patient the following measures to promote participation
in maintaining health status and improve ventilation: pursed lip
breathing, abdominal breathing, and relaxation techniques (deep
breathing, meditation, guided imagery), taking prescribed
medications (ensuring accuracy and frequency and monitoring side
effects); and scheduling of activities to allow for rest periods.
Teach caregivers to assist patient with ADLs in a way that maximizes
patient’s potential. This enables caregivers to participate in
patient’s care and encourages them to support patient’s independence.
Attend: Provide emotional support and encouragement to improve
patient’s self-concept and motivate patient to perform ADLs.
Involve patient in planning and decision making. Having the ability to
participate will encourage greater compliance with the plan for activity.
Have patient perform self-care activities. Begin slowly and increase
daily, as tolerated. Performing self-care activities will assist patient
to regain independence and enhance self-esteem.
Schedule activities to allow for periods of rest.
Manage: Refer to case manager/social worker to ensure that a home
assessment has been done and that whatever modifications were
needed to accommodate the patient’s level of mobility have been
made. Making adjustments in the home will allow the patient a
greater degree of independence in performing ADLs, allowing better
conservation of energy.
Refer patient for evaluation of exercise potential and development
of individualized exercise program. Gradual increase in exercise will
promote conditioning and ease breathing.
Airway Management; Anxiety Reduction; Oxygen therapy; Progressive
Muscle Relaxation; Respiratory Monitoring
Booker, R. (2005, January). Chronic obstructive pulmonary disease: Nonpharmacological
approaches. British Journal of Nursing, 14(1), 14–18.

Nursing diagnosis – ineffective breastfeeding

Ineffective Breastfeeding
Dissatisfaction or difficulty a mother, infant, or child experiences
with the breastfeeding process
• Actual or perceived inadequate milk supply (mother)
• Arching and crying when at the breast (infant)
• Evidence of inadequate intake (infant)
• Fussiness and crying within the first hour of feeding (infant)
• Inability to latch on to nipple correctly (infant)
• Insufficient emptying of each breast
• Unsatisfactory breastfeeding process (mother and infant)
• Infant anomaly
• Infant receiving supplemental
feeding with artificial nipple
• Knowledge deficit
• Maternal ambivalence
• Maternal anxiety
• Nonsupportive family
• Nonsupportive partner
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Communication
• Roles and relationships
• Values and beliefs
The mother will
• Express physical and psychological comfort in breastfeeding practice
and techniques.
• Show decreased anxiety and apprehension.
• State at least one resource for breastfeeding support.
The infant will
• Feed successfully on both breasts and appear satisfied for at least
2 hr after feeding.
• Grow and thrive.
Breastfeeding Assistance; Emotional Support; Lactation Counseling;
Nutritional Management; Parent Education; Support Group
Determine: Assess factors that influence mother’s decision to breastfeed.
Assessment information will be used to develop interventions.
Monitor condition of breasts and nipples to identify problems that
might interfere with feeding to pinpoint problem areas.
Assess readiness of mother to breast-feed and ability of infant to
Monitor mother’s breastfeeding technique. Improper technique,
which impedes feeding, will cause the mother to experience anxiety.
Perform: Position mother in Fowler’s position to enhance mother’s
relaxation during feeding. Place infant in proper position for optimal
feeding to produce proper sucking motion.
Inform: Teach mother and selected caregiver the techniques for
encouraging letdown, including warm shower, breast massage, physically
caring for the neonate, and holding the neonate close to the
Teach mother techniques (e.g., lying on her side, positioning the
infant correctly, holding the nipple with C position, talking to and
cuddling the infant) that will help the infant latch on to the breast.
Instruct mother to remove infant from the breast to be burped
midway during the feeding to allow for expulsion of air that is
Attend: Ask frequently during hospitalization whether the mother
has questions while she is attempting to breast-feed. This will give
her the confidence she needs to continue when she gets home.
Provide mother and infant with a quiet, private, comfortable environment
in which to breast-feed. Decreasing stressors will help to
promote successful breastfeeding experience.
Encourage expression of fears and anxieties between the mother
and the infant to reduce anxiety and increase the mother’s sense of
control over the process.
Manage: Offer written information, a reading list, or a referral to a
breastfeeding support group to allow for review of information after
Refer to home health nurse for a follow-up visit in the home.
Refer to a nutritionist for information on good nutrition and fluid
Breastfeeding Assistance; Emotional Support; Lactation Counseling;
Infant; Parent Education; Support Group
Lewallen, I. P., et al. (2006, August). Toward a clinically useful method of
predicting early breastfeeding attrition. Applied Nursing Research, 19(3),

Nursing diagnosis – ineffective airway clearance

Inneffective Airway Clearance
Inability to clear secretions or obstructions from the respiratory tract
to maintain a clear airway
• Adventitious breath sounds,
such as crackles, rhonchi, and
• Changes in respiratory rate
and rhythm
• Cyanosis
• Diminished breath sounds
• Difficulty vocalizing
• Dyspnea
• Ineffective or absent cough
• Orthopnea
• Restlessness
• Sputum production
• Wide-eyed
• Environmental: second-hand smoke, smoke inhalation, smoking
• Physiological: allergic airways, asthma, chronic obstructive
pulmonary disease, infection, neuromuscular dysfunction, and
hyperplasia of the bronchial walls
• Obstructed airway: airway spasm, excessive mucus, exudate in the
alveoli, foreign body in airway, presence of artificial airway,
retained secretions, secretions in the bronchi
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Activity/exercise
• Cardiac function
• Respiratory function
The patient will
• Maintain patent airway.
• Have no adventitious breath sounds.
• Have a normal chest x-ray.
• Have an oxygen level in normal range.
• Breathe deeply and cough to remove secretions.
• Expectorate sputum.
• Demonstrate controlled coughing techniques.
• Have adequate ventilation.
• Demonstrate skill in conserving energy while attempting to clear
• State understanding of changes needed to diminish oxygen demands.
Aspiration Prevention; Respiratory Status: Airway Patency; Respiratory
Status: Ventilation
Determine: Assess respiratory status at least every 4 hr or according
to established standards. Obstruction in the airway leads to atelectasis,
pneumonia, or respiratory failure. Monitor arterial blood gases values
and hemoglobin levels to assess oxygenation and ventilatory
status. Report deviations from baseline levels; oxygen saturation
should be higher than 90%.
Monitor sputum, noting amount, odor, and consistency. Sputum
amount and consistency may indicate hydration status and effectiveness
of therapy. Foul-smelling sputum may indicate respiratory infection.
Perform: Turn patient every 2 hr; place the patient in lateral, sitting,
prone, and upright positions as much as possible for maximal aeration
of lung fields and mobilization of secretions.
Mobilize patient to full capabilities to facilitate chest expansion
and ventilation.
Suction, as ordered, to stimulate cough and clear airways. Be alert
for progression of airway compromise. Perform postural drainage,
percussion, and vibration to facilitate secretion movement.
Provide adequate humidification to loosen secretions. Administer
expectorants, bronchodilators, and other drugs, as ordered, and monitor
effectiveness. Provide bronchodilator treatments before chest physiotherapy
to optimize results of the treatment. Administer oxygen, as
ordered, to promote oxygenation of cells throughout the body.
Inform: Teach patient an easily performed cough technique to clear
airway without fatigue.
Attend: Avoid placing patient in a supine position for extended periods
to prevent atelectasis.
When helping the patient cough and deep-breathe, use whatever
position best ensures cooperation and minimizes energy expenditure,
such as high Fowler’s position or sitting on side of bed. Such positions
promote chest expansion and ventilation of basilar lung fields.
Encourage adequate water intake (3–4 qt [3–4 L/day]) to ensure
optimal hydration and loosening of secretions, unless contraindicated.
Encourage sputum expectoration to remove pathogens and prevent
spread of infection. Provide tissues and paper bags for hygienic
Manage: If conservative measures fail to maintain partial pressure of
arterial oxygen (PaO2) within an acceptable range, prepare for endotracheal
intubation, as ordered, to maintain artificial airway and
optimize PaO2 Level.
Airway Management; Aspiration Precautions; Cough Enhancement;
Oxygen Therapy; Respiratory Monitoring; Ventilation Assistance
Cigna, J. A., & Turner-Cigna, L. M. (2005, September). Rehabilitation for the
home care patient with COPD. Home Healthcare Nurse, 23(9), 578–584.

Nursing diagnosis – ineffective activity planning

Ineffective Activity Planning
Inability to prepare for a set of actions fixed in time and under
certain conditions
• Verbalization of fear toward a task to be undertaken
• Verbalization of worries toward a task to be undertaken
• Excessive anxieties toward a task to be undertaken
• Failure pattern of behavior
• Procrastination
• Unmet goals for chosen activity
• Lack of sequential organization
• Lack of plan
• Lack of family support
• Lack of friend support
• Unrealistic perception of events
• Defensive flight behavior when
faced with proposed solution
• Hedonism
• Compromised ability to
process information
ASSESSMENT FOCUS (Refer to comprehensive assessment parameters.)
• Behavior
• Communication
The patient will
• Demonstrate improved self-confidence to accomplish tasks.
• Demonstrate improved concentration in task planning and execution.
• Minimize procrastination.
• Articulate personal goals for activity planning and completion.
• Verbalize diminished fear and anxiety concerning task planning
and execution.
Cognition; Cognition Orientation; Concentration; Decision-Making;
Information Processing; Memory
Determine: Assess patient’s concerns related to activity planning and
execution to be able to suggest strategies to overcome challenges.
Perform: Model effective techniques for planning and executing
activities. Patients who are challenged by planning and executing
activities often find it helpful to observe practical approaches instead
of solely hearing theoretical information.
Inform: Teach behavior management strategies to help the person
minimize fears of failure.
• Roles/relationships
• Self-perception
Attend: Praise successes in any steps of planning or executing activities;
positive reinforcement enhances self-confidence.
Manage: Refer or comanage with behavioral specialists. Colleagues
in related disciplines bring valuable additional perspectives to these
complex clinical situations.
Anxiety Reduction; Behavior Management; Behavior Modification;
Calming Technique; Memory Training; Planning Assistance;
Sequence Guidance
Adler, D. A., McLaughlin, T. J., Rogers, W. H., Chang, H., Lapitsky, L., &
Lerner, D. (2006). Job performance deficits due to depression. American
Journal of Psychiatry, 163, 1569–1576.