Nursing diagnosis – RISK FOR LONELINESS

RISK  FOR  LONELINESS

DEFINITION

At risk for experiencing discomfort associated with a desire or need

for more contact with others

RISK FACTORS

• Affectional deprivation

• Physical isolation

• Cathectic deprivation

• Social isolation

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Coping

• Roles/relationships

• Emotional

• Values/beliefs

EXPECTED OUTCOMES

The patient will

• Identify feelings of loneliness and express desire to socialize more.

• Identify behaviors that lead to loneliness.

• Identify people who will likely support and accept him.

• Spend time with others.

• Be comfortable in social settings, interact with peers, and receive

support from others.

• Make specific plans to continue involvement with others, such as

through recreational activities or social interaction groups.

SUGGESTED NOC OUTCOMES

Loneliness Severity; Risk Control; Social Involvement; Social Support

INTERVENTIONS AND RATIONALES

Determine:  Work with patient to identify factors and behaviors that

have contributed to loneliness to begin changing behaviors that may

have alienated others.

Help patient identify feelings associated with loneliness. This lessens

the impact of feelings and mobilizes energy to counteract them.

Perform:  Spend sufficient time with patient to allow him to express

his feelings of loneliness to establish trusting relationship.

Work with patient to establish goals for reducing feelings of lone-

liness after he leaves healthcare setting to focus energy on specific

objectives.

Inform:  Inform patient that assistance is available to help him

express feelings of loneliness and identify ways to increase social

activity to bring issue into open and help patient understand that

you want to help him.

Help patient curb feelings of loneliness by encouraging one-on-one

interaction with others who are likely to accept him (e.g., church

members or patients with similar health problems) to promote feelings

of acceptance and support.

Help patient identify social activities he can initiate, such as

becoming active in a support group or volunteer organization. This

fosters feelings of control and increase social contacts.

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Help patient accept that other people may view him differently

because of his illness, and explore ways of coping with their reactions

to help patient learn to cope with stigma associated with illness.

Attend:  Encourage patient to address his needs assertively. By being

assertive, patient assumes responsibility for meeting his needs with-

out anger or guilt.

As patient’s comfort level improves, encourage him to attend

group activities and social functions to promote the use of social

skills.

Manage:  Refer patient and family to social service agencies, mental

health center, and appropriate support groups to ensure continued

care and maintain social involvement.

SUGGESTED NIC INTERVENTIONS

Emotional Support; Socialization Enhancement; Spiritual Support;

Visitation Facilitation; Family Integrity Promotion

Reference

Perese, E. F., & Wolf, M. (2005, July). Combating loneliness among persons

with severe mental illness: Social network interventions’ characteristics,
effectiveness, and applicability. Issues in Mental Health Nursing, 6(6),
591–609.

Nursing diagnosis – RISK FOR IMPAIRED LIVER FUNCTION

RISK  FOR  IMPAIRED  LIVER  FUNCTION

DEFINITION

At risk for liver dysfunction

RISK FACTORS

• Hepatotoxic medications (e.g.,

• Viral infection (e.g., hepatitis

acetaminophen, statins)

A, B, or C, Epstein-Barr)

• HIV coinfection

• Chronic biliary obstruction

• Substance abuse (e.g., alcohol,

and infection

cocaine)

• Nutritional deficiencies

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Risk management

• Pharmacological function

• Fluids/electrolytes

EXPECTED OUTCOMES

The patient will

• State effects of environmental and ingested chemicals and

substances on their health and liver function.

• Work with industry managers and with public health officials to

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

• Have liver function indicators within normal limits.

• Modify lifestyle and risk behaviors to avoid behaviors leading to

hepatic dysfunction and inflammation.

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

provider.

• Manage concurrent disease processes that impact hepatic function.

• Optimize nutritional intake for needs.

• Acknowledge the impact of medications on hepatic function.

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

others.

SUGGESTED NOC OUTCOMES

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

Drug Use; Safe Home Environment; Substance Addiction

Consequences

INTERVENTIONS AND RATIONALES

Determine: Assist patient and family to assess workplace and home

environments for potential hepatotoxic substances to increase

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

potential for hepatic injury.

Monitor for clinical manifestations of hepatic inflammation and

dysfunction to notify physician in order to initiate treatment if liver

function is compromised. Clinical manifestations may include

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

pruritis, jaundice, bruising, or nontraumatic bleeding.

221
Monitor customary clinical laboratory tests to alert the healthcare

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

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

rent disorders on liver function. Clinical laboratory tests include

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

elevated WBC (increased immunocyte and inflammatory responses);

basic metabolic panel—altered electrolyte balance, elevated glucose,

elevated blood urea nitrogen and creatinine level, elevated HbA1c;

hepatic plasma markers: elevated liver enzymes (alanine aminotrans-

ferase, aspartate aminotransferase, and    -glutamyltranspeptidase);

positive immunoassays for pathogen and viral antigens; elevated

ammonia; elevated bilirubin; low coagulation factors; low total

protein/albumin; elevated lipid panel.

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

and/or minimize complications.

Inform: Teach patient about the following: perform hand hygiene

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

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

condition so that each observes barrier precautions; adhere to

prescribed plan of care and treatment with immune system modifiers

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

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

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

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

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

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

The patient and family need understanding of purpose for and

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

education helps the patient understand rationale for plan of treatment

and genetic counseling for genetically linked hepatic disorders.

Attend: Provide a nonjudgmental attitude toward patient’s lifestyle

choices to promote feelings of self-worth.

Manage: Refer patient to counseling and therapy to address lifestyle

choices and risk behaviors. Modification of behaviors will provide

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

substance pathogen infection.

SUGGESTED NIC INTERVENTIONS

Behavioral Modification; Environment Risk Protection; Infection

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

Modification Assistance; Sports Injury Prevention; Surveillance

Reference

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

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

Nursing diagnosis – RISK FOR PERIOPERATIVE POSITIONING INJURY

RISK  FOR  PERIOPERATIVE-POSITIONING

INJURY

DEFINITION

At risk for inadvertent anatomical and physical changes as a result

of posture on equipment used during an invasive/surgical procedure

RISK FACTORS

• Disorientation

• Muscle weakness

• Edema

• Obesity

• Emaciation

• Sensory–perceptual

• Immobilization

disturbances from anesthesia

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Physical regulation

• Fluid/electrolytes

• Risk management

• Pharmacological function

EXPECTED OUTCOMES

The patient will

• Maintain effective breathing patterns.

• Maintain adequate cardiac output.

• Have surgical positioning that facilitates gas exchange.

• Not show evidence of neurologic, musculoskeletal, or vascular

compromise.

• Maintain tissue integrity.

SUGGESTED NOC OUTCOMES

Aspiration Prevention, Blood Coagulation; Circulation Status; Neuro-

logical Status; Respiratory Status: Ventilation; Thermoregulation; Tissue

Integrity: Skin & Mucous Membranes; Tissue Perfusion: Peripheral

INTERVENTIONS AND RATIONALES

Determine: Document and report the results of the preoperative

nursing assessment. Identify factors predisposing patient to tissue

injury. This information guides interventions.

Perform: Use the appropriate mode of patient transportation

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

Make sure an adequate number of staff members assist with

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

operating room bed and at least four for moving anesthetized

patient off operating room bed. Adequate staffing enhances safety.

Check the operating room bed before surgery for proper function-

ing. Intraoperative bed malfunction can result in increased anesthe-

sia time and a more difficult surgical approach.

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

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

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

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

abrasions may result from drapes and other foreign material rubbing

against the eyes.

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

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

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

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

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

and subsequent foot drop.

Assess patient position following each positional change to ensure

proper body alignment and adequate padding and support.

Inform: Tell patient about positioning measures planned to reduce

preoperative anxiety.

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

carried to reduce worry about possible injury.

Manage: Consult with a physical or occupational therapist if special

protective equipment is needed to ensure safety for the patient.

SUGGESTED NIC INTERVENTIONS

Circulatory Care: Mechanical Assist Device, Circulatory

Precautions; Infection Control: Intraoperative; Positioning: Intraoper-

ative; Skin Surveillance; Surgical Precautions; Temperature

Regulation: Intraoperative

Reference

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

69(1), 59–63.

Nursing diagnosis – RISK FOR INJURY

DEFINITION

At risk for injury as a result of environmental conditions interacting

with the individual’s adaptive and defensive resources

RISK FACTORS

External

Internal

• Biological: Community immu-

• Abnormal blood profile:

nization level; microorganisms

Altered clotting factors;

• Chemical: Cosmetics; drugs,

decreased hemoglobin; leuko-

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

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

• Human: Nosocomial agents;

• Immune or autoimmune

staffing patterns; cognitive,
affective, psychomotor factors

disorder
• Developmental age: physiologi-

• Nutritional: Food types,

cal and/or psychosocial

vitamins

• Tissue hypoxia

• Physical: Design, structure, and

arrangement of community,
building, and/or equipment

• Mode of transport

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Knowledge

• Emotional

• Risk management

EXPECTED OUTCOMES

The patient will

• Acknowledge presence of environmental hazards in their everyday

surroundings.

• Take safety precautions in and out of home.

• Instruct children in safety habits.

• Childproof house to ensure safety of young children and

cognitively impaired adults.

SUGGESTED NOC OUTCOMES

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

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

Safety Status: Physical Injury

INTERVENTIONS AND RATIONALES

Determine: Help patient identify situations and hazards that can

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

Perform: Arrange environment of patient with dementia to minimize

risk of injury:

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

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

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

Prevent iatrogenic harm to hospitalized patient by following the

2007 National Patient Safety goals. This resource provides compre-

hensive measures designed to prevent harm.

Follow agency policy regarding the use of restraints—they are

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

Agency policies will provide clear direction to use restraints safely.

Inform: Encourage adult patient to discuss safety rules with children

to foster household safety. For example:

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

Attend: Encourage patient to make repairs and remove potential

safety hazards from environment to decrease possibility of injury.

Manage: Refer patient to appropriate community resources for more

information about identifying and removing safety hazards. This

enables patient and family to alter environment to achieve optimal

safety level.

SUGGESTED NIC INTERVENTIONS

Environmental Management: Safety; Fall Prevention; Health Educa-

tion; Parent Education: Adolescent; Parent Education: Childrearing

Family; Risk Identification; Surveillance: Safety

References

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

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

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

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

Nursing diagnosis – RISK FOR INFECTION

RISK  FOR  INFECTION

DEFINITION

At risk for being invaded by pathogenic organisms

RISK FACTORS

• Altered immune function

• Pharmaceutical agents

• Amniotic membrane rupture

• Inadequate primary (such as

• Chronic disease

skin) or secondary (such as

• Environmental exposure to

inflammatory response)

pathogens

defenses

• Invasive procedures

• Malnutrition

• Lack of knowledge about

• Tissue destruction

causes of infection

• Trauma

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid/electrolytes

• Risk management

• Neurocognition

• Sensation/perception

EXPECTED OUTCOMES

The patient will

• Have normal temperature, WBC count, and differential.

• Maintain good personal and oral hygiene.

• Have clear and odorless respiratory secretions.

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

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

intravenous sites with no signs of inflammation.

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

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

SUGGESTED NOC OUTCOMES

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

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

tion; Wound Healing: Primary Intention, and Secondary Intention

INTERVENTIONS AND RATIONALES

Determine: Monitor and record temperature after surgery at least

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

pulmonary complications, wound infection or dehiscence, UTI, or

thrombophlebitis

Monitor WBC count, as ordered. Report elevations or

depressions. Elevated total WBC count indicates infection. Markedly

decreased WBC count may indicate decreased production resulting

from extreme debilitation or severe lack of vitamins and amino

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

Monitor culture results of urine, respiratory secretions, wound

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

This identifies pathogens and guides antibiotic therapy.

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

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

203

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

strict sterile technique when handling would dressings to maintain

asepsis.

Offer frequent oral hygiene to prevent colonization of bacteria

and reduce risk of descending infection. Disease and malnutrition

may reduce moisture in mucous membranes of mouth and lips.

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

facility policy dictates to help keep pathogens from entering body.

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

to reduce chances of infection at individual sites.

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

help remove secretions and prevent pulmonary complications. Pro-

vide tissues to encourage expectoration and convenient disposal bags

for expectorated sputum to reduce spread of infection.

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

bony prominences to help prevent venous stasis and skin breakdown.

Assist patient when necessary to ensure that perianal area is clean

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

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

tion (anus) helps prevent genitourinary infections.

Use sterile water for humidification or nebulization of oxygen.

This prevents drying and irritation of respiratory mucosa, impaired

ciliary action, and thickening of secretions within respiratory tract.

Inform: Instruct patient to immediately report loose stools or

diarrhea which may indicate need to discontinue or change

antibiotic therapy; or to test for Clostridium difficile.

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

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

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

Attend: Unless contraindicated, encourage fluid intake of

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

protein supplements to help stabilize weight, improve muscle tone

and mass, and aid wound healing.

Manage: Arrange for protective isolation if patient has compromised

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

ures protect patient from pathogens in environment.

SUGGESTED NIC INTERVENTIONS

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

Wound Care

Reference

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

of Oncology Nursing, 10(2), 164–166.

Nursing diagnosis – RISK FOR DISORGANIZED INFANT BEHAVIOR

RISK FOR DISORGANIZED INFANT BEHAVIOR

DEFINITION

Risk for alteration in integration and modulation of the physiologi-

cal and behavioral systems of functioning (such as autonomic,

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

tional systems)

RISK FACTORS

• Environmental overstimulation

• Oral or motor problems

• Invasive or painful procedures

• Pain

• Lack of containment or

• Prematurity

boundaries

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Elimination

• Role/relationships

• Neurocognition

• Sensation/perception

• Nutrition

• Sleep/rest

• Physical regulation

EXPECTED OUTCOMES

The parents will

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

• Identify potential signs of behavioral disturbance in infant.

• Identify appropriate ways to interact with infant.

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

occasional frustration and anger).

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

• Identify resources for help with infant.

The infant will

• Maintain physiologic stability.

• Maintain an organized motor system.

• Respond to sensory information in an adaptive way.

SUGGESTED NOC OUTCOMES

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

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

Knowledge: Parent–Infant Attachment; Parenting; Preterm Infant

Organization; Sleep

INTERVENTIONS AND RATIONALES

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

ventive measures.

Perform: Demonstrate appropriate ways of interacting with the

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

cues and respond appropriately. For example, help them recognize

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

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

or held.

197

Inform: Explain to parents that infant maturation is a developmental

process and that their participation is crucial to their understanding

of the importance of nurturing the infant. Participation in the

process by the parents will both stimulate the developmental process

and alert to delays in development.

Explain to parents that their actions can help modify some of

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

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

the parent’s feelings of incompetence.

Explain to parents that certain risk factors may interfere with the

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

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

and painful medical procedures. Educating the parents will help

them understand their role in interpreting the infant’s behavioral

cues and providing appropriate stimulation.

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

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

failure to respond to human contact or tendency to become agitated

with human contact; physiologic regulatory problems, such as a

breathing disturbance in a premature infant; and apparent inability

to interact with the environment. Education will help the parents

recognize if the infant has a problem in behavioral development.

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

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

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

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

normal for parents to experience feelings of inadequacy, frustration,

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

Praise the parents when they demonstrate appropriate methods of

interacting with the infant to provide positive reinforcement.

Manage: Provide the parents with information on sources of support

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

term needs.

SUGGESTED NIC INTERVENTIONS

Attachment Process, Infant Care; Newborn Monitoring; Parent

Education: Infant; Positioning; Surveillance

Reference

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

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

Nursing diagnosis – RISK FOR URGE URINARY INCONTINENCE

RISK  FOR  URGE  URINARY  INCONTINENCE

DEFINITION

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

strong sensation or urinary urgency

RISK FACTORS

• Effects of medication, caffeine,

• Detrusor muscle instability

or alcohol

with impaired contractility

• Detrusor hyperreflexia from

• Ineffective toileting habits

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

• Involuntary sphincter
relaxation
• Small bladder capacity

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity/exercise

• Fluid and electrolytes

• Behavior

• Physical regulation

• Elimination

• Self-care

EXPECTED OUTCOMES

The patient will

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

• State understanding of potential causes of urge incontinence and

its treatment.

• Avoid or minimize complications of urge incontinence.

• Discuss potential effects of urologic dysfunction on self and family

members.

• Demonstrate skill in managing incontinence.

• Identify community resources to cope with alterations in urinary

status.

SUGGESTED NOC OUTCOMES

Knowledge: Treatment Regimen; Urinary Continence; Urinary Elimi-

nation

INTERVENTIONS AND RATIONALES

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

and output to ensure correct fluid replacement therapy and provide

information about the patient’s ability to void adequately.

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

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

Assess patient’s ability to sense and communicate elimination

needs to maximize self-care.

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

fluid daily to moisten mucous membranes and ensure adequate

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

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

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

bathroom. A bedside commode or convenient bathroom requires less

193

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

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

bathroom, provide good lighting from bed to bathroom to reduce

sensory misinterpretation; remove all obstacles between bed and bath-

room to reduce chance of falling. Prepare pleasant toilet environment

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

Have patient wear easily removed articles of clothing (a gown

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

to facilitate the removal of clothing and foster independence.

Have patient keep a diary recording episodes of incontinence to

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

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

maintaining proper hygiene, or notifying a healthcare professional if

urge incontinence occurs frequently. Individualized interventions help

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

Incorporate patient’s suggestions for managing incontinent

episodes into a care plan to foster motivation.

Inform:  Explain urge incontinence to patient and family members,

especially preventive measures and potential underlying causes, to

foster compliance.

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

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

Anxiety and rushing may increase bladder contraction.

Attend:  Encourage patient to express feelings about incontinence to

provide emotional support and identify needed areas for further

patient teaching.

Manage:  Use an interdisciplinary approach to caring for incontinence.

Incorporate recommendations from a urologist, urology nurse special-

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

report the patient’s response to interventions. An interdisciplinary

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

aging patient participation on the team will help foster motivation.

Note if patient expresses concern about the effect of incontinence

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

sexual health.

Refer patient and family members to community resources such as

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

SUGGESTED NIC INTERVENTIONS

Fluid Monitoring; Urinary Elimination Management; Urinary Habit

Training; Urinary Incontinence Care

Reference

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

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

Nursing diagnosis – RISK FOR DISPROPORTIONATE GROWTH

RISK  FOR  DISPROPORTIONATE  GROWTH

DEFINITION

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

centile for age, crossing the percentile channels

RISK FACTORS

· Altered nutritional status

· Inability to digest and absorb

· Any disease that persists over

nutrients

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

hardships

ASSESSMENT FOCUS                           (Refer  to  comprehensive  assessment  parameters.)

· Nutrition

· Sleep

· Activity

· Coping

EXPECTED OUTCOMES

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.

SUGGESTED NOC OUTCOMES

Appetite; Body Image; Child Development: Middle Childhood

Growth; Risk Control; Weight: Body Mass

INTERVENTIONS AND RATIONALES

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.

165

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

interruption.

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.

SUGGESTED NIC INTERVENTIONS

Active Listening; Behavior Modification; Coping Enhancement;

Counseling; Nutritional Management; Patient Contracting; Weight

Management

Reference

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.

Nursing diagnosis – DELAYED GROWTH AND DEVELOPMENT

DELAYED  GROWTH  AND  DEVELOPMENT

DEFINITION

Deviations from age-group norms

DEFINING CHARACTERISTICS

• 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

RELATED FACTORS

• Effect of physical disability

• Multiple caretakers

• Environmental deficiencies

• Prescribed dependence

• Inadequate caretaking

• Separation from significant

• Inconsistent responsiveness

others

• Indifference

• Stimulation deficiencies

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Activity

• Family roles and responsibilities

• Cardiac function

• Nutrition

• Communication

• Sleep

EXPECTED OUTCOMES

The child will

• Demonstrate skills appropriate for age.

• Participate in developmental stimulation program to increase skill

levels.

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.

SUGGESTED NOC OUTCOMES

Child Development: Middle Childhood; Growth; Physical

Maturation: Female; Physical Maturation: Male

INTERVENTIONS AND RATIONALES

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.

163

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.

SUGGESTED NIC INTERVENTIONS

Developmental Enhancement: Child; Health Screening; Nutrition

Management; Risk Identification; Self-Responsibility Facilitation

Reference

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

questionnaires for developmental screening. Pediatric Nursing, 32(5),
409–412.

Nursing diagnosis – RISK FOR COMPLICATED GRIEVING

RISK  FOR  COMPLICATED  GRIEVING

DEFINITION

At risk for a disorder that occurs after the death of a significant other,

in which the experience of distress accompanying bereavement fails to

follow normative expectations and manifests in functional impairment

RISK FACTORS

• Death of a significant other

• Emotional instability

• Lack of social support

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Coping

• Roles/relationships

• Emotional status

• Sleep/rest

• Nutrition status

• Values/beliefs

EXPECTED OUTCOMES

The patient will

• Express appropriate feelings of loss, guilt, fear, anger, or sadness.

• Identify loss and describe meaning of loss.

• Appropriately move through stages of grieving.

• Maintain healthy patterns of sleep, activity, and eating.

• List personal strengths.

• Use healthy coping mechanisms and social support systems.

• Seek fulfillment through preferred spiritual practices.

• Begin planning for future.

SUGGESTED NOC OUTCOMES

Grief Resolution; Life Change Adjustment

INTERVENTIONS AND RATIONALES

Determine: Identify areas of hope in patient’s life to help decrease

anger and feelings of frustration.

Identify previous losses and assess for depression to establish a

baseline.

Perform: Perform interventions to promote sleep such as giving

snack, pillows, backrub, or shower to enhance rest.

Inform: Teach patient relaxation techniques such as guided imagery,

meditation, or progressive muscle relaxation to promote feelings of

comfort.

Attend: Encourage patient to express grief and feelings of anger,

guilt, and sadness. Inability to express these feelings may result in

maladaptive behaviors.

Encourage patient to express feelings in a way he is most comfort-

able with, for example, crying, talking, writing, and/or drawing.

Dysfunctional grieving may result from an inability to express

feelings freely.

161
Encourage patient to keep a journal to express feelings of grief

and loss. The act of writing about feelings may aid in grieving

process. Help patient form goals for the future to place the loss in

perspective and to move on to new situations and relationships.

Manage: Refer patient to community support systems to assist with

grieving process. Contact patient’s preferred spiritual leader if

patient desires. This may provide relief from spiritual distress.

SUGGESTED NIC INTERVENTIONS

Coping Enhancement; Counseling; Emotional Support; Family Ther-

apy; Grief Facilitation Work

Reference

Pilkington, F. B. (2008, January). Expanding nursing perspectives on loss and

grieving. Nursing Science Quarterly, 21(1), 6–7.

Nursing diagnosis – RISK FOR UNSTABLE BLOOD GLUCOSE

RISK  FOR  UNSTABLE  BLOOD  GLUCOSE

DEFINITION

At risk for variation of blood glucose/sugar levels from the normal

range

RISK FACTORS

• Deficient knowledge of

• Lack of adherence to diabetes

diabetes management

management

• Developmental level

• Physical activity level

• Dietary intake

• Physical/mental health status

• Inadequate blood glucose

• Pregnancy

monitoring

• Stress

• Lack of acceptance of diagnosis

• Weight gain or loss

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Behavior

• Neurocognition

• Emotional

• Nutrition

• Physical regulation

• Tissue integrity

EXPECTED OUTCOMES

The patient will

• Be free from symptoms of hypoglycemia/hyperglycemia.

• Have serum glucose to the prescribed desired range.

• Verbalize understanding of how to control blood glucose level.

SUGGESTED NOC OUTCOMES

Blood Glucose Level; Diabetes Self-Management; Knowledge:

Diabetes Management, Weight Control

INTERVENTIONS AND RATIONALES

Determine: Assess patient for symptoms of low serum glucose level

and maintain a patient airway if indicated. A low serum glucose

may not be detected in some patients until moderate to severe cen-

tral nervous system impairment occurs, which can lead to a compro-

mised airway and cardiac arrest.

Assess for the underlying cause (e.g., inadequate dietary intake;

illness such as nausea, vomiting, or diarrhea; and too much insulin)

to help patient prevent future episodes and adapt treatment strate-

gies and lifestyle changes.

Monitor or instruct patient to monitor glucose levels with a glu-

cometer at regular intervals to identify and respond early to fluctua-

tions in glucose levels that occur outside normal parameters.

Assess family understanding of prescribed treatment regimen. The

family plays an important role in supporting the patient.

Assess patient’s knowledge of hypo/hyperglycemia to ensure ade-

quate management and prevent future episodes.

Monitor for signs and symptoms of hyperglycemia (polyuria, poly-

dipsia, polyphagia, lethargy, malaise, blurred vision, and headache).

Early detection ensures prompt intervention and management.

155
Assess for the underlying cause of elevated serum glucose level,

including inadequate dietary intake, illness, and poor medication

management to prevent future episodes and develope treatment

strategies such as changes in lifestyle.

Perform: Perform immediate finger stick with a glucometer to deter-

mine glucose level, which will guide treatment strategies. Administer

insulin, as prescribed, to treat elevated blood glucose levels.

Provide patient with glucose tablets or gel if he or she is

conscious and has ability to swallow. Administer intravenous glucose

if patient is unconscious or cannot swallow. Immediate treatment in

the form of oral or intravenous glucose must be administered to

reverse the low serum glucose level. If patient becomes nauseated,

turn patient on side to prevent aspiration.

Protect patient from injuries, such as falls. Symptoms of low

serum glucose place patient at risk for injury especially when driving

and performing other potentially dangerous activities.

Evaluate serum electrolyte levels. Administer potassium, as

prescribed. With elevated blood glucose levels, potassium and

sodium levels may be low, normal, or high, depending on the

amount of water loss. Consider performing serum testing for

HgbA1c (glycosylated hemoglobin A3C level) to evaluate average

blood glucose levels over a period of approximately 2–3 months and

to assess the adherence and effectiveness of the treatment regimen.

Inform: Teach patient and family self-management of hypoglycemia

and hyperglycemia including glucose monitoring at regular intervals

to treat abnormal glucose levels early and medication management,

nutritional intake, exercise, and regular follow-up visits with the

physician to ensure adequate understanding and management of the

treatment regimen to prevent future hyperglycemic events. Patient

and family teaching may include referrals to a diabetic educator, dia-

betic education classes, and a dietician.

Manage: Consult physician if signs and symptoms persist. Changes

in prescribed medications may be needed, such as with oral

hypoglycemic agents or insulin dosing. Call for emergency medical

services if patient is unstable outside the hospital.

SUGGESTED NIC INTERVENTIONS

Bedside Laboratory Testing; Health Education; Health Screening;

Nutritional Counseling; Teaching: Disease Process; Teaching:

Prescribed Medications

Reference

Oldroyd, J., et al. (2006). Randomized controlled trial evaluating lifestyle

interventions in people with impaired glucose tolerance. Diabetes Research
and Clinical Practice, 72(2), 117–127.

Nursing diagnosis – RISK FOR DYSFUNCTIONAL GASTROINTESTINAL MOTILITY

RISK  FOR  DYSFUNCTIONAL

GASTROINTESTINAL  MOTILITY

DEFINITION

Risk for increased, decreased, ineffective, or lack of peristaltic activity

within the gastrointestinal system

RISK FACTORS

• Abdominal surgery

• Gastroesophageal reflux

• Diabetes

disease (GERD)

• Prematurity

• Unsanitary food preparation

• Decreased gastrointestinal

• Anxiety

circulation

• Lifestyle

• Pharmaceutical agents (e.g.,

• Immobility

narcotics, antibiotics, proton
pump inhibitors, and laxatives)

• Food intolerance (e.g., gluten,
lactose)

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Nutrition

• Fluid and electrolytes

• Elimination

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Maintain adequate fluid and electrolyte balance.

• Identify diet selections and lifestyle changes that would promote

healthy GI function.

• Not experience altered GI motility related to prescribed

medications.

• Recognize chronic conditions that may contribute to altered GI

motility, for example, diabetes, GERD.

SUGGESTED NOC OUTCOMES

Electrolyte and Acid–Base Balance; Fluid Balance; Bowel Elimination

INTERVENTIONS AND RATIONALES

Determine: Assess patient for signs of fluid or electrolyte imbalance

related to increased or decreased GI motility. Fluid and electrolyte

alterations can result from either increased or decreased

gastrointestinal motility.

Assess patient for positive risk factors for altered GI motility. This

will allow for timely interventions to prevent complications associ-

ated with GI dysfunction.

Perform: Assist patients taking prescribed medications that affect

motility with strategies to avoid GI complications. Awareness of pre-

ventive measures will decrease GI complications.

Encourage early ambulation for postoperative patients receiving

opioids for pain control. Early ambulation will reduce the risk of

narcotic-related constipation.

Inform: Educate patient regarding the risk factors related to altered

GI motility, including certain food choices, fluid intake, medications,

153

and activity. Promotion of healthy lifestyle choices will contribute to

positive patient outcomes.

Attend: Provide encouragement and support for behaviors that

enhance gastrointestinal health. Positive reinforcement results in

improved confidence in self-management of health behaviors.

Manage: Coordinate care with other disciplines as needed to

reinforce positive behaviors or to assist with complex situations.

SUGGESTED NIC INTERVENTIONS

Diarrhea Management; Electrolyte Monitoring; Fluid Management;

Nutrition Management

Reference

Mazumdar, A., Mishra, S., Bhatnagar, S., & Gupta, D. (2008). Intravenous

morphine can avoid distressing constipation associated with oral morphine:
A retrospective analysis of our experience in 11 patients in the palliative
care in-patient unit. The American Journal of Hospice & Palliative Care,
25, 282–284.

Nursing diagnosis – RISK FOR IMBALANCED FLUID VOLUME

RISK  FOR  IMBALANCED  FLUID  VOLUME

DEFINITION

At risk for a decrease, increase, or rapid shift from one to the other

of intravascular, interstitial, and/or intracellular fluid. This refers to

body fluid loss, gain, or both

RISK FACTORS

• Receiving apheresis

• Intestinal obstruction

• Abdominal surgery

• Sepsis

• Traumatic injury

• Pancreatitis

• Burns

• Ascites

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Cardiac function

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Remain hemodynamically stable.

• Not experience electrolyte imbalance.

• Maintain adequate urine output.

• Identify risk factors contributing to possible imbalanced fluid volume.

SUGGESTED NOC OUTCOMES

Fluid Balance; Hydration; Vital Signs

INTERVENTIONS AND RATIONALES

Determine: Assess for conditions that may contribute to imbalanced

fluid volume. Prompt treatment of the underlying cause may prevent

serious complications of fluid imbalance.

Monitor vital signs and other assessment parameters frequently.

Changes in heart rate and rhythm, blood pressure, and breath

sounds may indicate altered fluid status.

Monitor intake and output to evaluate need for fluid replacement.

Perform: Collect and evaluate urine output frequently. Measure urine

specific gravity as indicated. Decreased urine volume and elevated

specific gravity indicate hypovolemia.

Collect and evaluate serum electrolyte levels. Fluid alterations may

affect electrolyte levels.

Administer intravenous fluids as indicated. Proactive fluid manage-

ment may prevent serious imbalances.

Inform: Educate patient and family regarding fluid restrictions or

need for increased fluids, depending on underlying condition. Knowl-

edge will enhance feeling of participation and sense of control.

Attend: Provide encouragement and support for cooperation with

prescribed treatment regimen. Positive reinforcement will promote

compliance.

147

Manage: Coordinate care with other members of healthcare team to

effectively manage underlying medical condition and prevent any

alteration in fluid balance.

SUGGESTED NIC INTERVENTIONS

Fluid Management; Fluid Monitoring; Intravenous Therapy

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 DEFICIENT FLUID VOLUME

RISK  FOR  DEFICIENT  FLUID  VOLUME

DEFINITION

At risk for experiencing vascular, cellular, or intracellular

dehydration

RISK FACTORS

• Conditions  that  influence  fluid

• Knowledge deficit related to

needs (e.g., hypermetabolic state)

fluid volume

• Excessive loss of fluid from

• Loss of fluid through abnor-

normal routes (e.g., diarrhea)

mal routes (e.g., drainage

• Extremes of age or weight

tube)

• Factors that affect intake or

• Medications that cause fluid

absorption of, or access to,
fluids (e.g., immobility)

loss

ASSESSMENT FOCUS    (Refer  to  comprehensive  assessment  parameters.)

• Fluid and electrolytes

• Physical regulation

EXPECTED OUTCOMES

The patient will

• Maintain stable vital signs.

• Have normal skin color.

• Maintain urine output of at least ___ ml/hr.

• Maintain electrolyte values within normal range.

• Maintain intake at _____ ml/24 hr.

• Have an intake equal to or exceeding output.

• Express understanding of need to maintain adequate fluid intake.

• Demonstrate skill in weighing himself or herself accurately and

recording weight.

• Measure and record own intake and output.

• Return to normal, appropriate diet.

SUGGESTED NOC OUTCOMES

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

Nutritional Status: Food & Fluid Intake; Risk Detection; Urinary

Elimination

INTERVENTIONS AND RATIONALES

Determine: Monitor and record vital signs every 4 hr. Fever, tachy-

cardia, dyspnea, or hypotension may indicate hypovolemia.

Determine patient’s fluid preferences to enhance intake.
Maintain accurate record of intake and output to aid estimation

of patient’s fluid balance. Measure urine output every hour. Record

and report output of less than ____ ml/hr. Decreased urine output

may indicate reduced fluid volume. Measure and record drainage

from all tubes and catheters to take such losses into account when

replacing fluid.

145
When copious drainage appears on dressings, weigh dressings

every 8 hr and record with other output sources. Excessive wound

drainage causes significant fluid imbalances (1 kg dressing equals

about 1 qt [1 L] of fluid).

Test urine specific gravity each shift. Monitor laboratory values

and report abnormal findings to physician. Increased urine specific

gravity may indicate dehydration. Elevated HCT and Hb levels also

indicate dehydration.

Monitor serum electrolyte levels and report abnormalities. Fluid

loss may cause significant electrolyte imbalance.

Obtain and record patient’s weight at same time every day to help

ensure accurate data. Daily weighing helps estimate body fluid status.

Monitor skin turgor each shift to check for dehydration; report

any decrease in turgor. Poor skin turgor is a sign of dehydration.

Examine oral mucous membranes each shift. Dry mucous

membranes are a sign of dehydration.

Perform: Cover wounds to minimize fluid loss and prevent skin

excoriation.

Keep oral fluids at bedside within patient’s reach and encourage

patient to drink. This gives patient some control over fluid intake

and supplements parenteral fluid intake.

Force oral fluids when possible and indicated to enhance replace-

ment of lost fluids. (Bowel sounds should be present and patient

awake before giving oral fluids.)

Administer parenteral fluids, as prescribed, to replace fluid losses.

Maintain parenteral fluids or blood transfusions at prescribed rate to

prevent further fluid loss or overload.

Progress patient to appropriate diet, as prescribed, to help achieve

fluid and electrolyte balance.

Inform: Instruct patient in maintaining appropriate fluid intake,

including recording daily weight, measuring intake and output, and

recognizing signs of dehydration. This encourages patient and care-

giver participation and enhances patient’s sense of control.

SUGGESTED NIC INTERVENTIONS

Acid–Base Management; Fluid Management; Fluid Monitoring;

Hypovolemia Management; Hypovolemia Intravenous Therapy;

Hypovolemia Monitoring; Surveillance

Reference

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

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

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 – 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.

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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.

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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 – 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 – 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.

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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.