Nursing diagnosis – NEONATAL JAUNDICE

NEONATAL  JAUNDICE

DEFINITION

The yellow orange tint of the neonate’s skin and mucous membranes

that occurs after 24 hours of life as a result of unconjugated biliru-

bin in the circulation

DEFINING CHARACTERISTICS

• Neonate age 1–7 days

• Yellow orange skin

• Yellow sclerae

• Yellow mucous membranes

• Abnormal blood profile (hemolysis; total serum bilirubin   2 mg/dl;

total serum bilirubin in high-risk range on age in hour-specific
nomogram)

RELATED FACTORS

• Abnormal weight loss (   7%– 8% in breast-feeding newborn)

• Feeding pattern not well established

• Infant experiences difficulty making transition to extrauterine

life

• Stool (meconium) passage delayed

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Growth and development

• Fluid and electrolytes

• Nutrition

EXPECTED OUTCOMES

The neonate will

• Establish effective feeding pattern (breast or bottle) that enhances

stooling.

• Not experience injury as a result of increasing bilirubin levels.

• Receive bilirubin assessment and screening within the first week of

life to detect increasing levels of serum bilirubin.

• Receive appropriate therapy to enhance bilirubin excretion.

• Receive nursing assessments to determine the risk for severity of

jaundice.

SUGGESTED NOC OUTCOMES

Bowel Elimination; Breast-Feeding Establishment: Infant; Nutritional

Status; Risk Control; Risk Detection

INTERVENTIONS AND RATIONALES

Determine:  Evaluate maternal and delivery history for risk factors

for neonatal jaundice (Rh, ABO, G6PD deficiency, direct Coombs,

prolonged labor, maternal viral illness, medications) to anticipate

which neonates are at higher risk for jaundice.

Perform:  Collect and evaluate laboratory blood specimens as ordered

or per unit protocol to permit accurate and timely diagnosis and

treatment of neonatal jaundice.

213

Inform: Educate parents regarding newborn care at home in relation

to appearance of jaundice in association with any of the following:

no stool in 48 hr, lethargy with refusal to nurse or bottle feed, less

than 1 wet diaper in 12 hr, abnormal infant behavior. Parent educa-

tion is crucial for the time after the neonate is discharged. Parents

are the major decision makers concerning whether and when to

bring the neonate back for medical and nursing assessments after

being discharged from the hospital.

Attend: Provide caring support to the family if a breast-fed neonate

must receive supplementation. It can be upsetting and result in feel-

ings of inadequacy to a breast-feeding mother for her neonate to

require supplementation.

Manage: Coordinate care and facilitate communication between fam-

ily, nursing staff, pediatrician, and lactation specialist. A multidisci-

plinary approach that includes the family enhances communication

and improves outcomes.

SUGGESTED NIC INTERVENTIONS

Attachment Promotion; Bottle Feeding; Bowel Management; Breast-

Feeding Assistance; Capillary Blood Sample; Discharge Planning;

Infant Care; Kangaroo Care; Newborn Monitoring; Nutritional

Monitoring; Risk Identification: Childbearing Family; Surveillance;

Teaching: Infant Nutrition; Vital Signs Monitoring

Reference

Bhutani, V. K., Johnson, L. H., Schwoebel, A., & Gennaro, S. (2006). A sys-

tems approach for neonatal hyperbilirubinemia in term and near-term new-
borns. Journal of Obstetric, Gynecologic and Neonatal Nursing, 35,
444–455.

Nursing diagnosis – DECREASED INTRACRANIAL ADAPTIVE CAPACITY

ADAPTIVE  CAPACITY

DEFINITION

Intracranial fluid dynamic mechanisms that normally compensate for

increases in intracranial volumes are compromised, resulting in

repeated disproportionate increases in intracranial pressure (ICP) in

response to a variety of noxious and nonnoxious stimuli

DEFINING CHARACTERISTICS

• Baseline ICP    10 mm Hg

• Disproportionate increase in ICP following single nursing

maneuver

• Elevated P2 ICP wave form

• Repeated increase of   10 mm Hg for more than 5 min following

external stimuli

• Volume pressure response test variation (volume–pressure ratio

greater than 2, pressure–volume index   10)

• Wide amplitude ICP waveform

RELATED FACTORS

• Brain injuries

• Sustained hypotension with

• Decreased cerebral perfusion

intracranial hypertension

• Sustained increased ICP

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac functioning

• Neurocognition

• Comfort

• Pharmacologic function

• Elimination

• Respiratory functioning

• Fluid and electrolytes

• Values/beliefs

EXPECTED OUTCOMES

The patient will

• Maintain effective breathing pattern and normal ABG levels.

• Show no evidence of fever.

• Modify environment to eliminate noxious stimuli.

• Maintain regular bowel function.

• Maintain skin integrity.

• Remain free of signs and symptoms of infection.

• Not show evidence of neurological compromise.

SUGGESTED NOC OUTCOMES

Electrolyte & Acid–Base Balance; Fluid Balance; Neurological Status:

Consciousness; Wound Healing: Primary Intention

INTERVENTIONS AND RATIONALES

Determine: Assess vital signs, temperature, pulses, heart sounds,

jugular vein distension; electrocardiogram, history of hypertension;

mental status, reflexes, response to pain, papillary size and response

to light; respiratory rate, depth, and pattern of respiration, ABG,

pulse oximetry; monitor ICP wave forms for trends over time. Mon-

itor for damped waves. Assess cerebral perfusion pressure.

211

Assessment information will assist in identifying appropriate

interventions.

Perform: Maintain ICP monitoring systems if used. Careful attention

must be paid to ensure that the system is functioning to provide

accurate information. Use sterile technique for dressing changes to

prevent contamination of equipment and infection.

Maintain a patent airway and suction only if needed. Suctioning

stimulates coughing and Valsalva maneuver; Valsalva increases

intrathoracic pressure, decreases cerebral venous drainage, and

increases cerebral blood volume, resulting in increased ICP. Elevate

head of the bed 15 –30   or as ordered, and use sandbags, rolled

towels, or small pillows to keep head in a neutral position. Reposi-

tion patient by using a draw sheet to prevent atrophy. Use minimal

amount of stimuli when caring for the patient. Turn and reposition

patient every 2 hr to prevent atelectasis.

Perform ROM exercises to maintain muscle tone.

Inform: Teach patient and family those aspects of care in which they

can participate without feeling anxious. Instruct family members in

gentle stroking of patient’s face, arms, or hand. Touch by family

members may lower the ICP in some cases.

Attend: Provide nursing care in a calm, reassuring manner. Avoid

discussion of upsetting topics near the bedside. This helps prevent

emotional upset that can increase ICP. Encourage patient and family

to express feelings associated with diagnosis, treatment, and recov-

ery. Expression of feelings helps patient and family cope with treat-

ment.

Manage: Arrange for frequent multidisciplinary/family care

conference in order to keep care goal-oriented. Refer patient and

family to support group to help deal with the injury, diagnosis, or

recovery. Refer to social worker/case manager for follow-up care,

home assessment, home visits, and referral to community agencies.

SUGGESTED NIC INTERVENTIONS

Acid–Base Management; Bedside Laboratory Testing; Cerebral

Edema Management; Fluid–Electrolyte Management; ICP Monitoring

Reference

Littlejohns, L., & Bader, M. K. (2005, October–December). Prevention of sec-

ondary brain injury: Targeting technology. AACN Clinical Issues, 16(4),
501–514.

Nursing diagnosis – INSOMNIA

INSOMNIA

DEFINITION

A disruption in the amount and quality of sleep that impairs func-

tioning

DEFINING CHARACTERISTICS

• Observed changes in affect

• Reports difficulty falling asleep

• Observed lack of energy, diffi-

and staying asleep

culty concentrating

• Reports dissatisfaction with

• Increased work or school

sleep

absenteeism

• Reports early morning awak-

• Reports changes in mood

ening

• Reports decreased health status,

• Reports nonrestorative sleep

quality of life

RELATED FACTORS

• Activity pattern

• Grief

• Anxiety

• Inadequate sleep hygiene

• Depression

• Intake of stimulants

• Environmental factors

• Intake of alcohol

• Fear

• Medication

• Gender-related hormonal shifts

• Physical discomfort

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Coping

• Sleep/rest

• Emotional

• Values/beliefs

EXPECTED OUTCOMES

The patient will

• Identify factors that prevent or promote sleep.

• Achieve sleep for ___ hours without interruption.

• Report feeling well-rested.

• Be free from signs of sleep deprivation.

• Alter diet and habits to promote sleep, such as reducing caffeine

and alcohol intake before bedtime.

• Not exhibit sleep-related behavioral symptoms, such as

restlessness, irritability, lethargy, and disorientation.

• Perform relaxation exercises at bedtime.

SUGGESTED NOC OUTCOMES

Anxiety Level; Fear Level; Mood Equilibrium; Personal Well-Being;

Rest

INTERVENTIONS AND RATIONALES

Determine: Assess patient’s daytime activity and work patterns;

travel history; normal bedtime; problems associated with sleep; qual-

ity of sleep; sleeping environment; personal beliefs about sleep; use

of alcohol, caffeine, hypnotics, and nicotine. Assessment information

will assist in selecting appropriate interventions.

209

Perform: Ask patient to help make changes in the environment that

would promote sleep. This allows patient to have an active role in

treatment.

Administer medications on a schedule that will allow for

maximum rest. Disturbing for medication administration during rest

periods will disrupt sleep patterns. If the patient requires diuretics

in the evening, give far enough in advance to allow peak effect

before bedtime. Other medications that may interfere with sleep are

-blockers, MAO inhibitors, and phenytoin.

Provide patient with sleep aids, such as pillows, bath before sleep,

food or drink, and reading materials to promote ease in falling

asleep. Milk and some high-protein snacks, such as cheese and nuts,

contain   L-tryptophan, a sleep promoter. Personal hygiene and

prebedtime rituals promote sleep in some patients.

Develop a sleep log with the patient describing sleep disturbances

and the effect on daytime functioning. The log will help both

patient and nurse to evaluate progress in evaluating sleep patterns.

Inform: Teach patient relaxation techniques such as guided imagery,

deep breathing, meditation, aromatherapy, and progressive muscle

relaxation. Practice with the patient at bedtime. Purposeful

relaxation efforts usually help promote sleep.

Instruct patient to eliminate or reduce caffeine and alcohol intake

and avoid foods that interfere with sleep (e.g., spicy foods). Foods

and beverages containing caffeine consumed fewer than 4 hr before

bedtime may interfere with sleep. Alcohol disrupts normal sleep,

especially when ingested immediately before retiring.

When anxiety is a factor in sleep deprivation, teach coping tech-

niques to reduce the frustration of being unable to sleep.

Attend: Listen to the patient’s description of insomnia. Allow time for

the patient to talk about his frustration. Being able to have a sensitive

listener may help reduce some of the frustration and may lead to new

ideas about how to help the patient resolve his sleep issues.

Ask the patient each day to describe the quality of his sleep. Patients

are sometimes unaware of the periods in which they do sleep.

Manage: Refer to case manager/social worker to ensure that follow-

up is provided.

SUGGESTED NIC INTERVENTIONS

Biofeedback; Calming Techniques; Coping Enhancement; Energy

Management; Security Enhancement; Simple Relaxation Therapy;

Sleep Enhancement

Reference

Holcomb, S. S. (2006, February). Recommendations for assessing insomnia.

The Nurse Practitioner, 3(2), 55–60.

Nursing diagnosis – RISK FOR PERIOPERATIVE POSITIONING INJURY

RISK  FOR  PERIOPERATIVE-POSITIONING

INJURY

DEFINITION

At risk for inadvertent anatomical and physical changes as a result

of posture on equipment used during an invasive/surgical procedure

RISK FACTORS

• Disorientation

• Muscle weakness

• Edema

• Obesity

• Emaciation

• Sensory–perceptual

• Immobilization

disturbances from anesthesia

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Physical regulation

• Fluid/electrolytes

• Risk management

• Pharmacological function

EXPECTED OUTCOMES

The patient will

• Maintain effective breathing patterns.

• Maintain adequate cardiac output.

• Have surgical positioning that facilitates gas exchange.

• Not show evidence of neurologic, musculoskeletal, or vascular

compromise.

• Maintain tissue integrity.

SUGGESTED NOC OUTCOMES

Aspiration Prevention, Blood Coagulation; Circulation Status; Neuro-

logical Status; Respiratory Status: Ventilation; Thermoregulation; Tissue

Integrity: Skin & Mucous Membranes; Tissue Perfusion: Peripheral

INTERVENTIONS AND RATIONALES

Determine: Document and report the results of the preoperative

nursing assessment. Identify factors predisposing patient to tissue

injury. This information guides interventions.

Perform: Use the appropriate mode of patient transportation

(stretcher, patient bed, wheelchair, or crib) to ensure patient safety.

Make sure an adequate number of staff members assist with

transferring patient—obtain at least two for moving patient onto an

operating room bed and at least four for moving anesthetized

patient off operating room bed. Adequate staffing enhances safety.

Check the operating room bed before surgery for proper function-

ing. Intraoperative bed malfunction can result in increased anesthe-

sia time and a more difficult surgical approach.

Ensure proper positioning (follow institutional policies):
– Check patient’s neck and spine for proper alignment to avoid
trauma.
– Check that patient’s legs are straight and ankles uncrossed.
Crossed ankles cause pressure on tissue, vessels, and nerves.

207
–  Place a safety strap 29 (5 cm) above patient’s knees, tight
enough to restrain without compromising superficial venous
return. Applied too tightly, the safety strap may cause venous
thrombosis or compression of tibial, peroneal, or sciatic nerves.
–  Secure patient’s arms at his sides with a draw sheet, with palms
down, making sure that no part of the arm or hand extends
over the mattress. Hyperextension can cause injury to the
brachial plexus. Supination of palms minimizes pressure.
Apply eye pads if patient’s eyelids don’t remain closed or if

surgery is being performed on his head, neck, or chest. If allowed to

remain open, the eyes may dry out and become infected. Corneal

abrasions may result from drapes and other foreign material rubbing

against the eyes.

If surgery is expected to last more than 2 hr or if patient is pre-

disposed to a pressure injury, place padding under his occiput,

scapulae, olecranon, sacrum, coccyx, and calcaneus to protect poten-

tial pressure points. Apply a padded footboard to support patient’s

feet. Avoid plantarflexion, and prevent stretching of the tibial nerve

and subsequent foot drop.

Assess patient position following each positional change to ensure

proper body alignment and adequate padding and support.

Inform: Tell patient about positioning measures planned to reduce

preoperative anxiety.

Attend: Assure patient that careful positioning of the body will be

carried to reduce worry about possible injury.

Manage: Consult with a physical or occupational therapist if special

protective equipment is needed to ensure safety for the patient.

SUGGESTED NIC INTERVENTIONS

Circulatory Care: Mechanical Assist Device, Circulatory

Precautions; Infection Control: Intraoperative; Positioning: Intraoper-

ative; Skin Surveillance; Surgical Precautions; Temperature

Regulation: Intraoperative

Reference

Millsaps, C. C. (2006, January). Pay attention to patient positioning! RN,

69(1), 59–63.

Nursing diagnosis – RISK FOR INJURY

DEFINITION

At risk for injury as a result of environmental conditions interacting

with the individual’s adaptive and defensive resources

RISK FACTORS

External

Internal

• Biological: Community immu-

• Abnormal blood profile:

nization level; microorganisms

Altered clotting factors;

• Chemical: Cosmetics; drugs,

decreased hemoglobin; leuko-

pharmaceutical agents; dyes;
alcohol, nicotine, preservatives;
poisons

cytosis/leucopenia; sickle cell;
thalassemia; thrombocytopenia
• Biochemical dysfunction

• Human: Nosocomial agents;

• Immune or autoimmune

staffing patterns; cognitive,
affective, psychomotor factors

disorder
• Developmental age: physiologi-

• Nutritional: Food types,

cal and/or psychosocial

vitamins

• Tissue hypoxia

• Physical: Design, structure, and

arrangement of community,
building, and/or equipment

• Mode of transport

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Knowledge

• Emotional

• Risk management

EXPECTED OUTCOMES

The patient will

• Acknowledge presence of environmental hazards in their everyday

surroundings.

• Take safety precautions in and out of home.

• Instruct children in safety habits.

• Childproof house to ensure safety of young children and

cognitively impaired adults.

SUGGESTED NOC OUTCOMES

Immune Status; Risk Control; Safety Behavior: Home Physical Envi-

ronment; Safety Behavior: Personal; Safety Status: Falls Occurrence;

Safety Status: Physical Injury

INTERVENTIONS AND RATIONALES

Determine: Help patient identify situations and hazards that can

cause accidents to increase patient’s awareness of potential dangers.

Perform: Arrange environment of patient with dementia to minimize

risk of injury:

–  Place furniture against walls.
–  Avoid use of throw rugs.

205
Maintain lighting so that patient can find her way around room

and to bathroom. Poor lighting is a major cause of falls.

Prevent iatrogenic harm to hospitalized patient by following the

2007 National Patient Safety goals. This resource provides compre-

hensive measures designed to prevent harm.

Follow agency policy regarding the use of restraints—they are

generally used as a last resort after other measures have failed.

Agency policies will provide clear direction to use restraints safely.

Inform: Encourage adult patient to discuss safety rules with children

to foster household safety. For example:

–  Don’t play with matches.
–  Use electrical equipment carefully.
–  Know location of the fire escape route.
–  Don’t speak to strangers.
–  Dial 911 in an emergency.

Attend: Encourage patient to make repairs and remove potential

safety hazards from environment to decrease possibility of injury.

Manage: Refer patient to appropriate community resources for more

information about identifying and removing safety hazards. This

enables patient and family to alter environment to achieve optimal

safety level.

SUGGESTED NIC INTERVENTIONS

Environmental Management: Safety; Fall Prevention; Health Educa-

tion; Parent Education: Adolescent; Parent Education: Childrearing

Family; Risk Identification; Surveillance: Safety

References

Bright, L. (2005, January). Strategies to improve the patient safety outcome

indicator: Preventing or reducing falls. Home Healthcare Nurse, 23(1),
29–36.

Yuan, J. R., & Kelly, J. (2006, February). Falls prevention, or “I think I can, I

think I can”: An ensemble approach to falls management. Home Healthcare
Nurse, 24(2), 103–111.

Nursing diagnosis – RISK FOR INFECTION

RISK  FOR  INFECTION

DEFINITION

At risk for being invaded by pathogenic organisms

RISK FACTORS

• Altered immune function

• Pharmaceutical agents

• Amniotic membrane rupture

• Inadequate primary (such as

• Chronic disease

skin) or secondary (such as

• Environmental exposure to

inflammatory response)

pathogens

defenses

• Invasive procedures

• Malnutrition

• Lack of knowledge about

• Tissue destruction

causes of infection

• Trauma

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid/electrolytes

• Risk management

• Neurocognition

• Sensation/perception

EXPECTED OUTCOMES

The patient will

• Have normal temperature, WBC count, and differential.

• Maintain good personal and oral hygiene.

• Have clear and odorless respiratory secretions.

• Have normal urine and be free from evidence of diarrhea.

• Exhibit wounds and incisions that show no signs of infection; and

intravenous sites with no signs of inflammation.

• Take ___ ml of fluid and ___ g of protein daily.

• Identify infection risk factors, and signs and symptoms of infection.

SUGGESTED NOC OUTCOMES

Immune Status; Infection Status; Knowledge: Treatment Procedure(s),

and Infection Control; Nutritional Status; Risk Control; Risk Detec-

tion; Wound Healing: Primary Intention, and Secondary Intention

INTERVENTIONS AND RATIONALES

Determine: Monitor and record temperature after surgery at least

every 4 hr; report elevations immediately as this may signal onset of

pulmonary complications, wound infection or dehiscence, UTI, or

thrombophlebitis

Monitor WBC count, as ordered. Report elevations or

depressions. Elevated total WBC count indicates infection. Markedly

decreased WBC count may indicate decreased production resulting

from extreme debilitation or severe lack of vitamins and amino

acids. Any damage to bone marrow may suppress WBC formation.

Monitor culture results of urine, respiratory secretions, wound

drainage, or blood according to facility policy and physician’s order.

This identifies pathogens and guides antibiotic therapy.

Perform: Perform hand hygiene before and after providing care, and

direct patient to do this before and after meals and after using

203

bathroom, bedpan, or urinal to avoid spread of pathogens; also, use

strict sterile technique when handling would dressings to maintain

asepsis.

Offer frequent oral hygiene to prevent colonization of bacteria

and reduce risk of descending infection. Disease and malnutrition

may reduce moisture in mucous membranes of mouth and lips.

Change intravenous tubing and give site care every 24–48 hr or as

facility policy dictates to help keep pathogens from entering body.

Rotate intravenous sites every 48–72 hr or as facility policy dictates

to reduce chances of infection at individual sites.

Have patient cough and deep-breathe every 4 hr after surgery to

help remove secretions and prevent pulmonary complications. Pro-

vide tissues to encourage expectoration and convenient disposal bags

for expectorated sputum to reduce spread of infection.

Help patient turn every 2 hr. Provide skin care, particularly over

bony prominences to help prevent venous stasis and skin breakdown.

Assist patient when necessary to ensure that perianal area is clean

after elimination. Cleaning perineal area by wiping from the area of

least contamination (urinary meatus) to the area of most contamina-

tion (anus) helps prevent genitourinary infections.

Use sterile water for humidification or nebulization of oxygen.

This prevents drying and irritation of respiratory mucosa, impaired

ciliary action, and thickening of secretions within respiratory tract.

Inform: Instruct patient to immediately report loose stools or

diarrhea which may indicate need to discontinue or change

antibiotic therapy; or to test for Clostridium difficile.

Instruct patient about good hand hygiene, factors that increase infec-

tion risk, and signs and symptoms of infection to encourage patient

to participate in care and modify lifestyle to maintain optimum health.

Attend: Unless contraindicated, encourage fluid intake of

3,000–4,000 ml daily to help thin mucus secretions; and offer high-

protein supplements to help stabilize weight, improve muscle tone

and mass, and aid wound healing.

Manage: Arrange for protective isolation if patient has compromised

immune system. Monitor flow and number of visitors. These meas-

ures protect patient from pathogens in environment.

SUGGESTED NIC INTERVENTIONS

Incision Site Care; Infection Protection; Teaching: Procedure/Treatment;

Wound Care

Reference

Marrs, J. A. (2006, April). Care of patients with neutropenia. Clinical Journal

of Oncology Nursing, 10(2), 164–166.

Nursing diagnosis – INEFFECTIVE INFANT FEEDING PATTERN

INEFFECTIVE  INFANT  FEEDING  PATTERN

DEFINITION

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

response resulting in inadequate oral nutrition for metabolic needs

DEFINING CHARACTERISTICS

• Inability to coordinate sucking, swallowing, and breathing

• Inability to initiate or sustain effective suck

RELATED FACTORS

• Anatomic abnormality

• Oral hypersensitivity

• Neurological delay or impair-

• Prematurity

ment

• Prolonged NPO status

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Nutrition

• Growth and development

• Roles/relationships

EXPECTED OUTCOMES

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-

ciently.

• 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.

SUGGESTED NOC OUTCOMES

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

Muscle Function; Nutritional Status: Food & Fluid Intake;

Swallowing Status

INTERVENTIONS AND RATIONALES

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

techniques.

201
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

dehydration.

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

phlebitis.

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

energy.

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.

SUGGESTED NIC INTERVENTIONS

Attachment Promotion; Breast-Feeding Assistance; Lactation Coun-

seling; Nonnutritive Sucking

Reference

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

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

Nursing diagnosis – READINESS FOR ENHANCED ORGANIZED INFANT BEHAVIOR

READINESS  FOR  ENHANCED  ORGANIZED

INFANT  BEHAVIOR

DEFINITION

A pattern of modulation of the physiologic and behavioral systems

of functioning (such as autonomic, motor, state-organizational, self-

regulatory, and attentional–interactional systems) in an infant that is

satisfactory but that can be improved

DEFINING CHARACTERISTICS

• Use of some self-regulatory behaviors

• Definite sleep–wake states

• Responsiveness to visual and auditory stimuli

• Stable physiologic measures

RELATED FACTORS

• Pain

• Immaturity

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Role/relationships

• Neurocognition

• Sensation/perception

• Nutrition

• Sleep/rest

• Physical regulation

EXPECTED OUTCOMES

The parents will

• Express understanding of their role in infant’s behavioral develop-

ment.

• Express confidence in their ability to interpret infant’s behavioral

cues.

• Identify means to promote infant’s behavioral development.

• Express positive feelings about their ability to care for infant.

• Identify resources for help with infant.

The infant will

• Maintain physiologic stability.

• Maintain an organized motor system.

• Respond to information in an adaptive way.

SUGGESTED NOC OUTCOMES

Knowledge: Child Development: 1, 2, 4, 6, and 12 Months; Infant

Care; Neurological Status; Sleep

INTERVENTIONS AND RATIONALES

Determine: Monitor infant’s responses to ensure effectiveness of

preventive measures.

Perform: Demonstrate appropriate ways of interacting with the

infant, such as moderate stimulation, gentle rocking, and quiet

vocalizations, to help the parents identify the most effective methods

of interacting with their child.

199

Inform: Explain to parents that infant maturation is a developmental

process. Further explain that infants exhibit three behavioral states:

sleeping, crying, and being awake and alert. Also explain that

infants provide behavioral cues that indicate their needs. Education

will help parents understand the importance of nurturing the infant

and prepare them to respond to the infant’s behavioral cues.

Explain to parents that their actions can help promote infant

development. Make it clear, however, that infant maturation isn’t

completely within their control. Explanation may decrease feelings

of anxiety and incompetence and help prevent unrealistic

expectations.

Help parents interpret behavioral cues from their infant to foster

healthy parent–child interaction. For example, help them recognize

when the infant is awake and alert, and point out to them that this

is a good time to provide stimulation.

Help parents identify ways they can promote the infant’s develop-

ment, such as providing stimulation by shaking a rattle in front of

the infant, talking to the infant in a gentle voice, and looking at the

infant when feeding him. This encourages practices that promote the

infant’s development. Sensory experiences promote cognitive devel-

opment.

Attend: Explore with parents ways to cope with stress caused by the

infant’s behavior to increase their coping skills.

Praise parents for their attempts to enhance their interaction with

the infant to provide positive reinforcement.

Manage: Provide parents with information on sources of support

and special infant services to encourage them to continue to foster

their infant’s development.

SUGGESTED NIC INTERVENTIONS

Attachment Promotion; Developmental Care; Environmental

Management: Attachment Process; Family Integrity Promotion:

Childbearing Family; Infant Care; Sleep Enhancement

Reference

Byers, J. F., et al. (2006, January–February). A quasi-experimental trial on

individualized, developmentally supportive family-centered care. Journal of
Obstetric, Gynecologic, and Neonatal Nursing, 35(1), 105–115.

Nursing diagnosis – RISK FOR DISORGANIZED INFANT BEHAVIOR

RISK FOR DISORGANIZED INFANT BEHAVIOR

DEFINITION

Risk for alteration in integration and modulation of the physiologi-

cal and behavioral systems of functioning (such as autonomic,

motor, state-organizational, self-regulatory, and attentional–interac-

tional systems)

RISK FACTORS

• Environmental overstimulation

• Oral or motor problems

• Invasive or painful procedures

• Pain

• Lack of containment or

• Prematurity

boundaries

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Role/relationships

• Neurocognition

• Sensation/perception

• Nutrition

• Sleep/rest

• Physical regulation

EXPECTED OUTCOMES

The parents will

• Identify factors that place infant at risk for behavioral disturbance.

• Identify potential signs of behavioral disturbance in infant.

• Identify appropriate ways to interact with infant.

• Identify their reactions to infant (including ways of coping with

occasional frustration and anger).

• Express positive feelings about their ability to care for infant.

• Identify resources for help with infant.

The infant will

• Maintain physiologic stability.

• Maintain an organized motor system.

• Respond to sensory information in an adaptive way.

SUGGESTED NOC OUTCOMES

Knowledge: Child Development: 1 Month, 2 Months, 4 Months,

6 Months, and 12 Months; Infant Care; Neurological Status;

Knowledge: Parent–Infant Attachment; Parenting; Preterm Infant

Organization; Sleep

INTERVENTIONS AND RATIONALES

Determine: Monitor infant’s responses to ensure effectiveness of pre-

ventive measures.

Perform: Demonstrate appropriate ways of interacting with the

infant to help parents identify and interpret the infant’s behavioral

cues and respond appropriately. For example, help them recognize

when the infant is awake and alert, and help them understand

when the infant needs more stimulation, such as being spoken to

or held.

197

Inform: Explain to parents that infant maturation is a developmental

process and that their participation is crucial to their understanding

of the importance of nurturing the infant. Participation in the

process by the parents will both stimulate the developmental process

and alert to delays in development.

Explain to parents that their actions can help modify some of

their infant’s behavior; however, make it clear that infant maturation

isn’t completely within their control. This explanation may decrease

the parent’s feelings of incompetence.

Explain to parents that certain risk factors may interfere with the

infant’s ability to achieve optimal development. These risk factors

include overstimulation, lack of stimulation, lack of physical contact,

and painful medical procedures. Educating the parents will help

them understand their role in interpreting the infant’s behavioral

cues and providing appropriate stimulation.

Describe for the parents the potential signs of a behavioral distur-

bance in the infant: inappropriate responses to stimuli, such as the

failure to respond to human contact or tendency to become agitated

with human contact; physiologic regulatory problems, such as a

breathing disturbance in a premature infant; and apparent inability

to interact with the environment. Education will help the parents

recognize if the infant has a problem in behavioral development.

Attend: Explore with parents ways to cope with the stress imposed

by the infant’s behavior to increase their coping skills. Help parents

identify their emotional responses to the infant’s behavior to help

them recognize and adjust their response patterns. Explain that it is

normal for parents to experience feelings of inadequacy, frustration,

or anger if the infant does not respond positively to them.

Praise the parents when they demonstrate appropriate methods of

interacting with the infant to provide positive reinforcement.

Manage: Provide the parents with information on sources of support

and special infant services to help them cope with the infant’s long-

term needs.

SUGGESTED NIC INTERVENTIONS

Attachment Process, Infant Care; Newborn Monitoring; Parent

Education: Infant; Positioning; Surveillance

Reference

Swartz, M. K. (2005, March–April). Parenting preterm infants: A meta-

synthesis. The American Journal of Maternal Child Nursing, 30(2),
115–120.

Nursing diagnosis – DISORGANIZED INFANT BEHAVIOR

DISORGANIZED  INFANT  BEHAVIOR

DEFINITION

Disintegrated physiological and neurobehavioral responses of infant

to the environment

DEFINING CHARACTERISTICS

• Attention–interaction system—abnormal response to sensory stimuli

(e.g., difficulty soothing, inability to sustain alert status)

• Motor-system—altered primitive reflexes; finger splaying; jittery,

uncoordinated movement; increased or decreased tone; startles,
tremors, or twitches

• Physiological—arrhythmias, bradycardia, or tachycardia; desatura-

tion; feeding intolerances; skin color changes

• Regulatory problems—inability to inhibit startle; irritability

• State-organizational system—active or quiet awake; diffuse sleep

RELATED FACTORS

• Caregiver—Cue knowledge

• Postnatal—feeding intolerance;

deficit; cue misreading; environ-
mental stimulation contribution

invasive procedures; malnutri-
tion; motor and/or oral prob-

• Environmental—physical envi-

lems; pain; prematurity

ronment inappropriateness;
sensory deprivation, inappro-
priateness, or overstimulation

• Prenatal—congenital or genetic
disorders; teratogenic exposure

• Individual—gestational or

postconceptual age; illness;
immature neurological system

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Role/relationships

• Neurocognition

• Sensation/perception

• Nutrition

• Sleep/rest

• Physical regulation

EXPECTED OUTCOMES

The parents will

• Learn to identify and understand infant’s behavioral cues.

• Identify their own emotional responses to infant’s behavior.

• Identify means to help infant overcome behavioral disturbance.

• Identify ways to improve their ability to cope with infant’s

responses.

• Express positive feelings about their ability to care for infant.

• Identify resources for help with infant.

The infant will

• Begin to show appropriate signs of maturation.

SUGGESTED NOC OUTCOMES

Knowledge: Infant Care; Mobility; Neonate; Neurological Status;

Preterm Infant Organization; Sleep Thermoregulation

195

INTERVENTIONS AND RATIONALES

Determine: Monitor infant’s responses to ensure effectiveness of pre-

ventive measures

Inform: Explain to parents that infant maturation is a developmental

process. Their participation is crucial to help them understand the

importance of nurturing the infant.

Explain to parents that their actions can help modify some of

infant’s behavior; however, make it clear that infant maturation isn’t

completely within their control. This explanation may help decrease

the parents’ feelings of incompetence.

Explain to parents that infant gives behavioral cues that indicate

needs. Discuss appropriate ways to respond to behavioral cues—for

example, providing stimulation that doesn’t overwhelm the infant;

stopping stimulation when the infant gives behavioral cues (such as

yawning, looking away, or becoming agitated); and finding methods

to calm the infant if she becomes agitated (such as swaddling, gentle

rocking, and quiet vocalizations). Monitoring responses aids in gaug-

ing effectiveness of meeting needs.

Help parents identify and cope with their responses to infant’s

behavioral disturbance to help them recognize and adjust their

response patterns. When the infant doesn’t respond positively, the

parents may feel inadequate or become frustrated. They need to

understand that these reactions are normal.

Attend: Explore with parents ways to cope with stress imposed by

infant’s behavior to help them develop better coping skills.

Praise parents when they demonstrate appropriate methods of

interacting with the infant to provide positive reinforcement.

Manage: Provide parents with information on sources of support

and special infant services to promote coping with infant’s long-term

needs.

SUGGESTED NIC INTERVENTIONS

Environmental Management; Neurologic Monitoring; Newborn

Care; Parent Education: Infant; Positioning; Sleep Enhancement

Reference

Beal, J. A. (2005, November–December). Evidence for best practices in the

neonatal period. The American Journal of Maternal Child Nursing, 30(6),
397–403.

Nursing diagnosis – RISK FOR URGE URINARY INCONTINENCE

RISK  FOR  URGE  URINARY  INCONTINENCE

DEFINITION

At risk for involuntary loss of urine associated with a sudden,

strong sensation or urinary urgency

RISK FACTORS

• Effects of medication, caffeine,

• Detrusor muscle instability

or alcohol

with impaired contractility

• Detrusor hyperreflexia from

• Ineffective toileting habits

cystitis, urethritis, tumors,
renal calculi, central nervous
system disorders above
pontine micturation center

• Involuntary sphincter
relaxation
• Small bladder capacity

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• State ability to anticipate if incontinence is likely to occur.

• State understanding of potential causes of urge incontinence and

its treatment.

• Avoid or minimize complications of urge incontinence.

• Discuss potential effects of urologic dysfunction on self and family

members.

• Demonstrate skill in managing incontinence.

• Identify community resources to cope with alterations in urinary

status.

SUGGESTED NOC OUTCOMES

Knowledge: Treatment Regimen; Urinary Continence; Urinary Elimi-

nation

INTERVENTIONS AND RATIONALES

Determine:  Observe patient’s voiding pattern, and document intake

and output to ensure correct fluid replacement therapy and provide

information about the patient’s ability to void adequately.

Determine patient’s premorbid elimination status to ensure that inter-

ventions are realistic and based on the patient’s health status and goals.

Assess patient’s ability to sense and communicate elimination

needs to maximize self-care.

Perform:  Unless contraindicated, provide 21⁄2 to 3 qt (2.5–3 L) of

fluid daily to moisten mucous membranes and ensure adequate

hydration. Space out fluid intake through the day and limit it to

150 ml after supper to reduce the need to void at night.

Place commode next to bed, or assign patient bed next to

bathroom. A bedside commode or convenient bathroom requires less

193

energy expenditure than bedpan. If using commode, keep bed and

commode at same level to facilitate patient’s movements. If using

bathroom, provide good lighting from bed to bathroom to reduce

sensory misinterpretation; remove all obstacles between bed and bath-

room to reduce chance of falling. Prepare pleasant toilet environment

that is warm, clean, and free from odors to promote continence.

Have patient wear easily removed articles of clothing (a gown

instead of pajamas, Velcro fasteners instead of buttons or zippers)

to facilitate the removal of clothing and foster independence.

Have patient keep a diary recording episodes of incontinence to

use as a basis for planning bladder training interventions; interven-

tions may include voiding every 2 hr, avoiding high fluid intake,

maintaining proper hygiene, or notifying a healthcare professional if

urge incontinence occurs frequently. Individualized interventions help

promote self-care, foster motivation, and avoid incontinence.

Incorporate patient’s suggestions for managing incontinent

episodes into a care plan to foster motivation.

Inform:  Explain urge incontinence to patient and family members,

especially preventive measures and potential underlying causes, to

foster compliance.

Instruct patient to stop and take a deep breath if he or she expe-

riences an intense urge to urinate before he can reach a bathroom.

Anxiety and rushing may increase bladder contraction.

Attend:  Encourage patient to express feelings about incontinence to

provide emotional support and identify needed areas for further

patient teaching.

Manage:  Use an interdisciplinary approach to caring for incontinence.

Incorporate recommendations from a urologist, urology nurse special-

ist, other healthcare providers, and the patient. Monitor progress and

report the patient’s response to interventions. An interdisciplinary

approach helps ensure that the patient receives adequate care. Encour-

aging patient participation on the team will help foster motivation.

Note if patient expresses concern about the effect of incontinence

on sexuality. If appropriate, refer him to a sex therapist to promote

sexual health.

Refer patient and family members to community resources such as

support groups, as appropriate, to help ensure continuity of care.

SUGGESTED NIC INTERVENTIONS

Fluid Monitoring; Urinary Elimination Management; Urinary Habit

Training; Urinary Incontinence Care

Reference

Dingwall, L., & McLafferty, E. (2006, October). Do nurses promote urinary

continence in hospitalized older people? An exploratory study. Journal of
Clinical Nursing, 15(10), 1276–1286.

Nursing diagnosis – URGE URINARY INCONTINENCE

URGE  URINARY  INCONTINENCE

DEFINITION

Involuntary passage of urine occurring shortly after a strong sense

of urgency to void

DEFINING CHARACTERISTICS

• Bladder contraction or spasm

• Increased or decreased volume

• Frequency

• Nocturia

• Inability to reach toilet in time

• Urgency

RELATED FACTORS

• Alcohol intake

• Decreased bladder capacity

• Atrophic urethritis

• Detrusor hyperactivity with

• Atrophic vaginitis

impaired bladder contractility

• Bladder infection

• Fecal impaction

• Caffeine intake

• Use of diuretics

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Have fewer episodes of incontinence.

• State increased comfort.

• State understanding of treatment.

• Have minimal, if any, complications.

• Discuss impact of disorder on himself and family members.

• Demonstrate skill in managing incontinence.

SUGGESTED NOC OUTCOMES

Tissue Integrity: Skin & Mucous Membranes; Urinary Continence;

Urinary Elimination

INTERVENTIONS AND RATIONALES

Determine: Observe voiding pattern; document intake and output.

This ensures correct fluid replacement therapy and provides informa-

tion about patient’s ability to void adequately.

Perform: Provide appropriate care for patient’s urologic condition,

monitor progress, and report patient’s responses to treatment.

Patient should receive adequate care and take part in decisions

about care as much as possible.

Assist with specific bladder elimination procedures, such as the

following:

bladder training—place patient on commode every 2 hr while

awake and once during night, provide privacy, and gradually

increase intervals between toileting (these measures aim to restore a

regular voiding pattern). As well as rigid toilet regimen—place

patient on toilet at specific times (to aid adaptation to routine

191

physiologic function), and keep baseline micturition record for

3–7 days (to monitor toileting effectiveness).

Administer pain medication; discuss effectiveness with patient to

reinforce that pain can be alleviated, which reduces tension and anxiety.

Place commode next to bed, or assign patient bed next to

bathroom. A bedside commode or convenient bathroom requires less

energy expenditure than bedpan. If using commode, keep bed and

commode at same level to facilitate patient’s movements. If using

bathroom, provide good lighting from bed to bathroom to reduce

sensory misinterpretation; remove all obstacles between bed and bath-

room to reduce chance of falling. Prepare pleasant toilet environment

that is warm, clean, and free from odors to promote continence.

Provide a clock to help patient maintain voiding schedule through

self-monitoring.

Unless contraindicated, maintain fluids to 3,000 ml daily to mois-

ten mucous membranes and ensure hydration; limit patient to 150

ml after dinner to reduce need to void at night.

Have patient wear easily removable clothes (gown instead of paja-

mas and Velcro fasteners instead of buttons or zippers) to reduce

frustration and delay in voiding routine.

If patient loses control on way to bathroom, instruct patient to

stop and take a deep breath. Anxiety and rushing may strengthen

bladder contractions.

Inform: Explain urologic condition to patient and family members;

include instructions on preventive measures and established bladder

schedule. Patient education begins with educational assessment and

depends on establishing a therapeutic relationship with patient and

family. Prepare patient for discharge according to individual needs to

allow patient to practice under supervision.

Instruct patient and family members on continence techniques for

home use. This reduces fear and anxiety resulting from lack of knowl-

edge of patient’s condition and reassures patient of continuing care.

Attend: Encourage patient to express feelings and concerns related to

his or her urologic problem to identify patient’s fears.

Manage: Refer patient and family members to psychiatric liaison

nurse, support group, or other resources, as appropriate.

Community resources typically provide healthcare not available from

other healthcare agencies.

SUGGESTED NIC INTERVENTIONS

Fluid Monitoring; Perineal Care; Self-Care Assistance: Toileting; Uri-

nary Elimination Management; Urinary Habit Training; Urinary

Incontinence Care

Reference

Dingwall, L., & McLafferty, E. (2006, October). Do nurses promote urinary

continence in hospitalized older people?: An exploratory study. Journal of
Clinical Nursing, 15(10), 1276–1286.

Nursing diagnosis – STRESS URINARY INCONTINENCE

STRESS  URINARY  INCONTINENCE

DEFINITION

Sudden leakage of urine with activities that increase intra-abdominal

pressure

DEFINING CHARACTERISTICS

• Dribbling with increased abdominal pressure

• Frequency

• Urgency

RELATED FACTORS

• Degenerative changes in pelvic

• Intrinsic urethral sphincter

muscles

deficiency

• High intra-abdominal pressure

• Weak pelvic muscles

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Maintain continence.

• State increased comfort.

• State understanding of treatment.

• State understanding of surgical procedure.

• Demonstrate skill in managing urinary elimination problems.

• Identify resources to assist with care following discharge.

SUGGESTED NOC OUTCOMES

Tissue Integrity: Skin & Mucous Membranes; Urinary Continence;

Urinary Elimination

INTERVENTIONS AND RATIONALES

Determine: Observe patient’s voiding patterns, time of voiding,

amount voided, and whether voiding is provoked by stimuli. Accu-

rate, thorough assessment forms basis of an effective treatment plan.

Perform: Provide appropriate care for patient’s urologic condition,

monitor progress, and report patient’s responses to treatment.

Patient expects to receive adequate care and to participate in

decisions regarding care.

Help patient to strengthen pelvic floor muscles by Kegel exercises

for sphincter control. Exercises increase muscle tone and restore cor-

tical control.

Promote patient’s awareness of condition through education to

help patient understand illness as well as treatment.

Help patient reduce intra-abdominal pressure by losing weight,

avoiding heavy lifting, and avoiding chairs or beds that are too high

189

or too low. These measures reduce intra-abdominal pressure and

bladder pressure.

Provide supportive measures:
– Respond to call bell quickly, assign patient to bed next to bath-

room, put night-light in bathroom, and have patient wear easily

removable clothing (gown rather than pajamas and Velcro fasteners

rather than buttons or zippers). Early recognition of problems pro-

motes continence; easily removed clothing reduces patient frustration

and helps achieve continence.

– Provide privacy during toileting to reduce anxiety and promote

elimination.

– Have patient empty bladder before meals, at bedtime, and

before leaving accessible bathroom area to promote elimination,

avoid accidents, and help relieve intra-abdominal pressure.

– Limit fluids to 150 ml after dinner to reduce need to void at

night.

– Encourage high fluid intake, unless contraindicated, to moisten

mucous membranes and maintain hydration.

– Suggest patient eat increased amount of salty food before going

on a long trip (unless contraindicated). Increased sodium decreases

urine production.

– Make protective pads available for patient’s undergarments, if

needed, to absorb urine, protect skin, and control odors.

If surgery is scheduled, give attentive, appropriate preoperative

and postoperative instructions and care to reduce patient’s anxiety

and build trust in caregivers.

Inform: Alert patient and family members about need for toilet

schedule. Prepare for discharge according to individual needs to

ensure that patient will receive proper care.

Attend: Encourage patient to express feelings and concerns related to

urologic problems. This helps patient focus on specific problem.

Manage: Refer patient and family members to psychiatric liaison

nurse, support group, or other resources, as appropriate.

Community resources typically provide healthcare not available from

other healthcare agencies.

SUGGESTED NIC INTERVENTIONS

Pelvic Muscle Exercise; Teaching: Individual; Urinary Elimination

Management; Urinary Habit Training; Urinary Incontinence Care

Reference

Anders, K. (2006, May). Recent developments in stress urinary incontinence in

women. Nursing Standard, 20(35), 48–54.

Nursing diagnosis – REFLEX URINARY INCONTINENCE

REFLEX  URINARY  INCONTINENCE

DEFINITION

Involuntary loss of urine at somewhat predictable intervals when a

specific bladder volume is reached

DEFINING CHARACTERISTICS

• Complete emptying (with lesion above pontine micturition center)

or incomplete emptying (with lesion above sacral micturition
center) of bladder

• Either inability to sense full bladder, urge to void, or voiding, or

ability to sense urge to void without ability to voluntarily inhibit
bladder contraction

• Inability to voluntarily inhibit or initiate voiding

• Predictable pattern of voiding

• Sensations associated with full bladder (sweating, restlessness, and

abdominal discomfort)

RELATED FACTORS

• Tissue damage (e.g., radiation therapy)

• Neurological impairment above level of pontine or sacral micturi-

tion center

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

• Maintain fluid balance, with intake approximately equaling output.

• Have minimal, if any, complications.

• Achieve urinary continence.

• Demonstrate skill in managing urinary incontinence.

• Discuss impact of incontinence on himself and family.

• Identify resources to assist with care following discharge.

SUGGESTED NOC OUTCOMES

Knowledge: Treatment Regimen; Nutritional Status: Food & Fluid

Intake; Tissue Integrity: Skin & Mucous Membranes; Urinary Conti-

nence; Urinary Elimination

INTERVENTIONS AND RATIONALES

Determine: Monitor intake and output to ensure correct fluid

replacement therapy. Report output greater than intake.

Perform: Implement and monitor effectiveness of specific bladder

elimination procedure, such as the following:

– Stimulate reflex arc. Patient who voids at somewhat predictable

intervals may be able to regulate voiding by reflex arc stimulation. Trig-

ger voiding at regular intervals (e.g., every 2 hr) by stimulating skin of

abdomen, thighs, or genitals to initiate bladder contractions. Avoid

187

stimulation at nonvoiding times. Stimulate primitive voiding reflexes by

giving patient water to drink while he sits on toilet or pouring water

over perineum. External stimulation triggers bladder’s spastic reflex.

– Apply external catheter according to established procedure and

maintaining patency. Observe condition of perineal skin and clean

with soap and water at least twice daily. Cleanliness prevents skin

breakdown and infection. External catheter protects surrounding

skin, promotes accurate output measurement, and keeps patient dry.

Applying foam strip in spiral fashion increases adhesive surface and

cuts risk of impaired circulation.

– Insert indwelling catheter. Monitor patency and keep tubing free

from kinks to avoid drainage pooling and ensure accurate therapy. Keep

drainage bag below level of bladder to avoid urine reflux into bladder.

Perform catheter care according to established procedure. Maintain

closed drainage system to prevent bacteriuria. Secure catheter to leg

(female) or abdomen (male) to avoid tension on bladder and sphincter.

– Apply suprapubic catheter. Change dressing according to estab-

lished procedure to avoid skin breakdown. Monitor patency and

keep tubing free from kinks to avoid drainage pooling in loops of

catheter. Keep drainage bag below bladder level to avoid urine reflux

into bladder. Maintain closed drainage system to prevent bacteriuria.

– Change wet clothes to prevent patient from becoming

accustomed to wet clothes.

Inform: Instruct patient and family members on continence

techniques to use at home. Have patient and family members return

demonstrations until they can perform procedure well. Patient edu-

cation begins with assessment and depends on nurse’s therapeutic

relationship with patient and family.

Attend: Encourage high fluid intake (3,000 ml daily, unless

contraindicated) to stimulate micturition reflex. Limit fluid intake

after 7 p.m. to prevent nocturia.

Encourage patient and family members to share feelings and con-

cerns regarding incontinence. A trusting environment allows nurse to

make specific recommendations to resolve patient’s problems.

Manage: Refer patient and family members to psychiatric liaison

nurse, home healthcare agency, support group, or other resources, as

appropriate. Community resources typically provide healthcare not

available from other healthcare agencies.

SUGGESTED NIC INTERVENTIONS

Pelvic Muscle Exercise; Urinary Bladder Training; Urinary Elimina-

tion Management; Urinary Incontinence Care

Reference

Zarowitz, B. J., & Ouslander, J. G. (2006, September–October). Management

of urinary incontinence in older persons. Geriatric Nursing, 27(5), 265–270.

Nursing diagnosis – DISTURBED PERSONAL IDENTITY

DISTURBED  PERSONAL  IDENTITY

DEFINITION

Inability to maintain an integrated and complete perception of self

DEFINING CHARACTERISTICS

• Disturbed body image

• Contradictory personal traits

• Fluctuating feelings about self

• Ineffective role performance

• Gender confusion

• Ineffective coping

• Unable to distinguish between

• Uncertainty about ideological

inner and outer stimuli

and cultural values

• Delusional description of self

• Uncertainty about goals

• Feelings of emptiness

• Disturbed relationships

• Feelings of strangeness

RELATED FACTORS

• Organic brain syndrome

• Situational crisis

• Dissociative identity disorder

• Dysfunctional family processes

• Psychiatric disorders

• Cultural discontinuity

• Low self-esteem

• Cult indoctrination

• Manic states

• Discrimination or prejudice

• Social role change

• Use of psychoactive drugs

• Stage of growth

• Ingestion of toxic chemicals

• States of development

• Inhalation of toxic chemicals

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Safety

• Sexual practices

• Mental status

• Cultural beliefs

• Self-care

• Relationships

EXPECTED OUTCOMES

The patient will

• Contract for safety.

• Identify internal versus external stimuli.

• Maintain adequate nutritional intake.

• Identify personal goals and realistic steps toward those goals.

• Compile a list of resources to call when needed.

• Remain free from substance abuse.

• Secure a safe place to live in.

SUGGESTED NOC OUTCOMES

Coping; Distorted Thought; Impulse self-Control; Self-Control;

Self-Esteem

INTERVENTIONS AND RATIONALES

Determine:  Assess for suicidal/homocidal ideation, self-induced cuts

or burns. Assess for self-induced vomiting or restricting of food.

Thorough mental status examination. Individuals struggling with

identified issues are at an increased safety risk.

179
Monitor mental status daily to be able to intervene if necessary.
Monitor weight weekly to be able to detect changes that may

require further intervention.

Perform:  Contract with patient for safety. Schedule meetings with

patient to process feelings and experiences. Demonstrating care and

compassion for the patient allows him or her to feel safe and pro-

motes healing.

Inform:  Instruct patient to journal feelings and list coping strategies.

Journaling can help a patient maintain self-control and may increase

insight.

Attend:  Accept patient in his or her struggle. Reinforce taking

healthy risks and appropriate expression of feelings. Appropriate

expression of feelings enhances self-esteem and promotes resiliency.

Manage:  Refer patients to mental health services for medication and

symptom management. Disturbed personal identity may require

ongoing mental health care.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Environmental Management: Safety; Role

Enhancement; Self-Esteem Enhancement

Reference

Boyd, M. A. (2008). Psychiatric nursing. Philadelphia: Lippincott Williams &

Wilkins.

Nursing diagnosis – HYPOTHERMIA

HYPOTHERMIA

DEFINITION

Body temperature below normal range

DEFINING CHARACTERISTICS

• Body temperature below normal range

• Cool, pale skin

• Cyanotic nail beds

• Increased blood pressure, heart rate, and capillary refill time

• Piloerection

• Shivering

RELATED FACTORS

• Aging

• Exposure to cool environment

• Consumption of alcohol

• Illness

• Damage to hypothalamus

• Inactivity

• Decreased ability to shiver

• Inadequate clothing

• Decreased metabolic rate

• Malnutrition

• Evaporation from skin in cool

• Medications

environment

• Trauma

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Neurocognition

• Pharmacological function

• Respiratory function

• Physical regulation

• Tissue integrity

EXPECTED OUTCOMES

The patient will

• Maintain body temperature within normal range.

• Have warm and dry skin.

• Maintain heart rate and blood pressure within normal range.

• Not shiver.

• Express feelings of comfort.

• Show no complications associated with hypothermia, such as soft-

tissue injury, fracture, dehydration, and hypovolemic shock, if
warmed too quickly.

• State an understanding of how to prevent further episodes of

hypothermia.

SUGGESTED NOC OUTCOMES

Neurological Status: Autonomic; Thermoregulation; Vital Signs

INTERVENTIONS AND RATIONALES

Determine: Monitor body temperature at least every 4 hr or more

frequently, if indicated, to evaluate effectiveness of interventions.

Record temperature and route to allow accurate data comparison.

Baseline temperatures vary, depending on route used. If temperature

drops below 95   F (35   C), use a low-reading thermometer to obtain

accurate reading.

177
Monitor and record neurologic status at least every 4 hr. Falling

body temperature and metabolic rate reduce pulse rate and blood

pressure, which reduces blood perfusion to brain, resulting in disori-

entation, confusion, and unconsciousness.

Monitor and record heart rate and rhythm, blood pressure, and

respiratory rate at least every 4 hr. Blood pressure and pulse

decrease in hypothermia. During rewarming, patient may develop

hypovolemic shock. During warming, ventricular fibrillation and car-

diac arrest may occur, possibly signaled by irregular pulse.

Perform: Provide supportive measures, such as placing patient in

warm bed and covering with warm blankets, removing wet or con-

strictive clothing, and covering metal or plastic surfaces that contact

patient’s body. These measures protect patient from heat loss.

Follow prescribed treatment regimen for hypothermia: As ordered,

administer medications to prevent shivering to avoid overheating.

Monitor and record effectiveness. As ordered, administer analgesic

to relieve pain associated with warming. Monitor and record effec-

tiveness.

Use hyperthermia blanket to warm patient if temperature drops

below 95   F (35   C). Warm patient to 97   F (36.1   C).

As appropriate, administer fluids during rewarming to prevent

hypovolemic shock. If administering large volumes of intravenous

fluids, consider using a fluid warmer to avoid heat loss.

Inform: Discuss precipitating factors with patient, if indicated.

Patient may require community outreach assistance with certain pre-

cipitating factors, including inadequate living conditions, insufficient

finances, and abuse of medications (such as sedatives and alcohol).

Instruct patient in precautionary measures to avoid hypothermia,

such as dressing warmly even when indoors, eating proper diet, and

remaining as active as possible. Precautions help to prevent acciden-

tal hypothermia.

Manage: Report lack of responses to interventions to physician to

prevent complications.

SUGGESTED NIC INTERVENTIONS

Comfort Level; Fluid Management; Hypothermia Treatment;

Temperature Regulation; Vital Signs Monitoring

Reference

Good, K. K., et al. (2006, May). Postoperative hypothermia—The chilling

consequences. AORN Journal, 83(5), 1055–1066.

Nursing diagnosis – HYPERTHERMIA

HYPERTHERMIA

DEFINITION

Body temperature elevated above normal range

DEFINING CHARACTERISTICS

• Fever

• Flushed, warm skin

• Increased heart and respiratory rate

• Seizures

RELATED FACTORS

• Anesthesia

• Increased metabolic rate

• Decreased perspiration

• Illness

• Dehydration

• Medications

• Exposure to hot environment

• Trauma

• Inappropriate clothing

• Vigorous activity

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Neurocognition

• Pharmacological function

• Respiratory function

• Physical regulation

• Tissue integrity

EXPECTED OUTCOMES

The patient will

• Remain afebrile.

• Maintain balance of intake and output within normal limits.

• Maintain urine specific gravity between 1.005 and 1.015.

• Exhibit moist mucous membranes.

• Exhibit good skin turgor.

• Remain alert and responsive.

SUGGESTED NOC OUTCOMES

Hydration; Infection Severity; Thermoregulation; Vital Signs

INTERVENTIONS AND RATIONALES

Determine: Monitor heart rate and rhythm, blood pressure, respira-

tory rate, LOC and level of responsiveness, and capillary refill time

every 1–4 hr to evaluate effectiveness of interventions and monitor

for complications.

Determine patient’s preferences for oral fluids, and encourage

patient to drink as much as possible, unless contraindicated. Moni-

tor and record intake and output, and administer intravenous fluids,

if indicated. Because insensible fluid loss increases by 10% for every

1.8   F (1   C) increase in temperature, patient must increase fluid

intake to prevent dehydration.

Perform: Take temperature every 1–4 hr to obtain an accurate core

temperature. Identify route and record measurements.

Administer antipyretics as prescribed and record effectiveness.

Antipyretics act on hypothalamus to regulate temperature.

175
Use nonpharmacologic measures to reduce excessive fever, such as

removing sheets, blankets, and most clothing; placing ice bags on

axillae and groin; and sponging with tepid water. Explain these

measures to patient. Nonpharmacologic measures lower body tem-

perature and promote comfort. Sponging reduces body temperature

by increasing evaporation from skin. Tepid water is used because

cold water increases shivering, thereby increasing metabolic rate and

causing temperature to rise.

Use a hypothermia blanket if patient’s temperature rises above

103   F (39.4   C), if ordered. Monitor vital signs every 15 min for

1 hr and then as indicated. Prolonged hyperthermia may lead to

complications such as seizures. Turn off blanket if shivering occurs.

Shivering increases metabolic rate, increasing temperature.

Manage: Report lack of responses to interventions to physician to

prevent complications.

SUGGESTED NIC INTERVENTIONS

Environmental Management; Fever Treatment; Fluid Management;

Temperature Regulation

Reference

Kayser-Jones, J. (2006, June). Preventable causes of dehydration: Nursing

home residents are especially vulnerable. American Journal of Nursing,
106(6), 45.

Nursing diagnosis – HOPELESSNESS

HOPELESSNESS

DEFINITION

Subjective state in which an individual sees few or no available alter-

natives or personal choices available and is unable to mobilize energy

on own behalf

DEFINING CHARACTERISTICS

• Decreased appetite, affect, response to stimuli, verbalization

• Increased or decreased sleep

• Lack of involvement in self-care

• Nonverbal cues, such as closing eyes, shrugging in response to

question, and turning away from speaker

• Passivity and lack of initiative

RELATED FACTORS

• Abandonment

• Lost belief in spiritual power

• Deteriorating physical

• Lost belief in transcendent

condition

power

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Roles/responsibilities

• Coping

• Values/beliefs

EXPECTED OUTCOMES

The patient will

• Identify feelings of hopelessness regarding present situation.

• Demonstrate more effective communication skills.

• Resume appropriate rest and activity pattern.

• Participate in self-care activities and decisions regarding care planning.

• Use diversional activities.

SUGGESTED NOC OUTCOMES

Acceptance: Health Status; Adaptation to Physical Disability;

Depression Control; Hope; Quality of Life

INTERVENTIONS AND RATIONALES

Determine: Assess the following: nature of current medical diagnosis;

patient’s knowledge about medical diagnosis; actual or perceived

self-care deficits; mental status; communication patterns and support

systems; nutritional status and appetite; and sleep patterns. Also

monitor heart rate and blood pressure; respiratory rate, quality and

depth of respirations, and breath sounds. Assessment factors will

help identify appropriate interventions.

Perform: Follow medical regimen to manage the patient’s physiologic

condition. Build non–care-related time into the daily schedule to

allow time to develop a trusting relationship with the patient.

Provide comfort measures: adjust lighting and sound to minimize

irritating stimuli; offer back rubs and space procedures to promote

relaxation.

173

Inform: Keep patient informed about what to expect and when to

expect it. Accurate information reduces anxiety.

Teach self-healing techniques to both the patient and the family,

such as meditation, guided imagery, yoga, and prayer, to enhance

coping strategies. Teach patient how to incorporate the use of self-

healing techniques in carrying out usual daily activities.

Attend: Encourage patient to talk about personal assets and accom-

plishments and about improvements in his or her condition, no mat-

ter how small they may seem. Give positive feedback. Conversation

assists evaluation of patient’s self-concept and adaptive abilities.

Direct the patient’s focus beyond the present state. For example,

“Your nasogastric tube will come out tomorrow and you will feel

more comfortable.” This helps instill hope.

Encourage patient to talk about appropriate diversions and to

participate in them. Pleasurable activity decreases potential hazard

of crisis.

Manage: Refer patient and family to other professional caregivers,

for example, dietitian, social worker, clergy, mental health

professional, and support groups such as Ostomy Club, I Can Cope,

and Reach for Recovery. Assist patient to utilize appropriate

resources by contacting family and scheduling follow-up

appointments. These measures help give the patient a sense of direc-

tion and control over his or her future care.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Decision-Making Support; Energy

Management; Mutual Goal Setting; Sleep Enhancement; Spiritual

Growth Facilitation; Support Group

Reference

Kronenwetter, C., et al. (2005, March–April). A qualitative analysis of inter-

views of men with early stage prostate cancer. Cancer Nursing, 28(2),
99–107.

Nursing diagnosis – READINESS FOR ENHANCED HOPE

READINESS  FOR  ENHANCED  HOPE

DEFINITION

A pattern of expectations and desires that is sufficient for mobilizing

energy on one’s own behalf and can be strengthened

DEFINING CHARACTERISTICS

Expresses desire to enhance:

• Ability to set personal goals

• Belief in possibilities

• Congruency of expectations with desires

• Hope

• Interconnectedness with others

• Problem solving to meet goals

• Sense of meaning to life

• Spirituality

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Roles/responsibilities

• Coping

• Self-perception

• Emotional status

EXPECTED OUTCOMES

The patient will

• Express desire for positive health outcomes.

• Share personal goals to increase autonomy and personal

satisfaction.

• Increase quality of life.

• Plan to promote maximal physical, mental, social, and psychologi-

cal abilities.

• Share strategies to live a meaningful life.

• Express awareness of the need for developing and maintaining a

positive attitude of hope.

• Seek spiritual support as needed.

SUGGESTED NOC OUTCOMES

Hope; Personal Well-Being; Quality of Life; Will to Live

INTERVENTIONS AND RATIONALES

Determine: Assess patient’s perception of ability to set personal goals.

Assess expression of desire to build on possibilities for the future,

and ability to align desires and expectations. Assess ability of patient

to maintain and enhance relationships with others. Assess patient’s

and family’s spiritual needs, including religious beliefs and affiliation.

Information from assessment will assist in determining appropriate

interventions.

Perform: Schedule time to meet with family and patient to listen to

ways in which they plan to enhance their coping skills in the present

situation.

171
Facilitate opportunities for spiritual nourishment and growth to

address patient’s holistic needs for maximal therapeutic environment.

Inform: Teach self-healing techniques to both the patient and family,

such as meditation, guided imagery, yoga, and prayer, to promote

relaxation.

Teach patient how to incorporate the use of self-healing techniques

in carrying out usual daily activities. Practicing will increase the

chance that the patient will himself use these techniques.

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

that maximizes patient’s comfort. Comfort will reduce anxiety and

help patient cooperate with his or her treatment.

Demonstrate procedures and encourage participation in patient’s

care.

Provide patient with concise information about patient’s condition.

Be aware of what the family members have already been told.

Attend: Reinforce family’s efforts to care for the patient. Let them

know they are doing well to ease adaptation to new caregiver roles.

Encourage family to support patient’s independence.

Encourage patient’s cooperation as you continue with healing

techniques, such as therapeutic touch. Cooperation will enhance the

effect of the therapy.

Provide emotional support to family and be available to answer

questions. Being available to answer questions and listen builds trust

of the family.

Manage: Refer family to community resources and support groups to

assist in managing patient’s illness and providing emotional and

financial assistance to caregivers.

Refer to a member of the clergy or a spiritual counselor, accord-

ing to the patient’s preference, to show respect for the patient’s

beliefs and provide spiritual care.

SUGGESTED NIC INTERVENTIONS

Hope Facilitation; Self-Esteem Enhancement; Spiritual Growth Facili-

tation

Reference

Davidson, P. M., et al. (2007, January–February). Maintaining hope in transi-

tion: A theoretical framework to guide interventions for people with heart
failure. Journal of Cardiovascular Nursing, 22(1), 58–64.

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.

169

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.