Nursing diagnosis – READINESS FOR ENHANCED FAMILY PROCESSES

READINESS  FOR  ENHANCED

FAMILY  PROCESSES

DEFINITION

A pattern of family functioning that is sufficient to support the well-

being of family members and can be strengthened

DEFINING CHARACTERISTICS

• Activities support the growth of family members

• Activities support the safety of family members

• Balance exists between autonomy and cohesiveness

• Boundaries of family members are maintained

• Energy level of family supports ADLs

• Family adapts to change

• Relationships are generally positive

• Respect for family members is positive

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Roles/relationship

• Coping

• Communication

• Values/beliefs

EXPECTED OUTCOMES

Family members will

• Identify family goals and structured directions.

• Express enjoyment and satisfaction with their roles in the family.

• Express a willingness to enhance roles in family dynamics.

• Participate regularly in traditional family activities.

• Maintain open and positive communication.

• Maintain a safe home environment.

• Seek regular health screenings and immunizations.

• Identify and acknowledge family risk factors.

• Make plans to deal with life changes and events.

SUGGESTED NOC OUTCOMES

Family Coping; Family Functioning; Family Health Status; Family

Integrity; Family Normalization; Family Social Climate

INTERVENTIONS AND RATIONALES

Determine: Assess family composition, roles within the family,

communication patterns, family developmental stages, developmen-

tal tasks, health patterns, coping mechanisms, socioeconomics,

educational levels, ethnicity, and cultural and religious beliefs.

Assessment information helps identify appropriate interventions.

Perform: Establish an environment in which family members can

openly share their issues and concerns in comfort to reduce anxiety

and develop their ability to resolve problems.

Inform: Explain importance of setting goals as a method of estab-

lishing boundaries that will be respected by all family members.

Family functioning with structural direction will enhance the poten-

tial to meet physical, social, and psychological needs.

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Show family how to develop a Genogram to identify genetic risk

factors. Information from the Genogram will highlight things that

can modify a family’s health patterns, lead to early identification of

genetically related diseases, and may delay onset of disease.

Teach value of daily exercise, well-balanced diet, and use of

proven holistic strategies to improve health.

Provide family with information on recommended health screen-

ings and immunization schedules. It is essential to keep immuniza-

tions given according to schedule to prevent loss of immunity.

Attend: Encourage family members to identify individual and family

goals and a structured direction toward sound health habits for the

entire family. Developing a structured plan will assist in having

everyone work together toward goals set by the family for

themselves.

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

ity to participate encourages greater compliance with the plan.

Encourage family to spend time together enjoying traditional

activities that everyone likes doing to promote a healthy lifestyle and

encourage strong family unity.

Manage: Refer, where requested, for follow-up for a family member

who needs exercise, weight management, diet assistance, health

screenings, and so forth. Providing referrals will help to provide

continuity of care for the patient.

SUGGESTED NIC INTERVENTIONS

Family Support; Family Integrity Promotion; Family Maintenance

Reference

Yanaka, L., et al. (2007, January–February). Barriers to screening for domestic

violence in the emergency departments. Journal of Continuing Education in
Nursing, 38(1), 37–45.

Nursing diagnosis – INTERRUPTED FAMILY PROCESSES

INTERRUPTED  FAMILY  PROCESSES

DEFINITION

Change in family relationship or functioning

DEFINING CHARACTERISTICS

Changes in:

• Assigned tasks

• Availability for affective responses and/or emotional support

• Communication patterns

• Effectiveness in completing assigned tasks

• Expressions of conflict within family and/or community resources

• Expressions of isolation from community resources

• Intimacy

• Participation in problem solving and/or decision making

• Stress-reduction behaviors

RELATED FACTORS

• Developmental crises

• Modification in family finances

• Developmental transition

• Modification in family social

• Family role shift

status

• Interaction with community

• Situational transition

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Communication

• Emotional

• Coping

• Roles/relationship

EXPECTED OUTCOMES

Family members will

• Not experience physical, verbal, emotional, or sexual abuse.

• Communicate clearly, honestly, consistently, and directly.

• Establish clearly defined roles and equitable responsibilities.

• Express understanding of rules and expectations.

• Report the methods of problem solving and resolving conflicts

have improved.

• Report a decrease in the number and intensity of family crises.

• Seek ongoing treatment.

SUGGESTED NOC OUTCOMES

Family Coping; Family Functioning; Family Normalization; Social

Interaction Skills; Substance Addiction Consequences

INTERVENTION AND RATIONALES

Determine: Assess family’s developmental stage, roles, rules, socioeco-

nomic status, health history, history of substance abuse; history of sex-

ual abuse of spouse or children, problem-solving and decision-making

131

skills, and patterns of communication. Assessment information will

provide development of appropriate interventions.

Perform: Meet with family members to establish levels of authority

and responsibility in the family. Understanding the family dynamics

provides information about the kinds of support the family needs to

work with the patient’s issues.

Create an environment in which family members can express

themselves openly and honestly to build trust and self-esteem.

Establish rules for communication during meetings with the family

to assist family members to take responsibility for their own behavior.

Inform: Teach family members basic communication skills to enable

them to discuss issues in a positive way. Have them role-play with

one another numerous times to demonstrate what has been learned.

Involve the family in exercises to reduce stress and deal with

anger.

Attend: Hold adults accountable for their alcohol or substance abuse

and have them sign a “Use contract” to decrease denial, increase

trust, and promote positive change.

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

ity to participate will encourage greater compliance with the plan.

Assist family to set limits on abusive behaviors and have them

sign “Abuse contracts” to foster feelings of safety and trust.

Manage: Refer to case manager/social worker to ensure that a home

assessment is done.

Refer to support groups that deal with substance abuse, domestic

violence, or sexual abuse depending on the needs of the patient

and/or family to enhance interpersonal skills and strengthen the fam-

ily unit.

Provide all appropriate phone numbers so that the family

members can initiate whatever follow-up is needed.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Family Integrity Promotion; Family Process

Maintenance; Family Support; Normalization Promotion; Substance

Use Prevention; Substance Use Treatment

Reference

Yonaka, L., et al. (2007, January–February). Barriers to screening for domestic

violence in the emergency department. Journal of Continuing Education for
Nursing, 38(1), 37–45.

Nursing diagnosis – DYSFUNCTIONAL FAMILY PROCESSES ALCOHOLISM

DYSFUNCTIONAL  FAMILY  PROCESSES:

ALCOHOLISM

DEFINITION

Psychosocial, spiritual, and physiological functions of the family unit

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

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

of self-perpetuating crises

DEFINING CHARACTERISTICS

• Alcohol abuse; agitation; blaming; broken promises

• Deficient knowledge about alcoholism

• Denial of problems; difficulty with intimate relationships

• Enabling to maintain alcoholic drinking pattern

• Rationalization; moodiness; rejection; tension

• Triangulating family relationships

• Marital problems; ineffective spousal communication

RELATED FACTORS

• Abuse of alcohol

• Family history of alcoholism

• Addictive personality

• Family history of resistance to

• Biochemical influences

treatment

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Communication

• Emotional

• Knowledge

• Coping

• Self-perception

• Values and beliefs

EXPECTED OUTCOMES

Family members will

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

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

• Communicate their needs, using “I” statements.

• Discuss problems in an open, safe environment.

• Acknowledge their strengths and progress in resolving problems.

• State plans to continue to seek counseling and attend appropriate

support group meetings.

SUGGESTED NOC OUTCOMES

Family Coping; Family Functioning; Family Normalization; Role

Performance; Substance Abuse Consequences

INTERVENTIONS AND RATIONALES

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

of withdrawal; ability of alcoholic member to function in

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

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

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

fying appropriate interventions.

Perform: Create an environment in which family members feel free

to express themselves honestly about the present situation to

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decrease their anxiety and help family members develop confidence

in their ability to resolve problems.

Inform alcoholic family member that he will have to acknowledge

his alcoholism before progress can be made in rebuilding family

relations to establish abstinence as a basis for treatment.

Inform: Teach family members to communicate their needs

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

ings to help them get in touch with their feelings.

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

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

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

Do interactive planning and role-playing with the patient and

family to help them gain the skills needed to effect necessary

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

create a realistic view of the behaviors that reinforce behaviors in

themselves and the patient.

Attend: Encourage family members to acknowledge that alcoholism is

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

Ask alcoholic family member to sign a contract stating he will

abstain from alcohol to help him take responsibility for his own

behavior.

Help family members evaluate the consequences of abusive and vio-

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

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

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

Being able to identify strengths provides the confidence the family

needs to continue working toward a positive outcome for both

patient and family.

Assist family members to identify their strengths and talk about

progress they have made in resolving problems associated with alco-

holism or living with a family member who has alcoholism.

Provide additional emotional support to the head of the family

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

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

tinue the process of restructuring their lives.

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

port group to establish the importance of abstinence.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Family Process Maintenance; Family Support;

Substance Use Prevention; Substance Use Prevention

Reference

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

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

Nursing diagnosis – RISK FOR FALLS

RISK  FOR  FALLS

DEFINITION

Increasing susceptibility to falling that may cause physical harm

RISK FACTORS

Adult

• Patient verbalizes faintness

• Age   65 years

when extending neck

• Lives alone

• Difficulties with hearing or

• Environmental hazards (e.g.,

vision

cluttered environment; poor
lighting)

• Incontinence
Child

• Presence of lower limb pros-

• Age   2 years

thesis; use of assistive devices
for walking

• Environmental hazards (e.g.,
bed located near window, lack

• Has history of falls

of gate on stairs)

• Use of alcohol, diuretics, and

• Lack of parental supervision

tranquilizers

• Unattended infant on elevated

• Presence of anemias, diarrhea

surface (e.g., bed/changing table)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition

• Cardiac function

• Sensation/perception

• Knowledge

EXPECTED OUTCOMES

Patient and family will

• Identify factors that increase potential for falling.

• Assist in identifying and applying safety measures to prevent injury.

• Make necessary changes in the physical environment to ensure

safety for the patient.

• Develop long-term strategies to promote safety and prevent falls.

• Optimize patient’s ability to carry out ADLs within sensor motor

limitations.

SUGGESTED NOC OUTCOMES

Ambulation; Balance; Cognition; Neurological Status; Risk Control;

Sensory Function: Vision; Sensory Function: Hearing

INTERVENTIONS AND RATIONALES

Determine: For adults, assess severity of sensory or motor deficits;

environmental hazards, and inadequate lighting; medication use;

improper use of assistive devices.

For children, assess sensory or motor deficits, recent illnesses,

unsteady balance, running at speeds beyond capability, and

inadequate supervision. Assessment factors will help identify appro-

priate interventions.

Perform: For older adults, make necessary changes in environment

(i.e., remove throw rugs). Orient patient to environment. Post a

127

notice that the patient is at risk for falling. Place side rails up and

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

within the patient’s reach. These measures prevent injury to patient.

For children, make necessary changes in environment (i.e., apply

window guards); keep toys and other objects from lying around on

the floor; use a gate when necessary to keep the child in a confined

area; provide adequate supervision to prevent injury to the patient.

Inform: Provide family with a list of all the things they need to do

to prevent the patient from falling. Go over each item and explain

the reason for each cautionary measure. Written instructions will

reinforce the need for prevention.

Teach patient with an unstable gait how to use assistive devices

properly. Improper use of assistive devices can put the patient at

greater risk of falling.

Teach patient and family about the use of safe lighting. Advise

patients to wear sunglasses to reduce glare. Proper lighting is always

considered as a preventive measure.

Teach patient about medications that have been prescribed for

him or her. Overmedication in older adults is one of the major risk

factors in falls. Understanding on the part of the patient and family

can reduce the incidence of falls in the home.

Attend: Ask frequently during hospitalization whether patient and

family have questions about the modifications needed to prevent

falls. Listen carefully to statement or ideas the patient and/or family

may present about potential for falls in their individual home

settings. Greater awareness on the part of both patient and family

can markedly reduce the risk of falls.

Encourage adult patient to express feelings about the fear of falling.

Being able to express the fear will raise the nurse’s awareness of

what the patient considers problem areas.

Manage: Arrange for social service/case manager to make a home

visit to help prepare the family for the patient’s return to a safe

environment.

Refer patient and family to community resources that may offer

assistance to the patient when needed.

Refer to home health nurse for a follow-up visit in the home.

SUGGESTED NIC INTERVENTIONS

Environmental Management; Exercise Therapy: Balance; Fall Preven-

tion; Medication Management; Teaching

Reference

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

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

Nursing diagnosis – ADULT FAILURE TO THRIVE

ADULT  FAILURE  TO  THRIVE

DEFINITION

Progressive functional deterioration of a physical and cognitive

nature. The individual’s ability to live with multisystem diseases,

cope with ensuing problems, and manage his/her care are remarkably

diminished

DEFINING CHARACTERISTICS

• Cognitive decline, as evidenced by problems with responding

appropriately to environmental stimuli and decreased
perception

• Consumption of limited to no food at most meals (i.e., consumes

less than 75% of normal replacements); weight loss

• Decreased participation in ADLs that were once enjoyed

• Decreased social skills or social withdrawal

• Difficulty performing simple self-care tasks

• Frequent exacerbations of chronic health problems, such as pneu-

monia or urinary tract problems

• Neglect of home environment or financial responsibilities

• Adequate elimination pattern for age

RELATED FACTOR

• Depression

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Knowledge

• Nutrition

• Coping

• Sleep patterns

• Emotional

• Values and beliefs

EXPECTED OUTCOMES

The patient will

• Express understanding of causes of failure to thrive.

• Express realization that he or she is depressed.

• Consume sufficient amounts of food and nutrients.

• Sleep for ___ hours without interruption.

• Gain weight.

• Verbalize feelings of safety.

• Follow up with psychiatric evaluation/social service assistance.

SUGGESTED NOC OUTCOMES

Nutritional Status: Physical Aging Status; Psychosocial Adjustment:

Life Change; Will to Live

INTERVENTIONS AND RATIONALES

Determine: Assess daily food intake; meal preparation; sleep

patterns; mobility status; education, activity, and exercise;

religious affiliation; involvement in social activities; and access to

transportation. Assessment factors will help identify appropriate

interventions.

125
Monitor fluids and electrolytes. Imbalance can be life-threatening.

Perform: Record daily weights at the same time each day to provide

consistent information.

Report abnormal electrolyte levels to ensure that therapy will

reverse and levels will not deteriorate.

Monitor fluid intake and output every 8 hr to ensure that fluids

are balanced. Imbalance can lead to heart failure or dehydration.

Record amount of food consumed and supplements given to

patient to ensure that the patient is getting sufficient nutrition.

Plan activities and exercise consistent with patient’s capabilities. It

is important that the patient be able to enjoy activity. Overexertion

can lead to cardiac problems.

Arrange for social interaction with other patients. Arrange for the

nurse to spend several short periods of uninterrupted time with the

patient each day to instill trust and a sense of caring.

Teach caregiver how to make meals that may be appetizing to the

patient. Encourage caregiver to record food consumed by patient.

Appetizing foods may help motivate the patient to eat when he or

she claims not to be hungry.

Attend: Create a pleasant mealtime environment for patient. Provide

unlimited access to nourishing foods and nutritional supplements.

Attempt to accommodate ethnic food preferences. This will encour-

age patient when he or she is hungry rather than when food is put

in front of him or her.

Encourage family members and caregivers to establish a plan for

addressing patient’s failure to thrive in order to take responsibility

for meeting the patient’s needs to the extent they are able.

Encourage patient to participate in active exercise during the day

to the extent he or she is able. Exercise is essential to a feeling of

well-being.

Manage: Refer patient and family to appropriate agencies in the

community such a meal programs, senior support/activities groups,

and so forth. This kind of follow-up will ensure that the plan has a

chance of succeeding.

Refer patient and family to social services for appropriate resources.
Refer to clergy person for spiritual help if patient wishes.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Home Maintenance Assistance; Nutritional

Monitoring; Spiritual Support

Reference

Lennie, T. A. (2006, March–April). Factors influencing food intake in patients

with heart failure: A comparison with healthy elders. The Journal of Car-
diovascular Nursing, 21(2), 123–129.

Nursing diagnosis – IMPAIRED ENVIRONMENTAL INTERPRETATION SYNDROME

IMPAIRED  ENVIRONMENTAL

INTERPRETATION  SYNDROME

DEFINITION

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

circumstances over more than 3 to 6 months necessitating a

protective environment

DEFINING CHARACTERISTICS

• Chronic confusion

• Consistent state of disorientation to environment

• Inability to reason, concentrate, or follow simple instructions

• Loss of occupation or social function resulting from memory decline

• Slow response to questions

RELATED FACTORS

• Dementia

• Depression

• Huntington’s disease

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Knowledge

• Communication

• Sensory perception

EXPECTED OUTCOMES

The patient will

• Acknowledge and respond to efforts by others to establish

communication.

• Identify physical changes without making disparaging comments.

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

• Remain free from injuries.

The caregiver will

• Describe measures for helping the patient cope with disorientation.

• Demonstrate reorientation techniques.

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

• Identify and contact appropriate support services for the patient.

SUGGESTED NOC OUTCOMES

Cognitive Orientation; Concentration; Fall-Prevention Behavior;

Memory; Safe Home Environment

INTERVENTIONS AND RATIONALES

Determine: Assess cultural status, functional ability and coordination,

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

hearing deficits. Assessment of these factors will help in identifying

appropriate interventions.

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

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

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

same place. Consistency and continuity will reduce confusion and

decrease frustration.

123
Place patient in a room near the nurse’s station to provide imme-

diate assistance from staff, if needed.

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

patient who wanders to prevent injury.

Work with patient and caregivers to establish goals for coping

with disorientation. Practice with coping skills can prevent fear.

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

to foster trust and communication.

Promote independence while performing ADL measures patient is

unable to perform to reduce feelings of dependence.

Inform: Provide written information to caregivers on reorientation

techniques. Demonstrate reorientation techniques to caregiver to

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

home.

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

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

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

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

order to inspire confidence in the caregiver.

Help patient and caregivers cope with feelings associated with the

disease. Understanding promotes affective coping.

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

tolerated to assist patient to regain independence and enhance self-

esteem. Provide reassurance and praise for completing simple tasks.

Focus on patient’s strengths.

Involve caregiver and patient in planning and decision making as

a cooperative effort supports patient’s needs.

Encourage patient to engage in social activities with people of

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

isolation.

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

that patient receives longer term assistance to ensure continued

care.

Refer caregiver to a support group. Caregivers need continuous

support from others to cope with the need to provide constant

supervision to the patient.

SUGGESTED NIC INTERVENTIONS

Anxiety Reduction; Behavior Management; Dementia Management;

Emotional Support; Mood Management; Reality Orientation

Reference

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

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

Nursing diagnosis – DISTURBED ENERGY FIELD

DISTURBED  ENERGY  FIELD

Disruption of the flow of energy surrounding a person’s being that

results in disharmony of body, mind, and/or spirit

DEFINING CHARACTERISTICS

Perceptions of changes in patterns of energy flow, such as changes in

• Hearing (tones, words).

• Perception of movement (wave spike, tingling, dense, flowing).

• Temperature.

• Sight (image, color).

RELATED FACTORS

Factors secondary to the slowing or blocking of energy flows may

be as follows:

• Maturational (age-related devel-

• Situational (anxiety, fear, griev-

opmental crisis and/or develop-
mental [mental] difficulties)

ing, and pain)
• Treatment-related (chemother-

• Pathophysiologic (illness,

apy, immobility, labor & deliv-

injury, and pregnancy)

ery, perioperative experience)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Emotional status

• Coping

• Sensation/perception

EXPECTED OUTCOMES

The patient will

• Feel increasingly relaxed by slower and deeper breathing, skin

flushing in treated area, audible sighing, or verbal reports of feel-
ing more relaxed.

• Visualize images that relax him.

• Report feeling less tension or pain.

• Use self-healing techniques such as meditation, guided imagery,

yoga, and prayer.

SUGGESTED NOC OUTCOMES

Comfort Level; Health Beliefs; Personal Health Status; Personal

Well-Being; Spiritual Health

INTERVENTIONS AND RATIONALES

Determine: Assess how much support patient desires. Evaluate the

presence of a disorder that is life threatening or requires surgery.

Monitor levels of pain and disorders that may affect the senses.

Assess patient’s spiritual needs, including religious beliefs and affilia-

tion. Assessment of these areas will help to identify appropriate

interventions.

Perform: Implement measures to promote therapeutic healing. Place

your hands 4   to 6   above the patient’s body. Pass hands over the

entire skin surface to become intoned to the patient’s energy fields,

which is the flow of energy that surrounds the human being. Identify

121

areas where there is energy disturbance considering cues such as

cold, heat, tingling, and electric sensation. This technique helps you

become attuned to patient’s energy field, the flow of energy that sur-

rounds a person’s being.

Administer medication as ordered to relieve pain.
Turn and reposition patient at least every 2 hr. Establish a turning

schedule for the dependent patient. Post schedule at bedside and

monitor frequency. Turning and repositioning prevent skin

breakdown, improve lung expansion, and prevent atelectasis.

Provide comfort measures such as bathing, massage, regulation of

environmental temperature, and mouth care, according to the

patient’s preferences. Comfort measures done for and with the

patient reduce anxiety and promote feelings of well-being.

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

(e.g., meditation, guided imagery, yoga, and prayer). Teach patient

how to incorporate the use of self-healing techniques in carrying out

usual daily activities. It will take repeated use of strategies to induce

a spirit of well-being.

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

that maximizes his or her comfort. Caregivers may need assistance

with techniques. Lack of skill can cause the patient unnecessary

pain.

Attend: Encourage patient’s cooperation as you continue with heal-

ing techniques, such as therapeutic touch. Listen for evidence of

effectiveness of treatment by patient’s statements about reduction in

tension or pain. One treatment rarely restores a full sense of well-

being.

Manage: Refer to mental health specialist or other community agen-

cies as needed. It is important for patient to have ongoing support.

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

Therapeutic Touch; Discharge Planning; Anxiety Reduction; Pain

Management

Reference

Robb, W. J. (2006, April–June). Self-healing: A concept analysis. Nursing

Forum, 41(2), 60–77.

Nursing diagnosis – RISK FOR ELECTROLYTE IMBALANCE

RISK  FOR  ELECTROLYTE  IMBALANCE

DEFINITION

At risk for change in serum electrolyte levels that may compromise

health

RISK FACTORS

• Fluid imbalance (e.g., dehydra-

• Renal dysfunction

tion, water intoxication)

• Endocrine dysfunction

• Treatment-related side effects

• Impaired regulatory mechanisms

(e.g., medications, drains)

(e.g., diabetes insipidus, syn-

• Diarrhea

drome of inappropriate

• Vomiting

antiduretic hormone (SIADH))

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Maintain electrolyte levels within the normal limits.

• Maintain adequate fluid balance consistent with underlying disease

restrictions.

• Identify health situations that increase risk for electrolyte

imbalance and verbalize interventions to promote balance.

• Verbalize signs and symptoms that require immediate intervention

by healthcare provider.

• Remain safe from injury associated with electrolyte imbalance.

SUGGESTED NOC OUTCOMES

Electrolyte & Acid–Base Balance, Fluid Balance

INTERVENTIONS AND RATIONALES

Determine: Assess patient’s fluid status. Patients who demonstrate

fluid volume alterations are likely to have electrolyte alterations as

well.

Monitor patient for physical signs of electrolyte imbalance. Many

cardiac, neurological, and musculoskeletal symptoms are indicative

of specific electrolyte abnormalities.

Perform: Collect and evaluate serum electrolyte results as ordered to

allow for prompt diagnosis and treatment of any abnormalities.

Treat underlying medical condition. Correction of the underlying

cause of electrolyte imbalance is the first step in correcting

electrolyte imbalance.

Inform: Educate patient and family regarding risks for electrolyte dis-

turbances associated with their particular medical condition and pos-

sible interventions if symptoms occur. Early identification and inter-

vention may prevent life-threatening complications of electrolyte

imbalance.

119

Attend: Provide support and encouragement to patient and family in

their efforts to participate in the management of the condition. Pos-

itive feedback will increase self-confidence and feeling of partnership

in care.

Manage: Coordinate care with other members of the healthcare team

to provide safe environment. Electrolyte imbalances can cause poor

coordination, weakness, and altered gait.

SUGGESTED NIC INTERVENTIONS

Electrolyte Management, Electrolyte Monitoring, Fluid–Electrolyte

Management

Reference

Noble, K. A. (2008). Fluid and electrolyte imbalance: A bridge over troubled

water. Journal of Perianesthesia Nursing, 23, 267–272.

Nursing diagnosis – RISK FOR DISTURBED MATERNAL–FETAL Dyad

RISK  FOR  DISTURBED  MATERNAL–FETAL

DYAD

DEFINITION

At risk for disruption of the symbiotic maternal–fetal dyad as a

result of comorbid or pregnancy-related conditions

DEFINING CHARACTERISTICS

• Complications of pregnancy (e.g., premature rupture of

membranes, placenta previa or abruption, late prenatal care, multi-
ple gestation)

• Compromised O2 transport (e.g., anemia, cardiac disease, asthma,

hypertension, seizures, premature labor, hemorrhage)

• Impaired glucose metabolism (e.g., diabetes, steroid use)

• Physical abuse

• Substance abuse (e.g., tobacco, alcohol, drugs)

• Treatment-related side effects (e.g., medications, surgery,

chemotherapy)

RELATED FACTORS

• Mental health status

• Cultural background

• Psychosocial issues

• Fetal well-being

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Emotional

• Roles/relationships

EXPECTED OUTCOMES

The patient will

• Be compliant with recommendations for self-care activities to mini-

mize prenatal complications and optimize maternal–fetal health.

• Verbalize fears and uncertainty related to prenatal condition.

• Actively involve significant other/support systems with pregnancy

expectations and plan of care.

• Demonstrate the “maternal tasks of pregnancy” culminating in an

unconditional acceptance of the fetus before delivery.

SUGGESTED NOC OUTCOMES

Prenatal Health Behavior; Knowledge: Pregnancy; Role Performance;

Family Integrity

INTERVENTIONS AND RATIONALES

Determine: At each prenatal visit, assess physical condition,

psychosocial well-being, and cultural beliefs to be able to counsel

and/or refer as needed.

Perform: Encourage support/involvement of significant other(s) dur-

ing course of pregnancy to enhance maternal role adaptation.

Incorporate the cultural beliefs, rites, and rituals of the childbear-

ing family into the plan of care to foster feelings of normalcy with

pregnancy.

117

Inform: Educate patient/significant other on role transition and

maternal tasks of pregnancy to provide anticipatory guidance on

expected psychosocial changes.

Teach trimester-specific risks/danger signs and emphasize

importance of self-monitoring to empower the patient and reduce

potential for adverse fetal effects.

Attend: Encourage patient to express disappointment/concerns

related to relationships, physical condition, and fetal well-being to

promote therapeutic communication.

Manage: Refer to community resources as needed (e.g., prenatal

classes, psychological counseling, pastoral care, social services) to

facilitate appropriate role adaptation.

SUGGESTED NIC INTERVENTIONS

Anticipatory Guidance; Childbirth Preparation; Coping

Enhancement; Role Enhancement

References

Olds, S., London, M., Ladewig, P., & Davidson, M. (2008). Maternal–

newborn nursing and women’s health care (8th ed.). Upper Saddle River,
NJ: Prentice-Hall Health.

Ward, S. L., & Hisley, S. M. (2009). Maternal–child nursing care: Optimizing

outcomes for mothers, children, and families. Philadelphia: F.A. Davis Com-
pany.

Nursing diagnosis – RISK FOR DISUSE SYNDROME

RISK  FOR  DISUSE  SYNDROME

DEFINITION

At risk for deterioration of body systems as the result of prescribed

or unavoidable musculoskeletal inactivity

RISK FACTORS

•   Altered LOC

•   Prescribed immobilization

•   Mechanical immobilization

•   Severe pain

•   Paralysis

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Neurocognition

• Cardiac function

• Respiratory function

• Coping

• Risk management

• Elimination; nutrition

• Tissue integrity

• Fluid and electrolytes

EXPECTED OUTCOMES

The patient will

• Have no evidence of altered mental, sensory, or motor ability.

• Have no evidence of thrombus formation or venous stasis.

• Have no evidence of decreased chest movement, cough stimulus,

depth of ventilation, pooling of secretions, or signs of infection.

• Maintain normal bowel elimination patterns.

• Maintain adequate dietary intake, hydration, and weight.

• Have no evidence of urine retention, infection, or renal calculi.

• Maintain muscle strength and tone and joint ROM.

• Have no evidence of contractures or skin breakdown.

• Maintain normal neurologic, cardiovascular, respiratory, GI, nutri-

tional, genitourinary, musculoskeletal, and integumentary function-
ing during period of inactivity.

SUGGESTED NOC OUTCOMES

Coordinated Movement; Endurance; Immobility Consequences: Phys-

iological; Immobility Consequences: Psychocognitive; Mobility; Risk

Control

INTERVENTIONS AND RATIONALES

Determine: Inspect skin every shift and follow facility policy for pre-

vention of pressure ulcers to prevent or mitigate skin breakdown.

Administer anticoagulant therapy, if ordered; monitor for signs and

symptoms of bleeding. Anticoagulant therapy may cause hemorrhage.

Monitor vital signs every 4 hr: Monitor breath sounds and respi-

ratory rate, rhythm, and depth to rule out respiratory complications.

Monitor arterial blood gas levels or pulse oximetry to assess

oxygenation, ventilation, and metabolic status.

Monitor urine characteristics and patient’s subjective complaints

typical of UTIs, such as burning, frequency, and urgency. Obtain urine

cultures, as ordered. These measures aid early detection of UTI.

115
Identify functional level to provide baseline for future assessment,

and encourage appropriate participation in care to prevent complica-

tions of immobility and increase patient’s feelings of self-esteem.

Perform: Avoid positions that put prolonged pressure on body parts

and compress blood vessels; reposition patient at least every 2 hr

within prescribed limits. These measures enhance circulation and

help prevent tissue or skin breakdown.

Use pressure-reducing or pressure-equalizing equipment, as

indicated or ordered (flotation pad, air pressure mattress, sheepskin

pads, or special bed). This helps prevent skin breakdown by reliev-

ing pressure.

Apply antiembolism stockings; remove for 1 hr every 8 hr. Stock-

ings promote venous return to heart, prevent venous stasis, and

decrease or prevent swelling of lower extremities.

Suction airway, as needed and ordered, to clear airway and stimu-

late cough reflex. Note secretion characteristics.

Provide small, frequent meals of favorite foods to increase dietary

intake. Increase fiber content to enhance bowel elimination. Increase

protein and vitamin C to promote wound healing; limit calcium to

reduce risk of renal and bladder calculi.

Perform active or passive ROM exercises at least once per shift.

Teach and monitor appropriate isotonic and isometric exercises.

These measures prevent joint contractures, muscle atrophy, and

other complications of prolonged inactivity.

Provide or help with daily hygiene; keep skin dry and lubricated

to prevent cracking and possible infection.

Inform: Teach and monitor deep breathing, coughing, and use of

incentive spirometer to help clear airways, expand lungs, and

prevent respiratory complications. Maintain regimen every 2 hr.

Instruct patient to avoid straining during bowel movements that

may be hazardous to patients with cardiovascular disorders and

increased intracranial pressure. Teach to administer stool softeners,

suppositories, or laxatives, as ordered, and monitor effectiveness.

Attend: Encourage fluid intake of 21⁄2–31⁄2 qt (2.5–3.5 L) daily,

unless contraindicated, to maintain urine output and aid bowel elim-

ination. Encourage patient and family to verbalize frustrations to

help patient and family cope with treatment.

SUGGESTED NIC INTERVENTIONS

Activity Therapy; Body Mechanics Promotion; Cognitive

Stimulation; Energy Management; Exercise Promotion; Exercise

Therapy: Ambulation; Fluid Management; Nutrition Management

Reference

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

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

Nursing diagnosis – MORAL DISTRESS

MORAL  DISTRESS

DEFINITION

Response to the inability to carry out one’s chosen moral/ethical

decision/action

DEFINING CHARACTERISTICS

Expresses anguish (e.g., powerlessness, guilt, frustration, anxiety,

self-doubt, fear) over difficulty acting on moral choice

RELATED FACTORS

• Conflict among decision makers

• Loss of autonomy

• Conflicting information guiding

• Physical distance of decision

ethical and/or moral decision
making

maker
• Time constraints for decision

• Cultural conflicts

making

• Decisions involving end-of-life

• Treatment decisions

matters

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Roles/relationship

• Coping

• Communication

• Values/beliefs

EXPECTED OUTCOMES

The patient and family will

• Understand medical diagnosis, treatment regimen, and limitations

related to extent of illness.

• Identify ethical/moral dilemma.

• Describe personal and family values and conflict with current situ-

ation.

• Identify healthcare ethics resources to assist in resolution of con-

flict.

• Verbalize relief from anguish, uneasiness, or distress.

SUGGESTED NOC OUTCOMES

Acceptance: Health Status; Client Satisfaction; Communication;

Decision Making; Family Integrity; Family Functioning; Family

Health Status; Family Integrity; Knowledge; Spiritual Health

Interventions and Rationales

INTERVENTIONS AND RATIONALES

Determine: Assess patient’s and family’s understanding of the diagno-

sis and prognosis, limitations, treatment options; description of their

personal values; and their physical expressions of suffering. Assess-

ment factors assist in identifying appropriate interventions.

Perform: Establish an environment in which family members can

share comfortably and openly their issues and concerns.

Enlist assistance of healthcare ethics resources such as ethics com-

mittee or consultants. Including experts in healthcare ethics will

assist in identifying the patient/family values and reason for the

113

dilemma. By identifying the source of the conflict, the process of

resolution may begin, thus leading to better understanding by all

parties and partial or full relief from moral suffering.

Enlist assistance of chaplain or personal clergy to assist in the

process of resolution through clarification of values related to

religious views. Chaplains and personal clergy may provide a more

neutral “third party” that can help defuse the situation. Personal

trusted clergy might recognize or facilitate patient/family verbal and

physical expressions of suffering or relief.

Inform: Educate patient and family about medical diagnosis,

treatment regimen, and limitations involved in to help both patient

and family understand the limits of and read on for medical treat-

ment related to medical diagnosis.

Attend: Provide or set aside ample time for patient and family to

express their feelings about the current situation. Open, honest com-

munication may clear misconceptions on both sides and facilitate

relief from suffering in the mid of dilemma.

Acknowledge ethical/moral position of the patient/family who may

feel that their positions or views will go unrecognized in the mid of

serious illness and high-tech treatments; they may not want to

“bother” nurses and physicians with these concerns. Acknowledging

their concerns, values, and moral position allows for holistic care.

Manage: Refer, where requested, for follow-up for a family member

who needs exercise, weight management, diet assistance, health

screenings, and so forth. Assisting patient to make referrals will help

ensure continued efforts on the part of the patient to live a healthier

lifestyle.

SUGGESTED NIC INTERVENTIONS

Active Listening: Anger Control Assistance; Anxiety Reduction; Con-

flict Mediation; Consultation; Counseling; Documentation; Family

Integrity Promotion; Family support; Multidisciplinary Care Confer-

ence; Spiritual Support Family Support; Family Integrity Promotion;

Family Maintenance; Truth Telling

Reference

Kopala, B., & Burkhart, L. (2005). Ethical dilemma and moral distress: Pro-

posed new NANDA diagnosis. International Journal of Nursing Terminolo-
gies and Classifications, 16(1), 3–13.

Nursing diagnosis – RISK FOR COMPROMISED HUMAN DIGNITY

RISK  FOR  COMPROMISED  HUMAN  DIGNITY

DEFINITION

At risk for perceived loss of respect and honor

DEFINING CHARACTERISTICS

• Cultural incongruity

• Disclosure of confidential information

• Exposure of the body

• Inadequate participation in decision making

• Loss of control of bodily functions

• Perceived dehumanizing treatment

• Perceived humiliation

• Perceived invasion of privacy

• Use of undefined medical terms

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Communication

• Values and beliefs

• Behavior

• Coping

EXPECTED OUTCOMES

The patient will

• Express satisfaction with level of respect.

• Identify those things that will reduce feelings of powerlessness and

vulnerability and increase perception of autonomy.

The patient and family will

• Agree on a plan to protect patient’s privacy and respect patient’s

confidentiality; family members will evaluate the progress they are
making in protecting the patient’s right to confidentiality.

• Express satisfaction with the level of respect shown to patient’s

human dignity.

SUGGESTED NOC OUTCOMES

Client Satisfaction; Protection of Rights; Coping; Personal

Autonomy; Self-Esteem

INTERVENTIONS AND RATIONALES

Determine: Assess patient’s perception of the current health problem

and problem-solving techniques he or she uses to cope. Determine

level of family involvement and support. Ask about support systems,

including family, friends, and clergy. Determine patient’s legal status,

including the authority to give consent for treatments or procedures.

Assessment of these factors will assist in identifying appropriate

interventions.

Perform: Schedule time to spend with the patient to listen to

concerns and feelings about current situation.

Develop a plan visiting with patient to ensure that the desirable

level of privacy is being maintained.

111
Incorporate questions into discussions with the patient that are

open-ended, and start with such words as “what,” “how,” and

“could,” rather than “why.” Open-minded, nonthreatening question-

ing encourages the patient to discuss issues of concern and improve

ability to articulate what he or she desires.

Schedule team meetings with staff to ensure that communication

with the patient is consistent and truthful.

Inform: Provide education on legal and ethical rights of the patient

to have his human dignity respected, as well as the hospital’s or

agency’s policies on respecting the rights of patients. Include family

in this process. Every patient is entitled to have a copy of the hospi-

tal’s Bill of Patient’s Rights.

Arrange a team conference with the staff to review with patient

and family information on bioethics and moral rights of patients.

Role model or provide case studies with situations to allow staff to

design strategies for handling difficult issues associated with patient’s

rights.

Attend: Encourage discussion of thoughts and feelings about the

overuse of negative expressions on the part of the patient by

suggesting strategies such as a rubber band on the wrist to snap

every time negative expressions begin. Negative expressions can

impair the patient’s progress toward a healthy lifestyle.

Encourage role-playing of verbal and nonverbal communication

techniques in a safe environment to enhance communication skills.

Provide support through active listening, appropriate periods of

silence, reflection on feelings, and paraphrasing and summarizing

comments. Active listening techniques encourage patient

participation in communication.

Make sure that patient has clear explanations for everything that

will happen to him. Ask for feedback to ensure that patient under-

stands. Anxiety may impair patient’s cognitive abilities.

Manage: Refer patient and/or family to a support network that will

relate to them in regards to caregiving, the pressures of illness, and

other issues related to respecting human dignity. A support network

will provide an outlet for the family members as they work through

the various issues.

SUGGESTED NIC INTERVENTIONS

Body Image Enhancement; Self-Awareness Enhancement; Self-Esteem

Enhancement

Reference

Coventry, M. L. (2006, May). Care with dignity: A concept analysis. Journal

of Gerontological Nursing, 32(5), 42–48.

Nursing diagnosis – DIARRHEA

DIARRHEA

DEFINITION

Passage of loose, unformed stools

DEFINING CHARACTERISTICS

• Abdominal pain and cramping

• At least three loose, liquid stools per day

• Hyperactive bowel sounds

• Urgency

RELATED FACTORS

• Psychological: anxiety, high stress levels

• Physiological: malabsorption, infectious processes, irritation, para-

sites, inflammation

• Situational: adverse effects of medications, alcohol abuse,

toxins, laxative abuse, contaminants, radiation, tube feedings,
travel

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Coping

• Fluid and electrolytes

• Emotional

• Nutrition

• Elimination

EXPECTED OUTCOMES

The patient will

• Have less or no diarrheal episodes.

• Resume usual bowel pattern.

• Maintain weight and fluid and electrolyte balance.

• Keep skin clean and free from irritation or ulcerations.

• Explain causative factors and preventive measures.

• Discuss relationship of stress and anxiety to episodes of diarrhea.

• State plans to use stress-reduction techniques (specify).

• Demonstrate ability to use at least one stress-reduction technique.

SUGGESTED NOC OUTCOMES

Bowel Continence; Hydration; Symptom Control

INTERVENTIONS AND RATIONALES

Determine: Monitor and record frequency and characteristics of

stools to monitor treatment effectiveness.

Identify stressors and help the patient solve problems to provide

more realistic approach to care.

Monitor perianal skin for irritation and ulceration; treat according

to established protocol to promote comfort, skin integrity, and free-

dom from infection.

Perform: Administer antidiarrheal medications, as ordered, to

improve body function, promote comfort, and balance body fluids,

salts, and acid–base levels. Monitor and report effectiveness of

medication.

109
Provide replacement fluids and electrolytes as prescribed. Maintain

accurate records to ensure balanced fluid intake and output.

Inform: Teach patient to use relaxation techniques to reduce muscle

tension and nervousness; recognize and reduce intake of diarrhea-

producing foods or substances (such as dairy products and fruit) to

reduce residual waste matter and decrease intestinal irritation.

Instruct patient to record diarrheal episodes and report them to

staff to promote comfort and maintain effective patient–staff

communication.

Attend: Encourage patient to ventilate stresses and anxiety; release of

pent-up emotions can temporarily relieve emotional distress.

Encourage and assist patient to practice relaxation techniques to

reduce tension and promote self-knowledge and growth.

Spend at least 10 min with patient twice daily to discuss stress-

reducing techniques; this can help patient pinpoint specific fears.

Manage: Consult with dietician to determine foods that may be

related to diarrheal episodes.

SUGGESTED NIC INTERVENTIONS

Diarrhea Management; Nutrition Management; Skin Surveillance;

Weight Management

Reference

Fletcher, P. C., & Schneider, M. A. (2006, September–October). Is there any

food I can eat? Living with inflammatory bowel disease and/or irritable
bowel syndrome. Clinical Nurse Specialist, 20(5), 241–247.

Nursing diagnosis – RISK FOR DELAYED DEVELOPMENT

RISK  FOR  DELAYED  DEVELOPMENT

DEFINITION

At risk for delay of 25% or more in one or more of the areas of

social or self-regulatory behavior, or in cognitive, language, gross or

fine motor skills

RISK FACTORS

• Adopted child

• Hearing impairment

• Behavior disorders

• Inadequate nutrition

• Brain damage

• Genetic disorders

• Chemotherapy

• Lead poisoning

• Chronic illness

• Substance abuse

• Congenital disorders

• Vision impairment

• Failure to thrive

• Poverty

• Foster child

• Violence

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Coping

• Roles/relationship

• Communication

• Values/beliefs

• Emotional

EXPECTED OUTCOMES

The child will

• Continue to grow and gain weight in accordance with growth

chart of age and sex.

• Consume _____ calories and ________ ml of fluids representing

________ servings (specify for each food group).

• Participate in activities and be provided with a supervised, uncon-

fined environment that includes age-appropriate toys and fosters
interaction with child’s development.

The parents will

• Express understanding of measures to reduce child’s risk for

delayed development.

• Identify risk factors that may interfere with child’s development.

SUGGESTED NOC OUTCOMES

Family Functioning; Growth; Parenting Performance; Personal

Health Status; Risk Control

INTERVENTION AND RATIONALES

Determine: Assess family’s developmental stage; family roles; family

rules; socioeconomic status; family health history; history of substance

abuse; history of sexual abuse of spouse or children; problem-solving

and decision-making skills; religious affiliation; ethnicity. Assessment

information will aid in developing a workable plan of care.

Perform: Weigh and measure child. Review growth chart to establish

current height and weight values.

Establish a meal program to meet the child’s nutritional needs.

107
Create an environment in which family members can express

themselves openly and honestly. Establish rules for communication

during meetings with the family. Having rules allows everyone to

participate and keep the discussion on the designated topic.

Inform: Teach parents about nutritional requirements needed for

child of specific weight and age. Discuss various meal choices avail-

able to the child. Providing instruction in writing simplifies the par-

ents’ role in selecting healthy foods.

Educate parents about child’s need for quality interaction with

family members and others. Inform parents about age-appropriate

activities and toys as well as potential playmates for a child of spe-

cific age. Emphasize importance of providing an unconfined, super-

vised environment in which the child can play to encourage play

that encourages the child to move freely.

Educate parents about risk factors that may lead to delayed devel-

opment, such as lack of supportive interactions or age-appropriate

activities. The ability to recognize risk factors will promote getting

help for the parents and child sooner.

Teach coping skills to parents to enable them to deal effectively

with the child’s needs.

Attend: Encourage parents to listen to the child and communicate in

a loving, supportive way in order to allow the child to maintain a

positive attitude.

Encourage parents to identify preventive measures they may initi-

ate at home to ensure continuity of care. Consistency in providing

care will help the child understand that the plan carries over to all

aspects of his or her life.

Manage: Provide parents with a copy of child’s teaching plan. This

helps to reinforce what the child is learning.

Refer to case manager/social worker to ensure that a home assess-

ment is done.

Refer to nutritionist for follow-up with food issues.

SUGGESTED NIC INTERVENTIONS

Nutrition Management; Family Process Maintenance; Coping

Enhancement; Family Integrity Promotion; Maintenance; Normaliza-

tion Promotion; Substance Use Prevention; Substance Use Treatment;

Risk Identification

Reference

Moss, J. (2005, March). Development of a functional ability scale for children

and young people with myalgic encephalopathy (ME)/chronic fatigue syn-
drome (CFS). Journal of Child Health Care, 9(1), 20–30.

Nursing diagnosis – IMPAIRED DENTITION

IMPAIRED  DENTITION

DEFINITION

Disruption in tooth development and eruption patterns or structural

integrity of individual teeth

DEFINING CHARACTERISTICS

• Caries; extractions; evidence of periodontal disease

• Evulsion

• Inability or unwillingness of parents or caregiver to provide child

with dental care; lack of access to dental care

• Lack of knowledge of appropriate dental hygiene practices

• Malocclusion; plaque; toothache

• Loose teeth; premature loss of primary teeth

• Erosion of enamel

RELATED FACTORS

• Barriers to self-care

• Ineffective oral hygiene

• Bruxism

• Nutritional deficits

• Chronic use of coffee, tea, red

• Sensitivity to cold

wine, tobacco

• Sensitivity to heat

• Chronic vomiting

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Knowledge

• Roles/responsibilities

• Nutrition

• Values and beliefs

EXPECTED OUTCOMES

The individual will

• Brush teeth with minimal supervision.

• Demonstrate good brushing technique.

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

clusion.

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

• Show evidence of good daily oral hygiene.

SUGGESTED NOC OUTCOME

Oral Hygiene; Self-Care: Oral Hygiene

INTERVENTIONS AND RATIONALES

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

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

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

tus. Assessment of these factors will help to identify appropriate

interventions.

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

Schedule times for brushing and have patient begin keeping a

record. Keeping a record will promote compliance.

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

methods appropriate to his age-group to foster compliance.

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

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

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

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

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

is a simple sugar that promotes dental decay.

Demonstrate good brushing technique. Stress the importance of

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

cedure.

Attend: Encourage parents to create a pleasant mealtime environment

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

child will learn to recognize nutritious foods.

Give positive reinforcement for good choices. Be supportive to the

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

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

choices, and parents benefit from encouragement to keep reinforcing

good healthy choices.

Encourage ample fluid intake to keep gums well hydrated.

Adequate fluids promote healthy gums.

Manage: Refer to dentist for assessment of dental health.

Schedule a follow-up appointment with parents to ensure they

have taken child to the dentist.

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

diet.

SUGGESTED NIC INTERVENTIONS

Oral Health Maintenance; Oral Health Promotion; Teaching:

Individual

Reference

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

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

Nursing diagnosis – INEFFECTIVE DENIAL

INEFFECTIVE  DENIAL

DEFINITION

Conscious or unconscious attempt to disavow the knowledge or

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

ment of health

DEFINING CHARACTERISTICS

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

health

• Displacement of fear about condition’s impact

• Displacement of sources of symptoms to other organs

• Failure to perceive personal relevance or danger of symptoms

• Inability to admit impact of disease on life pattern

• Inappropriate affect

• Minimization of symptoms

• Refusal to admit fear of death or invalidism

RELATED FACTORS

• Anxiety

• Lack of control of the situation

• Fear of death

• Overwhelming stress

• Fear of loss of autonomy

• Threat of unpleasant reality

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Coping

• Communication

• Values and beliefs

EXPECTED OUTCOMES

The patient will

• Describe knowledge and perception of present health problem.

• Describe life pattern and report any changes.

• Express knowledge of stages of grieving.

• Demonstrate behavior associated with the grief process.

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

ness of reality.

SUGGESTED NOC OUTCOMES

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

Health Beliefs: Perceived Threat; Symptom Control

INTERVENTIONS AND RATIONALES

Determine: Assess patient’s understanding and perception of present

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

evance on life pattern and description of symptoms.

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

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

tify appropriate interventions.

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

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

feelings and concerns.

103
Assist patient with ADLs as needed to conserve energy and avoid

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

makeup for women). Offer massage to enhance comfort and

promote relaxation.

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

device if needed). Exercise will promote positive attitude.

Inform: Discuss stages of anticipatory grieving to increase

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

cope.

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

strates readiness to learn. Provide brochures and simple written

materials to help with the learning process.

Attend: Provide emotional support and encouragement to help

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

involved in planning care.

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

ity to participate will encourage greater compliance with the plan

for treatment.

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

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

to regain independence and enhance self-esteem.

Schedule treatments apart from visiting to allow for periods of

rest.

Maintain frequent discussions with physicians and staff to be cer-

tain what patient has been told by other care providers.

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

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

SUGGESTED NIC INTERVENTIONS

Anxiety Reduction, Behavior Modification; Calming; Counseling;

Decision-Making Support; Truth Telling

Reference

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

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

Nursing diagnosis – READINESS FOR ENHANCED DECISION MAKING

READINESS  FOR  ENHANCED

DECISION  MAKING

DEFINITION

A pattern of choosing courses of action that is sufficient for meeting

short- and long-term health-related goals and can be strengthened

DEFINING CHARACTERISTICS

• Expresses desire to enhance decision making

• Expresses desire to enhance congruency of decisions with personal

values and goals

• Expresses desire to enhance congruency between decisions and

sociocultural goals and values

• Expresses desire to enhance risk–benefit analysis of decisions

• Expresses desire to enhance the understanding of choices

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Coping

• Knowledge

• Communication

• Values and beliefs

EXPECTED OUTCOMES

The patient will

• Express the desire to make effective decisions.

• Verbalize decision-making goals and concerns.

• Discuss measures used to evaluate decisions.

• Make decisions that promote maximal physical, mental, social,

and psychological well-being.

• Involve family, friends, and clergy in healthcare decision making

when appropriate.

SUGGESTED NOC OUTCOMES

Decision Making; Participation in Healthcare Decisions; Self-Care:

IADLs

INTERVENTIONS AND RATIONALES

Determine: Assess usual coping strategies employed by the patient

when making decisions; determine how the patient goes about mak-

ing difficult decisions; have the patient describe several challenging

decisions he or she made in the past year. Assessment information

will help identify appropriate interventions.

Evaluate support systems available to the patient when it is neces-

sary to make decisions. Patients often need support of families or

other support systems when they are faced with major decisions.

Perform: Provide assistance with ADLs as required. As the patient

receives assistance, it is important to allow him or her to be as inde-

pendent as possible.

Make changes in the environment to reduce unnecessary stimula-

tion and promote a sense of calm.

Inform: Teach patient simple decision-making techniques and role-

play the same. Return demonstration from the patient will give

101

him or her confidence that he or she can choose wisely among

options.

Educate family about the importance of allowing the patient to

think and act for himself or herself in order to give the patient a

sense of control over the present situation.

Attend: Provide emotional support and encouragement to help

improve patient’s confidence in his or her ability to make logical

decisions.

Provide patient with all necessary support during hospitalization

to prepare him and his family to continue the process of having the

patient make decisions about his own care.

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

ity to participate will encourage greater compliance with the treat-

ment plan.

Manage: If patient continues to have difficulty, refer to case

manager/social worker/mental health professional for continued

follow-up.

Provide appropriate assistance to the family members when they

are trying to provide; it might be helpful in working with the

patient.

SUGGESTED NIC INTERVENTIONS

Decision-Making Support; Health System Guidance; Self-Responsibility

Facilitation

Reference

Moser, A., et al. (2007, February). Patient autonomy in nurse-led shared care:

A review of theoretical and empirical literature. Journal of Advanced Nurs-
ing, 57(4), 357–365.

Nursing diagnosis – RISK FOR SUDDEN INFANT DEATH SYNDROME

RISK  FOR  SUDDEN  INFANT

DEATH  SYNDROME

DEFINITION

Presence of risk factors for an infant under 1 year of age

RISK FACTORS

Modifiable

• Consistent disorientation to

• Delayed prenatal care

environment

• Infant overheating

Partially Modifiable

• Infant over wrapping

• Low birth weight

• Infants placed to sleep in a

• Prematurity

prone position

• Young maternal age

• Infants placed to sleep in side-

Nonmodifiable

lying position

• Ethnicity

• Lack of prenatal care

• Male gender

• Postnatal infant smoke expo-

• Seasonality of sudden infant

sure

death syndrome (SIDS) (winter

• Prenatal infant smoke

and fall)

• Soft underlayment (loose arti-

• Infant age of 2–4 months

cles in the sleep environment)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Sleep/rest

• Roles/responsibilities

• Values/beliefs

EXPECTED OUTCOMES

The parents will

• Be receptive to teaching and guidance.

• Verbalize understanding of risk factors and provide all precautions

possible to prevent disorder.

• Verbalize feelings of preparedness and ability to handle emergen-

cies utilizing CPR techniques and services.

• Exhibit appropriate coping skills in dealing with high-risk infant.

The infant will

• Sleep alone in a crib on a firm sleep surface.

• Maintain normal body temperature as indicated by apnea monitor

worn during sleep.

SUGGESTED NOC OUTCOMES

Knowledge Infant Care; Knowledge Parenting; Parent Performance;

Risk Control; Risk Detection

INTERVENTIONS AND RATIONALES

Determine: Assess prenatal history; maternal history; parental experi-

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

depth of respirations, breath sounds; reflexes, response to touch. The

assessment information will assist in identifying appropriate

interventions.

99

Perform: Position infant on back when placed in the crib. Incidence

of SIDS is higher when infant is placed in a prone position.

Elevate infant’s head slightly when placed in the crib to decrease

abdominal pressure on diaphragm and allow better expansion of lungs.

Place infant on a firm sleep surface to prevent him or her from

sinking into the mattress cover or blanket.

Maintain room at appropriate temperature and avoid wrapping

the infant in heavy blankets. Excessive heat has been identified as a

possible risk factor.

Inform: Educate parents about risk factors of SIDS because modifica-

tion of current practices can reduce risk and prevent occurrence.

Instruct caregivers on ways to maintain a safe environment in the

home. Provide written information to caregivers on all important

aspects of the infant’s care.

Teach parents to avoid having loose blankets, toys, or other arti-

cles in the crib to decrease risk of accidental suffocation.

Encourage mother to breast-feed because there is a lower

incidence of SIDS in babies who are breast-fed.

Teach parents how to correctly apply leads and set alarms of the

apnea monitor. The benefit of the monitor can be achieved only if it

is used correctly.

Instruct parents in CPR to reduce anxiety and promote confidence

in performing correct technique. Allow time for return

demonstrations to prepare parents to cope with infant when he or

she returns home.

Attend: Encourage parents in their efforts to care for the infant. Pro-

vide suggestions for coping mechanisms to help reduce the anxieties

associated with caring for a high-risk infant. Be aware that parents

may be sensitive to your unspoken feelings about the situation.

Encourage parents to interact with other parents managing high-

risk infants well. Peer support may help to reduce fear in the parents.

Involve parents in planning and decision making for their infant.

Investment in decision making will promote compliance with the plan.

Manage: Refer to case manager/social worker/home health agency to

ensure that parents receive adequate support in caring for the infant.

Refer parents to support group if one is available.

SUGGESTED NIC INTERVENTIONS

Family Support; Infant Care; Risk Control

Reference

Thogmartin, J. R., et al. (2001).  Sleep position and bed-sharing in sudden

infant deaths and examination of autopsy findings. Journal of Pediatrics,
138(20), 212–217.

Nursing diagnosis – READINESS FOR ENHANCED COMMUNITY COPING

READINESS  FOR  ENHANCED

COMMUNITY  COPING

DEFINITION

Pattern of community activities for adaptation and problem solving

that is satisfactory for meeting the demands or needs of the commu-

nity but can be improved for management of current and future

problems/stressors

DEFINING CHARACTERISTICS

• Active planning to handle predicted stressors

• Active problem solving when faced with stressors

• Agreement that community carries responsibility for stress manage-

ment

• Positive communication among community members and between

community members and larger organizations

RELATED FACTORS

One or more characteristics that indicate effective coping:

• Acknowledges power

• Defines stressors as manageable

• Aware of possible environmen-

• Seeks knowledge of new

tal changes

strategies

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Communication

• Populations

• Coping

• Risk management

EXPECTED OUTCOMES

Community members will

• Express understanding of problems associated with failure to

immunize population and will recognize the needs to reduce the
number of adults and children who are not immunized.

• Initiate a plan to increase the number of immunizations in popula-

tion and provide adequate protection from communicable diseases.

• Work to reduce spread of communicable diseases and increase the

number of immunizations.

• Evaluate established plans for ensuring that all children become

immunized, and will make changes to plans as needed.

SUGGESTED NOC OUTCOMES

Community Competence; Community Health Status: Immunity;

Community Risk Control: Communicable Disease

INTERVENTIONS AND RATIONALES

Determine: Assess community member’s level of understanding of the

importance of immunization. If level of compliance is low, survey

community needs to determine why. Determine ease of access in the

community for members to comply with immunization

requirements/needs. Identify new members of the community, such

as immigrants or refugees. This assessment will assist in identifying

appropriate intervention.

95

Perform: Collect statistical data from community health sources,

such as the health department and schools to continue to identify

children who have not been immunized. Recruit local agencies with

an adequate number of professionals able to deliver the immuniza-

tion services.

Contact parents personally or by handwritten note about children

who have not been immunized. Make it clear to the parents that

your purpose is to protect the children.

Inform: Provide extensive educational opportunities in the

community about communicable diseases and the importance of

immunization. Educate persons in the community in their first lan-

guage to ensure adequate understanding.

Attend: Encourage community members to implement a program to

disseminate information about problems associated with inadequate

immunization to educate residents and promote the community’s

established immunization program.

Encourage health departments, clinics, and practitioners’ offices to

provide information on the recommended childhood immunization

schedule to the public to foster understanding about the importance

of educating the public.

Conduct a follow-up survey on immunization rates to measure the

effectiveness of educational initiatives.

Manage: Supply a list of referrals for the parents of children who

are not immunized. Include information on low-cost health

insurance, city health centers, and well-baby clinics to encourage

compliance. Helping the parents by giving referrals will empower

them to meet their child’s health care needs.

SUGGESTED NIC INTERVENTIONS

Communicable Disease Management; Community Health Develop-

ment; Health Education; Health Policy Monitoring; Immunization/

Vaccination Management

Reference

Pender, N. J., Murdaugh, C., et al. (2006). Health promotion in nursing prac-

tice (5th ed.). Upper Saddle River, NJ: Prentice Hall.

Nursing diagnosis – READINESS FOR ENHANCED COPING

READINESS  FOR  ENHANCED  COPING

DEFINITION

A pattern of cognitive and behavioral efforts to manage demands

that is sufficient for well-being and can be strengthened

DEFINING CHARACTERISTICS

• Defines stressors as manageable

• Seeks knowledge of new strategies

• Seeks social support

• Uses a broad range of problem-oriented and emotion-oriented

strategies

• Uses spiritual resources

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Roles/relationships

• Communication

• Self-perception

• Coping

EXPECTED OUTCOMES

The patient will

• Identify major issues that require ongoing enhancement of coping

strategies.

• Express feelings associated with coping strategies.

• Demonstrate readiness to develop enhanced strategies.

• Identify support persons and activities that will assist in goal

attainment.

SUGGESTED NOC OUTCOMES

Coping; Quality of Life

INTERVENTIONS AND RATIONALES

Determine: Assess patient’s usual coping mechanisms, roles and

responsibilities, social support, spiritual resources, and use of alcohol

and tobacco in order to decide on a focus for interventions.

Perform: Establish a trusting relationship with patient by spending

time with the patient each shift, which will encourage the patient to

be more honest and open.

Begin discussions at patient’s level of comfort. If patient wants to

express anger or other emotion, listen carefully. Until the patient has

had an opportunity to talk, you will not be able to move him to a

place where the issue can be discussed logically.

Inform: Provide information on informed consent because parents

will be making decisions for the child’s care.

Teach additional skills that enhance coping strategies. Help the

patient develop a program by using relaxation strategies (i.e., medi-

tation, guided imagery, yoga, exercise); these strategies will help to

reduce anxiety and allow the patient to concentrate.

Teach problem-solving skills. Have patient role-play to

demonstrate how to set up options and choose from among them.

93

Attend: Encourage patient to continue adhering to his plan for

enhanced coping strategies. Compliance with the plan will produce

results for the patient. It will also help patient measure success.

Encourage patient to continue involvement in a wide range of

activities. More activities will involve more choices.

Encourage patient to look for volunteer opportunities in the com-

munity as a way of keeping the patient involved with others.

Offer to meet with patient regularly, if desired, to help patient

continue developing enhanced coping skills.

Manage: Refer patients to support groups and offer ideas about edu-

cational opportunities in the community.

SUGGESTED NIC INTERVENTIONS

Active Listening; Coping Enhancement

Reference

Fiks, A. G., et al. (2006, December). Identifying factors predicting immuniza-

tions delay for children followed in an urban primary care network using
an electronic health record. Pediatrics, 118(6), 1680–1686.