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.

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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 – 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 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.

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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.