Nursing diagnosis – NONCOMPLIANCE



Behavior of person and/or caregiver that fails to coincide with a

health-promoting or therapeutic plan agreed on by the person

(and/or family and/or community) and health-care professional. In

the presence of an agreed-on, health-promoting or therapeutic plan,

person’s or caregiver’s behavior is fully or partially nonadherent and

may lead to clinically ineffective or partially ineffective outcomes


• Behavior indicative of failure to progress

• Complications or evidence of exacerbation of signs and symptoms

• Failure to keep appointments and adhere to treatment regimen

• Objective indications (e.g., laboratory tests, physiologic markers)


Health system


• Access to, convenience of care

• Cultural/spiritual values

• Client–provider relationships

• Developmental and personal

• Individual health coverage


• Provider communication skills,

• Health beliefs

credibility; continuity; teaching
skills; reimbursement

• Knowledge of regimen
• Motivational forces

Healthcare plan


• Complexity, intensity

• Involvement of members in

• Cost, financial flexibility, and

health plan

duration of plan

• Social value regarding plan

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Knowledge

• Beliefs/values

• Roles/responsibilities

• Coping

• Self-perception

• Emotional status


The patient will

• Identify factors that influence noncompliance.

• Demonstrate level of compliance that maintains safety.

• Contract to perform specific behaviors.

• Use support systems to modify noncompliant behaviors.


Acceptance: Health Status; Adherence Behavior; Compliance Behav-

ior; Symptom control; Treatment Behavior


Determine:  Assess patient’s perception of health problem, treatment

regimen and history of compliance, obstacles to compliance, financial


resources, ethnicity, and religious influences. Assessment information

may help select appropriate interventions.

Perform:  Provide an environment that is nonjudgmental. This

demonstrates unconditional respect for the patient.

Contract with the patient to practice only nonthreatening behav-

iors. This involves the patient in a formal commitment and gives the

patient a sense of personal control.

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

such as meditation, guided imagery, yoga, and prayer. These

techniques promote self-reliance.

Teach principles of good nutrition for patient’s specific condition.

Understanding importance of nutrition will encourage compliance.

Inform patient about diagnosis. Understanding essential informa-

tion needed to perform skills or give self-care increases compliance.

Demonstrate skills needed by patient to comply with treatment regi-

men to reinforce patient’s confidence in ability to replicate.

Attend:  Provide opportunities for the patient to discuss reasons for

noncompliance. The willingness of the nurse to listen allows the

patient the ability to listen to his or her own reasoning.

Help patient clarify his or her values about the importance of fol-

lowing a treatment plan to determine appropriate interventions.

Acknowledge patient’s right to choose not to comply with

prescribed regimen to respect autonomy. Control over patient’s

actions is legitimate only when dangerous to self or others. Offer

positive reinforcement.

Use support systems to reinforce negotiated behaviors. Support

from the family and friends help foster compliance.

Manage: When medically appropriate, support patient’s cultural

beliefs towards medical practices to demonstrate respect; and refer

to a member of the clergy or a spiritual counselor.

Refer family to community resources and support groups to pro-

mote compliance with modification of behavior. If patient’s situation

is complicated by lack of financial resources, contact agencies that

may offer help with costs of medical treatment.


Coping Enhancement; Counseling; Decision-Making Support; Health

Education; Patient Contracting; Self-Modification Assistance; Self-

Responsibility Facilitation


Riegel, B., et al. (2006, May–June). A motivational counseling approach to

improving heart failure self-care mechanisms of effectiveness. Journal of
Cardiovascular Nursing, 21(3), 232–241.

Nursing diagnosis – UNILATERAL NEGLECT



Impairment in sensory and motor response, mental representation,

and spatial attention of the body and the corresponding environ-

ment characterized by inattention to one side and overattention to

the opposite side. Left side neglect is more severe and persistent

than right side neglect


• Consistent inattention to stimuli/positioning on affected side

• Failure to eat food on plate on the affected side

• Inadequate self-care

• Failure to move eyes, head, limbs, or trunk in the affected hemi-

space despite awareness of stimulus in that space

• Marked deviation of the eyes, head, or trunk to the nonaffected

side by stimuli and activities on that side (as if drawn by Magnet)

• Perseveration of visual motor tasks on the nonaffected side


• Brain injury from tumor, or cerebrovascular, neurological, or trau-

matic causes

• Left hemiplegia from CVA of right hemisphere

• Hemianopsia

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Self-care

• Coping

• Sensation/perception

• Neurocognition

• Tissue integrity


The patient/family will

• Avoid injury, skin breakdown and contractures on affected body part.

• Recognize the neglected body part.

• Demonstrate exercises for the affected body part.

• Demonstrate measures for maximum functioning and arrange

environment to protect the affected body part.

• Express feelings about altered state of health and neurologic deficits.

• Identify community resources and support groups to help cope

with the effects of illness.


Adaptation to Physical Disability; Body Image; Body Mechanics Per-

formance; Body Positioning: Self-Initiated; Self-Care: ADLs


Determine:  Observe the position of the affected body part frequently

to prevent injury.

Perform:  Place a sling on the affected arm to prevent dangling or injury.

Support affected leg and foot and perform other measures, as

appropriate, to keep patient’s limbs in functional position and avoid


contractures. Use a drawsheet to move patient up in bed to avoid

skin abrasions.

Touch and rub the affected limb, and describe the limb in conversa-

tion with patient. This reminds the patient of the neglected body part.

Use safety belts or protective devices to remind patient of limita-

tions and prevent falls. Use devices according to facility policy.

Remove splints and other devices at least every 2 hr. Inspect the

skin for pressure areas. Reapply the splint. Proper use of splints and

other devices prevents deformities and maintains skin integrity.

Perform ROM exercises on the affected side at least once every

shift, unless medically contraindicated, to maintain joint flexibility

and prevent contractures. Establish and follow a regular turning

schedule to maintain skin integrity.

Arrange environment for maximum functioning; for example,

place water, television controls, and the call bell within reach. These

measures enhance orientation and encourage independence.

Assist patient with ADLs or provide supervision, as appropriate,

to protect patient’s affected side.

Inform:  Encourage patient to perform activities that require use of

the affected limb to more easily integrate paretic or paralyzed limb

into body image.

Instruct family and nursing personnel to observe the position of

the affected body part frequently; to remove food or drainage from

the face if unnoticed by patient; and to place the arm or leg in the

proper position as often as necessary. These measures help avoid

injury and maintain dignity.

Attend:  Encourage patient to check the position of the affected body

part with each repositioning or transfer to reestablish awareness of

the body part.

Encourage patient and family members to express their feelings

regarding patient’s condition and level of functioning to release ten-

sion and enhance coping.

Manage:  Request consultations with occupational and physical ther-

apists about adaptive equipment and exercise programs to promote

use of the affected limb.

Refer patient and family members to appropriate support groups

and other community resources to assist in adjusting to patient’s

altered state of health.


Body Image Enhancement; Exercise Therapy: Joint Mobility; Mutual

Goal-Setting; Self-Care Assistance; Unilateral Neglect Management


Macko, R. F., et al. (2005, Winter). Task-oriented aerobic exercise in chronic

hemiparetic stroke: Training protocols and treatment effects. Topics in
Stroke Rehabilitation, 12(1), 45–57.

Nursing diagnosis – NAUSEA



A subjective unpleasant, wavelike sensation in the back of the throat,

epigastrium, or abdomen that may lead to the urge or need to vomit


• Gagging sensation

• Gastric stasis

• Increased salivation, swallowing

• Sour taste in the mouth

• Uninterested in eating; does not have appetite

• Reports “nausea” or “sick to the stomach”




• Biochemical disorders

• Anxiety

• Esophageal disease

• Fear

• Gastric distention, irritation

• Noxious odors, taste, visual

• Increased intracranial pressure


• Motion sickness

• Pain

• Pain

• Physiological factors

• Pancreatic disease


• Tumors, intra-abdominal or

• Gastric distention, irritation

localized tumors

• Pharmaceuticals

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Nutrition

• Knowledge

• Fluid and electrolytes

• Comfort

• Pharmacological function


The patient will

• State reasons for nausea and vomiting.

• Take steps to manage episodes of nausea and vomiting.

• Ingest sufficient nutrients to maintain health.

• Take steps to ensure adequate nutrition when nausea abates.

• Maintain weight within specified limits.


Appetite; Comfort Level; Fluid Balance; Hydration; Nausea & Vom-

iting Control; Nutritional Status: Food & Fluid Intake; Suffering

Severity; Symptom Control


Determine:  Assess for illness, pregnancy, medication use (prescription

and over-the-counter); exposure to tainted foods, chemicals, occupational

hazards; weight (fluctuation in last 6 months); food preferences and usual

dietary patterns; history of gastric/esophageal problems. Assessment infor-

mation will help in identifying appropriate interventions.

Monitor direct observation of food and fluid intake to ensure

whether or not the patient is receiving adequate nutritional intake.

Perform:  Provide comfort measures (e.g., back massage, warm bath)

to promote feelings of comfort for the patient.

Reduce noise, control odors, and adjust light in the environment

to help the patient relax and to reduce environmental factors that

produce nausea.

Allow periods of uninterrupted sleep between procedures. Proce-

dures and medication administration sometimes trigger periods of


Offer small amount of cool liquids or ice chips to provide some

fluid to reduce the possibility of dehydration.

Suggest frequent mouth care to reduce unpleasant taste in the


Give dry, bland foods, such as dry toast or crackers, during peri-

ods of nausea to make it possible to eat. These foods have been

found to be effective.

Administer antinausea medications, as prescribed.

Inform:  Teach relaxation techniques and encourage patient to use

these techniques during mealtime to reduce stress and divert atten-

tion from the nausea.

Teach patient how to use food and fluid during periods of nausea

to avoid dehydration and lack of nutrients. Food should be taken in

small, frequent feedings. Avoid drinking with meals.

Attend:  When nausea abates, encourage patient to increase food

intake to assist with adequate intake of nutrients.

Assist patient to make a list of best tolerated and poorly tolerated

foods so he or she can choose quickly and wisely when nausea


Manage:  If nausea persists, refer patient to a nutritionist to assist

after discharge to ensure that adequate nutrients will be ingested.

Stress the importance of follow-up appointments with the physi-

cian. Nausea is a preventable problem and should respond to appro-

priate measures.


Diet Staging; Fluid and Electrolyte Management; Fluid Monitoring;

Medication Management; Nausea Management Nutritional Manage-



Mamaril, M. E., et al. (2006, December). Prevention and management of

postoperative nausea and vomiting: A look at contemporary techniques.
Journal of Perianesthesia Nursing, 21(6), 404–410.




Limitation of independent operation of wheelchair within environment


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

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


• Cognitive impairment

• Environmental constraints

• Deconditioning

• Impaired vision

• Deficient knowledge

• Limited endurance

• Depressed mood

• Musculoskeletal impairment

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Physical regulation

• Pharmacological function

• Neurocognition


The patient will

• Have no complications associated with impaired wheelchair mobil-

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

• Maintain or improve muscle strength and joint ROM.

• Achieve the highest level of independence and safety possible with

regard to wheelchair use.

• Express feelings regarding alteration in ability to use wheelchair.

• Participate in social and occupational activities to the greatest

extent possible.

• Demonstrate understanding of techniques to improve wheelchair



Ambulation: Wheelchair; Balance; Mobility Level; Muscle Function


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

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

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

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

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

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

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

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

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

motorized wheelchair to help maintain mobility and independence.

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

ity scale. Communicate findings to staff to promote continuity of

care and preserve the documented level of independence.

Monitor and record daily evidence of complications related to

impaired wheelchair mobility. Patients with neuromuscular dysfunc-

tion are at risk for complications.

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

cushion, if necessary, to maintain skin integrity.

Perform:  Perform ROM exercises for affected joints, unless

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

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

cle atrophy.

Inform:  Explain to patient location of vulnerable pressure points and

instruct to shift and reposition weight to prevent skin breakdown.

Ensure patient maintains anatomically correct and functional body

positioning to promote comfort.

Demonstrate techniques to promote wheelchair mobility to the

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

return demonstration to ensure continuity of care and use of proper


Attend:  Encourage patient to operate her wheelchair independently

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

prevent complications of immobility, and promote independence in

self-care and health maintenance skills.

Encourage attendance at physical therapy sessions and reinforce

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

techniques used in the therapy session. To maintain continuity of

care and promote patient safety.

Manage:  Refer patient to a physical therapist to enhance wheelchair

mobility and rehabilitation of musculoskeletal deficits.

Help patient identify resources for maintaining highest level of

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

people with disabilities, and the National Multiple Sclerosis Society)

to promote reintegration into the community.


Exercise Promotion: Strength Training; Exercise Therapy: Balance;

Exercise Therapy: Muscle Control; Positioning: Wheelchair


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

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




Limitation in independent, purposeful physical movement of the

body or of one or more extremities


• Gait changes, postural instability; difficulty turning

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

• Movement-induced tremor, uncoordinated or jerky movements

• Slowed and/or uncoordinated movements; reaction time.

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

increased attention to other’s activity and controlling behavior)


• Activity intolerance

• Decreased endurance; muscle

• Altered cellular metabolism

control, mass or strength

• Body mass index above

• Depressive mood state

75th percentile

• Deficient knowledge about

• Cognitive impairment

value of exercise

• Contractures

• Developmental delay

• Cultural beliefs regarding

• Discomfort

age-appropriate activity

• Disuse

• Deconditioning

• Joint stiffness

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition


The patient will

• Maintain muscle strength and joint ROM.

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

thrombus formation, skin breakdown, and hypostatic pneumonia).

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

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

• Carry out mobility regimen.

• Use resources to help maintain level of functioning.


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

Movement: Shoulder; Mobility; Transfer Performance


Determine:  Identify level of functioning using a functional mobility

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

vide continuity and preserve identified level of independence.

Monitor and record daily any evidence of immobility

complications as they may be more prone to develop complications.


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

least once every shift to prevent joint contractures and muscular

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

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

vent skin breakdown by relieving pressure. Place joints in functional

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

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

maintain joints in a functional position and prevent musculoskeletal


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

sided weakness or paralysis to promote patient’s independence.

Carry out medical regimen to manage or prevent complications

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

promotes patient’s health and well-being.

Provide progressive mobilization to the limits of patient’s

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

muscle tone and prevent complications of immobility.

Inform:  Instruct patient and family members in ROM exercises,

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

discharge and promote continuity of care. Request return

demonstration to ensure use of proper technique.

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

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

increase muscle tone.

Encourage physical therapy sessions and support activities on the

unit by using the same equipment and technique. Request written

mobility plans for reference. Ensure all members of the healthcare

team are reinforcing learned skills in the same manner.

Manage:  Refer patient to a physical therapist for development of

mobility regimen to help rehabilitate musculoskeletal deficits.

Assist patient in identifying resources such as American Heart

Association to provide a comprehensive approach to rehabilitation.


Exercise Promotion: Strength Training; Exercise Therapy: Joint

Mobility; Exercise Therapy: Muscle Control; Positioning: Wheelchair


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

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

Nursing diagnosis – IMPAIRED BED MOBILITY



Limitation of independent movement from one bed position to another


Impaired ability to perform the following actions while in bed:

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

• Move from supine to prone or prone to supine

• Move from supine to sitting or sitting to supine

• “Scoot” or reposition body

• Turn from side to side


• Cognitive impairment

• Musculoskeletal and/or

• Deconditioning

neuromuscular impairment

• Deficient knowledge

• Obesity

• Environmental constraints

• Pain

• Insufficient muscle strength

• Sedating medications

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Pharmacological function

• Physical regulation


The patient will

• Have no complications associated with impaired bed mobility,

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

• Maintain or improve muscle strength and joint ROM.

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

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

• Demonstrate ability to use equipment or devices to assist with

moving about in bed safely.

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

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

extent possible.


Body Positioning: Self-Initiated; Cognition; Immobility

Consequences: Physiological; Immobility Consequences: Psychocogni-

tive; Joint Movement, Mobility; Neurological Status: Consciousness


Determine:  Identify patient’s level of independence using functional

mobility scale and document findings to provide continuity of care.

Monitor and record daily evidence of complications related to

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


thrombus formation, depression, altered health maintenance or self-

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


Perform:  Perform ROM exercises to affected joints, unless

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

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


Assist patient in maintaining anatomically correct and functional

body positioning to relieve pressure, thereby preventing skin break-

down and fluid accumulation in dependent extremities. Encourage

repositioning every 2 hr while in bed.

Establish a turning schedule for immobile patient. Encourage pro-

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

prevent complications, and promote self-care.

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

request help from colleagues to maintain safety.

Inform:  Instruct patient and family members in techniques to

improve bed mobility and ways to prevent complications to help

prepare the patient and family members for discharge.

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

Have patient and family members perform a return demonstration

to ensure continuity of care and use of proper technique.

Attend:  Encourage patient to participate in physical and

occupational therapy sessions. Incorporate equipment, devices, and

techniques used by therapists into your care. Request written

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

help ensure continuity of care and reinforce learned skills.

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

ment in bed mobility and rehabilitate musculoskeletal deficits; and

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

Assist patient in identifying and contacting resources for social

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

community and help him maintain psychosocial health.


Bed Rest Care; Body Mechanics Promotion; Exercise Promotion:

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

apy: Muscle Control; Positioning


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

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

Nursing diagnosis – IMPAIRED MEMORY



Inability to remember or recall bits of information or behavioral



• Inability to determine whether a behavior was performed

• Inability to learn new skills or information or to perform

previously learned skills

• Inability to recall factual information and recent or past events

• Incidences of forgetting, including forgetting to perform a behavior

at a scheduled time


• Anemia

• Fluid and electrolyte

• Decreased cardiac output


• Excessive environmental

• Hypoxia


• Neurological disturbances

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Neurocognition

• Emotional

• Self-care

• Fluids and electrolytes


The patient/family will

• Express feelings about memory impairment.

• Acknowledge need to take measures to cope with memory


• Identify coping skills to deal with memory impairment.

• State specific plans to modify lifestyle.

• Establish realistic goals to deal with further memory loss.


Cognition; Cognitive Orientation; Concentration; Memory; Neuro-

logical Status: Consciousness


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

Document and report any changes. Changes may indicate progressive

improvement or a decline in patient’s underlying condition.

Perform:  Implement appropriate safety measures to protect patient

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

safety needs.

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

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

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

board to visually reinforce reality orientation.

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

able discussing memory loss and establish a trusting relationship.

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

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

explanations to patient each time you carry out any medical or

nursing procedure to avoid confusion.

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

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

a secure environment.

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

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

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

goal is to help him or her.

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

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

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

pocket calendar; having family members or friends remind her of

important tasks). Reminders help limit the amount of information

patient must maintain in her memory.

Help patient and family members establish goals for coping with

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

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

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

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

Demonstrate reorientation techniques to family members and pro-

vide time for supervised return demonstrations to prepare them to

cope with patient with memory impairment.

Attend:  Encourage patient to develop a consistent routine for

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

increase his self-awareness and awareness of his environment.

Encourage patient to interact with others to increase social

involvement, which may decline with memory loss.

Encourage patient to express the feelings associated with impaired

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

self-image and lessen anxiety.

Manage:  Help family members identify appropriate community sup-

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

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


Anxiety Reduction; Calming Technique; Cerebral Perfusion Promo-

tion; Dementia Management; Fluid and Electrolyte Management;

Memory Training; Neurologic Monitoring; Reality Orientation


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

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

Nursing diagnosis – SEDENTARY LIFESTYLE



Reports a habit of life that is characterized by a low physical activ-

ity level


• Chooses a daily routine lacking physical exercise

• Demonstrates physical deconditioning

• Verbalizes preference for activities low in physical activity


• Deficient knowledge of health benefits of physical exercise

• Lack of interest, motivation, resources, and/or training

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Nutrition

• Growth and development

• Risk management

• Knowledge


The patient will

• Maintain independent living status with reduced risk for falling.

• Identify barriers to increasing physical activity level.

• Identify health benefits to increasing physical activity level.

• Increase physical activity and limit inactive forms of diversion,

such as television and computer games.

• Seek professional consultation to develop an appropriate plan to

increase physical activity.

• Identify factors that enhance readiness for sleep.

• Demonstrate readiness for enhanced sleep through the use of

appropriate sleep hygiene measures.

• Have amount of sleep congruent with developmental needs and

experience rapid-eye-movement (REM) sleep.

• Express a feeling of being rested after sleep.

• Increase lean muscle and bone strength and decrease body fat.

• Demonstrate weight control and, if appropriate, weight loss.

• Exhibit enhanced psychological well-being and reduced risk of


• Have reduced depression and anxiety and an improved mood.

• Demonstrate increased ability to perform activities of daily living

within limits of chronic, disabling conditions.


Activity Intolerance; Endurance; Energy Conservation; Health-

Promoting Behavior; Immobility Consequences: Physiologic


Determine: Identify barriers and enhancers to increasing physical

activity, including time management, diet, lifestyle, access to


facilities, and safe environments in which to be active. Breaking

down barriers and building opportunities for activity increase the

probability of consistent physical activity.

Perform: Develop a behavior modification plan based on patient’s

condition, history, and precipitating factors to maximize physical

activity and compliance.

Inform: Instruct patient to keep a daily activity and dietary log to

help him or her achieve a more objective view of his or her behav-


Educate patient about how sedentary lifestyle affects cardiovascu-

lar risk factors (such as hypertension, dyslipidemia,

hyperinsulinemia, insulin resistance) to motivate patient to be more


Teach exercises for increasing strength and endurance to maintain

mobility and prevent musculoskeletal degeneration.

Educate patient about using the bedroom only for sleep or sexual

activity and avoiding other activities such as watching television,

reading, and eating to increase sleep efficiency.

Attend: Provide counseling tailored to patient’s risk factors, needs,

preferences, and abilities to enhance emotional well-being and moti-

vation for physical activity.

Discuss the need for activity that will improve psychosocial well-

being to encourage compliance with activities.

Discuss behavioral risk factors in lack of motivation such as

ingestion of carbohydrates, caffeine, nicotine, alcohol, sedatives, hyp-

notics, and fluid intake, to focus behavior on positive outcomes of

increased physical activity.

Manage: Provide education about community resources available to

increase physical activity to decrease barriers to activity.


Activity Therapy; Energy Management; Teaching: Prescribed Activity/



Zabinski, M. F., et al. (2007, January). Patterns of sedentary behavior among

adolescents. Health Psychology, 26(1), 113–120.

Nursing diagnosis – DEFICIENT KNOWLEDGE



Absence or deficiency of cognitive information related to a specific



• Inability to follow through with directions

• Inability to perform well on a test

• Inappropriate or exaggerated behaviors (hysteria, hostility,

agitation, apathy)

• Verbalization of the problem


• Cognitive limitation

• Lack of recall

• Information misinterpretation

• Unfamiliarity with information

• Lack of exposure


• Lack of interest in learning

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity

• Nutrition

• Communication

• Sleep

• Coping

• Values/beliefs

• Knowledge


The patient will

• Communicate desire to understand disease state and need for


• Demonstrate ability to perform new health-related procedures.

• Set realistic learning goals within target dates.

• State intention to make needed modifications in lifestyle.


Cognition; Concentration; Information Processing; Knowledge: Dis-

ease Process; Knowledge; Health Behaviors; Knowledge: Health

Resources; Knowledge: Illness Care; Stress Level


Determine: Determine level of knowledge and skills patient already

possesses about his or her health status; motivation to understand

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

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

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

tion will assist in identifying appropriate interventions.

Perform: Establish an environment of mutual trust and respect to

enhance learning. Consistency between action and words, combined

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

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

trusting relationship.

Develop with patient specific learning goals with target dates.

Involving patient in planning meaningful goals encourages


Select teaching strategies that will enhance teaching/learning effec-

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

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

This reduces frustration, aids learning, and minimizes dependence by

promoting self-care.

Inform: Teach those skills that the patient must incorporate into

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

aid in gaining confidence.

When teaching, go slowly and repeat frequently. Offer small

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

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

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

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

ter a sense of control.

Attend: Encourage family members to participate in and have

patience toward learning process (patient may need to repeat new

skills multiple times) to help create a therapeutic environment after


Manage: Have patient incorporate learned skills into care while still

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

Provide patient and/or family with names and telephone numbers

of resource people or community agencies so that care is continuous

and follow-up is possible after discharge.

If financial hardship interferes with the ability of the family to

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

to improve the family’s access to financial assistance.


Behavior Management; Behavior Modification; Decision-Making

Support; Energy Management; Family Support; Financial Resource

Assistance; Health Education; Healthcare Information Exchange:

Risk Identification; Learning Facilitation; Support System Enhance-

ment; Teaching Procedure/Treatment


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

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




Involuntary loss of urine associated with overdistention of the bladder


• Bladder distention

• High postvoid residual volume

• Nocturia

• Reported and observed involuntary leakage of small volumes of



• Bladder outlet obstruction

• Severe pelvic prolapse

• Detrusor external sphincter

• Side effects of anticholinergic,


calcium channel blocker, or

• Detrusor hypocontractility

decongestant medications

• Fecal impaction

• Urethral obstruction

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care


The patient will

• Void 200–300 mL of clear, yellow urine every 3–4 hr while


• Have postvoid residual of less than 50 ml.

• Have reduction in urinary incontinence episodes or complete

absence of urinary incontinence.

• Experience relief of most bothersome aspect of urinary


• Remain clean and dry without urine odor.

• Express understanding of condition and activities to prevent/reduce

overflow incontinence.

• Express improvement in quality of life.


Knowledge: Treatment Regimen; Urinary Continence


Determine: Monitor and record patient’s voiding patterns to

determine existence and extent of overflow incontinence.

Monitor and record patient’s intake and output to determine fluid


Perform: Ask patient to keep a bladder diary of continent and incon-

tinent voids to promote understanding of the extent of the problem

of overflow incontinence. Discuss voiding and fluid intake patterns.

Accurate understanding of patient’s pattern provides a baseline for

introducing new activities.

Provide privacy and adequate time to void to decrease anxiety

and promote relaxation of sphincter.

Assist patient to assume usual position for voiding. Some patients

are unable to void while lying in bed and may develop urinary

retention and overflow incontinence.

Massage (credé) the bladder area during urination to increase

pressure in the pelvic area to encourage drainage of urine from the


Institute indwelling or intermittent catheterization, as ordered.

Catheterization is used as a last resort to empty the bladder prevent-

ing overflow incontinence.

Assist with application of pads and protective garments (used only

as a last resort) to prevent skin breakdown and odor and to

promote social acceptance.

Inform: Teach patient and/or family to catheterize patient with

chronic overflow incontinence related to urinary retention using

clean technique to manage long-term overflow incontinence.

Teach stress management and relaxation techniques. Stress and

anxiety interfere with sphincter relaxation, causing urinary retention

and overflow incontinence.

Attend: Encourage patient to share feelings related to incontinence to

reduce anxiety.

Encourage patient to drink six to eight glasses of noncaffeinated,

nonalcoholic, and noncarbonated liquid, preferably water, per day

(unless contraindicated). 1,500–2000 mL/day promotes optimal renal

function and flushes bacteria and solutes from the urinary tract.

Caffeine and alcohol promote diuresis and may contribute to excess

fluid loss and irritation of the bladder wall.

Encourage patient to respond to the urge to void in a timely man-

ner. Ignoring the urge to urinate may cause incontinence.

Encourage patient to participate in regular exercise, including

walking and modified sit-ups (unless contraindicated). Weak abdomi-

nal and perineal muscles weaken bladder and sphincter control.

Encourage patient to avoid anticholinergics, opioids, psychotrop-

ics,    -adrenergic agonists,    -adrenergic agonists, and calcium-

channel blockers (unless contraindicated), which inhibit relaxation of

the urinary sphincter and cause urinary retention.

Manage: Provide referrals for physical therapy or psychological

counseling as necessary to enhance success.


Urinary Incontinence Care; Urinary Retention Care


DuBeau, C. (2006). Clinical presentation and diagnosis of urinary

incontinence. Retrieved December 12, 2006, from




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.




At risk for growth above the 97th percentile or below the 3rd per-

centile for age, crossing the percentile channels


· Altered nutritional status

· Inability to digest and absorb

· Any disease that persists over


time, especially during critical

periods of development

· Neuroendocrine factors, such

as altered levels of growth or

· Environmental hazards, such

thyroid hormones

as chemical or radiation expo-

sure, lead exposure, passive

inhalation of tobacco smoke,

and exposure to air, water, or

food contaminants

· Prenatal influences, such as

maternal exposure to drugs or

alcohol, severe maternal malnu-

trition, and maternal smoking

· Financial or socioeconomic

· Genetic abnormalities


ASSESSMENT FOCUS                           (Refer  to  comprehensive  assessment  parameters.)

· Nutrition

· Sleep

· Activity

· Coping


The child will

· Grow and gain weight as expected on the basis of growth-chart

norms for age and gender.

· Consume _____ calories and ___ml of fluids representing ____

servings (specify for each food group).

· Achieve ____ hours of uninterrupted sleep daily.

· Maintain age-appropriate activity level.

Parents will

· Identify risk factors that may lead to disproportionate growth.

· State understanding of preventive measures to reduce risk of dis-

proportionate growth.


Appetite; Body Image; Child Development: Middle Childhood

Growth; Risk Control; Weight: Body Mass


Determine: Monitor weight and height weekly to evaluate progress.

Monitor temperature, activity levels, sleep patterns, and changes

in nutritional status. Monitor prescribed and over-the-counter med-

ications taken. Determine exposure to tobacco smoke and/or other

environmental contaminants. These assessment parameters will assist

in developing appropriate interventions.

Perform: Weigh and measure the child weekly to evaluate progress.

Review growth-chart curve to compare with growth history.


Establish meal program that meets the child’s nutritional needs.

Establish routine sleep schedule for the child. Help child keep a

chart to encourage increased levels of self-care.

List age-appropriate activities and exercises for the child to stimu-

late bone and muscle development and promote cardiovascular health.

Administer prescribed drugs and treatments as ordered. Ensure

that the child and parents understand the intended action and side

effects that may occur to ensure that therapy can continue without


Provide an environment that is conducive to promote changes the

child must make. Environment can be a powerful motivator.

Inform: Educate child and parents on nutritional requirements for

child’s age and gender. Discuss meals available to the child at home

to promote growth.

Teach child and parents about risk factors associated with dispro-

portionate growth, such as poor nutrition, lack of regular sleep,

environmental hazards, or lack of age-appropriate activities. Help to

identify preventive measures to be taken in the home to promote

continuity of care.

Attend: Encourage healthy, loving interactions between child and

other family members. Demonstrate healthy and positive interactions

with the child. Disproportionate growth may be associated with

emotional deprivation.

Encourage child and parents to express feelings about present

state of child’s health. Listen attentively with understanding about

the self-esteem associated with what is considered by peers to be

other than normal. Parents will need help in supporting the child

through difficulties coping with normal peers.

Manage: If a medical or psychiatric illness places child at risk for dis-

proportionate growth, make sure child gets adequate follow-up med-

ical care and ensure that the care is appropriate and professional.

This will ensure the child’s right to receive remedial and educational

care in accordance with his disability, as guaranteed by federal law.

If financial hardship interferes with the family’s ability to provide

for child with disproportionate growth, offer a referral to a social

worker to improve the family’s access to community resources.


Active Listening; Behavior Modification; Coping Enhancement;

Counseling; Nutritional Management; Patient Contracting; Weight



Gregory, K. (2005, January–February). Update on nutrition for pre-term and

full term infants. Journal of Obstetric, Gynecology, and Neonatal Nursing,

34(1), 98–108.




Deviations from age-group norms


• Altered physical growth

• Delay or difficulty in performing motor, social, or expressive skills

typical of age group

• Flat affect

• Listlessness and decreased response

• Inability to perform self-care activities or maintain self-control at

age-appropriate level


• Effect of physical disability

• Multiple caretakers

• Environmental deficiencies

• Prescribed dependence

• Inadequate caretaking

• Separation from significant

• Inconsistent responsiveness


• Indifference

• Stimulation deficiencies

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity

• Family roles and responsibilities

• Cardiac function

• Nutrition

• Communication

• Sleep


The child will

• Demonstrate skills appropriate for age.

• Participate in developmental stimulation program to increase skill


The parents will

• Express understanding of norms for growth and development.

• Use community resources to promote child’s development.

• Provide play activities to promote child’s development.


Child Development: Middle Childhood; Growth; Physical

Maturation: Female; Physical Maturation: Male


Determine: Monitor weight and height weekly. Monitor nutritional

intake, activity level, and sleep patterns. Documentation of these

factors will help measure progress over time.

Assess cardiac functioning and respiratory status to ensure that

child is healthy enough to participate in activities.

Assess child’s motor skills, communication patterns, social skills, and

cognitive abilities to evaluate where skill development may be needed.

Assess support systems available to child and parents. Where there

are gaps, other sources of support may need to be put in place.


Perform: Establish a meal program to promote nutritional needs.

Weigh and measure child weekly and review growth-chart curve to

monitor progress.

Establish a routine sleep schedule for child to ensure that the

child is healthy enough to participate in an activity.

List age-appropriate activities and exercises to stimulate bone and

muscle development and promote cardiovascular health. Provide

appropriate play activities, such as building blocks, dolls, crayons,

or games to promote development.

Administer prescribed drugs and treatments as ordered. Ensure

parents and child understand intended action and possible side effects

to ensure therapy will continue as planned.

Provide an environment that is conducive to promote changes the

child must make. Environment can be a powerful motivator.

Inform: Provide parents with information about the causes of

delayed growth and development. Provide written information to

help them know what they can expect as a result of treatment.

Discuss age appropriate nutritional requirements with parents and

child and teach additional risk factors associated with delayed

growth (e.g., lack of regular sleep, environmental hazards). Teach

appropriate activities and encourage frequent play with child. These

measures promote continuity of care.

Attend: Five child positive reinforcement for demonstrating appropri-

ate skills and behavior and encourage parents to do the same to

encourage the child to continue developing skills.

Encourage child and parents to express feelings about present

state of child’s health. Listen attentively with understanding about

the self-esteem associated with what is considered by peers to be

other than normal. Parents need to be encouraged first to accept the

child as he is and then encourage the child to develop new skills

Development can occur only when parents and staff are both realis-

tic about the child’s present stage of development.

Manage: Provide parents with referrals to appropriate community

resources, including sources for financial assistance, child care, and

suppliers of adaptive equipment, to ensure the child’s right to receive

remedial and educational support in accordance with the disability,

as guaranteed by federal law.


Developmental Enhancement: Child; Health Screening; Nutrition

Management; Risk Identification; Self-Responsibility Facilitation


Wagner, J., et al. (2006, September–October). Nurses’ utilization of parent

questionnaires for developmental screening. Pediatric Nursing, 32(5),

Nursing diagnosis – GRIEVING



A normal complex process that includes emotional, physical, spiri-

tual, social, and intellectual responses and behaviors by which indi-

viduals, families, and communities incorporate an actual,

anticipated, or perceived loss into their daily lives


• Altered communication patterns

• Change in eating, sleep and dream patterns, activity level, or libido

• Denial of potential loss of life

• Difficulty taking on different roles

• Expressed guilt, anger, sorrow, and bargaining

• Expressions of distress over potential loss of life


• Anticipatory loss of significant object or other

• Death of a significant other

• Loss of significant object (e.g., possession, job, status)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Growth and Development

• Roles/relationships

• Risk management

• Behavior

• Emotional

• Communication

• Values/beliefs


The patient will

• Express and accept feelings about anticipated death.

• Progress through stages of grieving process in his or her own way.

• Practice religious rituals and use other coping mechanisms appro-

priate to end of life.

• Have participation of family members or significant other in pro-

viding supportive care and comfort to patient.


Coping; Family Coping; Grief Resolution; Psychosocial Adjustment:

Life Change


Determine: Assess stage of grieving to establish a baseline.

Perform: Demonstrate acceptance of patient’s response to his or her

anticipated death, whatever that response may be: crying, sadness,

anger, fear, or denial. Each patient responds to dying in his or her

own way. Helping patient express feelings freely will enhance ability

to cope.

Help patient progress through psychological stages associated with

anticipated death, including shock and denial, anger, bargaining,

depression, and acceptance, to help you anticipate the dying


patient’s psychological needs. Keep in mind, however, that not all

dying patients go through each stage.

Provide time for patient to express his or her feelings about death

or terminal illness. Active listening helps the patient lessen feelings

of loneliness and isolation. Refrain from approaching patient with a

busy, hurried attitude, which can block communication.

Establish a relationship that encourages patient to express

concerns about death. Basic nursing care combined with genuine

interest in the patient fosters trust and understanding.

Guide patient in life review. Encourage patient to write or tape-

record his or her life history as a lasting gift to family members.

Life review allows patient to survey events from his or her past and

give them meaningful interpretation.

Inform: Inform patient about hospice services that emphasize symp-

tomatic relief and caring, with the aim of improving patient and

family comfort until death occurs, instead of prolonging life for its

own sake. Hospice care is an appropriate alternative for a patient

with an incurable illness.

Attend: Encourage family members to become involved in the care

of the dying patient. Communicate with patient and family members

honestly and compassionately. Giving family members a role in

patient care helps relieve anxiety and lessen feelings of regret and

guilt. Honest communication is important because family members

need an opportunity to acknowledge their loss and say farewell.

Support patient’s spiritual coping behaviors. For example, arrange

for patient to have objects that provide spiritual comfort (such as a

copy of Bible, prayer shawl, pictures, statues, or rosary beads) at the

bedside. Even patients for whom religious practice hasn’t been a

dominant part of life may turn to religion when confronted by

death or serious illness.

Manage: Involve an interdisciplinary team (including a psychologist,

nurse, the patient, a nutritionist, physician, physical therapist, and

chaplain) in providing care for a dying patient. Each team member

offers unique expertise for meeting the dying patient’s needs.

Provide referrals for home healthcare assistance if the patient will be

cared for at home to support the patient’s decision to remain at home.


Anticipatory Guidance; Coping Enhancement; Family Support; Grief

Work Facilitation


Zimmerman, C., & Wennberg, R. (2006, August–September). Integrating pal-

liative care: A postmodern perspective. The American Journal of Hospice
and Palliative Care, 23(4), 255–258.

Nursing diagnosis – IMPAIRED GAS EXCHANGE



Excess or deficit in oxygenation and/or carbon dioxide elimination

at the alveolar-capillary membrane


• Abnormal pH and arterial

• Headache upon awakening

blood gases levels

• Hypoxia and hypoxemia

• Abnormal respiratory rate,

• Increased or decreased carbon

rhythm, and depth

dioxide levels

• Confusion

• Irritability/Restlessness

• Cyanosis

• Nasal flaring

• Diaphoresis

• Pale, dusky skin

• Dyspnea

• Tachycardia


• Alveolar-capillary membrane changes

• Ventilation–perfusion changes

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition

• Cardiac function

• Respiratory function


The patient will

• Carry out ADLs without weakness or fatigue.

• Maintain normal Hb and HCT levels.

• Express feelings of comfort in maintaining air exchange.

• Cough effectively and expectorate sputum.

• Be free from adventitious breath sounds.

• Perform relaxation techniques every 4 hr.

• Use correct bronchial hygiene.


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



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

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

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

early signs of respiratory failure.

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

changes in gas exchange.

Report signs of fluid overload or dehydration immediately. This

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

Perform: Elevate head 30 to facilitate lung expansion and prevent

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

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

postural drainage, and suctioning) to promote drainage and keep

airways clear. Administer bronchodilators, antibiotics, and steroids,

as ordered.

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

decreased or adventitious breath sounds.

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

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

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

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

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

falling. Move patient slowly to avoid hypostatic hypotension. Post

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

Inform: Teach and demonstrate correct breathing and coughing tech-

niques such as diaphragmatic or abdominal breathing and have

patient return demonstration to ensure patient understands proper

technique and promote effective coughing and deep breathing.

Teach patient correct way of using inhalers. Remind patient about

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

ing can cause candidiasis in the throat.

Review all medications with patient and family and list side

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

reports them to the physician.

Encourage relaxation techniques to reduce oxygen demand.

Attend: Encourage patient to express feelings. Attentive listening

helps build a trusting relationship.

Encourage family members to stay with the patient, especially

during times of anxiety to promote relaxation which reduces oxygen


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

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

Refer patient to community resources and offer written informa-

tion that can be referred to when needed.


Acid–Base Management; Airway Management; Airway suctioning;

Anxiety Reduction; Energy Management; Exercise Promotion; Fluid



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

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

Nursing diagnosis – EXCESS FLUID VOLUME



Increased isotonic fluid retention


• Altered mental status or respiratory pattern

• Anasarca

• Azotemia

• Changes in blood pressure, pulmonary artery pressure, urine

specific gravity, and electrolyte levels

• Crackles

• Decreased Hb and HCT levels

• Dyspnea

• Edema

• Increased central venous pressure (CVP)

• Intake greater than output

• Jugular vein distention

• Oliguria

• Orthopnea

• Pleural effusion

• Positive hepatojugular reflex

• Pulmonary congestion

• Rapid weight gain

• Restlessness and anxiety

• S3 heart sound


• Compromised regulatory mechanism

• Excess fluid intake

• Excess sodium intake

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Neurocognition

• Elimination

• Nutrition

• Fluid and electrolytes

• Respiratory function


The patient will

• State ability to breathe comfortably.

• Maintain fluid intake at ___ ml/day.

• Return to baseline weight.

• Maintain vital signs within normal limits (specify).

• Exhibit urine specific gravity of 1.005–1.010.

• Have normal skin turgor.

• Show electrolyte level within normal range (specify).

• Avoid complications of excess fluid.



Electrolyte Balance; Fluid Balance; Fluid Overload Severity; Kidney

Function; Nutritional Status: Food & Fluid Intake


Determine: Monitor and record vital signs at least every 4 hr.

Changes may indicate fluid or electrolyte imbalances. Measure and

record intake and output. Intake greater than output may indicate

fluid retention and possible overload.

Weigh patient at same time each day to obtain consistent

readings. Test urine specific gravity every 8 hr and record results.

Monitor laboratory values and report significant changes to

physician. High specific gravity indicates fluid retention. Fluid over-

load may alter electrolyte levels.

Assess patient daily for edema, including ascites and dependent or

sacral edema. Fluid overload or decreased osmotic pressure may

result in edema, especially in dependent areas.

Perform: Help patient into a position that aids breathing, such as

Fowler’s or semi-Fowler’s, to increase chest expansion and improve


Administer oxygen, as ordered, to enhance arterial blood oxygena-

tion. Restrict fluids to ____ ml per shift. Excessive fluids will worsen

patient’s condition.

Administer diuretics to promote fluid excretion. Record effects.

Maintain patient on sodium-restricted diet, as ordered, to reduce

excess fluid and prevent reaccumulation.

Reposition patient every 2 hr, inspect skin for redness with each

turn, and institute measures as needed to prevent skin breakdown.

Apply antiembolism stockings or intermittent pneumatic compres-

sion stockings to increase venous return. Remove for 1 hr every

8 hr or according to facility policy.

Inform: Educate patient regarding maintenance of daily weight

record, daily measuring and recording of intake and output, diuretic

therapy, and dietary restrictions, especially sodium. These measures

encourage patient and caregivers to participate more fully.

Attend: Encourage patient to cough and deep breathe every 2–4 hr

to prevent pulmonary complications.


Electrolyte Management; Fluid Management; Fluid Monitoring;

Nutrition Management


Bennett, S. J., et al. (2005, December). Medication and dietary compliance

beliefs in heart failure. Western Journal of Nursing Research, 27(8),

Nursing diagnosis – DEFICIENT FLUID VOLUME



Decreased intravascular, interstitial, or intracellular fluid; water loss

alone without change in sodium


• Changes in mental status

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


• Dry skin and mucous membranes

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


• Low blood pressure

• Poor turgor of skin or tongue

• Sudden weight loss

• Thirst

• Weakness


• Active fluid volume loss

• Failure of regulatory mechanisms

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Physical regulation


The patient will

• Maintain stable vital signs.

• Have normal skin color.

• Have electrolyte levels within normal range.

• Maintain an adequate fluid volume.

• Maintain an adequate urine volume.

• Have normal skin turgor and moist mucous membranes.

• Have a urine specific gravity between 1.005 and 1.010.

• Have normal fluid and blood volume.

• Express understanding of factors that caused fluid volume deficit.


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

tional Status: Food & Fluid Intake


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

necessary until stable. Then monitor and record vital signs every

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

volume deficit or electrolyte imbalance.

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

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


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

Low urine output and high specific gravity indicate hypovolemia.

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

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

Assess skin turgor and oral mucous membranes every 8 hr to

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

avoid dehydrating mucous membranes.

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

indicate dehydration.

Measure abdominal girth every shift to monitor for ascites and

third-space shift. Report changes.

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

lation, blood pooling in extremities, and reduced circulating blood


Administer fluids, blood or blood products, or plasma expanders

to replace fluids and whole blood loss and facilitate fluid movement

into intravascular space. Monitor and record effectiveness and any

adverse effects.

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

tion is compromised to avoid orthostatic hypotension and possible


Administer and monitor medications to prevent further fluid loss.

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

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

measuring intake and output. This encourages patient involvement

in personal care.


Acid–Base Management; Electrolyte Monitoring; Fluid Management;

Hypovolemia Management


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

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





A pattern of equilibrium between fluid volume and chemical compo-

sition of body fluids that is sufficient for meeting physical needs and

can be strengthened


• Verbalization of willingness to enhance fluid balance

• Stable weight

• Moist mucous membranes

• Food and fluid intake adequate for daily needs

• Straw-colored urine with specific gravity within normal limits

• Good tissue turgor

• No excessive thirst

• Urine output appropriate for intake

• No evidence of edema or dehydration

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Cardiac function

• Neurocognition

• Elimination

• Respiratory function


The patient will

• Have stable vital signs within normal ranges; electrocardiograph

shows no abnormality in rhythm.

• Have normal skin temperature, moistness, turgor, and color.

• Have moist and noncracked mucous membranes.

• Have stable weight.

• Have adequate fluid volume intake and thirst satiety.

• Produce adequate urine volume (approximately equal to fluid

intake) of light to straw-colored urine.

• Maintain a urine specific gravity between 1.015 and 1.025.

• Have normal values for plasma and serum for electrolytes, osmo-

larity, glucose, blood urea nitrogen, hematocrit (HCT), and hemo-
globin (Hb).

• Be alert and respond to demands of living; react appropriately to

reflex needs (i.e., thirst); have normal muscle reflexes, strength,
and tone.

• Express understanding of factors that contribute to normal fluid

and electrolyte balance.

• Adhere to prescribed therapies to manage such coexisting disease



Fluid Balance; Hydration; Nutritional Status: Food & Fluid Intake;

Tissue Integrity: Skin & Mucous Membranes; Vital Signs



Determine: Assess usual fluid intake and desire to improve fluid sta-

tus to establish a baseline.

Inform: Teach patient to read and interpret labels on beverage and

food containers. For example, humans require 0.5 g (500 mg) of

sodium per day; typical intake is 5–6 g daily. Reducing the amount

of sodium reduces the amount of fluid volume in the vascular


Encourage adequate water intake (1,200–2,000 ml) during

exercise or high environmental temperatures; unmeasured fluid losses

through diaphoresis and lung evaporation can be significant.

Teach signs and symptoms of dehydration (dry mouth and

mucous membranes), light-headedness (blood pressure and vital sign

changes), scant urine output (glycosuria and polyuria), and over-

hydration (cough, increased weight gain, dependent edema, and

jugular vein distention). Teaching prevents severe complications.

Attend: Encourage patient to select healthy beverages such as water

and limit beverages such as soda or sports drinks that have high

sugar content (which increase the osmolar content of the body, caus-

ing greater thirst and increased load on the renal system and diuresis)

and caffeine (which causes diuresis and may cause an increased fluid

loss), alcoholic beverages during hot weather because these can

cause fluid and electrolyte disturbances through excess diuresis.


Electrolyte Management; Fluid/Electrolyte Management; Fluid Man-

agement; Fluid Monitoring


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

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

Nursing diagnosis – FEAR



Response to a perceived threat that is consciously recognized as a



• Behaviors involving aggression, avoidance, impulsivness, increased

alertness, and narrowed focus of the source of fear

• Cognitive effects such as decreased self-assurance, productivity, and

ability to problem solve

• Feelings of alarm, apprehension, increased tension, panic, and terror

• Physiological changes including increased heart rate, respiration

rate, perspiration, and/or blood pressure; anorexia, nausea, vomit-
ing, diarrhea, muscle tightness, fatigue, and shortness of breath
and pallor


• Language barrier

• Separation from support

• Learned response


• Phobic stimulus

• Unfamiliarity with

• Sensory impairment

environmental experience

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Risk management

• Coping

• Sleep/rest

• Physical regulation


The patient will

• Identify source of fear.

• Communicate feelings about separation from support systems.

• Communicate feelings of comfort or satisfaction.

• Use situational supports to reduce fear.

• Integrate into daily behavior at least one fear-reducing coping

mechanism, such as asking questions about treatment progress or
making decisions about care.


Anxiety Control; Comfort Level; Coping; Fear Control; Pain Level


Determine: Ask patient to identify source of fear; assess patient’s

understanding of situation. Perceptions may be erroneously based.

Perform: Help patient maintain daily contact with family: Arrange

for telephone calls; help write letters; promptly convey messages to

patient from family and vice versa; encourage patient to have

pictures of loved ones; provide privacy for visits; take patient to day

room or other quiet area. These measures help patient reestablish

and maintain social relationships.

Involve patient in planning care and setting goals to renew confi-

dence and give a sense of control in a crisis situation. If patient has

no visitors, spend an extra 15 min each shift in casual conversation;

encourage other staff members to stop for brief visits. These meas-

ures help patient cope with separation.

Administer antianxiety medications, as ordered, and monitor effec-

tiveness. Drug therapy may be needed to manage high anxiety levels

or panic disorders.

Inform: Instruct patient in relaxation techniques such as imagery and

progressive muscle relaxation to reduce symptoms of sympathetic


Answer questions and help patient understand care to reduce anx-

iety and correct misconceptions.

Attend: When feasible and where policies permit, relax visiting

restrictions to reduce patient’s sense of isolation.

Allow a close family member or friend to participate in care to

provide an additional source of support.

Support family and friends in their efforts to understand patient’s

fear and to respond accordingly to help them understand that

patient’s emotions are appropriate in context of situation.

Manage: Refer patient to community or professional mental health

resources to provide assistance.


Active Listening; Anxiety Reduction; Cognitive Restructuring; Coun-

seling; Coping Enhancement; Decision-Making Support; Security

Enhancement; Presence; Support Group


Cookman, C. (2005, June). Attachment in older adulthood: Concept clarifica-

tion. Journal of Advanced Nursing, 50(5), 528–535.

Nursing diagnosis – FATIGUE



An overwhelming sustained sense of exhaustion and decreased

capacity for physical and mental work at usual level


• Decreased libido or performance

• Disinterest in surroundings

• Drowsiness

• Failure of sleep to restore energy

• Lack of energy

• Guilt for not meeting responsibilities

• Inability to maintain usual routines

• Impaired concentration

• Increased need for rest

• Increased physical complaints

• Lethargy or listlessness

• Perceived need for more energy for routine tasks

• Verbalization of overwhelming lack of energy


• Psychological, e.g., anxiety,

• Environmental, e.g., humidity,

depression, stress

lights, noise, temperature

• Physiological, e.g., anemia, dis-

• Situational, e.g., negative life

ease states, malnutrition, preg-
nancy, poor physical condition

events, occupation

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Reproduction

• Cardiovascular function

• Respiratory function

• Coping

• Risk management

• Neurocognition

• Sleep/rest

• Nutrition


The patient will

• Identify and employ measures to prevent or modify fatigue.

• Explain relationship of fatigue to disease process and activity level.

• Verbally express increased energy.

• Articulate plan to resolve fatigue problems.


Activity Tolerance; Endurance; Energy Conservation; Nutritional Sta-

tus: Energy; Psychomotor Energy; Personal Well-Being


Determine: Assess usual patterns of sleep and activity to establish a



Perform: Conserve energy through rest, planning, and setting priori-

ties to prevent or alleviate fatigue. Alternate activities with periods

of rest. Avoid scheduling two energy-draining procedures on the

same day. Encourage activities that can be completed in short peri-

ods. These measures help to avoid overexertion and increase stamina.

Reduce demands placed on patient (e.g., ask one family member

to call at specified times and relay messages to friends and other

family members) to reduce physical and emotional stress.

Structure environment (e.g., set up daily schedule on the basis of

patient needs and desires) to encourage compliance with treatment


Postpone eating when patient is fatigued, to avoid aggravating

condition. Provide small, frequent feedings to conserve patient’s

energy and encourage increased dietary intake.

Establish a regular sleeping pattern. Getting 8–10 hr of sleep

nightly helps reduce fatigue.

Inform: Discuss effect of fatigue on daily living and personal goals.

Explore with patient relationship between fatigue and disease

process to help increase patient compliance with schedule for activ-

ity and rest.

Attend: Encourage patient to eat foods rich in iron and minerals,

unless contraindicated to help avoid anemia and demineralization.

Manage: Encourage patient to explore feelings and emotions with a

supportive counselor, clergy, or other professional to help cope with

illness and avoid aggravating fatigue.


Activity Therapy; Coping Enhancement; Energy Management;

Exercise Promotion; Sleep Enhancement


Barsevick, A. M., et al. (2006, September–October). Cancer-related fatigue,

depressive symptoms, and functional status: A mediation model. Nursing
Research, 55(5), 366–372.