A FAMILY HEALTH ASSESSMENT

NANDA-I Diagnoses Activity intolerance, 122 Risk for Activity intolerance, 127 Ineffective Activity planning, 127 Risk for Ineffective Activity planning, 130 Ineffective Airway clearance, 130 Risk for Allergy response, 136 Anxiety, 139 Death Anxiety, 144 Risk for Aspiration, 147 Risk for impaired Attachment, 152 Autonomic Dysreflexia, 158 Risk for Autonomic Dysreflexia, 161 Risk for Bleeding, 162 Disturbed Body Image, 167 Insufficient Breast Milk, 171 Ineffective Breastfeeding, 174 Interrupted Breastfeeding, 176 Readiness for enhanced Breastfeeding, 179 Ineffective Breathing pattern, 181 Decreased Cardiac output, 187 Risk for decreased Cardiac output, 194 Risk for decreased Cardiac tissue perfusion, 195 Risk for impaired Cardiovascular function, 200 Caregiver Role Strain, 200 Risk for Caregiver Role Strain, 206 Risk for ineffective Cerebral tissue perfusion, 207 Ineffective Childbearing process, 209 Readiness for enhanced Childbearing process, 213 Risk for ineffective Childbearing process, 218 Impaired Comfort, 219 Readiness for enhanced Comfort, 222 Readiness for enhanced Communication, 228 Impaired verbal Communication, 230 Acute Confusion, 236 Chronic Confusion, 243 Risk for acute Confusion, 251 Constipation, 251 Chronic functional Constipation, 259 Perceived Constipation, 263 Risk for Constipation, 266 Risk for chronic functional Constipation, 267 Contamination, 267 Risk for Contamination, 272 Risk for adverse reaction to iodinated Contrast Media, 272 Compromised family Coping, 275 Defensive Coping, 280 Ineffective community Coping, 284 Ineffective Coping, 287 Disabled family Coping, 294 Readiness for enhanced Coping, 297 Readiness for enhanced community Coping, 302 Readiness for enhanced family Coping, 303 Readiness for enhanced Decision-Making, 306 Impaired emancipated Decision-Making, 309 Readiness for enhanced emancipated Decision-Making, 312 Risk for impaired emancipated Decision-Making, 315 Decisional Conflict, 317 Ineffective Denial, 321

Impaired Dentition, 324 Risk for delayed Development, 329 Diarrhea, 332 Risk for Disuse syndrome, 338 Deficient Diversional activity, 343 Risk for Electrolyte imbalance, 348 Labile Emotional Control, 350 Risk for dry Eye, 353 Risk for Falls, 355 Dysfunctional Family processes, 361 Interrupted Family processes, 366 Readiness for enhanced Family processes, 369 Fatigue, 372 Fear, 378 Ineffective infant Feeding pattern, 383 Readiness for enhanced Fluid balance, 386 Deficient Fluid volume, 388 Excess Fluid volume, 393 Risk for Deficient Fluid volume, 397 Risk for imbalanced Fluid volume, 397 Frail Elderly syndrome, 401 Risk for Frail Elderly syndrome, 403 Impaired Gas exchange, 404 Dysfunctional Gastrointestinal motility, 408 Risk for dysfunctional Gastrointestinal motility, 412 Risk for ineffective Gastrointestinal perfusion, 412 Risk for unstable blood Glucose level, 414 Grieving, 420 Complicated Grieving, 426 Risk for complicated Grieving, 431 Risk for disproportionate Growth, 431 Deficient community Health, 435 Risk-prone Health behavior, 438 Ineffective Health management, 443 Ineffective Family Health management, 448 Readiness for Enhanced Health management, 451 Ineffective Health maintenance, 455 Impaired Home maintenance, 459 Readiness for enhanced Hope, 463 Hopelessness, 466 Risk for compromised Human Dignity, 471 Hyperthermia, 473 Hypothermia, 478 Risk for Hypothermia, 484 Risk for Perioperative Hypothermia, 485 Disturbed personal Identity, 488 Risk for disturbed personal Identity, 495 Ineffective Impulse control, 495 Bowel Incontinence, 498 Functional urinary Incontinence, 503 Overflow urinary Incontinence, 507 Reflex urinary Incontinence, 507 Risk for urge urinary Incontinence, 511 Stress urinary Incontinence, 512 Urge urinary Incontinence, 517 Disorganized Infant behavior, 522 Readiness for enhanced organized Infant behavior, 527 Risk for disorganized Infant behavior, 527

Parental Role conflict, 727 Ineffective Role performance, 730 Sedentary lifestyle, 735 Readiness for enhanced Self-Care, 740 Bathing Self-Care deficit, 747 Dressing Self-Care deficit, 751 Feeding Self-Care deficit, 753 Toileting Self-Care deficit, 757 Readiness for enhanced Self-Concept, 760 Chronic low Self-Esteem, 763 Risk for chronic low Self-Esteem, 767 Risk for situational low Self-Esteem, 767 Situational low Self-Esteem, 770 Self-Mutilation, 772 Risk for Self-Mutilation, 775 Self-Neglect, 780 Sexual dysfunction, 784 Ineffective Sexuality pattern, 790 Risk for Shock, 797 Impaired Sitting, 802 Impaired Skin integrity, 805 Risk for impaired Skin integrity, 808 Readiness for enhanced Sleep, 811 Sleep deprivation, 814 Disturbed Sleep pattern, 817 Impaired Social interaction, 820 Social Isolation, 824 Chronic Sorrow, 829 Spiritual distress, 833 Risk for Spiritual distress, 838 Readiness for enhanced Spiritual well-being, 838 Impaired Standing, 842 Stress overload, 845 Risk for Sudden Infant Death syndrome, 849 Risk for Suffocation, 852 Risk for Suicide, 855 Delayed Surgical recovery, 865 Risk for delayed Surgical recovery, 870 Impaired Swallowing, 870 Risk for imbalanced body Temperature, 875 Risk for Thermal injury, 875 Ineffective Thermoregulation, 877 Impaired Tissue integrity, 882 Risk for impaired Tissue integrity, 886 Ineffective peripheral Tissue Perfusion, 886 Risk for ineffective peripheral Tissue Perfusion, 891 Impaired Transfer ability, 891 Risk for Trauma, 895 Unilateral Neglect, 900 Impaired Urinary elimination, 902 Readiness for enhanced Urinary elimination, 905 Urinary Retention, 907 Risk for Vascular Trauma, 912 Impaired spontaneous Ventilation, 916 Dysfunctional Ventilatory weaning response, 922 Risk for other-directed Violence, 927 Risk for self-directed Violence, 939 Impaired Walking, 939 Wandering, 943

Risk for Infection, 528 Risk for Injury, 534 Risk for corneal Injury, 540 Risk for urinary tract Injury, 542 Insomnia, 544 Decreased Intracranial adaptive capacity, 547 Neonatal Jaundice, 550 Risk for neonatal Jaundice, 554 Deficient Knowledge, 555 Readiness for enhanced Knowledge, 559 Latex Allergy response, 561 Risk for Latex Allergy response, 566 Risk for impaired Liver function, 568 Risk for Loneliness, 572 Risk for disturbed Maternal–Fetal dyad, 576 Impaired Memory, 579 Impaired bed Mobility, 583 Impaired physical Mobility, 588 Impaired wheelchair Mobility, 595 Impaired Mood regulation, 599 Moral Distress, 601 Nausea, 604 Noncompliance, 609 Readiness for enhanced Nutrition, 609 Imbalanced Nutrition: less than body requirements, 615 Obesity, 621 Impaired Oral Mucous Membrane, 625 Risk for impaired Oral Mucous Membrane, 630 Overweight, 631 Risk for Overweight, 635 Acute Pain, 639 Chronic Pain, 646 Labor Pain, 654 Chronic Pain syndrome, 654 Impaired Parenting, 655 Readiness for enhanced Parenting, 659 Risk for impaired Parenting, 662 Risk for Perioperative Positioning injury, 663 Risk for Peripheral Neurovascular dysfunction, 666 Risk for Poisoning, 668 Post-Trauma syndrome, 675 Risk for Post-Trauma syndrome, 679 Readiness for enhanced Power, 683 Powerlessness, 685 Risk for Powerlessness, 689 Risk for Pressure ulcer, 690 Ineffective Protection, 694 Rape-Trauma syndrome, 698 Ineffective Relationship, 704 Readiness for enhanced Relationship, 704 Risk for ineffective Relationship, 707 Impaired Religiosity, 708 Readiness for enhanced Religiosity, 710 Risk for impaired Religiosity, 711 Relocation stress syndrome, 712 Risk for Relocation stress syndrome, 717 Risk for ineffective Renal perfusion, 717 Impaired Resilience, 721 Readiness for enhanced Resilience, 723 Risk for impaired Resilience, 725

You can now purchase Elsevier products on Evolve! Go to evolve.elsevier.com/html/shop-promo.html to search and browse for products.

Evolve Student Resources for Ackley: Nursing Diagnosis Handbook, 11th Edition, include the following:

• Care Plan Constructor Build a comprehensive individualized care plan with ease and confidence! The

Ackley, Ladwig, and Makic Care Plan Constructor allows you to access a list of common medical diagnoses, diagnostic procedures, clinical states, symptoms, and problems that are linked to 100 2015-2017 NANDA-I approved nursing care plans.

• Case Studies Apply the nursing process when building

a care plan. Each case study is linked to the care plan constructor for a complete study tool.

• Review Questions for the NCLEX Exam (150 questions with answers and rationales)

Test your knowledge with 150 multiple-choice review questions with answers and rationales!

• Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) Lists

Choose the correct interventions to enhance patient outcomes and develop the appropriate client outcomes for your care plan by using the list of 544 NIC labels and 490 NOC labels.

Activate the complete learning experience that comes with each textbook purchase by registering at

http://evolve.elsevier.com/Ackley/NDH

YOU’VE JUST PURCHASED

MORE THAN A TEXTBOOK!

REGISTER TODAY!

2015v1.0

NURSING DIAGNOSIS

HANDBOOK AN EVIDENCE-BASED GUIDE TO PLANNING CARE

Eleventh Edition

Betty J. Ackley, MSN, EdS, RN Gail B. Ladwig, MSN, RN Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN

3251 Riverport Lane St. Louis, Missouri 63043

NURSING DIAGNOSIS HANDBOOK, ELEVENTH EDITION ISBN: 978-0-323-32224-9

Copyright © 2017 by Elsevier, Inc. All rights reserved.

No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

NANDA International, Inc. Nursing Diagnoses: Definitions & Classifications 2015-2017, Tenth Edition. Edited by T. Heather Herdman and Shigemi Kamitsuru. 2014 NANDA International, Inc. Published 2014 by John Wiley & Sons, Ltd. Companion website: www.wiley.com/go/nursingdiagnoses. In order to make safe and effective judgments using NANDA-I diagnoses it is essential that nurses refer to the definitions and defining characteristics of the diagnoses listed in this work.

Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions.

To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors, assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Previous editions copyrighted 2014, 2011, 2008, 2006, 2004, 2002, 1999, 1997, 1995, 1993.

Library of Congress Cataloging-in-Publication Data

Names: Ackley, Betty J., editor. | Ladwig, Gail B., editor. | Makic, Mary Beth Flynn, editor. Title: Nursing diagnosis handbook : an evidence-based guide to planning care / [edited by] Betty J. Ackley,

Gail B. Ladwig, Mary Beth Flynn Makic. Description: Eleventh edition. | St. Louis, Missouri : Elsevier, [2017] | Includes bibliographical references

and index. Identifiers: LCCN 2015042558 | ISBN 9780323322249 (pbk. : alk. paper) Subjects: | MESH: Nursing Diagnosis—Handbooks. | Evidence-Based Nursing—methods—Handbooks. |

Patient Care Planning—Handbooks. Classification: LCC RT48.6 | NLM WY 49 | DDC 616.07/5—dc23 LC record available at http://lccn.loc.gov/2015042558

Content Strategist: Sandra Clark Content Development Specialist:

Jennifer Wade Publishing Services Manager: Jeff Patterson

Printed in the United States of America

Last digit is the print number: 9 8 7 6 5 4 3 2 1

Book Production Specialist: Carol O’Connell

Production Manager: Andrea Villamero Design Direction: Paula Catalano

In Memory of Betty J. Ackley

Dreams Dreams come

Dreams go Whispers, shouts, images

Dreams come Dreams go

Follow, follow*

Betty believed in dreams. This textbook was our dream. We set out to write the best nursing diagnosis textbook ever. Our book is now in 1400 nursing programs. It has been high on Amazon’s best seller list. I think her dream is realized. From a handout to students to an international publication. Thank you, dear friend Betty.

Betty passed away in December 2014 at her home with her husband (Dale) and daughter (Dawn) present.

Betty fought a gallant battle with pancreatic cancer for nine months. She loved life, her family, and the profession of nursing. She was an active member of NANDA-I for more than two decades. She was also Professor Emeritus, Jackson Community College (Jackson, Michigan). Betty was an instructor at Jackson Community College for 34 years and was named Faculty of the Year.

Betty provided presentations on nursing diagnosis in Japan and across the United States. She wrote a column on nursing diagnosis for a Japanese journal, Expert Nurse. Betty was known for her work as a co-author of several textbooks on diagnoses, outcomes, and interventions. She served on several NANDA-I committees over the years, the most recent of which was as Chair of the most recent nomi- nating committee. She recruited one of the strongest slates of nominees that NANDA-I has had in many years, due to her tireless efforts.

Betty will be remembered as a very giving person. She had an ability to help others in their time of need and provide comfort and direction for them. She was a certified instructor in aerobics, spin- ning, Zumba, and Pilates. For years she loved to run, and she finished two Detroit Marathons. Her passion included gardening, traveling, authoring this textbook, and watching her two grandchil- dren grow.

The following is a quote from Betty’s husband: Betty saw a need and was able to help fill that need by working to complete this book and see it through to publication. She was very proud of each edition of this book. She always strived to make each edition as good as it could be.

Betty was a loving daughter, grandmother, mother, and wife. She cared about people and was always helping everyone to be their very best. This book will continue to be her way of giving to the profession she loved. Nursing gave a lot to Betty, and she returned the love of nursing by writing the most helpful book she could write.

Dale Ackley

Also Dedicated to Jerry Ladwig, my wonderful husband, who, after 51 years, is still supportive and helpful—he has been “my right-hand man” in every revision of this book. Also to my very special children, their spouses, and all of my grandchildren: Jerry, Kathy, Alexandra, Elizabeth, and Benjamin Ladwig; Christine, John, Sean, Ciara, and Bridget McMahon; Jennifer, Jim, Abby, Katelyn, Blake, and Connor Martin; Amy, Scott, Ford, and Vaughn Bertram—the greatest family anyone could ever hope for.

Gail B. Ladwig

My husband, Zlatko, and children, Alexander and Erik, whose unconditional love and support are ever present in my life. To my parents and sisters for always encouraging me to follow my passion. To Gail, for her incredible mentorship, guidance, and encouragement this past year. And finally to Betty, for believing in me and providing me with an opportunity to more fully contribute to this amazing textbook in support of nurses and the patients and families we serve.

Mary Beth Flynn Makic

*Gail Ladwig, 2015

vi

About the Authors

Betty Ackley worked in nursing for 40 years in many capacities. She was a staff nurse on a CCU unit, medical ICU unit, respiratory ICU unit, inten- sive care unit, and step-down unit. She worked on a gynecological surgery floor and on an orthopedic floor, and spent many years working in oncol-

ogy. She also was in management and nursing education in a hospital, and she spent 31 years as a professor of nursing at Jackson Community College. At the college she taught med- ical-surgical nursing, critical care nursing, fundamentals of nursing, nursing leadership, and nutrition. In addition she served as a nursing consultant for nursing continuing educa- tion at the college. In 1996 she began the online learning program at Jackson Community College, offering an online course in nutrition. In 2000, Betty was named Faculty of the Year at her college.

Betty presented conferences nationally and internationally in the areas of nursing diagnosis, nursing process, online learning, and evidence-based nursing. She wrote NCLEX- RN questions for the national licensure examination four times and was an expert in the area of testing and NCLEX preparation.

Betty obtained her BSN from Michigan State University, MS in nursing from the University of Michigan, and educa- tion specialist degree from Michigan State University.

Betty is co-author of Nursing Diagnosis: Guide to Planning Care, which has been a successful text for 20 years, and co- author for four editions of Mosby’s Guide to Nursing Diagno- sis. She was also a lead co-author/editor of Evidence-Based Nursing Care Guidelines: Medical-Surgical Interventions. This text is designed to help nurses easily find and use evidence to provide excellence in nursing care. The text was published in 2008 and was named AJN book of the year.

Her free time was spent exercising, especially teaching Zumba and Pilates, and also taking spinning classes, kick boxing, and keeping moving. She taught classes in Total Control, a program to help women with urinary inconti- nence. In addition, she loved to travel, read, garden, spend time with her grandchildren, and learn anything new!

Gail Ladwig is a professor emeritus of Jackson Community College. During her tenure, she served 4 years as the Department Chairperson of Nursing and as a nurse consultant for Continu- ing Education. She was instrumental in starting a BSN transfer program with the University of Michigan.

Gail has taught classroom and clinical at JCC in funda- mentals, med-surg, mental health, and a transfer course for BSN students. In addition, she has taught online courses in pharmacology, as well as a hybrid course (partially online) for BSN transfer students. She has also taught an online course in pathophysiology for the Medical University of South Carolina.

She worked as a staff nurse in medical-surgical nursing and intensive care for more than 20 years prior to beginning her teaching career. She was a certified critical-care nurse for several years and has a master’s degree in Psychiatric Mental Health Nursing from Wayne State University. Her master’s research was published in the International Journal of Addictions.

She has presented nationally and internationally, includ- ing Paris, Tokyo, and Puerto Rico, on many topics, including nursing diagnosis, computerized care planning, and holistic nursing topics.

Gail is co-author of Nursing Diagnosis: Guide to Planning Care, which has been a very successful text for more than 20 years, and she has been co-author for all editions of Mosby’s Guide to Nursing Diagnosis, now in its fifth edition. She is also a co-author/editor of Evidence-Based Nursing Care Guide- lines: Medical-Surgical Interventions. This text was published in 2008 and was named AJN book of the year.

Gail has been an active member and supporter of NANDA-I for many, many years.

Gail is the mother of 4 children and grandmother of 12 and loves to spend time with her grandchildren. She has been married to her husband Jerry for 51 years and is passionate about her family and the profession of nursing.

vii

Mary Beth Flynn Makic is an associate professor at the University of Colo- rado, College of Nursing, Aurora, Colorado. At the college she teaches in the undergraduate and graduate pro- grams. She is co-director of the Clini- cal Nurse Specialist graduate degree program at the College of Nursing. She

has worked predominately in critical care for 30 years. Mary Beth is best known for her publications and presentations, regionally and nationally, as an expert on evidence-based practice in nursing. Her practice expertise and research focuses on the care of the trauma, general surgical, and burn injured patient populations; acute wound healing; pressure ulcer prevention; and hospital-acquired conditions (HACs). She is passionate about nurses’ understanding and translating current best evidence into practice to optimize patient and family outcomes. She is co-author of Trauma Nursing: from Resuscitation through Rehabilitation and a section editor of American Association of Critical Care Nurses Procedure Manual for Critical Care. She is actively involved in several professional nursing and interprofessional organizations.

viii

Contributors

†Betty J. Ackley, MSN, EdS, RN President and Owner, The Betty Ackley, LLC; Consultant in Nursing Process, Evidence-Based Nursing,

and Pilates Jackson, Michigan

Michelle Acorn, DNP, NP PHC/adult, BA, BScN/ PHCNP, MN/ACNP, ENC(C), GNC(C), CAP, CGP Lead NP Lakeridge Health Whitby, Ontario; Primary Health Care NP, Global Health Coordinator Nursing Department University of Toronto Toronto, Ontario Canada

Keith A. Anderson, MSW, PhD Associate Professor School of Social Work University of Montana Missoula, Montana

Amanda Andrews, MA, Ed, BSc, DN, RN, HEA Fellow Program Lead Education for Health Group Warwick United Kingdom

Jessica Bibbo, MA Human Development and Family Science University of Missouri Columbia, Missouri

Kathaleen C. Bloom, PhD, CNM Professor and Associate Director Undergraduate Programs School of Nursing University of North Florida Jacksonville, Florida

Lina Daou Boudiab, MSN, RN VA Nursing Academic Partnership Faculty Nursing Services Aleda E. Lutz Veterans Affairs Medical Center Saginaw, Michigan

Lisa Burkhart, PhD, RN, ANEF Associate Professor Marcella Niehoff School of Nursing Loyola University Chicago, Illinois

Melodie Cannon, DNP, MSc/FNP, BHScN, RN(EC), NP-PHC, CEN, GNC(C) Nurse Practitioner Internal Medicine/Emergency Department Rouge Valley Health System Toronto, Ontario Canada; Adjunct Lecturer Lawrence S. Bloomberg Faculty of Nursing University of Toronto, Ontario Canada

Stacey M. Carroll, PhD, ANP-BC Nursing Department Rush University College of Nursing Chicago, Illinois; School of Nursing Anna Maria College Paxton, Massachusetts

Stephanie C. Christensen, PhD, CCC-SLP Senior Lecturer Health Sciences Northern Arizona University Flagstaff, Arizona

June M. Como, EdD, RN, CNS Assistant Professor–Nursing School of Health Sciences Graduate and Clinical Doctorate in Nursing Programs

Coordinator College of Staten Island—City University of New York Staten Island, New York

Maureen F. Cooney, DNP, FNP-BC Pain Management Nurse Practitioner Westchester Medical Center Valhalla, New York; Adjunct Associate Professor Pace University College of Health Professions Lienhard School of Nursing New York, New York

†Deceased.

Contributors ix

Vanessa Flannery, MSN, PHCNS-BC, CNE Associate Professor Nursing Department Morehead State University Morehead, Kentucky

Shari D. Froelich, DNP, MSN, MSBA, ANP, BC, ACHPN, PMHNP, BC Nurse Practitioner Alcona Health Center Alpena, Michigan

Tracy P. George, DNP, APRN-BC, CNE Instructor Nursing Department Francis Marion University Florence, South Carolina

Susanne W. Gibbons, PhD, C-ANP/GNP Assistant Professor Daniel K. Inouye Graduate School of Nursing Uniformed Services University of the Health Sciences Bethesda, Maryland

Barbara A. Given, PhD, RN, FAAN University Distinguished Professor College of Nursing Michigan State University East Lansing, Michigan

Mila W. Grady, MSN, RN Lecturer College of Nursing University of Iowa Iowa City, Iowa

Pauline McKinney Green, PhD, RN, CNE Professor Emeritus Graduate Nursing Howard University College of Nursing and Allied

Health Sciences Washington, DC

Sherry A. Greenberg, PhD, RN, GNP-BC Program Director, Advanced Certificate in Gerontology Adjunct Clinical Assistant Professor of Nursing The Hartford Institute for Geriatric Nursing NYU College of Nursing New York, New York

Dianne Frances Hayward, RN, MSN, WHNP Women’s Health Nurse Practitioner Nursing Education University of Michigan, Flint Flint, Michigan; Oakland Community College Waterford, Michigan

Ruth M. Curchoe, RN, BSN, MSN, CIC Independent Consultant, Infection Prevention Rochester, New York

Mary Alice DeWys, RN, BS, CIMI Infant Development and Feeding Specialist Grand Valley University Preemie Development Assessment

Team President of Hassle Free Feeding Program Division of

Harmony Through Touch Grand Rapids, Michigan

Susan M. Dirkes, RN, MS, CCRN Staff Nurse, Consultant Intensive Care University of Michigan Health System Ann Arbor, Michigan

Roberta Dobrzanski, MSN, RN Academic Instructional Staff College of Nursing University of Wisconsin Oshkosh Oshkosh, Wisconsin

Julianne E. Doubet, BSN, RN, CEN, NREMT-P Certified Emergency Nurse Pre-Hospital Care Educator Mason, Ohio

Lorraine Duggan, MSN, ACNP-BC United Health Group–Optum Clinical Stroudsburg, Pennsylvania

Shelly Eisbach, PhD, RN, PMHNP-BC Consulting Associate Duke University School of Nursing Durham, North Carolina

Dawn Fairlie, ANP, FNP, GNP, DNS(c) Faculty College of Staten Island The City University of New York Staten Island, New York

Arlene T. Farren, RN, PhD, AOCN, CTN-A Associate Professor College of Staten Island The City University of New York Staten Island, New York

Debora Yvonne Fields, RN, BSN, MA, LICDC, CCMC Cleveland, Ohio

Noelle L. Fields, PhD, LCSW Assistant Professor School of Social Work The University of Texas at Arlington Arlington, Texas

x Contributors

Marina Martinez-Kratz, MS, RN, CNE Professor of Nursing Nursing Department Jackson College Jackson, Michigan

Ruth McCaffrey, DNP, ARNP, FNP-BC, GNP-BC, FAAN Sharon Raddock Distinguished Professor Christine E. Lynn College of Nursing Florida Atlantic University Boca Raton, Florida

Graham J. McDougall, Jr., PhD, RN, FAAN, FGSA Professor, Martha Saxon Endowed Chair Capstone College of Nursing University of Alabama Tuscaloosa, Alabama

Laura Mcilvoy, PhD, RN, CCRN, CNRN Associate Professor School of Nursing Indiana University Southeast New Albany, Indiana

Marsha McKenzie, MA Ed, BSN, RN Associate Dean of Academic Affairs Big Sandy Community and Technical College Prestonsburg, Kentucky

Annie Muller, DNP, APN-BC Assistant Professor of Nursing Francis Marion Univeristy Florence, South Carolina

Katherina Nikzad-Terhune, PhD, LCSW Therapist Beaumont Behavior Health; Adjunct Professor College of Social Work University of Kentucky Lexington, Kentucky

Barbara J. Olinzock, MSN, EdD, RN Assistant Professor in Nursing School of Nursing Brooks College of Health University of North Florida Jacksonville, Florida

Wolter Paans, MSc, PhD, RN Professor in Nursing Diagnostics Hanze University of Applied Sciences Groningen, The Netherlands

Margaret Elizabeth Padnos, RN, AB, BSN, MA Independent Nurse Consultant/Poet and Essayist Holland, Michigan

Paula D. Hopper, MSN, RN, CNE Professor of Nursing, Emeritus Jackson College; Lecturer Eastern Michigan University Jackson, Michigan

Wendie A. Howland, MN, RN-BC, CRRN, CCM, CNLCP, LNCC Life Care Planner, Legal Nurse Consultant Howland Health Consulting, Inc. Pocasset, Massachusetts

Rebecca Johnson, PhD, RN, FAAN, FNAP Millsap Professor of Gerontological Nursing MU Sinclair School of Nursing; Professor & Director Research Center for Human Animal Interaction MU College of Veterinary Medicine University of Missouri Columbia, Missouri

Nicole Jones, MSN, FNP-BC Family Nurse Practitioner, Adjunct Professor of Nursing Department of Advanced Nursing Northern Kentucky University Highland Heights, Kentucky

Jane M. Kendall, RN, BS, CHT Holistic Health Consultant Hilton Head, South Carolina

Katharine Kolcaba, PhD, RN Professor Emeritus Nursing Department The University of Akron Akron, Ohio

Gail B. Ladwig, MSN, RN Consultant in Guided Imagery, Healing Touch, Nursing

Diangosis Hilton Head, South Carolina

Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN Associate Professor University of Colorado College of Nursing Aurora, Colorado

Mary P. Mancuso, MA, Counseling Psychology Professional Research Assistant & Patient Education

Development Assistant University of Colorado Hospital Aurora, Colorado

Victoria K. Marshall, RN, BSN Graduate Research Assistant College of Nursing Michigan State University East Lansing, Michigan

Contributors xi

A.B. St. Aubyn, BSc (Hons), RGN, RM, RHV, DPS:N (CHS), MSc, PGCert (Education), HEA Fellow Senior Lecturer Faculty of Health, Education, and Life Sciences Birmingham City University Birmingham, United Kingdom

Andrea G. Steiner, MS, RD, LD, CNSC Clinical Dietitian Houston, Texas

Elaine E. Steinke, PhD, APRN, CNS-BC, FAHA, FAAN Professor School of Nursing Wichita State University Wichita, Kansas

Laura May Struble, PhD, GNP-BC Clinical Assistant Professor School of Nursing University of Michigan Ann Arbor, Michigan

Denise Sullivan, MSN, ANP-BC Adult Nurse Practitioner, Anesthesiology/Pain Management

Service Jacobi Medical Center Bronx, New York

Dennis C. Tanner, PhD Professor of Health Sciences Program in Speech-Language Sciences and Technology Department of Health Sciences Northern Arizona University Flagstaff, Arizona

Janelle M. Tipton, MSN, RN, AOCN Oncology Clinical Nurse Specialist; Manager, Outpatient

Infusion Center Eleanor N. Dana Cancer Center University of Toledo Medical Center Toledo, Ohio

William J. Trees, DNP, FNP-BC, CNP, RN Nurse Practitioner Occupational Medicine Trihealth, Good Samaritan Hospital; Clinical Faculty Advance Nursing Studies Northern Kentucky University; Adjunct Faculty College of Nursing University of Cincinnati Cincinnati, Ohio

Barbara Baele Vincensi, PhD, RN, FNP Assistant Professor of Nursing Hope College Holland, Michigan

Chris Pasero, MS, RN-BC, FAAN Pain Management Educator and Clinical Consultant Rio Rancho, New Mexico

Kathleen L. Patusky, MA, PhD, RN, CNS Assistant Professor School of Nursing Rutgers University Newark, New Jersey

Sherry H. Pomeroy, PhD, RN Associate Professor School of Nursing D’Youville College; Professor Emeritus School of Nursing University at Buffalo, The State University of New York Buffalo, New York

Ann Will Poteet, MS, RN, CNS Clinical Nurse Specialist College of Nursing University of Colorado Aurora, Colorado

Lori M. Rhudy, PhD, RN, CNRN, ACNS-BC Clinical Associate Professor School of Nursing University of Minnesota; Clinical Nurse Researcher Mayo Clinic Rochester, Minnesota

Mary Jane Roth, RN, BSN, MA Nurse Clinician Outpatient Psychiatry Ann Arbor Veterans Medical Center Ann Arbor, Michigan

Paula Riess Sherwood, RN, PhD, CNRN, FAAN Professor and Vice Chair of Research Acute and Tertiary Care Department School of Nursing University of Pittsburgh Pittsburgh, Pennsylvania

Debra Siela, PhD, RN, CCNS, ACNS-BC, CCRN-K, CNE, RRT Associate Professor of Nursing School of Nursing Ball University Muncie, Indiana

Kimberly Silvey, MSN, RN Minimum Data Set Coordinator Signature Healthcare Lexington, Kentucky

xii Contributors

Linda S. Williams, RN, MSN Professor of Nursing Jackson College Jackson, Michigan

David Wilson, MS, RNC Staff Nurse Children’s Hospital at Saint Francis Tulsa, Oklahoma

Ruth A. Wittmann-Price, PhD, RN, CNS, CNE, CHSE, ANEF, FAAN Professor and Chairperson, Department of Nursing Francis Marion University Florence, South Carolina

Melody Zanotti, RN Strongsville, Ohio

Karen Zulkowski, DNS, RN Associate Professor Nursing Department Montana State University—Bozeman Bozeman, Montana

Kerstin West-Wilson, RNC, IBCLC, BA Biology, BSN, MS Nutrition, Safe Kids NRP Car Seat Certified, BLS Instructor NICU Discharge Nurse and Lactation Consultant Henry Zarro Neonatal Intensive Care Unit at the Children’s

Hospital at Saint Francis Saint Francis Health System Tulsa, Oklahoma

Barbara J. Wheeler, RN, BN, MN, IBCLC Clinical Specialist and Lactation Consultant Women and Child Program St. Boniface Hospital; Instructor II Faculty of Health Sciences College of Nursing University of Manitoba; Professional Affiliate Manitoba Centre for Nursing and Health Research Winnipeg, Manitoba Canada

Suzanne White, MSN, RN, PHCNS-BC Assistant Professor of Nursing Morehead State University Morehead, Kentucky

xiii

Reviewers

Debbie Bomgaars, RN, BSN, MSN, PhD Associate Professor of Nursing Chair of the Department of Nursing Dordt College Sioux Center, Iowa

Anna M. Bruch, RN, MSN Nursing Professor Illinois Valley Community College Ogelsby, Illinois

Ruth A. Chaplen, RN, DNP, ACNS-BC, AOCN Assistant Professor, Clinical Wayne State University Detroit, Michigan

Marianne Curia, PhD, MSN, RN Assistant Professor University of St. Francis Joliet, Illinois

Annie Marie Graf, MSN, RN Advanced Medical Surgical Nursing Lead Faculty Georgia Southern University Statesboro, Georgia

Jean Herrmann, MSN, CNRN, RN Professor, Junior Level Coordinator Augustana College Sioux Falls, South Dakota

Jorie L. Kulczak, RN, MSN Associate Professor Joliet Junior College Joliet, Illinois

Marianne F. Moore, PhD, CNM, RN Assistant Professor Sam Houston State University Huntsville, Texas

Laurie J. Palmer, MS, RN, AOCN Chairperson, Professor Monroe Community College Rochester, New York

Charnelle Parmelee, RN, MSN-Nursing Education Associate Professor of Nursing Western New Mexico University Silver City, New Mexico

JoAnne M. Pearce, MS, RN Assistant Professor Director of Nursing of Programs (ADRN/PN) College of Technology Idaho State University Pocatello, Idaho

Jane E. Ransom, PhD, RN Associate Professor University of Toledo College of Nursing Toledo, Ohio

Barbara Voshall, DNP Professor of Nursing School of Nursing Graceland University Lamoni, Iowa

Kim Webb, MN, RN Adjunct Nursing Instructor Ponca City, Oklahoma

xiv

Preface

Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care is a convenient reference to help the practicing nurse or nursing student make a nursing diagnosis and write a care plan with ease and confidence. This handbook helps nurses correlate nursing diagnoses with known information about clients on the basis of assessment findings; established medical, surgical, or psychiatric diagnoses; and the current treatment plan.

Making a nursing diagnosis and planning care are complex processes that involve diagnostic reasoning and critical think- ing skills. Nursing students and practicing nurses cannot pos- sibly memorize the extensive list of defining characteristics, related factors, and risk factors for the 235 diagnoses approved by NANDA-International. There are two additional diagnoses that the authors think are significant: Hearing Loss and Vision Loss. These diagnoses are contained in Appendix E. This book correlates suggested nursing diagnoses with what nurses know about clients and offers a care plan for each nursing diagnosis.

Section I, Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing, is divided into two parts. Part A includes an overview of the nursing process. This section provides information on how to make a nursing diagnosis and directions on how to plan nursing care. It also includes information on using clinical reasoning skills and eliciting the “client’s story.” Part B includes advanced nursing concepts: Concept mapping, QSEN (Quality and Safety Education for Nurses), Evidence-based nursing care, Quality nursing care, Patient-centered care, Safety, Informatics in nursing, Team/collaborative work with multidisciplinary team, and Root cause thinking.

In Section II, Guide to Nursing Diagnoses, the nurse can look up symptoms and problems and their suggested nursing diagnoses for more than 1450 client symptoms; medical, surgical, and psychiatric diagnoses; diagnostic procedures; surgical interventions; and clinical states.

In Section III, Guide to Planning Care, the nurse can find care plans for all nursing diagnoses suggested in Section II. We have included the suggested nursing outcomes from the Nursing Outcomes Classification (NOC) and interven- tions from the Nursing Interventions Classification (NIC) by the Iowa Intervention Project. We believe this work is a sig- nificant addition to the nursing process to further define nursing practice with standardized language.

Scientific rationales based on research are included for most of the interventions. This is done to make the evidence base of nursing practice apparent to the nursing student and practicing nurse.

New special features of the eleventh edition of Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care include the following: • Labeling of classic older research studies that are still rel-

evant as Classic Evidence Based (CEB) • Twenty-six new nursing diagnoses recently approved by

NANDA-I, along with retiring seven nursing diagnoses: Disturbed energy field, Adult failure to thrive, Readiness for enhanced immunization status, Imbalanced nutrition: more than body requirements, Risk for imbalanced nutri- tion: more than body requirements, Impaired environ- mental interpretation syndrome, and Delayed growth and development

• Five revisions of nursing diagnoses made by NANDA-I in existing nursing diagnoses • Old diagnosis: Ineffective Self-Health management

Revised diagnosis: Ineffective Health management • Old diagnosis: Readiness for enhanced Self-Health

management Revised diagnosis: Readiness for enhanced Health management

• Old diagnosis: Ineffective family Therapeutic Regimen Management Revised diagnosis: Ineffective family Health management

• Old diagnosis: Impaired individual Resilience Revised diagnosis: Impaired Resilience

• Old diagnosis: Risk for compromised Resilience Revised diagnosis: Risk for impaired Resilience

• Further addition of pediatric and critical care interven- tions to appropriate care plans

• An associated Evolve Online Course Management System that includes a care plan constructor, critical thinking case studies, Nursing Interventions Classification (NIC) and Nursing Outcomes Classification (NOC) labels, PowerPoint slides, and review questions for the NCLEX-RN® exam

• Appendixes for Nursing Diagnoses Arranged by Maslow’s Hierarchy of Needs, Nursing Diagnoses Arranged by Gor- don’s Functional Health Patterns, Motivational Interview- ing for Nurses, Wellness-Oriented Diagnostic Categories, and Nursing Care Plans for Hearing Loss and Vision Loss The following features of Nursing Diagnosis Handbook: A

Guide to Planning Care are also available: • Suggested nursing diagnoses for more than 1450 clinical

entities, including signs and symptoms, medical diagno- ses, surgeries, maternal-child disorders, mental health disorders, and geriatric disorders

Preface xv

• Inclusion of commonly used abbreviations (e.g., AIDS, MI, CHF) and cross-references to the complete term in Section II We acknowledge the work of NANDA-I, which is used

extensively throughout this text. In some rare cases, the authors and contributors have modified the NANDA-I work to increase ease of use. The original NANDA-I work can be found in NANDA-I Nursing Diagnoses: Definitions & Classi- fication 2015-2017. Several contributors are the original submitters/authors of the nursing diagnoses established by NANDA-I. These contributors include the following:

Lisa Burkhart, PhD, RN, ANEF Impaired Religiosity; Risk for impaired Religiosity; Readiness for enhanced Religiosity; Spiritual distress; Readiness for enhanced Spiritual well-being

Katharine Kolcaba, PhD, RN Impaired Comfort

Shelly Eisbach, PhD, PMHNP-BC, RN Risk for compromised Resilience; Impaired individual Resil- ience; Readiness for enhanced Resilience

David Wilson, MS, RNC Neonatal Jaundice

Susanne W. Gibbons, PhD, C-ANP/GNP Self-Neglect

Ruth A. Wittmann-Price, PhD, RN, CNS, CNE, CHSE, ANEF, FAAN

Impaired emancipated Decision-Making, Readiness for enhanced emancipated Decision-Making, Risk for impaired emancipated Decision-Making

Wolter Paans, MSCc, PhD, RN Labile Emotional Control

We and the consultants and contributors trust that nurses will find this eleventh edition of Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care a valuable tool that simplifies the process of identifying appropriate nursing diag- noses for clients and planning for their care, thus allowing nurses more time to provide evidence-based care that speeds each client’s recovery.

Betty J. Ackley Gail B. Ladwig

Mary Beth Flynn Makic

• Labeling of nursing research as EBN (Evidence-Based Nursing) and clinical research as EB (Evidence-Based) to identify the source of evidence-based rationales

• An Evolve Online Courseware System with the Ackley- Ladwig Care Plan Constructor that helps the student or nurse write a nursing care plan

• Rationales for nursing interventions that are for the most part based on nursing research

• Nursing references identified for each care plan • A complete list of NOC outcomes on the Evolve website • A complete list of NIC interventions on the Evolve website • Nursing care plans that contain many holistic

interventions • Care plans written by leading national nursing experts

from throughout the United States, along with interna- tional contributors, who together represent all of the major nursing specialties and have extensive experience with nursing diagnoses and the nursing process. Care plans written by experts include: • Caregiver Role Strain and Fatigue by Dr. Barbara A.

Given and Dr. Paula Riess Sherwood • Care plans for Spirituality by Dr. Lisa Burkhart • Care plans for Religiosity by Dr. Lisa Burkhart • Impaired Memory by Dr. Graham J. McDougall, Jr. • Decreased Intracranial adaptive capacity and Risk

for ineffective Cerebral tissue perfusion by Dr. Laura Mcilvoy

• Unilateral Neglect by Dr. Lori M. Rhudy • Anxiety, Death Anxiety, and Fear by Dr. Ruth

McCaffrey • Impaired Comfort by Dr. Katharine Kolcaba • Risk for Infection and Ineffective Protection by Ruth

M. Curchoe • Readiness for enhanced Communication and

Impaired verbal Communication by Dr. Stacey M. Carroll

• Sexual dysfunction and Ineffective Sexuality pattern by Dr. Elaine E. Steinke

• A format that facilitates analyzing signs and symptoms by the process already known by nurses, which involves using defining characteristics of nursing diagnoses to make a diagnosis

• Use of NANDA-I terminology and approved diagnoses • An alphabetical format for Sections II and III, which

allows rapid access to information • Nursing care plans for all nursing diagnoses listed in

Section II • Specific geriatric interventions in appropriate plans of care • Specific client/family teaching interventions in each plan

of care • Information on culturally competent nursing care included

where appropriate

xvi

Acknowledgments

We would like to thank the following people at Elsevier: Sandy E. Clark, Senior Content Strategist, who supported us with this eleventh edition of the text with intelligence and kindness; Jennifer Wade, Content Development Specialist, who was a continual source of support; a special thank you to Carol O’Connell for project management of this edition; and to Melanie Cole for her support.

We acknowledge with gratitude nurses and student nurses, who are always an inspiration for us to provide fresh and accurate material. We are honored that they continue to value this text and to use it in their studies and practice.

Care has been taken to confirm the accuracy of informa- tion presented in this book. However, the authors, editors, and publisher cannot accept any responsibility for conse-

quences resulting from errors or omissions of the information in this book and make no warranty, express or implied, with respect to its contents. The reader should use practices sug- gested in this book in accordance with agency policies and professional standards. Every effort has been made to ensure the accuracy of the information presented in this text.

We hope you find this text useful in your nursing practice.

Betty J. Ackley (Betty was very involved in planning and contributed much until she passed away)

Gail B. Ladwig Mary Beth Flynn Makic

xvii

How to Use Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

Nursing process, clinical reasoning, nursing diagnosis, and evidence-based nursing

and judgment, deliberative rationality, and clinical imagina- .) 0102 ,teyoM-otinepraC ( noit

STEP 1: ASSESSMENT ( A DPIE) lanoitadnuof si ssecorp gnisrun eht fo esahp tnemssessa ehT

for appropriate diagnosis, planning, and intervention. Data on all dimensions of the “patient’s story,” including biophysi- cal, psychological, sociocultural, spiritual, and environmental characteristics, are embedded in the assessment. It involves performing a thorough holistic nursing assessment of the cli- ent. This is the fi rst step needed to make an appropriate nurs- ing diagnosis, and it is done using the assessment format adopted by the facility or educational institution in which the practice is situated. Several organizational approaches to assessment are available, including Gordon’s Functional Health Patterns, a list of concepts relevant to the nurse (see Appendix B on the Evolve website), and head-to-toe and body systems approaches.

”yrots s’tneitap“ eht fo stnenopmoc sessessa esrun ehT every time they perform an assessment. Often, nurses focus on the physical component of the story (e.g., temperature, blood pressure, breath sounds). This component is certainly critical, but it is only one piece. Indeed, one of the unique and wonderful aspects of nursing is the holistic theory that is applied to clients and families. This process of meeting and getting to know the client as a person and bearing witness to the client’s situation or plight is one of the focal caring prac-

.) 0102 ,renneB ( sesrun fo secit fi deniatbo si noitamrofni tnemssessA rst by doing a thor-

ough health and medical history, and by listening to and observing the client. To elicit as much information as possi- ble, the nurse should use open-ended questions, rather than questions that can be answered by a simple yes or no.

gniwollof eht ,stneilc ylredle ni noisserped rof gnineercs nI open-ended questions were useful.

?yadot ereh emoc uoy edam tahW“ • ”?si melborp ruoy kniht uoy od tahW“ •

”?melborp ruoy desuac kniht uoy od tahW“ •

”?ralucitrap ni gnihtyna tuoba deirrow uoy erA“ • ”?raf os melborp eht tuoba od ot deirt uoy evah tahW“ • ”?melborp ruoy tuoba od ot em ekil uoy dluow tahW“ •

ssucsid ot ekil dluow uoy esle gnihtyna ereht sI“ • ) 1102 ,la te lingaM ( ”?yadot

evig ot tneilc eht egaruocne lliw snoitseuq fo sepyt esehT more information about his or her situation. Listen care- fully for cues and record relevant information that the client shares. Even when the client’s physical condition or devel- opmental age makes it impossible for them to verbally com- municate with the health care team, nurses may be able to communicate with the client’s family or signifi cant other to learn more about the client. This information that is obtained verbally from the client is considered subjective information.

lacisyhp a gnimrofrep yb deniatbo osla si noitamrofnI assessment, taking vital signs, and noting diagnostic test results. This information is considered objective .noitamrofni

-rof ot desu si secruos eseht fo lla morf noitamrofni ehT mulate a nursing diagnosis. All of this information needs to be carefully documented on the forms provided by the agency or school of nursing. When recording information, the HIPAA (Health Insurance Portability and Accountability

.ylluferac dewollof eb ot deen snoitaluger ) 7002 ,nworB ( )tcA To protect client confi dentiality, the client’s name should not be used on the student care plan. When the assessment is

.pets txen eht ot deecorp ,etelpmoc

STEP 2: NURSING DIAGNOSIS (A D PIE)

snigeb esrun eht ,ssecorp gnisrun eht fo esahp sisongaid eht nI clustering the information within the client story and formu- lates an evaluative judgment about a client’s health status. Only after a thorough analysis—which includes recognizing cues, sorting through and organizing or clustering the infor- mation, and determining client strengths and unmet needs— can an appropriate diagnosis be made. This process of thinking is called clinical reasoning. Clinical reasoning is the ability to think through a clinical situation as it changes, while taking into account the context and what is important to the

-loc dna senoJ-tteveL .) 0102 ,renneB ( ylimaf rieht dna tneilc fiitnedi evah )0102( seugael ed components of effective clini-

cal reasoning as the nurse’s ability to collect the right cues and to take the right action for the right client at the right time and for the right reason.

siht tuohguorht desu era taht sesongaid gnisrun ehT book are taken from North American Nursing Diagnosis

ehT .) 4102-2102 ,I-ADNAN ( lanoitanretnI—noitaicossA complete nursing diagnosis list is on the inside back cover of this text, and it can also be found on the EVOLVE website that accompanies this text. These diagnoses used throughout this text are listed in alphabetical order by the diagnostic concept. rof gnikool era uoy fI impaired wheelchair mobility, you would fi nd it under mobility, rednu ton wheelchair ro impaired .) 4102-2102 ,I-ADNAN (

Step II Nursing DiagnosisStep I

Assessment

Step III Planning

Outcomes Interventions

Step V Evaluation

Step IV Implementation

A D

P

I

E

Figure I-1 Nursing process.

STEP 2: DIAGNOSE Turn to Section II, Guide to Nursing Diagnoses, and locate the client’s symptoms, clinical state, medical or psychiatric diagnoses, and anticipated or prescribed diagnostic studies or surgical interventions (listed in alphabetical order). Note sug- gestions for appropriate nursing diagnoses.

Then use Section III, Guide to Planning Care, to evaluate each suggested nursing diagnosis and “related to” etiology statement. Section III is a listing of care plans according to NANDA-I, arranged alphabetically by diagnostic concept, for each nursing diagnosis referred to in Section II. Determine the appropriateness of each nursing diagnosis by comparing the Defining Characteristics and/or Risk Factors to the client data collected.

STEP 3: DETERMINE OUTCOMES

Use Section III, Guide to Planning Care, to find appropriate outcomes for the client. Use either the NOC outcomes with the associated rating scales or Client Outcomes as desired.

STEP 1: ASSESS Following the guidelines in Section I, begin to formulate your nursing diagnosis by gathering and documenting the objec- tive and subjective information about the client.

xviii How to Use Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

PLAN INTERVENTIONS Use Section III, Guide to Planning Care, to find appropriate interventions for the client. Use the Nursing Interventions as found in that section.

GIVE NURSING CARE Administer nursing care following the plan of care based on the interventions.

EVALUATE NURSING CARE Evaluate nursing care administered using either the NOC outcomes or Client Outcomes. If the outcomes were not met, and the nursing interventions were not effective, reassess the client and determine if the appropriate nursing diagnoses were made.

DOCUMENT Document all of the previous steps using the format provided in the clinical setting.

xix

Contents

SECTION I Nursing Process, Clinical Reasoning, Nursing Diagnosis, and Evidence-Based Nursing, 1 An explanation of how to make a nursing diagnosis using diagnostic reasoning, which is critical thinking. Then information on how to plan care using the nursing process, standardized nursing language, and evidence-based nursing.

SECTION II Guide to Nursing Diagnosis, 17 An alphabetized list of medical, surgical, and psychiatric diagnoses; diagnostic procedures, clinical states, symptoms, and problems, with suggested nursing diagnoses. This section enables the nursing student as well as the practicing nurse to make a nursing diagnosis quickly, to save time.

SECTION III Guide to Planning Care, 121 Section III contains the actual nursing diagnosis care plans for each accepted nursing diagnosis of the North American Nursing Diagnosis Association-International (NANDA-I): the definition, defining characteristics, risk factors, related factors, suggested NOC outcomes, client outcomes, suggested NIC interventions, inter- ventions with rationales, geriatric interventions, pediatric interventions, critical care interventions (when appropriate), home care interventions, culturally competent nursing interventions (when appropriate), and client/family teaching and discharge planning for each alphabetized nursing diagnosis.

APPENDIX A Nursing Diagnoses Arranged by Maslow’s Hierarchy of Needs, 949

APPENDIX B Nursing Diagnoses Arranged by Gordon’s Functional Health Patterns, 952

APPENDIX C Motivational Interviewing for Nurses, 955

APPENDIX D Wellness-Oriented Diagnostic Categories, 957

APPENDIX E Nursing Care Plans for Hearing Loss and Vision Loss, 960

This page intentionally left blank

1

SECTION

I Nursing Process, Clinical

Reasoning, Nursing Diagnosis, and Evidence-Based Nursing

Betty J. Ackley, MSN, EdS, RN, Gail B. Ladwig, MSN, RN,

Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN,

and Marina Martinez-Kratz, MS, RN, CNE

Section I is divided into two parts. Part A includes an overview of the nursing process. This section provides information on how to make a nursing diagnosis and directions on how to plan nursing care. It also includes information on using clinical reasoning skills and eliciting the “patient’s story.” Part B includes advanced nursing concepts.

Part A: The Nursing Process: Using Clinical Reasoning Skills to Determine Nursing Diagnosis and Plan Care 1. Assessing: performing a nursing assessment 2. Diagnosing: making nursing diagnoses 3. Planning: formulating and writing outcome statements and determining appropriate nursing interventions

based on appropriate best evidence (research) 4. Implementing care 5. Evaluating the outcomes and the nursing care that has been implemented. Make necessary revisions in

care interventions as needed

Part B: Advanced Nursing Concepts • Concept mapping • QSEN (Quality and Safety Education for Nurses) • Evidence-based nursing care • Quality nursing care • Patient-centered care • Safety • Informatics in nursing • Team/collaborative work with interprofessional team

2 Section i

The primary goals of nursing are to (1) determine client/ family responses to human problems, level of wellness, and need for assistance; (2) provide physical care, emotional care, teaching, guidance, and counseling; and (3) implement inter- ventions aimed at prevention and assisting the client to meet his or her own needs and health-related goals. The nurse must always focus on assisting clients and families to their highest level of functioning and self-care. The care that is provided should be structured in a way that allows clients the ability to influence their health care and accomplish their self- efficacy goals. The nursing process, which is a problem- solving approach to the identification and treatment of client problems, provides a framework for assisting clients and families to their optimal level of functioning. The nursing process involves five dynamic and fluid phases: assessment, diagnosis, planning, implementation, and evaluation. Within each of these phases, the client and family story is embedded and is used as a foundation for knowledge, judg- ment, and actions brought to the client care experience. A description of the “patient’s story” and each aspect of the nursing process follow.

THE “PATIENT’S STORY” The “patient’s story” is a term used to describe objective and subjective information about the client that describes who the client is as a person in addition to their usual medical history. Specific aspects of the story include physiological, psychological, and family characteristics; available resources; environmental and social context; knowledge; and motiva- tion. Care is influenced, and often driven, by what the client states—verbally or through their physiologic state. The “patient’s story” is fluid and must be shared and understood throughout the client’s health care experience.

There are multiple sources for obtaining the patient’s story. The primary source for eliciting this story is through communicating directly with the client and the client’s family. It is important to understand how the illness (or wellness) state has affected the client physiologically, psychologically, and spiritually. The client’s perception of his or her health state is important to understand and may have an impact on subsequent interventions. At times, clients will be unable to tell their story verbally, but there is still much they can com- municate through their physical state. The client’s family (as the client defines them) is a valuable source of information and can provide a rich perspective on the client. Other

valuable sources of the “patient’s story” include the client’s health record. Every time a piece of information is added to the health record, it becomes a part of the “patient’s story.” All nursing care is driven by the client’s story. The nurse must have a clear understanding of the story to effec- tively complete the nursing process. Understanding the full story also provides an avenue for identifying mutual goals with the client and family aimed at improving client out- comes and goals.

Note: The “patient’s story” is terminology that is used to describe a holistic assessment of information about the client, with the client’s and the family’s input as much as possible. In this text, we use the term “patient’s story” in quotes whenever we refer to the specific process. In all other places, we use the term client in place of the word patient; we think labeling the person as a client is more respectful and empowering for the person. Client is also the term that is used in the National Council Licensure Examination (NCLEX-RN) test plan (National Council of State Boards of Nursing, 2013).

Understanding the “patient’s story” is critically important, in that psychological, socioeconomic, and spiritual character- istics play a significant role in the client’s ability and desire to access health care. Also knowing and understanding the “patient’s story” is an integral first step in giving client- centered care. In today’s health care world, the focus is on the client, which leads to increased satisfaction with care. Improv- ing the client’s health care experience is part of the Affordable Care Act and is tied to reimbursement through value-based purchasing of care: “participating hospitals are paid for inpa- tient acute care services based on the quality of care, not just quantity of services they provide” (Centers for Medicare & Medicaid Services, 2014).

THE NURSING PROCESS The nursing process is an organizing framework for profes- sional nursing practice, a critical thinking process for the nurse to use to give the best care possible to the client. It is very similar to the steps used in scientific reasoning and problem solving. This section is designed to help the nursing student learn how to use this thinking process, the nursing process. Key components of the process include the steps listed below. An easy, convenient way to remember the steps of the nursing process is to use an acronym, ADPIE (Figure I-1):

PART

A The Nursing Process: Using Clinical Reasoning Skills to

Determine Nursing Diagnoses and Plan Care

nursing Process, clinical Reasoning, nursing Diagnosis, and evidence-Based nursing 3

the client. To elicit as much information as possible, the nurse should use open-ended questions, rather than questions that can be answered with a simple “yes” or “no.”

In screening for depression in older clients, the following open-ended questions are useful (Lusk & Fater, 2013): • What made you come here today? • What do you think your problem is? • What do you think caused your problem? • Are you worried about anything in particular? • What have you tried to do about the problem so far? • What would you like me to do about your problem? • Is there anything else you would like to discuss today?

These types of questions will encourage the client to give more information about his or her situation. Listen carefully for cues and record relevant information that the client shares. Even when the client’s physical condition or develop- mental age makes it impossible for them to verbally com- municate with the health care team, nurses may be able to communicate with the client’s family or significant other to learn more about the client. This information that is obtained verbally from the client is considered subjective information.

Information is also obtained by performing a physical assessment, taking vital signs, and noting diagnostic test results. This information is considered objective information.

The information from all of these sources is used to for- mulate a nursing diagnosis. All of this information needs to be carefully documented on the forms provided by the agency or school of nursing. When recording information, the HIPAA (Health Insurance Portability and Accountability Act) (Foster, 2012) regulations need to be followed carefully. To protect client confidentiality, the client’s name should not be used on the student care plan. When the assessment is complete, proceed to the next step.

STEP 2: NURSING DIAGNOSIS (ADPIE)

In the diagnosis phase of the nursing process, the nurse begins clustering the information within the client story and formulates an evaluative judgment about a client’s health status. Only after a thorough analysis—which includes recog- nizing cues, sorting through and organizing or clustering the information, and determining client strengths and unmet needs—can an appropriate diagnosis be made. This process of thinking is called clinical reasoning. Clinical reasoning is a cognitive process that uses formal and informal thinking strategies to gather and analyze client information, evaluate the significance of this information, and determine the value of alternative actions (Benner, 2010). Benner (2010) describes this cognitive process as “thinking like a nurse.” Watson and Rebair (2014) referred to “noticing” as a precursor to clinical reasoning. By noticing the nurse can preempt possible risks or support subtle changes toward recovery. Noticing can be the activity that stimulates nursing action before words are exchanged, preempting need. The nurse synthesizes the

1. Assess: perform a nursing assessment 2. Diagnose: make nursing diagnoses 3. Plan: formulate and write outcome/goal statements and

determine appropriate nursing interventions based on the client’s reality and evidence (research)

4. Implement care 5. Evaluate the outcomes and the nursing care that has been

implemented. Make necessary revisions in care interven- tions as needed. The following is an overview and practical application of

the steps of the nursing process. The steps are listed in the usual order in which they are performed.

STEP 1: ASSESSMENT (ADPIE) The assessment phase of the nursing process is foundational for appropriate diagnosis, planning, and intervention. Data on all dimensions of the “patient’s story,” including biophysi- cal, psychological, sociocultural, spiritual, and environmental characteristics, are embedded in the assessment. It involves performing a thorough holistic nursing assessment of the client. This is the first step needed to make an appropriate nursing diagnosis, and it is done using the assessment format adopted by the facility or educational institution in which the practice is situated.

The nurse assesses components of the “patient’s story” every time an assessment is performed. Often, nurses focus on the physical component of the story (e.g., temperature, blood pressure, breath sounds). This component is certainly critical, but it is only one piece. Indeed, one of the unique and wonderful aspects of nursing is the holistic theory that is applied to clients and families. Clients are active partners in the healing process. Nurses must increasingly develop the skills and systems to incorporate client preferences into care (Hess & Markee, 2014). “The challenge facing the nation, and the opportunity afforded by the Affordable Care Act, is to move from a culture of sickness to a culture of care and then to a culture of health” (Institute of Medicine, 2013). Assess- ment information is obtained first by completing a thorough health and medical history, and by listening to and observing

Figure I-1 Nursing process.

Step II Nursing DiagnosisStep I

Assessment

Step III Planning

Outcomes Interventions

Step V Evaluation

Step IV Implementation

A D

P

I

E

4 Section i

Here we use the example of a beginning nursing student who is attempting to understand the nursing process and how to make a nursing diagnosis:

Problem: Use the nursing diagnosis label deficient Knowl- edge from the NANDA-I list. Remember to check the definition: “Absence or deficiency of cognitive information related to a specific topic” (Herdman & Kamitsuru, 2014).

Etiology: r/t unfamiliarity with information about the nursing process and nursing diagnosis. At this point the beginning nurse would not be familiar with available resources regarding the nursing process.

Symptoms: Defining characteristics, as evidenced by (aeb) verbalization of lack of understanding: “I don’t understand this, and I really don’t know how to make a nursing diagnosis.”

When using the PES system, look at the S first, then for- mulate the three-part statement. (You would have gotten the S, symptoms, which are defining characteristics, from your assessment.)

Therefore, the three-part nursing diagnosis is: deficient Knowledge r/t unfamiliarity with information about the nursing process and nursing diagnosis aeb verbalization of lack of understanding.

Types of Nursing Diagnoses There are three different types of nursing diagnoses.

Problem-Focused Diagnosis. “A clinical judgment con- cerning an undesirable human response to a health condition/ process that exists in an individual, family, group or com- munity” (Herdman & Kamitsuru, 2014, p 22).

“Related factors are an integral part of all problem-focused diagnoses. They are etiologies, circumstances, facts or influ- ences that have some type of relationship with the nursing diagnosis” (Herdman & Kamitsuru, 2014, p 26).

Example of a Problem-Focused Nursing Diagnosis. Overweight related to excessive intake in relation to meta- bolic needs, concentrating food intake at the end of the day aeb weight 20% over ideal for height and frame. Note: This is a three-part nursing diagnosis.

Risk Nursing Diagnosis. Risk nursing diagnosis is a “clinical judgment concerning the vulnerability of an indi- vidual, family, group, or community for developing an unde- sirable human response to health conditions/life processes” (Herdman & Kamitsuru, 2014, p 22). “The risk diagnosis is supported by risk factors that increase the vulnerability of a client, family, group, or community to an unhealthy event” (Herdman & Kamitsuru, 2014, p 26). Defining characteristics and related factors are observable cues and circumstances or influences that have some type of relationship with the nursing diagnosis that may contribute to a health problem. Identification of related factors allows nursing interventions to be implemented to address the underlying cause of a nursing diagnosis (Herdman & Kamitsuru, 2014, p 26).

evidence while also knowing the client as part of clinical reasoning that informs client specific diagnoses (Cappelletti, Engel, & Prentice, 2014).

The nursing diagnoses that are used throughout this book are taken from North American Nursing Diagnosis Association—International (Herdman & Kamitsuru, 2014). The complete nursing diagnosis list is on the inside front cover of this text, and it can also be found on the EVOLVE website that accompanies this text. The diagnoses used throughout this text are listed in alphabetical order by the diagnostic concept. For example, impaired wheelchair mobil- ity is found under mobility, not under wheelchair or impaired (Herdman & Kamitsuru, 2014).

The holistic assessment of the client helps determine the type of diagnosis that follows. For example, if during the assessment a client is noted to have unsteady gait and balance disturbance and states, “I’m concerned I will fall while walking down my stairs,” but has not fallen previously, then the client would be identified as having a “risk” nursing diagnosis.

Once the diagnosis is determined, the next step is to deter- mine related factors and defining characteristics. The process for formulating a nursing diagnosis with related factors and defining characteristics follows. A client may have many nursing and medical diagnoses, and determining the priority with which each should be addressed requires clinical reason- ing and application of knowledge.

Formulating a Nursing Diagnosis with Related Factors and Defining Characteristics A working nursing diagnosis may have two or three parts. The two-part system consists of the nursing diagnosis and the “related to” (r/t) statement: “Related factors are factors that appear to show some type of patterned relationship with the nursing diagnosis: such factors may be described as ante- cedent to, associated with, relating to, contributing to, or abetting” (Herdman & Kamitsuru, 2014).

The two-part system is often used when the defining char- acteristics, or signs and symptoms identified in the assess- ment, may be obvious to those caring for the client.

The three-part system consists of the nursing diagnosis, the r/t statement, and the defining characteristics, which are “observable cues/inferences that cluster as manifestations of an actual or wellness nursing diagnosis” (Herdman & Kamitsuru, 2014).

Some nurses refer to the three-part diagnostic statement as the PES system:

P (problem)—The nursing diagnosis label: a concise term or phrase that represents a pattern of related cues. The nursing diagnosis is taken from the official NANDA- I list.

E (etiology)—“Related to” (r/t) phrase or etiology: related cause or contributor to the problem.

S (symptoms)—Defining characteristics phrase: symptoms that the nurse identified in the assessment.

nursing Process, clinical Reasoning, nursing Diagnosis, and evidence-Based nursing 5

his story, he is continually wringing his hands and looking out the window.

B. List the Symptoms (Subjective and Objective) “Difficulty breathing when walking short distances”; “heart feels like it is racing”; heart rate is 110 beats per minute; “tired all the time”; continually wringing his hands and looking out the window.

C. Cluster Similar Symptoms “Difficulty breathing when walking short distances” “Heart feels like it is racing”; heart rate = 110 bpm “Tired all the time” Continually wringing his hands Looking out the window

D. Analyze Interpret the Subjective Symptoms (What the Client Has Stated) • “Difficulty breathing when walking short distances” =

exertional discomfort: a defining characteristic of Activity intolerance

• “Heart feels like it is racing” = abnormal heart rate response to activity: a defining characteristic of Activity intolerance

• “Tired all the time” = verbal report of weakness: a defining characteristic of Activity intolerance

Interpret the Objective Symptoms (Observable Information) • Continually wringing his hands = extraneous movement,

hand/arm movements: a defining characteristic of Anxiety • Looking out the window = poor eye contact, glancing

about: a defining characteristic of Anxiety • Heart rate = 110 beats per minute

E. Select the Nursing Diagnosis Label In Section II, look up dyspnea (difficulty breathing) or dys- rhythmia (abnormal heart rate or rhythm), chosen because they are high priority, and you will find the nursing diagnosis Activity intolerance listed with these symptoms. Is this diagnosis appropriate for this client?

To validate that the diagnosis Activity intolerance is appropriate for the client, turn to Section III and read the NANDA-I definition of the nursing diagnosis Activity intol- erance: “Insufficient physiological or psychological energy to endure or complete required or desired daily activities” (Herdman & Kamitsuru, 2014, p 225). When reading the definition, ask, “Does this definition describe the symptoms demonstrated by the client?” “Is any more assessment infor- mation needed?” “Should I take his blood pressure or take an apical pulse rate?” If the appropriate nursing diagnosis has been selected, the definition should describe the condition that has been observed.

The client may also have defining characteristics for this particular diagnosis. Are the client symptoms that you

Example of a Risk Nursing Diagnosis. Risk for Over- weight: Risk factor: concentrating food at the end of the day. Note: This is a two-part nursing diagnosis.

Health Promotion Nursing Diagnosis. A clinical judg- ment concerning motivation and desire to increase well- being and to actualize human health potential that may be expressed by a readiness to enhance specific health behav- iors or health state. Health promotion responses may exist in an individual, family, group, or community (Herdman & Kamitsuru, 2014, p 22). Health promotion is different from prevention in that health promotion focuses on being as healthy as possible, as opposed to preventing a disease or problem. The difference between health promotion and disease prevention is that the reason for the health behavior should always be a positive one. With a health promotion diagnosis, the outcomes and interventions should be focused on enhancing health.

Example of a Health Promotion Nursing Diagnosis. Readiness for enhanced Nutrition aeb expresses willingness to change eating pattern and eat healthier foods. Note: This is a two-part nursing diagnosis.

Application and Examples of Making a Nursing Diagnosis When the assessment is complete, identify common patterns/ symptoms of response to actual or potential health problems from the assessment and select an appropriate nursing diag- nosis label using clinical reasoning skills. Use the steps with Case Study 1. (The same steps can be followed using an actual client assessment in the clinical setting or in a student assessment.) A. Highlight or underline the relevant symptoms (defining

characteristics). As you review your assessment informa- tion, ask: Is this normal? Is this an ideal situation? Is this a problem for the client? You may go back and validate information with the client.

B. Make a list of the symptoms (underlined or highlighted information).

C. Cluster similar symptoms. D. Analyze/interpret the symptoms. (What do these symp-

toms mean or represent when they are together?) E. Select a nursing diagnosis label from the NANDA-I list

that fits the appropriate defining characteristics and nursing diagnosis definition.

Case Study 1—An Older Client with Breathing Problems

A. Underline the Symptoms (Defining Characteristics) A 73-year-old man has been admitted to the unit with a diagnosis of chronic obstructive pulmonary disease (COPD). He states that he has “difficulty breathing when walking short distances.” He also states that his “heart feels like it is racing” (heart rate is 110 beats per minute) at the same time. He states that he is “tired all the time,” and while talking to you about

6 Section i

be appropriate for the individual client. If they are not appro- priate, the nurse should develop and write an r/t statement that is appropriate for the client. For the client from Case Study 1, a two-part statement could be made here:

Problem = Activity Intolerance Etiology = r/t imbalance between oxygen supply and demand

It was already determined that the client had Activity intolerance. With the respiratory symptoms identified from the assessment, imbalance between oxygen supply and demand is appropriate.

Defining Characteristics Phrase The defining characteristics phrase is the third part of the three-part diagnostic system, and it consists of the signs and symptoms that have been gathered during the assessment phase. The phrase “as evidenced by” (aeb) may be used to connect the etiology (r/t) with the defining characteristics. The use of identifying defining characteristics is similar to the process that the health care provider uses when making a medical diagnosis. For example, the health care provider who observes the following signs and symptoms—diminished inspiratory and expiratory capacity of the lungs, complaints of dyspnea on exertion, difficulty in inhaling and exhaling deeply, and sometimes chronic cough—may make the medical diagnosis of COPD. This same process is used to identify the nursing diagnosis of Activity intolerance.

Put It All Together: Writing the Three-Part Nursing Diagnosis Statement Problem—Choose the label (nursing diagnosis) using the

guidelines explained previously. A list of nursing diagnosis labels can be found in Section II and on the inside front cover.

Etiology—Write an r/t phrase (etiology). These can be found in Section II.

Symptoms—Write the defining characteristics (signs and symptoms), or the “as evidenced by” (aeb) list. A list of the signs and symptoms associated with each nursing diagno- sis can be found in Section III.

Case Study 1—73-Year-Old Male Client with COPD (Continued) Using the information from the earlier case study/example, the nursing diagnostic statement would be as follows:

Problem—Activity intolerance Etiology—r/t imbalance between oxygen supply and demand Symptoms—Verbal reports of fatigue, exertional dyspnea

(“difficulty breathing when walking”), and abnormal heart rate response to activity (“racing heart”), heart rate 110 beats per minute.

Therefore, the nursing diagnostic statement for the client with COPD is Activity intolerance r/t imbalance between

identified in the list of defining characteristics (e.g., verbal report of fatigue, abnormal heart rate response to activity, exertional dyspnea)?

Another way to use this text and to help validate the diagnosis is to look up the client’s medical diagnosis in Section II. This client has a medical diagnosis of COPD. Is Activity Intolerance listed with this medical diagnosis? Con- sider whether the nursing diagnosis makes sense given the client’s medical diagnosis (in this case, COPD). There may be times when a nursing diagnosis is not directly linked to a medical diagnosis (e.g., ineffective Coping) but is neverthe- less appropriate given nursing’s holistic approach to the client/family.

The process of identifying significant symptoms, cluster- ing or grouping them into logical patterns, and then choosing an appropriate nursing diagnosis involves diagnostic reason- ing (critical thinking) skills that must be learned in the process of becoming a nurse. This text serves as a tool to help the learner in this process.

“Related to” Phrase or Etiology The second part of the nursing diagnosis is the “related to” (r/t) phrase. Related factors are those that appear to show some type of patterned relationship with the nursing diagno- sis. Such factors may be described as antecedent to, associated with, related to, contributing to, or abetting. Pathophysiologi- cal and psychosocial changes, such as developmental age and cultural and environmental situations, may be causative or contributing factors.

Often, a nursing diagnosis is complementary to a medical diagnosis and vice versa. Ideally the etiology (r/t statement), or cause, of the nursing diagnosis is something that can be treated independently by a nurse. When this is the case, the diagnosis is identified as an independent nursing diagnosis.

If medical intervention is also necessary, it might be iden- tified as a collaborative nursing diagnosis. A carefully written, individualized r/t statement enables the nurse to plan nursing interventions and refer for diagnostic procedures, medical treatments, pharmaceutical interventions, and other inter- ventions that will assist the client/family in accomplishing goals and return to a state of optimum health. Diagnoses and treatments provided by the multidisciplinary team all con- tribute to the client/family outcome. The coordinated effort of the team can only improve outcomes for the client/family and decrease duplication of effort and frustration among the health care team and the client/family.

The etiology is not the medical diagnosis. It may be the underlying issue contributing to the nursing diagnosis, but a medical diagnosis is not something the nurse can treat inde- pendently, without health care provider orders. In the case of the man with COPD, think about what happens when someone has COPD. How does this affect the client? What is happening to him because of this diagnosis?

For each suggested nursing diagnosis, the nurse should refer to the statements listed under the heading “Related Factors (r/t)” in Section III. These r/t factors may or may not

nursing Process, clinical Reasoning, nursing Diagnosis, and evidence-Based nursing 7

This client states she is worrying too much, which may indicate anxiety; she also recently has increased job stress.

Look up Insomnia in Section III. Check the definition: “A disruption in amount and quality of sleep that impairs functioning” (Herdman & Kamitsuru, 2014). Does this describe the client in the case study? What are the related factors? What are the symptoms? Write the diagnostic statement:

Problem—Insomnia Etiology—r/t anxiety, stress Symptoms—Difficulty falling asleep, “I am so tired, I can’t

do anything.”

The nursing diagnostic statement is written in this format: Insomnia r/t anxiety and stress aeb (as evidenced by) diffi- culty falling asleep.

Note: There are more than 30 case studies available for both student and faculty use on the Evolve website that accompanies this text.

After the diagnostic statement is written, proceed to the next step: planning.

STEP 3: PLANNING (ADPIE) The planning phase of the nursing process includes the identification of priorities, as well as the determination of appropriate client-specific outcomes and interventions. The nurse in collaboration with the client and family (as appli- cable) and the rest of the health care team must determine the urgency of the identified problems and prioritize client needs. Mutual goal setting, along with symptom pattern rec- ognition and triggers, helps prioritize interventions and deter- mine which interventions are going to provide the greatest impact. Symptom pattern recognition and/or triggers is a process of identifying symptoms that clients have related to their illness, understanding which symptom patterns require intervention, and identifying the associated timeframe to intervene effectively. For example, a client with heart failure is noted to gain 5 pounds overnight. Coupling this symptom with other symptoms of edema and shortness of breath while walking can be referred to as “symptom pattern recogni- tion”—in this case, that the client is retaining fluid. The nurse, and often the client/family, recognize these symptoms as an immediate cause and that more action/intervention is needed to avoid a potential adverse outcome.

Nursing diagnoses should be prioritized first by immedi- ate needs based on ABC (airway, breathing, and circulation). The highest priority should also be determined by using Maslow’s hierarchy of needs. In this hierarchy, priority is given to immediate problems that may be life-threatening (thus ABC). For example, ineffective Airway clearance, as evidenced by the symptoms of increased secretions and increased use of inhaler related to asthma, creates an immedi- ate cause compared to the nursing diagnosis of Anxiety, a love and belonging or security need, which makes it a lesser

oxygen supply and demand aeb verbal reports of fatigue, exertional dyspnea, and abnormal heart rate in response to activity.

Consider a second case study:

Case Study 2—Woman with Insomnia As before, the nurse always begins with an assessment. To make the nursing diagnosis, the nurse follows the steps below.

A. Underline the Symptoms A 45-year-old woman comes to the clinic and asks for medi- cation to help her sleep. She states that she is worrying too much and adds, “It takes me about an hour to get to sleep, and it is very hard to fall asleep. I feel like I can’t do anything because I am so tired. My job has become very stressful because of a new boss and too much work.”

B. List the Symptoms (Subjective and Objective) Asks for medication to help her sleep; states she is worrying about too much; “It takes me about an hour to get to sleep”; “it is very hard to fall asleep”; “I feel like I can’t do anything because I am so tired”; “My job has become very stressful because of a new boss and too much work.”

C. Cluster Similar Symptoms Asks for medication to help her sleep “It takes me about an hour to get to sleep.” “It is very hard to fall asleep.” “I feel like I can’t do anything because I am so tired.” “I am worrying too much.” “My job is stressful.” “Too much work.”

D. Analyze/Interpret the Symptoms Subjective Symptoms • Asks for medication to help her sleep; “It takes me

about an hour to get to sleep”; “it is very hard to fall asleep”; “I feel like I can’t do anything because I am so tired.” (All defining characteristics = verbal complaints of difficulty with sleeping.)

• States she is worrying too much (anxiety): “My job is stressful.”

Objective Symptoms • None

E. Select a Nursing Diagnosis with Related Factors and Defining Characteristics Look up “sleep” in Section II. Listed under the heading “Sleep pattern, disturbed” in Section II is the following information:

Insomnia (nursing diagnosis) r/t anxiety and stress

8 Section i

outcome (NOC) is an individual, family or community state, behavior or perception that is measured along a continuum in response to nursing interventions. The outcomes are stated as concepts that reflect a client, caregiver, family, or commu- nity state, perception of behavior rather than as expected goals” (Moorhead et al, 2013).

It is very important for the nurse to involve the client and/ or family in determining appropriate outcomes. The use of outcomes information creates a continuous feedback loop that is essential to ensuring evidence-based care and the best possible client outcomes, not only for the patient care experi- ence, but also for improving the population’s health and reducing health care costs (Weston & Roberts, 2013). The minimum requirements for rating an outcome are when the outcome is selected (i.e., the baseline measure) and when care is completed (i.e., the discharge summary). This may be suf- ficient in short-stay, acute-care settings. Depending on how rapidly the client’s condition is expected to change, some set- tings may evaluate once a day or once a shift. Community agencies may evaluate every visit or every other visit, for example. Because measurement times are not standardized, they can be individualized for the client and the setting (Moorhead et al, 2013).

Development of appropriate outcomes can be done one of two ways: using the NOC list or developing an appropriate outcome statement, both of which are included in Section III. There are suggested outcome statements for each nursing diagnosis in this text that can be used as written or modified as necessary to meet the needs of the client.

The Evolve website includes a list of additional NOC out- comes. The use of NOC outcomes can be helpful to the nurse because they contain a five-point, Likert-type rating scale that can be used to evaluate progress toward achieving the outcome. In this text, the rating scale is listed, along with some of the more common indicators; for example, see the rating scale for the outcome Sleep (Table I-1).

Because the NOC outcomes are specific, they enhance the nursing process by helping the nurse measure and record the outcomes before and after interventions have been per- formed. The nurse can choose to have clients rate their own progress using the Likert-type rating scale. This involve- ment can help increase client motivation to progress toward outcomes.

After client outcomes are selected or written, and discussed with a client, the nurse plans nursing care with the client and establishes a means that will help the client achieve the selected outcomes. The usual means are nursing interventions.

Interventions Interventions are like roadmaps directing the best ways to provide nursing care. The more clearly a nurse writes an inter- vention, the easier it will be to complete the journey and arrive at the destination of desired client outcomes.

Section III includes suggested interventions for each nursing diagnosis. The interventions are identified as

priority than ineffective Airway clearance. Refer to Appendix A, Nursing Diagnoses Arranged by Maslow’s Hierarchy of Needs, for assistance in prioritizing nursing diagnoses.

The planning phase should be done—whenever possible— with the client/family and the multidisciplinary team to max- imize efforts and understanding, and increase compliance with the proposed plan and outcomes. For a successful plan of care, measurable goals and outcomes, including nursing interventions, must be identified.

SMART Outcomes When writing outcome statements, it can be helpful to use the acronym SMART, which means the outcome must be:

Specific Measurable Attainable Realistic Timed

The SMART acronym is used in business, education, and health care settings. This method assists the nurse in identify- ing patient outcomes more effectively.

Once priorities are established, outcomes for the client can be easily identified. Client-specific outcomes are determined based on the mutually set goals. Outcomes refer to the mea- surable degree of the client’s response. The client’s response/ outcome may be intentional and favorable, such as leaving the hospital 2 days after surgery without any complications. The client’s outcome can be negative and unintentional, such as demonstrating a surgical site infection. Generally, outcomes are described in relation to the client’s response to interven- tions, for example, the client’s cough becomes more produc- tive after the client begins using the controlled coughing technique.

Based on the “patient’s story,” the nursing assessment, the mutual goals and outcomes identified by the caregiving team and the client/family, and the clinical reasoning that the nurse uses to prioritize his or her work, the nurse then decides what interventions to employ. Based on the nurse’s clinical judg- ment and knowledge, nursing interventions are defined as all treatments that a nurse performs to enhance client outcomes.

The selection of appropriate, effective interventions can be individualized to meet the mutual goals established by the client/family. It is then the nurse’s education, experience, and skill that allow them to select and carry out interventions to meet that mutual goal.

Outcomes After the appropriate priority setting of the nursing diagnoses and interventions is determined, outcomes are developed or examined and decided upon. This text includes standardized Nursing Outcomes Classification (NOC) outcomes written by a large team of University of Iowa College of Nursing faculty and students in conjunction with clinicians from a variety of settings (Moorhead et al, 2013). “Nursing-sensitive

TABLE I-1

Example NOC Outcome

Sleep—0004

Domain—Functional Health (I) Care Recipient:

Class—Energy Maintenance (A) Data Source:

Scale(s)—Severely compromised to Not compromised (a) and Severe to None (n) Definition: Natural periodic suspension of consciousness during which the body is restored. Outcome Target Rating: Maintain at________ Increase to __________

Sleep Overall Rating

Severely Compromised

Substantially Compromised

Moderately Compromised

Mildly Compromised

Not Compromised

1 2 3 4 5

INDICATORS:

000401 Hours of sleep 1 2 3 4 5 NA

000402 Observed hours of sleep 1 2 3 4 5

000403 Sleep pattern 1 2 3 4 5 NA

000404 Sleep quality 1 2 3 4 5 NA

000405 Sleep efficiency 1 2 3 4 5 NA

000407 Sleep routine 1 2 3 4 5 NA

000418 Sleeps through the night consistently

1 2 3 4 5 NA

000408 Feelings of rejuvenation after sleep

1 2 3 4 5 NA

000410 Wakeful at appropriate times 1 2 3 4 5 NA

000419 Comfortable bed 1 2 3 4 5 NA

000420 Comfortable temperature in room

1 2 3 4 5 NA

000411 Electroencephalogram findings

1 2 3 4 5 NA

000412 Electromyogram findings 1 2 3 4 5 NA

000413 Electrooculogram findings 1 2 3 4 5 NA

Severe Substantial Moderate Mild None

000421 Difficulty getting to sleep 1 2 3 4 5 NA

000406 Interrupted sleep 1 2 3 4 5 NA

000409 Inappropriate napping 1 2 3 4 5 NA

000416 Sleep apnea 1 2 3 4 5 NA

000417 Dependence on sleep aids 1 2 3 4 5 NA

000422 Nightmares 1 2 3 4 5 NA

000423 Nocturia 1 2 3 4 5 NA

000424 Snoring 1 2 3 4 5 NA

000425 Pain 1 2 3 4 5 NA

Adapted from Moorhead S, Johnson, M, Maas ML, & Swanson E. (Eds.). (2013). Nursing outcomes classification (NOC) (5th ed.). St Louis: Elsevier.

10 Section i

independent (autonomous actions that are initiated by the nurse in response to a nursing diagnosis) or collaborative (actions that the nurse performs in collaboration with other health care professionals, and that may require a health care provider’s order and may be in response to both medical and nursing diagnoses). The nurse may choose the interventions appropriate for the client and individualize them accordingly, or determine additional interventions.

This text also contains several suggested Nursing Interven- tions Classification (NIC) interventions for each nursing diagnosis to help the reader see how NIC is used along with NOC and nursing diagnoses. The NIC interventions are a comprehensive, standardized classification of treatments that nurses perform. The classification includes both physiological and psychosocial interventions, and covers all nursing spe- cialties. A list of NIC interventions is included on the Evolve website. For more information about NIC interventions, refer to the NIC text (Bulechek et al, 2013).

Putting It All Together—Recording the Care Plan The nurse must document the actual care plan, including prioritized nursing diagnostic statements, outcomes, and interventions. This may be done electronically or in writing. To ensure continuity of care, the plan must be documented and shared with all health care personnel caring for the client. This text provides rationales, most of which are research based, to validate that the interventions are appropriate and workable.

The Evolve website includes an electronic care plan con- structor that can be easily accessed, updated, and individual- ized. Many agencies are using electronic records, and this is an ideal resource. See the inside front cover of this text for information regarding access to the Evolve website, or go to http://evolve.elsevier.com/Ackley/NDH.

STEP 4: IMPLEMENTATION (ADPIE)

The implementation phase includes the “carrying out” of the specific, individualized, jointly agreed upon interventions in the plan of care. Often, the interventions implemented are focused on symptom management, which is alleviating symp- toms. Typically, nursing care does not involve “curing” the medical condition causing the symptom. Rather, nursing care focuses on caring for the client/family so they can function at their highest level.

The implementation phase of the nursing process is the point at which you actually give nursing care. You perform the interventions that have been individualized to the client. All the hard work you put into the previous steps (ADP) can now be actualized to assist the client. As the interventions are performed, make sure that they are appropriate for the client. Consider that the client who was having difficulty breathing was also older. He may need extra time to carry out any

activity. Check the rationale or research that is provided to determine why the intervention is being used. The evidence should support the individualized actions that you are implementing.

Client outcomes are achieved by the performance of the nursing interventions in collaboration with other disciplines and the client/family. During this phase, the nurse continues to assess the client to determine whether the interventions are effective and the desired outcomes are met.

STEP 5: EVALUATION (ADPIE) The final phase of the nursing process is evaluation. Evalua- tion occurs not only at the end of the nursing process, but throughout the process. Evaluation of an intervention is, in essence, another nursing assessment; hence the dynamic feature of the nursing process. The nurse reassesses the client, taking into consideration where the client was before the intervention (i.e., baseline) and where the client is after the intervention. Nurses are also in a great place (at the bedside) to evaluate how clients respond to other, multidisciplinary interventions, and their assessment of the client’s response is valuable to determine whether the client’s plan of care needs to be altered or not. For example, the client may receive 2 mg of morphine intravenously for pain (a pharmaceutical inter- vention to treat pain), and the nurse is the member of the health care team who can best assess how the client responded to that medication. Did the client receive relief from pain? Did the client develop any side effects? The nurse’s docu- mented evaluation of the client’s response will be very helpful to the entire health care team.

The client/family can often tell the nurse how the interven- tion helped or did not help. This reassessment requires the nurse to revisit the mutual outcomes/goals set earlier and ask, “Are we moving toward that goal, or does the goal seem unreachable after the intervention?” If the outcomes were not met, the nurse begins again with assessment and determines the reason they were not met. Consider the SMART acronym and Case Study 1. Were the outcomes Specific? Were the outcomes Measurable? Did the client’s heart rate decrease? Did the client indicate that it was easier to breathe when walking from his bed to the bathroom? Were the outcomes Attainable and Realistic? Did he still report “being tired”? Did you allow adequate Time for a positive outcome? Also ask yourself whether you identified the correct nursing diag- nosis. Should the interventions be changed? At this point, the nurse can look up any new symptoms or conditions that have been identified and adjust the care plan as needed. Decisions about implementing additional interventions may be neces- sary; if so, they should be made in collaboration with the client/family if possible.

In some instances, the client/family/nurse triad will establish new, achievable goals and continue to cycle through the nursing process until the mutual goals are achieved.

nursing Process, clinical Reasoning, nursing Diagnosis, and evidence-Based nursing 11

Many health care providers use critical pathways or care maps to plan nursing care. The use of nursing diagnoses should be an integral part of any critical pathway/care map to ensure that nursing care needs are being assessed and appropriate nursing interventions are planned and implemented.

Another important part of the evaluation phase is docu- mentation. The nurse should use the facility’s tool for documentation and record the nursing activity that was per- formed as well as the results of the nursing interventions. Many facilities use problem-oriented charting, in which the nurse evaluates the care and client outcomes as part of charting. Documentation is also necessary for legal reasons, because in a legal dispute, if it wasn’t charted/recorded, it wasn’t done.

Conceptual Mapping and the Nursing Process Conceptual mapping is an active learning strategy that pro- motes critical thinking and clinical judgment, and helps increase clinical competency (Jamison & Lis, 2014; George et al, 2014). The process involves developing a diagram or pictorial representation of newly generated ideas. A concept map begins with a central theme or concept, and then related information is diagrammed radiating from the center theme. A concept map can be used to diagram the critical thinking strategy involved in using the nursing process.

Start with a blank sheet of paper; the client should be at the center of the paper. The next step involves linking to the person, via lines, the symptoms (defining characteristics) from the assessment to help determine the appropriate nursing diagnosis.

Figure I-2 is an example of how a concept map can be used to begin the nursing diagnostic process.

After the symptoms are visualized, similar ones can be put together to formulate a nursing diagnosis using another concept map (Figure I-3).

The central theme in this concept map is the nursing diag- nosis: Activity intolerance, with the defining characteristics/ client symptoms as concepts that lead to and support the nursing diagnosis. The conceptual map can then be used as a method for determining outcomes and interventions as desired. The nursing process is a thinking process. Using con- ceptual mapping is a method to help the nurse or nursing student think more effectively about the client.

Quality and Safety Education for Nurses The Quality and Safety Education for Nurses (QSEN, 2014) project represents the nursing profession’s response to the five health care competencies articulated by the Institute of Medi- cine (2013). The QSEN project defined those five competen- cies for nursing and also added the competency of safety. The

objective of the QSEN project is to provide nurses with the knowledge, skills, and attitudes critical to improve the quality and safety of health care systems.

The following are the competencies that were identified.

Patient-Centered Care The QSEN project defines patient-centered care as the ability to “recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated

PART

B Advanced Nursing Process Concepts

Figure I-2 Example of a concept map.

I can only walk short distances

Elderly man

COPD

I feel tired all the time Racing heart

Wringing hands

Looking out window

Difficulty breathing

12 Section i

assessments that enables them to identify client values, beliefs, and preferences. Cultural awareness can ensure safe and quality outcomes for all clients by assisting clients to become “safety allies” who can alert professionals to their preferences and deviations from their usual routines (Sherwood & Zomorodi, 2014). This text provides the addition of multicul- tural interventions that reflect the client’s cultural prefer- ences, values, and needs.

Patient-centered care can help nurses change attitudes toward clients, especially when caring for older clients (Pope, 2012). Caring for the retired school teacher who raised four children can be different from just caring for the client woman in Room 234 who has her call light on frequently and is incontinent of urine at too-frequent intervals.

Teamwork and Collaboration Teamwork and collaboration are defined by the QSEN project as the ability to “function effectively within nursing and inter- professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality client care” (QSEN, 2014). Interprofessional collaboration has the potential to shift the attitudes and perceptions of health care providers so there is an increased awareness of each other’s roles, values, and disciplinary knowledge (Wilson et al, 2014). The need for collaboration by health care professionals is a reality of contemporary health care practice and is written into this text. Collaborative interventions are designated with a triangular symbol Δ. In addition, many nursing interven- tions are referrals to other health care personnel to best meet the client’s needs.

Figure I-3 Formulating a nursing diagnosis using a concept map.

“Racing heart” Abnormal heart rate

response to activity

“I can only walk short distances”

“Difficulty breathing” Exertional dyspnea

“Tired all the time”

Verbal report of fatigue

Nursing diagnosis: Activity intolerance

care based on respect for patient’s preferences, values, and needs” (QSEN, 2014).

Patient-centered care begins with the nurse learning as much as possible about the client, including their “patient’s story” as explained in Part A of this text. The nursing process using nursing diagnosis is intrinsically all about patient- centered care. Here the client/family is a full partner in the entire process, including assessment, nursing diagnosis selection, outcomes, interventions, and evaluation. This competency is about giving care with the client and family in control as they are able, not giving care to them where the nurse is in complete control. The client, family, nurse, health care provider, and other health care workers form a team to partner with the client and family in every way possible.

Client education needs to be centered around the needs of the client, with behavior-changing techniques such as use of motivational interviewing to accomplish the defined goals. At present, too often new health information is given to clients in the form of a lecture, handout, admonishment, or direction where the client is powerless. Motivational interviewing is based on reinforcement of the client’s present thoughts and motivations on behavior change, and on respect for the client as an individual (Miller & Rollnick, 2013). This technique has been used for almost 30 years and has an extensive research base showing effectiveness. To learn more about motivational interviewing, refer to the appendix.

Addressing the unique cultural needs of clients is another example of patient-centered care. Nurses who are culturally competent base care planning on cultural awareness and

nursing Process, clinical Reasoning, nursing Diagnosis, and evidence-Based nursing 13

ate care. The QSEN project defines quality improvement as the ability to “use data to monitor the outcomes of care pro- cesses and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems” (QSEN, 2014). QSEN resources support- ing quality improvement initiatives are available at their website (http://qsen.org/competencies/quality-improvement- resources-2/). As with EBP, quality improvement initiatives need to critically examine research in supporting process changes. Research is the basis upon which best practice should be supported (Odom, 2013). It is essential for nurses to participate in the work of quality and performance improvement, which is key to attaining excellence in nursing care. As nurses are educated about performance and quality measures, they are more likely to value these activities and make quality improvement part of their nursing practice (Nelson, 2014). There is potential overlap of work in quality departments and EBN/research departments. These authors hope that the measurement of quality and quality depart- ments in health care collaborate closely with EBN depart- ments so that quality measurement always include relevant nursing research/evidence to effectively improve the practice of nursing.

Safety Safety is the competency that QSEN added to the five com- petencies identified by the Institute of Medicine. QSEN defines safety as “minimiz[ing] risk of harm to clients and providers through both system effectiveness and individual performance” (QSEN, 2014).

Client safety is a priority when health care is delivered. Nurses are required to adhere to established standards of care as a guideline for providing safe client care. Internal standards of care are policies and procedures established by health care institutions and are based on the most relevant and current evidence. External standards of care are established by regula- tory agencies (e.g., The Joint Commission), professional orga- nizations (e.g., the American Nurses Association), and health care organizations.

Client safety was identified as a priority of care by The Joint Commission through the launch of National Patient Safety Goals in 2002. The Joint Commission (2014) has estab- lished standards for improving client safety that include the need for increased handwashing, better client identification before receiving medications or treatments, and protection of suicidal clients from self-harm. Many of these safety stan- dards have been incorporated into the care plans in this text. A safety icon is used to designate specific safety nursing inter- ventions in this text.

Informatics QSEN defines informatics as the nurse’s ability to “use infor- mation and technology to communicate, manage knowledge, mitigate error, and support decision making” (QSEN, 2014). Informatics is now a critical part of the nurse’s professional role, and every nurse must be computer literate (TIGER,

Evidence-Based Practice Evidence-based practice is defined by the QSEN project as “integrat[ing] best current evidence with clinical expertise and client/family preferences and values for delivery of optimal health care” (QSEN, 2014). It is well established that evidence-based practice results in higher quality care for clients than care that is based on traditional nursing knowl- edge (Makic et al, 2014). Now it is imperative for each nurse and nursing student to develop clinical inquiry skills, which means the nurse continually questions whether care is being given in the best way possible based on research evidence when possible (Blazeck et al, 2011). Basing nursing practice on evidence or research is a concept that has been added to the nursing process, entitled evidence-based nursing (EBN). EBN is a systematic process that uses current evidence in making decisions about the care of clients, including evalua- tion of quality and applicability of existing research, client preferences, clinical expertise, and available health care resources (Melnyk & Fineout-Overholt, 2011). To determine the best way of giving care, use of evidence-based practice is needed. To make this happen, nurses need ready access to the evidence.

This text includes evidence (research)-based rationales whenever possible. The research ranges along a continuum from a case study about a single client to a systematic review performed by experts that gives quality information to guide nursing care. Every attempt has been made to supply the most current research for the nursing interventions. In Section III, the abbreviation EBN is used when interventions have a sci- entific rationale supported by nursing research. The abbrevia- tion EB is used when interventions have a scientific rationale supported by research that has been obtained from disci- plines other than nursing. CEB is used as a heading for classic research that has not been replicated or is older. It may be either nursing research or research from other disciplines. Many times the CEB-labeled research will be the most impor- tant studies that have been done on that nursing issue or intervention.

When using EBN, it is vitally important that the client’s concerns and individual situations be taken into consider- ation. The nurse must always use critical thinking when applying evidence-based guidelines to any particular nursing situation. Each client is unique in his or her needs and capa- bilities. To improve outcomes, clinicians and clients should collaborate to formulate a treatment plan that incorporates both evidence-based data and client preferences within the context of each client’s specific clinical situation (Muhrer, 2012). This text includes both research and the nursing process. By integrating these concepts, it assists the nurse in increasing the use of evidence-based interventions in the clinical setting.

Quality Improvement Quality improvement has been used for many years, with processes in place to ensure that the client receives appropri-

14 Section i

Nurses need access to technology to effectively bring evi- dence to the client bedside, because evidence is constantly evolving and books are often out of date before they are pub- lished. Use of informatics is integral to use of EBN practice as explained previously.

EBN, safety initiatives, informatics, patient-centered care, teamwork, and quality work together in a synergistic manner lead to excellence in nursing care. Quality care needs to be more than safe; the care should result in the best outcome possible for the client. For this to happen, the client should receive care that is based on evidence of the effectiveness of the care.

The nursing process is continually evolving. This text is all about thinking for the nurse to help the client in any way pos- sible. Our goal is to present state-of-the art information to help the nurse and nursing student provide the best care possible.

2014). Key computer proficiencies for nursing practice should include basic computer system and desktop skills, the ability to search for client information, communication using email, ability to search electronic health care databases, and use of technology for client education, client documentation, and client monitoring (Gracie, 2011; Tiger, 2014).

In addition to computer literacy, nurses must also acquire informatic knowledge that addresses client privacy and the security of health care information as it applies to the use of technology (Foster, 2012; TIGER, 2014). Because nurses document on the electronic medical record and use smartphones for access to information on medications, diag- noses, and treatments, there are constant threats to client confidentiality.

Nurses also use clinical decision support systems in many facilities that contain order sets tailored for conditions or types of clients. These systems include information vital to nurses and also may provide alerts about potentially danger- ous situations that should not be ignored when giving client care.

REFERENCES Benner, P. (2010). Educating nurses: a call for radical transformation

(p. 2010). San Francisco: Jossey-Bass. Blazeck, A., Klem, M. L., & Miller, T. (2011). Building evidence-based

practice into the foundations of practice. Nurse Educator, 36(3), 124–127.

Bulechek, G., et al. (2013). Nursing interventions classification (NIC) (6th ed.). St Louis: Mosby/Elsevier.

Cappelletti, A., Engel, J. E., & Prentice, D. (2014). Systematic review of clinical judgment and reasoning in nursing. Journal of Nursing Education, 53(8), 453–458.

Centers for Medicare and Medicaid Services: CMS issues final rule for the first year of hospital value-based purchasing program. (2014). At: <https://www.cms.gov/Medicare/Quality-Initiatives-Patient- Assessment-Instruments/hospital-value-based-purchasing/ index.html?redirect=/hospital-value-based-purchasing/> Accessed January 31, 2015.

Foster, C. (2012). Advocates of privacy. HIPPA 101. Washington Nurse, 42(3), 37.

George, A., et al. (2014). Concept mapping. Holistic Nursing Practice, 28(1), 43–47.

Gracie, D. (2011). Nursing informatics competencies and baccalaureate nursing students. ANIA-CARING Newslett, 26(2), 7–10.

Herdman, T. H., & Kamitsuru, S. (Eds.), (2014). NANDA International Nursing Diagnoses: Definitions & Classification, 2015–2017. Oxford: Wiley Blackwell.

Hess, D., & Markee, D. (2014). Holistic nursing and the patient protection and affordable health care act. New Mexico Nurse, 59(1), 10–11.

Institute of Medicine (IOM) (2013). Population health implications of the Affordable Care Act: Workshop summary. Washington, DC: The National Academies Press.

Jamison, T., & Lis, G. A. (2014). Engaging the learning by bridging the gap between theory and clinical competence. N Clinics of North America, 49(1), 69–80.

The Joint Commission: National Patient Safety Goals. (2014). Retrieved from <http://www.jointcommission.org/hap_2014_npsgs/> Accessed June 18, 2015.

Lusk, J. M., & Fater, K. (2013). A concept analysis of patient-centered care. Nursing Forum, 48(2), 89–98.

Makic, M. B., Rauen, C., Watson, R., et al. (2014). Examining the evidence to guide practice: challenging practice habits. Critical Care Nursing, 34(2), 28–45.

Melnyk, B., & Fineout-Overholt, E. (2011). Evidence-based practice in nursing & healthcare: A guide to best practice. Philadelphia: Lippincott Williams & Wilkins.

Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: helping people change (3rd ed.). New York: Guilford Press.

Moorhead, S. (Ed.), (2013). Nursing outcomes classification (NOC) (5th ed.). St Louis: Elsevier.

Muhrer, J. (2012). Making evidence-based health care relevant for patients. Journal of Nurse Practitioners, 8(1), 51–55.

National Council of State Boards of Nursing (2013). NCLEX-RN Examination, Detailed test plan. Retrieved from <www.ncsbn.org/2013_NCLEX_RN_Detailed_Test_Plan _Educator.pdf> Accessed June 18, 2015.

Nelson, A. M. (2014). Best practice in nursing: a concept analysis. International Journal of Nursing Studies, 51(11), 1507–1516.

Odom-Forren, J. (2013). Research: the foundation for evidence. Journal of Perianesthesia Nursing, 28(6), 331–332.

Pope, T. (2012). How person-centered care can improve nurses’ attitudes to hospitalized older patients. Nursing Older People, 24(1), 32–36.

Quality and Safety Education for Nurses (QSEN). (2014). Retrieved from <qsen.org/competencies/pre-licensure-ksas/> Accessed June 18, 2015.

Sherwood, G., & Zomorodi, M. (2014). A new mindset for quality and safety: the QSEN competencies redefine nurses’ roles in practice. Nephrology Nursing Journal, 41(1), 15–22, 72.

Technology Informatics Guiding Education Reform (TIGER) (2014). The TIGER Initiative: informatics competencies for every practicing nurse: recommendations from the TIGER Collaborative. Retrieved from <http://www.thetigerinitiative.org/default.aspx> Accessed June 18, 2015.

nursing Process, clinical Reasoning, nursing Diagnosis, and evidence-Based nursing 15

Wilson, L., Callender, B., Hall, T. L., et al. (2014). Identifying global health competencies to prepare 21st century global health professionals: report from the global health competency subcommittee of the consortium of universities for global health. Journal of Law, Medicine & Ethics, 42, 26–31.

Watson, F., & Rebair, A. (2014). The art of noticing: essential to nursing practice. British Journal of Nursing, 23(10), 514–517.

Weston, M., & Roberts, D. (2013). “The influence of quality improvement efforts on patient outcomes and nursing work: a perspective from chief nursing officers at three large health systems” OJIN. The Online Journal of Issues in Nursing, 18(3), Manuscript 2.

This page intentionally left blank

17

SECTION

II Guide to Nursing Diagnosis

Betty J. Ackley, MSN, EdS, RN, Gail B. Ladwig, MSN, RN,

Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN, and Melody Zanotti, RN

Section II is an alphabetical listing of client symptoms, client problems, medical diagnoses, psychosocial diag- noses, and clinical states. Each of these will have a list of possible nursing diagnoses. You may use this section to find suggestions for nursing diagnoses for your client. • Assess the client using the format provided by the clinical setting. • Locate the client’s symptoms, problems, clinical state, diagnoses, surgeries, and diagnostic testing in the

alphabetical listing contained in this section. • Note suggestions given for appropriate nursing diagnoses. • Evaluate the suggested nursing diagnoses to determine whether they are appropriate for the client and

have information that was found in the assessment. • Use Section III (which contains an alphabetized list of all NANDA-I approved nursing diagnoses) to

validate this information and check the definition, related factors, and defining characteristics. Determine whether the nursing diagnosis you have selected is appropriate for the client.

e1

List of Nursing Assessments by Letter: A

Abdominal Distention Abdominal Hysterectomy Abdominal Pain Abdominal Surgery Abdominal Trauma Ablation, Radiofrequency Catheter Abortion, Induced Abortion, Spontaneous Abruptio Placentae <36 Weeks Abscess Formation Abuse, Child Abuse, Spouse, Parent, or Significant

Other Accessory Muscle Use (to Breathe) Accident Prone Achalasia Acid-Base Imbalances Acidosis, Metabolic Acidosis, Respiratory Acne ACS (Acute Coronary Syndrome) Acquired Immunodeficiency Syndrome Acromegaly Activity Intolerance, Potential to

Develop Acute Abdominal Pain

Acute Alcohol Intoxication Acute Back Pain Acute Confusion Acute Coronary Syndrome Acute Lymphocytic Leukemia (ALL) Acute Renal Failure/Acute Kidney

Failure Acute Respiratory Distress Syndrome Adams-Stokes Syndrome Addiction Addison’s Disease Adenoidectomy Adhesions, Lysis of Adjustment Disorder Adjustment Impairment Adolescent, Pregnant Adoption, Giving Child Up for Adrenocortical Insufficiency Advance Directives Affective Disorders Age-Related Macular Degeneration Aggressive Behavior Aging Agitation Agoraphobia Agranulocytosis AIDS (Acquired Immunodeficiency

Syndrome) AIDS Dementia

AIDS, Child Airway Obstruction/Secretions Alcohol Withdrawal Alcoholism Alcoholism, Dysfunctional Family

Processes Alkalosis

ALL (Acute Lymphocytic Leukemia) Allergies Alopecia Altered Mental Status ALS (Amyotrophic Lateral Sclerosis) Alzheimer’s Disease AMD (Age-Related Macular Degeneration)

Amenorrhea AMI (Acute Myocardial Infarction)

e2 List of Nursing Assessments by Letter: A

Amnesia Amniocentesis Amnionitis Amniotic Membrane Rupture Amputation Amyotrophic Lateral Sclerosis (ALS) Anal Fistula Anaphylactic Shock Anaphylaxis Prevention Anasarca Anemia Anemia, in Pregnancy Anemia, Sickle Cell Anencephaly Aneurysm, Abdominal Surgery Aneurysm, Cerebral Anger Angina Angiocardiography (Cardiac Catheterization)

Angioplasty, Coronary Anomaly, Fetal/Newborn (Parent Dealing with)

Anorectal Abscess Anorexia Anorexia Nervosa Anosmia (Smell, Loss of Ability to) Antepartum Period Anterior Repair, Anterior

Colporrhaphy Anticoagulant Therapy Antisocial Personality Disorder Anuria Anxiety Anxiety Disorder Aortic Aneurysm Repair (Abdominal

Surgery) Aortic Valvular Stenosis Aphasia Aplastic Anemia Apnea in Infancy Apneustic Respirations Appendectomy Appendicitis Apprehension ARDS (Acute Respiratory Distress

Syndrome) Arrhythmia Arterial Insufficiency Arthritis Arthrocentesis Arthroplasty (Total Hip Replacement) Arthroscopy Ascites Asperger’s Syndrome Asphyxia, Birth Aspiration, Danger of Assault Victim Assaultive Client Asthma Ataxia Atelectasis Atherosclerosis Athlete’s Foot ATN (Acute Tubular Necrosis) Atrial Fibrillation Atrial Septal Defect Attention Deficit Disorder Auditory Problems Autism Autonomic Dysreflexia Autonomic Hyperreflexia

18 Abdominal Distention

A A Abdominal Distention

Constipation r/t decreased activity, decreased fluid intake, decreased fiber intake, pathological process Dysfunctional Gastrointestinal motility r/t decreased perfu- sion of intestines, medication effect Nausea r/t irritation of gastrointestinal tract Imbalanced Nutrition: less than body requirements r/t nausea, vomiting Acute Pain r/t retention of air, gastrointestinal secretions Delayed Surgical recovery r/t retention of gas, secretions

Abdominal Hysterectomy See Hysterectomy

Abdominal Pain Dysfunctional Gastrointestinal motility r/t decreased perfu- sion, medication effect Acute Pain r/t injury, pathological process

Abdominal Surgery Constipation r/t decreased activity, decreased fluid intake, anesthesia, opioids Dysfunctional Gastrointestinal motility r/t medication or anesthesia effect, trauma from surgery Imbalanced Nutrition: less than body requirements r/t high metabolic needs, decreased ability to ingest or digest food Acute Pain r/t surgical procedure Ineffective peripheral Tissue Perfusion r/t immobility, abdom- inal surgery Risk for delayed Surgical recovery r/t extensive surgical procedure Risk for Infection: Risk factor: invasive procedure Readiness for enhanced Knowledge: expresses an interest in learning See Surgery, Perioperative Care; Surgery, Postoperative Care; Surgery, Preoperative Care

Abdominal Trauma Disturbed Body Image r/t scarring, change in body function, need for temporary colostomy Ineffective Breathing pattern r/t abdominal distention, pain Deficient Fluid volume r/t hemorrhage, active fluid volume loss Dysfunctional Gastrointestinal motility r/t decreased perfusion Acute Pain r/t abdominal trauma Risk for Bleeding: Risk factor: trauma and possible contusion/ rupture of abdominal organs Risk for Infection: Risk factor: possible perforation of abdomi- nal structures

Ablation, Radiofrequency Catheter Fear r/t invasive procedure Risk for decreased Cardiac tissue perfusion: Risk factor: cath- eterization of heart

Abortion, Induced Compromised family Coping r/t unresolved feelings about decision Acute Pain r/t surgical intervention Chronic low Self-Esteem r/t feelings of guilt Chronic Sorrow r/t loss of potential child Risk for Bleeding: Risk factor: trauma from abortion Risk for delayed Development: Risk factors: unplanned or unwanted pregnancy Risk for Infection: Risk factors: open uterine blood vessels, dilated cervix Risk for Post-Trauma syndrome: Risk factor: psychological trauma of abortion Risk for Spiritual distress: Risk factor: perceived moral implica- tions of decision Readiness for enhanced Knowledge: expresses an interest in learning

Abortion, Spontaneous Disturbed Body Image r/t perceived inability to carry preg- nancy, produce child Disabled family Coping r/t unresolved feelings about loss Ineffective Coping r/t personal vulnerability Interrupted Family processes r/t unmet expectations for preg- nancy and childbirth Fear r/t implications for future pregnancies Grieving r/t loss of fetus Acute Pain r/t uterine contractions, surgical intervention Situational low Self-Esteem r/t feelings about loss of fetus Chronic Sorrow r/t loss of potential child Risk for Bleeding: Risk factor: trauma from abortion Risk for Infection: Risk factors: septic or incomplete abortion of products of conception, open uterine blood vessels, dilated cervix Risk for Post-Trauma syndrome: Risk factor: psychological trauma of abortion Risk for Spiritual distress: Risk factor: loss of fetus Readiness for enhanced Knowledge: expresses an interest in learning

Abruptio Placentae <36 Weeks Anxiety r/t unknown outcome, change in birth plans Death Anxiety r/t unknown outcome, hemorrhage, or pain Interrupted Family processes r/t unmet expectations for preg- nancy and childbirth Fear r/t threat to well-being of self and fetus Impaired Gas exchange: placental r/t decreased uteroplacen- tal area

Acromegaly 19

AAcute Pain r/t irritable uterus, hypertonic uterusImpaired Tissue integrity: maternal r/t possible uterine rupture Risk for Bleeding: Risk factor: separation of placenta from uterus causing bleeding Risk for disproportionate Growth: Risk factor: uteroplacental insufficiency Risk for Infection: Risk factor: partial separation of placenta Risk for disturbed Maternal–Fetal dyad: Risk factors: trauma of process, lack of energy of mother Risk for Shock: Risk factor: separation of placenta from uterus Readiness for enhanced Knowledge: expresses an interest in learning

Abscess Formation Ineffective Protection r/t inadequate nutrition, abnormal blood profile, drug therapy, depressed immune function Impaired Tissue integrity r/t altered circulation, nutritional deficit or excess Readiness for enhanced Knowledge: expresses an interest in learning

Abuse, Child See Child Abuse

Abuse, Spouse, Parent, or Significant Other

Anxiety r/t threat to self-concept, situational crisis of abuse Caregiver Role Strain r/t chronic illness, self-care deficits, lack of respite care, extent of caregiving required Impaired verbal Communication r/t psychological barriers of fear Compromised family Coping r/t abusive patterns Defensive Coping r/t low self-esteem Dysfunctional Family processes r/t inadequate coping skills Insomnia r/t psychological stress Post-Trauma syndrome r/t history of abuse Powerlessness r/t lifestyle of helplessness Chronic low Self-Esteem r/t negative family interactions Risk for impaired emancipated Decision-Making: Risk factor: inability to verbalize needs and wants Risk for self-directed Violence: Risk factor: history of abuse

Accessory Muscle Use (to Breathe) Ineffective Breathing pattern (See Breathing pattern, ineffec- tive, Section III) See Asthma; Bronchitis; COPD (Chronic Obstructive Pulmonary Disease); Respiratory Infections, Acute Childhood

Accident Prone Frail Elderly syndrome r/t history of falls Acute Confusion r/t altered level of consciousness Ineffective Coping r/t personal vulnerability, situational crises

Ineffective Impulse control (See Impulse control, ineffective, Section III) Risk for Injury: Risk factor: history of accidents

Achalasia Ineffective Coping r/t chronic disease Acute Pain r/t stasis of food in esophagus Impaired Swallowing r/t neuromuscular impairment Risk for Aspiration: Risk factor: nocturnal regurgitation

Acid-Base Imbalances Risk for Electrolyte imbalance: Risk factors: renal dysfunction, diarrhea, treatment-related side effects (e.g., medications, drains)

Acidosis, Metabolic Acute Confusion r/t acid-base imbalance, associated electrolyte imbalance Impaired Memory r/t effect of metabolic acidosis on brain function Imbalanced Nutrition: less than body requirements r/t inability to ingest, absorb nutrients Risk for Electrolyte imbalance: Risk factor: effect of metabolic acidosis on renal function Risk for Injury: Risk factors: disorientation, weakness, stupor Risk for decreased Cardiac tissue perfusion: Risk factor: dys- rhythmias from hyperkalemia Risk for Shock: Risk factors: abnormal metabolic state, presence of acid state impairing function, decreased tissue perfusion

Acidosis, Respiratory Activity intolerance r/t imbalance between oxygen supply and demand Impaired Gas exchange r/t ventilation-perfusion imbalance Impaired Memory r/t hypoxia Risk for decreased Cardiac tissue perfusion: Risk factor: dys- rhythmias associated with respiratory acidosis

Acne Disturbed Body Image r/t biophysical changes associated with skin disorder Ineffective Health management r/t insufficient knowledge of therapeutic regimen Impaired Skin integrity r/t hormonal changes (adolescence, menstrual cycle)

ACS (Acute Coronary Syndrome) See MI (Myocardial Infarction)

Acquired Immunodeficiency Syndrome See AIDS (Acquired Immunodeficiency Syndrome)

Acromegaly Activity intolerance (See Activity intolerance, Section III) Ineffective Airway clearance r/t airway obstruction by enlarged tongue Disturbed Body Image r/t changes in body function and appearance

20 Activity Intolerance, Potential to Develop

A Impaired physical Mobility r/t joint painRisk for decreased Cardiac tissue perfusion: Risk factor: increased atherosclerosis from abnormal health status Risk for unstable blood Glucose level: Risk factor: abnormal physical health status Sexual dysfunction r/t changes in hormonal secretions Risk for Overweight: Risk factor: energy expenditure less than energy intake

Activity Intolerance, Potential to Develop Activity intolerance (See Activity intolerance, Section III)

Acute Abdominal Pain Deficient Fluid volume r/t air and fluids trapped in bowel, inability to drink Acute Pain r/t pathological process Risk for dysfunctional Gastrointestinal motility: Risk factor: ineffective gastrointestinal tissue perfusion See Abdominal Pain

Acute Alcohol Intoxication Ineffective Breathing pattern r/t depression of the respiratory center from excessive alcohol intake Acute Confusion r/t central nervous system depression Dysfunctional Family processes r/t abuse of alcohol Risk for Aspiration: Risk factor: depressed reflexes with acute vomiting Risk for Infection: Risk factor: impaired immune system from malnutrition associated with chronic excessive alcohol intake Risk for Injury: Risk factor: chemical (alcohol)

Acute Back Pain Anxiety r/t situational crisis, back injury Constipation r/t decreased activity, effect of pain medication Ineffective Coping r/t situational crisis, back injury Impaired physical Mobility r/t pain Acute Pain r/t back injury Readiness for enhanced Knowledge: expresses an interest in learning

Acute Confusion See Confusion, Acute

Acute Coronary Syndrome Decreased Cardiac output r/t cardiac disorder Risk for decreased Cardiac tissue perfusion (See Cardiac tissue perfusion, risk for decreased, Section III)

Acute Lymphocytic Leukemia (ALL) See Cancer; Chemotherapy; Child with Chronic Condition; Leukemia

Acute Renal Failure/Acute Kidney Failure See Kidney Failure

Acute Respiratory Distress Syndrome See ARDS (Acute Respiratory Distress Syndrome)

Adams-Stokes Syndrome See Dysrhythmia

Addiction See Alcoholism; Drug Abuse

Addison’s Disease Activity intolerance r/t weakness, fatigue Disturbed Body Image r/t increased skin pigmentation Deficient Fluid volume r/t failure of regulatory mechanisms Imbalanced Nutrition: less than body requirements r/t chronic illness Risk for Injury: Risk factor: weakness Readiness for enhanced Knowledge: expresses an interest in learning

Adenoidectomy Acute Pain r/t surgical incision Ineffective Airway clearance r/t hesitation or reluctance to cough as a result of pain, fear Nausea r/t anesthesia effects, drainage from surgery Acute Pain r/t surgical incision Risk for Aspiration: Risk factors: postoperative drainage, impaired swallowing Risk for Bleeding: Risk factor: surgical incision Risk for deficient Fluid volume: Risk factors: decreased intake as a result of painful swallowing, effects of anesthesia Risk for imbalanced Nutrition: less than body requirements: Risk factor: reluctance to swallow Readiness for enhanced Knowledge: expresses an interest in learning

Adhesions, Lysis of See Abdominal Surgery

Adjustment Disorder Anxiety r/t inability to cope with psychosocial stressor Labile Emotional Control r/t emotional disturbance Risk-prone Health behavior r/t assault to self-esteem Disturbed personal Identity r/t psychosocial stressor (specific to individual) Situational low Self-Esteem r/t change in role function Impaired Social interaction r/t absence of significant others or peers

Adjustment Impairment Risk-prone Health behavior (See Health behavior, risk-prone, Section III)

Adolescent, Pregnant Anxiety r/t situational and maturational crisis, pregnancy Disturbed Body Image r/t pregnancy superimposed on devel- oping body Decisional Conflict: keeping child versus giving up child versus abortion r/t lack of experience with decision-making,

Aging 21

Ainterference with decision-making, multiple or divergent sources of information, lack of support system Disabled family Coping r/t highly ambivalent family rela- tionships, chronically unresolved feelings of guilt, anger, despair Ineffective Coping r/t situational and maturational crisis, per- sonal vulnerability Ineffective Denial r/t fear of consequences of pregnancy becom- ing known Interrupted Family processes r/t unmet expectations for ado- lescent, situational crisis Fear r/t labor and delivery Deficient Knowledge r/t pregnancy, infant growth and devel- opment, parenting Imbalanced Nutrition: less than body requirements r/t lack of knowledge of nutritional needs during pregnancy and as growing adolescent Ineffective Role performance r/t pregnancy Situational low Self-Esteem r/t feelings of shame and guilt about becoming or being pregnant Impaired Social interaction r/t self-concept disturbance Social isolation r/t absence of supportive significant others Risk for impaired Attachment: Risk factor: anxiety associated with the parent role Risk for delayed Development: Risk factor: unplanned or unwanted pregnancy Risk for urge urinary Incontinence: Risk factor: pressure on bladder by growing uterus Risk for disturbed Maternal–Fetal dyad: Risk factors: imma- turity, substance use Risk for impaired Parenting: Risk factors: adolescent parent, unplanned or unwanted pregnancy, single parent Readiness for enhanced Childbearing process: reports appro- priate prenatal lifestyle Readiness for enhanced Knowledge: expresses an interest in learning

Adoption, Giving Child Up for Decisional Conflict r/t unclear personal values or beliefs, per- ceived threat to value system, support system deficit Ineffective Coping r/t stress of loss of child Interrupted Family processes r/t conflict within family regard- ing relinquishment of child Grieving r/t loss of child, loss of role of parent Insomnia r/t depression or trauma of relinquishment of child Social isolation r/t making choice that goes against values of significant others Chronic Sorrow r/t loss of relationship with child Risk for Spiritual distress: Risk factor: perceived moral implica- tions of decision Readiness for enhanced Spiritual well-being: harmony with self regarding final decision

Adrenocortical Insufficiency Deficient Fluid volume r/t insufficient ability to reabsorb water Ineffective Protection r/t inability to tolerate stress Delayed Surgical recovery r/t inability to respond to stress Risk for Shock: Risk factors: deficient fluid volume, decreased cortisol to initiate stress response to insult to body See Addison’s Disease; Shock, Hypovolemic

Advance Directives Death Anxiety r/t planning for end-of-life health decisions Decisional Conflict r/t unclear personal values or beliefs, per- ceived threat to value system, support system deficit Grieving r/t possible loss of self, significant other Readiness for enhanced Spiritual well-being: harmonious inter- connectedness with self, others, higher power, God

Affective Disorders See Depression (Major Depressive Disorder); Dysthymic Disorder; Manic Disorder, Bipolar I; SAD (Seasonal Affective Disorder)

Age-Related Macular Degeneration See Macular Degeneration

Aggressive Behavior Fear r/t real or imagined threat to own well-being Risk for other-directed Violence (See Violence, other-directed, risk for, Section III)

Aging Death Anxiety r/t fear of unknown, loss of self, impact on significant others Impaired Dentition r/t ineffective oral hygiene Risk for Frail Elderly syndrome: Risk factors: >70 years, activity intolerance, impaired vision Grieving r/t multiple losses, impending death Ineffective Health management r/t powerlessness Hearing Loss r/t exposure to loud noises, aging Functional urinary Incontinence r/t impaired vision, impaired cognition, neuromuscular limitations, altered environmental factors Impaired Resilience r/t aging, multiple losses Sleep deprivation r/t aging-related sleep-stage shifts Ineffective Thermoregulation r/t aging Vision Loss r/t aging (see care plan in Appendix) Risk for Caregiver Role Strain: Risk factor: inability to handle increasing needs of significant other Risk for Impaired emancipated Decision-Making: Risk factor: inability to process information regarding health care decisions Risk for Injury: Risk factors: vision loss, hearing loss, decreased balance, decreased sensation in feet Risk for Loneliness: Risk factors: inadequate support system, role transition, health alterations, depression, fatigue

22 Agitation

A Readiness for enhanced community Coping: providing social support and other resources identified as needed for elderly client Readiness for enhanced family Coping: ability to gratify needs, address adaptive tasks Readiness for enhanced Health management: knowledge about medication, nutrition, exercise, coping strategies Readiness for enhanced Knowledge: specify need to improve health Readiness for enhanced Nutrition: need to improve health Readiness for enhanced Relationship: demonstrates under- standing of partner’s insufficient function Readiness for enhanced Sleep: need to improve sleep Readiness for enhanced Spiritual well-being: one’s experience of life’s meaning, harmony with self, others, higher power, God, environment Readiness for enhanced Urinary elimination: need to improve health

Agitation Acute Confusion r/t side effects of medication, hypoxia, decreased cerebral perfusion, alcohol abuse or withdrawal, sub- stance abuse or withdrawal, sensory deprivation or overload Sleep deprivation r/t sustained inadequate sleep hygiene, sundown syndrome

Agoraphobia Anxiety r/t real or perceived threat to physical integrity Ineffective Coping r/t inadequate support systems Fear r/t leaving home, going out in public places Impaired Social interaction r/t disturbance in self-concept Social isolation r/t altered thought process

Agranulocytosis Delayed Surgical recovery r/t abnormal blood profile Risk for Infection: Risk factor: abnormal blood profile Readiness for enhanced Knowledge: expresses an interest in learning

AIDS (Acquired Immunodeficiency Syndrome)

Death Anxiety r/t fear of premature death Disturbed Body Image r/t chronic contagious illness, cachexia Caregiver Role Strain r/t unpredictable illness course, pres- ence of situation stressors Diarrhea r/t inflammatory bowel changes Interrupted Family processes r/t distress about diagnosis of human immunodeficiency virus (HIV) infection Fatigue r/t disease process, stress, decreased nutritional intake Fear r/t powerlessness, threat to well-being Grieving: family/parental r/t potential or impending death of loved one Grieving: individual r/t loss of physical and psychosocial well-being

Hopelessness r/t deteriorating physical condition Imbalanced Nutrition: less than body requirements r/t decreased ability to eat and absorb nutrients as a result of anorexia, nausea, diarrhea; oral candidiasis Chronic Pain r/t tissue inflammation and destruction Impaired Resilience r/t chronic illness Situational low Self-Esteem r/t crisis of chronic contagious illness Ineffective Sexuality pattern r/t possible transmission of disease Social isolation r/t self-concept disturbance, therapeutic isolation Chronic Sorrow r/t chronic illness Spiritual distress r/t challenged beliefs or moral system Risk for deficient Fluid volume: Risk factors: diarrhea, vomiting, fever, bleeding Risk for Infection: Risk factor: inadequate immune system Risk for Loneliness: Risk factor: social isolation Risk for impaired Oral Mucous Membrane: Risk factor: immunological deficit Risk for impaired Skin integrity: Risk factors: immunological deficit, diarrhea Risk for Spiritual distress: Risk factor: physical illness Readiness for enhanced Knowledge: expresses an interest in learning See AIDS, Child; Cancer; Pneumonia

AIDS Dementia Chronic Confusion r/t viral invasion of nervous system See Dementia

AIDS, Child Impaired Parenting r/t congenital acquisition of infection sec- ondary to intravenous (IV) drug use, multiple sexual partners, history of contaminated blood transfusion See AIDS (Acquired Immunodeficiency Syndrome); Child with Chronic Condition; Hospitalized Child; Terminally Ill Child, Adolescent; Terminally Ill Child, Infant/Toddler; Terminally Ill Child, Preschool Child; Terminally Ill Child, School-Age Child/ Preadolescent; Terminally Ill Child/Death of Child, Parent

Airway Obstruction/Secretions Ineffective Airway clearance (See Airway clearance, ineffective, Section III)

Alcohol Withdrawal Anxiety r/t situational crisis, withdrawal Acute Confusion r/t effects of alcohol withdrawal Ineffective Coping r/t personal vulnerability Dysfunctional Family processes r/t abuse of alcohol Insomnia r/t effect of alcohol withdrawal, anxiety Imbalanced Nutrition: less than body requirements r/t poor dietary habits Chronic low Self-Esteem r/t repeated unmet expectations

AMD (Age-Related Macular Degeneration) 23

ARisk for deficient Fluid volume: Risk factors: excessive diapho-resis, agitation, decreased fluid intake Risk for other-directed Violence: Risk factor: substance withdrawal Risk for self-directed Violence: Risk factor: substance withdrawal Readiness for enhanced Knowledge: expresses an interest in learning

Alcoholism Anxiety r/t loss of control Risk-prone Health behavior r/t lack of motivation to change behaviors, addiction Acute Confusion r/t alcohol abuse Chronic Confusion r/t neurological effects of chronic alcohol intake Defensive Coping r/t denial of reality of addiction Disabled family Coping r/t codependency issues due to alcoholism Ineffective Coping r/t use of alcohol to cope with life events Labile Emotional Control r/t substance abuse Ineffective Denial r/t refusal to acknowledge addiction Dysfunctional Family processes r/t alcohol abuse Impaired Home maintenance r/t memory deficits, fatigue Insomnia r/t irritability, nightmares, tremors Impaired Memory r/t alcohol abuse Self-Neglect r/t effects of alcohol abuse Imbalanced Nutrition: less than body requirements r/t anorexia, inappropriate diet with increased carbohydrates Powerlessness r/t alcohol addiction Ineffective Protection r/t malnutrition, sleep deprivation Chronic low Self-Esteem r/t failure at life events Social isolation r/t unacceptable social behavior, values Risk for Injury: Risk factor: alteration in sensory or perceptual function Risk for Loneliness: Risk factor: unacceptable social behavior Risk for other-directed Violence: Risk factors: reactions to substances used, impulsive behavior, disorientation, impaired judgment Risk for self-directed Violence: Risk factors: reactions to substances used, impulsive behavior, disorientation, impaired judgment

Alcoholism, Dysfunctional Family Processes

Dysfunctional Family processes (See Family processes, dys- functional, Section III)

Alkalosis See Metabolic Alkalosis

ALL (Acute Lymphocytic Leukemia) See Cancer; Chemotherapy; Child with Chronic Condition; Leukemia

Allergies Latex Allergy response r/t hypersensitivity to natural rubber latex Risk for Allergy response: Risk factors: chemical factors, dander, environmental substances, foods, insect stings, medications Risk for Latex Allergy response: Risk factor: repeated expo- sure to products containing latex Readiness for enhanced Knowledge: expresses an interest in learning

Alopecia Disturbed Body Image r/t loss of hair, change in appearance Readiness for enhanced Knowledge: expresses an interest in learning

Altered Mental Status See Confusion, Acute; Confusion, Chronic; Memory Deficit

ALS (Amyotrophic Lateral Sclerosis) See Amyotrophic Lateral Sclerosis (ALS)

Alzheimer’s Disease Caregiver role strain r/t duration and extent of caregiving required Chronic Confusion r/t loss of cognitive function Compromised family Coping r/t interrupted family processes Frail Elderly syndrome r/t alteration in cognitive functioning Impaired Home maintenance r/t impaired cognitive function, inadequate support systems Hopelessness r/t deteriorating condition Insomnia r/t neurological impairment, daytime naps Impaired Memory r/t neurological disturbance Impaired physical Mobility r/t severe neurological dysfunction Self-Neglect r/t loss of cognitive function Powerlessness r/t deteriorating condition Self-Care deficit: specify r/t loss of cognitive function, psycho- logical impairment Social isolation r/t fear of disclosure of memory loss Wandering r/t cognitive impairment, frustration, physiologi- cal state Risk for chronic functional Constipation: Risk factor: impaired cognitive functioning Risk for Injury: Risk factor: confusion Risk for Loneliness: Risk factor: potential social isolation Risk for Relocation stress syndrome: Risk factors: impaired psychosocial health, decreased health status Risk for other-directed Violence: Risk factors: frustration, fear, anger, loss of cognitive function Readiness for enhanced Knowledge: Caregiver: expresses an interest in learning See Dementia

AMD (Age-Related Macular Degeneration) See Macular Degeneration

24 Amenorrhea

A AmenorrheaImbalanced Nutrition: less than body requirements r/t inade- quate food intake See Sexuality, Adolescent

AMI (Acute Myocardial Infarction) See MI (Myocardial Infarction)

Amnesia Acute Confusion r/t alcohol abuse, delirium, dementia, drug abuse Dysfunctional Family processes r/t alcohol abuse, inadequate coping skills Impaired Memory r/t excessive environmental disturbance, neurological disturbance Post-Trauma syndrome r/t history of abuse, catastrophic illness, disaster, accident

Amniocentesis Anxiety r/t threat to self and fetus, unknown future Decisional Conflict r/t choice of treatment pending results of test Risk for Infection: Risk factor: invasive procedure

Amnionitis See Chorioamnionitis

Amniotic Membrane Rupture See Premature Rupture of Membranes

Amputation Disturbed Body Image r/t negative effects of amputation, response from others Grieving r/t loss of body part, future lifestyle changes Impaired physical Mobility r/t musculoskeletal impairment, limited movement Acute Pain r/t surgery, phantom limb sensation Chronic Pain r/t surgery, phantom limb sensation Ineffective peripheral Tissue Perfusion r/t impaired arterial circulation Impaired Skin integrity r/t poor healing, prosthesis rubbing Risk for Bleeding: Risk factor: vulnerable surgical site Risk for Impaired Tissue integrity: Risk factor: mechanical factors impacting site Readiness for enhanced Knowledge: expresses an interest in learning

Amyotrophic Lateral Sclerosis (ALS) Death Anxiety r/t impending progressive loss of function leading to death Ineffective Breathing pattern r/t compromised muscles of respiration Impaired verbal Communication r/t weakness of muscles of speech, deficient knowledge of ways to compensate and alterna- tive communication devices

Decisional Conflict: ventilator therapy r/t unclear personal values or beliefs, lack of relevant information Impaired Resilience r/t perceived vulnerability Chronic Sorrow r/t chronic illness Impaired Swallowing r/t weakness of muscles involved in swallowing Impaired spontaneous Ventilation r/t weakness of muscles of respiration Risk for Aspiration: Risk factor: impaired swallowing Risk for Spiritual distress: Risk factor: chronic debilitating condition See Neurologic Disorders

Anal Fistula See Hemorrhoidectomy

Anaphylactic Shock Deficient Fluid volume r/t compromised regulatory mechanism Ineffective Airway clearance r/t laryngeal edema, bronchospasm Latex Allergy response r/t abnormal immune mechanism response Impaired spontaneous Ventilation r/t acute airway obstruction from anaphylaxis process

Anaphylaxis Prevention Risk for Allergy response (See Allergy response, risk for, Section III)

Anasarca Excess Fluid volume r/t excessive fluid intake, cardiac/renal dysfunction, loss of plasma proteins Risk for impaired Skin integrity: Risk factor: impaired circula- tion to skin from edema See Anasarca

Anemia Anxiety r/t cause of disease Impaired Comfort r/t feelings of always being cold from decreased hemoglobin and decreased metabolism Fatigue r/t decreased oxygen supply to the body, increased cardiac workload Impaired Memory r/t change in cognition from decreased oxygen supply to the body Delayed Surgical recovery r/t decreased oxygen supply to body, increased cardiac workload Risk for Bleeding (See Bleeding, risk for, Section III) Risk for Injury: Risk factor: alteration in peripheral sensory perception Readiness for enhanced Knowledge: expresses an interest in learning

Anemia, in Pregnancy Anxiety r/t concerns about health of self and fetus

Anomaly, Fetal/Newborn (Parent Dealing with) 25

AFatigue r/t decreased oxygen supply to the body, increased cardiac workload Risk for delayed Development: Risk factor: reduction in the oxygen-carrying capacity of blood Risk for Infection: Risk factor: reduction in oxygen-carrying capacity of blood Risk for disturbed Maternal–Fetal dyad: Risk factor: compro- mised oxygen transport Readiness for enhanced Knowledge: expresses an interest in learning

Anemia, Sickle Cell See Anemia; Sickle Cell Anemia/Crisis

Anencephaly See Neural Tube Defects

Aneurysm, Abdominal Surgery Risk for deficient Fluid volume: Risk factor: hemorrhage r/t potential abnormal blood loss Risk for Infection: Risk factor: invasive procedure Risk for ineffective Gastrointestinal perfusion (See Gastro­ intestinal perfusion, ineffective, risk for, Section III) Risk for ineffective Renal perfusion: Risk factor: prolonged isch- emia of kidneys See Abdominal Surgery

Aneurysm, Cerebral See Craniectomy/Craniotomy; Subarachnoid Hemorrhage

Anger Anxiety r/t situational crisis Defensive Coping r/t inability to acknowledge responsibility for actions and results of actions Labile Emotional Control r/t stressors Fear r/t environmental stressor, hospitalization Grieving r/t significant loss Risk-prone Health behavior r/t assault to self-esteem, disability requiring change in lifestyle, inadequate support system Powerlessness r/t health care environment Risk for compromised Human Dignity: Risk factors: inade- quate participation in decision-making, perceived dehumanizing treatment, perceived humiliation, exposure of the body, cultural incongruity Risk for Post-Trauma syndrome: Risk factor: inadequate social support Risk for other-directed Violence: Risk factors: history of vio- lence, rage reaction Risk for self-directed Violence: Risk factors: history of violence, history of abuse, rage reaction

Angina Activity intolerance r/t acute pain, dysrhythmias Anxiety r/t situational crisis Decreased Cardiac output r/t myocardial ischemia, medication effect, dysrhythmia

Ineffective Coping r/t personal vulnerability to situational crisis of new diagnosis, deteriorating health Ineffective Denial r/t deficient knowledge of need to seek help with symptoms Grieving r/t pain, loss of health Acute Pain r/t myocardial ischemia Ineffective Sexuality pattern r/t disease process, medications, loss of libido Readiness for enhanced Knowledge: expresses an interest in learning

Angiocardiography (Cardiac Catheterization)

See Cardiac Catheterization

Angioplasty, Coronary Fear r/t possible outcome of interventional procedure Ineffective peripheral Tissue Perfusion r/t vasospasm, hema- toma formation Risk for Bleeding: Risk factors: possible damage to coronary artery, hematoma formation Risk for decreased Cardiac tissue perfusion: Risk factors: ven- tricular ischemia, dysrhythmias Readiness for enhanced Knowledge: expresses an interest in learning

Anomaly, Fetal/Newborn (Parent Dealing with)

Anxiety r/t threat to role functioning, situational crisis Decisional Conflict: interventions for fetus or newborn r/t lack of relevant information, spiritual distress, threat to value system Disabled family Coping r/t chronically unresolved feelings about loss of perfect baby Ineffective Coping r/t personal vulnerability in situational crisis Interrupted Family processes r/t unmet expectations for perfect baby, lack of adequate support systems Fear r/t real or imagined threat to baby, implications for future pregnancies, powerlessness Grieving r/t loss of ideal child Hopelessness r/t long-term stress, deteriorating physical con- dition of child, lost spiritual belief Deficient Knowledge r/t limited exposure to situation Impaired Parenting r/t interruption of bonding process Powerlessness r/t complication threatening fetus or newborn Parental Role conflict r/t separation from newborn, intimida- tion with invasive or restrictive modalities, specialized care center policies Situational low Self-Esteem r/t perceived inability to produce a perfect child Social isolation r/t alterations in child’s physical appearance, altered state of wellness Chronic Sorrow r/t loss of ideal child, inadequate bereavement support

26 Anorectal Abscess

A Spiritual distress r/t test of spiritual beliefsRisk for impaired Attachment: Risk factor: ill infant unable to effectively initiate parental contact as result of altered behavioral organization Risk for disorganized Infant behavior: Risk factor: congenital disorder Risk for impaired Parenting: Risk factors: interruption of bonding process; unrealistic expectations for self, infant, or partner; perceived threat to own emotional survival; severe stress; lack of knowledge Risk for Spiritual distress: Risk factor: lack of normal child to raise and carry on family name

Anorectal Abscess Disturbed Body Image r/t odor and drainage from rectal area Acute Pain r/t inflammation of perirectal area Risk for Constipation: Risk factor: fear of painful elimination Readiness for enhanced Knowledge: expresses an interest in learning

Anorexia Deficient Fluid volume r/t inability to drink Imbalanced Nutrition: less than body requirements r/t loss of appetite, nausea, vomiting, laxative abuse Delayed Surgical recovery r/t inadequate nutritional intake Risk for delayed Surgical recovery: Risk factor: inadequate nutritional intake

Anorexia Nervosa Activity intolerance r/t fatigue, weakness Disturbed Body Image r/t misconception of actual body appearance Constipation r/t lack of adequate food, fiber, and fluid intake Defensive Coping r/t psychological impairment, eating disorder Disabled family Coping r/t highly ambivalent family relationships Ineffective Denial r/t fear of consequences of therapy, possible weight gain Diarrhea r/t laxative abuse Interrupted Family processes r/t situational crisis Ineffective family Health management r/t family conflict, exces- sive demands on family associated with complexity of condition and treatment Imbalanced Nutrition: less than body requirements r/t inade- quate food intake, excessive exercise Chronic low Self-Esteem r/t repeated unmet expectations Ineffective Sexuality pattern r/t loss of libido from malnutrition Risk for Infection: Risk factor: malnutrition resulting in depressed immune system Risk for Spiritual distress: Risk factor: low self-esteem See Maturational Issues, Adolescent

Anosmia (Smell, Loss of Ability to) Imbalanced Nutrition: less than body requirements r/t loss of appetite associated with loss of smell

Antepartum Period See Pregnancy, Normal; Prenatal Care, Normal

Anterior Repair, Anterior Colporrhaphy Urinary Retention r/t edema of urinary structures Risk for urge urinary Incontinence: Risk factor: trauma to bladder Readiness for enhanced Knowledge: expresses an interest in learning See Vaginal Hysterectomy

Anticoagulant Therapy Risk for Bleeding: Risk factor: altered clotting function from anticoagulant Risk for deficient Fluid volume: hemorrhage: Risk factor: altered clotting mechanism Readiness for enhanced Knowledge: expresses an interest in learning

Antisocial Personality Disorder Defensive Coping r/t excessive use of projection Ineffective Coping r/t frequently violating the norms and rules of society Labile Emotional Control r/t psychiatric disorder Hopelessness r/t abandonment Impaired Social interaction r/t sociocultural conflict, chemical dependence, inability to form relationships Spiritual distress r/t separation from religious or cultural ties Ineffective Health management r/t excessive demands on family Risk for Loneliness: Risk factor: inability to interact appropri- ately with others Risk for impaired Parenting: Risk factors: inability to function as parent or guardian, emotional instability Risk for Self-Mutilation: Risk factors: self-hatred, depersonal- ization Risk for other-directed Violence: Risk factor: history of vio- lence, altered thought patterns

Anuria See Kidney Failure

Anxiety See Anxiety, Section III

Anxiety Disorder Ineffective Activity planning r/t unrealistic perception of events Anxiety r/t unmet security and safety needs Death Anxiety r/t fears of unknown, powerlessness Decisional Conflict r/t low self-esteem, fear of making a mistake Defensive Coping r/t overwhelming feelings of dread

Arthroplasty (Total Hip Replacement) 27

ADisabled family Coping r/t ritualistic behavior, actionsIneffective Coping r/t inability to express feelings appropriately Ineffective Denial r/t overwhelming feelings of hopelessness, fear, threat to self Insomnia r/t psychological impairment, emotional instability Impaired Mood regulation r/t functional impairment, impaired social functioning, alteration in sleep pattern Labile Emotional Control r/t emotional instability Powerlessness r/t lifestyle of helplessness Self-Care deficit r/t ritualistic behavior, activities Sleep deprivation r/t prolonged psychological discomfort Risk for Spiritual distress: Risk factor: psychological distress Readiness for enhanced Knowledge: expresses an interest in learning

Aortic Aneurysm Repair (Abdominal Surgery)

See Abdominal Surgery; Aneurysm, Abdominal Surgery

Aortic Valvular Stenosis See Congenital Heart Disease/Cardiac Anomalies

Aphasia Anxiety r/t situational crisis of aphasia Impaired verbal Communication r/t decrease in circulation to brain Ineffective Coping r/t loss of speech Ineffective Health maintenance r/t deficient knowledge regard- ing information on aphasia and alternative communication techniques

Aplastic Anemia Activity intolerance r/t imbalance between oxygen supply and demand Fear r/t ability to live with serious disease Risk for Bleeding: Risk factor: inadequate clotting factors Risk for Infection: Risk factor: inadequate immune function Readiness for enhanced Knowledge: expresses an interest in learning

Apnea in Infancy See Premature Infant (Child); Premature Infant (Parent); SIDS (Sudden Infant Death Syndrome)

Apneustic Respirations Ineffective Breathing pattern r/t perception or cognitive impairment, neurological impairment See Apneustic Respirations

Appendectomy Deficient Fluid volume r/t fluid restriction, hypermetabolic state, nausea, vomiting Acute Pain r/t surgical incision Delayed Surgical recovery r/t rupture of appendix Risk for Infection: Risk factors: perforation or rupture of appen- dix, surgical incision, peritonitis

Readiness for enhanced Knowledge: expresses an interest in learning See Hospitalized Child; Surgery, Postoperative Care

Appendicitis Deficient Fluid volume r/t anorexia, nausea, vomiting Acute Pain r/t inflammation Risk for Infection: Risk factor: possible perforation of appendix Readiness for enhanced Knowledge: expresses an interest in learning

Apprehension Anxiety r/t threat to self-concept, threat to health status, situ- ational crisis Death Anxiety r/t apprehension over loss of self, consequences to significant others

ARDS (Acute Respiratory Distress Syndrome)

Ineffective Airway clearance r/t excessive tracheobronchial secretions Death Anxiety r/t seriousness of physical disease Impaired Gas exchange r/t damage to alveolar capillary mem- brane, change in lung compliance Impaired spontaneous Ventilation r/t damage to alveolar capil- lary membrane See Ventilated Client, Mechanically

Arrhythmia See Dysrhythmia

Arterial Insufficiency Ineffective peripheral Tissue Perfusion r/t interruption of arte- rial flow Delayed Surgical recovery r/t ineffective tissue perfusion

Arthritis Activity intolerance r/t chronic pain, fatigue, weakness Disturbed Body Image r/t ineffective coping with joint abnormalities Impaired physical Mobility r/t joint impairment Chronic Pain r/t progression of joint deterioration Self-Care deficit: specify r/t pain with movement, damage to joints Readiness for enhanced Knowledge: expresses an interest in learning See JRA (Juvenile Rheumatoid Arthritis)

Arthrocentesis Acute Pain r/t invasive procedure

Arthroplasty (Total Hip Replacement) See Total Joint Replacement (Total Hip/Total Knee/Shoulder); Surgery, Perioperative; Surgery, Postoperative Care; Surgery, Pre- operative Care

28 Arthroscopy

A Arthroscopy Impaired physical Mobility r/t surgical trauma of knee Readiness for enhanced Knowledge: expresses an interest in learning

Ascites Ineffective Breathing pattern r/t increased abdominal girth Imbalanced Nutrition: less than body requirements r/t loss of appetite Chronic Pain r/t altered body function Readiness for enhanced Knowledge: expresses an interest in learning See Ascites; Cancer; Cirrhosis

Asperger’s Syndrome Ineffective Relationship r/t poor communication skills, lack of empathy See Autism

Asphyxia, Birth Ineffective Breathing pattern r/t depression of breathing reflex secondary to anoxia Ineffective Coping r/t uncertainty of child outcome Fear (parental) r/t concern over safety of infant Impaired Gas exchange r/t poor placental perfusion, lack of initiation of breathing by newborn Grieving r/t loss of perfect child, concern of loss of future abilities Impaired spontaneous Ventilation r/t brain injury Risk for impaired Attachment: Risk factors: ill infant who is unable to initiate parental contact, hospitalization in critical care environment Risk for delayed Development: Risk factor: lack of oxygen to brain Risk for disproportionate Growth: Risk factor: lack of oxygen to brain Risk for disorganized Infant behavior: Risk factor: lack of oxygen to brain Risk for Injury: Risk factor: lack of oxygen to brain Risk for ineffective Cerebral tissue perfusion: Risk factor: poor placental perfusion or cord compression resulting in lack of oxygen to brain

Aspiration, Danger of Risk for Aspiration (See Aspiration, risk for, Section III)

Assault Victim Post-Trauma syndrome r/t assault Rape-Trauma syndrome r/t rape Impaired Resilience r/t frightening experience, post-trauma stress response Risk for Post-Trauma syndrome: Risk factors: perception of event, inadequate social support, unsupportive environment, diminished ego strength, duration of event

Risk for Spiritual distress: Risk factors: physical, psychological stress

Assaultive Client Risk for Injury: Risk factors: confused thought process, impaired judgment Risk for other-directed Violence: Risk factors: paranoid ideation, anger

Asthma Activity intolerance r/t fatigue, energy shift to meet muscle needs for breathing to overcome airway obstruction Ineffective Airway clearance r/t tracheobronchial narrowing, excessive secretions Anxiety r/t inability to breathe effectively, fear of suffocation Disturbed Body Image r/t decreased participation in physical activities Ineffective Breathing pattern r/t anxiety Ineffective Coping r/t personal vulnerability to situational crisis Ineffective Health management (See Health management, inef- fective, in Section III) Impaired Home maintenance r/t deficient knowledge regarding control of environmental triggers Sleep deprivation r/t ineffective breathing pattern, cough Readiness for enhanced Health management (See Health management, readiness for enhanced, in Section III) Readiness for enhanced Knowledge: expresses an interest in learning See Child with Chronic Condition; Hospitalized Child

Ataxia Anxiety r/t change in health status Disturbed Body Image r/t staggering gait Impaired physical Mobility r/t neuromuscular impairment Risk for Falls: Risk factors: gait alteration, instability

Atelectasis Ineffective Breathing pattern r/t loss of functional lung tissue, depression of respiratory function or hypoventilation because of pain Impaired Gas exchange r/t decreased alveolar-capillary surface Anxiety r/t alteration in respiratory pattern See Atelectasis

Atherosclerosis See MI (Myocardial Infarction); CVA (Cerebrovascular Accident); Peripheral Vascular Disease (PVD)

Athlete’s Foot Impaired Skin integrity r/t effects of fungal agent Readiness for enhanced Knowledge: expresses an interest in learning See Itching; Pruritus

ATN (Acute Tubular Necrosis) See Kidney Failure

Atrial Fibrillation See Dysrhythmia

Atrial Septal Defect See Congenital Heart Disease/Cardiac Anomalies

Attention Deficit Disorder Risk-prone Health behavior r/t intense emotional state Disabled family Coping r/t significant person with chron- ically unexpressed feelings of guilt, anxiety, hostility, and despair Ineffective Impulse control r/t (See Impulse control, ineffective, Section III) Chronic low Self-Esteem r/t difficulty in participating in expected activities, poor school performance Social isolation r/t unacceptable social behavior Risk for delayed Development: Risk factor: behavior disorders Risk for Falls: Risk factor: rapid non-thinking behavior Risk for Loneliness: Risk factor: social isolation Risk for impaired Parenting: Risk factor: lack of knowledge of factors contributing to child’s behavior Risk for Spiritual distress: Risk factor: poor relationships

Auditory Problems See Hearing Impairment

Autism Impaired verbal Communication r/t speech and language delays Compromised family Coping r/t parental guilt over etiology of disease, inability to accept or adapt to child’s condition, inability to help child and other family members seek treatment Disturbed personal Identity r/t inability to distinguish between self and environment, inability to identify own body as separate from those of other people, inability to integrate concept of self Self-Neglect r/t impaired socialization Impaired Social interaction r/t communication barriers, inabil- ity to relate to others, failure to develop peer relationships Risk for delayed Development: Risk factor: autism Risk for Loneliness: Risk factor: difficulty developing relation- ships with other people Risk for Self-Mutilation: Risk factor: autistic state Risk for other-directed Violence: Risk factors: frequent destruc- tive rages toward others secondary to extreme response to changes in routine, fear of harmless things Risk for self-directed Violence: Risk factors: frequent destruc- tive rages toward self, secondary to extreme response to changes in routine, fear of harmless things See Child with Chronic Condition

Autonomic Dysreflexia Autonomic Dysreflexia r/t bladder distention, bowel disten- tion, noxious stimuli Risk for Autonomic Dysreflexia: Risk factors: bladder disten- tion, bowel distention, noxious stimuli

Autonomic Hyperreflexia See Autonomic Dysreflexia

Battered Child Syndrome 29

B

B Baby Care

Readiness for enhanced Childbearing process: demonstrates appropriate feeding and baby care techniques, along with attach- ment to infant and providing a safe environment Anxiety r/t situational crisis, back injury Ineffective Coping r/t situational crisis, back injury Impaired physical Mobility r/t pain Acute Pain r/t back injury Chronic Pain r/t back injury Risk for Constipation: Risk factors: decreased activity, side effect of pain medication Risk for Disuse syndrome: Risk factor: severe pain Readiness for enhanced Knowledge: expresses an interest in learning

Bacteremia Risk for Infection: Risk factor: compromised immune system Risk for Shock: Risk factor: development of systemic inflamma- tory response from presence of bacteria in bloodstream See Infection; Infection, Potential for

Barrel Chest See Aging (if appropriate); COPD (Chronic Obstructive Pulmo- nary Disease)

Bathing/Hygiene Problems Impaired Mobility r/t chronic physically limiting condition Self-Neglect (See Self-Neglect, Section III) Bathing Self-Care deficit (See Self-Care deficit, bathing, Section III)

Battered Child Syndrome Dysfunctional Family processes r/t inadequate coping skills Sleep deprivation r/t prolonged psychological discomfort Chronic Sorrow r/t situational crises Risk for Post-Trauma syndrome: Risk factors: physical abuse, incest, rape, molestation Risk for Self-Mutilation: Risk factors: feelings of rejection, dys- functional family Risk for Suicide: Risk factor: childhood abuse See Child Abuse

e3

List of Nursing Assessments by Letter: B

Baby Care Bacteremia Barrel Chest Bathing/Hygiene Problems Battered Child Syndrome Battered Person Bedbugs, Infestation Bed Mobility, Impaired Bed Rest, Prolonged Bedsores Bedwetting Bell’s Palsy Benign Prostatic Hypertrophy Bereavement Biliary Atresia Biliary Calculus Biliary Obstruction Bilirubin Elevation in Neonate Biopsy Bioterrorism Bipolar Disorder I (Most Recent

Episode, Depressed or Manic) Birth Asphyxia Birth Control Bladder Cancer Bladder Distention Bladder Training Bladder Training, Child Bleeding Tendency Blepharoplasty Blindness Blood Disorder Blood Pressure Alteration Blood Sugar Control Blood Transfusion Body Dysmorphic Disorder Body Image Change Body Temperature, Altered Bone Marrow Biopsy Borderline Personality Disorder Boredom Botulism Bowel Incontinence Bowel Obstruction Bowel Resection Bowel Sounds, Absent or Diminished Bowel Sounds, Hyperactive Bowel Training Bowel Training, Child BPH (Benign Prostatic Hypertrophy) Bradycardia Bradypnea Brain Injury Brain Surgery Brain Tumor Braxton Hicks Contractions Breast Biopsy Breast Cancer Breast Examination, Self Breast Lumps Breast Pumping Breastfeeding, Effective Breastfeeding, Ineffective Breastfeeding, Interrupted Breast Milk, Insufficient Breath Sounds, Decreased or Absent Breathing Pattern Alteration Breech Birth Bronchitis Bronchopulmonary Dysplasia Bronchoscopy Bruits, Carotid Bryant’s Traction Buck’s Traction Buerger’s Disease Bulimia Bunion Bunionectomy Burn Risk Burns Bursitis Bypass Graft

30 Battered Person

B Battered Person

See Abuse, Spouse, Parent, or Significant Other

Bedbugs, Infestation Impaired Home maintenance r/t deficient knowledge regarding prevention of bedbug infestation Impaired Skin integrity r/t bites of bedbugs See Itching; Pruritus

Bed Mobility, Impaired Impaired bed Mobility (See Mobility, bed, impaired, Section III)

Bed Rest, Prolonged Deficient Diversional activity r/t prolonged bed rest Impaired bed Mobility r/t neuromuscular impairment Social isolation r/t prolonged bed rest Risk for chronic functional Constipation: Risk factor: insuffi- cient physical activity Risk for Disuse syndrome: Risk factor: prolonged immobility Risk for Frail Elderly syndrome: Risk factor: prolonged immobility Risk for Loneliness: Risk factor: prolonged bed rest Risk for Overweight: Risk factor: energy expenditure below energy intake Risk for Pressure ulcer: Risk factor: prolonged immobility

Bedsores See Pressure Ulcer

Bedwetting Ineffective Health maintenance r/t unachieved developmental level, neuromuscular immaturity, diseases of the urinary system

Bell’s Palsy Disturbed Body Image r/t loss of motor control on one side of face Imbalanced Nutrition: less than body requirements r/t diffi- culty with chewing Acute Pain r/t inflammation of facial nerve Risk for Injury (eye): Risk factors: decreased tears, decreased blinking of eye Readiness for enhanced Knowledge: expresses an interest in learning

Benign Prostatic Hypertrophy See BPH (Benign Prostatic Hypertrophy); Prostatic Hypertrophy

Bereavement Grieving r/t loss of significant person Insomnia r/t grief Risk for complicated Grieving: Risk factor: emotional instabil- ity, lack of social support Risk for Spiritual distress: Risk factor: death of a loved one

Biliary Atresia Anxiety r/t surgical intervention, possible liver transplantation Impaired Comfort r/t inflammation of skin, itching Imbalanced Nutrition: less than body requirements r/t decreased absorption of fat and fat-soluble vitamins, poor feeding Risk for Bleeding: Risk factors: vitamin K deficiency, altered clotting mechanisms Risk for ineffective Breathing pattern: Risk factors: enlarged liver, development of ascites Risk for impaired Skin integrity: Risk factor: pruritus See Child with Chronic Condition; Cirrhosis (as complication); Hospitalized Child; Terminally Ill: Child, Adolescent; Infant/ Toddler; Preschool Child; School-Age Child/Preadolescent; Death of Child, Parent

Biliary Calculus See Cholelithiasis

Biliary Obstruction See Jaundice

Bilirubin Elevation in Neonate Neonatal Jaundice (See Jaundice, Neonatal, Section III)

Biopsy Fear r/t outcome of biopsy Readiness for enhanced Knowledge: expresses an interest in learning

Bioterrorism Contamination r/t exposure to bioterrorism Risk for Infection: Risk factor: exposure to harmful biologi- cal agent Risk for Post-Trauma syndrome: Risk factor: perception of event of bioterrorism

Bipolar Disorder I (Most Recent Episode, Depressed or Manic)

Ineffective Activity planning r/t unrealistic perception of events Fatigue r/t psychological demands Risk-prone Health behavior r/t low state of optimism Ineffective Health maintenance r/t lack of ability to make good judgments regarding ways to obtain help Self-Care deficit: specify r/t depression, cognitive impairment Chronic low Self-Esteem r/t repeated unmet expectations Social isolation r/t ineffective coping Risk for complicated Grieving: Risk factor: lack of previous resolution of former grieving response Risk for Loneliness: Risk factors: stress, conflict Risk for Spiritual distress: Risk factor: mental illness Risk for Suicide: Risk factors: psychiatric disorder, poor support system See Depression (Major Depressive Disorder); Manic Disorder, Bipolar I

Borderline Personality Disorder 31

B Birth Asphyxia

See Asphyxia, Birth

Birth Control See Contraceptive Method

Bladder Cancer Urinary Retention r/t clots obstructing urethra See Cancer; TURP (Transurethral Resection of the Prostate)

Bladder Distention Urinary Retention r/t high urethral pressure caused by weak detrusor, inhibition of reflex arc, blockage, strong sphincter

Bladder Training Disturbed Body Image r/t difficulty maintaining control of urinary elimination Functional urinary Incontinence r/t altered environment; sensory, cognitive, mobility deficit Stress urinary Incontinence r/t degenerative change in pelvic muscles and structural supports Urge urinary Incontinence r/t decreased bladder capacity, increased urine concentration, overdistention of bladder Readiness for enhanced Knowledge: expresses an interest in learning

Bladder Training, Child See Toilet Training

Bleeding Tendency Risk for Bleeding (See Bleeding, risk for, Section III) Risk for delayed Surgical recovery: Risk factor: bleeding tendency

Blepharoplasty Disturbed Body Image r/t effects of surgery Readiness for enhanced Knowledge: expresses an interest in learning

Blindness Interrupted Family processes r/t shift in health status of family member (change in visual acuity) Impaired Home maintenance r/t decreased vision Ineffective Role performance r/t alteration in health status (change in visual acuity) Self-Care deficit: specify r/t inability to see to be able to perform activities of daily living Vision Loss r/t impaired sensory reception, transmission, or integration (see care plan in Appendix) Risk for delayed Development: Risk factor: vision impairment Risk for Injury: Risk factor: sensory dysfunction Readiness for enhanced Knowledge: expresses an interest in learning See Vision Impairment

Blood Disorder Ineffective Protection r/t abnormal blood profile

Risk for Bleeding: Risk factor: abnormal blood profile See ITP (Idiopathic Thrombocytopenic Purpura), Hemophilia, Lacerations, Shock, Hypovolemic

Blood Pressure Alteration See Hypotension; HTN (Hypertension)

Blood Sugar Control Risk for unstable blood Glucose level (See Glucose level, blood, unstable, risk for, Section III)

Blood Transfusion Anxiety r/t possibility of harm from transfusion See Anemia

Body Dysmorphic Disorder Anxiety r/t perceived defect of body Disturbed Body Image r/t overinvolvement in physical appearance Chronic low Self-Esteem r/t lack of self valuing because of perceived body defects Social isolation r/t distancing self from others because of per- ceived self body defects Risk for Suicide: Risk factor: perceived defects of body affecting self-valuing and hopes

Body Image Change Disturbed Body Image (See Body Image, disturbed, Section III)

Body Temperature, Altered Ineffective Thermoregulation (See Thermoregulation, inef- fective, Section III)

Bone Marrow Biopsy Fear r/t unknown outcome of results of biopsy Acute Pain r/t bone marrow aspiration Readiness for enhanced Knowledge: expresses an interest in learning See disease necessitating bone marrow biopsy (e.g., Leukemia)

Borderline Personality Disorder Ineffective Activity planning r/t unrealistic perception of events Anxiety r/t perceived threat to self-concept Defensive Coping r/t difficulty with relationships, inability to accept blame for own behavior Ineffective Coping r/t use of maladjusted defense mechanisms (e.g., projection, denial) Powerlessness r/t lifestyle of helplessness Social isolation r/t immature interests Ineffective family Health management r/t manipulative behavior of client Risk for Caregiver Role Strain: Risk factors: inability of care receiver to accept criticism, care receiver taking advantage of others to meet own needs or having unreasonable expectations Risk for Self-Mutilation: Risk factors: ineffective coping, feel- ings of self-hatred

32 Boredom

B Risk for Spiritual distress: Risk factor: poor relationships asso- ciated with abnormal behaviors Risk for self-directed Violence: Risk factors: feelings of need to punish self, manipulative behavior

Boredom Deficient Diversional activity r/t environmental lack of diver- sional activity Impaired Mood regulation r/t emotional instability Social isolation r/t altered state of wellness

Botulism Deficient Fluid volume r/t profuse diarrhea Readiness for enhanced Knowledge: expresses an interest in learning

Bowel Incontinence Bowel Incontinence r/t decreased awareness of need to defe- cate, loss of sphincter control, fecal impaction Readiness for enhanced Knowledge: expresses an interest in learning

Bowel Obstruction Constipation r/t decreased motility, intestinal obstruction Deficient Fluid volume r/t inadequate fluid volume intake, fluid loss in bowel Imbalanced Nutrition: less than body requirements r/t nausea, vomiting Acute Pain r/t pressure from distended abdomen

Bowel Resection See Abdominal Surgery

Bowel Sounds, Absent or Diminished Constipation r/t decreased or absent peristalsis Deficient Fluid volume r/t inability to ingest fluids, loss of fluids in bowel Delayed Surgical recovery r/t inability to obtain adequate nutritional status Risk for dysfunctional Gastrointestinal motility (See Gastro- intestinal motility, dysfunctional, risk for, Section III)

Bowel Sounds, Hyperactive Diarrhea r/t increased gastrointestinal motility

Bowel Training Bowel Incontinence r/t loss of control of rectal sphincter Readiness for enhanced Knowledge: expresses an interest in learning

Bowel Training, Child See Toilet Training

BPH (Benign Prostatic Hypertrophy) Ineffective Health maintenance r/t deficient knowledge regard- ing self-care with prostatic hypertrophy Insomnia r/t nocturia Urinary Retention r/t obstruction of urethra

Risk for urge urinary Incontinence: Risk factors: detrusor muscle instability with impaired contractility, involuntary sphincter relaxation Risk for Infection: Risk factors: urinary residual after voiding, bacterial invasion of bladder Readiness for enhanced Knowledge: expresses an interest in learning See Prostatic Hypertrophy

Bradycardia Decreased Cardiac output r/t slow heart rate supplying inad- equate amount of blood for body function Risk for ineffective Cerebral tissue perfusion: Risk factors: decreased cardiac output secondary to bradycardia, vagal response Readiness for enhanced Knowledge: expresses an interest in learning

Bradypnea Ineffective Breathing pattern r/t neuromuscular impairment, pain, musculoskeletal impairment, perception or cognitive impairment, anxiety, fatigue or decreased energy, effects of drugs See Sleep apnea (See Airway clearance, ineffective, Section III)

Brain Injury See Intracranial Pressure, Increased

Brain Surgery See Craniectomy/Craniotomy

Brain Tumor Acute Confusion r/t pressure from tumor Fear r/t threat to well-being Grieving r/t potential loss of physiosocial-psychosocial well-being Decreased Intracranial adaptive capacity r/t presence of brain tumor Acute Pain r/t pressure from tumor Vision Loss r/t tumor growth compressing optic nerve and/or brain tissue Risk for Injury: Risk factors: sensory-perceptual alterations, weakness Risk for Hyperthermia: Risk factor: loss of thermoregulation with hypothalamic dysfunction See Cancer; Chemotherapy; Child with Chronic Condition; Craniectomy/Craniotomy; Hospitalized Child; Radiation Therapy; Terminally Ill Child, Adolescent; Terminally Ill Child, Infant/ Toddler; Terminally Ill Child, Preschool Child; Terminally Ill Child, School-Age Child/Preadolescent; Terminally Ill Child/Death of Child, Parent

Braxton Hicks Contractions Activity intolerance r/t increased contractions with increased gestation Anxiety r/t uncertainty about beginning labor Fatigue r/t lack of sleep

Bulimia 33

B Stress urinary Incontinence r/t increased pressure on bladder with contractions Insomnia r/t contractions when lying down Ineffective Sexuality pattern r/t fear of contractions associated with loss of infant

Breast Biopsy Fear r/t potential for diagnosis of cancer Risk for Spiritual distress: Risk factor: fear of diagnosis of cancer Readiness for enhanced Knowledge: expresses an interest in learning

Breast Cancer Death Anxiety r/t diagnosis of cancer Ineffective Coping r/t treatment, prognosis Fear r/t diagnosis of cancer Sexual dysfunction r/t loss of body part, partner’s reaction to loss Chronic Sorrow r/t diagnosis of cancer, loss of body integrity Risk for Spiritual distress: Risk factor: fear of diagnosis of cancer Readiness for enhanced Knowledge: expresses an interest in learning See Cancer; Chemotherapy; Mastectomy; Radiation Therapy

Breast Examination, Self See SBE (Self-Breast Examination)

Breast Lumps Fear r/t potential for diagnosis of cancer Readiness for enhanced Knowledge: expresses an interest in learning

Breast Pumping Risk for Infection: Risk factors: possible contaminated breast pump, incomplete emptying of breast Risk for impaired Skin integrity: Risk factor: high suction Readiness for enhanced Knowledge: expresses an interest in learning

Breastfeeding, Effective Readiness for enhanced Breastfeeding (See Breastfeeding, readiness for enhanced, Section III)

Breastfeeding, Ineffective Ineffective Breastfeeding (See Breastfeeding, ineffective, Section III) See Infant Feeding Pattern, Ineffective; Painful Breasts, Engorge- ment; Painful Breasts, Sore Nipples

Breastfeeding, Interrupted Interrupted Breastfeeding (See Breastfeeding, interrupted, Section III)

Breast Milk, Insufficient Insufficient Breast Milk (See Breast Milk, insufficient, Section III)

Breath Sounds, Decreased or Absent See Atelectasis; Pneumothorax

Breathing Pattern Alteration Ineffective Breathing pattern r/t neuromuscular impairment, pain, musculoskeletal impairment, perception or cognitive impairment, anxiety, decreased energy or fatigue

Breech Birth Fear: maternal r/t danger to infant, self Impaired Gas exchange: fetal r/t compressed umbilical cord Risk for Aspiration: fetal: Risk factor: birth of body before head Risk for delayed Development: Risk factor: compressed umbil- ical cord Risk for impaired Tissue integrity: fetal: Risk factor: difficult birth Risk for impaired Tissue integrity: maternal: Risk factor: diffi- cult birth

Bronchitis Ineffective Airway clearance r/t excessive thickened mucus secretion Readiness for enhanced Health management: wishes to stop smoking Readiness for enhanced Knowledge: expresses an interest in learning

Bronchopulmonary Dysplasia Activity intolerance r/t imbalance between oxygen supply and demand Excess Fluid volume r/t sodium and water retention Imbalanced Nutrition: less than body requirements r/t poor feeding, increased caloric needs as a result of increased work of breathing See Child with Chronic Condition; Hospitalized Child; Respiratory Conditions of the Neonate

Bronchoscopy Risk for Aspiration: Risk factor: temporary loss of gag reflex Risk for Injury: Risk factors: complication of pneumothorax, laryngeal edema, hemorrhage (if biopsy done)

Bruits, Carotid Risk for ineffective Cerebral tissue perfusion: Risk factors: interruption of carotid blood flow to brain

Bryant’s Traction See Traction and Casts

Buck’s Traction See Traction and Casts

Buerger’s Disease See Peripheral Vascular Disease (PVD)

Bulimia Disturbed Body Image r/t misperception about actual appear- ance, body weight

34 Bunion

Compromised family Coping r/t chronically unresolved feelings of guilt, anger, hostility Defensive Coping r/t eating disorder Diarrhea r/t laxative abuse Fear r/t food ingestion, weight gain Imbalanced Nutrition: less than body requirements r/t induced vomiting, excessive exercise, laxative abuse Powerlessness r/t urge to purge self after eating Chronic low Self-Esteem r/t lack of positive feedback See Maturational Issues, Adolescent

Bunion Readiness for enhanced Knowledge: expresses an interest in learning

Bunionectomy Impaired physical Mobility r/t sore foot Impaired Walking r/t pain associated with surgery Risk for Infection: Risk factors: surgical incision, advanced age Readiness for enhanced Knowledge: expresses an interest in learning

Burn Risk Risk for Thermal injury (See Thermal injury, risk for, Section III)

Burns Anxiety r/t burn injury, treatments Disturbed Body Image r/t altered physical appearance Deficient Diversional activity r/t long-term hospitalization Fear r/t pain from treatments, possible permanent disfigurement Deficient Fluid volume r/t loss of protective skin Grieving r/t loss of bodily function, loss of future hopes and plans Hypothermia r/t impaired skin integrity Impaired physical Mobility r/t pain, musculoskeletal impair- ment, contracture formation Imbalanced Nutrition: less than body requirements r/t increased metabolic needs, anorexia, protein and fluid loss Acute Pain r/t burn injury, treatments Chronic Pain r/t burn injury, treatments Ineffective peripheral Tissue Perfusion r/t circumferential burns, impaired arterial/venous circulation Post-Trauma syndrome r/t life-threatening event Impaired Skin integrity r/t injury of skin Delayed Surgical recovery r/t ineffective tissue perfusion Risk for ineffective Airway clearance: Risk factors: potential tracheobronchial obstruction, edema Risk for deficient Fluid volume: Risk factors: loss from skin surface, fluid shift Risk for Infection: Risk factors: loss of intact skin, trauma, invasive sites

Risk for Peripheral Neurovascular dysfunction: Risk factor: eschar formation with circumferential burn Risk for Post-Trauma syndrome: Risk factors: perception, duration of event that caused burns Readiness for enhanced Knowledge: expresses an interest in learning See Hospitalized Child; Safety, Childhood

Bursitis Impaired physical Mobility r/t inflammation in joint Acute Pain r/t inflammation in joint

Bypass Graft See Coronary Artery Bypass Grafting (CABG)

C

C CABG (Coronary Artery Bypass Grafting)

See Coronary Artery Bypass Grafting (CABG)

Cachexia Frail Elderly syndrome r/t fatigue, feeding self-care deficit Imbalanced Nutrition: less than body requirements r/t inability to ingest food because of physiological factors Risk for Infection: Risk factor: inadequate nutrition

Calcium Alteration See Hypercalcemia; Hypocalcemia

Cancer Activity intolerance r/t side effects of treatment, weakness from cancer Death Anxiety r/t unresolved issues regarding dying Disturbed Body Image r/t side effects of treatment, cachexia Decisional Conflict r/t selection of treatment choices, con- tinuation or discontinuation of treatment, “do not resuscitate” decision Constipation r/t side effects of medication, altered nutrition, decreased activity Compromised family Coping r/t prolonged disease or disability progression that exhausts supportive ability of significant others Ineffective Coping r/t personal vulnerability in situational crisis, terminal illness Ineffective Denial r/t complicated grieving process Fear r/t serious threat to well-being Grieving r/t potential loss of significant others, high risk for infertility Ineffective Health maintenance r/t deficient knowledge regard- ing prescribed treatment Hopelessness r/t loss of control, terminal illness Insomnia r/t anxiety, pain Impaired physical Mobility r/t weakness, neuromusculoskeletal impairment, pain

e4

List of Nursing Assessments by Letter: C

CABG (Coronary Artery Bypass Grafting)

Cachexia Calcium Alteration

Cancer Candidiasis, Oral Capillary Refill Time, Prolonged Carbon Monoxide Poisoning Cardiac Arrest Cardiac Catheterization Cardiac Disorders Cardiac Disorders in Pregnancy Cardiac Dysrhythmia Cardiac Output, Decreased Cardiac Tamponade Cardiogenic Shock Cardiovascular Function: Risk for Impaired

Caregiver Role Strain Carious Teeth

Carotid Endarterectomy Carpal Tunnel Syndrome Carpopedal Spasm Casts Cataract Extraction Cataracts Catatonic Schizophrenia Catheterization, Urinary Cavities in Teeth Celiac Disease Cellulitis Cellulitis, Periorbital Central Line Insertion Cerebral Aneurysm Cerebral Palsy Cerebral Perfusion Cerebrovascular Accident (CVA) Cervicitis Cesarean Delivery Chemical Dependence Chemotherapy Chest Pain Chest Tubes Cheyne-Stokes Respiration CHF (Congestive Heart Failure) Chickenpox Child Abuse Childbearing Problems Child Neglect Child with Chronic Condition Childbirth Chills Chlamydia Infection Chloasma Choking or Coughing with Eating Cholecystectomy Cholelithiasis Chorioamnionitis Chronic Confusion Chronic Functional Constipation Chronic Lymphocytic Leukemia Chronic Obstructive Pulmonary

Disease (COPD) Chronic Pain Chronic Renal Failure (Chronic kidney

disease) Chvostek’s Sign

Circumcision Cirrhosis Cleft Lip/Cleft Palate Clotting Disorder Cocaine Abuse Cocaine Baby

List of Nursing Assessments by Letter: C e5

Codependency Cold, Viral Colectomy Colitis Collagen Disease Colostomy Colporrhaphy, Anterior Coma Comfort, Loss of Communicable Diseases, Childhood (e.g., Measles, Mumps, Rubella, Chickenpox, Scabies, Lice, Impetigo)

Communication Communication Problems

Community Coping Community Health Problems Compartment Syndrome Compulsion Conduction Disorders (Cardiac) Confusion, Acute Confusion, Chronic Confusion, Possible Congenital Heart Disease/Cardiac

Anomalies Congestive Heart Failure (CHF)/Heart Failure (HF)

Conjunctivitis Consciousness, Altered Level of

Constipation Constipation, Chronic Functional Constipation, Perceived Constipation, Risk for Contamination Continent Ileostomy (Kock Pouch) Contraceptive Method Convulsions COPD (Chronic Obstructive

Pulmonary Disease) Coping Coping Problems Corneal Injury Corneal Reflex, Absent Corneal Transplant Coronary Artery Bypass Grafting

(CABG) Costovertebral Angle Tenderness Cough, Ineffective Crack Abuse Crack Baby Crackles in Lungs, Coarse Crackles in Lungs, Fine Craniectomy/Craniotomy Crepitation, Subcutaneous Crisis Crohn’s Disease Croup Cryosurgery for Retinal Detachment Cushing’s Syndrome Cuts (Wounds) CVA (Cerebrovascular Accident) Cyanosis, Central with Cyanosis of Oral Mucous Membranes

Cyanosis, Peripheral with Cyanosis of Nail Beds

Cystic Fibrosis

Cystitis Cystocele Cystoscopy

Cardiac Disorders in Pregnancy 35

C

Imbalanced Nutrition: less than body requirements r/t loss of appetite, difficulty swallowing, side effects of chemotherapy, obstruction by tumor Impaired Oral Mucous Membrane r/t chemotherapy, effects of radiation, oral pH changes, decreased oral secretions Chronic Pain r/t metastatic cancer Powerlessness r/t treatment, progression of disease Ineffective Protection r/t cancer suppressing immune system Ineffective Role performance r/t change in physical capacity, inability to resume prior role Self-Care deficit: specify r/t pain, intolerance to activity, decreased strength Impaired Skin integrity r/t immunological deficit, immobility Social isolation r/t hospitalization, lifestyle changes Chronic Sorrow r/t chronic illness of cancer Spiritual distress r/t test of spiritual beliefs Risk for Bleeding: Risk factor: bone marrow depression from chemotherapy Risk for Disuse syndrome: Risk factors: immobility, fatigue Risk for impaired Home maintenance: Risk factor: lack of famil- iarity with community resources Risk for Infection: Risk factor: inadequate immune system Risk for compromised Resilience: Risk factors: multiple stress- ors, pain, chronic illness Risk for Spiritual distress: Risk factor: physical illness of cancer Readiness for enhanced Knowledge: expresses an interest in learning Readiness for enhanced Spiritual well-being: desire for harmony with self, others, higher power, God, when faced with serious illness See Chemotherapy; Child with Chronic Condition; Hospitalized Child; Leukemia; Radiation Therapy; Terminally Ill Child, Ado­ lescent; Terminally Ill Child, Infant/Toddler; Terminally Ill Child, Preschool Child; Terminally Ill Child, School­Age Child/ Preadolescent; Terminally Ill Child/Death of Child, Parent

Candidiasis, Oral Readiness for enhanced Knowledge: expresses an interest in learning Impaired Oral Mucous Membrane r/t overgrowth of infec- tious agent, depressed immune function Acute Pain r/t oral condition

Capillary Refill Time, Prolonged Impaired Gas exchange r/t ventilation perfusion imbalance Ineffective peripheral Tissue Perfusion r/t interruption of arte- rial flow See Shock, Hypovolemic

Carbon Monoxide Poisoning See Smoke Inhalation

Cardiac Arrest Post-Trauma syndrome r/t experiencing serious life event See Dysrhythmia, MI

Cardiac Catheterization Fear r/t invasive procedure, uncertainty of outcome of procedure Risk for Injury: hematoma: Risk factor: invasive procedure Risk for decreased Cardiac tissue perfusion: Risk factors: ven- tricular ischemia, dysrhythmia Risk for Peripheral Neurovascular dysfunction: Risk factor: vascular obstruction Risk for Impaired Tissue integrity: Risk factor: invasive procedure Readiness for enhanced Knowledge: expresses an interest in learning postprocedure care, treatment, and prevention of coro- nary artery disease

Cardiac Disorders Decreased Cardiac output r/t cardiac disorder Risk for decreased Cardiac tissue perfusion: Risk factor: cardiac disorder See specific cardiac disorder

Cardiac Disorders in Pregnancy Activity intolerance r/t cardiac pathophysiology, increased demand for cardiac output because of pregnancy, weakness, fatigue Death Anxiety r/t potential danger of condition Compromised family Coping r/t prolonged hospitalization or maternal incapacitation that exhausts supportive capacity of significant others Ineffective Coping r/t personal vulnerability Interrupted Family processes r/t hospitalization, maternal inca- pacitation, changes in roles Fatigue r/t physiological, psychological, and emotional demands Fear r/t potential maternal effects, potential poor fetal or mater- nal outcome Powerlessness r/t illness-related regimen Ineffective Role performance r/t changes in lifestyle, expecta- tions from disease process with superimposed pregnancy Situational low Self-Esteem r/t situational crisis, pregnancy Social isolation r/t limitations of activity, bed rest or hospitaliza- tion, separation from family and friends Risk for decreased Cardiac tissue perfusion: Risk factor: strain on compromised heart from work of pregnancy, delivery Risk for delayed Development: Risk factor: poor maternal oxygenation Risk for deficient Fluid volume: Risk factor: sudden changes in circulation after delivery of placenta Risk for excess Fluid volume: Risk factors: compromised regula- tory mechanism with increased afterload, preload, circulating blood volume Risk for impaired Gas exchange: Risk factor: pulmonary edema Risk for disproportionate Growth: Risk factor: poor maternal oxygenation

36 Cardiac Dysrhythmia

C

Risk for disturbed Maternal–Fetal dyad: Risk factor: compro- mised oxygen transport Risk for compromised Resilience: Risk factors: multiple stress- ors, fear Risk for Spiritual distress: Risk factor: fear of diagnosis for self and infant Readiness for enhanced Knowledge: expresses an interest in learning

Cardiac Dysrhythmia See Dysrhythmia

Cardiac Output, Decreased Decreased Cardiac output r/t cardiac dysfunction Decreased Cardiac output (See Cardiac output, decreased, Section III) Oliguria r/t cardiac dysfunction Risk for decreased Cardiac output (See Cardiac output, risk for decreased, Section III)

Cardiac Tamponade Decreased Cardiac output r/t fluid in pericardial sac See Pericarditis

Cardiogenic Shock See Shock, Cardiogenic

Cardiovascular Function: Risk for Impaired Risk for Impaired Cardiovascular Function (See impaired Cardiovascular function, risk for, Section III)

Caregiver Role Strain Caregiver Role Strain (See Caregiver Role Strain, Section III) Risk for compromised Resilience: Risk factor: stress of pro- longed caregiving

Carious Teeth See Cavities in Teeth

Carotid Endarterectomy Fear r/t surgery in vital area Risk for ineffective Airway clearance: Risk factor: hematoma compressing trachea Risk for Bleeding: Risk factor: possible hematoma formation, trauma to region Risk for ineffective Cerebral tissue perfusion: Risk factors: hemorrhage, clot formation Readiness for enhanced Knowledge: expresses an interest in learning

Carpal Tunnel Syndrome Impaired physical Mobility r/t neuromuscular impairment Chronic Pain r/t unrelieved pressure on median nerve Self-Care deficit: bathing, dressing, feeding r/t pain

Carpopedal Spasm See Hypocalcemia

Casts Deficient Diversional activity r/t physical limitations from cast Impaired physical Mobility r/t limb immobilization Self-Care deficit: bathing, dressing, feeding r/t presence of cast(s) on upper extremities Self-Care deficit: toileting r/t presence of cast(s) on lower extremities Impaired Walking r/t cast(s) on lower extremities, fracture of bones Risk for Peripheral Neurovascular dysfunction: Risk factors: mechanical compression from cast, trauma from fracture Risk for impaired Skin integrity: Risk factor: unrelieved pressure on skin from cast Readiness for enhanced Knowledge: expresses an interest in learning See Traction and Casts

Cataract Extraction Anxiety r/t threat of permanent vision loss, surgical procedure Vision Loss r/t edema from surgery (see care plan in Appendix) Risk for Injury: Risk factors: increased intraocular pressure, accommodation to new visual field Readiness for enhanced Knowledge: expresses an interest in learning See Vision Impairment

Cataracts Vision Loss r/t impaired sensory input (see care plan in Appendix) See Vision Impairment

Catatonic Schizophrenia Impaired verbal Communication r/t cognitive impairment Impaired Memory r/t cognitive impairment Impaired physical Mobility r/t cognitive impairment, mainte- nance of rigid posture, inappropriate or bizarre postures Imbalanced Nutrition: less than body requirements r/t decrease in outside stimulation, loss of perception of hunger, resistance to instructions to eat Social isolation r/t inability to communicate, immobility See Schizophrenia

Catheterization, Urinary Risk for Infection: Risk factor: invasive procedure Readiness for enhanced Knowledge: expresses an interest in learning

Cavities in Teeth Impaired Dentition r/t ineffective oral hygiene, barriers to self- care, economic barriers to professional care, nutritional deficits, dietary habits

Celiac Disease Diarrhea r/t malabsorption of food, immune effects of gluten on gastrointestinal system

Chemotherapy 37

C

Imbalanced Nutrition: less than body requirements r/t malab- sorption due to immune effects of gluten Readiness for enhanced Knowledge: expresses an interest in learning

Cellulitis Acute Pain r/t inflammatory changes in tissues from infection Impaired Tissue integrity r/t inflammatory process damaging skin and underlying tissue Ineffective peripheral Tissue Perfusion r/t edema of extremities Risk for Vascular Trauma: Risk factor: infusion of antibiotics Readiness for enhanced Knowledge: expresses an interest in learning

Cellulitis, Periorbital Acute Pain r/t edema and inflammation of skin/tissues Impaired Skin integrity r/t inflammation or infection of skin, tissues Vision Loss r/t decreased visual field secondary to edema of eyelids (see care plan in Appendix) Readiness for enhanced Knowledge: expresses an interest in learning See Hospitalized Child

Central Line Insertion Risk for Infection: Risk factor: invasive procedure Risk for Vascular Trauma (See Vascular Trauma, risk for, Section III) Readiness for enhanced Knowledge: expresses an interest in learning

Cerebral Aneurysm See Craniectomy/Craniotomy; Intracranial Pressure, Increased; Subarachnoid Hemorrhage

Cerebral Palsy Impaired verbal Communication r/t impaired ability to articu- late or speak words because of facial muscle involvement Deficient Diversional activity r/t physical impairments, limita- tions on ability to participate in recreational activities Impaired physical Mobility r/t spasticity, neuromuscular impair- ment or weakness Imbalanced Nutrition: less than body requirements r/t spastic- ity, feeding or swallowing difficulties Self-Care deficit: specify r/t neuromuscular impairments, sensory deficits Impaired Social interaction r/t impaired communication skills, limited physical activity, perceived differences from peers Chronic Sorrow r/t presence of chronic disability Risk for Falls: Risk factor: impaired physical mobility Risk for Injury: Risk factors: muscle weakness, inability to control spasticity Risk for impaired Parenting: Risk factor: caring for child with overwhelming needs resulting from chronic change in health status

Risk for Spiritual distress: Risk factor: psychological stress associated with chronic illness See Child with Chronic Condition

Cerebral Perfusion Risk for ineffective Cerebral tissue perfusion (See Cerebral tissue perfusion, ineffective, risk for, Section III)

Cerebrovascular Accident (CVA) See CVA (Cerebrovascular Accident)

Cervicitis Ineffective Health maintenance r/t deficient knowledge regard- ing care and prevention of condition Ineffective Sexuality pattern r/t abstinence during acute stage Risk for Infection: Risk factors: spread of infection, recurrence of infection

Cesarean Delivery Disturbed Body Image r/t surgery, unmet expectations for childbirth Interrupted Family processes r/t unmet expectations for childbirth Fear r/t perceived threat to own well-being, outcome of birth Impaired physical Mobility r/t pain Acute Pain r/t surgical incision Ineffective Role performance r/t unmet expectations for childbirth Situational low Self-Esteem r/t inability to deliver child vaginally Risk for Bleeding: Risk factor: surgery Risk for imbalanced Fluid volume: Risk factors: loss of blood, fluid shifts Risk for Infection: Risk factor: surgical incision Risk for Urinary Retention: Risk factor: regional anesthesia Readiness for enhanced Childbearing process: a pattern of preparing for, maintaining, and strengthening care of newborn Readiness for enhanced Knowledge: expresses an interest in learning

Chemical Dependence See Alcoholism; Drug Abuse; Cocaine Abuse; Substance Abuse

Chemotherapy Death Anxiety r/t chemotherapy not accomplishing desired results Disturbed Body Image r/t loss of weight, loss of hair Fatigue r/t disease process, anemia, drug effects Nausea r/t effects of chemotherapy Imbalanced Nutrition: less than body requirements r/t side effects of chemotherapy Impaired Oral Mucous Membrane r/t effects of chemotherapy Ineffective Protection r/t suppressed immune system, decreased platelets

38 Chest Pain

C

Risk for Bleeding: Risk factors: tumor eroding blood vessel, stress effects on gastrointestinal system Risk for Infection: Risk factor: immunosuppression Risk for Vascular Trauma: Risk factor: infusion of irritating medications Readiness for enhanced Knowledge: expresses an interest in learning See Cancer

Chest Pain Fear r/t potential threat of death Acute Pain r/t myocardial injury, ischemia Risk for decreased Cardiac tissue perfusion: Risk factor: ven- tricular ischemia See Angina; MI (Myocardial Infarction)

Chest Tubes Ineffective Breathing pattern r/t asymmetrical lung expansion secondary to pain Impaired Gas exchange r/t decreased functional lung tissue Acute Pain r/t presence of chest tubes, injury Risk for Injury: Risk factor: presence of invasive chest tube

Cheyne-Stokes Respiration Ineffective Breathing pattern r/t critical illness See Heart Failure

CHF (Congestive Heart Failure) See Heart Failure

Chickenpox See Communicable Diseases, Childhood

Child Abuse Interrupted Family processes r/t inadequate coping skills Fear r/t threat of punishment for perceived wrongdoing Insomnia r/t hypervigilance, fear Imbalanced Nutrition: less than body requirements r/t inade- quate caretaking Acute Pain r/t physical injuries Impaired Parenting r/t psychological impairment, physical or emotional abuse of parent, substance abuse, unrealistic expecta- tions of child Post-Trauma syndrome r/t physical abuse, incest, rape, molestation Chronic low Self-Esteem r/t lack of positive feedback, exces- sive negative feedback Impaired Skin integrity r/t altered nutritional state, physical abuse Social isolation: family imposed r/t fear of disclosure of family dysfunction and abuse Risk for delayed Development: Risk factors: shaken baby syn- drome, abuse Risk for disproportionate Growth: Risk factor: abuse

Risk for Poisoning: Risk factors: inadequate safeguards, lack of proper safety precautions, accessibility of illicit substances because of impaired home maintenance Risk for Suffocation: Risk factors: unattended child, unsafe environment Risk for Trauma: Risk factors: inadequate precautions, cogni- tive or emotional difficulties

Childbearing Problems Ineffective Childbearing process (See Childbearing process, ineffective, Section III) Risk for ineffective Childbearing process: See Childbearing process, risk for ineffective, Section III)

Child Neglect See Child Abuse; Failure to Thrive, Nonorganic

Child with Chronic Condition Activity intolerance r/t fatigue associated with chronic illness Compromised family Coping r/t prolonged overconcern for child; distortion of reality regarding child’s health problem, including extreme denial about its existence or severity Disabled family Coping r/t prolonged disease or disability progression that exhausts supportive capacity of significant others Ineffective Coping: child r/t situational or maturational crises Decisional Conflict r/t treatment options, conflicting values Deficient Diversional activity r/t immobility, monotonous environment, frequent or lengthy treatments, reluctance to par- ticipate, self-imposed social isolation Interrupted Family processes r/t intermittent situational crisis of illness, disease, hospitalization Ineffective Health maintenance r/t exhausting family resources (finances, physical energy, support systems) Impaired Home maintenance r/t overtaxed family members (e.g., exhausted, anxious) Hopelessness: child r/t prolonged activity restriction, long- term stress, lack of involvement in or passively allowing care as a result of parental overprotection Insomnia: child or parent r/t time-intensive treatments, exac- erbation of condition, 24-hour care needs Deficient Knowledge r/t knowledge or skill acquisition regard- ing health practices, acceptance of limitations, promotion of maximal potential of child, self-actualization of rest of family Imbalanced Nutrition: less than body requirements r/t anorexia, fatigue from physical exertion Risk for Overweight r/t effects of steroid medications on appetite Chronic Pain r/t physical, biological, chemical, or psychological factors Powerlessness: child r/t health care environment, illness- related regimen, lifestyle of learned helplessness Parental Role conflict r/t separation from child as a result of chronic illness, home care of child with special needs, interrup- tions of family life resulting from home care regimen

Cirrhosis 39

C

Chronic low Self-Esteem r/t actual or perceived differences; peer acceptance; decreased ability to participate in physical, school, and social activities Ineffective Sexuality pattern: parental r/t disrupted relationship with sexual partner Impaired Social interaction r/t developmental lag or delay, perceived differences Social isolation: family r/t actual or perceived social stigmatiza- tion, complex care requirements Chronic Sorrow r/t developmental stages and missed opportu- nities or milestones that bring comparisons with social or personal norms, unending caregiving as reminder of loss Risk for delayed Development: Risk factor: chronic illness Risk for disproportionate Growth: Risk factor: chronic illness Risk for Infection: Risk factor: debilitating physical condition Risk for impaired Parenting: Risk factors: impaired or dis- rupted bonding, caring for child with perceived overwhelming care needs Readiness for enhanced family Coping: impact of crisis on family values, priorities, goals, or relationships; changes in family choices to optimize wellness

Childbirth Readiness for enhanced Childbearing process (See Childbear- ing process, readiness for enhanced, Section III) See Labor, Normal; Postpartum, Normal Care

Chills Hyperthermia r/t infectious process

Chlamydia Infection See STD (Sexually Transmitted Disease)

Chloasma Disturbed Body Image r/t change in skin color

Choking or Coughing with Eating Impaired Swallowing r/t neuromuscular impairment Risk for Aspiration: Risk factors: depressed cough and gag reflexes

Cholecystectomy Imbalanced Nutrition: less than body requirements r/t high metabolic needs, decreased ability to digest fatty foods Acute Pain r/t trauma from surgery Risk for deficient Fluid volume: Risk factors: restricted intake, nausea, vomiting Readiness for enhanced Knowledge: expresses an interest in learning See Abdominal Surgery

Cholelithiasis Nausea r/t obstruction of bile Imbalanced Nutrition: less than body requirements r/t anorexia, nausea, vomiting Acute Pain r/t obstruction of bile flow, inflammation in gallbladder

Readiness for enhanced Knowledge: expresses an interest in learning

Chorioamnionitis Anxiety r/t threat to self and infant Grieving r/t guilt about potential loss of ideal pregnancy and birth Hyperthermia r/t infectious process Situational low Self-Esteem r/t guilt about threat to infant’s health Risk for Infection: Risk factors: infection transmission from mother to fetus; infection in fetal environment

Chronic Confusion See Confusion, Chronic

Chronic Functional Constipation (See Constipation, chronic functional, section III) (See Constipation, chronic functional, risk for, section III)

Chronic Lymphocytic Leukemia See Cancer; Chemotherapy; Leukemia

Chronic Obstructive Pulmonary Disease (COPD)

See COPD (Chronic Obstructive Pulmonary Disease)

Chronic Pain See Pain, Chronic

Chronic Renal Failure (Chronic kidney disease)

See Renal Failure

Chvostek’s Sign See Hypocalcemia

Circumcision Acute Pain r/t surgical intervention Risk for Bleeding: Risk factor: surgical trauma Risk for Infection: Risk factor: surgical wound Readiness for enhanced Knowledge: parent: expresses an interest in learning

Cirrhosis Chronic Confusion r/t chronic organic disorder with increased ammonia levels, substance abuse Defensive Coping r/t inability to accept responsibility to stop substance abuse Fatigue r/t malnutrition Ineffective Health maintenance r/t deficient knowledge regard- ing correlation between lifestyle habits and disease process Nausea r/t irritation to gastrointestinal system Imbalanced Nutrition: less than body requirements r/t loss of appetite, nausea, vomiting Chronic Pain r/t liver enlargement Chronic low Self-Esteem r/t chronic illness

40 Cleft Lip/Cleft Palate

C

Chronic Sorrow r/t presence of chronic illness Risk for Bleeding: Risk factors: impaired blood coagulation, bleeding from portal hypertension Risk for Injury: Risk factors: substance intoxication, potential delirium tremens Risk for impaired Oral Mucous Membrane: Risk factors: altered nutrition, inadequate oral care Risk for impaired Skin integrity: Risk factors: altered nutritional state, altered metabolic state

Cleft Lip/Cleft Palate Ineffective Airway clearance r/t common feeding and breathing passage, postoperative laryngeal, incisional edema Ineffective Breastfeeding r/t infant anomaly Impaired verbal Communication r/t inadequate palate func- tion, possible hearing loss from infected eustachian tubes Fear: parental r/t special care needs, surgery Grieving r/t loss of perfect child Ineffective infant Feeding pattern r/t cleft lip, cleft palate Impaired physical Mobility r/t imposed restricted activity, use of elbow restraints Impaired Oral Mucous Membrane r/t surgical correction Acute Pain r/t surgical correction, elbow restraints Impaired Skin integrity r/t incomplete joining of lip, palate ridges Chronic Sorrow r/t birth of child with congenital defect Risk for Aspiration: Risk factor: common feeding and breath- ing passage Risk for disturbed Body Image: Risk factors: disfigurement, speech impediment Risk for delayed Development: Risk factor: inadequate nutri- tion resulting from difficulty feeding Risk for deficient Fluid volume: Risk factor: inability to take liquids in usual manner Risk for disproportionate Growth: Risk factor: inability to feed with normal techniques Risk for Infection: Risk factors: invasive procedure, disruption of eustachian tube development, aspiration Readiness for enhanced Knowledge: parent: expresses an inter- est in learning

Clotting Disorder Fear r/t threat to well-being Risk for Bleeding: Risk factor: impaired clotting Readiness for enhanced Knowledge: expresses an interest in learning See Anticoagulant Therapy; DIC (Disseminated Intravascular Coagulation); Hemophilia

Cocaine Abuse Ineffective Breathing pattern r/t drug effect on respiratory center Chronic Confusion r/t excessive stimulation of nervous system by cocaine

Ineffective Coping r/t inability to deal with life stresses Risk for decreased Cardiac tissue perfusion r/t increase in sympathetic response in the body damaging the heart See Drug Abuse; Substance Abuse

Cocaine Baby See Crack Baby; Infant of Substance­Abusing Mother

Codependency Caregiver Role Strain r/t codependency Impaired verbal Communication r/t psychological barriers Ineffective Coping r/t inadequate support systems Decisional Conflict r/t support system deficit Ineffective Denial r/t unmet self-needs Powerlessness r/t lifestyle of helplessness

Cold, Viral Readiness for enhanced Comfort (See Comfort, readiness for enhanced, Section III) Readiness for enhanced Knowledge: expresses an interest in learning

Colectomy Constipation r/t decreased activity, decreased fluid intake Imbalanced Nutrition: less than body requirements r/t high metabolic needs, decreased ability to ingest or digest food Acute Pain r/t recent surgery Risk for Infection: Risk factor: invasive procedure Readiness for enhanced Knowledge: expresses an interest in learning See Abdominal Surgery

Colitis Diarrhea r/t inflammation in colon Deficient Fluid volume r/t frequent stools Acute Pain r/t inflammation in colon Readiness for enhanced Knowledge: expresses an interest in learning See Crohn’s Disease; Inflammatory Bowel Disease (Child and Adult)

Collagen Disease See specific disease (e.g., lupus erythematosus; JRA [juvenile rheumatoid arthritis]); Congenital Heart Disease/Cardiac Anomalies

Colostomy Disturbed Body Image r/t presence of stoma, daily care of fecal material Ineffective Sexuality pattern r/t altered body image, self-concept Social isolation r/t anxiety about appearance of stoma and pos- sible leakage of stool Risk for Constipation: Risk factor: inappropriate diet Risk for Diarrhea: Risk factor: inappropriate diet

Congenital Heart Disease/Cardiac Anomalies 41

C

Risk for impaired Skin integrity: Risk factor: irritation from bowel contents Readiness for enhanced Knowledge: expresses an interest in learning

Colporrhaphy, Anterior See Vaginal Hysterectomy

Coma Death Anxiety: significant others r/t unknown outcome of coma state Interrupted Family processes r/t illness or disability of family member Functional urinary Incontinence r/t presence of comatose state Self-Care deficit: r/t neuromuscular impairment Ineffective family Health management r/t complexity of thera- peutic regimen Risk for Aspiration: Risk factors: impaired swallowing, loss of cough or gag reflex Risk for Disuse syndrome: Risk factor: altered level of con- sciousness impairing mobility Risk for Hypothermia: Risk factors: Inactivity, possible phar- maceutical agents, possible hypothalamic injury Risk for Injury: Risk factor: potential seizure activity Risk for corneal Injury: Risk factor: suppressed corneal reflex Risk for urinary tract Injury: Risk factor: long-term use of urinary catheter Risk for impaired Oral Mucous Membrane: Risk factors: dry mouth, inability to do own mouth care Risk for Pressure ulcer: Risk factor: prolonged immobility Risk for impaired Skin integrity: Risk factor: immobility Risk for Spiritual distress: significant others: Risk factors: loss of ability to relate to loved one, unknown outcome of coma Risk for impaired Tissue integrity: Risk factor: impaired physi- cal mobility See Head Injury, Subarachnoid Hemorrhage, Increased Intracra­ nial Pressure

Comfort, Loss of Impaired Comfort (See Comfort, impaired, Section III) Readiness for enhanced Comfort (See Comfort, readiness for enhanced, Section III)

Communicable Diseases, Childhood (e.g., Measles, Mumps, Rubella, Chickenpox, Scabies, Lice, Impetigo)

Impaired Comfort r/t pruritus, inflammation or infection of skin, subdermal organisms Deficient Diversional activity r/t imposed isolation from peers, disruption in usual play activities, fatigue, activity intolerance Ineffective Health maintenance r/t nonadherence to appropriate immunization schedules, lack of prevention of transmission of infection Acute Pain r/t impaired skin integrity, edema

Risk for Infection: transmission to others: Risk factor: conta- gious organisms See Meningitis/Encephalitis; Respiratory Infections, Acute Child­ hood; Reye’s Syndrome

Communication Readiness for enhanced Communication (See Communica- tion, readiness for enhanced, Section III)

Communication Problems Impaired verbal Communication (See Communication, verbal, impaired, Section III)

Community Coping Ineffective community Coping (See Coping, community, inef- fective, Section III) Readiness for enhanced community Coping: community sense of power to manage stressors, social supports available, resources available for problem solving

Community Health Problems Deficient community Health (See Health, deficient, commu- nity, Section III)

Compartment Syndrome Fear r/t possible loss of limb, damage to limb Acute Pain r/t pressure in compromised body part Ineffective peripheral Tissue Perfusion r/t increased pressure within compartment

Compulsion See OCD (Obsessive­Compulsive Disorder)

Conduction Disorders (Cardiac) See Dysrhythmia

Confusion, Acute Acute Confusion r/t older than 70 years of age with hospitaliza- tion, alcohol abuse, delirium, dementia, drug abuse Frail Elderly syndrome r/t impaired memory

Confusion, Chronic Chronic Confusion r/t dementia, Korsakoff ’s psychosis, multi- infarct dementia, cerebrovascular accident, head injury Frail Elderly syndrome r/t impaired memory Impaired Memory r/t fluid and electrolyte imbalance, neuro- logical disturbances, excessive environmental disturbances, anemia, acute or chronic hypoxia, decreased cardiac output Impaired Mood regulation r/t emotional instability See Alzheimer’s Disease; Dementia

Confusion, Possible Risk for acute Confusion: Risk factor (See Confusion, acute, risk for, Section III)

Congenital Heart Disease/ Cardiac Anomalies

Activity intolerance r/t fatigue, generalized weakness, lack of adequate oxygenation

42 Congestive Heart Failure (CHF)/Heart Failure (HF)

C

Ineffective Breathing pattern r/t pulmonary vascular disease Decreased Cardiac output r/t cardiac dysfunction Excess Fluid volume r/t cardiac dysfunction, side effects of medication Impaired Gas exchange r/t cardiac dysfunction, pulmonary congestion Imbalanced Nutrition: less than body requirements r/t fatigue, generalized weakness, inability of infant to suck and feed, increased caloric requirements Risk for delayed Development: Risk factor: inadequate oxygen and nutrients to tissues Risk for deficient Fluid volume: Risk factor: side effects of diuretics Risk for disproportionate Growth: Risk factor: inadequate oxygen and nutrients to tissues Risk for disorganized Infant behavior: Risk factor: invasive procedures Risk for Poisoning: Risk factor: potential toxicity of cardiac medications Risk for ineffective Thermoregulation: Risk factor: neona- tal age See Child with Chronic Condition; Hospitalized Child

Congestive Heart Failure (CHF)/Heart Failure (HF)

See CHF (Congestive Heart Failure)

Conjunctivitis Acute Pain r/t inflammatory process Vision Loss r/t change in visual acuity resulting from inflammation

Consciousness, Altered Level of Acute Confusion r/t alcohol abuse, delirium, dementia, drug abuse, head injury Chronic Confusion r/t multi-infarct dementia, Korsakoff ’s psychosis, head injury, cerebrovascular accident, neurological deficit, Frail Elderly syndrome Functional urinary Incontinence r/t neurological dysfunction Decreased Intracranial adaptive capacity r/t brain injury Impaired Memory r/t neurological disturbances Self-Care deficit: specify r/t neuromuscular impairment Risk for Aspiration: Risk factors: impaired swallowing, loss of cough or gag reflex Risk for Disuse syndrome: Risk factor: impaired mobility result- ing from altered level of consciousness Risk for Falls: Risk factor: diminished mental status Risk for impaired Oral Mucous Membrane: Risk factors: dry mouth, interrupted oral care Risk for ineffective Cerebral tissue perfusion: Risk factors: increased intracranial pressure, altered cerebral perfusion Risk for impaired Skin integrity: Risk factor: immobility See Coma, Head Injury, Subarachnoid Hemorrhage, Increased Intracranial Pressure

Constipation Constipation (See Constipation, Section III)

Constipation, Chronic Functional Constipation (See Constipation, chronic functional, Section III)

Constipation, Perceived Perceived Constipation (See perceived Constipation, Section III)

Constipation, Risk for Risk for Constipation (See Constipation, risk for, Section III) Risk for chronic functional Constipation (See Constipation, chronic functional, risk for, Section III)

Contamination Contamination (See Contamination, Section III) Risk for Contamination (See Contamination, risk for, Section III)

Continent Ileostomy (Kock Pouch) Ineffective Coping r/t stress of disease, exacerbations caused by stress Imbalanced Nutrition: less than body requirements r/t malab- sorption from disease process Risk for Injury: Risk factors: failure of valve, stomal cyanosis, intestinal obstruction Readiness for enhanced Knowledge: expresses an interest in learning See Abdominal Surgery, Crohn’s Disease

Contraceptive Method Decisional Conflict: method of contraception r/t unclear per- sonal values or beliefs, lack of experience or interference with decision-making, lack of relevant information, support system deficit Ineffective Sexuality pattern r/t fear of pregnancy Readiness for enhanced Health management: requesting infor- mation about available and appropriate birth control methods

Convulsions Anxiety r/t concern over controlling convulsions Impaired Memory r/t neurological disturbance Risk for Aspiration: Risk factor: impaired swallowing Risk for delayed Development: Risk factor: seizures Risk for Injury: Risk factor: seizure activity Readiness for enhanced Knowledge: expresses an interest in learning See Seizure Disorders, Adult; Seizure Disorders, Childhood

COPD (Chronic Obstructive Pulmonary Disease)

Activity intolerance r/t imbalance between oxygen supply and demand Ineffective Airway clearance r/t bronchoconstriction, increased mucus, ineffective cough, infection

Crepitation, Subcutaneous 43

C

Anxiety r/t breathlessness, change in health status Death Anxiety r/t seriousness of medical condition, difficulty being able to “catch breath,” feeling of suffocation Interrupted Family processes r/t role changes Impaired Gas exchange r/t ventilation-perfusion inequality Ineffective Health management (See Health management, inef- fective, Section III) Imbalanced Nutrition: less than body requirements r/t decreased intake because of dyspnea, unpleasant taste in mouth left by medications, increased need for calories from work of breathing Powerlessness r/t progressive nature of disease Self-Care deficit: r/t fatigue from the increased work of breathing Chronic low Self-Esteem r/t chronic illness Sleep deprivation r/t breathing difficulties when lying down Impaired Social interaction r/t social isolation because of oxygen use, activity intolerance Chronic Sorrow r/t presence of chronic illness Risk for Infection: Risk factor: stasis of respiratory secretions Readiness for enhanced Health management (See Health man- agement, readiness for enhanced, Section III)

Coping Readiness for enhanced Coping (See Coping, readiness for enhanced, Section III)

Coping Problems Compromised family Coping (see Coping, compromised family, Section III) Defensive Coping (See Coping, defensive, Section III) Disabled family Coping (See Coping, disabled family, Section III) Ineffective Coping (See Coping, ineffective, Section III) Ineffective community Coping (see Coping, ineffective com- munity, Section III)

Corneal Injury Risk for corneal Injury (See corneal Injury, risk for, Section III)

Corneal Reflex, Absent Risk for Injury: Risk factors: accidental corneal abrasion, drying of cornea

Corneal Transplant Risk for Infection: Risk factors: invasive procedure, surgery Readiness for enhanced Health management: describes need to rest and avoid strenuous activities during healing phase

Coronary Artery Bypass Grafting (CABG)

Decreased Cardiac output r/t dysrhythmia, depressed cardiac function, change in preload, contractility or afterload Fear r/t outcome of surgical procedure Deficient Fluid volume r/t intraoperative blood loss, use of diuretics in surgery

Acute Pain r/t traumatic surgery Risk for Perioperative Positioning injury: Risk factors: hypo- thermia, extended supine position Risk for Impaired Tissue integrity: Risk Factor: surgical procedure Readiness for enhanced Knowledge: expresses an interest in learning

Costovertebral Angle Tenderness See Kidney Stone; Pyelonephritis

Cough, Ineffective Ineffective Airway clearance r/t decreased energy, fatigue, normal aging changes See Bronchitis; COPD (Chronic Obstructive Pulmonary Disease); Pulmonary Edema

Crack Abuse See Cocaine Abuse; Drug Abuse; Substance Abuse

Crack Baby Disorganized Infant behavior r/t prematurity, drug withdrawal, lack of attachment Risk for impaired Attachment: Risk factors: parent’s inability to meet infant’s needs, substance abuse Risk for disturbed Maternal–Fetal dyad: Risk factor: sub- stance abuse See Infant of Substance­Abusing Mother

Crackles in Lungs, Coarse Ineffective Airway clearance r/t excessive secretions in airways, ineffective cough See Heart Failure, Pneumonia, Pulmonary Edema

Crackles in Lungs, Fine Ineffective Breathing pattern r/t fatigue, surgery, decreased energy See Bronchitis or Pneumonia (if from pulmonary infection); CHF (Congestive Heart Failure) (if cardiac in origin); Infection

Craniectomy/Craniotomy Frail Elderly syndrome r/t alteration in cognition Fear r/t threat to well-being Decreased Intracranial adaptive capacity r/t brain injury, intra- cranial hypertension Impaired Memory r/t neurological surgery Acute Pain r/t recent brain surgery, increased intracranial pressure Risk for ineffective Cerebral tissue perfusion: Risk factors: cerebral edema, increased intracranial pressure Risk for Injury: Risk factor: potential confusion See Coma (if relevant)

Crepitation, Subcutaneous See Pneumothorax

44 Crisis

C

Crisis Anxiety r/t threat to or change in environment, health status, interaction patterns, situation, self-concept, or role functioning; threat of death of self or significant other Death Anxiety r/t feelings of hopelessness associated with crisis Compromised family Coping r/t situational or developmental crisis Ineffective Coping r/t situational or maturational crisis Fear r/t crisis situation Grieving r/t potential significant loss Impaired individual Resilience r/t onset of crisis Situational low Self-Esteem r/t perception of inability to handle crisis Stress overload (See Stress overload, Section III) Risk for Spiritual distress: Risk factors: physical or psychologi- cal stress, natural disasters, situational losses, maturational losses

Crohn’s Disease Anxiety r/t change in health status Ineffective Coping r/t repeated episodes of diarrhea Diarrhea r/t inflammatory process Ineffective Health maintenance r/t deficient knowledge regard- ing management of disease Imbalanced Nutrition: less than body requirements r/t diar- rhea, altered ability to digest and absorb food Acute Pain r/t increased peristalsis Powerlessness r/t chronic disease Risk for deficient Fluid volume: Risk factor: abnormal fluid loss with diarrhea

Croup See Respiratory Infections, Acute Childhood

Cryosurgery for Retinal Detachment See Retinal Detachment

Cushing’s Syndrome Activity intolerance r/t fatigue, weakness Disturbed Body Image r/t change in appearance from disease process Excess Fluid volume r/t failure of regulatory mechanisms Sexual dysfunction r/t loss of libido Impaired Skin integrity r/t thin vulnerable skin from effects of increased cortisol Risk for Infection: Risk factor: suppression of immune system caused by increased cortisol levels Risk for Injury: Risk factors: decreased muscle strength, brittle bones Readiness for enhanced Knowledge: expresses an interest in learning

Cuts (Wounds) See Lacerations

CVA (Cerebrovascular Accident) Anxiety r/t situational crisis, change in physical or emotional condition Disturbed Body Image r/t chronic illness, paralysis Caregiver Role Strain r/t cognitive problems of care receiver, need for significant home care Impaired verbal Communication r/t pressure damage, decreased circulation to brain in speech center informational sources Chronic Confusion r/t neurological changes Constipation r/t decreased activity Ineffective Coping r/t disability Interrupted Family processes r/t illness, disability of family member Frail Elderly syndrome r/t alteration in cognitive functioning Grieving r/t loss of health Impaired Home maintenance r/t neurological disease affecting ability to perform activities of daily living Functional urinary Incontinence r/t neurological dysfunction Reflex urinary Incontinence r/t loss of feeling to void Impaired Memory r/t neurological disturbances Impaired physical Mobility r/t loss of balance and coordination Unilateral Neglect r/t disturbed perception from neurological damage Self-Care deficit: specify r/t decreased strength and endurance, paralysis Impaired Social interaction r/t limited physical mobility, limited ability to communicate Impaired Swallowing r/t neuromuscular dysfunction Impaired Transfer Ability r/t limited physical mobility Vision Loss r/t pressure damage to visual centers in the brain (see care plan in Appendix) Impaired Walking r/t loss of balance and coordination Risk for Aspiration: Risk factors: impaired swallowing, loss of gag reflex Risk for chronic functional Constipation: Risk factor: immobility Risk for Disuse syndrome: Risk factor: paralysis Risk for Falls: Risk factor: paralysis, decreased balance Risk for Injury: Risk factors: vision loss, decreased tissue perfu- sion with loss of sensation Risk for ineffective Cerebral tissue perfusion: Risk factor: clot, emboli, or hemorrhage from cerebral vessel Risk for impaired Skin integrity: Risk factor: immobility Readiness for enhanced Knowledge: expresses an interest in learning

Cyanosis, Central with Cyanosis of Oral Mucous Membranes

Impaired Gas exchange r/t alveolar-capillary membrane changes

Cyanosis, Peripheral with Cyanosis of Nail Beds

Ineffective peripheral Tissue Perfusion r/t interruption of arte- rial flow, severe vasoconstriction, cold temperatures

Cystic Fibrosis Activity intolerance r/t imbalance between oxygen supply and demand Ineffective Airway clearance r/t increased production of thick mucus Anxiety r/t dyspnea, oxygen deprivation Disturbed Body Image r/t changes in physical appearance, treatment of chronic lung disease (clubbing, barrel chest, home oxygen therapy) Impaired Gas exchange r/t ventilation-perfusion imbalance Impaired Home maintenance r/t extensive daily treatment, medications necessary for health Imbalanced Nutrition: less than body requirements r/t anorexia; decreased absorption of nutrients, fat; increased work of breathing Chronic Sorrow r/t presence of chronic disease Risk for Caregiver Role Strain: Risk factors: illness severity of care receiver, unpredictable course of illness Risk for deficient Fluid volume: Risk factors: decreased fluid intake, increased work of breathing Risk for Infection: Risk factors: thick, tenacious mucus; harbor- ing of bacterial organisms; immunocompromised state Risk for Spiritual distress: Risk factor: presence of chronic disease See Child with Chronic Condition; Hospitalized Child; Terminally Ill Child, Adolescent; Terminally Ill Child, Infant/Toddler; Terminally Ill Child, Preschool Child; Terminally Ill Child, School­ Age Child/Preadolescent; Terminally Ill Child/Death of Child, Parent

Cystitis Acute Pain: dysuria r/t inflammatory process in bladder and urethra Impaired Urinary elimination: frequency r/t urinary tract infection Urge urinary Incontinence: Risk factor: infection in bladder Readiness for enhanced Knowledge: expresses an interest in learning

Cystocele Stress urinary Incontinence r/t prolapsed bladder Readiness for enhanced Knowledge: expresses an interest in learning

Cystoscopy Urinary Retention r/t edema in urethra obstructing flow of urine Risk for Infection: Risk factor: invasive procedure Readiness for enhanced Knowledge: expresses an interest in learning

Dehiscence, Abdominal 45

D

D Deafness

Impaired verbal Communication r/t impaired hearing Hearing Loss r/t alteration in sensory reception, transmission, integration Risk for delayed Development: Risk factor: impaired hearing Risk for Injury: Risk factor: alteration in sensory perception

Death Risk for Sudden Infant Death syndrome (SIDS) (See Sudden Infant Death syndrome, risk for, Section III)

Death, Oncoming Death Anxiety r/t unresolved issues surrounding dying Compromised family Coping r/t client’s inability to provide support to family Ineffective Coping r/t personal vulnerability Fear r/t threat of death Grieving r/t loss of significant other Powerlessness r/t effects of illness, oncoming death Social isolation r/t altered state of wellness Spiritual distress r/t intense suffering Readiness for enhanced Spiritual well-being: desire of client and family to be in harmony with each other and higher power, God See Terminally Ill Child, Adolescent; Terminally Ill Child, Infant/ Toddler; Terminally Ill Child, Preschool Child; Terminally Ill Child, School-Age Child/Preadolescent; Terminally Ill Child/Death of Child, Parent

Decisions, Difficulty Making Decisional Conflict r/t support system deficit, perceived threat to value system, multiple or divergent sources of informa- tion, lack of relevant information, unclear personal values or beliefs Readiness for enhanced Decision-Making (See Decision- Making, readiness for enhanced, Section III)

Decubitus Ulcer See Pressure Ulcer

Deep Vein Thrombosis (DVT) See DVT (Deep Vein Thrombosis)

Defensive Behavior Defensive Coping r/t nonacceptance of blame, denial of prob- lems or weakness Ineffective Denial r/t inability to face situation realistically

Dehiscence, Abdominal Fear r/t threat of death, severe dysfunction Acute Pain r/t stretching of abdominal wall Impaired Skin integrity r/t altered circulation, malnutrition, opening in incision

e6

List of Nursing Assessments by Letter: D

Deafness Death Death, Oncoming Decisions, Difficulty Making Decubitus Ulcer Deep Vein Thrombosis (DVT) Defensive Behavior Dehiscence, Abdominal Dehydration Delirium Delirium Tremens (DT) Delivery Delusions Dementia Denial of Health Status Dental Caries Depression (Major Depressive

Disorder) Dermatitis

Despondency Destructive Behavior Toward Others Developmental Concerns Diabetes in Pregnancy Diabetes Insipidus Diabetes Mellitus Diabetes Mellitus, Juvenile (IDDM Type 1)

Diabetic Coma Diabetic Ketoacidosis

Diabetic Retinopathy Dialysis Diaphragmatic Hernia Diarrhea DIC (Disseminated Intravascular

Coagulation) Digitalis Toxicity

Dignity, Loss of Dilation and Curettage (D&C) Dirty Body (for Prolonged Period) Discharge Planning Discomforts of Pregnancy Dislocation of Joint Dissecting Aneurysm Disseminated Intravascular

Coagulation (DIC) Dissociative Identity Disorder (Not Otherwise Specified)

Distress Disuse Syndrome, Potential to Develop Diversional Activity, Lack of Diverticulitis Dizziness Domestic Violence Down Syndrome Dress Self (Inability to) Dribbling of Urine Drooling Dropout from School Drug Abuse Drug Withdrawal Dry Eye DT (Delirium Tremens) DVT (Deep Vein Thrombosis) Dying Client Dysfunctional Eating Pattern Dysfunctional Family Unit Dysfunctional Ventilatory Weaning Dysmenorrhea Dyspareunia Dyspepsia Dysphagia Dysphasia Dyspnea Dysrhythmia Dysthymic Disorder Dystocia Dysuria

46 Dehydration

D

Delayed Surgical recovery r/t altered circulation, malnutrition, opening in incision Impaired Tissue integrity r/t exposure of abdominal contents to external environment Risk for deficient Fluid volume: Risk factor: altered circulation associated with opening of wound and exposure of abdominal contents Risk for Infection: Risk factors: loss of skin integrity, open surgical wound

Dehydration Deficient Fluid volume r/t active fluid volume loss Impaired Oral Mucous Membrane r/t decreased salivation, fluid deficit Risk for chronic functional Constipation: Risk factor: decreased fluid volume Risk for imbalanced body Temperature: Risk factor: hyper- thermia due to sensible water loss See Burns, Heat Stroke, Vomiting, Diarrhea

Delirium Acute Confusion r/t effects of medication, response to hospi- talization, alcohol abuse, substance abuse, sensory deprivation or overload, infection, polypharmacy Impaired Memory r/t delirium Sleep deprivation r/t sustained inadequate sleep hygiene Risk for Injury: Risk factor: altered level of consciousness

Delirium Tremens (DT) See Alcohol Withdrawal

Delivery See Labor, Normal

Delusions Impaired verbal Communication r/t psychological impair- ment, delusional thinking Acute Confusion r/t alcohol abuse, delirium, dementia, drug abuse Ineffective Coping r/t distortion and insecurity of life events Fear r/t content of intrusive thoughts Risk for other-directed Violence: Risk factor: delusional thinking Risk for self-directed Violence: Risk factor: delusional thinking

Dementia Chronic Confusion r/t neurological dysfunction Interrupted Family processes r/t disability of family member Frail Elderly syndrome r/t alteration in cognitive functioning Impaired Home maintenance r/t inadequate support system, neurological dysfunction Imbalanced Nutrition: less than body requirements r/t neuro- logical impairment Functional urinary Incontinence r/t neurological dysfunction

Insomnia r/t neurological impairment, naps during the day Impaired physical Mobility r/t alteration in cognitive function Self-Neglect r/t cognitive impairment Self-Care deficit: specify r/t psychological or neuromuscular impairment Chronic Sorrow: Significant other r/t chronic long-standing disability, loss of mental function Impaired Swallowing r/t neuromuscular changes associated with long-standing dementia Risk for Caregiver Role Strain: Risk factors: number of care- giving tasks, duration of caregiving required Risk for Chronic Functional Constipation: Risk factor: decreased fluid intake Risk for Falls: Risk factor: diminished mental status Risk for Frail Elderly syndrome: Risk factors: cognitive impairment Risk for Injury: Risk factors: confusion, decreased muscle coordination Risk for impaired Skin integrity: Risk factors: altered nutritional status, immobility

Denial of Health Status Ineffective Denial r/t lack of perception about the health status effects of illness Ineffective Health management r/t denial of seriousness of health situation

Dental Caries Impaired Dentition r/t ineffective oral hygiene, barriers to self- care, economic barriers to professional care, nutritional deficits, dietary habits Ineffective Health maintenance r/t lack of knowledge regarding prevention of dental disease

Depression (Major Depressive Disorder) Death Anxiety r/t feelings of lack of self-worth Constipation r/t inactivity, decreased fluid intake Fatigue r/t psychological demands Ineffective Health maintenance r/t lack of ability to make good judgments regarding ways to obtain help Hopelessness r/t feeling of abandonment, long-term stress Impaired Mood Regulation r/t emotional instability Insomnia r/t inactivity Self-Neglect r/t depression, cognitive impairment Powerlessness r/t pattern of helplessness Chronic low Self-Esteem r/t repeated unmet expectations Sexual dysfunction r/t loss of sexual desire Social isolation r/t ineffective coping Chronic Sorrow r/t unresolved grief Risk for complicated Grieving: Risk factor: lack of previous resolution of former grieving response Risk for Suicide: Risk factor: grieving, hopelessness

Dialysis 47

D

Dermatitis Anxiety r/t situational crisis imposed by illness Impaired Comfort r/t itching Impaired Skin integrity r/t side effect of medication, allergic reaction Readiness for enhanced Knowledge: expresses an interest in learning See Itching

Despondency Hopelessness r/t long-term stress See Depression (Major Depressive Disorder)

Destructive Behavior Toward Others Risk-prone Health behavior r/t intense emotional state Ineffective Coping r/t situational crises, maturational crises, dis- turbance in pattern of appraisal of threat Risk for other-directed Violence (See Violence, other-directed, risk for, Section III)

Developmental Concerns Risk for delayed Development (See Development, delayed, risk for, Section III) See Growth and Development Lag

Diabetes in Pregnancy See Gestational Diabetes (Diabetes in Pregnancy)

Diabetes Insipidus Deficient Fluid volume r/t inability to conserve fluid Ineffective Health maintenance r/t deficient knowledge regard- ing care of disease, importance of medications

Diabetes Mellitus Ineffective Health maintenance r/t complexity of therapeutic regimen Ineffective Health management (See Health management, inef- fective, Section III) Imbalanced Nutrition: less than body requirements r/t inability to use glucose (type 1 [insulin-dependent] diabetes) Risk for Overweight r/t excessive intake of nutrients (type 2 diabetes) Ineffective peripheral Tissue perfusion r/t impaired arterial circulation Powerlessness r/t perceived lack of personal control Sexual dysfunction r/t neuropathy associated with disease Vision Loss r/t ineffective tissue perfusion of retina Risk for unstable blood Glucose level (See Glucose level, blood, unstable, risk for, Section III) Risk for Infection: Risk factors: hyperglycemia, impaired healing, circulatory changes Risk for Injury: Risk factors: hypoglycemia or hyperglycemia from failure to consume adequate calories, failure to take insulin Risk for dysfunctional Gastrointestinal motility: Risk factor: complication of diabetes

Risk for impaired Skin integrity: Risk factor: loss of pain percep- tion in extremities Risk for delayed Surgical recovery: Risk factor: impaired healing due to circulatory changes Readiness for enhanced Health management (See Health man- agement, readiness for enhanced, Section III) Readiness for enhanced Knowledge: expresses an interest in learning See Hyperglycemia; Hypoglycemia

Diabetes Mellitus, Juvenile (IDDM Type 1) Risk-prone Health behavior r/t inadequate comprehension, inadequate social support, low self-efficacy, impaired adjustment attributable to adolescent maturational crises Disturbed Body Image r/t imposed deviations from bio- physical and psychosocial norm, perceived differences from peers Impaired Comfort r/t insulin injections, peripheral blood glucose testing Ineffective Health maintenance r/t (See Health maintenance, ineffective, Section III) Imbalanced Nutrition: less than body requirements r/t inability of body to adequately metabolize and use glucose and nutrients, increased caloric needs of child to promote growth and physical activity participation with peers Readiness for enhanced Knowledge: expresses an interest in learning See Diabetes Mellitus; Child with Chronic Condition; Hospital- ized Child

Diabetic Coma Acute Confusion r/t hyperglycemia, presence of excessive met- abolic acids Deficient Fluid volume r/t hyperglycemia resulting in polyuria Ineffective Health management r/t lack of understanding of preventive measures, adequate blood sugar control Risk for unstable blood Glucose level (See Glucose level, blood, unstable, risk for, Section III) Risk for Infection: Risk factors: hyperglycemia, changes in vas- cular system See Diabetes Mellitus

Diabetic Ketoacidosis See Ketoacidosis, Diabetic

Diabetic Retinopathy Grieving r/t loss of vision Ineffective Health maintenance r/t deficient knowledge regard- ing preserving vision with treatment if possible, use of low- vision aids Vision Loss r/t change in sensory reception See Vision Impairment; Blindness

Dialysis See Hemodialysis; Peritoneal Dialysis

48 Diaphragmatic Hernia

D

Diaphragmatic Hernia See Hiatal Hernia

Diarrhea Diarrhea r/t infection, change in diet, gastrointestinal disor- ders, stress, medication effect, impaction Deficient Fluid volume r/t excessive loss of fluids in liquid stools Risk for Electrolyte imbalance: Risk factor: effect of loss of electrolytes from frequent stools

DIC (Disseminated Intravascular Coagulation)

Fear r/t threat to well-being Deficient Fluid volume: hemorrhage r/t depletion of clotting factors Risk for Bleeding: Risk factors: microclotting within vascular system, depleted clotting factors Risk for ineffective Gastrointestinal perfusion (See Gastro- intestinal perfusion, ineffective, risk for, Section III)

Digitalis Toxicity Decreased Cardiac output r/t drug toxicity affecting cardiac rhythm, rate Ineffective Health management r/t deficient knowledge regard- ing action, appropriate method of administration of digitalis

Dignity, Loss of Risk for compromised Human Dignity (See Human Dignity, compromised, risk for, Section III)

Dilation and Curettage (D&C) Acute Pain r/t uterine contractions Risk for Bleeding: Risk factor: surgical procedure Risk for Infection: Risk factor: surgical procedure Risk for ineffective Sexuality pattern: Risk factors: painful coitus, fear associated with surgery on genital area Readiness for enhanced Knowledge: expresses an interest in learning

Dirty Body (for Prolonged Period) Self-Neglect r/t mental illness, substance abuse, cognitive impairment

Discharge Planning Impaired Home Maintenance r/t family member’s disease or injury interfering with home maintenance Deficient Knowledge r/t lack of exposure to information for home care Relocation stress syndrome: Risk factors: insufficient prede- parture counseling, insufficient support system, unpredictability of experience Readiness for enhanced Knowledge: expresses an interest in learning

Discomforts of Pregnancy Disturbed Body Image r/t pregnancy-induced body changes Impaired Comfort r/t enlarged abdomen, swollen feet

Fatigue r/t hormonal, metabolic, body changes Stress urinary Incontinence r/t enlarged uterus, fetal movement Insomnia r/t psychological stress, fetal movement, muscular cramping, urinary frequency, shortness of breath Nausea r/t hormone effect Acute Pain: headache r/t hormonal changes of pregnancy Acute Pain: leg cramps r/t nerve compression, calcium/ phosphorus/potassium imbalance Risk for Constipation: Risk factors: decreased intestinal motil- ity, inadequate fiber in diet Risk for Injury: Risk factors: faintness and/or syncope caused by vasomotor lability or postural hypotension, venous stasis in lower extremities

Dislocation of Joint Acute Pain r/t dislocation of a joint Self-Care deficit: r/t inability to use a joint Risk for Injury: Risk factor: unstable joint

Dissecting Aneurysm Fear r/t threat to well-being See Abdominal Surgery; Aneurysm, Abdominal Surgery

Disseminated Intravascular Coagulation (DIC)

See DIC (Disseminated Intravascular Coagulation)

Dissociative Identity Disorder (Not Otherwise Specified)

Anxiety r/t psychosocial stress Ineffective Coping r/t personal vulnerability in crisis of accurate self-perception Disturbed personal Identity r/t inability to distinguish self caused by multiple personality disorder, depersonalization, dis- turbance in memory Impaired Memory r/t altered state of consciousness See Multiple Personality Disorder (Dissociative Identity Disorder)

Distress Anxiety r/t situational crises, maturational crises Death Anxiety r/t denial of one’s own mortality or impend- ing death

Disuse Syndrome, Potential to Develop Risk for Disuse syndrome: Risk factors: paralysis, mechanical immobilization, prescribed immobilization, severe pain, altered level of consciousness

Diversional Activity, Lack of Deficient Diversional activity r/t environmental lack of diversional activity as in frequent hospitalizations, lengthy treatments

Diverticulitis Constipation r/t dietary deficiency of fiber and roughage

DVT (Deep Vein Thrombosis) 49

D

Diarrhea r/t increased intestinal motility caused by inflammation Deficient Knowledge r/t diet needed to control disease, medi- cation regimen Imbalanced Nutrition: less than body requirements r/t loss of appetite Acute Pain r/t inflammation of bowel Risk for deficient Fluid Volume: Risk factor: diarrhea

Dizziness Decreased Cardiac output r/t alteration in heart rate and rhythm, altered stroke volume Deficient Knowledge r/t actions to take to prevent or modify dizziness and prevent falls Impaired physical Mobility r/t dizziness Risk for Falls: Risk factor: difficulty maintaining balance Risk for ineffective Cerebral tissue perfusion: Risk factor: inter- ruption of cerebral arterial blood flow

Domestic Violence Impaired verbal Communication r/t psychological barriers of fear Compromised family Coping r/t abusive patterns Defensive Coping r/t low self-esteem Dysfunctional Family processes r/t inadequate coping skills Fear r/t threat to self-concept, situational crisis of abuse Insomnia r/t psychological stress Post-Trauma syndrome r/t history of abuse Powerlessness r/t lifestyle of helplessness Situational low Self-Esteem r/t negative family interactions Risk for compromised Resilience: Risk factor: effects of abuse Risk for other-directed Violence: Risk factor: history of abuse

Down Syndrome See Child with Chronic Condition; Intellectual Disability

Dress Self (Inability to) Dressing Self-Care deficit r/t intolerance to activity, decreased strength and endurance, pain, discomfort, perceptual or cogni- tive impairment, neuromuscular impairment, musculoskeletal impairment, depression, severe anxiety

Dribbling of Urine Overflow urinary Incontinence r/t degenerative changes in pelvic muscles and urinary structures Stress urinary Incontinence r/t degenerative changes in pelvic muscles and urinary structures

Drooling Impaired Swallowing r/t neuromuscular impairment, mechani- cal obstruction Risk for Aspiration: Risk factor: impaired swallowing

Dropout from School Impaired individual Resilience (See Resilience, individual, impaired, Section III)

Anxiety r/t conflict about life goals Ineffective Coping r/t inadequate resources

Drug Abuse Anxiety r/t threat to self-concept, lack of control of drug use Risk-prone Health behavior r/t addiction Ineffective Coping r/t situational crisis Ineffective Denial r/t use of drugs affecting quality of own life and that of significant others Insomnia r/t effects of drugs Imbalanced Nutrition: less than body requirements r/t poor eating habits Powerlessness r/t feeling unable to change patterns of drug abuse Impaired individual Resilience (See Resilience, individual, impaired, Section III) Sexual dysfunction r/t actions and side effects of drug abuse Sleep deprivation r/t prolonged psychological discomfort Impaired Social interaction r/t disturbed thought processes from drug abuse Spiritual distress r/t separation from religious, cultural ties Risk for Injury: Risk factors: hallucinations, drug effects Risk for other-directed Violence: Risk factor: poor impulse control See Cocaine Abuse; Substance Abuse

Drug Withdrawal Anxiety r/t physiological withdrawal Acute Confusion r/t effects of substance withdrawal Ineffective Coping r/t situational crisis, withdrawal Insomnia r/t effects of medication/substance withdrawal Imbalanced Nutrition: less than body requirements r/t poor eating habits Risk for other-directed Violence: Risk factors: poor impulse control, hallucinations Risk for self-directed Violence: Risk factors: poor impulse control, hallucinations See Drug Abuse

Dry Eye Risk for dry Eye: Risk factors: (See dry Eye, risk for, Section III) Risk for Corneal Injury: Risk factor: suppressed corneal reflex Readiness for enhanced Knowledge: expresses an interest in learning See Conjunctivitis; Keratoconjunctivitis Sicca

DT (Delirium Tremens) See Alcohol Withdrawal

DVT (Deep Vein Thrombosis) Constipation r/t inactivity, bed rest Impaired physical Mobility r/t pain in extremity

50 Dying Client

D

Acute Pain r/t vascular inflammation, edema Ineffective peripheral Tissue perfusion r/t deficient knowledge of aggravating factors Delayed Surgical recovery r/t impaired physical mobility Readiness for enhanced Knowledge: expresses an interest in learning Risk for imbalanced body Temperature: Risk factor: inactivity See Anticoagulant Therapy

Dying Client See Terminally Ill Adult; Terminally Ill Adolescent; Terminally Ill Child, Infant/Toddler; Terminally Ill Child, Preschool Child; Ter- minally Ill Child, School-Age Child/Preadolescent; Terminally Ill Child/Death of Child, Parent

Dysfunctional Eating Pattern Imbalanced Nutrition: less than body requirements r/t psycho- logical factors Risk for Overweight: Risk factor: psychological factors See Anorexia Nervosa; Bulimia; Maturational Issues, Adolescent; Obesity

Dysfunctional Family Unit See Family Problems

Dysfunctional Ventilatory Weaning Dysfunctional Ventilatory weaning response r/t physical, psy- chological, situational factors

Dysmenorrhea Nausea r/t prostaglandin effect Acute Pain r/t cramping from hormonal effects Readiness for enhanced Knowledge: expresses an interest in learning

Dyspareunia Sexual Dysfunction r/t lack of lubrication during intercourse, alteration in reproductive organ function

Dyspepsia Anxiety r/t pressures of personal role Acute Pain r/t gastrointestinal disease, consumption of irritat- ing foods Readiness for enhanced Knowledge: expresses an interest in learning

Dysphagia Impaired Swallowing r/t neuromuscular impairment Risk for Aspiration: Risk factor: loss of gag or cough reflex

Dysphasia Impaired verbal Communication r/t decrease in circulation to brain Impaired social Interaction r/t difficulty in communicating

Dyspnea Activity intolerance r/t imbalance between oxygen supply and demand

Ineffective Breathing pattern r/t compromised cardiac or pulmonary function, decreased lung expansion, neurological impairment affecting respiratory center, extreme anxiety Fear r/t threat to state of well-being, potential death Impaired Gas exchange r/t alveolar-capillary damage Insomnia r/t difficulty breathing, positioning required for effec- tive breathing Sleep deprivation r/t ineffective breathing pattern

Dysrhythmia Activity intolerance r/t decreased cardiac output Decreased Cardiac output r/t alteration in heart rate, rhythm Fear r/t threat of death, change in health status Risk for ineffective Cerebral tissue perfusion: Risk factor: decreased blood supply to the brain from dysrhythmia Readiness for enhanced Knowledge: expresses an interest in learning

Dysthymic Disorder Ineffective Coping r/t impaired social interaction Ineffective Health maintenance r/t inability to make good judg- ments regarding ways to obtain help Insomnia r/t anxious thoughts Chronic low Self-Esteem r/t repeated unmet expectations Ineffective Sexuality pattern r/t loss of sexual desire Social Isolation r/t ineffective coping See Depression (Major Depressive Disorder)

Dystocia Anxiety r/t difficult labor, deficient knowledge regarding normal labor pattern Ineffective Coping r/t situational crisis Fatigue r/t prolonged labor Grieving r/t loss of ideal labor experience Acute Pain r/t difficult labor, medical interventions Powerlessness r/t perceived inability to control outcome of labor Risk for Bleeding: Risk factor: hemorrhage secondary to uterine atony Risk for ineffective Cerebral tissue perfusion (fetal): Risk factor: difficult labor and birth Risk for delayed Development (Infant): Risk factor: difficult labor and birth Risk for disproportionate Growth: Risk factor: difficult labor and birth Risk for Infection: Risk factor: prolonged rupture of membranes Risk for impaired Tissue integrity (maternal and fetal): Risk factor: difficult labor

Dysuria Impaired Urinary elimination r/t infection/inflammation of the urinary tract

Risk for urge urinary Incontinence: Risk factor: detrusor hyperreflexia from infection in the urinary tract Acute Pain r/t infection/inflammation of the urinary tract

Elder Abuse 51

E

E ECMO (Extracorporeal Membrane Oxygenator)

Death Anxiety r/t emergency condition, hemorrhage Decreased Cardiac output r/t altered contractility of the heart Impaired Gas exchange (See Gas exchange, impaired, Section III) See Respiratory Conditions of the Neonate

E. coli Infection Fear r/t serious illness, unknown outcome Deficient Knowledge r/t how to prevent disease; care of self with serious illness See Gastroenteritis; Gastroenteritis, Child; Hospitalized Child

Ear Surgery Acute Pain r/t edema in ears from surgery Hearing Loss r/t invasive surgery of ears, dressings Risk for delayed Development: Risk factor: hearing impairment Risk for Falls: Risk factor: dizziness from excessive stimuli to vestibular apparatus Readiness for enhanced Knowledge: expresses an interest in learning See Hospitalized Child

Earache Acute Pain r/t trauma, edema, infection Hearing Loss r/t altered sensory reception, transmission

Ebola Virus Disease Fear r/t serious threat to well-being Ineffective Health maintenance r/t knowledge deficit regarding transmission, symptoms, and treatment Social isolation r/t fear of incurable disease Deficient Fluid volume r/t active fluid loss, vomiting, diarrhea, and failure of regulatory mechanisms Risk for Infection: Risk factor: lack of knowledge concerning transmission of disease

Eclampsia Interrupted Family processes r/t unmet expectations for preg- nancy and childbirth Fear r/t threat of well-being to self and fetus Risk for Aspiration: Risk factor: seizure activity Risk for ineffective Cerebral tissue perfusion: fetal: Risk factor: uteroplacental insufficiency Risk for delayed Development: Risk factor: uteroplacental insufficiency

Risk for excess Fluid volume: Risk factor: decreased urine output as a result of renal dysfunction Risk for disproportionate Growth: Risk factor: uteroplacental insufficiency

ECT (Electroconvulsive Therapy) Decisional Conflict r/t lack of relevant information Fear r/t real or imagined threat to well-being Impaired Memory r/t effects of treatment See Depression (Major Depressive Disorder)

Ectopic Pregnancy Death Anxiety r/t emergency condition, hemorrhage Disturbed Body Image r/t negative feelings about body and reproductive functioning Fear r/t threat to self, surgery, implications for future pregnancy Acute Pain r/t stretching or rupture of implantation site Ineffective Role performance r/t loss of pregnancy Situational low Self-Esteem r/t loss of pregnancy, inability to carry pregnancy to term Chronic Sorrow r/t loss of pregnancy, potential loss of fertility Risk for Bleeding: Risk factor: possible rupture of implantation site, surgical trauma Risk for ineffective Coping: Risk factor: loss of pregnancy Risk for interrupted Family processes: Risk factor: situational crisis Risk for Infection: Risk factors: traumatized tissue, surgical procedure Risk for Spiritual distress: Risk factor: grief process

Eczema Disturbed Body Image r/t change in appearance from inflamed skin Impaired Comfort: pruritus r/t inflammation of skin Impaired Skin integrity r/t side effect of medication, allergic reaction Readiness for enhanced Knowledge: expresses an interest in learning

ED (Erectile Dysfunction) See Erectile Dysfunction (ED); Impotence

Edema Excess Fluid volume r/t excessive fluid intake, cardiac dysfunc- tion, renal dysfunction, loss of plasma proteins Ineffective Health maintenance r/t deficient knowledge regard- ing treatment of edema Risk for impaired Skin integrity: Risk factors: impaired circula- tion, fragility of skin See Heart Failure, Kidney Failure

Elder Abuse See Abuse, Spouse, Parent, or Significant Other

e7

List of Nursing Assessments by Letter: E

ECMO (Extracorporeal Membrane Oxygenator)

E. coli Infection Ear Surgery

Earache Ebola Virus Disease Eclampsia ECT (Electroconvulsive Therapy) Ectopic Pregnancy Eczema ED (Erectile Dysfunction) Edema Elder Abuse Elderly Electroconvulsive Therapy Electrolyte Imbalance Emancipated Decision-Making, Impaired

Emaciated Person Embolectomy

Emboli Embolism in Leg or Arm Emesis Emotional Problems Empathy Emphysema Emptiness Encephalitis Endocardial Cushion Defect Endocarditis Endometriosis Endometritis Enuresis Environmental Interpretation Problems Epididymitis Epiglottitis Epilepsy Episiotomy Epistaxis Epstein-Barr Virus Erectile Dysfunction (ED) Esophageal Varices Esophagitis ETOH Withdrawal Evisceration Exhaustion Exposure to Hot or Cold Environment External Fixation Extracorporeal Membrane Oxygenator

(ECMO) Eye Discomfort

Eye Surgery

52 Elderly

E

Elderly See Aging; Frail Elderly Syndrome

Electroconvulsive Therapy See ECT (Electroconvulsive Therapy)

Electrolyte Imbalance Risk for Electrolyte imbalance (See Electrolyte imbalance, risk for, Section III)

Emancipated Decision-Making, Impaired Risk for impaired emancipated Decision-Making: Risk factor: inability or unwillingness to verbalize needs and wants Readiness for enhanced emancipated Decision-Making

Emaciated Person Frail Elderly syndrome r/t living alone, malnutrition, alteration in cognitive functioning Imbalanced Nutrition: less than body requirements r/t inability to ingest food, digest food, absorb nutrients because of biological, psychological, economic factors

Embolectomy Fear r/t threat of great bodily harm from embolus Ineffective peripheral Tissue Perfusion r/t presence of embolus Risk for Bleeding: Risk factors: postoperative complication, surgical area See Surgery, Postoperative Care

Emboli See Pulmonary Embolism

Embolism in Leg or Arm Ineffective peripheral Tissue Perfusion r/t arterial obstruction from clot See Deep Vein Thrombosis

Emesis Nausea (See Nausea, Section III) See Vomiting

Emotional Problems See Coping Problems

Empathy Readiness for enhanced community Coping: social supports, being available for problem solving Readiness for enhanced family Coping: basic needs met, desire to move to higher level of health Readiness for enhanced Spiritual Well-Being: desire to estab- lish interconnectedness through spirituality

Emphysema See COPD (Chronic Obstructive Pulmonary Disease)

Emptiness Social isolation r/t inability to engage in satisfying personal relationships Chronic Sorrow r/t unresolved grief

Spiritual distress r/t separation from religious or cultural ties

Encephalitis See Meningitis/Encephalitis

Endocardial Cushion Defect See Congenital Heart Disease/Cardiac Anomalies

Endocarditis Activity intolerance r/t reduced cardiac reserve, prescribed bed rest Decreased Cardiac output r/t inflammation of lining of heart and change in structure of valve leaflets, increased myocardial workload Risk for imbalanced Nutrition: less than body requirements: Risk factors: fever, hypermetabolic state associated with fever Risk for ineffective Cerebral tissue perfusion: Risk factor: pos- sible presence of emboli in cerebral circulation Risk for ineffective peripheral Tissue perfusion: Risk factor: possible presence of emboli in peripheral circulation Readiness for enhanced Knowledge: expresses an interest in learning

Endometriosis Grieving r/t possible infertility Nausea r/t prostaglandin effect Acute Pain r/t onset of menses with distention of endometrial tissue Sexual dysfunction r/t painful intercourse Readiness for enhanced Knowledge: expresses an interest in learning

Endometritis Anxiety r/t, fear of unknown Ineffective Thermoregulation r/t infectious process Acute Pain r/t infectious process in reproductive tract Readiness for enhanced Knowledge: expresses an interest in learning

Enuresis Ineffective Health maintenance r/t unachieved developmental task, neuromuscular immaturity, diseases of urinary system See Toilet Training

Environmental Interpretation Problems (See chronic Confusion)

Epididymitis Anxiety r/t situational crisis, pain, threat to future fertility Acute Pain r/t inflammation in scrotal sac Ineffective Sexuality pattern r/t edema of epididymis and testes Readiness for enhanced Knowledge: expresses an interest in learning

Epiglottitis See Respiratory Infections, Acute Childhood (Croup, Epiglottis, Pertussis, Pneumonia, Respiratory Syncytial Virus)

Epilepsy Anxiety r/t threat to role functioning Ineffective Health management r/t deficient knowledge regard- ing seizure control Impaired Memory r/t seizure activity Risk for Aspiration: Risk factors: impaired swallowing, exces- sive secretions Risk for delayed Development: Risk factor: seizure disorder Risk for Injury: Risk factor: environmental factors during seizure Readiness for enhanced Knowledge: expresses an interest in learning See Seizure Disorders, Adult; Seizure Disorders, Childhood

Episiotomy Anxiety r/t fear of pain Disturbed Body Image r/t fear of resuming sexual relations Impaired physical Mobility r/t pain, swelling, tissue trauma Acute Pain r/t tissue trauma Sexual dysfunction r/t altered body structure, tissue trauma Impaired Skin integrity r/t perineal incision Risk for Infection: Risk factor: tissue trauma

Epistaxis Fear r/t large amount of blood loss Risk for deficient Fluid volume: Risk factor: excessive blood loss

Epstein-Barr Virus See Mononucleosis

Erectile Dysfunction (ED) Situational low Self-Esteem r/t physiological crisis, inability to practice usual sexual activity Sexual dysfunction r/t altered body function Readiness for enhanced Knowledge: information regarding treatment for erectile dysfunction See Impotence

Esophageal Varices Fear r/t threat of death from hematemesis Risk for Bleeding: Risk factor: portal hypertension, distended variceal vessels that can easily rupture See Cirrhosis

Esophagitis Acute Pain r/t inflammation of esophagus Readiness for enhanced Knowledge: expresses an interest in learning

ETOH Withdrawal See Alcohol Withdrawal

Evisceration See Dehiscence, Abdominal

Exhaustion Impaired individual Resilience (See Resilience, individual, impaired, Section III) Disturbed Sleep pattern (See Sleep pattern, disturbed, Section III)

Exposure to Hot or Cold Environment Hyperthermia r/t exposure to hot environment, abnormal reaction to anesthetics Hypothermia r/t exposure to cold environment Risk for imbalanced Body temperature: Risk factors: extremes of environmental temperature; inappropriate clothing for envi- ronmental temperature

External Fixation Disturbed Body Image r/t trauma, change to affected part Risk for Infection: Risk factor: presence of pins inserted into bone See Fracture

Extracorporeal Membrane Oxygenator (ECMO)

See ECMO (Extracorporeal Membrane Oxygenator)

Eye Discomfort Risk for dry Eye (See Eye, dry, risk for, Section III) Risk for corneal Injury: Risk factors: exposure of the eyeball, blinking less than five times per minute

Eye Surgery Anxiety r/t possible loss of vision Self-Care deficit: specify r/t impaired vision Vision Loss r/t surgical procedure, eye pathology Risk for Injury: Risk factor: impaired vision Readiness for enhanced Knowledge: expresses an interest in learning See Hospitalized Child; Vision Impairment

Failure to Thrive, Child 53

F

F Failure to Thrive, Child

Disorganized Infant behavior (See Infant behavior, disorga- nized, Section III) Insomnia r/t inconsistency of caretaker; lack of quiet, consistent environment Imbalanced Nutrition: less than body requirements r/t inade- quate type or amounts of food for infant or child, inappropriate feeding techniques Impaired Parenting r/t lack of parenting skills, inadequate role modeling Chronic low Self-Esteem: parental r/t feelings of inadequacy, support system deficiencies, inadequate role model

e8

List of Nursing Assessments by Letter: F

Failure to Thrive, Child Falls, Risk for Family Problems Family Process Fatigue Fear Febrile Seizures Fecal Impaction Fecal Incontinence Feeding Problems, Newborn Femoral Popliteal Bypass Fetal Alcohol Syndrome Fetal Distress/Nonreassuring Fetal Heart Rate Pattern

Fever Fibrocystic Breast Disease

Filthy Home Environment Financial Crisis in the Home Environment

Fistulectomy

Flail Chest Flashbacks Flat Affect Flesh-Eating Bacteria (Necrotizing Fasciitis)

Fluid Balance Fluid Volume Deficit

Fluid Volume Excess Fluid Volume Imbalance, Risk for Food Allergies Foodborne Illness Food Intolerance Foreign Body Aspiration Formula Feeding of Infant Fracture Fractured Hip Frail Elderly Syndrome Frequency of Urination Friendship Frostbite Frothy Sputum Fusion, Lumbar

54 Falls, Risk for

F

Social isolation r/t limited support systems, self-imposed situation Risk for impaired Attachment: Risk factor: inability of parents to meet infant’s needs Risk for delayed Development (See Development, delayed, risk for, Section III) Risk for disproportionate Growth (See Growth, disproportion- ate, risk for, Section III)

Falls, Risk for Risk for Falls (See Falls, risk for, Section III)

Family Problems Compromised family Coping (See Coping, family, compro- mised, Section III) Disabled family Coping (See Coping, family, disabled, Section III) Interrupted Family Processes r/t situation transition and/or crises, developmental transition and/or crises Ineffective family Health management (See family Health man- agement, ineffective, Section III) Readiness for enhanced family Coping: needs sufficiently gratified, adaptive tasks effectively addressed to enable goals of self-actualization to surface

Family Process Dysfunctional Family processes (See Family processes, dysfunctional, Section III) Interrupted Family processes (See Family processes, inter- rupted, Section III) Readiness for enhanced Family processes (See Family pro- cesses, readiness for enhanced, Section III) Readiness for enhanced Relationship (See Relationship, readiness for enhanced, Section III)

Fatigue Fatigue (See Fatigue, Section III)

Fear Death Anxiety r/t fear of death Fear r/t identifiable physical or psychological threat to person

Febrile Seizures See Seizure Disorders, Childhood (Epilepsy, Febrile Seizures, Infan- tile Spasms)

Fecal Impaction See Impaction of Stool (See Constipation, Section III) (See Constipation, chronic functional, Section III)

Fecal Incontinence Bowel Incontinence r/t neurological impairment, gastrointes- tinal disorders, anorectal trauma, weakened perineal muscles

Feeding Problems, Newborn Ineffective Breastfeeding (See Breastfeeding, ineffective, Section III)

Insufficient Breastfeeding (See Breastfeeding, insufficient, Section III) Disorganized Infant behavior r/t prematurity, immature neuro- logical system Ineffective infant Feeding pattern r/t prematurity, neurological impairment or delay, oral hypersensitivity, prolonged nothing- by-mouth status Impaired Swallowing r/t prematurity Risk for delayed Development: Risk factor: inadequate nutrition Risk for deficient Fluid volume: Risk factor: inability to take in adequate amount of fluids Risk for disproportionate Growth: Risk factor: feeding problems

Femoral Popliteal Bypass Anxiety r/t threat to or change in health status Acute Pain r/t surgical trauma, edema in surgical area Ineffective peripheral Tissue Perfusion r/t impaired arterial circulation Risk for Bleeding: Risk factor: surgery on arteries Risk for Infection: Risk factor: invasive procedure

Fetal Alcohol Syndrome See Infant of Substance-Abusing Mother

Fetal Distress/Nonreassuring Fetal Heart Rate Pattern

Fear r/t threat to fetus Ineffective peripheral Tissue Perfusion: fetal r/t interruption of umbilical cord blood flow

Fever Ineffective Thermoregulation r/t infectious process Risk for Imbalanced body Temperature: Risk factors: acute brain injury; pharmaceutical agent

Fibrocystic Breast Disease See Breast Lumps

Filthy Home Environment Impaired Home maintenance (See Home maintenance, impaired, Section III) Self-Neglect r/t mental illness, substance abuse, cognitive impairment

Financial Crisis in the Home Environment Impaired Home maintenance r/t insufficient finances

Fistulectomy See Hemorrhoidectomy

Flail Chest Ineffective Breathing pattern r/t chest trauma Fear r/t difficulty breathing Impaired Gas exchange r/t loss of effective lung function Impaired spontaneous Ventilation r/t paradoxical respirations

Friendship 55

F

Flashbacks Post-Trauma syndrome r/t catastrophic event

Flat Affect Hopelessness r/t prolonged activity restriction creating isola- tion, failing or deteriorating physiological condition, long-term stress, abandonment, lost belief in transcendent values or higher power or God Risk for Loneliness: Risk factors: social isolation, lack of inter- est in surroundings See Depression (Major Depressive Disorder); Dysthymic Disorder

Flesh-Eating Bacteria (Necrotizing Fasciitis)

See Necrotizing Fasciitis (Flesh-Eating Bacteria)

Fluid Balance Readiness for enhanced Fluid balance (See Fluid balance, readi- ness for enhanced, Section III)

Fluid Volume Deficit Deficient Fluid volume r/t active fluid loss, vomiting, diarrhea, failure of regulatory mechanisms Risk for Shock: Risk factors: hypovolemia, sepsis, systemic inflammatory response syndrome (SIRS)

Fluid Volume Excess Excess Fluid volume r/t compromised regulatory mechanism, excess sodium intake

Fluid Volume Imbalance, Risk for Risk for imbalanced Fluid volume: Risk factor: major invasive surgeries

Food Allergies Diarrhea r/t immune effects of offending food on gastrointes- tinal system Risk for Allergy response: Risk factor: specific foods Readiness for enhanced Knowledge: expresses an interest in learning See Anaphylactic Shock if relevant

Foodborne Illness Diarrhea r/t infectious material in gastrointestinal tract Deficient Fluid volume r/t active fluid loss from vomiting and diarrhea Deficient Knowledge r/t care of self with serious illness, pre- vention of further incidences of foodborne illness Nausea r/t contamination irritating stomach Risk for dysfunctional Gastrointestinal motility: Risk factor: contaminated food See Gastroenteritis; Gastroenteritis, Child; Hospitalized Child; E. coli Infection

Food Intolerance Risk for dysfunctional Gastrointestinal motility: Risk factor: food intolerance

Foreign Body Aspiration Ineffective Airway clearance r/t obstruction of airway Ineffective Health maintenance r/t parental deficient knowledge regarding high-risk items Risk for Suffocation: Risk factor: inhalation of small objects See Safety, Childhood

Formula Feeding of Infant Grieving: maternal r/t loss of desired breastfeeding experience Risk for Constipation: infant: Risk factor: iron-fortified formula Risk for Infection: infant: Risk factors: lack of passive maternal immunity, supine feeding position, contamination of formula Readiness for enhanced Knowledge: expresses an interest in learning

Fracture Deficient Diversional activity r/t immobility Impaired physical Mobility r/t limb immobilization Acute Pain r/t muscle spasm, edema, trauma Post-Trauma syndrome r/t catastrophic event Impaired Walking r/t limb immobility Risk for ineffective peripheral Tissue Perfusion: Risk factors: immobility, presence of cast Risk for Peripheral Neurovascular dysfunction: Risk factors: mechanical compression, treatment of fracture Risk for impaired Skin integrity: Risk factors: immobility, pres- ence of cast Readiness for enhanced Knowledge: expresses an interest in learning

Fractured Hip See Hip Fracture

Frail Elderly Syndrome Activity intolerance r/t sensory changes Risk for Frail Elderly syndrome (see Frail Elderly syndrome, risk for, Section III) Risk for Injury: Risk factors: impaired vision, impaired gait Risk for Powerlessness: Risk factor: inability to maintain independence

Frequency of Urination Stress urinary Incontinence r/t degenerative change in pelvic muscles and structural support Urge urinary Incontinence r/t decreased bladder capacity, irritation of bladder stretch receptors causing spasm, alcohol, caffeine, increased fluids, increased urine concentration, over- distended bladder Impaired Urinary elimination r/t urinary tract infection Urinary retention r/t high urethral pressure caused by weak detrusor, inhibition of reflex arc, strong sphincter, blockage

Friendship Readiness for enhanced Relationship: expresses desire to enhance communication between partners

56 Frostbite

Frostbite Acute Pain r/t decreased circulation from prolonged exposure to cold Ineffective peripheral Tissue Perfusion r/t damage to extremi- ties from prolonged exposure to cold Impaired Tissue integrity r/t freezing of skin and tissues See Hypothermia

Frothy Sputum See CHF (Congestive Heart Failure); Pulmonary Edema; Seizure Disorders, Adult; Seizure Disorders, Childhood (Epilepsy, Febrile Seizures, Infantile Spasms)

Fusion, Lumbar Anxiety r/t fear of surgical procedure, possible recurring problems Impaired physical Mobility r/t limitations from surgical proce- dure, presence of brace Acute Pain r/t discomfort at bone donor site, surgical operation Risk for Injury: Risk factor: improper body mechanics Risk for Perioperative Positioning injury: Risk factor: immo- bilization during surgery Readiness for enhanced Knowledge: expresses an interest in learning

G

G Gag Reflex, Depressed or Absent

Impaired Swallowing r/t neuromuscular impairment Risk for Aspiration: Risk factors: depressed cough or gag reflex

Gallop Rhythm Decreased Cardiac output r/t decreased contractility of heart

Gallstones See Cholelithiasis

Gang Member Impaired individual Resilience (See Resilience, individual, impaired, Section III)

Gangrene Fear r/t possible loss of extremity Ineffective peripheral Tissue perfusion r/t obstruction of arte- rial flow See Diabetes Mellitus, Peripheral Vascular Disease

Gas Exchange, Impaired Impaired Gas exchange r/t ventilation-perfusion imbalance

Gastric Ulcer See GI Bleed (Gastrointestinal Bleeding); Ulcer, Peptic (Duodenal or Gastric)

Gastritis Imbalanced Nutrition: less than body requirements r/t vomit- ing, inadequate intestinal absorption of nutrients, restricted dietary regimen Acute Pain r/t inflammation of gastric mucosa Risk for deficient Fluid volume: Risk factors: excessive loss from gastrointestinal tract from vomiting, decreased intake

Gastroenteritis Diarrhea r/t infectious process involving intestinal tract Deficient Fluid volume r/t excessive loss from gastrointestinal tract from diarrhea, vomiting Nausea r/t irritation to gastrointestinal system Imbalanced Nutrition: less than body requirements r/t vomit- ing, inadequate intestinal absorption of nutrients, restricted dietary intake Acute Pain r/t increased peristalsis causing cramping Risk for Electrolyte imbalance: Risk factor: loss of gastrointes- tinal fluids high in electrolytes Readiness for enhanced Knowledge: expresses an interest in learning See Gastroenteritis, Child

Gastroenteritis, Child Impaired Skin integrity: diaper rash r/t acidic excretions on perineal tissues Readiness for enhanced Knowledge: expresses an interest in learning Acute Pain r/t increased peristalsis causing cramping See Gastroenteritis; Hospitalized Child

Gastroesophageal Reflux (GERD) Ineffective Airway clearance r/t reflux of gastric contents into esophagus and tracheal or bronchial tree Ineffective Health maintenance r/t deficient knowledge regard- ing anti-reflux regimen (e.g., positioning, change in diet) Acute Pain r/t irritation of esophagus from gastric acids Risk for Aspiration: Risk factor: entry of gastric contents in tracheal or bronchial tree

Gastroesophageal Reflux, Child Ineffective Airway clearance r/t reflux of gastric contents into esophagus and tracheal or bronchial tree Anxiety: parental r/t possible need for surgical intervention Deficient Fluid volume r/t persistent vomiting Imbalanced Nutrition: less than body requirements r/t poor feeding, vomiting Risk for Aspiration: Risk factor: entry of gastric contents in tracheal or bronchial tree Risk for impaired Parenting: Risk factors: disruption in bonding as a result of irritable or inconsolable infant; lack of sleep for parents Readiness for enhanced Knowledge: expresses an interest in learning See Child with Chronic Condition; Hospitalized Child

e9

Gag Reflex, Depressed or Absent Gallop Rhythm Gallstones Gang Member Gangrene Gas Exchange, Impaired Gastric Ulcer Gastritis Gastroenteritis Gastroenteritis, Child Gastroesophageal Reflux (GERD) Gastroesophageal Reflux, Child Gastrointestinal Bleeding (GI Bleed) Gastrointestinal Hemorrhage Gastrointestinal Surgery Gastroschisis/Omphalocele Gastrostomy Genital Herpes Genital Warts GERD Gestational Diabetes (Diabetes in

Pregnancy) GI Bleed (Gastrointestinal Bleeding) Gingivitis Glaucoma Glomerulonephritis Gluten Allergy Gonorrhea Gout Grandiosity Grand Mal Seizure Grandparents Raising Grandchildren Graves’ Disease Grieving Grieving, Complicated Groom Self (Inability to) Growth and Development Lag Guillain-Barré Syndrome Guilt

List of Nursing Assessments by Letter: G

Gout 57

G

Gastrointestinal Bleeding (GI Bleed) See GI Bleed (Gastrointestinal Bleeding)

Gastrointestinal Hemorrhage See GI Bleed (Gastrointestinal Bleeding)

Gastrointestinal Surgery Risk for Injury: Risk factor: inadvertent insertion of nasogastric tube through gastric incision line Risk for ineffective Gastrointestinal perfusion (See Gastroin- testinal perfusion, ineffective, risk for, Section III) See Abdominal Surgery

Gastroschisis/Omphalocele Ineffective Airway clearance r/t complications of anesthetic effects Impaired Gas exchange r/t effects of anesthesia, subsequent atelectasis Grieving r/t threatened loss of infant, loss of perfect birth or infant because of serious medical condition Risk for deficient Fluid volume: Risk factors: inability to feed because of condition, subsequent electrolyte imbalance Risk for Infection: Risk factor: disrupted skin integrity with exposure of abdominal contents Risk for Injury: Risk factors: disrupted skin integrity, ineffective protection

Gastrostomy Risk for impaired Skin integrity: Risk factor: presence of gastric contents on skin See Tube Feeding

Genital Herpes See Herpes Simplex II

Genital Warts See STD (Sexually Transmitted Disease)

GERD See Gastroesophageal Reflux (GERD)

Gestational Diabetes (Diabetes in Pregnancy)

Anxiety r/t threat to self and/or fetus Impaired Nutrition: less than body requirements r/t decreased insulin production and glucose uptake in cells Risk for Overweight: fetal: r/t excessive glucose uptake Impaired Nutrition: more than body requirements: fetal r/t excessive glucose uptake Risk for delayed Development: fetal: Risk factor: endocrine disorder of mother Risk for unstable blood Glucose: Risk factor: excessive intake of carbohydrates Risk for disproportionate Growth: fetal: Risk factor: endocrine disorder of mother Risk for disturbed Maternal–Fetal dyad: Risk factor: impaired glucose metabolism

Risk for impaired Tissue integrity: fetal: Risk factors: large infant, congenital defects, birth injury Risk for impaired Tissue integrity: maternal: Risk factor: deliv- ery of large infant Readiness for enhanced Knowledge: expresses an interest in learning See Diabetes Mellitus

GI Bleed (Gastrointestinal Bleeding) Fatigue r/t loss of circulating blood volume, decreased ability to transport oxygen Fear r/t threat to well-being, potential death Deficient Fluid volume r/t gastrointestinal bleeding, hemorrhage Imbalanced Nutrition: less than body requirements r/t nausea, vomiting Acute Pain r/t irritated mucosa from acid secretion Risk for ineffective Coping: Risk factors: personal vulnerability in crisis, bleeding, hospitalization Readiness for enhanced Knowledge: expresses an interest in learning

Gingivitis Impaired Oral Mucous Membrane r/t ineffective oral hygiene

Glaucoma Deficient Knowledge r/t treatment and self-care for disease Vision Loss r/t untreated increased intraocular pressure (see care plan in Appendix) See Vision Impairment

Glomerulonephritis Excess Fluid volume r/t renal impairment Imbalanced Nutrition: less than body requirements r/t anorexia, restrictive diet Acute Pain r/t edema of kidney Readiness for enhanced Knowledge: expresses an interest in learning

Gluten Allergy See Celiac Disease

Gonorrhea Acute Pain r/t inflammation of reproductive organs Risk for Infection: Risk factor: spread of organism throughout reproductive organs Readiness for enhanced Knowledge: expresses an interest in learning See STD (Sexually Transmitted Disease)

Gout Impaired physical Mobility r/t musculoskeletal impairment Chronic Pain r/t inflammation of affected joint Readiness for enhanced Knowledge: expresses an interest in learning

58 Grandiosity

Grandiosity Defensive Coping r/t inaccurate perception of self and abilities

Grand Mal Seizure See Seizure Disorders, Adult; Seizure Disorders, Childhood (Epi- lepsy, Febrile Seizures, Infantile Spasms)

Grandparents Raising Grandchildren Anxiety r/t change in role status Decisional Conflict r/t support system deficit Parental Role conflict r/t change in parental role Compromised family Coping r/t family role changes Interrupted Family processes r/t family roles shift Ineffective Role performance r/t role transition, aging Ineffective family Health management r/t excessive demands on individual or family Risk for impaired Parenting: Risk factor: role strain Risk for Powerlessness: Risk factors: role strain, situational crisis, aging Risk for Spiritual distress: Risk factor: life change Readiness for enhanced Parenting: physical and emotional needs of children are met

Graves’ Disease See Hyperthyroidism

Grieving Grieving r/t anticipated or actual significant loss, change in life status, style, or function

Grieving, Complicated Complicated Grieving r/t expected or sudden death of a signifi- cant other with whom there was a volatile relationship, emotional instability, lack of social support Risk for complicated Grieving: Risk factors: death of a signifi- cant other with whom there was a volatile relationship, emotional instability, lack of social support

Groom Self (Inability to) Bathing Self-Care deficit (See Self-Care deficit, bathing, Section III) Dressing Self-Care deficit (See Self-Care deficit, dressing, Section III)

Growth and Development Lag Risk for disproportionate Growth (See Growth, disproportion- ate, risk for, Section III)

Guillain-Barré Syndrome Impaired Spontaneous Ventilation r/t weak respiratory muscles Risk for Aspiration r/t ineffective cough; depressed gag reflex See Neurologic Disorders

Guilt Grieving r/t potential loss of significant person, animal, prized material possession, change in life role Impaired individual Resilience (See Resilience, individual, impaired, Section III) Situational low Self-Esteem r/t unmet expectations of self Risk for complicated Grieving: Risk factors: actual loss of sig- nificant person, animal, prized material possession, change in life role Risk for Post-Trauma syndrome: Risk factor: exaggerated sense of responsibility for traumatic event Readiness for enhanced Spiritual well-being: desire to be in harmony with self, others, higher power or God

H H

H1N1 See Influenza

Hair Loss Disturbed Body Image r/t psychological reaction to loss of hair Imbalanced Nutrition: less than body requirements r/t inability to ingest food because of biological, psychological, economic factors

Halitosis Impaired Dentition r/t ineffective oral hygiene Impaired Oral Mucous Membrane r/t ineffective oral hygiene

Hallucinations Anxiety r/t threat to self-concept Acute Confusion r/t alcohol abuse, delirium, dementia, mental illness, drug abuse Ineffective Coping r/t distortion and insecurity of life events Risk for Self-Mutilation: Risk factor: command hallucinations Risk for other-directed Violence: Risk factors: catatonic excite- ment, manic excitement, rage or panic reactions, response to violent internal stimuli Risk for self-directed Violence: Risk factors: catatonic excite- ment, manic excitement, rage or panic reactions, response to violent internal stimuli

Head Injury Ineffective Breathing pattern r/t pressure damage to breathing center in brainstem Acute Confusion r/t increased intracranial pressure Decreased Intracranial adaptive capacity r/t increased intra- cranial pressure Risk for ineffective Cerebral tissue perfusion: Risk factors: effects of increased intracranial pressure, trauma to brain Vision Loss r/t pressure damage to sensory centers in brain (see care plan in Appendix) See Neurologic Disorders

e10

H1N1 Hair Loss Halitosis Hallucinations Head Injury Headache Health Behavior, Risk-Prone Health Maintenance Problems Health-Seeking Person Hearing Impairment Heart Attack Heartburn Heart Failure Heart Surgery Heat Stroke Hematemesis Hematuria Hemianopia Hemiplegia Hemodialysis Hemodynamic Monitoring Hemolytic Uremic Syndrome Hemophilia Hemoptysis Hemorrhage Hemorrhoidectomy Hemorrhoids Hemothorax Hepatitis Hernia Herniated Disk Herniorrhaphy Herpes in Pregnancy Herpes Simplex I Herpes Simplex II Herpes Zoster HHNS (Hyperosmolar Hyperglycemic Nonketotic Syndrome)

Hiatal Hernia Hip Fracture

Hip Replacement Hirschsprung’s Disease Hirsutism Hitting Behavior HIV (Human Immunodeficiency

Virus) Hodgkin’s Disease

Homelessness Home Maintenance Problems Hope Hopelessness Hospitalized Child Hostile Behavior HTN (Hypertension) Human Immunodeficiency Virus

(HIV) Humiliating Experience

Huntington’s Disease Hydrocele Hydrocephalus Hygiene, Inability to Provide Own Hyperactive Syndrome Hyperbilirubinemia (Infant) Hypercalcemia Hypercapnia Hyperemesis Gravidarum Hyperglycemia Hyperkalemia Hypernatremia Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

Hyperphosphatemia Hypersensitivity to Slight Criticism

List of Nursing Assessments by Letter: H

List of Nursing Assessments by Letter: H e11

Hypertension (HTN) Hyperthermia Hyperthyroidism Hyperventilation Hypocalcemia Hypoglycemia Hypokalemia Hypomagnesemia Hypomania Hyponatremia Hypoplastic Left Lung Hypotension Hypothermia Hypothyroidism Hypovolemic Shock Hypoxia Hysterectomy

Hemodialysis 59

H

Headache Acute Pain r/t lack of knowledge of pain control techniques or methods to prevent headaches Ineffective Health management r/t lack of knowledge, identifi- cation, elimination of aggravating factors

Health Behavior, Risk-Prone Risk-prone Health behavior: Risk factors (See Health behavior, risk-prone, Section III)

Health Maintenance Problems Ineffective Health maintenance (See Health maintenance, ineffective, Section III) Ineffective Health management (See Health management, ineffective, Section III)

Health-Seeking Person Readiness for enhanced Health management (See Health man- agement, readiness for enhanced, Section III)

Hearing Impairment Impaired verbal Communication r/t inability to hear own voice Hearing Loss (See Hearing Loss, Section III) Social isolation r/t difficulty with communication

Heart Attack See MI (Myocardial Infarction)

Heartburn Nausea r/t gastrointestinal irritation Acute Pain: heartburn r/t inflammation of stomach and esophagus Risk for imbalanced Nutrition: less than body requirements: Risk factor: pain after eating Readiness for enhanced Knowledge: expresses an interest in learning See Gastroesophageal Reflux (GERD)

Heart Failure Activity intolerance r/t weakness, fatigue Decreased Cardiac output r/t impaired cardiac function, increased preload, decreased contractility, increased afterload Constipation r/t activity intolerance Fatigue r/t disease process with decreased cardiac output Fear r/t threat to one’s own well-being Excess Fluid volume r/t impaired excretion of sodium and water Impaired Gas exchange r/t excessive fluid in interstitial space of lungs Powerlessness r/t illness-related regimen Risk for Shock (cardiogenic): Risk factors: decreased contractil- ity of heart, increased afterload Readiness for enhanced Health management (See Health man- agement, readiness for enhanced, Section III) See Child with Chronic Condition; Congenital Heart Disease/ Cardiac Anomalies; Hospitalized Child

Heart Surgery See Coronary Artery Bypass Grafting (CABG)

Heat Stroke Deficient Fluid volume r/t profuse diaphoresis from high envi- ronmental temperature Hyperthermia r/t vigorous activity, high environmental tem- perature, inappropriate clothing

Hematemesis See GI Bleed (Gastrointestinal Bleeding)

Hematuria See Kidney Stone; UTI (Urinary Tract Infection)

Hemianopia Anxiety r/t change in vision Unilateral Neglect r/t effects of disturbed perceptual abilities Visual Loss r/t impaired sensory reception, transmission, integration Risk for Injury: Risk factor: disturbed sensory perception

Hemiplegia Anxiety r/t change in health status Disturbed Body Image r/t functional loss of one side of body Impaired physical Mobility r/t loss of neurological control of involved extremities Self-Care deficit: specify: r/t neuromuscular impairment Impaired Sitting r/t partial paralysis Impaired Standing r/t partial paralysis Impaired Transfer ability r/t partial paralysis Unilateral Neglect r/t effects of disturbed perceptual abilities Impaired Walking r/t loss of neurological control of involved extremities Risk for Falls: Risk factor: impaired mobility Risk for impaired Skin integrity: Risk factors: alteration in sensa- tion, immobility; pressure over bony prominence See CVA (Cerebrovascular Accident)

Hemodialysis Ineffective Coping r/t situational crisis Interrupted Family processes r/t changes in role responsibilities as a result of therapy regimen Excess Fluid volume r/t renal disease with minimal urine output Powerlessness r/t treatment regimen Risk for Caregiver Role Strain: Risk factor: complexity of care receiver treatment Risk for Electrolyte imbalance: Risk factor: effect of metabolic state on kidney function Risk for deficient Fluid volume: Risk factor: excessive removal of fluid during dialysis

60 Hemodynamic Monitoring

H

Risk for Infection: Risk factors: exposure to blood products, risk for developing hepatitis B or C, impaired immune system Risk for Injury: Risk factors: clotting of blood access, abnormal surface for blood flow Risk for impaired Tissue integrity: Risk factor: mechanical factor associated with fistula formation Readiness for enhanced Knowledge: expresses an interest in learning See Renal Failure; Renal Failure, Child with Chronic Condition

Hemodynamic Monitoring Risk for Infection: Risk factor: invasive procedure Risk for Injury: Risk factors: inadvertent wedging of catheter, dislodgment of catheter, disconnection of catheter Risk for impaired Tissue integrity: Risk factor: invasive procedure See Shock; Cardiogenic, Hypovolemic, Septic, Systemic Inflamma- tory Response Syndrome (SIRS)

Hemolytic Uremic Syndrome Fatigue r/t decreased red blood cells Fear r/t serious condition with unknown outcome Deficient Fluid volume r/t vomiting, diarrhea Nausea r/t effects of uremia Risk for Injury: Risk factors: decreased platelet count, seizure activity Risk for impaired Skin integrity: Risk factor: diarrhea See Hospitalized Child; Renal Failure, Acute/Chronic, Child

Hemophilia Fear r/t high risk for AIDS infection from contaminated blood products Impaired physical Mobility r/t pain from acute bleeds, imposed activity restrictions, joint pain Acute Pain r/t bleeding into body tissues Risk for Bleeding: Risk factors: deficient clotting factors, child’s developmental level, age-appropriate play, inappropriate use of toys or sports equipment Readiness for enhanced Knowledge: expresses an interest in learning See Child with Chronic Condition; Hospitalized Child; Matura- tional Issues, Adolescent

Hemoptysis Fear r/t serious threat to well-being Risk for ineffective Airway clearance: Risk factor: obstruction of airway with blood and mucus Risk for deficient Fluid volume: Risk factor: excessive loss of blood

Hemorrhage Fear r/t threat to well-being Deficient Fluid volume r/t massive blood loss See Hypovolemic Shock

Hemorrhoidectomy Anxiety r/t embarrassment, need for privacy Constipation r/t fear of pain with defecation Acute Pain r/t surgical procedure Urinary Retention r/t pain, anesthetic effect Risk for Bleeding: Risk factors: inadequate clotting, trauma from surgery Readiness for enhanced Knowledge: expresses an interest in learning

Hemorrhoids Impaired Comfort r/t itching in rectal area Constipation r/t painful defecation, poor bowel habits Impaired Sitting r/t pain and pressure Readiness for enhanced Knowledge: expresses an interest in learning

Hemothorax Deficient Fluid volume r/t blood in pleural space See Pneumothorax

Hepatitis Activity intolerance r/t weakness or fatigue caused by infection Deficient Diversional activity r/t isolation Fatigue r/t infectious process, altered body chemistry Imbalanced Nutrition: less than body requirements r/t anorexia, impaired use of proteins and carbohydrates Acute Pain r/t edema of liver, bile irritating skin Social isolation r/t treatment-imposed isolation Risk for deficient Fluid volume: Risk factor: excessive loss of fluids from vomiting and diarrhea Readiness for enhanced Knowledge: expresses an interest in learning

Hernia See Hiatal Hernia; Inguinal Hernia Repair

Herniated Disk See Low Back Pain

Herniorrhaphy See Inguinal Hernia Repair

Herpes in Pregnancy Fear r/t threat to fetus, impending surgery Situational low Self-Esteem r/t threat to fetus as a result of disease process Risk for Infection (infant): Risk factors: transplacental transfer during primary herpes, exposure to active herpes during birth process See Herpes Simplex II

Herpes Simplex I Impaired Oral Mucous Membrane r/t inflammatory changes in mouth

Hospitalized Child 61

H

Herpes Simplex II Ineffective Health maintenance r/t deficient knowledge regard- ing treatment, prevention, spread of disease Acute Pain r/t active herpes lesion Situational low Self-Esteem r/t expressions of shame or guilt Sexual dysfunction r/t disease process Impaired Tissue integrity r/t active herpes lesion Impaired Urinary elimination r/t pain with urination

Herpes Zoster See Shingles

HHNS (Hyperosmolar Hyperglycemic Nonketotic Syndrome)

See Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

Hiatal Hernia Ineffective Health maintenance r/t deficient knowledge regard- ing care of disease Nausea r/t effects of gastric contents in esophagus Imbalanced Nutrition: less than body requirements r/t pain after eating Acute Pain r/t gastroesophageal reflux

Hip Fracture Acute Confusion r/t sensory overload, sensory deprivation, medication side effects, advanced age, pain Constipation r/t immobility, opioids, anesthesia Fear r/t outcome of treatment, future mobility, present helplessness Impaired physical Mobility r/t surgical incision, temporary absence of weight bearing, pain when walking Acute Pain r/t injury, surgical procedure, movement Powerlessness r/t health care environment Self-Care deficit: specify r/t musculoskeletal impairment Impaired Transfer ability r/t immobilization of hip Impaired Walking r/t temporary absence of weight bearing Risk for Bleeding: Risk factors: postoperative complication, surgical blood loss Risk for Infection: Risk factor: invasive procedure Risk for Injury: Risk factors: activities such as greater than 90-degree flexion of hips that can result in dislodged prosthesis, unsteadiness when ambulating Risk for Perioperative Positioning injury: Risk factors: immo- bilization, muscle weakness, emaciation Risk for Peripheral Neurovascular dysfunction: Risk factors: trauma, vascular obstruction, fracture Risk for impaired Skin integrity: Risk factor: immobility

Hip Replacement See Total Joint Replacement (Total Hip/Total Knee/Shoulder)

Hirschsprung’s Disease Constipation: bowel obstruction r/t inhibited peristalsis as a result of congenital absence of parasympathetic ganglion cells in distal colon Grieving r/t loss of perfect child, birth of child with congenital defect even though child expected to be normal within 2 years Imbalanced Nutrition: less than body requirements r/t anorexia, pain from distended colon Acute Pain r/t distended colon, incisional postoperative pain Impaired Skin integrity r/t stoma, potential skin care problems associated with stoma Readiness for enhanced Knowledge: expresses an interest in learning See Hospitalized Child

Hirsutism Disturbed Body Image r/t excessive hair

Hitting Behavior Acute Confusion r/t dementia, alcohol abuse, drug abuse, delirium Risk for other-directed Violence (See Violence, other-directed, risk for, Section III)

HIV (Human Immunodeficiency Virus) Fear r/t possible death Ineffective Protection r/t depressed immune system See AIDS (Acquired Immunodeficiency Syndrome)

Hodgkin’s Disease See Anemia; Cancer; Chemotherapy

Homelessness Impaired Home maintenance r/t impaired cognitive or emo- tional functioning, inadequate support system, insufficient finances

Home Maintenance Problems Impaired Home maintenance (See Home maintenance, impaired, Section III) Self-Neglect r/t mental illness, substance abuse, cognitive impairment Powerlessness r/t interpersonal interactions Risk for Trauma: Risk factor: being in high-crime neighborhood

Hope Readiness for enhanced Hope (See Hope, readiness for enhanced, Section III)

Hopelessness Hopelessness (See Hopelessness, Section III)

Hospitalized Child Activity intolerance r/t fatigue associated with acute illness Anxiety: separation (child) r/t familiar surroundings and sepa- ration from family and friends

62 Hostile Behavior

H

Compromised family Coping r/t possible prolonged hospitaliza- tion that exhausts supportive capacity of significant people Ineffective Coping: parent r/t possible guilt regarding hospital- ization of child, parental inadequacies Deficient Diversional activity r/t immobility, monotonous environment, frequent or lengthy treatments, reluctance to par- ticipate, therapeutic isolation, separation from peers Interrupted Family processes r/t situational crisis of illness, disease, hospitalization Fear r/t deficient knowledge or maturational level with fear of unknown, mutilation, painful procedures, surgery Hopelessness: child r/t prolonged activity restriction, uncer- tain prognosis Insomnia: child or parent r/t 24-hour care needs of hospitalization Acute Pain r/t treatments, diagnostic or therapeutic procedures, disease process Powerlessness: child r/t health care environment, illness- related regimen Risk for impaired Attachment: Risk factor: separation Risk for delayed Development: regression: Risk factors: dis- ruption of normal routine, unfamiliar environment or caregivers, developmental vulnerability of young children Risk for Injury: Risk factors: unfamiliar environment, develop- mental age, lack of parental knowledge regarding safety (e.g., side rails, IV site/pole) Risk for imbalanced Nutrition: less than body requirements: Risk factors: anorexia, absence of familiar foods, cultural preferences Readiness for enhanced family Coping: impact of crisis on family values, priorities, goals, relationships in family See Child with Chronic Condition

Hostile Behavior Risk for other-directed Violence: Risk factor: antisocial per- sonality disorder

HTN (Hypertension) Ineffective Health management (See Health management, inef- fective, Section III) Readiness for enhanced Health management (See Health man- agement, readiness for enhanced, Section III) Risk for Overweight: Risk factor: lack of knowledge of relation- ship between diet and disease process

Human Immunodeficiency Virus (HIV) See AIDS (Acquired Immunodeficiency Syndrome); HIV (Human Immunodeficiency Virus)

Humiliating Experience Risk for compromised Human Dignity (See Human Dignity, compromised, risk for, Section III)

Huntington’s Disease Decisional Conflict r/t whether to have children See Neurologic Disorders

Hydrocele Acute Pain r/t severely enlarged hydrocele Ineffective Sexuality pattern r/t recent surgery on area of scrotum

Hydrocephalus Decisional Conflict r/t unclear or conflicting values regarding selection of treatment modality Interrupted Family processes r/t situational crisis Imbalanced Nutrition: less than body requirements r/t inade- quate intake as a result of anorexia, nausea, vomiting, feeding difficulties Risk for delayed Development: Risk factor: sequelae of increased intracranial pressure Risk for disproportionate Growth: Risk factor: sequelae of increased intracranial pressure Risk for Infection: Risk factor: sequelae of invasive procedure (shunt placement) Risk for ineffective Cerebral tissue perfusion: Risk factors: interrupted flow, hypervolemia of cerebral ventricles Risk for Falls: Risk factors: acute illness, alteration in cognitive functioning See Normal Pressure Hydrocephalus (NPH); Child with Chronic Condition; Hospitalized Child; Mental Retardation (if appropri- ate); Premature Infant (Child); Premature Infant (Parent)

Hygiene, Inability to Provide Own Frail Elderly syndrome r/t living alone Self-Neglect (See Self-Neglect, Section III) Bathing Self-Care deficit (See Self-Care deficit, bathing, Section III)

Hyperactive Syndrome Decisional Conflict r/t multiple or divergent sources of information regarding education, nutrition, medication regimens; willingness to change own food habits; limited resources Parental Role conflict: when siblings present r/t increased atten- tion toward hyperactive child Compromised family Coping r/t unsuccessful strategies to control excessive activity, behaviors, frustration, anger Ineffective Impulse control r/t disorder of development, envi- ronment that might cause frustration or irritation Ineffective Role performance: parent r/t stressors associated with dealing with hyperactive child, perceived or projected blame for causes of child’s behavior, unmet needs for support or care, lack of energy to provide for those needs Chronic low Self-Esteem r/t inability to achieve socially acceptable behaviors; frustration; frequent reprimands, punish- ment, or scolding for uncontrolled activity and behaviors; mood fluctuations and restlessness; inability to succeed academically; lack of peer support Impaired Social interaction r/t impulsive and overactive behaviors, concomitant emotional difficulties, distractibility and excitability

Hyperthyroidism 63

H

Risk for delayed Development: Risk factor: behavior disorders Risk for impaired Parenting: Risk factor: disruptive or uncon- trollable behaviors of child Risk for other-directed Violence: parent or child: Risk factors: frustration with disruptive behavior, anger, unsuccessful relationships

Hyperbilirubinemia (Infant) Anxiety: parent r/t threat to infant, unknown future Parental Role conflict r/t interruption of family life because of care regimen Neonatal Jaundice r/t abnormal breakdown of red blood cells following birth Imbalanced Nutrition: less than body requirements (infant) r/t disinterest in feeding because of jaundice-related lethargy Risk for disproportionate Growth: infant: Risk factor: disinter- est in feeding because of jaundice-related lethargy Risk for imbalanced body Temperature: infant: Risk factor: phototherapy Risk for Injury: infant: Risk factors: kernicterus, phototherapy lights

Hypercalcemia Decreased Cardiac output r/t bradydysrhythmia Impaired physical Mobility r/t decreased muscle tone Imbalanced Nutrition: less than body requirements r/t gastro- intestinal manifestations of hypercalcemia (nausea, anorexia, ileus) Risk for Disuse syndrome: Risk factor: comatose state impairing mobility

Hypercapnia Fear r/t difficulty breathing Impaired Gas exchange r/t ventilation-perfusion imbalance, retention of carbon dioxide See ARDS, COPD, Sleep Apnea,

Hyperemesis Gravidarum Anxiety r/t threat to self and infant, hospitalization Deficient Fluid volume r/t excessive vomiting Impaired Home maintenance r/t chronic nausea, inability to function Nausea r/t hormonal changes of pregnancy Imbalanced Nutrition: less than body requirements r/t exces- sive vomiting Powerlessness r/t health care regimen Social isolation r/t hospitalization Risk for Electrolyte imbalance: Risk factor: vomiting

Hyperglycemia Ineffective Health management r/t complexity of therapeutic regimen, decisional conflicts, economic difficulties, unsupport- ive family, insufficient cues to action, deficient knowledge, mis- trust, lack of acknowledgment of seriousness of condition

Risk for unstable blood Glucose level (See Glucose level, blood, unstable, risk for, Section III) See Diabetes Mellitus

Hyperkalemia Risk for Activity intolerance: Risk factor: muscle weakness Risk for decreased Cardiac tissue perfusion: Risk factor: abnor- mal electrolyte level affecting heart rate and rhythm Risk for excess Fluid volume: Risk factor: untreated renal failure

Hypernatremia Risk for deficient Fluid volume: Risk factors: abnormal water loss, inadequate water intake

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNS)

Acute Confusion r/t dehydration, electrolyte imbalance Deficient Fluid volume r/t polyuria, hyperglycemia, inadequate fluid intake Risk for Electrolyte imbalance: Risk factor: effect of metabolic state on kidney function Risk for Injury: seizures: Risk factors: hyperosmolar state, elec- trolyte imbalance See Diabetes Mellitus; Diabetes Mellitus, Juvenile (IDDM Type 1)

Hyperphosphatemia Deficient Knowledge r/t dietary changes needed to control phosphate levels See Renal Failure

Hypersensitivity to Slight Criticism Defensive Coping r/t situational crisis, psychological impair- ment, substance abuse

Hypertension (HTN) See HTN (Hypertension) Risk for decreased Cardiac output: Risk factors: decreased contractility and altered conductivity associated with myocardial damage Risk for impaired Cardiovascular function: Risk factors: obesity, inadequate physical activity and failure to alter diet

Hyperthermia Hyperthermia (See Hyperthermia, Section III)

Hyperthyroidism Anxiety r/t increased stimulation, loss of control Diarrhea r/t increased gastric motility Insomnia r/t anxiety, excessive sympathetic discharge Imbalanced Nutrition: less than body requirements r/t increased metabolic rate, increased gastrointestinal activity Risk for Injury: eye damage: Risk factor: protruding eyes without sufficient lubrication Readiness for enhanced Knowledge: expresses an interest in learning

64 Hyperventilation

Hyperventilation Ineffective Breathing pattern r/t anxiety, acid-base imbalance See Anxiety Disorder, Dyspnea, Heart Failure

Hypocalcemia Activity intolerance r/t neuromuscular irritability Ineffective Breathing pattern r/t laryngospasm Imbalanced Nutrition: less than body requirements r/t effects of vitamin D deficiency, renal failure, malabsorption, laxative use

Hypoglycemia Acute Confusion r/t insufficient blood glucose to brain Ineffective Health management r/t deficient knowledge regard- ing disease process, self-care Imbalanced Nutrition: less than body requirements r/t imbal- ance of glucose and insulin level Risk for unstable blood Glucose level (See Glucose level, blood, unstable, risk for, Section III) See Diabetes Mellitus; Diabetes Mellitus, Juvenile (IDDM Type 1)

Hypokalemia Activity intolerance r/t muscle weakness Risk for decreased Cardiac tissue perfusion: Risk factor: pos- sible dysrhythmia from electrolyte imbalance

Hypomagnesemia Imbalanced Nutrition: less than body requirements r/t defi- cient knowledge of nutrition, alcoholism See Alcoholism

Hypomania Insomnia r/t psychological stimulus See Manic Disorder, Bipolar I

Hyponatremia Acute Confusion r/t electrolyte imbalance Excess Fluid volume r/t excessive intake of hypotonic fluids Risk for Injury: Risk factors: seizures, new onset of confusion

Hypoplastic Left Lung See Congenital Heart Disease/Cardiac Anomalies

Hypotension Decreased Cardiac output r/t decreased preload, decreased contractility Risk for deficient Fluid volume: Risk factor: excessive fluid loss Risk for ineffective Cerebral tissue perfusion: Risk factors: hypovolemia, decreased contractility, decreased afterload Risk for ineffective Gastrointestinal perfusion (See Gastroin- testinal perfusion, ineffective, risk for, Section III) Risk for ineffective Renal perfusion: Risk factor: prolonged isch- emia of kidneys Risk for Shock (See Shock, risk for, Section III) See Dehydration, Heart Failure, MI

Hypothermia Hypothermia (See Hypothermia, Section III) Risk for Hypothermia (see Hypothermia, risk for, Section III)

Hypothyroidism Activity intolerance r/t muscular stiffness, shortness of breath on exertion Constipation r/t decreased gastric motility Impaired Gas exchange r/t respiratory depression Impaired Skin integrity r/t edema, dry or scaly skin Risk for Overweight: Risk factor: decreased metabolic process

Hypovolemic Shock See Shock, Hypovolemic

Hypoxia Acute Confusion r/t decreased oxygen supply to brain Fear r/t breathlessness Impaired Gas exchange r/t altered oxygen supply, inability to transport oxygen Risk for Shock (See Shock, risk for, Section III)

Hysterectomy Constipation r/t opioids, anesthesia, bowel manipulation during surgery Ineffective Coping r/t situational crisis of surgery Grieving r/t change in body image, loss of reproductive status Acute Pain r/t surgical injury Sexual dysfunction r/t disturbance in self-concept Urinary retention r/t edema in area, anesthesia, opioids, pain Risk for Bleeding: Risk factor: surgical procedure Risk for Constipation: Risk factors: opioids, anesthesia, bowel manipulation during surgery Risk for ineffective peripheral Tissue perfusion: Risk factor: deficient knowledge of aggravating factors Readiness for enhanced Knowledge: Expresses an interest in learning See Surgery, Perioperative; Surgery, Preoperative; Surgery, Postoperative

I

I IBS (Irritable Bowel Syndrome)

Constipation r/t low-residue diet, stress Diarrhea r/t increased motility of intestines associated with disease process, stress Ineffective Health management r/t deficient knowledge, powerlessness Chronic Pain r/t spasms, increased motility of bowel Risk for Electrolyte imbalance: Risk factor: diarrhea Readiness for enhanced Health management: expresses desire to manage illness and prevent onset of symptoms

e12

IBS (Irritable Bowel Syndrome) ICD (Implantable Cardioverter/ Defibrillator)

IDDM (Insulin-Dependent Diabetes)

Identity Disturbance/Problems Idiopathic Thrombocytopenic Purpura (ITP)

Ileal Conduit

Ileostomy Ileus Immobility Immunization Immunosuppression Impaction of Stool Imperforate Anus Impaired Sitting Impaired Standing Impetigo Implantable Cardioverter/Defibrillator

(ICD) Impotence

Impulsiveness Inactivity Incompetent Cervix Incontinence of Stool Incontinence of Urine Indigestion Induction of Labor Infant Apnea Infant Behavior Infant Care Infant Feeding Pattern, Ineffective Infant of Diabetic Mother Infant of Substance-Abusing Mother (Fetal Alcohol Syndrome, Crack Baby, Other Drug Withdrawal Infants)

Infantile Polyarteritis Infection

Infection, Potential for Infertility Inflammatory Bowel Disease (Child and Adult)

Influenza Inguinal Hernia Repair Injury Insanity Insomnia Insulin Shock Intellectual Disability Intermittent Claudication Internal Cardioverter/Defibrillator

(ICD) Internal Fixation Interstitial Cystitis Intervertebral Disk Excision Intestinal Obstruction Intestinal Perforation Intoxication Intraaortic Balloon Counterpulsation Intracranial Pressure, Increased Intrauterine Growth Retardation Intravenous Therapy Intubation, Endotracheal or

Nasogastric Iodine Reaction with Diagnostic Testing

Irregular Pulse Irritable Bowel Syndrome (IBS) Isolation Itching ITP (Idiopathic Thrombocytopenic

Purpura)

List of Nursing Assessments by Letter: I

Impaired Standing 65

I

ICD (Implantable Cardioverter/ Defibrillator)

Anxiety r/t possible dysrhythmia, threat of death Decreased Cardiac output r/t possible dysrhythmia Readiness for enhanced Knowledge: expresses an interest in learning

IDDM (Insulin-Dependent Diabetes) See Diabetes Mellitus

Identity Disturbance/Problems Disturbed personal Identity r/t situational crisis, psychological impairment, chronic illness, pain Risk for disturbed personal Identity (See Identity, personal, risk for disturbed in Section III)

Idiopathic Thrombocytopenic Purpura (ITP)

See ITP (Idiopathic Thrombocytopenic Purpura)

Ileal Conduit Disturbed Body Image r/t presence of stoma Ineffective Health management r/t new skills required to care for appliance and self Ineffective Sexuality pattern r/t altered body function and structure Social isolation r/t alteration in physical appearance, fear of accidental spill of urine Risk for Latex Allergy response: Risk factor: repeated expo- sures to latex associated with treatment and management of disease Risk for impaired Skin integrity: Risk factor: difficulty obtaining tight seal of appliance Readiness for enhanced Knowledge: expresses an interest in learning

Ileostomy Disturbed Body Image r/t presence of stoma Diarrhea r/t dietary changes, alteration in intestinal motility Deficient Knowledge r/t limited practice of stoma care, dietary modifications Ineffective Sexuality pattern r/t altered body function and structure Social isolation r/t alteration in physical appearance, fear of accidental spill of ostomy contents Risk for impaired Skin integrity: Risk factors: difficulty obtaining tight seal of appliance, caustic drainage Readiness for enhanced Knowledge: expresses an interest in learning

Ileus Deficient Fluid volume r/t loss of fluids from vomiting, fluids trapped in bowel Dysfunctional Gastrointestinal motility r/t effects of surgery, decreased perfusion of intestines, medication effect, immobility Nausea r/t gastrointestinal irritation

Acute Pain r/t pressure, abdominal distention Readiness for enhanced Knowledge: expresses an interest in learning

Immobility Ineffective Breathing pattern r/t inability to deep breathe in supine position Acute Confusion: elderly r/t sensory deprivation from immobility Constipation r/t immobility Risk for Frail Elderly syndrome: Risk factors: low physical activity, bed rest Impaired physical Mobility r/t medically imposed bed rest Ineffective peripheral Tissue Perfusion r/t interruption of venous flow Powerlessness r/t forced immobility from health care environment Impaired Walking r/t limited physical mobility, deconditioning of body Risk for Disuse syndrome: Risk factor: immobilization Risk for impaired Skin integrity: Risk factors: pressure over bony prominences, shearing forces when moved; pressure from devices Risk for Impaired Tissue Integrity: Risk factors: mechanical factors from pressure over bony prominences, shearing forces when moved; pressure from devices Risk for Overweight: Risk factor: energy expenditure less than energy intake Readiness for enhanced Knowledge: expresses an interest in learning

Immunization See Readiness for enhanced Health management, Section III

Immunosuppression Risk for Infection: Risk factors: immunosuppression; exposure to disease outbreak Impaired Social interaction r/t therapeutic isolation

Impaction of Stool Constipation r/t decreased fluid intake, less than adequate amounts of fiber and bulk-forming foods in diet, medication effect, or immobility

Imperforate Anus Anxiety r/t ability to care for newborn Deficient Knowledge r/t home care for newborn Impaired Skin integrity r/t pruritus

Impaired Sitting Impaired physical Mobility r/t musculoskeletal, cognitive, or neuromuscular disorder

Impaired Standing Activity intolerance r/t insufficient physiological or psychologi- cal energy Powerlessness r/t loss of function

66 Impetigo

I

Impetigo Impaired Skin integrity r/t infectious disease Readiness for enhanced Knowledge: expresses an interest in learning See Communicable Diseases, Childhood

Implantable Cardioverter/Defibrillator (ICD)

See ICD (Implantable Cardioverter/Defibrillator)

Impotence Situational low Self-Esteem r/t physiological crisis, inability to practice usual sexual activity Sexual dysfunction r/t altered body function Readiness for enhanced Knowledge: treatment information for erectile dysfunction See Erectile Dysfunction (ED)

Impulsiveness Ineffective Impulse control r/t (See Impulse control, ineffective in Section III)

Inactivity Activity intolerance r/t imbalance between oxygen supply and demand, sedentary lifestyle, weakness, immobility Hopelessness r/t deteriorating physiological condition, long- term stress, social isolation Impaired physical Mobility r/t intolerance to activity, decreased strength and endurance, depression, severe anxiety, musculo- skeletal impairment, perceptual or cognitive impairment, neuro- muscular impairment, pain, discomfort Risk for Constipation: Risk factor: insufficient physical activity

Incompetent Cervix See Premature Dilation of the Cervix (Incompetent Cervix)

Incontinence of Stool Disturbed Body Image r/t inability to control elimination of stool Bowel Incontinence r/t decreased awareness of need to defe- cate, loss of sphincter control Toileting Self-Care deficit r/t cognitive impairment, neuromus- cular impairment, perceptual impairment, weakness Situational low Self-Esteem r/t inability to control elimination of stool Risk for impaired Skin integrity: Risk factor: presence of stool

Incontinence of Urine Functional urinary Incontinence r/t altered environment; sensory, cognitive, or mobility deficits Overflow urinary Incontinence r/t relaxation of pelvic muscles and changes in urinary structures Reflex urinary Incontinence r/t neurological impairment Stress urinary Incontinence (See Incontinence, urinary, stress, Section III)

Urge urinary Incontinence (See Incontinence, urinary, urge, Section III) Toileting Self-Care deficit r/t cognitive impairment Situational low Self-Esteem r/t inability to control passage of urine Risk for impaired Skin integrity: Risk factor: presence of urine on perineal skin

Indigestion Nausea r/t gastrointestinal irritation Imbalanced Nutrition: less than body requirements r/t discom- fort when eating

Induction of Labor Anxiety r/t medical interventions, powerlessness Decisional Conflict r/t perceived threat to idealized birth Ineffective Coping r/t situational crisis of medical intervention in birthing process Acute Pain r/t contractions Situational low Self-Esteem r/t inability to carry out normal labor Risk for Injury: maternal and fetal: Risk factors: hypertonic uterus, potential prematurity of newborn Readiness for enhanced Family processes: family support during induction of labor

Infant Apnea See Premature Infant (Child); Respiratory Conditions of the Neonate; SIDS (Sudden Infant Death Syndrome)

Infant Behavior Disorganized Infant behavior r/t pain, oral/motor problems, feeding intolerance, environmental overstimulation, lack of containment or boundaries, prematurity, invasive or painful procedures Risk for disorganized Infant behavior: Risk factors: pain, oral/ motor problems, environmental overstimulation, lack of con- tainment or boundaries Readiness for enhanced organized Infant behavior: stable physi- ologic measures, use of some self-regulatory measures

Infant Care Readiness for enhanced Childbearing process: a pattern of preparing for, maintaining, and strengthening care of newborn infant

Infant Feeding Pattern, Ineffective Ineffective infant Feeding pattern r/t prematurity, neurological impairment or delay, oral hypersensitivity, prolonged nothing- by-mouth order

Infant of Diabetic Mother Decreased Cardiac output r/t cardiomegaly Deficient Fluid volume r/t increased urinary excretion and osmotic diuresis Imbalanced Nutrition: less than body requirements r/t hypo- tonia, lethargy, poor sucking, postnatal metabolic changes from hyperglycemia to hypoglycemia and hyperinsulinism

Injury 67

I

Risk for delayed Development: Risk factor: prolonged and severe postnatal hypoglycemia Risk for impaired Gas exchange: Risk factors: increased inci- dence of cardiomegaly, prematurity Risk for unstable blood Glucose level: Risk factor: metabolic change from hyperglycemia to hypoglycemia and hyperinsu- linism Risk for disproportionate Growth: Risk factor: prolonged and severe postnatal hypoglycemia Risk for disturbed Maternal–Fetal dyad: Risk factor: impaired glucose metabolism See Premature Infant (Child); Respiratory Conditions of the Neonate

Infant of Substance-Abusing Mother (Fetal Alcohol Syndrome, Crack Baby, Other Drug Withdrawal Infants)

Ineffective Airway clearance r/t pooling of secretions from the lack of adequate cough reflex, effects of viral or bacterial lower airway infection as a result of altered protective state Interrupted Breastfeeding r/t use of drugs or alcohol by mother Diarrhea r/t effects of withdrawal, increased peristalsis from hyperirritability Ineffective infant Feeding pattern r/t uncoordinated or ineffec- tive sucking reflex Disorganized Infant behavior r/t exposure and or withdrawal from toxic substances (alcohol and drugs) Ineffective Childbearing process r/t inconsistent prenatal health visits, suboptimal maternal nutrition, substance abuse Insomnia r/t hyperirritability or hypersensitivity to environ- mental stimuli Imbalanced Nutrition: less than body requirements r/t feeding problems; uncoordinated or ineffective suck and swallow; effects of diarrhea, vomiting, or colic associated with maternal sub- stance abuse Impaired Parenting r/t impaired or absent attachment behav- iors, inadequate support systems Risk for delayed Development: Risk factor: substance abuse Risk for disproportionate Growth: Risk factor: substance abuse Risk for Infection: skin, meningeal, respiratory: Risk factor: stress effects of withdrawal See Cerebral Palsy; Child with Chronic Condition; Crack Baby; Failure to Thrive, Nonorganic; Hospitalized Child; Hyperactive Syndrome; Premature Infant (Child); SIDS (Sudden Infant Death Syndrome)

Infantile Polyarteritis See Kawasaki Disease

Infection Hyperthermia r/t increased metabolic rate Ineffective Protection r/t inadequate nutrition, abnormal blood profiles, drug therapies, treatments

Impaired Social interaction r/t therapeutic isolation Risk for Vascular Trauma: Risk factor: infusion of antibiotics

Infection, Potential for Risk for Infection (See Infection, risk for, Section III)

Infertility Ineffective Health management r/t deficient knowledge about infertility Powerlessness r/t infertility Chronic Sorrow r/t inability to conceive a child Spiritual distress r/t inability to conceive a child

Inflammatory Bowel Disease (Child and Adult)

Ineffective Coping r/t repeated episodes of diarrhea Diarrhea r/t effects of inflammatory changes of the bowel Deficient Fluid volume r/t frequent and loose stools Imbalanced Nutrition: less than body requirements r/t anorexia, decreased absorption of nutrients from gastrointestinal tract Acute Pain r/t abdominal cramping and anal irritation Impaired Skin integrity r/t frequent stools, development of anal fissures Social isolation r/t diarrhea See Child with Chronic Condition; Crohn’s Disease; Hospitalized Child; Maturational Issues, Adolescent

Influenza Deficient Fluid volume r/t inadequate fluid intake Ineffective Health management r/t lack of knowledge regarding preventive immunizations Ineffective Thermoregulation r/t infectious process Acute Pain r/t inflammatory changes in joints Readiness for enhanced Knowledge: information to prevent or treat influenza

Inguinal Hernia Repair Impaired physical Mobility r/t pain at surgical site and fear of causing hernia to rupture Acute Pain r/t surgical procedure Urinary retention r/t possible edema at surgical site Risk for Infection: Risk factor: surgical procedure

Injury Risk for Falls: Risk factors: orthostatic hypotension, impaired physical mobility, diminished mental status Risk for Injury: Risk factor: environmental conditions interact- ing with client’s adaptive and defensive resources Risk for corneal Injury: Risk factors: blinking less than five times per minute, mechanical ventilation, pharmaceutical agent, prolonged hospitalization Risk for Thermal injury: Risk factors: cognitive impairment, inadequate supervision, developmental level Risk for urinary tract Injury: Risk factor: inflammation and/or infection from long-term use of urinary catheter

68 Insanity

I

Insanity See Mental Illness, Psychosis

Insomnia (See Insomnia, Section III)

Insulin Shock See Hypoglycemia

Intellectual Disability Impaired verbal Communication r/t developmental delay Interrupted Family processes r/t crisis of diagnosis and situa- tional transition Grieving r/t loss of perfect child, birth of child with congenital defect or subsequent head injury Deficient community Health r/t lack of programs to address developmental deficiencies Impaired Home maintenance r/t insufficient support systems Self-Neglect r/t learning disability Self-Care deficit: bathing, dressing, feeding, toileting r/t percep- tual or cognitive impairment Self-Mutilation r/t inability to express tension verbally Social isolation r/t delay in accomplishing developmental tasks Spiritual distress r/t chronic condition of child with special needs Stress overload r/t intense, repeated stressor (chronic condition) Impaired Swallowing r/t neuromuscular impairment Risk for ineffective Activity planning r/t inability to process information Risk for delayed Development: Risk factor: cognitive or per- ceptual impairment Risk for disproportionate Growth: Risk factor: mental retardation Risk for impaired Religiosity: Risk factor: social isolation Risk for Self-Mutilation: Risk factors: separation anxiety, depersonalization Readiness for enhanced family Coping: adaptation and accep- tance of child’s condition and needs See Child with Chronic Condition; Safety, Childhood

Intermittent Claudication Deficient Knowledge r/t lack of knowledge of cause and treat- ment of peripheral vascular diseases Acute Pain r/t decreased circulation to extremities with activity Ineffective peripheral Tissue Perfusion r/t interruption of arte- rial flow Risk for Injury: Risk factor: tissue hypoxia Readiness for enhanced Knowledge: prevention of pain and impaired circulation See Peripheral Vascular Disease (PVD)

Internal Cardioverter/Defibrillator (ICD) See ICD (Implantable Cardioverter/Defibrillator)

Internal Fixation Impaired Walking r/t repair of fracture Risk for Infection: Risk factors: traumatized tissue, broken skin See Fracture

Interstitial Cystitis Acute Pain r/t inflammatory process Impaired Urinary elimination r/t inflammation of bladder Risk for Infection: Risk factor: suppressed inflammatory response Readiness for enhanced Knowledge: expresses an interest in learning

Intervertebral Disk Excision See Laminectomy

Intestinal Obstruction See Ileus, Bowel Obstruction

Intestinal Perforation See Peritonitis

Intoxication Anxiety r/t loss of control of actions Acute Confusion r/t alcohol abuse Ineffective Coping r/t use of mind-altering substances as a means of coping Impaired Memory r/t effects of alcohol on mind Risk for Aspiration: Risk factors: diminished mental status, vomiting Risk for Falls: Risk factor: diminished mental status Risk for other-directed Violence: Risk factor: inability to control thoughts and actions

Intraaortic Balloon Counterpulsation Anxiety r/t device providing cardiovascular assistance Decreased Cardiac output r/t heart dysfunction needing counterpulsation Compromised family Coping r/t seriousness of significant other’s medical condition Impaired physical Mobility r/t restriction of movement because of mechanical device Risk for Peripheral Neurovascular dysfunction: Risk factors: vascular obstruction of balloon catheter, thrombus formation, emboli, edema Risk for Infection: Risk factor: invasive procedure Risk for impaired Tissue integrity: Risk factor: invasive procedure

Intracranial Pressure, Increased Ineffective Breathing pattern r/t pressure damage to breathing center in brainstem Acute Confusion r/t increased intracranial pressure

Decreased Intracranial adaptive capacity r/t sustained increase in intracranial pressure Impaired Memory r/t neurological disturbance Vision Loss r/t pressure damage to sensory centers in brain Risk for ineffective Cerebral tissue perfusion: Risk factors: body position, cerebral vessel circulation deficits See Head Injury, Subarachnoid Hemorrhage

Intrauterine Growth Retardation Anxiety: maternal r/t threat to fetus Ineffective Coping: maternal r/t situational crisis, threat to fetus Impaired Gas exchange r/t insufficient placental perfusion Imbalanced Nutrition: less than body requirements r/t insuf- ficient placenta Situational low Self-Esteem: maternal r/t guilt about threat to fetus Spiritual distress r/t unknown outcome of fetus Risk for Powerlessness: Risk factor: unknown outcome of fetus

Intravenous Therapy Risk for Vascular Trauma: Risk factor: infusion of irritating chemicals

Intubation, Endotracheal or Nasogastric Disturbed Body Image r/t altered appearance with mechanical devices Impaired verbal Communication r/t endotracheal tube Imbalanced Nutrition: less than body requirements r/t inability to ingest food because of the presence of tubes Impaired Oral Mucous Membrane r/t presence of tubes Acute Pain r/t presence of tube

Iodine Reaction with Diagnostic Testing Risk for adverse reaction to iodinated Contrast Media (See reaction to iodinated Contrast Media, risk for adverse, Section III)

Irregular Pulse See Dysrhythmia

Irritable Bowel Syndrome (IBS) See IBS (Irritable Bowel Syndrome)

Isolation Impaired individual Resilience (See Resilience, individual, impaired, Section III) Social isolation (See Social isolation, Section III)

Itching Impaired Comfort r/t inflammation of skin causing itching Risk for impaired Skin integrity: Risk factor: scratching, dry skin

ITP (Idiopathic Thrombocytopenic Purpura)

Deficient Diversional activity r/t activity restrictions, safety precautions

Ineffective Protection r/t decreased platelet count Risk for Bleeding: Risk factors: decreased platelet count, devel- opmental level, age-appropriate play See Hospitalized Child

Joint Dislocation 69

J

J Jaundice

Imbalanced Nutrition, less than body requirements r/t decreased appetite with liver disorder Risk for Bleeding: Risk factor: impaired liver function Risk for impaired Liver function: Risk factors: possible viral infection, medication effect Risk for impaired Skin integrity: Risk factors: pruritus, itching See Cirrhosis; Hepatitis

Jaundice, Neonatal Neonatal Jaundice (See Jaundice, neonatal, Section III) Risk for ineffective Gastrointestinal perfusion: Risk factor: liver dysfunction Readiness for enhanced Health management (parents): expresses desire to manage treatment: assessment of jaundice when infant is discharged from the hospital, when to call the physician, and possible preventive measures such as frequent breastfeeding See Hyperbilirubinemia

Jaw Pain and Heart Attacks See Angina; Chest Pain; MI (Myocardial Infarction)

Jaw Surgery Deficient Knowledge r/t emergency care for wired jaws (e.g., cutting bands and wires), oral care Imbalanced Nutrition: less than body requirements r/t jaws wired closed, difficulty eating Acute Pain r/t surgical procedure Impaired Swallowing r/t edema from surgery Risk for Aspiration: Risk factor: wired jaws

Jittery Anxiety r/t unconscious conflict about essential values and goals, threat to or change in health status Death Anxiety r/t unresolved issues relating to end of life Risk for Post-Trauma syndrome: Risk factors: occupation, sur- vivor’s role in event, inadequate social support

Jock Itch Ineffective Health management r/t prevention and treatment of disorder Impaired Skin integrity r/t moisture and irritating or tight-fitting clothing See Itching

Joint Dislocation See Dislocation of Joint

e13

Jaundice Jaundice, Neonatal Jaw Pain and Heart Attacks Jaw Surgery Jittery Jock Itch Joint Dislocation Joint Pain Joint Replacement JRA (Juvenile Rheumatoid Arthritis)

List of Nursing Assessments by Letter: J

70 Joint Pain

Joint Pain See Arthritis; Bursitis; JRA (Juvenile Rheumatoid Arthritis); Osteo- arthritis; Rheumatoid Arthritis

Joint Replacement Risk for Peripheral Neurovascular dysfunction: Risk factor: orthopedic surgery Risk for impaired Tissue integrity: Risk factor: invasive procedure See Total Joint Replacement (Total Hip/Total Knee/Shoulder)

JRA (Juvenile Rheumatoid Arthritis) Impaired Comfort r/t altered health status Fatigue r/t chronic inflammatory disease Impaired physical Mobility r/t pain, restricted joint movement Acute Pain r/t swollen or inflamed joints, restricted movement, physical therapy Self-Care deficit: feeding, bathing, dressing, toileting r/t restricted joint movement, pain Risk for compromised Human Dignity: Risk factors: perceived intrusion by clinicians, invasion of privacy Risk for Injury: Risk factors: impaired physical mobility, splints, adaptive devices, increased bleeding potential from antiinflam- matory medications Risk for compromised Resilience: Risk factor: chronic condition Risk for situational low Self-Esteem: Risk factor: disturbed body image Risk for impaired Skin integrity: Risk factors: splints, adaptive devices See Child with Chronic Condition; Hospitalized Child

K

K Kaposi’s Sarcoma

Risk for complicated Grieving: Risk factor: loss of social support Risk for impaired Religiosity: Risk factors: illness/hospitalization, ineffective coping Risk for impaired Resilience: Risk factor: serious illness See AIDS (Acquired Immunodeficiency Syndrome)

Kawasaki Disease Anxiety: parental r/t progression of disease, complications of arthritis, and cardiac involvement Impaired Comfort r/t altered health status Hyperthermia r/t inflammatory disease process Imbalanced Nutrition: less than body requirements r/t impaired oral mucous membranes Impaired Oral Mucous Membrane r/t inflamed mouth and pharynx; swollen lips that become dry, cracked, fissured Acute Pain r/t enlarged lymph nodes; erythematous skin rash that progresses to desquamation, peeling, denuding of skin Impaired Skin integrity r/t inflammatory skin changes

Risk for imbalanced Fluid volume: Risk factor: hypovolemia Risk for decreased Cardiac tissue perfusion: Risk factor: cardiac involvement See Hospitalized Child

Keloids Disturbed Body Image r/t presence of scar tissue at site of a healed skin injury Readiness for enhanced Health management: desire to have information to manage condition

Keratoconjunctivitis Sicca (Dry Eye Syndrome)

Risk for dry Eye: Risk factors: aging, staring at a computer screen for long intervals Risk for Infection: Risk factor: dry eyes that are more vulnerable to infection Risk for corneal Injury: Risk factors: dry eye; exposure of the eyeball Vision Loss r/t dry eye resulting in film or obstruction of vision (see care plan in Appendix) See Conjunctivitis

Keratoplasty See Corneal Transplant

Ketoacidosis, Alcoholic See Alcohol Withdrawal; Alcoholism

Ketoacidosis, Diabetic Deficient Fluid volume r/t excess excretion of urine, nausea, vomiting, increased respiration Impaired Memory r/t fluid and electrolyte imbalance Imbalanced Nutrition: less than body requirements r/t body’s inability to use nutrients Risk for unstable blood Glucose level: Risk factor: deficient knowledge of diabetes management (e.g., action plan) Risk for Powerlessness: Risk factor: illness-related regimen Risk for impaired Resilience: Risk factor: complications of disease See Diabetes Mellitus

Keyhole Heart Surgery See MIDCAB (Minimally Invasive Direct Coronary Artery Bypass)

Kidney Disease Screening Risk for ineffective Renal perfusion: Risk factors: hypovolemia, hypertension, alteration in metabolism Readiness for enhanced Health management: seeks informa- tion for screening

Kidney Failure Activity intolerance r/t effects of anemia, heart failure Death Anxiety r/t unknown outcome of disease Decreased Cardiac output r/t effects of heart failure, elevated potassium levels interfering with conduction system Impaired Comfort r/t pruritus

e14

Kaposi’s Sarcoma Kawasaki Disease Keloids Keratoconjunctivitis Sicca (Dry Eye Syndrome)

Keratoplasty Ketoacidosis, Alcoholic

Ketoacidosis, Diabetic Keyhole Heart Surgery Kidney Disease Screening Kidney Failure Kidney Failure Acute/Chronic, Child Kidney Failure, Nonoliguric Kidney Stone Kidney Transplantation, Donor Kidney Transplantation, Recipient Kidney Transplant Kidney Tumor Kissing Disease Knee Replacement Knowledge Knowledge, Deficient Kock Pouch Korsakoff ’s Syndrome

List of Nursing Assessments by Letter: K

Knee Replacement 71

K

Ineffective Coping r/t depression resulting from chronic disease Fatigue r/t effects of chronic uremia and anemia Excess Fluid volume r/t decreased urine output, sodium reten- tion, inappropriate fluid intake Ineffective Health management r/t complexity of health care regimen, inadequate number of cues to action, perceived barri- ers, powerlessness Imbalanced Nutrition: less than body requirements r/t anorexia, nausea, vomiting, altered taste sensation, dietary restrictions Impaired Oral Mucous Membrane r/t irritation from nitrog- enous waste products Chronic Sorrow r/t chronic illness Spiritual distress r/t dealing with chronic illness Impaired Urinary elimination r/t effects of disease, need for dialysis Risk for Electrolyte imbalance: Risk factor: renal dysfunction Risk for Infection: Risk factor: altered immune functioning Risk for Injury: Risk factors: bone changes, neuropathy, muscle weakness Risk for impaired Oral Mucous Membrane: Risk factors: dehydration, effects of uremia Risk for Powerlessness: Risk factor: chronic illness Risk for Sepsis: Risk factor: infection

Kidney Failure Acute/Chronic, Child Disturbed Body Image r/t growth retardation, bone changes, visibility of dialysis access devices (shunt, fistula), edema Deficient Diversional Activity r/t immobility during dialysis See Child with Chronic Condition; Hospitalized Child

Kidney Failure, Nonoliguric Anxiety r/t change in health status Risk for deficient Fluid volume: Risk factor: loss of large volumes of urine See Kidney Failure

Kidney Stone Acute Pain r/t obstruction from kidney calculi Impaired Urinary elimination: urgency and frequency r/t ana- tomical obstruction, irritation caused by stone Risk for Infection: Risk factor: obstruction of urinary tract with stasis of urine Readiness for enhanced Knowledge: expresses an interest in learning about prevention of stones

Kidney Transplantation, Donor Impaired emancipated Decision-Making r/t harvesting of kidney from traumatized donor Moral Distress r/t conflict among decision makers, end-of-life decisions, time constraints for decision-making Spiritual distress r/t grieving from loss of significant person Readiness for enhanced Communication: expressing thoughts and feelings about situation

Readiness for enhanced family Coping: decision to allow organ donation Readiness for enhanced emancipated Decision-Making: expresses desire to enhance understanding and meaning of choices Readiness for enhanced Resilience: decision to donate organs Readiness for enhanced Spirituality: inner peace resulting from allowance of organ donation See Nephrectomy

Kidney Transplantation, Recipient Anxiety r/t possible rejection, procedure Ineffective Health maintenance r/t long-term home treatment after transplantation, diet, signs of rejection, use of medications Deficient Knowledge r/t specific nutritional needs, possible paralytic ileus, fluid or sodium restrictions Impaired Urinary elimination r/t possible impaired renal function Risk for Bleeding: Risk factor: surgical procedure Risk for Infection: Risk factor: use of immunosuppressive therapy to control rejection Risk for ineffective Renal perfusion: Risk factor: transplanted kidney Risk for Shock: Risk factor: possible hypovolemia Risk for Spiritual distress: Risk factor: obtaining transplanted kidney from someone’s traumatic loss Readiness for enhanced Spiritual well-being: acceptance of situation

Kidney Transplant Ineffective Protection r/t immunosuppressive therapy Risk for ineffective Renal perfusion: Risk factor: complications from transplant procedure Readiness for enhanced Decision-making: expresses desire to enhance understanding of choices Readiness for enhanced Family processes: adapting to life without dialysis Readiness for enhanced Health management: desire to manage the treatment and prevention of complications after transplantation Readiness for enhanced Spiritual well-being: heightened coping, living without dialysis See Kidney Failure, Kidney Transplantation, Donor; Kidney Trans- plantation, Recipient; Nephrectomy; Perioperative Care; Surgery, Postoperative Care; Surgery, Preoperative Care

Kidney Tumor See Wilms’ Tumor

Kissing Disease See Mononucleosis

Knee Replacement See Total Joint Replacement (Total Hip/Total Knee/Shoulder)

72 Knowledge

Knowledge Readiness for enhanced Knowledge (See Knowledge, readi- ness for enhanced, Section III)

Knowledge, Deficient Ineffective Health maintenance r/t lack of or significant altera- tion in communication skills (written, verbal, and/or gestural) Deficient Knowledge (See Knowledge, deficient, Section III) Readiness for enhanced Knowledge (See Knowledge, readi- ness for enhanced, Section III)

Kock Pouch See Continent Ileostomy (Kock Pouch)

Korsakoff ’s Syndrome Acute Confusion r/t alcohol abuse Dysfunctional Family processes r/t alcoholism as possible cause of syndrome Impaired Memory r/t neurological changes associated with excessive alcohol intake Self-Neglect r/t cognitive impairment from chronic alcohol abuse Risk for Falls: Risk factor: cognitive impairment from chronic alcohol abuse Risk for Injury: Risk factors: sensory dysfunction, lack of coor- dination when ambulating from chronic alcohol abuse Risk for impaired Liver function: Risk factor: substance abuse (alcohol) Risk for imbalanced Nutrition: less than body requirements: Risk factor: lack of adequate balanced intake from chronic alcohol abuse

L

L Labor, Induction of

See Induction of Labor

Labor, Normal Anxiety r/t fear of the unknown, situational crisis Impaired Comfort r/t labor Fatigue r/t childbirth Deficient Knowledge r/t lack of preparation for labor Labor Pain r/t uterine contractions, stretching of cervix and birth canal Impaired Tissue integrity r/t passage of infant through birth canal, episiotomy Risk for ineffective Childbearing process (See Childbearing process, Section III) Risk for Falls: Risk factors: excessive loss or shift in intravascular fluid volume, orthostatic hypotension Risk for deficient Fluid volume: Risk factor: excessive loss of blood Risk for Infection: Risk factors: multiple vaginal examinations, tissue trauma, prolonged rupture of membranes

Risk for Injury: fetal: Risk factor: hypoxia Risk for Post-Trauma syndrome: Risk factors: trauma or vio- lence associated with labor pains, medical or surgical interven- tions, history of sexual abuse Readiness for enhanced Childbearing process: responds appropriately, is proactive, bonds with infant, uses support systems Readiness for enhanced family Coping: significant other pro- vides support during labor Readiness for enhanced Health management: prenatal care and childbirth education birth process Readiness for enhanced Power: expresses readiness to enhance participation in choices regarding treatment during labor

Labor Pain Labor Pain r/t uterine contractions, stretching of cervix and birth canal

Labyrinthitis Ineffective Health management r/t delay in seeking treatment for respiratory and ear infections Risk for Injury r/t dizziness Readiness for enhanced Health management: management of episodes See Ménière’s Disease

Lacerations Readiness for enhanced Health management: appropriate care of injury Risk for Infection: Risk factor: broken skin Risk for Trauma: Risk factor: children playing with dangerous objects

Lactation See Breastfeeding, Ineffective; Breastfeeding, Interrupted; Breast- feeding, Readiness for Enhanced

Lactic Acidosis Decreased Cardiac output r/t altered heart rate/rhythm, preload, and contractility Risk for Electrolyte imbalance: Risk factor: impaired regulatory mechanism Risk for decreased Cardiac tissue perfusion: Risk factor: hypoxia See Ketoacidosis, Diabetes Mellitus

Lactose Intolerance Readiness for enhanced Knowledge: interest in identifying lactose intolerance, treatment, and substitutes for milk products See Abdominal Distention; Diarrhea

Laminectomy Anxiety r/t change in health status, surgical procedure Impaired Comfort r/t surgical procedure Deficient Knowledge r/t appropriate postoperative and post- discharge activities

e15

Labor, Induction of Labor, Normal Labor Pain Labyrinthitis Lacerations Lactation Lactic Acidosis Lactose Intolerance Laminectomy Language Impairment Laparoscopic Laser Cholecystectomy Laparoscopy Laparotomy Large Bowel Resection Laryngectomy Laser Surgery LASIK Eye Surgery (Laser-Assisted in

Situ Keratomileusis) Latex Allergy

Laxative Abuse Lead Poisoning Left Heart Catheterization Legionnaires’ Disease Lens Implant Lethargy/Listlessness Leukemia Leukopenia Level of Consciousness, Decreased Lice Lifestyle, Sedentary Lightheadedness Limb Reattachment Procedures Liposuction Lithotripsy Liver Biopsy Liver Cancer Liver Disease Liver Function Liver Transplant Living Will Lobectomy Loneliness Loose Stools (Bowel Movements) Loss of Bladder Control Loss of Bowel Control Lou Gehrig’s Disease Low Back Pain Low Blood Pressure Low Blood Sugar Lower GI Bleeding Lumbar Puncture Lumpectomy Lung Cancer Lung Surgery Lupus Erythematosus Lyme Disease Lymphedema Lymphoma

List of Nursing Assessments by Letter: L

Lethargy/Listlessness 73

L

Impaired physical Mobility r/t neuromuscular impairment Acute Pain r/t localized inflammation and edema Urinary retention r/t competing sensory impulses, effects of opioids or anesthesia Risk for Bleeding: Risk factor: surgery Risk for Infection: Risk factor: invasive procedure, surgery Risk for Perioperative Positioning injury: Risk factor: prone position See Surgery, Perioperative; Surgery, Postoperative; Surgery, Preoperative

Language Impairment See Speech Disorders

Laparoscopic Laser Cholecystectomy See Cholecystectomy; Laser Surgery

Laparoscopy Urge urinary Incontinence r/t pressure on the bladder from gas Acute Pain: shoulder r/t gas irritating the diaphragm Risk for ineffective Gastrointestinal perfusion: Risk factor: complications from procedure

Laparotomy See Abdominal Surgery

Large Bowel Resection See Abdominal Surgery

Laryngectomy Ineffective Airway clearance r/t surgical removal of glottis, decreased humidification Death Anxiety r/t unknown results of surgery Disturbed Body Image r/t change in body structure and function Impaired Comfort r/t surgery Impaired verbal Communication r/t removal of larynx Interrupted Family processes r/t surgery, serious condition of family member, difficulty communicating Grieving r/t loss of voice, fear of death Ineffective Health management r/t deficient knowledge regard- ing self-care with laryngectomy Imbalanced Nutrition: less than body requirements r/t absence of oral feeding, difficulty swallowing, increased need for fluids Impaired Oral Mucous Membrane r/t absence of oral feeding Chronic Sorrow r/t change in body image Impaired Swallowing r/t edema, laryngectomy tube Risk for Electrolyte imbalance: Risk factor: fluid imbalance Risk for complicated Grieving: Risk factors: loss, major life event Risk for compromised Human Dignity: Risk factor: inability to communicate Risk for Infection: Risk factors: invasive procedure, surgery

Risk for Powerlessness: Risk factors: chronic illness, change in communication Risk for impaired Resilience: Risk factor: change in health status Risk for situational low Self-Esteem: Risk factor: disturbed body image

Laser Surgery Impaired Comfort r/t surgery Constipation r/t laser intervention in vulval and perianal areas Deficient Knowledge r/t preoperative and postoperative care associated with laser procedure Acute Pain r/t heat from laser Risk for Bleeding: Risk factor: surgery Risk for Infection: Risk factor: delayed heating reaction of tissue exposed to laser Risk for Injury: Risk factor: accidental exposure to laser beam

LASIK Eye Surgery (Laser-Assisted in Situ Keratomileusis)

Impaired Comfort r/t surgery Decisional Conflict r/t decision to have surgery Risk for Infection: Risk factor: invasive procedure/surgery Readiness for enhanced Health management: surgical proce- dure preoperative and postoperative teaching and expectations

Latex Allergy Latex Allergy response (See Latex Allergy response, Section III) Risk for Latex Allergy response (See Latex Allergy response, risk for, Section III) Readiness for enhanced Knowledge: prevention and treatment of exposure to latex products

Laxative Abuse Perceived Constipation r/t health belief, faulty appraisal, impaired thought processes

Lead Poisoning Contamination r/t flaking, peeling paint in presence of young children Impaired Home maintenance r/t presence of lead paint Risk for delayed Development: Risk factor: lead poisoning

Left Heart Catheterization See Cardiac Catheterization

Legionnaires’ Disease Contamination r/t contaminated water in air-conditioning systems See Pneumonia

Lens Implant See Cataract Extraction; Vision Impairment

Lethargy/Listlessness Frail Elderly syndrome r/t alteration in cognitive function

74 Leukemia

L

Fatigue r/t decreased metabolic energy production Insomnia r/t internal or external stressors Risk for ineffective Cerebral tissue perfusion: Risk factor: carbon dioxide retention and/or lack of oxygen supply to brain

Leukemia Ineffective Protection r/t abnormal blood profile Fatigue r/t abnormal blood profile and/or side effects of che- motherapy treatment Risk for imbalanced Fluid volume: Risk factors: nausea, vomit- ing, bleeding, side effects of treatment Risk for Infection: Risk factor: ineffective immune system Risk for impaired Resilience: Risk factor: serious illness See Cancer; Chemotherapy

Leukopenia Ineffective Protection r/t leukopenia Risk for Infection: Risk factor: low white blood cell count

Level of Consciousness, Decreased See Confusion, Acute; Confusion, Chronic

Lice Impaired Comfort r/t inflammation, pruritus Readiness for enhanced Health management: preventing and treating infestation Impaired Home maintenance r/t close unsanitary, overcrowded conditions Self-Neglect r/t lifestyle See Communicable Diseases, Childhood

Lifestyle, Sedentary Sedentary lifestyle (See Sedentary lifestyle, Section III) Risk for ineffective peripheral Tissue Perfusion: Risk factor: lack of movement

Lightheadedness See Dizziness; Vertigo

Limb Reattachment Procedures Anxiety r/t unknown outcome of reattachment procedure, use and appearance of limb Disturbed Body Image r/t unpredictability of function and appearance of reattached body part Grieving r/t unknown outcome of reattachment procedure Spiritual distress r/t anxiety about condition Stress overload r/t multiple coexisting stressors, physical demands Risk for Bleeding: Risk factor: severed vessels Risk for Perioperative Positioning injury: Risk factor: immobilization Risk for Peripheral Neurovascular dysfunction: Risk factors: trauma, orthopedic and neurovascular surgery, compression of nerves and blood vessels Risk for Powerlessness: Risk factor: unknown outcome of procedure

Risk for impaired Religiosity: Risk factors: suffering, hospitalization See Surgery, Postoperative Care

Liposuction Disturbed Body Image r/t dissatisfaction with unwanted fat deposits in body Risk for impaired Resilience: Risk factor: body image disturbance Readiness for enhanced Decision-Making: expresses desire to make decision regarding liposuction Readiness for enhanced Self-Concept: satisfaction with new body image See Surgery, Perioperative Care; Surgery, Postoperative Care; Surgery, Preoperative Care

Lithotripsy Readiness for enhanced Health management: expresses desire for information related to procedure and aftercare and preven- tion of stones See Kidney Stone

Liver Biopsy Anxiety r/t procedure and results Risk for deficient Fluid volume: Risk factor: hemorrhage from biopsy site Risk for Infection: Risk factor: invasive procedure Risk for Powerlessness: Risk factor: inability to control outcome of procedure

Liver Cancer Risk for Bleeding: Risk factor: liver dysfunction Risk for Falls: Risk factor: confusion associated with liver dysfunction Risk for ineffective Gastrointestinal perfusion: Risk factor: liver dysfunction Risk for impaired Liver function: Risk factor: disease process Risk for impaired Resilience: Risk factor: serious illness See Cancer; Chemotherapy; Radiation Therapy

Liver Disease See Cirrhosis; Hepatitis

Liver Function Risk for impaired Liver function (See Liver function, impaired, risk for, Section III)

Liver Transplant Impaired Comfort r/t surgical pain Decisional Conflict r/t acceptance of donor liver Ineffective Protection r/t immunosuppressive therapy Risk for impaired Liver function: Risk factors: possible rejection, infection Readiness for enhanced Family processes: change in physical needs of family member

Lyme Disease 75

L

Readiness for enhanced Health management: desire to manage the treatment and prevention of complications after transplantation Readiness for enhanced Spiritual well-being: heightened coping See Surgery, Perioperative Care; Surgery, Postoperative Care; Surgery, Preoperative Care

Living Will Moral Distress r/t end-of-life decisions Readiness for enhanced Decision-Making: expresses desire to enhance understanding of choices for decision making Readiness for enhanced Relationship: shares information with others Readiness for enhanced Religiosity: request to meet with reli- gious leaders or facilitators Readiness for enhanced Resilience: uses effective communication Readiness for enhanced Spiritual well-being: acceptance of and preparation for end of life See Advance Directives

Lobectomy See Thoracotomy

Loneliness Spiritual distress r/t loneliness, social alienation Risk for Loneliness (See Loneliness, risk for, Section III) Risk for impaired Religiosity: Risk factor: lack of social interaction Readiness for enhanced Hope: expresses desire to enhance interconnectedness with others Readiness for enhanced Relationship: expresses satisfaction with complementary relationship between partners

Loose Stools (Bowel Movements) Diarrhea r/t increased gastric motility Risk for dysfunctional Gastrointestinal motility (See Gastro- intestinal motility, dysfunctional, risk for, Section III) See Diarrhea

Loss of Bladder Control See Incontinence of Urine

Loss of Bowel Control See Incontinence of Stool

Lou Gehrig’s Disease See Amyotrophic Lateral Sclerosis (ALS)

Low Back Pain Impaired Comfort r/t back pain Ineffective Health maintenance r/t deficient knowledge regard- ing self-care with back pain Impaired physical Mobility r/t back pain Chronic Pain r/t degenerative processes, musculotendinous strain, injury, inflammation, congenital deformities Urinary Retention r/t possible spinal cord compression

Risk for Powerlessness: Risk factor: living with chronic pain Readiness for enhanced Health management: expresses desire for information to manage pain

Low Blood Pressure See Hypotension

Low Blood Sugar See Hypoglycemia

Lower GI Bleeding See GI Bleed (Gastrointestinal Bleeding)

Lumbar Puncture Anxiety r/t invasive procedure and unknown results Deficient Knowledge r/t information about procedure Acute Pain r/t possible loss of cerebrospinal fluid Risk for ineffective Cerebral tissue perfusion: Risk factor: treatment-related side effects Risk for Infection: Risk factor: invasive procedure

Lumpectomy Decisional Conflict r/t treatment choices Readiness for enhanced Knowledge: preoperative and postop- erative care Readiness for enhanced Spiritual well-being: hope of benign diagnosis See Cancer

Lung Cancer See Cancer; Chemotherapy; Radiation Therapy; Thoracotomy

Lung Surgery See Thoracotomy

Lupus Erythematosus Disturbed Body Image r/t change in skin, rash, lesions, ulcers, mottled erythema Fatigue r/t increased metabolic requirements Ineffective Health maintenance r/t deficient knowledge regard- ing medication, diet, activity Acute Pain r/t inflammatory process Powerlessness r/t unpredictability of course of disease Impaired Religiosity r/t ineffective coping with disease Chronic Sorrow r/t presence of chronic illness Spiritual distress r/t chronicity of disease, unknown etiology Risk for decreased Cardiac tissue perfusion: Risk factor: altered circulation Risk for impaired Resilience: Risk factor: chronic disease Risk for impaired Skin integrity: Risk factors: chronic inflamma- tion, edema, altered circulation

Lyme Disease Impaired Comfort r/t inflammation Fatigue r/t increased energy requirements

76 Lymphedema

Deficient Knowledge r/t lack of information concerning disease, prevention, treatment Acute Pain r/t inflammation of joints, urticaria, rash Risk for decreased Cardiac output: Risk factor: dysrhythmia Risk for Powerlessness: Risk factor: possible chronic condition

Lymphedema Disturbed Body Image r/t change in appearance of body part with edema Excess Fluid volume r/t compromised regulatory system; inflammation, obstruction, or removal of lymph glands Deficient Knowledge r/t management of condition Risk for Infection: Risk factors: abnormal lymphatic system allowing stasis of fluids with decreased resistance to infection Risk for situational low Self-Esteem: Risk factor: disturbed body image

Lymphoma See Cancer

M M

Macular Degeneration Ineffective Coping r/t visual loss Compromised family Coping r/t deteriorating vision of family member Risk-prone Health behavior r/t deteriorating vision while trying to maintain usual lifestyle Hopelessness r/t deteriorating vision Sedentary lifestyle r/t visual loss Self-Neglect r/t change in vision Social isolation r/t inability to drive because of visual changes Vision Loss r/t impaired visual function Risk for Falls: Risk factor: visual difficulties Risk for Injury: Risk factor: inability to distinguish traffic lights and safety signs Risk for Powerlessness: Risk factor: deteriorating vision Risk for impaired Religiosity: Risk factor: possible lack of trans- portation to church Risk for impaired Resilience: Risk factor: changing vision Readiness for enhanced Health management: appropriate choices of daily activities for meeting the goals of a treatment program

Magnetic Resonance Imaging (MRI) See MRI (Magnetic Resonance Imaging)

Major Depressive Disorder See Depression (Major Depressive Disorder)

Malabsorption Syndrome Diarrhea r/t lactose intolerance, gluten sensitivity, resection of small bowel

Dysfunctional Gastrointestinal motility r/t disease state Deficient Knowledge r/t lack of information about diet and nutrition Imbalanced Nutrition: less than body requirements r/t inability of body to absorb nutrients because of physiological factors Risk for Electrolyte imbalance: Risk factors: hypovolemia, hyponatremia, hypokalemia Risk for imbalanced Fluid volume: Risk factors: diarrhea, hypovolemia Risk for disproportionate Growth: Risk factor: malnutrition from malabsorption See Abdominal Distention

Maladaptive Behavior See Crisis; Post-Trauma Syndrome; Suicide Attempt

Malaise See Fatigue

Malaria Contamination r/t geographic area Risk for Contamination: Risk factors: increased environmen- tal exposure (not wearing protective clothing, not using insecti- cide or repellant on skin and in room in areas where infected mosquitoes are present); inadequate defense mechanisms (inap- propriate use of prophylactic regimen) Risk for impaired Liver function: Risk factor: complications of disease Readiness for enhanced community Coping: uses resources available for problem solving Readiness for enhanced Health management: expresses desire to enhance immunization status /vaccination status Readiness for enhanced Resilience: immunization status See Anemia

Male Infertility See Erectile Dysfunction (ED); Infertility

Malignancy See Cancer

Malignant Hypertension (Arteriolar Nephrosclerosis)

Decreased Cardiac output r/t altered afterload, altered contractility Fatigue r/t disease state, increased blood pressure Excess Fluid volume r/t decreased kidney function Risk for ineffective Cerebral tissue perfusion: Risk factor: ele- vated blood pressure damaging cerebral vessels Risk for acute Confusion: Risk factors: increased blood urea nitrogen or creatinine levels Risk for imbalanced Fluid volume: Risk factors: hypertension, altered kidney function Risk for ineffective Renal perfusion: Risk factor: elevated blood pressure damaging the kidney

e16

Macular Degeneration Magnetic Resonance Imaging (MRI) Major Depressive Disorder Malabsorption Syndrome Maladaptive Behavior Malaise Malaria Male Infertility Malignancy Malignant Hypertension (Arteriolar Nephrosclerosis)

Malignant Hyperthermia Malnutrition

Mammography Manic Disorder, Bipolar I Manipulative Behavior Marfan Syndrome Mastectomy Mastitis Maternal Infection Maturational Issues, Adolescent Maze III Procedure MD (Muscular Dystrophy) Measles (Rubeola) Meconium Aspiration Meconium Delayed Melanoma Melena Memory Deficit Ménière’s Disease Meningitis/Encephalitis Meningocele Menopause Menorrhagia Mental Illness Metabolic Acidosis Metabolic Alkalosis Metastasis Methicillin-Resistant Staphylococcus

aureus (MRSA) MI (Myocardial Infarction)

MIDCAB (Minimally Invasive Direct Coronary Artery Bypass)

Midlife Crisis Migraine Headache

Milk Intolerance Minimally Invasive Direct Coronary Bypass (MIDCAB)

Miscarriage

Mitral Stenosis Mitral Valve Prolapse Mobility, Impaired Bed Mobility, Impaired Physical Mobility, Impaired Wheelchair Modified Radical Mastectomy Mononucleosis Mood Disorders Moon Face Moral/Ethical Dilemmas Morning Sickness Motion Sickness Mottling of Peripheral Skin Mourning Mouth Lesions MRI (Magnetic Resonance Imaging) MRSA (Methicillin-Resistant

Staphylococcus aureus) Mucocutaneous Lymph Node Syndrome

Mucous Membrane, Impaired Oral Multi-Infarct Dementia Multiple Gestations

List of Nursing Assessments by Letter: M

List of Nursing Assessments by Letter: M e17

Multiple Personality Disorder (Dissociative Identity Disorder)

Multiple Sclerosis (MS) Mumps

Murmurs Muscular Atrophy/Weakness Muscular Dystrophy (MD) MVC (Motor Vehicle Crash) Myasthenia Gravis Mycoplasma Pneumonia Myelocele Myelomeningocele Myocardial Infarction (MI) Myocarditis Myringotomy Myxedema

Mastectomy 77

M

Readiness for enhanced Health management: expresses desire to manage the illness, high blood pressure

Malignant Hyperthermia Hyperthermia r/t anesthesia reaction associated with inher- ited condition Risk for ineffective Renal perfusion: Risk factors: hyperthermia and muscle destruction (rhabdomyolysis) Readiness for enhanced Health management: knowledge of risk factors

Malnutrition Insufficient Breast Milk r/t (See Breast Milk, insufficient, Section III) Frail Elderly syndrome r/t undetected malnutrition Deficient Knowledge r/t misinformation about normal nutri- tion, social isolation, lack of food preparation facilities Imbalanced Nutrition: less than body requirements r/t inability to ingest food, digest food, or absorb nutrients because of bio- logical, psychological, or economic factors; institutionalization (i.e., lack of menu choices) Ineffective Protection r/t inadequate nutrition Ineffective Health management r/t inadequate nutrition Self-Neglect r/t inadequate nutrition Risk for disproportionate Growth: Risk factor: malnutrition Risk for Powerlessness: Risk factor: possible inability to provide adequate nutrition

Mammography Readiness for enhanced Health management: follows guide- lines for screening Readiness for enhanced Resilience: responsibility for self-care

Manic Disorder, Bipolar I Anxiety r/t change in role function Ineffective Coping r/t situational crisis Ineffective Denial r/t fear of inability to control behavior Interrupted Family processes r/t family member’s illness Risk-prone Health behavior r/t low self-efficacy Ineffective Health management r/t unpredictability of client, excessive demands on family, chronic illness, social support deficit Impaired Home maintenance r/t altered psychological state, inability to concentrate Disturbed personal Identity r/t manic state Insomnia r/t constant anxious thoughts Imbalanced Nutrition: less than body requirements r/t lack of time and motivation to eat, constant movement Impaired individual Resilience r/t psychological disorder Ineffective Role performance r/t impaired social interactions Self-Neglect r/t manic state Sleep deprivation r/t hyperagitated state Risk for ineffective Activity planning r/t inability to process information

Risk for Caregiver Role Strain: Risk factor: unpredictability of condition Risk for imbalanced Fluid volume: Risk factor: hypovolemia Risk for Powerlessness: Risk factor: inability to control changes in mood Risk for Spiritual distress: Risk factor: depression Risk for Suicide: Risk factor: bipolar disorder Risk for self-directed Violence: Risk factors: hallucinations, delusions Risk for other-directed Violence: Risk factor: pathologic intoxication Readiness for enhanced Hope: expresses desire to enhance problem-solving goals

Manipulative Behavior Defensive Coping r/t superior attitude toward others Ineffective Coping r/t inappropriate use of defense mechanisms Self-Mutilation r/t use of manipulation to obtain nurturing relationship with others Self-Neglect r/t maintaining control Impaired Social interaction r/t self-concept disturbance Risk for Loneliness: Risk factor: inability to interact appropri- ately with others Risk for situational low Self-Esteem: Risk factor: history of learned helplessness Risk for Self-Mutilation: Risk factor: inability to cope with increased psychological or physiological tension in healthy manner

Marfan Syndrome Decreased Cardiac output r/t dilation of the aortic root, dissection or rupture of the aorta Risk for decreased Cardiac tissue perfusion: Risk factor: heart- related complications from Marfan syndrome Readiness for enhanced Health management: describes reduc- tion of risk factors See Mitral Valve Prolapse; Scoliosis

Mastectomy Disturbed Body Image r/t loss of sexually significant body part Impaired Comfort r/t altered body image; difficult diagnosis Death Anxiety r/t threat of mortality associated with breast cancer Fatigue r/t increased metabolic requirements Fear r/t change in body image, prognosis Deficient Knowledge r/t self-care activities Nausea r/t chemotherapy Acute Pain r/t surgical procedure Sexual dysfunction r/t change in body image, fear of loss of femininity Chronic Sorrow r/t disturbed body image, unknown long-term health status

78 Mastitis

M

Spiritual distress r/t change in body image Risk for Infection: Risk factors: surgical procedure, broken skin Risk for impaired physical Mobility: Risk factors: nerve or muscle damage, pain Risk for Post-Trauma syndrome: Risk factors: loss of body part, surgical wounds Risk for Powerlessness: Risk factor: fear of unknown outcome of procedure Risk for impaired Resilience: Risk factor: altered body image See Cancer; Modified Radical Mastectomy; Surgery, Perioperative; Surgery, Postoperative; Surgery, Preoperative

Mastitis Anxiety r/t threat to self, concern over safety of milk for infant Ineffective Breastfeeding r/t breast pain, conflicting advice from health care providers Deficient Knowledge r/t antibiotic regimen, comfort measures Acute Pain r/t infectious disease process, swelling of breast tissue Ineffective Role performance r/t change in capacity to function in expected role

Maternal Infection Ineffective Protection r/t invasive procedures, traumatized tissue See Postpartum, Normal Care

Maturational Issues, Adolescent Ineffective Coping r/t maturational crises Risk-prone Health behavior r/t inadequate comprehension, negative attitude toward health care Interrupted Family processes r/t developmental crises of ado- lescence resulting from challenge of parental authority and values, situational crises from change in parental marital status Deficient Knowledge: potential for enhanced health mainte- nance r/t information misinterpretation, lack of education regarding age-related factors Impaired Social interaction r/t ineffective, unsuccessful, or dys- functional interaction with peers Social isolation r/t perceived alteration in physical appearance, social values not accepted by dominant peer group Risk for Ineffective Activity planning: Risk factor: unrealistic perception of personal competencies Risk for disturbed personal Identity: Risk factor: maturational issues Risk for Injury: Risk factor: thrill-seeking behaviors Risk for chronic low Self-Esteem: Risk factor: lack of sense of belonging in peer group Risk for situational low Self-Esteem: Risk factor: developmen- tal changes Readiness for enhanced Communication: expressing willing- ness to communicate with parental figures

Readiness for enhanced Relationship: expresses desire to enhance communication with parental figures See Sexuality, Adolescent; Substance Abuse (if relevant)

Maze III Procedure See Dysrhythmia; Open Heart Surgery

MD (Muscular Dystrophy) See Muscular Dystrophy (MD)

Measles (Rubeola) See Communicable Diseases, Childhood

Meconium Aspiration See Respiratory Conditions of the Neonate

Meconium Delayed Risk for neonatal Jaundice: Risk factor: delayed meconium

Melanoma Disturbed Body Image r/t altered pigmentation, surgical incision Fear r/t threat to well-being Ineffective Health maintenance r/t deficient knowledge regard- ing self-care and treatment of melanoma Acute Pain r/t surgical incision Chronic Sorrow r/t disturbed body image, unknown long-term health status Readiness for enhanced Health management: describes reduc- tion of risk factors; protection from sunlight’s ultraviolet rays See Cancer

Melena Fear r/t presence of blood in feces Risk for imbalanced Fluid volume: Risk factor: hemorrhage See GI Bleed (Gastrointestinal Bleeding)

Memory Deficit Impaired Memory (See Memory, impaired, Section III)

Ménière’s Disease Risk for Injury: Risk factor: symptoms of disease Readiness for enhanced Health management: expresses desire to manage illness See Dizziness; Nausea; Vertigo

Meningitis/Encephalitis Ineffective Airway clearance r/t seizure activity Impaired Comfort r/t altered health status Excess Fluid volume r/t increased intracranial pressure, syn- drome of inappropriate secretion of antidiuretic hormone Decreased Intracranial adaptive capacity r/t sustained increase in intracranial pressure Impaired Mobility r/t neuromuscular or central nervous system insult Acute Pain r/t biological injury Risk for Aspiration: Risk factor: seizure activity

MI (Myocardial Infarction) 79

M

Risk for acute Confusion: Risk factor: infection of brain Risk for Falls: Risk factors: neuromuscular dysfunction and confusion Risk for Injury: Risk factor: seizure activity Risk for impaired Resilience: Risk factor: illness Risk for Shock: Risk factor: infection Risk for ineffective Cerebral tissue perfusion: Risk factors: cerebral tissue edema and inflammation of meninges, increased intracranial pressure; infection See Hospitalized Child

Meningocele See Neural Tube Defects

Menopause Impaired Comfort r/t symptoms associated with menopause Insomnia r/t hormonal shifts Impaired Memory r/t change in hormonal levels Sexual dysfunction r/t menopausal changes Ineffective Sexuality pattern r/t altered body structure, lack of lubrication, lack of knowledge of artificial lubrication Ineffective Thermoregulation r/t changes in hormonal levels Risk for urge urinary Incontinence: Risk factor: changes in hormonal levels affecting bladder function Risk for Overweight: Risk factor: change in metabolic rate caused by fluctuating hormone levels Risk for Powerlessness: Risk factor: changes associated with menopause Risk for impaired Resilience: Risk factor: menopause Risk for situational low Self-Esteem: Risk factors: developmen- tal changes, menopause Readiness for enhanced Health management: verbalized desire to manage menopause Readiness for enhanced Self-Care: expresses satisfaction with body image Readiness for enhanced Spiritual well-being: desire for harmony of mind, body, and spirit

Menorrhagia Fear r/t loss of large amounts of blood Risk for deficient Fluid volume: Risk factor: excessive loss of menstrual blood

Mental Illness Defensive Coping r/t psychological impairment, substance abuse Ineffective Coping r/t situational crisis, coping with mental illness Compromised family Coping r/t lack of available support from client Disabled family Coping r/t chronically unexpressed feelings of guilt, anxiety, hostility, or despair Ineffective Denial r/t refusal to acknowledge abuse problem, fear of the social stigma of disease

Risk-prone Health behavior r/t low self-efficacy Disturbed personal Identity r/t psychoses Ineffective Relationship r/t effects of mental illness in partner relationship Chronic Sorrow r/t presence of mental illness Stress overload r/t multiple coexisting stressors Ineffective family Health management r/t chronicity of condi- tion, unpredictability of client, unknown prognosis Risk for Loneliness: Risk factor: social isolation Risk for Powerlessness: Risk factor: lifestyle of helplessness Risk for impaired Resilience: Risk factor: chronic illness Risk for chronic low Self-Esteem: Risk factor: presence of mental illness/repeated negative reinforcement

Metabolic Acidosis See Ketoacidosis, Alcoholic; Ketoacidosis, Diabetic; Risk for Shock; Risk for Sepsis

Metabolic Alkalosis Deficient Fluid volume r/t fluid volume loss, vomiting, gastric suctioning, failure of regulatory mechanisms

Metastasis See Cancer

Methicillin-Resistant Staphylococcus aureus (MRSA)

See MRSA (Methicillin-Resistant Staphylococcus aureus)

MI (Myocardial Infarction) Activity intolerance r/t imbalance between oxygen supply and demand Anxiety r/t threat of death, possible change in role status Death Anxiety r/t seriousness of medical condition Constipation r/t decreased peristalsis from decreased physical activity, medication effect, change in diet Ineffective family Coping r/t spouse or significant other’s fear of partner loss Ineffective Denial r/t fear, deficient knowledge about heart disease Interrupted Family processes r/t crisis, role change Fear r/t threat to well-being Ineffective Health maintenance r/t deficient knowledge regard- ing self-care and treatment Acute Pain r/t myocardial tissue damage from inadequate blood supply Situational low Self-Esteem r/t crisis of MI Ineffective Sexuality pattern r/t fear of chest pain, possibility of heart damage Risk for Powerlessness: Risk factor: acute illness Risk for Shock: Risk factors: hypotension, myocardial dysfunc- tion, hypoxia Risk for Spiritual distress: Risk factor: physical illness

80 MIDCAB (Minimally Invasive Direct Coronary Artery Bypass)

M

Risk for decreased Cardiac output: Risk factors: alteration in heart rate, rhythm, and contractility Risk for decreased Cardiac tissue perfusion: Risk factors: coro- nary artery spasm, hypertension, hypotension, hypoxia Readiness for enhanced Knowledge: expresses an interest in learning about condition See Angioplasty (Coronary); Coronary Artery Bypass Grafting (CABG)

MIDCAB (Minimally Invasive Direct Coronary Artery Bypass)

Risk for Bleeding: Risk factor: surgery Readiness for enhanced Health management: preoperative and postoperative care associated with surgery Risk for Infection: Risk factor: surgical procedure See Angioplasty, Coronary; Coronary Artery Bypass Grafting (CABG)

Midlife Crisis Ineffective Coping r/t inability to deal with changes associated with aging Powerlessness r/t lack of control over life situation Spiritual distress r/t questioning beliefs or value system Risk for disturbed personal Identity Risk for chronic low Self-Esteem: Risk factor: ineffective coping with loss Readiness for enhanced Relationship: meets goals for lifestyle change Readiness for enhanced Spiritual well-being: desire to find purpose and meaning to life

Migraine Headache Ineffective Health maintenance r/t deficient knowledge regard- ing prevention and treatment of headaches Readiness for enhanced Health management: expresses desire to manage illness Acute Pain: headache r/t vasodilation of cerebral and extrace- rebral vessels Risk for impaired Resilience: Risk factors: chronic illness, dis- abling pain

Milk Intolerance See Lactose Intolerance

Minimally Invasive Direct Coronary Bypass (MIDCAB)

See MIDCAB (Minimally Invasive Direct Coronary Artery Bypass)

Miscarriage See Pregnancy Loss

Mitral Stenosis Activity intolerance r/t imbalance between oxygen supply and demand Anxiety r/t possible worsening of symptoms, activity intoler- ance, fatigue

Decreased Cardiac output r/t incompetent heart valves, abnor- mal forward or backward blood flow, flow into a dilated chamber, flow through an abnormal passage between chambers Fatigue r/t reduced cardiac output Ineffective Health maintenance r/t deficient knowledge regard- ing self-care with disorder Risk for decreased Cardiac tissue perfusion: Risk factor: incompetent heart valve Risk for Infection: Risk factors: invasive procedure, risk for endocarditis

Mitral Valve Prolapse Anxiety r/t symptoms of condition: palpitations, chest pain Fatigue r/t abnormal catecholamine regulation, decreased intravascular volume Fear r/t lack of knowledge about mitral valve prolapse, feelings of having heart attack Ineffective Health maintenance r/t deficient knowledge regard- ing methods to relieve pain and treat dysrhythmia and shortness of breath, need for prophylactic antibiotics before invasive procedures Acute Pain r/t mitral valve regurgitation Risk for ineffective Cerebral tissue perfusion: Risk factor: pos- tural hypotension Risk for Infection: Risk factor: invasive procedures Risk for Powerlessness: Risk factor: unpredictability of onset of symptoms Readiness for enhanced Knowledge: expresses interest in learning about condition

Mobility, Impaired Bed Impaired bed Mobility (See Mobility, bed, impaired, Section III)

Mobility, Impaired Physical Impaired physical Mobility (See Mobility, physical, impaired, Section III) Risk for Falls: Risk factor: impaired physical mobility

Mobility, Impaired Wheelchair Impaired wheelchair Mobility (See Mobility, wheelchair, impaired, Section III)

Modified Radical Mastectomy Impaired emancipated Decision-Making Readiness for enhanced Communication: willingness to enhance communication See Mastectomy

Mononucleosis Activity intolerance r/t generalized weakness Impaired Comfort r/t sore throat, muscle aches Fatigue r/t disease state, stress Ineffective Health maintenance r/t deficient knowledge con- cerning transmission and treatment of disease

Multiple Gestations 81

M

Acute Pain r/t enlargement of lymph nodes, oropharyngeal edema Impaired Swallowing r/t enlargement of lymph nodes, oropha- ryngeal edema Risk for Injury: Risk factor: possible rupture of spleen Risk for Loneliness: Risk factor: social isolation

Mood Disorders Caregiver Role Strain r/t overwhelming needs of care receiver, unpredictability of mood alterations Labile Emotional Control r/t (See Labile Emotional Control, Section III) Risk-prone Health behavior r/t hopelessness, altered locus of control Impaired Mood regulation r/t (See Mood regulation, impaired, Section III) Self-Neglect r/t inability to care for self Social isolation r/t alterations in mental status Risk for situational low Self-Esteem: Risk factor: unpredictable changes in mood Readiness for enhanced Communication: expresses feelings See specific disorder: Depression (Major Depressive Disorder); Dys- thymic Disorder; Hypomania; Manic Disorder, Bipolar I

Moon Face Disturbed Body Image r/t change in appearance from disease and medication(s) Risk for situational low Self-Esteem: Risk factor: change in body image See Cushing’s Syndrome

Moral/Ethical Dilemmas Impaired emancipated Decision-Making r/t questioning per- sonal values and belief, which alter decision Moral Distress r/t conflicting information guiding moral or ethical decision-making Risk for Powerlessness: Risk factor: lack of knowledge to make a decision Risk for Spiritual distress: Risk factor: moral or ethical crisis Readiness for enhanced emancipated Decision-Making: expresses desire to enhance congruency of decisions with per- sonal values and goals Readiness for enhanced Religiosity: requests assistance in expanding religious options Readiness for enhanced Resilience: vulnerable state Readiness for enhanced Spiritual well-being: request for inter- action with others regarding difficult decisions

Morning Sickness See Hyperemesis Gravidarum; Pregnancy, Normal

Motion Sickness See Labyrinthitis

Mottling of Peripheral Skin Ineffective peripheral Tissue Perfusion r/t interruption of arte- rial flow, decreased circulating blood volume Risk for Shock: Risk factor: inadequate circulation to perfuse body

Mourning See Grieving

Mouth Lesions See Mucous Membrane, Impaired Oral

MRI (Magnetic Resonance Imaging) Anxiety r/t fear of being in closed spaces Readiness for enhanced Health management: describes reduc- tion of risk factors associated with exam Deficient Knowledge r/t unfamiliarity with information resources; exam information Readiness for enhanced Knowledge: expresses interest in learning about exam

MRSA (Methicillin-Resistant Staphylococcus aureus)

Impaired Skin integrity r/t infection Delayed Surgical recovery r/t infection Ineffective Thermoregulation r/t severe infection stimulating immune system Impaired Tissue integrity r/t wound, infection Risk for Loneliness: Risk factor: physical isolation Risk for impaired Resilience: Risk factor: illness Risk for Shock: Risk factor: sepsis

Mucocutaneous Lymph Node Syndrome See Kawasaki Disease

Mucous Membrane, Impaired Oral Impaired Oral Mucous Membrane (See Oral Mucous Membrane, impaired, Section III)

Multi-Infarct Dementia See Dementia

Multiple Gestations Anxiety r/t uncertain outcome of pregnancy Death Anxiety r/t maternal complications associated with multiple gestations Insufficient Breast Milk r/t multiple births Ineffective Childbearing process r/t unavailable support system Fatigue r/t physiological demands of a multifetal pregnancy and/or care of more than one infant Impaired Home maintenance r/t fatigue Stress urinary Incontinence r/t increased pelvic pressure Insomnia r/t impairment of normal sleep pattern; parental responsibilities Deficient Knowledge r/t caring for more than one infant

82 Multiple Personality Disorder (Dissociative Identity Disorder)

M

Neonatal Jaundice r/t feeding pattern not well established Deficient Knowledge r/t caring for more than one infant Imbalanced Nutrition: less than body requirements r/t physi- ological demands of a multifetal pregnancy Stress overload r/t multiple coexisting stressors, family demands Impaired Walking r/t increased uterine size Risk for ineffective Breastfeeding: Risk factors: lack of support, physical demands of feeding more than one infant Risk for delayed Development: fetus: Risk factor: multiple gestations Risk for disproportionate Growth: fetus: Risk factor: multiple gestations Risk for neonatal Jaundice: Risk factors: abnormal weight loss, prematurity, feeding pattern not well-established Readiness for enhanced Childbearing process: demonstrates appropriate care for infants and mother Readiness for enhanced Family processes: family adapting to change with more than one infant

Multiple Personality Disorder (Dissociative Identity Disorder)

Anxiety r/t loss of control of behavior and feelings Disturbed Body Image r/t psychosocial changes Defensive Coping r/t unresolved past traumatic events, severe anxiety Ineffective Coping r/t history of abuse Hopelessness r/t long-term stress Disturbed personal Identity r/t severe child abuse Chronic low Self-Esteem r/t rejection, failure Risk for Self-Mutilation: Risk factor: need to act out to relieve stress Readiness for enhanced Communication: willingness to discuss problems associated with condition See Dissociative Identity Disorder (Not Otherwise Specified)

Multiple Sclerosis (MS) Ineffective Activity planning r/t unrealistic perception of per- sonal competence Ineffective Airway clearance r/t decreased energy or fatigue Impaired physical Mobility r/t neuromuscular impairment Self-Neglect r/t functional impairment Powerlessness r/t progressive nature of disease Self-Care deficit: specify r/t neuromuscular impairment Sexual dysfunction r/t biopsychosocial alteration of sexuality Chronic Sorrow r/t loss of physical ability Spiritual distress r/t perceived hopelessness of diagnosis Urinary Retention r/t inhibition of the reflex arc Risk for Disuse syndrome: Risk factor: physical immobility Risk for Injury: Risk factors: altered mobility, sensory dysfunction Risk for imbalanced Nutrition: less than body requirements: Risk factors: impaired swallowing, depression

Risk for Powerlessness: Risk factor: chronic illness Risk for impaired Religiosity: Risk factor: illness Risk for Thermal Injury: Risk factor: neuromuscular impairment Readiness for enhanced Health management: expresses a desire to manage condition Readiness for enhanced Self-Care: expresses desire to enhance knowledge of strategies and responsibility for self-care Readiness for enhanced Spiritual well-being: struggling with chronic debilitating condition See Neurologic Disorders

Mumps See Communicable Diseases, Childhood

Murmurs Decreased Cardiac output r/t altered preload/afterload Risk for decreased Cardiac tissue perfusion: Risk factor: incompetent valve Risk for Fatigue: Risk factor: decreased cardiac output

Muscular Atrophy/Weakness Risk for Disuse syndrome: Risk factor: impaired physical mobility Risk for Falls: Risk factor: impaired physical mobility

Muscular Dystrophy (MD) Activity intolerance r/t fatigue, muscle weakness Ineffective Activity planning r/t unrealistic perception of per- sonal competence Ineffective Airway clearance r/t muscle weakness and decreased ability to cough Constipation r/t immobility Fatigue r/t increased energy requirements to perform activities of daily living Impaired physical Mobility r/t muscle weakness and develop- ment of contractures Imbalanced Nutrition: less than body requirements r/t impaired swallowing or chewing Self-Care deficit: feeding, bathing, dressing, toileting r/t muscle weakness and fatigue Self-Neglect r/t functional impairment Impaired Transfer ability r/t muscle weakness Impaired Walking r/t muscle weakness Risk for Aspiration: Risk factor: impaired swallowing Risk for decreased Cardiac tissue perfusion: Risk factor: hypoxia associated with cardiomyopathy Risk for Disuse syndrome: Risk factor: complications of immobility Risk for Falls: Risk factor: muscle weakness Risk for Infection: Risk factor: pooling of pulmonary secretions as a result of immobility and muscle weakness Risk for Injury: Risk factors: muscle weakness and unsteady gait Risk for Overweight: Risk factor: inactivity

Risk for Powerlessness: Risk factor: chronic condition Risk for impaired Religiosity: Risk factor: illness Risk for impaired Resilience: Risk factor: chronic illness Risk for situational low Self-Esteem: Risk factor: presence of chronic condition Readiness for enhanced Self-Concept: acceptance of strength and abilities Risk for impaired Skin integrity: Risk factors: immobility, braces, or adaptive devices See Child with Chronic Condition; Hospitalized Child

MVC (Motor Vehicle Crash) See Fracture; Head Injury; Injury; Pneumothorax

Myasthenia Gravis Ineffective Airway clearance r/t decreased ability to cough and swallow Interrupted Family processes r/t crisis of dealing with diagnosis Fatigue r/t paresthesia, aching muscles, weakness of muscles Impaired physical Mobility r/t defective transmission of nerve impulses at the neuromuscular junction Imbalanced Nutrition: less than body requirements r/t diffi- culty eating and swallowing Impaired Swallowing r/t neuromuscular impairment Risk for Caregiver Role Strain: Risk factors: severity of illness of client, overwhelming needs of client Risk for impaired Religiosity: Risk factor: illness Risk for impaired Resilience: Risk factor: new diagnosis of chronic, serious illness Readiness for enhanced Spiritual well-being: heightened coping with serious illness See Neurologic Disorders

Mycoplasma Pneumonia See Pneumonia

Myelocele See Neural Tube Defects

Myelomeningocele See Neural Tube Defects

Myocardial Infarction (MI) See MI (Myocardial Infarction)

Myocarditis Activity intolerance r/t reduced cardiac reserve and prescribed bed rest Decreased Cardiac output r/t altered preload/afterload Deficient Knowledge r/t treatment of disease Risk for decreased Cardiac tissue perfusion: Risk factors: hypoxia, hypovolemia, cardiac tamponade Readiness for enhanced Knowledge: treatment of disease See Heart Failure, if appropriate

Myringotomy Fear r/t hospitalization, surgical procedure Ineffective Health maintenance r/t deficient knowledge regard- ing care after surgery Acute Pain r/t surgical procedure Risk for Infection: Risk factor: invasive procedure See Ear Surgery

Myxedema See Hypothyroidism

Near-Drowning 83

N

N Narcissistic Personality Disorder

Defensive Coping r/t grandiose sense of self Impaired emancipated Decision-Making r/t lack of realistic problem-solving skills Interrupted Family processes r/t taking advantage of others to achieve own goals Risk-prone Health behavior r/t low self-efficacy Disturbed personal Identity r/t psychological impairment Ineffective Relationship r/t lack of mutual support/respect between partners Impaired individual Resilience r/t psychological disorders Impaired Social interaction r/t self-concept disturbance Risk for Loneliness: Risk factors: emotional deprivation, social isolation

Narcolepsy Anxiety r/t fear of lack of control over falling asleep Disturbed Sleep pattern r/t uncontrollable desire to sleep Risk for Trauma: Risk factor: falling asleep during potentially dangerous activity Readiness for enhanced Sleep: expresses willingness to enhance sleep

Narcotic Use See Opiate Use (preferred terminology)

Nasogastric Suction Impaired Oral Mucous Membrane r/t presence of nasogas- tric tube Risk for Electrolyte imbalance: Risk factor: loss of gastrointes- tinal fluids that contain electrolytes Risk for imbalanced Fluid volume: Risk factor: loss of gastroin- testinal fluids without adequate replacement Risk for dysfunctional Gastrointestinal motility: Risk factor: decreased intestinal motility

Nausea Nausea (See Nausea, Section III)

Near-Drowning Ineffective Airway clearance r/t aspiration of fluid

e18

Narcissistic Personality Disorder Narcolepsy Narcotic Use Nasogastric Suction Nausea Near-Drowning Nearsightedness Nearsightedness; Corneal Surgery Neck Vein Distention Necrosis, Kidney Tubular; Necrosis, Acute Tubular

Necrotizing Enterocolitis Negative Feelings About Self

Neglect, Unilateral Neglectful Care of Family Member Neonatal Jaundice Neonate Neoplasm Nephrectomy Nephrostomy, Percutaneous Nephrotic Syndrome Neural Tube Defects (Meningocele,

Myelomeningocele, Spina Bifida, Anencephaly)

Neuralgia Neuritis (Peripheral Neuropathy) Neurogenic Bladder Neurologic Disorders Neuropathy, Peripheral Neurosurgery Newborn, Normal Newborn, Postmature Newborn, Small for Gestational Age

(SGA) Nicotine Addiction NIDDM (Non-Insulin-Dependent

Diabetes Mellitus) Nightmares

Nipple Soreness Nocturia Nocturnal Myoclonus Nocturnal Paroxysmal Dyspnea Noncompliance Non–Insulin-Dependent Diabetes

Mellitus (NIDDM) Normal Pressure Hydrocephalus (NPH)

Norovirus NSTEMI (non-ST-elevation myocardial infarction)

Nursing Nutrition Nutrition, Imbalanced

List of Nursing Assessments by Letter: N

84 Nearsightedness

N

Aspiration r/t aspiration of fluid into lungs Fear: parental r/t possible death of child, possible permanent and debilitating sequelae Impaired Gas exchange r/t laryngospasm, holding breath, aspi- ration, inflammation Grieving r/t potential death of child, unknown sequelae, guilt about accident Ineffective Health maintenance r/t parental deficient knowledge regarding safety measures appropriate for age Hypothermia r/t central nervous system injury, prolonged sub- mersion in cold water Risk for delayed Development: Risk factors: hypoxemia, cere- bral anoxia Risk for disproportionate Growth: Risk factor: exposure to violence Risk for complicated Grieving: Risk factors: potential death of child, unknown sequelae, guilt about accident Risk for Infection: Risk factors: aspiration, invasive monitoring Risk for ineffective Cerebral tissue perfusion: Risk factor: hypoxia Readiness for enhanced Spiritual well-being: struggle with sur- vival of life-threatening situation See Child with Chronic Condition; Hospitalized Child; Safety, Childhood; Terminally Ill Child/Death of Child, Parent

Nearsightedness Readiness for enhanced Health management: need for correc- tion of myopia

Nearsightedness; Corneal Surgery See LASIK Eye Surgery (Laser-Assisted in Situ Keratomileusis)

Neck Vein Distention Decreased Cardiac output r/t decreased contractility of heart resulting in increased preload Excess Fluid volume r/t excess fluid intake, compromised regu- latory mechanisms See Congestive Heart Failure; Heart Failure

Necrosis, Kidney Tubular; Necrosis, Acute Tubular

See Kidney Failure

Necrotizing Enterocolitis Ineffective Breathing pattern r/t abdominal distention, hypoxia Diarrhea r/t infection Deficient Fluid volume r/t vomiting, gastrointestinal bleeding Neonatal Jaundice r/t feeding pattern not well-established Imbalanced Nutrition: less than body requirements r/t decreased ability to absorb nutrients, decreased perfusion to gas- trointestinal tract Risk for dysfunctional Gastrointestinal motility: Risk factor: infection

Risk for ineffective Gastrointestinal perfusion: Risk factors: shunting of blood away from mesenteric circulation and toward vital organs as a result of perinatal stress, hypoxia Risk for Infection: Risk factors: bacterial invasion of gastroin- testinal tract, invasive procedures See Hospitalized Child; Premature Infant (Child)

Negative Feelings About Self Chronic low Self-Esteem r/t long-standing negative self-evaluation Self-Neglect r/t negative feelings Readiness for enhanced Self-Concept: expresses willingness to enhance self-concept

Neglect, Unilateral Unilateral Neglect (See Unilateral Neglect, Section III)

Neglectful Care of Family Member Caregiver Role Strain r/t overwhelming care demands of family member, lack of social or financial support Disabled family Coping r/t highly ambivalent family relation- ships, lack of respite care Interrupted Family processes r/t situational transition or crisis Deficient Knowledge r/t care needs Impaired individual Resilience r/t vulnerability from neglect Risk for compromised Human Dignity: Risk factor: inade- quate participation in decision-making

Neonatal Jaundice Neonatal Jaundice (See neonatal Jaundice, Section III)

Neonate Readiness for enhanced Childbearing process: appropriate care of newborn See Newborn, Normal; Newborn, Postmature; Newborn, Small for Gestational Age (SGA)

Neoplasm Fear r/t possible malignancy See Cancer

Nephrectomy Anxiety r/t surgical recovery, prognosis Ineffective Breathing pattern r/t location of surgical incision Constipation r/t lack of return of peristalsis Acute Pain r/t incisional discomfort Spiritual distress r/t chronic illness Risk for Bleeding: Risk factor: surgery Risk for imbalanced Fluid volume: Risk factors: vascular losses, decreased intake Risk for Infection: Risk factors: invasive procedure, lack of deep breathing because of location of surgical incision Risk for ineffective Renal perfusion: Risk factor: kidney disease

Nephrostomy, Percutaneous Acute Pain r/t invasive procedure

Neurologic Disorders 85

N

Impaired Urinary elimination r/t nephrostomy tube Risk for Infection: Risk factor: invasive procedure

Nephrotic Syndrome Activity intolerance r/t generalized edema Disturbed Body Image r/t edematous appearance and side effects of steroid therapy Excess Fluid volume r/t edema resulting from oncotic fluid shift caused by serum protein loss and kidney retention of salt and water Imbalanced Nutrition: less than body requirements r/t anorexia, protein loss Imbalanced Nutrition: more than body requirements r/t increased appetite attributable to steroid therapy Social isolation r/t edematous appearance Risk for Infection: Risk factor: altered immune mechanisms caused by disease and effects of steroids Risk for ineffective Renal perfusion: Risk factor: kidney disease Risk for impaired Skin integrity: Risk factor: edema See Child with Chronic Condition; Hospitalized Child

Neural Tube Defects (Meningocele, Myelomeningocele, Spina Bifida, Anencephaly)

Chronic functional Constipation r/t immobility or less than adequate mobility Grieving r/t loss of perfect child, birth of child with congenital defect Reflex urinary Incontinence r/t neurogenic impairment Total urinary Incontinence r/t neurogenic impairment Urge urinary Incontinence r/t neurogenic impairment Impaired Mobility r/t neuromuscular impairment Chronic low Self-Esteem r/t perceived differences, decreased ability to participate in physical and social activities at school Impaired Skin integrity r/t incontinence Risk for delayed Development: Risk factor: inadequate nutrition Risk for disproportionate Growth: Risk factor: congenital disorder Risk for Latex Allergy response: Risk factor: multiple expo- sures to latex products Risk for imbalanced Nutrition: more than body requirements: Risk factors: diminished, limited, or impaired physical activity Risk for Powerlessness: Risk factor: debilitating disease Risk for impaired Skin integrity: lower extremities: Risk factor: decreased sensory perception Readiness for enhanced family Coping: effective adaptive response by family members Readiness for enhanced Family processes: family supports each other See Child with Chronic Condition; Premature Infant (Child)

Neuralgia See Trigeminal Neuralgia

Neuritis (Peripheral Neuropathy) Activity intolerance r/t pain with movement Ineffective Health maintenance r/t deficient knowledge regard- ing self-care with neuritis Acute Pain r/t stimulation of affected nerve endings, inflamma- tion of sensory nerves See Neuropathy, Peripheral

Neurogenic Bladder Reflex urinary Incontinence r/t neurological impairment Urinary Retention r/t interruption in the lateral spinal tracts Risk for Latex Allergy response: Risk factor: repeated expo- sures to latex associated with possible repeated catheterizations

Neurologic Disorders Ineffective Airway clearance r/t perceptual or cognitive impair- ment, decreased energy, fatigue Acute Confusion r/t dementia, alcohol abuse, drug abuse, delirium Ineffective Coping r/t disability requiring change in lifestyle Interrupted Family processes r/t situational crisis, illness, or disability of family member Grieving r/t loss of usual body functioning Impaired Home maintenance r/t client’s or family member’s disease Risk for corneal Injury: Risk factor: lack of spontaneous blink reflex Impaired Memory r/t neurological disturbance Impaired physical Mobility r/t neuromuscular impairment Imbalanced Nutrition: less than body requirements r/t impaired swallowing, depression, difficulty feeding self Powerlessness r/t progressive nature of disease Self-Care deficit: specify r/t neuromuscular dysfunction Sexual dysfunction r/t biopsychosocial alteration of sexuality Social isolation r/t altered state of wellness Impaired Swallowing r/t neuromuscular dysfunction Risk for Disuse syndrome: Risk factors: physical immobility, neuromuscular dysfunction Risk for Injury: Risk factors: altered mobility, sensory dysfunc- tion, cognitive impairment Risk for ineffective Cerebral tissue perfusion: Risk factor: cere- bral disease/injury Risk for impaired Religiosity: Risk factor: life transition Risk for impaired Skin integrity: Risk factors: altered sensation, altered mental status, paralysis See specific condition: Alcohol Withdrawal; Amyotrophic Lateral Sclerosis (ALS); CVA (Cerebrovascular Accident); Delirium; Dementia; Guillain-Barré Syndrome; Head Injury; Huntington’s Disease; Spinal Cord Injury; Myasthenia Gravis; Muscular Dystro- phy; Parkinson’s Disease

86 Neuropathy, Peripheral

N

Neuropathy, Peripheral Chronic Pain r/t damage to nerves in the peripheral nervous system as a result of medication side effects, vitamin deficiency, or diabetes Ineffective Thermoregulation r/t decreased ability to regulate body temperature Risk for Injury: Risk factors: lack of muscle control, decreased sensation Risk for impaired Skin integrity: Risk factor: poor perfusion Risk for Thermal Injury r/t nerve damage See Peripheral Vascular Disease (PVD)

Neurosurgery See Craniectomy/Craniotomy

Newborn, Normal Breastfeeding r/t normal oral structure and gestational age greater than 34 weeks Ineffective Thermoregulation r/t immaturity of neuroendo- crine system Risk for Sudden Infant Death syndrome: Risk factors: lack of knowledge regarding infant sleeping in prone or side-lying position, prenatal or postnatal infant smoke exposure, infant overheating or overwrapping, loose articles in the sleep environment Risk for Infection: Risk factors: open umbilical stump, imma- ture immune system Risk for Injury: Risk factors: immaturity, need for caretaking Readiness for enhanced Childbearing process: appropriate care of newborn Readiness for enhanced organized Infant behavior: demon- strates adaptive response to pain Readiness for enhanced Parenting: providing emotional and physical needs of infant

Newborn, Postmature Hypothermia r/t depleted stores of subcutaneous fat Impaired Skin integrity r/t cracked and peeling skin as a result of decreased vernix Risk for ineffective Airway clearance: Risk factor: meconium aspiration Risk for unstable blood Glucose level: Risk factor: depleted glycogen stores

Newborn, Small for Gestational Age (SGA)

Neonatal Jaundice r/t neonate age and difficulty feeding Imbalanced Nutrition: less than body requirements r/t history of placental insufficiency Ineffective Thermoregulation r/t decreased brown fat, subcu- taneous fat Risk for delayed Development: Risk factor: history of placental insufficiency Risk for disproportionate Growth: Risk factor: history of pla- cental insufficiency

Risk for Injury: Risk factors: hypoglycemia, perinatal asphyxia, meconium aspiration Risk for Sudden Infant Death syndrome: Risk factor: low birth weight

Nicotine Addiction Risk-prone Health behavior r/t smoking Ineffective Health maintenance r/t lack of ability to make a judgment about smoking cessation Risk for impaired Skin integrity: Risk factor: poor tissue perfu- sion associated with nicotine Powerlessness r/t perceived lack of control over ability to give up nicotine Readiness for enhanced emancipated Decision-Making: expresses desire to enhance understanding and meaning of choices Readiness for enhanced Health management: expresses desire to learn measures to stop smoking

NIDDM (Non-Insulin-Dependent Diabetes Mellitus)

Readiness for enhanced Health management: expresses desire for information on exercise and diet to manage diabetes See Diabetes Mellitus

Nightmares Post-Trauma syndrome r/t disaster, war, epidemic, rape, assault, torture, catastrophic illness, or accident

Nipple Soreness Impaired Comfort r/t physical condition See Painful Breasts; Sore Nipples, Breastfeeding

Nocturia Urge urinary Incontinence r/t decreased bladder capacity, irritation of bladder stretch receptors causing spasm, alcohol, caffeine, increased fluids, increased urine concentration, overdis- tention of bladder Impaired Urinary elimination r/t sensory motor impairment, urinary tract infection Risk for Powerlessness: Risk factor: inability to control night- time voiding

Nocturnal Myoclonus See Restless Leg Syndrome; Stress

Nocturnal Paroxysmal Dyspnea See PND (Paroxysmal Nocturnal Dyspnea)

Noncompliance Ineffective Health management (See Health management, inef- fective, Section III)

Non–Insulin-Dependent Diabetes Mellitus (NIDDM)

See Diabetes Mellitus

Normal Pressure Hydrocephalus (NPH) Impaired verbal Communication r/t obstruction of flow of cerebrospinal fluid affecting speech Acute Confusion r/t increased intracranial pressure caused by obstruction to flow of cerebrospinal fluid Impaired Memory r/t neurological disturbance Risk for ineffective Cerebral tissue perfusion: Risk factor: fluid pressing on the brain Risk for Falls: Risk factor: unsteady gait as a result of obstruction of cerebrospinal fluid

Norovirus See Viral Gastroenteritis

NSTEMI (non-ST-elevation myocardial infarction)

See MI (Myocardial Infarction)

Nursing See Breastfeeding, Effective; Breastfeeding, Ineffective; Breastfeed- ing, Interrupted

Nutrition Readiness for enhanced Nutrition (See Nutrition, readiness for enhanced, Section III)

Nutrition, Imbalanced Imbalanced Nutrition: less than body requirements (See Nutri- tion: less than body requirements, imbalanced, Section III) Obesity (See Obesity, Section III) Overweight (See Overweight, Section III) Risk for Overweight (See Overweight, risk for, Section III)

Older Adult 87

O

O Obesity

Disturbed Body Image r/t eating disorder, excess weight Risk-prone Health behavior: r/t negative attitude toward health care Obesity (See Obesity, Section III) Chronic low Self-Esteem r/t ineffective coping, overeating Risk for ineffective peripheral Tissue Perfusion: Risk factor: sedentary lifestyle Readiness for enhanced Nutrition: expresses willingness to enhance nutrition

OBS (Organic Brain Syndrome) See Organic Mental Disorders; Dementia

Obsessive-Compulsive Disorder (OCD) See OCD (Obsessive-Compulsive Disorder)

Obstruction, Bowel See Bowel Obstruction

Obstructive Sleep Apnea Insomnia r/t blocked airway Obesity r/t excessive intake related to metabolic need See PND (Paroxysmal Nocturnal Dyspnea)

OCD (Obsessive-Compulsive Disorder) Ineffective Activity planning r/t unrealistic perception of events Anxiety r/t threat to self-concept, unmet needs Impaired emancipated Decision-Making r/t inability to make a decision for fear of reprisal Disabled family Coping r/t family process being disrupted by client’s ritualistic activities Ineffective Coping r/t expression of feelings in an unacceptable way, ritualistic behavior Risk-prone Health behavior r/t inadequate comprehension associated with repetitive thoughts Powerlessness r/t unrelenting repetitive thoughts to perform irrational activities Impaired individual Resilience r/t psychological disorder Risk for situational low Self-Esteem: Risk factor: inability to control repetitive thoughts and actions

ODD (Oppositional Defiant Disorder) Anxiety r/t feelings of anger and hostility toward authority figures Ineffective Coping r/t lack of self-control or perceived lack of self-control Disabled Family coping r/t feelings of anger, hostility; defiant behavior toward authority figures Risk-prone Health behavior r/t multiple stressors associated with condition Ineffective Impulse control r/t anger/compunction to engage in disruptive behaviors Chronic or situational low Self-Esteem r/t poor self-control and disruptive behaviors Impaired Social interaction r/t being touchy or easily annoyed, blaming others for own mistakes, constant trouble in school Social isolation r/t unaccepted social behavior Ineffective family Health management r/t difficulty in limit setting and managing oppositional behaviors Risk for ineffective Activity planning: Risk factors: unrealistic perception of events, hedonism, insufficient social support Risk for impaired Parenting: Risk factors: children’s difficult behaviors and inability to set limits Risk for Powerlessness: Risk factor: inability to deal with dif- ficult behaviors Risk for Spiritual distress: Risk factors: anxiety and stress in dealing with difficult behaviors Risk for other-directed Violence: Risk factors: history of vio- lence, threats of violence against others, history of antisocial behavior, history of indirect violence

Older Adult See Aging

e19

Obesity OBS (Organic Brain Syndrome) Obsessive-Compulsive Disorder (OCD)

Obstruction, Bowel Obstructive Sleep Apnea OCD (Obsessive-Compulsive Disorder)

ODD (Oppositional Defiant Disorder) Older Adult Oliguria Omphalocele Oophorectomy OPCAB (Off-Pump Coronary Artery

Bypass) Open Heart Surgery Open Reduction of Fracture with

Internal Fixation (Femur) Opiate Use

Opportunistic Infection Oppositional Defiant Disorder (ODD) Oral Mucous Membrane, Impaired Oral Thrush Orchitis Organic Mental Disorders Orthopedic Traction Orthopnea Orthostatic Hypotension Osteoarthritis Osteomyelitis Osteoporosis Ostomy Otitis Media Ovarian Carcinoma

List of Nursing Assessments by Letter: O

88 Oliguria

O

Oliguria Deficient Fluid volume r/t active fluid loss, failure of regulatory mechanism, inadequate intake See Cardiac Output, Decreased; Kidney Failure; Shock, Hypovolemic

Omphalocele See Gastroschisis/Omphalocele

Oophorectomy Risk for ineffective Sexuality pattern: Risk factor: altered body function See Surgery, Perioperative; Surgery, Postoperative; Surgery, Preoperative

OPCAB (Off-Pump Coronary Artery Bypass)

See Angioplasty, Coronary; Coronary Artery Bypass Grafting (CABG)

Open Heart Surgery Risk for decreased Cardiac tissue perfusion: Risk factor: cardiac surgery See Coronary Artery Bypass Grafting (CABG); Dysrhythmia

Open Reduction of Fracture with Internal Fixation (Femur)

Anxiety r/t outcome of corrective procedure Impaired physical Mobility r/t postoperative position, abduction of leg, avoidance of acute flexion Powerlessness r/t loss of control, unanticipated change in lifestyle Risk for Infection: Risk factor: surgical procedure Risk for Perioperative Positioning injury: Risk factor: immobilization Risk for Peripheral Neurovascular dysfunction: Risk factors: mechanical compression, orthopedic surgery, immobilization See Surgery, Postoperative Care

Opiate Use Chronic Pain syndrome r/t prolonged use of opiates Risk for Constipation: Risk factor: effects of opiates on peristalsis See Drug Abuse; Drug Withdrawal

Opportunistic Infection Delayed Surgical recovery r/t abnormal blood profiles, impaired healing Risk for Infection: Risk factor: abnormal blood profiles See AIDS (Acquired Immunodeficiency Syndrome); HIV (Human Immunodeficiency Virus)

Oppositional Defiant Disorder (ODD) See ODD (Oppositional Defiant Disorder)

Oral Mucous Membrane, Impaired Impaired Oral Mucous Membrane (See Oral Mucous Mem- brane, impaired, Section III)

Oral Thrush See Candidiasis, Oral

Orchitis Readiness for enhanced Health management: follows recom- mendations for mumps vaccination See Epididymitis

Organic Mental Disorders Frail Elderly syndrome r/t alteration in cognitive function Impaired Social interaction r/t disturbed thought processes Risk for disturbed personal Identity: Risk factor: delusions/ fluctuating perceptions of stimuli Risk for Infection: Risk factor: surgical procedure See Dementia

Orthopedic Traction Ineffective Role performance r/t limited physical mobility Impaired Social interaction r/t limited physical mobility Impaired Transfer ability r/t limited physical mobility Risk for impaired Religiosity: Risk factor: immobility See Traction and Casts

Orthopnea Ineffective Breathing pattern r/t inability to breathe with head of bed flat Decreased Cardiac output r/t inability of heart to meet demands of body

Orthostatic Hypotension See Dizziness

Osteoarthritis Acute Pain r/t movement Impaired Walking r/t inflammation and damage to joints See Arthritis

Osteomyelitis Deficient Diversional activity r/t prolonged immobilization, hospitalization Fear: parental r/t concern regarding possible growth plate damage caused by infection, concern that infection may become chronic Ineffective Health maintenance r/t continued immobility at home, possible extensive casts, continued antibiotics Impaired physical Mobility r/t imposed immobility as a result of infected area Acute Pain r/t inflammation in affected extremity Ineffective Thermoregulation r/t infectious process Risk for Constipation: Risk factor: immobility Risk for Infection: Risk factor: inadequate primary and second- ary defenses

Risk for impaired Skin integrity: Risk factor: irritation from splint or cast See Hospitalized Child

Osteoporosis Deficient Knowledge r/t diet, exercise, need to abstain from alcohol and nicotine Impaired physical Mobility r/t pain, skeletal changes Imbalanced Nutrition: less than body requirements r/t inade- quate intake of calcium and vitamin D Acute Pain r/t fracture, muscle spasms Risk for Injury: fracture: Risk factors: lack of activity, risk of falling resulting from environmental hazards, neuromuscular disorders, diminished senses, cardiovascular responses to drugs Risk for Powerlessness: Risk factor: debilitating disease Readiness for enhanced Health management: expresses desire to manage the treatment of illness and prevent complications

Ostomy See Child with Chronic Condition; Colostomy; Ileal Conduit; Ileostomy

Otitis Media Acute Pain r/t inflammation, infectious process Risk for delayed Development: speech and language: Risk factor: frequent otitis media Risk for Infection: Risk factors: eustachian tube obstruction, traumatic eardrum perforation, infectious disease process Readiness for enhanced Knowledge: information on treatment and prevention of disease

Ovarian Carcinoma Death Anxiety r/t unknown outcome, possible poor prognosis Fear r/t unknown outcome, possible poor prognosis Ineffective Health Maintenance r/t deficient knowledge regarding self-care, treatment of condition Readiness for enhanced Family Processes: family functioning meets needs of client Readiness for enhanced Resilience: participates in support groups See Chemotherapy; Hysterectomy; Radiation Therapy

Pancreatic Cancer 89

P

P Pacemaker

Anxiety r/t change in health status, presence of pacemaker Death Anxiety r/t worry over possible malfunction of pacemaker Deficient Knowledge r/t self-care program, when to seek medical attention Acute Pain r/t surgical procedure Risk for Bleeding: Risk factor: surgery

Risk for decreased Cardiac tissue perfusion: Risk factor: pace- maker malfunction Risk for Infection: Risk factors: invasive procedure, presence of foreign body (catheter and generator) Risk for Powerlessness: Risk factor: presence of electronic device to stimulate heart Readiness for enhanced Health management: appropriate health care management of pacemaker

Paget’s Disease Disturbed Body Image r/t possible enlarged head, bowed tibias, kyphosis Deficient Knowledge r/t appropriate diet high in protein and calcium, mild exercise Chronic Sorrow r/t chronic condition with altered body image Risk for Trauma: fracture: Risk factor: excessive bone destruction

Pain, Acute Acute Pain (See Pain, acute, Section III)

Pain, Chronic Chronic Pain (See Pain, chronic, Section III)

Painful Breasts, Engorgement Acute Pain r/t distention of breast tissue Ineffective Role performance r/t change in physical capacity to assume role of breastfeeding mother Impaired Tissue integrity r/t excessive fluid in breast tissues Risk for ineffective Breastfeeding: Risk factors: pain, infant’s inability to latch on to engorged breast Risk for Infection: Risk factor: milk stasis

Painful Breasts, Sore Nipples Insufficient Breast Milk r/t long breastfeeding time/pain response Ineffective Breastfeeding r/t pain Acute Pain r/t cracked nipples Ineffective Role performance r/t change in physical capacity to assume role of breastfeeding mother Impaired Skin integrity r/t mechanical factors involved in suck- ling, breastfeeding management Risk for Infection: Risk factor: break in skin

Pallor of Extremities Ineffective peripheral Tissue Perfusion r/t interruption of vas- cular flow See Shock; Peripheral Vascular disease (PVD)

Palpitations (Heart Palpitations) See Dysrhythmia

Pancreatic Cancer Death Anxiety r/t possible poor prognosis of disease process Ineffective family Coping r/t poor prognosis Fear r/t poor prognosis of the disease

e20

Pacemaker Paget’s Disease Pain, Acute Pain, Chronic Painful Breasts, Engorgement Painful Breasts, Sore Nipples Pallor of Extremities Palpitations (Heart Palpitations) Pancreatic Cancer Pancreatitis Panic Disorder (Panic Attacks) Paralysis Paralytic Ileus Paranoid Personality Disorder Paraplegia Parathyroidectomy Parent Attachment Parental Role Conflict Parenting Parenting, Impaired Parenting, Risk for Impaired Paresthesia Parkinson’s Disease Paroxysmal Nocturnal Dyspnea (PND) Patent Ductus Arteriosus (PDA) Patient-Controlled Analgesia (PCA) Patient Education PCA (Patient-Controlled Analgesia) Pectus Excavatum Pediculosis PEG (Percutaneous Endoscopic Gastrostomy)

Pelvic Inflammatory Disease (PID) Penile Prosthesis

Peptic Ulcer Percutaneous Transluminal Coronary Angioplasty (PTCA)

Pericardial Friction Rub

Pericarditis Periodontal Disease Perioperative Hypothermia Perioperative Positioning Peripheral Neuropathy Peripheral Neurovascular Dysfunction Peripheral Vascular Disease (PVD) Peritoneal Dialysis Peritonitis Pernicious Anemia Persistent Fetal Circulation Personal Identity Problems Personality Disorder Pertussis (Whooping Cough) Pesticide Contamination Petechiae Petit Mal Seizure Pharyngitis Phenylketonuria (PKU) Pheochromocytoma Phlebitis Phobia (Specific) Photosensitivity Physical Abuse Pica PID (Pelvic Inflammatory Disease) PIH (Pregnancy-Induced

Hypertension/Preeclampsia) Piloerection Pimples Pink Eye Pinworms Pituitary Tumor, Benign PKU (Phenylketonuria) Placenta Abruptio Placenta Previa Plantar Fasciitis

List of Nursing Assessments by Letter: P

List of Nursing Assessments by Letter: P e21

Pleural Effusion Pleural Friction Rub Pleural Tap Pleurisy PMS (Premenstrual Tension

Syndrome) PND (Paroxysmal Nocturnal Dyspnea)

Pneumonectomy Pneumonia Pneumothorax Poisoning, Risk for Poliomyelitis Polydipsia Polyphagia Polyuria Postoperative Care Postpartum Depression Postpartum Hemorrhage Postpartum, Normal Care Post-Trauma Syndrome Post-Trauma Syndrome, Risk for Post-Traumatic Stress Disorder (PTSD) Potassium, Increase/Decrease Power/Powerlessness Preeclampsia Pregnancy, Cardiac Disorders Pregnancy-Induced Hypertension/

Preeclampsia (PIH) Pregnancy Loss

Pregnancy, Normal Premature Dilation of the Cervix (Incompetent Cervix)

Premature Infant (Child)

Premature Infant (Parent) Premature Rupture of Membranes Premenstrual Tension Syndrome (PMS)

Prenatal Care, Normal Prenatal Testing Preoperative Teaching Pressure Ulcer Preterm Labor Problem-Solving Dysfunction Projection Prolapsed Umbilical Cord Prostatectomy Prostatic Hypertrophy Prostatitis Pruritus Psoriasis Psychosis PTCA (Percutaneous Transluminal

Coronary Angioplasty) PTSD (Posttraumatic Stress Disorder) Pulmonary Edema Pulmonary Embolism Pulmonary Stenosis Pulse Deficit Pulse Oximetry Pulse Pressure, Increased Pulse Pressure, Narrowed Pulses, Absent or Diminished

Peripheral Purpura Pyelonephritis Pyloric Stenosis Pyloromyotomy (Pyloric Stenosis Repair)

90 Pancreatitis

P

Grieving r/t shortened life span Deficient Knowledge r/t disease-induced diabetes, home management Spiritual distress r/t poor prognosis Risk for impaired Liver function: Risk factor: complications from underlying disease See Cancer; Chemotherapy; Radiation Therapy; Surgery, Periop- erative; Surgery, Postoperative; Surgery, Preoperative

Pancreatitis Ineffective Breathing pattern r/t splinting from severe pain, disease process and inflammation Ineffective Denial r/t ineffective coping, alcohol use Diarrhea r/t decrease in pancreatic secretions resulting in steatorrhea Deficient Fluid volume r/t vomiting, decreased fluid intake, fever, diaphoresis, fluid shifts Ineffective Health maintenance r/t deficient knowledge con- cerning diet, alcohol use, medication Nausea r/t irritation of gastrointestinal system Imbalanced Nutrition: less than body requirements r/t inade- quate dietary intake, increased nutritional needs as a result of acute illness, increased metabolic needs caused by increased body temperature, disease process Acute Pain r/t irritation and edema of the inflamed pancreas Chronic Sorrow r/t chronic illness Readiness for enhanced Comfort: expresses desire to enhance comfort

Panic Disorder (Panic Attacks) Ineffective Activity planning r/t unrealistic perception of events Anxiety r/t situational crisis Ineffective Coping r/t personal vulnerability Risk-prone Health behavior r/t low self-efficacy Disturbed personal Identity r/t situational crisis Post-Trauma syndrome r/t previous catastrophic event Social isolation r/t fear of lack of control Risk for Loneliness: Risk factor: inability to socially interact because of fear of losing control Risk for Post-Trauma syndrome: Risk factors: perception of the event, diminished ego strength Risk for Powerlessness: Risk factor: ineffective coping skills Readiness for enhanced Coping: seeks problem-oriented and emotion-oriented strategies to manage condition See Anxiety; Anxiety Disorder

Paralysis Disturbed Body Image r/t biophysical changes, loss of move- ment, immobility Impaired Comfort r/t prolonged immobility Constipation r/t effects of spinal cord disruption, inadequate fiber in diet

Ineffective Health maintenance r/t deficient knowledge regard- ing self-care with paralysis Impaired Home maintenance r/t physical disability Reflex urinary Incontinence r/t neurological impairment Impaired physical Mobility r/t neuromuscular impairment Impaired wheelchair Mobility r/t neuromuscular impairment Self-Neglect r/t functional impairment Powerlessness r/t illness-related regimen Self-Care deficit: specify r/t neuromuscular impairment Sexual dysfunction r/t loss of sensation, biopsychosocial alteration Chronic Sorrow r/t loss of physical mobility Impaired Transfer ability r/t paralysis Risk for Autonomic Dysreflexia: Risk factor: cause of paralysis Risk for Disuse syndrome: Risk factor: paralysis Risk for Falls: Risk factor: paralysis Risk for Injury: Risk factors: altered mobility, sensory dysfunction Risk for Latex Allergy response: Risk factor: possible repeated urinary catheterizations Risk for Post-Trauma syndrome: Risk factor: event causing paralysis Risk for impaired Religiosity: Risk factors: immobility, possible lack of transportation Risk for impaired Resilience: Risk factor: chronic disability Risk for situational low Self-Esteem: Risk factor: change in body image and function Risk for impaired Skin integrity: Risk factors: altered circulation, altered sensation, immobility Readiness for enhanced Self-Care: expresses desire to enhance knowledge and responsibility for strategies for self-care See Child with Chronic Condition; Hemiplegia; Hospitalized Child; Neural Tube Defects; Spinal Cord Injury

Paralytic Ileus Constipation r/t decreased gastrointestinal motility Deficient Fluid volume r/t loss of fluids from vomiting, retention of fluid in bowel Dysfunctional Gastrointestinal motility r/t recent abdominal surgery, electrolyte imbalance Nausea r/t gastrointestinal irritation Acute Pain r/t pressure, abdominal distention, presence of naso- gastric tube See Bowel Obstruction

Paranoid Personality Disorder Ineffective Activity planning r/t unrealistic perception of events Anxiety r/t uncontrollable intrusive, suspicious thoughts Risk-prone Health behavior r/t intense emotional state Disturbed personal Identity r/t difficulty with reality testing

Pelvic Inflammatory Disease (PID) 91

P

Impaired individual Resilience r/t psychological disorder Chronic low Self-Esteem r/t inability to trust others Social isolation r/t inappropriate social skills Risk for Loneliness: Risk factor: social isolation Risk for other-directed Violence: Risk factor: being suspicious of others and their actions

Paraplegia See Spinal Cord Injury

Parathyroidectomy Anxiety r/t surgery Risk for ineffective Airway clearance: Risk factors: edema or hematoma formation, airway obstruction Risk for Bleeding: Risk factor: surgery Risk for impaired verbal Communication: Risk factors: pos- sible laryngeal damage, edema Risk for Infection: Risk factor: surgical procedure See Hypocalcemia

Parent Attachment Risk for impaired Attachment (See Attachment, impaired, risk for, Section III) Readiness for enhanced Childbearing process: demonstrates appropriate care of newborn See Parental Role Conflict

Parental Role Conflict Parental Role conflict (See Role conflict, parental, Section III) Ineffective Relationship r/t unrealistic expectations Chronic Sorrow r/t difficult parent–child relationship Risk for Spiritual distress: Risk factor: altered relationships Readiness for enhanced Parenting: willingness to enhance parenting

Parenting Readiness for enhanced Parenting (See Parenting, readiness for enhanced, Section III)

Parenting, Impaired Impaired Parenting (See Parenting, impaired, Section III) Chronic Sorrow r/t difficult parent–child relationship Risk for Spiritual distress: Risk factor: altered relationships

Parenting, Risk for Impaired Risk for impaired Parenting (See Parenting, impaired, risk for, Section III) See Parenting, Impaired

Paresthesia Risk for Injury: Risk factors: inability to feel temperature changes, pain Risk for impaired Skin integrity: Risk factor: impaired sensation Risk for Thermal injury: Risk factor: neuromuscular impairment

Parkinson’s Disease Impaired verbal Communication r/t decreased speech volume, slowness of speech, impaired facial muscles Constipation r/t weakness of muscles, lack of exercise, inadequate fluid intake, decreased autonomic nervous system activity Frail Elderly syndrome r/t chronic illness Imbalanced Nutrition: less than body requirements r/t tremor, slowness in eating, difficulty in chewing and swallowing Chronic Sorrow r/t loss of physical capacity Risk for Injury: Risk factors: tremors, slow reactions, altered gait See Neurologic Disorders

Paroxysmal Nocturnal Dyspnea (PND) See PND (Paroxysmal Nocturnal Dyspnea)

Patent Ductus Arteriosus (PDA) See Congenital Heart Disease/Cardiac Anomalies

Patient-Controlled Analgesia (PCA) See PCA (Patient-Controlled Analgesia)

Patient Education Deficient Knowledge r/t lack of exposure to information misinterpretation, unfamiliarity with information resources to manage illness Readiness for enhanced emancipated Decision-Making: expresses desire to enhance understanding of choices for decision-making Readiness for enhanced Knowledge (specify): interest in learning Readiness for enhanced Health management: expresses desire for information to manage the illness

PCA (Patient-Controlled Analgesia) Deficient Knowledge r/t self-care of pain control Nausea r/t side effects of medication Risk for Injury: Risk factors: possible complications associated with PCA Risk for Vascular Trauma: Risk factors: insertion site and length of insertion time Readiness for enhanced Knowledge: appropriate management of PCA

Pectus Excavatum See Marfan Syndrome

Pediculosis See Lice

PEG (Percutaneous Endoscopic Gastrostomy)

See Tube Feeding

Pelvic Inflammatory Disease (PID) See PID (Pelvic Inflammatory Disease)

92 Penile Prosthesis

P

Penile Prosthesis Ineffective Sexuality pattern r/t use of penile prosthesis Risk for Infection: Risk factor: invasive surgical procedure Risk for situational low Self-Esteem: Risk factor: ineffective sexuality pattern Readiness for enhanced Health management: seeks informa- tion regarding care and use of prosthesis See Erectile Dysfunction (ED); Impotence

Peptic Ulcer See Ulcer, Peptic (Duodenal or Gastric)

Percutaneous Transluminal Coronary Angioplasty (PTCA)

See Angioplasty, Coronary

Pericardial Friction Rub Decreased Cardiac output Acute Pain r/t inflammation, effusion Risk for decreased Cardiac tissue perfusion: Risk factors: inflammation in pericardial sac, fluid accumulation compressing heart

Pericarditis Activity intolerance r/t reduced cardiac reserve, prescribed bed rest Decreased Cardiac output r/t impaired cardiac function from inflammation of pericardial sac Risk for decreased Cardiac tissue perfusion: Risk factor: inflammation in pericardial sac Deficient Knowledge r/t unfamiliarity with information sources Risk for imbalanced Nutrition: less than body requirements: Risk factors: fever, hypermetabolic state associated with fever Acute Pain r/t biological injury, inflammation

Periodontal Disease Risk for impaired Oral Mucous Membranes (See Oral Mucous Membranes, impaired, risk for, Section III)

Perioperative Hypothermia Risk for Perioperative Hypothermia (See Perioperative Hypothermia, risk for, Section III)

Perioperative Positioning Risk for Perioperative Positioning injury (See Perioperative Positioning injury, risk for, Section III)

Peripheral Neuropathy See Neuropathy, Peripheral

Peripheral Neurovascular Dysfunction Risk for Peripheral Neurovascular dysfunction (See Periph- eral Neurovascular dysfunction, risk for, Section III) See Neuropathy, Peripheral; Peripheral Vascular Disease (PVD)

Peripheral Vascular Disease (PVD) Ineffective Health maintenance r/t deficient knowledge regard- ing self-care and treatment of disease

Chronic Pain: intermittent claudication r/t ischemia Ineffective peripheral Tissue Perfusion r/t disease process Risk for Falls: Risk factor: altered mobility Risk for Injury: Risk factors: tissue hypoxia, altered mobility, altered sensation Risk for Peripheral Neurovascular dysfunction: Risk factor: possible vascular obstruction Risk for impaired Tissue integrity: Risk factor: altered circula- tion or sensation Readiness for enhanced Health management: self-care and treatment of disease See Neuropathy, Peripheral; Peripheral Neurovascular Dysfunction

Peritoneal Dialysis Ineffective Breathing pattern r/t pressure from dialysate Impaired Comfort r/t instillation of dialysate, temperature of dialysate Impaired Home maintenance r/t complex home treatment of client Deficient Knowledge r/t treatment procedure, self-care with peritoneal dialysis Chronic Sorrow r/t chronic disability Risk for ineffective Coping: Risk factor: disability requiring change in lifestyle Risk for unstable blood Glucose level: Risk factors: increased concentrations of glucose in dialysate, ineffective medication management Risk for imbalanced Fluid volume: Risk factor: medical procedure Risk for Infection: peritoneal: Risk factors: invasive procedure, presence of catheter, dialysate Risk for Powerlessness: Risk factors: chronic condition and care involved See Child with Chronic Condition; Hemodialysis; Hospitalized Child; Kidney Failure; Kidney Failure, Acute/Chronic, Child

Peritonitis Ineffective Breathing pattern r/t pain, increased abdominal pressure Constipation r/t decreased oral intake, decrease of peristalsis Deficient Fluid volume r/t retention of fluid in bowel with loss of circulating blood volume Nausea r/t gastrointestinal irritation Imbalanced Nutrition: less than body requirements r/t nausea, vomiting Acute Pain r/t inflammation and infection of gastrointestinal system Risk for dysfunctional Gastrointestinal motility: Risk factor: gastrointestinal disease

Pernicious Anemia Diarrhea r/t malabsorption of nutrients Fatigue r/t imbalanced nutrition: less than body requirements

PID (Pelvic Inflammatory Disease) 93

P

Impaired Memory r/t lack of adequate red blood cells Nausea r/t altered oral mucous membrane; sore tongue, bleed- ing gums Imbalanced Nutrition: less than body requirements r/t lack of appetite associated with nausea and altered oral mucous membrane Impaired Oral Mucous Membrane r/t vitamin deficiency; inability to absorb vitamin B12 associated with lack of intrinsic factor Risk for Falls: Risk factors: dizziness, lightheadedness Risk for Peripheral Neurovascular dysfunction: Risk factor: anemia

Persistent Fetal Circulation See Congenital Heart Disease/Cardiac Anomalies

Personal Identity Problems Disturbed personal Identity (See Identity, personal, disturbed, Section III) Risk for disturbed personal Identity (See disturbed personal Identity, risk for, Section III)

Personality Disorder Ineffective Activity planning r/t unrealistic perception of events Impaired individual Resilience r/t psychological disorder See specific disorder: Antisocial Personality Disorder; Borderline Personality Disorder; OCD (Obsessive-Compulsive Disorder); Paranoid Personality Disorder

Pertussis (Whooping Cough) Risk for impaired emancipated Decision-Making r/t whether to administer usual childhood vaccinations See Respiratory Infections, Acute Childhood

Pesticide Contamination Contamination r/t use of environmental contaminants; pesticides Risk for Allergy response r/t repeated exposure to pesticides Risk for disproportionate Growth: Risk factor: environmental contamination

Petechiae See Anticoagulant Therapy; Clotting Disorder; DIC (Disseminated Intravascular Coagulation); Hemophilia

Petit Mal Seizure Readiness for enhanced Health management: wears medical alert bracelet; limits hazardous activities such as driving, swim- ming, working at heights, operating equipment See Epilepsy

Pharyngitis See Sore Throat

Phenylketonuria (PKU) See PKU (Phenylketonuria)

Pheochromocytoma Anxiety r/t symptoms from increased catecholamines— headache, palpitations, sweating, nervousness, nausea, vomiting, syncope Ineffective Health maintenance r/t deficient knowledge regard- ing treatment and self-care Insomnia r/t high levels of catecholamines Nausea r/t increased catecholamines Risk for decreased Cardiac tissue perfusion: Risk factor: hypertension See Surgery, Perioperative; Surgery, Postoperative; Surgery, Preoperative

Phlebitis See Thrombophlebitis

Phobia (Specific) Fear r/t presence or anticipation of specific object or situation Powerlessness r/t anxiety about encountering unknown or known entity Impaired individual Resilience r/t psychological disorder Readiness for enhanced Power: expresses readiness to enhance identification of choices that can be made for change See Anxiety; Anxiety Disorder; Panic Disorder (Panic Attacks)

Photosensitivity Ineffective Health maintenance r/t deficient knowledge regard- ing medications inducing photosensitivity Risk for dry Eye: Risk factors: pharmaceutical agents, sunlight exposure Risk for impaired Skin integrity: Risk factor: exposure to sun

Physical Abuse See Abuse, Child; Abuse, Spouse, Parent, or Significant Other

Pica Anxiety r/t stress Imbalanced Nutrition: less than body requirements r/t eating nonnutritive substances Impaired Parenting r/t lack of supervision, food deprivation Risk for Constipation: Risk factor: presence of undigestible materials in gastrointestinal tract Risk for dysfunctional Gastrointestinal motility: Risk factor: abnormal eating behavior Risk for Infection: Risk factor: ingestion of infectious agents via contaminated substances Risk for Poisoning: Risk factor: ingestion of substances contain- ing lead See Anemia

PID (Pelvic Inflammatory Disease) Ineffective Health maintenance r/t deficient knowledge regard- ing self-care, treatment of disease Acute Pain r/t biological injury; inflammation, edema, conges- tion of pelvic tissues

94 PIH (Pregnancy-Induced Hypertension/Preeclampsia)

P

Ineffective Sexuality pattern r/t medically imposed abstinence from sexual activities until acute infection subsides, change in reproductive potential Risk for Infection: Risk factors: insufficient knowledge to avoid exposure to pathogens; proper hygiene, nutrition, other health habits See Maturational Issues, Adolescent; STD (Sexually Transmitted Disease)

PIH (Pregnancy-Induced Hypertension/ Preeclampsia)

Anxiety r/t fear of the unknown, threat to self and infant, change in role functioning Death Anxiety r/t threat of preeclampsia Deficient Diversional activity r/t bed rest Interrupted Family processes r/t situational crisis Impaired Home maintenance r/t bed rest Deficient Knowledge r/t lack of experience with situation Impaired physical Mobility r/t medically prescribed limitations Impaired Parenting r/t prescribed bed rest Powerlessness r/t complication threatening pregnancy, medi- cally prescribed limitations Ineffective Role performance r/t change in physical capacity to assume role of pregnant woman or resume other roles Situational low Self-Esteem r/t loss of idealized pregnancy Impaired Social interaction r/t imposed bed rest Risk for imbalanced Fluid volume: Risk factors: hypertension, altered kidney function Risk for Injury: fetal: Risk factors: decreased uteroplacental per- fusion, seizures Risk for Injury: maternal: Risk factors: vasospasm, high blood pressure Readiness for enhanced Knowledge: exhibits desire for infor- mation on managing condition

Piloerection Hypothermia r/t exposure to cold environment

Pimples See Acne

Pink Eye See Conjunctivitis

Pinworms Impaired Comfort r/t itching Impaired Home maintenance r/t inadequate cleaning of bed linen and toilet seats Insomnia r/t discomfort Readiness for enhanced Health management: proper hand- washing; short, clean fingernails; avoiding hand, mouth, nose contact with unwashed hands; appropriate cleaning of bed linen and toilet seats

Pituitary Tumor, Benign See Cushing’s Disease

PKU (Phenylketonuria) Risk for delayed Development: Risk factors: not following strict dietary program; eating foods extremely low in phenylala- nine; avoiding eggs, milk, any foods containing aspartame (e.g., NutraSweet) Readiness for enhanced Health management: testing for PKU and following prescribed dietary regimen

Placenta Abruptio Death Anxiety r/t threat of mortality associated with bleeding Fear r/t threat to self and fetus Ineffective Health maintenance r/t deficient knowledge regard- ing treatment and control of hypertension associated with pla- centa abruptio Acute Pain: abdominal/back r/t premature separation of pla- centa before delivery Risk for Bleeding: Risk factor: placenta abruptio Risk for deficient Fluid volume: Risk factor: maternal blood loss Risk for Powerlessness: Risk factors: complications of preg- nancy and unknown outcome Risk for Shock: Risk factor: hypovolemia Risk for Spiritual distress: Risk factor: fear from unknown outcome of pregnancy

Placenta Previa Death Anxiety r/t threat of mortality associated with bleeding Disturbed Body Image r/t negative feelings about body and reproductive ability, feelings of helplessness Ineffective Coping r/t threat to self and fetus Deficient Diversional activity r/t long-term hospitalization Interrupted Family processes r/t maternal bed rest, hospitalization Fear r/t threat to self and fetus, unknown future Impaired Home maintenance r/t maternal bed rest, hospitalization Impaired physical Mobility r/t medical protocol, maternal bed rest Ineffective Role performance r/t maternal bed rest, hospitalization Situational low Self-Esteem r/t situational crisis Spiritual distress r/t inability to participate in usual religious rituals, situational crisis Risk for Bleeding: Risk factor: placenta previa Risk for Constipation: Risk factors: bed rest, pregnancy Risk for deficient Fluid volume: Risk factor: maternal blood loss Risk for imbalanced Fluid volume: Risk factor: maternal blood loss Risk for Injury: fetal and maternal: Risk factors: threat to utero- placental perfusion, hemorrhage Risk for disturbed Maternal–Fetal dyad: Risk factor: complica- tion of pregnancy

Polydipsia 95

P

Risk for impaired Parenting: Risk factors: maternal bed rest, hospitalization Risk for ineffective peripheral Tissue Perfusion: placental: Risk factors: dilation of cervix, loss of placental implantation site Risk for Powerlessness: Risk factors: complications of preg- nancy, unknown outcome Risk for Shock: Risk factor: hypovolemia

Plantar Fasciitis Impaired Comfort r/t inflamed structures of feet Impaired physical Mobility r/t discomfort Acute Pain r/t inflammation Chronic Pain r/t inflammation

Pleural Effusion Ineffective Breathing pattern r/t pain Excess Fluid volume r/t compromised regulatory mechanisms; heart, liver, or kidney failure Acute Pain r/t inflammation, fluid accumulation

Pleural Friction Rub Ineffective Breathing pattern r/t pain Acute Pain r/t inflammation, fluid accumulation

Pleural Tap See Pleural Effusion

Pleurisy Ineffective Breathing pattern r/t pain Impaired Gas exchange r/t ventilation perfusion imbalance Acute Pain r/t pressure on pleural nerve endings associated with fluid accumulation or inflammation Impaired Walking r/t activity intolerance, inability to “catch breath” Risk for ineffective Airway clearance: Risk factors: increased secretions, ineffective cough because of pain Risk for Infection: Risk factor: exposure to pathogens

PMS (Premenstrual Tension Syndrome) Fatigue r/t hormonal changes Excess Fluid volume r/t alterations of hormonal levels inducing fluid retention Deficient Knowledge r/t methods to deal with and prevent syndrome Acute Pain r/t hormonal stimulation of gastrointestinal structures Risk for Powerlessness: Risk factors: lack of knowledge and ability to deal with symptoms Risk for impaired Resilience: Risk factor: PMS symptoms Readiness for enhanced Communication: willingness to express thoughts and feelings about PMS Readiness for enhanced Health management: desire for infor- mation to manage and prevent symptoms

PND (Paroxysmal Nocturnal Dyspnea) Anxiety r/t inability to breathe during sleep

Ineffective Breathing pattern r/t increase in carbon dioxide levels, decrease in oxygen levels Insomnia r/t suffocating feeling from fluid in lungs on awaken- ing from sleep Sleep deprivation r/t inability to breathe during sleep Risk for decreased Cardiac tissue perfusion: Risk factor: hypoxia Risk for Powerlessness: Risk factor: inability to control noc- turnal dyspnea Readiness for enhanced Sleep: expresses willingness to learn measures to enhance sleep

Pneumonectomy See Thoracotomy

Pneumonia Activity intolerance r/t imbalance between oxygen supply and demand Ineffective Airway clearance r/t inflammation and presence of secretions Impaired Gas exchange r/t decreased functional lung tissue Ineffective Health management r/t deficient knowledge regard- ing self-care and treatment of disease Imbalanced Nutrition: less than body requirements r/t loss of appetite Impaired Oral Mucous Membrane r/t dry mouth from mouth breathing, decreased fluid intake Ineffective Thermoregulation r/t infectious process Risk for acute Confusion: Risk factors: underlying illness, hypoxia Risk for deficient Fluid volume: Risk factor: inadequate intake of fluids Risk for Vascular Trauma: Risk factor: irritation from intrave- nous antibiotics See Respiratory Infections, Acute Childhood

Pneumothorax Fear r/t threat to own well-being, difficulty breathing Impaired Gas exchange r/t ventilation-perfusion imbalance, decreased functional lung tissue Acute Pain r/t recent injury, coughing, deep breathing Risk for Injury: Risk factor: possible complications associated with closed chest drainage system See Chest Tubes

Poisoning, Risk for Risk for Poisoning (See Poisoning, risk for, Section III)

Poliomyelitis See Paralysis

Polydipsia Readiness for enhanced Fluid balance: excessive thirst gone when diabetes is controlled See Diabetes Mellitus

96 Polyphagia

P

Polyphagia Readiness for enhanced Nutrition: knowledge of appropriate diet for diabetes See Diabetes Mellitus

Polyuria Readiness for enhanced Urinary elimination: willingness to learn measures to enhance urinary elimination See Diabetes Mellitus

Postoperative Care See Surgery, Postoperative

Postpartum Depression Anxiety r/t new responsibilities of parenting Disturbed Body Image r/t normal postpartum recovery Ineffective Childbearing process r/t depression/lack of support system Ineffective Coping r/t hormonal changes Fatigue r/t childbirth, postpartum state, crying child Risk-prone Health behavior r/t lack of support systems Impaired Home maintenance r/t fatigue, care of newborn Hopelessness r/t stress, exhaustion Deficient Knowledge r/t lifestyle changes Impaired Parenting r/t hormone-induced depression Ineffective Role performance r/t new responsibilities of parenting Sexual dysfunction r/t fear of another pregnancy, postpartum pain, lochia flow Sleep deprivation r/t environmental stimulation of newborn Impaired Social interaction r/t change in role functioning Risk for disturbed personal Identity r/t role change/depression/ inability to cope Risk for situational low Self-Esteem: Risk factor: decreased power over feelings of sadness Risk for Spiritual distress: Risk factors: altered relationships, social isolation Readiness for enhanced Hope: expresses desire to enhance hope and interconnectedness with others See Depression (Major Depressive Disorder)

Postpartum Hemorrhage Activity intolerance r/t anemia from loss of blood Death Anxiety r/t threat of mortality associated with bleeding Disturbed Body Image r/t loss of ideal childbirth Insufficient Breast Milk r/t fluid volume depletion Interrupted Breastfeeding r/t separation from infant for medical treatment Decreased Cardiac output r/t hypovolemia Fear r/t threat to self, unknown future Deficient Fluid volume r/t uterine atony, loss of blood Impaired Home maintenance r/t lack of stamina

Deficient Knowledge r/t lack of exposure to situation Acute Pain r/t nursing and medical interventions to control bleeding Ineffective peripheral Tissue Perfusion r/t hypovolemia Risk for Bleeding: Risk factor: postpartum complications Risk for impaired Childbearing: Risk factor: postpartum complication Risk for imbalanced Fluid volume: Risk factor: maternal blood loss Risk for Infection: Risk factors: loss of blood, depressed immunity Risk for impaired Parenting: Risk factor: weakened maternal condition Risk for Powerlessness: Risk factor: acute illness Risk for Shock: Risk factor: hypovolemia

Postpartum, Normal Care Anxiety r/t change in role functioning, parenting Effective Breastfeeding r/t basic breastfeeding knowledge, support of partner and health care provider Fatigue r/t childbirth, new responsibilities of parenting, body changes Acute Pain r/t episiotomy, lacerations, bruising, breast engorge- ment, headache, sore nipples, epidural or intravenous site, hemorrhoids Sexual dysfunction r/t recent childbirth Impaired Tissue integrity r/t episiotomy, lacerations Sleep deprivation r/t care of infant Impaired Urinary elimination r/t effects of anesthesia, tissue trauma Risk for Constipation: Risk factors: hormonal effects on smooth muscles, fear of straining with defecation, effects of anesthesia Risk for Infection: Risk factors: tissue trauma, blood loss Readiness for enhanced family Coping: adaptation to new family member Readiness for enhanced Hope: desire to increase hope Readiness for enhanced Parenting: expresses willingness to enhance parenting skills

Post-Trauma Syndrome Post-Trauma syndrome (See Post-Trauma syndrome, Section III)

Post-Trauma Syndrome, Risk for Risk for Post-Trauma syndrome (See Post-Trauma syndrome, risk for, Section III)

Post-Traumatic Stress Disorder (PTSD) See PTSD (Post-Traumatic Stress Disorder)

Potassium, Increase/Decrease See Hyperkalemia; Hypokalemia

Power/Powerlessness Powerlessness (See Powerlessness, Section III)

Premature Dilation of the Cervix (Incompetent Cervix) 97

P

Risk for Powerlessness (See Powerlessness, risk for, Section III) Readiness for enhanced Power (See Power, readiness for enhanced, Section III)

Preeclampsia See PIH (Pregnancy-Induced Hypertension/Preeclampsia)

Pregnancy, Cardiac Disorders See Cardiac Disorders in Pregnancy

Pregnancy-Induced Hypertension/ Preeclampsia (PIH)

See PIH (Pregnancy-Induced Hypertension/Preeclampsia)

Pregnancy Loss Anxiety r/t threat to role functioning, health status, situational crisis Compromised family Coping r/t lack of support by significant other because of personal suffering Ineffective Coping r/t situational crisis Grieving r/t loss of pregnancy, fetus, or child Acute Pain r/t surgical intervention Ineffective Role performance r/t inability to assume parenting role Ineffective Sexuality pattern r/t self-esteem disturbance result- ing from pregnancy loss and anxiety about future pregnancies Chronic Sorrow r/t loss of a fetus or child Spiritual distress r/t intense suffering from loss of child Risk for deficient Fluid volume: Risk factor: blood loss Risk for complicated Grieving: Risk factor: loss of pregnancy Risk for Infection: Risk factor: retained products of conception Risk for Powerlessness: Risk factor: situational crisis Risk for ineffective Relationship: Risk factor: poor communi- cation skills in dealing with the loss Risk for Spiritual distress: Risk factor: intense suffering Readiness for enhanced Communication: willingness to express feelings and thoughts about loss Readiness for enhanced Hope: expresses desire to enhance hope Readiness for enhanced Spiritual well-being: desire for accep- tance of loss

Pregnancy, Normal Anxiety r/t unknown future, threat to self secondary to pain of labor Disturbed Body Image r/t altered body function and appearance Interrupted Family processes r/t developmental transition of pregnancy Fatigue r/t increased energy demands Fear r/t labor and delivery Deficient Knowledge r/t primiparity Nausea r/t hormonal changes of pregnancy

Imbalanced Nutrition: less than body requirements r/t growing fetus, nausea Imbalanced Nutrition: more than body requirements r/t defi- cient knowledge regarding nutritional needs of pregnancy Sleep deprivation r/t uncomfortable pregnancy state Impaired Urinary elimination r/t frequency caused by increased pelvic pressure and hormonal stimulation Risk for Constipation: Risk factor: pregnancy Risk for Sexual dysfunction: Risk factors: altered body function, self-concept, body image with pregnancy Readiness for enhanced Childbearing process: appropriate prenatal care Readiness for enhanced family Coping: satisfying partner rela- tionship, attention to gratification of needs, effective adaptation to developmental tasks of pregnancy Readiness for enhanced Family processes: family adapts to change Readiness for enhanced Health management: seeks informa- tion for prenatal self care Readiness for enhanced Nutrition: desire for knowledge of appropriate nutrition during pregnancy Readiness for enhanced Parenting: expresses willingness to enhance parenting skills Readiness for enhanced Relationship: meeting developmental goals associated with pregnancy Readiness for enhanced Spiritual well-being: new role as parent See Discomforts of Pregnancy

Premature Dilation of the Cervix (Incompetent Cervix)

Ineffective Activity planning r/t unrealistic perception of events Ineffective Coping r/t bed rest, threat to fetus Deficient Diversional activity r/t bed rest Fear r/t potential loss of infant Grieving r/t potential loss of infant Deficient Knowledge r/t treatment regimen, prognosis for pregnancy Impaired physical Mobility r/t imposed bed rest to prevent preterm birth Powerlessness r/t inability to control outcome of pregnancy Ineffective Role performance r/t inability to continue usual pat- terns of responsibility Situational low Self-Esteem r/t inability to complete normal pregnancy Sexual dysfunction r/t fear of harm to fetus Impaired Social interaction r/t bed rest Risk for Infection: Risk factor: invasive procedures to prevent preterm birth Risk for Injury: fetal: Risk factors: preterm birth, use of anesthetics Risk for Injury: maternal: Risk factor: surgical procedures to prevent preterm birth (e.g., cerclage)

98 Premature Infant (Child)

P

Risk for impaired Resilience: Risk factor: complication of pregnancy Risk for Spiritual distress: Risk factors: physical/psychological stress

Premature Infant (Child) Insufficient Breast Milk r/t ineffective sucking, latching on of the infant Impaired Gas exchange r/t effects of cardiopulmonary insufficiency Disorganized Infant behavior r/t prematurity Insomnia r/t noisy and noxious intensive care environment Neonatal Jaundice r/t infant experiences difficulty making tran- sition to extrauterine life Imbalanced Nutrition: less than body requirements r/t delayed or understimulated rooting reflex, easy fatigue during feeding, diminished endurance Impaired Swallowing r/t decreased or absent gag reflex, fatigue Ineffective Thermoregulation r/t large body surface/weight ratio, immaturity of thermal regulation, state of prematurity Risk for delayed Development: Risk factor: prematurity Risk for disproportionate Growth: Risk factor: prematurity Risk for Infection: Risk factors: inadequate, immature, or unde- veloped acquired immune response Risk for Injury: Risk factor: prolonged mechanical ventilation, retinopathy of prematurity (ROP) secondary to 100% oxygen environment Risk for neonatal Jaundice: Risk factor: late preterm birth Readiness for enhanced organized Infant behavior: use of some self-regulatory measures

Premature Infant (Parent) Ineffective Breastfeeding r/t disrupted establishment of effective pattern secondary to prematurity or insufficient opportunities Decisional Conflict r/t support system deficit, multiple sources of information Compromised family Coping r/t disrupted family roles and disorganization, prolonged condition exhausting supportive capacity of significant persons Grieving r/t loss of perfect child possibly leading to complicated grieving Complicated Grieving (prolonged) r/t unresolved conflicts Parental Role conflict r/t expressed concerns, expressed inability to care for child’s physical, emotional, or developmental needs Chronic Sorrow r/t threat of loss of a child, prolonged hospitalization Spiritual distress r/t challenged belief or value systems regarding moral or ethical implications of treatment plans Risk for impaired Attachment: Risk factors: separation, physi- cal barriers, lack of privacy Risk for disturbed Maternal–Fetal dyad: Risk factor: complica- tion of pregnancy

Risk for Powerlessness: Risk factor: inability to control situation Risk for impaired Resilience: Risk factor: premature infant Risk for Spiritual distress: Risk factor: challenged belief or value systems regarding moral or ethical implications of treatment plans Readiness for enhanced Family process: adaptation to change associated with premature infant See Child with Chronic Condition; Hospitalized Child

Premature Rupture of Membranes Anxiety r/t threat to infant’s health status Disturbed Body Image r/t inability to carry pregnancy to term Ineffective Coping r/t situational crisis Grieving r/t potential loss of infant Situational low Self-Esteem r/t inability to carry pregnancy to term Risk for ineffective Childbearing process: Risk factor: compli- cation of pregnancy Risk for Infection: Risk factor: rupture of membranes Risk for Injury: fetal: Risk factor: risk of premature birth

Premenstrual Tension Syndrome (PMS) See PMS (Premenstrual Tension Syndrome)

Prenatal Care, Normal Readiness for enhanced Childbearing process: appropriate prenatal lifestyle Readiness for enhanced Knowledge: appropriate prenatal care Readiness for enhanced Spiritual well-being: new role as parent See Pregnancy, Normal

Prenatal Testing Anxiety r/t unknown outcome, delayed test results Acute Pain r/t invasive procedures Risk for Infection: Risk factor: invasive procedures during amniocentesis or chorionic villus sampling Risk for Injury: fetal r/t invasive procedures

Preoperative Teaching See Surgery, Preoperative Care

Pressure Ulcer Impaired bed Mobility r/t intolerance to activity, pain, cognitive impairment, depression, severe anxiety, severity of illness Imbalanced Nutrition: less than body requirements r/t limited access to food, inability to absorb nutrients because of biological factors, anorexia Acute Pain r/t tissue destruction, exposure of nerves Impaired Skin integrity: stage I or II pressure ulcer r/t physical immobility, mechanical factors, altered circulation, skin irritants, excessive moisture Impaired Tissue integrity: stage III or IV pressure ulcer r/t altered circulation, impaired physical mobility, excessive moisture

Psychosis 99

P

Risk for Infection: Risk factors: physical immobility, mechani- cal factors (shearing forces, pressure, restraint, altered circula- tion, skin irritants, excessive moisture, open wound) Risk for Pressure ulcer (See Pressure ulcer, risk for, Section III)

Preterm Labor Anxiety r/t threat to fetus, change in role functioning, change in environment and interaction patterns, use of tocolytic drugs Ineffective Coping r/t situational crisis, preterm labor Deficient Diversional activity r/t long-term hospitalization Grieving r/t loss of idealized pregnancy, potential loss of fetus Impaired Home maintenance r/t medical restrictions Impaired physical Mobility r/t medically imposed restrictions Ineffective Role performance r/t inability to carry out normal roles secondary to bed rest or hospitalization, change in expected course of pregnancy Situational low Self-Esteem r/t threatened ability to carry preg- nancy to term Sexual dysfunction r/t actual or perceived limitation imposed by preterm labor and/or prescribed treatment, separation from partner because of hospitalization Sleep deprivation r/t change in usual pattern secondary to con- tractions, hospitalization, treatment regimen Impaired Social interaction r/t prolonged bed rest or hospitalization Risk for Injury: fetal: Risk factors: premature birth, immature body systems Risk for Injury: maternal: Risk factor: use of tocolytic drugs Risk for Powerlessness: Risk factor: lack of control over preterm labor Risk for Vascular Trauma: Risk factor: intravenous medication Readiness for enhanced Childbearing process: appropriate prenatal lifestyle Readiness for enhanced Comfort: expresses desire to enhance relaxation Readiness for enhanced Communication: willingness to discuss thoughts and feelings about situation

Problem-Solving Dysfunction Defensive Coping r/t situational crisis Impaired Emancipated Decision-Making r/t problem solving dysfunction Risk for chronic low Self-Esteem: Risk factor: repeated failures Readiness for enhanced Communication: willing to share ideas with others Readiness for enhanced Relationship: shares information and ideas between partners Readiness for enhanced Resilience: identifies available resources Readiness for enhanced Spiritual well-being: desires to draw on inner strength and find meaning and purpose to life

Projection Anxiety r/t threat to self-concept Defensive Coping r/t inability to acknowledge that own behav- ior may be a problem, blaming others Chronic low Self-Esteem r/t failure Impaired Social interaction r/t self-concept disturbance, con- frontational communication style Risk for Loneliness: Risk factor: blaming others for problems See Paranoid Personality Disorder

Prolapsed Umbilical Cord Fear r/t threat to fetus, impending surgery Ineffective peripheral Tissue Perfusion: fetal r/t interruption in umbilical blood flow Risk for ineffective Cerebral tissue perfusion: fetal: Risk factor: cord compression Risk for Injury: maternal: Risk factor: emergency surgery

Prostatectomy See TURP (Transurethral Resection of the Prostate)

Prostatic Hypertrophy Ineffective Health maintenance r/t deficient knowledge regard- ing self-care and prevention of complications Sleep deprivation r/t nocturia Urinary Retention r/t obstruction Risk for Infection: Risk factors: urinary residual after voiding, bacterial invasion of bladder See BPH (Benign Prostatic Hypertrophy)

Prostatitis Impaired Comfort r/t inflammation Ineffective Health maintenance r/t deficient knowledge regard- ing treatment Urge urinary Incontinence r/t irritation of bladder Ineffective Protection r/t depressed immune system

Pruritus Impaired Comfort r/t itching Deficient Knowledge r/t methods to treat and prevent itching Risk for impaired Skin integrity: Risk factor: scratching from pruritus

Psoriasis Disturbed Body Image r/t lesions on body Impaired Comfort r/t irritated skin Ineffective Health maintenance r/t deficient knowledge regard- ing treatment modalities Powerlessness r/t lack of control over condition with frequent exacerbations and remissions Impaired Skin integrity r/t lesions on body

Psychosis Ineffective Activity planning r/t compromised ability to process information

100 PTCA (Percutaneous Transluminal Coronary Angioplasty)

P

Ineffective Health maintenance r/t cognitive impairment, inef- fective individual and family coping Self-Neglect r/t mental disorder Impaired individual Resilience r/t psychological disorder Situational low Self-Esteem r/t excessive use of defense mecha- nisms (e.g., projection, denial, rationalization) Risk for disturbed personal Identity: Risk factor: psychosis Impaired Mood regulation r/t psychosis Risk for Post-Trauma syndrome: Risk factor: diminished ego strength See Schizophrenia

PTCA (Percutaneous Transluminal Coronary Angioplasty)

See Angioplasty, Coronary

PTSD (Posttraumatic Stress Disorder) Anxiety r/t exposure to internal or external cues that symbolize or resemble an aspect of the traumatic event Chronic Sorrow r/t chronic disability (e.g., physical, mental) Death Anxiety r/t psychological stress associated with trau- matic event Ineffective Breathing pattern r/t hyperventilation associated with anxiety Ineffective Coping r/t extreme anxiety Ineffective Impulse control r/t thinking of initial trauma experience Insomnia r/t recurring nightmares Post-Trauma syndrome r/t exposure to a traumatic event Sleep deprivation r/t nightmares interrupting sleep associated with traumatic event Spiritual distress r/t feelings of detachment or estrangement from others Risk for impaired Resilience: Risk factor: chronicity of existing crisis Risk for Powerlessness: Risk factors: flashbacks, reliving event Risk for ineffective Relationship: Risk factor: stressful life events Risk for self- or other-directed Violence: Risk factors: fear of self or others Readiness for enhanced Comfort: expresses desire to enhance relaxation Readiness for enhanced Communication: willingness to express feelings and thoughts Readiness for enhanced Spiritual well-being: desire for harmony after stressful event

Pulmonary Edema Anxiety r/t fear of suffocation Ineffective Airway clearance r/t presence of tracheobronchial secretions Decreased Cardiac output r/t increased preload, infective forward perfusion

Impaired Gas exchange r/t extravasation of extravascular fluid in lung tissues and alveoli Ineffective Health maintenance r/t deficient knowledge regard- ing treatment regimen Sleep deprivation r/t inability to breathe Risk for acute Confusion: Risk factor: hypoxia See Heart Failure

Pulmonary Embolism Anxiety r/t fear of suffocation Decreased Cardiac output r/t right ventricular failure second- ary to obstructed pulmonary artery Fear r/t severe pain, possible death Impaired Gas exchange r/t altered blood flow to alveoli second- ary to embolus Deficient Knowledge r/t activities to prevent embolism, self- care after diagnosis of embolism Acute Pain r/t biological injury, lack of oxygen to cells Ineffective peripheral Tissue Perfusion r/t deep vein thrombus formation See Anticoagulant Therapy

Pulmonary Stenosis See Congenital Heart Disease/Cardiac Anomalies

Pulse Deficit Risk for Decreased Cardiac output r/t dysrhythmia See Dysrhythmia

Pulse Oximetry Readiness for enhanced Knowledge: information about treat- ment regimen See Hypoxia

Pulse Pressure, Increased See Intracranial Pressure, Increased

Pulse Pressure, Narrowed See Shock, Hypovolemic

Pulses, Absent or Diminished Peripheral Ineffective peripheral Tissue Perfusion r/t interruption of arterial flow Risk for Peripheral Neurovascular dysfunction: Risk factors: fractures, mechanical compression, orthopedic surgery trauma, immobilization, burns, vascular obstruction

Purpura See Clotting Disorder

Pyelonephritis Ineffective Health maintenance r/t deficient knowledge regard- ing self-care, treatment of disease, prevention of further urinary tract infections Acute Pain r/t inflammation and irritation of urinary tract Disturbed Sleep pattern r/t urinary frequency

Impaired Urinary elimination r/t irritation of urinary tract Risk for ineffective Renal perfusion: Risk factor: infection

Pyloric Stenosis Imbalanced Nutrition: less than body requirements r/t vomit- ing secondary to pyloric sphincter obstruction Acute Pain r/t abdominal fullness Risk for decreased Fluid volume: Risk factors: vomiting, dehydration See Hospitalized Child

Pyloromyotomy (Pyloric Stenosis Repair) See Surgery Preoperative, Perioperative, Postoperative

Rats, Rodents in Home 101

R

R RA (Rheumatoid Arthritis)

See Rheumatoid Arthritis (RA)

Rabies Ineffective Health maintenance r/t deficient knowledge regard- ing care of wound, isolation, and observation of infected animal Acute Pain r/t multiple immunization injections Risk for ineffective Cerebral tissue perfusion: Risk factor: rabies virus

Radial Nerve Dysfunction Acute Pain r/t trauma to hand or arm See Neuropathy, Peripheral

Radiation Therapy Activity intolerance r/t fatigue from possible anemia Disturbed Body Image r/t change in appearance, hair loss Diarrhea r/t irradiation effects Fatigue r/t malnutrition from lack of appetite, nausea, and vom- iting; side effect of radiation Deficient Knowledge r/t what to expect with radiation therapy, how to do self-care Nausea r/t side effects of radiation Imbalanced Nutrition: less than body requirements r/t an - orexia, nausea, vomiting, irradiation of areas of pharynx and esophagus Impaired Oral Mucous Membrane r/t irradiation effects Ineffective Protection r/t suppression of bone marrow Risk for impaired Oral Mucous Membranes: Risk factor: Radiation treatments Risk for Powerlessness: Risk factors: medical treatment and possible side effects Risk for impaired Resilience: Risk factor: radiation treatment Risk for impaired Skin integrity: Risk factor: irradiation effects Risk for Spiritual distress: Risk factors: radiation treatment, prognosis

Radical Neck Dissection See Laryngectomy

Rage Risk-prone Health behavior r/t multiple stressors Labile Emotional Control r/t psychiatric disorders and mood disorders Impaired individual Resilience r/t poor impulse control Stress overload r/t multiple coexisting stressors Risk for Self-Mutilation: Risk factor: command hallucinations Risk for Suicide: Risk factor: desire to kill self Risk for other-directed Violence: Risk factors: panic state, manic excitement, organic brain syndrome

Rape-Trauma Syndrome Rape-Trauma syndrome (See Rape-Trauma syndrome, Section III) Chronic Sorrow r/t forced loss of virginity Risk for ineffective Childbearing process r/t to trauma and violence Risk for Post-Trauma syndrome: Risk factor: trauma or vio- lence associated with rape Risk for Powerlessness: Risk factor: inability to control thoughts about incident Risk for ineffective Relationship r/t to trauma and violence Risk for chronic low Self-Esteem r/t perceived lack of respect from others/feeling violated Risk for Spiritual distress: Risk factor: forced loss of virginity

Rash Impaired Comfort r/t pruritus Impaired Skin integrity r/t mechanical trauma Risk for Infection: Risk factors: traumatized tissue, broken skin Risk for Latex Allergy response: Risk factor: allergy to prod- ucts associated with latex

Rationalization Defensive Coping r/t situational crisis, inability to accept blame for consequences of own behavior Ineffective Denial r/t fear of consequences, actual or per- ceived loss Impaired individual Resilience r/t psychological disturbance Risk for Post-Trauma syndrome: Risk factor: survivor’s role in event Readiness for enhanced Communication: expresses desire to share thoughts and feelings Readiness for enhanced Spiritual well-being: possibility of seeking harmony with self, others, higher power, God

Rats, Rodents in Home Impaired Home maintenance r/t lack of knowledge, insufficient finances

e22

RA (Rheumatoid Arthritis) Rabies Radial Nerve Dysfunction Radiation Therapy Radical Neck Dissection Rage Rape-Trauma Syndrome Rash Rationalization Rats, Rodents in Home Raynaud’s Disease RDS (Respiratory Distress Syndrome) Rectal Fullness Rectal Lump Rectal Pain/Bleeding Rectal Surgery Rectocele Repair Reflex Incontinence Regression Regretful Rehabilitation Relationship Relaxation Techniques Religiosity Religious Concerns Relocation Stress Syndrome Respiratory Acidosis Respiratory Conditions of the Neonate (Respiratory Distress Syndrome [RDS], Meconium Aspiration, Diaphragmatic Hernia)

Respiratory Distress Respiratory Distress Syndrome (RDS)

Respiratory Infections, Acute Childhood (Croup, Epiglottitis, Pertussis, Pneumonia, Respiratory Syncytial Virus)

Respiratory Syncytial Virus Restless Leg Syndrome

Retarded Growth and Development Retching Retinal Detachment Retinopathy, Diabetic Retinopathy of Prematurity (ROP) Rh Factor Incompatibility Rhabdomyolysis Rheumatic Fever Rheumatoid Arthritis (RA) Rib Fracture Ridicule of Others Ringworm of Body Ringworm of Nails Ringworm of Scalp Roaches, Invasion of Home with Role Performance, Altered ROP (Retinopathy of Prematurity) RSV (Respiratory Syncytial Virus) Rubella Rubor of Extremities Ruptured Disk

List of Nursing Assessments by Letter: R

102 Raynaud’s Disease

R

Risk for Allergy response r/t repeated exposure to environmen- tal contamination See Filthy Home Environment

Raynaud’s Disease Deficient Knowledge r/t lack of information about disease process, possible complications, self-care needs regarding disease process and medication Ineffective peripheral Tissue Perfusion r/t transient reduction of blood flow Acute Pain r/t transient reduction in blood flow

RDS (Respiratory Distress Syndrome) See Respiratory Conditions of the Neonate

Rectal Fullness Chronic functional Constipation r/t decreased activity level, decreased fluid intake, inadequate fiber in diet, decreased peristalsis, side effects of antidepressant or antipsychotic therapy Risk for chronic functional Constipation: Risk factor: habitual denial of or ignoring urge to defecate

Rectal Lump See Hemorrhoids

Rectal Pain/Bleeding Chronic functional Constipation r/t pain on defecation Deficient Knowledge r/t possible causes of rectal bleeding, pain, treatment modalities Acute Pain r/t pressure of defecation Risk for Bleeding: Risk factor: rectal disease

Rectal Surgery See Hemorrhoidectomy

Rectocele Repair Chronic functional Constipation r/t painful defecation Ineffective Health maintenance r/t deficient knowledge of post- operative care of surgical site, dietary measures, exercise to prevent constipation Acute Pain r/t surgical procedure Urinary retention r/t edema from surgery Risk for Bleeding: Risk factor: surgery Risk for Infection: Risk factors: surgical procedure, possible contamination of area with feces

Reflex Incontinence Reflex urinary Incontinence (See Incontinence, urinary, reflex, Section III)

Regression Anxiety r/t threat to or change in health status Defensive Coping r/t denial of obvious problems, weaknesses Self-Neglect r/t functional impairment Powerlessness r/t health care environment Impaired individual Resilience r/t psychological disturbance

Ineffective Role performance r/t powerlessness over health status See Hospitalized Child; Separation Anxiety

Regretful Anxiety r/t situational or maturational crises Death Anxiety r/t feelings of not having accomplished goals in life Risk for Spiritual distress: Risk factor: inability to forgive

Rehabilitation Ineffective Coping r/t loss of normal function Impaired physical Mobility r/t injury, surgery, psychosocial con- dition warranting rehabilitation Self-Care deficit: specify r/t impaired physical mobility Risk for Falls: Risk factor: physical deconditioning Readiness for enhanced Comfort: expresses desire to enhance feeling of comfort Readiness for enhanced Self-Concept: accepts strengths and limitations Readiness for enhanced Health Management: expresses desire to manage rehabilitation

Relationship Ineffective Relationship (See ineffective Relationship, Section III) Readiness for enhanced Relationship (See Risk for enhanced Relationship see Section III)

Relaxation Techniques Anxiety r/t situational crisis Readiness for enhanced Comfort: expresses desire to enhance relaxation Readiness for enhanced Health management: desire to manage illness Readiness for enhanced Religiosity: requests religious materials or experiences Readiness for enhanced Resilience: desire to enhance resilience Readiness for enhanced Self-Concept: willingness to enhance self-concept Readiness for enhanced Spiritual well-being: seeking comfort from higher power

Religiosity Impaired Religiosity (See Religiosity, impaired, Section III) Risk for impaired Religiosity (See Religiosity, impaired, risk for, Section III) Readiness for enhanced Religiosity (See Religiosity, readiness for enhanced, Section III)

Religious Concerns Spiritual distress r/t separation from religious or cultural ties Risk for impaired Religiosity: Risk factors: ineffective support, coping, caregiving

Rh Factor Incompatibility 103

R

Risk for Spiritual distress: Risk factors: physical or psychologi- cal stress Readiness for enhanced Spiritual well-being: desire for in - creased spirituality

Relocation Stress Syndrome Relocation stress syndrome (See Relocation stress syndrome, Section III) Risk for Relocation stress syndrome (See Relocation stress syndrome, risk for, Section III)

Respiratory Acidosis See Acidosis, Respiratory

Respiratory Conditions of the Neonate (Respiratory Distress Syndrome [RDS], Meconium Aspiration, Diaphragmatic Hernia)

Ineffective Airway clearance r/t sequelae of attempts to breathe in utero resulting in meconium aspiration Fatigue r/t increased energy requirements and metabolic demands Impaired Gas exchange r/t decreased surfactant, immature lung tissue Dysfunctional Ventilator weaning response r/t immature respi- ratory system Risk for Infection: Risk factors: tissue destruction or irritation as a result of aspiration of meconium fluid See Bronchopulmonary Dysplasia; Hospitalized Child; Premature Infant, Child

Respiratory Distress See Dyspnea

Respiratory Distress Syndrome (RDS) See Respiratory Conditions of the Neonate

Respiratory Infections, Acute Childhood (Croup, Epiglottitis, Pertussis, Pneumonia, Respiratory Syncytial Virus)

Activity intolerance r/t generalized weakness, dyspnea, fatigue, poor oxygenation Ineffective Airway clearance r/t excess tracheobronchial secretions Ineffective Breathing pattern r/t inflamed bronchial passages, coughing Fear r/t oxygen deprivation, difficulty breathing Deficient Fluid volume r/t insensible losses (fever, diaphoresis), inadequate oral fluid intake Impaired Gas exchange r/t insufficient oxygenation as a result of inflammation or edema of epiglottis, larynx, bronchial passages Imbalanced Nutrition: less than body requirements r/t anorexia, fatigue, generalized weakness, poor sucking and breathing coor- dination, dyspnea Ineffective Thermoregulation r/t infectious process

Risk for Aspiration: Risk factors: inability to coordinate breath- ing, coughing, sucking Risk for Infection: transmission to others: Risk factor: virulent infectious organisms Risk for Injury (to pregnant others): Risk factors: exposure to aerosolized medications (e.g., ribavirin, pentamidine), resultant potential fetal toxicity Risk for Suffocation: Risk factors: inflammation of larynx, epiglottis See Hospitalized Child

Respiratory Syncytial Virus See Respiratory Infections, Acute Childhood

Restless Leg Syndrome Disturbed Sleep pattern r/t leg discomfort during sleep relieved by frequent leg movement Chronic Pain r/t leg discomfort See Stress

Retarded Growth and Development See Growth and Development Lag

Retching Nausea r/t chemotherapy, postsurgical anesthesia, irritation to gastrointestinal system, stimulation of neuropharmacological mechanisms Imbalanced Nutrition: less than body requirements r/t inability to ingest food Risk for Fatigue: Risk factor: stress of retching, muscle contractions

Retinal Detachment Anxiety r/t change in vision, threat of loss of vision Deficient Knowledge r/t symptoms, need for early intervention to prevent permanent damage Vision Loss r/t impaired visual acuity Risk for impaired Home maintenance: Risk factors: postopera- tive care, activity limitations, care of affected eye Risk for impaired Resilience: Risk factor: possible loss of vision See Vision Impairment

Retinopathy, Diabetic See Diabetic Retinopathy

Retinopathy of Prematurity (ROP) Risk for Injury: Risk factors: prolonged mechanical ventilation, ROP secondary to 100% oxygen environment See Retinal Detachment

Rh Factor Incompatibility Anxiety r/t unknown outcome of pregnancy Neonatal Jaundice r/t Rh factor incompatibility Deficient Knowledge r/t treatment regimen from lack of expe- rience with situation

104 Rhabdomyolysis

Powerlessness r/t perceived lack of control over outcome of pregnancy Risk for Injury: fetal: Risk factors: intrauterine destruction of red blood cells, transfusions Risk for neonatal Jaundice r/t Rh factor incompatibility Readiness for enhanced Health management: prenatal care, compliance with diagnostic and treatment regimen

Rhabdomyolysis Ineffective Coping r/t seriousness of condition Impaired physical Mobility r/t myalgia and muscle weakness Risk for deficient Fluid volume: Risk factor: reduced blood flow to kidneys Risk for ineffective Renal perfusion: Risk factor: possible kidney failure from obstruction of kidney Risk for Shock: Risk factor: hypovolemia Readiness for enhanced Health management: seeks informa- tion to avoid condition See Kidney Failure

Rheumatic Fever See Endocarditis

Rheumatoid Arthritis (RA) Imbalanced Nutrition: less than body requirements r/t loss of appetite Chronic Pain r/t joint inflammation Risk for impaired Resilience: Risk factor: chronic, painful, pro- gressive disease See Arthritis; JRA (Juvenile Rheumatoid Arthritis)

Rib Fracture Ineffective Breathing pattern r/t fractured ribs Acute Pain r/t movement, deep breathing Impaired Gas exchange r/t ventilation-perfusion imbalance, decreased depth of ventilation

Ridicule of Others Defensive Coping r/t situational crisis, psychological impair- ment, substance abuse Risk for Post-Trauma syndrome: Risk factor: perception of event

Ringworm of Body Impaired Comfort r/t pruritus Impaired Skin integrity r/t presence of macules associated with fungus See Itching; Pruritus

Ringworm of Nails Disturbed Body Image r/t appearance of nails, removed nails

Ringworm of Scalp Disturbed Body Image r/t possible hair loss (alopecia) See Itching; Pruritus

Roaches, Invasion of Home with Impaired Home maintenance r/t lack of knowledge, insufficient finances See Filthy Home Environment

Role Performance, Altered Ineffective Role performance (See Role performance, ineffec- tive, Section III)

ROP (Retinopathy of Prematurity) See Retinopathy of Prematurity (ROP)

RSV (Respiratory Syncytial Virus) See Respiratory Infection, Acute Childhood

Rubella See Communicable Diseases, Childhood

Rubor of Extremities Ineffective peripheral Tissue Perfusion r/t interruption of arte- rial flow See Peripheral Vascular Disease (PVD)

Ruptured Disk See Low Back Pain

S

S SAD (Seasonal Affective Disorder)

Readiness for enhanced Resilience: uses SAD lights during winter months See Depression (Major Depressive Disorder)

Sadness Complicated Grieving r/t actual or perceived loss Impaired Mood regulation r/t chronic illness (See Mood regula- tion, impaired, Section III) Spiritual distress r/t intense suffering Risk for Powerlessness: Risk factor: actual or perceived loss Risk for Spiritual distress: Risk factor: loss of loved one Readiness for enhanced Communication: willingness to share feelings and thoughts Readiness for enhanced Spiritual well-being: desire for harmony after actual or perceived loss See Depression (Major Depressive Disorder); Major Depressive Disorder

Safe Sex Readiness for enhanced Health management: takes appropriate precautions during sexual activity to keep from contracting sexu- ally transmitted disease See Sexuality, Adolescent; STD (Sexually Transmitted Disease)

Safety, Childhood Deficient Knowledge: potential for enhanced health mainte- nance r/t parental knowledge and skill acquisition regarding appropriate safety measures

e23

SAD (Seasonal Affective Disorder) Sadness Safe Sex Safety, Childhood Salmonella Salpingectomy Sarcoidosis SARS (Severe Acute Respiratory

Syndrome) SBE (Self-Breast Examination)

Scabies Scared Schizophrenia Sciatica Scoliosis Sedentary Lifestyle Seizure Disorders, Adult Seizure Disorders, Childhood

(Epilepsy, Febrile Seizures, Infantile Spasms)

Self-Breast Examination (SBE)

Self-Care Self-Care Deficit, Bathing Self-Care Deficit, Dressing Self-Care Deficit, Feeding Self-Care Deficit, Toileting Self-Concept Self-Destructive Behavior Self-Esteem, Chronic Low Self-Esteem, Situational Low Self-Mutilation Senile Dementia Separation Anxiety Sepsis, Child Septicemia Severe Acute Respiratory Syndrome

(SARS) Sexual Dysfunction Sexuality, Adolescent Sexuality Pattern, Ineffective Sexually Transmitted Disease (STD) Shaken Baby Syndrome Shakiness Shame Shingles Shivering Shock, Cardiogenic Shock, Hypovolemic Shock, Septic Shoulder Repair Sickle Cell Anemia/Crisis SIDS (Sudden Infant Death Syndrome) Sitting Problems Situational Crisis SJS (Stevens-Johnson Syndrome) Skin Cancer Skin Disorders Skin Turgor, Change in Elasticity Sleep Sleep Apnea Sleep Deprivation Sleep Problems Sleep Pattern, Disturbed, Parent/Child Slurring of Speech Small Bowel Resection Smell, Loss of Ability to Smoke Inhalation Smoking Behavior Social Interaction, Impaired Social Isolation Sociopathic Personality Sodium, Decrease/Increase Somatization Disorder

List of Nursing Assessments by Letter: S

e24 List of Nursing Assessments by Letter: S

Sore Nipples, Breastfeeding Sore Throat Sorrow Spastic Colon Speech Disorders Spina Bifida Spinal Cord Injury Spinal Fusion Spiritual Distress Spiritual Well-Being Splenectomy Sprains Standing Problems Stapedectomy Stasis Ulcer STD (Sexually Transmitted Disease) STEMI (ST-Elevation Myocardial

Infarction) Stent (Coronary Artery Stent)

Sterilization Surgery Stertorous Respirations Stevens-Johnson Syndrome (SJS) Stillbirth Stoma Stomatitis Stone, Kidney Stool, Hard/Dry Straining with Defecation Strep Throat Stress Stress Urinary Incontinence Stridor Stroke Stuttering Subarachnoid Hemorrhage Substance Abuse Substance Abuse, Adolescent Substance Abuse in Pregnancy Sucking Reflex Sudden Infant Death Syndrome (SIDS) Suffocation, Risk for Suicide Attempt Support System, Inadequate Suppression of Labor Surgery, Perioperative Care Surgery, Postoperative Care Surgery, Preoperative Care Surgical Recovery, Delayed Suspected Child Abuse and Neglect

(SCAN), Child Suspected Child Abuse and Neglect (SCAN), Parent

Suspicion Swallowing Difficulties

Swine Flu (H1N1) Syncope Syphilis Systemic Lupus Erythematosus

Schizophrenia 105

S

Risk for Aspiration (See Aspiration, risk for, Section III) Risk for Injury: Risk factors: developmental age, altered home maintenance Risk for impaired Parenting: Risk factors: lack of available and effective role model, lack of knowledge, misinformation from other family members (old wives’ tales) Risk for Poisoning: Risk factors: use of lead-based paint; presence of asbestos or radon gas; drugs not locked in cabinet; household products left in accessible area (bleach, detergent, drain cleaners, household cleaners); alcohol and perfume within reach of child; presence of poisonous plants; atmospheric pollutants Risk for Thermal injury: Risk factor: inadequate supervision Readiness for enhanced Childbearing process: expresses appropriate knowledge for care of child

Salmonella Impaired Home maintenance r/t improper preparation or storage of food, lack of safety measures when caring for pet reptile Risk for Shock: Risk factors: hypovolemia, diarrhea, sepsis Readiness for enhanced Health management: avoiding improp- erly prepared or stored food, wearing gloves when handling pet reptiles or their feces See Gastroenteritis; Gastroenteritis, Child

Salpingectomy Decisional Conflict r/t sterilization procedure Grieving r/t possible loss from tubal pregnancy Risk for impaired Urinary elimination: Risk factor: trauma to ureter during surgery See Hysterectomy; Surgery, Perioperative Care; Surgery, Postopera- tive Care; Surgery, Preoperative Care

Sarcoidosis Anxiety r/t change in health status Impaired Gas exchange r/t ventilation-perfusion imbalance Ineffective Health maintenance r/t deficient knowledge regard- ing home care and medication regimen Acute Pain r/t possible disease affecting joints Ineffective Protection r/t immune disorder Risk for decreased Cardiac tissue perfusion: Risk factor: dysrhythmias Risk for impaired Skin integrity: Risk factor: immunological disorder

SARS (Severe Acute Respiratory Syndrome)

Risk for Infection: Risk factor: increased environmental expo- sure (travelers in close proximity to infected persons, traveling when a fever is present) Readiness for enhanced Knowledge: information regarding travel and precautions to avoid exposure to SARS See Pneumonia

SBE (Self-Breast Examination) Readiness for enhanced Health management: desires to have information about SBE Readiness for enhanced Knowledge: self-breast examination

Scabies See Communicable Diseases, Childhood

Scared Anxiety r/t threat of death, threat to or change in health status Death Anxiety r/t unresolved issues surrounding end-of-life decisions Fear r/t hospitalization, real or imagined threat to own well-being Impaired individual Resilience r/t violence Readiness for enhanced Communication: willingness to share thoughts and feelings

Schizophrenia Ineffective Activity planning r/t compromised ability to process information Anxiety r/t unconscious conflict with reality Impaired verbal Communication r/t psychosis, disorientation, inaccurate perception, hallucinations, delusions Ineffective Coping r/t inadequate support systems, unrealistic perceptions, inadequate coping skills, disturbed thought pro- cesses, impaired communication Deficient Diversional activity r/t social isolation, possible regression Interrupted Family processes r/t inability to express feelings, impaired communication Fear r/t altered contact with reality Ineffective Health maintenance r/t cognitive impairment, inef- fective individual and family coping, lack of material resources Ineffective family Health management r/t chronicity and unpre- dictability of condition Impaired Home maintenance r/t impaired cognitive or emo- tional functioning, insufficient finances, inadequate support systems Hopelessness r/t long-term stress from chronic mental illness Disturbed personal Identity r/t psychiatric disorder Impaired Memory r/t psychosocial condition Imbalanced Nutrition: less than body requirements r/t fear of eating, lack of awareness of hunger, disinterest toward food Impaired individual Resilience r/t psychological disorder Self-Care deficit: specify r/t loss of contact with reality, impair- ment of perception Self-Neglect r/t psychosis Sleep deprivation r/t intrusive thoughts, nightmares Impaired Social interaction r/t impaired communication pat- terns, self-concept disturbance, disturbed thought processes Social isolation r/t lack of trust, regression, delusional thinking, repressed fears

106 Sciatica

S

Chronic Sorrow r/t chronic mental illness Spiritual distress r/t loneliness, social alienation Risk for Caregiver Role Strain: Risk factors: bizarre behavior of client, chronicity of condition Risk for compromised Human Dignity: Risk factor: stigmatiz- ing label Risk for Loneliness: Risk factor: inability to interact socially Risk for Post-Trauma syndrome: Risk factor: diminished ego strength Risk for Powerlessness: Risk factor: intrusive, distorted thinking Risk for impaired Religiosity: Risk factors: ineffective coping, lack of security Risk for Suicide: Risk factor: psychiatric illness Risk for self-directed Violence: Risk factors: lack of trust, panic, hallucinations, delusional thinking Risk for other-directed Violence: Risk factor: psychotic disorder Readiness for enhanced Hope: expresses desire to enhance interconnectedness with others and problem-solve to meet goals Readiness for enhanced Power: expresses willingness to enhance participation in choices for daily living and health and enhance knowledge for participation in change

Sciatica See Neuropathy, Peripheral

Scoliosis Risk-prone Health behavior r/t lack of developmental maturity to comprehend long-term consequences of noncompliance with treatment procedures Disturbed Body Image r/t use of therapeutic braces, postsur- gery scars, restricted physical activity Impaired Comfort r/t altered health status and body image Impaired Gas exchange r/t restricted lung expansion as a result of severe presurgery curvature of spine, immobilization Ineffective Health maintenance r/t deficient knowledge regard- ing treatment modalities, restrictions, home care, postoperative activities Impaired physical Mobility r/t restricted movement, dyspnea caused by severe curvature of spine Acute Pain r/t musculoskeletal restrictions, surgery, reambula- tion with cast or spinal rod Impaired Skin integrity r/t braces, casts, surgical correction Chronic Sorrow r/t chronic disability Risk for Infection: Risk factor: surgical incision Risk for Perioperative Positioning injury: Risk factor: prone position Risk for impaired Resilience: Risk factor: chronic condition Readiness for enhanced Health management: desires knowl- edge regarding treatment for condition See Hospitalized Child; Maturational Issues, Adolescent

Sedentary Lifestyle Activity intolerance r/t sedentary lifestyle Sedentary lifestyle (See Sedentary lifestyle, Section III) Obesity (See Obesity, Section III) Overweight (See Overweight, Section III) Risk for Overweight (See Overweight, Section III) Risk for ineffective peripheral Tissue Perfusion: Risk factor: insufficient knowledge of aggravating factors (e.g., immobility, obesity) Readiness for enhanced Coping: seeking knowledge of new strategies to adjust to sedentary lifestyle

Seizure Disorders, Adult Acute Confusion r/t postseizure state Social isolation r/t unpredictability of seizures, community- imposed stigma Risk for ineffective Airway clearance: Risk factor: accumulation of secretions during seizure Risk for Falls: Risk factor: uncontrolled seizure activity Risk for Powerlessness: Risk factor: possible seizure Risk for impaired Resilience: Risk factor: chronic illness Readiness for enhanced Knowledge: anticonvulsive therapy Readiness for enhanced Self-Care: expresses desire to enhance knowledge and responsibility for self-care See Epilepsy

Seizure Disorders, Childhood (Epilepsy, Febrile Seizures, Infantile Spasms)

Ineffective Health maintenance r/t lack of knowledge regarding anticonvulsive therapy, fever reduction (febrile seizures) Social isolation r/t unpredictability of seizures, community- imposed stigma Risk for ineffective Airway clearance: Risk factor: accumulation of secretions during seizure Risk for delayed Development: Risk factors: effects of seizure disorder, parental overprotection Risk for disproportionate Growth: Risk factors: congenital dis- order, malnutrition Risk for Falls: Risk factor: possible seizure Risk for Injury: Risk factors: uncontrolled movements during seizure, falls, drowsiness caused by anticonvulsants See Epilepsy

Self-Breast Examination (SBE) See SBE (Self-Breast Examination)

Self-Care Readiness for enhanced Self-Care (See Self-Care, readiness for enhanced, Section III)

Self-Care Deficit, Bathing Bathing Self-Care deficit (See Self-Care deficit, bathing, Section III)

Sexuality, Adolescent 107

S

Self-Care Deficit, Dressing Dressing Self-Care deficit (See Self-Care deficit, dressing, Section III)

Self-Care Deficit, Feeding Feeding Self-Care deficit (See Self-Care deficit, feeding, Section III)

Self-Care Deficit, Toileting Toileting Self-Care deficit (See Self-Care deficit, toileting, Section III)

Self-Concept Readiness for enhanced Self-Concept (See Self-Concept, readiness for enhanced, Section III)

Self-Destructive Behavior Post-Trauma syndrome r/t unresolved feelings from trau- matic event Risk for Self-Mutilation: Risk factors: feelings of depres- sion, rejection, self-hatred, depersonalization; command hallucinations Risk for Suicide: Risk factor: history of self-destructive behavior Risk for self-directed Violence: Risk factors: panic state, history of child abuse, toxic reaction to medication

Self-Esteem, Chronic Low Chronic low Self-Esteem (See Self-Esteem, low, chronic, Section III) Risk for disturbed personal Identity: Risk factor: chronic low self-esteem

Self-Esteem, Situational Low Situational low Self-Esteem (See Self-Esteem, low, situational, Section III) Risk for situational low Self-Esteem (See Self-Esteem, low, situational, risk for, Section III)

Self-Mutilation Ineffective Impulse control r/t ineffective management of anxiety Self-Mutilation (See Self-Mutilation, Section III) Risk for Self-Mutilation (See Self-Mutilation, risk for, Section III)

Senile Dementia Ineffective Relationship r/t cognitive changes in one partner Sedentary lifestyle r/t lack of interest in movement See Dementia

Separation Anxiety Ineffective Coping r/t maturational and situational crises, vul- nerability related to developmental age, hospitalization, separa- tion from family and familiar surroundings, multiple caregivers Insomnia r/t separation for significant others Risk for impaired Attachment: Risk factor: separation See Hospitalized Child

Sepsis, Child Impaired Gas exchange r/t pulmonary inflammation associated with disease process Imbalanced Nutrition: less than body requirements r/t anorexia, generalized weakness, poor sucking reflex Delayed Surgical recovery r/t presence of infection Ineffective Thermoregulation r/t infectious process, septic shock Ineffective peripheral Tissue Perfusion r/t arterial or venous blood flow exchange problems, septic shock Risk for deficient Fluid volume: Risk factor: inflammation leading to decreased systemic vascular resistance Risk for impaired Skin integrity: Risk factor: desquamation caused by disseminated intravascular coagulation See Hospitalized Child; Premature Infant, Child

Septicemia Imbalanced Nutrition: less than body requirements r/t anorexia, generalized weakness Ineffective peripheral Tissue Perfusion r/t decreased systemic vascular resistance Risk for deficient Fluid volume: Risk factors: vasodilation of peripheral vessels, leaking of capillaries Risk for Shock: Risk factors: hypotension, hypovolemia See Sepsis, Child; Shock, Septic

Severe Acute Respiratory Syndrome (SARS)

See SARS (Severe Acute Respiratory Syndrome); Pneumonia

Sexual Dysfunction Sexual dysfunction (See Sexual dysfunction, Section III) Ineffective Relationship r/t reported sexual dissatisfaction between partners Chronic Sorrow r/t loss of ideal sexual experience, altered relationships Risk for chronic low Self-Esteem See Erectile Dysfunction (ED)

Sexuality, Adolescent Disturbed Body Image r/t anxiety caused by unachieved devel- opmental milestone (puberty) or deficient knowledge regarding reproductive maturation with expressed concerns regarding lack of growth of secondary sex characteristics Impaired emancipated Decision-Making: sexual activity r/t undefined personal values or beliefs, multiple or divergent sources of information, lack of relevant information Ineffective Impulse control r/t denial of consequences of actions Deficient Knowledge: potential for enhanced health mainte- nance r/t multiple or divergent sources of information or lack of relevant information regarding sexual transmission of disease, contraception, prevention of toxic shock syndrome See Maturational Issues, Adolescent

108 Sexuality Pattern, Ineffective

S

Sexuality Pattern, Ineffective Ineffective Sexuality pattern (See Sexuality pattern, ineffective, Section III)

Sexually Transmitted Disease (STD) See STD (Sexually Transmitted Disease)

Shaken Baby Syndrome Decreased intracranial Adaptive capacity r/t brain injury Impaired Parenting r/t stress, history of being abusive Impaired individual Resilience r/t poor impulse control Stress overload r/t intense repeated family stressors, family violence Risk for other-directed Violence: Risk factors: history of vio- lence against others, perinatal complications See Child Abuse; Suspected Child Abuse and Neglect (SCAN), Child; Suspected Child Abuse and Neglect (SCAN), Parent

Shakiness Anxiety r/t situational or maturational crisis, threat of death

Shame Situational low Self-Esteem r/t inability to deal with past traumatic events, blaming of self for events not in one’s control

Shingles Acute Pain r/t vesicular eruption along the nerves Ineffective Protection r/t abnormal blood profiles Social isolation r/t altered state of wellness, contagiousness of disease Risk for Infection: Risk factor: tissue destruction See Itching

Shivering Impaired Comfort r/t altered health status Fear r/t serious threat to health status Hypothermia r/t exposure to cool environment Ineffective Thermoregulation r/t serious infectious process resulting in immune response of fever See Shock, Septic

Shock, Cardiogenic Decreased Cardiac output r/t decreased myocardial contractil- ity, dysrhythmia

Shock, Hypovolemic Deficient Fluid volume r/t abnormal loss of fluid, trauma, third spacing

Shock, Septic Deficient Fluid volume r/t abnormal loss of intravascular fluid, pooling of blood in peripheral circulation, overwhelming inflam- matory response Ineffective Protection r/t inadequately functioning immune system See Sepsis, Child; Septicemia

Shoulder Repair Self-Care deficit: bathing, dressing, feeding r/t immobilization of affected shoulder Risk for Perioperative Positioning injury: Risk factor: immobility See Surgery, Preoperative; Surgery, Perioperative; Surgery, Postop- erative; Total Joint Replacement (Total Hip/Total Knee/Shoulder)

Sickle Cell Anemia/Crisis Activity intolerance r/t fatigue, effects of chronic anemia Deficient Fluid volume r/t decreased intake, increased fluid requirements during sickle cell crisis, decreased ability of kidneys to concentrate urine Impaired physical Mobility r/t pain, fatigue Acute Pain r/t viscous blood, tissue hypoxia Ineffective peripheral Tissue Perfusion r/t effects of red cell sickling, infarction of tissues Risk for decreased Cardiac tissue perfusion: Risk factors: effects of red cell sickling, infarction of tissues Risk for disproportionate Growth: Risk factor: chronic illness Risk for Infection: Risk factor: alterations in splenic function Risk for impaired Resilience: Risk factor: chronic illness Risk for ineffective cerebral Tissue perfusion: Risk factors: effects of red cell sickling, infarction of tissues Risk for ineffective Gastrointestinal perfusion: Risk factors: coagulopathy, sickle cell anemia. See Child with Chronic Condition; Hospitalized Child

SIDS (Sudden Infant Death Syndrome) Anxiety: parental worry r/t life-threatening event Interrupted Family processes r/t stress as a result of special care needs of infant with apnea Grieving r/t potential loss of infant Insomnia: parental/infant r/t home apnea monitoring Deficient Knowledge: potential for enhanced health mainte- nance r/t knowledge or skill acquisition of cardiopulmonary resuscitation and home apnea monitoring Impaired Resilience r/t sudden loss Risk for Sudden Infant Death syndrome (See Sudden Infant Death syndrome, risk for, Section III) Risk for Powerlessness: Risk factor: unanticipated life- threatening event See Terminally Ill Child/Death of Child, Parent

Sitting Problems Impaired Sitting (See Sitting, impaired, Section III)

Situational Crisis Ineffective Coping r/t situational crisis Interrupted Family processes r/t situational crisis Risk for ineffective Activity planning: Risk factor: inability to process information Risk for disturbed personal Identity: Risk factor: situational crisis

Somatization Disorder 109

S

Readiness for enhanced Communication: willingness to share feelings and thoughts Readiness for enhanced Religiosity: requests religious material and/or experiences Readiness for enhanced Resilience: desire to enhance resilience Readiness for enhanced Spiritual well-being: desire for harmony following crisis

SJS (Stevens-Johnson Syndrome) See Stevens-Johnson Syndrome (SJS)

Skin Cancer Ineffective Health maintenance r/t deficient knowledge regard- ing self-care with skin cancer Ineffective Protection r/t weakened immune system Impaired Tissue integrity r/t abnormal cell growth in skin, treat- ment of skin cancer Readiness for enhanced Health management: follows preven- tive measures Readiness for enhanced Knowledge: self-care to prevent and treat skin cancer

Skin Disorders Impaired Skin integrity (See Skin integrity, impaired, Section III)

Skin Turgor, Change in Elasticity Deficient Fluid volume r/t active fluid loss

Sleep Readiness for enhanced Sleep (See Sleep, readiness for enhanced, Section III)

Sleep Apnea Ineffective Breathing pattern r/t obesity, substance abuse, enlarged tonsils, smoking, or neurological pathology such as a brain tumor

Sleep Deprivation Fatigue r/t lack of sleep Sleep deprivation (See Sleep deprivation, Section III)

Sleep Problems Insomnia (See Insomnia, Section III)

Sleep Pattern, Disturbed, Parent/Child Insomnia: child r/t anxiety or fear Insomnia: parent r/t parental responsibilities, stress See Suspected Child Abuse and Neglect (SCAN), Child and Parent

Slurring of Speech Impaired verbal Communication r/t decrease in circulation to brain, brain tumor, anatomical defect, cleft palate Situational low Self-Esteem r/t speech impairment See Communication Problems

Small Bowel Resection See Abdominal Surgery

Smell, Loss of Ability to Risk for Injury: Risk factors: inability to detect gas fumes, smoke smells See Anosmia

Smoke Inhalation Ineffective Airway clearance r/t smoke inhalation Impaired Gas exchange r/t ventilation-perfusion imbalance Risk for acute Confusion: Risk factor: decreased oxygen supply Risk for Infection: Risk factors: inflammation, ineffective airway clearance, pneumonia Risk for Poisoning: Risk factor: exposure to carbon monoxide Readiness for enhanced Health management: functioning smoke detectors and carbon monoxide detectors in home and work, escape route planned and reviewed See Atelectasis; Burns; Pneumonia

Smoking Behavior Insufficient Breast Milk r/t smoking Risk-prone Health behavior r/t smoking Ineffective Health maintenance r/t denial of effects of smoking, lack of effective support for smoking withdrawal Readiness for enhanced Knowledge: expresses interest in smoking cessation Risk for dry Eye: Risk factor: smoking Risk for ineffective peripheral Tissue Perfusion: Risk factor: effect of nicotine Risk for Thermal injury: Risk factor: unsafe smoking behavior

Social Interaction, Impaired Impaired Social interaction (See Social interaction, impaired, Section III)

Social Isolation Social isolation (See Social isolation, Section III)

Sociopathic Personality See Antisocial Personality Disorder

Sodium, Decrease/Increase See Hyponatremia; Hypernatremia

Somatization Disorder Anxiety r/t unresolved conflicts channeled into physical com- plaints or conditions Ineffective Coping r/t lack of insight into underlying conflicts Ineffective Denial r/t displaced psychological stress to physical symptoms Nausea r/t anxiety Chronic Pain r/t unexpressed anger, multiple physical disorders, depression Impaired individual Resilience r/t possible psychological disorders

110 Sore Nipples, Breastfeeding

S

Sore Nipples, Breastfeeding Ineffective Breastfeeding r/t deficient knowledge regarding correct feeding procedure See Painful Breasts, Sore Nipples

Sore Throat Impaired Comfort r/t sore throat Deficient Knowledge r/t treatment, relief of discomfort Impaired Oral Mucous Membrane r/t inflammation or infec- tion of oral cavity Impaired Swallowing r/t irritation of oropharyngeal cavity

Sorrow Grieving r/t loss of significant person, object, or role Chronic Sorrow (See Sorrow, chronic, Section III) Readiness for enhanced Communication: expresses thoughts and feelings Readiness for enhanced Spiritual well-being: desire to find purpose and meaning of loss

Spastic Colon See IBS (Irritable Bowel Syndrome)

Speech Disorders Anxiety r/t difficulty with communication Impaired verbal Communication r/t anatomical defect, cleft palate, psychological barriers, decrease in circulation to brain

Spina Bifida See Neural Tube Defects

Spinal Cord Injury Deficient Diversional activity r/t long-term hospitalization, fre- quent lengthy treatments Fear r/t powerlessness over loss of body function Complicated Grieving r/t loss of usual body function Sedentary lifestyle r/t lack of resources or interest Impaired wheelchair Mobility r/t neuromuscular impairment Impaired Standing r/t spinal cord injury Urinary Retention r/t inhibition of reflex arc Risk for Latex Allergy response: Risk factor: continuous or intermittent catheterization Risk for Autonomic Dysreflexia: Risk factors: bladder or bowel distention, skin irritation, deficient knowledge of patient and caregiver Risk for ineffective Breathing pattern: Risk factor: neuromus- cular impairment Risk for Infection: Risk factors: chronic disease, stasis of body fluids Risk for Loneliness: Risk factor: physical immobility Risk for Powerlessness: Risk factor: loss of function Risk for Pressure ulcer: Risk factor: immobility and decreased sensation

See Child with Chronic Condition; Hospitalized Child; Neural Tube Defects; Paralysis

Spinal Fusion Impaired bed Mobility r/t impaired ability to turn side to side while keeping spine in proper alignment Impaired physical Mobility r/t musculoskeletal impairment associated with surgery, possible back brace Readiness for enhanced Knowledge: expresses interest in infor- mation associated with surgery See Acute Back; Back Pain; Scoliosis; Surgery, Preoperative Care; Surgery, Perioperative Care; Surgery, Postoperative Care

Spiritual Distress Spiritual distress (See Spiritual distress, Section III) Risk for chronic low Self-Esteem: Risk factor: unresolved spiritual issues Risk for Spiritual distress (See Spiritual distress, risk for, Section III)

Spiritual Well-Being Readiness for enhanced Spiritual well-being (See Spiritual well-being, readiness for enhanced, Section III)

Splenectomy See Abdominal Surgery

Sprains Acute Pain r/t physical injury Impaired physical Mobility r/t injury Impaired Walking r/t injury

Standing Problems Impaired Standing (see Impaired Standing, Section III)

Stapedectomy Hearing Loss r/t edema from surgery Acute Pain r/t headache Risk for Falls: Risk factor: dizziness Risk for Infection: Risk factor: invasive procedure

Stasis Ulcer Impaired Tissue integrity r/t chronic venous congestion Risk for Infection: Risk factor: open wound See CHF (Congestive Heart Failure); Varicose Veins

STD (Sexually Transmitted Disease) Impaired Comfort r/t infection Fear r/t altered body function, risk for social isolation, fear of incurable illness Ineffective Health maintenance r/t deficient knowledge regard- ing transmission, symptoms, treatment of STD Ineffective Sexuality pattern r/t illness, altered body function, need for abstinence to heal Social isolation r/t fear of contracting or spreading disease Risk for Infection: spread of infection: Risk factor: lack of knowledge concerning transmission of disease

Substance Abuse 111

S

Readiness for enhanced Knowledge: seeks information regard- ing prevention and treatment of STDs See Maturational Issues, Adolescent; PID (Pelvic Inflammatory Disease)

STEMI (ST-Elevation Myocardial Infarction)

See MI (Myocardial Infarction)

Stent (Coronary Artery Stent) Risk for Injury: Risk factor: complications associated with stent placement Risk for decreased Cardiac tissue perfusion: Risk factor: pos- sible restenosis Risk for Vascular Trauma: Risk factors: insertion site, cath- eter width Readiness for enhanced Decision-Making: expresses desire to enhance risk-benefit analysis, understanding and meaning of choices, and decisions regarding treatment See Angioplasty, Coronary; Cardiac Catheterization

Sterilization Surgery Decisional Conflict r/t multiple or divergent sources of infor- mation, unclear personal values or beliefs See Surgery, Preoperative Care; Surgery, Perioperative Care; Surgery, Postoperative Care; Tubal Ligation; Vasectomy

Stertorous Respirations Ineffective Airway clearance r/t pharyngeal obstruction

Stevens-Johnson Syndrome (SJS) Impaired Oral Mucous Membrane r/t immunocompromised condition associated with allergic medication reaction Acute Pain r/t painful skin lesions and painful mucosa lesions Impaired Skin integrity r/t allergic medication reaction Risk for deficient Fluid volume: Risk factors: factors affecting fluid needs (hypermetabolic state, fever), excessive losses through normal routes (vomiting and diarrhea) Risk for Infection: Risk factor: sloughing skin Risk for impaired Liver function: Risk factor: impaired immune response

Stillbirth See Pregnancy Loss

Stoma See Colostomy; Ileostomy

Stomatitis Impaired Oral Mucous Membrane r/t pathological condi- tions of oral cavity; side effects of chemotherapy Risk for impaired Oral Mucous Membranes (See impaired Oral Mucous Membranes, risk for, Section III)

Stone, Kidney See Kidney Stone

Stool, Hard/Dry Chronic functional Constipation r/t inadequate fluid intake, inadequate fiber intake, decreased activity level, decreased gastric motility

Straining with Defecation Chronic functional Constipation r/t less than adequate fluid intake, less than adequate dietary intake Risk for decreased Cardiac output: Risk factor: vagal stimulation with dysrhythmia resulting from Valsalva maneuver

Strep Throat Risk for Infection: Risk factor: exposure to pathogen See Sore Throat

Stress Anxiety r/t feelings of helplessness, feelings of being threatened Ineffective Coping r/t ineffective use of problem-solving process, feelings of apprehension or helplessness Fear r/t powerlessness over feelings Stress overload r/t intense or multiple stressors Readiness for enhanced Communication: shows willingness to share thoughts and feelings Readiness for enhanced Spiritual well-being: expresses desire for harmony and peace in stressful situation See Anxiety

Stress Urinary Incontinence Stress urinary Incontinence r/t degenerative change in pelvic muscles

Stridor Ineffective Airway clearance r/t obstruction, tracheobronchial infection, trauma

Stroke See CVA (Cerebrovascular Accident)

Stuttering Anxiety r/t impaired verbal communication Impaired verbal Communication r/t anxiety, psychological problems

Subarachnoid Hemorrhage Acute Pain: headache r/t irritation of meninges from blood, increased intracranial pressure Risk for ineffective Cerebral tissue perfusion: Risk factor: bleeding from cerebral vessel See Intracranial Pressure, Increased

Substance Abuse Compromised family Coping r/t codependency issues Defensive Coping r/t substance abuse Disabled family Coping r/t differing coping styles between support persons

112 Substance Abuse, Adolescent

S

Ineffective Coping r/t use of substances to cope with life events Ineffective Denial r/t refusal to acknowledge substance abuse problem Dysfunctional Family processes r/t substance abuse Deficient community Health r/t prevention and control of illegal substances in community Ineffective Impulse control r/t addictive process Ineffective Relationship r/t inability for well-balanced collabo- ration between partners Insomnia r/t irritability, nightmares, tremors Risk for impaired Attachment: Risk factor: substance abuse Risk for disturbed personal Identity: Risk factor: ingestion/ inhalation of toxic chemicals Risk for chronic low Self-Esteem: Risk factors: perceived lack of respect from others, repeated failures, repeated negative reinforcement Risk for Thermal injury: Risk factor: intoxication with drugs or alcohol Risk for Vascular Trauma: Risk factor: chemical irritant self injected into veins Risk for self-directed Violence: Risk factors: reactions to sub- stances used, impulsive behavior, disorientation, impaired judgment Risk for other-directed Violence: Risk factor: access to weapon Readiness for enhanced Coping: seeking social support and knowledge of new strategies Readiness for enhanced Self-Concept: accepting strengths and limitations See Alcoholism; Drug Abuse; Maturational Issues, Adolescent

Substance Abuse, Adolescent See Alcohol Withdrawal; Maturational Issues, Adolescent; Sub- stance Abuse

Substance Abuse in Pregnancy Ineffective Childbearing process r/t substance abuse Defensive Coping r/t denial of situation, differing value system Ineffective Health management r/t addiction Deficient Knowledge r/t lack of exposure to information regarding effects of substance abuse in pregnancy Risk for impaired Attachment: Risk factors: substance abuse, inability of parent to meet infant’s or own personal needs Risk for Infection: Risk factors: intravenous drug use, lifestyle Risk for Injury: fetal: Risk factor: effects of drugs on fetal growth and development Risk for Injury: maternal: Risk factor: drug or alcohol use Risk for impaired Parenting: Risk factor: lack of ability to meet infant’s needs due to addiction with use of alcohol or drugs See Alcoholism; Drug Abuse; Substance Abuse

Sucking Reflex Effective Breastfeeding r/t regular and sustained sucking and swallowing at breast

Sudden Infant Death Syndrome (SIDS) See SIDS (Sudden Infant Death Syndrome)

Suffocation, Risk for Risk for Suffocation (See Suffocation, risk for, Section III)

Suicide Attempt Risk-prone Health behavior r/t low self-efficacy Ineffective Coping r/t anger, complicated grieving Hopelessness r/t perceived or actual loss, substance abuse, low self-concept, inadequate support systems Ineffective Impulse control r/t inability to modulate stress, anxiety Post-Trauma syndrome r/t history of traumatic events, abuse, rape, incest, war, torture Impaired individual Resilience r/t poor impulse control Situational low Self-Esteem r/t guilt, inability to trust, feelings of worthlessness or rejection Social isolation r/t inability to engage in satisfying personal relationships Spiritual distress r/t hopelessness, despair Risk for Post-Trauma syndrome: Risk factor: survivor’s role in suicide attempt Risk for Suicide (See Suicide, risk for, Section III) Readiness for enhanced Communication: willingness to share thoughts and feelings Readiness for enhanced Spiritual well-being: desire for harmony and inner strength to help redefine purpose for life See Violent Behavior

Support System, Inadequate Readiness for enhanced family Coping: ability to adapt to tasks associated with care, support of significant other during health crisis Readiness for enhanced Family processes: activities support the growth of family members Readiness for enhanced Parenting: children or other dependent person(s) expressing satisfaction with home environment

Suppression of Labor See Preterm Labor; Tocolytic Therapy

Surgery, Perioperative Care Risk for imbalanced Fluid volume: Risk factor: surgery Risk for Perioperative Hypothermia: Risk factors: inade- quate covering of client, cold surgical room Risk for Perioperative Positioning injury: Risk factors: pre- disposing condition, prolonged surgery

Surgery, Postoperative Care Activity intolerance r/t pain, surgical procedure Anxiety r/t change in health status, hospital environment Deficient Knowledge r/t postoperative expectations, lifestyle changes

Systemic Lupus Erythematosus 113

S

Nausea r/t manipulation of gastrointestinal tract, postsurgical anesthesia Imbalanced Nutrition: less than body requirements r/t anorexia, nausea, vomiting, decreased peristalsis Ineffective peripheral Tissue Perfusion r/t hypovolemia, circu- latory stasis, obesity, prolonged immobility, decreased coughing, decreased deep breathing Acute Pain r/t inflammation or injury in surgical area Delayed Surgical recovery r/t extensive surgical procedure, postoperative surgical infection Urinary retention r/t anesthesia, pain, fear, unfamiliar sur- roundings, client’s position Risk for Bleeding: Risk factor: surgical procedure Risk for ineffective Breathing pattern: Risk factors: pain, loca- tion of incision, effects of anesthesia or opioids Risk for Constipation: Risk factors: decreased activity, decreased food or fluid intake, anesthesia, pain medication Risk for imbalanced Fluid volume: Risk factors: hypermetabolic state, fluid loss during surgery, presence of indwelling tubes, fluids used to distend organ structures being absorbed into body Risk for Infection: Risk factors: invasive procedure, pain, anesthesia, location of incision, weakened cough as a result of aging

Surgery, Preoperative Care Anxiety r/t threat to or change in health status, situational crisis, fear of the unknown Insomnia r/t anxiety about upcoming surgery Deficient Knowledge r/t preoperative procedures, postopera- tive expectations Readiness for enhanced Knowledge: shows understanding of preoperative and postoperative expectations for self-care

Surgical Recovery, Delayed Delayed Surgical recovery (See Surgical recovery, delayed, Section III) Risk for delayed Surgical recovery (See Surgical recovery, delayed, risk for, Section III)

Suspected Child Abuse and Neglect (SCAN), Child

Ineffective Activity planning r/t lack of family support Anxiety: child r/t threat of punishment for perceived wrongdoing Deficient community Health r/t inadequate reporting and follow-up of SCAN Disturbed personal Identity r/t dysfunctional family processes Rape-Trauma syndrome r/t altered lifestyle because of abuse, changes in residence Risk for impaired Resilience: Risk factor: adverse situation Readiness for enhanced community Coping: obtaining resources to prevent child abuse, neglect See Child Abuse; Hospitalized Child; Maturational Issues, Adolescent

Suspected Child Abuse and Neglect (SCAN), Parent

Disabled family Coping r/t dysfunctional family, underdevel- oped nurturing parental role, lack of parental support systems or role models Dysfunctional Family processes r/t inadequate coping skills Ineffective Health maintenance r/t deficient knowledge of par- enting skills as result of unachieved developmental tasks Impaired Home maintenance r/t disorganization, parental dys- function, neglect of safe and nurturing environment Ineffective Impulse control r/t projection of anger, frustration onto child Impaired Parenting r/t unrealistic expectations of child; lack of effective role model; unmet social, emotional, or maturational needs of parents; interruption in bonding process Impaired individual Resilience r/t poor impulse control Chronic low Self-Esteem r/t lack of successful parenting experiences Risk for other-directed Violence: parent to child: Risk factors: inadequate coping mechanisms, unresolved stressors, unachieved maturational level by parent

Suspicion Disturbed personal Identity r/t psychiatric disorder Powerlessness r/t repetitive paranoid thinking Impaired Social interaction r/t disturbed thought processes, paranoid delusions, hallucinations Risk for self-directed Violence: Risk factor: inability to trust Risk for other-directed Violence: Risk factor: impulsiveness

Swallowing Difficulties Impaired Swallowing (See Swallowing, impaired, Section III)

Swine Flu (H1N1) See Influenza

Syncope Anxiety r/t fear of falling Impaired physical Mobility r/t fear of falling Ineffective Health management r/t lack of knowledge in how to prevent syncope Social isolation r/t fear of falling Risk for decreased Cardiac output: Risk factor: dysrhythmia Risk for Falls: Risk factor: syncope Risk for Injury: Risk factors: altered sensory perception, tran- sient loss of consciousness, risk for falls Risk for ineffective Cerebral tissue perfusion: Risk factor: inter- ruption of blood flow

Syphilis See STD (Sexually Transmitted Disease)

Systemic Lupus Erythematosus See Lupus Erythematosus

e25

T & A (Tonsillectomy and Adenoidectomy)

Tachycardia Tachypnea

Tardive Dyskinesia Taste Abnormality TB (Pulmonary Tuberculosis) TBI (Traumatic Brain Injury) TD (Traveler’s Diarrhea) Temperature, Decreased Temperature, High Temperature Regulation, Impaired TEN (Toxic Epidermal Necrolysis) Tension Terminally Ill Adult Terminally Ill Child, Adolescent Terminally Ill Child, Infant/Toddler Terminally Ill Child, Preschool Child Terminally Ill Child, School-Age

Child/Preadolescent Terminally Ill Child/Death of Child, Parent

Tetralogy of Fallot Tetraplegia

Thermoregulation, Ineffective Thoracentesis Thoracotomy Thought Disorders Thrombocytopenic Purpura Thrombophlebitis Thyroidectomy TIA (Transient Ischemic Attack) Tic Disorder Tinea Capitis Tinea Corporis Tinea Cruris Tinea Pedis Tinea Unguium (Onychomycosis) Tinnitus Tissue Damage, Corneal Tissue Damage, Integumentary Tissue Perfusion, Peripheral Toileting Problems Toilet Training Tonsillectomy and Adenoidectomy

(T & A) Toothache Total Anomalous Pulmonary Venous

Return Total Joint Replacement (Total Hip/ Total Knee/Shoulder)

Total Parenteral Nutrition (TPN) Tourette’s Syndrome (TS) Toxemia Toxic Epidermal Necrolysis (TEN) (Erythema Multiforme)

TPN (Total Parenteral Nutrition) Tracheoesophageal Fistula

Tracheostomy Traction and Casts Transfer Ability Transient Ischemic Attack (TIA) Transposition of Great Vessels Transurethral Resection of the Prostate

(TURP)

List of Nursing Assessments by Letter: T

e26 List of Nursing Assessments by Letter: T

Trauma in Pregnancy Trauma, Risk for Traumatic Brain Injury (TBI) Traumatic Event Traveler’s Diarrhea (TD) Trembling of Hands Tricuspid Atresia Trigeminal Neuralgia Truncus Arteriosus TS (Tourette’s Syndrome) TSE (Testicular Self-Examination) Tubal Ligation Tube Feeding Tuberculosis (TB) TURP (Transurethral Resection of the

Prostate)

114 T & A (Tonsillectomy and Adenoidectomy)

T

T T & A (Tonsillectomy and Adenoidectomy)

Ineffective Airway clearance r/t hesitation or reluctance to cough because of pain Deficient Knowledge: potential for enhanced health main­ tenance r/t insufficient knowledge regarding postoperative nutritional and rest requirements, signs and symptoms of com- plications, positioning Nausea r/t gastric irritation, pharmaceuticals, anesthesia Acute Pain r/t surgical incision Risk for Aspiration: Risk factors: postoperative drainage and impaired swallowing Risk for deficient Fluid volume: Risk factors: decreased intake because of painful swallowing, effects of anesthesia (nausea, vomiting), hemorrhage Risk for imbalanced Nutrition: less than body requirements: Risk factors: hesitation or reluctance to swallow

Tachycardia See Dysrhythmia

Tachypnea Ineffective Breathing pattern r/t pain, anxiety, hypoxia See cause of Tachypnea

Tardive Dyskinesia Ineffective Health management r/t complexity of therapeutic regimen or medication Deficient Knowledge r/t cognitive limitation in assimilating information relating to side effects associated with neuroleptic medications Risk for Injury: Risk factor: drug-induced abnormal body movements

Taste Abnormality Frail Elderly syndrome r/t chronic illness

TB (Pulmonary Tuberculosis) Ineffective Airway clearance r/t increased secretions, exces- sive mucus Ineffective Breathing pattern r/t decreased energy, fatigue Fatigue r/t disease state Impaired Gas exchange r/t disease process Ineffective Health management r/t deficient knowledge of pre- vention and treatment regimen Impaired Home maintenance management r/t client or family member with disease Ineffective Thermoregulation r/t presence of infection Risk for Infection: Risk factor: insufficient knowledge regarding avoidance of exposure to pathogens Readiness for enhanced Health management: takes medica- tions according to prescribed protocol for prevention and treatment

TBI (Traumatic Brain Injury) Interrupted Family processes r/t traumatic injury to family member Chronic Sorrow r/t change in health status and functional ability Risk for Post-Trauma syndrome: Risk factor: perception of event causing TBI Risk for impaired Religiosity: Risk factor: impaired physical mobility Risk for impaired Resilience: Risk factor: crisis of injury See Head Injury; Neurologic Disorders

TD (Traveler’s Diarrhea) Diarrhea r/t travel with exposure to different bacteria, viruses Risk for deficient Fluid volume: Risk factors: excessive loss of fluids, diarrhea Risk for Infection: Risk factors: insufficient knowledge regard- ing avoidance of exposure to pathogens (water supply, iced drinks, local cheeses, ice cream, undercooked meat, fish and shellfish, uncooked vegetables, unclean eating utensils, improper handwashing)

Temperature, Decreased Hypothermia r/t exposure to cold environment

Temperature, High Hyperthermia r/t neurological damage, disease condition with high temperature, excessive heat, inflammatory response

Temperature Regulation, Impaired Ineffective Thermoregulation r/t trauma, illness, cerebral injury

TEN (Toxic Epidermal Necrolysis) See Toxic Epidermal Necrolysis (TEN)

Tension Anxiety r/t threat to or change in health status, situational crisis Readiness for enhanced Communication: expresses willing- ness to share feelings and thoughts See Stress

Terminally Ill Adult Death Anxiety r/t unresolved issues relating to death and dying Risk for Spiritual distress: Risk factor: impending death Readiness for enhanced Religiosity: requests religious material and/or experiences Readiness for enhanced Spiritual well­being: desire to achieve harmony of mind, body, spirit See Terminally Ill Child/Death of Child, Parent

Terminally Ill Child, Adolescent Disturbed Body Image r/t effects of terminal disease, already critical feelings of group identity and self-image Ineffective Coping r/t inability to establish personal and peer identity because of the threat of being different or not being healthy, inability to achieve maturational tasks

Thrombophlebitis 115

T

Impaired Social interaction r/t forced separation from peers See Child with Chronic Condition; Hospitalized Child, Terminally Ill Child/Death of Child, Parent

Terminally Ill Child, Infant/Toddler Ineffective Coping r/t separation from parents and familiar environment from inability to understand dying process See Child with Chronic Condition, Terminally Ill Child/Death of Child, Parent

Terminally Ill Child, Preschool Child Fear r/t perceived punishment, bodily harm, feelings of guilt caused by magical thinking (i.e., believing that thoughts cause events) See Child with Chronic Condition, Terminally Ill Child/Death of Child, Parent

Terminally Ill Child, School-Age Child/Preadolescent

Fear r/t perceived punishment, body mutilation, feelings of guilt See Child with Chronic Condition, Terminally Ill Child/Death of Child, Parent

Terminally Ill Child/Death of Child, Parent Compromised family Coping r/t inability or unwillingness to discuss impending death and feelings with child or support child through terminal stages of illness Decisional Conflict r/t continuation or discontinuation of treatment, do-not-resuscitate decision, ethical issues regarding organ donation Ineffective Denial r/t complicated grieving Interrupted Family processes r/t situational crisis Grieving r/t death of child Hopelessness r/t overwhelming stresses caused by terminal illness Insomnia r/t grieving process Impaired Parenting r/t risk for overprotection of surviving siblings Powerlessness r/t inability to alter course of events Impaired Social interaction r/t complicated grieving Social isolation: imposed by others r/t feelings of inadequacy in providing support to grieving parents Social isolation: self­imposed r/t unresolved grief, perceived inadequate parenting skills Spiritual distress r/t sudden and unexpected death, prolonged suffering before death, questioning the death of youth, question- ing the meaning of one’s own existence Risk for complicated Grieving: Risk factors: prolonged, unre- solved, obstructed progression through stages of grief and mourning Risk for impaired Resilience: Risk factor: impending death Readiness for enhanced family Coping: impact of crisis on family values, priorities, goals, or relationships; expressed inter- est or desire to attach meaning to child’s life and death

Tetralogy of Fallot See Congenital Heart Disease/Cardiac Anomalies

Tetraplegia Autonomic dysreflexia r/t bladder or bowel distention, skin irritation, infection, deficient knowledge of patient and caregiver Grieving r/t loss of previous functioning Powerlessness r/t inability to perform previous activities Impaired Sitting r/t paralysis of extremities Impaired spontaneous Ventilation r/t loss of innervation of respiratory muscles, respiratory muscle fatigue Risk for Aspiration: Risk factor: inadequate ability to protect airway from neurological damage Risk for Infection: Risk factor: urinary stasis Risk for impaired Skin integrity: Risk factor: physical immobi- lization and decreased sensation Risk for ineffective Thermoregulation: Risk factors: inability to move to increase temperature, possible presence of infection to increase temperature

Thermoregulation, Ineffective Ineffective Thermoregulation (See Thermoregulation, inef- fective, Section III)

Thoracentesis See Pleural Effusion

Thoracotomy Activity intolerance r/t pain, imbalance between oxygen supply and demand, presence of chest tubes Ineffective Airway clearance r/t drowsiness, pain with breathing and coughing Ineffective Breathing pattern r/t decreased energy, fatigue, pain Deficient Knowledge r/t self-care, effective breathing exercises, pain relief Acute Pain r/t surgical procedure, coughing, deep breathing Risk for Bleeding: Risk factor: surgery Risk for Infection: Risk factor: invasive procedure Risk for Injury: Risk factor: disruption of closed-chest drainage system Risk for Perioperative Positioning injury: Risk factors: lateral positioning, immobility Risk for Vascular Trauma: Risk factors: chemical irritant; antibiotics

Thought Disorders See Schizophrenia

Thrombocytopenic Purpura See ITP (Idiopathic Thrombocytopenic Purpura)

Thrombophlebitis See DVT

116 Thyroidectomy

T

Thyroidectomy Risk for ineffective Airway clearance r/t edema or hematoma formation, airway obstruction Risk for impaired verbal Communication: Risk factors: edema, pain, vocal cord or laryngeal nerve damage Risk for Injury: Risk factor: possible parathyroid damage or removal See Surgery, Preoperative Care; Surgery, Perioperative Care; Surgery, Postoperative Care

TIA (Transient Ischemic Attack) Acute Confusion r/t hypoxia Readiness for enhanced Health management: obtains knowl- edge regarding treatment prevention of inadequate oxygenation See Syncope

Tic Disorder See Tourette’s Syndrome (TS)

Tinea Capitis Impaired Comfort r/t inflammation from skin irritation See Ringworm of Scalp

Tinea Corporis See Ringworm of Body

Tinea Cruris See Jock Itch; Itching; Pruritus

Tinea Pedis See Athlete’s Foot; Itching; Pruritus

Tinea Unguium (Onychomycosis) See Ringworm of Nails

Tinnitus Ineffective Health maintenance r/t deficient knowledge regard- ing self-care with tinnitus Hearing Loss r/t ringing in ears obscuring hearing

Tissue Damage, Corneal Risk for corneal Injury (See corneal Injury, risk for, Section III)

Tissue Damage, Integumentary Impaired Tissue integrity (See Tissue integrity, impaired, Section III) Risk for impaired Tissue integrity (See Tissue integrity, impaired, risk for, Section III)

Tissue Perfusion, Peripheral Ineffective peripheral Tissue Perfusion (See Tissue Perfusion, peripheral, ineffective, Section III) Risk for ineffective peripheral Tissue Perfusion (See Tissue Perfusion, peripheral, ineffective, risk for, Section III)

Toileting Problems Toileting Self-Care deficit r/t impaired transfer ability, impaired mobility status, intolerance of activity, neuromuscular impair- ment, cognitive impairment Impaired Transfer ability r/t neuromuscular deficits

Toilet Training Deficient Knowledge: parent r/t signs of child’s readiness for training Risk for Constipation: Risk factor: withholding stool Risk for Infection: Risk factor: withholding urination

Tonsillectomy and Adenoidectomy (T & A) See T & A (Tonsillectomy and Adenoidectomy)

Toothache Impaired Dentition r/t ineffective oral hygiene, barriers to self- care, economic barriers to professional care, nutritional deficits, lack of knowledge regarding dental health Acute Pain r/t inflammation, infection

Total Anomalous Pulmonary Venous Return

See Congenital Heart Disease/Cardiac Anomalies

Total Joint Replacement (Total Hip/Total Knee/Shoulder)

Disturbed Body Image r/t large scar, presence of prosthesis Impaired physical Mobility r/t musculoskeletal impairment, surgery, prosthesis Risk for Injury: neurovascular: Risk factors: altered peripheral tissue perfusion, impaired mobility, prosthesis Risk for Peripheral Neurovascular dysfunction r/t immobi- lization, surgical procedure Ineffective peripheral Tissue perfusion r/t surgery See Surgery, Preoperative Care; Surgery, Perioperative Care; Surgery, Postoperative Care

Total Parenteral Nutrition (TPN) See TPN (Total Parenteral Nutrition)

Tourette’s Syndrome (TS) Hopelessness r/t inability to control behavior Impaired individual Resilience r/t uncontrollable behavior Risk for situational low Self-Esteem: Risk factors: uncontrol- lable behavior, motor and phonic tics See Attention Deficit Disorder

Toxemia See PIH (Pregnancy-Induced Hypertension/Preeclampsia)

Toxic Epidermal Necrolysis (TEN) (Erythema Multiforme)

Death Anxiety r/t uncertainty of prognosis See Stevens-Johnson Syndrome (SJS)

TPN (Total Parenteral Nutrition) Imbalanced Nutrition: less than body requirements r/t inability to digest food or absorb nutrients as a result of biological or psychological factors Risk for Electrolyte imbalance: Risk factor: need for regulation of electrolytes in TPN fluids

TS (Tourette’s Syndrome) 117

T

Risk for excess Fluid volume: Risk factor: rapid administration of TPN Risk for unstable blood Glucose level: Risk factor: high glucose levels in TPN to be regulated according to blood glucose levels Risk for Infection: Risk factors: concentrated glucose solution, invasive administration of fluids Risk for Vascular Trauma: Risk factors: insertion site, length of treatment time

Tracheoesophageal Fistula Ineffective Airway clearance r/t aspiration of feeding because of inability to swallow Imbalanced Nutrition: less than body requirements r/t difficul- ties swallowing Risk for Aspiration: Risk factor: common passage of air and food Risk for Vascular Trauma: Risk factors: venous medications and site See Respiratory Conditions of the Neonate; Hospitalized Child

Tracheostomy Ineffective Airway clearance r/t increased secretions, mucous plugs Anxiety r/t impaired verbal communication, ineffective airway clearance Disturbed Body Image r/t abnormal opening in neck Impaired verbal Communication r/t presence of mechanical airway Deficient Knowledge r/t self-care, home maintenance management Acute Pain r/t edema, surgical procedure Risk for Aspiration: Risk factor: presence of tracheostomy Risk for Bleeding: Risk factor: surgical incision Risk for Infection: Risk factors: invasive procedure, pooling of secretions

Traction and Casts Constipation r/t immobility Deficient Diversional activity r/t immobility Impaired physical Mobility r/t imposed restrictions on activity because of bone or joint disease injury Acute Pain r/t immobility, injury, or disease Self-Care deficit: feeding, dressing, bathing, toileting r/t degree of impaired physical mobility, body area affected by traction or cast Impaired Transfer ability r/t presence of traction, casts Risk for Disuse syndrome: Risk factor: mechanical immobilization See Casts

Transfer Ability Impaired Transfer ability (See Transfer ability, impaired, Section III)

Transient Ischemic Attack (TIA) See TIA (Transient Ischemic Attack)

Transposition of Great Vessels See Congenital Heart Disease/Cardiac Anomalies

Transurethral Resection of the Prostate (TURP)

See TURP (Transurethral Resection of the Prostate)

Trauma in Pregnancy Anxiety r/t threat to self or fetus, unknown outcome Deficient Knowledge r/t lack of exposure to situation Acute Pain r/t trauma Impaired Skin integrity r/t trauma Risk for Bleeding: Risk factor: trauma Risk for deficient Fluid volume: Risk factor: fluid loss Risk for Infection: Risk factor: traumatized tissue Risk for Injury: fetal: Risk factor: premature separation of placenta Risk for disturbed Maternal–Fetal dyad: Risk factor: complica- tion of pregnancy

Trauma, Risk for Risk for Trauma (See Trauma, risk for, Section III)

Traumatic Brain Injury (TBI) See TBI (Traumatic Brain Injury); Intracranial Pressure, Increased

Traumatic Event Post-Trauma syndrome r/t previously experienced trauma

Traveler’s Diarrhea (TD) See TD (Traveler’s Diarrhea)

Trembling of Hands Fear r/t threat to or change in health status, threat of death, situ- ational crisis

Tricuspid Atresia See Congenital Heart Disease/Cardiac Anomalies

Trigeminal Neuralgia Ineffective Health management r/t deficient knowledge regard- ing prevention of stimuli that trigger pain Imbalanced Nutrition: less than body requirements r/t pain when chewing Acute Pain r/t irritation of trigeminal nerve Risk for corneal Injury: Risk factor: possible decreased corneal sensation

Truncus Arteriosus See Congenital Heart Disease/Cardiac Anomalies

TS (Tourette’s Syndrome) See Tourette’s Syndrome (TS)

118 TSE (Testicular Self-Examination)

TSE (Testicular Self-Examination) Readiness for enhanced Health management: seeks informa- tion regarding self-examination

Tubal Ligation Decisional Conflict r/t tubal sterilization See Laparoscopy

Tube Feeding Risk for Aspiration: Risk factors: improperly administered feeding, improper placement of tube, improper positioning of client during and after feeding, excessive residual feeding or lack of digestion, altered gag reflex Risk for deficient Fluid volume: Risk factor: inadequate water administration with concentrated feeding Risk for imbalanced Nutrition: less than body requirements: Risk factors: intolerance to tube feeding, inadequate calorie replacement to meet metabolic needs

Tuberculosis (TB) See TB (Pulmonary Tuberculosis)

TURP (Transurethral Resection of the Prostate)

Deficient Knowledge r/t postoperative self-care, home mainte- nance management Acute Pain r/t incision, irritation from catheter, bladder spasms, kidney infection Urinary retention r/t obstruction of urethra or catheter with clots Risk for Bleeding: Risk factor: surgery Risk for deficient Fluid volume: Risk factors: fluid loss, possible bleeding Risk for urge urinary Incontinence: Risk factor: edema from surgical procedure Risk for Infection: Risk factors: invasive procedure, route for bacteria entry

U U Ulcer, Peptic (Duodenal or Gastric)

Fatigue r/t loss of blood, chronic illness Ineffective Health maintenance r/t lack of knowledge regarding health practices to prevent ulcer formation Nausea r/t gastrointestinal irritation Acute Pain r/t irritated mucosa from acid secretion Risk for ineffective Gastrointestinal perfusion: Risk factor: ulcer See GI Bleed (Gastrointestinal Bleeding)

Ulcerative Colitis See Inflammatory Bowel Disease (Child and Adult)

Ulcers, Stasis See Stasis Ulcer

Unilateral Neglect of One Side of Body Unilateral Neglect (See Unilateral Neglect, Section III)

Unsanitary Living Conditions Impaired Home maintenance r/t impaired cognitive or emo- tional functioning, lack of knowledge, insufficient finances, addiction Risk for Allergy response: Risk factor: exposure to environ- mental contaminants

Urgency to Urinate Urge urinary Incontinence (See Incontinence, urinary, urge, Section III) Risk for urge urinary Incontinence (See Incontinence, urinary, urge, risk for, Section III)

Urinary Catheter Risk for urinary tract Injury: Risk factors: confused client, long- term use of catheter, large retention balloon or catheter, perirec- tal burn injured client

Urinary Diversion See Ileal Conduit

Urinary Elimination, Impaired Impaired Urinary elimination (See Urinary elimination, impaired, Section III)

Urinary Incontinence See Incontinence of Urine

Urinary Retention Urinary Retention (See Urinary Retention, Section III)

Urinary Tract Infection (UTI) See UTI (Urinary Tract Infection)

Urolithiasis See Kidney Stone

Uterine Atony in Labor See Dystocia

Uterine Atony in Postpartum See Postpartum Hemorrhage

Uterine Bleeding See Hemorrhage; Postpartum Hemorrhage; Shock, Hypovolemic

UTI (Urinary Tract Infection) Ineffective Health maintenance r/t deficient knowledge regard- ing methods to treat and prevent UTIs, prolonged use of indwell- ing urinary catheter Acute Pain: dysuria r/t inflammatory process in bladder Impaired Urinary elimination: frequency r/t urinary tract infection Risk for urge urinary Incontinence: Risk factor: hyperreflexia from cystitis Risk for ineffective Renal perfusion: Risk factor: infection

e27

Ulcer, Peptic (Duodenal or Gastric) Ulcerative Colitis Ulcers, Stasis Unilateral Neglect of One Side of Body Unsanitary Living Conditions Urgency to Urinate Urinary Catheter Urinary Diversion Urinary Elimination, Impaired Urinary Incontinence Urinary Retention Urinary Tract Infection (UTI) Urolithiasis Uterine Atony in Labor Uterine Atony in Postpartum Uterine Bleeding UTI (Urinary Tract Infection)

List of Nursing Assessments by Letter: U

e28

VAD (Ventricular Assist Device) Vaginal Hysterectomy Vaginitis Vagotomy Value System Conflict Varicose Veins Vascular Dementia (Formerly Called Multiinfarct Dementia)

Vascular Obstruction, Peripheral Vasectomy

Venereal Disease Ventilated Client, Mechanically Ventricular Assist Device (VAD) Ventricular Fibrillation Vertigo Violent Behavior Viral Gastroenteritis Vision Impairment Vomiting VTE (Venous Thromboembolism)

List of Nursing Assessments by Letter: V

Vision Impairment 119

V

V VAD (Ventricular Assist Device)

See Ventricular Assist Device (VAD)

Vaginal Hysterectomy Urinary retention r/t edema at surgical site Risk for urge urinary Incontinence: Risk factors: edema, con- gestion of pelvic tissues Risk for Infection: Risk factor: surgical site Risk for Perioperative Positioning injury: Risk factor: lithot- omy position

Vaginitis Impaired Comfort r/t pruritus, itching Ineffective Health maintenance r/t deficient knowledge regard- ing self-care with vaginitis Ineffective Sexuality pattern r/t abstinence during acute stage, pain

Vagotomy See Abdominal Surgery

Value System Conflict Decisional Conflict r/t unclear personal values or beliefs Spiritual distress r/t challenged value system Readiness for enhanced Spiritual well-being: desire for harmony with self, others, higher power, God

Varicose Veins Ineffective Health maintenance r/t deficient knowledge regard- ing health care practices, prevention, treatment regimen Chronic Pain r/t impaired circulation Ineffective peripheral Tissue Perfusion r/t venous stasis Risk for impaired Tissue integrity: Risk factor: altered periph- eral tissue perfusion

Vascular Dementia (Formerly Called Multiinfarct Dementia)

See Dementia

Vascular Obstruction, Peripheral Anxiety r/t lack of circulation to body part Acute Pain r/t vascular obstruction Ineffective peripheral Tissue Perfusion r/t interruption of cir- culatory flow Risk for Peripheral Neurovascular dysfunction: Risk factor: vascular obstruction

Vasectomy Decisional Conflict r/t surgery as method of permanent sterilization

Venereal Disease See STD (Sexually Transmitted Disease)

Ventilated Client, Mechanically Ineffective Airway clearance r/t increased secretions, decreased cough and gag reflex Ineffective Breathing pattern r/t decreased energy and fatigue as a result of possible altered nutrition: less than body require- ments, neurological disease or damage Impaired verbal Communication r/t presence of endotracheal tube, inability to phonate Fear r/t inability to breathe on own, difficulty communicating Impaired Gas exchange r/t ventilation-perfusion imbalance Powerlessness r/t health treatment regimen Social isolation r/t impaired mobility, ventilator dependence Impaired spontaneous Ventilation r/t metabolic factors, respi- ratory muscle fatigue Dysfunctional Ventilatory weaning response r/t psychological, situational, physiological factors Risk for Falls: Risk factors: impaired mobility, decreased muscle strength Risk for Infection: Risk factors: presence of endotracheal tube, pooled secretions Risk for pressure Ulcer: Risk factor: decreased mobility Risk for impaired Resilience: Risk factor: illness See Child with Chronic Condition; Hospitalized Child; Respiratory Conditions of the Neonate

Ventricular Assist Device (VAD) Anxiety r/t possible failure of device Risk for Infection: Risk factor: device insertion site Risk for Vascular Trauma: Risk factor: insertion site Readiness for enhanced Decision-Making: expresses desire to enhance the understanding of the meaning of choices regarding implanting a ventricular assist device See Open Heart Surgery

Ventricular Fibrillation See Dysrhythmia

Vertigo See Syncope

Violent Behavior Risk for other-directed Violence (See Violence, other-directed, risk for, Section III) Risk for self-directed Violence (See Violence, self-directed, risk for, Section III)

Viral Gastroenteritis Diarrhea r/t infectious process, Norovirus Deficient Fluid volume r/t vomiting, diarrhea Ineffective Health management r/t inadequate handwashing See Gastroenteritis, Child

Vision Impairment Fear r/t loss of sight Social isolation r/t altered state of wellness, inability to see

120 Vomiting

Vision Loss r/t impaired visual function; integration; reception; and or transmission Risk for impaired Resilience: Risk factor: presence of new crisis See Blindness; Cataracts; Glaucoma

Vomiting Nausea r/t chemotherapy, postsurgical anesthesia, irritation to the gastrointestinal system, stimulation of neuropharmacological mechanisms Imbalanced Nutrition: less than body requirements r/t inability to ingest food Risk for Electrolyte imbalance: Risk factor: vomiting

VTE (Venous Thromboembolism) See DVT (Deep Vein Thrombosis)

W

W Walking Impairment

Impaired Walking (See Walking, impaired, Section III)

Wandering Wandering (See Wandering, Section III)

Weakness Fatigue r/t decreased or increased metabolic energy production Risk for Falls: Risk factor: weakness

Weight Gain Overweight (See Overweight, Section III)

Weight Loss Imbalanced Nutrition: less than body requirements r/t inability to ingest food because of biological, psychological, economic factors

Wellness-Seeking Behavior Readiness for enhanced Health management: expresses desire for increased control of health practice

Wernicke-Korsakoff Syndrome See Korsakoff ’s Syndrome

West Nile Virus See Meningitis/Encephalitis

Wheelchair Use Problems Impaired wheelchair Mobility (See Mobility, wheelchair, impaired, Section III)

Wheezing Ineffective Airway clearance r/t tracheobronchial obstructions, secretions

Wilms’ Tumor Chronic functional Constipation r/t obstruction associated with presence of tumor Acute Pain r/t pressure from tumor See Chemotherapy; Hospitalized Child; Radiation Therapy; Surgery, Preoperative Care; Surgery, Perioperative Care; Surgery, Postoperative Care

Withdrawal from Alcohol See Alcohol Withdrawal

Withdrawal from Drugs See Drug Withdrawal

Wound Debridement Acute Pain r/t debridement of wound Impaired Tissue integrity r/t debridement, open wound Risk for Infection: Risk factors: open wound, presence of bacteria

Wound Dehiscence, Evisceration Fear r/t client fear of body parts “falling out,” surgical procedure not going as planned Disturbed Body Image r/t change in body structure and wound appearance Imbalanced Nutrition: less than body requirements r/t inability to digest nutrients, need for increased protein for healing Risk for deficient Fluid volume: Risk factors: inability to ingest nutrients, obstruction, fluid loss Risk for Injury: Risk factor: exposed abdominal contents Risk for delayed Surgical recovery: Risk factors: separation of wound, exposure of abdominal contents

Wound Infection Disturbed Body Image r/t open wound Imbalanced Nutrition: less than body requirements r/t biologi- cal factors, infection, fever Ineffective Thermoregulation r/t infection in wound resulting in fever Impaired Tissue integrity r/t wound, presence of infection Risk for imbalanced Fluid volume: Risk factor: increased meta- bolic rate Risk for Infection: spread of: Risk factor: imbalanced nutrition: less than body requirements Risk for delayed Surgical recovery: Risk factor: presence of infection

Wounds, Open See Lacerations

e29

Walking Impairment Wandering Weakness Weight Gain Weight Loss Wellness-Seeking Behavior Wernicke-Korsakoff Syndrome West Nile Virus Wheelchair Use Problems Wheezing Wilms’ Tumor Withdrawal from Alcohol Withdrawal from Drugs Wound Debridement Wound Dehiscence, Evisceration Wound Infection Wounds, Open

List of Nursing Assessments by Letter: W

121

SECTION

III Guide to Planning Care

Section III is a collection of NANDA-I nursing diagnosis care plans. The care plans are arranged alphabetically by diagnostic concept. They contain definitions, defining characteristics, and related factors if appropriate. Risk Diagnoses, however, only contain “risk factors.” Care plans include suggested outcomes and interventions for all nursing diagnoses.

MAKING AN ACCURATE NURSING DIAGNOSIS Verify the accuracy of the previously suggested nursing diagnoses (from Section II) or from alphabetized list (inside back cover) for the client.

STEPS • Read the definition for the suggested nursing diagnosis and determine if it is appropriate. • Compare the Defining Characteristics with the symptoms that were identified from the client data

collected. or • Compare the Risk Factors with the factors that were identified from the client data collected.

WRITING OUTCOMES STATEMENTS AND NURSING INTERVENTIONS After selecting the appropriate nursing diagnosis, use this section to write outcomes and interventions:

STEPS • Use the Client Outcomes/Nursing Interventions as written by the authors and contributors (select ones

that are appropriate for your client). or • Use the NOC/NIC outcomes and interventions (as appropriate for your client). • Read the rationales; the majority of rationales are based on nursing or clinical research that validates

the efficacy of the interventions. Every attempt has been made to utilize current references; however, some significant research has not been replicated. Important research studies that are older than 5 years are included because they are the only evidence available. They are designated as CEB (Classic Evidence-Based).

Following these steps, you will be able to write an evidence-based nursing care plan. • Follow this care plan to administer nursing care to the client. • Document all steps and evaluate and update the care plan as needed.

e30

Activity intolerance Risk for Activity intolerance Ineffective Activity planning Risk for Ineffective Activity planning Ineffective Airway clearance Risk for Allergy response Anxiety Death Anxiety Risk for Aspiration Risk for impaired Attachment Autonomic Dysreflexia Risk for Autonomic Dysreflexia

List of Nursing Diagnoses by Letter: A

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A 122 Activity Intolerance

Activity intolerance Lorraine Duggan, MSN, ACNP-BC

NANDA-I

Definition

Insufficient physiological or psychological energy to endure or complete required or desired daily activities

Defining Characteristics

Abnormal blood pressure response to activity; abnormal heart rate response to activity; ECG change (e.g., arrhythmia, conduction abnormality, ischemia); exertional discomfort; exertional dyspnea; fatigue; general- ized weakness

Related Factors (r/t)

Bed rest; generalized weakness; imbalance between oxygen supply/demand; immobility; sedentary lifestyle

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Activity Tolerance; Endurance; Energy Conservation; Self-Care: Instrumental Activities of Daily Living (IADLs)

Example NOC Outcome with Indicators

Activity Tolerance as evidenced by the following indicators: Oxygen saturation with activity/Pulse rate with activity/ Respiratory rate with activity/Blood pressure with activity/Electrocardiogram findings/Skin color/Walking distance. (Rate the outcome and indicators of Activity Tolerance: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Participate in prescribed physical activity with appropriate changes in heart rate, blood pressure, and breathing rate; maintain monitor patterns (rhythm and ST segment) within normal limits

• State symptoms of adverse effects of exercise and report onset of symptoms immediately • Maintain normal skin color; skin is warm and dry with activity • Verbalize an understanding of the need to gradually increase activity based on testing, tolerance, and

symptoms • Demonstrate increased tolerance to activity

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Activity Therapy; Energy Management; Exercise Therapy: Ambulation

Example NIC Activities—Energy Management

Monitor cardiorespiratory response to activity; Monitor location and nature of discomfort or pain during movement/activity

Nursing Interventions and Rationales

• Determine cause of Activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational. QSEN: As nurses we are called upon to assure higher levels of safety and quality for our clients by our governments, professional organizations, and hospital administrations. It is essential that we implement evidence-based nursing care strategies to reduce avoidable errors in care so that clinical outcomes improve (Vollman, 2013).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Activity Intolerance 123

• If mainly on bed rest, minimize cardiovascular deconditioning by positioning the client in an upright position several times daily if possible. CEB: With bed rest there is a shift of fluids from the extremities to the thoracic cavity from the loss of gravitational stress. Positioning in an upright position helps maintain optimal fluid distribution and maintain orthostatic tolerance (Perme & Chandrashekar, 2009).

• Assess the client daily for appropriateness of activity and bed rest orders. Mobilize the client as soon as possible. EB: Mobilization is a cost-effective and simple method of maintaining stable cardiovascular param- eters (i.e., blood pressure, heart rate), countering orthostatic intolerance, and reducing the risk of secondary problems in clients during long-term immobilization (Wieser, 2014).

• If the client is mostly immobile, consider use of a transfer chair: a chair that becomes a stretcher. CEB: Using a transfer chair where the client is pulled onto a flat surface and then seated upright in the chair can help previously immobile clients get out of bed (Perme & Chandrashekar, 2009).

• When appropriate, gradually increase activity, allowing the client to assist with positioning, transferring, and self-care as able. Progress the client from sitting in bed to dangling, to standing, to ambulation. Always have the client dangle at the bedside before standing to evaluate for postural hypotension. EB: A reduction in plasma volume associated with bed rest impacts the physiological responses of autonomic control of circulation (Dorantes-Mendez et al, 2013).

• When getting a client up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs; manual blood pressure monitor- ing is best. When an adult rises to the standing position, blood pools in the lower extremities; symptoms of central nervous system hypoperfusion may occur, including feelings of weakness, nausea, headache, lightheadedness, dizziness, blurred vision, fatigue, tremulousness, palpitations, and impaired cognition. EBN: Automatic devices cannot reliably detect or rule out orthostatic hypotension, indicating that nurses need to use manual devices to take accurate postural blood pressures for optimal client care (Dind et al, 2011).

• If the client has symptoms of postural hypotension, such as dizziness, lightheadedness, or pallor, take precautions, such as dangling the client and applying leg compression stockings before the client stands. EB: Put graduated compression stockings on the client or use lower limb compression bandaging, if ordered, to return blood to the heart and brain. Have the client dangle at the side of the bed with legs hanging over the edge of the bed, flexing and extending the feet several times after sitting up, then standing slowly with someone holding the client. If the client becomes lightheaded or dizzy, return him to bed immediately (Tibaldi et al, 2014).

• Perform range-of-motion (ROM) exercises if the client is unable to tolerate activity or is mostly immobile. See care plan for Risk for Disuse syndrome.

• Monitor and record the client’s ability to tolerate activity: note pulse rate, blood pressure, respiratory pattern, dyspnea, use of accessory muscles, and skin color before, during, and after the activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately: ❍ Onset of chest discomfort or pain ❍ Dyspnea ❍ Palpitations ❍ Excessive fatigue ❍ Lightheadedness, confusion, ataxia, pallor, cyanosis, nausea, or any peripheral circulatory

insufficiency ❍ Dysrhythmia ❍ Exercise hypotension ❍ Excessive rise in blood pressure ❍ Inappropriate bradycardia ❍ Increased heart rate ❍ Decreased oxygen saturation

The above are symptoms of intolerance to activity and continuation of activity may result in client harm (Goldman, 2011). ▲ Instruct the client to stop the activity immediately and report to the health care provider if the client is

experiencing the following symptoms: new or worsened intensity or increased frequency of discomfort; tightness or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger. Pulse rate and arterial blood oxygenation indicate cardiac/exercise tolerance; pulse oximetry identifies hypoxia (Goldman, 2011).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A 124 Activity Intolerance

• Observe and document skin integrity several times a day. Activity intolerance, if resulting in immobility, may lead to pressure ulcers. Mechanical pressure, moisture, friction, and shearing forces all predispose to their development. Refer to the care plan Risk for impaired Skin integrity.

• Assess for constipation. If present, refer to care plan for Constipation. Activity intolerance is associated with increased risk of Constipation.

▲ Refer the client to physical therapy to help increase activity levels and strength. ▲ Consider a dietitian referral to assess nutritional needs related to Activity intolerance; provide nutrition

as indicated. If the client is unable to eat food, use enteral or parenteral feedings as needed. • Recognize that malnutrition causes significant morbidity due to the loss of lean body mass. • Provide emotional support and encouragement to the client to gradually increase activity. Work with the

client to set mutual goals that increase activity levels. Fear of breathlessness, pain, or falling may decrease willingness to increase activity. EB: In clients with Parkinson’s disease, motivations for exercising included hope that exercise would slow the disease or prevent a decline in function, feeling better with exercise, belief that exercise is beneficial, and encouragement from family members (Ene et al, 2011).

▲ Observe for pain before activity. If possible, treat pain before activity and ensure that the client is not heavily sedated. Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.

▲ Obtain any necessary assistive devices or equipment needed before ambulating the client (e.g., walkers, canes, crutches, portable oxygen).

▲ Use a gait walking belt when ambulating the client. CEB: Gait belts improve the caregiver’s grasp, reducing the incidence of injuries in clients and nurses (Nelson et al, 2003).

▲ Use evidence-based practices for safe client handling to reduce the risk of injury for both clients and health care workers (Elnitsky et al, 2014).

Activity Intolerance Due to Respiratory Disease

• If the client is able to walk and has chronic obstructive pulmonary disease (COPD), use the traditional 6-minute walk distance to evaluate ability to walk.

▲ Ensure that the chronic pulmonary client has oxygen saturation testing with exercise. Use supplemental oxygen to keep oxygen saturation 90% or above or as prescribed with activity. Oxygen therapy can improve exercise ability and long-term administration of oxygen can increase survival in clients with COPD (Gold Report, 2012).

• Monitor a respiratory client’s response to activity by observing for symptoms of respiratory intolerance, such as increased dyspnea, loss of ability to control breathing rhythmically, use of accessory muscles, nasal flaring, appearance of facial distress, and skin tone changes such as pallor and cyanosis.

• Instruct and assist the client with COPD in using conscious, controlled breathing techniques during exercise, including pursed-lip breathing, and inspiratory muscle use.

▲ Evaluate the client’s nutritional status. Refer to a dietitian if indicated. Use nutritional supplements to increase nutritional level if needed.

▲ For the client in the intensive care unit, consider mobilizing the client with passive exercise. EBN: Nurses should consider incorporating at least 20 minutes of passive exercise early in the plan of care for critically ill clients treated with mechanical ventilation so that opportunities to improve client outcomes are not missed (Amidei & Sole, 2013).

▲ Refer the COPD client to a pulmonary rehabilitation program. EB: Pulmonary rehabilitation is a highly effective and safe intervention to reduce hospital admissions and mortality and to improve health-related quality of life in clients with COPD who have recently suffered an exacerbation (Puhan et al, 2009).

Activity Intolerance Due to Cardiovascular Disease

• If the client is able to walk and has heart failure, consider use of the 6-minute walk test to determine physical ability.

• Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity.

▲ Refer to a heart failure program or cardiac rehabilitation program for education, evaluation, and guided support to increase activity and rebuild life. EB: Exercise-based cardiac rehabilitation is effective in reducing total and cardiovascular mortality and hospital admissions (Heran et al, 2011).

▲ Refer to a community support program that includes support of significant others.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Activity Intolerance 125

▲ EB: Contemporary studies now suggest that behavior change and multifactorial risk factor modification— especially smoking cessation and more intensive measures to control hyperlipidemia with diet, drugs, and exercise—may slow, halt, or even reverse (albeit modestly) the otherwise inexorable progression of athero- sclerotic CHD (Spring, 2013).

• See care plan for Decreased Cardiac output for further interventions. Pediatric

• Focus interview questions toward exercise tolerance specifically including any history of asthma exacer- bations. EB: Cardiopulmonary deconditioning should be considered as an important differential diagnosis for breathlessness among obese adolescents. Some of these children may need pulmonary rehabilitation if difficulty breathing is the perceived reason for not exercising (Shim et al, 2013).

Geriatric

• Slow the pace of care. Allow the client extra time to carry out physical activities. Slow gait in older adults may be related to fear of falling, decreased strength in muscles, reduced balance or visual acuity, knee flexion contractures, and foot pain. QSEN: Older patients with chronic cardiac conditions are more vulnerable to falls and injuries. Cardiovascular conditions, prevalent in older people, are also the frequent cause of poten- tially harmful fall injuries in this group. The need to identify the fall risk-related factors that cluster with arrhythmia and syncope is relevant, in that it will potentially reduce patients’ risk for falls and fall injuries (Belita et al, 2013).

• Encourage families to help/allow an older client to be independent in whatever activities possible. EB: Physi- cal activity and cognitive exercise may improve memory and executive functions in older people with mild cognitive impairment (Teixeira et al, 2012).

▲ Assess for swaying, poor balance, weakness, and fear of falling while older clients stand/walk. Refer to physical therapy if appropriate. CEB: Fear of falling and repeat falling is common in the older population. Balance rehabilitation provides individualized treatment for persons with various deficits associated with balance (Studer, 2008). Refer to the care plan for Risk for Falls and Impaired Walking.

▲ Initiate ambulation by simply ambulating a patient a few steps from bed to chair, once a health care provider’s out-of-bed order is obtained. EBN: Lack of ambulation and deconditioning effects of bed rest are one of the most predictable causes of loss of independent ambulation in hospitalized older persons. Nurses have been identified as the professional most capable of promoting walking independence in the hospital setting (Doherty-King & Bowers, 2013).

▲ Evaluate medications the client is taking to see if they could be causing Activity intolerance. EB: Medica- tions such as beta-blockers; lipid lowering agents, which can damage muscle; antipsychotics, which have a common side effect of orthostatic hypotension; some antihypertensives; and lowering the blood pressure to normal in older adults can result in decreased functioning (Society, 2012).

▲ If heart disease is causing Activity intolerance, refer the client for cardiac rehabilitation. ▲ Refer the disabled older client to physical therapy for functional training including gait training, stepping,

and sit-to-stand exercises, or for strength training. CEB: A Cochrane review found that progressive resis- tance strength training to improve function is effective in older clients (Liu & Latham, 2009).

Home Care

▲ Begin discharge planning as soon as possible with the case manager or social worker to assess the need for home support systems and the need for community or home health services. EB: Home-based exercise appears more effective in increasing daily ambulatory activity in the community setting than supervised exercise in clients with intermittent claudication (Gardner et al, 2011).

▲ Assess the home environment for factors that contribute to decreased activity tolerance such as stairs or distance to the bathroom. Refer the client for occupational therapy, if needed, to assist the client in restructuring the home and ADL patterns. During hospitalization, clients and families often estimate energy requirements at home inaccurately because the hospital’s availability of staff support distorts the level of care that will be needed.

▲ Refer the client for physical therapy for strength training and possible weight training to regain strength, increase endurance, and improve balance. If the client is homebound, the physical therapist can also initiate cardiac rehabilitation.

• Encourage progress with positive feedback. The client’s experience should be validated within expected norms. Recognition of progress enhances motivation.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A 126 Activity Intolerance

• Teach the client/family the importance of and methods for setting priorities for activities, especially those having a high energy demand (e.g., home/family events). Instruct in realistic expectations.

• Encourage routine low-level exercise periods such as a daily short walk or chair exercises. EB: Older adults participating in low levels of regular exercise can establish and maintain a home-based exercise program that yields immediate and long-term physical and affective benefits (Teri et al, 2011).

• Provide the client/family with resources such as senior centers, exercise classes, educational and recre- ational programs, and volunteer opportunities that can aid in promoting socialization and appropriate activity. Social isolation can be an outcome of and contribute to Activity intolerance. EB: Community-based resistance training and dietary modifications can improve body composition, muscle strength, and physical function in overweight and obese older adults (Straight et al, 2011).

• Instruct the client and family in the importance of maintaining proper nutrition. • Instruct the client in use of dietary supplements as indicated. Illness may suppress appetite, leading to

inadequate nutrition. ▲ Refer to medical social services as necessary to assist the family in adjusting to major changes in patterns

of living because of Activity intolerance. ▲ Assess the need for long-term supports for optimal activity tolerance of priority activities (e.g.,

assistive devices, oxygen, medication, catheters, massage), especially for a hospice client. Evaluate intermittently.

▲ Refer to home health aide services to support the client and family through changing levels of activity tolerance. Introduce aide support early. Instruct the aide to promote independence in activity as tolerated.

• Allow terminally ill clients and their families to guide care. Control by the client or family respects their autonomy and promotes effective coping.

• Provide increased attention to comfort and dignity of the terminally ill client in care planning. Interven- tions should be provided as much for psychological effect as for physiological support. For example, oxygen may be more valuable as a support to the client’s psychological comfort than as a booster of oxygen saturation.

▲ Institute case management of frail elderly to support continued independent living.

Client/Family Teaching and Discharge Planning

• Instruct the client on techniques for avoiding Activity intolerance, such as controlled breathing techniques.

• Teach the client techniques to decrease dizziness from postural hypotension when standing up. • Help client with energy conservation and work simplification techniques in ADLs. • Describe to the client the symptoms of Activity intolerance, including which symptoms to report to the

physician. • Explain to the client how to use assistive devices, oxygen, or medications before or during activity. • Help the client set up an activity log to record exercise and exercise tolerance.

REFERENCES Amidei, C., & Sole, M. (2013). Physiological responses to passive

exercise in adults receiving mechanical ventilation. American Journal of Critical Care, 22, 337–348.

Belita, L., Ford, P., & Kirkpatrick, H. (2013). The development of an assessment and intervention falls guide for older hospitalized adults with cardiac conditions. European Journal of Cardiovascular Nursing, 12, 302–309.

Dind, A., et al. (2011). The inaccuracy of automatic devices taking postural measurements in the emergency department. International Journal of Nursing Practice, 17, 525–533.

Doherty-King, B., & Bowers, B. (2013). Attributing the responsibility for ambulating patients: a qualitative study. International Journal of Nursing Studies, 50, 1240–1246.

Dorantes-Mendez, G., Baselli, G., Arbeille, P., et al. (2013). Comparison of Baroreflex Sensitivity Gain During Mild Lower Body Negative Pressure in Presence and Absence of Long Duration Bed Rest. Computing in Cardiology Conference, (pp. 763–766). Milan, Italy.

Elnitsky, C. A., et al. (2014). Implications in the use of patient safety in the use of safe patient handling equipment: a national survey. International Journal of Nursing Studies, 51(12), 1624–1633.

Ene, H., McRae, C., & Schenkman, M. (2011). Attitudes toward exercise following participation in an exercise intervention study. Journal of Neurologic Physical Therapy, 35, 34–40.

Gardner, A., et al. (2011). Efficacy of quantified home-based exercise and supervised exercise in patients with intermittent claudication: a randomized controlled trial. Circulation, 123, 491–498.

Global Initiative for Chronic Obstructive Lung Disease (GOLD Report). (2012, August 2). Guidelines Global Strategy for Diagnosis Management. Retrieved from GoldCOPD <www.goldcopd.org>.

Goldman, L. (2011). Goldman Cecil’s Medicine. St. Louis: Saunders. Heran, B., et al. (2011). Exercise-Based Cardiac Rehabilitation for

Coronary Heart Disease. Cochrane Database System Review. Retrieved from Database System Review.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Ineffective Activity Planning 127

Risk for Activity intolerance Betty J. Ackley, MSN, EdS, RN, and Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN

NANDA-I

Definition

Vulnerable to insufficient physiological or psychological energy to endure or complete required or desired daily activities, which may compromise health

Risk Factors

Circulatory problems; History of previous intolerance; Inexperience with an activity; Physical decondition- ing; Respiratory condition

NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family Teaching and Discharge Planning, Rationales, and References

Refer to care plan for Activity intolerance.

Ineffective Activity planning Annie Muller, DNP, APN-BC, and Gail B. Ladwig, MSN, RN

NANDA-I

Definition

Inability to prepare for a set of actions fixed in time and under certain conditions

Defining Characteristics

Absence of plan; excessive anxiety about a task to be undertaken; insufficient organizational skills; insuffi- cient resources (e.g., financial social, knowledge); pattern of failure; pattern of procrastination; unmet goals for chosen activity; worry about a task to be undertaken

Related Factors

Flight behavior when faced with proposed solution; hedonism; insufficient information processing ability; insufficient social support; unrealistic perception of event; unrealistic perception of personal abilities

Liu, C., & Latham, N.K. (2009). Progressive resistance strength training for improving physical function in older adults. Cochrane Database System Review.

Nelson, A., et al. (2003). Safe patient handling and movement. American Journal of Nursing, 32.

Perme, C., & Chandrashekar, R. (2009). Early mobility and walking program for patients in intensive care units: creating a standard of care. American Journal of Critical Care, 18, 212–221.

Puhan, M., et al. (2009). Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database System Review, (1), CD005305.

Shim, Y., Burnette, A., Lucas, S., et al. (2013). Physical deconditioning as a cause of breathlessness among obese adolescents with a diagnosis of asthma. PLoS ONE, 8(4), e61022.

Society, A. G. (2012, August 2). Beers Criteria. Retrieved from American Geriatrics <http://www.americangeriatrics.org>.

Spring, B. E. (2013, October 7). Better Population Health through Behavior Change in Adults: A Call to Action. Retrieved from Circulation <http://circ.ahajournals.org>.

Straight, C., et al. (2011). Effects of resistance training and dietary changes on physical function and body composition in overweight

and obese older adults. Journal of Physical Activity and Health, Epub.

Studer, M. (2008). Keep it moving: advances in gait training techniques help clients reduce balance issues. Rehabilitation Management, 21, 10–15.

Teixeira, C., et al. (2012). Non-pharmacological interventions on cognitive functions in older people with mild cognitive impairment. Archives of Gerontological Geriatrics, 54, 175–180.

Teri, L., et al. (2011). A randomized controlled clinical trial of the seattle protocol for activity in older adults. Journal of the American Geriatric Society, 59, 1188–1196.

Tibaldi, M., Brescianini, A., Sciarrillo, I., et al. (2014). Prevalence and clinical implications of orthostatic hypotension in elderly. Hypertension, 3, 155.

Vollman, K. (2013). Interventional patient hygiene: discussion of the issues and a proposed model for implementation of the nursing care basics. Intensive and Critical Care Nursing, 29, 250–255.

Wieser, M. G. (2014). Cardiovascular control and stabilization via inclination and mobilization during bed rest. Medical & Biological Engineering and Computing, 52, 53–64.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A 128 Ineffective Activity Planning

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Outcomes

Cognition; Cognition Orientation; Concentration; Decision-Making; Information Processing; Memory

Example NOC Outcome with Indicators

Cognition as evidenced by the following indicators: Communication clear and appropriate for age/Comprehension of the meaning of situations/Information processing/Alternatives weighed when making decisions. (Rate the outcome and indicators of Cognition: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Example NIC Activities—Coping Enhancement

Assist client in developing an objective appraisal of the event; Explore with client previous methods of dealing with life problems

Patient Outcomes Patient Will (Specify Time Frame)

• Verbalize need for self-directed activity • Choose the health care option that fits his or her lifestyle within an appropriate amount of time that

allows enactment of the choice • Describe how the chosen option fits into current lifestyle before or after the decision has been made • Verbalize the need for a behavioral change to improve physical activity

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Interventions

Anxiety Reduction; Behavior Management; Behavior Modification; Calming Technique; Coping Enhance- ment; Decision-Making Support; Life Skills Enhancement; Planning Assistance; Sequence Guidance

Nursing Interventions and Rationales

• Ask the client how he or she perceives the situation in order to gather his personal vision of the problem and how they envisage their self-involvement. Specify the goals. Clients and caregivers may have different priorities on what is important (Junius-Walker et al, 2011). ❍ Identify the informational needs of the client: understanding of the client’s state of health, supervision

of client’s treatment if he or she is receiving treatment, diet, and important telephone numbers. EBN: This study of clients with stage 4 chronic kidney disease validated the need for an individual assessment to determine the unique informational needs of each person (Lewis et al, 2010).

❍ Tackle the client’s fears and worries and encourage him to make a cognitive reconstruction. Use “desire thinking.” Drill and repeat: “I can change false ideas that make me believe that I am unable to carry out (achieve) my plan.” EBN: Desire thinking is a voluntary cognitive process involving verbal and ima- ginal elaboration of a desired target. Recent research has highlighted the role of desire thinking in the maintenance of addictive, eating, and impulse control disorders (Caselli & Spada, 2011).

• Client verbalizes need for behavioral change for improved physical activity. EB: This study reflects how combining planning and coping planning of a client’s self-worth can be beneficial in promoting an exercise program for those individuals who lack self-esteem (Kroon et al, 2014).

• Encourage clients to verbalize the need for physical activity to help reduce role overload. EB: This study demonstrated the need for planning activities for those individuals who were experiencing a role overload in life to allow them time for leisure activities (Lovell & Butler, 2015).

▲ Determine as fairly as possible the success factors needed for the planning and success of the project: financial resources; the family situation; prior medical, psychiatric, and psychosocial conditions; material resources; and the ability to manage stress. EBN: Discussions identifying resources help to handle past resources, the functional solutions of everyday life, favorable changes, exceptions and differences in everyday

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Ineffective Activity Planning 129

life, the availability of support, and the prospects of future. By noting and providing feedback to families, the nurse offers families a new perspective on themselves (Häggman-Laitila et al, 2010).

Pediatric

• Begin activity planning in preschool-aged children of working parents. EB: This study focused on the inactivity of migrant workers’ preschool-aged children and the need to have a more structured and planned activity for the migrant worker. The focus was on the child because not much is known and very little research has been done. Also, there is a wide disparity of health in this population. The results showed very little physical activity was encouraged by parents and there was a great need for intervention to help with develop- ing future healthy lifestyle for reducing potential long-term health problems (Grzywacz et al, 2014).

• Establish a contract. EBN: This study of adolescents with type 1 diabetes indicated that behavioral contracts may be an important adjunct to reduce nagging and improve outcomes with behavioral changes (Carroll et al, 2011).

• Provide support to the schools for physical activities in all venues of schools. EB: Depending on the loca- tion of the school and the available resources, schools may promote a physical activity program that is beneficial and available to the student. Schools with few resources have limited staff available, which can be a barrier to promoting a healthy lifestyle to the adolescent student. (Hobin et al, 2013).

Geriatric

• Plan activities for older clients. EB: In a study of stroke clients, it was found that physical activity may improve quality of life, physical function, and self-worth (Walter et al, 2015).

• Plan activities for older clients with impaired mental function. EB: In this study, it was found that clients with impaired mental function are often limited in their ability to become involved with planned physical activity; therefore, staff are needed to intervene and assist with the planned activity (Koring et al, 2012).

Multicultural

• Provide literature and information in the appropriate language for the client who speaks little to no English. EB: This study was able to show those clients who did not speak English fluently were not adequately prepared or educated to the needs for physical activity. Nor were they well represented in the study to show that culture was represented in understanding about cognitive health and risks of Alzheimer’s disease (Rose et al, 2013).

• Preplanning educational programs for the culturally diverse population needs to be developed. EB: Low level of preplanning and poor organization of physical activities for the culturally diverse causes a loss of participation by those involved due to lack of understanding the concepts involved (Jeong et al, 2015).

Home Care

• Have a preplanned activity exercise for the home client with a debilitating musculoskeletal disease to help improve functional status. EB: This study showed an improvement for those clients who were homebound due to a musculoskeletal disorder, thereby improving their personal commitment to exercise for increasing their functional ability by gaining some muscle strength and range of motion (Hideyuki & Hitoshi, 2014).

• Assess the home environment for barriers that can impact the client’s motivation to be a participant in the activity planned. EB: The research study done on homebound older adults showed that the client knew and understood the need for planned physical activity, but were not motivated to participate because they thought their age was a barrier. The idea is to teach the older client; while age may be a factor in some types of activity planning or exercise, there are many ways to adapt to the activity that can be accommodating to the client’s ability (Burton et al, 2013).

• For additional interventions, refer to care plans Anxiety, Readiness for enhanced family Coping, Readiness for enhanced Decision-Making, Fear, Readiness for enhanced Hope, Readiness for enhanced Power, Readiness for enhanced Spiritual well-being, and Readiness for enhanced Health management.

REFERENCES Burton, E., Lewin, G., & Boldy, D. (2013). Barriers and motivators to

being physically active for older home care patients. Physical & Occupational Therapy in Geriatrics, 31(1), 21–35.

Carroll, A. E., et al. (2011). Contracting and monitoring relationships for adolescents with type 1 diabetes: a pilot study. Diabetes Tech Therapeut, 13(5), 543–549.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A 130 Risk for Ineffective Activity Planning

Risk for Ineffective Activity planning Gail B. Ladwig, MSN, RN

NANDA-I

Definition

Vulnerable to an inability to prepare for a set of actions fixed in time and under certain conditions, which may compromise health

Risk Factors

Flight behavior when faced with proposed solution; hedonism; insufficient information processing ability; insufficient social support; pattern of procrastination; unrealistic perception of event; unrealistic perception of personal abilities

NOC, NIC, Client Outcomes, Nursing Interventions, Client/Family Teaching and Discharge Planning, Rationales, and References

Refer to ineffective Activity planning.

Ineffective Airway clearance Debra Siela, PhD, RN, CCNS, ACNS-BC, CCRN-K, CNE, RRT

NANDA-I

Definition

Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Defining Characteristics

Absent cough; adventitious breath sounds; alteration in respiratory pattern; alteration in respiratory rate; cyanosis; difficulty verbalizing; diminished breath sounds; dyspnea; excessive sputum; ineffective cough; orthopnea; restlessness; wide-eyed look

Related Factors (r/t) Environmental

Exposure to smoke; second-hand smoke; smoking

Caselli, G., & Spada, M. M. (2011). The Desire Thinking Questionnaire: development and psychometric properties. Addictive Behaviors, 36(11), 1061–1067.

Grzywacz, J. G., Suerken, C. K., Zapata-Roblyer, M. I., et al. (2014). Physical activity of preschool-aged Latino children in farm-worker families. American Journal of Health Behavior, 38(5), 717–725.

Häggman-Laitila, A., Tanninen, H., & Pietilä, A. (2010). Effectiveness of resource-enhancing family-oriented intervention. Journal of Clinical Nursing, 19(17/18), 2500–2510.

Hideyuki, N., & Hitoshi, T. (2014). Effects of home exercise on physical function and activity in home care patients with Parkinson’s disease. Journal of Physical Therapy Science, 26(11), 1701–1706.

Hobin, E. P., Leatherdale, S., Manske, S., et al. (2013). Are environmental influences on physical activity distinct for urban, suburban, and rural schools? A multilevel study among secondary school students in Ontario, Canada. Journal of School Health, 83(5), 357–367.

Jeong, S., Ohr, S., Pich, J., et al. (2015). Planning ahead among community-dwelling older people from culturally and linguistically diverse background: a cross-sectional survey. Journal of Clinical Nursing, 24(1/2), 244–255.

Junius-Walker, U., et al. (2011). Health and treatment priorities of older patients and their general practitioners: a cross-sectional study. Qual Primary Care, 19, 67–76.

Koring, M., Richert, J., Parchau, L., et al. (2012). A combined planning and self-efficacy intervention to promote physical activity: A multiple mediation analysis. Psychology, Health & Medicine, 17(4), 488–498.

Kroon, F. P., van der Burg, L. R., Buchbinder, R., et al. (2014). Self-management education programmes for osteoarthritis. The Cochrane Library.

Lewis, A. L., Stabler, K. A., & Welch, J. L. (2010). Perceived informational needs, problems, or concerns among patients with stage 4 chronic kidney disease. Nephrology Nursing Journal: Journal of the American Nephrology Nurses’ Association, 37(2), 143–149.

Lovell, G. P., & Butler, F. R. (2015). Physical activity behavior and role overload in mothers. Health Care for Women International, 36(3), 342–355.

Rose, I. D., Friedman, D. B., Marquez, D. X., et al. (2013). What are older Latinos told about physical activity and cognition? A content analysis of a top-circulating magazine. Journal of Aging & Health, 25(7), 1143–1158.

Walter, T., Hale, L., & Smith, C. (2015). Blue prescription: A single subject design intervention to enable physical therapy for people with stroke. International Journal of Therapy & Rehabilitation, 22(2), 87–95.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Ineffective Airway Clearance 131

Obstructed Airway

Airway spasm; chronic obstructive pulmonary disease; exudate in the alveoli; excessive mucus; foreign body in airway; hyperplasia of bronchial walls; presence of artificial airway; retained secretions

Physiological

Allergic airways; asthma; infection; neuromuscular impairment

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Aspiration Prevention; Respiratory Status: Airway Patency, Gas Exchange, Ventilation

Example NOC Outcome with Indicators

Respiratory Status: Ventilation as evidenced by the following indicators: Respiratory rate/Respiratory rhythm/Depth of inspiration/Chest expansion symmetrical/Ease of breathing/Tidal volume/Vital capacity (Rate each indicator of Respiratory Status: Ventilation: 1 = severe deviation from normal range, 2 = substantial deviation from normal range, 3 = moderate deviation from normal range, 4 = mild deviation from normal range, 5 = no deviation from normal range [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Demonstrate effective coughing and clear breath sounds • Maintain a patent airway at all times • Explain methods useful to enhance secretion removal • Explain the significance of changes in sputum to include color, character, amount, and odor • Identify and avoid specific factors that inhibit effective airway clearance

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Airway Management; Airway Suctioning; Cough Enhancement

Example NIC Activities—Airway Management

Instruct how to cough effectively; Auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds

Nursing Interventions and Rationales

• Auscultate breath sounds every 1 to 4 hours. Breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates an airway obstruction (Fauci et al, 2008).

• Monitor respiratory patterns, including rate, depth, and effort. A normal respiratory rate for an adult without dyspnea is 12 to 16 breaths per minute (Bickley & Szilagyi, 2012). With secretions in the airway, the respiratory rate will increase.

• Monitor blood gas values and pulse oxygen saturation levels as available. An oxygen saturation of less than 90% (normal: 95% to 100%) or a partial pressure of oxygen of less than 80 mm Hg (normal: 80 to 100 mm Hg) indicates significant oxygenation problems (Schultz, 2011).

▲ Administer oxygen as ordered. Oxygen administration has been shown to correct hypoxemia (Wong & Elliott, 2009).

• Position the client to optimize respiration (e.g., head of bed elevated 30 to 45 degrees). An upright position allows for maximal lung expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe. EB: In a mechanically ventilated client, there is a decreased incidence of ventilator-associated pneumonia if the client is positioned at a 30- to 45-degree semi- recumbent position rather than a supine position (Siela, 2010; Bell, 2011; Johanna Briggs Institute, 2014).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A 132 Ineffective Airway Clearance

• Help the client deep breathe and perform controlled coughing. Have the client inhale deeply, hold breath for several seconds, and cough two or three times with mouth open while tightening the upper abdominal muscles. CEB: Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective (Gosselink et al, 2008).

• If the client has obstructive lung disease, such as chronic obstructive pulmonary disease (COPD), cystic fibrosis, or bronchiectasis, consider helping the client use the forced expiratory technique, the “huff cough.” The client does a series of coughs while saying the word “huff.” This technique prevents the glottis from closing during the cough and is effective in clearing secretions (Bhowmik et al, 2009; Gosselink et al, 2008; GOLD, 2015).

▲ Encourage the client to use an incentive spirometer. Recognize that controlled coughing and deep breath- ing may be just as effective as incentive spirometry (Gosselink et al, 2008).

• Encourage activity and ambulation as tolerated. If the client cannot be ambulated, turn the client from side to side at least every 2 hours. Body movement helps mobilize secretions. (See interventions for impaired Gas exchange for further information on positioning a respiratory patient.)

• Encourage fluid intake of up to 2500 mL/day within cardiac or renal reserve. Fluids help minimize mucosal drying and maximize ciliary action to move secretions.

▲ Administer medications such as bronchodilators or inhaled steroids as ordered. Watch for side effects such as tachycardia or anxiety with bronchodilators, or inflamed pharynx with inhaled steroids. Bron- chodilators decrease airway resistance, improve the efficiency of respiratory movements, improve exercise tolerance, and can reduce symptoms of dyspnea on exertion (Barnett, 2008). Pharmacologic therapy in COPD is used to reduce symptoms, reduce the frequency and severity of exacerbation, and improve health strategies and exercise tolerance (GOLD, 2015).

▲ Provide percussion, vibration, and oscillation as appropriate (Gosselink et al, 2008). • Observe sputum, noting color, odor, and volume. Normal sputum is clear or gray and minimal; abnormal

sputum is green, yellow, or bloody; malodorous; and often copious. The presence of purulent sputum during a COPD exacerbation can be sufficient indication for starting empirical antibiotic treatment. Notify health care provider of purulent sputum (GOLD, 2015).

Critical Care

▲ In intubated patients, body positioning and mobilization may optimize airway secretion clearance. An early mobility and walking program can promote weaning from ventilator support as a patient’s overall strength and endurance improve (Gosselink et al, 2008; Perme & Chandrashekar, 2009).

▲ Early mobility and physical rehabilitation can reduce muscle weakness, mechanical ventilation duration, intensive care unit stay, and hospital stay (Mendez-Tellez & Needham, 2012; Spruit et al, 2013). The Awak- ening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle has criteria to determine when patients are candidates for early mobility (Balas et al, 2012). An early mobility and walking program can promote weaning from ventilator support as a patient’s overall strength and endurance improve (Gosselink et al, 2008; Perme & Chandrashekar, 2009).

• If the client is intubated and is stable, consider getting the client up to sit at the edge of the bed, transfer to a chair, or walk as appropriate, if an effective interdisciplinary team is developed to keep the client safe. For every week of bedrest, muscle strength can decrease 20%; early ambulation also helped patients develop a positive outlook (Perme & Chandrashekar, 2009).

▲ If the client is intubated, consider use of kinetic therapy, using a kinetic bed that slowly moves the client with 40-degree turns. Rotational therapy may decrease the incidence of pulmonary complications in high- risk patients with increasing ventilator support requirements, who are at risk for ventilator-associated pneumonia, and with clinical indications for acute lung injury or acute respiratory distress syndrome with worsening PaO2 :FIO2 ratio, presence of fluffy infiltrates via chest radiograph concomitant with pulmonary edema, and refractory hypoxemia (Bein et al, 2012).

• Reposition the client as needed. Use rotational or kinetic bed therapy in clients for whom side-to- side turning is contraindicated or difficult. EBN: Changing position frequently decreases the incidence of atelectasis, pooling of secretions, and resultant pneumonia (Burns, 2011). EB/EBN: Continuous, lateral rotational therapy has been shown to improve oxygenation and decrease the incidence of VAP (Burns, 2011).

• When suctioning an endotracheal tube or tracheostomy tube for a client on a ventilator, do the following:

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Ineffective Airway Clearance 133

❍ Explain the process of suctioning beforehand and ensure the client is not in pain or overly anxious. Suctioning can be a frightening experience; an explanation along with adequate pain relief or needed sedation can reduce stress, anxiety, and pain (Chulay & Seckel, 2011).

❍ Hyperoxygenate before and between endotracheal suction sessions. Studies have demonstrated that hyperoxygenation may help prevent oxygen desaturation in a suctioned client (Chulay & Seckel, 2011; Pedersen et al, 2009; Siela, 2010).

❍ Suction for less than 15 seconds. Studies demonstrated that because of a drop in the partial pressure of oxygen with suctioning, that preferably no more than 10 seconds be used actually suctioning, with the entire procedure taking 15 seconds (Chulay & Seckel, 2011; Pedersen et al, 2009).

❍ Use a closed, in-line suction system. Closed in-line suctioning has minimal effects on heart rate, respiratory rate, tidal volume, and oxygen saturation (Chulay & Seckel, 2011; Seymour et al, 2009).

❍ Avoid saline instillation during suctioning. EBN: Repeated studies have demonstrated that saline instil- lation before suctioning has an adverse effect on oxygen saturation in both adults and children (Chulay & Seckel, 2011; Rauen et al, 2008; Pederson et al, 2009; Siela, 2010).

❍ Use of a subglottic suctioning endotracheal tube reduces the incidence of ventilator-associated pneumonia (VAP) or ventilator-associated complications (Hass et al, 2014).

❍ Use of nonstick endotracheal tubes can reduce the formation of biofilm and hence VAP (Haas et al, 2014).

❍ Document results of coughing and suctioning, particularly client tolerance and secretion characteris- tics such as color, odor, and volume (Chulay & Seckel, 2011).

Pediatric

• Educate parents about the risk factors for ineffective airway clearance such as foreign body ingestion and passive smoke exposure.

• See the care plan Risk for Suffocation for more interventions on choking. EB: Passive smoke exposure significantly increases the risk of respiratory infections in children (Chatzimicael et al, 2008).

• Educate children and parents on the importance of adherence to peak expiratory flow monitoring for asthma self-management.

• Educate parents and other caregivers that cough and cold medication bought over the counter are not safe for a child younger than 2 unless specifically ordered by a health care provider. Over-the-counter cold and cough medications are no longer recommended for children younger than age 2 unless recommended by a health care provider. Minimal data exist to support their effectiveness, and overuse can cause harm (Woo, 2008).

Geriatric

• Encourage ambulation as tolerated without causing exhaustion. Immobility is often harmful to older adults because it decreases ventilation and increases stasis of secretions, leading to atelectasis or pneumonia.

• Actively encourage older adults to deep breathe and cough. Cough reflexes are blunted, and coughing is decreased in older adults.

• Ensure adequate hydration within cardiac and renal reserves. Older adults are prone to dehydration and therefore more viscous secretions, because they frequently use diuretics or laxatives and forget to drink adequate amounts of water.

Home Care

• Some of the above interventions may be adapted for home care use. ▲ Begin discharge planning as soon as possible with case manager or social worker to assess need for home

support systems, assistive devices, and community or home health services. • Assess home environment for factors that exacerbate airway clearance problems (e.g., presence of aller-

gens, lack of adequate humidity in air, poor air flow, stressful family relationships). • Assess affective climate within family and family support system. Problems with respiratory function

and resulting anxiety can provoke anger and frustration in the client. Feelings may be displaced onto caregiver and require intervention to ensure continued caregiver support. Refer to care plan for Caregiver Role Strain.

• Refer to GOLD guidelines for management of home care and indications of hospital admission criteria. http://www.goldcopd.org/.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A 134 Ineffective Airway Clearance

• When respiratory procedures are being implemented, explain equipment and procedures to family members and caregivers, and provide needed emotional support. Family members assuming responsibility for respiratory monitoring often find this stressful. They may not have been able to assimilate fully any instructions provided by hospital staff.

• When electrically based equipment for respiratory support is being implemented, evaluate home environ- ment for electrical safety, proper grounding, and so on. Ensure that notification is sent to the local utility company, the emergency medical team, and police and fire departments.

• Provide family with support for care of a client with chronic or terminal illness. Breathing difficulty can provoke extreme anxiety, which can interfere with the client’s ability or willingness to adhere to the treatment plan.

• Refer to care plan for Anxiety. Witnessing breathing difficulties and facing concerns of dealing with chronic or terminal illness can create fear in caregiver. Fear inhibits effective coping. Refer to care plan for Powerlessness.

• Instruct the client to avoid exposure to persons with upper respiratory infections, to avoid crowds of people, and wash hands after each exposure to groups of people, or public places.

▲ Determine client adherence to medical regimen. Instruct the client and family in importance of reporting effectiveness of current medications to health care provider. Inappropriate use of medications (too much or too little) can influence amount of respiratory secretions.

• Teach the client when and how to use inhalant or nebulizer treatments at home. • Teach the client/family importance of maintaining regimen and having “as-needed” drugs easily acces-

sible at all times. Success in avoiding emergency or institutional care may rest solely on medication compli- ance or availability.

• Instruct the client and family in the importance of maintaining proper nutrition, adequate fluids, rest, and behavioral pacing for energy conservation and rehabilitation.

• Instruct in use of dietary supplements as indicated. Illness may suppress appetite, leading to inadequate nutrition. Supplements will allow clients to eat with minimal energy consumption.

• Identify an emergency plan, including criteria for use. Ineffective airway clearance can be life- threatening.

▲ Refer for home health aide services for assistance with activities of daily living (ADLs). Clients with decreased oxygenation and copious respiratory secretions are often unable to maintain energy for ADLs.

▲ Assess family for role changes and coping skills. Refer to medical social services as necessary. Clients with decreased oxygenation are unable to maintain role activities and therefore experience frustration and anger, which may pose a threat to family integrity. Family counseling to adapt to role changes may be needed.

▲ For the client dying at home with a terminal illness, if the “death rattle” is present with gurgling, rattling, or crackling sounds in the airway with each breath, recognize that anticholinergic medications can often help control symptoms, if given early in the process. Anticholinergic medications can help decrease the accumulation of secretions, but do not decrease existing secretions. This medication must be administered early in the process to be effective (Hipp & Letizia, 2009; Fielding & Long, 2014).

▲ For the client with a death rattle, nursing care includes turning to mobilize secretions, keeping the head of the bed elevated for postural drainage of secretions, and avoiding suctioning. Suctioning is a distressing and painful event for clients and families, and is rarely effective in decreasing the death rattle (Hipp & Letizia, 2009; Fielding & Long, 2014).

Client/Family Teaching and Discharge Planning

▲ Teach the importance of not smoking. Refer to a smoking cessation program, and encourage clients who relapse to keep trying to quit. Ensure that the client receives appropriate medications to support smoking cessation from the primary health care provider. EB: A systemic review of research demonstrated that the combination of medications and an intensive, prolonged counseling program supporting smoking cessation were effective in promoting long-term abstinence from smoking (Fiore et al, 2008). A Cochrane review found that use of the antidepressant medications increased the rate of smoking withdrawal two to three times more than smoking withdrawal without use of medications (Hughes et al, 2014).

▲ Teach the client how to use a flutter clearance device if ordered, which vibrates to loosen mucus and gives positive pressure to keep airways open (Bhowmik et al, 2009; Gosselink et al, 2008). CEB: A study dem- onstrated that use of the mucus clearance device had improved exercise performance compared with COPD clients who use a sham device (Wolkove et al, 2004). A Cochrane review found that there was no clear

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Ineffective Airway Clearance 135

evidence that oscillation was more or less effective than other forms of physiotherapy for airway clearance in cystic fibrosis (Morrison & Agnew, 2009).

▲ Teach the client how to use peak expiratory flow rate (PEFR) meter if ordered and when to seek medical attention if PEFR reading drops. Also teach how to use metered dose inhalers and self-administer inhaled corticosteroids as ordered following precautions to decrease side effects.

• Teach the client how to deep breathe and cough effectively. CEB: Controlled coughing uses the diaphrag- matic muscles, making the cough more forceful and effective (Gosselink et al, 2008).

• Teach the client/family to identify and avoid specific factors that exacerbate ineffective airway clearance, including known allergens and especially smoking (if relevant) or exposure to secondhand smoke.

• Educate the client and family about the significance of changes in sputum characteristics, including color, character, amount, and odor. With this knowledge, the client and family can identify early the signs of infection and seek treatment before acute illness occurs.

• Teach the client/family the importance of taking antibiotics as prescribed, consuming all tablets until the prescription has run out. Taking the entire course of antibiotics helps eradicate bacterial infection, which decreases lingering, chronic infection.

• Teach the family of the dying client in hospice with a death rattle that rarely are clients aware of the fluid that has accumulated, and help them find evidence of comfort in the client’s nonverbal behavior (Hipp & Letizia, 2009; Fielding & Long, 2014).

REFERENCES Balas, M. C., Vasilevskis, E. E., Burke, W. J., et al. (2012). Critical care

nurses’ role in implementing the “ABCDE Bundle” into practice. Critical Care Nurse, 32(2), 35–38, 40–48.

Barnett, M. (2008). Nursing management of chronic obstructive pulmonary disease. British Journal of Nursing, 17(21), 1314–1318.

Bein, T., Zimmermann, M., Schiewe-Laggartner, F., et al. (2012). Continuous lateral rotation therapy and systematic inflammatory response in posttraumatic acute lung injury: Results from a prospective randomized study. Injury, 43, 1893–1897.

Bell, L. (2011). AACN Practice Alert-Prevention of Aspiration. American Association of Critical Care Nurses. Retrieved from <http://www.aacn.org/wd/practice/docs/practicealerts/prevention- aspiration-practice-alert.pdf?menu=aboutus>.

Bhowmik, A., Chahal, K., & Austin, G. (2009). Improving mucociliary clearance in chronic obstructive pulmonary disease. Respiratory Medicine, 103(4), 496–502.

Bickley, L. S., & Szilagyi, P. (2012). Bate’s Guide to physical examination (p. 11). Philadelphia: Lippincott, Williams and Wilkins.

Burns, S. M. (2011). Invasive Mechanical Ventilation (Through an artificial airway): volume and pressure modes. In D. J. Lynn- McHale (Ed.), AACN Procedure Manual for Critical Care (6th ed.). Philadelphia: Saunders Elsevier.

Chatzimicael, A., Tsalkidis, A., & Cassimos, D. (2008). Effect of passive smoking on lung function and respiratory infection. Indian Journal of Pediatrics, 75(4), 335–340.

Chulay, M., & Seckel, M. (2011). Suctioning: Endotracheal tube or tracheostomy tube. In D. J. Lynn-McHale (Ed.), AACN Procedure Manual for Critical Care (6th ed.). Philadelphia: Saunders Elsevier.

Fauci, A., Braunwald, E., & Kasper, D. L. (2008). Harrison’s principles of internal medicine (17th ed.). New York: McGraw-Hill.

Fielding, F., & Long, C. O. (2014). The death rattle dilemma. J of Hospice & Palliative Nursing, 16(8). Retrieved <http://www.medscape.com/viewarticle/834898>.

Fiore, M. C., Jaen, C. R., & Baker, T. B. (2008). Treating tobacco use and dependence clinical practice guideline 2008 update. Rockville MD: U.S. Department of Health and Human Services, Public Health Service.

GOLD. Global strategy for the diagnosis, management, and prevention of COPD (revised 2015), Global Initiative for Chronic Obstructive Lung Disease. http://www.goldcopd.org/uploads/users/files/ GOLD_Report_2015_Apr2.pdf. Retrieved April 23, 2015.

Gosselink, R., Bott, J., Johnson, M., et al. (2008). Physiotherapy for adult patients with critical illness: recommendations of the European respiratory society and European society of critical care medicine task force on physiotherapy for critically ill patients. Intensive Care Medicine, 34(7), 1188–1199.

Haas, C. F., Eakin, R. M., Konkle, M. A., et al. (2014). Endotracheal tubes: old and new. Respiratory Care, 59(6), 933–955.

Hipp, B., & Letizia, M. J. (2009). Understanding and responding to the death rattle in dying patients. Medsurg Nursing, 18(1), 17–21.

Hughes, J. R., Stead, L. F., Hartmann-Boyce, J., et al. (2014). Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews, 2014, (1), Art. No.: CD000031.

Joanna Briggs Institute (2014). Ventilator-associated pneumonia prevention.

Mendez-Tellez, P. A., & Needham, D. M. (2012). Early physical rehabilitation in the ICU and ventilator liberation. Respiratory Care, 57(10), 1663–1669.

Morrison, L., & Agnew, J. (2009). Oscillating devices for airway clearance in people with cystic fibrosis. Cochrane Database Systematic Review, (1), CD006842.

Pedersen, C. M., Rosendahl-Nielsen, M., Hjermind, J., et al. (2009). Endotracheal suctioning of the adult intubated patient—what is the evidence? Intensive and Critical Care Nursing, 25(1), 21–30.

Perme, C., & Chandrashekar, R. (2009). Early mobility and walking program for patients in intensive care units: creating a standard of care. American Journal of Critical Care, 18(3), 212–220.

Rauen, C. A., Chulay, M., Bridges, E., et al. (2008). Seven evidence- based practice habits: putting some sacred cows out to pasture. Critical Care Nurse, 28(2), 98–123.

Schultz, S. (2011). Oxygen saturation monitoring with pulse oximetry. In E. Lynn-McHale Weigand (Ed.), AACN Procedure Manual for Critical Care (6th ed.). Phildelphia, PA: Saunders Elsevier.

Seymour, C., Cross, B., & Cooke, C. (2009). Physiologic impact of closed-system endotracheal suctioning in spontaneously breathing patients receiving mechanical ventilation. Respiratory Care, 54(3), 367–374.

Siela, D. (2010). Evaluation standards for management of artificial airways. Critical Care Nurse, 30(4), 76–78.

Spruit, M. A., Singh, S. J., Garvey, C., et al. (2013). An official American Thoracic Society/European Respiratory Society Statement: Key concepts and advances in pulmonary rehabilitation.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A 136 Risk for Allergy Response

Risk for Allergy response Gail B. Ladwig, MSN, RN, and Marina Martinez-Kratz, MS, RN, CNE

NANDA-I

Definition

Vulnerable to exaggerated immune response or reaction to substances which may compromise health

Risk Factors

Allergy to insect sting; exposure to allergen (e.g., pharmaceutical agent); exposure to environmental allergen (e.g., dander, dust, mold, pollen); exposure to toxic chemical; food allergy (e.g., avocado, banana, chestnut, kiwi, peanut, shellfish, mushroom, tropical fruit); repeated exposure to allergen-producing environmental substance

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Outcomes

Allergic Response: Systemic; Immune Hypersensitivity Response; Knowledge: Health Behavior, Risk Control, Risk Detection; Tissue Integrity: Skin and Mucous Membranes

Example NOC Outcome with Indicators

Immune Hypersensitivity Response as evidenced by the following indicators: Respiratory, cardiac, gastrointestinal, renal and neurological function status IER/Free of allergic reactions. (Rate each indicator of Immune Hypersensitivity Response: 1 = not controlled, 2 = slightly controlled, 3 = moderately controlled, 4 = well controlled, 5 = very well controlled [see Section I].) IER, In expected range.

American Journal of Respiratory and Critical Care Medicine, 188(8), e13–e64.

Wolkove, N., et al. (2004). A randomized trial to evaluate the sustained efficacy of a mucus clearance device in ambulatory patients with chronic obstructive pulmonary disease. Canadian Respiratory Journal: Journal of the Canadian Thoracic Society, 11(8), 567–572.

Wong, M., & Elliott, M. (2009). The use of medical orders in acute care oxygen therapy. British Journal of Nursing, 18(8), 462–464.

Woo, T. (2008). Pharmacology of cough and cold medicines. Journal of Pediatric Health Care, 22(2), 73–79.

Client Outcomes Client Will (Specify Time Frame)

• State risk factors for allergies • Demonstrate knowledge of plan to treat allergic reaction

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Interventions

Allergy Management; Environmental Risk Protection

Example NIC Activity

Place an allergy band on client

Nursing Interventions and Rationales

• A careful history is important in detecting allergens and avoidance of allergen. EB: Spice allergy is rare but spices are widely used and may be in cosmetics. The diagnoses depend on a good history and well- designed testing; treatment is strict avoidance (Chen & Bahna, 2011). Food allergy is among the most common of the allergic disorders. If food allergy or lactose intolerance is suspected, workup should include a detailed allergy-focused clinical history to determine whether the adverse reaction is typically an immediate

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Risk for Allergy Response 137

(IgE-mediated) or more delayed-type (non–IgE-mediated) allergic reaction, or whether it may be lactose intolerance, a form of nonallergic hypersensitivity (Waddell, 2011).

• Obtain a precise history of allergies, as well as medications taken and foods ingested before surgery. EBN: A thorough nursing assessment of allergies supports and improves the plan of care by identifying the patient’s risk factors (Cochico, 2012).

▲ Teach the client about correct use of the injectable epinephrine and have the client do a return demon- stration. EB: Recent research on the correct use of the injectable epinephrine showed that 84% of the patients were unable to do correctly (Bonds et al, 2015).

▲ Carefully assess the client for allergies. Below is information that is important for clients with allergies. Refer for immediate treatment if anaphylaxis is suspected.

Causes

Common allergens include animal dander; bee stings or stings from other insects; foods, especially nuts, fish, and shellfish; insect bites; medications; plants; pollens

Symptoms

Common symptoms of a mild allergic reaction include hives (especially over the neck and face), itching, nasal congestion, rashes, watery, red eyes

Symptoms of a moderate or severe reaction include cramps or pain in the abdomen, chest discomfort or tightness, diarrhea, difficulty breathing, difficulty swallowing, dizziness or lightheadedness, fear or feeling of apprehension or anxiety, flushing or redness of the face, nausea and vomiting, palpitations, swelling of the face, eyes, or tongue, weakness, wheezing, unconsciousness

First Aid

For a mild to moderate reaction: Calm and reassure the person having the reaction, because anxiety can worsen symptoms. 1. Try to identify the allergen and have the person avoid further contact with it. If the allergic reaction is

from a bee sting, scrape the stinger off the skin with something firm (e.g., fingernail or plastic credit card). Do not use tweezers; squeezing the stinger will release more venom.

2. Apply cool compresses and over-the-counter hydrocortisone cream for itchy rash. 3. Watch for signs of increasing distress. 4. Get medical help. For a mild reaction, a health care provider may recommend over-the-counter medica-

tions (e.g., antihistamines).

For a Severe Allergic Reaction (Anaphylaxis)

1. Check the person’s airway, breathing, and circulation (the ABCs of Basic Life Support). A warning sign of dangerous throat swelling is a very hoarse or whispered voice, or coarse sounds when the person is breathing in air. If necessary, begin rescue breathing and cardiopulmonary resuscitation.

2. Call 911. 3. Calm and reassure the person. 4. If the allergic reaction is from a bee sting, scrape the stinger off the skin with something firm (e.g.,

fingernail or plastic credit card). Do not use tweezers; squeezing the stinger will release more venom.

5. If the person has emergency allergy medication on hand, help the person take or inject the medication. Avoid oral medication if the person is having difficulty breathing.

6. Take steps to prevent shock. Have the person lie flat, raise the person’s feet about 12 inches, and cover him or her with a coat or blanket. Do NOT place the person in this position if a head, neck, back, or leg injury is suspected or if it causes discomfort.

Do NOT

• Do NOT assume that any allergy shots the person has already received will provide complete protection.

• Do NOT place a pillow under the person’s head if he or she is having trouble breathing. This can block the airways.

• Do NOT give the person anything by mouth if the person is having trouble breathing.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A 138 Risk for Allergy Response

When to Contact a Medical Professional

Call for immediate medical emergency assistance if: • The person is having a severe allergic reaction—always call 911. Do not wait to see if the reaction is

getting worse. • The person has a history of severe allergic reactions (check for a medical ID tag). Prevention

Avoid triggers such as foods and medications that have caused an allergic reaction (even a mild one) in the past. Ask detailed questions about ingredients when you are eating away from home. Carefully examine ingredient labels. • If you have a child who is allergic to certain foods, introduce one new food at a time in small amounts

so you can recognize an allergic reaction. • People who know that they have had serious allergic reactions should wear a medical ID tag. • Preoperative patients should be closely assessed for allergies to soybeans and eggs. EBN: Allergies to

soybeans and eggs contraindicate the use of propofol, a short-acting hypnotic commonly used in anesthesia (Cochico, 2012).

▲ If you have a history of serious allergic reactions, carry emergency medications (e.g., a chewable form of diphenhydramine and injectable epinephrine or a bee sting kit) according to your health care provider’s instructions.

• Do not use your injectable epinephrine on anyone else. They may have a condition (e.g., a heart problem) that could be negatively affected by this drug. EB: Although first-time exposure may only produce a mild reaction, repeated exposures may lead to more serious reactions. Once a person has had an exposure or an allergic reaction (is sensitized), even a very limited exposure to a very small amount of allergen can trigger a severe reaction. Most severe allergic reactions occur within seconds or minutes after exposure to the aller- gen. However, some reactions can occur after several hours, particularly if the allergen causes a reaction after it has been eaten. In very rare cases, reactions develop after 24 hours.

• Anaphylaxis is a sudden and severe allergic reaction that occurs within minutes of exposure. Immediate medical attention is needed for this condition. Without treatment, anaphylaxis can get worse very quickly and lead to death within 15 minutes (Medline Plus, 2012).

▲ Refer the client for skin testing to confirm IgE-mediated allergic response. EB: Identifying clients who are less sensitive is important, so that they can be started on immunotherapy. An informal survey of low-reacting clients treated with immunotherapy showed a high degree of success (Boyles & John, 2011). Allergy testing serves to confirm an allergic trigger suspected on the basis of history (Sicherer & Wood, 2012).

• See care plans for Latex Allergy response and Risk for Latex Allergy response. Pediatric

▲ Teach parents and children with allergies to peanuts and tree nuts to avoid them and to identify them. EB: Dietary avoidance is the primary management of these allergies and requires the ability to identify peanuts or tree nuts. Treatment of nut allergies with dietary avoidance should include education for both adults and children on identification of peanuts and tree nuts (Hostetler et al, 2012).

▲ Teach parents and children with asthma about modifiable risk factors, which include allergy triggers. EB: Attention to these allergy triggers will improve asthma control and reduce the burden of disease (Schatz, 2012).

▲ Counsel parents to limit infant exposure to traffic-related air pollution. EB: Recent research demonstrates that higher traffic-related air pollution exposure during infancy was associated with higher hyperactivity scores in children (Newman et al, 2013).

▲ Suspect FPIES (food protein-induced enterocolitis syndrome) in formula-fed infants with repetitive emesis, diarrhea, dehydration, and lethargy 1 to 5 hours after ingesting the offending food (the most common are cow’s milk, soy, and rice). Remove the offending food. EB: Early recognition of FPIES and removal of the offending food is important to prevent misdiagnosis and mismanagement of symptoms from other causes. Close follow-up is required to determine when foods may be added back into the diet. FPIES typically occurs before 6 months of age. Diagnosis is made by history and physician-supervised oral food challenges (Leonard & Nowak-Wegrzyn, 2011).

▲ Children should be screened for seafood allergies and avoid seafood and any foods containing seafood if an allergy is detected. EB: Seafood allergy is now a leading cause of anaphylaxis in both the United States and Australia. This study confirmed a seafood as common and important cause of food allergy in Australian children, presenting with a high rate of anaphylaxis (Turner et al, 2011).

Anxiety 139

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

AREFERENCES Bonds, R. S., Asawa, A., & Ghazi, A. I. (2015). Misuse of medical

devices: a persistent problem in self-management of asthma and allergic disease. Annals of Allergy, Asthma and Immunology, 114(1), 74–76.e2.

Boyles, J. H., Jr., & John, H. (2011). A comparison of techniques for evaluating IgE-mediated allergies. ENT: Ear Nose Throat J, 90(4), 164–169.

Chen, J. L., & Bahna, S. (2011). Spice allergy. Annals of Allergy, Asthma and Immunology, 107(3), 191–199.

Cochico, S. G. (2012). Propofol allergy: assessing for patient risks. AORN Journal, 96(4), 398–408.

Hostetler, T. L., et al. (2012). The ability of adults and children to visually identify peanuts and tree nuts. Annals of Allergy, Asthma and Immunology, 108(1), 25–29.

Leonard, S. A., & Nowak-Wegrzyn, A. (2011). Food protein-induced enterocolitis syndrome: an update on natural history and review of management. Annals of Allergy, Asthma and Immunology, 107(2), 95–100.

Medline Plus. Allergic reactions: causes, symptoms, first aid, prevention. Retrieved May 2012 from <http://www.nlm.nih.gov/medlineplus/ ency/article/000005.htm>.

Newman, N. C., Ryan, P., LeMasters, G., et al. (2013). Traffic-Related Air Pollution Exposure in the First Year of Life and Behavioral Scores at 7 Years of Age. Environmental Health Perspectives, 121(6), 731–737.

Schatz, M. (2012). Predictors of asthma control: what can we modify? Current Opinion In Allergy & Clinical Immunology, 12(3), 263–268.

Sicherer, S., & Wood, R. (2012). Allergy testing in childhood: using allergen-specific IgE tests. Pediatrics, 129(1), 193–197.

Turner, P., et al. (2011). Seafood allergy in children: a descriptive study. Annals of Allergy, Asthma and Immunology, 106(6), 494–501.

Waddell, L. (2011). Living with food allergy. The Journal of Family Health Care, 21(4), 21–28.

Anxiety Ruth McCaffrey, DNP, ARNP, FNP-BC, GNP-BC, FAAN

NANDA-I

Definition

Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting sign that warns of impending danger and enables the individual to take measures to deal with threat

Defining Characteristics

Behavioral

Decrease in productivity; extraneous movement; fidgeting; glancing about; hypervigilance; insomnia; poor eye contact; restlessness; scanning behavior; worry about change in life event

Affective

Anguish; apprehensiveness; distress; fear; feelings of inadequacy; helplessness; increase in wariness; irritabil- ity; jitteriness; overexcitement; rattled; regretful; self-focused; uncertain; worried

Physiological

Facial tension; hand tremors; increased perspiration; increased tension; shakiness; trembling; voice quivering

Sympathetic

Alteration in respiratory pattern; anorexia; brisk reflexes; cardiovascular excitation; diarrhea; dry mouth; facial flushing; heart palpitations; increase in blood pressure; increase in heart rate; increase in respiratory rate; pupil dilation; superficial vasoconstriction; twitching; weakness

Parasympathetic

Abdominal pain; alteration in sleep pattern; decrease in heart rate; decreased blood pressure; diarrhea; faint- ness; fatigue; nausea; tingling in extremities; urinary frequency; urinary hesitancy; urinary urgency

Cognitive

Alteration in attention; alteration in concentration; awareness of physiological symptoms; blocking of thoughts; confusion; decrease in perceptual field; diminished ability to learn; diminished ability to problem solve; fear; forgetfulness; preoccupation; rumination; tendency to blame others

140 Anxiety

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Related Factors (r/t) Conflict about life goals; exposure to toxin; family history of anxiety; heredity; interpersonal contagion; interpersonal transmission; major change (e.g., economic status, environment, health status, role function, role status); maturational crisis; situational crisis; stressors; substance abuse; threat of death; threat to current status; unmet needs; value conflict

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Aggression Self-Restraint; Anxiety Level; Anxiety Self-Control; Coping; Impulse Self-Control

Example NOC Outcome with Indicators

Anxiety Self-Control as evidenced by the following indicators: Eliminates precursors of anxiety/Monitors physical manifestations of anxiety/Controls anxiety response (Rate the outcome and indicators of Anxiety Self-Control: 1 = never demonstrated, 2 = rarely demonstrated, 3 = sometimes demonstrated, 4 = often demonstrated, 5 = consistently demonstrated [see Section I].)

Example NIC Activities—Anxiety Reduction

Use calm, reassuring approach; Explain all procedures, including sensations likely to be experienced during the procedure

Client Outcomes Client Will (Specify Time Frame)

• Identify and verbalize symptoms of anxiety • Identify, verbalize, and demonstrate techniques to control anxiety • Verbalize absence of or decrease in subjective distress • Have vital signs that reflect baseline or decreased sympathetic stimulation • Have posture, facial expressions, gestures, and activity levels that reflect decreased distress • Demonstrate improved concentration and accuracy of thoughts • Demonstrate return of basic problem-solving skills • Demonstrate increased external focus • Demonstrate some ability to reassure self

NIC (Nursing Interventions Classification)

Suggested NIC Intervention

Anxiety Reduction

Nursing Interventions and Rationales

• Assess the client’s level of anxiety and physical reactions to anxiety (e.g., tachycardia, tachypnea, nonver- bal expressions of anxiety). Consider using the Hamilton Anxiety Scale, which grades 14 symptoms on a scale of 0 (not present) to 4 (very severe). Symptoms evaluated are mood, tension, fear, insomnia, concentration, worry, depressed mood, somatic complaints, and cardiovascular, respiratory, gastrointes- tinal, genitourinary, autonomic, and behavioral symptoms. EBN: Generalized anxiety disorder (GAD) is the most common anxiety with a 12-month prevalence of 3.1% in population-based survey and between 5.3% and 7.6% among patients who visit primary care offices. The highest rate of GAD (7.7%) occurs in persons 45 to 49 years of age, and the lowest rate (3.6%) occurs in persons 60 years and older. Women are almost twice as likely as men to be diagnosed with GAD over their lifetime (Kavan et al, 2009).

• Rule out withdrawal from alcohol, sedatives, or smoking as the cause of anxiety. EB: Military personnel sent to war zones have higher levels of depression that are often exacerbated by alcohol and sedative use (Gale et al, 2010). When withdrawing from either sedatives or alcohol, participants in this study demon- strated elevated levels of anxiety and nervousness (McCabe et al, 2011).

• Use empathy to encourage the client to interpret the anxiety symptoms as normal. EBN: The way a nurse interacts with a client influences his/her quality of life. Providing psychological and social support can reduce

Anxiety 141

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

Athe symptoms and problems associated with anxiety (Wagner & Bear, 2009). In another study, patients undergoing couples therapy felt significantly more trust and responded with more success to those therapists who provided empathetic and compassionate responses and suggestions (Benson et al, 2012).

• If irrational thoughts or fears are present, offer the client accurate information and encourage him or her to talk about the meaning of the events contributing to the anxiety. EBN: In one study providing cancer patients with accurate information about their disease, prognosis and outcomes significantly reduced their anxiety and increased empowerment (Lauzier et al, 2014).

• Encourage the client to use positive self-talk. EBN: Reducing negative self-talk and increasing positive self-talk can be beneficial for all types of anxiety (Hill, 2010). One research study showed that self- talk strengthens both actual behavior performance and prospective behavioral intentions (Dolcos & Albarracin, 2014).

• Intervene when possible to remove sources of anxiety. EBN: Removing or reducing sources of stress and anxiety among clients has been shown to decrease hypertension and comorbid conditions (Lobjanidze et al, 2010).

• Explain all activities, procedures, and issues that involve the client; use nonmedical terms and calm, slow speech. Do this in advance of procedures when possible, and validate the client’s understanding. EBN: In one study, preoperative information reduced the anxiety of clients undergoing surgery under regional anesthesia (Jiala et al, 2010).

▲ Use massage therapy to reduce anxiety. EBN: Massage was shown to be an excellent method for reducing anxiety (Labrique-Walusis et al, 2010).

▲ Consider massage therapy for preoperative clients. EBN: Patients were highly satisfied with massage, and no major barriers to implementing massage therapy were identified. Massage therapy may be an important component of the healing experience for patients after cardiovascular surgery (Sutshall et al, 2010).

• Use therapeutic touch and healing touch techniques. EBN: One study showed that Reiki therapeutic touch reduced anxiety and pain (Sagkal, et al, 2013).

• Use guided imagery to decrease anxiety. EBN: Anxiety was decreased with the use of guided imagery during an intervention for postoperative pain (Thomas & Sethares, 2010).

• Suggest yoga to the client. EB: Yoga and massage lessened anxiety in burn patients (Parlak et al, 2010). Seven days’ intensive residential yoga program reduces pain, anxiety, and depression, and improves spinal mobility in lower back pain (Tekur et al, 2012).

• Provide clients with a means to listen to music of their choice or audiotapes. EBN: Music can provide an effective method of reducing potentially harmful physiological responses arising from anxiety (Korhan et al, 2011). Among ICU patients receiving acute ventilatory support for respiratory failure, patient directed music resulted in greater reduction in anxiety compared with usual care, but not compared with NCH (noise cancelling headphones). Concurrently, patient directed music resulted in greater reduction in sedation fre- quency compared with usual care (Chlan et al, 2013).

Pediatric

• The above interventions may be adapted for the pediatric client.

Geriatric

▲ Monitor the client for depression. Use appropriate interventions and referrals. EB: GAD is a common and disabling disorder in later life that is highly comorbid with mood, anxiety, and personality disorders; psy- chiatric comorbidity is associated with an increased risk for medical conditions in this population. Consider- ing that late-life GAD is associated with impaired quality of life but low levels of professional help-seeking, increased effort is needed to help individuals with this disorder to access effective treatments (Mackenzie et al, 2011).

• Older adults report less worry than younger adults. EB: Generalized anxiety disorder is a common diag- nosis in older adults (Heinz et al, 2011).

• Observe for adverse changes if antianxiety drugs are taken. EB: Older adults are notably vulnerable to adverse drug reactions, particularly during unexpected hospitalizations (Bilyeu et al, 2011).

• Mindfulness meditation is successful in mediating anxiety. EBN: Mediation analyses indicated that mind- fulness fully mediated changes in acute anxiety symptoms, and partially mediated changes in worry and trait anxiety. These researchers concluded that mindful based stress reduction exercises are an effective treat- ment for anxiety disorders and related symptoms (Vollestad et al, 2011).

142 Anxiety

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Multicultural • Assess for the presence of culture-bound anxiety states. EBN: Prevalence and expression of social

anxiety/seasonal affective disorder (SAD) depends on the particular culture. Asian cultures typically show the lowest rates, whereas Russian and United States samples show the highest rates, of SAD (Hoffman et al, 2010).

• Identify how anxiety is manifested in the culturally diverse client. EBN: Clinical presentation of anxiety disorders, with respect to symptom presentation and the interpretation of symptoms, varies across cultures. A difference in catastrophic cognitions about anxiety symptoms across cultures is hypothesized to be a key aspect of cross-cultural variation in the anxiety disorders (Marques et al, 2011).

• For diverse clients experiencing preoperative anxiety, provide music of their choice. EBN: This exploratory study demonstrated the positive impact of live music as a holistic patient intervention directed toward reduc- ing pain, anxiety, and muscle tension during the preoperative, intraoperative, and postoperative periods (Sand-Jecklin & Emerson, 2010).

Home Care

• The above interventions may be adapted for home care use. ▲ Assess for suicidal ideation. Implement emergency plan as indicated. EBN: Suicidal ideation may occur

in response to co-occurring depression or a sense of hopelessness over severe anxiety symptoms or once antidepressant medications have been started (Mitchell et al, 2009). See care plan for Risk for Suicide.

• Assess for influence of anxiety on medical regimen. EBN: Anxiety can affect a patient’s ability to complete their medical regimen as prescribed, including taking medications, exercise, diet, and follow up therapies (Hynninen et al, 2010).

• Assess for presence of depression. EBN: Clinician report generally had the most favorable sensitivity and specificity for measuring depressive symptoms and treatment recommendations, respectively (Henry et al, 2014).

• Assist family to be supportive of the client in the face of anxiety symptoms. EBN: Supporting the formal and information caregivers of a patient with anxiety as well as the patient may improve overall patient outcomes and allows the family to fully understand the problems the patient is experiencing (Kang et al, 2011).

▲ Consider referral for the prescription of antianxiety or antidepressant medications for clients who have panic disorder (PD) or other anxiety-related psychiatric disorders. EBN: The use of antidepressants, especially SSRI medications, is effective in many cases of anxiety (Katzman, 2009).

▲ Assist the client/family to institute medication regimen appropriately. Instruct in side effects, importance of taking medications as ordered, and effects to report immediately to health care provider. EBN: Patient interviews revealed that patients’ values and beliefs, barriers to treatment, and prior medication- taking behavior were of primary importance in understanding medication discontinuance (Garavalia et al, 2011).

▲ Refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen. EBN: Providing home health services for patients with anxiety increases self efficacy and reduces symptoms of anxiety, stress, and depression (Shelby et al, 2009).

Client/Family Teaching and Discharge Planning

▲ Teach use of appropriate community resources in emergency situations (e.g., suicidal thoughts), such as hotlines, emergency departments, law enforcement, and judicial systems. EB: Identification and sharing of best practices associated with emergency and community services would provide an opportunity for improvement in care for families dealing with anxiety and depression (Weiss et al, 2012).

• Teach the client/family the symptoms of anxiety. EBN: Teach families to have a general understanding of what is happening to the patient with anxiety and help them to accept assistance to overcome their anxiety (Smith et al, 2011).

• Teach the client techniques to self-manage anxiety. EBN: Computerized self-help treatments have been shown to be a less-intensive, cost-effective way to deliver empirically validated treatments for a variety of psychological problems (Newman et al, 2011).

• Teach the client to visualize or fantasize about the absence of anxiety or pain, successful experience of the situation, resolution of conflict, or outcome of procedure. EBN: Use of guided imagery has been useful for reducing anxiety (Tyron & McKay, 2009).

Anxiety 143

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A• Teach relationship between a healthy physical and emotional lifestyle and a realistic mental attitude. EBN: Some aspects of healthy lifestyle for anxiety disorders include identifying unhealthy relationships, building a strong support system, and adopting general healthy lifestyle habits (Smith et al, 2011).

REFERENCES Benson, L., McGinn, M., & Christensen, A. (2012). Common

principals of couples therapy. Behavior Therapy, 43(1), 25–35. Bilyeu, K., et al. (2011). Cultivating quality: reducing the use of

potentially inappropriate medications in older adults. The American Journal of Nursing, 111(1), 47–52.

Chlan, L., Weinert, C., Heiderscheidt, A., et al. (2013). Effects of patient-directed music intervention on anxiety and sedative exposure in critically ill patients receiving mechanical ventilatory support: a randomized clinical trial. Journal of the American Medical Association, 309(22), 2335–2544.

Dolcos, S., & Albarracin, D. (2014). The inner speech of behavioral regulation: Intentions and task performance strengthen when you talk to yourself as a You. European Journal of Social Psychology, 44(6), 636–642.

Gale, C., Wilson, J., & Deary, I. (2010). Globus sensation and psychopathology in men: the Vietnam experience. Psychosomat Med, 71(9), 1026–1031.

Garavalia, L., et al. (2011). Medication discussion question: developing a guide to facilitate patient-clinician communication about heart medications. The Journal of Cardiovascular Nursing, 26(4), E12–E29.

Heinz, A., Mann, K., Weinberger, D. R., et al. (2011). Sooner or later: age at onset of generalized anxiety disorder in older adults. Depression and Anxiety, 29(1), 39–46.

Henry, S. G., Feng, B., Franks, P., et al. (2014). Methods for assessing patient–clinician communication about depression in primary care: what you see depends on how you look. Health Services Research.

Hill, J. (2010) Less perfection, less stress. Retrieved November 6, 2011, from <http://thestressreliefhandbook.com/2010/02/less-perfection -less-stress>.

Hoffman, A., Asnaani, A., & Hinton, D. (2010). Cultural aspects of social anxiety and social anxiety disorder. Depression and Anxiety, 27(2), 1117–1127.

Hynninen, M., Bjerke, N., Pallesen, S., et al. (2010). A randomized controlled trial of cognitive behavioral therapy for anxiety and depression in COPD. Respiratory Medicine, 104(7), 986–994.

Jiala, H. A., French, J. L., Foxall, G. L., et al. (2010). Effect of preoperative multimedia information on perioperative anxiety in patients undergoing procedures under regional anaesthesia. British Journal of Anesthesia, 104(3), 369–374.

Kang, X., Li, Z., & Nolan, M. (2011). Informal caregivers’ experiences of caring for patients with chronic heart failure: systematic review and metasynthesis of qualitative studies. The Journal of Cardiovascular Nursing, 26(5), 386–394.

Katzman, M. (2009). Current considerations in the treatment of generalized anxiety disorder. CNS Drugs, 23(2), 103–120.

Kavan, M., Elsasser, G., & Barone, E. (2009). General anxiety disorder assessment and management. American Family Physician, 79(9), 785–791.

Korhan, E. A., Khorshid, L., & Uyar, M. (2011). The effect of music therapy on physiological signs of anxiety in patients receiving mechanical ventilatory support. Journal of Clinical Nursing, 20, 1026–1034.

Labrique-Walusis, F., Keister, K., & Russell, A. (2010). Massage therapy for stress management: Implications for nursing practice. Orthopaedic Nursing, 29(4), 254–257.

Lauzier, S., Campbell, H. S., Livingston, P. M., et al. (2014). Indicators for evaluating cancer organizations’ support services: Performance and associations with empowerment. Cancer.

Lobjanidze, N., et al. (2010). Interaction between depression-anxiety disorders and hypertension. J Hypertension, 28, e94.

McCabe, S., et al. (2011). Medical misuse of controlled medications among adolescents. Archives of Pediatrics and Adolescent Medicine, 165(8), 729–735.

Mackenzie, C., Reynolds, K., Chou, K., et al. (2011). Prevalence and correlates of generalized anxiety disorder in a national sample of older adults. The American Journal of Geriatric Psychiatry, 19(4), 305–314.

Marques, L., Robinaugh, D., LaBlanc, N., et al. (2011). Cross-cultural variations in the prevalence and presentation of anxiety disorders. Review of Neurotherapeutics, 11(2), 313–322.

Mitchell, A., et al. (2009). Depression, anxiety and quality of life in suicide survivors. Archives of Psychiatric Nursing, 23(1), 2–10.

Newman, M., Szkodny, L., Llera, S., et al. (2011). A review of technology-assisted self-help and minimal contact therapies for anxiety and depression: Is human contact necessary for therapeutic efficacy? Clinical Psychology Review, 31(1), 89–103.

Parlak, G., Polat, S., & Nuran, A. (2010). Itching, pain, and anxiety levels are reduced with massage therapy and yoga stretching in burned adolescents. Journal of Burn Care and Research, 31(3), 429–432.

Sagkal, T., Eser, I., & Uyar, M. (2013). The effect of reiki touch therapy on pain and anxiety. Complementary Medicine, 3(4), 141–146.

Sand-Jecklin, K., & Emerson, H. (2010). The impact of a live therapeutic music intervention on patients’ experience of pain, anxiety, and muscle tension. Holistic Nursing Practice, 24(1), 7–15.

Shelby, R., et al. (2009). Pain catastrophizing in patients with noncardiac chest pain: relationships with pain, anxiety, and disability. Psychosomat Med, 71(8), 861–868.

Smith, M., Jaffe-Gill, E., & Segal, J. (2011). Generalized anxiety disorder (GAD): symptoms, treatment, and self-help. Accessed July 25, 2012, at <http://helpguide.org/mental/generalized_anxiety_disorder.htm>.

Sutshall, B., Wentworth, S., Engen, L., et al. (2010). Effect of massage therapy on pain, anxiety, and tension after cardiac surgery: A randomized study. Complementary Therapies in Clinical Practice, 16(2), 70–75.

Tekur, P., Nagarathna, R., Chametcha, S., et al. (2012). A comprehensive yoga programs improves pain, anxiety and depression in chronic low back pain patients more than exercise: An RCT. Complementary Therapies in Medicine, 20(3), 107–119.

Thomas, K., & Sethares, K. (2010). Is guided imagery effective in reducing pain and anxiety in the postoperative total joint arthroplasty patient? Orthopaedic Nursing, 29(6), 393–399.

Tyron, W., & McKay, D. (2009). Memory modification as an outcome variable in anxiety disorder treatment. Journal of Anxiety Disorders, 23(4), 546–556.

Vollestad, J., Silversten, V., & Nielson, G. (2011). Mindfulness-based stress reduction for patients with anxiety disorders: Evaluation in a randomized controlled trial. Behaviour Research and Therapy, 49(4), 281–288.

144 Death Anxiety

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A

Death Anxiety Ruth McCaffrey, DNP, ARNP, FNP-BC, GNP-BC, FAAN

NANDA-I

Definition

Vague uneasy feeling of discomfort or dread generated by perceptions of a real or imagined threat to one’s existence

Defining Characteristics

Concern about strain on the caregiver; deep sadness; fear of developing terminal illness; fear of loss of mental abilities when dying; fear of pain related to dying; fear of premature death; fear of prolonged dying process; fear of suffering related to dying; fear of the dying process; negative thoughts related to death and dying; powerlessness; worried about the impact of one’s death on significant other

Related Factors (r/t)

Anticipation of adverse consequences of anesthesia; anticipation of impact of death on others; anticipation of pain; anticipation of suffering; confronting the reality of terminal disease; discussions on topic of death; experiencing dying process; near-death experience; nonacceptance of own mortality; observations related to death; perceived imminence of death; uncertainty about encountering a higher power; uncertainty about life after death; uncertainty about the existence of a higher power; uncertainty of prognosis

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Dignified Life Closure; Fear; Self-Control; Health Beliefs: Perceived Threat

Example NOC Outcome with Indicators

Dignified Life Closure as evidenced by the following indicators: Expresses readiness for death/Resolves important issues/ Shares feelings about dying/Discusses spiritual concerns. (Rate the outcome and indicators of Dignified Life Closure: 1 = never demonstrated, 2 = rarely demonstrated, 3 = sometimes demonstrated, 4 = often demonstrated, 5 = consistently demonstrated [see Section I].)

Wagner, D., & Bear, M. (2009). Patient satisfaction with nursing care: a concept analysis within a nursing framework. Journal of Advanced Nursing, 65(3), 692–701.

Weiss, A., Chang, G., Rauch, S., et al. (2012). Patient- and practice- related determinants of emergency department length of stay for patients with psychiatric illness. Annals of Emergency Medicine, 60(2), 162–171.

Client Outcomes Client Will (Specify Time Frame)

• State concerns about impact of death on others • Express feelings associated with dying • Seek help in dealing with feelings • Discuss realistic goals • Use prayer or other religious practice for comfort

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Dying Care; Grief Work Facilitation; Spiritual Support

Example NIC Activities—Dying Care

Communicate willingness to discuss death; Support client and family through stages of grief

Death Anxiety 145

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

ANursing Interventions and Rationales ▲ Assess the psychosocial maturity of the individual. EB: In a large study, females scored higher on death

anxiety than males. Additional tests reported that life satisfaction, an altering consciousness coping style, and avoidance coping was significantly related to risk for developing a stress-related illness when faced with the death of a loved one (Moore, 2013).

▲ Assess clients for pain and provide pain relief measures. EBN: Providing pain management and pain relief measures is the factor that most improves dying clients’ quality of life at the end of life. Pain management should be a first priority for care providers during this time (Zhang et al, 2012).

• Assess client for fears related to death. EBN: Unbearable suffering is the outcome of an intensive process associated with death anxiety. According to clients, hopelessness is an essential element of unbearable suf- fering. Physical issues and feelings of loss may cause suffering during this time. Personality characteristics and biographical aspects greatly influence the burden of suffering. Unbearable suffering that accompanies death anxiety can only be understood in the continuum of the client’s perspectives of the past and present, and expectations of the future (Dees et al, 2011).

• Assist clients with life planning: consider and redefine main life goals, focus on areas of strength and/or goals that will provide satisfaction, adopt realistic goals, and recognize those that are impossible to achieve. EB: Advance planning improves end of life care and client and family satisfaction, and reduces stress, anxiety, and depression in surviving relatives (Detering et al, 2010).

• Assist clients with life review and reminiscence. EB: When challenges emerged, the participants implemented “the search to find an acceptable and satisfying completion to this life,” engaging family members, friends, and the hospice team in an effort to relieve discomfort and regain a degree of control (McSherry, 2011).

• Provide music of the client’s choosing. EBN: Traditionally, music has played an important role in human culture and has had a powerful influence on human behavior. Music has a unique capacity for immersing an individual to such a degree that the closeness can be felt and painful aloneness may be alleviated (Chi & Young, 2011).

• Provide social support for families, understanding what is most important to families who are caring for clients at the end of life. EBN: When nurses make the intensive care unit a comfortable place for the dying patients and their loved ones, we also make the patients’ deaths comfortable for us (Millner et al, 2009).

• Encourage clients to pray. EBN: Mindfulness and prayer allow for a step back from thoughts, increased coping for those who are dying, and their families (Monroe et al, 2012).

Geriatric

• Carefully assess older adults for issues regarding death anxiety. EB: Older adults in this study and review were more fearful for others than of the dying process. Women were more afraid of death of loved ones and of the consequences of their own death on those loved ones than were men (Azaiza et al, 2011).

• Provide back massage for clients who have anxiety regarding issues such as death. EBN: Back massage significantly reduced anxiety in the study population. Systolic BP decreased to a greater degree in the male participants, particularly in those with greater levels of anxiety and higher systolic BP (Chen et al, 2013).

• Refer to care plan for Grieving. Multicultural

• Assist clients to identify with their culture and its values. EB/EBN: Christians scored significantly lower for death anxiety than both nonreligious and Muslim groups, and Muslims scored significantly higher than the nonreligious group (Gareth & McAdie, 2009).

• Refer to care plans for Anxiety and Grieving. Home Care

• The above interventions may be adapted for home care. • Identify times and places when anxiety is greatest. Provide for psychological support at those times, using

such strategies as personal contact, telephone contact, diversionary activities, or therapeutic self. EBN: Participants across conditions reported similar levels of anxiety, suggesting that promoting an interest in sustained contact can be accomplished without reducing anxiety, but rather by shielding individuals from the negative effects of anxiety during social interactions (Stern & West, 2014).

146 Death Anxiety

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A • Support religious beliefs; encourage the client to participate in services and activities of choice. EBN: Enhancing the psychosocial and spiritual well-being of cancer patients can reduce their death anxiety and promote better quality of life (Shukla & Rishi, 2014).

▲ Refer to medical social services or mental health services, including support groups as appropriate (e.g., anticipatory grieving groups from hospice, visiting volunteers of hospice). EB: Preparatory grief was found to reduce emotional stress. Experience with hospice focused on the intense preoccupation with the dying, loneliness, tearfulness, cognitive dysfunction, irritability, anger, and social withdrawal. This study found that talking mobilizes strength to cope with the situation (Asa & Agneta, 2012).

• Encourage the client to verbalize feelings to family/caregivers, counselors, and self. Identify the client’s preferences for end-of-life care; provide assistance in honoring preferences as much as practicable. EB: Music may be an effective tool for reviewing one’s life, through which a client moves toward acceptance of death by giving meaning to his or her life. Near the end of life, prescriptive music may be used during bedside vigils to accompany the client in the transition from life to death (Black & Thompson, 2012).

▲ Assist the client in making contact with death-related planning organizations, if appropriate, such as the Cremation Society and funeral homes. EB: Advanced care planning is important to older clients. However, when clients are not accepting of death or if death is outside of the client’s understanding, it can be difficult to work on advanced care planning. Nurses should explore whether the client accepts dying as a likely outcome and assess the client’s fears of dying and need for control before attempting any planning (Piers et al, 2013).

• Refer to care plan for Powerlessness. Client/Family Teaching and Discharge Planning

• Promote more effective communication to family members engaged in the caregiving role. Encourage them to talk to their loved one about areas of concern. Both caregivers and care receivers often avoid discussing areas of concern. EBN: Encouraging loved ones to discuss their wishes and areas of concern will assist the family during the grieving process; they will know the wishes of the dying family member and can carry them out as much as possible (Webb & Guarino, 2011).

• Allow family members to be physically close to their dying loved one, giving them permission, instruc- tion, and opportunities to touch. Keep family members informed. EBN: A novel approach at one VA hospital was to use Skype as a tool for client and family/friend communication. This was especially useful when clinical symptoms, functional status, financial concerns, and geographic limitations prohibited in-person visits. It was very satisfying to both family/friends and clients (Brecher, 2012).

REFERENCES Asa, J., & Agneta, G. (2012). Anticipatory grief among close relatives of

patients at hospice and palliative care wards. American Journal of Hospice and Palliative Care, 30, 29–34.

Azaiza, F., et al. (2011). Death and dying anxiety among bereaved and nonbereaved elderly parents. Death Studies, 35(7), 610–624.

Black, B. P., & Thompson, P. P. (2012). Music as a therapeutic resource in end of life care. Journal of Hospice and Palliative Care, 14(2), 118–125.

Brecher, D. B. (2012). The use of Skype in a community hospital palliative medicine consultation service. Journal of Palliative Medicine, 16(1), 110–112.

Chen, W., Liu, L., Yeh, S., et al. (2013). Effect of back massage intervention on anxiety, comfort, and physiologic responses in patients with congestive heart failure. The Journal of Alternative and Complementary Medicine, May, 19(5), 464–470.

Chi, G., & Young, A. (2011). Selection of music for relaxation and alleviating pain: literature review. Holistic Nursing Practice, 25(3), 127–135.

Dees, M., Vernooji, M., Dekkers, W., et al. (2011). Unbearable suffering: a qualitative study on the perspectives of patients who request assistance in dying. Journal of Medical Ethics, 37, 727–734.

Detering, K. M., Hancock, A. D., Reade, M. C., et al. (2010). The impact of advance care planning on end of life care in elderly patients: randomized controlled trial. British Medical Journal, 340, c1345.

Gareth, J. M., & McAdie, T. (2009). Are personality, well-being and death anxiety related to religious affiliation? Ment Health Relig Cult, 12(2), 115–120.

McSherry, C. (2011). The inner life at the end of life. J Hospice Palliat Care, 13(2), 112–120.

Millner, P., Paskiewicz, S., & Kautz, D. (2009). A comfortable place to say good-bye. Dimen Crit Care Nurs, 28(1), 13–17.

Moore, G. (2013). The relationship between religious orientation, coping style, and psychological health on death anxiety and life satisfaction. Bachelors Final Year Project, Dublin Business School found online at <http://esource.dbs.ie/handle/10788/1604?show=full>.

Monroe, N., Lynch, C., Losasso, V., et al. (2012). Mindfulness to Reduce Psychosocial Stress. Mindfulness, 3(1), 22–29.

Piers, R., Eechoud, I., VanCamp, S., et al. (2013). Advance Care Planning in terminally ill and frail older persons. Patient Education and Counseling, 90(3), 323–329.

Shukla, P., & Rishi, P. (2014). A correlational study of psychosocial & spiritual well being and death anxiety among advanced stage cancer patients. American Journal of Applied Psychology, 2(3), 59–65.

Stern, C., & West, T. (2014). Circumventing anxiety during interpersonal encounters to promote interest in contact:

Risk for Aspiration 147

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A

Risk for Aspiration Debra Siela, PhD, RN, CCNS, ACNS-BC, CCRN-K, CNE, RRT

NANDA-I

Definition

Vulnerable to entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids to the tracheo- bronchial passages, which may compromise health

Risk Factors

Barrier to elevating upper body; decrease in gastrointestinal motility; decrease in level of consciousness; delayed gastric emptying; depressed gag reflex; enteral feedings; facial surgery; facial trauma; impaired ability to swallow; incompetent lower esophageal sphincter; increase in gastric residual; increase in intragastric pressure; ineffective cough; neck surgery; neck trauma; oral surgery; oral trauma; presence of oral/nasal tube (e.g., tracheal, feeding); treatment regimen; wired jaw

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Aspiration Prevention; Respiratory Status: Ventilation; Swallowing Status

An implementation intention approach. Journal of Experimental Psychology, 50, 82–93.

Webb, J., & Guarino, A. (2011). Life after death of a loved one: long term distress among surrogate decision makers. J Hospice Palliat Care, 13(6), 378–386.

Zhang, B., Nilsson, M., & Prigerson, H. (2012). Factors important to patients’ quality of life at the end of life. Archives of Internal Medicine, 172(15), 1133–1142.

Example NOC Outcome with Indicators

Aspiration Prevention as evidenced by the following indicators: Avoids risk factors/Maintains oral hygiene/Positions self upright for eating and drinking/Selects foods according to swallowing ability/Selects foods and fluid of proper consistency/Remains upright for 30 minutes after eating. (Rate the outcome and indicators of Aspiration Prevention: 1 = never demonstrated, 2 = rarely demonstrated, 3 = sometimes demonstrated, 4 = often demonstrated, 5 = continually demonstrated [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Maintain patent airway and clear lung sounds • Swallow and digest oral, nasogastric, or gastric feeding without aspiration

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Aspiration Precautions

Example NIC Activities—Airway Management

Monitor level of consciousness, cough reflex, gag reflex, and swallowing ability; Check nasogastric or gastrostomy residual before feeding

Nursing Interventions and Rationales

• Monitor respiratory rate, depth, and effort. Note any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, hoarseness, foul-smelling sputum, or fever. If new onset of symptoms, perform oral suction and notify provider immediately. CEB/EB: Signs of aspiration should be detected as soon as possible to prevent further aspiration and to initiate treatment that can be lifesaving (Buckley & Cabrera, 2011;

148 Risk for Aspiration

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Swaminathan et al, 2015). Because of laryngeal pooling and residue in clients with dysphagia, silent aspira- tion may occur (Metheny, 2011b).

• Auscultate lung sounds frequently and before and after feedings; note any new onset of crackles or wheez- ing. CEB: With decreased symptoms of pneumonia, an increased respiratory rate and/or crackles may be the first sign of pneumonia (Metheny, 2011b).

• Take vital signs frequently, noting onset of a fever, increased respiratory rate, and increased heart rate.

• Before initiating oral feeding, check client’s gag reflex and ability to swallow by feeling the laryngeal prominence as the client attempts to swallow (Rees, 2013). If client is having problems swallowing, see nursing interventions for Impaired Swallowing.

• If client needs to be fed, feed slowly and allow adequate time for chewing and swallowing. CEB: Slowed feeding allows time for more deliberate swallowing, reducing aspiration (Rees, 2013).

• When feeding client, watch for signs of impaired swallowing or aspiration, including coughing, choking, and spitting food.

• Have suction machine available when feeding high-risk clients. If aspiration does occur, suction imme- diately. A client with aspiration needs immediate suctioning and may need further lifesaving interventions such as intubation and mechanical ventilation (Rees, 2013).

• Keep the head of the bed (HOB) elevated at 30 to 45 degrees, preferably with the client sitting up in a chair at 90 degrees when feeding. Keep head elevated for an hour after eating. EBP: Decreased gastric reflux occurs at both 30- and 45-degree HOB elevation. Thus, gastric fed patients should be maintained at the highest HOB elevation that is comfortable to prevent aspiration (Metheny & Franz, 2013).

• Note presence of nausea, vomiting, or diarrhea. Treat nausea promptly with antiemetics. • If the client shows symptoms of nausea and vomiting, position on side. The side-lying position can help

the client expel the vomitus and decrease the risk for aspiration (Chard, 2013). • Assess the abdomen and listen to bowel sounds frequently, noting if they are decreased, absent, or hyper-

active. Decreased or absent bowel sounds can indicate an ileus with possible vomiting and aspiration; increased high-pitched bowel sounds can indicate a mechanical bowel obstruction with possible vomiting and aspiration (Longo et al, 2012).

• Note new onset of abdominal distention or increased rigidity of abdomen. EB: Abdominal distention or rigidity can be associated with paralytic or mechanical obstruction and an increased likelihood of vomiting and aspiration (Longo et al, 2012).

• If client has a tracheostomy, ask for referral to speech pathologist for swallowing studies before attempting to feed. EB: There is an increased risk for aspiration when tracheostomy tubes are in place, and inflating the cuff does not prevent aspiration (Rees, 2013).

• Provide meticulous oral care including brushing of teeth at least two times per day. Good oral care can prevent bacterial or fungal contamination of the mouth, which can be aspirated. EB: Research has shown that excellent dental care/oral care can be effective in preventing hospital-acquired (or extended care– acquired) pneumonia (Munro, 2014).

• Sedation agents can reduce cough and gag reflexes as well as interfere with the client’s ability to manage oropharyngeal secretions. EB: Using the smallest effective level of sedation may help reduce risk of aspiration (Bell, 2011; Barr et al, 2013).

Enteral Feedings

• Insert nasogastric feeding tube using the internal nares to distal-lower esophageal-sphincter distance, an updated version of the Hanson method. The ear-to-nose-to-xiphoid-process is often inaccurate. CEB: A study demonstrated that the revised Hanson’s method was more accurate in predicting the correct distance than the traditional method (Ellett et al, 2011).

• Verification of gastric tube placement should initially be obtained by radiography. Other methods of assessing proper gastric tube placement include capnography, aspirate assessment, tube markings, and pH tests. Auscultation should not be used to assess gastric tube placement (Bell, 2011; Amirlak et al, 2012; Williams et al, 2014).

• Tape the feeding tube securely to the nose using a skin protectant under the tape. EBN: A research study found that insertion of the feeding tube into the small intestine and keeping the HOB position elevated to at least 30 degrees reduced the incidence of aspiration and aspiration-related pneumonia drastically in critically ill clients (Metheny et al, 2010). Another study found that aspiration and pneumonia were reduced by feeding the clients in the mid-duodenum or farther in the small intestine (Metheny et al, 2011).

Risk for Aspiration 149

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A• Check to make sure the initial nasogastric feeding tube placement was confirmed by x-ray, with the openings of the tube in the stomach, not the esophagus or lungs. This is especially important if a small- bore feeding tube is used, although larger tubes used for feedings or medication administration should be verified by radiography also. Radiographic verification of placement remains the gold standard for determining safe placement of feeding tubes (Guenter, 2010; Bell, 2011; Metheny et al, 2012a; Williams et al, 2014).

• After radiographic verification of correct placement of the tube or the intestines, mark the tube’s exit site clearly with tape or a permanent marker (Simons & Abdallah, 2012).

• Measure and record the length of the tube that is outside of the body at defined intervals to help ensure correct placement. Note the length of the tube outside of the body; it is possible for a tube to slide out and be in the esophagus, without obvious disruption of the tape (Bankhead et al, 2009).

• Note the placement of the tube on any chest or abdominal radiographs that are obtained for the client. Acutely ill clients receive frequent x-ray examinations. These are available for the nurse to determine con- tinued correct placement of the nasogastric tube (Bell, 2011; Simons & Abdallah, 2012). When using elec- tromagnetic feed tube placement, radiographic confirmation of tube position is preferred due to the variance of the ability of clinicians to place the tube (Metheny & Meert, 2014).

• Check the pH of the aspirate. If the pH reading is 4 or less, the tube is probably in the stomach. Recognize that the pH may not indicate correct placement if the client is receiving continuous tube feedings, is receiving a hydrogen ion blocker or proton pump inhibitor, has blood in the aspirate, or is receiving antacids (Bell, 2011; Simons & Abdallah, 2012).

• Use a number of determinants for verification of correct placement before each feeding or every 4 hours if the client is on continuous feeding. Measure length of tube outside the body, and review recent x-ray results, check pH of aspirate if relevant, and characteristic appearance of aspirate. If findings do not ensure correct placement of the tube, obtain a radiograph to verify placement. Do not rely on the air insufflation method to assess correct tube placement. CEB/EBN: The ausculatory air insufflation method is not reliable for differentiating between gastric or respiratory placement; the “whooshing” sound can be heard even if the tube is incorrectly placed in the lung (Bell, 2011; Simons & Abdallah, 2012; Williams et al, 2014).

• Capnography (CO2 sensor) may be used to assess proper tube placement (Gilbert & Burns, 2012; Williams et al, 2014).

• Follow unit policy regarding checking for gastric residual volume during continuous feedings or before feedings, and holding feedings if increased residual is present. CEB/EBN: There is little evidence to support the use of measurement of gastric residual volume, and the practice may or may not be effective in preventing aspiration (Makic et al, 2011). It is still done at intervals (Metheny et al, 2012b; Bell, 2011) especially if there is a question of tube feeding intolerance. The practice of holding tube feedings if there is increased residual reduces the amount of calories given to the client. If the client has a small-bore feeding tube, it is difficult to check gastric residual volume and may be inaccurate. It is unclear if aspiration for residual volumes helps reduce the risk of aspiration (Metheny et al, 2012b); practice guidelines suggest con- tinuing to feed the patient until the residual is greater than 500 mL (Canadian Clinical Practice Guidelines, 2013; Elke et al, 2015).

• Follow unit protocol regarding returning or discarding gastric residual volume. At this time there is not a definitive research base to guide practice. CEB/EBN: A study of the effectiveness of either returning gastric residual volumes to the client or discarding them resulted in inconclusive findings and more research is needed in the area (Williams & Leslie, 2010).

• Do not use glucose testing to determine correct placement of enteral tube, and to identify aspirated enteral feeding. Glucose was found in tracheal secretions of clients who were not receiving enteral feedings (Guenter, 2010).

• Do not use blue dye to tint enteral feedings (Guenter, 2010). The presence of blue and green skin and urine and serum discoloration from use of blue dye has been associated with the death of clients. The U.S. Food and Drug Administration (2009) has reported at least 12 deaths from the use of blue dye in enteral feedings.

• During enteral feedings, position client with HOB elevated 30 to 45 degrees (Bell, 2011; Schallom et al, 2015). CEB: A study of mechanically ventilated clients receiving tube feedings demonstrated that there was an increase of the presence of pepsin (from gastric contents) in pulmonary secretions if the client was in a flat position versus being positioned with head elevated (Metheny & Franz, 2013). Generally do not turn off the tube feeding when repositioning clients. Stopping the tube feeding during repositioning is counterproduc- tive because the client receives less nutrition and the rate of emptying of the stomach is slow. If it is imperative

150 Risk for Aspiration

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A to keep the HOB elevated, consider use of reverse Trendelenburg (head higher than feet) when repositioning (Metheny, 2011a).

• Take actions to prevent inadvertent misconnections with enteral feeding tubes into intravenous (IV) lines or other harmful connections. Safety actions that should be taken to prevent misconnections include: ❍ Trace tubing back to origin. Recheck connections at time of client transfer and at change of shift. ❍ Label all tubing. ❍ Use oral syringes for medications through the enteral feeding; do not use IV syringes. ❍ Teach nonprofessional personnel “Do Not Reconnect” if a line becomes dislodged; rather, find the

nurse instead of taking the chance of plugging the tube into the wrong place. Enteral feeding tube lines have been inadvertently plugged into IV peripheral catheters, peritoneal dialysis catheters, central lines, medical gas tubing, and tracheostomies, resulting in death in some cases (Guenter, 2010).

Critical Care

• Recognize that critically ill clients are at an increased risk for aspiration because of severe illness and interventions that compromise the gag reflex. Predisposing causes of aspiration include sedation, endotra- cheal intubation and mechanical ventilation, neurological disorders, altered level of consciousness, hemody- namic instability, and sepsis (Makic et al, 2011).

• Recognize that intolerance to feeding as defined by increased gastric residual is more common early in the feeding process. EB: A study found that feeding intolerance in critical care clients happened commonly in the first 5 days of feeding, and feeding intolerance was associated with increased length of both critical care and hospital length of stay (O’Connor et al, 2011).

• Maintain endotracheal cuff pressures at an appropriate level to prevent leakage of secretions around the cuff (Bell, 2011).

• Pepsin and amylase are biomarkers of microaspiration of gastric contents in tracheal aspirate. Amylase pres- ence is a better biomarker of aspiration of oral contents in the tracheal aspirate. Both pepsin and amylase were present in tracheal aspirate of critically ill patients even with backrest elevation of 30 degrees. HOB elevation is inversely related to the presence of pepsin (Sole et al, 2014).

Geriatric

• Carefully check older client’s gag reflex and ability to swallow before feeding. A slowed rate of swallowing is common in older adults (Rees, 2013).

• Watch for signs of aspiration pneumonia in older adults with cerebrovascular accidents, even if there are no apparent signs of difficulty swallowing or of aspiration. Bedside evaluation for swallow and aspiration can be inaccurate. EB: Silent aspiration can occur in the older population (Metheny, 2011b).

• Recognize that older adults with aspiration pneumonia have fewer symptoms than younger people; repeat cases of pneumonia in older adults are generally associated with aspiration (Eisenstadt, 2010). Aspiration pneumonia can be undiagnosed in older adults because of decreased symptoms; sometimes the only obvious symptom may be new onset of delirium (Metheny, 2011b).

• Use central nervous system depressants cautiously; older clients may have an increased incidence of aspiration with altered levels of consciousness. Older clients have altered metabolism, distribution, and excretion of drugs. Many medications can interfere with the swallowing reflex, including antipsychotic drugs, proton pump inhibitors, and angiotensin-converting enzyme inhibitors (van der Maarel-Wierink et al, 2011).

• Keep an older, mostly bedridden client sitting upright for 45 minutes to 1 hour after meals. • Recommend to families that enteral feedings may or may not be indicated for clients with advanced

dementia. Instead, if possible use hand-feeding assistance, modified food consistency as needed, and feeding favorite foods for comfort (Sorrell, 2010). EB/CEB: Research has demonstrated that tube feedings in this population do not prevent malnutrition or aspiration, improve survival, reduce infections, or result in other positive outcomes (Teno et al, 2010).

Home Care

• The above interventions may be adapted for home care use. • For clients at high risk for aspiration, obtain complete information from the discharging institution

regarding institutional management. • Assess the client and family for willingness and cognitive ability to learn and cope with swallowing,

feeding, and related disorders.

Risk for Aspiration 151

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A• Assess caregiver understanding and reinforce teaching regarding positioning and assessment of the client for possible aspiration.

• Provide the client with emotional support in dealing with fears of aspiration. Fear of choking can provoke extreme anxiety, which can interfere with the client’s ability or willingness to adhere to the treatment plan. Refer to care plan for Anxiety.

• Establish emergency and contingency plans for care of the client. Clinical safety of the client between visits is a primary goal of home care nursing.

• Have a speech and occupational therapist assess the client’s swallowing ability and other physiological factors and recommend strategies for working with the client in the home (e.g., pureeing foods served to the client; providing adequate adaptive equipment for independence in eating). Successful strategies allow the client to remain part of the family.

• Obtain suction equipment for the home as necessary. • Teach caregivers safe, effective use of suctioning devices. Inform the client and family that only individuals

instructed in suctioning should perform the procedure. • Institute case management of frail elderly to support continued independent living. Client/Family Teaching and Discharge Planning

• Teach the client and family signs of aspiration and precautions to prevent aspiration. • Teach the client and family how to safely administer tube feeding. • Teach the family about proper client positioning to facilitate feeding and reduce risk of aspiration. • Verify client family/caregiver knowledge about feeding, aspiration precautions, and signs of aspiration.

REFERENCES Amirlak, B., et al. (2012). Pneumothorax following feeding tube

placement: Precaution and treatment. Acta Medica Iranica, 50(5), 355–358.

Bankhead, R., Boullata, J., Brantley, S., et al. (2009). A A.S.P.E.N. enteral nutrition practice recommendations. Journal of Parenteral Enteral Nutrition, 33(2), 122–167.

Barr, J., Fraser, G. L., Puntillo, K., et al. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine, 41(1), 263–306.

Bell, L. (2011). AACN Practice Alert-Prevention of Aspiration. American Association of Critical Care Nurses. Retrieved from <http://www.aacn.org/wd/practice/docs/practicealerts/prevention- aspiration-practice-alert.pdf?menu=aboutus>.

Buckley, L., & Cabrera, G. (2011). Pneumonia aspiration (anaerobic). CINAHL Information Systems.

Canadian Clinical Practice Guidelines (2013). Strategies to optimize the delivery of EN: Use of and threshold for gastric residual volumes. Retrieved from <http://www.criticalcarenutrition.com/docs/ cpgs2012/5.5.pdf>.

Chard, R. (2013). Care of postoperative patients. In D. Ignatavicius & M. L. Workman (Eds.), (2013). Medical-Surgical Nursing: Patient- Centered Collaborative Care (7th ed., pp. 284–301). St. Louis, MO: W.B. Saunders Company.

Eisenstadt, E. S. (2010). Dysphagia and aspiration pneumonia in older adults. Journal of American Academy Nursing Practitioners, 22(1), 17–22.

Elke, G., Felbinger, T. W., & Heyland, D. K. (2015). Gastric residual volume in critically ill patients: A dead marker or still alive? Nutrition in Clinical Practice, 30(1), 59–71.

Ellett, M. L., Cohen, M. D., Perkins, S. M., et al. (2011). Predicting the insertion length for gastric tube placement in neonates. Journal of Obstetric, Gynecologic, & Neonatal Nurses, 40(4), 412–421.

Gilbert, R. T., & Burns, S. M. (2012). Increasing the safety of blind gastric tube placement in pediatric patients. Journal of Pediatric Nursing, 27(5), 528–532.

Guenter, P. (2010). Safe practices for enteral nutrition in critically ill patients. Critical Care Nurse Clinics of North America, 22(2), 197–208.

Longo, D., et al. (2012). Harrison’s principles of internal medicine (18th ed.). New York: McGraw-Hill.

Makic, M. B. F., VonRueden, K. T., Rauen, C. A., et al. (2011). Evidence-based practice habits: Putting more sacred cows out to pasture. Critical Care Nurse, 31(2), 38–62.

Metheny, N. A. (2011a). Turning tube feeding off while repositioning patients in bed: ask the experts. Critical Care Nurse, 31(2), 96–97.

Metheny, N. A. (2011b). Preventing aspiration in older adults with dysphagia. Med-Surg Matters, 20(5), 6–7.

Metheny, N. A., Davis-Jackson, J., & Stewart, B. (2010). Effectiveness of an aspiration risk-reduction protocol. Nursing Research, 59(1), 18–25.

Metheny, N. A., & Frantz, R. A. (2013). Head-of-bed elevation in critically ill patients: A review. Critical Care Nurse, 33(3), 53–67.

Metheny, N. A., & Meert, K. L. (2014). Effectiveness of an electromagnetic feeding tube placement device in detecting inadvertent respiratory placement. American Journal of Critical Care, 23(3), 240–248.

Metheny, N. A., Mills, A. C., & Stewart, B. J. (2012b). Monitoring for intolerance to gastric tube feedings: A national survey. American Journal of Critical Care, 21(2), e33–e40.

Metheny, N. A., Stewart, B. J., & McClave, S. A. (2011). Relationship between feeding tube site and respiratory outcomes. Journal of Parenteral and Enteral Nutrition, 35(3), 346–355.

Metheny, N. A., Stewart, B. J., & Mills, A. C. (2012a). Blind insertion of feeding tubes in intensive care units: A national survey. American Journal of Critical Care, 21(5), 352–360.

Munro, C. L. (2014). Oral Health: Something to smile about! American Journal of Critical Care, 23(4), 282–289.

O’Connor, S., Rivett, J., Deane, A., et al. (2011). Nasogastric feeding intolerance in the critically ill—a prospective observational study. Australian Critical Care, 24(1), 22.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A 152 Risk for Impaired Attachment

Risk for impaired Attachment Mary Alice DeWys, RN, BS, CIMI, and Margaret Elizabeth Padnos, RN, AB, BSN, MA

NANDA-I

Definition

Vulnerable to disruption of the interactive process between parent/significant other and child that fosters the development of a protective and nurturing reciprocal relationship

Risk Factors

Anxiety; child’s illness prevents effective initiation of parental contact; disorganized infant behavior; inability of parent to meet personal needs; insufficient privacy; parental conflict resulting from disorganized infant behavior; parent-child separation; physical barrier (e.g., infant in isolette); prematurity; substance abuse

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Parent-Infant Attachment; Parenting Performance

Rees, H. C. (2013). Care of patients requiring oxygen therapy or tracheostomy. In D. Ignatavicius & M. L. Workman (Eds.), (2013). Medical-Surgical Nursing: Patient-Centered Collaborative Care (7th ed., pp. 562–580). St. Louis, MO: W.B. Saunders Company.

Schallom, M., Dykeman, B., Kirby, J., et al. (2015). Head-of-Bed elevation and early outcomes of gastric reflux, aspiration, and pressure ulcers: A feasibility study. American Journal of Critical Care, 24(1), 57–66.

Simons, S. R., & Abdallah, L. M. (2012). Bedside assessment of enteral tube placement aligning practice with evidence. American Journal of Nursing, 112(2), 40–48.

Sole, M. L., Conrad, J., Bennett, M., et al. (2014). Pepsin and amylase in oral and tracheal secretions: A pilot study. American Journal of Critical Care, 23(4), 334–338.

Sorrell, J. (2010). Use of feeding tubes in patients with advanced dementia. J Psychosoc Nurs, 48(5), 15–18.

Swaminathan, A., Stearns, D. A., Varkey, A. B., et al. (2015). Aspiration pneumonitis and pneumonia. Medscape. Retrieved <http:// emedicine.medscape.com/article/296198-overview#aw2aab6b2>.

Teno, J. M., Mitchell, S. L., Gozalo, P. L., et al. (2010). Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment. Journal of American Medical Association, 303, 544–550.

U.S. Food and Drug Administration (USFDA). (2009). Reports of blue dye discoloration and death in patients receiving enteral feedings tinted with the dye, FD & C Blue no. 1.FDA Public Health Advisory. Accessed April 27, 2015 from <http://www.fda.gov/ ForIndustry/ColorAdditives/ColorAdditivesinSpecificProducts/ InMedicalDevices/ucm142395.htm>.

van derMaarel-Wierink, C., Vanobbergen, J. N. O., Bronkhorst, E. M., et al. (2011). Risk factors for aspiration pneumonia in frail older people: a systematic review. Journal of American Medical Directors Association, 12(5), 344–354.

Williams, T., & Leslie, G. (2010). Should gastric aspirate be discarded or retained when gastric residual volume is removed from gastric tubes? Australian Critical Care, 23(4), 215–217.

Williams, T. A., et al. (2014). Frequency of aspirating gastric tubes for patients receiving enteral nutrition in the ICU: A randomized controlled trial. JPEN, 38(7), 809–816.

Example NOC Outcomes with Indicators

Holds infant close, touches, strokes, pats infant, responds to infant cues, holds infant for feeding, vocalizes to infant. (Rate the outcome and indicators of appropriate parent and infant behaviors that demonstrate an enduring affectionate bond: 1 = never demonstrated, 2 = rarely demonstrated, 3 = sometimes demonstrated, 4 = often demonstrated, 5 = consistently demonstrated [see Section I].)

Client Outcomes Parent(s)/Caregiver(s) Will (Specify Time Frame)

• Be willing to consider pumping breast milk (and storing appropriately) or breastfeeding, if feasible • Demonstrate behaviors that indicate secure attachment to infant/child • Provide a safe environment, free of physical hazards • Provide nurturing environment sensitive to infant/child’s need for nutrition/feeding, sleeping, comfort,

and social play • Read and respond contingently to infant/child’s distress • Support infant’s self-regulation capabilities, intervening when needed • Engage in mutually satisfying interactions that provide opportunities for attachment

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Risk for Impaired Attachment 153

• Give infant nurturing sensory experiences (e.g., holding, cuddling, stroking, rocking) • Demonstrate an awareness of developmentally appropriate activities that are pleasurable, emotionally

supportive, and growth fostering • Avoid physical and emotional abuse and/or neglect as retribution for parent’s perception of infant/child’s

misbehavior • State appropriate community resources and support services

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Anticipatory Guidance; Attachment Process; Attachment Promotion; Coping Enhancement; Developmental Care; Parent Education: Infant

Example NIC Activities—Anticipatory Guidance

Instruct about normal development and behavior, as appropriate; Provide a ready reference for the client (e.g., educational materials, pamphlets), as appropriate.

Nursing Interventions and Rationales

• Establish a trusting relationship with parent/caregiver. EBN: “Overall, the research indicates that health care professionals urgently need to address the concerns of parents (N = 600) and their emotional reactions, be positive with communication exchanges, encourage parents to seek help, enhance parents’ capability to positively explore the sources of social support and fully mobilize all social forces to ease psychological pres- sure” (Kong et al, 2013).

• Support mothers of preterm infants in providing pumped breast milk to their babies until they are ready for oral feedings and transitioning from gavage to breast. EBN: A Turkish study found stimulation with breast milk odor effective in decreasing length of transition of preterm infants from gavage to oral feeding and associated with shorter length of hospital stay (Yildiz et al, 2011).

• Identify factors related to postpartum depression (PPD)/major depression and offer appropriate interventions/referrals. EB: An Australian study of nulliparous women (N = 1507) highlights the need to “integrate concern for physical health with initiatives to address psychological well-being” for extreme tired- ness, lower back pain, breast problems, urinary incontinence, perineal pain, constipation, hemorrhoids, and cesarean wound pain (Woolhouse et al, 2014). EBN: Because a mother’s unpreparedness for premature childbirth may predispose her to “multiple and continuous waves of emotional responses, which will conse- quently lead to decline in performance … and mental irritation,” more attention should be given to support these mothers as the main caregivers of their infants (Valizadeh et al, 2014).

• Identify eating disorders/comorbid factors related to depression and offer appropriate interventions/ referrals. CEB: Combined psychological stressors of new motherhood and body image concerns of pregnancy may predispose exacerbation of eating disorder symptoms and development of postpartum mood disorders, in which mothers can be nonresponsive, inconsistent, or rejecting of the infant (Astrachan-Fletcher et al, 2008). EBN: Even though they may have prioritized food before their children’s need—or in the words of one participant (N = 9), “food comes before anything,” overall, mothers juggled the competing demands of their eating disorder with their children’s needs” (Stitt & Reupert, 2014).

• Nurture parents so that they in turn can nurture their infant/child. EBN: The principles of family-centered care (FCC)—respect, honoring diversity, supporting parents’ choice, tailoring practice to individual family needs—help families feel supported in helping achieve the best outcome for their child at all levels of care (Gephart & McGrath, 2012).

• Offer parents opportunities to verbalize their childhood fears associated with attachment. CEB: “Parental lack of resolution concerning loss or trauma has been proposed to result in atypical parenting behaviors, which may have a disorganizing effect on the parent-child relationship” (Bernier & Meins, 2008).

• Suggest journaling or scrapbooking as a way for parents of hospitalized infants to cope with stress and emotions. EB: Beyond the obvious value of providing lifetime family mementoes, taking digital photos and writing journal notes have been found (1) to give a sense of parental empowerment, (2) to reduce maternal psychological distress, (3) to facilitate parent-infant bonding, (4) to reaffirm mutual trust between parents and staff (Subhani & Kanwal, 2012).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A 154 Risk for Impaired Attachment

• Offer parent-to-parent support to parents of infants in the neonatal intensive care unit (NICU). EBN: In one neonatal unit, parent-support volunteers collaborated with staff to create an innovative educational and psychosocial support program specifically targeting teen parents in order to help them increase engagement with their hospitalized infants and their caregiving confidence (Walsh & Goser, 2013).

• Encourage parents of hospitalized infants to “personalize the baby” by bringing in clothing, pictures of themselves, toys, and tapes of their voices. CEB: These actions help parents claim the infant as their own and support families’ confidence/competence in caring for their infants at their own pace (Lawhon, 2002).

• Encourage physical closeness using skin-to-skin experiences as appropriate. EB: Because kangaroo mother care (KMC) provides proven health benefits to high-risk infants, involves parents in their care, and human- izes the NICU experience/environment, it is a commonly recognized model of care for very preterm infants as well as infants who “are not so preterm and not so tiny babies who are transferred from or admitted to the NICU (Davanzo et al, 2013).

• Plan ways for parents to interact/assist with infant/child caregiving. EB: The COPE program (Creating Opportunities for Family Empowerment), an audiotaped educational program, has been effective in (1) teaching parents how to engage with and care for their hospitalized infant and (2) reducing maternal stress (Gooding et al, 2011). “In the beginning, having parents lay hands on their infant is enough to develop a bond and connection”; in time, wiping their infant’s mouth and helping with diaper changes “facilitate the parents’ participation in care” (Zimmerman & Bauersachs, 2012).

• Educate parents about the importance of the infant-caregiver relationship as a foundation for the devel- opment of the infant’s self-regulation capacities. EB: Both contingent responsiveness and emotional-affective support model socialization practices and allow parents to support management of infant arousal states (Lynn et al, 2011).

• Assist parents in developing new caregiving competencies and/or revising/extending old ones. CEB: Five caregiving domains are identified: (1) being with infant, (2) knowing infant as a person, (3) giving care, (4) communicating/engaging with others regarding infant/parent needs, (5) problem-solving/decision-making/ learning (Pridham et al, 1998).

• Educate parents in reading/responding sensitively to their infant’s unique “body language” (behavior cues) that communicate approach (“I’m ready to play”), avoidance/stress (“I’m unhappy. I need a change.”), and self-calming (“I’m helping myself ”). CEBN: Mothers with lower competence and more technology- dependent children may perceive their children as more vulnerable and their cues as harder to read (Holditch- Davis et al, 2011).

• Educate and support parents’ ability to relieve infant/child’s stress/distress. CEBN: In facilitated tucking by parents (FTP), a parent holds the infant in a side-lying, fetal position and offers skin-to-skin contact with the hands during a stressful/painful situation (Axelin et al, 2010). EB: Controlled music stimulation appears safe and effective in ameliorating pain/stress in premature infants after undergoing heel-sticks (Tramo et al, 2011).

• Guide parents in adapting their behaviors/activities with infant/child cues and changing needs. EB: “For patterns of positive communication to lead to successful regulation of affect, the caregiver must be receptive to the infant’s cues, appropriately responsive, and motivated to foster further opportunities for interactions” (Lynn et al, 2011).

• Attend to both parents and infant/child to strengthen high-quality interactions. CEB: A mother’s behav- ioral and brain responses to her infant’s cues may be important predictors of infant development; in cases of maternal depression or substance abuse, an infant’s smiling face may fail to elicit positive caregiving (Strathearn et al, 2008). EB: “Positive facial expressions from one’s own infant may play a particularly important role in eliciting maternal responses and strengthening the mother-infant bond” (Strathearn & Kim, 2013).

• Assist parents with providing pleasurable sensory learning experiences (i.e., sight, sound, movement, touch, and body awareness). EB: A Finnish study found that, when combined with kangaroo care, music therapy helped parents of preterm infants (N = 61) feel more relaxed and able to focus on “being together with the infant” in a “calm space” in which they were able to exclude disturbing and stressful sounds, as well as stress and anxiety” (Teckenberg-Jansson et al, 2011).

• Encourage physical closeness using skin-to-skin experiences as appropriate. EB: When intermittent KMC is not deemed appropriate, parents must be taught alternative ways to minimize negative effects of separation from their baby (e.g., gentle containing touch, proprioceptive sense stimulation, face-to-face visual contact, talking, reading, singing soothing lullabies, and olfactory stimulation (Davanzo et al, 2013).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Risk for Impaired Attachment 155

• Encourage parents and caregivers to massage their infants and children. CEB: Preliminary studies suggest that infant massage combined with kinesthetic stimulation may have positive effects on preterm infants: greater weight gain, improved bone mineralization, earlier hospital discharge, and more optimal behavioral and motor responses compared to controls (Massaro et al, 2009). EB: A study of preterm and low-birth- weight infants who received massage reported the following results: greater alert and daytime activity in the first month of life; less awakening during sleep, and less crying in the second and third months; significantly greater weight gain at 2 and 3 months of age compared to infants who did not receive massage (Karbasi et al, 2014).

• Identify mothers who may need assistance in enhancing maternal role attainment (MRA). CEBN: “Mothers with more illness-related distress and less alert infants, and unmarried and less educated mothers may need interventions to enhance MRA” (Miles et al, 2011).

• Recognize that fathers, compared to mothers, may have different starting points in the attachment process in the NICU as nurses encourage parents to have early skin-to-skin contact. CEBN: One study showed that after giving birth prematurely, mothers felt powerless, experiencing the immediate postnatal period as surreal and strange. Fathers, however, experienced the birth as a shock but were ready to become immediately involved (Fegran et al, 2008). CEB: Specific experiences (e.g., receiving information consistently, speaking to a male health care provider may help fathers regain a sense of control to help them fulfill their various roles as protectors/partners/breadwinners (Arockiasamy et al, 2008). EB: A study conducted in an Irish NICU raises awareness of the need for health care professionals to consider the unique perspective of fathers regard- ing (1) “feeling like a second parent” because the primary focus is on the mother and infant and (2) viewing information sharing as a “double-edged sword” with both positive and negative effects (Hollywood & Hollywood, 2011).

Pediatric

• Recognize and support infant/child’s capacity for self-regulation and intervene when appropriate. CEB: Infants must learn to take in sensory information while simultaneously managing not to become overaroused and overwhelmed by stimuli (DeGangi & Breinbauer, 1997; Greenspan, 1992).

• Provide lyrical, soothing music in nursery and home that is age-appropriate (i.e., corrected, in the case of premature infants) and contingent with state/behavioral cues. EBN: “Before adopting an intervention such as music for use in the NICU, nurses should (1) consider the parents’ viewpoints about their preferences (e.g., recorded, classical, lullabies, mother’s humming/singing) and (2) offer guidance as needed regarding the individual infant’s response to musical stimuli” (Pölkki et al, 2012).

• Recognize and support infant/child’s attention capabilities. CEB: “The ability to take an interest in the sights, sounds, and sensations of the world” is a significant developmental milestone (Greenspan & Wieder, 1998).

• Encourage opportunities for mutually satisfying interactions between infant and parent. CEB: The process of attachment involves communication and synchronous and rhythmic patterns of interaction (Rossetti, 1999).

• Encourage opportunities for physical closeness. CEB: Despite overwhelming evidence provided by this comprehensive literature review regarding benefits of infant massage (e.g., increased weight gain and bone density), “preterm infant massage is only practiced in 38% of NICUs (Field et al, 2010). EB: A Finnish study proposes “that repeated combination of music therapy and kangaroo care may be more beneficial for preterm infants than KC alone” in terms of beneficial physiological outcomes (e.g., increased oxygen saturation) and parent reports of feeling calm and relaxed (Teckenberg-Jansson et al, 2011).

Multicultural

• Provide culturally sensitive parent support to non–English-speaking mothers and families. CEBN: In a study contrasting NICU norms in Christchurch, New Zealand, and Tokyo, Japan, areas of difference in parental support needs included (1) establishment of oral feeding, (2) nursing care–related decision-making, (3) parental information/involvement early in hospitalization, (4) visiting regulations, and (5) Western- based interventions (Ichijima, 2009). EB: Congruent parent-to-parent matching is an important way to help non-Anglophone mothers mobilize their strengths; cope with feelings of loss, guilt, helplessness, and anxiety; and increase access to services (Ardal et al, 2011).

• Discuss cultural norms with families to provide care that is appropriate for enhancing attachment with the infant/child. EB: Recognition of the NICU norms that may hinder parent-staff communication is impor- tant in nursing practice (Ichijima et al, 2011).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A 156 Risk for Impaired Attachment

• Promote the attachment process in women who have abused substances by providing a culturally based, women-centered treatment environment. CEB: Pregnant/postpartum Asian/Pacific Islander women identified provisions for the newborn, infant health care, parent education, and infant-mother bonding as conducive to their treatment (Morelli et al, 2001).

• Promote attachment process/development of maternal sensitivity in incarcerated women. EB: By creating a simple and uncomplicated plan for an incarcerated mother to pump and store her breast milk, “nurses have the opportunity to change the mothering experience” as they promote maternal-infant attachment and improve health for mother and infant (Allen & Baker, 2013).

• Empower family members to draw on personal strengths in which multiple worldviews/values are rec- ognized, incorporated, and negotiated. CEBN: According to a Thai study of NICU parents, the need to be strong, to be there, and to care for infants emerged as main themes in parents’ stories (Sitanon, 2009). EBN: A study by Heidari et al (2012) found that “having a premature infant with anomalies is viewed as a family flaw,” carrying with it the “stigma of shame.”

• Encourage positive involvement and relationship development between children and fathers. EB: A study by Kadivar and Mozafarinia (2013) confirmed that using the HUG Your Baby DVD and family- friendly instructional program with NICU fathers increased their knowledge of infant behavior and is likely to boost their confidence, promote the parent-child relationship, and strengthen the family unit (Kadivar & Mozafarinia, 2013).

Home Care

• The above interventions may be adapted for home care use. • Assess quality of interaction between parent and infant/child. CEB: In a study regarding effectiveness

of home visiting by paraprofessionals/nurses, outcomes of nurse visitations in particular included more responsive mother-child interaction, less emotional vulnerability in response to fear stimuli among infants, greater infant emotional vitality in response to joy/anger stimuli, and less likelihood of language delays (Olds et al, 2002).

• Use “interaction coaching” (i.e., teaching mother to let the infant lead) so that the mother will match her interaction style to the baby’s cues. EBN: Although delivery of personalized interventions is labor intensive, and testing ways to provide targeted interventions in order to promote sensitive, responsive maternal-infant interactions is challenging, these are supported by current research (Mayberry & Horowitz, 2011).

▲ Provide supportive care for infants and children whose parents have been deployed during wartime. EB: Given the stressful task facing returning service members (i.e., reintegrating themselves into families “whose internal rhythms have changed and where children have taken on new roles”), the authors advocate for strengthening community support services and adopting public health education measures that reduce the stigma of seeking treatment for post-traumatic stress disorder (Lester & Flake, 2013).

• Encourage custodial grandparents to utilize support groups available for caregivers of children. A strengths-based support group for caregiving grandmothers recommended five interventions adaptable to nursing practice: (1) disseminate health information regarding chronic conditions (e.g., diabetes, heart disease, high cholesterol, arthritis, migraines, ocular hypertension); (2) expand practical information regard- ing social service, financial and legal resources; (3) explore spiritual and religious connections that could serve as sources of psychological well-being and sustenance; (4) provide socioemotional support to help manage mental health issues; (5) utilize youth “lock-ins” and outings to give needed breaks from childcare responsibilities (Collins, 2011). EB: The Family Child Care Network Impact Study found that relationship- based network supports delivered by specially trained staff were associated with higher quality caregiving by childcare providers (Bromer & Bibbs, 2011).

REFERENCES Allen, D., & Baker, B. (2013). Supporting mothering through

breastfeeding for incarcerated women. Journal of Obstetrical & Gynecological Nursing, 42(Suppl. 1), S103.

Ardal, F., Sulman, J., & Fuller-Thompson, E. (2011). Support like a walking stick: parent-buddy matching for language and culture in the NICU. Neonat Netw, 30(2), 89–98.

Arockiasamy, V., Holsti, L., & Albersheim, S. (2008). Fathers’ experience in the neonatal intensive care unit: a search for control. Pediatrics, 121(2), e215–e222.

Astrachan-Fletcher, E., Veldhuis, C., Lively, N., et al. (2008). The reciprocal effects of eating disorders and the postpartum period: a review of the literature and recommendations for clinical care. Journal of Women’s Health, 17(2), 227–239.

Axelin, A., Lehtonen, L., Pelander, T., et al. (2010). Mothers’ different styles of involvement in preterm infant pain care. Journal of Obstetrical & Gynecological Nursing, 39(4), 415–424.

Bernier, A., & Meins, E. (2008). A threshold approach to understanding the origins of attachment disorganization. Developmental Psychology, 44(4), 969–982.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Risk for Impaired Attachment 157

Bromer, J., & Bibbs, T. (2011). Improving support services for family child care through relationship-based training. Zero to Three, 31(5), 22–29.

Collins, W. L. (2011). A strengths-based support group to empower African-American grandmothers raising grandchildren. Social Work and Christianity, 38(4), 453–466.

Davanzo, R., Pierpaolo, B., Travan, L., et al. (2013). Intermittent kangaroo mother care: a NICU protocol. Journal of Human Lactation, 29(3), 332–338.

DeGangi, G. A., & Breinbauer, C. (1997). The symptomatology of infants and toddlers with regulatory disorders. Journal of Developmental Learning Disabilities, 1(1), 183–215.

Fegran, L., Helseth, S., & Fagermoen, M. S. (2008). A comparison of mothers’ and fathers’ experiences of the attachment process in a neonatal intensive care unit. Journal of Clinical Nursing, 17(6), 810–816.

Field, T., Diego, M., & Hernandez-Reif, M. (2010). Preterm infant massage therapy research: A review. Infant Behavior and Development, 33(2), 115–124.

Gephart, S. M., & McGrath, J. M. (2012). Family-centered care of the surgical neonate. Newborn and Infant Nursing Reviews, 12(1), 5–7.

Gooding, J. S., Cooper, L. G., Blaine, A. I., et al. (2011). Family support and family-centered care in the neonatal intensive care unit: Origins, advances, impact. Seminars in Perinatology, 35(1), 20–28.

Greenspan, S. I. (1992). Infancy and early childhood: the practice of clinical assessment and intervention with emotional and developmental challenges. Madison, CT: International Universities Press.

Greenspan, S. I., & Wieder, S. (1998). The child with special needs: encouraging intellectual and emotional growth. Reading, MA: Perseus Books.

Heidari, H., Hasanpour, M., & Fooladi, M. (2012). The Iranian parents of premature infants in NICU experience stigma of shame. Medical Archives, 66(1), 35–40.

Holditch-Davis, D., Miles, M. S., Burchinal, M. R., et al. (2011). Maternal role attainment with medically fragile infants: part 2. Relationship to the quality of parenting. Research Nursing Health, 34(1), 35–48.

Hollywood, M., & Hollywood, E. (2011). The lived experiences of fathers of a premature baby on a neonatal intensive care unit. Journal of Neonatal Nursing, 17, 32–40.

Ichijima, E. (2009). Nursing roles in parental support: a cross-cultural comparison between neonatal intensive care units in New Zealand and Japan. Canterbury, UK: University of Canterbury.

Ichijima, E., Kirk, R., & Hornblow, A. (2011). Parental support in neonatal intensive care units: a cross-cultural comparison between New Zealand and Japan. Journal of Pediatric Nursing, 26(3), 206–215.

Kadivar, M., & Mozafarinia, S. M. (2013). Supporting fathers in a NICU: Effects of the HUG your baby program on fathers’ understanding of preterm infant behavior. Journal of Perinatal Education, 22(2), 113–119.

Karbasi, S. S., Golestan, M., & Fallah, R. (2014). Effect of massage therapy on sleep behavior in low birth weight infants. Iranian Journal of Pediatrics, 24(S2), S47.

Kong, L.-P., Cui, Y., Qiu, Y.-F., et al. (2013). Anxiety and depression in parents of sick neonates: a hospital-based study. Journal of Clinical Nursing, 22, 1163–1172.

Lawhon, G. (2002). Integrated nursing care: vital issues important in the humane care of the newborn. Seminars in Neonatology, 7, 441–446.

Lester, P., & Flake, E. (2013). How wartime military service affects children and families. The Future of Children, 23(2).

Lynn, L. N., Cuskelly, M., O.’Callaghan, M. J., et al. (2011). Self- regulation: a new perspective on learning problems experienced by children born extremely preterm. Australian Journal of Educational and Developmental Psychology, 11, 1–10.

Massaro, A. N., Hammad, T. A., Jazzo, B., et al. (2009). Massage with kinesthetic stimulation improves weight gain in preterm infants. J Perinat, 29(5), 352–357.

Mayberry, L., & Horowitz, J. A. (2011). Postpartum depression. In J. J. Fitzpatrick & M. Kazer (Eds.), Encyclopedia of Nursing Research (3rd ed.). New York: Springer.

Miles, M. S., Holditch-Davis, D., Burchinal, M. R., et al. (2011). Maternal role attainment with medically fragile infants: part 1. Measurement and correlates during the first year of life. Research in Nursing and Health, 34(1), 20–34.

Morelli, P. T., Fong, R., & Oliveira, J. (2001). Culturally competent substance abuse treatment for Asian/Pacific Islander women. Journal of Human Behavior Soc Environment, 3(3/4), 263.

Olds, D. L., et al. (2002). Home visiting by paraprofessionals and by nurses: a randomized, controlled trial. Pediatrics, 110(3), 486–496.

Pölkki, T. 1., Korhonen, A., & Laukkala, H. (2012). Expectations associated with the use of music in neonatal intensive care: a survey from the viewpoint of parents. Journal for Specialists in Pediatric Nursing, 17(4), 321–328.

Pridham, K. F., Schulte, H. D., Limbo, R., et al. (1998). Guided participation and development of care-giving competencies for families of low-birth-weight infants. Journal of Advanced Nursing, 28(5), 948–958.

Rossetti, L. M. (1999). Infant-toddler Assessment. Boston: Little, Brown and Company.

Sitanon, T. (2009). Thai parents’ experiences of parenting preterm infants during hospitalization in the neonatal intensive care unit, unpublished doctoral dissertation. University of Washington, School of Nursing.

Subhani, M. T., & Kanwal, I. (2012). Digital scrapbooking as a standard of care in neonatal intensive care units: Initial experience. Neonatal Network, 31(3), 162–168.

Stitt, N., & Reupert, A. (2014). Mothers with an eating disorder: ‘food comes before anything.’ Journal of Psychiatric & Mental Health Nursing, 21(6), 509–517.

Strathearn, L., & Kim, S. (2013). Mothers’ amygdala response to positive or negative infant affect is modulated by personal relevance. Frontiers in Neuroscience, 7, 176.

Strathearn, L., Li, J., Fonagy, P., et al. (2008). What’s in a smile? Maternal brain responses to infant facial cues. Pediatrics, 122(1), 40–51, Jul.

Teckenberg-Jansson, P., Huotilainen, M., Pölkki, T., et al. (2011). Rapid effects of neonatal music therapy combined with kangaroo care on prematurely-born infants. Nordic Journal of Music Therapy, 20(1), 22–42.

Tramo, M. J., Lense, M., Van Ness, C., et al. (2011). Effects of music on physiological and behavioral indices of acute pain and stress in premature infants: clinical trial and literature review. Music Med, 3(2), 72–83.

Valizadeh, L., Zamanzadeh, V., Mohammadi, E., et al. (2014). Continuous and multiple waves of emotional responses: Mother’s experience with a premature infant. Iran Journal of Nurse Midwifery, 19(4), 340–348.

Walsh, J., & Goser, L. (2013). Development of an innovative NICU teen parent support program: One unit’s experience. Journal of Perinatal & Neonatal Nursing, 27(2), 176–183.

Woolhouse, H., Gartland, D., Perlen, S., et al. (2014). Physical health after childbirth and maternal depression in the first 12 months post partum: Results of an Australian nulliparous pregnancy cohort study. Midwifery, 20, 378–384.

Yildiz, A., Arikan, D., Gözüm, S., et al. (2011). The effect of the odor of breast milk on the time needed for transition from gavage to total oral feeding in preterm infants. Journal of Nursing Scholarship, 43(3), 265–273, 2011.

Zimmerman, K., & Bauersachs, C. (2012). International Journal of Childbirth Education, 27(1), 50–53.

158 Autonomic Dysreflexia

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A Autonomic Dysreflexia Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN NANDA-I

Definition

Life-threatening, uninhibited sympathetic response of the nervous system to a noxious stimulus after a spinal cord injury at T7 or above

Defining Characteristics

Blurred vision; bradycardia; chest pain; chilling; conjunctival congestion; diaphoresis (above the injury); headache (diffuse pain in different areas of the head and not confined to any nerve distribution area); Horner’s syndrome; metallic taste in mouth; nasal congestion; pallor (below injury); paresthesia; paroxysmal hypertension; pilomotor reflex; red blotches on skin (above the injury); tachycardia

Related Factors

Bladder distention; bowel distention; insufficient caregiver knowledge of disease process; insufficient knowl- edge of disease process; skin irritation

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Neurological Status; Neurological Status: Autonomic; Vital Signs

Example NOC Outcome with Indicators

Neurological Status: Autonomic as evidenced by the following indicators: Systolic blood pressure/Diastolic blood pressure/Apical heart rate/Perspiration response pattern/Goose bumps response pattern/Pupil reactivity/Peripheral tissue perfusion. (Rate each indicator of Neurological Status: Autonomic: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Maintain normal vital signs • Remain free of dysreflexia symptoms • Explain symptoms, prevention, and treatment of dysreflexia

NIC (Nursing Interventions Classification)

Suggested NIC Intervention

Dysreflexia Management

Example NIC Activities—Dysreflexia Management

Identify and minimize stimuli that may precipitate dysreflexia; Monitor for signs and symptoms of autonomic dysreflexia

Nursing Interventions and Rationales

• Monitor the client for symptoms of dysreflexia, particularly those with high-level and more extensive spinal cord injuries. See Defining Characteristics. EB: Autonomic dysreflexia (AD) occurs in up to 90% of clients with high level spinal cord injury (Cragg & Krassioukov, 2013). Because most clients are asymptom- atic, it is important to recognize risk factors for AD, such as higher and more complete injuries and injuries related to trauma (Huang et al, 2011).

▲ Collaborate with providers and caregivers to identify the cause of dysreflexia. AD is triggered by a stimu- lus from below the level of injury. The most common triggers are distention of the bladder, kidney stones,

Autonomic Dysreflexia 159

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

Akink in urinary catheter, urinary tract infection, fecal impaction, pressure ulcer, ingrown toenail, men- struation, hemorrhoids, invasive testing, and sexual intercourse (Cragg & Krassioukov, 2013; Wan & Krassioukov, 2014). EB: Health care practitioners and caregivers should assess for conditions that place the client at risk for AD. Clients with upper thoracic and cervical injuries often have lower resting blood pressure, thus elevated blood pressure with AD may be less obvious, necessitating the importance of always assessing the condition (Jackson & Acland, 2011; Cragg & Krassioukov, 2013).

▲ If symptoms of dysreflexia are present, place client in high Fowler’s position, remove all support hoses or binders, loosen clothing, and immediately determine the noxious stimulus causing the response. If blood pressure cannot be decreased within 1 minute, notify the provider emergently (i.e., STAT). EB: These steps promote venous pooling, decrease venous return, and decrease blood pressure. The client should be rapidly evaluated by both the health care provider and nurse to find the possible cause (Jackson & Acland, 2011; Furlan, 2013; Urden et al, 2013). To determine the stimulus for dysreflexia: ❍ First, assess bladder function. Check for distention, and if present catheterize the client using an

anesthetic jelly as a lubricant. Do not use the Valsalva maneuver or Crede’s method to empty the bladder. Ensure existing catheter patency. Also assess for signs of urinary tract infection. EB: AD is commonly associated with bowel or bladder dysfunction in persons with a spinal cord injury (Furusawa et al, 2011; Cragg & Krassioukov, 2013).

❍ Second, assess bowel function. Numb the bowel area with a topical anesthetic as ordered and gently check for impaction. EB: For clients who require manual removal of stool, pretreatment with lidocaine cream may decrease the flow of impulses from the bowel and lower blood pressure during removal (Urden et al, 2013; Faaborg et al, 2014).

❍ Third, assess the skin, looking for any points of pressure and ingrown toenails. ▲ Initiate antihypertensive therapy as soon as ordered and monitor for cardiac dysrhythmias. EB: Due to

the large amount of sympathetic discharge following AD, clients in hypertensive crisis are at risk for arrhyth- mias, myocardial infarction, and cerebral hemorrhage (Furlan, 2013; Wan & Krassioukov, 2014).

▲ Be careful not to increase noxious sensory stimuli during assessment for cause of AD. If numbing agent is ordered, use it on anus and 1 inch of rectum before attempting to remove a fecal impaction. If neces- sary to replace an obstructed catheter, use an anesthetic jelly as ordered during the insertion. EB: Increased noxious sensory stimuli can exacerbate the abnormal response and worsen the client’s prognosis (Urden et al, 2013).

• Monitor vital signs every 3 to 5 minutes during acute event; continue to monitor vital signs after event is resolved (e.g., symptoms resolve and vital signs return to baseline, usually up to 2 hours post event). EB: It is possible for the client to develop rebound hypotension after the acute event because of the use of antihypertensive medications, or symptoms of dysreflexia may reoccur (Urden et al, 2013; Furlan, 2013).

• Watch for complications of dysreflexia, including signs of cerebral hemorrhage, seizures, cardiac dysfunc- tion, or intraocular hemorrhage. EB: Extremely high blood pressure can cause intracranial hemorrhage, myocardial injury and dysfunction, and death (Wan & Krassioukov, 2014).

• Accurately and completely record any incidences of dysreflexia; especially note the precipitating stimuli. It is imperative to determine noxious stimuli that precipitated AD and whether the condition is persistent, requiring the client to take medications routinely or implement different interventions to prevent repeat incidences (Cragg & Krassioukov, 2013).

• Use the following interventions to prevent dysreflexia: ❍ Ensure that drainage from an indwelling catheter is good and that bladder is not distended. Assess

the client frequently for signs and symptoms of urinary tract infection. ❍ Ensure a regular pattern of defecation to prevent fecal impaction. EB: AD is commonly associated with

bowel dysfunction in persons with a spinal cord injury (Wan & Krassioukov, 2014). A recent study found that bowel management with transanal irrigation was less traumatic than bowel management by digital rectal evacuation (Faaborg et al, 2014).

❍ Frequently change position of client to relieve pressure and prevent formation of pressure ulcers. ▲ If ordered, apply an anesthetic agent to any wound below the level of injury before performing wound

care. EB: Stimuli that would cause pain in persons without spinal cord injury can lead to AD (Furlan 2013; Urden et al, 2013).

▲ Because episodes can recur, notify all health care team members of the possibility of a dysreflexia episode. All health care personnel working with the client should be aware of the condition and how to treat it.

▲ For female clients with spinal cord injury, assess the client for AD during menstrual cycle. If the client becomes pregnant, collaborate with obstetrical health care practitioners to monitor for signs and

160 Autonomic Dysreflexia

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A symptoms of dysreflexia. EB: Autonomic dysreflexia may signal the onset of labor or be a sign of preterm labor. Women undergoing cesarean section should be carefully monitored intraoperatively and postopera- tively (Walsh et al, 2010).

Home Care

• The above interventions may be adapted for home care use. • Provide the client and caregiver with written information on common causes of AD and initial treatment.

An AD card is available from the SCI-INFO-PAGES online resource for clients with quadriplegia and paraplegia (http://www.sci-info-pages.com/ad.html) as well as from the Christopher and Dana Reeve Foundation (http://www.christopherreeve.org/site/c.mtKZKgMWKwG/b.7717499/k.D633/Autonomic _Dysreflexia_AD_Card__Send_to_a_Friend/apps/ka/ecard/choosecard.asp).

• Provide resources to the client with any known proclivity toward dysreflexia to wear a medical alert bracelet and carry a medical alert wallet card when not in a safe environment (i.e., not with someone who knows client has the condition and can respond appropriately).

▲ Establish an emergency plan: obtain provider orders for medications to be used in situations in which first aid does not work and plans to identify potential stimuli. EB: Medication administered immediately can reverse early stage dysreflexia. Notify health care provider of emergency (Craig Hospital, 2013). If orders have not been obtained or client does not have emergency medications, contact emergency medical services.

• When episode of dysreflexia is resolved, monitor blood pressure every 30 to 60 minutes for next 2 hours or admit to institution for observation. EB: Autonomic dysreflexia can have a profound effect on vascula- ture, leading to chronic cardiovascular dysfunction (Furlan, 2013).

Client/Family Teaching and Discharge Planning

• Teach recognition of the earliest symptoms of dysreflexia, the actions that should be taken when they occur, and the need to obtain help immediately. Give client a written card describing signs and symptoms of AD and initial actions. CEB: Clients and caregivers at risk for not understanding the key elements of AD occurrence and management are clients with nontraumatic etiologies, those with T5 or lower injuries, those in the youngest age group at injury, and those who had a shorter duration of injury (Schottler et al, 2009). Clients have reported knowledge gaps regarding AD and having symptoms of AD but not recognizing the condition (McGillivray et al, 2009).

• Teach steps to prevent dysreflexia episodes: care of bladder, bowel, and skin and prevention of other forms of noxious stimuli (e.g., not wearing clothing that is too tight, nail care). Discuss the potential impact of sexual intercourse and pregnancy on autonomic dysreflexia. EB: Autonomic dysreflexia may be triggered by ejaculation and sperm retrieval for men (McGuire et al, 2011).

REFERENCES Christopher and Dana Reeve Foundation. Paralysis Resource Center,

AD Card. Retrieved June 15, 2015 <http://www.christopherreeve .org/site/c.mtKZKgMWKwG/b.7717499/k.D633/Autonomic _Dysreflexia_AD_Card__Send_to_a_Friend/apps/ka/ecard/ choosecard.asp>.

Craig Hospital. (2013). Autonomic Dysreflexia. Retrieved April 11, 2015 <http://craighospital.hostworks.net/repository/documents/ HeathInfo/PDFs/765.AutonomicDysreflexia.pdf>.

Cragg, J., & Krassioukov, A. (2013). Autonomic dysreflexia: Five things to know about. CMAJ.

Faaborg, P. M., Christensen, P., Krassioukov, A., et al. (2014). Autonomic dysreflexia during bowel evacuation procedures and bladder filling in subjects with spinal cord injury. Spinal Cord, 52, 494–498.

Furlan, J. C. (2013). Autonomic dysreflexia: A clinical emergency. J Trauma Acute Care Surg, 75(3), 496–500.

Furusawa, K., et al. (2011). Incidence of symptomatic autonomic dysreflexia varies according to the bowel and bladder management techniques in patients with spinal cord injury. Spinal Cord, 49(1), 49–54.

Huang, Y. H., et al. (2011). Autonomic dysreflexia during urodynamic examinations in patients with suprasacral spinal cord injury. Archives of Physical Medicine and Rehabilitation, 92(9), 1450–1454.

Jackson, C. R., & Acland, R. (2011). Knowledge of autonomic dysreflexia in the emergency department. Emergency Medicine Journal, 28(10), 866–869.

McGillivray, C. F., Hitzig, S. L., Craven, B. C., et al. (2009). Evaluating knowledge of autonomic dysreflexia among individuals with spinal cord injury and their families. The Journal of Spinal Cord Medicine, 32(1), 54–62.

McGuire, C., et al. (2011). Electroejaculatory stimulation for male infertility secondary to spinal cord injury. Urology, 77(1), 83–87.

Schottler, J., et al. (2009). Patient and caregiver knowledge of autonomic dysreflexia among youth with spinal cord injury. Spinal Cord, 47(9), 681–686.

Quadriplegic, Paraplegic & Caregiver Resources. SCI-INFO-PAGES. (2015). Autonomic Dysreflexia. Retrieved April 11, 2015 <http:// www.sci-info-pages.com/ad.html>.

Risk for Autonomic Dysreflexia 161

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

A

Risk for Autonomic Dysreflexia Betty J. Ackley, MSN, EdS, RN, and Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN

NANDA-I

Definition

Vulnerable to life-threatening, uninhibited response of the sympathetic nervous system after spinal shock in an individual with spinal cord injury or lesion at T6 or above (has been demonstrated in clients with injuries at T7 and T8), which may compromise health

Risk Factors

Cardiopulmonary Stimuli

Deep vein thrombosis; pulmonary emboli

Gastrointestinal Stimuli

Bowel distention; constipation; difficult passage of feces; digital stimulation; enemas; esophageal reflux disease; fecal impaction; gallstones; gastric ulcer; gastrointestinal system pathology; hemorrhoids; suppositories

Musculoskeletal-Integumentary Stimuli

Cutaneous stimulations (e.g., pressure ulcer, ingrown toenail, dressings, burns, rash); fracture; heterotrophic bone; pressure over bony prominence; pressure over genitalia; range-of-motion exercises; spasm; sunburn; wound

Neurological Stimuli

Irritating stimuli below level of injury; painful stimuli below level of injury

Regulatory Stimuli

Extremes of environmental temperature; temperature fluctuations

Reproductive Stimuli

Ejaculation; labor and delivery period; menstruation; ovarian cyst; pregnancy; sexual intercourse

Situational Stimuli

Constrictive clothing (e.g., straps, stockings, shoes); pharmaceutical agent; positioning; substance with- drawal (e.g., narcotic, opiate); surgical procedure

Urological Stimuli

Bladder distention; bladder spasm; cystitis; detrusor sphincter dyssynergia; epididymitis; instrumentation; renal calculi; surgical procedure; urethritis; urinary catheterization; urinary tract infection

NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family Teaching and Discharge Planning, Rationales, and References

Refer to care plan for Autonomic Dysreflexia.

Urden, L. D., Stacy, K. M., & Lough, M. E. (2013). Critical Care Nursing 7th ed., Nursing Management Plan: Autonomic dysreflexia. St. Louis, MO: Elsevier, Mosby.

Walsh, P., Grange, C., & Beale, N. (2010). Anaesthetic management of an obstetric patient with idiopathic acute transverse

myelitis. International Journal of Obstetric Anesthesia, 18(1), 98–101.

Wan, D., & Krassioukov, A. (2014). Life-threatening outcomes associated with autonomic dysreflexia: A clinical review. The Journal of Spinal Cord Medicine, 37(1), 1–9.

e31

Risk for Bleeding Disturbed Body Image Insufficient Breast Milk Ineffective Breastfeeding Interrupted Breastfeeding Readiness for enhanced Breastfeeding Ineffective Breathing pattern

List of Nursing Diagnoses by Letter: B

162 Risk for Bleeding

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B Risk for Bleeding June M. Como, EdD, RN, CNS

NANDA-I

Definition

Vulnerable to a decrease in blood volume, which may compromise health

Risk Factors

Aneurysm; circumcision; disseminated intravascular coagulopathy; gastrointestinal condition (e.g., ulcer, polyps, varices); history of falls; impaired liver function (e.g., cirrhosis, hepatitis); inherent coagulopathy (e.g., thrombocytopenia); insufficient knowledge of bleeding precautions; postpartum complications (e.g., uterine atony, retained placenta); pregnancy complications (e.g., premature rupture of membranes, placenta previa/abruption, multiple gestation); trauma; treatment regimen

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Blood Coagulation; Blood Loss Severity; Circulation Status; Fall Prevention Behavior; Gastrointestinal Function; Knowledge: Personal Safety, Maternal Status, Physical Injury Severity, Risk Control, Safe Home Environment, Vital Signs

Example NOC Outcome with Indicators

Blood Coagulation as evidenced by the following indicators: Clot formation, International normalized ratio (INR), Hemoglobin (HGB), Platelet Count, Bleeding, Bruising, Hematuria, Hematemesis. (Rate the outcome and indicators of Blood Coagulation: 1 = severe deviation from normal range, 2 = substantial deviation from normal range, 3 = moderate deviation from normal range, 4 = mild deviation from normal range, 5 = no deviation from normal range.)

Example NIC Activities—Bleeding Precautions

Monitor the client closely for hemorrhage; Monitor coagulation studies; Monitor orthostatic vital signs, including blood pressure; Instruct the client and/or family on signs of bleeding and appropriate actions in case bleeding occurs

Client Outcomes Client Will (Specify Time Frame)

• Discuss precautions to prevent bleeding complications • Explain actions that should be taken if bleeding happens • Maintain adherence to agreed upon anticoagulant medication and lab work regimens • Monitor for signs and symptoms of bleeding • Maintain a mean arterial pressure above 70 mm Hg, a heart rate between 60 and 100 bpm with a normal

rhythm, and urine output greater than 0.5 mL/kg/hr • Maintain warm, dry skin

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Admission Care; Bleeding Precautions; Bleeding Reduction; Blood Product Administration; Circumcision Care; Fluid Management; Health Screening; Hemorrhage Control; Neurologic Monitoring; Postpartum Care; Risk Identification; Teaching: Disease Process; Teaching: Prescribed Medication; Oxygen Therapy; Shock Prevention; Surveillance; Vital Signs Monitoring

Nursing Interventions and Rationales

• Perform admission risk assessment for falls and for signs of bleeding. Safety precautions should be imple- mented for all at risk clients. EBN: Upon client admission to any health care facility, nurses should assess for fall risk factors that could increase the risk of bleeding (Holmes, 2011).

Risk for Bleeding 163

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B • Monitor the client closely for hemorrhage, especially in those at increased risk for bleeding. Watch for

any signs of bleeding, including bleeding of the gums, blood in sputum, emesis, urine or stool, bleeding from a wound, bleeding into the skin with petechiae, and purpura. EB: Clients at increased risk for bleed- ing may include older individuals (>60 years of age), individuals with active gastroduodenal ulcer, intrapar- tum and postpartum women, previous bleeding episode, hypertension, labile INRs, low platelet count, active malignancy, renal or liver failure, intensive care unit stay, drug or alcohol use, coadministration of antiplate- lets and nonsteroidal antiinflammatory drugs (NSAIDs), and antithrombotic and anticoagulant therapies (Hastings-Tolsma et al, 2013; Chen et al, 2011; Chua et al, 2011; Decousus et al, 2011). Individuals who take selective serotonin reuptake inhibitors (SSRIs) with or without a history of gastrointestinal bleeding may be at increased risk for bleeding especially if also taking NSAIDs or low-dose aspirin (Lanbos et al, 2011; Andrade et al, 2010). Use of aspirin and clopidogrel in the treatment of clients with image verified “small” subcortical strokes demonstrated higher rates of bleeding when compared with treatment with aspirin alone (Stiles, 2011).

• If bleeding develops, apply pressure over the site or appropriate artery as needed. Apply pressure dressing if indicated. EB: Nonpharmacological means, such as application of pressure, may reduce bleeding (Makris et al, 2013; Matteucci et al, 2011).

▲ Collaborate on an appropriate bleeding management plan, including nonpharmacological and pharma- cological measures to stop bleeding based on the antithrombotic used. EB: Recommendations for bleeding risk prevention and management carefully weigh the risks and benefits of nonpharmacological and phar- macological interventions (Makris et al, 2013).

▲ Monitor coagulation studies, including prothrombin time, INR, activated partial thromboplastin time (aPTT), fibrinogen, fibrin degradation/split products, and platelet counts as appropriate. EB: New oral anticoagulants often have no requirement for routine coagulation studies; however, vigilance is still war- ranted in that risk for bleeding without benefit of reversal agents exists (Levy, 2014; Siegal & Crowther, 2013). INR is the preferred method to evaluate warfarin therapy, typically at least 16 hours after the last dose is administered. Dose adjustments will not result in a steady-state INR value for up to 3 weeks (ICSI, 2011). CEB: The aPTT is most commonly used to assess unfractionated heparin (UH) therapy but some clients may require additional testing to assess for heparin resistance (Russo, 2011). Replacement of UH with low-molecular-weight heparin and other new anticoagulants may be forthcoming but UH is still a drug of choice because of its ability to rapidly reverse effect with protamine sulfate (Lehman & Frank, 2009).

• Assess vital signs at frequent intervals to assess for physiological evidence of bleeding, such as tachycardia, tachypnea, and hypotension. Symptoms may include dizziness, shortness of breath, and fatigue. EB: Carefully assess for compensatory changes associated with bleeding, including increased heart rate and respiratory rate. Initially blood pressure may be stable, before beginning to decrease. Assess for orthostatic blood pressure changes (drop in systolic by >20 mm Hg and/or a drop in diastolic by >10 mm Hg in 3 minutes) by taking blood pressure with the client in lying, sitting, and standing positions (Matteucci et al, 2011; Urden et al, 2009). Prospective identification of clients at risk for massive transfusion is an imprecise science (Vandromme et al, 2011), although higher shock index (≥0.9) has been associated with increased bleeding risk (Olaussen et al, 2014).

▲ Monitor all medications for potential to increase bleeding, including aspirin, NSAIDs, SSRIs, and comple- mentary and alternative therapies such as coenzyme Q10 and ginger. EB: Antiplatelet medications can increase the risk of bleeding in high-risk clients (ICSI, 2011). Ginger, when taken with medicines that slow clotting, may increase the chances for bruising and bleeding (Medline Plus, 2011). CEB: In a study of adults receiving warfarin, coenzyme Q10 and ginger appeared to increase the risk of bleeding (Shalansky et al, 2007).

Consensus on Delivery of Inpatient Anticoagulant Therapy 2013

▲ QSEN: Systems-based process should be used for the management of inpatient anticoagulant therapy (Nutescu et al, 2013).

▲ QSEN: Multidisciplinary involvement that is accountable and provides leadership should be incorporated (Nutescu et al, 2013).

▲ QSEN: Seamless integration of anticoagulant system with all client resources including electronic health records (Nutescu et al, 2013;Villanueva et al, 2013).

▲ QSEN: Evidence-based standards, periodically reviewed, should be used to ensure appropriate use of anticoagulant therapies in all situations (Nutescu et al, 2013).

164 Risk for Bleeding

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B ▲ QSEN: Competency based education for all multidisciplinary personnel engaged in anticoagulant man-

agement (Nutescu et al, 2013). ▲ QSEN: Ensure safe and effective use of therapies during care transitions and discharge through appropri-

ate client education (Nutescu et al, 2013). ▲ QSEN: Ensure safe care transitions and maintenance of prescribed anticoagulants (Nutescu et al, 2013). ▲ QSEN: Measure quality indicators and assess client outcomes with a focus on quality improvement

(Nutescu et al, 2013).

Safety Guidelines for Anticoagulant Administration: Joint Commission National Patient Safety Goals

Follow approved protocol for anticoagulant administration: • Use prepackaged medications and prefilled or premixed parenteral therapy as ordered • Check laboratory tests (i.e., INR) before administration • Use programmable pumps when using parenteral administration • Ensure appropriate education for client/family and all staff concerning anticoagulants used • Notify dietary services when warfarin is prescribed (to reduce vitamin K in diet) • Monitor for any symptoms of bleeding before administration. EB: Standard defined protocols can decrease

errors in administration (Joint Commission, 2011). • Anticoagulation therapy is complex. EBN: Nurses have an integral role in medication management through

the education of clients (Howland, 2012). EB: Medication reconciliation techniques and predischarge educa- tion employed by pharmacists in an emergency department setting demonstrated enhanced accuracy of preadmission medication listings, resulting in a reduction in readmission rates (Gardella et al, 2012). CEB: Risk of bleeding is reduced in clients who receive appropriate education in anticoagulant therapy use (Metlay et al, 2008).

▲ Before administering anticoagulants, assess the clotting profile of the client. If the client is on warfarin, assess the INR. Hold the medication if the INR is outside of the recommended parameters and notify the health care provider or advanced practice nurse. EB: Target INR for warfarin is between 2 and 3 for nonvalvular atrial fibrillation and between 2.5 and 3.5 for valvular atrial fibrillation. Risk for bleeding is increased when INR is >4 and risk for thromboembolism increases when INR is <1.7. A 2% to 4% risk for bleeding remains in individuals within therapeutic range of INR. Dose adjustments of 15% usually change the INR level by 1 (ICSI, 2011). A safety advisory was issued by the Australian regulatory authority for the anticoagulant dabigatran (Pradaxa) due to an increase in the number of bleeding-related adverse events (Hughes, 2011).

▲ Recognize that vitamin K for vitamin K antagonists (e.g., warfarin, phenprocoumon, Sinthrome, and phenindione) may be given orally or intravenously as ordered for INR levels greater than 5. In some circumstances, pro-hemostatic therapies may be warranted (tranexamic acid, desmopressin, fresh frozen plasma, cryoprecipitate, platelet transfusion, fibrinogen concentrate, prothrombin complex concentrate, activated prothrombin complex concentrate and/or recombinant factor VIIa) if serious or life-threatening bleeding occurs (Makris et al, 2013). EB: With INR levels above 5, it is recommended to give vitamin K rather than withholding the warfarin; administration of vitamin K is by oral or intravenous route, because subcutaneous and intramuscular routes result in erratic absorption (ICSI, 2011).

▲ Manage fluid resuscitation and volume expansion as ordered. EB: A Cochrane systematic review including 86 trials and more than 5000 subjects suggests that there is no evidence that any one colloidal solution is safer or more effective than any other (Bunn & Trivedi, 2012). Prehospital administration of plasma may mitigate trauma-induced coagulopathy (Moore et al, 2014). CEB: Blood products (including human albumin), non–blood products or combinations can be used to restore circulating blood volume in individuals at risk for blood losses from trauma, burns, or surgery. Administration of albumin over normal sterile saline does not alter survival rates (Alderson et al, 2004).

▲ Consider use of permissive hypotension and restrictive transfusion strategies when treating bleeding episodes. EB: Hypotensive resuscitation (permissive hypotension), which maintains effective although low mean arterial pressures, may allow adequate perfusion without disruption of coagulation mechanisms, although additional research is warranted (Gourgiotis et al, 2013). A study of 921 subjects with upper gas- trointestinal bleeding suggests that restrictive strategies (transfusing when hemoglobin level fell to below 7 g per deciliter) improved survival (P = .02) and resulted in fewer adverse events (P = .02) (Villanueva, 2013).

▲ Consider discussing the coadministration of a proton-pump inhibitor alongside traditional NSAIDs, or with the use of a cyclo-oxygenase 2 inhibitor with the prescriber. EB: Risk of NSAID-related bleeding may

Risk for Bleeding 165

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B be reduced with the use of a proton-pump inhibitor or cyclo-oxygenase 2 inhibitor (van Soest et al, 2012; Chua et al, 2011; Rahme & Bernatsky, 2011; Wu et al, 2011).

• Ensure adequate nurse staffing to provide a high level of surveillance capability. EBN/QSEN: A key com- ponent in surveillance is monitoring; additional research is warranted in this area to identify new technolo- gies and processes to optimize surveillance (Henneman et al, 2012). CEB: The size and mix of nurse staffing in hospitals has been demonstrated to have a direct impact on client outcomes. Lower levels of nurse staffing have been associated with higher rates of poor client outcomes, including those outcomes caused by gastro- intestinal bleeding and “failure to rescue” (Needleman et al, 2002).

Pediatric

▲ Recognize that prophylactic vitamin K administration should be used in neonates for vitamin K defi- ciency bleeding (VKDB). EB: A dose of 0.5 to 1 mg vitamin K remains a standard administration for neonates to avoid VKDB and associated problems (Lippi & Franchini, 2011).

▲ Recognize warning signs of VKDB, including minimal bleeds, evidence of cholestasis (icteric sclera, dark urine, irritability), and failure to thrive. EB: Signs of classic VKDB may be mild and include delayed or difficulty feeding or bruising in 24 hours to 1 week, whereas late VKDB associated with breastfeeding may occur at 2 to 12 weeks (Lippi & Franchini, 2011).

▲ Use caution in administering NSAIDs in children. CEB: A study of children aged 2 months to 16 years found that although upper gastrointestinal bleeding is rare, one third of the cases seen were attributable to exposure to NSAIDs at doses used for analgesia or antipyretic purposes (Grimaldi-Bensouda et al, 2010). EB: A Cochrane review of 15 trials including about 1000 children found insufficient evidence to exclude an increase in bleeding risk after using NSAIDs, although the findings supported use of NSAIDs to reduce emesis (Lewis et al, 2013).

▲ Monitor children and adolescents for potential bleeding after trauma. EB: Trauma in children aged 1 through 12 years has been associated with early coagulopathy and subsequent bleeding (Christiaans et al, 2014). CEB: Children and adolescents who take SSRIs need to be closely monitored because the potential for bleeding exists across age groups (Andrade et al, 2010).

▲ Closely monitor children after cardiac surgery for excessive blood loss. EB: In a study of 182 children aged from neonate to older than 3 years, postoperative blood loss was found to be significantly associated with age (P = .003) and presence of cyanotic disease (P = .01) (Faraoni & Van der Linden, 2014).

Client/Family Teaching and Discharge Planning

• Teach client and family or significant others about any anticoagulant medications prescribed, including when to take, how often to have lab tests done, signs of bleeding to report, dietary restrictions needed, and precautions to be followed. Instruct the client to report any adverse side effects to his or her health care provider. Medication teaching includes the drug name, purpose, administration instructions (e.g., with or without food), necessary lab tests, and any side effects to be aware of. Provision of such information using clear communication principles and an understanding of the client’s health literacy level may facilitate appropriate adherence to the therapeutic regimen by enhancing knowledge base (Joint Commission, 2011; National Institutes of Health [NIH], 2011).

• Instruct the client and family on disease process and rationale for care. When clients and their family members have sufficient understanding of their disease process they can participate more fully in care and healthy behaviors. Knowledge empowers clients and family members, allowing them to be active participants in their care. CEBN: Use of written and verbal education enhances client retention of informa- tion needed when managing potent medications (Nurit et al, 2009).

• Provide client and family or significant others with both oral and written educational materials that meet the standards of client education and health literacy. EB: The use of clear communication, materials written at a fifth grade level, and the teach-back method enhance the client’s ability to understand important health- related information and improves self-care safety (NIH, 2011).

REFERENCES Alderson, P., et al. (2004). Human albumin solution for

resuscitation and volume expansion in critically ill patients. Cochrane Database of Systematic Reviews, (4), CD001208.

Andrade, C., et al. (2010). Serotonin reuptake inhibitor antidepressants and abnormal bleeding: a review for clinicians and a reconsideration of mechanisms. Journal of Clinical Psychology, 71, 1565–1575.

166 Risk for Bleeding

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B Bunn, F., & Trivedi, D. (2012). Colloid solutions for fluid resuscitation.

Cochrane Database of Systematic Reviews. Chen, W., et al. (2011). Association between CHADS2 risk factors and

anticoagulation-related bleeding: a systematic literature review. Mayo Clinic Proceedings, 86, 509–521.

Christiaans, S. C., Duhachek-Stapelman, A. L., Russell, R. T., et al. (2014). Coagulopathy After Severe Pediatric Trauma. Shock (Augusta, Ga.), 41, 476–490.

Chua, S., et al. (2011). Gastrointestinal bleeding and outcomes after percutaneous coronary intervention for ST-segment elevation myocardial infarction. American Journal of Critical Care, 20, 218–225.

Decousus, H., et al. (2011). Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest, 139, 69–79.

Faraoni, D., & Van der Linden, P. (2014). Factors affecting postoperative blood loss in children undergoing cardiac surgery. Journal of Cardiothoracic Surgery, 9, 32.

Gardella, J. E., Cardwell, T. B., & Nnadi, M. (2012). Improving medication safety with accurate preadmission medication lists and postdischarge education. Joint Commission Journal on Quality & Patient Safety, 38, 452–458.

Gourgiotis, S., Gemenetzis, G., Kocher, H. M., et al. (2013). Permissive hypotension in bleeding trauma patients: helpful or not and when? Critical Care Nurse, 33, 18–25.

Grimaldi-Bensouda, L., et al. (2010). Clinical features and risk factors for upper gastrointestinal bleeding in children: a case-crossover study. European Journal of Clinical Pharmacology, 6, 831–837.

Hastings-Tolsma, M., Bernard, R., Brody, M., et al. (2013). Chorioamnionitis: Prevention and management. Maternal Child Health, 38, 206–212.

Henneman, E. A., Gawlinski, A., & Giuliano, K. K. (2012). Surveillance: a strategy for improving patient safety in acute and critical care units. Critical Care Nurse, 32, e9–e18.

Holmes, S. (2011). Risk for bleeding. In B. Ackley & G. Ladwig (Eds.), Nursing diagnosis handbook (ed. 9). St Louis, MO: Mosby.

Howland, R. H. (2012). Effective medication management. Journal of Psychosocial Nursing and Mental Health Services, 50, 13–15.

Hughes, S. (2011). Dabigatran: Australia issues bleeding warning. Heartwire, From: <http://www.medscape.com/viewarticle/751161_ print>. Retrieved October 9, 2011.

Institute for Clinical Systems Improvement (ICSI) (2011). Antithrombotic therapy supplement, Bloomington, MN: ICSI.

Joint Commission (2011). Hospital national patient safety goals. From: <http://www.jointcommission.org/hap_2011_npsgs/>. Retrieved October 10, 2011.

Lanbos, C., Dasgupta, K., Nedjar, H., et al. (2011). Risk of bleeding associated with combined use of selective serotonin reuptake inhibitors and antiplatelet therapy following acute myocardial infarction. Canadian Medical Association Journal, 183, 1835–1843.

Lehman, C., & Frank, E. (2009). Laboratory monitoring of heparin therapy: partial thromboplastin time or anti-Xa assay? Labmed, 40(1), 47–51.

Levy, J. H. (2014). Pharmacology and safety of new oral anticoagulants: the challenge of bleeding persists. Clinics in Laboratory Medicine, 34, 443–452.

Lewis, S., Nicholson, A., Cardwell ME, et al. (2013). Nonsteroidal anti-inflammatory drugs and perioperative bleeding in paediatric tonsillectomy. Cochrane Database of Systematic Reviews.

Lippi, G., & Franchini, M. (2011). Vitamin K in neonates: facts and myths. Blood Transfusion, 9, 4–9.

Makris, M., Van Veen, J. J., Tait, C. R., et al. (2013). Guideline on the management of bleeding in patients on antithrombotic agents. British Journal of Haematology, 160, 35–46.

Matteucci, R., Schub, T., & Pravikoff, D. (2011). Shock, hypovolemic. CINAHL nursing guide. Nursing Reference Center.

Medline Plus. (2011). Ginger. MedLine Plus, 11. <http:// www.nlm.nih.gov/medlineplus/druginfo/natural/961.html>. Retrieved: November 11, 2011.

Metlay, J., et al. (2008). Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events. J Gen Intern Med, 23(10), 1589–1594.

Moore, E. E., Chin, T. L., Chapman, M. C., et al. (2014). Plasma first in the field for postinjury hemorrhagic shock. Shock (Augusta, Ga.), 41, 35–38.

National Institutes of Health (NIH) (2011). Clear communication: An NIH health literacy initiative. From: <http://www.nih.gov/ clearcommunication/plainlanguage.htm>. Retrieved August 3, 2012.

Needleman, J., et al. (2002). Nurse staffing and quality of care in hospitals in the United States. Policy Politics & Nursing Practice, 3, 306–308.

Nurit, P., et al. (2009). Evaluation of a nursing intervention project to promote patient medication education. Journal of Clinics in Nursing, 18, 2530–2536.

Nutescu, E. A., Wittkowsky, A. K., Burnett, A., et al. (2013). Delivery of optimized inpatient anticoagulation therapy: consensus statement from the anticoagulation forum. Annals of Pharmacotherapy, 47, 714–724.

Olaussen, A., Blackburn, T., Mitra, B., et al. (2014). Review article: shock index for prediction of critical bleeding post-trauma: a systematic review. Emergency Medicine Australasia, 26, 223–228.

Rahme, E., & Bernatsky, S. (2011). NSAIDs and risk of lower gastrointestinal bleeding. Lancet, 376, 7.

Russo, W. (2011). Laboratory monitoring of heparin therapy. UTMB Health, 11. Retrieved November 12, 2011, <http://www.utmb.edu/ lsg/hem/HEPARIN_THERAPY.htm>.

Shalansky, S., et al. (2007). Risk of warfarin-related bleeding events and supratherapeutic international normalized ratios associated with complementary and alternative medicine: a longitudinal analysis. Pharmacotherapy, 27, 1237–1247.

Siegal, D. M., & Crowther, M. A. (2013). Acute management of bleeding in patients on novel oral anticoagulants. European Heart Journal, 34, 489–498b.

Stiles, S. (2011). Clopidogrel-aspirin arm halted in SPS3 stroke trial. Heartwire, 10. Retrieved October 7, 2011, <http://www.medscape .com/viewarticle/751011_print>.

Urden, L., Stacy, K., & Lough, M. (2009). Thelan’s critical care nursing: diagnosis and management (ed. 6). Philadelphia, PA: Mosby.

Vandromme, M., et al. (2011). Prospective identification of patients at risk for massive transfusion: an imprecise endeavor. American Surgeon, 77, 155–161.

van Soest, E. M., Valkhoff, V. E., Mazzaglia, G., et al. (2012). Suboptimal gastroprotective coverage of NSAID use and the risk of upper gastrointestinal complications. Gastroenterology, 140, S–45.

Villanueva, C., Colomo, A., Bosch, A., et al. (2013). Transfusion strategies for acute upper gastrointestinal bleeding. New England Journal of Medicine, 368, 11–21.

Wu, H., et al. (2011). Pantoprazole for the prevention of gastrointestinal bleeding in high-risk patients with acute coronary syndromes. Journal of Critical Care, 26, 434.e1–434.e6.

Disturbed Body Image 167

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B Disturbed Body Image Gail B. Ladwig, MSN, RN, and Marsha McKenzie, MA Ed, BSN, RN

NANDA-I

Definition

Confusion in mental picture of one’s physical self

Defining Characteristics

Absence of body part; alteration in body function; alteration in body structure; alteration in view of one’s body (e.g., appearance, structure, function); avoids looking at one’s body; avoids touching one’s body; behav- ior of acknowledging one’s body; behavior of monitoring one’s body; change in ability to estimate spatial relationship of body to environment; change in lifestyle; change in social involvement; depersonalization of body part by use of impersonal pronouns; depersonalization of loss by use of impersonal pronouns; emphasis on remaining strengths; extension of body boundary (e.g., includes external object); fear of reaction by others; focus on past appearance; focus on past function; focus on previous strength; heightened achieve- ment; hiding of body part; negative feeling about body; nonverbal response to change in body (e.g., appear- ance, structure, function); nonverbal response to perceived change in body (e.g., appearance, structure, function); overexposure of body part; perceptions that reflect an altered view of one’s body appearance; personalization of body part by name; personalization of loss by name; preoccupation with change; preoc- cupation with loss; refusal to acknowledge change; trauma to nonfunctioning body part

Related Factors (r/t)

Alteration in body function (due to, for example, anomaly, disease, medication, pregnancy, radiation, surgery, trauma); alteration in cognitive functioning; alteration in self perception; cultural incongruence; develop- mental transition; illness; impaired psychosocial functioning; injury; spiritual incongruence; surgical proce- dure; trauma; treatment regimen

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Body Image; Self-Esteem; Acceptance Health Status: Coping, Identity

Example NOC Outcome with Indicators

Body Image as evidenced by the following indicators: Congruence between body reality, body ideal, and body presentation/ Satisfaction with body appearance/Adjustment to changes in physical appearance. (Rate the outcome and indicators of Body Image: 1 = never positive, 2 = rarely positive, 3 = sometimes positive, 4 = often positive, 5 = consistently positive [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Demonstrate adaptation to changes in physical appearance or body function as evidenced by adjustment to lifestyle change

• Identify and change irrational beliefs and expectations regarding body size or function • Recognize health-destructive behaviors and demonstrate willingness to adhere to treatments or methods

that will promote health • Verbalize congruence between body reality and body perception • Describe, touch, or observe affected body part • Demonstrate social involvement rather than avoidance and use adaptive coping and/or social skills • Use cognitive strategies or other coping skills to improve perception of body image and enhance

functioning • Use strategies to enhance appearance (e.g., wig, clothing)

168 Disturbed Body Image

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Body Image Enhancement; Eating Disorder Management; Referral; Self-Awareness Enhancement; Self- Esteem Enhancement; Support Group Weight Gain Assistance

Example NIC Activities—Body Image Enhancement

Determine client’s body image expectations based on developmental stage; Assist client to identify actions that will enhance appearance

Nursing Interventions and Rationales

• Incorporate psychosocial questions related to body image as part of nursing assessment to identify clients at risk for body image disturbance (e.g., body builders; cancer survivors; clients with eating disorders, burns, skin disorders, polycystic ovary disease; or those with stomas/ostomies/colostomies or other disfiguring conditions). CEB: Assessment of psychosocial issues can help identify clients at risk for body image concerns as a result of a disfiguring condition (Borwell, 2009). Nurses, caring for clients during their hospital stay, are in the ideal position to assess how they are emotionally adapting to having a disfigurement (Bowers, 2008).

▲ Discuss treatment options and outcomes for women diagnosed with breast cancer. Be prepared to explore options of lumpectomy vs. mastectomy and the potential for reconstructive surgery. Include cosmetic and appliance options available to mitigate effects of mastectomy and/or chemotherapy, such as wigs and customized mastectomy bras. EB: Disturbance of body image has a relationship to the extent of the surgical procedure and the perceived ability to mitigate these body alterations (Rosenberg et al, 2013).

• Discuss individual emphasis placed on body image before mastectomy. Be aware of increased psychoso- cial distress for women who maintain great emphasis on personal appearance. EB: A study of 46 women undergoing mastectomy found higher rates of depression and psychological distress in women with a history of high body maintenance and appearance ideals (Arroyo & Lopez, 2011).

▲ Assess for history of childhood maltreatment in clients suffering from body dissatisfaction, anorexia, or other eating disorders and make appropriate psychosocial referrals if indicated. EB: The results from this study indicate specific forms of childhood maltreatment (emotional and sexual abuse) are significantly associ- ated with body dissatisfaction, depressive symptoms, and eating disorders (Dunkley et al, 2010).

▲ Assess for body dysmorphic disorder (BDD) (pathological preoccupation with muscularity and leanness; occurs more often in males than in females), and refer to psychiatry or other appropriate provider. EB: BDD is a prevalent and disabling preoccupation with a slight or imagined defect in appearance. Results from the small number of available randomized controlled trials suggest that serotonin reuptake inhibitors and cognitive behavioral therapy (CBT) may be useful in treating clients with BDD (Ipser et al, 2009; Phillips, 2010).

▲ Determine if body image impairment is actual or perceived and extent to which it affects the social actions and behaviors through the use of assessment tools such as Assessment of the Attitudinal Component of Body Image in Children or the Measures of Body Satisfaction and Related Concepts in Adolescents and Adults. EB: Perceived defects or alterations in appearance do not necessarily reflect actual observed changes and psychosocial distress must be determined through individual assessment (Bolton et al, 2010).

• Assess for lipodystrophy (an abnormal redistribution of adipose tissue) in clients receiving antiretroviral therapy for HIV/AIDS. This condition is common and can be a source of distress to clients. EBN: Lipo- dystrophy is often an unavoidable side effect of antiretroviral therapy. Clients suffering from this syndrome are often ignored when expressing concerns about body changes. Nurses are uniquely qualified to assess these clients as well as provide education and psychosocial support (Gagnon & Holmes, 2011).

• Discuss expectations for weight loss and anticipated body changes with clients planning to undergo bariatric surgery for morbid obesity. Assist the client in identifying realistic goals. EB: Morbidly obese clients often set unrealistic goals for ideal body weight and appearance following bariatric surgery. Guidance is necessary to help them understand limitations of the surgery (Munoz et al, 2010).

Disturbed Body Image 169

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B ▲ Use cognitive-behavioral therapy (CBT) to assist the client to express his emotions and feelings. EBN:

This study of clients with bulimia used CBT and helped the clients to disentangle themselves regarding body image and weight (Huang & Hsieh, 2010).

• Provide education and support for clients receiving treatments or medications that have the potential to alter body image. Discuss alternatives if available. EBN: Men receiving androgen-deprivation therapy as a treatment for prostate cancer may be at greater risk for body image dissatisfaction (Harrington et al, 2009).

• Take cues from clients regarding their readiness to look at a wound (ask if the client has seen the wound yet) and use clients’ questions or comments as way to teach about wound care and healing. CEB: Tailoring interventions to individual clients and reading their nonverbal cues likely contribute to their ability to heal emotionally from impact of wound on body image (Birdsall & Weinberg, 2001).

▲ Encourage clients to participate in regular aerobic and/or nonaerobic exercise when feasible. CEB: Par- ticipants of this study demonstrated higher levels of body satisfaction following the very first exercise session (Vocks et al, 2009).

▲ Provide client with a list of appropriate community support groups (e.g., Reach to Recovery, Ostomy Association). EB: This study of three different cancer groups (a group for women with metastatic cancer, a colorectal cancer support group, and a group for Chinese cancer clients) showed their perceived benefits were similar; the groups provided information, acceptance, and understanding (Bell et al, 2010).

Pediatric

Many of the above interventions are appropriate for the pediatric client. ▲ Refer parents of children with eating disorders to a support group. EB: Parents indicated that support

groups assisted them in understanding eating disorder symptoms and treatment and in supporting their child struggling with an eating disorder. Additionally, the group was a source of emotional support. Results suggest that inclusion of a parent support group in the outpatient treatment of children and adolescents with eating disorders has important implications for parents (Pasold et al, 2010).

▲ When caring for teenagers, be aware of the impact of acne vulgaris on quality of life. The impact was proportional to the severity of acne. Assess for symptoms of social withdrawal, limited eye contact, and expressions of low self-esteem. Educate teens on skin care and hygiene, and assist with referrals to a dermatologist when needed. EB: Research performed by Tasoula et al (2012) showed that feelings of unworthiness attributable to negative appraisal by peers were present in half of subjects with acne in their study.

▲ Refer families of children with severe facial burns for psychosocial support. EB: Severe facial burn influences health-related quality of life in children. Additional psychosocial support is suggested to enhance recovery for clients with severe face burns and their families during the years following injury (Stubbs et al, 2011).

▲ Assess family dynamics and refer parents of adolescents with anorexia or other eating disorders to profes- sional family counseling if indicated. EB: This study indicated that when adolescents’ basic psychological needs are met, they are less likely to worry about the adequacy of body appearance and engage in unhealthy weight control behaviors. Parenting practices such as lack of emotional support or demanding conformity have negative impacts on adolescents suffering from eating disorders (Thøgersen-Ntoumani et al, 2010).

Geriatric

• Focus on remaining abilities. Have client make a list of strengths. CEB: Results from unstructured inter- views with women aged 61 to 92 years regarding their perceptions and feelings about their aging bodies suggest that women exhibit the internalization of ageist beauty norms, even as they assert that health is more important to them than physical attractiveness and comment on the “naturalness” of the aging process (Hurd, 2000).

• Encourage regular exercise for older adults. EB: Research done by Mortensen et al (2012) supports the importance of physical activity to preserve functioning in older adults.

Multicultural

• Assess for the influence of cultural beliefs, regional norms, and values on the client’s body image. EB: A study of young adults living in Hawaii and Australia demonstrated a tolerance for body sizes that are sig- nificantly larger than the body mass index size considered healthy (Knight et al, 2010). EBN: Each client

170 Disturbed Body Image

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B should be assessed for body image based on the phenomenon of communication, time, space, social organiza- tion, environmental control, and biological variations (Giger & Davidhizar, 2008). EB: A study of Muslim women found that the strength of their religious faith was inversely related to body dissatisfaction (Mussap, 2009).

• Acknowledge that body image disturbances can affect all individuals regardless of culture, race, or ethnic- ity. EB: Results in this study suggest that gender and cultural differences in body image among adolescents are significant (Ceballos & Czyzewska, 2010). Body image disorders are becoming increasingly prevalent in developing non-Western countries such as China (Xu et al, 2010).

Home Care

• The above interventions may be adapted for home care use. • Assess client’s level of social support. Social support is one of the determinants of the client’s recovery

and emotional health. CEB: Females who perceived they have good social support were found to adapt better to changes in body image after stoma surgery (Brown & Randle, 2005).

• Assess family/caregiver level of acceptance of client’s body changes. CEB: Family members’ expressions and reactions were found to impact women’s coping, and negative reactions in particular increased the women’s level of anxiety (Brown & Randle, 2005).

• Encourage clients to discuss concerns related to sexuality and provide support or information as indi- cated. Many conditions that affect body image also affect sexuality. CEB: Brown & Randle (2005) found that clients (particularly females) with stomas often believe they are less sexually attractive after surgery, even though their sexual partner may not share that view. However, clients who underwent urostomy surgery often experienced a decrease in sexual functioning.

• Teach all aspects of care. Involve clients and caregivers in self-care as soon as possible. Do this in stages if clients still have difficulty looking at or touching changed body part. EB: Prostate cancer clients need interventions that assist them to manage the effects of their disease. Programs need to include spouses because they also are negatively affected by the disease and can influence client outcomes (Kershaw et al, 2008).

Client/Family Teaching and Discharge Planning

• Teach appropriate care of surgical site (e.g., mastectomy site, amputation site, ostomy site). CEB: Integra- tion of a cosmetic program into the routine nursing care for oral cancer clients is highly recommended. This study confirmed that cosmetic rehabilitation had positive effects on the body image of oral cancer clients (Huang & Liu, 2008).

• Encourage significant others to offer support. CEB: Clients with heart failure in this study managed depres- sive symptoms that affect health-related quality of life by engaging in activities such as exercise and reading, and by using positive thinking, spirituality, and social support. Helping clients find enhanced social support is important (Dekker et al, 2009).

▲ Refer clients who are having difficulty with personal acceptance, personal and social body image disrup- tion, sexual concerns, reduced self-care skills, and management of surgical complications to an interdis- ciplinary team or specialist (e.g., ostomy nurse) if available. CEB: There is sufficient research-based evidence to conclude that intestinal ostomy surgery exerts a clinically relevant impact on health-related quality of life and that nursing interventions can ameliorate this effect (Pittman et al, 2009).

REFERENCES Arroyo, J. M. G., & López, M. L. D. (2011). Psychological

problems derived from mastectomy: a qualitative study. International Journal of Surgical Oncology, 2011, 132461.

Bell, K., et al. (2010). Is there an “ideal cancer” support group? Key findings from a qualitative study of three groups. Journal of Psychosocial Oncology, 28(4), 432–449.

Birdsall, C., & Weinberg, K. (2001). Adult clients looking at their burn injuries for the first time. The Journal of Burn Care and Rehabilitation, 22(5), 360–364.

Bolton, M. A., Lobben, I., & Stern, T. A. (2010). The impact of body image on patient care. Primary Care Companion to the Journal of Clinical Psychiatry, 12(2), PCC.10r00947.

Borwell, B. (2009). Rehabilitation and stoma care: addressing the psychological needs. British Journal of Nursing (Mark Allen Publishing), 18(4), S20-2–S24-5.

Bowers, B. (2008). Providing effective support for patients facing disfiguring surgery. British Journal of Nursing (Mark Allen Publishing), 17(2), 94–98.

Brown, H., & Randle, J. (2005). Living with a stoma: a review of the literature. Journal of Clinical Nursing, 14(1), 74–81.

Ceballos, N., & Czyzewska, M. (2010). Body image in Hispanic/ Latino vs. European American adolescents: implications for treatment and prevention of obesity in underserved populations. Journal of Health Care for the Poor and Underserved, 21(3), 823–838.

Insufficient Breast Milk 171

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B

Insufficient Breast Milk Kerstin West-Wilson, RNC, IBCLC, and David Wilson, MS, RNC

NANDA-I

Definition

Low production of maternal breast milk

Defining Characteristics Infant

Constipation; frequent crying; frequently seeks to suckle at breast; prolonged breastfeeding time; suckling time at breast appears unsatisfactory; voids small amounts of concentrated urine; weight gain less than 500 g in a month

Mother

Absence of milk production with nipple stimulation; delay in milk production; expresses breast milk less than prescribed volume

Related Factors Infant

Ineffective latching on to breast; ineffective sucking reflex; insufficient opportunity for suckling at the breast; insufficient suckling time at breast; rejection of breast

Dekker, R. L., et al. (2009). Living with depressive symptoms: patients with heart failure. American Journal of Critical Care, 18(4), 310–318.

Dunkley, D. M., Masheb, R. M., & Grilo, C. M. (2010). Childhood maltreatment, depressive symptoms, body dissatisfaction in patients with binge eating disorder: the mediating role of self-criticism. The International Journal of Eating Disorders, 43(3), 274–281.

Gagnon, M., & Holmes, D. (2011). Bodies in mutation: understanding lipodystrophy among women living with HIV/AIDS. Research and Theory for Nursing Practice, 25(1), 23–39.

Giger, J., & Davidhizar, R. (2008). Transcultural nursing: assessment and intervention (ed. 4). St Louis: Mosby.

Harrington, J. M., Jones, E. G., & Badger, T. (2009). Body image perceptions in men with prostate cancer. Oncology Nursing Forum, 36(2), 167–172.

Huang, C., & Hsieh, C. (2010). Treating bulimia nervosa: a nurse’s experience using cognitive behavior therapy [Chinese]. Hu Li Za Zhi the Journal of Nursing, 57(Suppl. 2), 29–34.

Huang, S., & Liu, H. E. (2008). Effectiveness of cosmetic rehabilitation on the body image of oral cancer patients in Taiwan. Supportive Care in Cancer, 16(9), 981–986.

Hurd, L. C. (2000). Older women’s body image and embodied experience: an exploration. Journal of Women and Aging, 12(3–4), 77–97.

Ipser, J. C., Sander, C., & Stein, D. J. (2009). Pharmacotherapy and psychotherapy for body dysmorphic disorder. Cochrane Database of Systematic Reviews, (1), CD005332.

Kershaw, T. S., et al. (2008). Longitudinal analysis of a model to predict quality of life in prostate cancer patients and their spouses. Annals of Behavioral Medicine: A Publication of the Society of Behavioral Medicine, 36(2), 117–128.

Knight, T., Latner, J. D., & Illingworth, D. (2010). Tolerance of larger body sizes by young adults living in Australia and Hawaii. Eating Disorders, 18, 425–434.

Mortensen, S. P., Nyberg, M., Winding, K., et al. (2012). Lifelong physical activity preserves functional sympatholysis and purinergic signalling in the ageing human leg. The Journal of Physiology, 590(Pt. 23), 6227–6236.

Munoz, D., et al. (2010). Changes in desired body shape after bariatric surgery. Eating Disorders, 18, 347–354.

Mussap, A. J. (2009). Strength of faith and body image in Muslim and non-Muslim women. Mental Health, Religion & Culture, 12(2), 121–127.

Pasold, T. L., Boateng, B. A., & Portilla, M. G. (2010). The use of a parent support group in the outpatient treatment of children and adolescents with eating disorders. Eating Disorders, 18(4), 318–332.

Phillips, K. A. (2010). Body dysmorphic disorder. Dialogues in Clinical Neuroscience, 12(2), 221–232.

Pittman, J., Kozell, K., & Gray, M. (2009). Should WOC nurses measure health-related quality of life in patients undergoing intestinal ostomy surgery? Journal of Wound, Ostomy, and Continence Nursing, 36(3), 254–265.

Rosenberg, S. M., Tamimi, R. M., Gelber, S., et al. (2013). Body image in recently diagnosed young women with early breast cancer. Psycho-Oncology, 22(8), 1849–1855.

Stubbs, T. K., et al. (2011). Psychosocial impact of childhood face burns: a multicenter, prospective, longitudinal study of 390 children and adolescents. Burns: Journal of the International Society for Burn Injuries, 37(3), 387–394.

Tasoula, E., Gregoriou, S., Chalikias, J., et al. (2012). The impact of acne vulgaris on quality of life and psychic health in young adolescents in Greece. Results of a population survey. Anais Brasileiros de Dermatologia, 87(6), 862–869.

Thøgersen-Ntoumani, C., Ntoumanis, N., & Mikitaras, N. (2010). Unhealthy weight control behaviors in adolescent girls: a process model based on self-determination theory. Psychology and Health, 25(5), 535–550.

Vocks, S., et al. (2009). Effects of a physical exercise session on state body image: the influence of pre-experimental body dissatisfaction and concerns about weight and shape. Psychology and Health, 24(6), 713–729.

Xu, X., et al. (2010). Body dissatisfaction, engagement in body change behaviors and sociocultural influences on body image among Chinese adolescents. Body Image, 7(2), 156–164.

172 Insufficient Breast Milk

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B Mother

Alcohol consumption; insufficient fluid volume; malnutrition; pregnancy; smoking; treatment regimen

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Breastfeeding Establishment: Infant, Maternal; Breastfeeding Maintenance; Anxiety Self-control; Parent- Infant Attachment

Example NOC Outcome with Indicators

Breastfeeding Establishment: as evidenced by the following indicators: Proper alignment/latch on/areolar compression/ suck reflex/Nursing minimum of 15 minutes per breast/Urinations and stools appropriate for age/Weight gain appropriated for age. (Rate the outcome and indicators of Breastfeeding Establishment: 1 = not adequate, 2 = slightly adequate, 3 = moderately adequate, 4 = substantially adequate, 5 = totally adequate [see Section I].)

Example NIC Activities—Lactation Counseling

Correct misconceptions, misinformation, and inaccuracies about breastfeeding; Provide educational material, as needed; Encourage attendance at breastfeeding classes and support groups for “perceived insufficient milk supply” (Gatti, 2008).

Client Outcomes Client Will (Specify Time Frame)

• State knowledge of indicators of adequate milk supply • State and demonstrate measures to ensure adequate milk supply

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Lactation Counseling; Lactation Suppression; Kangaroo Care; Parent Education: Infant

Nursing Interventions and Rationales

• Provide lactation support at all phases of lactation (Neifert & Bunick, 2013; Nielsen et al, 2011). • Communicate routine advice to mothers without making them feel pressured or guilty and nurses should be

aware of “how” they give routine instructions (Flaherman et al, 2012). • Initiate skin-to-skin contact at birth and undisturbed contact for the first hour following birth; the mother

should be encouraged to watch the baby, not the clock. These behaviors are associated with an abundant milk supply (Noonan, 2011; Parker et al, 2013).

• Encourage postpartum women to start breastfeeding based on infant need as early as possible and reduce formula use to increase breastfeeding frequency. Use nonnarcotic analgesics as early as possible. EBN: These interventions are suggested to decrease early weaning in this study of women who had cesarean deliv- eries and perceived insufficient milk supply (Lin et al, 2011; Chantry, 2014; Gatti, 2008; Kent et al, 2013; Lou et al, 2014; Nielsen et al, 2011).

• Provide suggestions for mothers on how to increase milk production and how to determine whether there is insufficient milk supply. EBN: Teach mothers how to determine low intake of breast milk by check- ing baby’s wet diapers (fewer than 6 to 8) and monitoring the frequency and amount of baby’s bowel move- ments. Provide suggestions to women on how to increase milk production, such as improving latch-on, increasing frequency of feedings, offering both breasts during each breastfeeding session, and drinking enough fluids (Yen-Ju & McGrath, 2011; Gatti, 2008; Ndikom et al, 2014).

• Instruct mothers that breastfeeding frequency, sucking times, and amounts are variable and normal. Assist mothers in optimal milk removal frequency. EBN: Breastfeeding rates may be affected by a maternal perception of insufficient milk production and less than optimal milk removal frequency (Kent et al, 2012; Kent et al, 2013).

Insufficient Breast Milk 173

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B ▲ Consider the use of medication for mothers of preterm infants with insufficient expressed breast milk.

EBN: Breast milk remains the optimal form of enteral nutrition for term and preterm infants until up to 6 months postnatal age. In these studies there was modest improvement in expressing breast milk (EBM) values with the use of a galactogogue medication (Donovan & Buchanan, 2012).

▲ Need to be more cautious with recommending galactagogues. ▲ Not in the scope of practice for IBLC lactation consultants to recommend galactagogues (Academy of Breast-

feeding Medicine Protocol Committee, 2011; Donovan & Buchanan, 2012).

Pediatric

• Provide individualized follow-up with extra home visits or outpatient visits for teen mothers within the first few days after hospital discharge and encourage schools to be more compatible with breastfeeding. Adolescent mothers in the United States are much less likely to imitate breastfeeding than older mothers. This study indicated that these interventions may be helpful for teens who desire to breastfeed (Tucker et al, 2011).

Multicultural

• Provide information and support to mothers on benefits of breastfeeding at antenatal visits. EB: A study of mothers of infants in Bhaktapur, Nepal, found that, although proper breastfeeding is the most cost- effective intervention for reducing childhood morbidity and mortality, adherence to breastfeeding recom- mendations in developing countries is not satisfactory. Although many mothers instituted breastfeeding within 1 hour of delivery, continuation for up to 6 months was not common. Very few mothers received any information on breastfeeding during the antenatal visit (Ulak et al, 2012; Neifert & Bunik, 2013; Sultana et al, 2013).

• Refer to care plans Interrupted Breastfeeding and Readiness for enhanced Breastfeeding for additional interventions.

REFERENCES Academy of Breastfeeding Medicine Protocol Committee, ABM

Clinical Protocol #9. (2011). Use of galactagogues in initiating or augmenting the rate of maternal milk secretion (First Revision January 2011). Breastfeeding Medicine, 6(1), 41–49.

Chantry, C. J. (2014). In-hospital formula use increases early breastfeeding cessation among first-time mothers intending to exclusively breastfeed. Journal of Pediatrics, 164(6), 1339–1348.

Donovan, T. J., & Buchanan, K. (2012). Medications for increasing milk supply in mothers expressing breastmilk for their preterm hospitalised infants. Cochrane Database of Systematic Reviews, (3), CD005544.

Flaherman, V. J., et al. (2012). Maternal experience of interactions with providers among mothers with milk supply concern. Clinical Pediatrics, 51(8), 778–784.

Gatti, L. (2008). Maternal perceptions of insufficient milk supply in breastfeeding. Journal of Nursing Scholarship, 40(4), 355–363.

Kent, J., Prime, D., & Garbin, C. (2012). Principles for maintaining or increasing breast milk production. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 41(1), 114–121.

Kent, J. C., et al. (2013). Longitudinal changes in breastfeeding patterns from 1 to 6 months of lactation. Breastfeeding Medicine, 8(4), 401–407.

Lin, S. Y., et al. (2011). Factors related to milk supply perception in women who underwent cesarean section. The Journal of Nursing Research, 19(2), 94–101.

Lou, Z., et al. (2014). Maternal reported indicators and causes of insufficient milk supply. Journal of Human Lactation, (on line publication).

Ndikom, C. M., et al. (2014). Extra fluids for breastfeeding mothers for increasing milk production. Cochrane Database of Systematic Reviews, (6).

Neifert, M., & Bunik, M. (2013). Overcoming clinical barriers to exclusive breastfeeding. Pediatric Clinics of North America, 60, 115–145.

Nielsen, S., et al. (2011). Adequacy of milk intake during exclusive breastfeeding: a longitudinal study. Pediatrics, 128(4), 907–914.

Noonan, M. (2011). Breastfeeding: is my baby getting enough milk? British Journal of Midwifery, 19(2), 82–89.

Parker, L. A., et al. (2013). Strategies for increased milk volume in mothers of VLBW infants. The American Journal of Maternal Child Nursing, 38(6), 385–390.

Sultana, A., et al. (2013). Clinical update and treatment of lactation insufficiency. Medical Journal of Islamic World Academy of Sciences, 21(1), 19–28.

Tucker, C. M., Wilson, E. K., & Samandari, G. (2011). Infant feeding experiences among teen mothers in North Carolina: findings from a mixed-methods study. International Breastfeeding Journal, 6, 14.

Ulak, M., et al. (2012). Infant feeding practices in Bhaktapur, Nepal: a cross-sectional, health facility based survey. International Breastfeeding Journal, 7(1), 1–8.

Yen-Ju, H., & McGrath, J. (2011). Predicting breastfeeding duration related to maternal attitudes in a Taiwanese sample. The Journal of Perinatal Education: An ASPO, 20(4), 188–199.

174 Ineffective Breastfeeding

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B Ineffective Breastfeeding Barbara J. Wheeler, RN, BN, MN, IBCLC

NANDA-I

Definition

Difficulty providing milk to an infant or young child directly from the breasts, which may compromise nutritional status of the infant/child

Defining Characteristics

Inadequate infant stooling; infant arching at breast; infant crying at breast; infant crying within first hour after breastfeeding; infant fussing within 1 hour of breastfeeding; infant inability to latch on to maternal breast correctly; infant resisting latching on to breast; infant unresponsive to other comfort measures; insuf- ficient infant weight gain; insufficient emptying of each breast per feeding; insufficient signs of oxytocin release; perceived inadequate milk supply; sore nipples persisting beyond first week; sustained infant weight loss; unsustained suckling at the breast

Related Factors (r/t)

Delayed lactogenesis II; inadequate milk supply; insufficient family support; insufficient opportunity for suckling at breast; insufficient parental knowledge regarding breastfeeding techniques; insufficient parental knowledge regarding importance of breastfeeding; interrupted breastfeeding ; maternal ambivalence; mater- nal anxiety; maternal breast anomaly; maternal fatigue; maternal obesity; maternal pain; oropharyngeal defect; pacifier use; poor infant sucking reflex; prematurity; previous breast surgery; previous history of breastfeeding failure; short maternity leave; supplemental feedings with artificial nipple

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes and Example

Refer to care plan for Readiness for enhanced Breastfeeding.

Client Outcomes Client Will (Specify Time Frame)

• Achieve effective breastfeeding (dyad) • Verbalize/demonstrate techniques to manage breastfeeding problems (mother) • Manifest signs of adequate intake at the breast (infant) • Manifest positive self-esteem in relation to the infant feeding process (mother) • Explain alternative method of infant feeding if unable to continue exclusive breastfeeding

(mother)

NIC (Nursing Interventions Classification)

Suggested NIC Interventions and Example

Refer to care plan Readiness for enhanced Breastfeeding.

Nursing Interventions and Rationales

• Identify women with risk factors for lower breastfeeding initiation and continuation rates (lack of infor- mation, inadequate family and social support) as well as factors contributing to ineffective breastfeeding as early as possible in the perinatal experience. EBN: Nurses are well positioned to provide accurate infor- mation and support the development of breastfeeding skills, which facilitates breastfeeding confidence and success (Neifert & Bunik, 2013).

• Provide time for clients to express expectations and concerns, and provide emotional support as needed. EBN: Lactation consultants, nurses, and peers play a key role in the establishment and continuation of breastfeeding (Neifert & Bunik, 2013).

• Encourage skin-to-skin holding, beginning immediately after delivery. EB: Skin-to-skin holding is associ- ated with improved milk supply, early initiation of breastfeeding, and improved breastfeeding duration (Moore et al, 2012).

Ineffective Breastfeeding 175

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B • Use valid and reliable tools to measure breastfeeding performance and to predict early discontinuance of

breastfeeding whenever possible/feasible. CEB: Ho and McGrath (2010) compared and contrasted the clinical usefulness and psychometric properties of seven self-report instruments and found that they each contribute to our understanding of breastfeeding in various ways. The Breastfeeding Self-Efficacy Scale has demonstrated an ability to predict breastfeeding success or failure, thus providing opportunity for focused education and support for mothers who need it (Dennis, 2003).

• Promote comfort and relaxation to reduce pain and anxiety. CEB: Discomfort and increased tension are factors associated with reduced let-down reflex and premature discontinuance of breastfeeding. Anxiety and fear are associated with decreased milk production (Mezzacappa & Katkin, 2002).

• Avoid supplemental feedings. EB: A correlation exists between hospital staff providing formula and/or water supplements and failure to succeed with exclusive breastfeeding (Kaikini & Hyrkas, 2014).

• Teach mother to observe for infant behavioral cues and responses to breastfeeding. EBN: Monitor and assess the mom and baby for several breastfeeding sessions. Teaching mother will build her confidence and knowledge base, which facilitates successful breastfeeding (Noonan, 2011).

▲ Provide necessary equipment/instruction/assistance for milk expression as needed. EBN: Expressing breast milk by hand may be more effective in the removal of milk, particularly in the immediate postpartum period, than the use of electric pumps (Flaherman et al, 2012).

▲ Provide referrals and resources: lactation consultants, nurse and peer support programs, community organizations, and written and electronic sources of information. EBN: Systematic reviews support the use of professionals with special skills in breastfeeding, peer support programs, and written and electronic information to promote continued breastfeeding (Neifert & Bunik, 2013).

• See care plan for Readiness for enhanced Breastfeeding. Multicultural

• Assess whether the client’s cultural beliefs about breastfeeding are contributing to ineffective breastfeed- ing. CEB: Some cultures may add semisolid food within the first month of life as a result of concerns that the infant is not getting enough to eat and the perception that “big is healthy” (Higgins, 2000). EBN: Some traditional cultures, including the Turkish, consider colostrum unsuitable to feed the newborn, thus formula may be required to prevent hypoglycemia and dehydration (Demirtas, 2012).

• Assess the influence of family support on the decision to continue or discontinue breastfeeding. EB: Family members’ impressions and ideas about breastfeeding influence breastfeeding initiation and duration (Odom et al, 2014).

• Provide traditional ethnic foods for breastfeeding mothers. CEB: One barrier to breastfeeding is a lack of hospital foods that allow women to follow a traditional diet postpartum. After a staff training program on breastfeeding, and the creation of a Cambodian menu, initiation rates increased significantly more in Cam- bodians than in non-Cambodians. Postintervention, there was no significant difference between breastfeed- ing initiation rates among Cambodian women (66.7%) compared with non-Cambodians (68.9%) (Galvin et al, 2008).

• See care plan for Readiness for enhanced Breastfeeding. Home Care

• The above interventions may be adapted for home care use. • Provide anticipatory guidance in relation to home management of breastfeeding. EB: The two most

common problems experienced by breastfeeding women are nipple and/or breast pain and low (or perceived low) milk supply; these problems may be preventable with anticipatory guidance (Amir, 2014). For mothers returning to the workforce, longer maternity leaves and regularly pumping milk during the workday are associated with longer breastfeeding duration (Neifert & Bunik, 2013).

▲ Investigate availability of and refer to public health department, hospital home follow-up breastfeeding program, or other postdischarge support. EBN: Postdischarge follow-up has been associated with improved breastfeeding duration (Mejdoubi et al, 2014).

• See care plan for Risk for impaired Attachment. Client/Family Teaching and Discharge Planning

• Instruct the client on maternal breastfeeding behaviors/techniques (preparation for, positioning, initiation of/promoting latch-on, burping, completion of session, and frequency of feeding). Consider use of a video. EBN: Assess breastfeeding mothers to determine knowledge deficits and provide teaching.

176 Interrupted Breastfeeding

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B Assisting with breastfeeding and addressing the mother’s concerns facilitate breastfeeding success (Neifert & Bunik, 2013).

• Teach the client self-care measures for the breastfeeding woman (e.g., breast care, management of breast/ nipple discomfort, nutrition/fluid, rest/activity). CEB: Painful nipples, mastitis, adequate hydration, and fatigue are some of the problems a breastfeeding woman may experience (Ladewig et al, 2010).

• Provide information regarding infant cues and behaviors related to breastfeeding and appropriate mater- nal responses (e.g., cues that the infant is ready to feed, behaviors during feeding that contribute to effective breastfeeding, measures of infant feeding adequacy). Improved knowledge base and ongoing support to learn psychomotor skills facilitates effective breastfeeding (Neifert & Bunik, 2013).

• Provide education to partner/family/significant others as needed. EBN/EB: Family members’ impressions and ideas about breastfeeding influence breastfeeding initiation and duration (Odom et al, 2014).

REFERENCES See Readiness for enhanced Breastfeeding for additional references. Amir, L. H. (2014). Managing common breastfeeding problems in the

community. British Medical Journal, 348, g2954. Demirtas, B. (2012). Strategies to support breastfeeding: a review.

International Nursing Review, 59, 474–481. Dennis, C. L. (2003). The breastfeeding self-efficacy scale: psychometric

assessment of the short form. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 32(6), 734–744.

Flaherman, V. J., Gay, B., Scott, C., et al. (2012). Randomised trial comparing hand expression with breast pumping for mothers of term newborns feeding poorly. Archives of Disease in Childhood. Fetal and Neonatal Edition, 97, F19–F23.

Galvin, S., et al. (2008). A practical intervention to increase breastfeeding initiation among Cambodian women in the U.S. Maternal and Child Health Journal, 12(4), 545–547.

Higgins, B. (2000). Puerto Rican cultural beliefs: influence on infant feeding practices in western New York. Journal of Transcultural Nursing, 11(1), 19–30.

Ho, Y. J., & McGrath, J. M. (2010). A review of the psychometric properties of breastfeeding assessment tools. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 39(4), 386–400.

Kaikini, K. L., & Hyrkas, K. (2014). Mothers’ intention to breastfeed and hospital practices on breastfeeding: a longitudinal study at 6 months after birth on predictors of breastfeeding in a cohort of mothers from a large northern New England Medical Centre. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 43, S78.

Ladewig, A. P., London, M. L., & Davidson, M. R. (2010). Breastfeeding nutrition and newborn nutrition. In M. Davidson, M. London, & P. Ladewig (Eds.), Contemporary maternal-newborn nursing care (ed. 7). Upper Saddle River, NJ: Pearson.

Mejdoubi, J., van den Heijkant, S. C. C. M., van Leerdam, F. J. M., et al. (2014). Effects of nurse home visitation on cigarette smoking, pregnancy outcomes, and breastfeeding: a randomized controlled trial. Midwifery, 30, 688–695.

Mezzacappa, E. S., & Katkin, E. S. (2002). Breast-feeding is associated with reduced perceived stress and negative mood in mothers. Health Psychology, 21(2), 187–193.

Moore, E. R., Anderson, G. C., Bergman, N., et al. (2012). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Systematic Reviews, (5), CD003519.

Neifert, M., & Bunik, M. (2013). Overcoming clinical barriers to exclusive breastfeeding. Pediatric Clinics of North America, 60, 115–145.

Noonan, M. (2011). Breastfeeding: Is my baby getting enough milk? British Journal of Midwifery, 19(2), 82–89.

Odom, E. C., Li, R., Scanlong, K. S., et al. (2014). Association of family and health care provider opinion on infant feeding with mother’s breastfeeding decision. Journal of the Academy of Nutrition and Dietetics, 114(8), 1203–1207.

Interrupted Breastfeeding Barbara J. Wheeler, RN, BN, MN, IBCLC

NANDA-I

Definition

Break in the continuity of providing milk to an infant or young child directly from the breasts, which may compromise breastfeeding success and/or nutritional status of the infant/child.

Defining Characteristics

Nonexclusive breastfeeding

Related Factors (r/t)

Contraindications to breastfeeding (e.g., pharmaceutical agents); hospitalization of child; infant illness; maternal employment; maternal illness; maternal infant separation; need to abruptly wean infant; prematurity

Interrupted Breastfeeding 177

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Breastfeeding Maintenance; Knowledge: Breastfeeding; Parent-Infant Attachment

Example NOC Outcome with Indicators

Breastfeeding Maintenance as evidenced by the following indicators: Infant’s growth and development in normal range/Ability to safely collect and store breast milk/Awareness that breastfeeding can continue beyond infancy/Knowledge of benefits from continued breastfeeding. (Rate the outcome and indicators of Breastfeeding Maintenance: Infant: 1 = not adequate, 2 = slightly adequate, 3 = moderately adequate, 4 = substantially adequate, 5 = totally adequate [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

Infant

• Receive mother’s breast milk if not contraindicated by maternal conditions (e.g., certain drugs, infections) or infant conditions (e.g., galactosemia)

Maternal

• Maintain lactation • Achieve effective breastfeeding or satisfaction with the breastfeeding experience • Demonstrate effective methods of breast milk collection and storage

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Bottle Feeding; Emotional Support; Lactation Counseling

Example NIC Activities—Lactation Counseling

Instruct patient to contact lactation consultant to assist in determining status of milk supply (i.e., whether insufficiency is perceived or actual); Encourage employers to provide opportunities for and private facilities for lactating mothers to pump and store breast milk during the work day

Nursing Interventions and Rationales

• Discuss and provide support for mother’s desire/intention to begin or resume breastfeeding. EB: Mothers who perceived that care providers favored exclusive breastfeeding achieved significantly higher rates of exclu- sive breastfeeding at 1 and 3 months, as compared with those who perceived care providers were neutral about the method of infant feeding (Ramakrishnan et al, 2014). EBN: Breastfeeding rates are improved when hospitals have written breastfeeding policies and when staff has enhanced education regarding breastfeeding knowledge, attitudes, and skills (Li et al, 2014).

• Clarify that interruption in breastfeeding is truly necessary. (Expert recommendation): Mothers are sometimes inappropriately advised to discontinue breastfeeding (Sachs & AAP Committee on Drugs, 2013). When there is a question of possible contraindication to breastfeeding, a discussion of potential risks versus probable, known benefits of breastfeeding must be held with mother and family (Lawrence, 2013).

• Provide anticipatory guidance to the mother/family regarding potential duration of the interruption when possible/feasible. Reassure mother/family that measures to sustain or restart lactation and promote parent-infant attachment can make it possible to resume breastfeeding when the condition/ situation requiring interruption is resolved. EB: Mothers who had never breastfed, and those who had stopped, were successful in establishing or reestablishing breastfeeding with the help of lactation support (Nyati et al, 2014).

• Reassure the mother/family that the infant will benefit from any amount of breast milk provided. EBN: One of the most common reasons mothers supplement or stop breastfeeding is their perception of the baby not getting milk and/or enough milk (Noonan, 2011).

178 Interrupted Breastfeeding

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B • Assess mother’s concerns, and observe mother performing psychomotor skills (expression, storage, alter-

native feeding, skin to skin care, and/or breastfeeding) and assist as needed. EBN: Individualized support and instruction improves likelihood of breastfeeding success (Demirtas, 2012).

• Collaborate with mother/family/health care providers (as needed) to develop a plan for skin-to-skin contact. EBN: Skin-to-skin contact between mothers and newborns results in improved rates of exclusive breastfeeding (Brown et al, 2014).

• Collaborate with the mother/family/health care provider/employer (as needed) to develop a plan for expression/pumping of breast milk and/or infant feeding. EB: Workplaces whose environments include supervisor or peer support, space (not in the bathroom) in which to pump, a fridge, rental pump, and on-site daycare were associated with improved duration of exclusive breastfeeding (Bai & Wunderlich, 2013).

• Monitor for signs indicating infant’s ability to breastfeed and interest in breastfeeding. EBN: Teach the mother to recognize and respond to her baby’s feeding cues and signs that her breasts are filling (Noonan, 2011).

▲ Use supplementation only as medically indicated. EBN: A correlation exists between hospital staff providing formula and/or water supplements and failure to succeed with breastfeeding (Kaikini & Hyrkas, 2014).

• Provide anticipatory guidance for common problems associated with interrupted breastfeeding (e.g., incomplete emptying of milk glands, diminishing milk supply, infant difficulty with resuming breastfeed- ing, or infant refusal of alternative feeding method). EBN: Emotional support, as well as information regarding how to prevent and respond to breastfeeding problems, contributes to promotion of exclusive breastfeeding (Neifert & Bunik, 2013).

▲ Initiate follow-up and make appropriate referrals. • Assist the client to accept and learn an alternative method of infant feeding if effective breastfeeding is

not achieved. CEB: If it is clear that breastfeeding cannot be achieved after the interruption and an alterna- tive feeding method must be instituted, the mother needs support and education (Mozingo et al, 2000).

• See care plans for Readiness for enhanced Breastfeeding and Ineffective Breastfeeding. Multicultural

• Teach culturally appropriate techniques for maintaining lactation. CEB: The Oketani method of breast massage is used by Japanese and other Asian women. Oketani breast massage improved quality of human milk by increasing total solids, lipids, casein concentration, and gross energy (Foda et al, 2004). Some tra- ditional cultures, including the Turkish, consider colostrum unsuitable to feed the newborn, thus formula may be required to prevent hypoglycemia and dehydration (Demirtas, 2012).

• See care plans for Readiness for enhanced Breastfeeding and Ineffective Breastfeeding. Home Care

• The above interventions may be adapted for home care use. Client/Family Teaching and Discharge Planning

• Teach mother effective methods to express breast milk. EBN: Expressing breast milk by hand may be more effective in the removal of milk, particularly in the immediate postpartum period, than the use of electric pumps (Flaherman et al, 2012).

• Teach mother/parents about skin-to-skin care. EBN: Skin-to-skin care promotes attachment, facilitates improved milk production, and contributes to improved rate and duration of breastfeeding (Brown et al, 2014).

• Instruct mother on safe breast milk handling techniques. EB: Breastfeeding mothers can retain the high quality of breast milk and the health of their infant by using safe preparation guidelines and storage methods (CDC, 2014).

• See care plans for Readiness for enhanced Breastfeeding and Ineffective Breastfeeding.

REFERENCES See readiness for enhanced Breastfeeding for additional references. Bai, Y., & Wunderlich, S. M. (2013). Lactation accommodation in the

workplace and duration of exclusive breastfeeding. Journal of Midwifery & Women’s Health, 58(6), 690–696.

Brown, P. A., Kaiser, K. L., & Nailon, R. E. (2014). Integrating quality improvement and translational research models to increase exclusive breastfeeding. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 43, 545–553.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B

Readiness for Enhanced Breastfeeding 179

Readiness for enhanced Breastfeeding Barbara J. Wheeler, RN, BN, MN, IBCLC

NANDA-I

Definition

A pattern of providing milk to an infant or young child directly from the breasts, which may be strengthened

Defining Characteristics

Mother expresses desire to enhance ability to provide breast milk for child’s nutritional needs; mother expresses desire to enhance ability to exclusively breastfeed

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Breastfeeding Establishment: Infant, Maternal; Breastfeeding Maintenance

Centers for Disease Control and Prevention (CDC) (2014). Proper Handling and Storage of Human Milk. U.S. Department of Health and Human Services, CDC. From: <http://www.cdc.gov/ breastfeeding/recommendations/handling_breastmilk.htm>. Retrieved 30 October 2014.

Demirtas, B. (2012). Strategies to support breastfeeding: a review. International Nursing Review, 59, 474–481.

Flaherman, V. J., Gay, B., Scott, C., et al. (2012). Randomised trial comparing hand expression with breast pumping for mothers of term newborns feeding poorly. Archives of Disease in Childhood. Fetal and Neonatal Edition, 97, F19–F23.

Foda, M. I., et al. (2004). Composition of milk obtained from unmassaged versus massaged breasts of lactating mothers. Journal of Pediatric Gastroenterology and Nutrition, 38(5), 484–487.

Kaikini, K. L., & Hyrkas, K. (2014). Mothers’ intentions to breastfeed and hospital practices on breastfeeding: a longitudinal study at 6 months after birth on predictors of breastfeeding in a cohort of mothers from a large northern New England Medical Centre. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 43, S78.

Lawrence, R. M. (2013). Circumstances when breastfeeding is contraindicated. Pediatrics Clinics of North America, 60(1), 295–318.

Li, C. M., Li, R., Ashley, C. G., et al. (2014). Associations of hospital staff training and policies with early breastfeeding practices. Journal of Human Lactation, 30(1), 88–96.

Mozingo, J. N., et al. (2000). “It wasn’t working.” Women’s experiences with short-term breastfeeding. MCN. the American Journal of Maternal Child Nursing, 25(3), 120–126.

Neifert, M., & Bunik, M. (2013). Overcoming clinical barriers to exclusive breastfeeding. Pediatric Clinics of North America, 60, 115–145.

Noonan, M. (2011). Breastfeeding: Is my baby getting enough milk? British Journal of Midwifery, 19(2), 82–89.

Nyati, M., Kim, H. Y., Goga, A., et al. (2014). Support for relactation among mothers of HIV-infected children: a pilot study in Soweto. Breastfeeding Medicine, At: <http://www-ncbi-nlm-nih- gov.proxy2.lib.umanitoba.ca/pubmed/25188674>; epub ahead of print. Accessed 30 October 2014.

Ramakrishnan, R., Oberg, C. M., & Kirby, R. S. (2014). The association between maternal perception of obstetric and pediatric care providers’ attitudes and exclusive breastfeeding outcomes. Journal of Human Lactation, 30(1), 80–87.

Sachs, H. C., & AAP Committee on Drugs. (2013). The transfer of drugs and therapeutics into human breast milk: an update on selected topics. Pediatrics, 132(3), e796–e809.

Client Outcomes Client Will (Specify Time Frame)

• Maintain effective breastfeeding without supplementation with formula • Maintain normal growth patterns (infant) • Verbalize satisfaction with breastfeeding process (mother)

Example NOC Outcome with Indicators

Breastfeeding Establishment: Infant as evidenced by the following indicators: Proper alignment and latch-on/Proper areolar grasp/Proper areolar compression/Correct suck and tongue placement/Audible swallow/Nursing a minimum of 5 to 10 minutes per breast/Minimum eight feedings per day/Urinations per day appropriate for age/Weight gain appropriate for age. (Rate the outcome and indicators of Breastfeeding Establishment: Infant: 1 = not adequate, 2 = slightly adequate, 3 = moderately adequate, 4 = substantially adequate, 5 = totally adequate [see Section I].)

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B

180 Readiness for Enhanced Breastfeeding

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Lactation Counseling

Example NIC Activities—Lactation Counseling

Provide information about psychological and physiological benefits of breastfeeding; Provide mother the opportunity to breastfeed after birth, when possible

Nursing Interventions and Rationales

• Encourage expectant mothers to learn about breastfeeding before and during pregnancy. EBN: Systematic reviews have identified that health education, particularly individualized education, significantly increases breastfeeding initiation rates (Neifert & Bunik, 2013).

• Encourage and facilitate early skin-to-skin contact (position includes contact of the naked baby with the mother’s bare chest). EB: Skin-to-skin holding is associated with improved milk supply, early initiation of breastfeeding, and improved breastfeeding duration (Moore et al, 2012).

• Encourage rooming-in and breastfeeding on demand. EBN: Mothers who room-in with their infants have greater percentages of exclusive breastfeeding when released from the hospital (Neifert & Bunik, 2013).

• Monitor the breastfeeding process and identify opportunities to enhance knowledge and experience regarding breastfeeding. EB: While mothers and babies are in the hospital it is essential that hospital per- sonnel support their effort to learn to breastfeed (CDC, 2011).

• Give encouragement/positive feedback related to breastfeeding mother-infant interactions. CEB: Positive feedback builds confidence. The Breastfeeding Self-Efficacy Scale, which measures maternal breastfeeding confidence, has demonstrated higher self-efficacy (confidence) is associated with longer duration of breast- feeding (Dennis, 2003).

• Discuss prevention and treatment of common breastfeeding problems, such as nipple pain and/or trauma. EB: Common problems experienced by breastfeeding women may be preventable with anticipatory guidance, or successfully managed with prompt assistance from a health care provider (Amir, 2014).

• Teach mother to observe for infant behavioral cues and responses to breastfeeding. EBN: Monitor and assess the mom and baby for several breastfeeding sessions. Teaching mother will build her confidence and knowledge base, which facilitates successful breastfeeding (Noonan, 2011).

• Identify current support-person network and opportunities for continued breastfeeding support. EB: Family members’ impressions and ideas about breastfeeding influence breastfeeding initiation and duration (Odom et al, 2014).

• Avoid supplemental bottle feedings and do not provide samples of formula on discharge. EB: A correla- tion exists between hospital staff providing formula and/or water supplements and failure to succeed with exclusive breastfeeding (Kaikini & Hyrkas, 2014).

▲ Provide follow-up contact; as available provide home visits and/or peer counseling. EBN: Systematic reviews support the use of professionals with special skills in breastfeeding and peer support programs to promote continued breastfeeding (Neifert & Bunik, 2013).

Multicultural

• Assess for the influence of cultural beliefs, norms, and values on current breastfeeding practices. CEB: The Hispanic mother may believe stress and anger make bad milk, which makes a breastfeeding infant ill. Some Hispanic women neutralize the bowel when weaning from breast to bottle by feeding only anise tea for 24 hours (Gonzalez et al, 2008). EBN: Some traditional cultures, including the Turkish, consider colostrum unsuitable to feed the newborn, thus formula may be required to prevent hypoglycemia and dehydration (Demirtas, 2012).

Home Care

• The above interventions may be adapted for home care use.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B

Ineffective Breathing Pattern 181

Client/Family Teaching and Discharge Planning

• Include the partner and other family members in education about breastfeeding. EB: Family members’ impressions and ideas about breastfeeding influence breastfeeding initiation and duration (Odom et al, 2014).

• Teach the client the importance of maternal nutrition. EB: Consumption or avoidance of specific foods or drinks is generally not necessary. Breastfeeding mothers should consume 450 to 500 calories more than nonpregnant, nonnursing women. Adequate intake of DHA is important with an average daily intake of 200 to 300 mg (the amount ingested with consumption of one to two portions of fish per week) recommended (AAP, 2012).

• Teach mother about the infant’s subtle hunger cues (e.g., rooting, sucking, mouthing, hand-to-mouth, hand-to-hand activity) and encourage her to breastfeed whenever signs are apparent. EB: Evidence-based practice guidelines support the teaching/reinforcement of these skills as important to effective breastfeeding (Holmes et al, 2013).

• Review guidelines for frequency (at least every 2 to 3 hours, or 8 to 12 feedings per 24 hours) and dura- tion (until suckling and swallowing slow down and satiety is reached) of feeding times. EB: In the first few days, frequent and regular stimulation of the breasts is important to establish an adequate milk supply; after breastfeeding is established, feeding lasts until the breasts are drained (Holmes et al, 2013).

• Provide information about common infant behaviors related to breastfeeding, and appropriate maternal responses. EBN: Improved knowledge base and ongoing support to learn psychomotor skills facilitates effec- tive breastfeeding (Neifert & Bunik, 2013).

▲ Provide referrals and resources: lactation consultants, nurse and peer support programs, community organizations, and written and electronic sources of information. EBN: Systematic reviews support the use of professionals with special skills in breastfeeding, peer support programs, and written and electronic information to promote continued breastfeeding (Neifert & Bunik, 2013).

REFERENCES American Academy of Pediatrics (AAP), Section on Breastfeeding.

(2012). Breastfeeding and the use of human milk. Pediatrics, 129(3), e827–e841.

Amir, L. H. (2014). Managing common breastfeeding problems in the community. British Medical Journal, 348, g2954.

Centers for Disease Control and Prevention (CDC) (2011). Breastfeeding report card-United States. Atlanta, GA: U.S. Department of Health and Human Services, CDC. <http:// www.cdc.gov/breastfeeding/data/reportcard.htm>.

Demirtas, B. (2012). Strategies to support breastfeeding: a review. International Nursing Review, 59, 474–481.

Dennis, C. L. (2003). The breastfeeding self-efficacy scale: psychometric assessment of the short form. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 32(6), 734–744.

Gonzalez, E., Owens, D., & Esperat, C. (2008). Mexican Americans. In J. Giger & R. Davidhizar (Eds.), Transcultural nursing: assessment and intervention. St Louis: Mosby.

Holmes, A. V., McLeod, A. Y., Bunik, M., et al. (2013). Clinical Protocol # 5: Peripartum breastfeeding management for the

healthy mother and infant at term. Breastfeeding Medicine, 8(6), 469–473.

Kaikini, K. L., & Hyrkas, K. (2014). Mothers’ intention to breastfeed and hospital practices on breastfeeding: a longitudinal study at 6 months after birth on predictors of breastfeeding in a cohort of mothers from a large northern New England Medical Centre. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 43, S78.

Moore, E. R., Anderson, G. C., Bergman, N., et al. (2012). Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Systematic Reviews, (5), CD003519.

Neifert, M., & Bunik, M. (2013). Overcoming clinical barriers to exclusive breastfeeding. Pediatric Clinics of North America, 60, 115–145.

Noonan, M. (2011). Breastfeeding: Is my baby getting enough milk? British Journal of Midwifery, 19(2), 82–89.

Odom, E. C., Li, R., Scanlong, K. S., et al. (2014). Association of family and health care provider opinion on infant feeding with mother’s breastfeeding decision. Journal of the Academy of Nutrition and Dietetics, 114(8), 1203–1207.

Ineffective Breathing pattern Debra Siela, PhD, RN, CCNS, ACNS-BC, CCRN-K, CNE, RRT

NANDA-I

Definition

Inspiration and/or expiration that does not provide adequate ventilation

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B

182 Ineffective Breathing Pattern

Defining Characteristics

Abnormal breathing pattern (e.g., rate, rhythm, depth); altered chest excursion; bradypnea; decrease in expiratory pressure; decrease in inspiratory pressure; decrease in minute ventilation; decrease in vital capac- ity; dyspnea; increase in anterior-posterior chest diameter; nasal flaring; orthopnea; prolonged expiration phase; pursed-lip breathing; tachypnea; use of accessory muscles to breathe; use of three-point position

Related Factors (r/t)

Anxiety; body position that inhibits lung expansion; bony deformity; chest wall deformity; fatigue; chest wall deformity; fatigue; hyperventilation; hypoventilation syndrome; musculoskeletal impairment; neuro- logical immaturity; neurological impairment (e.g., positive electroencephalogram, head trauma, seizure disorders); neuromuscular impairment; obesity; pain; respiratory muscle fatigue; spinal cord injury

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Respiratory Status: Airway Patency, Ventilation; Vital Signs

Example NOC Outcome with Indicators

Respiratory Status: Ventilation as evidenced by the following indicators: Respiratory rate/Moves sputum out of airway/Adventitious breath sounds not present/Shortness of breath not present/Auscultated breath sounds/Auscultated vocalization/ Chest x-ray findings (Rate each indicator of Respiratory Status: Ventilation: 1 = severe deviation from normal range, 2 = substantial deviation from normal range, 3 = moderate deviation from normal range, 4 = mild deviation from normal range, 5 = no deviation from normal range [see Section I].)

Example NIC Activities—Airway Management

Encourage slow, deep breathing, turning, and coughing; Monitor respiratory and oxygenation status as appropriate

Client Outcomes Client Will (Specify Time Frame)

• Demonstrate a breathing pattern that supports blood gas results within the client’s normal parameters • Report ability to breathe comfortably • Demonstrate ability to perform pursed-lip breathing and controlled breathing • Identify and avoid specific factors that exacerbate episodes of ineffective breathing patterns

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Airway Management; Respiratory Monitoring

Nursing Interventions and Rationales

• Monitor respiratory rate, depth, and ease of respiration. Normal respiratory rate is 10 to 20 breaths/min in the adult (Jarvis, 2015). EBN: When the respiratory rate exceeds 30 breaths/min, along with other physi- ological measures, a study demonstrated that a significant physiological alteration existed (Hagle, 2008).

• Note pattern of respiration. If client is dyspneic, note what seems to cause the dyspnea, the way in which the client deals with the condition, and how the dyspnea resolves or gets worse. EBN: Ask the patient if they are short of breath (Campbell, 2011). Use a tool such as the Respiratory Distress Observation Scale (RDOS) for assessing acutely ill or critically ill patients in respiratory distress who cannot self-report dyspnea (Campbell et al, 2010).

• Note amount of anxiety associated with the dyspnea. A normal respiratory pattern is regular in a healthy adult. To assess dyspnea, it is important to consider all of its dimensions, including antecedents, mediators, reactions, and outcomes.

• Attempt to determine if client’s dyspnea is physiological or psychological in cause. The evaluation of a client with dyspnea continues to be dependent on a thorough history and physical examination. In the client

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B

Ineffective Breathing Pattern 183

with acute worsening of chronic breathlessness, the health care provider must be attuned to the possibility of a new pathophysiological derangement superimposed on a known disorder. Instruments or sections of instruments pertaining to dyspnea should be classified as addressing domains of sensory-perceptual experi- ence, affective distress, or symptom/disease impact or burden (Parshall et al, 2012). EB: Maximal respiratory work is less unpleasant than moderately intense air hunger, and unpleasantness of dyspnea can vary inde- pendently from perceived intensity, consistent with pain. Separate dimensions should be measured (Banzett et al, 2008). A study found that when the cause was psychological (medically unexplained dyspnea), there was affective dyspnea, anxiety, and tingling in the extremities. Whereas, when the dyspnea was physiological, there was associated wheezing, cough, sputum, and palpitations (Han et al, 2008).

• The rapidity of which the onset of dyspnea is noted is also an indicator of the severity of the pathological condition (Croucher, 2014).

Psychological Dyspnea—Hyperventilation

• Monitor for symptoms of hyperventilation including rapid respiratory rate, sighing breaths, lightheaded- ness, numbness and tingling of hands and feet, palpitations, and sometimes chest pain (Bickley & Szilagyi, 2012).

• Assess cause of hyperventilation by asking client about current emotions and psychological state. • Ask the client to breathe with you to slow down respiratory rate. Maintain eye contact and give reassur-

ance. By making the client aware of respirations and giving support, the client may gain control of the breathing rate.

▲ Consider having the client breathe in and out of a paper bag as tolerated. This simple treatment helps associated symptoms of hyperventilation including helping to retain carbon dioxide, which will decrease associated symptoms of hyperventilation (Bickley & Szilagyi, 2012).

▲ If client has chronic problems with hyperventilation, numbness and tingling in extremities, dizziness, and other signs of panic attacks, refer for counseling.

Physiological Dyspnea

▲ Ensure that client in acute dyspneic state has received any ordered medications, oxygen, and any other treatment needed.

• Determine intensity, unpleasantness, or distress of dyspnea using a rating scale such as an intensity focused modified Borg scale or visual analogue scale (Parshall et al, 2012).

• Note client description of the quality of breathing discomfort, such as chest tightness, air hunger, inability to breathe deeply, urge to breathe, starved for air, feeling of suffocation (Parshall et al, 2012).

• Note use of accessory muscles, nasal flaring, retractions, irritability, confusion, or lethargy. These symp- toms signal increasing respiratory difficulty (Campbell, 2011).

• Observe color of tongue, oral mucosa, and skin for signs of cyanosis. In central cyanosis, both the skin and mucous membranes are affected due to seriously impaired pulmonary function from unventilated or underventilated alveoli. Peripheral cyanosis (skin only) usually indicates vasoconstriction or obstruction to blood flow (Loscalzo, 2013).

• Auscultate breath sounds, noting decreased or absent sounds, crackles, or wheezes. These abnormal lung sounds can indicate a respiratory pathology associated with an altered breathing pattern (Croucher, 2014).

• Assess for hemodynamic stability for the client with acute dyspnea. Rapid evaluation for impending respira- tory failure is essential and includes fragmented speech, tripod positioning, diaphoresis, cyanosis, Pao2 less than 50 mm Hg, Paco2 greater than 70, and use of accessory muscles. Hypotension along with dyspnea indicates threat of cardiopulmonary collapse (Croucher, 2014).

▲ Monitor oxygen saturation continuously using pulse oximetry. Note blood gas results as available. An oxygen saturation of less than 90% (normal: 95% to 100%) or a partial pressure of oxygen of less than 80 mm Hg (normal: 80 to 100 mm Hg) indicates significant oxygenation problems.

• Using touch on the shoulder, coach the client to slow respiratory rate, demonstrating slower respirations, making eye contact with the client, and communicating in a calm, supportive fashion. The nurse’s pres- ence, reassurance, and help in controlling the client’s breathing can be beneficial in decreasing anxiety. EB: Anxiety is an important indicator of severity of client’s disease with chronic obstructive pulmonary disease (COPD) (Campbell et al, 2011).

• Support the client in using pursed-lip and controlled breathing techniques. Pursed-lip breathing may relieve dyspnea in advanced COPD (Pashall et al, 2012). Pursed-lip breathing results in increased use of intercostal muscles, decreased respiratory rate, increased tidal volume, and improved oxygen saturation levels

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B

184 Ineffective Breathing Pattern

(Faager et al, 2008). EBN: A systematic review found pursed-lip breathing effective in decreasing dyspnea (Carrieri-Kohlman & Donesky-Cuenco, 2008).

• If the client is acutely dyspneic, consider having the client lean forward over a bedside table, resting elbows on the table if tolerated. Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm (Langer et al, 2009). This is called the tripod position and is used during times of distress, including when walking.

• Position the client in an upright or semi-Fowler’s position. Most patients will have optimal vital capacity, oxygenation, and reduced dyspnea when upright with arms elevated on pillows or a bedside table (Campbell, 2011). See Nursing Interventions and Rationales for Impaired Gas exchange for further information on positioning.

▲ Administer oxygen as ordered. Oxygen administration has been shown to correct hypoxemia, which causes dyspnea (Wong & Elliott, 2009; Campbell, 2011). But, supplemental oxygen may not relieve all dyspnea (Parshall et al, 2012).

• Mechanical ventilation, invasive or noninvasive, is a reliable means of reducing dyspnea associated with respiratory failure (Campbell, 2011).

• Opioids may be used for both acute and terminal dyspnea, considering careful safe dosing for relief and side effect of constipation (Campbell, 2011; Parshall et al, 2012).

• Increase client’s activity to walking three times per day as tolerated. Assist the client to use oxygen during activity as needed. See Nursing Interventions and Rationales for Activity intolerance. Walking 20 minutes per day is recommended for those unable to be in a structured program (GOLD, 2015). Supervised exer- cise has been shown to decrease dyspnea and increase tolerance to activity (GOLD, 2015).

• Schedule rest periods before and after activity. Respiratory clients with dyspnea are easily exhausted and need additional rest. Nurses coordinate all patient care and are integral to ensuring spacing of activity to minimize or prevent dyspnea (Campbell, 2011).

▲ Evaluate the client’s nutritional status. Refer to a dietitian if needed. Use nutritional supplements to increase nutritional level if needed. Improved nutrition may help increase inspiratory muscle function and decrease dyspnea. CEB: A study found that almost half of a group of clients with COPD were malnourished, which can lead to an exacerbation of the disease (Odencrants et al, 2008).

• Provide small, frequent feedings. Small feedings are given to avoid compromising ventilatory effort and to conserve energy. Clients with dyspnea often do not eat sufficient amounts of food because their priority is breathing.

• Offer a fan to move the air in the environment. EBN: A systematic review found that the movement of cool air on the face can be effective in relieving dyspnea in pulmonary clients (Carrieri-Kohlman & Donesky- Cuenco, 2008). EBP: Handheld fans can significantly reduce dyspnea in clients with chronic breathlessness (Galbraith et al, 2010).

• Encourage the client to take deep breaths at prescribed intervals and do controlled coughing. • Help the client with chronic respiratory disease to evaluate dyspnea experience to determine whether

previous incidences of dyspnea were similar and to recognize that the client survived those incidences. Encourage the client to be self-reliant if possible, use problem-solving skills, and maximize use of social support. The focus of attention on sensations of breathlessness has an impact on judgment used to determine the intensity of the sensation (Campbell et al, 2011).

• See Ineffective Airway clearance if client has a problem with increased respiratory secretions. ▲ Refer the client with COPD for pulmonary rehabilitation. EB: A Cochrane study found pulmonary reha-

bilitation programs highly effective and safe for a client who has an exacerbation of COPD (Puhan et al, 2009). Among the beneficial effects of pulmonary rehabilitation are a reduction in exertional dyspnea during exercise and improved exercise tolerance, as well as decreases in self-reported dyspnea with activity (Parshall et al, 2012). Appropriately resourced home-based exercise training has proven effective in reducing dyspnea and increasing exercise performance activity in the context of pulmonary rehabilitation (Spruit et al, 2013). Pulmonary rehabilitation benefits for COPD patients include reduction of the perceived intensity of breath- lessness (GOLD, 2015).

Geriatric

• Assess respiratory systems in older adults with the understanding that inspiratory muscles weaken, resulting in a slight barrel chest. Expiratory muscles work harder with use of accessory muscles (Martin-Plank, 2014).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B

Ineffective Breathing Pattern 185

• Encourage ambulation as tolerated. Immobility is harmful to older adults because it decreases ventilation and increases stasis of secretions (Thomas, 2009).

• Encourage older clients to sit upright or stand and to avoid lying down for prolonged periods during the day. Thoracic aging results in decreased lung expansion; an erect position fosters maximal lung expansion (Thomas, 2009).

Home Care

• The above interventions may be adapted for home care use. • Work with the client to determine what strategies are most helpful during times of dyspnea. Educate

and empower the client to self-manage the disease associated with impaired gas exchange. EBN/EB: A study found that use of oxygen, self-use of medication, and breathing fresh air were most helpful in dealing with dyspnea (Thomas, 2009). Evidence-based reviews have found that self-management offers clients with COPD effective options for managing the illness, leading to more positive outcomes (Kaptein et al, 2008).

• Assist the client and family with identifying other factors that precipitate or exacerbate episodes of inef- fective breathing patterns (i.e., stress, allergens, stairs, activities that have high energy requirements). Awareness of precipitating factors helps clients avoid them and decreases risk of ineffective breathing episodes (Campbell et al, 2011).

• Assess client knowledge of and compliance with medication regimen. Client/family may need repetition of instructions received at hospital discharge, and may require reiteration as fear of a recent crisis decreases. Fear interferes with the ability to assimilate new information.

▲ Refer the client for telemonitoring with a pulmonologist as appropriate, with use of an electronic spirom- eter or an electronic peak flowmeter. EB: A systematic review of home telemonitoring for conditions such as COPD, asthma, and lung transplantation found that use of telemonitoring resulted in early detection of deterioration of clients’ respiratory status, and positive client receptiveness to the approach (Jaana et al, 2009).

• Teach the client and family the importance of maintaining the therapeutic regimen and having as-needed drugs easily accessible at all times. Appropriate and timely use of medications can decrease the risk of exacerbating ineffective breathing. The 2015 GOLD Report states that bronchodilator medications are central to management of dyspnea (GOLD, 2015).

• Provide the client with emotional support in dealing with symptoms of respiratory difficulty. Provide family with support for care of a client with chronic or terminal illness. Refer to care plan for Anxiety. Witnessing breathing difficulties and facing concerns of dealing with chronic or terminal illness can create fear in caregiver. Fear inhibits effective coping (Campbell et al, 2011).

• When respiratory procedures (e.g., apneic monitoring for an infant) are being implemented, explain equipment and procedures to family members, and provide needed emotional support. Family members assuming responsibility for respiratory monitoring often find this stressful. They may not have been able to assimilate fully any instructions provided by hospital staff (Martin-Plank et al, 2014).

• When electrically based equipment for respiratory support is being implemented, evaluate home environ- ment for electrical safety, such as proper grounding. Ensure that notification is sent to the local utility company, the emergency medical team, police and fire departments. Notification is important to provide for priority service.

• Refer to GOLD guidelines for management of home care and indications of hospital admission criteria.

• Support clients’ efforts at self-care. Ensure they have all the information they need to participate in care.

• Identify an emergency plan including when to call your health care provider or 911. Having a ready emergency plan reassures the client and promotes client safety.

▲ Refer to occupational therapy for evaluation and teaching of energy conservation techniques (Langer et al, 2009).

▲ Refer to home health aide services as needed to support energy conservation. Energy conservation decreases the risk of exacerbating ineffective breathing (Langer et al, 2009).

▲ Institute case management of frail elderly to support continued independent living (Martin-Plank et al, 2014).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

B

186 Ineffective Breathing Pattern

Client/Family Teaching and Discharge Planning

• Teach pursed-lip and controlled breathing techniques. EB: Studies have demonstrated that pursed-lip breathing was effective in decreasing breathlessness and improving respiratory function (Faager et al, 2008). Pursed-lip breathing may relieve dyspnea in advanced COPD (Parshall et al, 2012).

• Teach about dosage, actions, and side effects of medications. Inhaled steroids and bronchodilators can have undesirable side effects, especially when taken in inappropriate doses.

• Using a pre-recorded tape, teach client progressive muscle relaxation techniques. EB: Relaxation therapy can help reduce dyspnea and anxiety (Langer et al, 2009). Benefits of pulmonary rehabilitation include reduction of anxiety and depression associated with COPD (GOLD, 2015).

• Teach the client to identify and avoid specific factors that exacerbate ineffective breathing patterns, such as exposure to other sources of air pollution, especially smoking. If client smokes, refer to the smoking cessation section in the impaired Gas exchange care plan.

REFERENCES Banzett, R., Pedersen, S., Schwartzstein, R., et al. (2008). The affective

dimension of laboratory dyspnea. American Journal of Respiratory and Critical Care Medicine, 177, 1384–1390.

Bickley, L. S., & Szilagyi, P. (2012). Bate’s guide to physical examination (ed. 11). Philadelphia: Lippincott.

Campbell, M. L. (2011). Dyspnea. AACN Advanced Critical Care, 22(3), 257–264.

Campbell, M. L., Templin, T., & Walch, J. A. (2010). A respiratory distress observation scale for patients unable to self-report dyspnea. Journal of Palliative Medicine, 13(3), 285–290.

Carrieri-Kohlman, V., & Donesky-Cuenco, D. (2008). Dyspnea management. An EBP guideline. In B. Ackley, G. Ladwig, & B. A. Swann (Eds.), Evidence-based nursing care guidelines: medical- surgical Interventions. Philadelphia: Mosby Elsevier.

Croucher, B. (2014). The challenge of diagnosing dyspnea. AACN Advanced Critical Care, 25(3), 284–290.

Faager, G., Stahle, A., & Larsen, F. F. (2008). Influence of spontaneous pursed lips breathing on walking endurance and oxygen saturation in patients with moderate to severe chronic obstructive pulmonary disease. Clinical Rehabilitation, 22(8), 675–683.

Galbraith, S., Fagan, P., Perkins, P., et al. (2010). Does the use of a handheld fan improve chronic dyspnea? A randomized controlled crossover trial. Journal of Pain and Symptom Management, 39, 831–838.

GOLD Global strategy for the diagnosis, management, and prevention of COPD (revised 2015), Global Initiative for Chronic Obstructive Lung Disease. <http://www.goldcopd.org/uploads/users/files/ GOLD_Report_2015_Apr2.pdf>. Retrieved April 23, 2015.

Hagle, M. (2008). Vital signs monitoring. An EBP guideline. In B. Ackley, G. Ladwig, & B. A. Swann (Eds.), Evidence-based nursing care guidelines: medical-surgical interventions. Philadelphia: Mosby.

Han, J., Zhu, Y., Li, S., et al. (2008). The language of medically unexplained dyspnea. Chest, 133(4), 961–968.

Jaana, M., Paré, G., & Sicotte, C. (2009). Home telemonitoring for respiratory conditions: a systematic review. American Journal of Managed Care, 15(5), 313–320.

Jarvis, C. (2015). General Survey, Measurement, Vital Signs. In C. Jarvis (Ed.), Physical Examination & Health Assessment (ed. 7). St. Louis: Saunders Elsevier.

Kaptein, A. A., Scharloo, M., & Fischer, M. J. (2008). 50 years of psychological research on patients with COPD—road to ruin or highway to heaven? Respiratory Medicine, 103(1), 3–11.

Langer, D., Hendriks, E., & Burtin, C. (2009). A clinical practice guideline for physiotherapists treating patients with chronic obstructive pulmonary disease based on a systematic review of available evidence. Clinical Rehabilitation, 23(5), 445–462.

Loscalzo, J. (2013). Hypoxia and cyanosis. In J. Loscalzo (Ed.), Harrison’s pulmonary and critical care medicine (ed. 2, pp. 21–25). New York: McGraw Hill Education Medical.

Martin-Plank, L. (2014). Chest Disorders. In L. Kennedy-Malone, K. R. Fletcher, & L. Martin-Plank (Eds.), Advanced Practice Nursing in the Care of Older Adults. Philadelphia: F.A. Davis Company.

Odencrants, S., Ehnfors, M., & Ehrenbert, A. (2008). Nutritional status and patient characteristics for hospitalized older patients with chronic obstructive pulmonary disease. Journal of Clinical Nursing, 17(13), 1771–1778.

Parshall, M. B., Schwartzstein, R. M., Adams, L., et al. (2012). An official American Thoracic Society statement: update on the mechanisms, assessment, and management of dyspnea. American Journal of Respiratory and Critical Care Medicine, 185(4), 435–452.

Puhan, M., Scharplatz, M., & Troosters, T. (2009). Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Systematic Review, (1), CD005305.

Spruit, M. A., Singh, S. J., Garvey, C., et al. (2013). An official American Thoracic Society/European Respiratory Society Statement: Key concepts and advances in pulmonary rehabilitation. American Journal of Respiratory and Critical Care Medicine, 188(8), e13–e64.

Thomas, L. (2009). Effective dyspnea management strategies identified by elders with end-stage chronic obstructive pulmonary disease. Applied Nursing Research, 22(2), 79–85.

Wong, M., & Elliott, M. (2009). The use of medical orders in acute care oxygen therapy. British Journal of Nursing, 18(8), 462–464.

e32

Decreased Cardiac output Risk for decreased Cardiac output Risk for decreased Cardiac tissue perfusion

Risk for impaired Cardiovascular function

Caregiver Role Strain Risk for Caregiver Role Strain

Risk for ineffective Cerebral tissue perfusion

Ineffective Childbearing process Readiness for enhanced Childbearing process

Risk for ineffective Childbearing process

Impaired Comfort Readiness for enhanced Comfort

Readiness for enhanced Communication

Impaired verbal Communication Acute Confusion

Chronic Confusion Risk for acute Confusion Constipation Chronic functional Constipation Perceived Constipation Risk for Constipation Risk for chronic functional Constipation

Contamination Risk for Contamination

Risk for adverse reaction to iodinated Contrast Media

Compromised family Coping Defensive Coping

Ineffective community Coping Ineffective Coping Disabled family Coping Readiness for enhanced Coping Readiness for enhanced community

Coping Readiness for enhanced family Coping

List of Nursing Diagnoses by Letter: C

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Decreased Cardiac Output 187

Decreased Cardiac output Ann Will Poteet, MS, RN, CNS

NANDA-I

Definition

Inadequate blood pumped by the heart to meet the metabolic demands of the body

Defining Characteristics Altered Heart Rate/Rhythm

Bradycardia, electrocardiogram change (e.g., arrhythmia, conduction abnormality, ischemia)

Altered Preload

Decreased central venous pressure (CVP); Decrease in pulmonary artery wedge pressure (PAWP); edema; fatigue; heart murmur; increase in CVP; increase in PAWP; jugular vein distention; weight gain

Altered Afterload

Abnormal skin color (e.g., pale, dusky, cyanosis); alteration in blood pressure; clammy skin; decrease in peripheral pulses; decrease in pulmonary vascular resistance (PVR); decrease in systemic vascular resistance (SVR); dyspnea; increase in PVR; increase in SVR; oliguria, prolonged capillary refill

Altered Contractility

Adventitious breath sounds; coughing; decreased cardiac index; decrease in ejection fraction; decrease in left ventricular stroke work index; decrease in stroke volume index; orthopnea; paroxysmal nocturnal dyspnea; presence of S3 heart sound; presence of S4 heart sound

Behavioral/Emotional

Anxiety; restlessness

Related Factors (r/t)

Alteration in heart rate; alteration in heart rhythm; altered afterload, altered contractility; altered preload; altered stroke volume

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Cardiac Pump Effectiveness; Circulation Status; Tissue Perfusion: Abdominal Organs, Peripheral; Vital Signs

C

Example NOC Outcome with Indicators

Cardiac Pump Effectiveness as evidenced by the following indicators: Blood pressure/Heart rate/Cardiac index/Ejection fraction/Activity tolerance/Peripheral pulses/Neck vein distention not present/Heart rhythm/Heart sounds/Angina not present/ Peripheral edema not present/Pulmonary edema not present. (Rate the outcome and indicators of Cardiac Pump Effectiveness: 1 = severe deviation from normal range, 2 = substantial deviation from normal range, 3 = moderate deviation from normal range, 4 = mild deviation from normal range, 5 = no deviation from normal range [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Demonstrate adequate cardiac output as evidenced by blood pressure, pulse rate and rhythm within normal parameters for client; strong peripheral pulses; maintained level of mentation, lack of chest dis- comfort or dyspnea, and adequate urinary output; an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain

• Remain free of side effects from the medications used to achieve adequate cardiac output • Explain actions and precautions to prevent primary or secondary cardiac disease

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

188 Decreased Cardiac Output

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Cardiac Care; Cardiac Care: Acute

Example NIC Activities—Cardiac Care

Evaluate chest pain (e.g., intensity, location, radiation, duration, and precipitating and alleviating factors); Document cardiac dysrhythmias

Nursing Interventions and Rationales

• Recognize primary characteristics of decreased cardiac output as fatigue, dyspnea, edema, orthopnea, paroxysmal nocturnal dyspnea, and increased CVP. Recognize secondary characteristics of decreased cardiac output as weight gain, hepatomegaly, jugular venous distention, palpitations, lung crackles, oli- guria, coughing, clammy skin, and skin color changes. EBN: A nursing study to validate characteristics of the nursing diagnosis decreased cardiac output in a clinical environment identified and categorized related client characteristics that were present as primary or secondary (Martins et al, 2010).

• Monitor and report presence and degree of symptoms including dyspnea at rest or with reduced exercise capacity, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, distended abdomen, fatigue, or weakness. Monitor and report signs including jugular vein distention, S3 gallop, rales, positive hepato- jugular reflux, ascites, laterally displaced or pronounced point of maximal impact, heart murmurs, narrow pulse pressure, cool extremities, tachycardia with pulsus alternans, and irregular heartbeat. EB: These are symptoms and signs consistent with heart failure (HF) and decreased cardiac output (Yancy et al, 2013). EB: In a study of primary care clients, breathlessness during exercise, limitations in physical activity, and orthopnea were the three most significant symptoms most often associated with HF (Devroey & Van Casteren, 2011).

• Monitor orthostatic blood pressures and daily weights. EB: These interventions assess for fluid volume status (Yancy et al, 2013).

• Recognize that decreased cardiac output can occur in a number of noncardiac disorders such as septic shock and hypovolemia. Expect variation in orders for differential diagnoses related to decreased cardiac output, because orders will be distinct to address the primary cause of the altered cardiac output.

• Obtain a thorough history. EB: It is important to assess for cardiac and noncardiac disorders and/or behav- iors that might accelerate the progression of HF symptoms, such as high sodium diet, excess fluid intake, or missed medication doses (Yancy et al, 2013).

▲ Monitor pulse oximetry and administer oxygen as needed per health care provider’s order. Supplemental oxygen increases oxygen availability to the myocardium and can relieve symptoms of hypoxemia. Resting hypoxia or oxygen desaturation may indicate fluid overload or concurrent pulmonary disease.

• Place client in semi-Fowler’s or high Fowler’s position with legs down or in a position of comfort. Elevat- ing the head of the bed and legs in down position may decrease the work of breathing and may also decrease venous return and preload.

• During acute events, ensure client remains on short-term bed rest or maintains activity level that does not compromise cardiac output.

• Provide a restful environment by minimizing controllable stressors and unnecessary disturbances. Reduc- ing stressors decreases cardiac workload and oxygen demand.

▲ Apply graduated compression stockings or intermittent sequential pneumatic compression (ISPC) leg sleeves as ordered. Ensure proper fit by measuring accurately. Remove stocking at least twice a day, then reapply. Assess the condition of the extremities frequently. Graduated compression stockings may be contraindicated in clients with peripheral arterial disease (Kahn et al, 2012). EB: A study that assessed effects of ISPC on healthy adults found that there were significant increases in cardiac output, stroke volume, and ejection fraction due to increased preload and decreased afterload (Bickel et al, 2011); EB: A Cochrane review that assessed use of knee-length graduated compression stockings versus thigh-length graduated compression stockings found no difference in effectiveness. Type of stocking should be determined by patient preference, cost, and ease of use (Sajid et al, 2012). EB: Graduated compression stockings, alone or used in conjunction with other prevention modalities, help promote venous return and reduce the risk of deep vein thrombosis in hospitalized clients (Sachdeva et al, 2014).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Decreased Cardiac Output 189

▲ Check blood pressure, pulse, and condition before administering cardiac medications such as angiotensin- converting enzyme inhibitors, angiotensin receptor blockers, digoxin, and beta-blockers. Notify health care provider if heart rate or blood pressure is low before holding medications. It is important that the nurse evaluate how well the client is tolerating current medications before administering cardiac medica- tions; do not hold medications without health care provider input. The health care provider may decide to have medications administered even though the blood pressure or pulse rate has lowered.

• Observe for and report chest pain or discomfort; note location, radiation, severity, quality, duration, and associated manifestations such as nausea, indigestion, or diaphoresis; also note precipitating and relieving factors. Chest pain/discomfort may indicate an inadequate blood supply to the heart, which can further compromise cardiac output. EB: Clients with decreased cardiac output may present with myocardial isch- emia. Those with myocardial ischemia may present with decreased cardiac output and HF (Amsterdam et al, 2014; Yancy et al, 2013).

▲ If chest pain is present, refer to the interventions in risk for Decreased Cardiac tissue perfusion care plan. • Recognize the effect of sleep disordered breathing in HF and that sleep disorders are common in patients

with HF (Yancy et al, 2013). EB: Central sleep apnea is recognized as an independent risk factor for worsen- ing HF and reduced survival in patients with HF. The pathological effects of sleep apnea that contribute to worsening cardiac function include sympathetic nervous system stimulation, systemic inflammation, oxida- tive stress, and endothelial dysfunction (Costanzo et al, 2015).

• Administer continuous positive airway pressure (CPAP) or supplemental oxygen at night as ordered for management of suspected or diagnosed sleep apnea. EB: Both CPAP and nocturnal oxygen supplementa- tion have been shown to reduce episodes of sleep apnea, reduce sympathetic nervous system stimulation, and improve cardiac function (Costanzo et al, 2015).

▲ Closely monitor fluid intake, including intravenous lines. Maintain fluid restriction if ordered. In clients with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volumes. EB: Fluid restriction along with sodium restriction can enhance volume management with diuretics, and in some patients can improve outcomes (Yancy et al, 2013).

• Monitor intake and output (I&O). If client is acutely ill, measure hourly urine output and note decreases in output. Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output. EB: Clinical practice guidelines cite that monitoring I&Os is useful for monitoring effects of HF treatment, including diuretic therapy (Yancy et al, 2013).

▲ Note results of initial diagnostic studies, including electrocardiography, echocardiography, and chest radiography. EB: Clinical practice guidelines suggest that chest radiography, echocardiography, and electro- cardiogram are recommended in the initial assessment of HF (Yancy et al, 2013).

▲ Note results of further diagnostic imaging studies such as radionuclide imaging, stress echocardiography, cardiac catheterization, or magnetic resonance imaging (MRI). EB: Clinical practice guidelines state that radionuclide and MRI are useful studies when assessing left ventricular ejection fraction and volume if echocardiography is not sufficient (Yancy et al, 2013).

▲ Review laboratory data as needed including arterial blood gases, complete blood count, serum electrolytes (sodium, potassium, magnesium, calcium), blood urea nitrogen, creatinine, urinalysis, glucose, fasting lipid profile, liver function tests, thyroid stimulating hormone, B-type natriuretic peptide (BNP assay), or N-terminal pro-B-type natriuretic peptide (NTpro-BNP). Routine blood work can provide insight into the etiology of HF and extent of decompensation. EB: Clinical practice guidelines recommend that BNP or NTpro-BNP assay should be measured in clients when the cause of HF is not known, and to determine prognosis or disease severity in chronic or acute decompensated HF (Yancy et al, 2013).

• Gradually increase activity when the client’s condition is stabilized by encouraging slower paced activities, or shorter periods of activity, with frequent rest periods following exercise prescription; observe for symptoms of intolerance. Take blood pressure and pulse before and after activity and note changes. Activ- ity of the cardiac client should be closely monitored. See Activity intolerance.

▲ Serve small, frequent, sodium-restricted, low saturated fat meals. Sodium-restricted diets help decrease fluid volume excess. Low saturated fat diets help decrease atherosclerosis, which can cause coronary artery disease. Clients with cardiac disease tolerate smaller meals better because they require less cardiac output to digest (Hooper et al, 2012). EB: Excess sodium can contribute to elevation of blood pressure, renal impairment, ventricular hypertrophy, diastolic dysfunction, and fibrosis of coronary arteries (Whelton et al, 2012). EB: A study that compared cardiac event-free survival between clients who ingested more or less than 3 g of dietary sodium daily found that those who were NYHA class III or IV clients benefited the most from dietary intake less than 3 g daily (Lennie et al, 2011); EBN: A study that compared HF symptoms with

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

190 Decreased Cardiac Output

dietary sodium intake found that those with sodium intake greater than 3 g per day had more HF symptoms (Son et al, 2011).

▲ Monitor bowel function. Provide stool softeners as ordered. Caution client not to strain when defecating. Decreased activity, pain medication, and diuretics can cause constipation. EBN: Clients with HF have autonomic dysfunction, which places them at risk for reduced mean arterial blood pressure and reduced cerebral blood flow. Autonomic challenges, such as the Valsalva maneuver, can put the HF client at risk for hypoperfusion, ischemia, and stroke (Serber et al, 2014).

• Weigh the client at the same time daily (after voiding). Daily weight is a good indicator of fluid balance. Use the same scale if possible when weighing clients for consistency. Increased weight and severity of symptoms can signal decreased cardiac function with retention of fluids. EB: Clinical practice guidelines state that weighing at the same time daily is useful to assess effects of diuretic therapy (Yancy et al, 2013).

▲ Provide influenza and pneumococcal vaccines as needed before client discharge for those who have yet to receive those inoculations (Centers for Disease Control, 2015).

• Assess for presence of anxiety and refer for treatment if present. See Nursing Interventions and Rationales for Anxiety to facilitate reduction of anxiety in clients and family. EB: A study that assessed the relation- ship between anxiety and incidence of death, emergency department visits, or hospitalizations found that those with higher anxiety had significantly worse outcomes than those with lower anxiety (De Jong et al, 2011).

▲ Assess for presence of depression and refer for treatment if needed. EB: Depression is common in clients with HF, and it has been found that individuals with depressive symptoms have poorer quality of life, use health care services more frequently, have poorer self-care, and have worse clinical outcomes (Yancy et al, 2013). EBN: A study on combined depression and level of perceived social support found that depressive symptoms were an independent predictor of increased morbidity and mortality, and those with lower per- ceived social support had 2.1 times higher risk of events than nondepressed clients with high perceived social support (Chung et al, 2011).

▲ Refer to a cardiac rehabilitation program for education and monitored exercise. EB: Exercise training or regular physical activity is recommended for HF patients. Cardiac rehabilitation can improve quality of life and functional capacity, and decrease mortality (Arena et al, 2012; Smith et al, 2011; Yancy et al, 2013). A systematic review of outcomes of exercise based interventions in clients with systolic HF found that hospi- talizations and those for systolic HF were reduced for clients in an exercise program and quality of life was improved (Taylor et al, 2014). In a study to assess effects of exercise in HF clients, exercise tolerance and left ventricular ejection fraction increased with exercise training (Alves et al, 2012).

▲ Refer to an HF program for education, evaluation, and guided support to increase activity and rebuild quality of life. Support for the HF client should be patient-centered, culturally sensitive, and include family and social support. EB: Multidisciplinary systems of care that are designed to support clients with HF can improve outcomes (Arena et al, 2012; Weintraub et al, 2010; Yancy et al, 2013). CEB: A study assessing the 6-month outcomes of a nurse practitioner-coordinated HF center found that readmissions, length of stay, and cost per case were all significantly reduced, while quality of life was significantly improved (Crowther et al, 2002).

Critically Ill

▲ Observe for symptoms of cardiogenic shock, including impaired mentation, hypotension, decreased peripheral pulses, cold clammy skin, signs of pulmonary congestion, and decreased organ function. If present, notify health care provider immediately. Cardiogenic shock is a state of circulatory failure from loss of cardiac function associated with inadequate organ perfusion and a high mortality rate. EB: Critical cardiogenic shock presents with severe hypotension, increasing inotropic and vasopressor support, organ hypoperfusion, and worsening acidosis and lactate levels (Yancy et al, 2013).

▲ If shock is present, monitor hemodynamic parameters for an increase in pulmonary wedge pressure, an increase in systemic vascular resistance, or a decrease in stroke volume, cardiac output, and cardiac index. EB: Hemodynamic monitoring with a pulmonary artery catheter can be beneficial in patients with respiratory distress, impaired systemic perfusion, and dependence on intravenous inotropic support, and when clinical assessment is inadequate or severe symptoms persist despite recommended therapies (Yancy et al, 2013).

▲ Titrate inotropic and vasoactive medications within defined parameters to maintain contractility, preload, and afterload per health care provider’s order. By following parameters, the nurse ensures maintenance of a delicate balance of medications that stimulate the heart to increase contractility, while maintaining

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Decreased Cardiac Output 191

adequate perfusion of the body. EB: Clinical practice guidelines recommend that intravenous inotropic drugs might be reasonable for HF clients presenting with low blood pressure and low cardiac output to maintain systemic perfusion and preserve end-organ performance (Yancy et al, 2013; Weintraub et al, 2010).

▲ Identify significant fluid overload and initiate intravenous diuretics as ordered. Monitor I&Os, daily weight, and vital signs, as well as signs and symptoms of congestion. Watch laboratory data, including serum electrolytes, creatinine, and urea nitrogen. EB: Intravenous loop diuretics should be initiated in the HF client who presents with significant fluid overload as either intermittent boluses or continuous infusion to reduce morbidity (Yancy et al, 2013).

▲ When using pulmonary arterial catheter technology, be sure to appropriately level and zero the equip- ment, use minimal tubing, maintain system patency, perform square wave testing, position the client appropriately, and consider correlation to respiratory and cardiac cycles when assessing waveforms and integrating data into client assessment. EB: Clinical practice guidelines recommend that invasive hemody- namic monitoring can be useful in acute HF with persistent symptoms when therapy is refractory, fluid status is unclear, systolic pressures are low, renal function is worsening, vasoactive agents are required, or when considering advanced device therapy or transplantation (Yancy et al, 2013).

▲ Observe for worsening signs and symptoms of decreased cardiac output when using positive pressure ventilation. EB: Positive pressure ventilation and mechanical ventilation are associated with a decrease in preload and cardiac output (Lukacsovitis et al, 2012; Yucel et al, 2011).

▲ Recognize that clients with cardiogenic pulmonary edema may have noninvasive positive pressure ven- tilation ordered. EB: Clinical practice guidelines for HF state that continuous positive airway pressure improves daily functional capacity and quality of life for those with HF and obstructive sleep apnea and is reasonable for clients with refractory HF not responding to other medical therapies (Costanzo et al, 2015; Yancy et al, 2013).

▲ Monitor client for signs and symptoms of fluid and electrolyte imbalance when clients are receiving ultrafiltration or continuous renal replacement therapy (CRRT). Clients with refractory HF may have ultrafiltration or CRRT ordered as a mechanical method to remove excess fluid volume. EB: Clinical practice guidelines cite that ultrafiltration is reasonable for clients with obvious volume overload and conges- tion, and refractory congestion not responsive to medical therapy (Yancy et al, 2013).

• Recognize that hypoperfusion from low cardiac output can lead to altered mental status and decreased cognition. CEB: A study that assessed an association among cardiac index and neuropsychological ischemia found that decreased cardiac function, even with normal cardiac index, was associated with accelerated brain aging (Jefferson et al, 2010).

• Recognize that clients with severe HF may undergo additional therapies, such as internal pacemaker or defibrillator placement, and/or placement of a ventricular assist device (VAD). EB: The use of VADs is a reasonable treatment as a bridge to recovery, transplant, or decision making in selected HF clients with reduced ejection fraction and profound hemodynamic compromise (Yancy et al, 2013).

Geriatric

• Recognize that older clients may demonstrate fatigue and depression as signs of HF and decreased cardiac output.

▲ If the client has heart disease causing activity intolerance, refer for cardiac rehabilitation. EB: Cardiac rehabilitation can positively affect an individual’s overall health outcome, especially in the older population, due to increased frailty and functional limitations (Arena et al, 2012). EBN: A study that assessed clients’ acceptance of a cardiac rehabilitation program found knowledge and perceived quality of life had increased significantly, and anxiety and depression had been reduced at the end of the program and at 6-month follow-up (Muschalla et al, 2011).

▲ Recognize that edema can present differently in the older population. EB: In the older population, lower extremity edema is often related to peripheral causes, such as dependency, rather than cardiac causes (Yancy et al, 2013).

▲ Recognize that blood pressure control is beneficial for older clients to reduce the risk of worsening HF. EB: Hypertension treatment is particularly beneficial in the older population, and control of both systolic and diastolic hypertension has been shown to reduce the risk of incident HF (Yancy et al, 2013).

▲ Recognize that renal function is not always accurately represented by serum creatinine in the older popu- lation due to less muscle mass (Yancy et al, 2013).

▲ Observe for side effects from cardiac medications. Older adults can have difficulty with metabolism and excretion of medications due to decreased function of the liver and kidneys; therefore, toxic side effects

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

192 Decreased Cardiac Output

are more common. EB: Older adults are at increased risk for digoxin toxicity, especially at larger doses, due to lower body mass and impaired renal function (Yancy et al, 2013).

▲ Older adults may require more frequent visits, closer monitoring of medication dose changes, and more gradual increases in medications, due to changes in the metabolism of medications and impaired renal function (Yancy et al, 2013).

▲ As older adults approach end of life, clinicians should help to facilitate a comprehensive plan of care that incorporates the patient and family’s values, goals, and preferences (Allen et al, 2012).

Home Care

• Some of the above interventions may be adapted for home care use. Home care agencies may use special- ized staff and methods to care for chronic HF clients. CEB: A study assessing HF outcomes over a 10-year period between a multidisciplinary home care intervention and usual care found significantly improved survival and prolonged event-free survival and was both cost- and time-effective (Ingles et al, 2006).

• Assess for fatigue and weakness frequently. Assess home environment for safety, as well as resources/ obstacles to energy conservation.

• Help family adapt daily living patterns to establish life changes that will maintain improved cardiac functioning in the client. Take the client’s perspective into consideration and use a holistic approach in assessing and responding to client planning for the future.

• Assist client to recognize and exercise power in using self-care management to adjust to health change. Refer to care plan for Powerlessness.

▲ Refer to medical social services, cardiac rehabilitation, telemonitoring and case management as necessary for assistance with home-care, access to resources, and counseling about the impact of severe or chronic cardiac diseases. EB: Access to systems that promote care coordination is essential for successful care of the HF client. Good communication and documentation between services, health care providers, and transitions of care is essential to ensure improved outcomes in HF clients (Albert et al, 2015; Smith et al, 2011; Yancy et al, 2013).

▲ As the client chooses, refer to palliative care for care, which can begin earlier in the care of the HF client. Palliative care can be used to increase comfort and quality of life in the HF client before end-of-life care (Buck & Zambroski, 2012). EB: Palliative care should address quality of life, ongoing symptom control, preferences about end-of-life, psychosocial distress, and caregiver support (Yancy et al, 2013).

▲ If the client’s condition warrants, refer to hospice. EB: The palliative care and HF teams are best suited to determine when end-of-life care is appropriate for the patient and family (Yancy et al, 2013). CEB: The multidisciplinary hospice team can reduce hospital readmission, increase functional capacity, and improve quality of life in end-stage HF (Coviello et al, 2002).

Client/Family Teaching and Discharge Planning

• Begin discharge planning as soon as possible upon admission to the emergency department (ED) if appropriate with a case manager or social worker to assess home support systems and the need for community or home health services. EB: Discharge planning should include adherence to the treatment plan, medication management, follow-up with health care providers and care coordination, dietary and physical activities, cardiac rehabilitation, and secondary prevention recommendations (Albert et al, 2015; Yancy et al, 2013).

• Discharge education should be comprehensive, evidence based, culturally sensitive, and include both the client and family (Yancy et al, 2013).

• Teach client about any medications prescribed. Medication teaching includes the drug name, its purpose, administration instructions, such as taking it with or without food, and any side effects to be aware of. Instruct the client to report any adverse side effects to his/her health care provider.

• Teach the importance of performing and recording daily weights upon arising for the day, and to report weight gain. Ask if client has a scale at home; if not, assist in getting one. EB: Clinical practice guidelines suggest that daily weight monitoring leads to early recognition of excess fluid retention, which, when reported, can be offset with additional medication to avoid hospitalization from heart failure decompensation (Yancy et al, 2013).

• Teach the types and progression patterns of worsening heart failure symptoms, when to call a health care provider for help, and when to go to the hospital for urgent care (Yancy et al, 2013).

• Stress the importance of ceasing tobacco use. EB: Tobacco use can cause or worsen decreased blood flow in the coronaries, as well as cause vasoconstriction, which can lead to atherosclerotic disease. Effects of

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Decreased Cardiac Output 193

nicotine include increasing pulse and blood pressure and constricting of blood vessels. Tobacco use is a primary factor in heart disease. (American Heart Association, 2014; Smith et al, 2011).

▲ Individuals should be screened for electronic cigarette use (e-cigarette). EB: While more studies are needed regarding the health effects of e-cigarette use, the American Heart Association recommends that all health care providers educate their patients regarding the long-term use of e-cigarettes given the known toxicities present in e-cigarettes, as well as the presence of nicotine in most types of e-cigarettes (Bhatnagar et al, 2014).

• Upon hospital discharge, educate clients about low sodium, low saturated fat diet, with consideration to client education, literacy, and health literacy level. EB: Excess sodium intake is directly related to elevated blood pressure (Whelton et al, 2012). A Cochrane review recommended that there be a permanent reduction in dietary saturated fats and replacement with unsaturated fats to reduce the risk of cardiovascular disease (Hooper et al, 2012).

• Instruct client and family on the importance of regular follow-up care with health care providers. EB: Post discharge support can significantly reduce hospital readmissions and improve health care outcomes, quality of life, and costs (Hernandez et al, 2010; Yancy et al, 2013).

▲ Teach stress reduction (e.g., imagery, controlled breathing, and muscle relaxation techniques). CEB: A study that assessed effects of relaxation or exercise in heart failure clients versus controls found that those who participated in regular relaxation therapy or exercise training reported greater improvements in psy- chological outcomes, with the relaxation group significantly improving depression and the exercise training group more improving fatigue (Yu et al, 2007).

• Discuss advance directives with the HF client, including resuscitation preferences. EB: Evidence suggests that advance directives can help to reduce overall health care costs, reduce in-hospital deaths, and increase hospice use (Yancy et al, 2013).

• Patients should be provided with education regarding the influenza vaccine and pneumococcal vaccine prior to discharge. EB: The influenza vaccine is recommended for all adults, and the pneumococcal vaccine is recommended for individuals greater than 65 years old and for individuals who are at high risk for car- diovascular disease (Centers for Disease Control, 2015).

• Teach the importance of physical activity as tolerated. EB: Exercise helps control blood pressure and weight, which are the most important controlled risk factors for cardiovascular disease. Individuals should engage in aerobic physical activity of moderate to vigorous intensity, three to four times per week (Eckel et al, 2013).

REFERENCES Albert, N. M., Barnason, S., Deswal, A., et al. (2015). Transitions of

care in heart failure: a scientific statement from the American Heart Association. Circulatory Heart Failure, 8, 384–409.

Allen, L. A., Stevenson, L. W., Grady, K. L., et al. (2012). Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation, 125, 1928–1952.

Alves, A. J., et al. (2012). Exercise training improves diastolic function in heart failure patients. Medicine and Science in Sports and Exercise, 44(5), 776–785.

American Heart Association. (2014). Smoking & cardiovascular disease (heart disease). Retrieved from: <http://www.heart.org/ HEARTORG/GettingHealthy/QuitSmoking/-/HEARTORG/ GettingHealthy/QuitSmoking/QuittingResources/Smoking- Cardiovascular-Disease_UCM_305187_Article.jsp>.

Amsterdam, E. A., Wenger, N. K., Brindis, R. G., et al. (2014). AHA/ ACC guideline for the management of patients with non-ST elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 23(30), e344–e426.

Arena, R., Williams, M., Forman, D. E., et al. (2012). Increasing referral and participation rates to outpatient cardiac rehabilitation: the valuable role of healthcare professionals in the inpatient and home health settings: a science advisory from the American Heart Association. Circulation, 125, 1321–1329.

Bhatnagar, A., Whitsel, L. P., Ribisl, K. M., et al. (2014). Electronic cigarettes: a policy statement from the American Heart Association. Circulation, 130, 1418–1436.

Bickel, A., et al. (2011). The physiological impact of intermittent sequential pneumatic compression (ISPC) leg sleeves on cardiac activity. American Journal of Surgery, 202, 15–22.

Buck, H. G., & Zambroski, C. H. (2012). Upstreaming palliative care for patients with heart failure. Journal of Cardiovascular Nursing, 27(2), 147–153.

Centers for Disease Control. (Updated 2015). Adult immunization schedules. Retrieved from: <http://www.cdc.gov/vaccines/schedules/ hcp/adult.html>.

Chung, M. L., et al. (2011). Depressive symptoms and poor social support have a synergistic effect on event-free survival in patients with heart failure. Heart and Lung: The Journal of Critical Care, 40(6), 492–501.

Costanzo, M. R., Khayat, R., Ponikowski, P., et al. (2015). Mechanisms and clinical consequences of untreated central sleep apnea in heart failure. Journal of American Colleges of Cardiology, 65(1), 72–84.

Coviello, J. S., Hricz, L., & Masulli, P. S. (2002). Client challenge: accomplishing quality of life in end-stage heart failure: a hospice multidisciplinary approach. Home Healthcare Nurse, 20, 195–198.

Crowther, M., et al. (2002). Evidence-based development of a hospital-based heart failure center. Reflections on Nursing Leadership, 28(2), 32–33.

De Jong, M. J., et al. (2011). Linkages between anxiety and outcomes in heart failure. Heart and Lung: The Journal of Critical Care, 40(5), 393–404.

Devroey, D., & Van Casteren, V. (2011). Signs for early diagnosis of heart failure in primary health care. Vascular Health Risk Management, 7, 591–596.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

194 Risk for Decreased Cardiac Output

Risk for decreased Cardiac output Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN, and Ann Will Poteet, MS, RN, CNS

NANDA-I

Definition

Vulnerable to inadequate blood pumped by the heart to meet metabolic demands of the body, which may compromise health

Risk Factors

Alteration in heart rate; alteration in heart rhythm; alteration in afterload; altered contractility; altered preload; altered stroke volume

NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family Teaching and Discharge Planning, Rationales, and References

Refer to care plan for Decreased Cardiac output.

Eckel, R. H., Jakicic, J. M., Ard, J. D., et al. (2013). 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 129(Suppl. 2), S76–S99.

Hernandez, A. F., et al. (2010). Relationship between early physician follow-up and 30-day readmission among Medicare beneficiaries hospitalized for heart failure. JAMA: The Journal of the American Medical Association, 303(17), 1716–1722.

Hooper, L., Summerbell, C. D., Thompson, R., et al. (2012). Reduced or modified dietary fat for preventing cardiovascular disease (review). The Cochrane Library, (Issue 5). Retrieved from: <http:// onlinelibrary.wiley.com.hsl-ezproxy.ucdenver.edu/ doi/10.1002/14651858.CD002137.pub3/pdf>.

Ingles, S. C., et al. (2006). Extending the horizon in chronic heart failure: effects of multidisciplinary, home-based intervention relative to usual care. Circulation, 114(23), 2466–2473.

Jefferson, A. L., et al. (2010). Cardiac index is associated with brain aging: the Framingham Heart study. Circulation, 122(7), 690–697.

Kahn, S., et al. (2012). Antithrombotic therapy and prevention of thrombosis, ed 9, American College of Chest Physician Evidence- Based Clinical Practice Guidelines Online Only Articles. Chest, 141(Suppl. 2), e195S–e226S.

Lennie, T. A., et al. (2011). Three gram sodium intake is associated with longer event-free survival only in patients with advanced heart failure. Journal of Cardiac Failure, 17(4), 325–330.

Lukacsovitis, J., Carlussi, A., & Hill, N. (2012). Physiological changes during low and high intensity non-invasive ventilation. European Respiratory Journal, 39(4), 869–875.

Martins, Q. C., Alita, G., & Rabelo, E. R. (2010). Decreased cardiac output: clinical validation in patients with decompensated heart failure. International Journal of Nursing Terminology Classification, 21(4), 156–165.

Muschalla, B., Glatz, J., & Karger, G. (2011). Cardiac rehabilitation with a structured education programme for patients with chronic heart failure-illness-related knowledge, mental wellbeing and acceptance in participants. Rehabilitation, 50(2), 103–110.

Sachdeva, A., Dalton, M., Amaragiri, S. V., et al. (2014). Graduated compression stockings for prevention of deep vein thrombosis. The Cochrane Library, (Issue 12). Retrieved from: <http:// onlinelibrary.wiley.com.hsl-ezproxy.ucdenver.edu/ doi/10.1002/14651858.CD001484.pub3/abstract>.

Sajid, M. S., Desai, M., Morris, R. W., et al. (2012). Knee length versus thigh length graduated compression stockings for prevention of deep vein thrombosis in postoperative surgical patients: review. The Cochrane Library, (Issue 5). Retrieved from: <http:// onlinelibrary.wiley.com.hsl-ezproxy.ucdenver.edu/ doi/10.1002/14651858.CD007162.pub2/abstract>.

Serber, S. L., Rinsky, B., Kumar, R., et al. (2014). Cerebral blood flow velocity and vasomotor reactivity during autonomic challenges in heart failure. Nursing Research, 63(3), 194–202.

Smith, S. C., Benjamin, E. J., Bonow, R. O., et al. (2011). AHA/ACCF secondary prevention and risk reduction therapy for patient with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation. Circulation, 124, 2458–2473.

Son, Y. J., Lee, Y., & Song, E. K. (2011). Adherence to a sodium- restricted diet is associated with lower symptom burden and longer cardiac event-free survival in patients with heart failure. Journal of Clinical Nursing, 20(21/22), 3029–3038.

Taylor, R. S., Sagar, V. A., Davies, E. J., et al. (2014). Exercise based rehabilitation for heart failure. The Cochrane Library, (Issue 4). Retrieved from: <http://onlinelibrary.wiley.com.hsl- ezproxy.ucdenver.edu/doi/10.1002/14651858.CD003331.pub4/ abstract>.

Weintraub, N. L., Collins, S. P., Pang, P. S., et al. (2010). Acute heart failure syndromes: emergency department presentation, treatment, and disposition: current approaches and future aims: a scientific statement from the American Heart Association. Circulation, 122, 1975–1996.

Whelton, P. K., Appel, L. J., Sacco, R. L., et al. (2012). Sodium, blood pressure, and cardiovascular disease: further evidence supporting the American Heart Association sodium reduction recommendations. Circulation, 126, 2880–2889.

Yancy, C. W., Jessup, M., Bozkurt, B., et al. (2013). ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 128, e240–e327.

Yu, D. S., et al. (2007). Non-pharmacological interventions in older people with heart failure: effects of exercise training and relaxation therapy. Gerontology, 53(2), 74–81.

Yucel, S., et al. (2011). Nursing diagnoses in patients having mechanical ventilation support in a respiratory intensive care unit in Turkey. International Journal of Nursing Practice, 17(5), 502–508.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Risk for Decreased Cardiac Tissue Perfusion 195

Risk for decreased Cardiac tissue perfusion Ann Will Poteet, MS, RN, CNS

NANDA-I

Definition

Vulnerable to a decrease in cardiac (coronary) circulation, which may compromise health

Risk Factors

Cardiac tamponade; cardiovascular surgery; coronary artery spasm; diabetes mellitus; family history of cardiovascular disease; hyperlipidemia; hypertension; hypovolemia; hypoxemia; hypoxia; increase in C-reactive protein; insufficient knowledge about modifiable risk factors (e.g., smoking, sedentary lifestyle, obesity); pharmaceutical agent; substance abuse

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Cardiac Pump Effectiveness; Circulation Status; Tissue Perfusion: Cardiac; Tissue Perfusion: Cellular; Vital Signs

Example NOC Outcome with Indicators

Tissue Perfusion: Cardiac as evidenced by the following indicators: Angina/Arrhythmia/Tachycardia/Bradycardia/Nausea/ Vomiting/Profuse diaphoresis. (Rate the outcome and indicators of Tissue Perfusion: Cardiac: 1 = severe, 2 = substantial, 3 = moderate, 4 = mild, 5 = none [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Maintain vital signs within normal range • Retain an asymptomatic cardiac rhythm (have absence of arrhythmias, tachycardia, or bradycardia) • Be free from chest and radiated discomfort as well as associated symptoms related to acute coronary

syndromes (ACSs) • Deny nausea and be free of vomiting • Have skin that is dry and of normal temperature

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Cardiac Care; Cardiac Precautions; Embolus Precautions; Dysrhythmia Management; Vital Signs Monitor- ing; Shock Management: Cardiac

Example NIC Activity—Cardiac Precautions

Avoid causing intense emotional situations; Avoid overheating or chilling the client; Provide small frequent meals; Substitute artificial salt and limit sodium intake if appropriate; Promote effective techniques for reducing stress; Restrict smoking

Nursing Interventions and Rationales

• Be aware that the primary cause of ACS—unstable angina (UA), non–ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI)—is an imbalance between myocardial oxygen consumption and demand that is associated with partially or fully occlusive thrombus develop- ment in coronary arteries (Amsterdam et al, 2014).

• Assess for symptoms of coronary hypoperfusion and possible ACS, including chest discomfort (pressure, tightness, crushing, squeezing, dullness, or achiness), with or without radiation (or originating) in the retrosternum, back, neck, jaw, shoulder, or arm discomfort or numbness; shortness of breath (SOB); associated diaphoresis; abdominal pain; dizziness, lightheadedness, loss of consciousness, or unexplained

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

196 Risk for Decreased Cardiac Tissue Perfusion

fatigue; nausea or vomiting with chest discomfort, heartburn, or indigestion; associated anxiety. EB: These symptoms are signs of decreased cardiac perfusion and ACS such as UA, NSTEMI, or STEMI, as well as other cardiovascular disorders such as aortic aneurysm, valve disorders, and pericarditis. A physical assess- ment will aid in assessment of the extent, location, and presence of, and complications resulting from a myocardial infarction (MI). It will promote rapid triage and treatment. It is also important to assess whether the client had a prior stroke, heart failure, or other cardiovascular disorder. It is important to note that certain psychiatric disorders (somatoform disorders, panic attack, anxiety disorders) can mimic ACS, but are typically noncardiac causes of chest pain (Amsterdam et al, 2014).

• Consider atypical presentations of ACS for women, older adults, and individuals with diabetes mellitus, impaired renal function, and dementia. EB/CEB: Women, older adults, and individuals with diabetes mellitus, impaired renal function, and dementia may present with atypical findings (Amsterdam et al, 2014; Mieres et al, 2014). A systematic review of differences showed that women had significantly less chest dis- comfort and were more likely to present with fatigue, neck pain, syncope, nausea, right arm pain, dizziness, and jaw pain (Coventry et al, 2011).

• Review the client’s medical, surgical, social, and familial history. EB: A medical history must be concise and detailed to determine the possibility of ACSs and to help determine the possible cause of cardiac symp- toms and pathology (Amsterdam et al, 2014).

• Perform physical assessments for both CAD and noncoronary findings related to decreased coronary perfusion, including vital signs, pulse oximetry, equal blood pressure in both arms, heart rate, respiratory rate, and pulse oximetry. Check bilateral pulses for quality and regularity. Report tachycardia, bradycar- dia, hypotension or hypertension, pulsus alternans or pulsus paradoxus, tachypnea, or abnormal pulse oximetry reading. Assess cardiac rhythm for arrhythmias; skin and mucous membrane color, tempera- ture, and dryness; and capillary refill. Assess neck veins for elevated central venous pressure, cyanosis, and pericardial or pleural friction rub. Examine client for cardiac S4 gallop, new heart murmur, lung crackles, altered mentation, pain on abdominal palpation, decreased bowel sounds, or decreased urinary output. EB: These indicators help assess for cardiac and noncardiac etiologies of symptoms and differential diagnoses (Amsterdam et al, 2014).

▲ Administer supplemental oxygen as ordered and needed for clients presenting with ACS, respiratory distress, or other high-risk features of hypoxemia to maintain a PO2 of at least 90%. EB: American Heart Association guidelines for emergency cardiovascular care during ACS recommend administering oxygen for breathlessness, hypoxemia, signs of heart failure, or if signs of shock are present, and the need for oxygen should be guided by noninvasive monitoring of oxygen saturation. There is limited evidence to support or refute the use of high-flow or low-flow supplemental oxygen if a normal oxygen level (>90%) is present (Amsterdam et al, 2014; O’Connor et al, 2010). EB: A Cochrane review found there was limited evidence to support or refute the use of routine supplemental oxygen with ACS, recommending further studies (Cabello et al, 2013).

▲ Use continuous pulse oximetry as ordered. EB: Prevention and treatment of hypoxemia includes maintain- ing arterial oxygen saturation over 90% (Amsterdam et al, 2014).

▲ Insert one or more large-bore intravenous catheters to keep the vein open. Routinely assess saline locks for patency. Clients who come to the hospital with possible decrease in coronary perfusion or ACS may have intravenous fluids and medications ordered routinely or emergently to maintain or restore adequate cardiac function and rhythm.

▲ Observe the cardiac monitor for hemodynamically significant arrhythmias, ST depressions or elevations, T-wave inversions and/or q-waves as signs of ischemia or injury. Report abnormal findings. EB: Arrhyth- mias and electrocardiogram (ECG) changes indicate myocardial ischemia, injury, and/or infarction. Note that left ventricular hypertrophy, ventricular pacing, and bundle branch blocks can mask signs of ischemia or injury (Amsterdam et al, 2014).

• Have emergency equipment and defibrillation capability nearby and be prepared to defibrillate immedi- ately if ventricular tachycardia with clinical deterioration or ventricular fibrillation occurs. EB: Life- threatening ventricular arrhythmias require defibrillation (Hazinski et al, 2010).

▲ Perform a 12-lead ECG as ordered, to be interpreted within 10 minutes of emergency department arrival and during episodes of chest discomfort or angina equivalent. EB: A 12-lead ECG should be performed within 10 minutes of emergency department arrival for all clients who are having chest discomfort. ECGs are used to identify the area of ischemia or injury, such as ST depressions or elevations, new left-bundle branch block, T-wave inversions, and/or q waves, and to guide treatment (Amsterdam et al, 2014).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Risk for Decreased Cardiac Tissue Perfusion 197

▲ Administer nonenteric coated aspirin as ordered, as soon as possible after presentation and for mainte- nance. EB: Aspirin has been shown to prevent platelet clumping, aggregation, and activation that leads to thrombus formation, which in coronary arteries leads to ACSs. Contraindications include active peptic ulcer disease, bleeding disorders, and aspirin allergy (Amsterdam et al, 2014; O’Gara et al, 2013).

▲ Administer nitroglycerin tablets sublingually as ordered, every 5 minutes until the chest pain is resolved while also monitoring the blood pressure for hypotension, for a maximum of three doses as ordered. Administer nitroglycerin paste or intravenous preparations as ordered. EB: Nitroglycerin causes coronary arterial and venous dilation, and at higher doses peripheral arterial dilation, thus reducing preload and afterload and decreasing myocardial oxygen demand while increasing oxygen delivery (Amsterdam et al, 2014).

• Do not administer nitroglycerin preparations to individuals with hypotension, or individuals who have received phosphodiesterase type 5 inhibitors, such as sildenafil, tadalafil, or vardenafil, in the last 24 hours (48 hours for long-acting preparations). EB: Synergistic effect causes marked exaggerated and prolonged vasodilation/hypotension (Amsterdam et al, 2014).

▲ Administer morphine intravenously as ordered every 5 to 30 minutes until pain is relieved while moni- toring blood pressure when nitroglycerin alone does not relieve chest discomfort. EB: Morphine has potent analgesic and antianxiolytic effects and causes mild reductions in blood pressure and heart rate that reduce myocardial oxygen consumption. Hypotension and respiratory depression are the most serious complications of morphine use, and naloxone may be administered as ordered for morphine overdose (Amsterdam et al, 2014).

▲ Assess and report abnormal lab work results of cardiac enzymes, specifically troponin I or T, B-type natriuretic peptide, chemistries, hematology, coagulation studies, arterial blood gases, finger stick blood sugar, elevated C-reactive protein, or drug screen. EB: Abnormalities can identify the cause of the decreased perfusion and identify complications related to the decreased perfusion such as anemia, hypovolemia, coagu- lopathy, drug abuse, hyperglycemia, kidney (renal) failure, and heart failure. Markedly elevated cardiac enzymes are usually indicative of an MI, and the cardiac enzymes can also help determine short- and long- term prognosis (Amsterdam et al, 2014).

• Assess for individual risk factors for coronary artery disease, such as hypertension, dyslipidemia, cigarette smoking, diabetes mellitus, or family history of heart disease. Other risk factors including sedentary lifestyle, obesity, or cocaine or amphetamine use. Note age and gender as risk factors. EB: Certain conditions place clients at higher risk for decreased cardiac tissue perfusion (Amsterdam et al, 2014; Mieres et al, 2014).

▲ Administer additional heart medications as ordered, including beta blockers, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, aldosterone antagonists, antiplatelet agents, and anticoagulants. Always check blood pressure and pulse rate before administering these medications. If the blood pressure or pulse rate is low, contact the health care provider to establish whether the medication should be withheld. Also check platelet counts, renal function, and coagulation studies as ordered to assess proper effects of these agents. EB: These medications are useful to optimize cardiac and kidney function, including blood pressure, heart rate, myocardial oxygen demand, intravascular fluid volume, and cardiac rhythm (Amsterdam et al, 2014).

▲ Administer lipid-lowering therapy as ordered. EB: Use of statin drugs has been shown to reduce an indi- vidual’s risk of recurrent MI, stroke, and coronary heart disease mortality, especially with high-intensity statins that lower low-density lipoprotein cholesterol levels (Amsterdam et al, 2014, Stone et al, 2013). A systematic review of statin use in primary prevention of cardiovascular disease showed reductions in all- cause mortality, major vascular events, and revascularizations (Taylor et al, 2014).

▲ Prepare client with education, withholding of meals and/or medications, and intravenous access for early invasive therapy with cardiac catheterization, reperfusion therapy, and possible percutaneous coronary intervention in individuals with refractory angina or hemodynamic or electrical instability, and first medical contact to device time of less than 90 minutes if STEMI is suspected. EB: First medical contact to device time of less than 90 minutes was associated with improved client outcomes (Amsterdam et al, 2014; O’Gara et al, 2013).

▲ Prepare clients with education, withholding of meals and/or medications, and intravenous access for noninvasive cardiac diagnostic procedures such as 2D echocardiogram, exercise, or pharmacological stress test, and cardiac computed tomography scan as ordered. EB: Clients suspected of decreased coronary perfusion should receive these diagnostic procedures as appropriate to evaluate for coronary artery disease (Amsterdam et al, 2014; Fletcher et al, 2013; Mieres et al, 2014).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

198 Risk for Decreased Cardiac Tissue Perfusion

▲ Request a referral to a cardiac rehabilitation program. EB: Cardiac rehabilitation programs are designed to limit the physiological and psychological effects of cardiac disease, reduce the risk for sudden cardiac death and reinfarction, control symptoms and stabilize or reverse the process of plaque formation, and enhance psychosocial and vocational status of clients (Amsterdam et al, 2014).

Geriatric

• Consider atypical presentations of possible ACS in older adults. CEB: Older adults may present with atypical signs and symptoms such as weakness, stroke, syncope, or change in mental status (Amsterdam et al, 2014).

▲ Ask the prescriber about possible reduced dosage of medications for older clients, considering weight, creatinine clearance, and glomerular filtration rate. EB: Older clients can have reduced pharmacokinetics and pharmacodynamics, including reduced muscle mass, reduced renal and hepatic function, and reduced volume of distribution that can alter drug dosing, efficacy, and safety, as well as some drug-drug interactions (Amsterdam et al, 2014; Stone et al, 2013).

• Consider issues such as quality of life, palliative care, end-of-life care, and differences in sociocultural aspects for clients and families when supporting them in decisions regarding aggressiveness of care. Ask about living wills, as well as medical and durable power of attorney. EB: Management decisions, including decisions regarding invasive treatment, should be client-centered and take into account client preferences and goals, comorbidities, cognitive and functional status, and life expectancy (Amsterdam et al, 2014).

Client/Family Teaching and Discharge Planning

▲ Client and family education regarding a multidisciplinary plan of care should start early. Special attention to client and family education should occur during transitions of care. EB: It is important to provide the client and family with a comprehensive plan of care and education materials that are evidence-based to assist with client compliance and to potentially reduce hospital readmissions related to ACS. The plan of care should take into consideration the client’s psychosocial and socioeconomic status, access to care, risk for depression and/or social isolation, and health care disparities (Amsterdam et al, 2014).

• Teach the client and family to call 911 for symptoms of new angina, existing angina unresponsive to rest and sublingual nitroglycerin tablets, or heart attack, or if an individual becomes unresponsive. EB/CEB: Morbidity and mortality from MI can be reduced significantly when symptoms are recognized and emergency medical services activated, shortening time to definitive treatment (Hazinski et al, 2010).

• Upon discharge, instruct clients about symptoms of ischemia, when to cease activity, when to use sub- lingual nitroglycerin, and when to call 911. EB/CEB: Degree and extent of myocardial ischemia is related to duration of time with inadequate supply of oxygen-rich blood (Hazinski et al, 2010).

• Teach client about any medications prescribed. Medication teaching includes the drug name, its purpose, administration instructions such as taking it with or without food, and any side effects to be aware of. Instruct the client to report any adverse side effects to the health care provider.

• Upon hospital discharge, educate clients and significant others about discharge medications, including nitroglycerin sublingual tablets or spray, with written, easy to understand, culturally sensitive informa- tion. EB: Clients and significant others need to be prepared to act quickly and decisively to relieve ischemic discomfort (Amsterdam et al, 2014).

• Provide client education related to risk factors for decreased cardiac tissue perfusion, such as hyperten- sion, hypercholesterolemia, diabetes mellitus, tobacco use, advanced age, and gender (female). EB: Those with two or more risk factors should have a 10-year risk screening for development of symptomatic coronary heart disease. Client education is a vital part of nursing care for the client. Start with the client’s base level of understanding and use that as a foundation for further education. It is important to factor in cultural and/or religious beliefs in the education provided (Amsterdam et al, 2014; Eckel et al, 2013; Goff et al, 2013).

• Instruct the client on antiplatelet and anticoagulation therapy, and about signs of bleeding, need for ongoing medication compliance, and international normalized ratio monitoring. EB: Special attention and education should be provided to older individuals, because they are at greater risk for bleeding (Amsterdam et al, 2014).

• After discharge, continue education and support for client blood pressure and diabetes control, weight management, and resumption of physical activity. EB: Reducing risk factors acts as secondary prevention of coronary artery disease (Amsterdam et al, 2014; Eckel et al, 2013).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Risk for Decreased Cardiac Tissue Perfusion 199

▲ Clients should be provided with education regarding the influenza vaccine and pneumococcal vaccine before hospital discharge. EB: The influenza vaccine is recommended for all adults, and the pneumococcal vaccine is recommended for individuals older than 65 years and for individuals who are at high risk for cardiovascular disease (Amsterdam et al, 2014; Centers for Disease Control, 2014).

▲ Stress the importance of ceasing tobacco use. EB: Tobacco use can cause or worsen decreased blood flow in the coronaries, as well as cause vasoconstriction, which can lead to atherosclerotic disease. Effects of nico- tine include increasing pulse and blood pressure and constricting blood vessels. Tobacco use is a primary factor in heart disease (American Heart Association, 2014; Amsterdam et al, 2014).

▲ Individuals should be screened for electronic cigarette use (e-cigarette). EB: While more studies are needed regarding the health effects of e-cigarette use, the American Heart Association recommends that all health care providers educate their clients regarding the long-term use of e-cigarettes given the known toxicities present in e-cigarettes, as well as the presence of nicotine in most types of e-cigarettes (Bhatnagar et al, 2014).

▲ Upon hospital discharge, educate clients about a low sodium, low saturated fat diet, with consideration to client education, literacy, and health literacy level. EB: Reducing risk factors acts as secondary prevention of coronary artery disease (Amsterdam et al, 2014; Eckel et al, 2013). A Cochrane review recommended that there be a permanent reduction in dietary saturated fats and replacement with unsaturated fats to reduce the risk of cardiovascular disease (Hopper et al, 2012).

• Teach the importance of physical activity. EB: Exercise helps control blood pressure and weight, which are the most important controlled risk factors for cardiovascular disease. Individuals should engage in aerobic physical activity of moderate to vigorous intensity, three to four times per week (Amsterdam et al, 2014; Eckel et al, 2013).

REFERENCES American Heart Association. (2014). Smoking & cardiovascular disease

(heart disease). Retrieved from: <http://www.heart.org/ HEARTORG/GettingHealthy/QuitSmoking/-/HEARTORG/ GettingHealthy/QuitSmoking/QuittingResources/Smoking- Cardiovascular-Disease_UCM_305187_Article.jsp>.

Amsterdam, E. A., Wenger, N. K., Brindis, R. G., et al. (2014). AHA/ ACC guideline for the management of patients with non-ST elevation acute coronary syndromes: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 23(30), e344–e426.

Bhatnagar, A., Whitsel, L. P., Ribisl, K. M., et al. (2014). Electronic cigarettes: a policy statement from the American Heart Association. Circulation, 130, 1418–1436.

Cabello, J. B., Burls, A., Emparanza, J. I., et al. (2013). Oxygen therapy for acute myocardial infarction. The Cochrane Library, (Issue 8). Retrieved from: <http://onlinelibrary.wiley.com.hsl- ezproxy.ucdenver.edu/doi/10.1002/14651858.CD007160.pub3/pdf>.

Centers for Disease Control and Prevention (2014). Influenza. <http:// www.cdc.gov/flu/about/season/flu-season-2015-2016.htm>.

Coventry, L. L., Finn, J., & Bremner, A. P. (2011). Sex differences in symptom presentation in acute myocardial infarction: a systematic review and meta-analysis. Heart and Lung: The Journal of Critical Care, 40(6), 477–491.

Eckel, R. H., Jakicic, J. M., Ard, J. D., et al. (2013). 2013 AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 129(Suppl. 2), S76–S99.

Fletcher, G. F., Ades, P. A., Kligfield, P., et al. (2013). Exercise standards for testing and training: a scientific statement from the American Heart Association. Circulation, 128, 873–934.

Goff, D. C., Lloyd-Jones, D. M., Bennett, G., et al. (2013). 2013 ACC/ AHA guideline on the assessment of cardiovascular risk: a report of American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 129(Suppl. 2), S49–S73.

Hazinski, M. F., et al. (2010). Executive summary: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Curculation, 122(Suppl.), S250–S275.

Hooper, L., Summerbell, C. D., Thompson, R., et al. (2012). Reduced or modified dietary fat for preventing cardiovascular disease (review). The Cochrane Library, (Issue 5). Retrieved from: <http:// onlinelibrary.wiley.com.hsl-ezproxy.ucdenver.edu/ doi/10.1002/14651858.CD002137.pub3/pdf>.

Mieres, J. H., Gulati, M., Bairey Merz, N., et al. (2014). Role of noninvasive testing in the clinical evaluation of women with suspected ischemic heart disease: a consensus statement from the American Heart Association. Circulation, 130, 350–379.

O’Connor, R. E., Bossaert, L., Arntz, H. R., et al. (2010). Part 9: acute coronary syndromes: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations. Circulation, 122(Suppl. 2), S422–S465.

O’Gara, P. T., et al. (2013). 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation, 127(4), 529–555.

Stone, N. J., Robinson, J. G., Lichtenstein, A. H., et al. (2013). 2013 ACC/AHA guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 129(Suppl. 2), S1–S45.

Taylor, F., Huffman, M. D., Macedo, A. F., et al. (2014). Statins for the primary prevention of cardiovascular disease. The Cochrane Library, (Issue 1). Retrieved from: <http://onlinelibrary.wiley.com .hsl-ezproxy.ucdenver.edu/doi/10.1002/14651858.CD004816 .pub5/pdf>.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

200 Risk for Impaired Cardiovascular Function

Risk for impaired Cardiovascular function Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN, and Ann Will Poteet, MS, RN, CNS

NANDA-I

Definition

Vulnerable to internal or external causes that can damage one or more vital organs and the circulatory system itself

Risk Factors

Age older than 65 years; diabetes mellitus; dyslipidemia; family history of cardiovascular disease; history of cardiovascular disease; hypertension; insufficient knowledge of modifiable risk factors; obesity; pharmaceuti- cal agent; sedentary lifestyle; smoking

NOC, NIC, Client Outcomes, Nursing Interventions, Client/Family Teaching and Discharge Planning, Rationales, and References

Refer to care plan for Decreased Cardiac output, Risk for decreased Cardiac tissue perfusion, and Sedentary lifestyle.

Caregiver Role Strain Paula Riess Sherwood, RN, PhD, CNRN, FAAN, and Barbara A. Given, PhD, RN, FAAN

NANDA-I

Definition

Difficulty in performing family/significant other caregiver role Defining Characteristics

Caregiving Activities

Apprehension about future ability to provide care; apprehension about the future health of receiver; appre- hension about possible institutionalization of care receiver; apprehension about well-being of care receiver if unable to provide care; difficulty completing required tasks; difficulty performing required tasks; dysfunc- tional change in caregiving activities; preoccupation with care routine

Caregiver Health Status: Physiological

Cardiovascular disease; diabetes mellitus; fatigue; gastrointestinal distress; headache; hypertension; rash; weight change

Caregiver Health Status: Emotional

Alteration in sleep pattern; anger; depression; emotional vacillation; frustration; impatience; ineffective coping strategies; insufficient time to meet personal needs; nervousness; somatization; stressors

Caregiver Health Status: Socioeconomic

Changes in leisure activities; low work productivity; refusal of career advancement; social isolation

Caregiver-Care Receiver Relationship

Difficulty watching care receiver with illness; grieving of changes with care recipient; uncertainty about changes in relationship with care receiver

Family Processes

Concerns about family members; family conflict Related Factors (r/t)

Care Recipient Health Status

Alteration in cognitive functioning; chronic illness; codependency; dependency; illness severity; increase in care needs; problematic behavior; psychiatric disorder; substance abuse; unpredictability of illness trajectory; unstable health condition

Caregiver Role Strain 201

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Caregiver Health Status

Alteration in cognitive functioning; codependency; ineffective coping strategies; insufficient fulfillment of others’ expectations insufficient fulfillment of self-expectations; physical conditions; substance abuse; unre- alistic self-expectations

Caregiver-Care Receiver Relationship

Abusive relationship; care receiver’s condition inhibits conversation; pattern of ineffective relationships; unrealistic care receiver expectations; violent relationship

Caregiving Activities

Around-the-clock care responsibilities; change in nature care of activities; complexity of care activities; dura- tion of caregiving; excessive caregiving activities; recent discharge home with significant care needs; unpre- dictability of care situation

Family Processes

Pattern of family dysfunction; pattern of ineffective family coping

Resources

Caregiver not developmentally ready for caregiver role; difficulty accessing assistance; difficulty accessing community resources; difficulty accessing support; financial crisis (e.g., debt, insufficient finances); inexperi- ence with caregiving; insufficient assistance; insufficient caregiver privacy; insufficient community resources (e.g., respite services, recreation, social support); insufficient emotional resilience; insufficient equipment for providing care; insufficient knowledge about community resources; insufficient physical environment for providing care; insufficient time; insufficient transportation

Socioeconomic

Alienation; competing role commitments; insufficient recreation; social isolation

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Caregiver Adaptation to Patient Institutionalization; Caregiver Emotional Health; Caregiver Home Care Readiness; Caregiver Lifestyle Disruption; Caregiver-Patient Relationship; Caregiver Performance: Direct Care; Caregiver Performance: Indirect Care; Caregiver Physical Health; Caregiver Role Support; Caregiver Role Endurance; Caregiver Stressors; Caregiver Well-Being

Example NOC Outcome with Indicators

Caregiver Emotional Health with plans for a positive future as evidenced by the following indicators: Satisfaction with life/Sense of control/Self-esteem/Perceived social connectedness/Perceived spiritual well-being. (Rate the outcome and indicators of Caregiver Emotional Health: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes Throughout the Care Situation, the Caregiver Will

• Feel supported by health care professionals, family, and friends; Report reduced or acceptable feelings of burden or distress; Take part in self-care activities to maintain own physical and psychological/emotional health; Identify resources available to help in giving care or to support the caregiver to give care; Verbalize mastery of the care situation; Feel confident and competent to provide care;

• Ask for help Throughout the Care Situation, the Care Recipient Will

• Obtain quality and safe care

202 Caregiver Role Strain

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

NIC (Nursing Interventions Classification)

Suggested NIC Intervention

Caregiver Support

Example NIC Activities—Caregiver Support

Determine caregiver’s acceptance of role; Accept expressions of negative emotion

Nursing Interventions and Rationales

• Regularly monitor signs of depression, anxiety, burden, and deteriorating physical health in the caregiver throughout the care situation, especially if the relationship is poor, the care recipient has cognitive or neuropsychiatric symptoms, there is little social support available, the caregiver becomes enmeshed in the care situation, the caregiver is older, female, or has poor preexisting physical or emotional health. Refer to the care plan for Hopelessness when appropriate. EBN: High levels of distress in caregivers are linked to multiple variables (van der Lee et al, 2014). EB: Caregiving may weaken the immune system and predispose the caregiver to illness, particularly cardiac illness and poor response to acquired infections (Fonareva & Oken, 2014; Lovell et al, 2012).

• The impact of providing care on the caregiver’s emotional health should be assessed at regular intervals using a reliable and valid instrument such as the Caregiver Strain Risk Index, which was validated with caregivers of clients with diagnosed Parkinson’s disease. EBN: Family caregivers face potential strain in caring for persons with Parkinson’s disease because of the unpredictability of symptom presentation. The Care- giver Strain Risk Screen (CSRS) was developed and tested for initial validation. The 28-item CSRS demon- strated acceptable validity and reliability in measuring caregiver strain (Abendroth, 2015). Caregiver assessment should be done at regular intervals throughout the care trajectory (Adelman et al, 2014).

• Identify potential caregiver resources such as mastery, social support, optimism, and positive aspects of care. EB/EBN: Research has shown that caregivers can have simultaneous positive and negative responses to providing care. Positive responses may help buffer the negative effects of providing care on caregivers’ emotional health and may also increase the effectiveness of interventions to reduce strain (Kruithof et al, 2011).

• Screen for caregiver role strain at the onset of the care situation, at regular intervals throughout the care situation, and with changes in care recipient status and care transitions, including institutionalization. EB/EBN: Care situations that last for several months or years can cause wear and tear that exhaust caregiv- ers’ coping mechanisms and available resources, and that may continue after the care recipient has been institutionalized (Paun & Farran, 2011). In addition, changes in the care recipient’s health status necessitate new skills and monitoring from the caregiver and affect the caregiver’s ability to continue to provide care (Given et al, 2011). Providing caregiver support throughout the care situation may decrease care recipient institutionalization (Matsuzawa et al, 2011).

• Watch for caregivers who become enmeshed in the care situation. EBN: Caregivers are at risk for becoming overinvolved or unable to disentangle themselves from the caregiver role, particularly in the absence of adequate social support (Hricik et al, 2011).

• Arrange for intervals of respite care for the caregiver; encourage use if available. EB: Respite care provides time away from the care situation and may help alleviate some caregiver distress (Maayan et al, 2014).

• Regularly monitor social support for the caregiver and help the caregiver identify and use appropriate support systems for varying times in the care situation. EBN: Lower levels of perceived support can cause caregivers to feel abandoned and increase their distress (Hwang et al, 2011).

• Encourage the caregiver to grieve over changes in the care recipient’s condition and give the caregiver permission to share angry feelings in a safe environment. Refer to nursing interventions for Grieving. EB: Caregivers grieve the loss of personhood of their loved one, especially when dementia is involved (Kramer et al, 2011).

• Help the caregiver find personal time to meet his or her needs, learn stress management techniques, schedule regular health screenings, and schedule regular respite time. EB: Due to increased risk for poor physical health as a result of providing care, caregivers must feel empowered to maintain self-care activities (Merluzzi et al, 2011). Interventions to provide support for family caregivers have shown improvements in caregiver health (Basu et al, 2013).

Caregiver Role Strain 203

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

• Encourage the caregiver to talk about feelings, concerns, uncertainties, and fears. Support groups can be used to gain mutual and educational support. EBN: Support groups can improve depressive symptoms and burden, particularly for female caregivers (Chien et al, 2011). EB: Social support groups can be effective over the Internet, using forums such as Facebook (Bender et al, 2011).

• Observe for any evidence of caregiver or care recipient violence or abuse, particularly verbal abuse; if evidence is present, speak with the caregiver and care recipient separately. EB/CEB: Caregiver violence is possible and screening should be done at regular intervals (Hoover & Polson, 2014).

▲ Involve the family in care transitions; use a multidisciplinary team to provide medical and social services for instruction and planning specific to the care situation. EBN: Family members need education specific to their situation beyond what is traditionally provided at discharge; this educational approach should be proactive and anticipate potential problems in the home (Loupis & Faux, 2013).

▲ Encourage regular communication with the care recipient and with the health care team. EB: There can be a large discrepancy between what the health care professional feels he or she has communicated and what the caregiver reports hearing (Molinuevo et al, 2011).

• Help caregiver assess his or her financial resources (services reimbursed by insurance, available support through community and religious organizations) and the impact of providing care on his or her financial status. EB/EBN: Better physical and mental health outcomes were common for caregivers and non-caregivers who reported having more resources (e.g., higher income, better preparedness for future financial need, higher satisfaction with transportation and housing, and no limitation of usual daily activi- ties) (Ahn et al, 2012).

• Help the caregiver identify competing occupational demands and potential benefits to maintaining work as a way of providing normalcy. Guide caregivers to seek ways to maintain employment through mecha- nisms such as job sharing or decreasing hours at work. EB: Employed caregivers report that work can provide a sense of fulfillment, refuge, and satisfaction (Eldh & Carlsson, 2011).

• Help the caregiver problem solve to meet the care recipient’s needs. EBN: Interventions that teach caregiv- ers problem-solving skills have been shown to positively influence caregivers’ psychosocial well-being (Cheng et al, 2014).

Geriatric

• Monitor the caregiver for psychological distress and signs of depression, especially if caring for a mentally impaired older adult or if there was an unsatisfactory marital relationship before caregiving. EBN: As the majority of family caregivers are spouses, degree of marital satisfaction is strongly linked with caregiver role strain (Green & King, 2011).

• Assess the health of caregivers, particularly their control over chronic diseases, at regular intervals. CEB: Caregivers with high levels of depressive symptoms have demonstrated poor health and increased health care utilization and cost (Zhu et al, 2014).

• Assess the presence of and use of social support and encourage the use of secondary caregivers with older caregivers. EBN: Social support has been shown to be an integral part of maintaining caregiver health (Quinn et al, 2014).

• To improve the ability to provide safe care: provide skills training related to direct care, perform complex monitoring tasks, supervise and interpret client symptoms, assist with decision-making, assist with medi- cation adherence, provide emotional support and comfort, and coordinate care. CEB: Each task demands different skills and knowledge, and caregivers show a desire to master these skills (Moon & Adams, 2013).

• Teach symptom management techniques (assessment, potential causes, aggravating factors, potential alleviating factors, reassessment), particularly for fatigue, constipation, anorexia, and pain. EBN: Caregiv- ers require training in care recipient monitoring symptom management and interpretation, and can benefit from a problem-solving approach (Sherwood et al, 2012).

Multicultural

• Assess for the influence of cultural beliefs, norms, and values on the client’s ability to modify health behavior. EBN: What the client considers normal and abnormal health behavior may be based on cultural perceptions (Giger, 2014). EBN: Each client should be assessed for ability to modify health behavior based on the phenomenon of communication, time, space, social organization, environmental control, and biologi- cal variations (Giger, 2014).

• Despite the importance of cultural differences in perceptions of caregiver role strain, there are certain characteristics that are distressing to caregivers across multiple cultures. EBN: Social support and care

204 Caregiver Role Strain

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

recipients’ behavioral difference have been shown to be an important factor in caregiver distress across mul- tiple cultures (Chiao & Schepp, 2012; Hwang et al, 2011; Zahid & Ohaeri, 2010).

• Persons with different cultural backgrounds may not perceive the provision of care with equal degrees of distress. EB: A group of caregivers in Belize did not report providing care as negative, although they did exhibit physical symptoms of distress (Vroman & Morency, 2011).

• Recognize that cultures often play a role in identifying who will be recognized as a family caregiver and form partnerships with those groups. EB: In a study of American Indians, people who attended and par- ticipated in Native events and endorsed traditional healing practices were more likely to be caregivers. The study also reported that gender played a role in identifying caregivers in some tribes, but not all (Goins et al, 2011).

• Encourage spirituality as a source of support for coping. EBN: Many African Americans and Latinos identify spirituality, religiousness, prayer, and church-based approaches as coping resources. Socioeconomic status, geographical location, and risks associated with health-seeking behavior all influence the likelihood that clients will seek health care and modify health behavior (Giger, 2014).

• Assess for the presence of conflicting values within the culture. EBN: Whereas sharing and caring is part of the Amish community, females with breast cancer were found to value privacy issues related to their body image and health status and to prefer this was shared in the closed community (Schwartz, 2008).

• Recognize that different cultures value and use caregiving resources in different ways. CEB: When Korean and Caucasian American caregivers were compared, there was more family support in Korean caregivers while Caucasian Americans were more likely to use formal support (Kong, 2007).

Home Care

• Assess the client and caregiver at every visit for quality of relationship, and for the quality of caring that exists. EB: Quality of the caregiver-care recipient relationship and the impact of the care situation on that relationship can be an important source of distress or support for the caregiver (van der Lee et al, 2014). Chronic illness, especially dementia, can represent a gradual and devastating loss of the marital relationship as it existed formerly.

• Assess preexisting strengths and weaknesses the caregiver brings to the situation, as well as current responses, depression, and fatigue levels. EB/EBN: Caregivers’ personality type, mastery, self-efficacy, optimism, and social support have all been linked to the amount of distress the caregiver will perceive as a result of providing care (Adelman et al, 2014).

▲ Refer the client to home health aide services for assistance with activities of daily living and light house- keeping. Allow the caregiver to gain confidence in the respite provider. Home health aide services can provide physical relief and respite for the caregiver. EB: The need for caregiver respite has been linked with the number of hours per week spent providing care (Hughes et al, 2014).

Client/Family Teaching and Discharge Planning

• Identify client and caregiver factors that necessitate the use of formal home care services, that may affect provision of care, or that need to be addressed before the client can be safely discharged from home care. EBN: Although home care resources can be useful in decreasing caregiver distress, they are not used with regularity across client populations. Health care practitioners should assess for the need for support resources prior to discharge and at routine intervals throughout the care situation, tailoring community resources to individual caregiver needs (Greene et al, 2011). Interventions prior to discharge may include medication management, medication reconciliation, identification of medical red flags, identification of community- based resources, and specific caregiver concerns about home care (Hendrix et al, 2011).

• Collaborate with the caregiver and discuss the care needs of the client, disease processes, medications, and what to expect; use a variety of instructional techniques (e.g., explanations, demonstrations, visual aids) until the caregiver is able to express a degree of comfort with care delivery. EB: Knowledge and confidence are separate concepts. Self-assurance in caregiving will decrease the amount of distress the care- giver perceives as a result of providing care (Giovannetti et al, 2012; Ostwald et al, 2014) and may improve the quality of care provided.

• Assess family caregiving skill. The identification of caregiver difficulty with any of a core set of processes highlights areas for intervention. CEB: The ability to engage effectively and smoothly in nine processes has been identified as constituting family caregiving skill: monitoring client behavior, interpreting changes accu- rately, making decisions, taking action, making adjustment to care, accessing resources, providing hands-on care, working together with the ill person, and negotiating the health care system (Schumacher et al, 2000).

Caregiver Role Strain 205

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

EB: Caregiver skills training has been shown to improve caregiver knowledge and skills and may be reim- bursable within governmental health care plans (Gitlin et al, 2010).

• Discharge care should be individualized to specific caregiver needs and care situations, and enable them to be prepared. EBN: Interventions implemented by advanced practice nurses have been successful in pre- venting negative outcomes (Bradway et al, 2012; Stone, 2014).

• Assess the caregiver’s need for information such as information on symptom management, disease pro- gression, specific skills, and available support. EBN: Caregiver interventions should be individualized to meet specific caregiver needs (Greene et al, 2011; Hendrix et al, 2011). Multicomponent strategies to provide education, support, counseling, and linkage to community resources to ease transitions from the hospital to the home can improve caregiver health and coping (Ostwald et al, 2014).

• Teach the caregiver warning signs for burnout, depression, and anxiety. Help them identify a resource in case they begin to feel overwhelmed.

• Teach the caregiver methods for managing disruptive behavioral symptoms if present. Refer to the care plan for Chronic Confusion. CEB: Behavioral interventions that consist of nine to 12 sessions over several months have been shown to be as effective as pharmacological interventions to control behavioral problems in the care recipient (Brodaty & Arasaratnam, 2012).

• Teach the caregiver how to provide the care needed and put a plan in place for monitoring the care provided.

• Provide ongoing support and evaluation of care skills as the care situation and care demands change. • Provide information regarding the care recipient’s diagnosis, treatment regimen, and expected course of

illness. ▲ Refer to counseling or support groups to assist in adjusting to the caregiver role and periodically evaluate

not only the caregiver’s emotional response to care but the safety of the care delivered to the care recipient.

REFERENCES Abendroth, M. (2015). Development and initial validation of a

Parkinson’s disease caregiver strain risk screen. Journal of Nursing Measurement, 23(1), 4–21.

Adelman, R. D., et al. (2014). Caregiver burden: A clinical review. JAMA: The Journal of the American Medical Association, 311(10), 1052–1060.

Ahn, S., Hochhalter, A. K., Moudouni, D. K., et al. (2012). Self- reported physical and mental health of older adults: The roles of caregiving and resources. Maturitas, 71(1), 62–69.

Basu, R., Hochhalter, A. K., & Stevens, A. B. (2013). The impact of the REACH II intervention on caregivers’ perceived health. Journal of Applied Gerontology.

Bender, J. L., Jimenez-Marroquin, M. C., & Jadad, A. R. (2011). Seeking support on Facebook: a content analysis of breast cancer groups. Journal of Medical Internet Research, 13(1), e16.

Bradway, C., et al. (2012). A qualitative analysis of an advanced practice nurse-directed transitional care model intervention. The Gerontologist, 52(3), 394–407.

Brodaty, H., & Arasaratnam, C. (2012). Meta-analysis of nonpharmacological interventions for neuropsychiatric syptoms of dementia. The American Journal of Psychiatry, 169(9), 946–953.

Cheng, H. Y., Chair, S. Y., & Chau, J. P. (2014). The effectiveness of psychosocial interventions for stroke family caregivers and stroke survivors. Patient Education and Counseling, 95(1), 30–44.

Chien, L. Y., et al. (2011). Caregiver support groups in patients with dementia: a meta-analysis. International Journal of Geriatric Psychiatry, 26(10), 1089–1098.

Chiao, C. Y., & Schepp, K. G. (2012). The impact of foreign caregiving on depression among older people in Taiwan: model testing. Journal of Advanced Nursing, 68(5), 1090–1099.

Eldh, A. C., & Carlsson, E. (2011). Seeking a balance between employment and the care of an ageing parent. Scandinavian Journal of Caring Sciences, 25(2), 285–293.

Fonareva, I., & Oken, B. S. (2014). Physiological and functional consequences of caregiving for relatives with dementia. International Psychogeriatrics, 26(5), 725–747.

Giger, J. (2014). Transcultural nursing: Assessment and Intervention (6th ed., Kindle Edition). St Louis: Mosby.

Giovannetti, E. R., et al. (2012). Difficulty assisting with health care tasks among caregivers of multimorbid older adults. Journal of General Internal Medicine, 27(1), 37–44.

Gitlin, L. N., Jacobs, M., & Earland, T. V. (2010). Translation of a dementia caregiver intervention for delivery in homecare as a reimbursable Medicare service: outcomes and lessons learned. The Gerontologist, 50(6), 847–854.

Given, B. A., Sherwood, P., & Given, C. W. (2011). Support for caregivers of cancer patients: transition after active treatment. Cancer Epidemiology, Biomarkers and Prevention: A Publication of the American Association for Cancer Research, Cosponsored by the American Society of Preventive Oncology, 20(10), 2015–2021.

Goins, R. T., et al. (2011). Adult caregiving among American Indians: the role of cultural factors. The Gerontologist, 51(3), 310–320.

Green, T. L., & King, K. M. (2011). Relationships between biophysical and psychosocial outcomes following minor stroke. Canadian Journal of Neuroscience Nursing, 33(2), 15–23.

Greene, A., et al. (2011). Can assessing caregiver needs and activating community networks improve caregiver-defined outcomes? A single-blind, quasi-experimental pilot study: community facilitator pilot. Palliative Medicine, 26(7), 917–923.

Hendrix, C. C., et al. (2011). Pilot study: individualized training for caregivers of hospitalized older veterans. Nursing Research, 60(6), 436–441.

Hoover, R. M., & Polson, M. (2014). Detecting elder abuse and neglect: Assessment and intervention. American Family Physician, 89(6), 453–460.

206 Risk for Caregiver Role Strain

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Risk for Caregiver Role Strain Jane M. Kendall, RN, BS, CHT

NANDA-I

Definition

Vulnerable to difficulty in performing the family/significant other caregiver role, which may compromise health

Risk Factors

Alteration in cognitive functioning in care receiver; care receiver discharged home with significant needs; care receiver exhibits bizarre behavior; care receiver exhibits deviant behavior; caregiver health impairment; caregiver isolation; caregiver not developmentally ready for caregiver role; caregiver’s competing role com- mitments; caregiving task complexity; codependency; congenital disorder; developmental delay; develop- mental delay of caregiver; excessive caregiving activities; exposure to violence; extended duration of caregiving required family isolation; female caregiver; illness severity of care receiver; inadequate physical environment for providing care; ineffective caregiver coping pattern; ineffective family adaptation; experience with care- giving; instability in care receiver’s health; insufficient caregiver recreation; insufficient respite for caregiver;

Hricik, A., et al. (2011). Changes in caregiver perceptions over time in response to providing care for a loved one with a primary malignant brain tumor. Oncology Nursing Forum, 38(2), 149–155.

Hughes, T. B., et al. (2014). Correlates of objective and subjective measures of caregiver burden among dementia caregivers: Influence of unmet patient and caregiver dementia-related care needs. International Psychogeriatrics, 26(11), 1875–1883.

Hwang, B., et al. (2011). Caregiving for patients with heart failure. American Journal of Critical Care, 20(6), 431–442.

Kong, E. H. (2007). The influence of culture on the experiences of Korean, Korean American, and Caucasian-American family caregivers of frail older adults: a literature review. Taehan Kanho Hakhoe chi, 37(2), 213–220.

Kramer, B. J., et al. (2011). Complicated grief symptoms in caregivers of persons with lung cancer. Omega, 62(3), 201–220.

Kruithof, W. J., Visser-Meily, J. M., & Post, M. W. (2011). Positive caregiving experiences are associated with life satisfaction in spouses of stroke survivors. Journal of Stroke and Cerebrovascular Diseases, [Epub ahead of print].

Loupis, Y. M., & Faux, S. G. (2013). Family conferences in stroke rehabilitation: A literature review. Journal of Stroke and Cerebrovascular Diseases, 22(6), 883–893.

Lovell, B., Moss, M., & Wetherell, M. (2012). The psychosocial, endocrine and immune consequences of caring for a child with autism or ADHD. Psychoneuroendocrinology, 37(4), 534–542.

Maayan, N., Soares-Weiser, K., & Lee, H. (2014). Respite care for people with dementia and their carers. Cochrane Database of Systematic Reviews.

Matsuzawa, T., et al. (2011). Predictive factors for hospitalized and institutionalized caregiving of the aged patients with diabetes mellitus in Japan. The Kobe Journal of Medical Sciences, 56(4), E173–E183.

Merluzzi, T. V., et al. (2011). Assessment of self-efficacy for caregiving: the critical role of self-care in caregiver stress and burden. Palliative and Supportive Care, 9(1), 15–24.

Molinuevo, J. L., & Hernandez, B. (2011). TRACE: Assessment of the information provided by the medical specialist on Alzheimer’s disease and that retained by the patient caregivers. Neurologia (Barcelona, Spain), [Epub ahead of print].

Moon, H., & Adams, K. B. (2013). The effectiveness of dyadic interventions for people with dementia and their caregivers. Dementia (Basel, Switzerland), 12(6), 821–839.

Ostwald, S. K., Godwin, K. M., Cron, S. G., et al. (2014). Home-based psychoeducational and mailed information programs for stroke- caregiving dyads post-discharge: A randomized trial. Disability and Rehabilitation, 36(1), 55–62.

Paun, O., & Farran, C. J. (2011). Chronic grief management for dementia caregivers in transition. Journal of Gerontological Nursing, 37(12), 28–35.

Quinn, K., Murray, C., & Malone, C. (2014). Spousal experiences of coping with and adapting to caregiving for a partner who has a stroke: A meta-analysis of qualitative research. Disability and Rehabilitation, 36(3), 185–198.

Schumacher, K. L., Stewart, B. J., Archbold, P. G., et al. (2000). Family caregiving skill: development of the concept. Research in Nursing and Health, 23(3), 191–203.

Schwartz, K. (2008). Breast cancer and health care beliefs, values, and practices of Amish women. Dissertation Abstracts, 29(1), 587.

Sherwood, P. R., et al. (2012). The impact of a problem-solving intervention on increasing caregiver assistance and improving caregiver health. Supportive Care in Cancer, 20(9), 1937–1947.

Stone, K. (2014). Enhancing preparedness and satisfaction of caregivers of patients discharged from an inpatient rehabilitation facility using an interactive website. Rehabilitation Nursing, 39(2), 76–85.

Van der Lee, J., et al. (2014). Multivariate models of subjective caregiver burden in dementia: A systematic review. Ageing Research Reviews, 15, 76–93.

Vroman, K., & Morency, J. (2011). “I do the best I can”: caregivers’ perceptions of informal caregiving for older adults in Belize. International Journal of Aging and Human Development, 72(1), 1–25.

Zahid, M. A., & Ohaeri, J. U. (2010). Relationship of family caregiver burden with quality of care and psychopathology in a sample of Arab subjects with schizophrenia. BMC Psychiatry, 10, 71.

Zhu, C. W., et al. (2014). Health-care use and cost in dementia caregivers: Longitudinal results from the Predictors Caregiver Study. Alzheimer’s & Dementia, [Epub ahead of print].

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Risk for Ineffective Cerebral Tissue Perfusion 207

partner as caregiver; pattern of family dysfunction prior to the caregiving situation; pattern of ineffective relationship between caregiver and care receiver; prematurity; presence of abuse (e.g., physical, psychologi- cal, sexual); psychological disorder in caregiver; psychological disorder in care receiver; stressors; substance abuse; unpredictability of illness trajectory

NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family Teaching, Rationales, and References

Refer to care plan for Caregiver Role Strain.

Risk for ineffective Cerebral tissue perfusion Laura Mcilvoy, PhD, RN, CCRN, CNRN

NANDA-I

Definition

Vulnerable to a decrease in cerebral tissue circulation, which may compromise health

Risk Factors

Abnormal partial thromboplastin time; abnormal prothrombin time; akinetic left ventricular wall segment; aortic atherosclerosis; arterial dissection; atrial fibrillation; atrial myxoma; brain injury (e.g., cerebrovascular impairment, neurological illness, trauma, tumor); brain neoplasm; carotid stenosis; cerebral aneurysm; coagulopathy (e.g., sickle cell anemia); dilated cardiomyopathy; disseminated intravascular coagulopathy; embolism; hypercholesterolemia; hypertension; infective endocarditis; mechanical prosthetic valve; mitral stenosis; pharmaceutical agent; recent myocardial infarction; sick sinus syndrome; substance abuse; treat- ment regimen

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Acute Confusion Level; Tissue Perfusion: Cerebral; Agitation Level; Neurological Status; Cognition; Seizure Control; Motor Strength

Example NOC Outcome with Indicators

Tissue Perfusion: Cerebral as evidenced by the following indicators: Headache/Restlessness/Listlessness/Agitation/Vomiting/ Fever/Impaired Cognition/Decreased level of consciousness/Motor weakness/Dysphagia/Slurred speech. (Rate the outcome and indicators of Tissue Perfusion: Cerebral: 1 = severe, 2 = substantial, 3 = moderate, 4 = mild, 5 = none [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• State absence of headache • Demonstrate appropriate orientation to person, place, time, and situation • Demonstrate ability to follow simple commands • Demonstrate equal bilateral motor strength • Demonstrate adequate swallowing ability

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Medication Management; Neurologic Monitoring; Positioning: Neurologic; Cerebral Perfusion Promotion; Fall Prevention; Cognitive Stimulation; Environmental Management: Safety

Example NIC Activities—Neurological Monitoring

Monitor pupillary size, shape, symmetry, and reactivity; Monitor level of consciousness; Monitor level of orientation; Monitor trend of Glasgow Coma Scale; Monitor facial symmetry; Note complaint of headache

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

208 Risk for Ineffective Cerebral Tissue Perfusion

Nursing Interventions and Rationales

• To decrease risk of reduced cerebral perfusion related to stroke or transient ischemic attack: ❍ Obtain a family history of hypertension and stroke to identify persons who may be at increased risk

of stroke. EB: A positive family history of stroke increases risk of stroke by approximately 30% (Goldstein et al, 2011).

❍ Monitor blood pressure (BP) regularly, because hypertension is a major risk factor for both ischemic and hemorrhagic stroke. EB: Systolic BP should be treated to a goal of less than 140 mm Hg and diastolic BP to less than 90 mm Hg, while clients with diabetes or renal disease have a BP goal of less than 130/80 mm Hg (Goldstein et al, 2011).

❍ Teach hypertensive clients the importance of taking their health care provider-ordered antihyperten- sive agent to prevent stroke. EB: Treatment of hypertension in adults with diabetes with an angiotensin converting enzyme inhibitor (ACEI) or an angiotensin receptor blockers (ARB) is useful (Goldstein et al, 2011).

❍ Stress smoking cessation at every encounter with clients, using multimodal techniques to aid in quit- ting, such as counseling, nicotine replacement, and oral smoking cessation medications. EB: Epide- miological studies show a consistent and overwhelming relationship between smoking and both ischemic and hemorrhagic stroke (Goldstein et al, 2011).

❍ Teach clients who experience a transient ischemic attack (TIA) that they are at increased risk for a stroke. EB: The 90-day risk for stroke after a TIA is as high as 17%, with the greatest risk occurring in the first week (Furie et al, 2011).

❍ Screen clients 65 years of age and older for atrial fibrillation with pulse assessment. EB: Atrial fibril- lation is associated with a fivefold increase in stroke. Systematic pulse assessment in primary care setting resulted in a 60% increase in the detection of atrial fibrillation (Goldstein et al, 2011).

❍ Call 911 or activate the rapid response team of a hospital immediately when clients display symptoms of stroke as determined by the Cincinnati Stroke Scale (F: facial drooping; A: arm drift on one side; S: speech slurred), being careful to note the time of symptom appearance. Additional symptoms of stroke include sudden numbness/weakness of face, arm or leg, especially on one side, sudden confu- sion, trouble speaking or understanding, sudden difficulty seeing with one or both eyes, sudden trouble walking, dizziness, loss of balance or coordination, or sudden severe headache (National Stroke Association, 2012). EB: The Cincinnati Stroke Scale (derived from the NIH Stroke Scale) is used to identify clients having a stroke who may be candidates for thrombolytic therapy (Jauch et al, 2013). EMS activation results in faster health care provider assessment, computed tomography, and neurological evaluation, which facilitates administering thrombolytics to eligible stroke victims within the required 3-hour time period (Jauch et al, 2013).

❍ Use clinical practice guidelines for glycemic control and BP targets to guide the care of clients with diabetes who have had a stroke or TIA. EB: The American Stroke Association recommends that evidence- based guidelines be used in the care of clients with diabetes. Good glycemic control has been associated with decreased incidence of strokes (Furie et al, 2011; Handelsman et al, 2011).

❍ Maintain head of bed less than 30 degrees in the acute phase (<72 hours of symptom onset) of ischemic stroke. EB: Cortical cerebral blood flow is decreased when head of bed is elevated from 0 degrees to 30 degrees in clients with acute ischemic stroke (Favilla et al, 2014).

❍ Head of bed may be elevated to sitting position without detrimental effect to cerebral blood flow in clients with ischemic stroke or subarachnoid hemorrhagic at 72 hours after symptom onset. EB: Head of bed elevation of 45 degrees and 70 degrees in the subacute phase of ischemic stroke resulted in minor changes in cerebral blood flow velocities (Aries et al, 2013). EB: Cerebral blood flow had no significant changes in head of bed elevations from 0 degree to 90 degrees in clients with subarachnoid hemorrhage at day 3, 7, and 10 (Kung et al, 2013).

❍ Administer oral nimodipine as prescribed by the healthcare provider after subarachnoid hemorrhagic strokes for 21 days. EB: Nimodipine, a calcium channel blocker, has been shown by multiple randomized clinical trials to improve outcome by limiting delayed cerebral ischemia after subarachnoid hemorrhage strokes (Diringer et al, 2011).

▲ To decrease risk of reduced cerebral perfusion pressure (CPP): Cerebral perfusion pressure = Mean arterial pressure − intracranial pressure (CPP = MAP − ICP): See care plan for Decreased Intracranial adaptive capacity. ❍ Maintain euvolemia. CEB: Infusing intravenous fluids to sustain normal circulating volume helps main-

tain normal cerebral blood flow (Bullock et al, 2001).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Ineffective Childbearing Process 209

▲ To treat decreased CPP: ❍ Clients with subarachnoid hemorrhagic stroke experiencing delayed cerebral ischemia, as evidenced

by declining neurological exam, should undergo a trial of induced hypertension. EB: Hypertension increased cerebral blood flow and produced neurological improvement in the majority of clients (Diringer et al, 2011).

❍ Administer phenylephrine infusion to raise MAP per collaborative protocol. EB: Phenylephrine was more effective than dopamine in raising MAP and more effective than norepinephrine in raising CPP in severely injured clients with traumatic brain injury (Sookplung et al, 2011).

REFERENCES Aries, M. J., Elting, J. W., Stewart, R., et al. (2013). Cerebral blood flow

velocity changes during upright positioning in bed after acute stroke: an observational study. British Medical Journal Open, 3, 1–4. Retrieved from: <http://dx.doi.org/10.1136/bmjopen- 2013-002960>.

Bullock, R., Chestnut, R., & Clifton, G. (2001). Management and prognosis of severe traumatic brain injury. Journal of Neurotrauma, 17(6&7), 451–627.

Diringer, M. N., Bleck, T. P., Claude, H. J., et al. (2011). Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocritical Care, 15(2), 211–240.

Favilla, C. G., Mesquita, R. C., Mullen, M., et al. (2014). Optical bedside monitoring of cerebral blood flow in acute ischemic stroke patients during head-of-bed manipulation. Stroke; a Journal of Cerebral Circulation, 45, 1269–1274.

Furie, K. L., Kasner, S. E., Adams, R. J., et al. (2011). Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack: a guideline for healthcare professionals from the AHA/ASA. Stroke; a Journal of Cerebral Circulation, 42, 227–276.

Goldstein, L. B., Bushnell, C. D., Adams, R. J., et al. (2011). Guidelines for the primary prevention of stroke: a guideline for healthcare professionals from AHA/ASA. Stroke; a Journal of Cerebral Circulation, 42, 517–584.

Handelsman, Y., Mechanick, J. I., Blonde, L., et al. (2011). American Association of Clinical Endocrinologist medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocrine Practice, 17(Suppl. 2), 1–53.

Jauch, E. C., Saver, J. L., Adams, H. P., et al. (2013). Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the AHA/ASA. Stroke; a Journal of Cerebral Circulation, 44, 870–947.

Kung, D. K., Chalouhi, N., Jabbour, P. M., et al. (2013). Cerebral blood flow dynamics and head-of-bed changes in the setting of subarachnoid hemorrhage. BioMed Research International, 2013, 1–4. Retrieved from: <http://dx.doi.org/10.1155/2013/640638>.

National Stroke Association. (2012). Recognizing Stroke. <http://www. stroke.org/understand-stroke/recognizing-stroke>.

Sookplung, P., Siriussawakul, A., Malakouti, A., et al. (2011). Vasopressor use and effect on blood pressure after severe adult traumatic brain injury. Neurocritical Care, 15(1), 46–54.

Ineffective Childbearing process Dianne Frances Hayward, RN, MSN, WHNP

NANDA-I

Definition

Pregnancy and childbirth process and care of the newborn that does not match the environmental context, norms, and expectations

Definition During Pregnancy

Inadequate prenatal care; inadequate prenatal lifestyle (e.g., elimination, exercise, nutrition personal hygiene, sleep); inadequate preparation of newborn care items; inadequate preparation of the home environment; ineffective management of unpleasant symptoms in pregnancy; insufficient access of support system; insuf- ficient respect for unborn baby; unrealistic birth plan

During Labor and Delivery

Decrease in proactivity during labor and delivery; inadequate lifestyle for stage of labor (e.g., elimination, exercise, nutrition, personal hygiene, sleep); inappropriate response to onset of labor; insufficient access or support system; insufficient attachment behavior

After Birth

Inadequate baby care techniques; inadequate postpartum lifestyle (e.g., elimination, exercise, nutrition per- sonal hygiene, sleep); inappropriate baby feeding techniques; inappropriate breast care; insufficient access of support system; insufficient attachment behavior; unsafe environment for infant

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

210 Ineffective Childbearing Process

Example NIC Activities—High-Risk Pregnancy Care

Instruct patient on importance of receiving regular prenatal care and to follow plan of care by taking prescribed medications and following nutrition guidelines; Encourage identification of psychosocial/psychological issues and substance use and appropriate treatment and referrals as needed

Related Factors

Domestic violence; inconsistent prenatal heath visits; insufficient knowledge of childbearing process; inad- equate maternal nutrition; insufficient parental role model; insufficient prenatal care; insufficient support system; low maternal confidence; maternal powerlessness; maternal psychological distress; substance abuse; unplanned pregnancy; unrealistic birth plan; unsafe environment; unwanted pregnancy

NOC Nursing Outcomes Classification

Suggested NOC Outcomes

Fetal Status: Antepartum, Intrapartum; Maternal Status: Antepartum, Intrapartum; Depression Level; Family Resiliency; Knowledge: Substance Use Control; Social Support; Spiritual Support

Example NOC Outcome with Indicators

Maternal Status: Antepartum as evidenced by the following indicators: Emotional attachment to fetus/Coping with discomforts of pregnancy/Mood lability/Has realistic birth plan/Has support system. (Rate each indicator of Maternal Status: Antepartum: 1 = severe deviation from normal range, 2 = substantial deviation from normal range, 3 = moderate deviation from normal range, 4 = mild deviation from normal range, 5 = no deviation from normal range [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

Antepartum

• Obtain early prenatal care in the first trimester and maintain regular visits • Obtain knowledge level needed for appropriate care of oneself during pregnancy including good nutrition

and psychological health • Understand the risks of substance abuse and resources available • Feel empowered to seek social and spiritual support for emotional well-being during pregnancy • Use support systems for labor and emotional support • Develop a realistic birth plan, taking into account any high-risk pregnancy issues • Understand the labor and delivery process and comfort measures to manage labor pain Postpartum

• Use a safe environment for self and infant • Obtain knowledge to provide appropriate newborn care and postpartum care of self • Obtain knowledge to develop appropriate bonding and parenting skills

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

High-Risk Pregnancy Care; Intrapartal Care

Nursing Interventions and Rationales

• Encourage early prenatal care and regular prenatal visits. EB/EBN: Women who attended for less than four visits or started care late were at risk for a poorer outcome. Culture must also be assessed to provide appropriate prenatal care (Beeckman et al, 2013; Lewallen, 2011). EBN: A study compared outcomes of infants born to women who received Medicaid and prenatal care coordination (PNCC) services versus women who received Medicaid but did not receive PNCC. Women who received PNCC services resulted

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Ineffective Childbearing Process 211

in delivery of fewer low-birth-weight infants, fewer preterm infants, and fewer infants transferred to the neonatal intensive care unit. PNCC is an effective strategy for preventing adverse birth outcomes (Van Dijk et al, 2011).

▲ Identify any high-risk factors that may require additional surveillance, such as preterm labor, hypertensive disorders of pregnancy, diabetes, depression, other chronic medical conditions, presence of fetal anoma- lies, or other high-risk factors. EB: Timely and accurate antenatal screening is believed to be an important factor in preventing preterm birth, screening for gestational diabetes, preeclampsia, intrauterine growth restriction, and depression, to mention a few. Finding and treating problems early improves outcome (Beeckman et al, 2013).

▲ Assess and screen for signs and symptoms of depression during pregnancy and in the postpartum period including history of depression or postpartum depression, poor prenatal care, poor weight gain, hygiene issues, sleep problems, substance abuse, and preterm labor. If depression is present, refer for behavioral- cognitive counseling, and/or medication (postpartum period only). Both counseling and medication are considered relatively equal to help with depression. EB/EBN: Screen pregnant women using a tool like the Patient Health Questionnaire (PHQ-9) for depression risk identification. When comprehensive screening is not included during antepartum care, there is less likelihood that significant information will be revealed. Subsequently, undiagnosed clinical depression in pregnancy may lead to serious perinatal complications such as inadequate maternal weight gain, preterm birth, and low infant birth weight (Breedlove & Fryzelka, 2011; Sidebottom et al, 2012; Rollans et al, 2013).

▲ Observe for signs of alcohol use and counsel women to stop drinking during pregnancy. Give appropriate referral for treatment if needed. EB: Alcohol is teratogenic, and prenatal exposure may result in growth impairment, facial abnormalities, central nervous system and/or intellectual impairment, and behavioral disorders. Evidence suggests women’s past pregnancy, current drinking behavior, and attitude toward alcohol use in pregnancy were the strongest predictors of alcohol consumption in pregnancy (Barclay, 2011; Peadon et al, 2011).

▲ Obtain a smoking history and counsel women to stop smoking for the safety of the baby. Give appropriate referral to smoking cessation program if needed. CEB: Tobacco smoking in pregnancy remains one of the few preventable factors associated with pregnancy complications. Use the 5As (tobacco cessation interven- tions) to treat tobacco use and dependence in pregnant women. According to the USDHHS Clinical Practice Guidelines, health care professionals should at every contact (1) ask if a woman is a tobacco user, (2) advise her to quit, (3) assess her willingness to quit, (4) assist with the quit attempt (such as counseling, medication), and (5) arrange for follow-up (telephone support 1-800-QUIT-NOW). The evidence is compelling, even a minimal (less than 3 minute) intervention can make a difference in motivation to quit smoking (USDHHS, 2008).

▲ Monitor for substance abuse with recreational drugs. Refer to drug treatment program as needed. Refer opiate-dependent women to methadone clinics to improve maternal and fetal pregnancy outcomes. EBN: The drug addict is obsessed by the drug of choice because of a change in the pathophysiology of the brain. Treating addiction as a chronic disease instead of a moral weakness is more supportive to women who abuse drugs. It is important to involve a pregnant woman in a treatment program like a methadone clinic to help to stabilize the maternal–fetal dyad. Methadone prevents withdrawal symptoms and eliminates drug craving. Methadone blocks the euphoric effects of illegal self-administered narcotics. It also supports stable maternal opioid levels to protect the fetus from repeated occurrences of withdrawal and decreases the risk for sexually transmitted infections by decreasing drug-seeking behaviors such as prostitution. When a woman makes the decision to enroll in a methadone treatment program, she is taking a significant step toward recovery (Maguire, 2014).

▲ Monitor for psychosocial issues including lack of social support system, loneliness, depression, lack of confidence, maternal powerlessness, domestic violence, and socioeconomic problems. CEB: A study that compared psychosocial assessment versus routine care for pregnant women concluded that the health care providers who assessed psychosocial factors were more likely to identify psychosocial concerns, including family violence, and to rate the level of concern as high. In two trials, women identified they did not want to feel so alone, be judged, or be misunderstood, and they wanted to feel an increased sense of their own worth. Social support interventions can improve health. The use of doulas or labor coaches can provide assistance in addressing social-psychological issues and socioeconomic disparities (Austin et al, 2008; Gentry et al, 2010; Small et al, 2011).

▲ Monitor for signs of domestic violence. Refer to a community program for abused women that provides safe shelter as needed. EB: Women who were involved in intimate partner violence were more

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

212 Ineffective Childbearing Process

likely to experience negative outcomes such as preterm delivery and delivery of low-birth-weight infants (Shneyderman & Kiely, 2013). Women enduring domestic violence are often in denial. Pregnancy and immediately postpartum are highly vulnerable times for mothers and their infants to experience domestic violence. These women also need to be assessed regularly because they may not be ready to seek help at first. This may be the only time a pregnant victim of domestic violence comes in contact with a health care provider who can assess for the abuse and take action to resolve it (Menezes Cooper, 2013).

• Provide antenatal education to increase the woman’s knowledge needed to make informed choices during pregnancy, labor, and delivery and to promote a healthy lifestyle. EB: Antenatal classes must be interesting enough to maintain attention, relevant to the attendees, and understandable. The parents should feel empow- ered that the decisions they make about maternity care and parenthood are made with up-to-date evidence- based information and fit into their lifestyle. O’Sullivan et al (2014) found that class sizes tended to be too large to include class participation. They also reported educators sometimes just focused on maternity care and not on parenthood, healthy lifestyle, and changing relationships. Although resources are available, the educators reported their facility had limited educational resources.

• Encourage expectant parents to prepare a realistic birth plan in order to prepare for the physical and emotional aspects of the birth process and to plan ahead for how they want various situations handled. CEB: The degree of satisfaction the mothers have with the birth of their baby is increased when they have made an individualized birth plan and the medical team and parents are able to follow it (Sato & Umeno, 2011).

• Encourage good nutritional intake during pregnancy to facilitate proper growth and development of the fetus. Women should consume an additional 300 calories per day during pregnancy, take a multi- micronutrient supplement containing at least 400 µg folic acid, and achieve a total weight gain of 25 to 30 lb. EB: A healthy, varied diet (e.g., Choosemyplate.gov) is of vital importance for optimal birth outcome, including taking a multivitamin with folic acid from before conception to at least the twelfth week of preg- nancy, as well as a vitamin D supplement throughout pregnancy. Many women are not following the guide- lines and there are concerns for these vulnerable groups (USDA, 2014; Williamson & Wyness, 2013). Inadequate levels of key nutrients during crucial periods of fetal development may lead to changes within fetal tissues, predisposing the infant to chronic illnesses and conditions in later life (Procter & Campbell, 2014).

Multicultural

▲ Provide for a translator if needed. EB: The health care industry must recognize that providing translators for language assistance is an important tool for improving quality of care, saving lives, and avoiding costly and dangerous medical errors. Although costly, the American health care industry needs to comply with federal and state laws as well as accreditation standards by being prepared to provide care in at least 100 different languages (Rivers & Rivers, 2013).

▲ Provide depression screening for clients of all ethnicities. EB: Race and ethnicity are important risk factors for antenatal depression. A study found that non-Hispanic white women, black women, and Asian/Pacific Islander women had an increased risk for antenatal depression. The prevalence of antenatal depression was 15.3% in black women, 6.9% in Latinas, and 3.6% in non-Hispanic white women (Gavin et al, 2011). EB: Screening Latina women for depression, 20.4% were positive for depressive symptoms and 36.7% reported psychosocial issues such as intimate partner violence and substance abuse while pregnant (Connelly et al, 2013). CEB: Women who are depressed are at risk for unhealthy behaviors such as using tobacco, alcohol, and or drugs. They either sleep too much or not enough, their hygiene suffers, and they are less likely to attend prenatal visits. Maternal levels of corticosteroids and catecholamine are increased, which directly affect the growth and development of the fetus. Maternal depression may also affect bonding (Bowen & Muhajarine, 2006).

• Perform a cultural assessment and provide obstetrical care that is culturally appropriate to ensure a safe and satisfying childbearing experience. EBN: Just because a woman is a part of a certain culture, it is not safe to assume she follows all the beliefs of that culture. Asking about what she needs and expects is vital. Nurses must acknowledge that the maternity health care system has a unique culture that may clash with the cultures of many of our clients. Women not accustomed to this culture of potential risk in prenatal care, childbirth, and neonatal care may be frightened, overwhelmed, or made to feel guilty if they are not willing to undergo some of the expected interventions (Lewallen, 2011).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Readiness for Enhanced Childbearing Process 213

Readiness for enhanced Childbearing process Gail B. Ladwig, MSN, RN, and Dianne Frances Hayward, RN, MSN, WHNP

NANDA-I

Definition

A pattern of preparing for and maintaining a healthy pregnancy, childbirth process, and care of newborn for ensuring well-being that can be strengthened

Defining Characteristics During Pregnancy

Expresses desire to enhance knowledge of childbearing process; expresses desire to enhance management of unpleasant pregnancy symptoms; expresses desire to enhance prenatal lifestyle (e.g., elimination, exercise, nutrition, personal hygiene, sleep); expresses desire to enhance preparation for newborn

REFERENCES Austin, M. P., Priest, S. R., & Sullivan, E. A. (2008). Antenatal

psychosocial assessment for reducing perinatal mental health morbidity. Cochrane Database of Systematic Reviews, (4), CD005124.

Barclay, L. (2011). ACOG calls for alcohol screen annually and at prenatal visit. Obstetrics and Gynecology, 18, 383–388.

Beeckman, K., Louckx, F., Downe, S., et al. (2013). The relationship between antenatal care and preterm birth: the importance of content of care. European Journal of Public Health, 23(3), 366–371.

Bowen, A., & Muhajarine, N. (2006). Antenatal depression: nurses who understand the prevalence, signs and symptoms, and risk factors associated with antenatal depression (AD) can play a valuable role in identifying AD and preventing the sequelae in pregnant women and their families. Canadian Nurse, 102(9), 27–30.

Breedlove, G., & Fryzelka, D. (2011). Depression screening during pregnancy. Journal of Midwifery and Women’s Health, 56(1), 18–25.

Connelly, C. D., Hazen, A. L., Baker-Ericzén, M. J., et al. (2013). Is screening for depression in the perinatal period enough? The co-occurrence of depression, substance abuse, and intimate partner violence in culturally diverse pregnant women. Journal of Women’s Health (15409996), 22(10), 844–852.

Gavin, A. R., Melville, J. L., Rue, T., et al. (2011). Racial differences in the prevalence of antenatal depression. General Hospital Psychiatry, 33(2), 87–93.

Gentry, Q., Nolte, K., Gonzalez, A., et al. (2010). “Going beyond the call of doula”: A grounded theory analysis of the diverse roles community-based doulas play in the lives of pregnant and parenting adolescent mothers. Journal of Perinatal Education, 19(4), 24–40.

Lewallen, L. P. (2011). The importance of culture in childbearing. Journal of Obstetric, Gynecologic, and Neonatal Nursing: JOGNN/ NAACOG, 40, 4–8.

Maguire, D. (2014). Drug addiction in pregnancy: Disease not moral failure. Neonatal Network, 33(1), 11–18.

Menezes Cooper, T. (2013). Domestic Violence and Pregnancy: A Literature Review. International Journal of Childbirth Education, 28(3), 30–33.

O’Sullivan, C., O’Connell, R., & Devane, D. (2014). A descriptive survey of the educational preparation and practices of antenatal educators in Ireland. Journal of Perinatal Education, 23(1), 33–40.

Peadon, E., Payne, J., Henley, N., et al. (2011). Attitudes and behaviour predict women’s intention to drink alcohol during pregnancy:

the challenge for health professionals. BMC Public Health, 11, 584.

Procter, S. B., & Campbell, C. G. (2014). Position of the Academy of Nutrition and Dietetics: Nutrition and lifestyle for a healthy pregnancy outcome. Journal of The Academy of Nutrition & Dietetics, 114(7), 1099–1103.

Rivers, K., & Rivers, D. L. (2013). Foreign language difficulties in American healthcare: The challenges of medical translation regulation and remuneration. National Social Science Proceedings, 52(1), 150–160.

Rollans, M., Schmied, V., Kemp, L., et al. (2013). ‘We just ask some questions…’ the process of antenatal psychosocial assessment by midwives. Midwifery, 29(8), 935–942.

Sato, S., & Umeno, Y. (2011). The relationship between the recognition of postpartum mothers’ birth plan and the degree of satisfaction with delivery. Journal of Japan Academy of Midwifery, 25(1), 27–35.

Shneyderman, Y., & Kiely, M. (2013). Intimate partner violence during pregnancy: victim or perpetrator? Does it make a difference? BJOG: An International Journal Of Obstetrics & Gynaecology, 120(11), 1375–1385.

Sidebottom, A., Harrison, P., Godecker, A., et al. (2012). Validation of the Patient Health Questionnaire (PHQ)-9 for prenatal depression screening. Archives Of Women’s Mental Health, 15(5), 367–374.

Small, R., Taft, A. J., & Brown, S. J. (2011). The power of social connection and support in improving health: lessons from social support interventions with childbearing women. BMC Public Health, 11, S4.

US Department of Agriculture, (USDA). (2014). Nutritional needs during pregnancy. Choosemyplate.gov/pregnancy. Retrieved from: <http://www.choosemyplate.gov/pregnancy-breastfeeding/ pregnancy-nutritional-needs.html>.

U.S. Department of Health and Human Services (USDHHS). (2008). Treating tobacco use and dependence: clinical practice guideline 2008 update. Pregnant smokers. Retrieved from: <http://www.ahrq.gov/ clinic/tobacco/treating_tobacco_use08.pdf>.

Van Dijk, J. W., Anderko, L., & Stetzer, F. (2011). The impact of prenatal care coordination on birth outcomes. J Obstet Gynecol Neonat Nurs, 40, 98–108.

Williamson, C., & Wyness, L. (2013). Nutritional requirements in pregnancy and use of dietary supplements. Community Practitioner, 86(8), 44–47.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

214 Readiness for Enhanced Childbearing Process

Example NOC Outcome with Indicators

Knowledge: Pregnancy as evidenced by client conveying understanding of the following indicators: Importance of frequent prenatal care/Importance of prenatal education/Benefits of regular exercise/Healthy nutritional practices/Anatomic and physiological changes with pregnancy/Psychological changes associated with pregnancy/Birthing options/Effective labor techniques/ Signs and symptoms of labor. (Rate the outcome and indicators of Knowledge: Pregnancy: 1 = no knowledge, 2 = limited knowledge, 3 = moderate knowledge, 4 = substantial knowledge, 5 = extensive knowledge [see Section I].)

Example NIC Activities—Prenatal Care

Encourage prenatal class attendance; Discuss nutritional needs and concerns (e.g., balanced diet, folic acid, food safety, and supplements); Discuss activity level with client (e.g., appropriate exercise, activities to avoid, and importance of rest); Discuss importance of participating in prenatal care throughout entire pregnancy while encouraging involvement of client’s partner or other family member

During Labor and Delivery

Expresses desire to enhance lifestyle appropriate for stage of labor (e.g., elimination, exercise, nutrition, personal hygiene, sleep); expresses desire to enhance proactivity during labor and delivery

After Birth

Expresses desire to enhance attachment behavior; expresses desire to enhance baby care techniques; expresses desire to enhance baby feeding techniques; expresses desire to enhance breast care; expresses desire to enhance environmental safety for the baby; expresses desire to enhance postpartum lifestyle (e.g., elimina- tion, exercise, nutrition, personal hygiene, sleep); expresses desire to enhance use of support system

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Knowledge: Pregnancy; Knowledge: Infant Care; Knowledge: Postpartum Maternal Health

Client Outcomes Client Will (Specify Time Frame)

During Pregnancy

• State importance of frequent prenatal care/education • State knowledge of anatomic, physiological, psychological changes with pregnancy • Report appropriate lifestyle choices prenatal: Activity and exercise/healthy nutritional practices During Labor and Delivery

• Report appropriate lifestyle choices during labor • State knowledge of birthing options, signs and symptoms of labor, and effective labor techniques After Birth

• Report appropriate lifestyle choices postpartum • State normal physical sensations following delivery • State knowledge of recommended nutrient intake, strategies to balance activity and rest, appropriate

exercise, time frame for resumption of sexual activity, strategies to manage stress • List strategies to bond with infant • State knowledge of proper handling and positioning of infant/infant safety • State knowledge of feeding technique and bathing of infant

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Prenatal Care; Intrapartal Care; Postpartal Care; Attachment Promotion; Infant Care: Newborn

Nursing Interventions and Rationales

Refer to care plans: Risk for impaired Attachment; Readiness for enhanced Breastfeeding; Readiness for enhanced family Coping; Readiness for enhanced Family processes; Risk for disproportionate Growth; Readiness for enhanced Nutrition; Readiness for enhanced Parenting; Ineffective Role performance.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Readiness for Enhanced Childbearing Process 215

Prenatal Care

▲ Ensure that pregnant clients have an adequate diet and take multi-micronutrient supplements containing at least 400 micrograms of folic acid during pregnancy. EB: A healthy, varied diet (i.e., Choosemyplate. gov) is of vital importance for optimal birth outcome, and this includes taking a folic acid supplement from before conception to the 12th week of pregnancy, as well as a vitamin D supplement throughout pregnancy; many women are not following these guidelines and there are concerns for vulnerable groups (USDA, 2014; Williamson & Wyness, 2013).

• Encourage pregnant clients to include enriched cereal grain products in their diets. EB: Folate is a B vitamin that helps prevent neural tube defects, serious abnormalities of the brain and spinal cord. Fortified cereals are great sources of folic acid. (Mayo Clinic, 2014). CEB: The number of pregnancies affected by neural tube defects greatly decreased in the United States after the fortification of cereal grain products with folic acid was mandated (CDC, 2010).

• Assess smoking status of pregnant clients and offer effective smoking-cessation interventions. EB: Pre- natal smoking prevalence remains high in the United States. It is one of the most significant modifiable risk factors for adverse infant outcomes (e.g., low birth weight, preterm birth [preterm], and sudden infant death syndrome). To reduce prenatal smoking prevalence, efforts should focus on delivering evidence-based cessa- tion interventions (Tong et al, 2011; Batech et al, 2013; USDHHS Clinical Practice Guidelines, 2008).

• Also see Risk for disturbed Maternal–Fetal dyad for USDHHS guidelines. ▲ Assess for signs of depression and make appropriate referral: inadequate weight gain, underutilization of

prenatal care, increased substance use, and premature birth. Past personal or family history of depression, single, poor health functioning, and alcohol use. EBN: Social and emotional health problems associated with depression in the perinatal period can lead to poor outcomes for women, their infants, and their families (Rollans et al, 2013).

• Discuss breastfeeding with a pregnant client, including all the benefits both to the infant and the mother EB: Pregnant women need information about overcoming potential breastfeeding problems and the physiol- ogy of breastfeeding. Interventions designed to promote breastfeeding confidence need to be directed to pri- miparas and women with a lack of breastfeeding knowledge (Laanterä et al, 2012).

Intrapartal Care

• Encourage psychosocial support during labor, especially by the father of the baby or the woman’s mother if possible. EB: When a husband provides continuous support during his wife’s labor, his presence is con- sidered effective in reducing her dissatisfaction with the childbirth process. According to Lacerda et al (2014), the ideal companion is someone with whom the client has a bond and is trusted. The father of the child ranked first, followed by the mother of the postpartum woman. EBN: The key to promoting a normal birth and reducing medical interventions is high-quality continuous support. This support increases a woman’s perception of a positive birth experience, fosters a positive adaptation to motherhood, and reduces the risk for posttraumatic stress disorder and other postpartum mental health problems (Ross-Davie & Cheyne, 2014; Sapkota et al, 2013).

• Consider using aromatherapy during labor. EB: Aromatherapy has been used in childbirth to reduce anxiety and pain (Horowitz, 2011).

• Provide massage and relaxation techniques during labor. EB: There is some evidence to suggest that relax- ation and massage may improve management of labor pain, with few adverse effects. These interventions relieved pain and improved satisfaction with pain and childbirth experience when compared with placebo or standard care. Relaxation was associated with fewer assisted vaginal births (Jones et al, 2012).

• Offer the client in labor a clear liquid diet and water if allowed. EB: There is insufficient evidence to make conclusions about the relationship between fasting times for clear liquids and the risk for emesis, reflux, or pulmonary aspiration during labor. Although there is some disagreement, the majority of experts agree that oral intake of clear liquids during labor does not lead to increased maternal complications (ACOG, 2013).

Multicultural

Prenatal

• Assess the client’s beliefs and concerns about prenatal care. Provide culturally appropriate prenatal care for clients. EBN: Most Samoan women attended their first antenatal appointment in their first trimester of pregnancy. Fewer attended antenatal care later in pregnancy (fifteenth week or after). Samoan women

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

216 Readiness for Enhanced Childbearing Process

viewed pregnancy as wellness. Most participants did not relate to the content of mainstream antenatal classes because they were not culturally appropriate (Tanuvasa et al, 2013; Torres et al, 2012).

▲ Refer the client to a centering pregnancy group (8 to 10 women of similar gestational age receive group prenatal care after initial obstetrical visit) or group prenatal care. EB: Group prenatal care appears to have created a benefit to the women, not just with their birth experiences, but also with the psychological and social aspects of this life change (Risisky et al, 2013).

Intrapartal

• Assess client’s beliefs and concerns about labor. Consider the client’s culture when assisting in labor and delivery. EBN: A culturally appropriate OB/GYN service has input from the community, provides options, and respects choices (Simmonds et al, 2012). According to van Dijk et al (2013), most clients of these services desired the option of culturally appropriate care but typically did not receive it.

Postpartal

• Assess client’s beliefs and concerns about the postpartum period. Provide culturally appropriate health and nutrition information and guidance on contemporary postpartum practices and take away common misconceptions about traditional dietary and health behaviors (e.g., fruit and vegetables should be restricted because of cold nature). Encourage a balanced diet and discourage unhealthy hygiene taboos. EB: Many cultures practice food taboos surrounding pregnancy with consequent depletion of vital nutrients, which can be detrimental to both the mother and fetus (Oni & Tukur, 2012). EBN: In some cultures, women refuse to bathe and wash their hair after childbirth and during the postpartum period. The influence of beliefs and taboos offers health risks for the postpartum woman and newborn. In contrast, beliefs and taboos that do not offer health risks should not be countered because they contribute to the well-being of postpartum women (Trettene & Manci, 2012).

Home Care

Prenatal

▲ Involve pregnant drug users in drug treatment programs that include coordinated interventions in several areas: drug use, infectious diseases, mental health, personal and social welfare, and gynecological/ obstetric care. EBN: The drug addict is obsessed by the drug of choice because of a change in the patho- physiology of the brain. Treating addiction as a chronic disease instead of a moral weakness will be more supportive to women who abuse drugs. It is important to involve a pregnant woman in a treatment program like a methadone clinic to help to stabilize the maternal–fetal dyad. Methadone prevents withdrawal symp- toms and eliminates drug craving. Methadone blocks the euphoric effects of illegal self-administered narcotics. It also supports stable maternal opioid levels to protect the fetus from repeated occurrences of withdrawal and decreases the risk for STIs (sexually transmitted infections) by decreasing drug-seeking behaviors such as prostitution. When a woman makes the decision to enroll in a methadone treatment program, she is taking a significant step toward recovery (Maguire, 2014).

Postpartal

• Provide video conferencing to support new parents. EBN: Parents viewed videoconferencing as a possible chance to obtain extra support after returning home with their newborns (Lindberg, 2013).

• Consider reflexology for postpartum women to improve sleep quality. EBN: A systematic review and meta-analysis indicates that foot reflexology is a useful nursing intervention to relieve fatigue and to promote sleep (Lee et al, 2011).

Client/Family Teaching and Discharge Planning

Prenatal

• Provide dietary and lifestyle counseling as part of prenatal care to pregnant women. EB: A healthy pre- pregnancy weight, appropriate weight gain, physical activity during pregnancy, intake of a wide variety of foods, appropriate vitamin and mineral supplementation, avoidance of alcohol and other harmful sub- stances, regular prenatal visits, and safe food handling are all components leading to a healthy pregnancy outcome. Pregnancy is a crucial period and maternal nutrition and lifestyle choices are major influences on mother and infant/child health. Healthy lifestyle changes are the key to the health of the next generation (Procter & Campbell, 2014).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Readiness for Enhanced Childbearing Process 217

• Provide the following information in parenting classes via DVD and Internet: support mechanisms, information and antenatal education, breastfeeding, practical baby care, and relationship changes. Include fathers in the parenting classes. EB: Most fathers, expectant and experienced, felt there were not enough resources to support their education, spaces to support their involvement, or recognition of their experiences and feelings about pregnancy, labor, birth, and fathering. As the findings from the St. George and Fletcher (2011) study indicate, receiving encouragement and education that supports involved fathers is welcomed by many men. Although fathers’ contribution to their children’s well-being varies across cultures and roles, the effect of a father’s positive involvement reaches far into the future of the child’s social, emotional, and cognitive well-being.

• Provide group prenatal care to families in the military. EB: A 3-year randomized clinical trial was conducted to examine differences in perinatal health behaviors, perinatal and infant health outcomes, and family health outcomes for women receiving group prenatal care (GPC) when compared with those receiving individual prenatal care. Women in GPC were almost 6 times more likely to receive adequate prenatal care than women in individual prenatal care and were considerably more satisfied with their care (Kennedy et al, 2011).

Postpartal

• Encourage physical activity in postpartum women, after being cleared by health care provider; provide telephone counseling, teach postpartum women that exercise may reduce anxiety and depression, encour- age to download phone apps that help track exercise like Fitbit or Pedometer Master. EBN: Exercise during the postpartum period is important for healthy weight loss and decreasing anxiety (Lewis et al, 2011). EB: Research on anxiety, depression, and exercise shows that the psychological and physical benefits of exercise can help reduce anxiety and improve mood (Mayo Clinic Staff, 2014).

▲ Provide breastfeeding mothers contact information for a lactation consultant, phone numbers and website information for La Leche League (http://www.lalecheleague.org), and local breastfeeding support groups. EB: Problems with breastfeeding are encountered in up to 80% of mother–infant dyads. In Western societies, the difficulties decrease the breastfeeding rate within the first months considerably. Dealing with the problems of breastfeeding efficiently requires a profound understanding of its physiology, as well as of its psychological, cultural, and social factors (Bergmann et al, 2014).

• Teach mothers of young children principles of a healthy lifestyle: Substitute foods high in saturated fat with foods moderate in polyunsaturated fatty acids (PUFAs) such as avocados, tuna, walnuts, and olive oil. Include lean protein, fruits and vegetables, and complex carbohydrates. It is also important to increase physical activity. EB: Parents are the most important influence on their child. Parents can do many things to help their children develop healthy eating habits for life. Offering a variety of foods helps children get the nutrients they need from every food group. They will also be more likely to try new foods and to like more foods (USDA, 2011). It is not recommended to feed children a low-fat diet but to make sure fats are good fats (PUFAs). EBN: Omega 3 PUFAs are required for very early brain development, and that need continues throughout life. These essential fatty acids are crucial in cell functioning. Humans are not able to synthesize omega 3 PUFAs; therefore, they must be included in the daily diet (Helvig & Decker, 2014).

REFERENCES ACOG Committee Opinion No. 441: Oral intake during labor (2009

reaffirmed 2013). Obstetrics & Gynecology, 114(3), 714. Batech, M., Tonstad, S., Job, J., et al. (2013). Estimating the impact of

smoking cessation during pregnancy: The San Bernardino County experience. Journal of Community Health, 38, 838–846.

Bergmann, R. L., Bergmann, K. E., von Weizsäcker, K., et al. (2014). Breastfeeding is natural but not always easy: Intervention for common medical problems of breastfeeding mothers—a review of the scientific evidence. Journal of Perinatal Medicine, 42(1), 9–18.

Centers for Disease Control and Prevention (CDC). (2010). CDC grand rounds: Additional opportunities to prevent neural tube defects with folic acid fortification. MMWR. Morbidity and Mortality Weekly Report, 59(31), 980–984.

Helvig, A., & Decker, M. (2014). Omega 3 fatty acids and the brain: Implications for nursing practice. British Journal of Neuroscience Nursing, 10(1), 29–37.

Horowitz, S. (2011). Aromatherapy: current and emerging applications. Alternative and Complementary Therapies, 17(1), 26–31.

Jones, L., Othman, M., Dowswell, T., et al. (2012). Pain management for women in labour: An overview of systematic reviews. Cochrane Database of Systematic Reviews, 14;3:CD009234.

Kennedy, H., Farrell, T., Paden, R., et al. (2011). A randomized clinical trial of group prenatal care in two military settings. Military Medicine, 176(10), 1169–1177.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

218 Risk for Ineffective Childbearing Process

Risk for ineffective Childbearing process Jane M. Kendall, RN, BS, CHT

NANDA-I

Definition

Vulnerable to not matching environmental context, norms and expectations of pregnancy, childbirth process, and the care of the newborn

Risk Factors

Domestic violence; inconsistent prenatal health visits; insufficient cognitive readiness for parenting; insuf- ficient knowledge of childbearing process; inadequate maternal nutrition; insufficient parental role model; insufficient prenatal care; insufficient support system; low maternal confidence; maternal powerlessness; maternal psychological distress; substance abuse; unplanned pregnancy; unrealistic birth plan; unwanted pregnancy

Laanterä, S., Pietilä, A., Ekström, A., et al. (2012). Confidence in breastfeeding among pregnant women. Western Journal of Nursing Research, 34(7), 933–951.

de Lacerda, A. B., da Silva, R. R., & Davim, R. B. (2014). Women’s perception about the companion during labor. Journal of Nursing: UFPE Online, 8(8), 2710–2715. Available from: CINAHL Complete, Ipswich, MA.

Lee, J., Han, M., Chung, Y., et al. (2011). Effects of foot reflexology on fatigue, sleep and pain: A systematic review and meta-analysis. Journal of Korean Academy of Nursing, 41(6), 821–833.

Lewis, B. A., Martinson, B. C., Sherwood, N. E., et al. (2011). A pilot study evaluating a telephone-based exercise intervention for pregnant and postpartum women. Journal Midwifery Womens Health, 56(2), 127–131.

Lindberg, B. (2013). Access to videoconferencing in providing support to parents of preterm infants: Ascertaining parental views. Journal of Neonatal Nursing, 19(5), 259–265.

Maguire, D. (2014). Drug addiction in pregnancy: Disease not moral failure. Neonatal Network, 33(1), 11–18.

Mayo Clinic. (2014). Drugs and supplements: Folate. This evidence- based monograph was prepared by The Natural Standard Research Collaboration <www.naturalstandard.com>.

Mayo Clinic Staff. (2014). Depression and anxiety: Exercise eases symptoms. Mayo Foundation for Medical Education and Research. Retrieved from: <http://www.mayoclinic.org/diseases-conditions/ depression/in-depth/depression-and-exercise/art-20046495>.

Oni, O. A. 1., & Tukur, J. (2012). Identifying pregnant women who would adhere to food taboos in a rural community: A community- based study. African Journal of Reproductive Health, 16(3), 68–76.

Procter, S. B., & Campbell, C. G. (2014). Position of the Academy of Nutrition and Dietetics: Nutrition and lifestyle for a healthy pregnancy outcome. Journal of The Academy Of Nutrition & Dietetics, 114(7), 1099–1103.

Rollans, M., Schmied, V., Kemp, L., et al. (2013). “We just ask some questions…” the process of antenatal psychosocial assessment by midwives. Midwifery, 29(8), 935–942.

Risisky, D., Asghar, S., Chaffee, M., et al. (2013). Women’s perceptions using the centering pregnancy model of group prenatal care. Journal of Perinatal Education, 22(3), 136–144.

Ross-Davie, M., & Cheyne, H. (2014). Intrapartum support: what do women want? A literature review. Evidence Based Midwifery, 12(2), 52–58.

Sapkota, S., Kobayashi, T., & Takase, M. (2013). Impact on perceived postnatal support, maternal anxiety and symptoms of depression in

new mothers in Nepal when their husbands provide continuous support during labour. Midwifery, 29(11), 1264–1271.

Simmonds, D. M., West, L., Porter, J., et al. (2012). The role of support person for Ngaanyatjarra women during pregnancy and birth. Women and Birth: Journal of the Australian College of Midwives, 25(2), 79–85.

St. George, J. M., & Fletcher, R. J. (2011). Fathers online: Learning about fatherhood through the Internet. The Journal of Perinatal Education: An ASPO, 20(3), 154–162.

Tanuvasa, A., Cumming, J., Churchward, M., et al. (2013). Samoan women’s attitudes towards antenatal and midwifery care. British Journal of Midwifery, 21(10), 710–721.

Tong, V., Dietz, P., England, L., et al. (2011). Age and racial/ethnic disparities in prepregnancy smoking among women who delivered live births. Preventing Chronic Disease, 8(6), A121.

Torres, M. E., Smithwick, J., Luchok, K. J., et al. (2012). Reducing maternal and child health disparities among Latino immigrants in South Carolina through a tailored, culturally appropriate and participant-driven initiative. Californian Journal of Health Promotion, 10(2), 1–14.

Trettene, A., & Manci, M. (2012). Influence of beliefs and taboos in the puerperal period: Performance of the nurse [Portuguese]. Revista Nursing, 15(169), 315–320.

US Department of Agriculture, (USDA). (2011). Be a healthy role model for children: 10 tips for setting good examples. Choosemyplate.gov. Retrieved from: <www.choosemyplate.gov/food -groups/downloads/TenTips/DGTipsheet12BeAHealthyRoleModel>.

US Department of Agriculture, (USDA). (2014). Nutritional needs during pregnancy. Choosemyplate.gov/pregnancy. Retrieved from: <http://www.choosemyplate.gov/pregnancy-breastfeeding/ pregnancy-nutritional-needs.html>.

U.S. Department of Health and Human Services (USDHHS). (2008). Treating tobacco use and dependence: Clinical practice guideline 2008 update. Pregnant smokers. Retrieved from: <http:// www.ahrq.gov/clinic/tobacco/treating_tobacco_use08.pdf>.

van Dijk, M., Ruiz, M. J., Letona, D., et al. (2013). Ensuring intercultural maternal health care for Mayan women in Guatemala: a qualitative assessment. Culture, Health & Sexuality, 15, S365–S382.

Williamson, C., & Wyness, L. (2013). Nutritional requirements in pregnancy and use of dietary supplements. Community Practitioner, 86(8), 44–47.

Impaired Comfort 219

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

NOC, NIC, Client Outcomes, Nursing Interventions, Client/Family Teaching, Rationales, and References

Refer to care plan for Ineffective Childbearing process.

Impaired Comfort Katharine Kolcaba, PhD, RN

NANDA-I

Definition

Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental, cultural and/ or social dimensions

Defining Characteristics

Alteration in sleep pattern; anxiety; crying; discontent with situation; distressing symptoms; fear feeling cold; feeling hot; feeling of discomfort; feeling of hunger; inability to relax; irritability; itching; moaning; restless- ness; sighing; uneasy in situation

Related Factors (r/t)

Illness-related symptoms; insufficient environmental control; insufficient privacy; insufficient resources (e.g., financial, social, knowledge); insufficient situational control; noxious environmental stimuli; treatment regimen

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Client Satisfaction; Symptom Control; Comfort Status; Coping; Hope; Pain and/or Anxiety Management; Personal Well-Being; Spiritual Health

Example NOC Outcomes with Indicators

Comfort Status as evidenced by the following indicators: Physical and psychological well-being/Symptom control/Enhanced comfort. (Rate the outcome and indicators of Comfort Status: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Provide evidence for improved comfort compared to baseline • Identify strategies, with or without significant others, to improve and/or maintain acceptable comfort

level • Perform appropriate interventions, with or without significant others, as needed to improve and/or

maintain acceptable comfort level • Evaluate the effectiveness of strategies to maintain/and or reach an acceptable comfort level • Maintain an acceptable level of comfort when possible

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Calming Techniques; Massage; Healing Touch; Still Point Induction; Heat/Cold Application; Hope Inspira- tion; Humor; Meditation Facilitation; Music Therapy; Pain Management; Presence; Progressive Muscle Relaxation; Spiritual Growth Facilitation; Distraction

Example NIC Activities—Hope Inspiration

Assist the client/significant others to identify areas of hope in life; Help expand spiritual self; Involve the client actively in own care

220 Impaired Comfort

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Nursing Interventions and Rationales

• Assess client’s understanding of ranking his or her comfort level. CEB: Performing accurate comfort measurements is essential for providing evidence about which strategies and interventions are effective (Kolcaba, 2003).

• Ask about client’s current level of comfort. This is the first step in helping clients achieve improved comfort. CEB: It is important for nurses to address detractors from comfort (Kolcaba, 2003). Sources of assessment data to determine level of comfort can be subjective, objective, primary, or secondary (Kolcaba, 2014).

• Comfort is a holistic state under which pain management is included. CEB: Management of discomforts, however, can be better managed, and with fewer analgesics, by also addressing other comfort needs such as anxiety, insufficient information, social isolation, and financial difficulties (Kolcaba, 2003). CEB: One ran- domized study (N = 53) found that female breast cancer clients undergoing radiation therapy rated their overall comfort as being greater than the sum of the hypothesized components of comfort, which provided evidence for the theory of the holistic nature of comfort (Kolcaba, 2014).

• Assist clients to understand how to rate their current state of holistic comfort, using the institution’s preferred method of documentation. CEB: Documentation of comfort pre-nursing and post-nursing inter- actions is essential to demonstrate efficacy of nursing activities (Kolcaba et al, 2014).

• Enhance feelings of trust between the client and the health care provider. To attain the highest comfort level, clients must be able to trust their nurse. CEB: This randomized design (N = 31) demonstrated the importance of promoting open relationships with clients, which helps to acknowledge their individuality. Knowing the client/significant others is essential in the provision of optimum palliative and terminal care (Kolcaba, 2014).

• Manipulate the environment as necessary to improve comfort. CEB: Addressing clients’ environmental preferences or needs enhances holistic comfort (Kolcaba, 2003). CEB: In two experimental studies, the protocol included that all clients be asked about preferences for light, furnishings, body position, television settings, and so on (Dowd et al, 2007).

• Encourage early mobilization and provide routine position changes. Range of motion and weight bearing decrease physical discomforts and disability associated with bed rest. CEB: Before hand massage, positions of comfort were assured to maximize the effect of the intervention (Kolcaba et al in Kolcaba, 2000).

• Provide simple massage. Massage has many therapeutic effects, including improved relaxation, circula- tion, and well-being. EBN: Several quantitative studies support the efficacy of simple massage for enhancing holistic comfort (Townsend et al, 2014; Kolcaba et al in Kolcaba, 2000).

• Provide healing touch, which is well-suited for clients who cannot tolerate more stimulating interven- tions. CEB: Inform the client of options for control of discomfort such as meditation and guided imagery, and provide these interventions if appropriate (Dowd et al, 2007).

• Use empathy as a response to a client’s negative emotions. EBN: An evaluation interaction analysis found that an accurate empathic response to a client’s expressions of negative emotions can contribute to comfort (Eide et al, 2011).

• Encourage clients to use relaxation techniques to reduce pain, anxiety, depression, and fatigue. EBN: In a quantitative study with 22 participants, the effects of traditional massage and cranial still point induction were statistically significant in improving comfort and decreasing chronic pain (Townsend et al, 2014).

Geriatric

• Use hand massage for older adults. Most older adults respond well to touch and the health care provider’s presence. Lines of communication open naturally during hand massage. CEB: In an experiment (N = 60), the effects of hand massage on comfort of nursing home residents was found to be significant immediately after the massage compared to residents who did not receive hand massage (Kolcaba et al in Kolcaba, 2014).

• Discomfort from cold can be treated with warmed blankets. There are physiological dangers associated with hypothermia. EBN: A study (N = 126) found significantly increased comfort and decreased anxiety in clients who used self-controlled warming gowns (Wagner et al, 2006, in Kolcaba, 2014).

• Use complementary therapies such as doll therapy in clients with dementia to increase comfort and reduce stress. EBN: In a review of the literature, doll therapy reduced panic, anxiety, and aggression while improving the dining experience and social interaction (Mitchell & O’Donnell, 2013).

• Address any unmet physical, psychological, emotional, spiritual, and environmental needs when attempt- ing to mediate the behavior of an older client with dementia. EBN: A case study demonstrated that all

Impaired Comfort 221

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

possible causes for demented older clients’ behavior must be considered to maximize comfort (Gallagher & Long, 2011).

• Provide simple massage. CEB: Simple massage addresses four contexts of holistic comfort (Kolcaba, 2003). CEB: A prospective study (N = 52) found that providing massage to nursing home residents with dementia was effective in controlling agitation (Holliday-Welsh et al, 2009).

Multicultural

• Identify and clarify cultural language used to describe pain and other discomforts. Expressions of pain and discomfort vary across cultures. CEB: Clients may interchange words meaning discomfort and pain, may not admit to having pain, may refer to minor discomforts as pain, or may not discuss nonpainful discomforts at all (Kolcaba, 2003).

• Assess skin for ashy or yellow-brown appearance. CEB: Black skin appears ashy and brown skin appears yellow-brown when clients have pallor sometimes associated with discomfort (Peters, 2007).

• Use soap sparingly if the skin is dry. Black skin tends to be dry, and soap exacerbates this condition. • Encourage and allow clients to practice their own cultural beliefs and recognize the impact that different

cultures have on a client’s belief about health care, comforting measures, and decision-making. Hindus believe in reincarnation, which gives them comfort during the dying process. Hindus also believe that physical suffering can lead to spiritual growth (Thrane, 2010).

• Assess for cultural and religious beliefs when providing care. EB: In a hermeneutic phenomenological study in six medical-surgical wards in Iran (N = 22), it was found that family members play an important role in the comfort of the client. It was also found that caregivers should allow clients to follow religious and tradi- tional principles to facilitate comfort despite physical constraints (Yousefi et al, 2009).

Client/Family Teaching and Discharge Planning

• Teach techniques to use when the client is uncomfortable, including relaxation techniques, guided imagery, hand massage, and music therapy. CEB: Interventions such as progressive muscle relaxation train- ing, guided imagery, and music therapy can effectively decrease the perception of uncomfortable sensations, including pain (Kolcaba, 2003). CEB: Families want to learn how to provide comfort measures to their loved ones who are uncomfortable (Kolcaba et al, 2004, in Kolcaba, 2014).

• At end of life, the dying client is comforted by having a companion. EBN: A grounded theory study dem- onstrated the importance of teaching the family of a dying client how to accompany the client on his or her final journey, sharing stories, thoughts, doubts, feelings, and emotions (Martins & Basto, 2011).

• Instruct the client and family about prescribed medications and complementary therapies that improve comfort (Kolcaba, 2003).

• Teach the client to follow up with the health care provider if discomfort persists. There are many avenues for enhancing comfort (Kolcaba, 2003).

• Encourage clients to use the Internet as a means of providing education to complement medical care for those who may be homebound or unable to attend face-to-face education. CEB: In a randomized trial with intervention (N = 41), it was found that the Internet was an effective mode for delivering self-care education to older clients with chronic pain (Berman et al, 2009).

Mental Health

• Encourage clients to use guided imagery techniques. Guided imagery helps distract clients from stressful situations and facilitates relaxation. CEB: A quasi-experimental study (N = 60) found that clients who listened to a guided imagery compact disk once a day for 10 days had improved comfort and decreased depression, anxiety, and stress over time (Apùstolo & Kolcaba, 2009, in Kolcaba, 2014).

• Provide psychospiritual support and a comforting environment to enhance comfort during emotional crises. EBN: A case study demonstrates the importance of reducing stimuli in the environment of clients with dementia (Gallagher & Long, 2011). CEB: In a cross-sectional descriptive study (N = 98), it was found that cancer clients had lower comfort levels relating to psychospiritual and environmental comfort than to physical and sociocultural comfort. Improvements in psychospiritual and environmental support will enhance overall comfort (Kim & Kwon, 2007).

• When nurses attend to the comfort of perioperative clients, the clients’ sense of hope for a full recovery increases. EBN: In a quantitative study with 191 participants, direct and significant relationships were observed between comfort and hope (Seyedfatemi et al, 2014).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

222 Readiness for Enhanced Comfort

• Providing music and verbal relaxation therapy enhances holistic comfort by reducing anxiety. EBN: A literature review found that music and verbal relaxation therapy provided reduced chemotherapy-induced anxiety (Lin et al, 2011).

• Caregivers should not hesitate to use humor when caring for their clients. CEB: Analysis of two studies found that humor can be comforting and can contribute to a positive experience for both client and caregiver (Kinsman-Dean & Major, 2008).

REFERENCES Berman, R., Iris, M., Bode, R., et al. (2009). The effectiveness of an

online mind-body intervention for older adults with chronic pain. The Journal of Pain, 10(1), 68–79.

Dowd, T., et al. (2007). Comparison of healing touch and coaching on stress and comfort in young college students. Holistic Nursing Practice, 21(4), 194–202.

Eide, H., Sibbern, T., & Johannessen, T. (2011). Empathic accuracy of nurses’ immediate response to fibromyalgia patients’ expressions of negative emotions: an evaluation using interaction analysis. Journal of Advanced Nursing, 67(6), 1242–1253.

Gallagher, M., & Long, D. O. (2011). Demystifying behaviors, addressing pain, and maximizing comfort research and practice: partners in care. J Hospice Palliat Nurs, 13(2), 71–78.

Holliday-Welsh, D., Gessert, C., & Renier, C. (2009). Massage in the management of agitation in nursing home residents with cognitive impairment. Geriatric Nursing (New York, N.Y.), 30(2), 108–117.

Kim, K. S., & Kwon, S. H. (2007). Comfort and quality of life of cancer patients. Asian Nursing Research, 1, 125–135.

Kinsman-Dean, R. A., & Major, J. E. (2008). From critical care to comfort care: the sustaining value of humour. Journal of Clinical Nursing, 17, 1088–1095.

Kolcaba, K. (2003). Comfort theory and practice: a holistic vision for health care. New York: Springer.

Kolcaba, K. (2014). TheComfortLine.com. Retrieved Nov 15 from: <www.TheComfortLine.com>.

Lin, M. F., et al. (2011). A randomized controlled trial of the effect of music therapy and verbal relaxation on chemotherapy-induced anxiety. Journal of Clinical Nursing, 20, 988–999.

Martins, C., & Basto, M. (2011). Relieving the suffering of end-of-life patients: A Grounded Theory study. Journal of Hospice and Palliative Nursing, 13(3), 161–171.

Mitchell, G., & O’Donnell, H. (2013). The therapeutic use of doll therapy in dementia. The British Journal of Nursing, 22(6), 329–334.

Peters, J. (2007). Examining and describing skin conditions. The Journal of Practical Nursing, 34(8), 39–40, 43, 45.

Seyedfatemi, N., Rafi, F., Rezaei, M., et al. (2014). Comfort and hope in the preanesthesia stage in patients undergoing surgery. Journal of Perianesthesia Nursing, 29(3), 213–220.

Thrane, S. (2010). Hindu end of life. Journal of Hospice and Palliative Nursing, 12(6), 337–342.

Townsend, C., Bonham, E., Chase, L., et al. (2014). A comparison of still point induction to massage therapy in reducing pain and increasing comfort in chronic pain. Holistic Nursing Practice, 28(2), 78–84.

Wagner, D., Byrne, M., & Kolcaba, K. (2006). Effect of comfort warming on preoperative patients. AORN Journal, 84(3), 1–13.

Yousefi, H., et al. (2009). Comfort as a basic need in hospitalized patients in Iran: hermeneutic phenomenology study. Journal of Clinical Nursing, 65(9), 1891–1898.

Readiness for enhanced Comfort Lina Daou Boudiab, MSN, RN

NANDA-I

Definition

A pattern of ease, relief, and transcendence in physical, psychospiritual, environmental, and/or social dimen- sions that is sufficient for well-being and can be strengthened

Defining Characteristics

Expresses desire to enhance comfort; expresses desire to enhance feelings of contentment; expresses desire to enhance relaxation; expresses desire to enhance resolution of complaints

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Outcomes

Client Satisfaction: Caring; Symptom Control; Comfort Status; Coping; Hope; Motivation; Pain Control; Participation in Health Care Decisions; Spiritual Health

Example NOC Outcomes with Indicators

Comfort Status as evidenced by the following indicators: Physical well-being/Symptom control/Psychological well-being. (Rate the outcome and indicators of Comfort Level: 1 = not at all satisfied, 2 = somewhat satisfied, 3 = moderately satisfied, 4 = very satisfied, 5 = completely satisfied [see Section I].)

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Readiness for Enhanced Comfort 223

Client Outcomes Client Will (Specify Time Frame)

• Assess current level of comfort as acceptable • Express the need to achieve an enhanced level of comfort • Identify strategies to enhance comfort • Perform appropriate interventions as needed for increased comfort • Evaluate the effectiveness of interventions at regular intervals • Maintain an enhanced level of comfort when possible

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Interventions

Calming Technique; Cutaneous Stimulation; Environmental Management; Comfort; Heat/Cold Application; Hope Inspiration; Humor; Meditation Facilitation; Music Therapy; Pain Management; Presence; Simple Guided Imagery; Simple Massage; Simple Relaxation Therapy; Spiritual Growth Facilitation; Therapeutic Play; Therapeutic Touch; Touch; Distraction

Example NIC Activities—Spiritual Growth Facilitation

Assist the client with identifying barriers and attitudes that hinder growth or self-discovery; Assist the client to explore beliefs as related to healing of the body, mind, and spirit; Model healthy relating and reasoning skills

Nursing Interventions and Rationales

• Assess clients’ comfort needs and current level of comfort in various contexts, as outlined in Kolcaba’s (2003) Comfort theory and practice: physical, psychospiritual, sociocultural, and environmental. CEB: Assessing comfort needs helps develop holistic, client-centered comfort interventions, while establishing a baseline helps evaluate their effectiveness by comparing comfort levels after each intervention to the previous baseline (Kolcaba, 2003).

• Educate clients about the various contexts of comfort and help them understand that enhanced comfort is a desirable, positive, and achievable goal. CEB: Human beings strive to have their basic comfort needs met, with comfort being more than just the absence of pain (Kolcaba, 2003). Having clients view comfort more holistically may be especially helpful when total relief and ease of symptoms may not be achievable, and the goal of health care becomes helping clients transcend their comfort needs (Kolcaba, 2003).

• Enhance feelings of trust between the client and the health care provider in order to maintain an effective and therapeutic relationship. CEB: To attain the highest comfort level, a client must be able to trust the nurse (Hupcey et al, 2000). EBN: Trust is an essential element in the nurse-client relationship that is fostered through caring attitudes, availability, respect, empathy, sensitivity to client needs, competence, and good communication (Dinç & Gastmans, 2013).

• Maintain an open and effective communication with clients and keep them informed about their health, their plan of care, and their environment. EBN: Evidence suggests that sharing of information genuinely and empathetically with adult oncology clients and encouraging them to ask questions strengthen the nurse- client relationship and empower clients to reach out to nurses for emotional support (Joanna Briggs Institute, 2011), and it enhances their psychospiritual comfort. EBN: Communicating to hospitalized cardiothoracic clients the source of sounds heard or expected to be heard around the unit, such as alarms, staff conversa- tions, and rolling carts alleviated their anxiety and enhanced relaxation (Mackrill et al, 2013), hence pro- moting their environmental comfort.

• Implement comfort rounds that regularly assess for clients’ comfort needs. EBN: Regular 1-hour or 2-hour rounds that address pain, positioning, personal needs, and environment were found to increase client satisfaction, decrease call light usage, and promote safety by decreasing fall rates (Ciccu-Moore et al, 2014; Chu, 2014).

• Collaborate with other health care professionals, such as health care providers, pharmacists, social workers, chaplains, occupational and physical therapists, dietitians, among others, in planning interven- tions that address comfort needs in various contexts: physical, psychospiritual, sociocultural, and environmental.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

224 Readiness for Enhanced Comfort

• Educate clients about and encourage the use of various integrative therapies and modalities to provide options that enhance comfort, beyond the traditional plan of care. Institute of Medicine (IOM) AND PAIN—Examples of such modalities are listed below: ❍ Therapeutic massage and touch therapy. EBN: Massage and touch therapy have been found to promote

comfort in clients with dementia by decreasing anxiety and agitation (Battaglini, 2014). There is evidence to support recommending massage to clients with subacute and chronic back pain, mechanical neck pain, and labor pain, as well as to decrease anxiety and blood pressure and to improve quality of life in clients with HIV/AIDS (D’Arcy, 2014). Furthermore, case studies on using the M-technique (M standing for manual), a structured light stroking technique, seemed to decrease agitation and pain in palliative care clients and promote their and their families’ comfort (Roberts & Campbell, 2011).

❍ Guided imagery. EBN: Guided imagery was also effective in improving chronic tension headaches and body pain, as well as promoting overall mental health and energy level (Read, 2013).

❍ Mindfulness and mindfulness-based interventions such as mindfulness-based stress reduction (MBSR), mantra repetition (silent repetition of a sacred word), mindfulness meditation, and mindful breathing and walking, among others. Since the original research by Kabat-Zinn, founder of MBSR, and colleagues established the effectiveness of mindfulness in helping clients manage chronic pain and improving body image and other symptoms, including anxiety and depression (Kabat-Zinn, Lipworth, & Burney, 1985), mindfulness-based interventions have been used to promote physical and psychospiritual comfort. EB: A study of MBSR in cancer clients concluded that mindfulness promotes a sense of calmness, inner peace, and personal and spiritual growth (Labellea et al, 2014), while a small randomized controlled trial found MBSR to be effective in treating chronic insomnia (Gross et al, 2011). EBN: Mantra repetition is found to decrease posttraumatic stress disorder (PTSD) symptoms and increase sense of well-being in veterans, when added to their traditional PTSD treatment plan (Bormann et al, 2014).

❍ Energy therapy or biofield therapy such as healing touch, therapeutic touch, and reiki. Biofield therapy seems to be promising in promoting comfort and relaxation, but more sound and systematic research is needed to build a strong body of evidence. EBN/EB: Healing touch has been found effective as an adjunct therapy in relieving anxiety and depression (Harlow, 2013), as well as symptoms of PTSD when coupled with guided imagery in returning active military exposed to combat (Jain et al, 2012). EBN: Biofield therapy strengthens the immune system, decreases stress, and allows the body to heal. It can be integrated in the care of cancer clients in various settings for relaxation and symptom management, as well as in those with musculoskeletal and joint pain, agitation and dementia, and other chronic conditions (Gonella et al, 2014).

❍ Acupuncture and auricular acupuncture. EB: There is strong evidence that acupuncture is effective in alleviating nausea and vomiting, headache, and back and neck pain (Rathnayake, 2014). A study of acupuncture in women in later stages of pregnancy concluded that the modality decreased low back and pelvic pain and increased function (Pennick & Liddle, 2013), while another found that it improved pain and stiffness in clients with fibromyalgia (Deare et al, 2013). EB: The National Acupuncture Detox Association five-point ear acupuncture protocol has been effective in reducing cravings and withdrawal symptoms associated with substance abuse. Growing research suggests it may be promising as well for pain relief, promotion of comfort and relaxation, and decrease in PTSD symptoms in veterans.

❍ Aromatherapy ❍ Music ❍ Other mind-body therapies. EB: The most common therapies used were meditation, imagery, and yoga.

Research demonstrating the connection between the mind and body has therefore increased interest in the potential use of these therapies (Wolsko et al, 2004). EBN: Meditation has been shown to reduce anxiety, relieve pain, decrease depression, enhance mood and self-esteem, decrease stress, and generally improve clinical symptoms (Bonadonna, 2003). A review of clinical trials for meditation and massage used in end of life found that there was a significant relationship between meditation and pain reduction in the two studies that assessed pain (Lafferty et al, 2006).

• Foster and instill hope in clients whenever possible. EBN: A study of clients undergoing surgery in the preanesthesia stage found a strong correlation between hope and comfort (Seyedfatemi et al, 2014). See the care plan for Hopelessness.

• Provide opportunities for and enhance spiritual care activities. The need for comfort and reassurance may be perceived as spiritual needs. To meet these needs, nurses engaged in interaction when they com- forted and assured clients. Participants also identified absolution as a spiritual need, and there is evidence

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Readiness for Enhanced Comfort 225

that forgiveness may bring one feelings of joy, peace, and elation, and a sense of renewed self-worth (Narayanasomy et al, 2004). Individuals who practiced spiritual meditation were found to have a greater increase in pain tolerance (Wachholtz & Pargament, 2008).

▲ Enhance social support and family involvement. EBN: Methods to help terminally ill clients and their families transition from cure to comfort care included spending an increased amount of time with one’s family, appointing one close friend to act as a contact person for other friends, and establishing an email listserv for updates of a client’s status and care (Duggleby & Berry, 2005). Promote participation in creative arts and activity programs. CEBN: A creative arts program for caregivers of cancer clients was shown to decrease anxiety, and positive emotions were expressed (Walsh et al, 2004). The use of an individualized music protocol program by older women was shown to promote and maintain sleep (Johnson, 2003).

▲ Encourage clients to use health information technology (HIT) as needed. Client services can now include management of medications, symptoms, emotional support, health education, and health information (Moody, 2005). EBN: In this study, clients experienced significantly lower dimensions of pain and discomfort with nursing intervention via telephone (Franzen et al, 2009).

• Evaluate the effectiveness of all interventions at regular intervals and adjust therapies as necessary. It is important for nurses to determine comfort and pain management goals because comfort goals will change with circumstances. Ask questions and ask them frequently, such as, “How is your comfort?” Establish guidelines for frequency of assessment and document responses, noting whether goals are being met (Kolcaba, 2003). EB: A comprehensive palliative care project was conducted at 11 sites. The interdisciplinary review process built trust, endorsed creativity, and ultimately resulted in better meeting the needs of clients, families, and the community (London et al, 2005). Evaluation must be planned for, ongoing, and systematic. Evaluation demonstrates caring and responsibility on the part of the nurse (Wilkinson & VanLeuven, 2007).

Geriatric

• Refer to above interventions for geriatric interventions. Pediatric

• Assess and evaluate child’s level of comfort at frequent intervals. Comfort needs should be individually assessed and planned for. With assessment of pain in children, it is best to use input from the parents or a primary care provider. Use only accepted scales for standardized pain assessment (Remke & Chrastek, 2007).

• Skin-to-skin contact (SSC) and selection of the most effective method improves the comfort of newborns during routine blood draws. EB: Premature infants who received skin-to-skin contact demonstrated a decrease in pain reaction during heel lancing (Castral et al, 2008).

• Adjust the environment as needed to enhance comfort. Environmental comfort measures include main- taining orderliness; quiet; minimizing furniture; special attention to temperature, light and sound, color, and landscape (Kolcaba & DeMarco, 2005).

• Encourage parental presence whenever possible. The same basic principles for managing pain in adults and children apply to neonates. In addition to other comfort measures, parental presence should be encouraged whenever possible (Pasero, 2004). EBN: This study reported the effects of co-residence and caregiving on the parents of children dying with AIDS. Although parents who did more caregiving did experi- ence anxiety, insomnia, and fatigue, the caregiving experiences for many parents gave them an opportunity to fulfill their perceived duty as parents before their child died. This in turn resulted in better physical and emotional health outcomes (Kespichayawattana & VanLandingham, 2003).

• Promote use of alternative comforting strategies such as positioning, presence, massage, spiritual care, music therapy, art therapy, and story-telling to enhance comfort when needed. In addition to oral sucrose, other comfort measures should be used to alleviate pain such as swaddling, skin-to-skin contact with mother, nursing, rocking, and holding (Pasero, 2004). EBN: Building on the belief that parents are the primary care providers and health care resource for families, the blended infant massage-parenting program is effective for both mother and infant (Porter & Porter, 2004). EBN: In this study, focus groups were con- ducted with Moroccan pediatric oncology nurses and health care providers to better understand how pain management was achieved in children with cancer. When no medication was available to relieve pain, other techniques were used to comfort clients. These included using cold therapy, being present, holding a child’s hand, using distraction techniques, playing with the child, story-telling, and encouraging parental engagement activities (McCarthy et al, 2004). EB: In a study that examined the effects of music on pain in a pediatric burn unit during nursing procedures, the use of music during procedures reduced pain

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

226 Readiness for Enhanced Comfort

(Whitehead-Pleaux et al, 2007). EBN: A talk-and-touch intervention by the mothers of infants in the preanesthesia care unit found that 62% of the mothers thought that the intervention made a difference in the pain the infant experienced and 73% thought that talk and touch decreased their infant’s distress (Rennick et al, 2011).

• Support the child’s spirituality. CEB: Children are born with an intrinsic spiritual essence that can be enhanced. Spirituality promotes a sense of hope, comfort, and strength and creates a sense of being loved and nurtured by a higher power (Elkins & Cavendish, 2004).

Multicultural

• Identify cultural beliefs, values, lifestyles, practices, and problem-solving strategies when assessing clients. Cultural sensitivity must always be a component of pain assessment. The nurse must remember that pain expression will vary among clients and that variation must also be acknowledged within cultures (Andrews & Boyle, 2003). EBN: In a qualitative study that identified issues in pain management, cultural beliefs were cited as impediments or barriers to pain management; for example, some Moroccan health care provid- ers thought illness-related pain was inevitable, that suffering was normal, and that it had to be endured, especially by boys (McCarthy et al, 2004). EBN: In a qualitative study, Muslim clients, particularly Shiites, expressed feeling more comfortable when they were allowed to practice their religious beliefs (Yousefi et al, 2009).

• Enhance cultural knowledge by actively seeking out information regarding different cultural and ethnic groups. Cultural knowledge is the process of actively seeking information about different cultural and ethnic groups such as their world views, health conditions, health practices, use of home remedies or self-medication, barriers to health care, and risk-taking or health-seeking behaviors (Institute of Medicine, 2002).

▲ Recognize the impact of culture on communication styles and techniques. Communication and culture are closely intertwined, and communication is the way culture is transmitted and preserved. It influences how feelings are expressed, decisions are made, and what verbal and nonverbal expressions are acceptable. By the age of 5, cultural patterns of communication can be identified in children (Giger & Davidhizar, 2004).

• Provide culturally competent care to clients from different cultural groups. Cultural competency requires health care providers act appropriately in the context of daily interactions with people who are different from themselves. Health care providers need to honor and respect the beliefs, interpersonal styles, atti- tudes, and behaviors of others. This level of cultural awareness requires health care providers to refrain from forming stereotypes and judgments based on one’s own cultural framework (Institute of Medicine, 2002). EBN: The findings from a review of two studies of Japanese and American women suggest that although there were common ethical concerns between the two cultures, the cultural context of the underlying values may create very different meanings and result in different nursing practices (Wros et al, 2004).

Home Care

• The nursing interventions described for Readiness for enhanced Comfort may be used with clients in the home care setting. When needed, adaptations can be made to meet the needs of specific clients, fami- lies, and communities.

▲ Make appropriate referrals to other organizations or health care providers as needed to enhance comfort. Referrals should have merit, be practical, timely, individualized, coordinated, and mutually agreed upon by all involved (Hunt, 2005).

▲ Promote an interdisciplinary approach to home care. Members of the interdisciplinary team who provide specialized care to enhance comfort can include the health care provide, physical therapist, occupational therapist, nutritionist, music therapist, and social worker, among others (Stanhope & Lancaster, 2006).

• Evaluate regularly if enhanced comfort is attainable in the home care setting. Home health agencies monitor client outcomes closely. Evaluation is an ongoing process and is essential for the provision of quality care (Stanhope & Lancaster, 2006).

• Use music therapy at home. EBN: The use of music 30 minutes before peak agitation in clients with dementia demonstrated that their mean pain levels after listening to music were significantly lower than before the music intervention (Park, 2010).

Client/Family Teaching and Discharge Planning

• Teach client how to regularly assess levels of comfort. • Instruct client that a variety of interventions may be needed at any given time to enhance comfort. • Help clients understand that enhanced comfort is an achievable goal.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Readiness for Enhanced Comfort 227

• Teach techniques to enhance comfort as needed. ▲ When needed, empower clients to seek out other health professionals as members of the interdisciplinary

team to assist with comforting measures and techniques. • Encourage self-care activities and continued self-evaluation of achieved comfort levels to ensure enhanced

comfort is maintained.

REFERENCES Andrews, M., & Boyle, J. (2003). Transcultural concepts in nursing

(4th ed.). Philadelphia: Lippincott Williams & Wilkins. Battaglini, E. (2014). Dementia: Massage and Touch. Joanna

Briggs Institute [Evidence Summaries]. Retrieved from: <www.Joannabriggs.org>.

Bonadonna, R. (2003). Meditation’s impact on chronic illness. Holistic Nursing Practice, 17(6), 309–319.

Bormann, J. E., Oman, D., Walter, K. H., et al. (2014). Mindful Attention Increases and Mediates Psychological Outcomes Following Mantram Repetition Practice in Veterans with Posttraumatic Stress Disorder. Medical Care, 52(12 (Suppl. 5)), S13–S18.

Castral, T., et al. (2008). The effects of skin-to-skin contact during acute pain in preterm newborns. European Journal of Pain, 12(4), 464–471.

Chu, V. (2014). Nursing Rounds: Clinician Information. Joanna Briggs Institute [Evidence Summaries]. Retrieved from: <www.Joannabriggs.org>.

Ciccu-Moore, R., Grant, F., Niven, B., et al. (2014). Care and comfort rounds: Improving standards. Nursing Management—UK, 20(9), 18–23.

D’Arcy, M. (2014). Massage Therapy: Various Conditions. Joanna Briggs Institute [Evidence Summaries]. Retrieved from: <www.Joannabriggs.org>.

Deare, J. C., Zheng, Z., Xue, C. C. L., et al. (2013). Acupuncture for treating fibromyalgia (Review). The Cochrane Library. Retrieved from: <http://www.thecochranelibrary.com>.

Dinç, L., & Gastmans, C. (2013). Trust in nurse-patient relationships: a literature review. Nursing Ethics, 20(5), 501–516. [Epub 2013 Feb 20].

Duggleby, W., & Berry, P. (2005). Transitions and shifting goals of care for palliative patients and their families. Clinical Journal of Oncology Nursing, 9(4), 425–428.

Elkins, M., & Cavendish, R. (2004). Developing a plan for pediatric spiritual care. Holistic Nursing Practice, 18(4), 179–184.

Franzen, C., et al. (2009). Injured road users’ health-related quality of life after telephone intervention: a randomized controlled trial. Journal of Clinical Nursing, 18(1), 108–116.

Giger, J., & Davidhizar, R. (2004). Transcultural nursing: assessment and intervention (4th ed.). St. Louis: Mosby.

Gonella, S., Garrino, L., & Dimonte, G. (2014). Biofield Therapies and Cancer-Related Symptoms: A Review. Clinical Journal of Oncology Nursing, 18(5), 568–576.

Gross, C. R., Kreitzer, M. J., Reilly-Spong, M., et al. (2011). Mindfulness-based stress reduction versus pharmacotherapy for chronic primary insomnia: a randomized controlled clinical trial. Explore (New York, N,Y.), 7(2), 76–87.

Harlow, C. R. (2013). A critical analysis of healing touch for symptoms of depression and anxiety. (Unpublished doctoral dissertation). University of Arizona: Tucson, AZ.

Hunt, R. (2005). Introduction to community-based nursing (3rd ed.). Philadelphia: Lippincott.

Hupcey, J. E., Penrod, J., & Morse, J. M. (2000). Establishing and maintaining trust during acute care hospitalizations, including commentary by Robinson CA. Scholarly Inquiry for Nursing Practice, 14(3), 227–248.

Institute of Medicine. (2002). Speaking of health. Washington, DC: National Academies Press.

Jain, S., McMahon, G. F., Hasen, P., et al. (2012). Healing Touch with Guided Imagery for PTSD in returning active duty military: a randomized controlled trial. Military Medicine, 177(9), 1015–1021.

Joanna Briggs Institute. (2011). Effective communication between registered nurses and adult oncology patients in inpatient settings. Best Practice: Evidence-based information sheets for health professionals, 15(1), 1–4.

Johnson, J. (2003). The use of music to promote sleep in older women. Journal of Community Health Nursing, 20, 27–35.

Kabat-Zinn, J., Lipworth, L., & Burney, R. (1985). The clinical use of mindfulness meditation for the self-regulation of chronic pain. Journal of Behavioral Medicine, 8(2), 163–190.

Kespichayawattana, J., & VanLandingham, M. (2003). Effects of coresidence and caregiving on health of Thai parents of adult children with AIDS. Journal of Nursing Scholarship: an Official Publication of Sigma Theta Tau International Honor Society of Nursing/Sigma Theta Tau, 35(3), 217–224.

Kolcaba, K. (2003). Comfort theory and practice. New York: Springer.

Kolcaba, K., & DeMarco, M. (2005). Comfort theory and application to pediatric nursing. Pediatric Nursing, 31(3), 187–194.

Labellea, L. E., Lawlor-Savagea, L., Campbella, T. S., et al. (2014). Does self-report mindfulness mediate the effect of Mindfulness-Based Stress Reduction (MBSR) on spirituality and posttraumatic growth in cancer patients? The Journal of Positive Psychology. Retrieved from: <http://dx.doi.org/10.1080/17439760.2014.927902>.

Lafferty, W., et al. (2006). Evaluating CAM treatment at the end of life: a review of clinical trials for massage and meditation. Complementary Therapies in Medicine, 14(2), 100–112.

London, M., et al. (2005). Evaluation of a comprehensive, adaptable, life-affirming, longitudinal palliative care project. Journal of Palliative Medicine, 8(6), 1214–1225.

Mackrill, J., Cain, R., Jennings, P., et al. (2013). Sound source information to improve cardiothoracic patients’ comfort. British Journal of Nursing, 22(7), 387–393.

McCarthy, P., et al. (2004). Managing children’s cancer pain in Morocco. Journal of Nursing Scholarship, 36(1), 11–15.

Moody, L. (2005). E-health web portals: delivering holistic healthcare and making home the point of care. Holistic Nursing Practice, 19(4), 156–160.

Narayanasomy, A., et al. (2004). Responses to the spiritual needs of older people. Journal of Advanced Nursing, 48(1), 6–16.

Park, H. (2010). Effects of music on pain for home-dwelling persons with dementia. Pain Management Nursing, 11(3), 141–147.

Pasero, C. (2004). Pain relief for neonates. The American Journal of Nursing, 104(5), 44–47.

Pennick, V., & Liddle, S. D. (2013). Interventions for preventing and treating pelvic and back pain in pregnancy (Review). The Cochrane Library. Retrieved from: <http://www.thecochranelibrary.com>.

Porter, L., & Porter, B. (2004). A blended infant massage-parenting enhancement program for recovering substance abusing mothers. Pediatric Nursing, 30(5), 363–401.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

228 Readiness for Enhanced Communication

Readiness for enhanced Communication Stacey M. Carroll, PhD, ANP-BC, and Suzanne White, MSN, RN, PHCNS-BC

NANDA-I

Definition

A pattern of exchanging information and ideas with others that can be strengthened

Defining Characteristics

Expresses desire to enhance communication

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Communication; Communication: Expressive, Receptive

Example NOC Outcome with Indicators

Communication as evidenced by the following indicators: Use of spoken language/Use of written language/Acknowledgment of messages received/Exchanges messages accurately with others. (Rate the outcome and indicators of Communication: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, mildly compromised, 5 = not compromised [see Section I].)

Rathnayake, T. (2014). Acupuncture: Effectiveness Review. Joanna Briggs Institute [Evidence Summaries]. Retrieved from: <www.Joannabriggs.org>.

Read, S. (2013). Chronic pain: Nursing interventions. Joanna Briggs Institute [Evidence Summaries]. Retrieved from: <www.Joannabriggs.org>.

Remke, S., & Chrastek, J. (2007). Improving care in the home for children with palliative care needs. Home Healthcare Nurse, 25(1), 45–51.

Rennick, J., et al. (2011). Mothers’ experiences of touch and talk nursing intervention to optimise pain management in the PICU: a qualitative study. Intensive and Critical Care Nursing, 27(3), 151–157.

Roberts, K., & Campbell, H. (2011). Using the M technique as therapy for patients at the end of life: Two case studies. International Journal of Palliative Nursing, 17(3), 114–118.

Seyedfatemi, N., Rafii, F., Rezaei, M., et al. (2014). Comfort and hope in the preanesthesia stage in patients undergoing surgery. Journal of Perianesthesia Nursing, 29(3), 213–220.

Stanhope, M., & Lancaster, J. (2006). Foundation of nursing in the community (2nd ed.). St. Louis: Mosby.

Wachholtz, A., & Pargament, K. (2008). Migraines and meditation: does spirituality matter? Journal of Behavioral Medicine, 31(4), 351–366.

Walsh, S., Martin, S., & Schmidt, L. (2004). Testing the efficacy of a creative-arts intervention with family caregivers of patients with cancer. Journal of Nursing Scholarship, 36(3), 214–219.

Whitehead-Pleaux, A. M., et al. (2007). Exploring the effects of music therapy on pediatric pain: phase 1. Journal of Music Therapy, 46(3), 217–241.

Wilkinson, J., & VanLeuven, K. (2007). Fundamentals of nursing. Philadelphia: FA Davis.

Wolsko, P., et al. (2004). Use of mind-body medical therapies. Journal of General Internal Medicine, 19, 43–50.

Wros, P., Doutrich, D., & Izumi, S. (2004). Ethical concerns: comparison of values from two cultures. Nursing and Health Sciences, 6(2), 131–140.

Yousefi, H., et al. (2009). Comfort as a basic need in hospitalized patients in Iran: a hermeneutic phenomenology study. Journal of Advanced Nursing, 65(9), 1891–1898.

Client Outcomes Client Will (Specify Time Frame)

• Express willingness to enhance communication • Demonstrate ability to speak or write a language • Form words, phrases, and language • Express thoughts and feelings • Use and interpret nonverbal cues appropriately • Express satisfaction with ability to share information and ideas with others

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Readiness for Enhanced Communication 229

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Active Listening; Communication Enhancement: Hearing Deficit; Communication Enhancement: Speech Deficit

Example NIC Activities—Communication Enhancement: Hearing Deficit

Listen attentively; Allow patient adequate time to process communication and respond; Verify what was said or written using patient’s response before continuing

Nursing Interventions and Rationales

• Establish a therapeutic nurse-client relationship: provide appropriate education for the client, demon- strate caring by being present to the client. CEB: Clients who were nonvocal and ventilated appreciated nursing care that was delivered in an individualized, caring manner (Carroll, 2007).

• Assess the client’s readiness to communicate, using an individualized approach, and avoid making assumptions regarding the client’s preferred communication method. EBN: Using varied communication approaches improved communication efficiency and client engagement (Radtke et al, 2011). EB: Increased numbers of communication methods decreased fear and anger in those who were mechanically ventilated (Khalaila et al, 2011).

• Assess the client’s literacy level so information can be tailored accordingly. The Rapid Estimate of Adult Literacy in Medicine—Short Form (REALM-SF) provides a quick valid assessment (AHRQ, 2014).

• Use these practical guidelines to assist in communication: Listen attentively and provide a comfortable environment for communicating; slow down and listen to the client’s story; use augmentative and alterna- tive communication methods (e.g., lip reading, communication boards, writing, body language, and computer/electronic communication devices) as appropriate; repeat instructions if necessary; limit the amount of information given; have the client “teach back” to confirm understanding; avoid asking, “Do you understand?”; be respectful, caring, and sensitive. EB: Multiple augmentative and alternative communication methods, applied with an individualized and creative approach, aid in facilitating communication (Radtke et al, 2011).

▲ Use interdisciplinary collaboration to ensure continuity of enhanced communication. EB: Effective inter- disciplinary collaboration and follow-up was recommended when working with clients with significant communication impairments after having a stroke (Jones et al, 2013).

▲ Refer couples in maladjusted relationships for psychosocial intervention and social support to strengthen communication; consider nurse specialists. EB: Being part of a strong dyad may serve as a buffering factor regarding posttraumatic stress related to a cancer diagnosis (Brosseau et al, 2011).

• Consider using music to enhance communication between a client who is dying and his or her family. CEB: In clients with communication difficulties, music therapy resulted in improvement in communication (Leow et al, 2010).

• Encourage clients with aphasia to sing. EB: Participation in a community choir led by a neurologic music therapist resulted in qualitatively identified improvement/changes in communication among clients with aphasia (Tamplin et al, 2013).

• See care plan for Impaired verbal Communication. Pediatric

• All individuals involved in the care and everyday life of children with learning difficulties need to have a collaborative approach to communication. EBN: Collaboration in tasks requires the formation of personal relationships based on mutual trust and respect (Callery & Milnes, 2012).

• See care plan for Impaired verbal Communication. Geriatric

▲ Assess for hearing and vision impairments, and make appropriate referrals for hearing aids. EB: Healthy People 2020 recommends early identification of people with hearing and vision loss (Healthy People 2020, 2014).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

230 Impaired Verbal Communication

• Use touch if culturally acceptable when communicating with older clients and their families. EBN: Touch has a calming effect on a client who may be frightened due to difficulty with communication (Grossbach et al, 2011).

• Consider singing during caregiving of clients with dementia. EB: When professional caregivers sang to clients with dementia during care, enhanced communication and cooperation resulted (Hammar et al, 2011).

• See care plan for Impaired verbal Communication. Multicultural

• See care plan for Impaired verbal Communication. Home Care

• The interventions described previously may be used in home care. • See care plan for Impaired verbal Communication. Client/Family Teaching and Discharge Planning

• See care plan for Impaired verbal Communication.

REFERENCES See impaired verbal Communication for additional references. Agency for Healthcare Research and Quality (AHRQ). (2014). Health

literacy measurement tools, Retrieved September 10, 2014, from: <http://www.ahrq.gov/professionals/quality-patient-safety/ quality-resources/tools/literacy/index.html>.

Brosseau, D. C., McDonald, M. J., & Stephen, J. E. (2011). The moderating effect of relationship quality in partner secondary traumatic stress among couples coping with cancer. Families, Systems and Health: The Journal of Collaborative Family Healthcare, 29(2), 114–126.

Callery, P., & Milnes, L. (2012). Communication between nurses, children and their parents in asthma review consultations. Journal of Clinical Nursing, 21(11/12), 1641–1650.

Carroll, S. M. (2007). Silent, slow lifeworld: the communication experiences of nonvocal ventilated patients. Qualitative Health Research, 17(9), 1165–1177.

Grossbach, I., Stranberg, S., & Chlan, L. (2011). Promoting effective communication for patients receiving mechanical ventilation. Critical Care Nurse, 31(3), 46–61.

Hammar, L. M., et al. (2011). Communicating through caregiver singing during morning care situations in dementia care. Scandinavian Journal of Caring Sciences, 25, 160–168.

Healthy People 2020. Hearing and other sensory or communication disorders, Retrieved September 12, 2014, from: <www.healthypeople.gov/2020/topicsobjectives2020/overviewaspx ?topicid=20>.

Jones, C., et al. (2013). Alleviating psychosocial issues for individuals with communication impairments and their families following stroke: a case series of interdisciplinary assessment and intervention. Neurorehabilitation, 32(2), 351–358.

Khalaila, R., et al. (2011). Communication difficulties and psychoemotional distress in patients receiving mechanical ventilation. American Journal of Critical Care, 20(6), 470–479.

Leow, M., Drury, V., & Hong, P. (2010). The experience and expectations of terminally ill patients receiving music therapy in the palliative setting: a systematic review. JBI Library of Systematic Reviews, 8(27), 1088–1111.

Radtke, J. V., et al. (2011). Listening to the voiceless patient: case reports in assisted communication in the intensive care unit. Journal of Palliative Medicine, 14(6), 791–795.

Tamplin, J., et al. (2013). “Stroke a Chord”: the effect of singing in a community choir on mood and social engagement for people living with aphasia following a stroke. Neurorehabilitation, 32(4), 929–941.

Impaired verbal Communication Stacey M. Carroll, PhD, ANP-BC, and Suzanne White, MSN, RN, PHCNS-BC

NANDA-I

Definition

Decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols

Defining Characteristics

Absence of eye contact; difficulty comprehending communication; difficulty expressing thoughts verbally (e.g., aphasia, dysphasia, apraxia, dyslexia); difficulty forming sentences; difficulty forming words (e.g., aphonia, dyslalia, dysarthria); difficulty in selective attending; difficulty in use of body expressions; difficulty in use of facial expressions; difficulty maintaining communication; difficulty speaking; difficulty verbalizing; disoriented to person; disoriented to place; disoriented to time; does not speak; dyspnea; inability to speak; inability to speak language of caregiver; inability to use body expressions; inability to use facial expressions;

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Impaired Verbal Communication 231

inappropriate verbalization; partial visual deficit; refusal to speak; slurred speech stuttering; total visual deficit

Related Factors (r/t)

Absence of significant other; alteration in development; alteration if perception; alteration in self concept; central nervous system impairment; cultural incongruence; emotional disturbance; environmental barrier; insufficient information; insufficient stimuli; low self-esteem; oropharyngeal defect; physical barrier (e.g., tracheostomy, intubation); physiological condition (e.g., brain tumor, decreased circulation to brain, weak- ened musculoskeletal system); psychotic disorder; treatment regimen; vulnerability

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Communication; Communication: Expressive, Receptive

Example NOC Outcome with Indicators

Communication as evidenced by the following indicators: Use of spoken and written language/Acknowledgment of messages received/Exchanges messages accurately with others. (Rate the outcome and indicators of Communication: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Use effective communication techniques • Use alternative methods of communication effectively • Demonstrate congruency of verbal and nonverbal behavior • Demonstrate understanding even if not able to speak • Express desire for social interactions

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Active Listening; Communication Enhancement: Hearing Deficit; Communication Enhancement: Speech Deficit

Example NIC Activities—Communication Enhancement: Hearing Deficit

Listen attentively; Allow client adequate time to process communication and respond; Verify what was said or written using client’s response before continuing

Nursing Interventions and Rationales

• Use a comprehensive nursing assessment to determine the language spoken, cultural considerations, literacy level, cognitive level, and use of glasses and/or hearing aids. EBN: Language barriers, low literacy, and lack of understanding are barriers to effective communication (Taylor et al, 2013).

• Determine client’s own perception of communication difficulties and potential solutions when possible. In clients with aphasia, nurses should avoid making assumptions regarding communication (Borthwick, 2012). EB: The Communication Confidence Rating Scale for Aphasia (CCRSA) was found to be an effective tool for assessment of the self-report of communication confidence among clients with aphasia (Babbitt et al, 2011).

• Involve a familiar person when attempting to communicate with a client who has difficulty with com- munication, if accepted by the client. EB: A competent communication partner—family member or not— reduced stress in the client by facilitating effective communication (Laasko et al, 2011).

• Listen carefully. Validate verbal and nonverbal expressions particularly when dealing with pain and use appropriate scales for pain when appropriate. EB/EBN: The critical care pain observation tool and the

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

232 Impaired Verbal Communication

behavioral pain scale are valid and reliable options for use in clients who are nonverbal (Aust, 2013; Flynn Makic, 2013).

• Use appropriate scales to assess communication and behavior in clients who are nonvocal and mechani- cally ventilated. EBN: Although further testing is needed, preliminary research shows that the revised Com- munication Interaction Behavior Instrument scale has good face validity and shows good interrater reliability for use with older adults who are ventilated and nonvocal (Nilsen et al, 2014).

• Use therapeutic communication techniques: speak in a well-modulated voice, use simple communication, maintain eye contact at the client’s level, get the client’s attention before speaking, and show concern for the client. EBN: Effective communication entails involving clients, being sensitive to client needs, and ensur- ing client understanding (O’Hagan et al, 2014).

• Avoid ignoring the client with verbal impairment; be engaged and provide meaningful responses to client concerns. Place call light or bell within reach of client who cannot verbally call for help. Safety is at risk when communication barriers are present (Giammarino et al, 2012). EBN: Ignoring clients was found to be a negative communication strategy (O’Hagan et al, 2014).

• Use touch as appropriate. Touch has a calming effect on a client who may be frightened due to difficulty with communication (Grossbach et al, 2011).

• Use presence: spend time with the client, allow time for responses, and make the call light readily avail- able. Client-centered care involves respect, communication, and comfort (Bechtold & Fredericks, 2014).

• Explain all health care procedures. CEBN: Clients who were nonvocal and ventilated were attuned to everything occurring around them, and they appreciated explanations from the nurse (Carroll, 2007).

• Be persistent in deciphering what the client is saying, and do not pretend to understand when the message is unclear. In clients with aphasia, nurses should allow the client extra time to communicate and should not interrupt the client (Borthwick, 2012). CEBN: Persons who were nonvocal and ventilated appreciated per- sistence on the nurses’ part with respect to being understood, and found it bothersome when others pretended to understand them (Carroll, 2007).

• Use an individualized and creative multidisciplinary approach to augmentative and alternative communication (AAC) assistance and other interventions. Ensure the choice of AAC is driven by clients’ communication needs rather than by the device (Light & McNaughton, 2013). EB: A combination of high- technology (with voice output) and low-technology options improved communication efficiency (Radtke et al, 2011). EB: AAC improved communication among those with intellectual disabilities (Hagan & Thompson, 2014).

• Use consistent nursing staff for those with communication impairments. CEBN: Consistent nursing care increased client-nurse communication and decreased client powerlessness (Carroll, 2007).

▲ Consult communication specialists from various disciplines as appropriate. Speech language pathologists, audiologists, and interpreters provide comprehensive communication assistance for those with impaired communication. Lip reading therapists (LRTs) are proficient lip readers who determine what a nonvocal client is mouthing and then verbalize the client’s words verbatim to others, in order to facilitate communica- tion (Carroll, 2003; Grossbach et al, 2011). EB: Lip reading interpreters can assist in meeting nonvocal clients’ communication needs (Meltzer et al, 2012). EB: Interprofessional communication was found to be important for client safety (Brock et al, 2013).

▲ When the client is having difficulty communicating, assess and refer for audiology consultation for hearing loss. Suspect hearing loss when: ❍ Client frequently complains that people mumble, claims that others’ speech is not clear, or client hears

only parts of conversations. ❍ Client often asks people to repeat what they said. ❍ Client’s friends or relatives state that client doesn’t seem to hear very well, or plays the television or

radio too loudly. ❍ Client does not laugh at jokes due to missing too much of the story. ❍ Client needs to ask others about the details of a meeting that the client attended. ❍ Client cannot hear the doorbell or the telephone. ❍ Client finds it easier to understand others when facing them, especially in a noisy environment.

• People with hearing loss do not hear sounds clearly. The loss may range from hearing speech sounds faintly or in a distorted way to profound deafness (American Academy of Audiology, 2011).

• When communicating with a client with a hearing loss: ❍ Obtain client’s attention before speaking and face toward his or her unaffected side or better ear while

allowing client to see speaker’s face at a reasonably close distance; use gestures as appropriate to aid

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Impaired Verbal Communication 233

in communication. Correct positioning increases the client’s awareness of the interaction and enhances the client’s ability to communicate (Alexander Graham Bell Association for the Deaf and Hard of Hearing, 2011; Thiart & Saxby, 2011). EB: Gestures are helpful communication tools both for those with hearing loss and those with normal hearing who are faced with environmental noises or other factors impeding hearing (Obermeier et al, 2012).

❍ Provide sufficient light and do not stand in front of window. Light illuminates the speaker’s face, making expressions and lip movements clearer; standing in front of a window causes glare, which impedes the client’s ability to clearly see the speaker (Alexander Graham Bell Association for the Deaf and Hard of Hearing, 2011; Thiart & Saxby, 2011).

❍ Remove masks if safe to do so, or use see-through masks. Information on see-through masks: www.amphl.org.

❍ Reduce background noise whenever possible. Noise reduction facilitates understanding (Cleveland Clinic, 2012).

❍ Do not raise voice or over-enunciate. This practice distorts the voice and lips, inhibiting effective lip- reading (Cleveland Clinic, 2012).

❍ Avoid making assumptions about the communication choice of those with hearing loss or voice impairments. CEBN: After seeking client input, communication rounds or communication care plans can be completed (Happ et al, 2010).

❍ Encourage physical activity among those with hearing loss. EB: Lower levels of physical activity were found among those with moderate or greater hearing loss (Chen et al, 2014). EB: Hearing loss in older adults is associated with frailty (Kamil et al, 2014).

Pediatric

• Observe behavioral communication cues in infants. EB: Reissland et al (2012) studied mothers and infants (N = 50) and found that preverbal infants express pain by crying and with facial and body behaviors, which have to be interpreted by the caregiver.

• Identify and define at least two new forms of socially acceptable communication alternatives that may be used by children with significant disabilities. EB: Pasco and Tohill (2011) conducted a study of nonverbal children with autism spectrum disorder (N = 23) and found that the Picture Exchange Communication System (PECS) may provide valuable predictive information regarding social communication skills. EB: Brady et al (2013) investigated a model of language development for nonverbal school-aged children (N = 93) and found the importance of enriching social communication input across home and school envi- ronments, as well as assessments of and interventions aimed at improving comprehension, play, visual dis- crimination, and communication complexity.

• Teach children with severe disabilities functional communication skills. EB: Allen and Marshall (2011) conducted a study involving parent-child interaction therapy (PCIT) (N = 16) for school-aged children with specific language impairment and found that PCIT offered a single block of therapy where the parents’ com- munication and interaction skills are developed to provide the child with an appropriate language-rich environment.

▲ Refer children with primary speech and language delay/disorder for speech and language therapy inter- ventions. EB: Pasco and Tohill (2011) conducted a study of nonverbal children with autism spectrum dis- order (N = 23) and found the assessment of the developmental level of potential PECS users may provide valuable predictive information for speech-and-language therapists and other professionals in relation to the likely degree of progress and in setting realistic and achievable targets.

Geriatric

• Carefully assess all clients for hearing difficulty using an audiometer. Healthy People 2020 encourages early identification of people with hearing loss (Healthy People 2020, 2014).

• Avoid use of “elderspeak.” CEB: Using elderspeak, a speech style similar to baby talk that fails to commu- nicate appropriate respect, increases resistiveness to care in clients with dementia (Williams et al, 2009).

• Initiate communication with the client with dementia, and give client time to respond. The responsibility to use a creative approach and take the time to listen and understand clients who have dementia lies with the clinician (Jootun & McGhee, 2011).

• Encourage the client to wear hearing aids, if appropriate. EB: Hearing aid usage is low among older adults with hearing loss, despite the benefits of hearing aids (Gopinath et al, 2011).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

234 Impaired Verbal Communication

• Facilitate communication through reminiscing with memory boxes that contain objects, photographs, and writings that have meaning for the client. Reminiscence stimulates memories, thus improving com- munication (Swann, 2013). CEB: Collage creation as a means of reminiscence facilitated the conveying of information by older adults with dementia who had difficulty communicating verbally (Stallings, 2010).

• Continue to find means to communicate even with those who are completely nonverbal. EB: Spontaneous reciprocal interaction promoted family harmony among nonvocal clients with severe dementia (Walmsley & McCormack, 2014).

Multicultural

• Nurses should become more sensitive to the meaning of a culture’s nonverbal communication modes, such as eye contact, facial expression, touching, and body language. EBN: Kozlowska and Doboszynska (2012) conducted a study among nurses (N = 95) and found that among nonverbal means of communication in everyday practice, those who participated most frequently used touch, facial expression, and visual contact in a conscious way when delivering care.

• Assess for the influence of cultural beliefs, norms, and values on the client’s communication process. EBN: In a 2011 study by El-Amouri and O’Neill that aimed to identify cross-cultural communication needs of hospitals, findings suggested that recognition of the importance of cross-cultural communication skills and intercultural literacy in nurse education were of significant importance in providing culturally competent care.

• Assess personal space needs, acceptable communication styles, acceptable body language, interpretation of eye contact, perception of touch, and use of paraverbal modes when communicating with the client. EB: A 2011 study by Hasnain et al (N = 27) found that the majority (93.8%) of responding clients reported that their health care provider did not understand their religious or cultural needs.

• Assess for how language barriers contribute to health disparities among ethnic and racial minorities. EBN: Taylor et al (2013) found that language barriers were the main obstacle in eliciting an accurate medical history, explaining and gaining pain scores, communicating reasons for client transport delays, arranging appointments by telephone, explaining medication and side effects, or diagnosing and communicating problems (N = 34).

• Although touch is generally beneficial, there may be times when it may not be advisable due to cultural considerations. CEB/EBN: Touch is largely culturally defined and conveys various meanings depending on the client’s culture (Leininger & McFarland, 2002; Lewis et al, 2011).

• Modify and tailor the communication approach in keeping with the client’s particular culture. A 2011 study by Fakhr-Movahedi et al conducted among eight Iranian nurses and nine clients suggested that socio- cultural-economic issues between nurses and clients influence nurse-client communication.

• Use reminiscence therapy as a language intervention. EB: Issues of culture, language, and aging are chal- lenging. Less engaged residents and clients who are nonverbal, immobile, or who have other occupational performance issues may become engaged in occupations of reminiscence that are rich in personal meaning and relevance (Hodges & Schmidt, 2009).

• The Office of Minority Health of the U.S. Department of Health and Human Services standards on cul- turally and linguistically appropriate services (CLAS) in health care should be used as needed. EB: The National Standards for Culturally and Linguistically Appropriate Services in Health and Health Care (The National CLAS Standards) aim to improve health care quality and advance health equity by establishing a framework for organizations to serve the nation’s increasingly diverse communities (CLAS, 2014).

Home Care

The interventions described previously may be adapted for home care use.

Client/Family Teaching and Discharge Planning

▲ Refer the client to a speech-language pathologist (SLP) or audiologist. Audiological assessment quantifies and qualifies hearing in terms of the degree of hearing loss, the type of hearing loss, and the configuration of the hearing loss. Once a particular hearing loss has been identified, a treatment and management plan can be put into place by an SLP (Baumgartner et al, 2008).

▲ Teach the client and family techniques to increase communication, including the use of communication devices and tactile touch. Incorporate multidisciplinary recommendations. The nurse plays a critical role in individualized communication assessment as clients transition from hospital to home (Cerantola & Happ, 2012). EB: Recommendations by SLPs were omitted from discharge summaries at a high rate, placing

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Impaired Verbal Communication 235

clients at risk for lack of continuity of care (Kind et al, 2011). EB: Clients who are mechanically ventilated at home have a long struggle to find effective communication methods (Laasko et al, 2011).

REFERENCES Alexander Graham Bell Association for the Deaf and Hard of

Hearing. Communicating with people who have a hearing loss. Retrieved July 13, 2011, from: <http://agbell.org/NetCommunity/ Document.Doc?id=343>.

Allen, J., & Marshall, C. R. (2011). Parent-Child Interaction Therapy (PCIT) in school-aged children with specific language impairment. International Journal of Language & Communication Disorders, 46(4), 397–410.

American Academy of Audiology. How’s your hearing? Retrieved July 13, 2011, from: <http://www.howsyourhearing.org>.

Aust, M. P. (2013). Pain assessment in nonverbal patients. American Journal of Critical Care, 22(3), 256.

Babbitt, E. M., et al. (2011). Psychometric properties of the Communication Confidence Rating Scale for Aphasia (CCRSA): phase 2. Aphasiology, 25(6/7), 727–735.

Baumgartner, C. A., Bewyer, E., & Bruner, D. (2008). Management of communication and swallowing in intensive care: the role of the speech pathologist. AACN Advance Critical Care, 19(4), 433–443.

Bechtold, A., & Fredericks, S. (2014). Key concepts in patient-centered care. American Nurse Today, 9(7), 35–36.

Borthwick, S. (2012). Communication impairment in patients following stroke. Nursing Standard, 26(19), 35–41.

Brock, D., et al. (2013). Interprofessional education in team communication: working together to improve patient safety. BMJ Quality & Safety, 22(5), 414–423.

Brady, N. C., Thiemann-Bourque, K., Fleming, K., et al. (2013). Predicting language outcomes for children learning augmentative and alternative communication: child and environmental factors. Journal of Speech, Language & Hearing Research, 56(5), 1595–1612.

Carroll, S. M. (2003). Lip-reading translating for non-vocal ventilated patients. JAMPHL Online, 1(2), Retrieved November 26, 2006, from: <www.amphl.org>.

Carroll, S. M. (2007). Silent, slow lifeworld: the communication experiences of nonvocal ventilated patients. Qualitative Health Research, 17(9), 1165–1177.

Cerantola, C., & Happ, M. B. (2012). Transitional care for communication impaired older adults: ICU to home. Geriatric Nursing, 33(6), 489–492.

Chen, D. S., et al. (2014). Association between hearing impairment and self-reported difficulty in physical functioning. Journal of the American Geriatrics Society, 62(5), 850–856.

CLAS (Culturally and Linguistically Appropriate Services), Retrieved October 25, 2014 from: <http://minorityhealth.hhs.gov/omh/ browse.aspx?lvl=2&lvlid=53>.

Cleveland Clinic. (2012). Tips to improve communication when talking to someone with hearing loss. Retrieved September 10, 2014, from: <http://my.clevelandclinic.org/disorders/hearing_loss/hic-tips- improve-communication-when-talking-someone-hearing- loss.aspx>.

El-Amouri, S., & O’Neill, S. (2011). Supporting cross-cultural communication and culturally competent care in the linguistically and culturally diverse hospital settings of UAE. Contemporary Nurse: A Journal for the Australian Nursing Profession, 39(2), 240–255.

Fakhr-Movahedi, A., Salsali, M., Negharandeh, R., et al. (2011). A qualitative content analysis of nurse-patient communication in Iranian nursing. International Nursing Review, 58(2), 171–180.

Flynn Makic, M. B. (2013). Pain management in the nonverbal critically ill patient. Journal of Perianesthesia Nursing, 28(2), 98–101.

Giammarino, C., et al. (2012). Safety considerations for patients with communication disorders in rehabilitation medicine settings. Physical Medicine & Rehabilitation Clinics of North America, 23(2), 343–347.

Gopinath, B., et al. (2011). Incidence and predictors of hearing aid use and ownership among older adults with hearing loss. Annals of Epidemiology, 21(7), 497–506.

Grossbach, I., Stranberg, S., & Chlan, L. (2011). Promoting effective communication for patients receiving mechanical ventilation. Critical Care Nurse, 31(3), 46–61.

Hagan, L., & Thompson, H. (2014). It’s good to talk: Developing the communication skills of an adult with intellectual disability through augmentative and alternative communication. British Journal of Learning Disabilities, 42(1), 66–73.

Happ, M. B., et al. (2010). SPEACS-2: intensive care unit “communication rounds” with speech language pathology. Geriatric Nursing (New York, N.Y.), 31(3), 170–177.

Hasnain, M., Connell, K. J., Menon, U., et al. (2011). Patient-centered care for Muslim women: provider and patient perspectives. Journal of Women’s Health (15409996), 20(1), 73–83.

Healthy People 2020. Hearing and other sensory or communication disorders. Retrieved September 12, 2014, from: <www .healthypeople.gov/2020/topicsobjectives2020/overviewaspx ?topicid=20>.

Hodges, C., & Schmidt, R. (2009). An exploration of reminiscence and post-war European immigrants living in a multicultural aged-care setting in Australia. Occupational Therapy International, 16(2), 154–168.

Jootun, D., & McGhee, G. (2011). Effective communication with people who have dementia. Nursing Standard, 25(25), 40–46.

Kamil, R. J., Li, L., & Lin, F. R. (2014). Association between hearing impairment and frailty in older adults. Journal of the American Geriatrics Society, 62(6), 1186–1188.

Kind, A., et al. (2011). Omission of dysphagia therapies in hospital discharge communications. Dysphagia, 26(1), 49–61.

Kozlowska, L., & Doboszynska, A. (2012). Nurses’ nonverbal methods of communicating with patients in the terminal phase. International Journal of Palliative Nursing, 18(1), 40–46.

Laasko, K., et al. (2011). Communication experience of individuals treated with home ventilation. International Journal of Language and Communication Disorders, 46(6), 686–699.

Leininger, M. M., & McFarland, M. R. (2002). Transcultural nursing: concepts, theories, research and practices (ed. 3). New York: McGraw-Hill.

Lewis, S. L., et al. (2011). Medical surgical nursing: assessment and management of clinical problems (ed. 8). St Louis: Elsevier.

Light, J., & McNaughton, D. (2013). Putting people first: re-thinking the role of technology in augmentative and alternative communication intervention. AAC: Augmentative & Alternative Communication, 29(4), 299–309.

Meltzer, E. C., et al. (2012). Lip-reading and the ventilated patient. Critical Care Medicine, 40(5), 1529–1531.

Nilsen, M. L., et al. (2014). Adaptation of a communication interaction behavior instrument for use in mechanically ventilated, nonvocal older adults. Nursing Research, 63(1), 3–13.

Obermeier, C., Dolk, T., & Gunter, T. C. (2012). The benefit of gestures during communication: evidence from hearing and hearing- impaired individuals. Cortex; a Journal Devoted to the Study of the Nervous System and Behavior, 48(7), 857–870.

236 Acute Confusion

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Acute Confusion Mila W. Grady, MSN, RN

NANDA-I

Definition

Abrupt onset of reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time

Defining Characteristics

Agitation; alteration in cognitive functioning; alteration in level of consciousness; alteration in psychomotor functioning; hallucinations; inability to initiate goal-directed behavior; inability to initiate purposeful behav- ior; insufficient follow-through with goal directed behavior; insufficient following-through with purposeful behavior; misperception; restlessness

Related Factors (r/t)

Age >60 years; alteration in sleep-wake cycle; delirium; dementia; substance abuse, polypharmacy

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Cognition; Distorted Thought Self-Control; Information Processing

Example NOC Outcome with Indicators

Cognition as evidenced by the following indicators: Communication clear for age/Comprehension of the meaning of situations/ Attentiveness/Concentration/Cognitive orientation. (Rate the outcome and indicators of Cognition: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

O’Hagan, S., et al. (2014). What counts as effective communication in nursing? Evidence from nurse educators’ and clinicians’ feedback on nurse interactions with simulated patients. Journal of Advanced Nursing, 70(6), 1344–1355.

Pasco, G., & Tohill, C. (2011). Predicting progress in Picture Exchange Communication System (PECS) use by children with autism. International Journal of Language & Communication Disorders, 46(1), 120–125.

Radtke, J. V., et al. (2011). Listening to the voiceless patient: case reports in assisted communication in the intensive care unit. Journal of Palliative Medicine, 14(6), 791–795.

Reissland, N., Harvey, H., & Mason, J. (2012). Effects of maternal parity, depression and stress on two-month-old infant expression of pain. Journal of Reproductive & Infant Psychology, 30(4), 363–376.

Stallings, J. W. (2010). Collage as a therapeutic modality for reminiscence in patients with dementia. Art Therapy, 37(3), 136–140.

Swann, J. I. (2013). Dementia and reminiscence: not just a focus on the past. Nursing & Residential Care, 15(12), 790–795.

Taylor, S. P., Nicolle, C., & Maguire, M. (2013). Cross-cultural communication barriers in health care. Nursing Standard, 27(31), 35–43.

Thiart, M., & Saxby, H. Augmentative and alternative communication manual for nursing personnel. Retrieved 2011, from: <www.patientprovidercommunication.org>.

Walmsley, B. D., & McCormack, L. (2014). The dance of communication: retaining family membership despite severe non-speech dementia. Dementia (Basel, Switzerland), 13(5), 626–641.

Williams, K. N., et al. (2009). Elderspeak communication: impact on dementia care. American Journal of Alzheimer’s Disease and Other Dementias, 24(1), 11–20.

Client Outcomes Client Will (Specify Time Frame)

• Demonstrate restoration of cognitive status to baseline • Be oriented to time, place, and person • Demonstrate appropriate motor behavior • Maintain functional capacity

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Delirium Management; Delusion Management

Acute Confusion 237

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Example NIC Activities—Delirium Management

Inform client of time, place, and person as needed; Provide information slowly and in small doses with frequent rest periods

Nursing Interventions and Rationales

• Recognize that delirium is characterized by an acute onset, a fluctuating course, inattention, and disor- dered thinking.

• Identify the three distinct types of delirium: hyperactive (easy to recognize), hypoactive (commonly missed), and mixed (the most commonly occurring). (Downing et al, 2013).

• Hyperactive: delirium characterized by restlessness, agitation, irritability, hypervigilance, hallucinations, and delusions; client may be combative or may attempt to remove tubes, lines ❍ Hypoactive: delirium characterized by decreased motor activity, decreased vocalization, detachment,

apathy, lethargy, somnolence, reduced awareness of surroundings, and confusion ❍ Mixed: delirium characterized by the client fluctuating between periods of hyperactivity and agitation

and hypoactivity and sedation. EBN: Delirium is underrecognized by both medical and nursing staff, particularly the hypoactive form (Cerejeira & Mukaetova-Ladinska, 2011).

• Obtain an accurate history and perform a mental status examination that includes the following assessment: ❍ History from a reliable source that documents an acute and fluctuating change in cognitive function,

attention, and behavior from baseline ❍ Cognition as evidenced by level of consciousness; orientation to time, person, and place; thought

process (thinking may be disorganized, distorted, fragmented, slow, or accelerated with delirium; conversation may be irrelevant or rambling); and content (perceptual disturbances such as visual, auditory or tactile delusions or hallucinations)

❍ Level of attention (may be decreased or may fluctuate with delirium; may be unable to focus, shift, or sustain attention; may be easily distracted or may be hypervigilant)

❍ Behavior characteristics and level of psychomotor behavior (activity may be increased or decreased and may include restlessness, finger tapping, picking at bedclothes, changing position frequently, spastic movements or tremors, or decreased psychomotor activity such as sluggishness, staring into space, remaining in the same position for prolonged periods)

❍ Level of consciousness (may be easily aroused, lethargic, drowsy, difficult to arouse, unarousable, hyperalert, easily startled, overly sensitive to stimuli)

❍ Mood and affect (may be paranoid or fearful with delirium; may have rapid mood swings) ❍ Insight and judgment (may be impaired) ❍ Memory (recent and immediate memory is impaired with delirium; unable to register new

information) ❍ Language (may have rapid, rambling, slurred, incoherent speech) ❍ Altered sleep-wake cycle (insomnia, excessive daytime sleepiness) ❍ EB: Establishing the client’s baseline mental status by obtaining an accurate history and performing a

brief cognitive assessment observing for key diagnostic criteria are important in the diagnosis of delirium (Inouye et al, 2014).

• Assess the client’s behavior and cognition systematically and continually throughout the day and night; use a validated tool to assess presence of delirium, such as the Confusion Assessment Method (CAM) or Delirium Observation Screening Scale (DOS). EB: The CAM is accurate, brief, and easy to use (Grover & Kate, 2012); the DOS was found to be a useful screening tool in a small study of verbally active palliative care clients (Detroyer et al, 2014).

• Recognize that delirium may be superimposed on dementia; the nurse must be aware of the client’s baseline cognitive function. EB: Dementia increases the risk and severity of delirium (Voyer et al, 2011b); delirium superimposed on dementia was a strong predictor of decline in function and resultant institution- alization of older adults admitted to a rehabilitation facility (Morandi et al, 2014).

• Identify predisposing factors that may precede the development of delirium: dementia, cognitive impair- ment, functional impairment, visual impairment, alcohol misuse, multiple comorbidities, severe illness, history of transient ischemic attack or stroke, depression, history of delirium, and advanced age (older than 70). EB: Delirium is a multifactorial syndrome most commonly seen in the intensive care unit (ICU),

238 Acute Confusion

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

palliative care, and postoperative settings; identification of risk factors is important for prevention (Inouye et al, 2014).

• Identify precipitating factors that may precede the development of delirium, especially for individuals with predisposing factors: use of restraints, indwelling bladder catheter, metabolic disturbances, poly- pharmacy, pain, infection, dehydration, blood loss, constipation, electrolyte imbalances, immobility, general anesthesia, hospital admission for fractures or hip surgery, anticholinergic medications, anxiety, sleep deprivation, lack of use of vision and/or hearing aids, and environmental factors. EB: Prevention of delirium must be a high priority in light of frequency of occurrence, high treatment costs, longer hospital length of stay, higher rates of functional decline and resultant institutional care, and greater mortality; delirium may persist and lead to long-term cognitive decline (O’Mahoney et al, 2011). EB: Interventions to prevent or lessen the length and severity of delirium may be developed when early identification of delirium risk is instituted (van Boogaard et al, 2012).

▲ Assess for and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypoxia, hypotension, infection, changes in temperature, fluid and electrolyte imbalance, and use of medications with known cognitive and psychotropic side effects). EB: Systemic disturbances, including immunologic, metabolic, neuroinflammatory, endocrinological, and neurological factors lead to alterations in neurotransmitter syn- thesis and availability, which leads to delirium (Maldonado, 2013). ❍ Treat the underlying risk factors or the causes of delirium in collaboration with the health care team:

establish/maintain normal fluid and electrolyte balance, normal body temperature, normal oxygen- ation (if the client experiences low oxygen saturation, deliver supplemental oxygen), normal blood glucose levels, and normal blood pressure, and address malnutrition and anemia. EB: Early recognition of risk factors may help to prevent the negative sequelae of delirium (Fineberg et al, 2013).

▲ Conduct a medication review and eliminate unnecessary medications; potentially inappropriate medica- tions for older adults at risk for delirium include anticholinergics, benzodiazepines, corticosteroids, H2 receptor antagonists, sedative hypnotics, tricyclic antidepressants (American Geriatrics Society, 2012). EB: A software based program that identified potential delirium-causing medications and triggered a medi- cation review and monitoring plan by pharmacists led to a decreased incidence of delirium in long-term care (Clegg et al, 2014); polypharmacy is associated with delirium and a reduction of polypharmacy improves cognition (Van der Cammen et al, 2014). ❍ Communicate client status, cognition, and behavioral manifestations to all necessary health care

providers. ❍ Monitor for any trends occurring in these manifestations, including laboratory tests. CEB: Careful

monitoring is needed to identify the potential etiologic factors for delirium (Sendelbach & Guthrie, 2009). • Identify, evaluate and treat pain quickly and adequately (see care plans for Acute Pain or Chronic

Pain). EB: Untreated pain is a potential cause of delirium, as is excessive opioid administration (Clegg & Young, 2011).

• Promote regulation of bowel and bladder function; use bladder scanning to identify retention; avoid prolonged insertion of urinary catheters and remove catheters as soon as possible. EB: Stool impaction may cause urinary retention, which is associated with delirium (Boddaert et al, 2014). EB: Constipation may precipitate delirium (O’Mahoney et al, 2011); urinary catheterization is associated with delirium (Ahmed et al, 2014).

• Ensure adequate nutritional and fluid intake. EB: Malnutrition is significantly associated with delirium (Ahmed et al, 2014); attending to correct levels of B vitamins, antioxidants, glucose, water, and lipids may lead to resolution of delirium (Sanford & Flaherty, 2014).

• Promote early mobilization and rehabilitation in a progressive manner. EB: Avoiding immobility and promoting early mobilization postoperatively reduces delirium (Butler et al, 2013). EBN: Standardized early mobilization protocols promote functional status, prevent complications associated with functional decline, and contribute to greater well-being and/or decreased length of stay for medical-surgical inpatients (Pashikanti & Von Ah, 2012).

• Promote continuity of care; avoid frequent changes in staff and surroundings. EB: Changes may contribute to feelings of disorientation and confusion (O’Mahoney et al, 2011).

• Plan care that allows for an appropriate sleep-wake cycle. Refer to the care plan for Sleep deprivation. EB: Interventions to promote sleep were associated with a decreased incidence of delirium (Patel et al, 2014).

• Facilitate appropriate sensory input by having clients use aids (e.g., glasses, hearing aids, dentures) as needed; check for impacted ear wax. EB: Delirium can be addressed with nonpharmacologic interven- tions, such as decreasing sensory impairment (Javedan & Tulebaev, 2014) or avoiding sensory overload

Acute Confusion 239

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

for clients with agitation. EB: Multicomponent interventions, such as encouraging use of vision and hearing aids, may assist in the prevention of delirium in individuals who are not cognitively impaired (Khan et al, 2012).

• Modulate sensory exposure; eliminate excessive noise, use appropriate lighting based on the time of day, and establish a calm environment. EB: Noise levels in the hospital, often from staff conversation and other avoidable sources, are higher than recommended and lead to significant sleep loss (Yoder et al, 2012).

• Provide cognitive stimulation through conversation about current events, viewpoints, relationships and encourage reminiscence or word games. EBN: Daily cognitive stimulation can prevent cognitive decline and promote cognitive recovery (Cheng et al, 2012).

• Provide reality orientation, including identifying self by name at each encounter with the client, calling the client by their preferred name, and the gentle use of orientation techniques; when reorientation is not effective, use distraction. EB: Efforts to reorient may agitate some clients; changing the subject may help calm the client (Flaherty & Little, 2011).

• Provide clocks and calendars, update dry erase white boards each shift, encourage family to visit regularly and to bring familiar objects from home, such as family photos or an afghan, and gently correct misper- ceptions. EB: Persons at risk for delirium should be provided clocks and calendars that are easily visible; family and friends may help with reorientation (O’Mahoney et al, 2011).

• Use gentle, caring communication; provide reassurance of safety; give simple explanations of procedures.

• Provide supportive nursing care, including meeting basic needs such as feeding, regular toileting, and ensuring adequate hydration; closely observe behaviors that provide clues to what might be distressing the client. Delirious clients are unable to care for themselves due to their confusion (Rubin et al, 2011). EB: Understanding and anticipating behaviors promotes client comfort and safety (Flaherty & Little, 2011).

▲ Recognize that delirium is frequently treated with antipsychotic medications or sedatives; if there is no other way to keep the client safe, administer these medications cautiously, as ordered, while monitoring for medication side effects. EB: Reducing unnecessary medications, pain, stress, sleep deprivation, inflam- mation and other neurological insults is crucial, because antipsychotics and sedatives may actually prolong the duration of delirium and worsen outcomes (Inouye et al, 2014). ❍ For clients nearing the end of life, for whom delirium may be irreversible, focus on relief of symptoms

by increasing supervision, reducing invasive lines and devices that restrict movement, keeping the bed in low position, and placing mats on the floor; support of family, caregivers, and the health care team is also of prime importance. EB: Nonpharmacologic means should always be used to ameliorate delirium and may be used in conjunction with medication; delirium is distressing to those caring for the client (Irwin et al, 2013).

❍ Choose the appropriate medication and consider the type and reversibility of the delirium; titrate the medication to control the symptoms and minimize side effects. EB: Pharmacologic means can be rapid, safe, and effective using the lowest effective dose of the appropriate medication based on the type of delirium (Irwin et al, 2013).

Critical Care

• Recognize admission risk factors for delirium. EB: ICU clients are at increased risk for delirium due to greater use of sedatives, analgesics, severity of illness, age, infection, multiorgan failure, sleep deprivation, surgery, fracture, restraint use, immobility, tubes, catheters, hypovolemia, polypharmacy, malnutrition, electrolyte imbalance, and stroke (Mistraletti et al, 2012).

• Obtain an accurate history regarding cognitive impairment and mental health, including history of anxiety and depression, alcohol use, medication use, chronic pain, and use of benzodiazepines. EBN: An accurate history guides appropriate interventions to maximize neurocognitive status of older adults with complex illnesses in the ICU (Tate & Happ, 2011).

• Assess level of arousal using the Richmond Agitation Sedation Scale; clients receiving a score of −5 to −4 are comatose and unable to be assessed for delirium. EB: Establishing level of arousal before using the Confusion Assessment Method for the ICU (CAM-ICU) decreases the incidence of inappropriate “unable to assess” (UTA) ratings on the CAM-ICU; it was found that noncomatose clients were inappropriately deter- mined to be UTA (Swan, 2014).

• Assess for pain every 2 to 3 hours or more frequently as needed with a standardized assessment tool, which includes either a numerical rating scale or one with behavioral indicators, such as the Behavioral Pain Scale (BPS) or Critical Care Pain Observation Tool (CPOT). EB: The self-report is the gold standard

240 Acute Confusion

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

for pain assessment (Barr & Pandharipande, 2013); the BPS and CPOT are the most valid and reliable tools to use for adult ICU clients (excluding brain injured) with intact motor function and observable behaviors, who are unable to self-report (Barr et al, 2013). EBN: Uncontrolled pain is common in the ICU and can contribute to delirium; routine assessment of pain may decrease duration of ventilation and ICU length of stay, and increase client satisfaction (Stites, 2013); clients are less likely to communicate symptoms such as pain when delirious (Tate et al, 2013).

▲ Incorporate the Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) ICU delirium and weakness prevention bundle in conjunction with the inter- disciplinary team. EB: Interdisciplinary communication and daily rounds and staff education facilitate optimal ABCDE bundle implementation (Balas et al, 2013); bundle implementation leads to less delirium, reduced ventilator time, and more time out of bed (Balas et al, 2014). ❍ Assess safety of and implement a spontaneous awakening trial (SAT) using an established protocol.

EB: Daily interruption of sedation may be beneficial when it results in a reduced total dose of sedative administered; minimizing the depth and duration of sedation is beneficial for reducing delirium (Reade & Finfer, 2014).

❍ Assess safety of and implement a spontaneous breathing trial (SBT). EBN: Implementing SAT/SBT protocols reduces the duration and use of mechanical ventilation, which may lead to decreased complica- tions and does not increase self-extubation (Jones et al, 2014).

❍ Assess sedation and agitation level using a valid and reliable tool; titrate sedation to target sedation level. EB: Sedatives and analgesics prescribed to improve client-ventilator dyssynchrony and treat anxiety and pain may precipitate delirium (Banerjee et al, 2011); for most clients being ventilated in the ICU, a score of 3-4 on the Riker or a score of −2-0 on the Richmond are appropriate targets (Reade & Finfer, 2014).

❍ Screen for delirium using a reliable and valid monitoring tool once per shift or more often if delirium is present, and recognize that hypoactive delirium is the form most often present in the ICU; com- municate and discuss results with the interdisciplinary team. EB: The CAM-ICU and the Intensive Care Delirium Screening Checklist are the most valid and reliable tools for adult ICU clients (Barr et al, 2013); staff education, discussion of delirium during bedside rounds, and documentation promote successful screening and treatment (Brummel et al, 2013). EBN: The hypoactive form of delirium is the most common form seen in the ICU and contributes to the under-recognition of delirium by clinicians (Tate et al, 2013).

❍ Assess safety to begin mobilization; collaborate with physical therapy (PT), occupational therapy (OT), and respiratory therapy (RT) to implement an early mobility plan using a progressive approach. EB: Early mobilization of stable ICU clients may significantly reduce the length of delirium and length of stay and prevent other complications related to immobility (Hunter et al, 2014).

• Encourage visits from families and educate families about delirium if it occurs. EB: Delirium is distressing to clients and families; providing education can alleviate distress (Irwin et al, 2013). EBN: Families are most familiar with the client’s baseline behavior, assist in the diagnosis of delirium, and by their presence, may help to prevent and ameliorate delirium (Keyser et al, 2012).

• Promote uninterrupted sleep by grouping cares at night to avoid sleep interruption, offering eye mask, soft music, and earplugs; optimizing room temperature; reducing noise and light after 10 PM; and avoiding excessive daytime napping. EB: Sleep deprivation and delirium in the ICU may be iatrogenic; engaging clients to keep them more awake during the day may ensure better outcomes (Weinhouse, 2014). EBN: Multifaceted approaches are required to promote sleep in the ICU in order to avoid the negative consequences of disrupted sleep (Kamdar et al, 2013).

Geriatric

• The interventions described previously are relevant to the geriatric client. • Reorient high-risk clients frequently, answer questions, discuss concerns; use a white board, clock, watch,

and calendar, and encourage family members to bring familiar objects from home such as family photos or afghan to assist with orientation. EB: Environmental factors may be modified to improve outcomes for clients with delirium (McCusker et al, 2013).

• Provide cognitive stimulation by discussing current events, reading the newspaper, promoting reminis- cence, or using games. EB: Therapeutic activities can minimize cognitive decline (Zaubler et al, 2013).

• Promote use of glasses, assistive hearing devices, hearing aids, and dentures. CEB: Sensory impairment is a modifiable risk factor for delirium.

Acute Confusion 241

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

• Provide feeding assistance as needed. See care plan for Imbalanced Nutrition: less than body requirements.

▲ Determine whether the client is adequately nourished; watch for protein-calorie malnutrition. Consult with health care provider or dietitian as needed. EB: Malnutrition is significantly associated with delirium (Ahmed et al, 2014); attending to correct levels of B vitamins, antioxidants, glucose, water, and lipids may lead to resolution of delirium (Sanford & Flaherty, 2014).

• Promote adequate hydration; keep a glass of water within easy reach of the client and offer fluids fre- quently. EB: Keeping a glass of water within reach abated dehydration and delirium in the long-term care population (McCusker et al, 2013).

• Avoid use of restraints; remove all nonessential equipment such as telemetry, blood pressure cuffs, cath- eters, and intravenous lines as soon as possible. EBN: In a study of long-term care residents with dementia, the use of physical restraints was the factor most associated with delirium; initiate alternative interventions (Voyer et al, 2011a).

• Evaluate all medications for potential to cause or exacerbate delirium; potentially inappropriate medica- tions for older adults at risk for delirium include tricyclic antidepressants, anticholinergics, antipsychotics, benzodiazepines, corticosteroids, H2 receptor antagonists, and sedative hypnotics. EB: To enhance client safety, medications used for older adults should be routinely assessed for inappropriateness (Morandi et al, 2011).

• Assess pain frequently and treat pain with the lowest dose of regularly scheduled medication as well as with nonpharmacologic approaches; use client self-report or a validated behavioral pain scale to assess pain accurately. EB: Uncontrolled pain can lead to delirium (Stites, 2013).

▲ Assess risk for falls and implement fall prevention strategies. EB: Geriatric syndromes are more common in older adults with delirium discharged to postacute care facilities; proactively addressing risk factors may improve outcomes (Anderson et al, 2012).

• Recognize that delirium may be superimposed on dementia; determine client’s baseline cognitive status. EB: Dementia increases the risk and severity of delirium (Voyer et al, 2011b); delirium superimposed on dementia was a strong predictor of decline in function and resultant institutionalization of older adults admitted to a rehabilitation facility (Morandi et al, 2014).

▲ Determine whether the client is nourished; watch for protein-calorie malnutrition. Consult with health care provider or dietitian as needed. EB: Malnutrition is significantly associated with delirium (Ahmed et al, 2014); attending to correct levels of B vitamins, antioxidants, glucose, water, and lipids may lead to resolution of delirium (Sanford & Flaherty, 2014).

• Explain hospital routines and procedures slowly and in simple terms; repeat information as necessary. • Provide continuity of care when possible, avoid room changes, and encourage frequent visits from family

members or significant others. EB: Frequent changes may contribute to confusion (O’Mahoney et al, 2011). • Educate family members about delirium assessment and strategies to use to prevent and lessen delirium;

use the Family Confusion Assessment Method (FAM-CAM) assessment tool to solicit accurate informa- tion from caregivers regarding the presence of delirium. EBN: A small pilot study found that forming a trusting and respectful partnership with family caregivers in delirium prevention impacts family and nurse satisfaction (Rosenbloom & Fick, 2013); the FAM-CAM is a sensitive screening tool to assist in the early diagnosis of delirium in individuals with preexisting dementia (Steis et al, 2012).

• If clients know that they are not thinking clearly, acknowledge the concern. Fear is frequently experienced by people with delirium. EB: Confusion is frightening; the memory of the delirium can be distressing to clients and families (Partridge et al, 2013).

Home Care

• The interventions described previously are relevant to home care use. Assess and monitor for acute changes in cognition and behavior. EB: Delirium has an acute onset and fluctuating course, and is char- acterized by disordered thinking and a change in behavior (Downing et al, 2013).

• Recognize that delirium is reversible but can become chronic if untreated in a multidisciplinary fashion; the client may be discharged from the hospital to home care in a state of undiagnosed delirium. EB: Complete recovery may be possible with appropriate multidisciplinary care (Wakefield et al, 2014).

• Avoid preconceptions about the source of acute confusion; assess each occurrence on the basis of avail- able evidence.

▲ Institute case management of frail elderly clients to support continued independent living if possible once delirium has resolved.

242 Acute Confusion

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Client/Family Teaching and Discharge Planning

▲ Teach the family to recognize signs of early confusion and seek medical help. • Counsel the client and family regarding the management of delirium and its sequelae. Increased care

requirements at discharge may be needed for clients who have experienced delirium; frailty and delirium can lead to functional decline and institutionalization (Quinlan et al, 2011).

REFERENCES Ahmed, S., Leurent, B., & Sampson, E. L. (2014). Risk factors for

incident delirium among older people in acute hospital medical units: A systematic review and meta-analysis. Age and Ageing, 43(3), 326–333.

American Geriatrics Society. (2012). Beers Criteria Update Expert Panel. (2012). American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Journal of the American Geriatrics Society, 60(4), 616–631.

Anderson, C. P., Ngo, L. H., & Marcantonio, E. R. (2012). Complications in postacute care are associated with persistent delirium. Journal of the American Geriatrics Society, 60(6), 1122–1127.

Balas, M. C., Burke, W. J., & Gannon, D., et al. (2013). Implementing the awakening and breathing coordination, delirium monitoring/ management, and early exercise/mobility bundle into everyday care: Opportunities, challenges, and lessons learned for implementing the ICU Pain, Agitation, and Delirium Guidelines. Critical Care Medicine, 41(9 Suppl. 1), S116–S127.

Balas, M. C., Vasilevskis, E. E., & Olsen, K. M., et al. (2014). Effectiveness and safety of the awakening and breathing coordination, delirium monitoring/management, and early exercise/mobility bundle. Critical Care Medicine, 42(5), 1024–1036.

Banerjee, A., Girard, T. D., & Pandharipande, P. (2011). The complex interplay between delirium, sedation, and early mobility during critical illness: Applications in the trauma unit. Current Opinion in Anesthesiology, 24(2), 195–201.

Barr, J., & Pandharipande, P. P. (2013). The pain, agitation, and delirium care bundle: Synergistic benefits of implementing the 2013 Pain, Agitation, and Delirium Guidelines in an integrated and interdisciplinary fashion. Critical Care Medicine, 41(9 Suppl. 1), S99–S115.

Barr, J., Fraser, G. L., & Puntillo, K., et al. (2013). Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Critical Care Medicine, 41(1), 263–306.

Boddaert, J., Cohen-Bittan, J., & Khiami, F., et al. (2014). Postoperative admission to a dedicated geriatric unit decreases mortality in elderly patients with hip fracture. PLoS One, 9(1), e83795.

Brummel, N. E., Vasilevskis, E. E., & Han, J. H., et al. (2013). Implementing delirium screening in the ICU: Secrets to success. Critical Care Medicine, 41(9), 2196–2208.

Butler, I., Sinclair, L., & Tipping, B. (2013). Current concepts in the management of delirium. Continuing Medical Education, 31(10), 363–366.

Cerejeira, J., & Mukaetova-Ladinska, E. B. (2011). A clinical update on delirium: From early recognition to effective management. Nursing Research and Practice, 2011, 875196.

Cheng, C. M., Chiu, M. J., & Wang, J. H., et al. (2012). Cognitive stimulation during hospitalization improves global cognition of older Taiwanese undergoing elective total knee and hip replacement surgery. Journal of Advanced Nursing, 68(6), 1322–1329.

Clegg, A., & Young, J. B. (2011). Which medications to avoid in people at risk of delirium: A systematic review. Age and Aging, 40(1), 23–29.

Clegg, A., Siddiqi, N., & Heaven, A., et al. (2014). Interventions for preventing delirium in older people in institutional long-term care. The Cochrane Database of Systematic Reviews, (1), CD009537, Jan 31.

Detroyer, E., Clement, P. M., & Baeten, N., et al. (2014). Detection of delirium in palliative care unit patients: A prospective descriptive study of the Delirium Observation Screening Scale administered by bedside nurses. Palliative Medicine, 28(1), 79–86.

Downing, L. J., Caprio, T. V., & Lyness, J. M. (2013). Geriatric psychiatry review: Differential diagnosis and treatment of the 3 D’s—delirium, dementia, and depression. Current Psychiatry Reports, 15(6), 365.

Fineberg, S. J., Nandyala, S. V., & Marquez-Lara, A., et al. (2013). Incidence and risk factors for postoperative delirium after lumbar spine surgery. Spine (Phila Pa 1976), 38(20), 1790–1796.

Flaherty, J. H., & Little, M. O. (2011). Matching the environment to patients with delirium: Lessons learned from the delirium room, a restraint-free environment for older hospitalized adults with delirium. Journal of the American Geriatrics Society, 59(Suppl. 2), S295–S300.

Grover, S., & Kate, N. (2012). Assessment scales for delirium: A review. World Journal of Psychiatry, 2(4), 58–70.

Hunter, A., Johnson, L., & Coustasse, A. (2014). Reduction of intensive care unit length of stay: The case of early mobilization. Health Care Management (Frederick), 33(2), 128–135.

Inouye, S. K., Westendorp, R. G., & Saczynski, J. S. (2014). Delirium in elderly people. Lancet, 383(9920), 911–922.

Irwin, S. A., Pirrello, R. D., & Hirst, J. M., et al. (2013). Clarifying delirium management: Practical, evidenced-based, expert recommendations for clinical practice. Journal of Palliative Medicine, 16(4), 423–435.

Javedan, H., & Tulebaev, S. (2014). Management of common postoperative complications: Delirium. Clinics in Geriatric Medicine, 30(2), 271–278.

Jones, K., Newhouse, R., & Johnson, K., et al. (2014). Achieving quality health outcomes through the implementation of a spontaneous awakening and spontaneous breathing trial protocol. AACN Advanced Critical Care, 25(1), 33–42.

Kamdar, B. B., Yang, J., & King, L. M., et al. (2013). Developing, implementing, and evaluating a multifaceted quality improvement intervention to promote sleep in an ICU. American Journal of Medical Quality, [Epub ahead of print]; Nov 22.

Keyser, S. E., Buchanan, D., & Edge, D. (2012). Providing delirium education for family caregivers of older adults. Journal of Gerontological Nursing, 38(8), 24–31.

Khan, B. A., Zawahiri, M., & Campbell, N. L., et al. (2012). Delirium in hospitalized patients: Implications of current evidence on clinical practice and future avenues for research: A systematic evidence review. Journal of Hospital Medicine, 7(7), 580–589.

Chronic Confusion 243

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Chronic Confusion Mila W. Grady, MSN, RN

NANDA-I

Definition

Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; manifested by disturbances of memory, orientation, and behavior

Koster, S., Hensens, A. G., & Schuurmans, M. J., et al. (2011). Risk factors of delirium after cardiac surgery: A systematic review. European Journal of Cardiovascular Nursing, 10(4), 197–204.

Maldonado, J. R. (2013). Neuropathogenesis of delirium: Review of current etiologic theories and common pathways. American Journal of Geriatric Psychiatry, 21(12), 1190–1222.

McCusker, J., Cole, M. G., & Voyer, P., et al. (2013). Environmental factors predict the severity of delirium symptoms in long-term care residents with and without delirium. Journal of the American Geriatrics Society, 61(4), 502–511.

Mistraletti, G., Pelosi, P., & Mantovani, E. S., et al. (2012). Delirium: Clinical approach and prevention. Best Practice and Research. Clinical Anaesthesiology, 26(3), 311–326.

Morandi, A., Davis, D., & Fick, D. M., et al. (2014). Delirium superimposed on dementia strongly predicts worse outcomes in older rehabilitation inpatients. Journal of the American Medical Directors Association, 15(5), 349–354.

Morandi, A., Vasilevskis, E. E., & Pandharipande, P. P., et al. (2011). Inappropriate medications in elderly ICU survivors: Where to intervene? Archives of Internal Medicine, 171(11), 1032–1034.

O’Mahoney, R., Murthy, L., & Akunne, A., et al. (2011). Synopsis of the National Institute for Health and Clinical Excellence guideline for prevention of delirium. Annals of Internal Medicine, 154(11), 746–751.

Partridge, J. S., Martin, F. C., & Harari, D., et al. (2013). The delirium experience: What is the effect on patients, relatives and staff and what can be done to modify this? International Journal of Geriatric Psychiatry, 28(8), 804–812.

Pashikanti, L., & Von Ah, D. (2012). Impact of early mobilization protocol on the medical-surgical inpatient population: An integrated review of literature. Clinical Nurse Specialist, 26(2), 87–94.

Patel, J., Baldwin, J., & Bunting, P., et al. (2014). The effect of a multicomponent multidisciplinary bundle of interventions on sleep and delirium in medical and surgical intensive care patients. Anaesthesia, 69(6), 540–549.

Quinlan, N., Marcantonio, E. R., & Inouye, S. K., et al. (2011). Vulnerability: The crossroads of frailty and delirium. Journal of the American Geriatrics Society, 59(Suppl. 2), S262–S268.

Reade, M. C., & Finfer, S. (2014). Sedation and delirium in the intensive care unit. New England Journal of Medicine, 370(5), 444–454.

Rosenbloom, D. A., & Fick, D. M. (2013). Nurse/family caregiver intervention for delirium increases delirium knowledge and improves attitudes toward partnership. Geriatric Nursing, [Epub ahead of print].

Rubin, F. H., Neal, K., & Fenlon, K., et al. (2011). Sustainability and scalability of the hospital elder life program at a community hospital. Journal of the American Geriatrics Society, 59(2), 359–365.

Sanford, A. M., & Flaherty, J. H. (2014). Do nutrients play a role in delirium? Current Opinion in Clinical Nutrition and Metabolic Care, 17(1), 45–50.

Sendelbach, S., & Guthrie, P. F. (2009). Acute confusion/delirium evidence-based guideline. Iowa City, IA: The University of Iowa John A. Hartford Foundation Center of Geriatric Nursing Excellence.

Steis, M. R., Evans, L., & Hirschman, K. B., et al. (2012). Screening for delirium using family caregivers: Convergent validity of the Family Confusion Assessment Method and interviewer-rated Confusion Assessment Method. Journal of the American Geriatrics Society, 60(11), 2121–2126.

Stites, M. (2013). Observational pain scales in critically ill adults. Critical Care Nursing, 33(3), 68–78.

Swan, J. T. (2014). Decreasing inappropriate unable-to-assess ratings for the confusion assessment method for the intensive care unit. American Journal of Critical Care, 23(1), 60–69.

Tate, J. A., & Happ, M. B. (2011). Neurocognitive problems in critically ill older adults: The importance of history. Geriatric Nursing, 32(4), 285–287.

Tate, J. A., Sereika, S., & Divirgilio, D., et al. (2013). Symptom communication during critical illness: The impact of age, delirium, and delirium presentation. Journal of Gerontological Nursing, 39(8), 28–38.

van den Boogaard, M., Pickkers, P., & Slooter, A. J., et al. (2012). Development and validation of PRE-DELIRIC (PREdiction of DELIRium in ICu patients) delirium prediction model for intensive care patients: Observational multicenter study. British Medical Journal, 344, e420.

van der Cammen, T. J., Rajkumar, C., & Onder, G., et al. (2014). Drug cessation in complex older adults: Time for action. Age and Ageing, 43(1), 20–25.

Voyer, P., Richard, S., & Doucet, L., et al. (2011a). Factors associated with delirium severity among older persons with dementia. Journal of Neuroscience Nursing, 43(2), 62–69.

Voyer, P., Richard, S., & Doucet, L., et al. (2011b). Precipitating factors associated with delirium among long-term care residents with dementia. Applied Nursing Research, 24(3), 171–178.

Wakefield, D., Thompson, L., & Bruce, S. (2014). A Lilliputian army under the floorboards: Persistent delirium with complete though prolonged recovery. BMJ Case Reports, pii: bcr2013202639.

Weinhouse, G. L. (2014). Delirium and sleep disturbances in the intensive care unit: Can we do better? Current Opinion in Anaesthesiology, [epub ahead of print].

Yoder, J. C., Staisiunas, P. G., & Meltzer, D. O., et al. (2012). Noise and sleep among adult medical inpatients: Far from a quiet night. Archive of Internal Medicine, 172(1), 68–70.

Zaubler, T. S., Murphy, K., & Rizzuto, L., et al. (2013). Quality improvement and cost savings with multicomponent delirium interventions: Replication of the Hospital Elder Life Program in a community hospital. Psychosomatics, 54(3), 219–226.

244 Chronic Confusion

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Defining Characteristics

Alteration in interpretation; alteration in personality; alteration in response to stimuli; alteration in short- term memory; impaired social functioning; chronic cognitive impairment; normal level of consciousness; organic brain disorder; progressive alteration in cognitive impairment

Related Factors (r/t)

Alzheimer’s disease; cerebrovascular accident; Korsakoff ’s psychosis; multi-infarct dementia

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Cognition; Cognitive Orientation; Distorted Thought Self-Control

Example NOC Outcome with Indicators

Cognition as evidenced by the following indicators: Cognitive orientation/Communicates clearly for age/Comprehends the meaning of situations/Attentiveness/Concentration. (Rate the outcome and indicators of Cognition: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Example NIC Activities—Dementia Management

Use distraction rather than confrontation to manage behavior; Give one simple direction at a time

Client Outcomes Client Will (Specify Time Frame)

• Remain content and free from harm • Function at maximal cognitive level • Participate in activities of daily living at the maximum of functional ability • Have minimal episodes of agitation (agitation occurs in up to 70% of clients with dementia)

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Dementia Management; Environmental Management; Surveillance: Safety

Nursing Interventions and Rationales

• Determine the client’s cognitive level using a screening tool such as the Mini-Mental State Exam (MMSE), Mini-Cog (includes a three-item recall and clock drawing test), or Montreal Cognitive Assessment. Culture and ethnicity (Struble & Sullivan, 2011), and language and education (Velayudhan et al, 2014) must be taken into account when interpreting the results of cognitive testing; an abnormal score necessitates further evaluation. For older adults with mild cognitive impairment, the Short Test of Mental Status and Montreal Cognitive Assessment are more sensitive diagnostic tools than the MMSE (Petersen, 2011).

▲ In clients who are complaining of memory loss, assess for depression, alcohol use, medication use, problems with sleep, and nutrition status. These factors may be implicated in memory loss (Struble & Sullivan, 2011).

▲ Recognize that pharmacological treatment to slow the progression of Alzheimer’s disease is most effective when used early in the course of the disease. The U.S. Food and Drug Administration has approved five drugs that slow the progression of symptoms for approximately 6 to 12 months (Thies et al, 2011).

• If the client is hospitalized, gather information about the client’s preadmission cognitive functioning, daily routines and care, and decision-making capacity. Establishing continuity of care lessens risk for hospitalized clients. Informed consent may create a dilemma; decision-making capacity will vary depend- ing on the degree of cognitive impairment (Weitzel et al, 2011). EBN: Individuals with a history of cogni- tive dysfunction are at higher risk for acute confusion during acute illness (Voyer et al, 2011a).

• Assess the client for signs of depression: anxiety, sadness, irritability, agitation, somatic complaints, tension, loss of concentration, insomnia, poor appetite, apathy, flat affect, and withdrawn behavior. EB:

Chronic Confusion 245

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Depression in dementia is common (Enache et al, 2011), and often unrecognized and undertreated. The Cornell Scale for Depression in Dementia and the Montgomery-Asberg Depression Rating Scale may be used for screening purposes in individuals who cannot be interviewed and may enhance recognition of depression in nursing home practice (Leontjevas et al, 2012).

• Assess the client for anxiety if he or she reports worry regarding physical or cognitive health; reports feelings of being anxious, short of breath, or dizzy; or exhibits behaviors such as restlessness, irritability, sensitivity to noise, motor tension, fatigue, or disturbed sleep. The Rating Anxiety in Dementia (RAID) scale may be used; this may require caregiver input. Recognize that anxiety is common in dementia, is often undiagnosed, and may significantly impact quality of life. EB: The RAID scale is a reliable and valid tool for identifying and measuring anxiety in dementia (Snow et al, 2012).

▲ Recognize that clients with Alzheimer’s disease may experience neuropsychiatric symptoms such as apathy, anxiety and depression, delusions, disinhibition, euphoria, hallucinations, agitation, including verbal/vocal behavior, and aggression; nonpharmacological interventions for management should be attempted first. EB: Neuropsychiatric symptoms are common in individuals with dementia living in nursing homes; agitation and apathy are the most prevalent symptoms (Selbaek et al, 2013). Nonpharmacological and individualized behavioral interventions should be the first approach to treatment; medications should be used selectively and sparingly (Borisovskaya et al, 2014).

• Obtain information about the client’s life history, interests, routines, needs, and preferences from the family or significant others; collaborate with family members to engage in reminiscence. EBN: Understanding the individual’s past and sharing memories enhances communication and client and staff satisfaction (Cooney et al, 2014).

• Begin each interaction with the client by gaining and maintaining eye contact, identifying yourself, and calling the client by name. Approach the client with a caring, accepting, and empathetic attitude, and speak calmly and slowly. EB: Specific communication skills training for caregivers improves the well-being and quality of life in individuals with dementia and increases positive interactions (Eggenberger et al, 2013).

• To enhance communication, use a calm approach, avoid distractions, show interest, keep communication simple, give clear choices and one-step instructions, give the client time with word finding, use repetition and rephrasing, and use gestures, prompts, and cues or visual aids. Listen attentively to understand non- verbal messages, and engage in topics of interest to the client. EB: These communication techniques assist in focusing attention, incorporate nonverbal means of communication, simplify memory demands, compen- sate for cognitive slowing, and assist with retrieval and comprehension (Smith et al, 2011).

• Engage the client in scheduled activities that relate to past interests, experiences, and hobbies and are matched to current preferences and abilities. CEB: Activities that were once meaningful to the client in terms of self-identity are more likely to result in engagement, even for those with severe cognitive impairment. Residents with current interests in art, music, and pets were more engaged in stimuli that reflected those current interests (Cohen-Mansfield et al, 2010).

• Promote regular exercise. EB: Exercise programs can improve the ability to perform activities of daily living (Forbes et al, 2013); a small study demonstrated that a specific walking program for individuals in the later stages of dementia can reduce functional and cognitive decline (Venturelli et al, 2011).

• Provide opportunities for contact with nature or nature-based stimuli, such as facilitating time spent outdoors or indoor gardening. EBN: Gardens and horticultural activities stimulate the senses, may improve well-being, and may reduce disruptive behavior in individuals with dementia (Gonzalez & Kirkevold, 2013).

• Provide animal-assisted therapy to enhance the care environment. EB: In a study of animal-assisted therapy with a group of clients with severe Alzheimer’s disease, animal-assisted therapy was associated with a decrease in sadness and anxiety and an increase in motor activity and positive emotions (Mossello et al, 2011). EBN: Centrally located aquariums were found to decrease problematic behaviors in individuals resid- ing in dementia specific units and improved staff satisfaction (Edwards et al, 2014).

• Break down self-care tasks into simple steps, giving one direction at a time. For example, instead of saying, “Take a shower,” say to the client, “Please follow me. Sit down on the bed. Take off your shoes. Now take off your socks.” Use gestures when giving directions; allow for adequate time and model the desired action if needed or possible. EB: Assistance in focusing attention, modeling behavior, and using prompts and cues maximizes communication with individuals with dementia (Smith et al, 2011).

• Promote engagement in individual client routines and facilitate success by keeping frequently used items in a visible and consistent location. EBN: Person-centered care environments facilitate the completion of activities of daily living in individuals with dementia and positively impact quality of life (Sjögren et al, 2013).

246 Chronic Confusion

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

• Use reminiscence and life review therapeutic interventions for clients in the early to middle stages of dementia; ask questions about the client’s past activities and important events and experiences from the past while using photographs, videos, artifacts, music, newspaper clippings, or multimedia technology to stimulate memories. EB: In a small preliminary study using YouTube videos, it was found that reminis- cence and life review may improve well-being and social engagement (O’Rourke et al, 2011); reminiscence positively impacts quality of life in clients with dementia living in long-term care (O’Shea et al, 2014). Memories from childhood or young adulthood are generally intact in the early and middle stages of Alzheimer’s (Smith et al, 2011).

• Engage clients in the middle to late stages of dementia in creative expression through the use of Time Slips story-telling groups or through person-centered art activities. EB: A small qualitative study demon- strated that Time Slips positively impacted creativity, quality of life, and behavior of clients with dementia and assisted staff to gain a better understanding of residents in the nursing home community (George & Houser, 2014). An exploratory study that used an intergenerational and person-centered arts activity program called Opening Minds through Art demonstrated an improvement in pleasure and engagement for participants using this program versus using a program with traditional arts activities such a scrapbooking and coloring (Sauer et al, 2014).

• If the client is verbally agitated (repetitive verbalizations, complaints, moaning, muttering, threats, screaming), assess for and address unsatisfied basic needs or environmental factors that may be addressed and redirect the individual. EB: Disruptive vocalizations may be an indication that the client with dementia has the need for comfort, attention, or more or less stimulation (Bédard et al, 2011); redirection may be an effective nonpharmacological means to reduce vocalizations (Yusupov & Galvin, 2014).

• Assist clients in wayfinding, monitoring them so that they do not get lost in unfamiliar settings; place cues and familiar objects in the environment. EB: Living in a familiar environment that provides oppor- tunities for privacy as well as social contact is associated with better quality of life for individuals with dementia (Fleming et al, 2014).

• For clients who wander, refer to the Wandering care plan. • Promote sleep by promoting daytime activity, creating a restful sleep environment, decreasing waking,

and promoting quiet. EB: Sleep disorders are very common in those with dementia; individuals with Lewy body dementia experience disturbed sleep twice as often as those without Lewy Body dementia (Bliwise et al, 2011). CEB: Promoting a dark and quiet nighttime environment, providing a comfortable sleeping tempera- ture for the client, encouraging physical activity, especially in the afternoon, maintaining a consistent schedule of meals and activities, maintaining a bright daytime environment, and facilitating outdoor activity are all methods of improving sleep (Neikrug & Ancoli-Israel, 2010).

• Provide activities for the client, such as folding, sorting, or stacking activities, arranging flowers, or other hobbies or routines the individual enjoyed before the onset of dementia. CEB: The purposeful use of activities tailored to an individual’s abilities may allow the individual to maintain social roles and feelings of connectedness, express themselves in a positive way, enhance self-identity, reduce frustration, and prevent boredom, resulting in less agitation (Gitlin et al, 2009). EBN: A small pilot study demonstrated that volun- teers may be trained to engage clients in meaningful individualized activities in order to enhance quality of life (Van der Ploeg et al, 2014).

• Anticipate and assess for physical stressors such as fatigue, hunger, thirst, constipation, urinary symptoms, and pain. EBN: Safe function is enhanced through the establishment of consistent routines and anticipation of basic needs (Lavoie-Vaughan, 2014).

▲ If the client becomes increasingly confused and/or agitated, perform the following steps: ❍ Assess the client for physiological causes, including acute hypoxia, pain, medication effects, malnutri-

tion, and infections such as urinary tract infection, fatigue, electrolyte disturbances, and constipation. Dementia increases the risk and severity of delirium, which may be precipitated by several factors (Voyer et al, 2011b).

❍ Assess for psychological causes, including changes in the environment, caregiver, or routine; demands to perform beyond capacity; or multiple competing stimuli, including discomfort. Encourage com- munication by addressing the client in a calm, gentle tone of voice and by using appropriate body language, facial expressions, and gestures. EB: Agitated behaviors can be an expression of a need that is not being met; needs assessment is facilitated through methods to enhance communication so that needs may be expressed (Cohen-Mansfield et al, 2014).

❍ Use music as a nonpharmacological approach to managing agitation. Identify the client’s music prefer- ences; interview family members if necessary. EB: Music therapy may lead to a short-term decrease in

Chronic Confusion 247

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

agitation in individuals with dementia (Vink et al, 2013). EBN: Using percussion instruments with familiar music was found to be a cost effective method for decreasing anxiety and improving psychological well-being (Sung et al, 2012); both active and passive musical interventions may improve quality of life (Vasionyte & Madison, 2013).

❍ In clients with agitated behaviors, rather than confronting the client, decrease stimuli in the environ- ment or provide gentle stimulation through diversional activities such as quiet music, looking through a photo album with a staff member, or providing the client with textured items to handle. EBN: Sooth- ing music at mealtimes may improve agitated behavior (Ho et al, 2011); clients with dementia are fre- quently overstimulated or understimulated, and activities that provide one-to-one attention from staff may decrease agitation (Maseda et al, 2014).

❍ If clients with dementia become more agitated, assess for pain. EBN: Pain assessment should include the use of a valid and reliable observer-rated tool such as the Pain Assessment in Advanced Dementia Scale (PAINAD); self-report, the gold standard of pain assessment, may be difficult as dementia advances (Lukas et al, 2013).

▲ Avoid using restraints if possible. EB: The use of trunk restraints is associated with higher fall risk for clients with dementia (Luo et al, 2011).

▲ Use as-needed or low-dose regular dosing of psychotropic or antianxiety drugs only as a last resort; start with the lowest possible dose. EB: Psychotropic medications can cause serious adverse effects such as seda- tion, cardiovascular symptoms, and falls; use nonpharmacological interventions to reduce their use (Richter et al, 2012).

▲ Avoid the use of anticholinergic medications such as diphenhydramine. Anticholinergic medications have a high side-effect profile that includes disorientation, urinary retention, and excessive drowsiness, espe- cially in those with decreased cognition. EB: Older adults with dementia are especially sensitive to the side effects of anticholinergics; one study found that 23% of older adults with dementia use anticholinergic medi- cations (Sura et al, 2013).

• For interventions on bathing, refer to the geriatric interventions in the care plan for Bathing Self-Care deficit.

• For care of early dementia clients with primarily symptoms of memory loss, see the care plan for Impaired Memory.

• For clients nearing the end of life, consider a hospice referral. EB: Family members of individuals with dementia reported higher perceptions of the quality of care and quality of dying experience with hospice care (Teno et al, 2011).

• For care of clients with self-care deficits, see the appropriate care plan (Feeding Self-Care deficit; Dressing Self-Care deficit; Toileting Self-Care deficit).

Geriatric

NOTE: All interventions are appropriate for geriatric clients.

Multicultural

• Assess for the influence of cultural beliefs, norms, and values on the family’s or caregiver’s understanding of chronic confusion or dementia; assist the family or caregiver in identifying barriers that would prevent the use of social services or other supportive services that could help reduce the impact of caregiving and refer to social services or other supportive services. EB: African Americans are at a higher risk for Alzheimer’s disease; cultural diversity exists within the older age group of African Americans, influences perceptions of health and knowledge of Alzheimer’s disease, and may lead to health disparity (Rovner et al, 2013). Individuals from minority ethnic groups are more cognitively impaired at the time of diagnosis and seek care later in the disease process; a variety of barriers exist for seeking care (Sayegh & Knight, 2013).

• Inform the client’s family or caregiver of the meaning of and reasons for common behavior observed in clients with dementia. EB: An understanding of behavior enables the client’s family or caregiver to provide the client with a safe environment. Disease expression may vary in different ethnoracial groups; Latinos were found in one study to have more depressive symptoms (Livney et al, 2011).

Home Care

NOTE: Keeping the client as independent as possible is important. Because community-based care is usually less structured than institutional care, in the home setting the goal of maintaining safety for the client takes on primary importance.

248 Chronic Confusion

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

• The interventions described previously may be adapted for home care use. • Provide information to the family and home care client regarding advance directives. A variety of factors

influence the initiation of advance care planning discussions (van der Steen et al, 2014); determining health care preferences and goals in the early stages of dementia is preferable for facilitating optimal end of life care.

• Assess the client’s memory and executive function deficits before assuming the inability to make any medical decisions; driving capacity and financial capacity should be assessed for clients with mild cogni- tive impairment. Decisional capacities for informed consent include understanding and demonstrating comprehension of diagnosis and treatment-related information, appreciation of the significance of the infor- mation, reasoning regarding alternatives and consequences, and expressing a choice (Weitzel et al, 2011).

• Assess the home for safety features and client needs for assistive devices. Refer to the interventions for Feeding Self-Care deficit, Dressing Self-Care deficit, and Bathing Self-Care deficit as needed.

• Promote cognitive stimulation and memory training exercises for individuals in the early stages of dementia. EBN: Cognitive stimulation therapy may positively impact mood, quality of life, and cognitive function (Yamanaka et al, 2013).

• Provide education and support to the family regarding effective communication, home safety, fall preven- tion, engagement in meaningful activities, ways to manage cognitive and behavioral changes, and com- prehensive health care including screening for depression; be prepared to offer support and information to family members who live at a distance as well. EB: The need for care, services, and support for individu- als in the community with dementia and their caregivers is often unmet; evaluation and diagnosis of demen- tia, personal and home safety, physical and mental health care, advanced care planning, and legal issues are needs that should be addressed (Black et al, 2013).

• Use familiar aspects of the environment (smells, music, foods, pictures) to cue the client, capitalizing on habit to remind the client of activities in which the client can participate. CEB: While clients with dementia are probably unable to learn new activities because of deteriorated explicit memory, preserved implicit memory or habit may be useful in maximizing functional ability (Hong & Song, 2009).

• Instruct the caregiver to provide a balanced activity schedule that does not stress the client or deprive him or her of stimulation; avoid sustained low- or high-stimulation activity. CEB: Planned individualized structured activities can prevent agitation (Gitlin et al, 2009).

• Encourage the caregiver to plan leisure activities that promote cognitive and physical stimulation. EB: One study that tested the effects of engaging in both tai chi exercises and the game of mahjong found that these activities were beneficial in preserving cognitive function and delayed cognitive decline in some domains of cognitive function (Cheng et al, 2014).

▲ If the client will require extensive supervision on an ongoing basis, evaluate the client for adult day health care programs. Refer the family to medical social services to assist with this process if necessary. Day care programs provide safe, structured care for the client and respite for the family, provide care on a sliding scale fee basis, and provide stress relief and respite for the caregiver (Alzheimer’s Association, 2014). EB: Adult day services use can decrease care-related stressors for the caregiver, which can positively impact the health of the caregiver (Zarit et al, 2013).

• Encourage the family to include the client in family activities when possible. Reinforce the use of thera- peutic communication guidelines (see Client/Family Teaching and Discharge Planning) and sensitivity to the number of people present. These steps help the client maintain dignity and lead to familial socializa- tion of the client.

• Assess family caregivers for caregiver stress, loneliness, and depression. Refer to the care plan for Care- giver Role Strain.

▲ Refer the client to medical social services as necessary to evaluate financial resources and initiate benefits, and to facilitate access to health care providers and community-based organizations such as support groups and training programs for caregivers. EB: Comprehensive and coordinated care has the potential to maximize function and independence and reduce caregiver stress while reducing overall costs (Reuben et al, 2013).

▲ Institute case management for frail elderly clients to support continued independent living.

Client/Family Teaching and Discharge Planning

• In the client’s early stages of dementia, provide the caregiver with information on illness processes, needed care, available services, role changes, and importance of advance directives discussion; facilitate family cohesion. EB: Education provided to caregivers early in the disease trajectory may assist them to anticipate

Chronic Confusion 249

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

care needs and role changes and to facilitate involving the individual with dementia in care decisions (de Vugt & Verhey, 2013).

• Teach the family communication strategies, personal care techniques, mobility enhancement, prevention, recognition and management of anxiety and depression, strategies for handling challenging behaviors and legal and financial considerations. EBN: Clients and caregivers reported overwhelming satisfaction with in-home care delivery provided by a nurse practitioner who addressed dementia care issues proactively (Fortinsky et al, 2014).

• Discuss with the family what to expect as the dementia progresses. ▲ Counsel the family about resources available regarding end-of-life decisions and legal concerns. CEB:

Family members report distress regarding decision-making throughout the course of dementia, having insuf- ficient information, lack of support in having these discussions with family members in the early stages of dementia, role conflict, maintaining the dignity of their family member, family conflict, supporting caregivers throughout the process and assisting them in advocacy is essential (Livingston et al, 2010).

▲ Inform the family that as dementia progresses, hospice care may be available in the home or nursing home in the terminal stages to help the caregiver. EB: Goals for care include appropriate management of delirium and pain, avoidance of polypharmacy, and promotion of quality of life, comfort, and family and caregiver support (Merel et al, 2014).

REFERENCES Alzheimer’s Association. (2014). Alzheimer’s and dementia caregiver

center. Retrieved from: <http://www.alz.org/care/alzheimers- dementia-adult-day-centers.asp#cost>.

Bédard, A., Landreville, P., Voyer, P., et al. (2011). Reducing verbal agitation in people with dementia: Evaluation of an intervention based on the satisfaction of basic needs. Aging and Mental Health, 15(7), 855–865.

Black, B. S., Johnston, D., Rabins, P. V., et al. (2013). Unmet needs of community-residing persons with dementia and their informal caregivers: Findings from the maximizing independence at home study. Journal of the American Geriatrics Society, 61(12), 2087–2095.

Bliwise, D. L., Mercaldo, N. D., Avidan, A. Y., et al. (2011). Sleep disturbance in dementia with Lewy bodies and Alzheimer’s disease: A multicenter analysis. Dementia and Geriatric Cognitive Disorders, 31(3), 239–246.

Borisovskaya, A., Pascualy, M., & Borson, S. (2014). Cognitive and neuropsychiatric impairments in Alzheimer’s Disease: Current treatment strategies. Current Psychiatry Reports, 16(9), 470.

Cheng, S. T., Chow, P. K., Song, Y. Q., et al. (2014). Mental and physical activities delay cognitive decline in older persons with dementia. American Journal of Geriatric Psychiatry, 22(1), 63–74.

Cohen-Mansfield, J., Thein, K., & Marx, M. S. (2014). Predictors of the impact of nonpharmacologic interventions for agitation in nursing home residents with advanced dementia. Journal of Clinical Psychiatry, 75(7), e666–e671.

Cohen-Mansfield, J., Marx, M. S., Thein, K., et al. (2010). The impact of past and present preferences on stimulus engagement in nursing home residents with dementia. Aging in Mental Health, 14(1), 67–73.

Cooney, A., Hunter, A., & Murphy, K., et al. (2014). Seeing me through my memories: A grounded theory study on using reminiscence with people with dementia living in long-term care. Journal of Clinical Nursing, [epub before print].

de Vugt, M. E., & Verhey, F. R. (2013). The impact of early dementia diagnosis and intervention on informal caregivers. Progress in Neurobiology, 110(11), 54–62.

Edwards, N. E., Beck, A. M., & Lim, E. (2014). Influence of aquariums on resident behavior and staff satisfaction in dementia units. Western Journal of Nursing Research, [epub ahead of print].

Eggenberger, E., Heimerl, K., & Bennett, M. I. (2013). Communication skills training in dementia care: A systematic review of effectiveness, training content, and didactic methods in different care settings. International Psychogeriatrics, 25(3), 345–358.

Enache, D., Winblad, B., & Aarsland, D. (2011). Depression in dementia: Epidemiology, mechanisms, and treatment. Current Opinion in Psychiatry, 24(6), 461–472.

Fleming, R., Goodenough, B., Low, L. F., et al. (2014). The relationship between the quality of the built environment and the quality of life of people with dementia in residential care. Dementia (Basel, Switzerland), [epub ahead of print].

Forbes, D., Thiessen, E. J., Blake, C. M., et al. (2013). Exercise programs for people with dementia. Cochrane Database of Systematic Reviews, (12), Art. No.: CD006489.

Fortinsky, R. H., Delaney, C., Harel, O., et al. (2014). Results and lessons learned from a nurse practitioner-guided dementia care intervention for primary care patients and their family caregivers. Research in Gerontological Nursing, 7(3), 126–137.

George, D. R., & Houser, W. S. (2014). “I’m a storyteller!”: Exploring the benefits of TimeSlips Creative Expression Program at a nursing home. American Journal of Alzheimer’s Disease and Other Dementias, [epub ahead of print].

Gitlin, L. N., Winter, L., Vause Earland, T., et al. (2009). The tailored activity program to reduce behavioral symptoms in individuals with dementia: Feasibility, acceptability, and replication potential. The Gerontologist, 49(3), 428–439.

Gonzalez, M. T., & Kirkevold, M. (2013). Benefits of sensory garden and horticultural activities in dementia: A modified scoping review. Journal of Clinical Nursing, [epub ahead of print].

Hong, G. R., & Song, J. A. (2009). Relationship between familiar environment and wandering behaviour among Korean elders with dementia. Journal of Clinical Nursing, 18(9), 1365–1373.

Ho, S.-Y., Lai, H.-L., Jeng, S.-Y., et al. (2011). The effects of researcher- composed music at mealtime on agitation in nursing home residents with dementia. Archives of Psychiatric Nursing, 25(6), e49–e55.

Lavoie-Vaughan, N. (2014). A critical analysis and adaptation of a clinical practice guideline for the management of behavioral problems in residents with dementia in long-term care. Nursing Clinics of North America, 49(1), 103–113.

250 Chronic Confusion

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Leontjevas, R., Gerritsen, D. L., Vernooij-Dassen, M., et al. (2012). Comparative validation of proxy-based Montgomery-Asberg depression rating scale and Cornell scale for depression in dementia in nursing home residents with dementia. American Journal of Geriatric Psychiatry, 20(11), 985–993.

Livingston, G., Leavey, G., Manela, M., et al. (2010). Making decisions for people with dementia who lack capacity: Qualitative study of family carers in UK. British Medical Journal, 341, c4184.

Livney, M. G., Clark, C. M., Karlawish, J. H., et al. (2011). Ethnoracial differences in the clinical characteristics of Alzheimer’s disease at initial presentation at an urban Alzheimer’s disease center. American Journal of Geriatric Psychiatry, 19(5), 430–439.

Lukas, A., Barber, J. B., Johnson, P., et al. (2013). Observer-rated pain assessment instruments improve both the detection of pain and the evaluation of pain intensity in people with dementia. European Journal of Pain, 17(10), 1558–1568.

Luo, H., Lin, M., & Castle, N. (2011). Physical restraint use and falls in nursing homes: A comparison between residents with and without dementia. American Journal of Alzheimer’s Disease and Other Dementias, 26(1), 44–50.

Maseda, A., Sanchez, A., Marante, M. P., et al. (2014). Multisensory stimulation on mood, behavior, and biomedical parameters in people with dementia: Is it more effective than conventional one-to-one stimulation? American Journal of Alzheimer’s Disease and Other Dementias, [Epub ahead of print].

Merel, S., DeMers, S., & Vig, E. (2014). Palliative care in advanced dementia. Clinics of Geriatric Medicine, 30(3), 469–492.

Mossello, E., Ridolfi, A., Mello, A. M., et al. (2011). Animal-assisted activity and emotional status of patients with Alzheimer’s disease in day care. International Psychogeriatrics, 23(6), 899–905.

Neikrug, A. B., & Ancoli-Israel, S. (2010). Sleep disturbances in nursing homes. Journal of Nutrition, Health and Aging, 14(3), 207–211.

O’Shea, E., Devane, D., Cooney, A., et al. (2014). The impact of reminiscence on the quality of life of residents with dementia in long-stay care. International Journal of Geriatric Psychiatry, [epub ahead of print].

O’Rourke, J., Tobin, F., O’Callaghan, S., et al. (2011). You tube: A useful tool for reminiscence therapy in dementia? Age and Ageing, 40(6), 742–744.

Petersen, R. C. (2011). Mild cognitive impairment. New England Journal of Medicine, 364(23), 2227–2234.

Reuben, D. B., Evertson, L. C., Wenger, N. S., et al. (2013). The University of California at Los Angeles Alzheimer’s and dementia care program for comprehensive, coordinated, patient-centered care: Preliminary data. Journal of the American Geriatrics Society, 61(12), 2214–2218.

Richter, T., Meyer, G., Möhler, R., et al. (2012). Psychosocial interventions for reducing antipsychotic medication in care home residents. Cochrane Database Systems Review, (12), CD008634.

Rovner, B. W., Casten, R. J., & Harris, L. F. (2013). Cultural diversity and views on Alzheimer disease in older African Americans. Alzheimer’s Disease and Associated Disorders, 27(2), 133–137.

Sauer, P. E., Fopma-Loy, J., Kinney, J. M., et al. (2014). It makes me feel like myself ”: Person-centered versus traditional visual arts activities for people with dementia. Dementia (Basel, Switzerland), [epub ahead of print].

Sayegh, P., & Knight, B. G. (2013). Cross-cultural differences in dementia: The sociocultural health belief model. International Psychogeriatrics, 25(4), 517–530.

Selbaek, G., Engedal, K., & Bergh, S. (2013). The prevalence and course of neuropsychiatric symptoms in nursing home patients with

dementia: A systematic review. Journal of the American Medical Directors Association, 14(3), 161–169.

Sjögren, K., Lindkvist, M., Sandman, P. O., et al. (2013). Person- centeredness and its association with resident well-being in dementia care units. Journal of Advanced Nursing, 69(10), 2196–2206.

Smith, E. R., Broughton, M., Baker, R., et al. (2011). Memory and communication support in dementia: Research-based strategies for caregivers. International Psychogeriatrics, 23(2), 256–263.

Snow, A. L., Huddleston, C., Robinson, C., et al. (2012). Psychometric properties of a structured interview guide for the rating for anxiety in dementia. Aging and Mental Health, 16(5), 592–602. [Epub 2012 Feb 28].

Struble, L. M., & Sullivan, B. J. (2011). Cognitive health in older adults. Nurse Practitioner, 36(4), 24–34.

Sung, H. C., Lee, W. L., Li, T. L., et al. (2012). A group music intervention using percussion instruments with familiar music to reduce anxiety and agitation of institutionalized older adults with dementia. International Journal of Geriatric Psychiatry, 27(6), 621–627.

Sura, S. D., Carnahan, R. M., Chen, H., et al. (2013). Prevalence and determinants of anticholinergic medication use in elderly dementia patients. Drugs and Aging, 30(10), 837–844.

Teno, J. M., Gozalo, P. L., Lee, I. C., et al. (2011). Does hospice improve quality of care for persons dying from dementia? Journal of the American Geriatrics Society, 59(8), 1531–1536.

Thies, W., Bleiler, L., & Alzheimer’s Association. (2011). 2011 Alzheimer’s disease facts and figures. Alzheimer’s and Dementia, 7(2), 208–244.

Van der Ploeg, E. S., Walker, H., & O’Connor, D. W. (2014). The feasibility of volunteers facilitating personalized activities for nursing home residents with dementia and agitation. Geriatric Nursing, 35(2), 142–146.

van der Steen, J. T., van Soest-Poortvliet, M. C., Hallie-Heierman, M., et al. (2014). Factors associated with initiation of advance care planning in dementia: a systematic review. Journal of Alzheimer’s Disease, 40(3), 743–757.

Vasionyte, I., & Madison, G. (2013). Musical intervention for patients with dementia: A meta-analysis. Journal of Clinical Nursing, 22(9–10), 1203–1216.

Velayudhan, L., Ryu, S. H., Raczek, M., et al. (2014). Review of brief cognitive tests for patients with suspected dementia. International Psychogeriatrics, 26(8), 1247–1262.

Venturelli, M., Scarsini, R., & Schena, F. (2011). Six-month walking program changes cognitive and ADL performance in patients with Alzheimer. American Journal of Alzheimer’s Disease and Other Dementia, 26(5), 381–388.

Vink, A. C., Zuidersma, M., Boersma, F., et al. (2013). The effect of music therapy compared with general recreational activities in reducing agitation in people with dementia: A randomized controlled trial. International Journal of Geriatric Psychiatry, 28(10), 1031–1038.

Voyer, P., Richard, S., Doucet, L., et al. (2011a). Factors associated with delirium severity among older persons with dementia. Journal of Neuroscience Nursing, 43(2), 62–69.

Voyer, P., Richard, S., Doucet, L., et al. (2011b). Precipitating factors associated with delirium among long-term care residents with dementia. Applied Nursing Research, 24(3), 171–178.

Weitzel, T., Robinson, S., Barnes, M. R., et al. (2011). The special needs of the hospitalized patient with dementia. Medsurg Nursing, 20(1), 13–18.

Yamanaka, K., Kawano, Y., Noguchi, D., et al. (2013). Effects of cognitive stimulation therapy Japanese version (CST-J) for people

Constipation 251

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C Risk for acute Confusion Betty J. Ackley, MSN, EdS, RN

NANDA-I

Definition

Vulnerable to reversible disturbances of consciousness, attention, cognition, and perception that develop over a short period of time, which may compromise health

Risk Factors

Age ≥ 60 years; alteration in cognitive functioning; alteration in sleep-wake cycle; dehydration; dementia; history of cerebral vascular accident; impaired metabolic functioning (e.g., azotemia, decreased hemoglobin, electrolyte imbalance, increase in blood urea nitrogen/creatinine); impaired mobility; inappropriate use of restraints; infection; male gender; malnutrition; pain; pharmaceutical agent; sensory deprivation; substance abuse; urinary retention

NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family Teaching, Rationales, and References

Refer to care plan for Acute Confusion.

with dementia: A single-blind, controlled clinical trial. Aging and Mental Health, 17(5), 579–586.

Yusupov, A., & Galvin, J. E. (2014). Vocalization in dementia: A case report and review of the literature. Case Reports in Neurology, 6(1), 126–133.

Zarit, S. H., Kim, K., Femia, E. E., et al. (2013). The effects of adult day services on family caregivers’ daily stress, affect, and health: Outcomes from the daily stress and health (DaSH) study. The Gerontologist, 54(4), 570–579.

Constipation Amanda Andrews, MA, Ed, BSc, DN, RN, HEA Fellow, and A.B. St. Aubyn, BSc (Hons), RGN, RM, RHV, DPS:N (CHS), MSc, PGCert (Education), HEA Fellow

NANDA-I

Definition

Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool

Defining Characteristics

Abdominal pain; abdominal tenderness with palpable muscle resistance; abdominal tenderness without palpable muscle resistance; anorexia; atypical presentations in older adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated body temperature); borborygmi; bright red blood with stool; change in bowel pattern; decrease in stool frequency; decrease in stool volume; distended abdomen; fatigue; hard, formed stool; headache; hyperactive bowel sounds; hypoactive bowl sounds; inability to def- ecate; increase in intra-abdominal pressure; indigestion; liquid stool; pain with defecation; palpable abdomi- nal mass; palpable rectal mass; percussed abdominal dullness; rectal fullness; rectal pressure; severe flatus; soft, paste-like stool in rectum; straining with defecation; vomiting

Related Factors Functional

Abdominal muscle weakness; average daily physical activity is less than recommended for gender and age; habitually ignores urge to defecate; inadequate toileting habits; irregular defecation habits; recent environ- mental change

Mechanical

Electrolyte imbalance; hemorrhoids; Hirschsprung’s disease; neurological impairment (e.g., positive electro- encephalogram, head trauma, seizure disorders); obesity; postsurgical bowel obstruction; pregnancy; pros- tate enlargement; rectal abscess; rectal anal fissures; rectal anal stricture; rectal prolapsed; rectal ulcer; rectocele; tumors

252 Constipation

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Pharmacological

Laxative abuse; pharmaceutical agent Physiological

Decrease in gastrointestinal motility; dehydration; eating habit change (e.g., foods, eating times); inadequate dentition; inadequate oral hygiene; insufficient dietary habits; insufficient fiber intake; insufficient fluid intake Psychological

Confusion; depression; emotional disturbance

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Bowel Elimination; Hydration

Example NOC Outcome with Indicators

Bowel Elimination as evidenced by the following indicators: Elimination pattern/Stool soft and formed/Passage of stool without aids/Ease of stool passage. (Rate each indicator of Bowel Elimination: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

Maintain passage of soft, formed stool every 1 to 3 days without straining; State relief from discomfort of constipation; Identify measures that prevent or treat constipation

NIC (Nursing Interventions Classification)

Suggested NIC Intervention

Constipation/Impaction Management

Example NIC Activities—Constipation/Impaction Management

Identify factors (e.g., medications, bed rest, and diet) that may cause or contribute to constipation/impaction; Institute a toileting schedule, as appropriate

Nursing Interventions and Rationales

• Introduce yourself to the client and any companions, and inform them of your role. Introducing yourself to a client helps establish and develop a therapeutic relationship that recognizes the person within the client and forms the basis for building trust upon which to base the provision of care (Howatson-Jones et al, 2012).

• Gain consent to carry out care before proceeding further with the assessment. Clients have the right of autonomy both legally and morally and therefore should be fully involved in the decision-making process (Avery, 2013).

• Wash hands using a recognized technique. EB: Performing strict hand-hygiene regimens significantly reduces the incidence of infection with methicillin-resistant Staphylococcus aureus and Clostridium difficile (Health Protection Agency, 2013).

• Assess usual pattern of defecation and establish the extent of the constipation problem. EB: A detailed and accurate assessment of the patient enables the nurse to plan interventions, monitor outcomes, and evalu- ate care, ensuring no unnecessary treatment is rendered (Matthews, 2011). ❍ Bowel habits

• Time of day • Amount and frequency of stool • Consistency of stool (using the Bristol Stool Scale) • Bleeding/passing mucus on defecation • History of bowel habits and/or laxative use

Constipation 253

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

❍ Lifestyle assessment • Fiber content in diet • Daily fluid intake • Exercise patterns • Personal remedies for constipation • Recently stopped smoking • Alcohol consumption/recreational drug use

❍ Past medical history • Obstetrical/gynecological/urological history and surgeries • Diseases that affect bowel motility • Bleeding/passing mucous on defecation • Current medications

❍ Emotional influences • Anxiety and depression • Long-term defecation issues • Stress

• Assess usual pattern of defecation, including time of day, amount and frequency of stool, consistency of stool; history of bowel habits or laxative use; diet, including fiber and fluid intake; exercise patterns; personal remedies for constipation; obstetrical/gynecological history; surgeries; diseases that affect bowel motility; alterations in perianal sensation; present bowel regimen. Individual bowel habits vary and clients with constipation experience a variety of symptoms (Spinzi et al, 2009; Kyle 2011a).

• Consider emotional influences (e.g., depression and anxiety) on defecation. Emotions influence gastro- intestinal function, possibly because control of both emotions and gastrointestinal function is located in the limbic system of the brain. Difficulties with defecation often begin in childhood (e.g., during toilet training), and constipation is also associated with sexual and physical abuse, depression, and anxiety (Whitehead et al, 2009). EBN: In a study, clients with functional constipation were compared to normal controls; subjects with functional constipation had significantly higher anxiety and depression scores (Zhou et al, 2010).

• Complete a physical examination (palpation for abdominal distention, percussion for dullness, and aus- cultation for bowel sounds). A physical examination provides positive and negative findings and may provide the diagnosis without the need for further testing. It may also reveal unsuspected findings or confirm normality (Rhoads & Murphy-Jensen, 2014).

• Encourage the client or family to keep a 7-day diary of bowel habits to include time of day, length of time spent on the toilet, consistency, amount and frequency of stool, and any straining (using the Bristol Stool Scale). EB: Keeping a diary helps establish a patient’s bowel pattern and may contribute to the patient’s adherence to the proposed care plan (Andrews & Morgan, 2013).

• Encourage the client or family to keep a 7-day diary of lifestyle issues in relation to bowel habits to include fluid consumption, fiber content in diet, usual bowel stimulus and exercise regimen. EB: Enabling patients to present their condition in their own words ensures that they feel the health care professionals understand their concerns (Smith, 2012).

• Use the Bristol Stool Scale to assess stool consistency. The Bristol Stool Scale is widely used as a more objective measure to describe stool consistency (Tack et al, 2011).

▲ Review the client’s current medications. EB: Many medications are associated with chronic constipation including opioids, anticholinergics, antidepressants, antihypertensives (e.g., clonidine, calcium channel block- ers), antispasmodics, diuretics, anticonvulsants, and psychotropics (Eoff & Lembo, 2008; Spinzi et al, 2009). If clients are suffering from constipation and are taking constipating medications, consult with the health care provider about the possibilities of decreasing the medication dosages or finding an alternative medication that is less constipating (Gallagher et al, 2008; Kyle, 2011b).

• Discuss with clients already taking opioids (temporarily or long term) that constipation is a common side effect. Advise them to contact their health care provider for a prescription of an appropriate laxative. The thorough and comprehensive assessment of patients on opioids experiencing constipation will also allow for a bowel function approach for laxative prescribing rather than one based on the opioid dose alone (Andrews & Morgan, 2012).

▲ Recognize that opioids cause constipation. If the client is receiving temporary opioids (e.g., for acute postoperative pain), request an order for routine stool softeners from the primary care provider, monitor bowel movements, and request a laxative for the client if constipation develops. If the client is receiving

254 Constipation

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

around-the-clock opiates (e.g., for palliative care), request an order for Senokot-S and institute a bowel regimen. Opioids cause constipation because they decrease propulsive movement in the colon and enhance sphincter tone, making it difficult to defecate. Senokot-S is recommended to prevent constipation when opioids are given around the clock (Kyle, 2007). EB: In a study of clients with hip fracture who received opioids following surgery, clients who received prophylactic laxatives were less likely to develop constipation than those who did not (Davies et al, 2008).

▲ If the client is terminally ill and is receiving around-the-clock opioids for palliative care, speak with the prescribing health care provider about ordering methylnaltrexone, a drug that blocks opioid effects on the gastrointestinal tract without interfering with analgesia. Methylnaltrexone is FDA approved for clients in palliative care when other laxatives are ineffective (Greenwood-Van Meerveld & Standifer, 2008). Meth- ylnaltrexone does not replace, but is given in addition to, the usual laxative regimen (Kyle, 2009). EB: In a randomized control trial (RCT) of subjects with opioid-induced constipation, a significantly greater percent- age of those who received methylnaltrexone had a bowel movement within 4 hours (without other laxatives) than those who received placebo (Thomas et al, 2008). In a randomized study of clients who took opioids for chronic, nonmalignant pain, those who received subcutaneous methylnaltrexone daily or every other day had significantly more bowel movements than subjects who received placebo (Michna et al, 2011).

• If new onset of constipation, determine whether the client has recently stopped smoking. Constipation is common, but usually transient, when people stop smoking (Wilcox et al, 2010). CEB: In a survey about perceived effects of various foods and beverages on constipation, cigarettes was the item that was most often perceived to have a laxative effect among smokers in all three groups (Müller-Lissner et al, 2005).

• Palpate for abdominal distention, percuss for dullness, and auscultate bowel sounds. In clients with con- stipation the abdomen is often distended and tender, and stool in the colon produces a dull percussion sound. Bowel sounds will be present.

▲ Check for impaction; if present, perform digital removal of stool per the health care provider’s order. An impaction is hard stool that is too large to move through the sphincter and must be removed manually. Clients with neurogenic bowel dysfunction (e.g., spinal cord injury) commonly require manual evacua- tion of stool (Coggrave & Norton, 2010).

▲ Advise a fiber intake of 18 to 25 g daily and suggest foodstuffs high in fiber (e.g., prune juice, leafy green vegetables, whole meal bread and pasta). Fiber creates bulky feces and stretches the bowel wall to stimulate peristalsis, thus shortening bowel transit time (Kyle, 2012).

• Add fiber gradually to the diet to decrease bloating and flatus. Larger stools move through the colon faster than smaller stools, and dietary fiber makes stools bigger because it is undigested in the upper intestinal tract. Fiber fermentation by bacteria in the colon produces gas. The effectiveness of water-insoluble fibers (e.g., wheat bran) on bowel function is well supported by research, and there is growing evidence that water- soluble fibers (e.g., psyllium) also promote laxation (Vuksan et al, 2008). CEB: The Nurses’ Health Study found that women with a median fiber intake of 20 g/day were less likely to experience constipation than those with a median intake of 7 g/day (Dukas et al, 2003). In a study of subjects receiving each of five treat- ments in a randomized design, the five treatments included (1) bran cereal, (2) bran with corn cereal, (3) bran with psyllium cereal, (4) a cereal blend of 70% glucomannan and 30% xanthan, and (5) the low-fiber control diet. All four cereals produced significantly greater bowel movement than the low-fiber control diet and all were well tolerated (Vuksan et al, 2008). Researchers found that rye bread shortened intestinal transit time, softened the feces, and eased defecation in women with constipation, and that yogurt lessened the bloating and flatulence resulting from rye bread (Hongisto et al, 2006).

• Use a mixture of bran cereal, applesauce, and prune juice; begin administration in small amounts and gradually increase amount. Keep refrigerated. Always check with the primary care provider before initiat- ing this intervention. It is important that the client also ingest sufficient fluids. CEB: This bran mixture has been shown to be effective even with short-term use in older clients recovering from acute conditions; however, it has not been tested with an RCT (Joanna Briggs Institute, 2008). Note: Giving fiber without sufficient fluid may result in worsening of constipation. Additional dietary fiber and bulk-forming laxatives are inappropriate for those who have difficulty ingesting adequate fluids, such as clients in palliative care (Kyle, 2007).

• Provide prune or prune juice daily. Each 100 g of prunes contains about 6 g of fiber, 15 g of sorbitol, and 184 mg of polyphenol; all have laxative effects (Attaluri et al, 2011). CEB: In a study about the perceived effects of various foods and beverages on stool consistency, more than half of subjects surveyed reported that prunes had a softening effect on their stools (Müller-Lissner et al, 2005). In a randomized study, dried prunes

Constipation 255

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

produced significantly more complete spontaneous bowel movements per week than psyllium, and both treatments produced significantly more complete spontaneous bowel movements than at baseline (Attaluri et al, 2011).

• Advise a fluid intake of 1.5 to 2 L of fluid per day (ideally, 6 to 8 glasses of water), unless contraindicated by comorbidities, such as kidney or heart disease. Water passes into the gut to promote the formation of a softer fecal mass and provides lubrication to prevent a blockage of the gut (Boyle, 2013).

▲ If the client is uncomfortable or in pain due to constipation or has acute or chronic constipation that does not respond to increased fiber, fluid, activity, and appropriate toileting, refer the client to the primary care provider for an evaluation of bowel function and health status. There can be multiple causes of constipation, such as endocrine disorders (e.g., hypothyroidism), depression, neurological conditions (e.g., multiple sclerosis and Parkinson’s disease), anorectal disorders, and Hirschsprung’s disease (Eoff & Lembo, 2008).

• Encourage physical activity within the client’s current ability to mobilize. Encourage turning and changing position in bed if immobile. For clients with reduced mobility, encourage knee to chest raises, waist twists, and stretching the arms away from the body. For fully mobile clients, encourage walking and swimming. Physical activity can help stimulate peristaltic waves in the colon and encourage the transit of feces to the rectum (Rogers, 2013; Andersen et al, 2006).

• Demonstrate the use of gentle external abdominal massage, using aroma therapy oils, following the direc- tion of colon activity. Abdominal massage encourages rectal loading by increasing intra-abdominal pressure and in some cases it may elicit rectal waves, which may stimulate the somato-autonomic reflex and enhance bowel sensation (McClurg et al, 2011).

• Recommend clients establish a regular elimination routine. If required assist clients to the bathroom at the same time every day, being mindful of the need for privacy (closing of bathroom doors). Establishing a routine allows for the use of the gastrocolic reflex, especially in the morning, which aids defecation (Rogers, 2013).

• Provide privacy for defecation. If not contraindicated, help the client to the bathroom and close the door. Bowel elimination is a private act in Western cultures, and a lack of privacy can hinder the defecation urge, thus contributing to constipation (Kyle, 2011a).

• Help clients onto a bedside commode or toilet so they can either squat or lean forward while sitting. Recognize that it is difficult to impossible to defecate in the lying supine position. Sitting upright allows gravity to aid defecation. CEB: A study of men found that flexing the hip to 90 degrees or more straightens the angle between the anus and the rectum and pulls the anal canal open, decreasing the resistance to the movement of feces from the rectum and the amount of pressure needed to empty the rectum. Hip flexion is greatest when squatting or when leaning forward while sitting (Tagart, 1966). In a study involving volunteers, defecation required significantly less time and was significantly easier when squatting than when sitting (Sikirov, 2003). In another study, researchers found a significant decrease in the ability of subjects to defecate both a water-filled balloon and a silicone device in the lying position versus the sitting position (Rao et al, 2006).

• Educate the client how to adopt the best posture for defecation. Keep knees slightly higher than hips, keep feet flat on the floor and lean forward putting elbows onto knees. EB: Adopting the correct position to open one’s bowels allows the angle of the rectum and anal canal to straighten out. This facilitates an increase in abdominal pressure, which makes defecation more effective (Rogers, 2013).

• Teach clients of the importance of responding promptly to the urge to defecate. EB: The body’s natural “call to stool” should be heeded in that it is a response to the stimulation of nerve endings in the rectum when a stool is present. Ignoring this urge will result in the rectum becoming desensitized to a stool in situ (Coggrave et al, 2014). CEB: A study of male volunteers determined that the defecation urge can be delayed and that delaying defecation decreased bowel movement frequency, stool weight, and transit time (Klauser et al, 1990).

• Consider the use of laxatives, suppositories, enemas, and bowel irrigation as required if other more natural interventions are not effective. Laxative therapies can be used in conjunction with lifestyle changes (while waiting for the lifestyle changes to take effect or if the change is not sufficient in itself) (Marples, 2011).

• Discourage the use of long-term laxatives and enemas and advise clients to gradually reduce their use if taken regularly. Long-term use or overuse of laxatives can cause health problems (e.g., electrolyte imbal- ance) or hide symptoms that may be from a serious medical condition, such as cardiac arrhythmias (Aschenbrenner, 2014).

256 Constipation

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Geriatric

• Assess older adults for the presence of factors that contribute to constipation, including dietary fiber and fluid intake (less than 1.5 L/day), physical activity, use of constipating medications, and diseases that are associated with constipation.

• Explain the importance of adequate fiber intake, fluid intake, activity, and established toileting routines to ensure soft, formed stool. EB: Strong evidence exists for the efficacy of adequate hydration and dietary fiber in the prevention of constipation in older adults; moderate evidence exists for the effectiveness of increased activity for those restricted to bed rest (Joanna Briggs Institute, 2008). In an RCT of older nursing home residents who were chronically ill and regularly used laxatives, those who received an additional 5.1 g of oat bran with their usual diets had significant reductions in laxative use when compared to those who did not (Sturtzel & Elmadfa, 2008). CEB: A study involving institutionalized older men with chronic con- stipation demonstrated that, with use of a bran mixture, clients were able to discontinue use of oral laxatives (Howard et al, 2000).

• Determine the client’s perception of normal bowel elimination and laxative use; promote adherence to a regular schedule. EB: In a survey in the United States, United Kingdom, Germany, France, Italy, Brazil, and South Korea, older subjects reported more constipation and used laxatives more often than younger subjects (Wald et al, 2008).

• Explain why straining (Valsalva maneuver) should be avoided. Excessive straining can cause syncope or cardiac dysrhythmias in susceptible people (Gallagher et al, 2008).

• Respond quickly to the client’s call for assistance with toileting. • Offer food, fluids, activity, and toileting opportunities to older clients who are cognitively impaired. Even

cognitively impaired individuals who are unable to initiate a request for food, fluids, and so forth may respond when opportunities are offered (Gallagher et al, 2008). EB: In an RCT involving nursing home resi- dents, subjects who received the treatment protocol (offering of food, fluid, activity, and toileting opportuni- ties) had significantly more bowel movements than the control group. Both cognitively intact and cognitively impaired subjects benefited from the treatment (Schnelle et al, 2010).

• Avoid regular use of enemas in older adults. Enemas can cause fluid and electrolyte imbalances (Gallagher et al, 2008) and damage to the colonic mucosa (Schmelzer et al, 2004). However, judicious enema use may help prevent impactions (Gallagher et al, 2008).

▲ Use opioids cautiously. Opioids cause constipation (Davies et al, 2008). • Position the client on the toilet or commode and place a small footstool under the feet. Placing a small

footstool helps the client assume a squatting posture to facilitate defecation.

Home Care

• The interventions described previously may be adapted for home care use. • Take complaints seriously and evaluate claims of constipation in a matter-of-fact manner. Continued

constipation can lead to bowel obstruction, a medical emergency. Use of a matter-of-fact manner will limit positive reinforcement of the behavior if actual constipation does not exist. Refer to the care plan for Perceived Constipation.

• Assess the self-care management activities the client is already using. CEB: Many older adults seek solutions to constipation, with laxative use a frequent remedy that creates its own problems (Annells & Koch, 2002).

• Offer the following treatment recommendations: ❍ Acknowledge the client’s life-long experience of bowel function; respect beliefs, attitudes, and prefer-

ences, and avoid patronizing responses. ❍ Make available comprehensive, useful written information about constipation and possible solutions. ❍ Make available empathetic and accessible professional care to provide treatment and advice; a multi-

disciplinary approach (including health care provider, nurse, and pharmacist) should be used. ❍ Institute a bowel management program. ❍ Consider affordability when suggesting solutions to constipation; discuss cost-effective strategies. ❍ Discuss a range of solutions to constipation and allow the client to choose the preferred options. ❍ Have orders in place for a suppository and enema as the need may occur. As part of a bowel manage-

ment program, suppositories or enemas may become necessary. • Although the use of a bedside commode may be necessitated by the client’s condition, allow the client to

use the toilet in the bathroom when possible and provide assistance. Bowel elimination is a private act, and a lack of privacy can contribute to constipation.

Constipation 257

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

• In older clients, routinely advise consumption of fluids, fruits, and vegetables as part of the diet, and ambulation if the client is able. Introduce a bowel management program at the first sign of constipation. Constipation is a major problem for terminally ill or hospice clients, who may need very high doses of opioids for pain management (Sykes, 2006).

▲ Refer for consideration of the use of polyethylene glycol 3350 (PEG-3350) for constipation. CEB: In a study of PEG-3350 use for idiopathic constipation, researchers concluded that it appeared to be safe and efficacious when dietary and lifestyle changes were ineffective. Clients reported increased perceived bowel control, with reduced complaints of straining, stool hardness, bloating, and gas (Stoltz et al, 2001). There is good evidence to support the use of PEG for chronic constipation (Ramkumar & Rao, 2005).

• Advise the client against attempting to remove impacted feces on his or her own. Older or confused clients in particular may attempt to remove feces and cause rectal damage.

• When using a bowel program, establish a pattern that is very regular and allows the client to be part of the family unit. Regularity of the program promotes psychological and/or physiological readiness to evacuate stool. Families of home care clients often cannot proceed with normal daily activities until bowel programs are complete.

Client/Family Teaching and Discharge Planning

• Instruct the client on normal bowel function and the need for adequate fluid and fiber intake, activity, and a defined toileting pattern in a bowel program.

• Encourage the client to heed defecation warning signs and develop a regular schedule of defecation by using a stimulus such as a warm drink or prune juice. Most cases of constipation are mechanical and result from habitual neglect of impulses that signal the appropriate time for defecation.

• Encourage the client to avoid long-term use of laxatives and enemas and to gradually withdraw from their use if they are used regularly. Use of stimulant laxatives should be avoided; long-term use can result in dependence on laxative for defecation (Roerig et al, 2010).

• If not contraindicated, teach the client how to do bent-leg sit-ups to increase abdominal tone; also encour- age the client to contract the abdominal muscles frequently throughout the day. Help the client develop a daily exercise program to increase peristalsis.

• Provide client with comprehensive written information about constipation and its management. EB: Providing patients with well-written, evidence-based information about their condition and treatment can have a beneficial effect on the outcomes of treatment. In addition, patients are more likely to retain important information that will assist them in making informed decisions about their care (Coulter, 2011).

▲ Collaborate with members of the interprofessional team to provide treatment and advice to clients and caregivers. Team working is a central process in health care organizations. It increases the capacity of teams to absorb and develop new knowledge, which will improve patient health and well-being (Ortega et al, 2013).

• Formalize all advice by providing a bowel management program reiterating the mechanism of normal bowel function and the need for adequate fluid and fiber intake, physical activity, and a defined toileting pattern in an agreed bowel program. EB: The implementation of an organized bowel management program is effective and significantly reduces hospital admissions in patients with severe idiopathic constipation (Russell et al, 2013).

• Document all care and advice given in a factual and comprehensive manner. Good record keeping is an integral part of nursing practice and is essential to the provision of safe and effective care (St. Aubyn & Andrews, 2012).

REFERENCES Andersen, C., et al. (2006). The effect of a multidimensional exercise

program on symptoms and side-effects in cancer patient undergoing chemotherapy-the use of semi-structured diaries. European Journal of Oncology Nursing, 10, 247–262.

Andrews, A., & Morgan, G. (2012). Constipation management in palliative care: treatments and the potential of independent nurse prescribing. International Journal of Palliative Nursing, 18(1), 17–22.

Andrews, A., & Morgan, G. (2013). Constipation in palliative care: treatment options and considerations for individual patient

management. International Journal of Palliative Nursing, 19(6), 226–273.

Annells, M., & Koch, T. (2002). Older people seeking solutions to constipation: the laxative mire. Journal of Clinical Nursing, 11, 603.

Aschenbrenner, D. S. (2014). Overuse of certain OTC laxatives may be dangerous. American Journal of Nursing, 114(5), 25.

Attaluri, A., et al. (2011). Randomised clinical trial: dried plums (prunes) vs psyllium for constipation. Alimentary Pharmacology and Therapeutics, 33, 822–828.

258 Constipation

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Avery, G. (2013). Law and Ethics in Nursing and Healthcare an Introduction. London: Sage Publications Inc.

Boyle, J. (2013). Roughage to regulate. World of Irish Nursing and Midwifery, 21(7), 53–55.

Coggrave, M. J., & Norton, C. (2010). The need for manual evacuation and oral laxatives in the management of neurogenic bowel dysfunction after spinal cord injury: a randomized controlled trial of a stepwise protocol. Spinal Cord, 48, 504–510.

Coggrave, K., Norton, C., & Cody, J. D. (2014). Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database of Systematic Reviews, (1), CD002115.

Coulter, A. (2011). Engaging Patients in Health Care. Berkshire: McGraw Hill Open University Press.

Davies, E. C., et al. (2008). The use of opioids and laxatives, and incidence of constipation, in patients requiring neck-of-femur (NOF) surgery: a pilot study. Journal of Clinical Pharmacy and Therapeutics, 33, 561–566.

Dukas, L., Willett, W. C., & Giovannucci, E. L. (2003). Association between physical activity, fiber intake, and other lifestyle variables and constipation in a study of women. The American Journal of Gastroenterology, 98(8), 1790–1796.

Eoff, J. C., & Lembo, A. G. (2008). Optimal treatment of chronic constipation in managed care: review and roundtable discussion. Journal of Managed Care & Specialty Pharmacy, 14(9–a), S1–S17.

Gallagher, P. F., O’Mahony, D., & Quigley, M. M. (2008). Management of chronic constipation in the elderly. Drugs and Aging, 25(10), 807–821.

Greenwood-Van Meerveld, B., & Standifer, K. M. (2008). Methylnaltrexone in the treatment of opioid-induced constipation. Clin and experimental gastroenterology, 1, 49–58.

Health protection Agency. (2013). Hand Washing Technique. Available at: <www.hpa.org.uk/Topics/InfectiousDiseases/infectionsAZ/ Handwashing>.

Hongisto, S.-M., et al. (2006). A combination of fibre-rich rye bread and yoghurt containing Lactobacillus GG improves bowel function in women with self-reported constipation. European Journal of Clinical Nutrition, 60, 319–324.

Howard, L. V., West, D., & Ossip-Klein, D. J. (2000). Chronic constipation management for institutionalized older adults. Geriatric Nursing (New York, N.Y.), 21(2), 78.

Howatson-Jones, L., Standing, M., & Roberts, S. (Eds.), (2012). Patient Assessment and Care Planning in Nursing. London: Sage Publications Inc.

Joanna Briggs Institute. (2008). Management of constipation in older adults. Australian Nursing Journal (July 1993), 16(5), 32–35.

Klauser, A. G., et al. (1990). Behavioral modification of colonic function. Can constipation be learned? Digestive Diseases and Sciences, 35(10), 1271–1275.

Kyle, G. (2007). Constipation and palliative care-where are we now? International Journal of Palliative Nursing, 13(1), 6–16.

Kyle, G. (2009). Methylnaltrexone: a subcutaneous treatment for opioid-induced constipation in palliative care patients. International Journal of Palliative Nursing, 15(11), 533–540.

Kyle, G. (2011a). Risk assessment and management tools for constipation. British Journal of Community Nursing, 16(5), 224–230.

Kyle, G. (2011b). Managing constipation in adult patients. Nurse Prescribing, 9(10), 482–490.

Kyle, G. (2012). The older person: management of constipation. British Journal of Community Nursing, 15(2), 60–63.

Matthews, E. (2011). Nursing Care Planning. London: Lippincott Williams & Wilkins.

Marples, G. (2011). Diagnosis and management of slow transit constipation in adults. Nursing Standard, 26(8), 41–48.

McClurg, D., Hagen, S., & Dickinson, L. (2011). Abdominal massage for the treatment of constipation (Protocol). Cochrane Database of Systematic Reviews, (4), CD009089.

Michna, E., et al. (2011). Subcutaneous methylnaltrexone for treatment of opioid-induced constipation in patients with chronic, nonmalignant pain: a randomized controlled study. The Journal of Pain, 12(5), 554–562.

Müller-Lissner, S. A., et al. (2005). The perceived effect of various foods and beverages on stool consistency. European Journal of Gastroenterology and Hepatology, 17, 109–112.

Ortega, A., Sanchez-Manzanares, M., Gil, F., et al. (2013). Enhancing team learning in nursing teams through beliefs about interpersonal contexts. The Journal of advanced Nursing, 69(1), 363–370.

Rao, S. S. C., Kavolic, R., & Rao, S. (2006). Influence of body position and stool characteristics on defecation in humans. The American Journal of Gastroenterology, 206(101), 2790–2796.

Ramkumar, D., & Rao, S. S. (2005). Efficacy and safety of traditional medical therapies for chronic constipation: systematic review. The American Journal of Gastroenterology, 100(4), 936–971.

Rhoads, J., & Murphy-Jensen, M. (2014). Differential diagnoses for the advanced practice nurse. NY: Springer Publishing Company.

Roerig, J. L., et al. (2010). Laxative abuse: epidemiology, diagnosis and management. Drugs, 70(12), 1487–1503.

Rogers, J. (2013). Management of constipation in the community. Journal of Community Nursing, 27(1), 20–24.

Russell, K. W., et al. (2013). The implementation of an organised bowel management programme is effective and significantly reduces hospital admissions in patients with severe idiopathic constipation. Available at: <https://aap.confex.com/aap/2013/webprogram/ Paper21641.html>.

Schmelzer, M., et al. (2004). Safety and effectiveness of large-volume enema solutions. Applied Nursing Research, 17(4), 265–274.

Schnelle, J. F., et al. (2010). A controlled trial of an intervention to improve urinary and fecal incontinence and constipation. Journal of the American Geriatrics Society, 58(8), 1504–1511.

Sikirov, D. (2003). Comparison of straining during defecation in three positions: results and implications for human health. Digestive Diseases and Sciences, 48(7), 1201–1205.

Smith, G. D. (2012). Diagnosis and assessment of irritable bowel syndrome: current perspectives. Gastrointestinal Nursing, 10(2), 39.

Spinzi, G., et al. (2009). Constipation in the elderly. Drugs and Aging, 26(6), 469–474.

Stoltz, R., et al. (2001). An efficacy and consumer preference study of polyethylene glycol 3350 for the treatment of constipation in regular laxative users. Home Health Consult, 8(2), 21.

Sturtzel, B., & Elmadfa, I. (2008). Intervention with dietary fiber to treat constipation and reduce laxative use in residents of nursing homes. Annals of Nutrition and Metabolism, 52(Suppl. 1), 54–56.

St. Aubyn, B., & Andrews, A. (2012). Documentation. In M. Aldridge & S. Wanless (Eds.), Developing Healthcare Skills through Simulation. London: Sage Publications Inc.

Sykes, N. P. (2006). The pathogenesis of constipation. The Journal of Supportive Oncology, 4(5), 213–218.

Tack, J., et al. (2011). Diagnosis and treatment of chronic constipation-a European perspective. Neurogastroenterology and Motility, 23, 697–710.

Tagart, R. E. B. (1966). The anal canal and rectum: their varying relationship and its effect on anal continence. Diseases of the Colon and Rectum, 9(6), 449–452.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Chronic Functional Constipation 259

Chronic functional Constipation Amanda Andrews, MA, Ed, BSc, DN, RN, HEA Fellow, and A.B. St. Aubyn, BSc (Hons), RGN, RM, RHV, DPS:N (CHS), MSc, PGCert (Education), HEA Fellow

NANDA-I

Definition

Infrequent or difficult evacuation of feces, which has been present for at least three of the prior 12 months

Defining Characteristics

Abdominal distention; adult: presence of ≥ 2 of the following symptoms on Rome III classification system; lumpy or hard stools in ≥ 25% defecations; straining during ≥ 25% of defecations; sensation of incomplete evacuation for ≥ 25% of defecations; sensation of anorectal obstruction/blockage for ≥ 25% of defecations; manual maneuvers to facilitate ≥ 25% of defecations (digital manipulation, pelvic floor support); ≤3 evacu- ations per week.; child: ≤4 years; presence of ≥ 2 criteria on Roman III pediatric classification system for ≥ 1 month; ≤2 defecations per week; ≥1 episode of fecal incontinence per week; stool retentive posturing; painful or hard bowel movements; presence of large fecal mass in the rectum; large diameter stools that may obstruct the toilet; child: ≥4 years: presence of ≥ 2 criteria on Roman III pediatric classification system for ≥ 2 months; ≤2 defecations per week; ≥1 episode of fecal incontinence per week; stool retentive posturing; painful or hard bowel movements; presence of large fecal mass in the rectum; large diameter stools that may obstruct the toilet; fecal impaction; fecal incontinence (in children); leakage of stool with digital stimulation; pain with defecation; palpable abdominal mass; positive fecal occult blood test; prolonged straining; type 1 or 2 on Bristol Stool Chart; amyloidosis; anal fissure; anal stricture; autonomic neuropathy; cerebral vascular accident; chronic intestinal pseudo-obstruction; chronic renal insufficiency; colorectal cancer; dehydration; dementia; depression; dermatomyositis; diabetes mellitus; diet disproportionally high in protein and fat; extraintestinal mass; failure to thrive; habitually ignores urge to defecate; hemorrhoids; Hirschsprung’s disease; hypercalcemia; hypothyroidism; impaired mobility; inflammatory bowel disease; insufficient dietary intake; insufficient fluid intake; ischemic stenosis; low caloric intake; low fiber diet; multiple sclerosis; myo- tonic dystrophy; panhypopituitarism; paraplegia; Parkinson’s disease; pelvic floor dysfunction; perineal damage; pharmaceutical agent; polypharmacy; porphyria; postinflammatory stenosis; pregnancy; proctitis; scleroderma; sedentary lifestyle; slow solon transit time; spinal cord injury; surgical stenosis

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Bowel Elimination; Symptom SeverityExample NOC Outcome with Indicators Bowel Elimination as evidenced by the following indicators: Elimination pattern/Stool soft and formed/Passage of stool without aids/Ease of stool passage. (Rate each indicator of Bowel Elimination: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Maintain passage of soft, formed stool every 1 to 3 days without straining • State relief from discomfort of constipation • Identify measures that prevent or treat constipation

Thomas, J., et al. (2008). Methylnaltrexone for opioid-induced constipation in advanced illness. The New England Journal of Medicine, 358(22), 2332–2343.

Vuksan, V., et al. (2008). Using cereal to increase dietary fiber intake to the recommended level and the effect of fiber on bowel function in healthy persons consuming North American diets. The American Journal of Clinical Nutrition, 88, 1256–1262.

Wald, A., et al. (2008). A multinational survey of prevalence and patterns of laxative use among adults with self-defined constipation. Alimentary Pharmacology and Therapeutics, 28, 917–930.

Whitehead, W. E., et al. (2009). Conservative and behavioral management of constipation. Neurogastroenterology and Motility, 21(Suppl. 2), 55–61.

Wilcox, C. S., et al. (2010). An open-label study of naltrexone and bupropion combination therapy for smoking cessation in overweight and obese subjects. Addictive Behaviors, 35(3), 229–234.

Zhou, L., et al. (2010). Functional constipation: implications for nursing interventions. Journal of Clinical Nursing, 19, 1838–1843.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

260 Chronic Functional Constipation

NIC (Nursing Interventions Classification)

Suggested NIC Intervention

Constipation/Impaction Management

Example NIC Activities—Constipation/Impaction Management

Identify factors (e.g., medications, bed rest, and diet) that may cause or contribute to constipation/impaction; Institute a toileting schedule, as appropriate

Nursing Interventions and Rationales All Client Ages

• Introduce yourself to the client and anyone accompanying him or her and inform them of your role. Introducing yourself to a client helps establish and develop a therapeutic relationship that recognizes the person within the client and forms the basis for building trust on which to base the provision of care (Howatson-Jones et al, 2012).

• Gain consent to carry out care before proceeding further with the assessment. Clients have the right of autonomy both legally and morally and therefore should be fully involved in the decision-making process (Avery, 2013)

• Wash hands using a recognized technique. Strict hand-hygiene regimens significantly reduce the incidence of methicillin-resistant Staphylococcus aureus and Clostridium difficile (Health Protection Agency, 2013).

• Assess usual pattern of defecation and establish the extent of the constipation problem to include: ❍ Bowel habits

• Time of day • Amount and frequency of stool • Consistency of stool (using the Bristol Stool Scale) • Bleeding/passing mucus on defecation • History of bowel habits and/or laxative use • Assess children younger than 4 years using the Rome III pediatric classification (for at least

1 month) • Assess children older than age 4 years using the Rome III pediatric classification (for at least

2 months) • Assess adults using the Rome III classification. Rome III criteria, devised in 2006, specify that clients

must be symptomatic with at least two or more of the criteria that are relevant to their specific age range (Leung et al, 2011).

❍ Lifestyle assessment • Fiber content in diet • Daily fluid intake • Exercise patterns • Personal remedies for constipation • Recently stopped smoking • Alcohol consumption/recreational drug use • Personal habits related to defecation

❍ Past medical history • Obstetrical/gynecological/urological history and surgeries • Existing anatomical anomalies (e.g., anal fissures, anal strictures and hemorrhoids) • Diseases that affect bowel motility (e.g., colorectal cancer, chronic intestinal pseudo-obstruction

and Hirschsprung’s disease) • Bleeding/passing mucus on defecation • Current medications • Established algorithms and guidelines recommend that secondary pathology and causes of consti-

pation are identified and firstly excluded before moving on to assessment of diet and lifestyle issues (Tack et al, 2011)

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Chronic Functional Constipation 261

❍ Emotional influences • Anxiety and depression • Long-term defecation issues • Stress

• EB: A detailed and accurate assessment of the client enables the nurse to plan interventions, monitor out- comes, and evaluate care, ensuring no unnecessary treatment is carried out (Matthews, 2011).

• Complete a physical assessment (palpation for abdominal distention, percussion for dullness, auscultation for bowel sounds, observation for anal fissures, anal strictures, and hemorrhoids). A physical examination provides positive and negative findings and may provide the diagnosis without the need for further testing. It may also reveal unsuspected findings or confirm normality (Rhoads & Murphy-Jensen, 2014).

• Encourage the client or family to keep a 7-day diary of bowel habits to include time of day, length of time spent on the toilet, consistency, amount and frequency of stool, and any straining (using the Bristol Stool Scale). Keeping a diary helps establish a client’s bowel pattern and may contribute to the client’s adherence to the proposed care plan (Andrews & Morgan 2013).

• Encourage the client or family to keep a 7-day diary of lifestyle issues in relation to bowel habits to include fluid consumption, fibre content in diet, usual bowel stimulus and exercise regime. Enabling clients to present their condition in their own words ensures that they feel the health care professionals understand their concerns (Smith, 2012).

• Actively encourage the use of reward/star charts with children when establishing regular bowel routines. Research highlights that children respond better to positive enforcement when learning to manage constipa- tion with regular toileting rather than confrontation about the problem (Afzal et al, 2011).

• Discuss with clients already taking opioids (temporarily or long term) that constipation is a common side effect. Advise the client to contact their primary health care provider for a prescription of an appropriate laxative. The thorough and comprehensive assessment of clients on opioids experiencing constipation will also allow for a bowel function approach for laxative prescribing rather than one based on the opioid dose alone (Andrews & Morgan, 2012).

• Advise a fiber intake of 18 to 25 g of fiber daily and suggest foodstuffs to facilitate this diet (e.g., prune juice, leafy green vegetables, wholemeal bread and pasta). Fiber creates bulky feces and stretches the bowel wall to stimulate peristalsis, thus shortening bowel transit time (Kyle, 2012).

• Advise a fluid intake of 1.5 to 2 L of fluid per day (ideally, 6 to 8 glasses of water), unless this is contraindicated by comorbidities such as renal or heart disease. Water passes into the gut to promote the formation of a softer fecal mass and provides lubrication to prevent a blockage of the gut (Boyle, 2013).

• Encourage physical activity within the client’s current ability to mobilize. Encourage turning and changing position in bed if immobile. For reduced mobility clients, encourage knee to chest raises, waist twists, and stretching the arms away from the body. For fully mobile clients, encourage walking and swimming. Physical activity can help stimulate peristaltic waves in the colon and encourage the transit of feces to the rectum (Rogers, 2013).

• Demonstrate the use of gentle external abdominal massage, using aroma therapy oils, following the direc- tion of colon activity. EB: Abdominal massage encourages rectal loading by increasing intraabdominal pressure and in some cases it may elicit rectal waves that may stimulate the somatoautonomic reflex and enhance bowel sensation (McClurg et al, 2011).

• Recommend clients establish a regular elimination routine. If required, assist clients to the bathroom at the same time every day, being mindful of the need for privacy (closing of bathroom doors). Establishing a routine allows for the use of the gastrocolic reflex, especially in the morning, which aids defecation (Rogers, 2013).

• Educate the client how to adopt the best posture for defecation: keep knees slightly higher than hips, keep feet flat on the floor and lean forward, putting elbows onto knees. Adopting the correct position to open one’s bowels allows the angle of the rectum and anal canal to straighten. This facilitates an increase in abdominal pressure, which makes defecation more effective (Rogers, 2013).

• Consider the teaching of biofeedback therapy to encourage a “new normal” bowel routine for clients to adopt. EB: A meta-analysis random control trial concluded that the use of biofeedback therapy in chronic constipation was successful and warranted the time and effort involved in establishing a bowel routine (Enck et al, 2009).

• Teach clients of the need to respond promptly to the defecation urge. EB: The body’s natural “call to stool” should be heeded because it is a response to the stimulation of nerve endings in the rectum when a stool is

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

262 Chronic Functional Constipation

present. Ignoring this urge results in the rectum becoming desensitized to a stool in situ (Coggrave et al, 2014).

• Consider the use of laxatives, suppositories, enemas, and bowel irrigation as required when other more natural interventions are not effective. EB: Laxative therapies can be used in conjunction with lifestyle changes (while waiting for the lifestyle changes to take effect or if the change is not sufficient in itself) (Marples, 2011; Kyle, 2011). Bowel irrigation is thought to both stimulate colonic reflex and act as a mechani- cal bowel washout (Coggrave et al, 2014).

• Discourage the use of long-term laxatives and enemas, and advise clients to gradually reduce their use if taken regularly. Long-term use or overuse of laxatives can cause health problems (e.g., electrolyte imbalance) or hide symptoms of a serious medical condition, such as cardiac arrhythmias (Aschenbrenner, 2014).

• Provide client with comprehensive written information about constipation and its management. EB: Research shows that providing clients with well-written evidence-based information about their condition and treatment can have a beneficial effect on the outcomes of treatment. In addition clients are more likely to retain important information that will assist them in making informed decisions about their care (Coulter, 2011).

• Provide written instructions for children about taking their medication and about how the bowel works. Written clear information provided to children with chronic functional constipation will help them under- stand and therefore recognize when they are at risk for constipation recurrence (NICE, 2010).

• Liaise with members of the interprofessional team as appropriate to provide treatment and advice to clients and caregivers. Team work is a central process in health care organizations. It increases the capacity of teams to absorb and develop new knowledge, which will improve clients’ health and well-being (Ortega et al, 2013).

• Educate the client on the mechanism of normal bowel function and the need for adequate fluid and fiber intake, physical activity, and a defined toileting pattern in an agreed-upon bowel management program. The implementation of an organized bowel management program is effective and significantly reduces hos- pital admissions in clients with severe idiopathic constipation (Russell et al, 2013).

• Document all care and advice given in a factual and comprehensive manner. Good record keeping is an integral part of nursing practice and is essential to the provision of safe and effective care (St. Aubyn & Andrews, 2012).

REFERENCES Andrews, A., & Morgan, G. (2012). Constipation management in

palliative care: treatments and the potential of independent nurse prescribing. International Journal of Palliative Nursing, 18(1), 17–22.

Andrews, A., & Morgan, G. (2013). Constipation in palliative care: treatment options and considerations for individual patient management. International Journal of Palliative Nursing, 19(6), 226–273.

Aschenbrenner, D. S. (2014). Overuse of certain OTC laxatives may be dangerous. American Journal of Nursing, 114(5).

Afzal, N. A., Tighe, M. P., & Thomas, M. A. (2011). Constipation in Children. Available at: <http://www.biomedcentral.com/content/ pdf/1824-7288-37-28.pdf>.

Avery, G. (2013). Law and Ethics in Nursing and Healthcare an Introduction. London: Sage Publications Inc.

Boyle, J. (2013). Roughage to regulate. World of Irish Nursing and Midwifery, 21(7), 53–55.

Coggrave, K., Norton, C., & Cody, J. D. (2014). Management of faecal incontinence and constipation in adults with central neurological diseases. Cochrane Database of Systematic Reviews, (1), CD002115.

Coulter, A. (2011). Engaging Patients in Health Care. Berkshire: McGraw Hill Open University press.

Enck, P., Van Dervoort, I. R., & Klosterhalfen, S. (2009). Biofeedback therapy in faecal incontinence and constipation. Neurogastroentrology Motility, 21(11), 1131–1141.

Health Protection Agency. (2013). Ayliffe Hand Washing Technique. Available at: <www.hpa.org.uk/Topics/InfectiousDiseases/ infectionsAZ/Handwashing>.

Howatson-Jones, L., Standing, M., & Roberts, S. (Eds.), (2012). Patient Assessment and Care Planning in Nursing. London: Sage Publications Inc.

Kyle, G. (2011). Managing constipation in adult patients. Nurse Prescribing, 9(10), 482–490.

Kyle, G. (2012). The older person: Management of Constipation. British Journal of Community Nursing, 15(2), 60–63.

Leung, L., Riutta, T., Kotecha, J., et al. (2011). Chronic constipation: an evidence-based review. The Journal of the American Board of Family Medicine, 24(4), 436–452.

Matthews, E. (2011). Nursing Care Planning. London: Lippincott Williams & Wilkins.

Marples, G. (2011). Diagnosis and management of slow transit constipation in adults. Nursing Standard, 26(8), 41–48.

McClurg, D., Hagen, S., & Dickinson, L. (2011). Abdominal massage for the treatment of constipation (Protocol). Cochrane Database of Systematic Reviews, (4), CD009089.

Ortega, A., Sanchez-Manzanares, M., Gil, F., et al. (2013). Enhancing team learning in nursing teams through beliefs about interpersonal contexts. The Journal of advanced Nursing, 69(1).

Rhoads, J., & Murphy-Jensen, M. (2014). Differential diagnoses for the advanced practice nurse. NY: Springer Publishing Company.

Rogers, J. (2013). Management of constipation in the community. Journal of Community Nursing, 27(1), 20–24.

Russell, K. W., Zobell, S., Barnhart, D. C., et al. (2013). The implementation of an organised bowel management programme is

Perceived Constipation 263

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Perceived Constipation Amanda Andrews, MA, Ed, BSc, DN, RN, HEA Fellow, and A.B. St. Aubyn, BSc (Hons), RGN, RM, RHV, DPS:N (CHS), MSc, PGCert (Education), HEA Fellow

NANDA-I

Definition

Self-diagnosis of constipation combined with abuse of laxatives, enemas, and/or suppositories to ensure a daily bowel movement

Defining Characteristics

Enema abuse; expects a daily bowel movement; expects a daily bowel movement at the same time every day; laxative abuse; suppository abuse

Related Factors

Cultural health believes; family health beliefs; impaired thought process

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Bowel Elimination; Health Beliefs; Health Beliefs: Perceived Threat

effective and significantly reduces hospital admissions in patients with severe idiopathic constipation. Available at: <https://aap.confex.com/ aap/2013/webprogram/Paper21641.html>.

Smith, G. D. (2012). Diagnosis and assessment of irritable bowel syndrome: current perspectives. Gastrointestinal Nursing, 10(2).

St. Aubyn, B., & Andrews, A. (2012). Documentation. In M. Aldridge & S. Wanless (Eds.), Developing Healthcare Skills through Simulation. London: Sage Publications Inc.

Tack, J., Muller – Lissner, S., Stanghellini, V., et al. (2011). Diagnosis and Treatment of Chronic Constipation—a European Perspective. Neurogastroentrology Motility, 23(8), 697–710.

The National Institute for Health and Care Excellence (NICE). (2010). Constipation in children and young people: Diagnosis and management of idiopathic childhood constipation in primary and secondary care. Available: <https://www.nice.org.uk/guidance/cg99> Accessed 15.04.22.

Example NOC Outcome with Indicators

Bowel Elimination as evidenced by the following indicators: Elimination pattern/Stool soft and formed/ Passage of stool without aids/Ease of stool passage. (Rate each indicator of Bowel Elimination: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Regularly defecate soft, formed stool without use of aids • Explain the need to decrease or eliminate the use of stimulant laxatives, suppositories, and enemas • Identify alternatives to stimulant laxatives, enemas, and suppositories for ensuring defecation • Explain that defecation does not have to occur every day

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

• Bowel Management; Medication Management Example NIC Activities—Bowel Management

Note preexistent bowel problems, bowel routine, and use of laxatives; Initiate a bowel training program, as appropriate

Nursing Interventions and Rationales

• Introduce yourself to the client and any companions, and inform them of your role. Introducing yourself to a client helps establish and develop a therapeutic relationship that recognizes the person within the client and forms the bases for building trust upon which to base the provision of care (Howatson-Jones et al, 2012).

264 Perceived Constipation

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

• Gain consent before proceeding further with the assessment. Clients have the right of autonomy both legally and morally and therefore should be fully involved in the decision-making process (Avery, 2013).

• Wash hands using a recognized technique. EB: Performing strict hand-hygiene regimens significantly reduces the incidence of infection with methicillin-resistant Staphylococcus aureus and Clostridium difficile (Health Protection Agency, 2013).

• Assess usual pattern of defecation and establish the extent of the perceived constipation problem to include: ❍ Bowel Habits

• Time of day • Amount and frequency of stool • Consistency of stool (using the Bristol Stool Scale) • Bleeding/passing mucus on defecation • Patient history of bowel habits and/or laxative use • Family history of bowel habits and/or laxative use EB: A detailed and accurate assessment of the patient enables the nurse to plan interventions, monitor outcomes, and evaluate care, ensuring no unnecessary treatment is rendered (Matthews, 2011).

❍ Lifestyle Assessment • Fiber content in diet • Daily fluid intake • Exercise patterns • Personal remedies for constipation • Cultural remedies for constipation • Recently stopped smoking • Alcohol consumption/recreational drug use EB: Alcohol has a dehydrating effect on the body. One of the key causes of constipation is dehydration of stools. A lack of water in the bowel leads to hard fecal matter, which is difficult to pass (Derbyshire, 2011).

❍ Past Medical History • Obstetrical/gynecological/urological history and surgeries • Diseases that affect bowel motility • Bleeding/passing mucus on defecation • Current medications

❍ Emotional Influences • Anxiety and depression/psychological disorders • History of eating disorders • History of physical/or sexual abuse • Long-term defecation issues • Stress EB: Clients’ psychological reactions to the experience of constipation change over time. Anxiety and fear about the anticipated health-related consequences of constipation are often expressed. The absence of a bowel movement or the failure of constipation treatment can lead to anxiety and depression (Dhingra et al, 2012). EB: Stress can alter the mucosal immune function of the central nervous system. This causes afferent signals to the gut to be reduced, causing constipation (Drossman, 2011).

• Encourage the client or family to keep a 7-day diary of bowel habits to include time of day, length of time spent on the toilet, consistency, amount and frequency of stool, and any straining (using the Bristol Stool Scale). EB: Keeping a diary helps establish a patient’s bowel pattern and may contribute to the patient’s adherence to the proposed care plan (Andrews & Morgan, 2013).

• Encourage the client or family to keep a 7-day diary of lifestyle issues in relation to bowel habits to include fluid consumption, fiber content in diet, usual bowel stimulus, and exercise regimen. EB: Enabling patients to present their condition in their own words ensures that they feel the health care professionals understand their concerns (Smith, 2012).

• Educate the client that it is not necessary to have a daily bowel movement. EB: A healthy bowel function can vary from three stools each day to three stools each week. The criteria of choice for establishing a diagnosis of constipation are often the Rome III criteria. The criteria based definition calls for the presence of two or more of the symptom for at least 3 months for a definition of constipation (Leung et al, 2011).

• Encourage the client to record use of laxatives, suppositories, or enemas, and suggest replacing them with an increase in fluid and fiber intake. EB: Overtreatment with laxatives can result in iatrogenic diarrhea,

Perceived Constipation 265

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

which can lead to dehydration, delirium, and the false-positive labeling and unnecessary treatment of C. difficile carriers. This can result in increased morbidity and mortality, and a longer stay in hospital. By improving the assessment and treatment of constipation, patient outcomes should improve, resulting in significant hospital cost savings (Linton, 2014).

• Advise a fiber intake of 18 to 25 g daily and suggest foodstuffs high in fiber (e.g., prune juice, leafy green vegetables, whole meal bread and pasta). Fiber creates bulky feces and stretches the bowel wall to stimulate peristalsis, thus shortening bowel transit time (Kyle, 2012). For further information on use of fiber, please refer to the care plan for Constipation.

• Advise a fluid intake of 1.5 to 2 L of fluid per day (ideally, 6 to 8 glasses of water), unless contraindicated by comorbidities, such as kidney or heart disease. Water passes into the gut to promote the formation of a softer fecal mass and provides lubrication to prevent a blockage of the gut (Boyle, 2013).

• Obtain a referral to a dietitian for analysis of the client’s diet and fluid intake to provide strategies to improve diet and nutrition.

• Encourage physical activity within the client’s current ability to mobilize. Encourage turning and changing position in bed if immobile. For clients with reduced mobility, encourage knee to chest raises, waist twists, and stretching the arms away from the body. For fully mobile clients, encourage walking and swimming. Physical activity can help stimulate peristaltic waves in the colon and encourage the transit of feces to the rectum (Rogers, 2013).

• Demonstrate the use of gentle external abdominal massage, using aroma therapy oils, following the direc- tion of colon activity. Abdominal massage encourages rectal loading by increasing intra-abdominal pressure and in some cases it may elicit rectal waves, which may stimulate the somato-autonomic reflex and enhance bowel sensation (McClurg et al, 2011).

• Recommend clients establish a regular elimination routine. If required assist clients to the bathroom at the same time every day, being mindful of the need for privacy (closing of bathroom doors). Establishing a routine allows for the use of the gastrocolic reflex, especially in the morning, which aids defecation (Rogers, 2013).

• Observe for the presence of an eating disorder, the use of laxatives to control or decrease weight; refer for counseling if needed. People with eating disorders suffer from constipation and other gastrointestinal symptoms, or use laxatives as part of inducing weight loss (Roerig et al, 2010). CEB: Laxative abuse is found in clients with both anorexia and bulimia nervosa and may be associated with worsening of the eating disorder as a form of self-harm (Tozzi et al, 2006).

• Observe family cultural patterns related to eating and bowel habits. Cultural patterns may control bowel habits.

Client/Family Teaching and Discharge Planning

• Provide education to the client on ways to adopt the best posture for defecation. Keep knees slightly higher than hips, keep feet flat on the floor and lean forward putting elbows onto knees. Adopting the correct position to open one’s bowels allows the angle of the rectum and anal canal to straighten out. This facilitates an increase in abdominal pressure, which makes defecation more effective (Rogers, 2013).

• Teach clients of the importance of responding promptly to the urge to defecate. EB: The body’s natural “call to stool” should be heeded in that it is a response to the stimulation of nerve endings in the rectum when a stool is present. Ignoring this urge will result in the rectum becoming desensitized to a stool in situ (Coggrave et al, 2014).

• Discourage the use of long-term laxatives and enemas and explain the potential harmful effects of the continual use of defecation aids such as laxatives and enemas. EB: “Lazy bowel syndrome” may occur if laxatives are used too frequently, causing the bowel to become dependent on laxatives to stimulate a bowel movement. Overuse of laxatives can also lead to poor absorption of vitamins and other nutrients, and to damage of the gastrointestinal tract (Mayo Foundation for Medical Education and Research, 2011).

• Advise clients to gradually reduce their use of laxatives, if taken regularly, which may take months to achieve. Long-term use or overuse of laxatives can cause health problems (e.g., electrolyte imbalance) or hide symptoms that may be from a serious medical condition, such as cardiac arrhythmias (Aschenbrenner, 2014).

• Provide client with comprehensive written information about constipation and its management. EB: Providing patients with well-written, evidence-based information about their condition and treatment can have a beneficial effect on the outcomes of treatment. In addition, patients are more likely to retain important information that will assist them in making informed decisions about their care (Coulter, 2011).

266 Risk for Constipation

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

• Collaborate with members of the interprofessional team to provide treatment and advice to clients and caregivers. Team working is a central process in health care organizations. It increases the capacity of teams to absorb and develop new knowledge, which will improve patient health and well-being (Ortega et al, 2013).

• Formalize all advice by providing a bowel management program reiterating the mechanism of normal bowel function and the need for adequate fluid and fiber intake, physical activity, and a defined toileting pattern in an agreed bowel program. EB: The implementation of an organized bowel management program is effective and significantly reduces hospital admissions in patients with severe idiopathic constipation (Russell et al, 2013).

• Document all care and advice given in a factual and comprehensive manner. Good record keeping is an integral part of nursing practice and is essential to the provision of safe and effective care (St. Aubyn & Andrews, 2012).

REFERENCES Andrews, A., & Morgan, G. (2013). Constipation in palliative care:

treatment options and considerations for individual patient management. International Journal of Palliative Nursing, 19(6), 226–273.

Aschenbrenner, D. S. (2014). Overuse of certain OTC laxatives may be dangerous. American Journal of Nursing, 114(5), 25.

Avery, G. (2013). Law and Ethics in Nursing and Healthcare: An Introduction. London: Sage Publications Inc.

Boyle, J. (2013). Roughage to regulate. World of Irish Nursing and Midwifery, 21(7), 53–55.

Coggrave, K., Norton, C., & Cody, J. D. (2014). Management of Faecal Incontinence and Constipation in Adults with Central Neurological Diseases. Cochrane Database of Systematic Reviews, (1), CD002115.

Coulter, A. (2011). Engaging Patients in Health Care. Berkshire: McGraw Hill Open University Press.

Derbyshire, S. (2011). Dehydration in hospitals. Available at: <www.naturalhydrationcouncil.org.uk> Accessed 14.09.04.

Dhingra, L., et al. (2012). A Qualitative Study to explore psychological distress an illness burden associated with opioid induced constipation in cancer patients with advanced disease. Palliative Medicine, 27(5).

Drossman, D. A. (2011). Abuse, Trauma and GI illness: Is there a link? American Journal of Gastroenterology, 106(1).

Health Protection Agency. (2013). Ayliffe Hand Washing Technique. Available at: <www.hpa.org.uk/Topics/InfectiousDiseases/ infectionsAZ/Handwashing>.

Howatson-Jones, L., Standing, M., & Roberts, S. (Eds.), (2012). Patient Assessment and Care Planning in Nursing. London: Sage Publications Inc.

Kyle, G. (2012). The older person: Management of Constipation. British Journal of Community Nursing, 15(2), 60–63.

Leung, L., Riutta, T., Kotecha, J., et al. (2011). Chronic Constipation: An Evidence-based Review. Journal of American Board of Family Medicine, 24(4).

Linton, A. (2014). Improving Management of Constipation in an inpatient setting using a care bundle. British medical Journal Quality Improvement Reports. Available at: <http://qir.bmj.com/content/3/1/ u201903.w1002.full> Accesses 14.09.04.

Matthews, E. (2011). Nursing Care Planning. London: Lippincott Williams & Wilkins.

Mayo Foundation for Medical Education and Research Mayo Clinic. (2011). Constipation, Diseases and Condition. Available at: <www.mayoclinic.com/health/constipation/DS00063/ DSECTION=symptoms> Accessed 14.09.04.

McClurg, D., Hagen, S., & Dickinson, L. (2011). Abdominal massage for the treatment of constipation (Protocol). Cochrane Database of Systematic Reviews, (4), CD009089.

Ortega, A., Sanchez-Manzanares, M., Gil, F., et al. (2013). Enhancing team learning in nursing teams through beliefs about interpersonal contexts. The Journal of advanced Nursing, 69(1), 363–370.

Roerig, J. S., et al. (2010). Laxative abuse: epidemiology, diagnosis and management. Drugs, 70(12), 1487–1503.

Rogers, J. (2013). Management of Constipation in the Community. Journal of Community Nursing, 27(1), 20–24.

Russell, K. W., et al. (2013). The implementation of an organised bowel management programme is effective and significantly reduces hospital admissions in patients with severe idiopathic constipation. Available at: <https://aap.confex.com/aap/2013/webprogram/ Paper21641.html>.

Smith, G. D. (2012). Diagnosis and assessment of irritable bowel syndrome: current perspectives. Gastrointestinal Nursing, 10(2), 39.

St. Aubyn, B., & Andrews, A. (2012). Documentation. In M. Aldridge & S. Wanless (Eds.), Developing Healthcare Skills through Simulation. London: Sage Publications Inc.

Tozzi, F., et al. (2006). Features associated with laxative abuse in individuals with eating disorders. Psychosomat Medicine, 68(3), 470–477.

Risk for Constipation Betty J. Ackley, MSN, EdS, RN

NANDA-I

Definition

Vulnerable to a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool, which may compromise health

Contamination 267

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Risk Factors Functional

Abdominal weakness; average daily physical activity is less than recommended for gender and age; habitually ignores urge to defecate; inadequate toileting habits; irregular defecation habits; recent environmental change

Psychological

Confusion; depression; emotional disturbance

Physiological

Decrease in gastrointestinal motility; dehydration; eating habit change (e.g., foods, eating times); inadequate dentition; inadequate oral hygiene; insufficient dietary habits; insufficient fiber intake; insufficient fluid intake

Pharmacological

Iron salts; laxative abuse; pharmaceutical agent

Mechanical

Electrolyte imbalance; hemorrhoids; Hirschsprung’s disease; neurological impairment (e.g., positive electro- encephalogram, head trauma, seizure disorders); obesity; postsurgical obstruction; pregnancy; prostate enlargement; rectal abscess; rectal anal fissures; rectal anal stricture; rectal prolapse; rectal ulcer; rectocele; tumor

NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family Teaching, Rationales, and References

Refer to care plans for Constipation.

Risk for chronic functional Constipation Mary Beth Flynn Makic, PhD, RN, CNS, CCNS, FAAN

NANDA-I

Definition

Vulnerable to infrequent or difficult evacuation of feces, which has been present nearly 3 of the prior 12 months, which may compromise health

Risk Factors

Aluminum-containing antacids; antiepileptics; antihypertensives; anti-Parkinsonian agents (anticholinergic or dopaminergic); calcium-channel antagonists; chronic intestinal pseudo-obstruction; decreased food intake; dehydration; depression; diet proportionally high in protein and fat; diuretics; failure to thrive; habitual ignoring of urge to defecate; impaired mobility; low-fiber diet; insufficient fluid intake; inactive lifestyle; iron preparations; low caloric intake; nonsteroidal anti-inflammatories; opioids; polypharmacy; slow colon transit time; tricyclic antidepressants

NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family Teaching and Discharge Planning, Rationales, and References

Refer to care plan for Chronic functional Constipation.

Contamination Pauline McKinney Green, PhD, RN, CNE

NANDA-I

Definition

Exposure to environmental contaminants in doses sufficient to cause adverse health effects

268 Contamination

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Defining Characteristics Pesticides

Dermatological effects of pesticide exposure; gastrointestinal effects of pesticide exposure; neurological effects of pesticide exposure; pulmonary effects of pesticide exposure; renal effects of pesticide exposure

Chemicals

Dermatological effects of chemical exposure; gastrointestinal effects of chemical exposure; immunological effects of chemical exposure; neurological effects of chemical exposure; pulmonary effects of chemical expo- sure; renal effects of chemical exposure

Biologicals

Dermatological effects of exposure to biological; gastrointestinal effects of biological exposure; neurological effects of biological exposure; pulmonary effects of biological exposure; renal effects of biological exposure

Pollution

Neurological effects of pollution exposure; pulmonary effects of pollution exposure

Waste

Dermatological effects of waste exposure; gastrointestinal effects of waste exposure; hepatic effects of waste exposure; pulmonary effects of waste exposure

Radiation

Exposure to radioactive material; genetic effects of radiation exposure; immunological effects of radiation exposure; neurological effects of radiation exposure; oncological effects of radiation exposure

Related Factors (r/t) External

Carpeted flooring; chemical contamination of food; chemical contamination of water; economically disad- vantaged; exposure to areas with high contaminant level; exposure to atmospheric pollutants; exposure to bioterrorism; exposure to disaster (natural or man-made); exposure to radiation; flaking, peeling surface in presence of young children (e.g., paint, plaster); household hygiene practices; inadequate breakdown of contaminant; inadequate municipal services (e.g., trash removal, sewage treatment facilities); inadequate protective clothing; inappropriate use of protective clothing; ingestion of contaminated material (e.g., radio- active, food, water); personal hygiene practices; playing where environmental contaminants are used; unpro- tected exposure to chemical (e.g., arsenic); use of environmental contaminates in the home; use of noxious material in insufficiently ventilated area (e.g., lacquer, paint); use of noxious material without effective pro- tection (e.g., lacquer, paint)

Internal

Age (e.g., children < 5 years, older adults); concomitant exposure; developmental characteristics of children; extremes of age; female gender; gestational age during exposure; inadequate nutrition; preexisting disease; pregnancy; previous exposure to contaminant; smoking

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Community Health Status; Family Physical Environment; Anxiety Level; Fear Level

Example NOC Outcome with Indicators

Community Health Status as evidenced by the following indicators: Evidence of health protection measures/Compliance with environmental health standards/Health status of population. (Rate the outcome and indicators of Community Health Status: 1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent [see Section I].)

Contamination 269

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Client Outcomes Client Will (Specify Time Frame)

• Have minimal health effects associated with contamination • Cooperate with appropriate decontamination protocol • Participate in appropriate isolation precautions Community Will (Specify Time Frame)

• Use health surveillance data system to monitor for contamination incidents • Use disaster plan to evacuate and triage affected members • Have minimal health effects associated with contamination • Employ measures to reduce household environmental risks

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Triage: Disaster; Infection Control; Anxiety Reduction; Crisis Intervention; Health Education

Nursing Interventions and Rationales

▲ Help individuals cope with contamination incident by doing the following: ❍ Use groups that have survived terrorist attacks as useful resource for victims ❍ Provide accurate information on risks involved, preventive measures, use of antibiotics and vaccines ❍ Assist to deal with feelings of fear, vulnerability, and grief ❍ Encourage individuals to talk to others about their fears ❍ Assist victims to think positively and to move toward the future

▲ In a crisis situation, interventions aimed at supporting an individual’s coping help the person deal with feel- ings of fear, helplessness, and loss of control that are normal reactions in a crisis situation.

• Triage, stabilize, transport, and treat affected community members. EB: Accurate triage and early treat- ment provide the best chance of survival to affected persons (Veenema, 2013).

• Prioritize mental health care for highly vulnerable risk groups or those with special needs (deeply affected groups, women, older persons, children and adolescents, displaced persons—especially those living in shelters, persons with preexisting mental health disorders (including those living in institutions) (Pan American Health Organization, 2012).

• Collaborate with other agencies (local health department, emergency medical service [EMS], state and federal agencies). Communication among agencies increases ability to handle crisis efficiently (CDC, 2014a; Veenema, 2013).

• Use approved procedures for decontamination of persons, clothing, and equipment. Victims may first require decontamination before entering health facility to receive care in order to prevent the spread of contamination (U.S. Army Medical Research Institute of Infectious Diseases, 2011).

• Use appropriate isolation precautions: universal, airborne, droplet, and contact isolation. Proper use of isolation precautions prevents cross-contamination by contaminating agents (U.S. Army Medical Research Institute of Infectious Diseases, 2011). EB: A study of health care workers’ client interactions found transfer of multidrug-resistant bacteria to workers’ gowns and gloves increased after client contact with environmen- tal contamination and recommended improved compliance with contact precautions and aggressive envi- ronmental cleaning (Morgan et al, 2012).

• Monitor individual for therapeutic effects, side effects, and compliance with post-exposure drug therapy. Drug therapy may extend over a long period of time and requires monitoring for compliance as well as for therapeutic and side effects (Veenema, 2013).

• Perform effective hand washing before and after handling medical charts, entering case notes, touching clients, and performing procedures, especially in intensive care unit environments. EB: A prospective study to identify and compare the incidence of bacterial contamination of hospital charts found the plastic chart

Example NIC Activities—Triage: Disaster

Initiate appropriate emergency measures, as indicated; Monitor for and treat life-threatening injuries or acute needs

270 Contamination

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

covers to be contaminated (63.5% for general wards and 83.2% for special units); chart covers can act as vectors and potential sources of infection (Chen et al, 2014).

• Prevent cross contamination by systematically disinfecting stethoscopes (diaphragm and tubing) after each use. EB: A study of the contamination level of health care providers’ hands and stethoscopes found that the contamination level of the stethoscope is substantial after a single health care provider examination and is comparable to the contamination of parts of the health care provider’s hand (Longtin et al, 2014).

• Complete proper hand washing after touching the client’s privacy curtain and before touching the client. EB: A longitudinal study determined that privacy curtains are contaminated with potentially pathogenic bacteria within 1 week of use; following the correct order for hand washing prevents contact with contami- nated surfaces of privacy curtains (Ohl et al, 2012).

Geriatric

• Help the client identify age-related factors that may affect response to contamination incidents. • Advise older adults to follow public notices related to drinking water. Contaminated water can harm the

health of older persons and those with chronic conditions (CDC, 2014b). • Encourage older adults to receive influenza vaccination when it is available, beginning as early as late

August and continuing through the end of February. Flu vaccination protects against influenza and protects those in proximity who are more vulnerable to serious flu illness (CDC, 2013a).

• Instruct older adults with special needs or chronic conditions to plan for emergencies and keep medica- tions, prescriptions, and special devices on hand (Federal Emergency Management Agency, 2014).

Pediatric

• Provide environmental health hazard information. Developing children are more vulnerable to environ- mental toxicants due to greater and longer exposure and particular susceptibility windows (Children’s Environmental Health Network, 2013).

• Reduce risks from exposure to environmental contaminants by identifying the ages and life stages of children. EB: The World Health Organization recommends coordination of hazard and exposure assessment using children’s ages and life stages to accommodate for children’s physiology and developmental stage that contribute to opportunities for environmental exposure and contamination (Hubal et al, 2014).

• Screen newly arrived immigrant and refugee children for elevated blood lead levels secondary to lead hazards in older housing. EB: Resettlement in areas with older housing stock increases risk for lead poison- ing (CDC, 2013b).

• Be aware that the risk for lead exposure is much higher in many of the countries from which children are adopted than in the United States (CDC, 2014c).

• Use the latest reference level of 5 µg/dL to identify children and environments associated with lead- exposure hazards. EB: CDC currently recommends using 5 µg/dL as the reference value in place of the previously recommended level of 10 µg/dL; reference values are updated every 4 years based on the most recent population-based blood lead surveys among children (CDC, 2012).

Multicultural

• Ask about use of imported or culture-specific products that contain lead, such as greta and azarcon (Hispanic folk medicine for upset stomach and diarrhea), ghasard (Indian folk medicine tonic), and ba- baw-san (Chinese herbal remedy). Immigrant children are at increased risk for contamination, particularly from lead, related to exposure to imported culture-specific products (CDC, 2013c).

• Nurses need to consider the cultural and social factors that impact access to and understanding of the health care system, particularly for groups such as migrant workers who do not have consistent health care providers. EB: Subtle cultural biases in how nurses approach care can affect outcomes (Holmes, 2011; Hubal et al, 2014).

Home Care

• Assess current environmental stressors and identify community resources. Accessing resources decreases stress and increases ability to cope.

• Recognize that relocated and unemployed individuals/families are at risk for psychological distress. EB: People who lose their social network are at a very high risk for post-event psychological distress and require appropriate care (Oyama et al, 2012).

Contamination 271

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

• Support policy and program initiatives that provide emergency mental health services following large- scale contamination events. EB: A study of the utilization of mental health services following a major disaster found community mental health service use increased in the period following the event and that brief interventions were more effective than conventional multisession interventions (Boscarino et al, 2011).

• Instruct community members concerned about lead in drinking water from plumbing pipes and fixtures to have the water tested by calling the EPA drinking water hotline at 800-426-4791.

• Educate community members to reduce exposure to lead by inquiring about lead-based paint before buying a home or renting an apartment built before 1978; Federal law requires disclosure of known information about lead-based paint (EPA, 2014).

• Instruct individuals and families that food contamination occurs through a variety of mechanisms and that food safety is associated with proper washing of hands and utensils, prompt refrigeration of food, and cooking foods at the correct temperature. EB: Pathogens can be introduced into food from infected humans who handle food without thoroughly washing their hands, from food that touches surfaces or utensils contaminated by pathogens in raw food, and improper refrigeration or heating of food (CDC, 2013d).

Client/Family Teaching and Discharge Planning

• Provide truthful information to the person or family affected. • Discuss signs and symptoms of contamination. • Explain decontamination protocols. • Explain need for isolation procedures. • Well-managed efforts at communication of contamination information ensure that messages are correctly

formulated, transmitted, and received and that they result in meaningful actions. • Emphasize the importance of pre- and post-exposure treatment of contamination. Early treatment

decreases associated complications related to contamination (ATSDR, 2014). • Provide parents with actionable information to reduce environmental contamination in the home. EBN:

A randomized educational intervention to reduce contamination in the home demonstrated significant reduction in biomarker levels and improved environmental health self-efficacy and precaution adoption (Butterfield et al, 2011).

REFERENCES Agency for Toxic Substances and Disease Registry (ATSDR).

(2014). Medical management guideline for parathion. Retrieved from: <http://www.atsdr.cdc.gov/MMG/MMG.asp?id=1140& tid=246>.

Boscarino, J. A., Adams, R. E., & Figley, C. R. (2011). Mental health service use after the World Trade Center disaster. Utilization trends and comparative effectiveness. The Journal of Nervous and Mental Diseases, 199, 91–99.

Butterfield, P. G., Hill, W., & Postma, J. (2011). Effectiveness of a household environmental health intervention delivered by rural public health nurses. American Journal of Public Health, 101(Suppl. 1), S262–S270.

Centers for Disease Control & Prevention (CDC). (2012). CDC response to advisory committee on childhood lead poisoning prevention recommendations in “Low level lead exposure harms children: A renewed call for primary prevention”. Retrieved from: <http://www.cdc.gov/nceh/lead/acc/pp/cdc_response-lead_ exposure_recs.pdf>.

Centers for Disease Control & Prevention (CDC). (2013a). What are the benefits of flu vaccination? Retrieved from: <http://www.cdc.gov/ flu/pdf/freeresources/general/flu-vaccine-benefits.pdf>.

Centers for Disease Control & Prevention (CDC). (2013b). Lead screening during the domestic medical examination for newly arrived refugees. Retrieved from: <http://www.cdc.gov/ immigrantrefugeehealth.pdf/lead-guidelines.pdf>.

Centers for Disease Control & Prevention (CDC). (2013c). Folk medicine. Retrieved from: <http://www.cdc.gov/nceh/lead.tips/ folkmedicine.htm>.

Centers for Disease Control & Prevention (CDC). (2013d). Food safety. Prevention and education. Retrieved from: <http://www.cdc.gov/ foodsafety/prevention.html>.

Centers for Disease Control and Prevention (CDC). (2014a). Office of Public Health Preparedness and Response. 2013-2014 national snapshot of public health preparedness. Retrieved from: <http:// www.cdc.govphpr/pubs- links/2013/documents/2013_ Preparedness_Report_Section3.pdf>.

Centers for Disease Control & Prevention (CDC). (2014b). Water- related diseases and contamination in public water systems. Retrieved from: <http://www.cdc.gov/healthywater/drinking/public/ water_diseases.html>.

Centers for Disease Control and Prevention (CDC). (2014c). International adoption and prevention of lead poisoning. Retrieved from: <http://www.cdc.gov/nceh/lead.tips/ adoption.htm>.

Chen, K.-H., Chen, L.-R., & Wang, Y.-K. (2014). Contamination of medical charts: An important source of potential infection in hospitals. PLoS ONE, 9(2), e78512.

Children’s Environmental Health Network. (2013). Children’s environmental health 101. Retrieved from: <http://www.cehn,org/ resources/ceh101>.

Environmental Protection Agency (EPA). (2014). Protect your family. Retrieved from: <http://www2.epa.gov/lead>.

Federal Emergency Management Agency (FEMA). (2014). Individuals with disabilities or access and functional needs. Retrieved from: <http://www.cdc.ready.gov/individuals-access-functional -needs>.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

272 Risk for Adverse Reaction to Iodinated Contrast Media

Risk for Contamination Betty J. Ackley, MSN, EdS, RN

NANDA-I

Definition

Vulnerable to exposure to environmental contaminants, which may compromise health

Risk Factors External

Carpeted flooring; chemical contamination of food; chemical contamination of water; economically disad- vantaged; exposure to areas with high contaminant level; exposure to atmospheric pollutants; exposure to bioterrorism; exposure to disaster (natural or man-made); exposure to radiation; flaking, peeling surface in presence of young children (e.g., paint, plaster); inadequate breakdown of contaminant; inadequate house- hold hygiene practices; inadequate municipal services (e.g., trash removal, sewage treatment facilities); inadequate personal hygiene practices; inadequate protective clothing; inappropriate use of protective cloth- ing; playing where environmental contaminants are used; unprotected exposure to chemical (e.g., arsenic); unprotected exposure to heavy metal (e.g., chromium, lead); use of environmental contaminant in the home; use of noxious material insufficiently ventilated area (e.g., lacquer, paint); use of noxious material without effective protection (e.g., lacquer, paint)

Internal

Concomitant exposure; developmental characteristics of children; extremes of age; female gender; gesta- tional age during exposure; inadequate nutrition; preexisting disease; pregnancy; previous exposure to contaminant; smoking

NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family Teaching, Rationales, and References

Refer to care plans for Contamination.

Risk for adverse reaction to iodinated Contrast Media Paula D. Hopper, MSN, RN, CNE, and Betty J. Ackley, MSN, EdS, RN

NANDA-I

Definition

Vulnerable to noxious or unintended reaction associated with the use of iodinated contrast media that can occur within 7 days after contrast agent injection, which may compromise health

Holmes, S. M. (2011). The clinical gaze in the practice of migrant health: Mexican migrants in the United States. Social Science and Medicine, 74(6), 873–881.

Hubal, E., de Wet, T., & Du Toit, L. (2014). Identifying important life stages for monitoring and assessing risks from exposures to environmental contaminants: Results of a World Health Organization review. Regulatory Toxicology and Pharmacology, 69, 113–124.

Longtin, Y., Schneider, A., & Tschopp, C. (2014). Contamination of stethoscopes and physicians’ hands after a physical examination. Mayo Clinic Proceedings, 89(3), 291–299.

Morgan, D. J., Rogawski, B. S., & Thom, K. A. (2012). Transfer of multidrug-resistant bacteria to healthcare workers’ gloves and gowns after patient contact increases with environmental contamination. Critical Care Medicine, 40(4), 1045–1051.

Ohl, M., Schweizer, M., & Graham, M. (2012). Hospital privacy curtains are frequently and rapidly contaminated with potentially

pathogenic bacteria. American Journal of Infection Control, 40, 904–906.

Oyama, M., Nakamura, K., Suda, Y., et al. (2012). Social network disruption as a major factor associated with psychological distress 3 years after 2004 Niigata-Chuetsu earthquake in Japan. Environmental Health and Prevention Medicine, 17, 118–123.

Pan American Health Organization. (2012). Mental health and psychosocial support in disaster situations in the Caribbean. Washington, DC: PAHO.

U. S. Army Medical Research Institute of Infectious Diseases. (2011). USAMRIID’s medical management of biological casualties handbook (7th ed.). Fort Detrick, MD: Author.

Veenema, T. G. (2013). Disaster nursing and emergency preparedness for chemical, biological and radiological terrorism and other hazards (3rd ed.). New York: Springer.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Risk for Adverse Reaction to Iodinated Contrast Media 273

Risk Factors

Anxiety; chronic illness; concurrent use of pharmaceutical agents (e.g., beta blockers, interleukin-2, metfor- min nephrotoxins); contrast media precipitates adverse event (e.g., iodine concentration, viscosity, ion toxic- ity); dehydration; extremes of age; fragile vein (e.g., chemotherapy/radiation in limb to be injected, indwelling line for more than 24 hours, axillary lymph node dissection in limb to be injected, distal intravenous [IV] access site); generalized debilitation; history of allergy; history of previous adverse effect from iodinated contrast media; unconsciousness

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Tissue Perfusion: Renal; Kidney Function

Example NOC Outcome with Indicators

Kidney Function as evidenced by 24-hour intake and output balance/Blood urea nitrogen/Serum creatinine/Urine color/ Serum electrolytes. (Rate the outcome and indicators of Kidney Function: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Maintain normal blood urea nitrogen and serum creatinine levels • Maintain urine output of 0.5 mL/kg/hr • Maintain serum electrolytes (K+, PO4, Na+) within normal limits

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Fluid/Electrolyte Management; Laboratory Data Interpretation

Example NIC Activities—Fluid/Electrolyte Management

Monitor for serum electrolytes levels, as available; Weigh daily and monitor trends; Monitor vital signs, as appropriate

Nursing Interventions and Rationales

Recognize that iodinated contrast media can be harmful to clients in a number of ways, including onset of contrast-induced nephropathy, allergic reactions to the dye, and damage to veins and vascular access devices.

Contrast-Induced Nephropathy (CIN)

Protect clients from contrast media induced nephropathy by taking the following actions: ▲ Assess clients for low body mass index (BMI) or history of heart failure. Low BMI and heart failure are

risk factors for CIN (Balemans et al, 2012). ▲ In nondiabetic clients with acute coronary syndrome, assess for presence of hyperglycemia on admission

and report to health care provider. “[Index] admission high blood glucose in acute coronary syndrome patients not known to be diabetic is associated with increased incidence of contrast induced nephropathy after percutaneous coronary intervention” (Islam et al, 2013).

• Identify clients who have had multiple doses of iodinated contrast media in less than 24 hours and report to health care provider. Repeat administration of contrast material may be a risk factor for CIN (American College of Radiology, 2013).

• Notify the health care provider and the radiology staff if the client has preexisting renal disease. Clients with preexisting impaired renal function are susceptible to develop acute contrast media–induced nephropa- thy (Schilcher et al, 2011; Wong et al, 2011).

▲ Ensure that clients having diagnostic testing with contrast are well hydrated with isotonic IV fluids as ordered before and after the examination. EB: Incidence of CIN is reduced by IV hydration with isotonic fluids (lactated Ringer’s or 0.9% normal saline) before and after IV contrast administration (American

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

274 Risk for Adverse Reaction to Iodinated Contrast Media

College of Radiology, 2013). Low incidence of CIN is associated with the use of hydration (Balemans et al, 2012).

▲ Verify that a baseline serum creatinine has been drawn from clients at risk for CIN. A baseline value is important for comparison following the contrast injection (American College of Radiology, 2013).

• Recognize that many clients with decreased renal function are not aware of their health status and that a questionnaire checklist administered before testing may not be satisfactory to determine which clients with impaired renal function should receive contrast media carefully or which are not candidates for testing utilizing contrast media. EB: A study found that use of a preprocedure checklist was not effective in identifying all the clients with a history of chronic kidney disease to protect them from further kidney damage; instead, point-of-care creatinine testing was recommended (Kalisz et al, 2011).

• Be vigilant for signs of CIN in clients who have cancer. Clients with cancer are vulnerable to CIN, especially within 45 days of chemotherapy and in those with hypertension (Cicin et al, 2014).

• Monitor the client carefully for symptoms of hypovolemia following use of contrast media, including measuring intake and output, obtaining blood pressure measurements, and assessing for new onset of postural hypotension with dizziness. Hypovolemia can result following contrast media administration due to the increased osmolarity of the contrast media, resulting in postprocedure diuresis (O’Donovan, 2011).

▲ Monitor for and report signs of acute kidney injury for 48 hours following iodinated contrast administra- tion in clients at risk: absolute serum creatinine increase ≥ 0.3 mg/dL, percentage increase in serum creatinine ≥ 50%, or urine output reduced to ≤ 0.5 mL/kg/hr for at least 6 hours. These are signs of acute kidney injury (American College of Radiology, 2013).

Allergic Reaction to Contrast Media

▲ Discuss premedication with steroids or diphenhydramine with health care provider for clients who have had previous reactions to contrast media. Premedication may reduce the incidence of allergic reaction in some clients (American College of Radiology, 2013).

▲ Monitor carefully for symptoms of a reaction, which can be mild, moderate, or severe. Report all symp- toms to primary care provider because symptoms can advance rapidly from mild to severe. ❍ Mild reactions: Urticaria, pruritus, rhinorrhea, nausea, emesis, diaphoresis, coughing, dizziness ❍ Moderate reactions: Persistent emesis, widespread urticaria, headache, edema of the face, laryngeal

edema, mild dyspnea, palpitations, tachycardia/bradycardia, hypertension, abdominal cramps ❍ Severe reactions: Severe bronchospasm, severe arrhythmias, severe hypotension, pulmonary edema,

laryngeal edema, seizures, syncope, death (Wilson, 2011) ❍ Both allergic and allergic-like (anaphylactoid) reactions can occur. Life-threatening events usually occur

within 20 minutes after injection (American College of Radiology, 2013).

Vein Damage and Damage to Vascular Access Devices

• Recognize that only vascular access devices labeled “power injectable” can be used to administer power injected contrast media. These include a power port, a power PICC line, and a power central venous catheter (Radiology and Biomedical Imaging, 2014). A regular vascular access device used for administra- tion of contrast media can rupture from the high pressures used to administer the contrast media. EB: A retrospective study of the function of 204 power ports found that they are safe for use with power injections of contrast media (Goltz et al, 2012). The U.S. Food and Drug Administration has received more than 250 adverse event reports in which vascular access devices have ruptured when used with power injectors. The adverse events include rupture and device fragmentation (Earhart & McMahon, 2011).

• Reduce the risk of vein and vascular access device damage with the following: ❍ Maintain constant communication with the client during the injection. Discontinue the injection if

the client reports pain or the sensation of swelling at the injection site. These are signs of complications (American College of Radiology, 2013).

❍ Be vigilant in clients at increased risk of extravasation. Clients at increased risk include those who cannot communicate such as infants, older adults, or those with altered consciousness; severely ill or debilitated clients; clients with abnormal circulation in the affected limb; clients receiving the injection via a periph- eral IV line that has been in place for more than 24 hours or into a vein that has been punctured multiple times; clients with arterial insufficiency or compromised venous or lymphatic drainage in the affected extremity (American College of Radiology, 2013).

❍ Assess for venous backflow before injecting contrast. If backflow is not obtained, the catheter may need adjustment (American College of Radiology, 2013).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Compromised Family Coping 275

❍ Directly monitor and palpate the venipuncture site during the first 15 seconds of injection. A critical step in preventing significant extravasation is direct monitoring of the venipuncture site (American College of Radiology, 2013).

• After diagnostic testing using contrast media given intravenously, inspect the IV site used for administra- tion for possible problems, such as extravasation or development of compartment syndrome with exces- sive amounts of contrast pushed into the tissues under pressure. The incidence of serious complications associated with the media has increased since advent of use of power or pressure mechanical injectors. Although rare, compartment syndrome can result in infection, loss of use of the affected extremity, necrosis, skin sloughing, amputation, need for skin grafting, paralysis, and death (Wilson, 2011).

Geriatric

• Screen the older client thoroughly before diagnostic testing utilizing contrast media. Older adults are more likely to have preexisting renal failure along with other comorbidities and are more vulnerable to development of renal damage (O’Donovan, 2011).

REFERENCES American College of Radiology. (2013). ACR manual on contrast

media: version 9 (pp. 38–39). Reston, VA: American College of Radiology.

Balemans, C. E. A., et al. (2012). Epidemiology of contrast material- induced nephropathy in the era of hydration. Radiology, 263(3), 706–713.

Cicin, I., et al. (2014). Incidence of contrast-induced nephropathy in hospitalized patients with cancer. European Radiology, 24(1), 184–190.

Earhart, A., & McMahon, P. (2011). Vascular access and contrast media. Journal of Infusion Nursing: the Official Publication of the Infusion Nurses Society, 34(2), 97–105.

Goltz, J. P., et al. (2012). Totally implantable venous power ports of the forearm and the chest: initial clinical experience with port devices approved for high-pressure injections. The British Journal of Radiology, 85(1019), e966–e972.

Islam, N., et al. (2013). Impact of blood glucose levels on contrast induced nephropathy after percutaneous coronary intervention in patients not known to be diabetic with acute coronary syndrome. Cardiovascular Journal, 6(1), 23–30.

Kalisz, K. R., et al. (2011). Detection of renal dysfunction by point-of- care creatinine testing in patients undergoing peripheral MR

angiography. AJR. American Journal of Roentgenology, 197(2), 430–435.

O’Donovan, K. (2011). Preventing contrast-induced nephropathy part 2: preventive strategies. British Journal of Community Nursing, 6(1), 6–10.

Radiology and Biomedical Imaging. (2014). Patient Care: Vascular access and use of central lines and ports in adults. University of California San Francisco. Retrieved from: <http://www.radiology .ucsf.edu/patient-care/patient-safety/contrast/iodinated/vascular -access-adults>.

Schilcher, G., et al. (2011). Early detection and intervention using neutrophil gelatinase-associated lipocalin (NGAL) may improve renal outcome of acute contrast media induced nephropathy: a randomized controlled trial in patients undergoing intra- arterial angiography (ANTI-CIN Study). BMC Nephrology, 17, 12–39.

Wilson, B. (2011). Contrast media-induced compartment syndrome. Radiologic Technology, 83(1), 63–77.

Wong, P. C., Li, Z., Guo, J., et al. (2011). Pathophysiology of contrast- induced nephropathy. International Journal of Cardiology, 158(2), 186–192.

Compromised family Coping Katherina Nikzad-Terhune, PhD, LCSW

NANDA-I

Definition

A usually supportive primary person (family member, significant other, or close friend) provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that may be needed by the client to manage or master adaptive tasks related to his or her health challenge

Defining Characteristics

Assistive behaviors by support person produce unsatisfactory results; client complaint about support person’s response to health problems; client concern about support person’s response to health problem; limitation in communication between support person and client; protective behavior by support person incongruent with client’s abilities; protective behavior by support person incongruent with client’s need for autonomy; support person reports inadequate understanding that interferes with effective behaviors; support person

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

276 Compromised Family Coping

reports insufficient knowledge that interferes with effective behaviors; support person reports preoccupation with own reaction to client’s need; support person withdraws from client

Related Factors (r/t)

Coexisting situations affecting the support person; developmental crises experienced by support person; exhaustion of support person’s capacity; family disorganization; family role change; insufficient information available to support person; insufficient reciprocal support; insufficient support given by client to support person; insufficient understanding of information by support person; misinformation obtained by support person; preoccupation by support person with concern outside of family; prolonged disease that exhausts capacity of support person; situational crisis faced by support person

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Caregiver Emotional Health; Caregiver-Client Relationship; Family Coping; Family Participation in Profes- sional Care; Family Support During Treatment

Example NOC Outcome with Indicators

Family Coping as evidenced by the following indicators: Confronts family problems/Manages family problems/Reports needs for family assistance. (Rate each indicator of Family Coping: 1 = never demonstrated, 2 = rarely demonstrated, 3 = sometimes demonstrated, 4 = often demonstrated, 5 = consistently demonstrated [see Section I].)

Example NIC Activitis—Family Support

Appraise family’s emotional reaction to client’s condition; Promote trusting relationship with family

Client Outcomes Family/Significant Person Will (Specify Time Frame)

• Verbalize internal resources to help deal with the situation • Verbalize knowledge and understanding of illness, disability, or disease • Provide support and assistance as needed • Identify need for and seek outside support

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Caregiver Support; Coping Enhancement; Family Involvement Promotion; Family Mobilization; Family Support; Mutual Goal Setting; Normalization Promotion; Sibling Support

Nursing Interventions and Rationales

• Assess the strengths and deficiencies of the family system. EBN: Thorough and comprehensive assessments offer valuable information regarding how problems evolve within the family context over time, and allow for anticipatory care and guidance to help family members acquire and maintain support and coping strategies (Wright & Leahey, 2012).

• Establish rapport with families by providing accurate communication. EBN: Enthusiasm or interest dem- onstrated by health care professionals helps establish stronger rapport and a therapeutic relationship with clients (Bahrami, 2011).

• Assist family members to recognize the need for help and teach them how to ask for it. • Encourage expression of positive thoughts and emotions to help reduce stress. EB: A comprehensive survey

of meta-analyses examining the efficacy of cognitive behavioral therapy (CBT) found it to be a strong evidence-based intervention to use with a variety of complex issues, including stress reduction (Hofmann et al, 2012).

• Encourage family members to verbalize feelings. Spend time with them, sit down and make eye contact, and offer coffee and other nourishment.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Compromised Family Coping 277

• Incorporate family variables, including dyadic adjustment, into assessment protocols and intervention strategies. EB: Pereira et al (2012) revealed a positive relationship among dyadic adjustment, psychological morbidity, and family coping in clients and their partners, in that better dyadic adjustment predicted family coping in the client.

• Provide privacy during family visits. If possible, maintain flexible visiting hours to accommodate more frequent family visits. If possible, arrange staff assignments so the same staff members have contact with the family. Familiarize other staff members with the situation in the absence of the usual staff member. Providing privacy, maintaining flexible hours, and arranging consistent staff assignments reduces stress, enhances communication, and facilitates the building of trust.

• Provide education to clients regarding active coping strategies to use in situations involving chronic ill- nesses. EBN: Active coping strategies, including planning, giving priority, reappraisal, waiting, and accep- tance, were predictive of better quality of life and lower levels of depression and hopelessness in cancer clients (van Laarhoven et al, 2011).

• Use evidence-based tools to assess for post-intensive care syndrome (e.g., anxiety, acute stress disorder, posttraumatic stress, depression, and complicated grief) in families who have experienced a critical illness. EB: Prevention strategies for post-intensive care syndrome include adequate communication and involving families in decision-making processes, while treatment strategies include support groups and refer- rals for treatment (Davidson et al, 2012).

• Refer the family with ill family members to appropriate resources for assistance as indicated (e.g., coun- seling, psychotherapy, financial assistance, or spiritual support).

Pediatric

• Provide screening for postpartum depression (PPD) during the prenatal period and during the 6-week postpartum check-up to identify symptoms of depression in mothers. CEB: The Edinburgh Postnatal Depression Scale (EPDS) is the most widely used screening tool for detecting PPD and has been shown to be effective both prenatally and postnatally for detecting symptoms of depression in women (Cox et al, 1987).

▲ Consider medication management and psychosocial interventions, including individual therapy, group therapy, support groups, and brief psychotherapy. EB: These are effective treatment strategies for managing PPD (Miniati et al, 2014; Kleiman & Raskin, 2013).

▲ Use preventive strategies, such as screening, psychoeducation, postpartum debriefing, and companion- ship in the delivery room (e.g., community volunteer). EBN: These strategies play an important role in the prevention of and recovery from PPD (Dennis & Dowswell, 2013).

• Provide educational and psychosocial interventions, such as coping skills training, in treatment for fami- lies and their adolescents who have diabetes. EBN: Educational and support interventions help improve coping skills for parents of adolescents with diabetes (Konradsdottir & Svavarsdottir, 2011).

• Provide readily available resources to support parents of children with autism and their families. EBN: Study findings from Hall (2011) highlighted the association between the low adaptive functioning of the child with autism and increased parental stress, the need for additional family support, and the need for effective coping strategies.

• Provide family-centered care during neonatal intensive care to encourage family members to play an active role in providing emotional, social, and developmental support. EBN: When neonatal intensive care unit staff collaborate with parents, families become more involved in decision-making processes and care planning, and are empowered to impact the process of their infant’s recovery (Gooding et al, 2011).

• Provide evidence-based psychological therapies for parents with children with chronic conditions. EB: Psychological therapies (e.g., cognitive behavioral therapy and problem-solving therapy) that included parents significantly improved child symptoms for painful conditions immediately after treatment (Eccleston et al, 2012).

• Assist with fostering co-parenting alliances in fragile families. EB: Providing preventive interventions to support the development of a positive co-parenting alliance between parents who have not made an enduring relationship commitment to one another can help benefit children and families (McHale et al, 2012).

• Provide options for home-based interventions when severe childhood illnesses make it difficult for chil- dren and families to participate in interventions. EBN: A home-based 12-week cognitive training program for child cancer survivors yielded significant increases in working memory and decreases in parent-rated attention problems following the intervention (Hardy et al, 2011).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

278 Compromised Family Coping

Geriatric

▲ Perform a holistic assessment of all needs of informal spousal caregivers. EBN: Caregiver assessments should be systematic, should take into consideration the caregiver’s perspective, and should include follow-up on care coordination and linkages to services (Levine, 2011). Refer caregivers of clients with Alzheimer’s disease to a monthly psychoeducational support group (i.e., the Alzheimer’s Association), and incorporate nonpharmacological support programs for caregivers. EB: Nonpharmacological interventions, such as skill training programs for stress management, in home support, individual or group psychotherapy, and respite programs, demonstrate efficacy in reducing caregiver stress and burden (Gallagher-Thompson et al, 2012).

▲ Provide caregivers with options for Internet-based support strategies to enhance coping. EB: Creating bonds between caregivers using online support programs produces beneficial psychological outcomes among caregivers, including improved coping (Namkoong et al, 2012).

• Assist in finding transportation to enable family members to visit. EB: If a family member is homebound and unable to visit, encourage alternative contact (e.g., telephone, cards and letters, email) to provide ongoing scheduled progress reports and to help reduce loneliness and isolation. Visually impaired older adults, who experience more limitations with driving, have a higher risk for loneliness (Alma et al, 2011).

• Assist informal caregivers with reducing unmet needs by helping them obtain the information and educa- tion necessary for caring for an older adult with a chronic health condition. EB: Evidence supports the use of a health information delivery system (e.g., providing information that is proactive, understandable, and individualized) specifically designed to meet the unique needs of informal caregivers of older adults with chronic health conditions (Washington et al, 2011).

Multicultural

• Acknowledge racial/ethnic differences at the onset of care. EBN: Accurate cultural knowledge assists in enhancing the ability of health care service providers to identify and understand cultural factors that influ- ence diagnosis, treatment, and illness management, and create warm and trusting relationships with their clients (Higginbottom et al, 2011).

• Assess for the influence of cultural beliefs, norms, and values on the individual/family/community’s perceptions of coping. EB: Cultural values are a valid predictor of coping when traits are taken into account (Bardi & Guerra, 2011).

• Use valid and culturally competent assessment tools and procedures when working with families with different racial/ethnic backgrounds. EBN: The cultural information in nursing models and assessments should encompass health beliefs and practices, communication styles, religious orientation, and the degree of acculturation amongst others (Higginbottom et al, 2011).

• Provide culturally relevant interventions by understanding and using treatment strategies that are accept- able and effective for a particular culture. EB: Interventions should be theoretical based and incorporate cultural beliefs within a contextual framework in order for prevention and risk reduction messages to reach targeted at risk populations (Wyatt et al, 2012).

• Provide opportunities for families to discuss spirituality. EBN: African American women with breast cancer use more positive religious coping and experience less distress and greater spiritual well-being (Gaston- Johansson et al, 2013).

• Determine how the family’s cultural context impacts their decisions in regard to managing and coping with a child’s illness; recognize and validate the cultural context. EBN: Nurses and other clinicians working with families must include cultural variables when assisting family members with ill children, and demon- strating competency and respect for one’s cultural values helps ensure the good of the client as well as client autonomy (Leever, 2011).

Home Care

• The interventions described previously may be adapted for home care use. • Assess the reason behind the breakdown of family coping. Knowledge of the reasons behind compromised

coping will assist in identification of appropriate interventions. Refer to the care plan for Caregiver Role Strain.

• During the time of compromised coping, increase visits to ensure the safety of the client, support of the family, and reassurance regarding expectations for prognosis as appropriate. EBN: When providing care in the home setting, conforming to the norms and values of clients and their families is extremely important for building rapport and ensuring a sense of safety (Lindahl et al, 2011).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Compromised Family Coping 279

▲ Assess the needs of the caregiver in the home, and intervene to meet needs as appropriate; explore all available resources that may be used to provide adequate home care (e.g., parish nursing as an effective adjunct, home health aide services to relieve the caregiver’s fatigue).

▲ Encourage caregivers to attend to their own physical, mental, and spiritual health, and give more specific information about the client’s needs and ways to meet them.

▲ Refer the family to medical social services for evaluation and supportive counseling. Serve as an advocate, mentor, and role model for caregiving; provide written information for the care needed by the client.

▲ A positive approach and caring by the nurse and concrete task definition and assignment reinforce positive coping strategies and allow caregivers to feel less guilty when tasks are delegated to multiple caregivers.

▲ When a terminal illness is the precipitating factor for ineffective coping, offer hospice services and support groups as possible resources. EBN: Research suggests that clients and their families highly value hospice care services and report experiencing beneficial outcomes as a result of using hospice services, including effective pain management and avoiding death in the hospital setting (Candy et al, 2011).

• Encourage the client and family to discuss changes in daily functioning and routines created by the cli- ent’s illness, and validate discomfort resulting from changes. Individuals who live together for a long period tend to become familiar with each other’s patterns: for example, meals are expected at certain times or a spouse becomes accustomed to the client’s sleep habits.

• Support positive individual and family coping efforts. Positive feedback reinforces desired behaviors and supports the family unit.

▲ If compromised family coping interferes with the ability to support the client’s treatment plan, refer for psychiatric home health care services for family counseling and/or Internet-based behavioral interven- tions. EBN: Schubart et al (2011) identified two characteristics contributing to Internet interventions that engage users: (1) the intervention targets participants with serious health concerns, and (2) the intervention adapts to individual needs.

Client/Family Teaching and Discharge Planning

• Assess for and address grief issues that arise in the process, including anticipatory grief. EB: Research conducted by Garand et al (2012) revealed high levels of anticipatory grief in dementia caregivers, suggesting that this grief reaction may be highest at the earliest stages of Alzheimer’s disease caregiving, or when family members begin to provide care assistance to their loved one with mild cognitive impairment.

▲ Refer women with breast cancer and their family caregivers to support groups and other services that provide assistance with daily coping. Refer women with breast cancer and their family caregivers to support groups, including social network sites and online communities, to provide assistance with daily coping. EB: Social network sites and online communities present a convenient way to exchange information and support for breast cancer survivors, including awareness, service promotion, client/caregiver support, and fundraising (Bender et al, 2011).

• Promote individual and family relaxation and stress-reduction strategies. The immune system weakens in response to stress; persistent relaxation may elicit positive effects on one’s immune system (Kang et al, 2011).

▲ Refer parents to support and education groups to provide opportunities for parents to access support, learn new parenting skills, and ultimately, optimize their relationships with their children after divorce. EB: Through education, parents can be taught to improve the quality of their parenting, which has been linked to improvements in children’s academic functioning and reductions in children’s mental health and substance use problems (Sigal et al, 2011).

• Provide Internet-based resources, including online social networking groups, to enhance social support, bonding, and coping for caregivers. EB: Perceived bonding through social support yields positive effects on caregivers’ problem-focused coping strategies (Namkoong et al, 2012).

REFERENCES Alma, M., Van der Mei, S. F., & Feitsma, W. N. (2011). Loneliness and

self-management abilities in the visually impaired elderly. Journal of Aging and Health, 23, 843–861.

Bahrami, M. (2011). Why differences exist? An interpretive approach to nurses’ perceptions of cancer patients’ quality of life. Iranian Journal of Nursing and Midwifery Research, 16(1), 117–124.

Bardi, A., & Guerra, V. M. (2011). Cultural values predict coping using culture as an individual difference variable in multicultural samples. Journal of Cross-Cultural Psychology, 42(6), 908–927.

Bender, J., Jimenez-Marroquin, M., & Jadad, A. R. (2011). Seeking support on Facebook: A content analysis of breast cancer groups. Journal of Medical Internet Research, 13(1), e16.

280 Defensive Coping

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Defensive Coping Arlene T. Farren, RN, PhD, AOCN, CTN-A

NANDA-I

Definition

Repeated projection of falsely positive self-evaluation based on a self-protective pattern that defends against underlying perceived threats to positive self-regard

Candy, B., Holman, A., Leurent, B., et al. (2011). Hospice care delivered at home, in nursing homes and in dedicated hospice facilities: A systematic review of quantitative and qualitative evidence. International Journal of Nursing Studies, 48(1), 121–133.

Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression: Development of the 10-item Edinburgh Postnatal Depression Scale. The British Journal of Psychiatry: The Journal of Mental Science, 150, 782–786.

Davidson, J., Jones, C., & Bienvenu, J. (2012). Family response to critical illness: Postintensive care syndrome—family. Critical Care Medicine, 40(2), 618–624.

Dennis, C. L., & Dowswell, T. (2013). Psychosocial and psychological interventions for preventing postpartum depression. The Cochrane database of Systematic Reviews.

Eccleston, C., Palermo, T., Fisher, E., et al. (2012). Psychological interventions for parents of children and adolescents with chronic illness. The Cochrane database of Systematic Reviews, Advance online publication.

Gallagher-Thompson, D., Tzuang, Y. M., Au, L., et al. (2012). International perspectives on nonpharmacological best practices for dementia family caregivers: A review. Clinical Gerontologist, 35(4), 316–355.

Garand, L., Lingler, J. H., & Dew, M. A. (2012). Anticipatory grief in new family caregivers of persons with mild cognitive impairment and dementia. Alzheimer Disease and Associated Disorders, 26(2), 159–165.

Gaston-Johansson, F., Haisfield-Wolfe, M. E., Reddick, B., et al. (2013). The relationships among coping strategies, religious coping, and spirituality in African American women with breast cancer receiving chemotherapy. Oncology Nursing Forum, 40(2), 120–131.

Gooding, J., Cooper, L., Blaine, A., et al. (2011). Family support and family-centered care in the neonatal intensive care unit: Origins, advances, impact. Seminars in Perinatology, 35(1), 20–28.

Hall, H. (2011). The relationships among adaptive behaviors of children with autism, family support, parenting stress, and coping. Issues in Comprehensive Pediatric Nursing, 34, 4–25.

Hardy, K., Willard, V., & Bonner, M. (2011). Computerized cognitive training in survivors of childhood cancer: A Pilot Study. Journal of Pediatric Oncology Nursing, 28(1), 27–33.

Higginbottom, G., Richter, M. S., Mogale, R. S., et al. (2011). Identification of nursing assessment models/tools validated in clinical practice for use with diverse ethno-cultural groups: An integrative review of the literature. BMC Nursing, 10(16), 1–11.

Hofmann, S., Asnaani, A., Vonk, I., et al. (2012). The efficacy of cognitive behavioral therapy: A review of meta-analyses. Cognitive Therapy and Research, 36(5), 427–440.

Kang, D. H., McArdle, T., Park, N., et al. (2011). Dose effects of relaxation practice on immune responses in women newly diagnosed with breast cancer: An exploratory study. Oncology Nursing Forum, 38(3), E240–E252.

Kleiman, K. R., & Raskin, V. D. (2013). This isn’t what I expected: Overcoming postpartum depression (2nd ed.). Boston, MA: Da Capo.

Konradsdottir, E., & Svavarsdottir, E. K. (2011). How effective is a short-term educational and support intervention for families of an adolescent with type 1 diabetes? Journal for Specialists in Pediatric Nursing, 16(4), 295–304.

Leever, M. (2011). Cultural competence: Reflections on patient autonomy and patient good. Nursing Ethics, 18(4), 560–570.

Levine, C. (2011). Supporting family caregivers: The hospital nurse’s assessment of family caregiver needs. American Journal of Nursing, 111(10), 47–51.

Lindahl, B., Lide’n, E., & Lindblad, B. (2011). A meta-synthesis describing the relationships between patients, informal caregivers and health professionals in home-care settings. Journal of Clinical Nursing, 20(3–4), 454–463.

McHale, J., Waller, M., & Pearson, J. (2012). Coparenting interventions for fragile families: What do we know and where do we need to go next? Family Process, 51(3), 284–306.

Miniati, M., Callari, A., Calugi, S., et al. (2014). Interpersonal psychotherapy for postpartum depression: A systematic review. Archives of Women’s Mental Health, 17(4), 257–268.

Namkoong, K., DuBenske, L., Shaw, B., et al. (2012). Creating a bond between caregivers online: Effect on caregivers’ coping strategies. Journal of Health Communication: International Perspectives, 17(2), 125–140.

Pereira, M., Brito, L., & Smith, T. (2012). Dyadic adjustment, family coping, body image, quality of life and psychological morbidity in patients with psoriasis and their partners. International Journal of Behavioral Medicine, 19(3), 260–269.

Schubart, J., Stuckey, H., Ganeshamoorthy, A., et al. (2011). Chronic health conditions and Internet behavioral interventions: A review of factors to enhance user engagement. Computers, Informatics, Nursing, 29(2), 81–92.

Sigal, A., Sandler, I., Wolchik, S., et al. (2011). Do parent education programs promote healthy postdivorce parenting? Critical distinctions and a review of the evidence. Family Court Review, 49(1), 120–139.

van Laarhoven, H., Schilderman, J., Bleijenberg, G., et al. (2011). Coping, quality of life, depression, and hopelessness in cancer patients in a curative and palliative, end-of-life care setting. Cancer Nursing, 34(4), 302–314.

Washington, K., Meadows, S., Elliot, S., et al. (2011). Information needs of informal caregivers of older adults with chronic health conditions. Patient Education and Counseling, 83, 37–44.

Wright, L. M., & Leahey, M. (2012). Nurses and families: A guide to family assessment and intervention. Philadelphia: FA Davis.

Wyatt, G. E., Williams, J. K., Gupta, A., et al. (2012). Are cultural values and beliefs included in U.S. based HIV interventions? Preventative Medicine, 55(5), 362–370.

Defensive Coping 281

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Defining Characteristics

Alteration in reality testing; denial of problems; denial of weaknesses; difficulty establishing relationships; difficulty maintaining relationships; grandiosity; hostile laughter; hypersensitivity to a discourtesy; hyper- sensitivity to criticism; insufficient follow through with treatment; insufficient participation in treatment; projection of blame; projection of responsibility; rationalization of failures; reality distortion; ridicule of others; superior attitude toward others

Related Factors

Conflict between self-perception and value system; fear of failure; fear of humiliation; fear of repercussions; insufficient confidence in others; insufficient resilience; insufficient self-confidence; insufficient support system; uncertainty unrealistic self-expectations

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Coping; Decision-Making; Impulse Self-Control; Information Processing

Example NOC Outcome with Indicators

Coping as evidenced by the following indicators: Identifies effective and ineffective coping patterns/Modifies lifestyle to reduce stress. (Rate the outcome and indicators of Coping: 1 = never demonstrated, 2 = rarely demonstrated, 3 = sometimes demonstrated, 4 = often demonstrated, 5 = consistently demonstrated [see Section I].)

Client Outcomes Client Will (Specify Time Frame)

• Acknowledge need for change in coping style • Accept responsibility for own behavior • Establish realistic goals with validation from caregivers • Solicit caregiver validation in decision-making

NIC (Nursing Interventions Classification)

Suggested Nursing Interventions

Body Image Enhancement; Complex Relationship Building; Coping Enhancement; Patient Contracting; Resiliency Promotion; Self-Awareness Enhancement; Self-Esteem Enhancement; Socialization Enhance- ment; Surveillance

Example NIC Activities—Self-Awareness Enhancement

Encourage client to recognize and discuss thoughts and feelings; Assist client in identifying behaviors that are self-destructive

Nursing Interventions and Rationales

• Assess for possible symptoms associated with defensive coping: depressive symptoms, excessive self- focused attention, negativism and anxiety, hypertension, posttraumatic stress disorder (e.g., exposure to terrorism), unjust world beliefs. EB: In a study of coping styles and anxiety in a small sample (N = 47) of persons with chronic low back pain, researchers found evidence of more defensiveness than in the general population. Researchers suggested that individuals with defensive high-anxious coping styles may be at risk for poorer psychological and physical outcomes and recommended assessment of these characteristics and further research to ensure appropriate treatments and improved outcomes (Lewis et al, 2012). EB: Defensive reactions were present in a sample of college women (N = 1679) who identified as having experience with childhood abuse or other traumas; researchers concluded that victims’ defensive reactions to trauma may contribute to the unique effects of trauma (Bottoms et al, 2012).

▲ Use cognitive behavioral interventions. EBN: In a randomized control trial (N = 240), 120 in each group— experimental and control), a nurse-led cognitive behavioral intervention addressed inaccurate thinking and

282 Defensive Coping

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

promoted more positive self-regard; the experimental group had improved quality of life, which included physical and psychological health, relief of symptom, and social functioning (Zhuang et al, 2013).

• Ask appropriate questions to assess whether denial (defensive coping) is being used in association with health problems including alcoholism, myocardial infarction (MI), or rheumatoid arthritis. EBN: In a qualitative study of 28 people after MI, researchers found that those who used negative coping, including denial and defensive coping, did not make the necessary changes toward physical and psychological health and experienced depression; researchers recommended follow-up care including psychoeducational interven- tions (Salminen-Tuomaala et al, 2012). EBN: In a case-based article, Wilson (2013) demonstrates a nurse- provided approach to Screening, Brief Intervention, and Referral to Treatment (SBIRT), an approach recommended by the Substance Abuse and Mental Health Services Administration (2015), in a client requir- ing a peripherally inserted central catheter for a man with liver disease due to alcoholism. EB: In a 5-year prospective study of adults with rheumatoid arthritis (N = 74), researchers found that defensive coping impacted responses to pain and overall health, leading to poorer outcomes (Goulia et al, 2015).

• Promote interventions with multisensory stimulation environments. EB: In a review of the literature regarding sharing multisensory body space with others for those with altered bodies, such as amputations or congenital limb absence, researchers concluded that sharing multisensory body space is pertinent and may close the gap between neurology and psychiatry in the treatment of persons with altered bodies (Brugger & Lenggenhager, 2014).

• Empower the client/caregiver’s self-knowledge. EB: In a qualitative study of adults receiving highly active antiretroviral treatment for HIV and methadone maintenance, participants described tension between nega- tive feelings such as denial and positive feelings of empowerment (Batchelder et al, 2013).

Geriatric

▲ Identify problems with alcohol in older adults with the appropriate tools and make suitable referrals. EB: Community-dwelling older adults (N = 370) completed the Drinking Motives Questionnaire (DMQ); findings indicated that the most frequent motivation for drinking was social, with enhancement and coping motives, respectively, as the top three motivations (Gilson et al, 2013). CEB: Tools such as the Alcohol Use Disorders Identification Test (AUDIT), Michigan Alcohol Screening Test-Geriatric Version (MAST-G), and the Alcohol- Related Problems Survey (ARPS) may have additional use in this population. Brief interventions have been shown to be effective in producing sustained abstinence or reducing levels of consumption, thereby decreasing hazardous and harmful drinking (Culberson, 2006).

• Encourage exercise for positive coping. EBN: One research group identified that exercise is known to facilitate maintenance of functional abilities in older adults and tested an intervention to encourage older adults (N = 106) to engage in physical activity/exercise using peer mentors. The researchers found high participation and retention and improved fitness scores in all mentored groups (Dorgo et al, 2013). EB: Researchers performed a secondary analysis of data to examine the use of physical activity (PA) in mid and older adults during a smoking cessation attempt (N = 799), the researchers found that physical activity, primarily walking, was used by only a small percent of participants (11.6%); women were more likely to use PA as a coping strategy than men; the researchers recommend further study and approaches that encourage older adults to engage in PA for general health and quality of life (Treviño et al, 2014).

• Stimulate individual reminiscence therapy. EBN: Structured reminiscence is an evidence-based, indepen- dent nursing intervention that is used with individuals and groups and is used to increase emotional aware- ness and enhance social interactions in older adults (Stinson & Long, 2014).

• Stimulate group reminiscence therapy. EBN: Stinson’s structured group reminiscence is a multisession evidence-based approach used with older adults (Stinson & Long, 2014). EB: A multimedia intergenera- tional reminiscence program was tested in a small (N = 26) group of community-dwelling older adults; qualitative data from stories and focus groups indicated the intervention showed promise as a group inter- generational intervention (Chonody & Wang, 2013).

Multicultural

• Acknowledge racial/ethnic differences at the onset of care. EB: In a qualitative study of white professionals working with racial minority immigrant clients, researchers found that while some professionals reported being comfortable discussing race and cultural differences, some expressed discomfort and difficulty, and others did not perceive race and culture to be a priority; the researchers recommended further attention to cultural competence training in clinical programs (Singer & Tummala-Narra, 2013).

Defensive Coping 283

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

• Assess an individual’s sociocultural backgrounds in teaching self-management and self-regulation. EBN: A systematic review of qualitative evidence related to women’s coping with type 2 diabetes indicated that in multiple countries self-management is challenged by the complexities of regimens and women’s multiple- caregiving roles; researchers recommended recognition of the coping and emotional factors by health care providers; families, and friends, psychoeducation programs for clients and families, and enhanced support of family and friends (Li et al, 2014). EB: In a study of the Cellie Coping Kit for Sickle Cell Disease, research- ers provided the intervention to 15 black/African American children aged 6 to 14 years and their health care providers; although the researchers reported strong acceptability, some sociocultural issues like living situa- tion and health literacy did provide challenges to the use of the tool (Marsac et al, 2014).

• Encourage the client to use spiritual coping mechanisms such as faith and prayer. CEB/EBN: In a qualita- tive study of Thai Buddhist and Muslim women’s (N = 48) use of religion and spiritual practices related to self-management of type 2 diabetes, researchers found four themes that related to cultural or spiritual prac- tices, including prayer, that helped them cope, despite poor glycemic control (Lundberg & Thrakul, 2013). EB: In a study of religion and coping with racial discrimination among African American (N = 2032) and Caribbean blacks (N = 857), researchers found that both groups were similar in their likelihood of using prayer for coping with discrimination (Hayward & Krause, 2015).

• Encourage spirituality as a source of support for coping. EBN: In a small (N = 17) pilot study of African American women with breast cancer, women reported high levels of spiritual and positive religious coping (sense of purpose in life) strategies such as prayer; researchers recommended that although the findings of the pilot are not generalizable, spirituality and religious coping need to be explored as core coping mecha- nisms for African American women with breast cancer (Gaston-Johansson et al, 2013).

Home Care

▲ Refer the client for programs that teach coping skills. EBN: In a small pilot study of an intervention with mothers and their children who were exposed to domestic violence, researchers found preliminary evidence that the intervention (a relationally based multi-method program) improved defensive avoidance (Kearney & Cushing, 2012). EB: Researchers examining bullying and the association with cultural/family factors, substance use, and depressive symptoms in ninth and tenth grade Hispanic youth (N = 1167) found the stress of acculturation was associated with substance use and depressive symptoms and the need for the develop- ment of coping skills in youth; recommendations included school-based programs to teach coping skills (Forster et al, 2013).

Client/Family Teaching and Discharge Planning

• Teach coping skills to clients and caregivers. EBN: Teaching and modeling problem-solving skills to mothers with children who were exposed to domestic violence improved defensive avoidance (Kearney & Cushing, 2012). EBN: In a trial of a culturally adapted cognitive behavioral therapy intervention to promote coping skills among Chinese Americans with type 2 diabetes, strategies and coping skills that addressed personal, family, and illness specific topics were included; researchers reported enhanced efficacy for self-management (Chesla et al, 2013).

• Teach reflexive and expressive writing to address emotions. EBN: Journaling was used in an intervention study to enhance civility among nursing students; researchers found coping improvements in self-controlling and positive reappraisal (Jenkins et al, 2013). EB: In a randomized trial of expressive writing in the third person, 44 undergraduates wrote about their deepest thoughts and feelings about a traumatic or very stressful life event; findings included less intrusive thinking in both groups but third-person writers had better out- comes in overall health than did the first-person writers; researchers recommend third-person expressive writing for those recovering from traumatic or highly stressful events (Andersson & Conley, 2013).

REFERENCES Refer to ineffective Coping for additional references. Andersson, M. A., & Conley, C. S. (2013). Optimizing the perceived

benefits and health outcomes of writing about traumatic life events. Stress and Health: Journal of the International Society for the Investigation of the Stress, 29, 40–49.

Batchelder, A. W., Brisban, M., Litwin, A. H., et al. (2013). “Damaging what wasn’t damaged already”: Psychological tension and

antiretroviral adherence among HIV-infected methadone- maintained drug users. AIDS Care, 25, 1370–1374.

Bottoms, B. L., Najdowski, C. J., Epstein, M. A., et al. (2012). Trauma severity and defensive emotion-regulation reactions as predictors of forgetting childhood trauma. Journal of Trauma & Dissociation: the official journal of the International Society for the Study of Dissociation (ISSD), 13, 291–310.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

284 Ineffective Community Coping

Ineffective community Coping Roberta Dobrzanski, MSN, RN

NANDA-I

Definition

A pattern of community activities for adaptation and problem solving that is unsatisfactory for meeting the demands or needs of the community

Defining Characteristics

Community does not meet expectations of its members; deficient community participation; elevated com- munity illness rate; excessive community conflict; excessive stress; high incidence of community problems (e.g., homicides, vandalism, terrorism, robbery, abuse, unemployment, poverty, militancy, mental illness); perceived community powerlessness; perceived community vulnerability

Related Factors

Exposure to disaster (natural or man-made); history of disaster (e.g., natural, man-made); inadequate resources for problem solving; insufficient community resources (e.g., respite, recreation, social support); nonexistent community systems

Brugger, P., & Lenggenhager, B. (2014). The bodily self and its disorders: Neurological, psychological, and social aspects. Current Opinion in Neurology, 27, 644–652.

Chesla, C. A., Chun, K. M., Kwan, C. M. L., et al. (2013). Testing the efficacy of culturally adapted coping skills training for Chinese American immigrants with type 2 diabetes using community-based participatory research. Research in Nursing & Health, 36, 359–372.

Chonody, J., & Wang, D. (2013). Connecting older adults to the community through multimedia: An intergenerational reminiscence program. Activities, Adaptation, & Aging, 37, 79–93.

Culberson, J. W. (2006). Alcohol use in the elderly: beyond the CAGE. Part 2: Screening instruments and treatment strategies. Geriatrics, 61(11), 20–26.

Dorgo, S., King, G. A., Bader, J. O., et al. (2013). Outcomes of a peer mentor implemented fitness program in older adults: A quasi- randomized controlled trial. International Journal of Nursing Studies, 50, 1156–1165.

Forster, M., Dyal, S. R., Baezconde-Garbanati, L., et al. (2013). Bullying victimization as a mediator of associations between cultural/ familial variables, substance use, and depressive symptoms among Hispanic youth. Ethnicity & Health, 18, 415–432.

Gaston-Johansson, F., Haisfield-Wolfe, M. E., Reddick, B., et al. (2013). The relationships among coping strategies, religious coping, and spirituality in African American Women with breast cancer receiving chemotherapy. Oncology Nursing Forum, 40, 120–131.

Gilson, K., Bryant, C., Bei, B., et al. (2013). Validation of the drinking motives questionnaire in older adults. Addictive Behaviors, 38, 2196–2202.

Goulia, P., Voulgari, P. V., Tsifetaki, N., et al. (2015). Sense of coherence and self-sacrificing defense style as predictors of psychological distress and quality of life in rheumatoid arthritis: A 5-year prospective study. Rheumatology International, 35, 691–700.

Hayward, R. D., & Krause, N. (2015). Religion and strategies for coping with racial discrimination among African Americans and Caribbean Blacks. International Journal of Stress Management, 22, 70–91.

Jenkins, S. D., Kerber, C. S., & Woith, W. M. (2013). An intervention to promote civility among nursing students. Nursing Education Perspectives, 34, 95–100.

Kearney, J. A., & Cushing, E. (2012). A multi-modal pilot intervention with violence-exposed mothers in a child psychiatric trauma- focused treatment program. Issues in Mental Health Nursing, 33, 544–552.

Lewis, S. E., Fowler, N. E., Woby, S. R., et al. (2012). Defensive coping styles, anxiety, and chronic low back pain. Physiotherapy, 98(1), 86–88.

Li, J., Drury, V., & Taylor, B. (2014). A systematic review of the experience of older women living and coping with type 2 diabetes. International Journal of Nursing Practice, 20, 126–134.

Lundberg, P. C., & Thrakul, S. (2013). Religion and self-management of Thai Buddhist and Muslim women with type 2 diabetes. Journal of Clinical Nursing, 22, 1907–1916.

Marsac, M. L., Alderfer, M. A., Smith-Whitely, K., et al. (2014). Clinical Practice in Pediatric Psychology, 2, 389–399.

Salminen-Tuomaala, M., Åstedt-Kurki, P., Rekiaro, M., et al. (2012). Coping experiences: A pathway toward different coping orientations four and twelve months after myocardial infarction—A grounded theory approach. Nursing Research and Practice, 2012, Article ID 674783, 9 pages.

Singer, R. R., & Tummala-Narra, P. (2013). White clinicians’ perspectives on working with racial minority immigrant clients. Professional Psychology, Research and Practice, 44, 290–298.

Stinson, C., & Long, E. M. (2014). Reminiscence: Improving the quality of life for older adults. Geriatric Nursing, 35, 399–404.

Substance Abuse and Mental Health Services Administration. (2015). Screening, brief intervention, and referral to treatment (SBIRT). Retrieved from: <http://www.samhsa.gov/sbirt> June 2015.

Treviño, L. A., Baker, L., McIntosh, S., et al. (2014). Physical activity as a coping strategy for smoking cessation in mid-life and older adults. Addictive Behaviors, 39, 885–888.

Wilson, K. M. (2013). Integrating procedural care with addiction support: An example from a PICC nurse. Medsurg Nursing, 22, 128–135.

Zhuang, S., An, S., & Zhao, Y. (2013). Effect of cognitive behavioral interventions on the quality of life in Chinese heroin-dependent individuals in detoxification: A randomized controlled trial. Journal of Clinical Nursing, 23, 1239–1248.

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Ineffective Community Coping 285

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Community Competence; Community Health Status; Community Violence Level

Example NOC Outcome with Indicators

Community Competence as evidenced by the following indicators: Participation rates in community activities/ Consideration of common and competing interests among groups when solving community problems/Representation of all segments of the community in problem solving/Effective use of conflict management strategies. (Rate the outcome and indicators of Community Competence: 1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent [see Section I].)

Community Outcomes A Broad Range of Community Members Will (Specify Time Frame)

• Participate in community actions to improve power resources • Develop improved communication among community members • Participate in problem solving • Demonstrate cohesiveness in problem solving • Develop new strategies for problem solving • Express power to deal with change and manage problems

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Community Health Development; Program Development

Example NIC Activities—Community Health Development

Enhance community support networks; Identify and develop potential community leaders; Unify community members behind a common mission; Ensure that community members maintain control over decision-making

Nursing Interventions and Rationales

NOTE: The diagnosis of Ineffective Coping does not apply and should not be used when stress is being imposed by external sources or circumstance. If the community is a victim of circumstances, using the nursing diagnosis Ineffective Coping is equivalent to blaming the victim. See the care plan for Readiness for enhanced community Coping. ▲ Establish a collaborative partnership with the community (see the care plan for Readiness for enhanced

community Coping for additional references). EBN: Community activation to promote health encom- passes organized efforts in increased community awareness, establishes a general consensus about health problems, coordinates partnerships to change environmentally based health issues, allocates resources across organizations, and promotes citizen participation in positive health outcomes (Pender et al, 2011).

• Assist the community with team building. EBN: Health partnerships across various community settings help optimize the health of the community, promote continuity of care, and synergistically use resources to achieve optimal efficiency and enhanced effectiveness (Pender et al, 2011).

• Participate with community members in the identification of stressors and assessment of distress; for example, observe and participate in faith-based organizations that want to improve community stress management. EBN: Health programs in faith-based organizations are increasingly forming partnerships with nursing for health promotion programs and make a significant difference in health outcomes (Anderson & McFarlane, 2011).

▲ Identify the health services and information resources that are currently available in the community. EBN: Gynecological cancer survivors in Queensland were studied to identify awareness of, utilization of, and factors associated with use of community support services. Seventy-two percent were aware of the primary cancer support organization, Cancer Council Queensland; 74% were aware of booklets; 66% were aware of helplines; 56% were aware of support groups, and 50% were aware of Internet resources. Less than half were aware of other services (Beesley et al, 2010).

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

286 Ineffective Community Coping

▲ Consult with community mediation services, for example, the National Association of Community Mediation. EB: Community mediation services effectively resolve conflicts and encourage stakeholders to exert direct and indirect pressure within the community (Handley & Howell-Moroney, 2010).

• Work with community members to increase awareness of ineffective coping behaviors (e.g., conflicts that prevent community members from working together, anger and hate that paralyze the community, health risk behaviors of adolescents). EBN: Problem solving is essential for effective coping. Community members in partnership with health care providers can modify behaviors that interfere with problem solving (Anderson & McFarlane, 2011).

• Provide support to the community and help community members identify and mobilize additional sup- ports. EBN: Often people need help mobilizing supports that are available (Pender et al, 2011).

• Advocate for the community in multiple arenas (e.g., television, newspapers, and governmental agencies). EBN: Advocacy is a specific form of caring that enhances power resources for community coping (Anderson & McFarlane, 2011).

• Write grant proposals to help community members obtain funds for programs that reduce stress or improve coping. EBN: The programs that are necessary may be expensive, and often funds may not be available without the assistance of public or privately funded grants (Anderson & McFarlane, 2011).

• Work with members of the community to identify and develop coping strategies that promote a sense of power (e.g., obtaining sources for funding, collaborating with other communities). EBN: A first step in power enhancement is for the community to identify and develop its own coping strategies (Anderson & McFarlane, 2011).

• Protect children from exposure to community conflicts. EB: McKelvey et al (2011) examined the extent to which community violence impacts 18-year-old adolescents’ psychosocial outcomes and found that the effects of community violence differ based on gender and family conflict in the home during childhood, influencing adolescent depression, anxiety, risk taking, and antisocial behavior.

Multicultural

• Acknowledge the stressors unique to racial/ethnic communities. EBN: Understanding ethnic interpreta- tions and cultural determinants that contribute to clients’ stress assists the nurse in promoting health within a community (Anderson & McFarlane, 2011).

• Identify community strengths with community members. EB: Latino men from three urban housing com- munities in the southeastern United States identified Latino community strengths and general community strengths as factors that promote health and prevent risk (Rhodes et al, 2009).

• Work with members of the community to prioritize and target health goals specific to the community. EB: Such prioritization and targeting will increase feelings of control over and sense of ownership of programs (Anderson & McFarlane, 2011; Chinn, 2012).

• Establish and sustain partnerships with key individuals within communities when developing and imple- menting programs. EB: Health partnerships between collaborating parties are a crucial strategy to optimize the health of a community (Pender et al, 2011).

• Use mentoring strategies for community members. EB: In a study of child vaccination in Haiti, it was found that mother’s use of traditional healer services was negatively associated with vaccination of their children, underscoring the potential of enlisting the support of traditional healers in promoting child health by mentoring and educating traditional healers in supporting vaccination efforts (Muula et al, 2009).

• Use community church settings as a forum for advocacy, teaching, and program implementation. EBN: Participant and pastor feedback supported the feasibility of ongoing faith-based screening and education programs as one way to reduce risk factors for diabetes, cardiovascular disease, and stroke in Southern rural African Americans (Frank & Grubbs, 2008).

Community Teaching

• Teach strategies for stress management. • Explain the relationship between enhancing power resources and coping.

REFERENCES Anderson, E. T., & McFarlane, J. (2011). Community as partner: theory

and practice in nursing (6th ed.). Philadelphia: Lippincott Williams & Wilkins.

Beesley, V. L., et al. (2010). Gynecological cancer survivors and community support services: referral, awareness, utilization and satisfaction. Psycho-Oncology, 19(1), 54–61.

Ineffective Coping 287

• = Independent CEB = Classic Research ▲ = Collaborative EBN = Evidence-Based Nursing EB = Evidence-Based

C

Ineffective Coping Arlene T. Farren, RN, PhD, AOCN, CTN-A

NANDA-I

Definition

Inability to form a valid appraisal of the stressors, inadequate choices of practiced responses, and/or inability to use available resources

Defining Characteristics

Alteration in concentration; alteration in sleep pattern; change in communication pattern; destructive behav- ior toward others; destructive behavior toward self; difficulty organizing information; fatigue; frequent illness; inability to ask for help; inability to attend to information; inability to deal with a situation; inability to meet basic needs; inability to meet role expectation; ineffective coping strategies; insufficient access of social support; insufficient goal directed behavior; insufficient problem resolution; insufficient problem- solving skills; risk taking behavior; substance abuse

Related Factors

Gender differences in coping strategies; high degree of threat; inability to conserve adaptive energies; inac- curate threat appraisal; Inadequate confidence in ability to deal with a situation; inadequate opportunity to prepare for stressor; inadequate resources; ineffective tension release strategies; insufficient sense of control; insufficient social support; maturational crisis; situational crisis; uncertainty

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Coping; Decision-Making; Impulse Self-Control; Information Processing

Chinn, P. L. (2012). New directions for building community (8th ed.). Boston: Jones and Bartlett.

Frank, D., & Grubbs, L. (2008). A faith-based screening/education program for diabetes, CVD, and stroke in rural African Americans. The ABNF Journal: Official Journal of the Association of Black Nursing Faculty in Higher Education, Inc, 19(3), 96–101.

Handley, D. M., & Howell-Moroney, M. (2010). Ordering stakeholder relationships and citizen participation: evidence from the community development block grant program. Public Administration Review, 70, 601–609.

McKelvey, L. M., et al. (2011). Growing up in violent communities: do family conflict and gender moderate impacts on adolescents’

psychosocial development? Journal of Abnormal Child Psychology, 39, 95–107.

Muula, A. S., et al. (2009). Association between maternal use of traditional healer services and child vaccination coverage in Pont-Sonde, Haiti. International Journal for Equity in Health, 8, 1.