Professional Documents
Culture Documents
NURSING DIAGNOSES
ACCEPTED FOR USE AND RESEARCH (2007-2008)
GORDON’S FUNCTONAL
HEALTH PATTERNS*
HEALTH PERCEPTION-HEALTH Autonomic dysreflexia, 299 ROLE-RELATIONSHIP PATTERN
MANAGEMENT PATTERN Decreased cardiac output, 313 Anticipatory grieving, 654
Decreased intracranial adaptive capacity, 450 Caregiver role strain, 618
Disturbed energy field, 36
Deficient diversonal activity, 327 Chronic sorrow, 695
Effective therapeutic regimen management, 75
Delayed growth and development, 353 Dysfunctional family processes: alcoholism, 635
Health-seeking behaviors (specify), 49
Delayed surgical recovery, 107 Dysfunctional grieving, 654
Ineffective community therapeutic regimen
Disorganized infant behavior, 365 Impaired parenting, 662
management, 80
Dysfunctional ventilatory weaning response, 331 Impaired social interaction, 684
Ineffective family therapeutic regimen
Fatigue, 340 Impaired verbal communication, 626
management, 80
Impaired spontaneous ventilation, 393 Ineffective role performance, 678
Ineffective health maintenance, 42
Impaired bed mobility, 304 Interrupted family processes, 635
Ineffective protection, 100
Impaired gas exchange, 346 Parental role conflict, 662
Ineffective therapeutic regimen management, 80
Impaired home maintenance, 360 Readiness for enhanced communication, 626
Noncompliance (specify), 80
Impaired physical mobility, 373 Readiness for enhanced family processes, 635
Readiness for enhanced immunization status, 30
Impaired transfer ability, 406 Readiness for enhanced parenting, 662
Readiness for enhanced therapeutic regimen
Impaired walking, 408 Relocation stress syndrome, 673
management, 92
Impaired wheelchair mobility, 415 Risk for caregiver role strain, 618
Risk for falls, 336
Ineffective airway clearance, 292 Risk for violence directed at others, 700
Risk for infection, 54
Ineffective breathing pattern, 307 Risk for dysfunctional grieving, 654
Risk for injury (trauma), 59
Ineffective tissue perfusion (specify), 396 Risk for impaired parent/infant/child
Risk for perioperative positioning injury, 96
Readiness for enhanced organized infant behavior, 365 attachment, 659
Risk for suffocation, 60
Readiness for enhanced self care, 386 Risk for impaired parenting, 662
Risk for poisoning, 60
Risk for delayed development, 353 Risk for relocation stress syndrome, 673
Sudden infant death syndrome, 111–115
Risk for disorganized infant behavior, 365 Social isolation, 688
Risk for disproportionate growth, 353
NUTRITIONAL-METABOLIC PATTERN Risk for activity intolerance, 283
Adult failure to thrive, 127 SEXUALITY-REPRODUCTIVE PATTERN
Risk for autonomic dysreflexia, 299
Deficient fluid volume, 161 Ineffective sexuality patterns, 731
Risk for disuse syndrome, 321
Effective breastfeeding, 144 Rape-trauma syndrome, 717
Risk for peripheral neurovascular dysfunction, 370
Excess fluid volume, 167 Rape-trauma syndrome: compound reaction, 717
Sedentary lifestyle, 381
Hyperthermia, 176 Rape-trauma syndrome: silent reaction, 717
Self-care deficit (specify: bathing/hygiene,
Hypothermia, 182 Sexual dysfunction, 718
dressing/grooming, feeding, toileting), 386
Imbalanced nutrition: more than body Wandering, 411
requirements, 204 COPING-STRESS TOLERANCE
Imbalanced nutrition: less than body SLEEP-REST PATTERN PATTERN
requirements, 194 Compromised family coping, 760
Disturbed sleep pattern, 431
Impaired dentition, 155 Defensive coping, 771
Readiness for enhanced sleep, 437
Impaired oral mucous membrane, 216 Disabled family coping, 760
Sleep deprivation, 425
Impaired skin integrity, 216 Impaired adjustment, 747
Impaired swallowing, 209 Ineffective community coping, 756
Impaired tissue integrity (specify type), 216 COGNITIVE-PERCEPTUAL
Ineffective coping, 772
Ineffective breastfeeding, 148 PATTERN Ineffective denial, 781
Ineffective infant feeding pattern, 186 Acute confusion, 454 Post-trauma syndrome, 785
Ineffective thermoregulation, 213 Acute pain, 483 Readiness for enhanced community coping, 756
Interrupted breastfeeding, 152 Chronic confusion, 454 Readiness for enhanced coping, 767
Latex allergy response, 70 Chronic pain, 483 Readiness for enhanced family coping, 767
Nausea, 189 Decisional conflict (specify), 463 Risk for self-mutilation, 598
Readiness for enhanced fluid balance, 158 Deficient knowledge (specify), 474 Risk for suicide, 791
Readiness for enhanced nutrition, 193 Disturbed sensory perception (specify), 497 Risk for post-trauma syndrome, 785
Risk for aspiration, 136 Disturbed thought processes, 506 Self-mutilation, 598
Risk for deficient fluid volume, 161 Impaired environmental interpretation Stress overload, 740
Risk for imbalanced fluid volume, 173 syndrome, 469
Risk for imbalanced body temperature, 139 Impaired memory, 480 VALUE-BELIEF PATTERN
Risk for imbalanced nutrition: more than body Readiness for enhanced knowledge (specify), 474
Impaired religiosity, 804
requirements, 204 Risk for acute confusion, 454
Readiness for enhanced religiosity, 808
Risk for impaired skin integrity, 216 Unilateral neglect, 514
Readiness for enhanced spiritual well-being, 824
Risk for latex allergy response, 70
Risk for impaired religiosity, 804
SELF-PERCEPTION AND SELF- Risk for spiritual distress, 818
ELIMINATION PATTERN CONCEPT PATTERN Spiritual distress, 812
Bowel incontinence, 236 Anxiety, 527
Constipation, 240 Body image disturbed, 541 *Modified by Marjory Gordon, 2007, with permission.
Diarrhea, 248 Chronic low self-esteem, 590 †New from NANDA 2007-2008
Functional urinary incontinence, 254 Death anxiety, 548 Contamination
Perceived constipation, 240 Disturbed personal identity, 575 Risk for exposure to contamination
Readiness for enhanced urinary elimination, 252 Fear, 553 Risk for impaired liver function
Reflex urinary incontinence, 254 Hopelessness, 562 Risk for unstable blood glucose
Risk for constipation, 240 Powerlessness, 579 Impaired urinary elimination
Risk for urge urinary incontinence, 255 Readiness for enhanced hope, 523 Overflow urinary incontinence
Stress urinary incontinence, 254 Readiness for enhanced self-concept, 586 Readiness for enhanced comfort
Total incontinence, 254 Risk for loneliness, 569 Readiness for enhanced decision-making
Urge urinary incontinence, 255 Risk for violence, self-directed, 700 Readiness for enhanced power
Urinary retention, 263 Risk for powerlessness, 579 Risk for compromised human dignity
Risk for situational low self-esteem, 590 Moral distress
ACTIVITY-EXERCISE PATTERN Situational low self-esteem, 590
Activity intolerance, 283
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COX’S CLINICAL
APPLICATIONS OF
NURSING DIAGNOSIS
00Newfield (F)-FM 4/18/07 7:31 PM Page ii
COX’S CLINICAL
APPLICATIONS OF
NURSING DIAGNOSIS
Adult, Child, Women’s, Mental Health,
Gerontic, and Home Health Considerations
Susan A. Newfield, PhD, RN, APRN, BC
Associate Professor
West Virginia University
Morgantown, West Virginia
Program Administrator
Hamot For Women
Hamot Medical Center
Erie, Pennsylvania
Fifth Edition
Donna Scott Tilley, RN, PhD, CNE
Associate Professor
Texas Christian University
Fort Worth, Texas
F. A. Davis Company
1915 Arch Street
Philadelphia, PA 19103
www.fadavis.com
Copyright © 1989, 1993, 1997, 2002 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No
part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical,
photocopying, recording, or otherwise, without written permission from the publisher.
As new scientific information becomes available through basic and clinical research, recommended treatments and drug
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and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for
errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard
to the contents of the book. Any practice described in this book should be applied by the reader in accordance with
professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is
advised always to check product information (package inserts) for changes and new information regarding dose and
contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs.
Cox’s clinical applications of nursing diagnosis : adult, child, women’s, mental health,
gerontic and home health considerations / Susan A. Newfield … [et al.]. — 5th ed.
p. ; cm.
Rev. ed. of: Clinical applications of nursing diagnosis. 4th ed. c2002.
Includes bibliographical references and index.
ISBN-13: 978-0-8036-1655-4
ISBN-10: 0-8036-1655-4
1. Nursing diagnosis. 2. Nursing assessment. 3. Nursing. I. Cox, Helen C. II. Newfield, Susan A.
III. Clinical applications of nursing diagnosis. IV. Title: Clinical applications of nursing diagnosis.
[DNLM: 1. Nursing Diagnosis. 2. Nursing Process. WY 100.4 C879 2007]
RT48.6.C6 2007
610.73—dc22 2007009325
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00Newfield (F)-FM 4/18/07 7:31 PM Page v
To Dr. Helen Cox, colleague, mentor, and friend, on her retirement. You took ambitious,
naive, young faculty members and turned us into authors and for that, we will be
eternally grateful.
vii
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•
•
• by F. A. Davis.
Copyright © 2007
•
•
x • Preface to the Fourth Edition
the pattern is given to simplify location of the diagnoses. The pattern assessment serves to
pinpoint information from the initial assessment base and was specifically written to direct
the reader to the most likely diagnosis within the pattern. Each assessment factor is
designed to allow an answer of “yes” or “no.” If the patient’s answer or signs are indica-
tive of a diagnosis within the pattern, the reader is directed to the most likely diagnosis or
diagnoses. The conceptual and developmental information is included to provide a quick,
ready reference to the physiologic, psychological, sociologic, and age-related factors that
could cause modification of the nursing actions in order to make them more specific for
your patient. The conceptual and developmental information can be used to determine the
rationale for each nursing action.
Each nursing diagnosis within the pattern is then introduced with accompanying
information of definition, defining characteristics, and related factors. We have added a
section titled “Related Clinical Concerns.” This section serves to highlight the most com-
mon medical diagnoses or cluster of diagnoses that could involve the individual nursing
diagnosis.
Immediately after the related clinical concerns section is a section titled “Have you
selected the correct diagnosis?” This section was included as a validation check because
we realize that several of the diagnoses appear very closely related and that it can be diffi-
cult to distinguish between them. This is, in part, related to the fact that the diagnoses
have been accepted for testing, not as statements of absolute, discrete diagnoses. Thus,
having this section assists the reader in learning how to pinpoint the differences between
diagnoses and in feeling more comfortable in selecting a diagnosis that most clearly
reflects a patient’s problem area that can be helped by nursing actions.
After the diagnosis validation section is an outcome. The expected outcome serves
as the end point against which progress can be measured. Different agencies may call the
expected outcome an objective, a patient goal, or an outcome standard. Readers may also
choose to design their own patient-specific expected outcome using the given expected
outcome as a guideline.
Target dates are suggested following the expected outcome. The target dates do not
indicate the time or day the outcome must be fully achieved; instead, the target date signi-
fies the time or day when evaluation should be completed in order to measure the patient’s
progress toward achievement of the expected outcome. Target dates are given in reference
to short-term care. For home health, particularly, the target date would be in terms of
weeks and months rather than days.
Nursing actions/interventions and rationales are the next information given. In most
instances, the adult health nursing actions serve as the generic nursing actions. Subsequent
sets of nursing actions (child health, women’s health, psychiatric health, gerontic health,
and home health) show only the nursing actions that are different from the generic nursing
actions. The different nursing actions make each set specific for the target population, but
must be used in conjunction with the adult health nursing actions to be complete.
Rationales have been included to assist the student in learning the reason for particular
nursing actions. Although some of the rationales are scientific in nature, that is, supported
by documented research, other rationales could be more appropriately termed “common
sense” or “usual practice rationales.” These rationales are reasons nurses have cited for
particular nursing actions and result from nursing experience, but research has not been
conducted to document these rationales. After the home health actions, evaluation algo-
rithms are shown that help judge the patient’s progress toward achieving the expected out-
come.
Evaluation of the patient’s care is based on the degree of progress the patient has
made toward achieving the expected outcome. For each stated outcome, there is an evalua-
tion flowchart (algorithm). The flowcharts provide minimum information, but demonstrate
the decision-making process that must be used.
In all instances, the authors have used the definitions, defining characteristics, and
related factors that have been accepted by NANDA for testing. A grant was provided to
NANDA by the F. A. Davis Company for the use of these materials. All these materials
may be ordered from NANDA (1211 Locust Street, Philadelphia, PA 19107). Likewise, a
00Newfield (F)-FM 4/18/07 7:31 PM Page xi
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Copyright © 2007 by F. A. Davis. •
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Preface to the Fourth Edition • xi
fee was paid to Mosby for the use of the domains and classes from McCloskey, JC, and
Bulechek, GM (eds): Nursing Interventions Classification (NIC), edition 3 (Mosby, St.
Louis, 2000) and Johnson, M, Maas, M, and Moorhead, S (eds): Nursing Outcomes
Classification, edition 2 (Mosby, St. Louis, 2000).
In some instances, additional information is included following a set of nursing
actions. The additional information includes material that either needs to be highlighted or
does not logically fall within the defined outline areas.
Throughout the nursing actions we have used the terms patient and client inter-
changeably. The terms refer to the system of care and include the individual as well as the
family and other social support systems. The nursing actions are written very specifically.
This specificity aids in communication between and among nurses and promotes consis-
tency of care for the patient.
There has been a tremendous increase in the activity of NANDA. In 1998 alone, 16
new diagnoses were accepted, 32 diagnoses were revised, and one diagnosis was deleted.
The official journal of NANDA became an international journal in 1999.
The fourth edition incorporates new and revised diagnoses from both the Thirteenth
(1998) and Fourteenth (2000) NANDA Conferences. The proposed NANDA Taxonomy 2
has been inserted to replace the old Taxonomy 1, Revised. The Nursing Interventions
Classification (NIC) system and the Nursing Outcomes Classification (NOC) system
domains and classes have been incorporated.
Other revisions have been made to be consistent with current NANDA thought and
publications. One example is the deletion of major and minor defining characteristics and
their assimilation under one heading of “Defining Characteristics.”
We continue to appreciate the feedback we have received from various sources and
urge you to continue to assist us in this way. It is our sincerest wish that this book will
continue to assist nurses and nursing students in their day-to-day use of nursing diagnosis.
ACKNOWLEDGMENTS
The publication of a book necessitates the involvement of many persons beyond the
authors. We wish to acknowledge the support and assistance of the following persons who
indeed made this book possible:
Our families and friends, who supported our taking time away from life activities.
Joanne DaCunha, Publisher, Nursing, F. A. Davis, who has provided patient direction
toward our goal.
Bob Martone, Publisher, Nursing, F. A. Davis, for his continuing enthusiasm and belief in
the book.
Our students and colleagues, who consistently challenge us to rethink each care plan and
hold us to exacting standards.
AND
A special acknowledgment to Dr. Marjory Gordon, a most gracious lady who freely
shared ideas, materials, support, and encouragement.
To each of these persons we wish to say a heartfelt “Thank you.” Please accept our deep-
est gratitude and appreciation.
xiii
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REVIEWERS
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CONTENTS
CHAPTER 1 INTRODUCTION 1
WHY THIS BOOK? 2
THE NURSING PROCESS 2
Purpose 2
Definition 3
Role in Planning Care 3
Care Plan versus Planning of Care 5
Surgical Recovery, Delayed 107
NURSING PROCESS STEPS 5 Sudden Infant Death Syndrome,
Assessment 5 Risk for 111
Diagnosis 7
Planning 8
Implementation 9
Documentation 11 CHAPTER 3 NUTRITIONAL–METABOLIC
Evaluation 13 PATTERN 119
NURSING PROCESS AND CONCEPTUAL
FRAMEWORKS 14 PATTERN DESCRIPTION 120
Nursing Models 14 PATTERN ASSESSMENT 120
Patterns 14
CONCEPTUAL INFORMATION 121
VALUE PLANNING OF CARE AND
DEVELOPMENTAL CONSIDERATIONS 123
CARE PLANS 22
APPLICABLE NURSING DIAGNOSES 131
SUMMARY 23
Adult Failure to Thrive 131
Aspiration, Risk for 135
Body Temperature, Imbalanced,
CHAPTER 2 HEALTH PERCEPTION– Risk for 139
HEALTH MANAGEMENT PATTERN 25 Breastfeeding, Effective 144
Breastfeeding, Ineffective 148
PATTERN DESCRIPTION 26 Breastfeeding, Interrupted 152
PATTERN ASSESSMENT 26 Dentition, Impaired 155
Fluid Balance, Readiness for Enhanced 158
CONCEPTUAL INFORMATION 26
Fluid Volume, Deficient, Risk for
DEVELOPMENTAL CONSIDERATIONS 29 and Actual 161
APPLICABLE NURSING DIAGNOSES 36 Fluid Volume, Excess 167
Energy Field, Disturbed 36 Fluid Volume, Imbalanced,
Health Maintenance, Ineffective 42 Risk for 173
Health-Seeking Behaviors (Specify) 49 Hyperthermia 176
Infection, Risk for 54 Hypothermia 182
Injury, Risk for 59 Infant Feeding Pattern, Ineffective 186
Latex Allergy Response, Risk for and Actual 70 Nausea 189
Management of Therapeutic Regimen, Nutrition, Readiness for Enhanced 192
Effective 75 Nutrition, Imbalanced, Less Than Body
Management of Therapeutic Regimen Requirements 194
(Individual, Family, Community), Ineffective 80 Nutrition, Imbalanced, More Than Body
Management, Readiness for Enhanced Requirements, Risk for and Actual 204
Therapeutic Regimen 92 Swallowing, Impaired 209
Perioperative-Positioning Injury, Risk for 96 Thermoregulation, Ineffective 213
Protection, Ineffective 100 Tissue Integrity, Impaired 216
xvii
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Copyright © 2007 •
by F. A. Davis.
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xviii • Contents
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Copyright © 2007 by F. A. Davis. •
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Contents • xix
INTRODUCTION
1
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• by F. A. Davis.
Copyright © 2007
•
•
2 • Introduction
WHY THIS BOOK? contributions from many countries and an alliance between
NANDA International, the Nursing Interventions Classifica-
When the first edition of this book was published, all the tion (NIC),4 and Nursing Outcomes Classification (NOC),5
authors were faculty members at the same school of nursing. which resulted in the creation of the NANDA, NIC, and
We had become frustrated with the books that were available NOC (NNN) Taxonomy of Nursing Practice. This taxonomy
for teaching nursing diagnosis and found that the students was based on a modified framework of Gordon’s6 functional
were also expressing some of the same frustration. health patterns with “the final taxonomic structure less like
The students felt they needed to bring several books to Gordon’s original, but with reduced misclassification errors
the clinical area because the books for nursing diagnosis had and redundancies to near zero.”3 Taxonomy II has been rec-
limited information on pathophysiology and psychosocial or ognized as an international nursing language. Designed to be
developmental factors that had an impact on individualized multiaxial in form, it provides greater flexibility of nomen-
care planning. The students were also confused regarding clature and allows for easy additions and modifications, thus
the different definitions, defining characteristics, and related providing a more clinically useful tool that better supports
factors each of the authors used. They were having difficulty nursing practice. In spite of these revisions, some in nursing
writing individualized nursing actions for their patients service organizations continue to view Nursing Diagnosis as
because the various authors appeared to focus on specifics an academic exercise, good for students to learn, but highly
related to the etiology or signs and symptoms of the nursing impractical in the fast-paced world of nursing operations.
diagnosis rather than on the concept represented by the nurs- When service settings utilize nursing diagnosis, it is most
ing diagnosis that had been emphasized to our students. The often in electronic documentation systems. The care plans in
authors were also concerned about the number of books our these systems are most often standardized and demonstrate
students had to buy, because most books focused on just one little adaptation to the individual or their health status. A
clinical area, such as adult health or pediatrics. Thus, as the review of the documentation shows that once a diagnosis is
students progressed through the school, they had to buy dif- chosen the care plan is not updated during the contact with
ferent books for different clinical areas even though each of the patient. Care planning, involving telling the computer
the books had the common theme of the use of nursing diag- that the nurse saw the patient during that shift and looked at
nosis. Another concern we, as faculty, had was the lack of the care plan to determine whether it was still pertinent, sim-
information in the various books regarding the final phase of ply becomes a “task” the nurse must perform. The multiax-
the nursing process—evaluation. This most vital phase was ial format of Taxonomy II can provide the clinician with the
mentioned only briefly, and very little guidance was given tools necessary to better format his or her clinical documen-
on how to proceed through this phase. tation, showing the “whole picture” of diagnosis, treatment,
The final concern that led to the writing of the book evaluation, re-evaluation, and nursing outcomes.
was our desire to focus on nursing actions and nursing care, It is however, important that this tool be used cor-
not medical care and medical diagnosis. We strongly believe rectly. “Using a multiaxial structure allows many diagnoses
and support the vital role of nurses in the provision of health to be constructed that have no defining characteristics and
care for our nation, and so we have focused strictly on nurs- may even be nonsense.”3 For this reason the authors of this
ing in this book. After all, the majority of health-care book felt that it was important to continue to provide
providers are nurses, and statistics consistently show the NANDA, NIC and NOC, and the NNN Taxonomy of nurs-
general public has high respect for them.1 In a 2004 poll ing practice in this fifth edition. This inclusion will hope-
conducted by USA Today,2 the public considered nursing fully better clarify the work and give not only the academic
the most honest profession and trusted the information setting, but also the clinical setting a guide that will provide
that nurses give them. This increases the importance of the individual student and practitioner a resource that leads
utilizing a standard nursing language to provide the founda- to better understanding and operational use of nursing diag-
tion for quality nursing care and continued development of noses and, ultimately, better patient outcomes. To facilitate
evidence-based practice. this integration we have provided charts in each chapter that
For these reasons, we have written this book particu- provide basic links between the taxonomies.
larly geared to student use. Specifically, we wrote the first
book to assist students in learning how to apply nursing
diagnosis in the clinical area. By using the framework of the THE NURSING PROCESS
nursing process and the materials generated by the North
PURPOSE
American Nursing Diagnosis Association International
(NANDA),3 we believe this book makes it easier for you, the Gordon7 indicates that Lydia Hall was one of the first nurses
student, to learn and use nursing diagnosis in planning care to use the term nursing process in the early 1950s. Since that
for your patients. (Nursing diagnoses were developed by time, the term nursing process has been used to describe the
and used with permission of North American Nursing accepted method of delivering nursing care. Iyer, Taptich,
Diagnosis Association.3) and Bernocchi-Losey state, “The major purpose of the nurs-
Since the writing of that first book, NANDA has ing process is to provide a framework within which the indi-
grown to become an international organization with nursing vidualized needs of the client, family, and community can be
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Copyright © 2007 by F. A. Davis. •
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The Nursing Process • 3
met.”8 Today, the concept of the nursing process has the protection, promotion, and optimization of health and
expanded to include critical thinking processes that con- abilities, prevention of illness and injury, alleviation of
tribute to the decisions needed to choose the correct method suffering through the diagnosis and treatment of human
of delivering nursing care.9 The nursing process is utilized by responses, and advocacy in the care of individuals, families,
nursing education to teach critical thinking, by professional communities, and populations.” Alfaro’s definition is further
nursing organizations to test performance (NCLEX and spe- supported by the ANA Nursing: Scope and Standards
cialty certification exams), and by acute care institutions as a of Practice14 (Table 1.1), practice standards written by sev-
basis for care plans and critical pathways.10 eral boards of Nursing in the United States, and the defi-
It may be easier to think of a framework as a blueprint nition of nursing that is written into the majority of nurse
or outline that guides the planning of care for a patient.* As practice acts in the United States. (The standards of Nursing
Doenges and Moorhouse write,11 “The nursing process is Practice of the State of Texas are used as an example.15
central to nursing actions in any setting because it is an effi- See Table 1.2.)
cient method of organizing thought processes for clinical Basically, the nursing process provides each nurse a
decision making and problem solving.” Use of the nursing framework to utilize in working with the patient. The
process framework is beneficial for both the patient and the process begins at the time the patient needs assistance with
nurse because it helps ensure that care is planned, individu- health care, and continues until the patient no longer needs
alized, and reviewed over the period of time that the nurse assistance to meet health-care maintenance. The nursing
and patient have a professional relationship. It must be process utilizes the cognitive (intelligence, critical thinking,
emphasized that patient involvement is required throughout and reasoning), psychomotor (physical), and affective (emo-
all phases of the nursing process. If the patient is not involved tion and values) skills and abilities a nurse needs to plan care
in all phases, then the plan of care is not individualized. for a patient.
T A B L E 1 . 1 Standards of Care
Standard I. Assessment: The registered nurse collects comprehensive data pertinent to the patient’s health or the
situation.
Standard II. Diagnosis: The registered nurse analyzes the assessment data to determine diagnoses or issues.
Standard III. Outcome Identification: The registered nurse identifies expected outcomes for a plan individualized to
the patient or the situation.
Standard VI. Evaluation: The registered nurse evaluates progress toward attainment of outcomes.
Source: From American Nurses Association: Nursing: Scope and Standards of Practice. ANA, Silver
Spring, MD, 2004, pp 21–32, with permission.
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• by F. A. Davis.
Copyright © 2007
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4 • Introduction
Source: Adapted from Board of Nurse Examiners for the State of Texas: Standards of Nursing
Practice. Texas Nurse Practice Act. Author, Austin, TX, 2004, with permission.
ical–surgical unit who would have been in a critical care unit guideline for documentation and promotes practicing within
ten years ago. We are now sending patients home in 1 to 3 legally defined standards.
days whom we previously would have kept in the hospital Third, care planning provides legal protection for the
another 5 to 10 days. Procedures that required a 3- to 5-day nurse. We are practicing in one of the most litigious societies
hospital stay in the past are now being performed in day sur- that has ever existed. In the past, nurses were not frequently
gery or outpatient facilities. A variety of factors have led to named in legal actions; however, this has changed, as a brief
this situation, including advances in technology; advent of review of suits being filed would show. In a legal suit, nurs-
the use of diagnosis related groups (DRGs) for patient ing care is measured against the idea of what a reasonably
billing; managed care insurance plans; prospective payment prudent nurse would do in the same circumstances. The
insurance plans, capitated payment insurance plans; move- accepted standards of nursing practice, as published by
ment from acute care to longer term care settings such as ANA (see Table 1.1) and the individual boards of nursing
home health, nursing homes, and rehabilitation units; and, (see Table 1.2), are the accepted definitions of reasonable,
most importantly, the desire to contain the rapidly rising prudent nursing care.
costs of health care. These problems, which together have Finally, accrediting and approval agencies such as the
been labeled the “quicker, sicker” phenomenon, in combi- Joint Commission on Accreditation of Healthcare Organiza-
nation with a national shortage of registered nurses, have tions (JCAHO), the National League for Nursing Accredit-
created a situation in which the contact time a professional ing Commission (NLNAC), Medicare, and Medicaid have
nurse has with a patient is being cut to a minimum. Given criteria that specifically require documentation of planning
this set of circumstances, if care planning is not done there of care. The accreditation status of a health-care agency can
is no doubt that gaps will exist in the nursing care given to a depend on consistent documentation that planning of care
patient. Such care will be incomplete, inconsistent, unsafe, has been done. Particularly with the third-party payers, such
and certainly not of high quality, which will result in an as Medicare, Medicaid, and insurance companies, lack of
increase in negative outcomes. documentation regarding the planning and implementation
Second, care planning and its documentation provide of care results in no reimbursement for care. Ultimately,
a means of professional communication. This communica- nonreimbursement for care leads to lack of new equipment,
tion promotes consistency of care for the patient and pro- no pay raises, and, in some extreme cases, has led to hospi-
vides a comfort level for the nurse. Any patient admitted to tal closures.
a health-care agency is going to have some level of anxiety. With the advent of electronic documentation in the
Imagine how this anxiety will increase when each nurse who acute care setting and other nursing agencies (outpatient
enters the room does each procedure differently, answers clinics, home health care, and departments of health) it has
questions differently, or uses different time lines for care become even more critical to possess knowledge and
(e.g., a surgical dressing that has been changed in the morn- resources that allow practicing nurses in any setting to show
ing every day since surgery is not changed until the after- the progress from nursing diagnosis to nursing interventions
noon). Care planning provides a comfort level for the nurse and finally the nursing outcomes in their documentation.
because it gives the nurse a ready reference to help ensure Measurement of outcomes is the basis for measuring the
that care is complete. In addition, when the care is planned quality, safety, and results of the care rendered to a patient
using practices with evidence that supports their use, con- or client and are today’s “yardstick” on which the general
sistency in implementation improves efficacy resulting in public, regulatory agencies, and third-party payers base their
improved patient outcomes. Care planning also provides a decisions and actions.
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Nursing Process Steps • 5
c
essment
Dis
Ad
As s
Revisions of nursing standards by JCAHO created questions
regarding the necessity of nursing care plans. According to
Brider,16 Henry,17 and Webster,18 some authors predicted the
tion of
demise of the care plan, but review of the revised nursing ina
Text/image rights not available.
Ca
Coor
standards shows that the standards require not less, but more
re
of Care
detailed care planning documentation in the patient’s med-
ical record.
The Joint Commission on Accreditation of Healthcare
re
ion
Ca
Organizations (JCAHO), like all health-care organizations,
vis
of
o
is experiencing change. To better serve the public and Pr g
nin
Plan
health-care organizations, JCAHO dramatically changed
its accreditation process in 2005. Rather than focusing only
on “nursing process,” policies and procedures review, and FIGURE 1.1 Provision of care system. (Source:
JCAHO.)
other isolated factors within the organization, they now
focus on the patients and their journey through the health-
care system. This journey includes “Care, treatment, and longer a separate, often discarded, and irrelevant page, the
services provided through the successful coordination and plan of care is an integral part of the permanent record. The
completion of a series of processes that include appropri- flow sheets developed for this book offer guidelines for com-
ate initial assessment of needs; development of a plan for puterizing information regarding nursing care.
care, treatment, and services; the provision of care, treat- Faculty can use the revised JCAHO guidelines19 to
ment, and services; ongoing assessment of whether the care, assist students in developing expertise beyond writing
treatment, and services are meeting the patient’s needs and extensive nursing care plans. This additional expertise
either the successful discharge of the patient or referral or requires the new graduate to envision the patient’s journey
transfer of the patient for continuing care, treatment, and through the health-care system and to integrate all phases of
services.”19 the nursing process into the permanent record. Rather than
Review of the new criteria indicates that the standards eliminating the need for care planning and nursing diagno-
require documentation related to not only the nursing sis, these standards have reinforced the importance of nurs-
process, but also the development and implementation of ing care and nursing diagnosis for not only nursing, but also
a plan encompassing the provision of care, treatment, and the entire health-care organization.
services provided the patient. Instead of defining plan, per se,
the new guidelines define nursing care as: “Professional
processes of assessment, diagnosis, planning, implementa- NURSING PROCESS STEPS
tion, and evaluation based on the art and science of nursing
There are five steps, or phases, in the nursing process: assess-
to promote health, its recovery, or a peaceful and dignified
ment, diagnosis, planning, implementation, and evaluation.
death.”19
These steps are not distinct; rather, they overlap and build on
This provision of care is still based on data gathering
each other. To carry out the entire nursing process, you must
during patient assessment, which identifies the patient’s
be sure to complete each step accurately and then build upon
care needs, tests the strategy for providing services to meet
the information in that step to complete the next one.
those needs, documents treatment goals or objectives, out-
lines the criteria for terminating specified interventions,
ASSESSMENT
and documents the individual’s progress in meeting speci-
fied goals and objectives. The elements that make up the The first step, or phase, of the nursing process is assessment.
provision of care, as defined by JCAHO, are “related to each During this phase, you are collecting data (factual informa-
other through an integrated and cyclical process that may tion) from several sources. The collection and organization
occur over minutes, hours, days, weeks, months, or years, of these data allow you to:
depending on the setting and the needs of the patient”19
1. Determine the patient’s current health status.
(Fig. 1.1).
2. Determine the patient’s strengths and problem areas
Rather than eliminating care plans, the new JCAHO
(both actual and potential).
requirements expand the concept and increase the impor-
3. Prepare for the second step of the process—diagnosis.
tance of the coordination and documentation of the patient’s
journey guided by nursing assessment. This documentation Data Sources and Types
must be in the medical record. The care plan is not dead; The sources for data collection are numerous, but it is essen-
rather, it is revised to more clearly reflect the important role tial to remember that the patient is the primary data source.
of nursing assessment and planning in the patient’s care. No No one else can explain as accurately as the patient can the
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6 • Introduction
start of the problem, the reason for seeking assistance or the admission assessment specifically related to the Functional
exact nature of the problem, and the effect of the problem on Health Patterns is given in Appendix B.
the patient. Other sources include the patient’s family or sig- The physical assessment calls for four skills: inspec-
nificant others; the patient’s admission sheet from the admit- tion, palpation, percussion, and auscultation. Inspection
ting office; the physician’s history, physical, and orders; means careful and systematic observation throughout the
laboratory and x-ray examination results; information from physical examination, such as observation for and recording
other caregivers; and current nursing literature. of any skin lesions. Palpation is assessment by feeling and
Assessment data can be further classified as types of touching. Assessing the differences in temperature between
data. According to Iyer and associates,8 the data types are a patient’s upper and lower arm would be an example of pal-
subjective, objective, historical, and current. pation. Another common example of palpation is breast self-
Subjective data are the facts presented by the patient examination. Percussion involves touching, tapping, and
that show his or her perception, understanding, and interpre- listening. Percussion allows determination of the size, den-
tation of what is happening. An example of subjective data sity, locations, and boundaries of the organs. Percussion is
is the patient’s statement, “The pain begins in my lower back usually performed by placing the index or middle finger of
and runs down my left leg.” one hand firmly on the skin and striking with the middle fin-
Objective data are facts that are observable and ger of the other hand. The resultant sound is dull if the body
measurable by the nurse. These data are gathered by the is solid under the fingers (such as at the location of the liver)
nurse through physical assessment, interviewing, and observ- and hollow if there is a body cavity under the finger (such
ing, and involve the use of the senses of seeing, hearing, as at the location of the abdominal cavity). Auscultation
smelling, and touching. An example of objective data is the involves listening with a stethoscope and is used to help
measurement and recording of vital signs. Objective data assess respiratory, circulatory, and gastrointestinal status.
are also gathered through such diagnostic examinations as The physical assessment may be performed using a
laboratory tests, x-ray examinations, and other diagnostic head-to-toe approach, a body system approach, or a func-
procedures. tional health pattern approach. In the head-to-toe approach,
Historical data refer to health events that happened you begin with the patient’s general appearance and vital
prior to this admission or health problem episode. An exam- signs. You then progress, as the name indicates, from the
ple of historical data is the patient statement, “The last time head to the extremities.
I was in a hospital was 1996 when I had an emergency The body system approach to physical assessment
appendectomy.” focuses on the major body systems. As the nurse is conduct-
Current data are facts specifically related to this ing the nursing history interview, she or he will get a firm
admission or health problem episode. An example of this idea of which body systems need detailed examination. An
type of data is vital signs on admission: T 99.2⬚F, P 78, R 18, example is a cardiovascular examination, in which the api-
BP 134/86. Please note, that just as there is overlapping of cal and radial pulses, blood pressure (BP), point of maxi-
the nursing process steps, there is also overlapping of the mum intensity (PMI), heart sounds, and peripheral pulses
data types. Both historical and current data may be either are examined.
subjective or objective. Historical and current data assist in The functional health pattern approach is based on
establishing time references and can give an indication of Gordon’s Functional Health Patterns typology and allows
the patient’s usual functioning. the collection of all types of data according to each pattern.
This is the approach used by this book and leads to three lev-
Essential Skills els of assessment. First is the overall admission assessment,
Assessment requires the use of the skills needed for inter- where each pattern is assessed through the collection of
viewing, conducting a physical examination, and observing. objective and subjective data. This assessment indicates pat-
As with the nursing process itself, these skills are not used terns that need further attention, which requires implemen-
one at a time. While you are interviewing the patient, you tation of the second level of pattern assessment. The second
are also observing and determining physical areas that level of pattern assessment indicates which nursing diag-
require a detailed physical assessment. While completing a noses within the pattern might be pertinent to this patient,
physical assessment, you are asking questions (interview- which leads to the third level of assessment, the defining
ing) and observing the patient’s physical appearance as well characteristics for each individual nursing diagnosis. Having
as the patient’s response to the physical examination. a three-tiered assessment might seem complicated, but each
Interviewing generally starts with gathering data for assessment is so closely related that completion of the
the nursing history. In this interview, you ask for general assessment is easy. A primary advantage in using this type
demographic information such as name, address, date of last of assessment is the validation it gives the nurse that the
hospitalization, age, allergies, current medications, and the resulting nursing diagnosis is the most accurate diagnosis.
reason the patient was admitted. Depending on the agency’s Another benefit to using this type of assessment is that
admission form, you may then progress to other specific grouping of data is already accomplished and does not have
questions or a physical assessment. An example of an to be a separate step.
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8 • Introduction
teristics or observable signs and symptoms demonstrated or to 3-day hospitalization (today’s average length of stay). In
described by the patient. The S component can be readily the long-term care facilities, such as home health, rehabili-
connected to the P and E statements through the use of the tation, and nursing homes, long-range problem solving is
phrase as evidenced by. Using this format, a complete nurs- possible, but setting priorities of care is still necessary.
ing diagnostic statement would read: Pain related to surgical Several methods of assigning priorities are available.
incision as evidenced by verbal comments and body posture. Some nurses assign priorities based on the life threat posed
As discussed in the preface, we recommend starting by a problem. For example, Ineffective Airway Clearance
with stating the nursing diagnosis only. Therefore, the nurs- would pose more of a threat to life than the diagnosis Risk
ing diagnosis would be listed in the patient’s chart in the for Impaired Skin Integrity. Some nurses base their prioriti-
same manner as it is given in the nomenclature: Pain. zation on Maslow’s Hierarchy of Needs. In this instance,
Remember that the objective and subjective data related to physiologic needs would require attention before social
the patient’s pain have already been recorded in the health needs. One way to establish priorities is to simply ask the
record in the assessment section, so there is no need to patient which problem he or she would like to pay attention
repeat it. to first. Another way to establish priorities is to analyze the
The nursing diagnostic statement examples given pre- relationships between problems. For example, a patient has
viously describe the existence of an actual problem. been admitted with a medical diagnosis of headaches and
Professional nurses are strong supporters of preventive possible brain tumor. The patient exhibits the defining char-
health care—cases in which a problem does not yet exist and acteristics of both Pain and Anxiety. In this instance, we
measures that can be taken to ensure that the problem does might want to implement nursing actions to reduce anxiety,
not arise. In such instances, the nursing diagnostic statement knowing that if the anxiety is not reduced, pain control
is prefaced by the words “Risk for.” Nursing diagnoses that actions will not be successful. Once priorities have been
carry the preface “Risk for” also carry with them risk factors established, you are ready to establish expected outcomes.
rather than defining characteristics.
Expected Outcomes
Whereas other books include a variety of nursing diag-
Outcomes, goals, and objectives are terms that are fre-
noses, this book uses only the actual and risk (formerly
quently used interchangeably because all indicate the end
labeled “potential”) diagnoses accepted by NANDA-I (30)
point we will use to measure the effectiveness of our plan
for testing. Probable related factors (formerly “etiologic fac-
of care. Because so many published sets of standards
tors”) are grouped, as are the defining characteristics (for-
and JCAHO talk in terms of outcome standards or criteria,
merly “signs and symptoms”), under each specific nursing
we have chosen to use the term “expected outcomes” in
diagnosis. As indicated in the preface, nursing actions in this
this book.
book reflect a conceptual approach rather than a specific (to
Several authors23–25 give guidelines for writing clini-
related factors or defining characteristics) approach.
cally useful expected outcomes:
To illustrate this approach, let us use the diagnosis
Pain. There are common nursing orders related to the inci- 1. Expected outcomes are clearly stated in terms of patient
dence of pain regardless of whether the pain is caused by behavior or observable assessment factors.
surgery, labor, or trauma. You can take this conceptual EXAMPLE
approach and make an individualized adaptation according
to the etiologic factors affecting your patient and the reac- POOR Will increase fluid balance by time of dis-
tion your patient is exhibiting to pain. charge.
Identifying and specifying the nursing diagnoses leads GOOD Will increase oral fluid intake to 1500 mL per
to the next phase of the process— planning. Now that you 24 hours by 9/11.
know what the problems, responses, and strengths are, you 2. Expected outcomes are realistic, achievable, safe, and
can decide how to resolve the problem areas while building acceptable from the patient’s viewpoint.
on the strength areas.
EXAMPLE
PLANNING Mrs. Braxton is a 28-year-old woman who has delayed
healing of a surgical wound. She is to receive discharge
Planning involves three subsets: setting priorities, writing
instructions regarding a high-protein diet. She is a widow
expected outcomes, and establishing target dates. Planning
with three children under the age of 10. Her only source
sets the stage for writing nursing actions by establishing
of income is Social Security.
where we are going with our plan of care. Planning further
POOR Will eat at least two 8-oz servings of steak
assists in the final phase of evaluation by defining the stan-
daily. [unrealistic, unachievable, unaccept-
dard against which we will measure progress.
able, etc.]
Setting Priorities GOOD Will eat at least two servings from the follow-
With the sicker, quicker problem discussed earlier, you are ing list each day:
going to find yourself in the situation of having identified Lean ground meat
many more problems than can possibly be resolved in a 1- Eggs
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10 • Introduction
performs, using his or her own discretionary judgment, that 4. Specific time units (e.g., for 15 minutes at least four
require no validation or guidelines from any other health- times a day).
care practitioner. An example is deciding which noninvasive 5. Signature of the nurse who writes the initial action order
technique to use for pain control or deciding when to teach (i.e., accepting legal and ethical accountability).
the patient self-care measures. Collaborative activities are
A nursing action should not be implemented unless all
those actions that involve mutual decision making between
five components are present. A nurse would not administer
two or more health-care practitioners. For example, a physi-
a medication if the physician order read, “Give Demerol”;
cian and nurse decide which narcotic to use when meperi-
neither should a nurse be expected to implement a nursing
dine is ineffective in controlling the patient’s pain, or a
action that reads, “Increase ambulation gradually.”
physical therapist and nurse decide on the most beneficial
Additional criteria that should be remembered to
exercise program for a patient. Implementing a physician’s
ensure complete, safe, quality nursing action include:
order and referral to a dietitian are other common examples
of collaborative actions. 1. Consistency between the prescribed actions, the nursing
Written nursing actions guide both actual patient care diagnosis, and expected outcome (including numbering).
and proper documentation, and they must therefore be
EXAMPLE
detailed and exact. Written nursing actions should be even
more definite than what is generally found in physician Nursing Diagnosis 1
orders. For example, a physician writes the order, “Increase Impaired physical mobility, level 2.
ambulation as tolerated” for a patient who has been immo- Expected Outcome 1
bile for 2 weeks. The nursing actions should reflect specified Will ambulate length of hall by 11/8.
increments of ambulation as well as ongoing assessment:
Nursing Action 1
11/21. a. Prior to activity, assess BP, P, and R. After activ- 11/21. a. Prior to activity, assess BP, P, and R. After
ity assess: (1) BP, P, R; (2) presence/absence activity assess: (1) BP, P, R; (2)
of vertigo; (3) circulation; (4) presence/absence presence/absence of vertigo; (3) circulation;
of pain. (4) presence/absence of pain.
b. Assist to dangle on bedside for 15 minutes at b. Assist to dangle on bedside for 15 minutes at
least 4 times a day on 11/2. least 4 times a day on 11/2.
c. If BP, P, or R change significantly or vertigo is c. If BP, P, or R changes significantly or vertigo is
present or circulation is impaired or pain is pres- present or circulation is impaired or pain is
ent, return to supine position immediately. present, return to supine position immediately.
Elevate head of bed 30 degrees for 1 hour; then Elevate head of bed 30 degrees for 1 hour; then
45 degrees for 1 hour; then 90 degrees for 1 hour. 45 degrees for 1 hour; then 90 degrees for 1
If tolerated with no untoward signs or symptoms, hour. If tolerated with no untoward signs or
initiate order 1b again. symptoms, initiate action 1b again.
d. Assist up to chair at bedside for 30 minutes at d. Assist up to chair at bedside for 30 minutes at
least 4 times a day on 11/3. least 4 times a day on 11/3.
e. Assist to ambulate to bathroom and back at least e. Assist to ambulate to bathroom and back at
4 times a day on 11/4. least 4 times a day on 11/4.
f. Supervise ambulation of one-half length of hall at f. Supervise ambulation of one-half length of hall
least 4 times a day on 11/5 and 11/6. at least 4 times a day on 11/5 and 11/6.
g. Supervise ambulation of length of hall at least 4 g. Supervise ambulation of length of hall at least
times a day on 11/7. 4 times a day on 11/7.
S. J. Smith, RN S. J. Smith, RN
Nursing actions further differ from physician orders in 2. Consideration of both patient and facility resources. It
that the patient’s response is directly related to the imple- would be senseless to make referrals to physical and
mentation of the action. It is rare to see a physician order occupational therapy services if these were not available.
that includes alternatives if the first order has minimal, neg- Likewise, from the patient’s resource viewpoint, it
ative, or no effect on the patient. A complete written nursing would be foolish to teach a patient and his or her family
action incorporates at least the following five components how to manage care in a hospital bed if this bed would
according to Bolander.24 not be available to the patient at home.
3. Careful scheduling to include the patient’s significant
1. Date the action was initially written. others and to incorporate usual activities of daily living
2. A specific action verb that tells what the nurse is going (i.e., rest, meals, sleep, and recreation).
to do (e.g., “assist” or “supervise”). 4. Incorporation of patient teaching and discharge planning
3. A prescribed activity (e.g., ambulation). from the first day of care.
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12 • Introduction
The POR with its SOAPIER progress note emphasizes database, a problem list (FOCUS), a plan of care, and
the problem-solving component within the nursing process progress notes. However, the FOCUS (problem list) is
and provides documentation of the care provided. For fur- broader than POR. In addition to nursing and medical diag-
ther information about the POR system, you are directed to noses, the FOCUS of care may also be treatments, proce-
the Weed17 reference. dures, incidents, patient concerns, changes in condition, or
FOCUS charting, which is actually an offshoot of other significant events. The medical record incorporates
POR, is a documentation system that uses the nursing the plan of care in a three-column format (in addition
process to document care. Unlike the interdisciplinary to date/signature) labeled “FOCUS,” “expected patient out-
POR, FOCUS charting is entirely oriented to nursing docu- comes,” and “nursing interventions.” To illustrate, again
mentation. Like the POR system, FOCUS charting has a with Mr. Kit:
11/1 Pain Will progress to 4 or more Monitor for pain at least every 2 hours. Have pt rate
J. Jones, RN hours between requests pain on 0–10 scale.
for analgesics by 11/3. Administer pain med as ordered.
Monitor response.
Spend at least 30 minutes once a shift teaching
patient deep muscle relaxation. Talk patient through
relaxation every 4 hours, while awake, at [list times
here] once initial teaching is done.
The progress notes incorporate a flow sheet for docu- and signature; a FOCUS column; and a patient care note col-
menting daily interventions and treatments and a narrative umn. When the progress note is written in the patient care
progress note using a three-column format. The three-column note column, it is organized using the acronym DAR—Data,
format for the progress note includes a column for date, time, Action, and Response. To illustrate, again using Mr. Kit:
11/1 1500 J. Jones, RN Pain D C/o pain, “My side hurts. It is a 9 on a 0–10 scale.” BP 130/84, P 88, R 22.
11/1 1530 J. Jones, RN A Demerol 100 mg given in rt gluteus. Turned to left side. Back rub given.
11/1 1615 J. Jones, RN R States pain is better. Rates it 2 on a 0–10 scale. BP 120/80, P 82, R 18.
FOCUS charting provides a succinct system for docu- rather than having to restate the problem. Interventions (I),
menting the nursing process. It reflects all the elements directed to the problem are documented relative to the prob-
required by JCAHO. It is flexible, provides cues to docu- lem number (e.g., IP#1 or IP#2). Evaluation (E) reflects
mentation with its DAR format, and makes it easy to retrieve patient response to or outcomes of nursing intervention and
pertinent data. For more information on FOCUS, use the is labeled according to the problem number (e.g., EP#1 or
information written by Lampe.26 EP#2). To illustrate, again using Mr. Kit:
The PIE documentation system emphasizes the nurs-
ing process and nursing diagnosis. PIE is the acronym for
Problem, Intervention, and Evaluation. A timesaving aspect DATE TIME NURSE’S NOTES
of this system is that PIE does not require a separate plan of
care. The initial database and ongoing assessments are 11/1 1500 P#1 Pain.
recorded on special forms or flow sheets. Assessment data IP#1 BP 130/84, P 88, R 22.
are not included in the progress note unless a change in the J. Jones, RN
patient’s condition occurs. If a change occurs, “A” for
11/1 1530 IP#1 Demerol 100 mg given IM in rt
assessment would be recorded in the progress note. Routine
gluteus. Turned to left side. Back
interventions are recorded on a flow sheet, and the progress rub given. J. Jones, RN
note is used for specific numbered problems.
When a problem is identified, it is entered into the 11/1 1615 EP#1 States pain relieved. Rates
progress note as a nursing diagnosis. Each problem is num- pain as 2 on a 0–10 scale. BP
bered consecutively during a 24-hour period, for example, 120/80, P 82, R 18. J. Jones, RN
P#1 and P#2. Therefore, the nurse may refer to the number
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Nursing Process Steps • 13
Each problem is evaluated at least every 8 hours, and assessment is the data collection form we use to measure
all problems are reviewed and summarized every 24 hours. patient progress.
Continuing problems with appropriate interventions and
Data Collection
evaluation are renumbered and redocumented daily, thus
Initially, specific data should be collected to measure the
promoting continuity of care. When a problem is resolved, it
progress made toward achieving the stated expected out-
no longer is documented.
come. As an example, let us return to the outcome written
The PIE documentation system reflects the nursing
for Mr. Kit, the 19-year-old college student who had an
process and simplifies documentation by integrating the
appendectomy. The expected outcome was “Will have dis-
plan of care into the progress notes. This saves time and pro-
continued use of PCA and will request oral pain medication
motes easy retrieval of pertinent data. Siegrist, Deltor, and
as needed for analgesia by 11/3.” It is now 11/3, and the
Stocks27 are the originators of the PIE system.
nurse caring for Mr. Kit notes the date and initiates evalua-
Charting by Exception was developed by nurses at
tion of the outcome. She first checks the chart and counts the
Saint Luke’s Hospital in Milwaukee, Wisconsin.28 Docu-
number of complaints of pain, number and types of anal-
menting in this system differs significantly from traditional
gesics given, and Mr. Kit’s response to the pain medication.
systems in that nurses chart only significant findings or
She looks for any change in medication or a change in Mr.
exceptions to a predetermined norm.
Kit’s condition. She then interviews Mr. Kit regarding his
This system centers on the development of clinical
perception of pain acuity and level of relief. At the same
standards that describe accepted norms. The system makes
time, the nurse completes other assessments, such as observ-
extensive use of flow sheets and is becoming increasingly
ing the wound condition and the ease of ambulation or
popular because of its streamlined format and cost-effec-
noting the presence of any other untoward signs or symp-
tiveness.
toms. The nurse then studies the data to see what action is
A patient care plan is established based on described
necessary.
standards. Nursing actions are used as the base for docu-
mentation. Flow sheets are used to highlight significant find- Action Following Data Collection
ings and define assessment parameters and findings. For Action following data collection simply means making a
example, for the postpartum patient, the standard for the nursing judgment of what modifications in the plan of care
cardiovascular assessment is: are needed. There are essentially only three judgments that
can be made:
Cardiovascular assessment: Apical pulse, CRT, periph-
eral pulses, edema, calf tenderness. 1. Resolved
Standard: Regular apical pulse, CRT ⬍3 s, peripheral 2. Revise
pulses palpable, no edema, no calf tenderness, nail beds 3. Continue
and mucous membranes pink. Resolved means that the evaluative data indicate the
If the assessment findings were the same as the stan- health-care problem reflected in the nursing diagnosis and
dard, the nurse simply makes a check mark on the flow sheet its accompanying expected outcome no longer exist; that is,
by cardiovascular assessment. If the assessment findings are the expected outcome has been met. The nurse documents
different from the standard, the nurse marks an asterisk by the data collected and records the judgment—“Resolved.”
cardiovascular assessment and explains the deviation from To illustrate, let us return to Mr. Kit.
the standard in the narrative notes. First, the nurse reviews the chart. She finds that Mr.
Charting by Exception has been shown to reduce doc- Kit requested pain medication every three to four hours for
umentation time and costs and increase attention to abnor- the first 18 hours after surgery. The nurses taught Mr. Kit
mal data. In addition, documentation is more consistent. relaxation exercises and turned him, positioned him, and
More information about this system and examples of flow gave him a back rub immediately after the administration of
charts can be found in the publication Charting by each analgesic. Mr. Kit has requested only one analgesic in
Exception.28 the past 24 hours and none in the past 12 hours. He can
To complete the nursing process cycle and, depending return-demonstrate relaxation exercises and states he has
on its outcome, perhaps start another cycle, the final phase only a mild “twinge” when he gets out of bed. He is looking
of the process—evaluation—must be done. forward to returning to school next week.
The nurse returns to the patient’s chart and records the
following: “11/3 Data—1 oral analgesic in past 24 hours;
EVALUATION
none in past 12 hours. Ambulates without pain; states hav-
Evaluation simply means assessing what progress has been ing no pain. Resolved.” She then will draw one line through
made toward meeting the expected outcomes; it is the most the nursing diagnosis, related expected outcome(s), and
ignored phase of the nursing process. The evaluation phase nursing actions to show they have been discontinued.
is the feedback and control part of the nursing process. Revise can indicate two actions. In one instance, the
Evaluation requires continuation of assessment that was initial nursing diagnosis was not correct, so the diagnosis
begun in the initial assessment phase. In this instance, itself is revised. For example, the nurse may have made an
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14 • Introduction
initial diagnosis of Self-Esteem Disturbance. During col- gram will assist you in developing concept boxes and link-
lection of evaluation data, the patient and his family share ing the arrows. Some schools of nursing provide this
further information that indicates that the more appropriate resource for their students. You can also find this tool on the
diagnosis is Powerlessness, Moderate. The plan of care program’s Web site (http://www.inspiration.com).
is then modified to reflect the change in the nursing diagno-
sis. For evaluation purposes, the nurse again records the data
and the word, “Revised.” She then adds the new nursing NURSING PROCESS AND
diagnosis and marks one line through the initial nursing CONCEPTUAL FRAMEWORKS
diagnosis.
NURSING MODELS
In the second instance, while the nurse is collecting
evaluation data for one nursing diagnosis and expected out- Many nurses do not see a direct relationship between nurs-
come, she finds assessment factors that show another prob- ing models (nursing theories) and nursing process, but a
lem has arisen. She simply records the appropriate judgment direct relationship does exist. Nursing models present a sys-
for the initial diagnosis and expected outcome (e.g., tematic method for assessing and directing nursing practice
“Resolved”) and revises the plan to include the new nursing through promoting organization and integration of what is
diagnosis with its appropriate expected outcome and nursing known about human health, illness, and nursing. The nurs-
actions. ing process is the action phase of a nursing model. Kataoka-
Continue indicates that the expected outcome has not Yahiro and Saylor35 indicate that the nursing process is a
been met. The nurse again collects the appropriate data and, method of problem solving and decision making and can be
based on the data, makes the nursing judgment that the seen as a discipline specific method for critical thinking. In
expected outcome has not been met. She records the data essence, models guide the use of the nursing process,36 and,
and adds the phrase, “Continue, reevaluate on [date].” She as previously stated, the care planning presented in this book
then modifies the plan of care by going back to the stated is a result of the nursing process.
expected outcome, marking one line through the date, and For further clarification, let us look at a few examples.
adding a new date. Likewise, the nursing actions would be If you are a supporter of Levine’s Conservation Model, you
modified as necessary. would assess your patient in keeping with this model and
With evaluation, the nursing process cycle is com- then design your care plan to reflect prioritizing of the nurs-
pleted (Fig. 1.1). Another cycle can begin with both the ing diagnoses and nursing actions in a manner that would
nurse and the patient insuring that quality care is being given best promote conservation principles. Likewise, if you are a
and received. To assist you with the evaluation process, we proponent of Roy’s Adaptation Model, you would assess the
have provided an evaluation flowchart template (Fig. 1.2). four adaptation modes, and then prioritize your diagnoses
You can use this format to evaluate any nursing diagnosis by in an order that would best promote adaptive responses. In
completing the chart with your specific information. summation, current nursing models affect care planning in
terms of assessment and prioritizing of nursing diagnoses
Building Conceptual Understandings rather than requiring different diagnostic statements and dif-
with Care Plans ferent nursing actions.
Care plans, in the format of concept maps, have emerged as
an innovative teaching tool.29,30 This format will help you, as PATTERNS
a student, to understand the links between assessment and
Several typologies have emerged as a result of the work
care, build clinical decision-making skills by increasing
done with nursing diagnosis. The typologies are representa-
understanding of information relationships, and link theory
tive of another step in theory development and are designed
to practice. Concept maps also assist with the development
to facilitate the use of nursing diagnosis. The typologies pro-
of critical thinking skills.29,31-33
vide an organizational framework that enables the nurse to
The concept map care plan begins with the client’s
focus on the pattern description and assessment rather than
reasons for seeking health care. Branching from this are the
trying to remember all the details of individual diagnoses.
related nursing diagnoses with the supporting data. Links
The nurse can easily locate the individual diagnoses by
that designate the relationships between the diagnoses and
being familiar with the patterns.
reasons for seeking care are developed. Links between the
diagnoses show their relationships.34 This information is Functional Health Patterns
then transferred to a problem or diagnosis work sheet, and Gordon7 writes that the Functional Health Patterns were
the goals and interventions are developed followed by an identified, circa 1974, to assist in the teaching of assessment
evaluation of the client response.29 A sample concept map and diagnosis at Boston College School of Nursing. The
for Mr. Kit is provided for you in Fig. 1.3. You can find fur- Functional Health Patterns organize the individual diag-
ther information on concept mapping in Concept Mapping: noses into categories, thus providing for the organized col-
A Critical-Thinking Approach to Care Planning.29 When lection of assessment data.
you are developing a concept map you may find a program The advantages offered by assessment according to the
such as Inspiration® a helpful development tool. This pro- Functional Health Patterns include having a standardized
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Nursing Process and Conceptual Frameworks • 15
Yes No
Record data, e.g., record assessment data. Reassess using initial assessment factors
Record RESOLVED. Delete nursing
diagnosis, expected outcome, target date,
and nursing actions.
No Is diagnosis validated?
No Finished
method that does not have to be relearned if the setting, these behaviors by promoting the patient’s describing his
patient’s age, or condition changes; having an assessment or her own perception as well as incorporating the
tool specifically designed to lead to identification of perti- nurse’s observations. Both the patient’s description and the
nent nursing diagnoses; and having an assessment method nurse’s observations must be included to ensure a complete
that is holistic in nature.37 assessment.
Functional Health Patterns focus on the client’s usual Use of the Functional Health Patterns for assessment
ways of living37 and direct attention to all the factors that allows identification of three major types of data:
impact the individual in these ways of living. Gordon7
defines a pattern as “a sequence of behavior across time.” 1. Functional patterns: The functional patterns are client
The Functional Health Patterns allow the nurse to assess strengths that can be used to deal with either dysfunc-
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16 • Introduction
Anxiety
Verbalization of anxiety
Reason for needing health care Impaired skin integrity
BP 130/84, P88, R22 Induces Induces
Appendectomy Surgical wound
difficulty concentrating
Key assessment: pain, VS, dressings less than 24 hours old
expresses fear
of unknown
De
cre
ase
s/E
s
s
Ind
ffe
uc e
uce
En
cts
Ind
ha
uce
Ind
nc
s
es
tional or potentially dysfunctional patterns; for example, model. Thus, the nurse can readily differentiate between
Assessment of the Coping–Stress Tolerance Pattern areas for independent nursing intervention and areas requir-
shows no problem areas. The nurse can then use this ing collaboration or referral.
functional pattern to assist the patient in learning to cope Table 1.3 lists the Functional Health Patterns along
with the identified problem areas. with a brief description of each pattern as designed by
2. Dysfunctional patterns: The Dysfunctional Health Gordon.37 The titles of the patterns are, in essence, self-
Patterns identify problem areas and the nursing diag- explanatory. Because the titles are self-explanatory, the
noses related to each problem area; for example, in Functional Health Patterns are easy to use. The chapters in
assessing the Elimination Pattern, the nurse identified this book are organized using the Functional Health Patterns
problems with urination and specifically with Urinary and each chapter includes more detail regarding each func-
Retention. Knowing that the patient has effective indi- tional health pattern as introductory information for the spe-
vidual coping, the nurse then plans teaching that will cific chapter.
utilize this strength rather than interventions that are
Human Response Patterns
totally nursing focused such as intermittent catheteriza-
Patterns of Unitary Persons were first presented at the Fourth
tion. The nurse could teach the patient to use Credé’s
National Conference of NANDA. A group of nursing theo-
maneuver, pouring warm water over the genital area,
rists met in between, as well as during, conferences to design
running tap water, and so on to use the client’s already
a framework for classification of nursing diagnoses.38,39 The
demonstrated strength.
NANDA Taxonomy Committee and Special Interest Group
3. Potential dysfunctional patterns: The Potential
on Taxonomy40 reviewed, clarified, and relabeled the pat-
Dysfunctional Patterns are risk conditions; for example,
terns as Human Response Patterns. These revisions were
a client who has urinary retention is at risk for the devel-
presented at the Fifth and Sixth National Conferences. The
opment of Excess Fluid Volume. Utilizing this knowl-
patterns proposed by the theorist group describe clustering
edge, the nurse would identify areas of observation to
factors that represent person-environment interaction.41 The
monitor and to teach the patient to monitor.
Unitary Persons categories were not mutually exclusive; that
Use of the Functional Health Patterns in assessment is, one nursing diagnosis might relate to one, two, or even
stresses focus on a nursing model of assessment, diagnosis, three of the patterns. From the Fifth through the Ninth
planning, intervention, and evaluation rather than a medical National Conferences, refinement of the Human Response
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Nursing Process And Conceptual Frameworks • 17
Health Perception–Health Management The client’s perceived pattern of health and well-being and how health is
managed.
Nutritional–Metabolic Describes pattern of food and fluid consumption relative to metabolic
need and pattern indicators of local nutrient supply.
Elimination Describes pattern of excretory function (bowel, bladder, and skin). Also
included are any devices used to control excretion.
Activity–Exercise Describes pattern of exercise, activity, leisure, and recreation. Includes
activities of daily living, requiring energy expenditure. Emphasis is on
the activities of high importance or significance and any limitations.
Sleep–Rest Describes patterns of sleep, rest and relaxation periods during the 24-
hour day. Includes client’s perception of the quantity and quality of
sleep and rest.
Cognitive–Perceptual Describes sensory-perceptual and cognitive pattern.
Self-Perception and Self-Concept Describes self-concept pattern and perceptions of mood state.
Role–Relationship Describes patterns of role engagement and relationships. Includes the
individual’s perception of the major roles and responsibilities of the
current life situation.
Sexuality–Reproductive Describes patterns of satisfaction-dissatisfaction with sexuality. Describes
reproductive pattern.
Coping–Stress Tolerance General coping pattern and the effectiveness of the pattern in terms of
stress tolerance.
Value–Belief Describes patterns of values, goals, or beliefs (including spiritual) that
guide choices or decisions. Includes what is perceived as important to
life, quality of life, and any perceived conflicts in values, beliefs, or
expectations that are health related.
Source: From Gordon, M: Manual of Nursing Diagnosis. Tenth edition, 2002. CV Mosby, St. Louis,
pp 2–5, with permission.
Patterns has continued. At the Seventh National Conference Diagnostic Divisions: Taxonomy II
the Human Response Patterns were presented as the frame- Following the Twelfth NANDA Conference, the Taxonomy
work for NANDA Nursing Diagnosis Taxonomy I,42 and the Committee initiated work on Taxonomy II. NANDA mem-
taxonomy was endorsed by NANDA members attending this bers had expressed concerns regarding the ease of use of
conference. To assist in applying this typology, each diagno- Taxonomy I Revised and the unclear classification of diag-
sis has information regarding its category and coding place noses into the taxonomic patterns.
in the Human Response Pattern. After reviewing multiple taxonomic structures, the
This endorsement indicated acceptance of the Taxon- Taxonomy Committee voted to use an adaptation of
omy I as a working document that would require further Marjorie Gordon’s Functional Health Patterns (FHP) as the
testing, revision, refinement, and expansion. Additional basic taxonomic structure for Taxonomy II. The Taxonomy
input regarding Taxonomy I Revised was solicited at the Committee received permission from Dr. Gordon and her
Eighth National Conference. Much of the discussion at publishers to adapt and use the FHP. Table 1.5 demonstrates
the Eighth Conference focused on the various levels of the this new structure.
taxonomy with specific questions of the clinical usefulness At the Thirteenth Conference, the proposed Taxonomy
of level I. II was presented for members’ review and discussion.
The first level of abstraction in Taxonomy I is the Additionally, members attending the conference participated
Human Response Patterns. The second level is alterations in in a Q-sort project. This project requested the participants to
functions. Levels II through V become increasingly con- sort the individual nursing diagnoses into the proposed
crete, with levels IV and V reflecting the diagnostic labels. classes and served to validate diagnosis placement.
Table 1.4 lists the Human Response Patterns with accompa- Subsequent to the Thirteenth Conference, the Taxon-
nying brief definitions. In this book we have focused on level omy Committee continued to work on the refinement of
II and include levels IV and V in the conceptual information Taxonomy II. At the Fourteenth Conference held in April
and “Have You Selected the Correct Diagnosis?” sections. 2000, Taxonomy II was presented to the NANDA mem-
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18 • Introduction
Exchanging To give, relinquish, or lose something while receiving something in return; the substitution
of one element for another; the reciprocal act of giving and receiving
Communicating To converse; to impart, confer, or transmit thoughts, feelings, or information, internally or
externally, verbally or nonverbally
Relating To connect, to establish a link between, to stand in some association to another thing,
person, or place; to be borne or thrust in between things
Valuing To be concerned about, to care; the worth or worthiness; the relative status of a thing, or
the estimate in which it is held, according to its real or supposed worth, usefulness, or
importance; one’s opinion of like for a person or thing; to equate in importance
Choosing To select between alternatives; the action of selecting or exercising preference in regard
Source: From Fitzpatrick, JJ: Taxonomy II: Definitions and development. In Carroll-Johnson, RM (ed):
Classification of Nursing Diagnosis: Proceedings of the Ninth Conference. Lippincott, Philadelphia,
1991, with permission.
Domain 1 Health Promotion: Diagnoses that refer to the awareness of well-being or normality of
function and the strategies used to maintain control of and enhance that well-being
or normality of function
Class 1 Health Awareness: Recognition of normal function and well-being
Class 2 Health Management: Identifying, controlling, performing, and integrating activities to
maintain health and well-being
Domain 2 Nutrition: Diagnoses that refer to the activities of taking in, assimilating, and using
nutrients for the purposes of tissue maintenance, tissue repair, and the production of
energy
Class 1 Ingestion: Taking food or nutrients into the body
Class 2 Digestion: The physical and chemical activities that convert foodstuffs into substances
suitable for absorption and assimilation
Class 3 Absorption: The act of taking up nutrients through body tissue
Class 4 Metabolism: The chemical and physical processes occurring in living organisms and
cells for the development and use of protoplasm, production of waste and energy,
with the release of energy for all vital processes
Class 5 Hydration: The taking in and absorption of fluids and electrolytes
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Nursing Process and Conceptual Frameworks • 19
Class 2 Gastrointestinal System: Excretion and expulsion of waste products from the bowel
Class 3 Integumentary System: Process of secretions and excretion through the skin
Class 4 Pulmonary System: Removal of byproducts of metabolic products, secretions, and
foreign material from the lung or bronchi
Domain 5 Perception/Cognition: Diagnoses that refer to the human information processing system,
including attention, orientation, sensation, perception, cognition, and communication
Class 1 Attention: Mental readiness to notice or observe
Class 2 Orientation: Awareness of time, place, and person
Class 3 Sensation/Perception: Receiving information through the senses of touch, taste, smell,
vision, hearing, and kinesthesia and the comprehension of sense data resulting in
naming, associating, and/or pattern recognition
Class 4 Cognition: Use of memory, learning, thinking, problem solving, abstraction, judgment,
insight, intellectual capacity, calculation, and language
Class 5 Communication: Sending and receiving verbal and nonverbal information
Domain 7 Role Relationships: Diagnoses that refer to the positive and negative connections or
associations between persons or groups of persons and the means by which those
connections are demonstrated
Class 1 Caregiving Roles: Socially expected behavior patterns by persons providing care who are
not health-care professionals
Class 2 Family Relationships: Associations of people who are biologically related or related by
choice
Class 3 Role Performance: Quality of functioning in socially expected behavior patterns
Domain 8 Sexuality: Diagnoses that refer to sexual identity, sexual function, and reproduction
Class 1 Sexual Identity: The state of being a specific person in regard to sexuality and/or gender
Class 2 Sexual Function: The capacity or ability to participate in sexual activities
Class 3 Reproduction: Any process by which new individuals (people) are produced
Domain 9 Coping/Stress Tolerance: Diagnoses that refer to the contending with life events/life
processes
Class 1 Post-Trauma Responses: Reactions occurring after physical or psychological trauma
Class 2 Coping Responses: The process of managing environmental stress
Class 3 Neurobehavioral Stress: Behavioral responses reflecting nerve and brain function
Domain 10 Life Principles: Diagnoses that refer to principles underlying conduct, thought and behavior
about acts, customs, or institutions viewed as being true or having intrinsic worth
Class 1 Values: The identification and ranking of preferred modes of conduct or end states
Class 2 Beliefs: Opinions, expectations, or judgments about acts, customs, or institutions viewed
as being true or having intrinsic worth
Class 3 Value/Belief/Action Congruence: The correspondence or balance achieved between
values, beliefs, and actions
(table continued on page 20)
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20 • Introduction
Domain 11 Safety/Protection: Diagnoses that refer to freedom from danger, physical injury or
immune system damage, preservation from loss, and protection of safety and security
Class 1 Infection: Host responses following pathogenic invasion
Class 2 Physical Injury: Bodily harm or hurt
Class 3 Violence: The exertion of excessive force or power so as to cause injury or abuse
Class 4 Environmental Hazards: Sources of danger in the surroundings
Class 5 Defensive Processes: The processes by which the self protects itself from the nonself
Class 6 Thermoregulation: The physiologic process of regulating heat and energy within the
body for purposes of protecting the organism
Domain 12 Comfort: Diagnoses that refer to the sense of mental, physical, or social well-being or
ease
Class 1 Physical Comfort: Sense of well-being or ease
Class 2 Environmental Comfort: Sense of well-being or ease in/with one’s environment
Class 3 Social Comfort: Sense of well-being or ease with one’s social situations
Domain 14 Other: Diagnoses that are unclassifiable until new categories or classes are developed or
old ones are redefined
Source: From North American Nursing Diagnosis Association: NANDA Nursing Diagnoses: Definitions
and Classification 2005–2006. NANDA-I, Philadelphia, 2005, with permission.
bership for further consideration. The NANDA Board of which, in turn, increases the probability of successful inter-
Directors approved Taxonomy II following the Fourteenth vention for the individual patient.
Conference and additional revision by the Taxonomy
Committee. Additional Taxonomy Development
A unique feature of Taxonomy II is the use of axes. With the ongoing development of language to describe the
The use of axes simplifies wording structure of the diag- whole of nursing practice, NANDA, NIC, and NOC have
noses, allows a broader use of diagnostic terminology, is developed taxonomies to organize their concepts, including
more clinically expressive, and promotes inclusion of nurs- human responses, nursing interventions, and nursing out-
ing diagnoses into computerized databases. The proposed comes. Since each of these taxonomies represent stages of
axes are illustrated in Table 1.6. the nursing process, it is only logical that they be linked
To illustrate the use of the multiaxial structure, this to assist the practitioner in the process of care plan devel-
example is provided. A client is assessed at a clinic. The opment. To facilitate this linking, the NNN Alliance
client is a 15-year-old who is 5 ft 2 in tall and weighs 190 lb. of NANDA-I, NIC, and NOC developed NNN Taxonomy of
The nurse decides the applicable diagnostic concept (Axis 1) Nursing Practice. This taxonomy has blended features of
is Nutrition. She then chooses a modifier from Axis 6— each of the parent taxonomies. There are four Domains and
“Altered” and “More than Body Requirements.” The nurse 28 Classes3 (see Table 1.7). In this edition, the authors of this
does not add “Adolescent” from the Development Stage Axis book have provided tables that demonstrate the suggested
(Axis 4) because further assessment documents that the linkages between NANDA-I,3 NIC,4 and NOC.5 It is impor-
client’s entire family (brother, mother, and father) are also tant to remember that these linkages are only suggested by
above standard weights for their age and height. Therefore, NNN, and that the ultimate decisions related to diagnosis,
she selects “Family” from Axis 3 (Unit of Care). Because the intervention, and outcome area are those of the practitioners
problem is currently present, the nurse selects “Actual” from who are responsible for providing safe, effective, individual-
the Potentiality Axis (Axis 5). The diagnostic statement then ized care to their client systems. Our decision to present the
becomes: Actual Altered Nutrition, More than Body linkages in a chart form, rather than listing the taxonomy
Requirements by a Family. Stating the diagnostic statement designations, was based on the evolving nature of nursing
in this fashion promotes intervention for the whole family, taxonomies and a desire to provide this information to you in
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Nursing Process and Conceptual Frameworks • 21
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22 • Introduction
Domain III Psychosocial: Includes diagnoses, outcomes, and interventions to promote optimal mental
and emotional health and social functioning
Class Behavior: Actions that promote, maintain, or restore health
Class Communication: Receiving, interpreting, and expressing spoken, written, and nonverbal
messages
Class Coping: Adjusting or adapting to stressful events
Class Emotional: A mental state or feeling that may influence perceptions of the world
Class Knowledge: Understanding and skill in applying information to promote, maintain, and
restore health
Class Roles/Relationships: Maintenance and/or modification of expected social behaviors and
emotional connectedness with others
Class Self-Perception: Awareness of one’s body and personal identity
Domain IV Environmental: Includes diagnoses, outcomes, and interventions to promote and protect
the environmental health and safety of individuals, systems, and communities
Class Health-Care System: Social, political, and economic structures and processes for the
delivery of healthcare services
Class Populations: Aggregates of individuals or communities having characteristics in common
Class Risk Management: Avoidance of identifiable health threats
Source: From North American Nursing Diagnosis Association International: NANDA Nursing
Diagnoses: Definitions & Classification 2005–2006. NANDA International, Philadelphia, 2005.
Practice is an attempt to resolve this issue and continues to those things that are of value to us. It is only recently that
be developed. Currently, new work of NANDA-I, NIC, and completing and evaluating the quality of care planning has
NOC continues to be placed within their unique taxonomic begun to show up on employee evaluation forms. Likewise,
systems. The linking charts in each chapter will help you it is still rare to see “complete nursing care plan” or “update
begin integrating these powerful languages into your nurs- care plan” on the patient assignment form.
ing vocabulary and practice. To develop further expertise in With the changes that are occurring in health care, due
these nursing languages you are encouraged to review the to federal and state legislated mandates, completion and use
publications of NANDA-I,3 NIC,4 and NOC.5 of nursing care planning is going to increase in importance.
Several insurance companies now audit charts, care plans,
and the like in detail. No documentation of care means no
reimbursement for care. Likewise, one of the first places a
VALUE PLANNING OF lawyer looks when hunting evidence for health-related court
CARE AND CARE PLANS cases is the patient’s chart. The basic principle in lawsuits
The nursing process and the resultant plan for nursing care has been “not charted, not done.” Planning care as we pro-
have not been given the attention or credit that they deserve. pose in this book would furnish additional documentation
Part of the problem is that planned nursing care has not had that reasonably prudent care was given as well as providing
value attached to it. All of us will make time or a place for a guideline for better charting.
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Summary • 23
Use of nursing diagnosis helps ensure that teaching national standards. By using the NANDA nomenclature and
and discharge planning are considered from the start of care. by providing feedback to NANDA, you can help develop
As we increase our knowledge and begin to think in terms this nomenclature and help ensure that nursing is recognized
related to nursing nomenclature, nursing actions for many for the contributions it makes to our nation’s health.
of the diagnoses will relate to teaching and planning for
home care.
Many of the standards supported by JCAHO, the R E F E R E N C E S
ANA, and state boards of nursing are automatically imple- 1. Ulrich, B: A matter of trust: Public continues to regard nurses highly
mented when the nursing process is completed, imple- in honesty and ethics. Nurse Week, Dec. 17, 2001.
mented, and documented. A review of these standards by the 2. Beaumont, L: Nurses win public’s trust. USA Today, January 8, 2004
www.theage.com.
reader will show that the nursing process and careful plan- 3. North American Nursing Diagnosis Association International.
ning of care can meet several standards just by writing a NANDA Nursing Diagnoses: Definitions and Classification,
nursing care plan. 2005–2006, NANDA International, Philadelphia, 2005.
4. McCloskey-Dochterman, J, and Bulechek, GM: Nursing Interventions
It is not uncommon to hear, “I don’t do care plans Classification. CV Mosby, St. Louis, 2004.
because I don’t have time to do them.” It is true that there is 5. Moorhead, S, Johnson, M, and Mass, M: Nursing Outcomes
an investment of time in completing and documenting Classification. CV Mosby, St. Louis, 2004.
6. Gordan, M: Nursing Diagnoses: Process and Application, ed 3.
the nursing process, but in the long-range view, such plan- Mosby-Year Book, St. Louis, 1994.
ning of care actually saves time. To illustrate, one nurse, 7. Gordon, M: Manual of Nursing Diagnoses. CV Mosby, St. Louis,
known to the authors, works full time in nursing educa- 2002.
8. Iyer, PW, Taptich, BJ, and Bernocchi-Losey, D: Nursing Process and
tion but works part time at a local hospital to keep her Nursing Diagnosis, ed. 3. WB Saunders, Philadelphia, 1995.
clinical skills current. One afternoon she went to work at 9. Lunney, M: Critical Thinking and Nursing Diagnosis: Case Studies
the hospital, received her patient assignments and a brief and Analyses, NANDA, Philadelphia, 2001.
10. Gardner, P: Nursing Process in Action. Thomson Delmar Learning,
report, and then began to implement patient care. One nurs- Clifton Park, NY, 2003.
ing order read, “Change dressing as needed.” Assessment 11. Doenges, ME, and Moorhouse, MF: Nurse’s Pocket Guide: Nursing
of the dressing showed a change was needed. In the patient’s Diagnosis with interventions, ed 6. FA Davis, Philadelphia, 1998.
12. Alfaro, R: Applying Nursing Diagnosis and Nursing Process: A step
room were all kinds of dressings, fluids, and ointments. by step approach. Lippincott-Raven, Philadelphia, 1988.
There were no instructions for changing the dressing on the 13. American Nurses Association: Nursing’s Social Policy Statement,
care plan or the patient’s chart. The nurse then requested Washington, DC: nurse books.org, 2003.
14. American Nurses Association: Nursing: Scope and Standards of
information from the patient who stated, “I don’t like to look Practice. American Nurses Association, Silver Spring, MD, 2004.
at it, so I don’t know.” The nurse then began to search for 15. Texas Board of Nurse Examiners: Standards of Nursing Practice. Rule
a staff member who had cared for this patient and could 217.11.2004. Texas Administrative Code Title 22 Part 11 Chapter 217,
Austin, Texas, 2004.
teach her the routine for the special dressing change. After 16. Brider, P: Who killed the nursing care plan? Am J Nurs 91:35, 1991.
30 minutes, she finally found a nurse who had cared for the 17. Henry, SB, Holzemer, WL, and Reilly, CA: The relationship between
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AIDS patients. J Adv Nurs 19:691, 1994.
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in 3 minutes recorded the way to change the dressing under Nurse 14(2):85, 1998.
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Official Handbook, Joint Commission Accreditation of Healthcare
Comparing the time it took to locate the information Organizations, Chicago, 2005.
and the time it took to record the information gives a graphic 20. Carroll-Johnson, R: Reflections on the ninth biennial conference. Nurs
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21. Kozier, BB, Erb, GH, and Olivieri, R: Fundamentals of Nursing,
menting the nursing process. Consider the time saved if the updated ed 6. Addison-Wesley Nursing, Menlo Park, CA, 2002.
written nursing actions are used as an outline for charting, or 22. Tartaglia, MJ: Nursing diagnosis: Keystone of your care plan. Nursing
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25. Cox, HC: Developing Nursing Care Plan Objectives: A Programmed
Making time to use and document the nursing process Unit of Study. Texas Tech University Health Sciences Center School
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the long run. 26. Lampe, S: FOCUS Charting, ed 4. Creative Nursing Management,
Minneapolis, MN, 1988.
27. Siegrist, L, Deltor, R, and Stocks, B: The PIE system: Planning and
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28. Burke, LJ, and Murphy, J: Charting by Exception. John Wiley &
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29. Schuster, P: Concept Mapping: A critical-thinking approach to care
The nursing process provides a strong framework that planning, FA Davis, Philadelphia, 2002
gives direction to the practice of nursing. By completing 30. Schuster, P: Concept maps in clinical settings: Improved clinical per-
formance and effective patient care. Dean’s Notes 23(3):1, 2003.
each phase, you can reassure yourself that you are provi- 31. Pehler, S, and Bodenbender, K: Concept maps as a tool for learning
ding quality, individualized care that meets local, state, and standardized languages. Int J Nurs Terminol Classif 14(4):39, 2003.
01Newfield (F)-01 3/31/07 6:50 PM Page 24
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Copyright © 2007
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24 • Introduction
32. All, AC, Huycle, L, and Fisher, M: Instructional tools for nursing edu- Classification of Nursing Diagnosis: Proceedings of the Third and
cation: Concept maps. Nurs Educ Perspect 24(6):311, 2003. Fourth National Conferences. McGraw-Hill, New York, 1982, p 235.
33. Jaco, MK, Gordon, MD, and Marvin, JA: Nursing rounds link nursing 39. Roy, C, Sr: Framework for classification system development:
diagnoses to clinical practice. Int J Nurs Terminol Classif 14(4):53, Progress and issues. In Kim, MJ, McFarland, GK, and McLane, AM
2003. (eds): Classification of Nursing Diagnosis: Proceedings of the Fifth
34. Hsu, L, and Hsieh, S: Concept maps as an assessment tool in a nurs- National Conference. McGraw-Hill, New York, 1984, p 29.
ing course. J Prof Nurs 21(3):141, 2005. 40. Kritek, PB: Report of the group who worked on taxonomies. In
35. Kataoka-Yahiro, M, and Saylor C: A critical thinking model for nurs- Kim MJ, McFarland GK and McLane AM (eds): Classification of
ing judgment. Nurs Educ 33(8):351,1994. Nursing Diagnosis: Proceedings of the Fifth National Conference.
36. Yura, H, and Walsh, MB: The Nursing Process: Assessing, Planning, McGraw-Hill, New York, 1984, p 46.
Implementing, Evaluating, ed 5. Appleton-Century-Crofts, East 41. Newman, MA: Looking at the whole. Am J Nurs 84:1496, 1984.
Norwalk, CT, 1988. 42. North American Nursing Diagnosis Association: Taxonomy I with
37. Gordon, M: Manual of Nursing Diagnosis: 1995–1996. McGraw-Hill, Complete Diagnoses. Author, St. Louis, 1987.
New York, 1995. 43. Fitzpatrick, JJ: Taxonomy II: Definitions and development. In Carroll-
38. Roy, C, Sr: Historical perspective of the theoretical framework for the Johnson, RM (ed): Classification of Nursing Diagnosis: Proceedings
classification of nursing diagnosis. In Kim, MJ and Moritz, DA (eds): of the Ninth Conference. Lippincott, Philadelphia, 1991.
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HEALTH
2
PERCEPTION–HEALTH
MANAGEMENT PATTERN
1. ENERGY FIELD, DISTURBED 36
2. HEALTH MAINTENANCE, INEFFECTIVE 42
3. HEALTH-SEEKING BEHAVIORS (SPECIFY) 49
4. INFECTION, RISK FOR 54
5. INJURY, RISK FOR 59
A. Suffocation, Risk for
B. Poisoning, Risk for
C. Trauma, Risk for
6. LATEX ALLERGY RESPONSE, RISK FOR AND ACTUAL 70
7. MANAGEMENT OF THERAPEUTIC REGIMEN, EFFECTIVE 75
8. MANAGEMENT OF THERAPEUTIC REGIMEN (INDIVIDUAL,
FAMILY, COMMUNITY), INEFFECTIVE 80
9. MANAGEMENT, READINESS FOR ENHANCED THERAPEUTIC
REGIMEN 92
10. PERIOPERATIVE-POSITIONING INJURY, RISK FOR 96
11. PROTECTION, INEFFECTIVE 100
12. SURGICAL RECOVERY, DELAYED 107
13. SUDDEN INFANT DEATH SYNDROME, RISK FOR 111
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26 • Health Perception–Health Management Pattern
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Copyright © 2007 by F. A. Davis. •
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Conceptual Information • 27
Another major factor affecting health promotion is an actions than the objective reality of the situation. The Health
intact sensory system. Sensory organs provide information Belief Model states that for an individual to take action to
to the individual regarding the environment. An intact nerv- avoid a disease, she or he needs to believe the following:
ous system is required because it provides for optimum
1. That she or he is personally susceptible to disease.
functioning of sensory, motor, and cognitive activities. An
2. That the occurrence of the disease will have at least a
accurate cognitive–perceptual pattern and self-perception/
moderate impact on some part of her or his life.
self-concept pattern are necessary to achieve the optimal
3. That taking action will be beneficial.
level of health perception and management. The ability to
4. That such action will not involve overcoming psycho-
think and understand greatly impacts basic knowledge of
logical barriers such as cost, pain, or embarrassment.
health and illness. Likewise, the individual’s feeling of self-
worth and interpretation of the meanings of health and ill- These beliefs can be described as variables that define
ness to the self, influences his or her health practices. perceived benefits and barriers to taking actions under the
Knowledge related to health promotion and disease preven- headings “perceived susceptibility” and “severity.” Because
tion is essential for the individual to fully maintain health these variables do not account for the activation of the
management. behavior, the originators of the Health Belief Model have
Cultural, societal, and familial values and beliefs added another class of variable called “cues to action.” The
influence the capacity to achieve positive health perception individual’s level of readiness provides the energy to act,
and health management. Values and beliefs influence what is and the perception of benefits provides a preferred manner
identified as optimal health. Availability of appropriate of action that offers the path of least resistance. A cue to
health-care resources in a community impacts the health- action is required to set off this appropriate action. The
care delivery system and the ability of the community to model suggests that by manipulating any combination of
manage a therapeutic regimen. The development of nursing variables affecting action, the inclination to seek preventive
diagnoses for communities requires nurses to also develop care can be changed.
interventions to influence health policy and to work with The Health Belief Model does not contain concepts
advocacy groups.3 related to knowledge of disease as a potential factor in deter-
The Health Belief Model4 (Fig. 2.1) provides a frame- mining an individual’s decision to engage in preventive
work in which to study actions taken by individuals to avoid behavior. Several authors point out that knowledge of health
illness. A basic assumption of the model is that the subjec- consequences has only a limited relationship to the occur-
tive state of the individual is more important in determining rence of the desired health behavior.5–7 Yet, quite often,
Cues to action:
Mass media campaigns
Advice from others
Reminder postcard from
physician or dentist
Illness of family member or
friend
Newspaper or magazine
article
F I G U R E 2 . 1 The Health Belief Model. (From Becker, MH, et al: Selected psychoso-
cial models and corrrelates of individual health-related behaviors, Medical Care 15:27,
1977 [Suppl], with permission.)
02Newfield (F)-02 4/18/07 7:32 PM Page 28
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28 • Health Perception–Health Management Pattern
imparting knowledge about diseases to the patient, in an tive–perceptual factors in behavior regulation. Cognitive–
effort to encourage future preventive behavior, is the main perceptual factors—for example, understanding of the
method used by nurses. importance of health, the definition of health, perceived self-
The Health Belief Model is disease specific. The competency, and perceived control of health—are primary
model does not adequately explain positive health actions motivational mechanisms for health-promoting behavior.
designed to maximize wellness, fulfillment, and self-actual- Healthy People 2010 (http://www.healthypeople.
ization. Although the Health Belief Model is useful in pre- gov/)8 describes the national health promotion and disease
dicting preventive behavior, it does not fully explain prevention objectives. Two major goals are addressed:
behavior motivated by health promotion.8 More research is
1. Increase quality and years of healthy life
needed to identify the determinants of health-promoting
2. Eliminate health disparities.
behavior to increase our ability to assist the patient in
achieving health promotion. Preventing energy field distur- The document presents baseline epidemiologic data
bances, for example, is an area of research appropriate to and projected goals for health promotion, health protection,
nursing practice. and preventive services. Special emphasis is placed on vul-
The Health Belief Model provides the nurse with the nerable populations, for example, individuals who are dis-
conceptual notion that by considering the patient’s percep- abled or elderly and those in lower socioeconomic status and
tion of the situation, increasing the patient’s cues to action, certain ethnic groups. This document is recommended as a
and decreasing the patient’s barriers to action, the nurse can guide for identifying factors that influence the health per-
enhance the possibility that the patient will engage in dis- ception–health management pattern. Strategies for interven-
ease prevention and early detection activities. tion and evaluation are also included.
Pender8 points out that health promotion and disease Whether working with individuals, families, or com-
prevention are complementary, but very separate, concepts. munities, the nurse should plan interventions appropriate for
Health promotion is directed toward growth and improve- the learning needs of those being targeted. Mass media cam-
ment in well-being, whereas disease prevention conceptu- paigns are useful when conveying general information to
ally operates to maintain the status quo.9 large groups of people, but one-to-one communication is
The Health Promotion Model as developed by Pender8 more effective for instructing individuals in their particular
(Fig. 2.2) provides the framework for nursing research and circumstances. Put Prevention into Practice (http://www.
practice. This model emphasizes the importance of cogni- ahcpr.gov/clinic/ppipix.htm)11 is a comprehensive system
Activity-related affect
Commitment Health
to a promoting
Personal factors: plan of action behavior
Biologic
Psychological Interpersonal influences:
Sociocultural Family, peers, providers
Norms, support, models
Situational influences:
Options
Demand characteristics
Aesthetics
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Copyright © 2007 by F. A. Davis. •
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•
Developmental Considerations • 29
that was developed to assist the clinician, and the patient and 3. Seek consultation from experts in area requiring inter-
his or her family, to establish a routine of preventive behav- vention, for example, individual practitioners and sup-
iors and services. The kit includes a clinician’s handbook, port groups.
preventive care timelines, office reminders, and patient-
oriented materials to promote preventive behaviors.
The concepts of primary, secondary, and tertiary pre- DEVELOPMENTAL CONSIDERATIONS
vention11 are also useful to the nurse when using the health
Health-care providers can encourage the acceptance of
management pattern. It is important for the nurse to recog-
responsibility for health-promoting activities and adherence
nize that a focus on the patient’s strengths, not just his or her
to agreed-upon treatment plans by giving appropriate atten-
problems, is an integral part of health promotion.12,13
tion to the impact developmental levels have on the individ-
Primary prevention consists of activities that prevent a
ual or the primary caregiver. Publications such as Put
disease from occurring. A patient engaged in primary pre-
Prevention into Practice11,15 can assist the nurse, patient,
vention activities would:
family, and community in establishing a routine of health-
1. Maintain up-to-date immunizations. promoting behaviors and practices. The US Administration
2. Have adequate water supply and sanitation facilities. on Aging (AoA) offers many publications and programs to
3. Use seat belts and infant car seats, and properly store support the healthy aging of older Americans (http://
household poisons to minimize accident fatalities. www.aoa.gov/). One of the programs of the AoA, You Can!
4. Eliminate tobacco products. Steps to Healthier Aging, provides specific suggestions and
5. Maintain adequate nutrition, elimination, exercise, activities for older adults to stay active and healthy (http://
social, and personal relationships, etc. www.aoa.gov/youcan/youcan.asp).
6. Practice good oral hygiene and receive dental examina-
tions on a regular basis. INFANT AND TODDLER
7. Avoid excessive sun exposure and use sunscreens and
Because the neonate is totally dependent on others for care,
protective clothing.
it is the primary caregiver who is entrusted with carrying out
8. Maintain weight within normal range for age, sex, and
the therapeutic interventions. As the infant grows and devel-
height.
ops, self-care abilities increase. The following information
9. Maintain an environment free of chemical, biologic,
outlines developmental milestones from birth to approxi-
and physical hazards.
mately 24 months, as described by Piaget’s sensorimotor
10. Maintain regular sleep and rest patterns.
stage of cognitive development.14 During this period of
11. Practice healthy nutritional intake (i.e., low amounts of
development, the individual must be protected from hazards
salt, sugar, and fat; follow food pyramid recommenda-
in the environment, and the primary caregiver must assume
tions for daily servings per food group and total calo-
the major share of responsibility for compliance with the
ries as appropriate for age, sex, and condition).
treatment program.
12. Maintain regular relaxation, recreation, and exercise
Providing a safe environment includes the following
activities.
accident prevention strategies:
Secondary prevention indicates activities designed to
1. Placing infants to sleep on their back (“back to sleep”)
detect disease before symptoms are recognized. Screening
2. Minimizing prenatal and postnatal infant smoke
activities are the most common type of secondary preven-
exposure
tion activities and include:
3. Avoiding overwrapping or overheating of infants
1. Diabetes screening 4. Early and regular prenatal care for expectant mothers
2. Glaucoma screening 5. Turning pot handles away from edge of stove
3. Hypertension screening 6. Storing medicines, matches, alcohol, plastic bags, and
4. Hearing and vision testing house and garden chemicals in child-proofed areas
5. Pap smears 7. Using a cold-water, not a hot-water, humidifier
6. Breast examinations 8. Avoiding heating formula in microwave
7. Prostate and testicle examinations 9. Using protection screens on heaters, fireplaces, and
8. Well-baby examinations electrical outlets
9. Colon and rectal examinations 10. Using nonflammable clothing
11. Gating stairways and windows
Tertiary prevention refers to the treatment, care, and
12. Supervising children at play, while bathing, in car, or in
rehabilitation of current illness. This area indicates the
shopping cart
patient needs to:
13. Controlling pets or stray animals
1. Adhere to medical and nursing treatments. 14. Avoiding items hung around neck
2. Make lifestyle changes necessitated by condition. 15. Providing a smoke-free environment
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30 • Health Perception–Health Management Pattern
16. Avoiding small objects that can be inserted in mouth that is higher than that of the normal adult. The normal
or nose white blood cell count decreases gradually throughout child-
17. Avoiding pillows and plastic in crib hood until reaching the adult norms.27,28 It is essential that
18. Removing poisonous plants from house and garden the nurse be very familiar with the blood cell count norms
19. Removing lead-based paint from the home for this age group.
During fetal life, maternal antibodies (assuming the
Children should be screened at birth for congenital mother has developed them) protect the fetus from diseases
anomalies, phenylketonuria (PKU), thyroid function, cystic such as diphtheria, tetanus, measles, and polio. This tempo-
fibrosis, vision impairment, and hearing deficiency. A new- rary immunity lasts 3 to 6 months. Colostrum contains anti-
born assessment should be performed, and anticipatory bodies that provide protection against enteric pathogens.
guidance should be provided for patients regarding growth Some infections can cross the placental barrier, leading to
and development, safety, health promotion, and disease pre- the development of congenital (present at birth) infections.
vention. Syphilis, human immunodeficiency virus (HIV), and rubella
Well-baby examinations and developmental assess- are examples of such infections. Pathogenic organisms such
ments are recommended at 2, 4, 6, 15, and 18 months.11,16–18 as herpes simplex may be acquired during passage through
Height and weight should be recorded on growth charts, and the birth canal. Because infants do not begin to produce
hemoglobin and hematocrit should be checked at least once immunoglobulins until 2 to 3 months after birth, they are
during infancy. Parent counseling includes discussion of susceptible to infections for which they have not gained pas-
nutrition with attention paid to iron-rich foods; safety and sive immunity.
accident prevention; oral, perineal and perirectal hygiene; Infections can be of serious concern during the peri-
sensory stimulation of the infant; baby-bottle tooth decay; natal period, especially TORCH infections (Toxoplasmosis,
and the effects of passive smoking. Immunizations are given Hepatitis B, Rubella, Cytomegalovirus, Herpes). Other
during the well-baby checks according to the following infections such as Chlamydia, group B Streptococcus,
schedule19,20: syphilis, HIV, and acquired immunodeficiency syndrome
1. Hepatitis B-1 at birth to 2 months (AIDS) are also of great concern as all of these infections
2. Hepatitis B-2 at 1 to 4 months have consequences for not only the pregnancy, but also the
3. DTaP (diphtheria and tetanus toxoids and acellular newborn.29 When caring for a pregnant woman or a new-
pertussis) or DTP (diphtheria, tetanus toxoids, and per- born, it is important to teach techniques to prevent acquisi-
tussis), HiB (Haemophilus influenzae type B), pneumo- tion and transmission of these disorders and to recognize
coccal conjugate (PCV), and polio at 2 and 4 months early signs and symptoms so that early interventions can be
4. DTaP, CPV, and HiB at 6 months instituted. For newborns, the HBv series should be initiated
5. Hepatitis B-3 and polio at 6 to 18 months at birth before discharge from the hospital.20–24,26
6. HiB at 12 to 15 months20–23 Child-care practices must include hygienic disposal of
7. MMR (measles, mumps, and rubella), varicella, PCV, soiled diapers and cleaning of the perineum. Proper hand-
and tuberculin test at 12 to 18 months washing techniques are required of the care provider. Proper
8. DTaP or DTP at 15 to 18 months formula preparation and storage are also critical if the new-
9. PCV at 2 to 5 years born is to be bottle-fed. Anatomically, the eustachian tube of
10. DTaP or DTP, polio, and MMR at 4 to 6 years the newborn and infant facilitates the passage of infection-
11. Hepatitis B, Td (tetanus and diphtheria toxoid), MMR, causing organisms into the middle ear. It is important for
and varicella at 11 to 12 years23 care providers not to prop bottles, but rather to hold the new-
born or infant while feeding. Passive exposure to tobacco
For children who have not been immunized during the smoke irritates the bronchial tree and increases the possibil-
first year of life, you will need to consult the latest estab- ity of respiratory infection.
lished standards for appropriate timetables.19,24 Hepatitis B The infant may respond to an infection with a very
vaccine (HBv) should be given at birth, 2 to 4 months, and high fever. Care providers should be taught how to do the
6 to 18 months.19,24 HBv can be administered at the same following: take axillary or tympanic temperatures, provide
time as DTP and/or Haemophilus influenzae type B con- hydration to an ill infant, give tepid baths when fever is ele-
jugate vaccine (HibCV).24 The Centers for Disease Control vated, and seek professional evaluation when an infant has a
and Prevention recommends yearly administration of febrile illness.
influenza vaccine beginning at age 6 months (2005).25–27
Host factors such as age and behavior affect the sus- TODDLER AND PRESCHOOLER
ceptibility to infectious disease. In general, most infectious
diseases produce the greatest morbidity and mortality in During the preoperational period, children learn how to
the very old and the very young (http://www.cdc.gov/nip/ teach themselves through trial and error, exploration, and
vaccine/tdap/tdap_adult_recs.pdf).26,28 It is also important to repetition. From age 2 to 4 years, the child is egocentric,
note that the normal newborn has a white blood cell count using him- or herself as a standard for others; he or she can
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Developmental Considerations • 31
categorize on the basis of a single characteristic. Because of dental hygiene can be taught to the child to help prevent
the child’s curiosity and exploration of the environment, it is tooth and gum infections.
important for the care provider to provide a safe environ-
ment. During this period the words “no,” “hot,” “sharp,” and SCHOOL-AGE CHILD
“hurt” should be introduced and repeatedly reinforced by
This period is characterized by developing logical
the care provider. Safety rules should also be taught and
approaches to concrete problems. The concepts of reversibil-
reinforced repeatedly.
ity and conservation are developed, and the child can organ-
From ages 4 to 7 years, the child can begin to see sim-
ize objects and events into classes and arrange them in order
ple relationships and is developing the ability to think in log-
of increasing values. The child can be responsible for per-
ical classes. The child can learn his or her own address and
sonal hygiene and simple household tasks. The child will
can follow directions of three steps. Rules need to be rein-
need assistance when ill, but he or she can be taught self-care
forced. The child can be responsible for personal hygiene
activities as required, such as insulin injections or taking
with instruction and coaching.
medications on a regular basis. The child can distinguish and
Strategies used to provide a safe environment for the
describe physical symptoms and report them to the appro-
infant should also be used during childhood. Discipline, acci-
priate caregiver, and he or she can follow instructions.
dent prevention, and the development of self-care proficiency
Strategies used by care providers to establish a safe
related to eating, dressing, bathing, and dental hygiene are
environment, prevent disease, and promote health can be
important areas of concern. Developmental assessments with
taught to the child. The child can perform many of these
emphasis on hearing, vision, and speech are recommended.
functions with supervision. Emphasis is placed on health
DPT or DTaP, and OPV (oral polio vaccine) or IPV (inacti-
education of the child in safety and accident prevention,
vated polio vaccine) are given once between 4 and 6 years of
nutrition, substance abuse, and anticipated changes with
age, at or before school entry. Consult guidelines if the child
puberty. Anticipatory guidance for both the parents and the
has not been immunized during the first year of life.19–24 The
child should include the development of industry and avoid-
Immunizations Practices Advisory Committee (ACIP) of the
ance of inferiority. A preadolescent immunization status
U.S. Public Health Service30 recommends that a second dose
check is recommended at 11 to 12 years of age.20,21 Hepatitis
of MMR be given at 4 to 5 years of age, when the child enters
B vaccine is recommended for those who did not receive the
kindergarten.
vaccine as a child. Screening of high-risk groups for tuber-
Anticipatory guidance should be given to parents on
culosis is recommended.11
the development of initiative and guilt, nutrition and exer-
cise, safety and accident prevention, toothbrushing and den-
ADOLESCENT
tal care, effects of passive smoking, and skin protection
from ultraviolet light.17 In addition, the parents should be True logical thought is developed and abstract concepts can
taught that, as the child begins to explore the environment be manipulated by individuals at this developmental level. A
and put objects and foods into his or her mouth, it will be scientific approach to problem solving can be planned and
important to ensure that contact with infectious pathogens or implemented. The adolescent can develop, with guidance,
foreign bodies is controlled. Foreign-object-induced infec- responsibility for total self-care. With experience, the ado-
tion should be considered in childhood infections of the lescent requires less guidance and can assume full decision-
external ear, nose, and vagina. making responsibility and total responsibility for self-care.
If the preschooler has been exposed to other children, Emphasis should be placed on health education of the
he or she most likely will have experienced several middle adolescent in healthy living habits, safe driving, sex educa-
ear, gastrointestinal, and upper respiratory tract infections. If tion, skin care, substance abuse, career choices, relation-
the child has not been around other children, he or she will ships, dating and marriage, breast self-examination for
likely experience such infections when entering preschool female adolescents, and testicular self-examination for male
or kindergarten. Preventing injury will also assist in the pre- adolescents. Screening for pregnancy, sexually transmitted
vention of infection. The adenoidal and tonsillar lymphoid diseases, depression, high blood pressure, and substance
tissue may normally enlarge during the early school years, abuse can be done. Anticipatory guidance should be given to
partly in response to the exposure to pathogens in school. parents and adolescents about the development of identity,
The child will require assistance with toileting role confusion, and formal operational thought.17
hygiene until 4 to 5 years of age. Handwashing techniques The hormonal changes of puberty may lead to acne
can be introduced along with toilet training and followed vulgaris. If severe, proper hygiene and dermatologic evalua-
with consistent role modeling by the adults and older chil- tion will prevent serious complications. The changes in the
dren who provide assistance to the child. Bubble baths and vaginal tissue secondary to hormonal changes provide an
other scented soaps and toilet tissue may irritate the urethra environment conducive to yeast infections. If the adoles-
in the female child and lead to urinary tract or vaginal infec- cent is engaging in sexual activity, he or she is at risk for
tions. Parents, grandparents, other caregivers, and the child exposure to sexually transmitted diseases. Irritants such as
should be taught to avoid such items. In addition, proper soap and bubble bath may increase the possibility of urinary
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32 • Health Perception–Health Management Pattern
tract infection in female adolescents. Improper genital Regular breast self-examination (women) and testicu-
hygiene also predisposes the female adolescent to urinary lar self-examination (men) should be taught and encour-
tract infections. aged. Women should have a baseline mammogram at age 35
Persons born after 1956 who lack evidence of immu- and all women 40 and above should have a clinical breast
nity to measles should receive the MMR vaccine.20,30 The exam and mammogram annually. Women should be advised
MMR vaccine should not be given during pregnancy. to have Pap smears every 1 to 2 years, or more often as rec-
Individuals susceptible to mumps should be vaccinated as ommended by their primary care provider. Screening for
well.25,31 A diphtheria and tetanus vaccination (Td) should be glaucoma; high blood pressure; high blood cholesterol level;
given at 14 to 16 years of age. Hepatitis B vaccines should rubella antibodies; sexually transmitted diseases; and colon,
be given to anyone who did not receive immunizations as a endometrial, oral, or breast cancer should be done if the
child.21 Screening of high-risk groups for tuberculosis is rec- patient is in a risk category.
ommended.11 Adolescents living in a group setting, such as a As the body develops more antibodies to pathogens,
dormitory, have an increased risk of contracting a communi- adults may find that they do not have as many colds as they
cable disease. Good personal hygiene is important to used to. Some viral infections (e.g., mumps) may present
decrease this risk. serious consequences to adults (particularly men in the case
Meningococcal vaccine is recommended for all chil- of mumps). The adult female is as susceptible to genitouri-
dren at their routine preadolescent visit (11 to 12 years of nary infections as the adolescent. Sexually active adults are
age). For those who have not previously received the menin- at risk for sexually transmitted diseases.
gitis vaccine, a dose is recommended on entry to high Tetanus-diphtheria (Td) boosters should be given
school. Other adolescents who want to decrease their risk of every 10 years. Hepatitis B vaccine should be given to peo-
meningococcal disease can also get the vaccine. Other peo- ple at risk for exposure. Remember, persons born after 1956
ple at increased risk, for whom routine vaccination is rec- who lack evidence of immunity to measles should receive
ommended, are college freshmen living in dormitories.32 the MMR vaccine, but the MMR vaccine should not be
Risk-taking behavior of adolescents32 may increase the given during pregnancy. Individuals susceptible to mumps
risk of infection and accidents. Examples of these risk-taking should be vaccinated. Pneumococcal and influenza vaccines
behaviors include sexual intercourse; IV drug use; use of are recommended annually, especially for persons at risk for
alcohol and tobacco; traumatic injury, tattooing or body acquiring the flu, and for persons at risk for complications
piercing, that breaks the skin, allowing a portal of entry for from infection.25 Advanced age; conditions associated with
pathogenic organisms; fad diets or other activities that decline in antibody levels; Native American ethnicity; and
decrease the overall health status; improper technique or institutional settings such as military training camps, cor-
equipment in water sports; motor vehicle accidents; running rectional facilities, and boardinghouses all are identified as
a vehicle or other combustion engines when not properly risk factors33–35 for the development of pneumonia and
ventilated; substance abuse; choking on food; smoke inhala- influenza. Tuberculosis screening of high-risk populations is
tion; improper storage and handling of guns, ammunition, recommended.11
and knives; smoking in bed; improper use or storage of flam-
mable items, hazardous tools, and equipment; drug inges-
OLDER ADULT
tion; playing or working around toxic vegetation; improper
preparation and storage of food; and improper precautions In the absence of illness affecting cognitive functioning, the
and use of insecticides, fertilizers, cleaning products, med- older adult maintains formal operational abilities. The older
ications, alcohol, and other toxic substances. adult can assume total responsibility for decision making
and self-care. The older adult also often assumes responsi-
bility for the care of others, such as a spouse, child, or
ADULT
grandchild. As with other developmental levels, illness or
Adult thought is more refined than adolescent thought physical disability can alter the cognitive functioning and
because experience and education allow the adult to differ- lead to self-care deficits.
entiate among many points of view and potential outcomes Emphasis is on health education related to retirement,
in an objective and realistic manner. The adult can consider safety in the home, medication use, living with chronic ill-
more options and can apply inductive, as well as deductive, ness, and grandparenting.36 Anticipatory guidance is related
approaches to problem solving. The adult assumes total to the development of ego integrity. The importance of reg-
responsibility for the care of a child. In middle adult years, ularly scheduled breast self-examinations, Pap smears,
the adult may also care for an elderly parent. mammography (women), and testicular self-examination
The adult is concerned about many of the same health (men) should be taught and the practices encouraged.
promotion and disease prevention issues the adolescent wor- Glaucoma, blood pressure, cholesterol, and colon cancer
ries about. Emphasis should be placed on lifestyle counsel- screenings should also be done.37 Podiatry care should be
ing related to family planning, parenting, stress management, given as needed. Tetanus-diphtheria (Td) boosters; hepatitis
career advancement, relationship enhancement, hazards at B and A vaccines; and pneumonia, and varicella immuniza-
work, and development of intimacy and generativity. tions are given according to the same conditions discussed
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Developmental Considerations • 33
in the adult health section.38,39 Older adults, who are often at to increase client demand for vaccination services include
risk for serious complications resulting from influenza client reminder systems and client education.
infection, should have an annual influenza immunization.25 Older adults may have a decreased ability to remove
The influenza vaccine should be given annually both themselves from hazardous situations as a result of changes
to people 65 and older and to younger people in high-risk in mobility. Olfactory alterations may lead to an inability to
groups. The pneumococcal vaccine should be given one smell smoke or gas fumes.40 The risk for injury and increases
time to people 65 years of age or older and to younger peo- in self-care deficits may result from sensory, motor, or per-
ple in high-risk groups. If the older adult is at very high risk ceptual difficulties.
for pneumococcal infection, the vaccine may be given again Age-related changes in the immune system can lead to
6 years after the initial immunization.38,39 Although the increased severity and number of infections in the older
worldwide incidence of tetanus is decreasing, older adults adult.38–40 Physical aging changes in the skin, respiratory,
remain more susceptible to the disease. Tuberculosis cases gastrointestinal tract, and genitourinary system can lead to
in the United States remain disproportionately distributed in increases in infection. Skin breakdown due to epidermal
the older population and in people with acquired immunity thinning and decreased skin elasticity, less effective cough-
diseases.40 ing, diminished gag reflex, decreased gastrointestinal motil-
The inability to achieve adult immunization recom- ity, and urinary stasis can be problematic for the older adult
mendations is a serious problem in the United States. It is with a less efficient immune system. Changes in the number
estimated that only 58 percent of adults age 65 and older and maturity of T-lymphocyte cells lead to decreased ability
receive the influenza vaccine, and only 35 percent receive of the body to destroy infectious organisms. B-lymphocyte
the pneumococcal vaccine.10 This number is markedly cells, producing immunoglobulins, are less efficient in the
decreased for older Hispanic and African American adults.10 presence of fewer and weaker T cells.38,41
To improve vaccination coverage of older adults, the Older adults with chronic illnesses who are hospi-
National Guidelines Clearinghouse guidelines (http://www. talized or who are in a nursing home are at increased risk
guideline.gov) recommends interventions to enhance access for infection. When assessing older adults for infection, it
to vaccination services, provider or system based interven- is important for the nurse to realize that the signs of infec-
tions, and interventions in increase client demand for vacci- tion can be altered with aging. With the aging-related
nation services. Interventions to enhance access to changes of the immune system, and problems with temper-
vaccination services for older adults include expanded ature regulation, it is not unusual for seriously ill older
access to vaccinations in health-care settings and reducing adults to be afebrile while suffering from an infection.
the client’s out-of-pocket costs for vaccinations. Provider or Atypical symptoms leading the nurse to suspect infection in
system based interventions include provision of standing the older adult include mental status changes, anorexia,
orders for clients when indicated, provider reminder sys- functional decline, fatigue, falls, and new or worsened uri-
tems, and provider assessment and feedback. Interventions nary incontinence.40–43
Health Perception/Health Energy Field Disturbed Therapeutic Touch Personal Health Status
Management Pattern Personal Well-Being
Spiritual Health
Health Maintenance, Health System Health Belief: Perceived
Ineffective Guidance Resources
Support System Health-Promoting Behavior
Enhancement Health-Seeking Behavior
Knowledge: Health Behavior;
Health Promotion; Health
Resources; Treatment Regime
Participation in Health-Care
Decisions
Personal Health Status
Risk Detection
Self-Care Status
Student Health Status
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*Linkages to these concepts are not present in current NANDA, NIC, and/or NOC literature.
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Energy Field, Disturbed • 37
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38 • Health Perception–Health Management Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Redirect areas of accumulated energy, reestablish the Energy transfer or transformation can occur without
energy flow, and direct energy to depleted areas. direct physical contact between two systems.45 Hands
Repattern or rebalance patient’s energy field. are focal points for the direction and modulation of
energy.45
Do therapeutic touch for no longer than 10 minutes. Could disrupt the energy field of the therapist.
Assess the patient’s subjective reaction to therapeutic Nurse acts as a conduit through which the environmental
touch. Patient should feel more relaxed, less anxious, or universal energy passes to the patient.45,46
and less pain (if there were complaints of pain prior to
therapeutic touch).
Teach the patient relaxation exercises using some of the
same techniques as therapeutic touch:
• Assist the patient to center self. Relaxation requires the patient to stop trying and to step
• Teach the patient to imagine a peaceful place. Help the outside of self and adopt a nontrying attitude. This
patient to visualize place through all the senses and to allows the person to release and use the inherent
allow the energy of the imagined place to bring about a energy of self.46
state of calmness.
• Teach the patient to scan his or her body to self-assess
areas of body or muscle tension.
• Assist the patient to consciously relax that tense area of Rebalances energy flow through the body.46
the body.
• Practice relaxation at least 10 to 20 minutes a day.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for reciprocity of maternal–infant dyad. Provides assessment for causative factors and the mutual-
ity or responsiveness between infant and caregiver.
*Consider potential effects of medications as antiseizure
meds.
Identify developmentally appropriate parameters to deter- Disturbed energy fields may be related to numerous other
mine the most conducive and therapeutic method for altered patterns due to the infant or child’s basic cop-
monitoring the child’s energy field.47,48 ing repertoire, especially altered thermoregulation–
altered neurologic status. Approaching the infant or
child according to cues for behavior potential yields
greater likelihood of stress reduction.
Monitor energy field with a focus on maintaining self- Will enhance assessment of energy field.
comforting activities for the child. May begin with soft
music and/or soothing voice.47,48
Begin with gentle but firm pressure of hands on one Warms hands.
another.
Assess energy field from head to toe. Focus on determin- Routine assessment.
ing sites where differences are present. Refer to Adult
Health-Care Plan for additional details.
Attempt to redirect areas of lesser flow or greater flow Restores balance. The infant or child has a small energy
within an overall free-flowing energy field, allowing 1/2 field.
to 1 inches between nurse’s hands and the child.
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Energy Field, Disturbed • 39
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the client’s responses to therapeutic touch. Focus Permits evaluation of success of therapy.
on identifying stimulus response.
Teach the client (or family, depending on client’s age) to Promotes early intervention.
note physical and mental cues that alter energy field,
especially stressors.49,50
Offer age-appropriate relaxation techniques (e.g., imagi- Pays attention to developmental level.
nary floating like a feather to suggest lightness for a
school-ager vs. gentle rocking to rhythmic music for an
infant).51,52
Be mindful of contributing factors of self. Offer ways to Provides long-term assistance.
assist the caregiver in learning techniques for mainte-
nance of energy field balance.
As appropriate, assist family to develop ways to reduce Provides long-term balance.
sensitivity to external triggering cues.
Women’s Health
Same as Adult Health except for the following:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Instruct in use of therapeutic touch, relaxation, imagery Provides a natural source of dealing with the discomfort
and visualization, paced breathing, music, acupressure, of labor.53–60 Allows the woman and her newborn to
and hypnosis as a means of coping with labor pain.53 experience a drug-free labor and delivery.
Instruct women in the use of NAC for relaxation and self- NAC (Natural, alternative, complementary health-care
care during times of illness and stress throughout their practices) have a limited research base at the present
life span. Some of these therapies include such practices time; but women throughout the ages have used these
as acupressure and acupuncture, artistic expression, techniques to become tuned into the energy surround-
biofeedback, deep breathing, healing touch hypnosis, ing a person’s being and the harmony of body, mind
imagery, music, prayer, relaxation, therapeutic touch and spirit. “Women have always been healers. Cultural
and other practices which support women’s psychoso- myths from around the world describe a time when
cial and spiritual components, as well as their physical only women knew the secrets of life and death, and
domain.58–60 therefore they alone could practice the magical art of
healing.”60
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Explain intervention to the client in terms that facilitate Prevents reinforcement of delusional system and facili-
reality orientation and do not exacerbate thought disor- tates the development of a trusting relationship.61
ders.
• Use examples that elicit the client’s past experiences
with personal energy fields that do not reinforce delu-
sional beliefs (e.g., EEG and EKG measure electrical
energy that flows from the body; walking across the
floor and then touching something releases the buildup
of energy that can be seen or felt as a mild shock).
Rubbing a balloon over the hair and watching it stand
up when the balloon is moved away is another example.
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Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Instruct the client that these techniques facilitate his or
her own healing potential and are used in conjunction
with other treatments.
Discuss with the client his or her perceptions or concerns Understanding the client’s cognitive map facilitates the
about their alterations. development of interventions that facilitate client
change.61,64
Discuss with the client interventions that can assist with All these techniques have been demonstrated to have
energy balance. In consultation with the client select effects on the body’s energy fields.45,46,53,57,62–64
one of the following methods for altering energy fields Application of these interventions by the nurse is
based on the assessment: related to having appropriate training in the technique.
• Therapeutic touch If the nurse is unskilled in the techniques, efforts
• Foot or hand reflexology should be made for appropriate referrals at this point.
• Visual imagery Additional information on these techniques can be
• Visualization with relaxation techniques found in the references.
• Acupressure
• Transcutaneous electrical nerve stimulation (TENS)
• Biofeedback
Note referral information here with date and time of
appointment with practitioner.
If the nurse is prepared to implement the intervention, Increases the client’s level of comfort.55,64
prepare the client and environment for the application
of the intervention:
• Provide private, quiet environment.
• Teach the client about the intervention.
• Obtain the client’s permission to utilize the Builds trust and promotes the client’s sense of
intervention. control.55,64
• Provide appropriate music that increases the client’s Sound that is loud and irritating can have a negative
feelings of comfort. impact on psychological and physiologic well-being.44
• Provide essential oils or other scents that enhance the Odors have impact on the limbic system and impact
client’s sense of well-being. affect.
Focus own attention on the intent of the interaction. The nurse’s intention provides a crucial basis for these
interventions.45,48,58
Inform the client that he or she should tell the practitioner Changes that occur with alterations in the energy fields
if there are any differences in the way he or she feels may be perceived by the client before the practitioner
during the application of the technique. This could notices a difference. The goal of these interventions
include feelings of relaxation, warmth, or change in is to promote balance, so the treatment should stop
breathing patterns. when these differences are observed by the client or
practitioner.45,46,65 Also promotes the client’s sense of
control.45,46
Assist the client into a comfort position that will facilitate It is important that the client is well supported because
treatment. the techniques do promote the relaxation response.
Utilize selected technique [number] times a day for The ability of the client to maintain balance is based on
[number] minutes. Observe the client for signs that general levels of wellness, lifestyle, and stressors.65
indicate that the desired effect has occurred. This could
include:
• Sigh
• Relaxation in muscles
• Slower, deeper breathing
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Drop in voice volume
• Peripheral flush on the face and neck
• Client’s report of feeling different
• Reassessment indicates balance has occurred
Assist the client into a comfortable, relaxed position after
treatment.
Teach the client techniques that can maintain balance Maintenance of energy field balance involves a holistic
between treatments and that do not require the assis- approach to care and has been demonstrated to have
tance of a practitioner, including: effects on human energy fields.45–53,62,65–68
• Relaxation
• Cross crawl exercises
• Stress reduction
• Cognitive reframing
• Visualization
• Improved nutrition
• Decreasing use of tobacco and alcohol
Note teaching schedule and content here.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Obtain medication profile (prescription and over-the- Medications may contribute to disturbed energy fields.
counter) to determine whether drug actions or reactions
contribute to the disturbance.
Ensure adequate padding and proper position for any Proper positioning prevents pain, pressure, and thus dis-
sessions. turbances in concentration.
Adjust massage efforts and pressure to compensate for Older adults, with aging changes in the nervous sys-
changes in an older patient’s tactile sensation. tem, may have a decreased perception of being
touched.
Use teaching materials, as needed, that are appropriate Uncompensated sensory changes of aging can affect the
for the patient (such as printed information of a size ability to use audio–visual sources if the information is
that is easily read, or quality audiotapes that are not not adjusted to meet the older adult’s needs.
distorted or high pitched).
Discuss with the client use of complementary or alterna- Older adults may experience psychological or spiritual
tive therapies prior to initiating therapies. distress if therapies used cause a conflict with their
belief system. (Some adults may react negatively to
therapeutic touch, perceiving it as “laying on of hands”
in a religious manner.)70
Teach clients or caregivers relaxation strategies, use of The therapies listed are recommended for older adults
guided imagery, massage, or music therapies to pro- who would benefit from the reduced sympathetic
mote stress reduction. response to stress. The physical and psychological
changes associated with aging can increase stress and
impede body/mind healing.63,71
Ensure that therapeutic touch sessions, if used, are of Caution is recommended when using therapeutic touch
brief duration and gently done. with infants, very debilitated patients, and the elderly.59
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Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Document older adult’s use of any complementary or Many adults are reluctant to discuss use of alternative
alternative therapies, to include preferred treatment, therapies. Nondisclosure may lead to adverse reactions
frequency of treatments, and effects experienced. from drug, food, or herb interactions.69,70
Discuss with clients potential effects from complemen- Little research is currently available on the effects of
tary or alternative therapies, such as dizziness or weak- complementary or alternative therapies on older adults.
ness after acupuncture, risk for fractures with Cautioning clients on potential effects may reduce the
chiropractic, and drug or herb interactions. risk for injury or adverse reactions.70
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client and family to identify disturbances in Early identification assists in providing early intervention.
energy field.
Teach the client and family techniques to prevent and/or Involvement improves motivation and improves the out-
treat disturbed energy field, such as: come. Self-care is enhanced.
• Therapeutic touch
• Foot or hand reflexology
• Visual imagery
• Visualization with relaxation techniques
• TENS
• Biofeedback
Assist the client and family in providing a private, quiet Client comfort is increased, and response to intervention
environment. is enhanced.61,67
Assist the client and family in identifying resources in the Use of existing community services is efficient use of
community, such as: resources.
• Massage therapist
• Reflexologists
• Stress reduction classes
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44 • Health Perception–Health Management Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Stopping smoking53,71–74
• Ceasing drug and alcohol use
• Establishing exercise patterns75
• Following good nutritional habits
• Using stress management techniques
• Using family and community support systems
• Using over-the-counter medications
• Using herb, vitamins, food supplements, or cleansing
programs76
Develop with the patient a list of assets and deficits as Increases the patient’s sense of control and keeps the idea
he or she perceives them. From this list, assist the of multiple changes from being overwhelming.
patient in deciding what lifestyle adjustments will
be necessary.
Identify, with the patient, possible solutions, modifica- The more the patient is involved with decisions, the
tions, etc., to cope with each adjustment. higher the probability that the patient will incorporate
the changes.
Develop a plan with the patient that shows both short- Avoids overwhelming the patient by indicating that not
term and long-term goals. For each goal, specify the all goals have to be accomplished at the same time.
time the goal is to be reached.
Have the patient identify at least two support persons. Provides additional support for patient in maintaining
Arrange for these persons to come to the unit and plan.
participate in designing the health maintenance plan.
Assist the patient and significant others in developing a People most often approach change with “more of the
list of potential strategies that will assist in the devel- same” solutions. If the individual does not think that
opment of the lifestyle changes necessary for health the strategy will have to be implemented, he or she will
maintenance. (This list should be a brainstorming be more inclined to develop creative strategies for
process and include both solutions that appear to be change.76
very unrealistic as well as those that appear most real-
istic.) After the list is developed, review each item with
the patient, combining and eliminating strategies when
appropriate.
Develop with the patient a list of the benefits and disad- Placing items in priority according to the patient’s moti-
vantages of behavior changes. Discuss each item with vation increases probability of success.
the patient as to the strength of motivation that each
item has.
Develop a behavior change contract with the patient, Positive reinforcement enhances self-esteem and supports
allowing the patient to identify appropriate rewards and continuation of desired behaviors. This also promotes
consequences. Remember to establish modest goals patient control, which in turn increases motivation to
and short-term rewards. [Note reward schedule here.] implement the plan.55
Teach the patient appropriate information to improve Provides the patient with the basic knowledge needed to
health maintenance (e.g., hygiene, diet, medication enact the needed changes.
administration, relaxation techniques, and coping
strategies).
Review activities of daily living (ADLs) with the patient Incorporation of usual activities personalizes the plan.
and support person. Incorporate these activities into the
design for a health maintenance plan.
● N O T E : May have to either increase or decrease ADLs.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient and support person to design a monthly Provides a visual reminder.
calendar that reflects the daily activities needed to suc-
ceed in health maintenance.
Have the patient and support person return/demonstrate Permits practice in a nonthreatening environment where
health maintenance procedures at least once a day for immediate feedback can be given.
at least 3 days before discharge. Times and types of
skills should be noted here.
Set a time to reassess with the patient and support person Provides an opportunity to evaluate and to give the
progress toward the established goals. This should be patient positive feedback and support for achievements.
on a frequent schedule initially and can then gradually
decrease as the patient demonstrates mastery. [Note
evaluation times here.]
Provide the patient with appropriate positive feedback on
goal achievement. Remember to keep this behaviorally
oriented and specific.
Communicate the established plan to the collaborative Provides continuity and consistency in care.
members of the health-care team.
Refer the patient to appropriate community health agen- Ensures the service can complete their assessment and
cies for follow-up care. Be sure referral is made at initiate operations before the patient is discharged from
least 3 to 5 days before discharge. the hospital. Use of the network of existing community
services provides for effective utilization of resources.
Schedule appropriate follow-up appointments for patient Facilitates patient’s keeping of appointments and rein-
before discharge. Notify transportation service and forces importance of health maintenance.
support persons of these appointments. Write appoint-
ment on brightly colored cards for attention. Include
date, time, appropriate name (physician, physical thera-
pist, nurse practitioner, etc.), address, telephone num-
ber, and name and telephone number of person who
will provide transportation.
Child Health
● N O T E : Developmental consideration should always guide the health maintenance
planned for the child patient. Also, identification of primary defects is stressed to reduce
the likelihood of secondary and tertiary delays.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine who is the patient’s primary caregiver. Fosters the likelihood for continuity of care and who is
accountable for care of child.
Teach the patient and family essential information to An individualized plan of care more definitively reflects
establish and maintain health according to age, devel- specific health maintenance needs and increases the
opment, and status. Well checks are suggested at time value of the plan to the patient and his or her family.
of immunization with access to a health-care provider
for annual checks or in time of illness after 1 year in
the absence of a chronic health-care need.
Assist the patient and family in designing a calendar to Reinforcement in a more tangible mode facilitates com-
monitor progress in meeting goals. Offer developmen- pliance with the plan of health maintenance, especially
tally appropriate methods (e.g., toddlers enjoy stickers with long-term situations.
of favorite cartoon or book characters).
(care plan continued on page 46)
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46 • Health Perception–Health Management Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Identify risk factors that will impact health-care mainte- Identification of risk factors allows for more appropriate
nance (e.g., prematurity, congenital defects, altered anticipatory planning of health care, assists in minimiz-
neurosensory functioning, errors of metabolism, or ing crises and escalation of simple needs, and serves to
altered parenting). reduce anxiety.
Begin to prepare for health maintenance on initial meet- A holistic plan of care realistically includes futuristic
ing with child and family. goals, not merely immediate health needs.
Provide appropriate telephone numbers for health team Anticipatory planning for potential need for communica-
members and clinics to the child and parents to assist tion allows the patient or family realistic methods for
in follow-up. assuming health care while enjoying the back-up of
resources.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient to describe her perception and under- Allows assessment of the patient’s basic level of knowl-
standing of essential information related to her individ- edge so that a plan can begin at the patient’s current
ual lifestyle and the adjustment necessary to establish level of understanding.
and maintain health in each cycle of reproductive life.
Develop with the patient a list of stress-related problems Provides essential information to assist patient in plan-
at work and at home as she perceives them. From this ning a healthy lifestyle.
list, assist the patient in deciding what lifestyle adjust-
ments will be necessary to establish and maintain
health.
Cigarette smoking is not only detrimental to the health of Experts recommend following PHS (US Public Health
women, but it is also the causing factor involved with Service: Treating Tobacco Use and Dependence
morbidity and mortality. One in four women smoke Practice Guidelines)79 guidelines, which recommend
and more than 3.1 million adolescents in America are three types of effective counseling and therapy79,80:
cigarette smokers.78 • Skill training
• Intra-treatment-clinician support
• Extra-treatment-social support
Consider psychosocial elements of women’s lifestyle
when offering interventions to stop smoking. Augment
strategies with specific information related to each life
cycle. (Adolescence, reproductive, mid-life, elder)78
Identify, with the patient, possible solutions and Provides sequential steps to alternate health maintenance
modification to facilitate coping with adjustments. within a defined time period. Keeps the patient from
Develop a plan that includes short-term and long- being overwhelmed by all the changes that might be
term goals. For each goal, specify the time frame for necessary.
reaching the goal.
Provide factual information to the patient about menstrual Provides basic information and knowledge that is needed
cycle patterns throughout the life span. Include prepu- throughout life span.
bertal, menarcheal, menstrual, premenopausal,
menopausal, and postmenopausal phases.81
Teach the patient how to record accurate menstrual cycle, Provides the patient with the information necessary to
obstetric, and sexual history. Assist the patient in rec- cope with changes throughout the reproductive cycle.
ognizing lifestyle changes that occur as a part of nor-
mal development.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss pregnancy and the changes that occur during Provides patient with the information needed to plan for a
pregnancy and childbearing. Stress the importance healthy pregnancy.
of a physical examination before becoming pregnant
to include a Pap smear, rubella titer, AIDS profile,
and genetic workup (if indicated by family history).
Describe to and assist the patient in planning routines that Provides the expectant family with information to enable
will maintain well-being for the mother and fetus dur- them to make informed choices about pregnancy, child-
ing pregnancy (e.g., reducing fatigue, eating a nutri- birth, and beginning parenting.
tionally adequate diet, exercising properly, obtaining
early prenatal care, and attending classes to obtain
information about infant nutrition, infant care, and the
birthing experience).
Provide information and support during postpartum
period to assist the new mother in establishing and
maintaining good infant nutrition, whether breastfeed-
ing or formula feeding.
Refer the patient to appropriate groups for support and
encouragement after birth of baby (e.g., La Leche
League and parenting groups).
Teach terminology and factual information related to Allows the patient to grieve and reduces fear regarding
spontaneous abortion or the interruption of pregnancy. subsequent pregnancies.
Encourage expression of feelings by the patient and her
family. Provide referrals to appropriate support groups
within the community.
Provide contraceptive information to the patient, includ- Allows the patient to plan appropriate contraceptive
ing describing different methods of contraception and measures according to personal values and beliefs.
their advantages and disadvantages.
Emphasize the importance of lifestyle changes necessary Provides the patient with basic information that will
to cope with postmenopausal changes in the body, such assist in planning a healthy lifestyle during and follow-
as estrogen replacement therapy, calcium supplements, ing menopause. Discuss use of alternative therapies for
balanced diet, exercise, and routine sleep patterns. hormone replacement therapy.60,80–83
Teach the patient the importance of routine physical Provides knowledge that allows the patient to plan a
assessment throughout the reproductive life cycle, healthy lifestyle.
including breast self-examination, Pap smears, and
routine examinations by the health-care provider of
her choice (e.g., nurse midwife, nurse practitioner, or
physician).
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend 30 minutes once a day discussing client’s percep- Behavior change that is developed with the client using
tion of current situation and life/personal goals before the client’s identified needs and co-evolved solutions
the changes occurred: improves outcomes.84-86
• Use open-ended questions and reflective listening.
• Let the client be the expert.
• Do not provide advice.
Provide positive verbal reinforcement for the client’s Positive reinforcement increases behavior.87
strengths and previous successes.
(care plan continued on page 48)
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48 • Health Perception–Health Management Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss client’s understanding of the options to facilitate Positive reinforcement increases behavior.87
the identified changes. Reflect to client nurse’s under-
standings of the client’s solutions and goals.
Summarize the solutions and goals that the client iden-
tified. Develop a schedule for positive reinforcement
when goals are attained. [Note the reinforcers and
schedule of reinforcement here.]
Discuss with client sources of social support: Social support improves health outcomes.88
• Schedule meeting with client and social support sys-
tem. Note the date and time of that meeting here.
• Spend 1 hour one time per week meeting with client
and social support system to focus on:
• With client’s permission educate support system
about client’s health-care needs
• Model communication and assist support system in
developing positive communication skills
Include the client in group therapy to provide positive Group provides opportunities to relate and react to others
role models and peer support and to permit assessment while exploring behavior with each other.87
of goals and exposure to differing problem solutions.
Gerontic Health
● N O T E : Interventions provided in the adult health section are applicable to older
adults. The major emphasis here is on client education. Ageism may present barriers to
teaching older clients. The older adult is capable of learning new information.89
Teaching strategies are available to enhance the learning experience for older adults.90
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ensure privacy, comfort, and rapport prior to teaching Reduces anxiety and promotes a non-distracting environ-
sessions. ment to enhance learning.
Avoid presenting large amounts of information at one This encourages increased opportunity to process and
time. store new information.
Monitor energy level as teaching session progresses. Reduces possibility of fatigue which can impair learning.
Present small units of information, with repetition, and Compensates for delayed reaction time associated with
encourage patient to use cues that enhance ability to aging. Promotes retention of information by connecting
recall information. information to previously mastered skills.90
Use multisensory approach to learning sessions whenever Hearing, vision, touch, and smell used in conjunction can
possible. stimulate multiple areas in the cerebral cortex to pro-
mote retention.91
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client and family to identify home and work- This action enhances safety and assists in preventing
place factors that can be modified to promote health accidents. Promoting a nonsmoking environment helps
maintenance (e.g., ramps instead of steps, elimination reduce the damaging effects of passive smoke.
of throw rugs, use of safety rails in showers, and main-
tenance of a nonsmoking environment).92,93
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Health-Seeking Behaviors (Specify) • 49
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client and family in planning, implementing, Involvement improves motivation and outcomes.
and promoting a health maintenance pattern through:
• Establish family conferences to discuss strategies for
meeting client health maintenance needs.
• Engage in mutual goal setting with client and family.
Plan strategies with the client/family to establish goals
for their involvement in managing the therapeutic
regimen.
• Assist family members in acquiring family or commu-
nity based assistance for specified tasks as appropriate
(e.g., cooking, cleaning, transportation, companionship,
or support person for exercise program).
Teach the family and caregivers about disease manage- Provides a sense of autonomy and prevents premature
ment for existing illness: progression of illness.
• Symptom management
• Medication effects, side effects, and interactions with
over-the-counter medications
• Reporting the use of over-the-counter remedies, herbal
supplements and medicines to the health-care provider
• Wound care as appropriate. Prevention of skin break-
down for clients with illnesses contributing to immo-
bility.
Teach the client and family health promotion and disease These activities promote a healthy lifestyle.
prevention activities:
• Relaxation techniques
• Nutritional habits to maintain optimal weight and phys-
ical strength
• Techniques for developing and strengthening support
networks (e.g., communication techniques or mutual
goal setting)
• Physical exercise to increase flexibility, cardiovascular
conditioning, and physical strength and endurance94
• Evaluation of occupational conditions94
• Control of harmful habits (e.g., control of substance
abuse)
• Therapeutic value of pets95
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50 • Health Perception–Health Management Pattern
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Health-Seeking Behaviors (Specify) • 51
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the child and family for perceived value of Values are formulated in the first 6 years of life and will
health. Incorporate into any plan personal and family serve as primary factors in how health is perceived and
needs identified through this monitoring. enjoyed by the individual and family. If values are in
question, there is greater likelihood that how health to
be maintained will be subject to this values conflict.
Until health-seeking behavior is identified as a value,
follow-up care will not be deemed to be beneficial.
Assist the child and family to identify appropriate health Knowing available resources and incorporating these
maintenance needs and resources (e.g., immunizations, resources into the plan for health care facilitate long-
nutrition, daily hygiene, basic safety, how to obtain term attention to health.
medical services when needed [including health educa-
tion], how to take temperature of an infant, basic skills
and care for health problems, health insurance,
Medicaid, and related state resources).
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the patient the importance of seeking information Provides the basic information needed to support health-
and support during the reproductive life cycle. Include seeking behaviors.
information about prepubertal, menarcheal, menstrual,
childbearing, parenting, menopausal, and post-
menopausal periods of the life cycle.
Provide woman with information about health tests and Most chronic diseases that affect women can be pre-
screenings at various life stages. These tests include: vented. Knowing the risk factors and the modifying
• Blood glucose behaviors can greatly reduce the number of women
• Blood pressure facing chronic illness and even death. Cardiac disease
• Bone density test (osteoporosis) is the number one killer of women in this country.
• Breast cancer screenings Research has shown that most morbidity and mortality
• Cardiovascular disease risk assessment of women can be greatly decreased by routing screen-
• Cholesterol ing, diagnosis, counseling and behavior modification.96
• Colorectal exam
• Dental checkup
• Eye exam
• Hearing test
• Pap test and pelvic exam
• Routine physical
• Thyroid screening
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assign the client a primary care nurse. Provides increased individuation and continuity of care,
facilitating the development of a therapeutic relation-
ship. The nursing process requires that a trusting and
functional relationship exist between nurse and client.61
(care plan continued on page 52)
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52 • Health Perception–Health Management Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Primary care nurse will spend 30 minutes twice a day Promotes the client’s trust in the nurse and perception of
with client [note times here]. The focus of these inter- control.85–87
actions will conform to the following schedule:
• Interaction 1: Have the client identify specific areas of Promotes the client’s perception of control.
concern. List the identified concerns on the care plan.
Also identify the primary source of this concern (i.e.,
client, family member, member of the health-care team,
or other members of the client’s social system).
• Interaction 2: List specific goals for each concern the Promotes the client’s self-esteem when goals can be
client has identified. These goals should be achievable accomplished.87
within a 2- to 3-day period. (One way of setting realis-
tic, achievable goals is to divide the goal described by
the client by 50 percent.)
• Interaction 3: Have the client identify steps that have Promotes the client’s self-esteem and provides motivation
been previously taken to address the concern. for continued efforts.
• Interaction 4: Determine the client’s perceptions of
abilities to meet established goals and areas where assis-
tance may be needed. (If the client indicates a perception
of inability to pursue goals without a great deal of assis-
tance, the alternative nursing diagnoses of Powerlessness
and Knowledge Deficit may need to be considered.)
Assist client in developing strategies to achieve the estab-
lished goals, developing action plans, evaluating the
outcome of these plans, and then revising future
actions in future interactions. [Note schedule of these
interactions here.]
Provide positive verbal reinforcement for client’s achieve-
ments of goals. This reinforcement should be specific
to the client’s goals. [Note those things that are reward-
ing to the client here and the kind of behavior to be
rewarded.]
Gerontic Health
In addition to interventions for Adult Health, the following may be used with the older client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage the client to participate in health-screening Provides a cost-effective, easily accessible, long-term
and health-promotion programs such as Senior support mechanism for the patient.
Wellness Programs. These programs are often offered
by hospitals, clinics, and senior citizens centers.
Ensure privacy, comfort, and rapport prior to teaching Reduces anxiety and promotes a nondistracting environ-
sessions. ment to enhance learning.
Avoid presenting large amounts of information at one This encourages increased opportunity to process and
time. store new information.
Monitor energy level as teaching session progresses. Reduces possibility of fatigue which can impair learning.
Present small units of information, with repetition, and Compensates for delayed reaction time associated with
encourage patient to use cues that enhance ability to aging. Promotes retention of information by connecting
recall information. information to previously mastered skills.90
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Health-Seeking Behaviors (Specify) • 53
ACTIONS/INTERVENTIONS R AT I O N A L E S
Use multisensory approach to learning sessions whenever Hearing, vision, touch, and smell used in conjunction can
possible. stimulate multiple areas in the cerebral cortex to pro-
mote retention.91
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Help the client identify his or her personal definition Awareness of definition of health, locus of control, per-
of health, perceived personal control, perceived self- ceived efficiency, and health status identifies potential
efficacy, and perceived health status. facilitators and barriers to action.
Assist the client in identifying required lifestyle changes. Lifestyle changes require change in behavior. Self-
Assist the client to develop potential strategies that evaluation and support facilitate these changes.
would assist in the lifestyle changes required.
Assist the client and family to identify home and work- This action enhances safety and assists in preventing
place factors that can be modified to promote health accidents. Promoting a nonsmoking environment helps
maintenance (e.g., ramps instead of steps, elimination reduce the damaging effects of passive smoke.
of throw rugs, use of safety rails in showers, and main-
tenance of a nonsmoking environment).74,89,90
Involve the client and family in planning, implementing, Involvement improves motivation and outcomes.
and promoting a health maintenance pattern through:
• Helping to establish family conferences to discuss
strategies for meeting client health maintenance needs.
• Engaging in mutual goal setting with client and family.
Encourage the client/family to establish goals for their
own involvement in managing the therapeutic regimen.
• Assisting family members in acquiring family or
community-based assistance for specified tasks as
appropriate (e.g., cooking, cleaning, transportation, com-
panionship, or support person for exercise program)
Teach the family and caregivers about disease manage- Provides a sense of autonomy and prevents premature
ment for existing illness: progression of illness.
• Symptom management
• Medication effects, side effects, and interactions with
over-the-counter medications
• Reporting the use of over-the-counter remedies, herbal
supplements and medicines to the health-care provider
• Wound care as appropriate. Prevention of skin breakdown
for clients with illnesses contributing to immobility.
Teach the client and family health promotion and disease These activities promote a healthy lifestyle.
prevention activities:
• Relaxation techniques
• Nutritional habits to maintain optimal weight and physi-
cal strength
• Techniques for developing and strengthening support
networks (e.g., communication techniques or mutual
goal setting)
• Physical exercise to increase flexibility, cardiovascular
conditioning, and physical strength and endurance
• Evaluation of occupational conditions
• Control of harmful habits (e.g., control of substance
abuse)
• Therapeutic value of pets95
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Infection, Risk For • 55
ACTIONS/INTERVENTIONS R AT I O N A L E S
Maintain adequate nutrition and fluid and electrolyte bal- Helps prevent disability that would predispose infection.
ance. Provide a well-balanced diet with increased
amounts of vitamin C, sufficient iron, and 2400 to
2600 mL of fluid daily.
Collaborate with the physician regarding screening speci- Allows accurate determination of the causative organism
mens for culture and sensitivity (e.g., blood, urine, spu- and identification of the antibiotic that will be most
tum, and spinal fluid). effective against the organism.
Monitor the administration of antibiotics for maintenance Antibiotics have to be maintained at a consistent blood
of blood levels and for side effects (e.g., diarrhea or level, usually 7–10 days, to kill causative organisms.
toxicity). Antibiotics may destroy normal bowel flora, predispos-
ing the patient to the development of diarrhea and
increasing the chance of infection in the lower gas-
trointestinal tract.
Maintain a neutral thermal environment. Avoids overheating or overcooling of room that would
contribute to complications for the patient.
Assist the patient with a thorough shower at least once Reduces microorganisms on the skin.
daily (dependent on age) or total bed bath daily.
Provide good genital hygiene, and teach the patient how Also enhances feeling of well being, and prevents spread
to care for the genital area. of opportunistic infections.97,99
Wash your hands thoroughly between each treatment. Prevents cross-contamination and nosocomial infections.
Teach the patient the value of frequent handwashing.
Use sterile technique when changing dressings or per- Protects the patient from exposure to pathogens.100
forming invasive procedures.
Turn every 2 hours on [odd/even] hour. Promotes tissue perfusion.
Perform passive exercises or have the patient perform
active range of motion (ROM) exercises every 2 hours
on [odd/even] hour. Remember that the patient may
have decreased tolerance of activity.
Cough and deep-breathe every 2 hours on [odd/even] Mobilizes static pulmonary secretions, thereby improving
hour. gas exchange.
Consult with appropriate assistive resources as indicated. Appropriate use of existing community service is effi-
cient use of resources.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for all contributing factors to include pharmaco- Widest consideration will likely identify how the threat of
logic agents, recent exposures, and deviations in infection will be met.
immune status.
Monitor axillary temperature every 2 hours on [odd/even] Most appropriate route for frequent measurements for the
hour. (May be assessed per rectal or tympanic accord- very young child. Oral temperature measurements
ing to health-care provider’s preference.) would not be accurate.
Institute aseptic precautions. Provides basis for decreased likelihood of reinfection.
Provide instructions to child at developmentally appropri- Allows for meeting child’s needs for understanding as
ate level and to parents while instituting infectious pre- questions are answered. This helps to insure appropri-
cautions as applicable. ate precautions are upheld to prevent spread to others
including family members.
If neutropenic precautions are necessary, monitor CBC Provides essential basis for diagnosis and treatment.
and absolute neutrophil count.
Obtain specimens as required, esp. blood, urine, and stool. Ensures baseline and follow-up monitoring for adequacy
(May require lumbar puncture for septic work-up.) of treatment/status.
(care plan continued on page 56)
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56 • Health Perception–Health Management Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Administer medications as scheduled with attention to Abides by safe practice of administration of medications
appropriate dosage for weight/indication, peak and within desired blood levels.
trough results, and potential for allergenic response. Monitoring for side effects yields likelihood of early
detection to lessen severity of possible anaphylaxis.
Encourage the child and parents to verbalize fears, con- Provides support, decreases anxiety and fears, and pro-
cerns, or feelings related to infection by scheduling at vides teaching opportunity.
least 30 minutes per shift to counsel with family. Note
times here.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
During prenatal period, inform the mother about and how Infections acquired during pregnancy can cause signifi-
to prevent perinatal infections: cant morbidity and even mortality for both mother
• Encourage the mother to avoid frequent changing of and/or infant.29
partners and other high-risk sexual behaviors while Pregnancy is considered an immunosuppressed state.
pregnant. Responses of the immune system during pregnancy
Teach the mother good preventive health-care behaviors may decrease the mother’s ability to fight infection.
such as:
• Maintaining good nutrition Researchers agree that strong links exist between good
• Teach strategies that allow women to gain and utilize nutrition and the prevention of diseases such as osteo-
maximum energy by eating nutritiously, including porosis, cardiac disease, and certain female cancers. In
identifying supplements that can augment energy fact, nutrition is one of the biggest factors in women’s
levels. health throughout all the stages of her life.101,102
• Perform a dietary assessment and provide a nutri- The recommended energy intake during the first 6 months
tional education to the breastfeeding woman. of lactation can be reached by having one extra meal
• Getting correct amount of sleep per day (approximately 500 kcal).103
• Exercise
• Reducing stress levels
Test the mother for presence of TORCH infections. This is a group of organisms that cross the placenta and
interfere with the development of the fetus and health
of the newborn infant.
Toxoplasmosis, Hepatitis B, Rubella, Cytomegalovirus,
Herpes. Other infections such as Chlamydia, Group B
Streptococcus, Syphilis, HIV and AIDS are also of
great concern as all of these infections have conse-
quences for not only the pregnancy but also the
newborn.29
In the presence of ruptured amniotic membranes, monitor Provides clinical data needed to quickly recognize the
for signs of infection at least every 4 hours at [state presence of infection.
times here] (e.g., elevated temperature or vaginal dis-
charge odor).
Use aseptic technique when performing vaginal examina- Reduces the opportunities to introduce infection.
tions, and limit the number of vaginal examinations
during labor.
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Infection, Risk For • 57
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the mother to take only showers (no tub baths) and Teaches the patient basic information to recognize and
to monitor and record temperature. Have her take tem- prevent infection.
perature at least every 4 hours on a set schedule.
Keep linens and underpads clean and changed as neces- Reduces the likelihood of nosocomial infections.
sary during labor.
Monitor incisions (cesarean section or episiotomy) at Provides clinical data needed to quickly recognize the
least every 4 hours at [state times here] for redness, presence of infection.
drainage, oozing, hematoma, or loss of approximation.
During postpartum period, monitor fundal height at least Provides database necessary to screen for infection.
every 4 hours at [state times here] around the clock for
48 hours.
During postpartum period, monitor the patient at least Provides clinical data needed to quickly recognize the
every 4 hours at [state times here] for any signs of foul presence of infection.
smelling lochia, uterine tenderness, or increased tem-
perature.
In instances of abortion, obtain a complete obstetric
history.
Monitor abdomen at least every 4 hours at [state times
here] for any swelling, tenderness, or foul-smelling
vaginal discharge following an abortion.
If meconium is present in amniotic fluid, immediately Helps prevent aspiration pneumonia in the infant.
clear airway of the infant by suctioning (preferably
done by physician immediately on delivery of the
infant’s head).
Suction gastric contents immediately. Observe for sternal Indicates development of respiratory complications sec-
retractions, grunting, trembling, jitters, or pallor. If any ondary to meconium.
of these signs are present, notify the physician at once.
Wash hands each time before and after you handle the Prevents development of nosocomial infections.
baby.
Avoid wearing sharp jewelry that could scratch the baby.
Keep umbilical cord clean and dry by cleansing at each
diaper change or at least every 2 hours on [odd/even]
hour.
Monitor circumcision site for swelling, odor, or bleeding Gives parents basic information regarding prevention
each diaper change or at least every 2 hours on of infection and monitoring for the development of
[odd/even] hour. infection.
Demonstrate and have parent return/demonstrate:
• How to take the baby’s temperature measurement
• How to properly care for umbilical cord and
circumcision
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the temperature of clients receiving antipsychotic These clients are at risk for developing agranulocytosis.
medications twice a day, and report any elevations to The greatest risk is 3 to 8 weeks after therapy has
physician. [Note times for temperature measurement begun. Can occur any time during the first 12 weeks
here.] of treatment.104
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58 • Health Perception–Health Management Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the client for the presence of a sore throat in the These could be symptoms of agranulocytosis.104
absence of a cold or other flu-like symptoms, mouth
sores, skin ulcerations, and peripheral edema at least
daily. Report any occurrence. Note schedule for this
assessment here.
Teach the client to report any signs of infection (lethargy,
weakness, fever, sore throat, temperature elevations)
symptoms to their health-care team.
During the first 12 weeks of treatment with an antipsy-
chotic, report any signs of infection in the client to the
physician for assessment of white cell count.
Review the client’s CBC or WBC before antipsychotics Provides a baseline for comparison after the client has
are started, and report any abnormalities on this and begun antipsychotic therapy.
any subsequent CBCs to the physician.
Teach client and support systems about special WBC
monitoring programs (i.e., Clozapine requires a
monthly WBC monitoring during the first 6 months
and after 6 months every other week).
Teach the client and family handwashing techniques, These measures can help prevent or decrease the risk of
nutrition, appropriate antibiotic use, hazards of sub- infection.
stance abuse, and universal precautions.
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage clients to maintain immunization status, espe- Older adults, with aging changes to the immune system,
cially annual influenza, tetanus and diphtheria every are at increased risk for infection.
10 years, and annual pneumonia vaccine.
Teach importance of avoiding crowds in the presence of Decreases potential for contact with infectious processes
flu or cold outbreaks. at high-risk times.
Teach the client and caregiver atypical signs and symp- Older adults may not have fever, localized pain, or other
toms that may indicate infection in an older adult. classic signs in the presence of infection.
Assist the client in maintaining adequate hydration of Adequate hydration status has a preventive effect.
2000 cc daily.
Assist the client in maintaining adequate vitamin intake, These nutrients are known to assist in infection
particularly vitamins A, C, and E; zinc; and selenium. prevention.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family measures to prevent transmis- Many infectious diseases can be prevented by appropriate
sion of infectious disease to others. Assist the patient measures. The client and family members require this
and family with lifestyle changes that may be required: information and the opportunity to practice these skills.
• Handwashing
• Isolation as appropriate
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Injury, Risk For • 59
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Proper disposal of infectious waste (e.g., bagging)
• Proper treatment of linens soiled with infectious matter. Hot water provides an effective means of destroying
• Proper use of disinfectants microorganisms, and a temperature of at least 160⬚ F
• Appropriate medical intervention (e.g., antibiotics or for a minimum of 25 minutes is commonly recom-
antipyretics) mended for hot-water washing. Chlorine bleach pro-
• Immunization as recommended by CDC vides an extra margin of safety. A total available
• Signs and symptoms of infection chlorine residual of 50 to 150 ppm is usually achieved
• Treatment for lice and removal of nits during the bleach cycle.98,105–107
• Asepsis for wound care
● N O T E : Items can be sterilized at home by immersing in boiling water for 10 min-
utes. The water needs to be boiling for the entire 10 minutes. Equipment, such as bed-
side commodes, bedpans, and other items exposed to blood and body fluids can also
be cleaned with a 1:10 bleach and water solution.
Participate in tuberculosis screening and prevention This action serves as the database to identify the need for
program.108–110 interventions to prevent infections.
Monitor for factors contributing to the risk for
infection.
Involve the client and family in planning, implementing, Family involvement is important to ensure success.
and promoting reduction in the risk for infection: Communication and mutual goals improve the
• Family conference outcome.
• Mutual goal setting
• Communication
Teach the client and family measures to prevent or These measures reduce the risk of infection.
decrease potential for infection:
• Handwashing techniques, including the use of alcohol-
based antimicrobial gels.
• Universal precautions for blood and body fluids
• Personal hygiene and health habits
• Nutrition
• Immunization schedule
• Proper food storage and preparation
• Elimination of environmental hazards such as rodents
or insects
• Proper sewage control and trash collection
• Appropriate antibiotic use to include instruction to take
the entire prescribed dose, to refrain from using par-
tially used prescriptions or prescriptions written for
other persons.
• Hazards of substance abuse
• Preparation and precautions when traveling to areas in
which infectious diseases are endemic
• Signs and symptoms of infectious diseases for which
the client and family are at risk
• Preparation for disaster (water storage, canned or dried
food, and emergency waste disposal)
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Injury, Risk For • 61
z. Contact with rapidly moving machinery, indus- 3. Diseases of the eye such as cataracts or glaucoma
trial belts, or pulleys 4. Medications, for example, hallucinogens, barbiturates,
aa. Sliding on coarse bed linen or struggling within opioids, or benzodiazepines
bed restraints 5. Epilepsy
bb. Faulty electrical plugs, frayed wires, or defective 6. Substance abuse or dependence
appliances
cc. Contact with acids or alkalis
dd. Playing with fireworks or gunpowder
ee. Contact with intense cold ✔ Have You Selected the Correct Diagnosis?
ff. Overexposure to sun, sunlamps, or radiotherapy Activity Intolerance
gg. Use of cracked dinnerware or glasses This diagnosis should be considered if the nurse
hh. Knives stored uncovered observes or validates reports of the patient’s inability
ii. Guns or ammunition stored unlocked to complete required tasks because of insufficient
jj. Large icicles hanging from roof energy. Insufficient energy could lead to accidents
through, for example, falling or dropping of items.
kk. Exposure to dangerous machinery
ll. Children playing with sharp-edged toys
Impaired Physical Mobility
mm. High-crime neighborhood and vulnerable clients
This diagnosis is appropriate if the patient has diffi-
nn. Driving a mechanically unsafe vehicle culty with coordination, range of motion, muscle
oo. Driving after partaking of alcoholic beverages or strength and control, or activity restrictions related to
drugs treatment. This could be manifested by the frequent
pp. Driving at excessive speed occurrence of accidents or injury.
qq. Driving when tired
rr. Driving without necessary visual aid Deficient Knowledge
ss. Children riding in the front seat in car This diagnosis may exist if the client or family verbal-
tt. Smoking in bed or near oxygen izes less-than-adequate understanding of injury pre-
uu. Overloaded electrical outlet vention.
vv. Grease waste collected on stoves
ww. Use of thin or worn potholders Impaired Home Maintenance
This diagnosis is demonstrated by the inability of the
xx. Misuse of necessary headgear for motorized
patient or the family to provide a safe living environ-
cyclists or young children carried on adult bicy-
ment.
cles
yy. Unsafe road or road-crossing conditions Disturbed Thought Process
zz. Play or work near vehicle pathways (e.g., drive- This diagnosis should be considered if the patient
ways, laneways, or railroad tracks) exhibits impaired attention span; impaired ability to
aaa. Nonuse or misuse of seat restraints recall information; impaired perception, judgment, and
2. Internal (individual) decision making; or impaired conceptual reasoning
a. Lack of safety education abilities. This diagnosis could certainly be reflected in
b. Insufficient finances to purchase safety equipment increased accidents or injuries.
or effect repairs
c. History of previous trauma Risk for Violence
d. Lack of safety precautions This diagnosis exists if the accidents or injuries can
be related to the risk factors for self-inflicted or other-
e. Poor vision
directed physical trauma (e.g., self-destructive behav-
f. Reduced temperature or tactile sensation
ior, substance abuse, rage, and hostile verbalizations).
g. Balancing difficulties
h. Cognitive or emotional difficulties
i. Reduced large or small muscle coordination
j. Weakness EXPECTED OUTCOME
k. Reduced hand–eye coordination
Will identify hazards [list] contributing to risk for injury and
RELATED FACTORS44 at least one corrective measure [list] for each hazard by
[date].
The risk factors serve as the related factors for risk
diagnoses.
TARGET DATES
RELATED CLINICAL CONCERNS Although preventing injury may be a lifelong activity, estab-
1. AIDS lishing a mindset to avoid injury can be begun rapidly. An
2. Dementias such as Alzheimer’s disease or multi-infarct appropriate target date would be within 3 days of admission.
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62 • Health Perception–Health Management Pattern
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Injury, Risk For • 63
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Heimlich maneuver
• Cardiopulmonary resuscitation (CPR)
• Recognition of signs and symptoms of choking and
carbon monoxide poisoning
• Necessity of chewing food thoroughly and cutting food
into small bites
Refer to appropriate agency for safety check of home. Allows time for checking and correction of problem
Make referral at least 3 days prior to discharge. areas.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Maintain appropriate supervision of the infant at all Will prevent medication or treatment errors.
times. Allow respite time for the parents. Do not leave Anticipatory safety is an ongoing requisite for care of
the infant unattended. Have bulb syringe available in children.
case of need to suction oropharynx. If regular equip-
ment for suctioning is required, validate by checking
label that all safety checks have been completed on
equipment. Be aware of potential for young children to
answer to any name. Validate identification for proce-
dures in all young children.
Keep siderails of crib up, and monitor safety of all attach- Infants and small children are prone to putting small
ments for crib or infant’s bassinet. pieces in mouth, nose, or ears. Basic safety measures.
Check temperature of water before bathing and formula Helps prevent scalding or chilling of the infant.
or food before feeding. Do not microwave formula.
Maintain contact at all times during bathing. Infants
unable to sit must be held constantly. Older children
should be monitored as well, with special attention
given to mental or physical needs for a handicapped
child.
Place the infant on back with pacifier, for sleeping. Helps maintain airway. New updates regarding sudden
Recommendations include infant to sleep in same infant death syndrome (SIDS) now provide this man-
room as caregivers. Special instructions may be date from the American Academy of Pediatrics. (See
required with preterm infants and/or those with special section on High Risk for SIDS.)
conditions, for example, gastroesophageal reflux.
Investigate any signs and symptoms that warrant potential Provides assistance for the child and family in instances
child protective service referral. of child abuse and is mandated by law.
Teach family basic safety measures: Ensures environmental safety for the infant or child.
• Store plastic bags in cabinet out of child’s reach. Prevents possible suffocation.
• Do not cover mattress or pillows of the infant or child Adheres to new guidelines to prevent suffocation/reduces
with plastic. SIDS risk.
• Make certain crib design follows federal regulations Same as above.
and that mattress has appropriate fit with crib frame.
• Discourage co-sleeping in bed with the infant. Danger of infant being rolled on.
• Avoid use of homemade pacifiers (use only those of Danger of aspiration.
one-piece construction with loop handle).
• Do not tie pacifier around the infant’s neck. Danger of strangulation.
• Untie bibs, bonnets, or other garments with snug fit Danger of strangulation.
around neck of the infant before sleep.
• Inspect toys for removable parts and check for safety Danger of aspiration.
approval.
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Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Do not feed the infant foods that do not readily dis- Danger of aspiration.
solve, such as grapes, nuts, and popcorn.
• Keep doors of large appliances, especially refrigerators, Danger of child being trapped inside refrigerator.
closed at all times.
• Maintain fence and constant supervision around swim- Prevents possible drowning.
ming pool.
• Exercise caution while cleaning, with attention to pails Prevents possible drowning/aspiration.
of water and cleaning solutions.
• As the infant or child is able, encourage swimming les- Offers primary prevention to foster long-term water
sons with supervision and foster water safety. safety.
• Use caution in exposure to sun for periods of longer Offers protective safety measure.
than 10 minutes. Use SPF sunblock for children, avoid
direct sunlight esp. from 11 A.M. to 4 P.M.
• Use appropriate seat belts and car seats according to
weight and development.
• Keep matches and pointed objects, such as knives, in a
safe place out of the child’s reach.
• Use lead-free paint on the child’s furniture and
environment.
• Keep toxic substances locked in cabinet and out of the
child’s reach.
• Hang plants and avoid placement on floor and tables.
• Discard used poisonous substances.
• Do not store toxic substances in food or beverage
containers.
• Administer medication as a drug, not as candy.
• Use childproof medication containers.
• Keep syrup of ipecac on hand in case of accidental
poisoning.
• As applicable, use any special monitoring equipment as
recommended for the child.
• Monitor mealtimes to prevent aspiration with giggling.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the patient and family the risk for injury to the Provides initial safety information regarding the well-
fetus and patient when the pregnant woman smokes, is being of the fetus.
exposed to secondhand smoke, or engages in substance
abuse (e.g., alcohol and drugs [legal or illegal]).
Ask all patients about the existence of violence in their A legal requirement in some states.
homes. Report child and elder abuse to proper authori-
ties and any suspicion of family violence. Some states
require reporting of violence against women. (See
Chapters 9 and 11 for more detailed nursing actions.)
Provide atmosphere that allows the patient considering Allows the patient to receive nonjudgmental information
abortion to relate her concerns and experiences and to about the pros and cons of all choices available.
obtain detailed information about the method of abor-
tion that is being considered.
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Injury, Risk For • 65
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage questions and verbalization of the patient’s
life expectations.
Provide information on options available to the patient. This Some states require that information about local women’s
is especially important in cases of domestic violence. shelters be provided when domestic violence is suspected.
Assist the patient in identifying lifestyle adjustments that
the decision could entail.
Involve significant others, if so desired by the patient, in
discussion and problem-solving activities regarding
lifestyle adjustments.
In instances where the patient has performed a self- In self-induced abortion, there is high probability of injury
induced abortion, obtain detailed information regarding and subsequent infection. This information provides the
the method used. Provide atmosphere that allows the health team with basic data to begin assessing the
patient to relate her experience. degree of injury.
Ascertain whether abortifacients (castor oil, turpentine,
lye, ammonia, etc.) or mechanical means (coat hanger,
knitting needles, broken bottle, or knife) were used.
Regardless of the type of abortion, obtain a history from Provides basic database to initiate planning of care.
the patient that includes:
• Date of last menstrual period
• Method of contraception, if any
• Previous obstetric history
• Known allergies to anesthetics, analgesics, antibiotics,
or other drugs
• Current drug usage
• Past medical history
• Note the patient’s mental state (e.g., anxious, fright-
ened, or ambivalent).
Perform physical assessment with special notice of:
• Amount and character of vaginal discharge
• Temperature elevation
• Pain
• Bleeding: consistency, amount, and color
Teach the patient the importance of proper storage of To keep out of reach of children or others who should not
birth control pills, spermicides, and medications. use these medications.
Assist the patient in identifying drugs that are teratogenic Provides information that allows the patient to plan for
to the fetus. safety during pregnancy.
Assist the patient in becoming aware of environmental
hazards when pregnant, such as x-rays, people with
infections, cats (litter boxes), and hazards on the job
(surgical gases, industrial hazards).
Mental Health
In addition to the following interventions, refer to the applicable interventions provided in the Adult Health and Home
Health sections of this diagnosis.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Orient the client to person, place, and time on each inter- Disorientation can increase the client’s risk for injury if
action. the environment is perceived as dangerous.
Provide appropriate assistance to the client as he or she Prevents falls and possible injury.
moves about the environment.
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66 • Health Perception–Health Management Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor level of consciousness every 15 minutes when Patient safety is of primary importance. Provides infor-
the client is acutely disoriented following special treat- mation about the client’s current status so interventions
ments or when consciousness is affected by drugs or can be adapted appropriately. Prevents aspiration by
alcohol. If level of consciousness is impaired, place the facilitating drainage of fluids away from airway and
client on side to prevent aspiration of vomitus, and prevents falls and possible injury.
withhold solid food until level of consciousness
improves. Place the client in bed with siderails, and
keep siderails raised.
Do not allow the client to smoke without supervision
when disoriented or when consciousness is clouded.
Provide supervision for clients using new tools that could
precipitate injury in special activities such as occupa-
tional therapy.
Teach the client and members of support system:
• Risks associated with excessive use of drugs and
alcohol.
• Appropriate methods for compensating for
sensory–perceptual deficits (e.g., use of pictures or
colors to distinguish environmental cues when ability
to read is lost).
Remove all environmental hazards (e.g., personal groom- Prevents the client from acting impulsively to injure self
ing items that could produce a hazard, cleaning agents, with items easily found in environment. This allows
foods that produce a hazard when taken with certain staff time to offer alternative coping strategies when
medicines, plastic bags, clothes hangers, belt and ties, clients are experiencing difficulty with coping.
or shoestrings). Remove unnecessary pillows and blan-
kets from the bed.
Maintain close supervision of the client. (If the client is Prevents the client from acting impulsively.
suicidal, refer to nursing actions for Risk for Violence,
Chapter 9, for specific interventions.)
Check the client’s mouth carefully after oral medicines Basic safety precaution.
are given for any amounts that might be held in the
mouth to be used at a later date.
If the client is at risk for holding pills in the mouth to be
used later, collaborate with physician to have doses
changed to liquids or injections.
Keep lavage setup and airway and oxygen equipment on
standby.
Talk with the client and members of support system about
situations that increase the risk for poisoning, and
develop a list of these situations.
Label all medicines and poisonous substances appro-
priately.
If client is in physical restraints: Safety of client, other clients, and staff are of primary
• Ensure that all least restrictive measures have been importance.87,104
attempted before restraints were initiated and orders
for restraint meet JCAHO and institutional policy.
• Provide one-to-one monitoring at all times
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Monitor client’s vital signs every 15 minutes
• Offer food, water and toileting every 15 minutes
• Inform client of conditions for restraint release
• Release restraints, one limb at a time, on a scheduled
basis and assess circulation and sensation in affected
body part. Note schedule here.
• Release client from restraint when client’s behavior is
under control and no longer poses a risk to themselves
or others.
Gerontic Health
In addition to the following interventions, refer to the applicable interventions provided in the Adult Health and Home
Health sections of this diagnosis.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Refer the independent elder to home health for home Provides timely home care planning, and allows imple-
safety assessment at least 3 days prior to discharge mentation of safety measures before patient is dis-
from hospital. charged.
Minimize the use of or refrain from the use of physical Use of chemical and physical restraints in elders is asso-
and chemical restraints. ciated with risk of injury.
Utilize restraint alternatives: These alternatives can prevent falls without using poten-
• Environmental changes tially dangerous restraints.
• Bed safety
• Seating and position support
• Toileting and continence programs
• Increased supervision and staffing for high-risk clients
• Alarms
Conduct a fall evaluation including an assessment of his- Assists in determining modifiable risk factors for falls.
tory of falls, medications, vision, gait and balance,
lower limb joints, and neurologic and cardiovascular
function.
Utilize the “Get Up and Go” test to determine risk for Assists in objectifying the client’s risk for falls.
falls.112
I. Technique: Direct patient to do the following
A. Rise from sitting position.
B. Walk 10 feet.
C. Turn around.
D. Return to chair and sit down.
II. Interpretation
A. Patient takes ⬍20 seconds to complete test.
1. Adequate for independent transfers and mobility.
B. Patient requires ⬎30 seconds to complete test.
1. Suggests higher dependence and risk of falls.
Ensure that any sensory adaptations are made prior to The client may experience increased risks for injury if
activities. (Client has clean glasses and/or functional sensory losses are not addressed.111,112
hearing aid available, as needed, adequate lighting to
safely move about, and clear pathway for ambulation.)
Initiate fall precautions, as indicated, on admission to Use of fall prevention strategies reduces the risk for falls
care facility, or on an as-needed basis. in older adults and potential loss of function associated
with falls and injuries.112,114
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68 • Health Perception–Health Management Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach at-risk older adults fall prevention strategies: Falls at home or in health-care settings are one of the
• Clients using mobility aids main causes of morbidity and mortality in older
• Clients on medications that increase the potential for adults.111–115
vertigo, weakness, or orthostatic changes
• Clients with motor or sensory deficits
Instruct the patient on safe administration of medication. Basic medication safety measures.
Monitor for knowledge of drug dosage, reason for
medication, expected effect, and possible side effects.
Reinforce teaching on a daily basis.
If the patient suffers from dementia, teach the caregiver Older adults with the diagnosis of dementia often display
the following safety adaptations116: signs of poor judgment. The listed teaching factors
• Place in a locked closet articles, such as power tools, decrease the risk for injury in the home setting.
medications, or appliances, that the individual may
misuse and injure self or others.
• Ensure that water temperature is low enough to prevent
scalding.
• Remove knobs from stove if cooking is a fire hazard.
• Install gates at the top of stairs to prevent falls.
• Tape door latches or remove tumblers from locks to
prevent the patient from accidentally locking himself or
herself in rooms.
• Place two locks on entry and exit doors if the individ-
ual is prone to wandering.
• Ensure that furnishings do not have sharp edges or large
areas of glass that could cause injury during a fall.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client and family in obtaining a referral for gait Prevention activities reduce the risk of injury.
training and training for appropriate use of assistive
devices. These can usually be obtained through a phys-
ical therapy department.
Review medications with the client and family. Determine These medications may increase risk of falls.
if medications may increase the client’s risk for falls;
clients taking more than four medications, psychotropic
medications and antihypertensives. Collaborate with
physician or health-care practitioner to modify medica-
tions as indicated.
Assist the client and family in locating and accessing an Prevention activities reduce the risk of injury.
exercise program with balance training as one of the
components that is appropriate for the client’s health
status. These can usually be recommended by a physi-
cal therapy department.
Assess the client for postural hypotension. Collaborate Postural hypotension is a modifiable risk factor for falls.
with a physician as indicated for treatment of postural
hypotension.
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Injury, Risk For • 69
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client and family in adhering to the therapeutic Cardiovascular disorders and cardiac arrhythmias are
regimen for cardiovascular disorders and cardiac modifiable risk factors for falls.
arrhythmias.
Involve the client and family in planning, implementing, Involvement of the client and family enhances motivation
and promoting reduction in the risk for injury: and increases the possibility of positive outcomes and
• Arrange family conferences to clarify risk factors the long-term lifestyle changes required.
for injury and preventive measures the family can
implement.
• Assist the family to define mutual goals for prevention
of injury.
• Promote communication.
• Assist family members with specific tasks as appropri-
ate to reduce the risk for injury.
● N O T E : Restraining the client may increase, not decrease, the risk for injury.117
It is important to arrange the environment so that the
client can avoid injury (e.g., use bedside commode or
raised toilet seat; remove unnecessary furniture;
remove throw rugs, repair or remove loose or damaged
flooring, pick up objects that may be blocking path-
ways118–120; remove unsafe or improperly stored chemi-
cals, weapons, cooking utensils, and appliances; use
and store toxic substances safely; obtain certification in
first aid and CPR; properly store food; obtain knowl-
edge of poisonous plants; learn to swim; remove fire
hazards from environment; design and practice an
emergency plan for action if fire occurs; and properly
use machines powered by petroleum products).
• Teach the client and family injury prevention activities Prevention activities reduce the risk of injury. Many peo-
as appropriate: ple either do not know these prevention strategies or
need to have them reinforced.
• Avoid the use of restraints for all clients, particularly Restraints have not been demonstrated to prevent falls and
confused clients. may increase risk for other types of injuries. (National
• Proper lifting techniques Guideline Clearinghouse, http://www.guideline.gov.)
• Assist family in securing patient lift equipment for
immobilized clients to prevent family/caregiver injury.
• Removal of hazardous environmental conditions, such
as improper storage of hazardous substances, improper
use of electrical appliances, smoking in bed or near
supplemental oxygen, open heaters and flames, and
congested walkways
• Proper ventilation when using toxic substances
• First aid for poisoning
• Proper labeling, storage, and disposal of toxic materials
such as household cleaning products, lawn and garden
chemicals, and medications
• Proper food preparation and storage
• Proper skin, lung, and eye protection when using toxic
substances
• Toxic substances out of reach of infants and young
children
• Recognition of toxic plants and removal from environ-
ment as indicated
• Plan of action if accidental poisoning occurs
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70 • Health Perception–Health Management Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client and family in lifestyle adjustments that For long-term change, lifestyle adjustments are often
may be required. required. Many people require assistance with these
changes.
Refer to appropriate assistive community resources as Use of existing community services is an efficient use of
indicated resources.
Participate in early-return-to-work programs.121 Such programs lead to better client outcomes.
Participate in local, state, and national immunization Community participation in immunization initiatives
initiatives.122 improves the rate of appropriate immunization and
reduces the risk of outbreak of the diseases for which
vaccines are available.
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Latex Allergy Response, Risk for and Actual • 71
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72 • Health Perception–Health Management Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Do not inject through intravenous tubing injection ports.
Use stopcock as needed. Use only latex-safe syringes.
Do not aspirate medications through rubber stopper of
multidose vials; remove stopper and aspirate contents
directly.
Check the manufacturer’s product label for latex content. Ensures a latex-safe environment.
Prohibit latex balloons in the patient’s room. Mylar bal-
loons are a latex-safe alternative.
Include allergy information in all reports given to other
departments.
Document the use of latex-free products during care. Documentation is vitally important in patient care.
Monitor for any adverse reactions.
If a reaction does occur, document the presence of the
reaction, and the steps that were taken to treat it.
Document the patient’s response to treatment.
Notify the physician immediately if the patient does have
an allergic reaction to latex.
Assess the patient’s and family’s need for education
related to latex allergy and provide that which is
needed.
Common sources of latex at home and at work:
• Art supplies
• Bandages
• Balloons
• Balls
• Carpet backing
• Cleaning gloves
• Condoms or diaphragms
• Diapers
• Douche bulbs
• Elastic in clothing
• Elastic in hair accessories
• Erasers
• Eye drop bulbs
• Feeding nipples
• Food handled with latex gloves
• Handles (rubber) on tools, racquets, and bicycles
• Hot water bottles
• Infant toothbrush massager
• Koosh balls
• Pacifiers
• Paints
• Rubber clothing (e.g., raincoats)
• Rubber toys
• Shoes
• Tires
• Wheelchair cushions
Document the patient’s and family’s response to the
teaching.
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Latex Allergy Response, Risk for and Actual • 73
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Risk for
Assess for signs and symptoms suggestive of latex Identification of at-risk populations aids in diagnosis of
allergy, including sneezing, coughing, rash, hives, or latex allergy.
wheezing in the presence of balloons, Koosh balls,
catheters, or other rubber items.127,128
Determine the history for the infant or child to note any Knowledge of individual’s status assists in identifica-
allergic reactions, including triggering event or sub- tion of at-risk or actual latex allergy and treatment
stance, actual symptoms, treatment required, and exac- as reference in event of recurrence and for preventive
erbations. suggestions.
Determine whether the infant or child has undergone Documentation of known status is essential to consider
allergy testing, has received results, and has undergone possible change from potential to actual allergenic
a treatment regimen. status.
Ask whether the infant or child has been diagnosed Identification of risk factors assists in prevention of latex
with a condition that requires contact with catheters or allergy development for all populations.
other hospital products, such as gloves or monitoring
equipment.
Ask whether the infant or child has ever experienced an Surgery imposes a risk for latex allergy development.
allergic reaction during surgery.
List any known foods, drugs, or allergenic substances for Evidence of absence is essential; presence of history will
the infant or child. be needed for risk reduction for exacerbation.
Provide appropriate identification alerts for records and Proper identification serves to lessen the likelihood of
identification bands as the child is cared for to signify repeated exposure and precipitation of latex allergic
allergenic status to latex.127,128 response.
Ask the parents how they would identify an allergic reac- Individualized assessment provides validation of knowl-
tion in their child. edge and values the importance of each possible mani-
festation of allergic response.
Find out whether the parents are aware of emergency Assessment for treatment is vital to management of pos-
equipment and treatment that may be required in the sible allergic response to expedite intervention and
event of latex allergenic response. minimize delay in event of emergency.
As dismissal planning is done, ensure the availability of Anticipatory planning assists in empowerment of parents
emergency medical services (EMS), how to summon to act in event of emergency, thereby ensuring best
EMS, appropriate use of equipment, and how to main- chance for treatment without delay.
tain a plan in event of need.
Carry out health interview with focus on components to Determination of a latex allergic client alerts all to need
determine positive history or likelihood of latex for precautionary measures.
allergy* medical diagnosis of spina bifida Exposure to latex early in life with repeated exposures in
(myelomeningocele is a high risk). first years of life increases likelihood for latex allergy.
Note most recent allergy testing, known allergies, current Documentation of status provides appropriate basis for
treatment, and plan for how best to prepare for elective precautionary treatment of client.
surgery or treatments within hospital or clinic.
Note history of allergenic responses to latex with atten- Identification of risk indices alerts caregivers to likeli-
tion to ongoing risk indices such as implants or need hood of precautions to be implemented.
for special medical equipment such as catheters.127,128
Identify appropriate treatment for known latex allergies to Anticipatory planning will best provide for possible
include need for special airway and oxygen delivery emergency without delay.
equipment, medications such as epinephrine, and spe-
cialists who will be available to assist in event of acute
allergenic response.
(care plan continued on page 74)
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74 • Health Perception–Health Management Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide identification bracelet and appropriate designa- Anticipatory planning and valuing of risk for acute aller-
tion of latex allergy status for the infant or child per genic response is best met with dissemination to signif-
medical record and ensure its appropriate sharing with icant caregivers for provision of greater freedom from
all who will provide care for client (including daycare risk and prevention of latex allergic recurrence.
providers, teachers, or sitters).
Assess parental knowledge of current plan of care with a Anticipatory planning for the individual places value on
focus on potential allergenic triggers prior to dismissal the preventive component.
and for ongoing care.
Assess for stressors related to the infant or child’s latex Valuing feelings and perceptions of the client and family
allergy status. fosters open communication and provides cues for
related nursing needs.
Women’s Health
● N O T E : The nursing actions for a woman with the nursing diagnosis of latex allergy
are the same as those for Adult Health. Be aware that infants born to mothers with latex
allergies could themselves be allergic to latex, and all the precautions taken with the
mother should be followed with infants. This includes padding the crib well to keep the
infant away from the crib mattress covers, which usually have latex in them.
Research studies have shown that glove powder binds to latex proteins and is
therefore a major hazard and contributor to the amount of latex found in the air in oper-
ating rooms and patient rooms where gloves are routinely used. It has been shown that
patients and health-care workers are exposed on a continuous basis when working in
rooms in which there is a high usage of gloves with powder, as bound proteins are
aerosolized when gloves are dispensed, put on, used, and/or removed from the hands.
Health-care personnel and patients in labor and delivery are particularly vulnerable and
at risk for latex allergy because of the high use of gloves during vaginal examinations of
the patient in labor and during cesarean sections. Likewise, the health-care worker
needs to be aware of the presence of latex in nipples on infant bottles.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Replace all examination gloves and sterile gloves in A major reason for the increase in sensitization rates in
obstetric units with vinyl or low-allergen, powder-free health-care workers and patients is the use of products
latex gloves. containing high levels of extractable proteins, such as
powdered, high-allergen gloves.124,125
When using vinyl gloves during pelvic examinations, in Because of the high failure rate of vinyl gloves, it is rec-
surgery, or when dealing in any situation requiring ommended to use low-allergen, powder-free latex
standard precautions, always double glove. gloves during high-risk situations involving standard
precautions; however, if there is a need for the use of
no latex products (such as with the latex-sensitive
patient or health-care worker), then the health-care
worker using vinyl gloves should double glove for his
or her own protection.
Carefully interview the pregnant client and screen for risk Because of the frequent use of gloves, catheters, etc. in
for latex allergy. Question about past pregnancy out- the care of these babies, both the baby and the care-
comes, particularly if they have had any infants with taker may have developed a sensitivity to latex.
neural tube defects (e.g., spina bifida). (Approximately 72 percent of patients with spina bifida
are allergic to latex.)127,128
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Management of Therapeutic Regimen, Effective • 75
ACTIONS/INTERVENTIONS R AT I O N A L E S
Pregnant mothers who have been involved with the care This mother and her newborn are at risk for a potential
of a previous child that could have involved exposure reaction to latex.126,127
to latex products, and/or their newborn infant, should
be treated with latex avoidance regardless of their
allergy status.
Carefully monitor the mother and her newborn for
symptoms of an allergic reaction, including a systemic
reaction.
Teach the mother and her family the essentials of latex
precautions:
• Review of routes of exposure
• Use of infant and toddler supplies and toys
Mental Health
Nursing interventions and rationales for this diagnosis are the same as those for Adult Health.
Gerontic Health
Use information provided in Adult Health section for this diagnosis. Currently there is no evidence available to suggest
specific interventions for this diagnosis based on age of the client.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Inquire about sensitivity to latex or other related factors Allows early identification of potential for allergic
at onset of care. reactions.
Assist the client in acquiring a MedicAlert bracelet when Prevents further exposure to latex products.
latex allergy is present.
Assist the client in securing latex-free supplies for Prevents further exposure to latex products.
home use.
Educate the client, family members, and potential Encourages family participation in client care and
caregivers about latex-containing devices and reduces potential for accidental exposure.
equipment, as well as the signs of acute allergic
reactions.
Educate the client, family members, and potential Prevents further morbidity.
caregivers how to access emergency medical care
should an accidental exposure precipitate an acute
reaction.
Assist the client and family in obtaining an epineprhrine Prevents further morbidity.
pen for use in case of anaphylactic reaction to latex.
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Management of Therapeutic Regimen, Effective • 77
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Utilize appropriate age and developmental commu- Assists in developing a trusting relationship with the
nication. client and primary caregiver.
Determine the client’s and primary caregiver’s perception Provides a starting point for discussing and teaching ther-
of condition. apeutic regimen.
Assist the family to determine when and where follow-up Promotes long-term management.
care will be utilized.49,50
Offer verbal and emotional reinforcement for appropriate Provides positive reinforcement.
attendance to mutually agreed-to criteria. State criteria
here (e.g., maintain immunizations).
Acknowledge need for the caregiver to be relieved (at Assists in preventing caregiver role strain. Promotes
regular intervals) of total responsibilities of dependent effective management.
infant or child. Encourage the caregiver to express feel-
ings regarding responsibility. Delineate community
resources that can augment care.49,50
Identify subsequent factors that are likely to resurface Anticipatory guidance is central to nursing.
over time (e.g., developmental concerns).
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Utilize Prenatal Risk Indicator Tools to identify women Provides the patient with the information needed to make
who are high risk for pregnancy and birth. Assess and informed choices and necessary lifestyle changes in
counsel those mothers identified as high risk. Assist the order to maximize health for herself and her fetus.
patient to plan changes necessary in her lifestyle to
maintain pregnancy and health of mother and fetus
until birth.29
Provide the new mother with information about various Provides the patient with the information needed to make
support groups and health-care programs when early informed choices and necessary lifestyle changes in
postpartum discharge occurs. Provide teaching and order to maximize health for herself and her fetus.
support on an ongoing basis from time of conception
until end of postpartum period for the new mother, her
family, and her baby. Provide new parents with written
handouts, help-line telephone numbers, follow-up
appointments with advanced practice nurse, pediatri-
cian, and obstetrician following postpartum discharge.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Sit with the client [number] minutes [number] times a Promotes the development of a trusting relationship by
day to discuss: communicating respect for the client.69 Provides
• His or her understanding of the current situation assessment data that will assist in the development of a
• Strategies that assist the client in this management plan to support client’s current behaviors.
• Support systems Support systems promote healthy behaviors.88
• Stressors
[Note important data from these discussions here.]
Discuss with the client signs and symptoms that would Promotes the client’s sense of control.97
indicate that assistance is needed with management.
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Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Develop with the client a plan for obtaining the necessary
assistance when needed.
Provide positive social reinforcement and other behavioral Positive reinforcement encourages adaptive behavior and
rewards for demonstration of adaptive management. enhances self-esteem.87
(Those things that the client finds rewarding should be
listed here with a schedule for use. The kinds of behav-
iors that are to be rewarded should also be listed.)
Discuss with the client the impact of stress on physio- Anxiety decreases coping abilities and physiologic well-
logic and psychological well-being. Develop with the being. Repeated rehearsal of a behavior internalizes
client a plan for learning relaxation techniques, and and personalizes it.87
have client practice technique for 30 minutes 2 times a
day at [times] while hospitalized. Remain with the
client during practice session to provide verbal cues
and encouragement as necessary. These techniques can
include:
• Meditation
• Progressive deep muscle relaxation
• Visualization techniques that require the client to visu-
alize scenes that enhance the relaxation response
• Biofeedback
• Prayer
• Autogenic training
Develop with the client a plan for integrating relaxation Having a concrete plan increases the probability that the
techniques into daily schedule at home. behavior will be implemented in the new environment.
Develop with the client a plan to include play into daily Play provides a sense of joy and rejuvenates inner vital-
activities. Note the plan and specific activities here. ity, enhancing coping abilities.69
Establish a time to meet with the client and those mem- Interactions between members of the support system
bers of his or her support system identified as most and the individual can impact individual health and
important. Note time here. Utilize this time to discuss: coping.87,88 Provides an opportunity to assess sup-
• Support system’s understanding of the client’s situation port system’s perspective to assist in developing
• Support system’s perceptions of their involvement with interventions and further their acceptance of the
the management of the illness intervention.69,88
• Support system’s perceptions of their needs at this time
Develop with the members of the support system a plan Increases support system’s sense of control while enhanc-
to meet the perceived needs. [Note this plan here.] ing self-esteem. Provides opportunities for increasing
support system coping by recognizing that the illness
has an impact on this system.69,88
Identify, with the client, community support groups that Groups can provide hope, information, and role models
can be utilized when he or she returns home. Note for coping and support.88
those groups identified here with a plan for contacting
them before the client leaves the hospital.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor at each subsequent contact for continued ability Physiologic aging or exacerbation of chronic illness may,
to effectively manage regimen. over time, diminish continued ability to implement
regimen.
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Management of Therapeutic Regimen, Effective • 79
ACTIONS/INTERVENTIONS R AT I O N A L E S
Refer to community resources as indicated. The older patient may have concerns related to availabil-
ity of support systems, costs of medication, and avail-
ability of transportation. Use of already available
community resources provides a long-term, cost-
effective support system.
Establish communication link with primary caregiver and Family members may not be geographically available.
family.
Advise family members of availability of managed care Provides care options for family to consider.
resources in the community where older client resides.
Provide follow-up support via home visits and telephone Presents opportunities for continued problem solving and
contacts. increasing trust.
Assist caregivers in establishing and meeting their needs. Enables continuation of care while decreasing the poten-
tial for burnout.
Review with the client and family the therapeutic Helps determine possible areas of difficulty for client or
regimen. caregiver.
Provide multisensory teaching materials (tapes, websites, Provides quick access to information for the caregiver or
literature) on therapeutic regimen to assist client and client.
caregiver in adhering to regimen.
Incorporate a variety of local, regional, or state social Information flow may be impeded because of temporary
services to ensure that needed information about the relocation or social isolation.
regimen is available to older patients.
Identify older community leaders, via age-related groups Peer or cohort influences may assist in identifying and
or associations, who can identify strengths or weak- promoting problem solving.
nesses of the community (such as senior citizen center
members, church groups, and support groups focused
on problems common to older adults).
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess the client/family understanding of the current dis- Identifies knowledge deficits or misunderstanding to pre-
ease process and therapeutic regimen. vent problems.
Assess client/family strategies for managing the therapeu- Supports the continued use of effective strategies.
tic regimen and assist in the provision of community
resources that might support continued use of these
strategies.
Discuss the therapeutic regimen and strategies for manag- Clients/families may not be able to maintain sustained
ing the regimen with client and family regularly (as management, this will allow for early identification of
determined to be appropriate by the nurse) to ensure problems.
continued accurate understanding and effective use of
strategies.
Provide education as the client’s condition or regimen Ensures that the client/family can maintain their current
changes. therapeutic management of the regimen.
Involve the client, family, and community in planning, Involvement increases motivation and improves the prob-
implementing, and promoting the treatment plan ability of success.
through129,135,137:
• Assisting with family conferences.
• Coordinating mutual goal setting.
• Promoting increased communication.
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Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Assigning family members specific tasks as appropriate
to assist in maintaining the therapeutic regimen plan
(e.g., support person for patient, transportation, or com-
panionship in meeting mutual goals).
• Utilizing population surveillance to detect changes in
illness patterns for the community.
• Support the client, family, or community in eliminating Many barriers are institutional and can be eliminated or
barriers to implementing the regimen by: reduced.
• Providing for privacy.
• Referring to community services (e.g., church, home
health volunteer, transportation service, or financial
assistance).
• Providing for interpreters and for community-based
language classes for English speakers to learn other
languages as well as for non-English speakers to learn
English.
• Serving as social activist to encourage necessary
participants to complete their tasks. This may
include fund-raising, testifying before governing
bodies, or coordinating efforts of several groups
and organizations.
Assign one health-care provider or social service worker, Continuity of care provides a means for effective problem
as much as possible, to provide continuity in care solving and early identification of problems.
provision.
Make timely telephone calls to clients to discuss care Follow-up with clients reinforces positive behaviors and
(e.g., 1 day after being seen in clinic for minor acute may aid in early identification of problems. Follow-up
infection, or weekly or monthly on a routine schedule also implies support of health-care professionals.
for chronically ill person).140
Reteach the client and family appropriate therapeutic Reinforcement of information and continued assistance
activities as the need arises. may be required to improve implementation of the
therapeutic regimen.137
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Management of Therapeutic Regimen (Individual, Family, Community), Ineffective • 81
DEFINING CHARACTERISTICS44
✔ Have You Selected the Correct Diagnosis?
Deficient Knowledge
A. Ineffective Management of Therapeutic Regimen This is the most appropriate diagnosis if the patient
(Individual) or family verbalizes less than adequate understanding
1. Choices of daily living ineffective for meeting the of health management or recalls inaccurate health
goals of a treatment or prevention program information.
2. Verbalized desire to manage the treatment of illness Ineffective Individual Coping or Compromised
and prevention of sequelae or Disabled Family Coping
3. Verbalized that he or she did not take action to reduce These diagnoses are suspected if there are major dif-
risk factors for progression of illness and sequelae ferences between the patient and family reports of
4. Verbalized difficulty with regulation and/or integra- health status, health perception, and health-care
tion of one or more prescribed regimens for treatment behavior. Verbalizations by the patient or family
of illness and its effects or prevention of complica- regarding inability to cope also indicate this differential
tions nursing diagnosis.
5. Acceleration (expected or unexpected) of illness Dysfunctional Family Processes
symptoms Through observing family interactions and communi-
6. Verbalized that he or she did not take action to cation, the nurse may assess that Altered Family
include treatment regimens in daily routines Processes is a consideration. Poorly communicated
B. Noncompliance messages, rigidity of family functions and roles, and
failure to accomplish expected family developmental
1. Behavior indicative of failure to adhere (by direct
tasks are a few observations that alert the nurse to
observation or by statements of patient or significant
this possible diagnosis.
others)
2. Evidence of development of complications Activity Intolerance or Self-Care Deficit
3. Evidence of exacerbation of symptoms These diagnoses should be considered if the nurse
observes or validates reports of inability to complete
4. Failure to keep appointments
the tasks required because of insufficient energy or
5. Failure to progress
because of inability to feed, bathe, toilet, dress, and
6. Objective tests (physiologic measures or detection of groom self.
markers)
C. Ineffective Management of Therapeutic Regimen Disturbed Thought Processes
The nursing diagnosis of Disturbed Thought Processes
(Family)
should be considered if the patient exhibits impaired
1. Inappropriate family activities for meeting the goals
attention span; impaired ability to recall information;
of a treatment or prevention program impaired perception, judgment, and decision making;
2. Acceleration (expected or unexpected) of illness or impaired conceptual and reasoning abilities.
symptoms of a family member
Impaired Home Maintenance
3. Lack of attention to illness and its sequelae
This diagnosis is demonstrated by the inability of
4. Verbalized desire to manage the treatment of illness
the patient or family to provide a safe home living
and prevention of the sequelae environment.
5. Verbalized difficulty with regulation and/or integration
of one or more effects or prevention of complication
6. Verbalized that family did not take action to reduce
risk factors for progression of illness and sequelae
RELATED FACTORS44
D. Ineffective Management of Therapeutic Regimen A. Ineffective Management of Therapeutic Regimen
(Community) (Individual)
1. Illness symptoms above the norm expected for the 1. Perceived barriers
number and type of population 2. Social support deficits
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Management of Therapeutic Regimen (Individual, Family, Community), Ineffective • 83
ments in collaboration with the patient will benefit from the TARGET DATES
wisdom of people experiencing illness.130,134
The specific target dates for these objectives will be directly
related to the barriers identified, the patient’s enter-
EXPECTED OUTCOME
ing level of knowledge, and the comfort the patient feels in
Will return-demonstrate appropriate technique or proce- expressing satisfaction or dissatisfaction. The target date
dures [list] for self-care by [date]. could range from 1 to 5 days following the date of admission.
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84 • Health Perception–Health Management Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Design a chart to assist the patient to visually see the Visualization of actual progress promotes implementation
effectiveness of therapeutic regimen (e.g., weight loss of prescribed regimen.
chart, days without smoking, blood pressure measure-
ments). Begin the chart in hospital within 1 day of
admission. Follow up 1 week after discharge.
Assist in the development of a schedule that will allow Demonstrates importance of schedule to patient,
the patient to keep appointments and not miss work. employer, and physician. Coordinated effort encour-
Forward plan to employer and physician. ages adherence to regimen.
Assist the patient in developing time-management skills Individualizes schedule and highlights need for relaxation
to incorporate time for relaxation and exercise. Have and exercise.
patient develop a typical 1 week schedule, then work
with patient to adapt schedule as needed.
Contract, in writing, with the patient and/or significant Demonstrates, in writing, the importance of the plan, and
others for specifics regarding regimen. Have patient by listing definitive follow-up times, enhances the
and family establish mutual goal setting sessions. probability of regimen implementation. Involvement
Assign specific family members specific tasks. Follow increases motivation and improves the probability of
up 1 week after discharge; recheck 6 weeks following success.
discharge.
Design techniques that encourage the patient’s or family’s Prevents multiple changes from overwhelming patient,
implementation of the regimen, such as setting single, thus avoiding one major contributor to ineffective man-
easy-to-accomplish, short-term goals first and progress- agement of therapeutic regimen.
ing to long-term goals as the short-term goals are met.
If the idea of stopping smoking is too overwhelming,
help the patient design a personal adaptive program. For
example, change to a lower tar/nicotine cigarette, imple-
ment timed smoking (e.g., only one cigarette every 30
or 60 minutes), stabilize, then make further reductions.
Teach the patient and significant others assertive tech- Long waiting periods in offices, unanswered questions,
niques that can be used to deal with dissatisfaction being rushed, etc. increase the likelihood of abandon-
with caregivers. ing the regimen. Assertiveness helps the patient and
family overcome the feelings of powerlessness and
increases the sense of control.
Assist in correction of sensory, motor, and other deficits
to the extent possible through referrals to appropriate
consultants (e.g., occupational therapist, physical thera-
pist, ophthalmologist, audiologist).
Have the patient and/or family design a home care plan.
Assist the patient to modify the plan as necessary.
Forward the plan to home health service, social serv-
ice, physician, etc.
Relate any information regarding dissatisfaction to the
appropriate caregiver (e.g., to physician, problems with
the time spent in waiting room, cultural needs, privacy
needs, costs, need for generic prescriptions).
Make follow-up appointments prior to the patient’s leav- Demonstrates exactly how to make appointments for
ing the hospital. Do it from the patient’s room, and put patient.
appropriate information regarding appointment on
brightly colored card (i.e., name, address, time, date,
and telephone number).
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Management of Therapeutic Regimen (Individual, Family, Community), Ineffective • 85
ACTIONS/INTERVENTIONS R AT I O N A L E S
Refer the patient and/or family to appropriate follow-up Allows time for home care assessment and initiation of
personnel (e.g., nurse practitioner, visiting nurse serv- service.
ice, social service, or transportation service). Make
referral at least 3 days prior to discharge.
Request follow-up personnel to remind the patient of Shares the responsibility for implementing the regimen,
appointments via card or telephone. and demonstrates the importance attached to follow-up
care by those providers.
When discharge is imminent, transfer responsibility of Allows sufficient practice time that provides immediate
self-care to patient. Supervise performance, critique, feedback on skills, etc.
and reteach as necessary.
Have the patient and significant others restate principles
at least three interactions prior to discharge.
● N O T E : For Ineffective Management of Therapeutic Regimen (Community), see
Home Health.
Child Health
● N O T E : Because of the dependency of the infant or child, ineffective management will
always include both the individual and the family.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist in developing health values of regimen adherence Initiates idea of individual health management for child’s
before the infant’s birth through emphasis of these health before birth. Allows sufficient time for parents
aspects in childbirth education classes. to incorporate these ideas.
Allow for the infant or child’s schedule in appointment Facilitates comfort for the child, parents, and health-care
scheduling (e.g., respect for naps, mealtimes). Involve provider. Demonstrates individuality and increases
the family in planning care for the infant or child. likelihood of regimen implementation.
Provide appropriate criteria for monitoring follow-up of Anticipatory specific planning and knowledge of condi-
the infant or child’s status, especially in instance of tion enhances self-management behaviors, thereby
chronic condition, to also demarcate when to call doc- valuing self-esteem and likelihood of continued appro-
tor or case manager. priate follow-up.
Reward progress in the appropriate manner for age and Reinforcement increases valuing for desired behaviors.
development.
Depending on needs of the infant or child, may, when The weakest component of many communities relates to
services cannot be procured, require a change in loca- care of the young, thus making consideration of the
tion with the goal of seeking effective therapeutic regi- child a critical component.
men services. This may depend on state and/or local
funding with referral on regional basis. Language or
educational needs must also be addressed.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Develop a sensitivity for cultural differences of women’s Demonstration of understanding of the patient’s culture
roles and the impact on their implementation of a ther- and inclusion of these differences in planning increase
apeutic regimen.144 the probability of effective management of the thera-
peutic regimen.
Encourage the family to share views of childbirth with The health-care worker needs to be aware of how cultural
health-care personnel through classes and inter- beliefs can impact the care of the new mother and her
views.144 newborn. Understanding the cultural beliefs of the
patient will help the health-care provider to plan care
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Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
in a manner that will insure the safety of both mother
and infant, as well as gain compliance from the
family.144
Discuss with the family their traditions and taboos for Increases patient satisfaction and compliance, as well as
mother and baby during transitional period after child- allowing the childbirth instructor and nursing personnel
birth. For example, in some Far Eastern cultures, the to plan with the patient and family appropriate care
mother does not touch the infant for several days after during childbearing.
birth. The grandmother or aunts become the primary
caregivers for the infant.145,146
Family
Assess the pregnant woman’s and her family’s perception Provides basis for plan of care and allows the family to
of the tasks of pregnancy complicated by high-risk fac- make informed choices about care needs during and
tors, such as premature rupture of membranes, prema- after pregnancy.
ture labor, maternal or fetal illness, and socioeconomic
hardships.145,146
Encourage the family to share concerns of the changes Allows caregivers to determine importance of compliance
and restrictions on family lifestyle as a result of the with treatment regimen to the family and to refer them
high-risk pregnancy. (Example: Restrictions on preg- to the proper resources.
nant woman involving changes in homemaking, child-
rearing, sexuality, social and recreational activities,
disruptions in career, and financial commitments.) Help
the family identify community agencies and resources
that can assist them to better follow the treatment
regimen.
Community
Inform appropriate agencies when new mothers (parents) Allows for appropriate support and follow-up for the new
exhibit signs and symptoms of nonattachment to their mother and her newborn infant.
newborn, substance abuse, homelessness, and dysfunc-
tional family dynamics that could result in violence or
neglect.147–149
Refer clients to appropriate community agencies (home Ensures smooth, safe transition for new mother and her
visiting nurses, public health nurses, child protective family into parenting roles. Ensures physical and psy-
agencies, etc.) to provide new mothers and their infants chological stability for the new mother and her infant.
transitional care during postpartum period (particularly Provides continuity of care from the hospital to the
after early discharge). home to the primary caregiver (physician, advanced
practice nurse, etc.).
Mental Health
● N O T E : It is important to remember that the mental health client is influenced by a
larger social system and that this social system plays a crucial role in the client’s ongo-
ing participation with the health-care team. The conceptualization that may be most use-
ful in intervention and assessment of the client who does not follow the recommendations
of the health-care team in this area may be system persistence. Hoffman148 uses this con-
cept to communicate the idea that the system is signaling that it desires to continue in its
present manner of organization. This could present a situation in which the individual
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Management of Therapeutic Regimen (Individual, Family, Community), Ineffective • 87
client indicates to the health-care team that he or she desires change, and yet change is
not demonstrated because of the constraints placed on the individual by the larger social
system (i.e., the family). This places the responsibility on the nurse to initiate a compre-
hensive assessment of the client system when the diagnosis of Ineffective Management of
Therapeutic Regimen or Noncompliance is considered.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client system in discussions on the treatment Promotes the client’s perceived control and increases
plan. This should include: potential for the client’s involvement in the treatment
• Family plan.69,88,143
• Individuals the client identifies as important in making
decisions related to health (e.g., cultural healers, social
institutions such as probation officers, public welfare
workers, officials in the school system, etc.)
Discuss with the family their perception of the current Communicates respect of the family and their experience
situation. This should include each family member, and of the situation, which promotes the development of a
each should be given an opportunity to present his or trusting relationship. Provides information about the
her perspective. Questions to ask the family include: family’s strengths, and provides the nurse with an
• What do you think is the difficulty here? opportunity to support these strengths in a manner that
• Who is most affected by the current situation? will facilitate the development of treatment program
• Who is least affected? that the family will implement.69,88,143
• What have you done that has helped the most?
• The least?
• What happened when you tried to work on the situa-
tion?
• What has changed in the family since the beginning of
the current situation?
• What is the best advice you have received about this
situation?
• What is the worst?
For further guidance in this process, refer to Wright and
Leahey.69
Discuss with the identified system those factors that Recognition of those factors that inhibit change can facil-
inhibit system reorganization: itate the development of a plan that eliminates these
• Knowledge and skills related to necessary change problems.
• Resources available
• Ability to use these resources
• Belief system about treatment plan
• Cultural values related to the treatment plan
Discuss with the system involvement of other systems Larger systems often impose “rules” on families that
such as social services, school systems, and health-care maintain the larger system by sacrificing the families’
providers in the family situation. coping abilities or becoming overinvolved to the
degree that families feel in a one-down position. The
primary “rule” blames the family for problems.69
Assist the system in making the appropriate adjustments Affirms and promotes client’s strengths.61
in system organization. Note the specific type of assis-
tance the system requests here with the nursing actions
needed identified.
Enhance, with positive reinforcement, current patterns
that facilitate system reorganization. Note the type of
positive reinforcers to be utilized and behaviors to be
reinforced here.
Role model effective communication by: Models for the family effective communication that can
enhance their problem-solving abilities.69
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Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Seeking clarification
• Demonstrating respect for individual, family members,
and the family system
• Listening to expression of thoughts and feelings
• Setting clear limits
• Being consistent
• Communicating with the individual being addressed in
a clear manner
• Encouraging sharing of information among appropriate
system subgroups
Demonstrate an understanding of the complexity of fam- Promotes the development of a trusting relationship while
ily problems by: developing a positive orientation.61,69
• Not taking sides in family problem solving
• Providing alternative explanations of behavior patterns
that recognize the contributions of all persons involved
in the situation, including health-care providers, if
appropriate.
Make small changes in those patterns that inhibit system Promotes the client’s control and provides realistic,
changes. For example, ask the client to talk with the achievable goals for the client, thus preserving self-
family in the group room instead of in an open public esteem when change can be accomplished.61
area on the unit, or ask the client who washes his or
her hands frequently to use a special soap and towel
and then gradually introduce more changes in the
patterns.
Advise the client to make changes slowly. It is important Increases self-esteem and increases desire to continue
not to expect too much too soon. those behaviors that elicit this response.69,139
Provide the appropriate positive verbal feedback to all
parts of the system involved in assisting with the
changes. It is important not to focus on the demonstra-
tion of old patterns of behavior at this time. The small-
est change should be recognized.
Develop goals with the family that are based on the data Promotes the family’s sense of control and the develop-
obtained in the assessment. These goals should be spe- ment of a trusting relationship by communicating
cific and behavioral in nature. respect for the client system. Accomplishment of goals
provides positive reinforcement, which motivates con-
tinued behavior and enhances self-esteem.61,69
Provide positive reinforcement to families for the Positive reinforcement motivates continued behavior and
strengths observed during the assessment and subse- enhances self-esteem.69
quent interviews.
Encourage communication between family members by: Assists the family in developing problem-solving skills
• Having family members discuss alternative solutions that will serve in future situations, and promotes
and goal setting. healthy family functioning.69
• Having each family member indicate how he or she
might contribute to resolution of the concerns.
• Having family members identify strengths of one
another and how these can contribute to the resolution
of the situation.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Develop teaching plan to provide the family with infor- Lack of information about the situation can interfere with
mation that will enhance their problem solving. Note problem solving.69
the content and schedule for this plan here.
Provide opportunities for the expression of a range of Validates family members’ emotions and helps identify
affect; this can mean having the family discuss situa- appropriateness of their affective responses. Persistent,
tions that promote laughing and crying together. intense emotions can inhibit problem solving.69
Express to the family that their emotional experiences Normalizing decreases sense of isolation and assists in
are normal. making connections between family members.69
Contract with the family for specific behavioral home- Suggesting specific tasks can provide the family with new
work assignments that will be implemented before the ways to interact that can improve problem solving.69
next meeting. These should be concrete and involve
only minor changes in the family’s normal patterns.
For example, have them start with calling a resource
for the information they may need to do something dif-
ferent. If it is difficult for the family to accomplish
these tasks, the family system may be having unusual
problems with the change process and should be
referred to an advanced practitioner for further care.
If the task is not completed, do not chastise the family.
Indicate that the nurse misjudged the complexity of the
task, and assess what made it difficult for the family to
complete the task. Develop a new, less complex task
based on this information. If the nurse and family con-
tinue to have difficulty developing a plan of coopera-
tion, a referral may need to be made to a nurse with
advanced training in family systems work. Promotes
positive orientation and recognizes that the develop-
ment of change strategies is an interactive process
between the family and the health-care system.61,69
Communicate the plan to all members of the health-care Promotes continuity of care and builds trust.
team.
Refer the family to community resources for continued Community resources can provide ongoing support. A
support. Assist family in making these contacts by specific plan increases opportunities for success.61,69
developing a specific plan. [Note the specific plan here
with the types of support needed.]
Develop with the family opportunities for them to have Provides families with positive experiences with one
time together and in various subgroupings (parents, another and opportunities to rebuild resources for
parents with children, children) that involve activities coping. Also assists them in developing a broader
other than those directly related to the current problem. identity of the family. They are more than the pro-
This could include respite activities, family play time, blem or illness.61,69
relaxation, and other stress reduction activities. Note
this plan here.
Before termination, praise the family’s accomplishments. Reinforces family’s strengths and promotes self-esteem.
Give the family credit for the change. Reminds family of the new skills they have
acquired.61,69
● N O T E : Refer to Home Health for primary interventions for Ineffective Management
of Therapeutic Regimen (Community). The primary agencies that are available to assist
with community mental health resources are the Mental Health Association and National
Alliance for the Mentally Ill (NAMI). NAMI publishes a journal titled Innovations &
Research. Both these associations open their membership to professionals, consumers,
families of consumers, and members of the community interested in mental health issues.
The purpose of these organizations is to provide community resources and support for
mental health consumers and their families and advocate for mental health consumers.
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Gerontic Health
Refer to the Adult Health section for list of potential/actual factors present that may impede use of therapeutic
regimen plan.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Refer to mental health specialist to rule out depression. Depression in the elderly is frequently underdiagnosed
and undertreated.
Refer to community resources. The older patient may have concerns related to availabil-
ity of support systems, costs of medication, and avail-
ability of transportation. Use of already available
community resources provides a long-term, cost-
effective support system.
Establish communication link with primary caregiver and Family members may not be geographically available.
family.
Advise family members of availability of managed care Provides care options for family to consider.
resources in the community where older client resides.
Provide follow-up support via home visits and telephone Presents opportunities for continued problem solving and
contacts. increasing trust.
Assist caregivers in establishing and meeting their needs. Enables continuation of care while decreasing the poten-
tial for burnout.
Review with the client and family the therapeutic Helps determine possible areas of difficulty for client or
regimen. caregiver.
Provide multisensory (written, computer, audio) informa- Provides quick access to information for the caregiver or
tion on therapeutic regimen to assist client and care- client.
giver in adhering to regimen.
Incorporate a variety of local, regional, or state social Information flow may be impeded because of temporary
services to ensure that needed information about the relocation or social isolation.
regimen is available to older patients.
Identify older community leaders, via age-related groups Peer or cohort influences may assist in identifying and
or associations, who can identify strengths or weak- promoting problem solving.
nesses of the community (such as senior citizen center
members, church groups, and support groups focused
on problems common to older adults).
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client, family, or community to delineate fac- Barriers and facilitators to ineffective management can be
tors contributing to ineffective therapeutic regimen altered to improve outcomes.
management by helping them to assess:
• Level of knowledge and skill related to treatment plan
• Resources available to meet treatment plan objectives
• Appropriate use of resources to meet treatment plan
objectives
• Complexity of treatment plan
• Current response to treatment plan
• Use of nonprescribed interventions
• Barriers to adherence to prescribed plan or medication
Involve the client, family, and community in planning, Involvement increases motivation and improves the prob-
implementing, and promoting the treatment plan.147,148 ability of success.
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Management of Therapeutic Regimen (Individual, Family, Community), Ineffective • 91
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Assisting with family conferences.
• Coordinating mutual goal setting.
• Promoting increased communication.
• Assigning family members specific tasks as appropriate
to assist in maintaining the therapeutic regimen plan
(e.g., support person for patient, transportation, or com-
panionship in meeting mutual goals).
• Identifying deficits in community resources.
• Identifying appropriate community resources.
• Utilizing population surveillance to detect changes in
illness patterns for the community.
Support the client, family, or community in eliminating Many barriers are institutional and can be eliminated or
barriers to implementing the regimen by: reduced.
• Providing for privacy.
• Referring to community services (e.g., church, home
health volunteer, transportation service, or financial
assistance).
• Alerting other health-care providers and social service
personnel of the problem that long waiting periods create.
• Providing for interpreters and for community-based
language classes for English speakers to learn other
languages as well as for non-English speakers to learn
English.
• Identifying community leaders to develop coalitions to
address the problems identified.
• Serving as social activist to encourage necessary par-
ticipants to complete their tasks. This may include fund-
raising, testifying before governing bodies, or coordi-
nating efforts of several groups and organizations.
Assign one health-care provider or social service worker, Continuity of care provides a means for effective problem
as much as possible, to provide continuity in care pro- solving and early identification of problems.
vision.
Assist health-care providers and social service workers to Provides motivation for health-care providers to take
understand the destructive nature of noncompliance in appropriate action when noncompliance is a problem.
chronic illness.148
Make timely telephone calls to clients to discuss care Follow-up with clients reinforces positive behaviors and
(e.g., 1 day after being seen in clinic for minor acute may aid in early identification of problems. Follow-up
infection, or weekly or monthly on a routine schedule also implies support of health-care professionals.
for chronically ill person).148
Collaborate with other health-care professionals and Complex medication and treatment regimens may be dif-
social service workers to reduce the number and vari- ficult for some clients to adhere to.
ety of medications and treatments for chronically ill
clients.149–151
Reteach the client and family appropriate therapeutic Reinforcement of information and continued assistance
activities as the need arises. may be required to improve implementation of the
therapeutic regimen.150
Identify unmet needs of the community. Accurate community needs assessment provides data to
set community goals.
Involve community leaders and representative sampling Collaboration among community leaders and citizens
of the community population in focus groups to iden- provides support for long-term change
tify issues and to develop action plan to meet the
unmet needs.
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Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Identify resources available and those needed to imple- Appropriate use of existing resources. Provides direction
ment action plan. for development of needed resources.
Create marketing plan to disseminate information and Communication of the plan is necessary to sustain inter-
generate interest in plan. est and increase participation.
Foster community partnerships to ensure the continuation Long-term maintenance of the plan will require commit-
of the plan. ment and collaboration among many groups.
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Readiness for Enhanced Therapeutic Regimen Management • 93
ACTIONS/INTERVENTIONS R AT I O N A L E S
Have patient identify the rewards for goal achievement.
Have patient identify their preferred and most effective Appropriate teaching methods enhance transfer of infor-
way of learning (e.g., visual, auditory, or participatory) mation.
Spend 15 minutes one time per day reviewing the plan Imparts relevancy to the goal.
with the client and providing an opportunity for ques-
tions. Discuss with client rationale for various compo-
nents of plan.
Have patient verbalize plan and ensure that patient’s
understanding is congruent achieving therapeutic goal
Identify and secure adequate post-discharge support sys-
tem. This could include community agencies, family
and friends.88,153
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for all possible contributing factors related to Provides the most realistic basis for care.
infant or child such as new or ongoing health/safety
needs that comprise the therapeutic regimen.
Assess for caregiver’s (or child’s as appropriate) current Serves as a basis for validation and clarification of cur-
knowledge for therapeutic regimen. rent knowledge and best plan for how to begin to assist
in plan.
Assess the caregiver’s and/or child’s priorities in Provides mutual planning basis with respect for client
learning. input.
Provide environmental privacy and freedom from inter- Offers a therapeutic milieu for learning.
ruption with pediatric-appropriate setting if child is
also included.
Utilize basic knowledge/developmental level language for Honors the caregiver/child’s ability to best understand
child in teaching. plan.
Offer time for question/answer with examples to generate Reinforcement of learning in a timely manner creates
validation of knowledge. likelihood for retention.
Provide appropriate resource materials and creative devel- Provides greater likelihood of learning.
opmentally appropriate teaching aids (e.g., puppets).
Assist in development of plan for care calendar and file Offers reinforcement and ability to remember access to
for maintaining important resources. health-care providers and follow-up.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Women’s health follows the patterns, interventions and
rationales of the Adult Health section. The following
comments are specifically related to diseases that occur
in women and/or diseases with a high incidence among
the female population.
Discuss with women the effect of environmentally Usually women of poor economic and minority classes
acquired diseases and how to reduce exposure to envi- are those exposed to environmental toxins. Substandard
ronmental toxins. Provide them with information about housing, exposure to “dump sites” or exposure to envi-
hazardous substances, perform risk assessment, and ronmental disaster sites (such as New Orleans’ Ninth
collaborate with community agencies. Work with legis- Ward after hurricane Katrina).154
lators to pass and enforce environmentally related leg-
islation.154
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Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Agricultural pesticides have been directly linked with
birth defects and some causal effects upon pregnancy,
such as an increased incidence of PIH in agricultural
areas of the country.154
Discuss the dangers of smoking and the effects of second Smoking has been identified as the most hazardous expo-
hand smoke on those about them (families, children, sure that women today face. Even if the individual
co-workers, etc). Guide them to programs for smoking does not smoke, exposure to second hand smoke can
cessation not only during pregnancy, but for all life lead to menstrual cycle irregularities, osteoporosis,
cycles. decreased fertility and lung cancer.155
Discuss alternatives to reducing symptoms of premen- Ninety-seven percent of women are affected by premen-
strual syndrome. Lifestyle changes to include exercise strual syndrome at some point in their life.155–157
and good nutrition. Refer to classes to help decrease
stress and provide emotional support.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend 30 minutes once a day discussing client’s percep- Behavior change that is developed with the client using
tion of current situation and life/personal goals. the client’s identified needs and co-evolved solutions
• Use open-ended questions and reflective listening improves outcomes.84–86
• Let the client be the expert
• Do not provide advice
Discuss client’s needs and resources necessary to support
ongoing care
Reflect to client nurse’s understandings of the client’s
solutions and goals
Summarize the solutions and goals that the client
identified
Develop a schedule for positive reinforcement when goals Positive reinforcement increases behavior.87
are attained. Note the reinforcers and schedule of rein-
forcement here.
Discuss with client sources of social support. Social support improves health outcomes.88,153
• Schedule meeting with client and social support sys-
tem. [Note the date and time of that meeting here.]
• Spend 1 hour one time per week meeting with client
and social support system to focus on:
• With client’s permission educate support system about
client’s health-care needs
Model communication and assist support system in devel-
oping positive communication skills
Include the client in group therapy to provide positive Group provides opportunities to relate and react to others
role models and peer support and to permit assessment while exploring behavior with each other.87
of goals and exposure to differing problem solutions.
Provide client with information that will facilitate contact Ongoing support from the health-care team facilitates
with health-care team. adherence to therapeutic regimens.69,84,158
Schedule regular contact with the client to provide posi-
tive reinforcement for their efforts and refer to commu-
nity support systems before discharge.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Schedule time for the client to talk with community
support systems before discharge.
Discuss with client potential problems that might arise Prevents client burnout and enhances self-esteem.
and develop plans to adjust self-care as necessary. Planned relapse becomes no relapse.69
Normalize times when client’s adherence to the therapeu-
tic regimen is not perfect and schedule “safe holidays”
from perfect adherence.
Provide client with educational materials. Provides self–care information that is readily accessible
Provide materials that address client’s best learning mode to the client.84
(auditory/visual) and at client’s level of understanding
(proper reading level). [Note client’s reading level here.]
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine the client’s existing knowledge regarding the This allows the nurse to focus on strengths and existing
therapeutic regimen. knowledge and also assists in determining knowledge
deficits or misunderstandings.
Determine the client’s priorities for learning. Client involvement in the learning process facilitates
success.
Ensure privacy, comfort, and rapport prior to teaching Reduces anxiety and promotes a nondistracting environ-
sessions. ment to enhance learning.
Avoid presenting large amounts of information at one This encourages increased opportunity to process and
time. store new information.
Monitor energy level as teaching session progresses. Reduces possibility of fatigue which can impair learning.
Present small units of information, with repetition, and Compensates for delayed reaction time associated with
encourage the patient to use cues that enhance ability aging. Promotes retention of information by connecting
to recall information. information to previously mastered skills.90
Use multisensory approach to learning sessions whenever Hearing, vision, touch, and smell used in conjunction can
possible. stimulate multiple areas in the cerebral cortex to pro-
mote retention.91
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess the client and family’s understanding of the cur- Identifies potential misunderstanding or knowledge
rent therapeutic regimen. deficit.
Assist the client/family in the development of a therapeu- Enhances the support and educational resources of the
tic network to include informal relationships with family/client.
informal structures in the nuclear family to select
laypersons and professionals.174
Educate the client/family about risk factors and preven- Involvement improves motivation and improves the out-
tion for progression of their illness and sequelae. come. Self-care is enhanced.
Assist the client and family to identify home and work- This action enhances safety and assists in preventing
place factors that can be modified to promote health accidents. Promoting a nonsmoking environment helps
maintenance (e.g., ramps instead of steps, elimination reduce the damaging effects of passive smoke.
of throw rugs, use of safety rails in showers, and main-
tenance of a nonsmoking environment).92,93
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96 • Health Perception–Health Management Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client and family in planning, implementing, Involvement improves motivation and outcomes.
and promoting a health maintenance pattern through:
• Helping to establish family conferences to discuss
strategies for meeting client health maintenance needs.
• Engaging in mutual goal setting with client and family.
Encourage the client/family to establish goals for their
own involvement in managing the therapeutic regimen.
• Assisting family members in acquiring family or com-
munity-based assistance for specified tasks as appropri-
ate (e.g., cooking, cleaning, transportation,
companionship, or support person for exercise program).
• Teach the family and caregivers about disease manage- Provides a sense of autonomy and prevents premature
ment for existing illness: progression of illness.
• Symptom management
• Medication effects, side effects, and interactions with
over-the-counter medications.
• Reporting the use of over-the-counter remedies, herbal
supplements and medicines to the health-care provider.
• Wound care as appropriate. Prevention of skin break-
down for clients with illnesses contributing to immo-
bility.
Teach the client and family health promotion and disease These activities promote a healthy lifestyle.
prevention activities:
• Relaxation techniques
• Nutritional habits to maintain optimal weight and
physical strength.
• Techniques for developing and strengthening support
networks (e.g., communication techniques or mutual
goal setting).
• Physical exercise to increase flexibility, cardiovascular
conditioning, and physical strength and endurance.94
• Evaluation of occupational conditions92
• Control of harmful habit, such as substance abuse
• Therapeutic value of pets95
PERIOPERATIVE-POSITIONING 4. Immobilization
INJURY, RISK FOR 5. Muscle weakness
6. Obesity
DEFINITION44 7. Sensory or perceptual disturbances due to anesthesia
A state in which the client is at risk for injury as a result
RELATED FACTORS44
of the environmental conditions found in the perioperative
setting. The risk factors also serve as the related factors.
DEFINING CHARACTERISTICS RELATED CLINICAL CONCERNS
(RISK FACTORS)44
1. Any condition requiring surgical intervention
1. Disorientation 2. Peripheral vascular disease
2. Edema 3. Diabetes mellitus
3. Emaciation 4. Malnutrition
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98 • Health Perception–Health Management Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Place arms at right angles to the patient. Do not hyperex- Avoids strain on arms.
tend the arms. Secure the arms with a restraint around
the wrist.
Place the safety belt above the patient’s knees (depending Avoids compromising circulation in popliteal area.
on operative site).
Ensure that all supports are padded. Basic safety measures.
Specific Positions
Lithotomy
Raise or lower legs at the same time. Reduces strain on hip joints.
Lower legs, slowly at the same time.
Adjust height of stirrups to fit the patient’s legs.
Be sure that no part of the legs touch metal. Prevents electrical burns.
Cover stirrups with linen or place long leg booties on the Protects nerves and circulation.
patient’s legs (up to mid thigh).
Pad popliteal space.
Ensure that the patient’s buttocks are over lower break in
table.
Nephro or Thoracic Surgery
Move the patient slowly and carefully, as a unit; have suf- Basic safety measure.
ficient assistance.
The patient will be on side over the middle break of the
table.
Position lower arm at a 90-degree angle away from body.
Place upper arm parallel to lower arm on a separate and Facilitates respiration; maintains circulation.
high armboard or straight above the head. Restrain as
needed. Protect nerves and muscles.
Support the patient’s sides with padded kidney rests. Provides support for side and back.
Bend bottom leg 45 to 90 degrees. Top leg should be Stabilizes the patient.
straight.
Place pillow(s) between knees and legs and feet Protects pressure points.
Jacksonian (Modified Knee–Chest)
● N O T E : Patient will probably be put to sleep on the stretcher and then rolled onto
the OR table.
Have sufficient assistance to move the patient. Basic safety measure.
Extend arms on armboards above the head. Facilitates respiration; maintains circulation.
Place pillow under ankles. Protects pressure points.
Support chest. Stabilizes patient’s position.
Turn head to side; ensure an adequate airway. Allows good expansion of chest and promotes gas
exchange.
Prone (Upper and Lower Back Surgery)
● N O T E : Patient will probably be put to sleep on the stretcher and then rolled onto a
back frame. This allows the back to be hyperextended and supports the chest for good
respiration. Actions are the same as for Jacksonian position except:
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Place pillows under upper chest, thighs, legs, ankles, and Avoids pressure and strains. Provides good anatomic
feet. alignment.
Trendelenburg
Support shoulders with padded shoulder rests. Provides stabilization of the patient’s position.
Child Health
● N O T E : Any procedure requiring prolonged stabilization in a fixed position places neonates and children at risk for
this diagnosis (e.g., ECMO [extracorporeal membranous oxygenation] with cannulation of major vessels requires fixed
positioning for several days to 1 week).
Safeguard the child with nursing actions relevant from Adult Health for positioning plus the following:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor skin integrity from head to toes with specific Decreases likelihood of impact of shearing forces or
attention to head, ears, elbows, back, and heels, or burns and demonstrates appropriate caution to diminish
other body parts in direct contact with surface of mat- possible injury.
tress or lines from monitoring equipment.49
*Recognize the need for ongoing monitoring for infants, Offers anticipatory planning for prevention and early
young children, or any client under the influence of detection of injury related to potential positional
anesthesia regarding loss of sensation or cues of verbal factors.
nature to warn of pain/injury.
Infants and children with spina bifida (myelomeningo-
cele) may have diminished neuro-sensation in legs
and feet depending on the level of involvement.
Women’s Health
Same as for Adult Health except for the following:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine proper alignment and positioning of mother Enhances circulation and oxygen supply to the placenta
during the cesarean section and any other procedure in and the fetus.159
which mother must lie on back. Place a wedge cushion
under the left buttock when positioning mother on sur-
gical table.
Assist the mother’s chosen partner (support person) to Reassures and supports the partner (support person) dur-
prepare for the cesarean section by describing the ing surgery, allowing him to be supportive to the preg-
events that will take place, explaining his role and nant woman.
where he will sit (a stool or chair next to the mother’s
head) during the surgery, and identifying who will
assist him.
Mental Health
Nursing interventions and rationales for this diagnosis are the same as for Adult Health. Mental health clients who are
most commonly at risk for this diagnosis are those receiving electroconvulsive therapy (ECT) treatments.
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Gerontic Health
In addition to the interventions for Adult Health, the following may be applied to the older client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor closely for signs of hypothermia, especially in Frail elders are at high risk for hypothermia as a result of
frail elders. changes associated with aging. Elimination of an anes-
thetic agent may be reduced because of hypothermia.
Older adults may have increased oxygen demand sec-
ondary to shivering if hypothermia is not
treated.151,160,161
Provide head and neck support that prevents head rotation Hyperextension or rotation may cause vertebral circula-
or hyperextension. tory compromise in older patients.
Ensure adequate padding over pressure-prone areas. Decreases potential for circulatory compromise as well as
nervous system or skin injury in older patients at risk
for these problems.
Observe, especially intraoperatively, for external pressure Compromised circulation or increased skin pressure can
caused by leaning on patient. result in patient injury.
Position extremities with caution. Older patients are at an increased risk for osteoporosis
and, consequently, fractures.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Begin preoperative teaching to the client and family as Involvement of the client and family increases motiva-
soon as possible prior to surgery. Include the need for tion. Correct knowledge supports the behavior and
early ambulation, deep-breathing exercises, and ade- assists in preventing complications.
quate pain control. Reinforce teaching as needed post-
operatively.
Instruct patient and family/caregivers about situations that Early intervention prevents exacerbation of com-
require immediate intervention from their health-care plications.
provider:
• abrupt increase in temperature
• changes in skin integrity
• alterations in the patient’s level of consciousness
Involve the home caregiver in developing plan of care to Involvement in the planning increases motivation and
decrease risk of complications. success of the intervention.
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Protection, Ineffective • 101
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102 • Health Perception–Health Management Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Side effects of blood and blood products: Monitor for
possibility of blood reaction. Take vital signs every 15
minutes, hour times an hour, then every 30 minutes
until transfusion is completed. In the event of transfu-
sion reaction, stop the transfusion immediately, main-
tain IV line with saline, and notify physician while
monitoring patient for further anaphylactic signs and
symptoms.
• Effects and side effects of steroids: Improved general
status, decreased inflammatory signs and symptoms
versus untoward effects including bleeding, sodium
(Na) or potassium (K) imbalance. Calculate and record
intake and output at least once per shift.
• Effects and side effects of antineoplastics, such as nau-
sea, cardiac arrhythmias, extrapyramidal signs and
symptoms. These side effects vary according to the
specific agents used. Take vital signs every 5 to 10
minutes during actual administration and use a cardiac
monitor.
• Signs and symptoms of infection such as lymphoid
interstitial pneumonia or recurrent oral candidiasis
Apply pressure after each injection and after removal of Assists in stopping of bleeding.
IV needle.
Provide oral hygiene or assist the patient with oral Prevents opportunistic infection.
hygiene at least 3 times per day, taking appropriate
precautions for vulnerable mucous membranes.
Provide body hygiene or assist the patient with body
hygiene at least once daily at time of the patient’s
choosing.
Measure and record intake and output at end of each Monitors effectiveness of bowel and bladder function.
shift.
Provide the patient with food choices and portions that Ensures balanced intake of necessary vitamins, minerals,
will facilitate their eating nutritious meals. Collaborate etc., to assist in tissue repair. Assists in lessening
with diet therapist regarding the patient’s likes, dis- impact of infections.
likes, and planning for dietary needs after hospital
discharge.
Collaborate with appropriate members of the health-care Gives guidelines for future therapeutic regimen as well as
team regarding therapeutic regimen assessing effectiveness of current regimen.
Teach the patient and significant others: Provides basic knowledge needed for the patient and fam-
• Medication administration ily to make modifications necessitated by alteration in
• Signs and symptoms to be reported protective mechanisms.
• Special laboratory or other procedures to be done at
home
• Anticipatory safety needs
• Routine daily care
• Appropriate clean and sterile technique
• Isolation or reverse-isolation technique
• Common antigens and/or allergens and seasonal
variations
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• How to avoid or reduce exposure to antigens and/or
allergens (alteration of environment)
• Type and use of protective equipment
• Standard precautions
• Rationale for compliance with prescribed regimen
• Resources available for assistance with health care,
legal questions, or ethical questions
Identify community resources for patient and family. Allows time for agencies to initiate service. Use of exist-
Make referrals at least 3 days before discharge from ing community services is effective use of resources.
hospital.
Child Health
● N O T E : Infants at risk for this diagnosis are premature infants, infants with family
history of hemophilia or sickle cell anemia, infants whose mothers have a history of drug
abuse or HIV, and children who have histories of medication reaction. In infants espe-
cially, incubation for HIV depends on acquisition time. The infant may be exposed any
time during pregnancy, but sero-con/retroversion to a negative HIV status may occur,
with a later positive HIV status again. The more symptomatic the mother, the greater the
effect on the infant due to constant reinfection (in the infant). For infants whose mothers
are HIV positive, 26 percent are HIV positive in the first 5 months of life, an additional
24 percent are HIV positive by 12 months of life, and the remaining 50 percent are HIV
positive by 2 years of age. Key symptoms are intercurrent infection and weight loss.
Other conditions noted include failure to thrive, hepatomegaly, cardiomegaly, lymphoid
interstitial pneumonia, chronic diarrhea, cardiomyopathy, encephalopathy, and oppor-
tunistic infections. Even tuberculosis may be seen in these infants, with a tendency to
progress from primary to miliary phase. In these infants there may be disseminated
bacille Calmette-Guérin (BCG) infection. It is important to be aware of laboratory stud-
ies requiring large amounts of blood to study the course of sero HIV status. This blood
drawing is problematic in the already depressed immune and reticuloendothelial systems
of these infants. It is imperative that these infants not be given live polio vaccine because
of their HIV-positive status.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Maintain monitoring for: Essential monitoring to avoid overwhelming of child’s
• Observable lesions of ecchymotic nature or evidence of system by infection, etc.
tendency toward bruising
• Decreased absorption of nutrients (especially the pre-
mature infant because of the possibility of necrotizing
enterocolitis)
Provide at least one 30 to 60 minute opportunity per day Reduces anxiety, fear, and anger, and provides an oppor-
for the family to ventilate feelings about the specific tunity for teaching.
illness of their child.
Teach the child and family essential care. Basics of home care for child with diagnosis of
Ineffective Protection.
As applicable, exercise caution for any medications or
blood products to be administered.
Provide diversionary therapy according to child’s status, Prevents boredom and restlessness and fosters continued
developmental level, and interests. development of child in spite of illness.
Be aware of current frustration with use of DDC Avoid unrealistic hope. Ideally, toxicity is balanced
(dideoxycytidine) and AZT (zidovudine) in children. against the need to reach therapeutic central nervous
At this time, protocols dictate doses. system (CNS) dosage levels.
(care plan continued on page 104)
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104 • Health Perception–Health Management Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Remind the family that current treatment for AIDS is Avoids unrealistic hope while providing knowledge and
only palliative. Be sensitive to the unique nature of this support necessary to deal with a fatal illness.
health concern for all involved. Promote attention to
the need for:
• Spiritual and emotional support
• Nutritional support
• Treatment of HIV-related infections
• Administration of IV immune globulin
• Treatment of tumors and end organ failure
• Chronic pain
Acknowledge potential loss of mother for the infant with Anticipatory planning will assist in health maintenance in
HIV, and plan appropriately for foster care status as best interest of infant in event of need for separation
indicated. from the mother.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
HELLP syndrome (a severe form of pregnancy-induced Understanding the laboratory values for a preeclamptic
hypertension): Monitor laboratory results for low mother progressing toward HELLP syndrome allows
platelets (less than 100,000/cc), elevated liver enzymes, the health-care provider to prevent and/or begin early
elevated SGOT/SGPT, intravascular hemolysis, schisto- treatment of this dangerous variant of severe
cytes or burr cells on peripheral smear, low hematocrit preeclampsia.
(Hct) (without evidence of significant blood loss), and H ⫽ hemolysis
hypertension.29,159 EL ⫽ elevated liver enzymes
LP ⫽ low platelets159
Other high-risk history in the mother such as history of Allows nursing staff time and information to plan individ-
preterm labor, chronic hypertension, sickle cell anemia, ual care for the mother and her newborn infant.
and other blood disorders.
Signs and symptoms of infection.
Mother’s history of drug abuse, alcohol abuse, HIV, or Safety of the mother and the infant is of utmost impor-
domestic violence. tance. Provides opportunity for assessment of home
environment and provision of assistance.
Mental Health
● N O T E : Clients receiving antipsychotic neuroleptic drugs are at risk for development
of agranulocytosis. This can be a life-threatening side effect and usually occurs in the
first 8 weeks of treatment. Any rapid onset of sore throat and fever should be immedi-
ately reported and actively treated. Tricyclic antidepressants can cause blood dyscrasias
with long-term therapy. Initial symptoms of these dyscrasias include fever, sore throat,
and aching.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Immediately report the client’s complaint of sore throat Alterations could be symptoms of agranulocytosis or
or development of temperature elevation to physician. blood dyscrasias, which would place the client at risk
Institute nursing actions for hyperthermia. (See for infection. Prompt recognition and intervention pre-
Chapter 3.) vent progression and improve client outcome.104
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Protection, Ineffective • 105
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client who has had this type of response to
antipsychotic neuroleptics or tricyclic antidepressants
that he or she should not take this drug again.
If the client is experiencing severe alterations in thought Client safety is of primary importance. Provides opportu-
processes, provide one-to-one observation until mental nity for ongoing assessment of the quality of the con-
status improves or until the client can again participate tent of the client’s thought and provides ongoing
in unit activities. reality orientation.
Refer to the nursing care plans for Sensory Perception:
Distributed and Thought Processes: Disturbed for more
detailed plans of care.
Gerontic Health
● N O T E : The older adult is subject to impaired protection due to age related changes
in the immune system which include decreased resistance to bacterial, fungal, and viral
infections; increased risk of reactivating latent infections; absence of the classic signs of
infection; changes in hypersensitivity responses; diminished response to vaccines; con-
current chronic diseases and debilitation; institutionalization; increased incidence of
autoimmune disorders.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor sensory status at each encounter. Ensure, if nec- Uncorrected sensory impairments may negatively impact
essary, that sensory-enhancing aids (glasses, contacts, the communication process.
hearing aids) are clean and functioning.
Monitor for subtle signs of infection, such as new onset Changes in immune system with aging can cause
of falls, incontinence, confusion, or decreased level of increased potential for infection. Infection may present
function. in an atypical manner in older adults.42
Teach the client to avoid soaps that may cause dry skin. Dry skin predisposes to potential skin breakdown and
loss of protective barrier against pathogens.162
Initiate measures to maintain skin integrity such as: Intact skin acts as a protective barrier against infection.162
• Using pressure-relieving devices for use in chairs or
in bed
• Ensuring frequent weight shifting to reduce pressure on
vulnerable areas (bony prominences)
• Monitoring and documenting skin status with each con-
tact according to care setting and client condition
• Avoiding shearing forces that may cause epidermal
damage
• Prompting client and caregiver to change position fre-
quently to avoid skin integrity problems
Teach clients and/or caregivers need for AIDS testing as AIDS is often undetected in older adults in the early
appropriate. stages because of lack of knowledge about risk for the
disease and false assumptions that AIDS is not a dis-
ease present in older adults.164,165
Monitor renal and hepatic function in older adults who Antiretroviral therapy can further compromise kidney and
receive antiretroviral therapy. liver function.
Assist the client in maintaining adequate hydration of Adequate hydration status has a preventive effect.
2000 cc daily.
Assist the client in maintaining adequate vitamin intake, These nutrients are known to assist in infection
particularly vitamins A, C and E, zinc, and selenium. prevention.
(care plan continued on page 106)
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106 • Health Perception–Health Management Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Develop, with the client, family, and caregiver, plans for Advance planning improves the response and outcomes
dealing with emergency situations, such as: in crisis situations.
• Decision making regarding calling ambulance
• Decision tree for calling nurse or physician
Assist the client and family to identify learning needs This action describes knowledge required to protect the
such as: client and the family.
• Universal precautions
• How to disinfect surfaces contaminated with blood or
body fluids (use 1:10 solution of bleach)
• Protective isolation
• Proper handwashing
• Use of separate razors, toothbrushes, eating utensils,
etc.
• Proper cooking of food
• Avoidance of pet excrement
• Avoidance of others with infection
• Skin care, oral hygiene, and wound care
• Use of protective equipment
• Signs and symptoms of infection, fluid and electrolyte
imbalance, malnutrition, pathologic changes in behav-
ior, and underlying disease process
• CPR and first aid
• Hazardous waste disposal (e.g., soiled dressings, nee-
dles, or chemotherapy vials)
• Advanced directive (e.g., living wills and durable
power of attorney for health care)
• Financial and/or estate planning
• Symptom management and pain control
• Administration of required medications
• Nutrition
• Care of catheters, IVs, respiratory therapy equip-
ment, etc.
• Proper treatment of linens soiled with infectious matter Hot water provides an effective means of destroying
• Environmental cleanliness microorganisms, and a temperature of at least 160⬚F
for a minimum of 25 minutes is commonly recom-
mended for hot-water washing. Chlorine bleach pro-
vides an extra margin of safety. A total available
chlorine residual of 50 to 150 ppm is usually achieved
during the bleach cycle.98
Assist the client and the family to identify resources to Involvement of the client and family improves their abil-
meet identified learning needs. ity to identify resources and to function more inde-
pendently.
Involve the client and family in planning and implement- Involvement of the client and family improves motivation
ing environmental, social, and family adaptations to and outcomes.
protect the client.
Plan with the family and client for safe as well as mean- Provides for activity while protecting the client and
ingful activities according to the client’s level of func- family.
tioning and interests.
Assist the client and family in lifestyle adjustments that Lifestyle changes often require support.
may be required.
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Surgical Recovery, Delayed • 107
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108 • Health Perception–Health Management Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Promote rest at night. Note those things that assists Increases quantity and quality of rest and sleep.
client’s rest here.
Avoid sensory overload or sensory deprivation. Provide Sensory aspects can deplete energy stores. Diversional
diversional activities. activities help prevent overload or deprivation by
focusing patient’s concentration on an activity he or
she personally enjoys.
Address unresolved stressors by instructing the patient in Mental and physical stress greatly contributes to sense of
stress reduction techniques. Note those techniques to inability to resume ADLs and stimulates undesirable
be taught here. effects from stress response.
• Have patient return—demonstrate at least once a day
through day of discharge.
Assist the patient to develop coping skills:
• Review past coping behaviors and success or lack of Determines what has helped in the past, and determines if
success. the measures are still useful.
• Help identify and practice new coping strategies. Allows the patient to practice and become comfortable
with skills in a supportive environment.
• Challenge unrealistic assumptions or goals. Assists the patient to avoid placing extra stress on self.
Turn, cough, and deep breathe every 2 hours on Mobilizes static pulmonary secretions.
[odd/even] hour.
Incorporate passive or active ROM exercises as appropri- Promotes tissue perfusion and can benefit pulmonary sys-
ate every 2 hours on [odd/even] hour. tem.168
Initiate early mobilization strategies Has been shown to improve oxygen saturation and
decrease length of stay.151
Protect with a sterile dressing for 24 to 48 hours. Wash
hands before and after dressing changes or any contact
with the surgical site, or when an incision dressing
must be changed. Use sterile technique, and educate
the patient and family regarding proper:
• Incision care, symptoms of SSI, and the need to report
such symptoms.
• Monitor for hyperglycemia Hyperglycemia lends to decreased wound healing.
• Assess cultural and religious norms. Cultural and religious norms influence the perception of
“the sick role.”
• Collaborate with psychiatric nurse practitioner, ostomy Collaboration helps to provide holistic care. Specialist
or wound care management specialist as appropriate may help discover underlying events for delayed surgical
regarding care. recovery and assist in designing an alternate plan of care.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for all contributing factors, such as diet, altered Thorough assessment will best offer ways to address fac-
organic or pathophysiologic functions, medications, tors that are impeding healing.
environmental issues, psychological components, and
circumstantial issues.
Determine appropriate treatment with attention to unique Anticipatory planning provides holistic avenues to con-
status per client’s situation, with specific attention to sider for recovery.
medications, formula or diet, and surgical
procedure/expected recovery.
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Surgical Recovery, Delayed • 109
ACTIONS/INTERVENTIONS R AT I O N A L E S
Note specific treatment protocols to satisfy unique heal- Unique protocols will best offer appropriate healing like-
ing or surgically related needs for client. lihood when implemented per intended plan.
Reassess every 8 hours for progress in healing Frequent ongoing assessment provides feedback to assist
(wound color, tissue status, drainage, and all in determination of success of plan versus need for
related parameters). consideration of alternate modalities.
Reassess for potential additional delays of recovery as Primary delays in surgical recovery may contribute to
initial delays are identified. likelihood of delays to be noted later, with multiple
delays made more likely to be noted before greater
complications arise.
Assess for other nursing problems that may be identified Multifactorial problems in recovery are best managed by
as critical to resolution in relation to current surgical separation and identification according to known etiol-
delay. ogy and treatment.
Women’s Health
This nursing diagnosis pertains to women the same as to any other adult, with exception of the following:
ACTIONS/INTERVENTIONS R AT I O N A L E S
After a Cesarean Section
Monitor abdomen at least every 4 hours (state times here) Monitor the patient for signs and symptoms of incisional
for any distention, redness or swelling at incision site, and/or puerperal infection.
tenderness, foul-smelling lochia, or vaginal discharge.
Wash hands each time before and after you or family Prevents development of nosocomial infection in the
members handle the baby. infant.
Maternal delay in recovering can involve a longer separa-
tion from the infant:
• Act as a liaison between the family, nursery, and the
mother.
• Keep the mother informed and reassured about her
baby.
If the mother is unable to care for the infant, develop a
schedule in which the infant is brought to the mother’s
room for frequent visiting.
Let significant other or chosen family member care for
the infant in the mother’s room.
If unable to transport the infant to the mother, obtain pic-
tures of infant and set them up where the mother can
view them.
Involve other family members in the care of the infant.
• Prepare the family to take the infant home without the
mother.
• Teach the family, and have them return—demonstrate,
care and feeding of the infant.
• If the mother desires to breast-feed:
• Collaborate with physician regarding advisability of
breast-feeding.
• Involve lactation consultant to assist mother in pump-
ing and
• dumping milk if unable to use for infant, or
• storing milk, if able to use, and sending home with
the family.
(care plan continued on page 110)
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110 • Health Perception–Health Management Pattern
Mental Health
Nursing interventions and rationales for this diagnosis are the same as those for Adult Health.
Gerontic Health
● N O T E : The older adult undergoing surgical treatment, either elective or emergency,
is at great risk for problems with delayed recovery. Age-related changes in numerous
systems and protective mechanisms increase the potential for complications pre-, intra-,
and postoperatively. It is not uncommon for older adults to have a preexisting medical
disease, atypical signs and symptoms of infection, cardiac or respiratory problems, and
less ability to deal with stressors such as hypoxia, volume depletion, or volume overload.
Gerontologic nursing groups are actively designing research-based protocols to ensure
“best practices” in caring for older adults. The reader is referred to the work of NICHE
(Nurses Improving the Care of the Hospitalized Elderly) at the Hartford Institute for
Geriatric Nursing and the University of Iowa Research-Based Protocols developed by
the University of Iowa Gerontological Nursing Interventions Research Center
(http://www.hartfordign.org/programs/niche/)129,130
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine the client’s mental status upon admission, and Older adults are at risk for developing acute confusion
monitor the client for signs of acute confusion (delir- because of the multiple risk factors they experience
ium). Document results of mental status determinations (relocation, pain, physiologic changes associated with
in the client’s record. The Mini-Mental State Exam by surgical procedures).
Folstein and/or the NEECHAM Confusion Scale are
tools commonly used or recommended to determine
mental status.
Initiate protocol (if available in your facility) for interven- Delays in determining the presence of acute confusion
tions addressing care of the acutely confused client if may lead to extended hospital stays, decreases in func-
mental status changes warrant such action. tional status, and nursing home placement for older
adults.
Manage postoperative acute pain aggressively to assist Older adults and some health-care providers may have
clients in recovery from the effects of surgery. Teach concerns regarding use of pain medication. Some older
clients and family or significant others the benefits of adults may have fears of becoming addicted to medica-
adequate pain control in the recuperative process. Pain tions. Health-care providers may be reluctant to med-
management can promote early ambulation, facilitate icate older adults because of concerns about
effective coughing and deep breathing, and decrease overdosing or oversedating older clients.153,154
postoperative complications.
Plan caregiving activities that avoid stressing the client Physiologic reserves are decreased with aging. Too many
due to prolonged duration or intensity. demands can lead to increased fatigue and decreased
ability to tolerate mobility efforts and postoperative
activities to improve respiratory and cardiovascular
status.
Monitor for evidence of poor wound healing. Medications, poor nutritional status, systemic disease,
and a history of smoking can have a negative effect on
the normal wound repair response.155
Arrange for a nutrition consult if the client shows evi- Alterations in nutrition, such as protein–calorie malnutri-
dence of altered nutritional status. tion or nutrient deficiencies, can affect wound healing.
Refer older adults for evaluation of possible depression, Older adults who have depressive symptoms have nega-
especially if declining functional ability is noted. tive postoperative outcomes.156,157
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Sudden Infant Death Syndrome, Risk For • 111
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Educate the client, family members, and potential care- Allows the family to participate in care and prevents
givers how to care for the wound appropriately and infection or exacerbation of existing infection.
have them demonstrate proper wound care.
Assist the client and caregivers in obtaining necessary Maximizes the client and caregiver’s ability to provide
supplies for appropriate wound care. appropriate wound care.
Instruct the client and caregivers in signs and symptoms Prevents further morbidity.
of infection, hemorrhage, and dehiscence, as well as
how and when to seek medical care.
Educate the client, family members, and potential care- Treats existing infection and prevents possible super-
givers of the importance of taking all antibiotics as infection.
prescribed until the regimen is complete.
Encourage the client to eat small frequent meals that are Allows maximum nutrition without discomfort from
high in calories and protein. large meals.
Weigh the client twice weekly. Early identification of excessive weight loss can help
identify complications such as dehydration.
Encourage the client to identify times of day when Allows the client some control of activities.
fatigue is worse, and space activities around the times
when they are less fatigued.
Assist the client in obtaining durable medical equipment Makes self-care activities less tiring.
for the home (e.g., bedside commodes and shower
chairs) until the fatigue improves.
Encourage the client to rest before scheduled activities. May help avoid exacerbation of the fatigue.
Encourage the client to participate in walking activity as Fatigue seems to show improvement with walking
tolerated. programs
Encourage the client and caregivers to adhere to a round- Keeps pain at a tolerable level and avoids highs and lows
the-clock analgesic regimen rather than using medica- in pain intensity.
tions on a prn basis until pain is controlled.
Actively listen to the client and family members’ con- Allows verbalization of frustration and aids in realistic
cerns about delayed recovery and provide honest planning for the future.
answers about the client’s progress.
Assist the client in obtaining letters and/or documentation Helps eliminate a source of anxiety.
as needed for employers regarding extended recovery
time.
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112 • Health Perception–Health Management Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess caregiver(s) readiness for learning to prevent Readiness offers cues for likelihood of effective learning
SIDS. as prevention education increases likelihood for reduc-
tion of risk for SIDS to extent possible.173
Provide educational materials to primary caregiver(s) Adheres to standards currently endorsed by the SIDS
to include the following as applicable. (Confirm those Task Force of the American Academy of Pediatrics.173
aspects that may be inappropriate with pediatrician
or primary care provider.):
• Universal precautions
• Place infant on back with pacifier from birth to Assists in maintenance of airway.
6 months of age.
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Sudden Infant Death Syndrome, Risk For • 113
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Use of firm sleep mattress with basic sheet covering. Lessens likelihood of infant airway being obstructed sec-
Avoid placing soft materials such as pillows, quilts, ondary to blanket or other surface bedding obstructing
comforters, or sheepskins under a sleeping infant. airway.
• Avoid soft objects (such as stuffed animals) and loose Lessens likelihood of objects or blankets covering
bedding (no pillow-like bumper pads, instead use thin, infant’s face or obstructing the infant’s airway.
fixed to crib bumper pads). Tuck blankets from chest
level down or utilize sleep sacks designed to keep
infant warm but not constricted or head covering.
• Have infant’s crib in same room as caregiver(s) but no Risk of SIDS reduced and allows for close contact for
co-sleeping. feeding and potential need for intervention.
• Refrain from smoking; do not expose the infant to Lessens irritants to reduce SIDS and numerous other res-
second-hand smoke. piratory conditions.
• Consider offering a pacifier at nap time and bedtime. Mechanism is unknown, but evidence is compelling for
reducing risk of SIDS.
• Do not reinsert pacifier once infant falls asleep. Same as above.
• If infant refuses pacifier, do not force infant to take it. Same as above.
• Pacifiers are to be free of any sweet solution. Lessens likelihood of infection with such organisms as
botulism as found in honey.
• Pacifiers are to be cleaned often and replaced regularly Lessens likelihood of infection or likelihood of broken
every 3 to 4 weeks. pieces being aspirated by infant.
• For breast-fed infants, delay pacifier introduction until Lessens likelihood of nipple confusion as breastfeeding is
1 month of age established.
• Avoid overheating: infant to be lightly clothed for sleep Overheating is shown to be a risk factor for SIDS.
with room temperature maintained for adult with light
clothing-infant should not feel hot to the touch.
• Avoid commercial devices marketed to reduce the risk Efficacy or safety is not yet sufficiently upheld in studies
of SIDS including positional devices or rebreathing done thus far.
devices.
• Do not use home monitors as a strategy for reducing Does not decrease the threat of SIDS.
the risk of SIDS. Electronic respiratory and cardiac
monitors are suited to detect cardiorespiratory arrest
and may be of value for home monitoring of those
infants deemed to be at risk for instability from a car-
diorespiratory standpoint.
• If concurrent risk exists for apnea of infancy or prema- Offers caregiver(s) sense of confidence for ability to
turity, caregiver(s) are taught basic CPR. intervene in instance of actual cardiorespiratory arrest.
*May vary per institution or preference of pediatrician or
neonatologist.
• Avoid possible development of positional plagio- Recommendations for alternative positioning and move-
cephaly (malshapen flatness of the occiput). ment during waking time is likely to prevent the mal-
• Encourage tummy time while infant is awake and in shaping of the infant’s head while also fostering
close observation. appropriate motor development and time for interaction
• Avoid excessive time in carriers, car-seat carriers, or with primary caregiver(s).
bouncers in which the occiput is pressured.
• Alternate position of head turning week by week and
alternate crib position to provide alternate views to rest
of room.
*Special attention should be addressed to these compo-
nents if neurologic injury or developmental delay of
the infant is suspected.
Early referral for plagiocephaly is encouraged to help
avoid the need for surgery. In some instances, orthotics
may help avoid surgical intervention.
(care plan continued on page 114)
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114 • Health Perception–Health Management Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor primary caregiver for support need(s). Provides backup to help value and support caregiver(s),
esp. in instance of young age or those for whom sup-
port is vital.
Teach caregiver(s) to maintain close observation of infant Maintains safe environment.
at all times.
Monitor caregiver’s ability to provide this care.
Teach caregiver(s) to utilize national and local resources Provides support to strengthen knowledge and sense of
for additional support for education and support in ability to cope with reinforcement of basic risk reduc-
dealing with the risk for SIDS. National SIDS ing principles for SIDS with shared sense of valuing.
Resource Center: http://www.sidscenter.org, American
Sudden Infant Death Syndrome (SIDS) Institute.
(http://www.sids.org)
Monitor for concurrent risk factors that place the mater- Assists in secondary prevention of related problems.
nal–infant dyad at increased likelihood for stressors
that suggest other nursing needs, especially role strain
and primary caregiving needs.
Monitor caregiver(s) compliance with plan for reduction Values the importance of compliance with SIDS risk
of SIDS risk. reduction and offers confirmation of caregiver(s) ability
• Provide positive verbal reinforcement for to demonstrate accuracy of techniques.
progress/identification of unmet preventive goals.
Remind caregiver(s) of need for other caregivers to com- Ensures uniform risk reduction for SIDS to degree
ply with essential SIDS risk reduction measures, espe- possible.
cially day care and babysitters.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
The education and advice recorded in the child health
section apply to women’s health, as women are the
major caretakers of children. However all caregivers,
whether grandparents, or other family members should
be aware how to comply with the essential SIDS risk
reduction measures.
Care of self during the prenatal period can contribute The risk of SIDS is five to ten times greater in infants of
to the reduction of the incidence of SIDS. Good nutri- mothers who abused drugs during pregnancy. This is
tion, proper exercise, no smoking, no exposure to particularly true of the infant who goes through with-
second-hand smoke, and no drug or alcohol use drawal after birth.29
during pregnancy.
Mental Health
The interventions for Child/Women’s Health apply to this population.
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Sudden Infant Death Syndrome, Risk For • 115
Gerontic Health
This diagnosis does not apply to the aging population unless the infant caregiver is elderly. In such cases, the interventions
for Child/Women’s Health would apply.
Home Health
The interventions for Child/Women’s Health would be applied in the home setting.
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116 • Health Perception–Health Management Pattern
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Springhouse Corporation, Springhouse, 1995. 82. Lindsay, SH: Menopause naturally: Exploring alternatives to tradi-
50. McCoy, PA, and Votroubek, W: Pediatric Home Care: A Comprehen- tional HRT, AWHONN Lifelines 3(5):32, 1999.
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138. Beauchamp, TL, and Childress, JF: Principles of Biomedical Ethics, 170. Weksler, ME: Wound repair in older patients: Preventing problems
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3
METABOLIC PATTERN
1. ADULT FAILURE TO THRIVE 131
2. ASPIRATION, RISK FOR 136
3. BODY TEMPERATURE, IMBALANCED, RISK FOR 139
4. BREASTFEEDING, EFFECTIVE 144
5. BREASTFEEDING, INEFFECTIVE 148
6. BREASTFEEDING, INTERRUPTED 152
7. DENTITION, IMPAIRED 155
8. FLUID BALANCE, READINESS FOR ENHANCED 158
9. FLUID VOLUME, DEFICIENT, RISK FOR AND ACTUAL 161
10. FLUID VOLUME, EXCESS 167
11. FLUID VOLUME, IMBALANCED, RISK FOR 173
12. HYPERTHERMIA 176
13. HYPOTHERMIA 182
14. INFANT FEEDING PATTERN, INEFFECTIVE 186
15. NAUSEA 189
16. NUTRITION, READINESS FOR ENHANCED 192
17. NUTRITION, IMBALANCED, LESS THAN BODY
REQUIREMENTS 194
18. NUTRITION, IMBALANCED, MORE THAN BODY
REQUIREMENTS, RISK FOR AND ACTUAL 204
19. SWALLOWING, IMPAIRED 209
20. THERMOREGULATION, INEFFECTIVE 213
21. TISSUE INTEGRITY, IMPAIRED 216
A. Skin Integrity, Impaired, Risk for and Actual
B. Oral Mucous Membrane, Impaired
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Conceptual Information • 121
20. Weigh the infant. Is his or her weight within normal moved away from using servings as the benchmark for nutri-
limits for his or her age? ent intake to daily amounts expressed in cups or ounces. The
a. Yes (Effective Breastfeeding) current recommendations (based on a 2000-calorie diet)
b. No (Ineffective Breastfeeding) include a daily intake of:
21. Ask the patient: “Do you have any problems or con- • 6 ounces of grains, at least half of which should be
cerns about breastfeeding?” whole grains
a. Yes (Ineffective Breastfeeding) • 21/2 cups of vegetables
b. No (Effective Breastfeeding) • 2 cups of fruits
• 3 cups of milk (or dairy products)*
• 51/2 ounces of lean meats and beans
CONCEPTUAL INFORMATION
The recommendation to limit fats and oils has
The nutritional–metabolic pattern requires looking at four remained unchanged. The new guidelines also encourage
separate but closely aligned aspects: nutrition, fluid balance, more individualization of diet plans. Individuals can tailor
tissue integrity, and thermoregulation. All four functionally their diet according to age, activity, and body mass index.
interrelate to maintain the integrity of the overall nutri- More information can be obtained at http://www.mypyra-
tional–metabolic functioning of the body. mid.gov.
Food and fluid intake provides carbohydrates, pro- ● N O T E : Many adults may be lactose intolerant. Lactase
teins, fats, vitamins, and minerals, which are metabolized by enzymes are now available over-the-counter as a digestive
the body to meet energy needs, maintain intracellular and aid for lactose intolerance.*
extracellular fluid balances, prevent deficiency syndromes,
An inadequate nutritional state may be reflective of
and act as catalysts for the body’s biochemical reactions.1
intake (calories), use of the intake (metabolism), or a change
in activity level. Underweight and overweight are the most
NUTRITION
commonly seen conditions that reflect alteration in nutrition.4
Nutrition refers to the intake, assimilation, and use of food Underweight can be caused by inadequate intake
for energy, maintenance, and growth of the body.2 Assisting of calories. In some instances, the intake is within RDA,
the patient in maintaining a good nutritional–metabolic sta- but there is malabsorption of the intake. The malabsorp-
tus facilitates health promotion and illness prevention, and tion or inadequate intake can be due to physiologic causes
provides dietary support in illness.1 (pathophysiology), psychological causes (anorexia or
Swallowing is associated with the intake of food or flu- bulimia), or cultural factors (lack of resources or religious
ids. Swallowing is a complex activity that integrates sensory, proscriptions).4
muscular, and neurologic functions that generally occur in Special notice needs to be given to maternal nutri-
four phases: (1) oral preparatory phase, during which the tional needs during the postpartum period. New mothers
food is chewed, mixed with saliva, and prepared for diges- need optimal nutrition to promote healing of the tissues trau-
tion; (2) oral phase, during which food is moved backward matized during labor and delivery, to restore balance in fluid
past the hard palate and downward to the pharynx; (3) pha- and electrolytes created by all the rapid changes in the body,
ryngeal phase, when the larynx closes and the food enters and, if the mother is breastfeeding, to produce adequate
the esophagus; and (4) esophageal phase, during which the amounts of milk containing fluid and nutrients for the
food passes through the esophagus, in peristaltic movement, infant.5 Infants have very little room for fluctuation in fluid
to the stomach. The first two phases are voluntarily con- balance, especially in the immediate postpartum period.
trolled, and the last two phases are involuntarily controlled. Some researchers believe the infant is behind on fluid intake
Many factors affect a person’s nutritional status, such immediately after birth due to inadequate maternal hydra-
as food availability and food cost; the meaning food has for tion during labor and birth. Human milk has large amounts
an individual; cultural, social, and religious mores; and of fat content to provide the infant with the adequate amount
physiologic states that might alter a person’s ability to eat.3 of calories for growth, digestion, physical activity, and
In essence, we are initially concerned with the adequacy or maintenance of organ metabolic function.5 Breastfeeding
inadequacy of the patient’s nutritional state. If the diet is demands energy and the mother will experience a gradual
adequate, there is no major reason for concern, but we must weight loss while breastfeeding, as fat deposits stored dur-
be sure that all are defining “adequacy” in a similar manner. ing pregnancy are used. However, mothers should not diet
Most people are likely to define an adequate diet as one that during breastfeeding, as fat-soluble environmental contami-
prevents hunger; however, professionals look at an adequate nants to which she has been exposed are stored in her body’s
diet as being one in which nutrient intake balances with fat reserves. Quick, large amounts of weight loss will release
body needs. these contaminants into her breastmilk.5
The familiar Food Pyramid was recently revised to The breastfeeding woman can generally meet her
reflect an evolving philosophy/outlook regarding the state of nutritional needs and those of her infant through adequate
nutrition in the U.S. Dietary Guidelines. The guidelines dietary intake of food and fluids; however, because the
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122 • Nutritional–Metabolic Pattern
energy demand is greater during lactation, RDA standards trolytes (anions) are chloride, bicarbonate, and phosphate.
recommend an additional 200 to 500 extra calories per The electrolyte compositions of the two extracellular com-
day be added to the diet to provide adequate nutrients for partments (interstitial and intravascular) are nearly identical.
both mother and infant, without catabolism of lean tissue The intracellular fluid contains the same number of elec-
of the mother.5 trolytes as the extracellular fluid does, but the intracellular
An overweight condition is rarely due to a physiologic electrolytes carry opposite electrical charges from the elec-
disturbance, although a genetic predisposition may exist. trolytes in the extracellular fluid. This difference between
Overweight is most commonly due to an imbalance between extracellular and intracellular electrolytes is necessary for
food and activity habits (i.e., increased intake and decreased the electrical activity of nerve and muscle cells.1,3 Therefore,
activity).4 However, research indicates there is a metabolic electrolytes help regulate cell functioning as well as the fluid
set point, and, in actuality, overweight people may be eating volume in each compartment.
less than normal-weight people. Usually the body governs intake through thirst and
Either underweight or overweight may be a sign of output through increasing or decreasing body fluid excretion
malnutrition (inadequate nutrition), with the result that the via the kidneys, GI tract, and respiration. Because of the
patient exhibits signs and symptoms of less than or more way the body governs intake and output, in addition to the
than body requirements. In either instance, the nurse must effects of pathophysiologic conditions such as shock, hem-
assess the patient carefully for his or her overall concept orrhage, diabetes, and vomiting on intake and output, the
of malnutrition. patient may enter a state of metabolic acidosis or alkalosis.
Acid–base balance reflects the acidity or alkalinity of
FLUID VOLUME body fluids and is expressed as the pH. In essence, the pH
is a function of the carbonic acid:bicarbonate ratio.3
Fluid volume incorporates the aspects of actual fluid
Acid–base balance is regulated by chemical, biologic, and
amount, electrolytes, and metabolic acid-base balance.
physiologic mechanisms. Chemical regulation involves
Regardless of how much or how little a patient’s intake, or
buffers in the extracellular fluid, whereas biologic regulation
how much or how little a patient’s output, the fluid, elec-
involves ion exchange across cell membranes. Physiologic
trolyte, and metabolic acid-base balances are maintained
regulation is governed in the lungs by carbon dioxide excre-
within a relatively narrow margin. This margin is essential
tion, and in the kidneys through metabolism of bicarbonate,
for normal functioning in all body systems, and so it must
acid, and ammonia.1
receive close attention in providing care.
Metabolic acidosis is caused by situations in which
Approximately 60 percent of an adult’s weight is body
the cellular production of acid is excessive (e.g., diabetic
fluid (liquid plus electrolytes plus minerals plus cells), and
ketoacidosis), high doses of drugs (e.g., aspirin) have to be
approximately 75 percent of an infant’s weight is body
metabolized, or excretion of the produced acid is impaired
fluid. These various parts of body fluid are taken in daily
(e.g., renal failure).3 Weight reduction practices (fad diets or
through food and drink and are formed through the meta-
diuretics) can contribute to the development of acidosis, as
bolic activities of the body.1,3 The body fluid distribution
can chemical substance abuse.1
includes intracellular (within the cells), interstitial (around
Fluid volume is affected by regulatory mechanisms,
the cells), and intravascular (in blood cells) fluids. The com-
body fluid loss, or increased fluid intake. Because fluid vol-
bination of interstitial and intravascular is known as extra-
ume is so readily affected by such a variety of factors,
cellular (outside the cells) fluid. Distribution of body fluid
continuous assessment for alterations in fluid volume must
is influenced by both the fluid volume and the concentration
be made.
of electrolytes. Body fluid movement, between the compart-
ments, is constant and occurs through the mechanisms of
TISSUE INTEGRITY
osmosis, diffusion, active transport, and osmotic and hydro-
static pressure.1,3 Nutrition and fluid are vitally important to tissue mainte-
Body fluid balance is regulated by intake (food and nance and repair. Underlying tissues are protected from
fluid), output (kidney, gastrointestinal [GI] tract, skin, and external damage by the skin and mucous membranes. Thus,
lungs), and hormones (antidiuretic hormones, glucocorti- the integrity of the skin is extremely important in the pro-
coids, and aldosterone). The largest amount of fluid is motion of health, because the skin and mucous membranes
located in the intracellular compartment, with the volume of are the body’s first line of defense. The skin also plays a role
each compartment being regulated predominantly by the in temperature regulation and in excretion.
solute (mainly the electrolytes). The skin and mucous membranes act as protection
Electrolytes are either positively or negatively charged through their abundant supply of nerve receptors that alert
particles (ions). The major positively charged electrolytes the body to the external environment (i.e., temperature, pres-
(cations) are sodium (the main extracellular electrolyte), sure, or pain). The skin and mucous membranes also act as
potassium (the most common intracellular electrolyte), cal- barriers to pathogens, thus protecting the internal tissues
cium, and magnesium. The major negatively charged elec- from these organisms.3
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Developmental Considerations • 123
The skin’s superficial blood vessels and sweat glands 25 percent is lost through insensible mechanisms of the lungs
(eccrine and apocrine) assist in thermoregulation. As the and evaporation from the skin and about 5 percent is lost in
body temperature rises, the superficial blood vessels dilate urine and feces. When the body is able to produce and dissi-
and the sweat glands increase secretion. These two actions pate heat within a normal range, the body is in heat balance.7
result in increased perspiration, which, through evaporation,
cools the body. During instances of excessive perspiration, SUMMARY
water, sodium chloride, and nonprotein nitrogen are excreted
The interrelationship of nutrition, fluid balance, thermoreg-
through the skin; this affects fluid volume and osmotic bal-
ulation, and tissue integrity explains the nursing diagnoses
ance. As the body temperature drops, the opposite reactions
that have been accepted in the nutritional–metabolic pattern.
occur; there is vessel constriction and decreased sweat gland
Indeed, if there is an alteration in any one of these four fac-
secretion so that body heat is retained internally.
tors, it would be wise for the nurse to assess the other three
To fulfill their protective function of the underlying
factors to ensure a complete assessment.
tissues, the skin and mucous membranes must be intact. Any
change in skin or mucous membrane integrity can allow
pathogen invasion, and will also allow fluid and electrolyte
DEVELOPMENTAL CONSIDERATIONS
loss. Skin and mucous membrane integrity relies on ade-
quate nutrition and removal of metabolic wastes (internally INFANT
and externally), cleanliness, and proper positioning. In emer-
Swallowing is a reflex present before birth, because during
gency surgical settings or in cases of patients in poor health
intrauterine life the fetus swallows amniotic fluid. Following
(e.g., very elderly and medically indigent), age and serum
the transition to extrauterine life, the infant learns very rap-
albumin levels might also be predictive of increased risk for
idly (within 12 to 24 hours) to coordinate sucking and swal-
skin breakdown.6 Any factor that compromises nutrition,
lowing. There are really no developmental considerations of
fluid, or electrolyte balance can result in impairment of skin
the act of swallowing, because it is a reflex.
or mucous membrane integrity or, at least, a high risk for
The normal process for swallowing involves both the
impairment of skin integrity or mucous membrane integrity.
epiglottis and the true vocal cords. These two structures
move together to close off the trachea, and to allow saliva or
THERMOREGULATION
solid and liquid foods to pass into the esophagus. The respi-
Thermoregulation refers to the body’s ability to adjust its ratory system is thus protected from foreign bodies.
internal core temperature within a narrow range. The core Salivation is adequate at birth to maintain sufficient
temperature must remain fairly constant for metabolic activ- moisture in the mouth. However, maturation of many sali-
ities and cellular metabolism to function for the mainte- vary glands does not occur until the third month, and
nance of life. The core temperature rarely varies as much as corresponds with the baby’s learning to swallow at other
2⬚F. In fact, the range of temperature that is compatible with than a reflex level.8 Tooth eruption begins at about 6 months
life ranges only from approximately 90 to 104⬚F. of age and stimulates saliva flow and chewing. The infant
Both the hypothalamus and the thyroid gland are has a small amount of the enzyme ptyalin, which breaks
involved in thermoregulation. The hypothalamus regulates down starches.
temperature by responding to changes in electrolyte bal- Water constitutes the greatest proportion of the
ances. Both extracellular cations—sodium and calcium— infant’s body weight. Approximately 75 to 78 percent of
affect the action potential and depolarization of cells. When an infant’s body weight is water, with about 45 percent of
there is an imbalance of sodium and calcium within the this water found in the extracellular fluid. The newborn
hypothalamus, hypothermia or hyperthermia can result. The infant loses significant water through insensible methods
thyroid glands regulate core body temperature by increasing (approximately 35 to 45 percent) because of the relatively
or decreasing metabolic activities and cellular metabolism, greater ratio of body surface area to body weight. The respi-
thus altering heat production. ratory rate of an infant is approximately two times that of
Many factors influence thermoregulation. The skin the adult; therefore, the infant is also losing water through
has previously been mentioned as a thermoregulatory organ. insensible loss from the lungs. The newborn also loses water
Heat is gained or lost to the environment by evaporation, through direct excretion in the urine (50 to 60 percent)
conduction, convection, and radiation. Evaporation occurs and through fairly rapid peristalsis as a result of the imma-
when body heat transforms the liquid on a person’s skin to turity of the GI tract.
vapor. Conduction is the loss of heat to a colder object The newborn is unable to concentrate urine well, so is
through direct contact. When heat is lost to the surrounding more sensitive to inadequate fluid intake or uncompensated
cool air, it is called convection. Radiation occurs when heat water loss.9 The body fluid reserve of the infant is less than
is given off to the environment, helping to warm it. that of the adult, and because the infant excretes a greater
A person generally loses approximately 70 percent of volume per kilogram of body weight than the adult, infants
all heat from radiation, convection, and conduction. Another are very susceptible to deficient fluid volume. The infant
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124 • Nutritional–Metabolic Pattern
needs to consume fluids equal to 10 to 15 percent of body newborn infant to lose 1 to 2⬚F immediately after birth.) The
weight. Fluid and electrolyte requirements for the newborn infant is not able to shiver to produce heat, nor does the
are 70 to 100 mL/kg per 24 hours, 2 mEq of sodium and infant have much subcutaneous fat to insulate the body.
potassium per kilogram per 24 hours, and 2 to 4 mEq of However, the infant does have several protective mecha-
chloride per kilogram per 24 hours. nisms by which he or she is able to conserve heat to keep the
The kidney function of the infant does not reach adult body temperature fairly stable. These mechanisms include
levels until 6 months to 1 year of age.9 The functional capac- vasoconstriction so that heat is maintained in the inner body
ity of the kidneys is limited, especially during stress. In core, an increased metabolic rate that increases heat produc-
addition, the glomerular filtration rate is low, tubular reab- tion, a closed body position (the so-called fetal position) that
sorption or secretory capacity is limited, sodium reabsorp- reduces the amount of exposed skin, and the metabolism of
tion is decreased, and the metabolic rate is higher. adipose tissue. This particular adipose tissue is called
Therefore, there is a greater amount of metabolic wastes to “brown fat” because of the rich supply of blood and nerves.
be excreted. An infant’s kidney is less able to excrete large Brown fat comprises 2 to 6 percent of body weight of the
loads of solute-free water than a more mature kidney.10 infant. Brown fat aids in adaptation of the thermoregulation
Feeding behavior is important not only for fluid, but mechanisms.8 The ability of the body to regulate tempera-
also for food. The caloric need of the infant for the first 3 ture at the adult level matures at approximately 3 to 6
months is 110 kcal/kg per day, from 3 to 6 months 100 months of age.
kcal/kg per day, and from 6 to 9 months 95 kcal/kg per day.5
Breast milk contains adequate nutrients and vitamins for
6 months of life. The American Academy of Pediatrics rec- TODDLER AND PRESCHOOLER
ommends breastfeeding exclusively for the first 6 months of By the end of the second year, the child’s salivary glands are
life, and continued breastfeeding with inclusion of other adult size and have reached functional maturity.8 The toddler
foods for at least 12 months.5 Some bottle formulas are is capable of chewing food, so it stays longer in his or her
overly high in carbohydrates and fat (especially cholesterol), mouth, and the salivary enzymes have an opportunity to
which may lead to an increase in fat cells. begin breaking down the food. The saliva also covers the
Solid foods should not be introduced until the infant is teeth with a protective film that helps prevent decay.
6 months of age. Studies have indicated that there is a rela- Drooling no longer occurs because the toddler easily swal-
tionship between the early introduction of solid food lows saliva.
(younger than 4 months of age) and overfeeding of either Dental caries occur infrequently in children younger
milk or food, leading to infant and adult obesity.5 The infant than 3 years; but rampant tooth decay in very young children
should be made to feel secure, loved, and unhurried at feed- is almost always related to prolonged bottle feeding at nap
ing time, regardless of whether the mother is breastfeeding time and bedtime (bottle mouth syndrome). The toddler
or bottle feeding. Skin contact is very important for the should be weaned from the bottle, or at least not allowed to
infant for brain development and other physiologic and psy- fall asleep with the bottle in her or his mouth.11 Parents
chological reasons. should be taught that the adverse effects of bedtime feeding
The skin of an infant is functionally immature, and are greater than thumb sucking or the use of pacifiers.
thus the baby is more prone to skin disorders. Both the der- Affected teeth remain susceptible to decay after nurs-
mis and the epidermis are loosely connected, and both are ing stops. If deciduous teeth decay and disintegrate early,
relatively thin, which easily leads to chafing and rub burns.8 spacing of the permanent teeth is affected, and immature
Epidermal layers are permeable, resulting in greater fluid speech patterns develop. Discomfort is felt and emotional
loss. Sebaceous glands, which produce sebum, are very problems may result.11
active in late fetal life and early infancy, causing milia and The first dental examination should occur between the
“cradle cap,” which goes away at about 6 months of age. ages of 18 and 24 months. Dental hygiene should be started
Dry, intact skin is the greatest deterrent to bacterial invasion. when the first tooth erupts by cleansing the teeth with gauze
Sweat glands (eccrine or apocrine) are not functional in or cotton moistened with hydrogen peroxide and flavored
response to heat and emotional stimuli until a few months with a few drops of mouthwash. After 18 months, the child’s
after birth, and their function remains minimal through teeth may be brushed with a soft or medium toothbrush.11
childhood. The inability of the skin to contract and shiver in Fluoride supplements are believed to prevent cavities.
response to heat loss causes ineffective thermal regulation.4 In the toddler, the transition to the appropriate propor-
Also, the infant has no melanocytes to protect against the tion of body water to body weight (62 percent water)
rays of the sun. This is true of dark-skinned infants as well begins.12 The extracellular fluid is about 26 percent, whereas
as light-skinned infants. the adult has about 19 percent extracellular fluid. Toddlers
The infant’s core body temperature ranges from 97 to have less reserve of body fluid than adults and lose more
100⬚F. Temperature in the infant fluctuates considerably, body water daily, both from sensible and insensible loss.
because the regulatory mechanisms in the hypothalamus are This age group is highly predisposed to fluid imbalances.13
not fully developed. (It is not considered abnormal for the These imbalances relate to the fact that the kidney still is
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Developmental Considerations • 125
immature, so water conservation is poor, and the toddler still surface area, and metabolic activity. The school-age child
has an increased metabolic rate and therefore greater insen- needs approximately 1.5 to 3 quarts of fluid a day. In addi-
sible water loss than the adult. However, GI motility slows, tion, the child needs a slightly positive water balance. The
so this age group is better able to tolerate fluid loss through electrolyte values are similar to those for the adult except for
diarrhea. The 2- to 3-year-old needs 1100 to 1200 mL (four phosphorus and calcium (because of bone growth).13
to five 8-ounce glasses) of fluid every 24 hours, whereas the The caloric need of the school-age child is greater
preschooler needs 1300 to 1400 mL of fluids every 24 hours. than that of an adult (approximately 80 calories/kg or 1600
The caloric need in the toddler is 1000 calories/day or to 2200 calories/day). The ages of 10 to 12 reflect the peak
100 calories/kg at 1 year and 1300 to 1500 calories/day at 3 ages of caloric and protein needs of the school-age child (50
years. A child should not be forced to “clean the plate” at to 60 calories/kg per day), because of accelerated growth,
mealtime, and food should not be viewed as a reward or muscle development, and bone mineralization. “The school
punishment. Instead, caloric intake should be related to the age child reflects the nutritional experiences of early child-
growing body and energy expenditures. hood and the potential for adulthood.”4
The caloric need of the preschooler is 85 calories/kg.
Eating assumes increasing social significance, and continues ADOLESCENT
to be an emotional, as well as a physiologic, experience.4
By age 21, all 32 permanent teeth have erupted. The adoles-
Frustrating or unsettled mealtimes can influence caloric
cent needs frequent dental visits because of cavities, and
intake, as can manipulative behavior on the part of the child
also for orthodontic work that may be in progress. There is
or parent. The child may also be eating foods with empty
a growth spurt and sexual development changes. A total
calories between meals.
increase in height of 25 percent and a doubling of weight are
In the toddler, functional maturity of skin creates
normally attained.14 Muscle mass increases and total body
a more effective barrier against fluid loss; the skin is not
water declines with increasing sexual development.15 The
as soft as the infant’s, and there is more protection against
adolescent needs 34 to 45 calories/kg per day and tends to
outside bacterial invasion. The skin remains dry because
have eating patterns based on external environmental cues
sebum secretion is limited. Eccrine sweat gland function
rather than hunger. Eating becomes more of a social event.
remains limited, eczema improves, and the frequency of
There is a high probability of eating disorders such as
rashes declines.
anorexia and bulimia arising during this age period.
Skin, as a perceptual organ, experiences significant
The basal metabolic rate increases, lung size
development during this period. Children like to “feel” dif-
increases, and maximal breathing capacity and forced expi-
ferent objects and textures and like to be hugged. Melanin is
ratory volume increase, leading to increased insensible loss
formed during these years, and thus the toddler, preschooler,
of fluid through the lungs. Total body water decreases from
and school-age child are more protected against sun rays.8 In
61 percent at age 12 to 54 percent by age 18 as a result of an
addition, small capillaries in the periphery become more
increase in fat cells. Fat cells do not have as much water as
capable of constriction and thus thermoregulation. Also, the
tissue cells.15 The water intake need of the adolescent is
child is able to sense and interpret that he or she is hot or
about 2200 to 2700 mL per 24 hours.
cold, and can voluntarily do something about it.
Sebaceous glands become extremely active during
adolescence and increase in size. Eccrine sweat glands are
SCHOOL-AGE CHILD fully developed and are especially responsive to emotional
stimuli (and are more active in males); apocrine sweat
At this age, the child begins losing baby teeth as permanent
glands also begin to secrete in response to emotional stim-
teeth erupt. The child should not be evaluated for braces
uli.16 Stopped-up sebaceous glands lead to acne, and the
until after all 6-year molars have erupted. The permanent
adolescent’s skin is usually moist.
teeth are larger than the baby teeth and appear too large for
the small face, causing some embarrassment. Good oral
YOUNG ADULT
hygiene is important.
For the school-age child, the percentage of total body The amount of ptyalin in the saliva decreases after 20 years
water to total body weight continues to decrease until about of age; otherwise the digestive system remains fully func-
12 years of age, when it approaches adult norms.13 tioning. The appearance of “wisdom teeth,” or third molars,
Extracellular fluid changes from 22 percent of body weight occurs at 20 to 21 years. There are normally four third
at 6 years to 17.5 percent at age 12 as a result of the propor- molars, although some individuals may not fully develop all
tion of body surface area to mass, increasing muscle mass four. Third molars can create problems for the individual.
and connective tissue, and increasing percentage of body fat. Eruptions are unpredictable in time and presentation, and
Water is needed for excretion of the solute load. molars may come in sideways or facing any direction. This
Balance is maintained through mature kidneys, leading to can force other teeth out of alignment, which makes chew-
mature urine concentration and acidifying capacities. Fluid ing difficult and painful. Often these molars need to be
requirements can be calculated in terms of height, weight, removed to prevent irreparable damage to proper occlusion
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126 • Nutritional–Metabolic Pattern
of the jaws. Even normally erupting third molars may be effects compound nutritional problems for older adults.22
painful. The young adult must see a dentist regularly. Aging causes atrophy of the olfactory organs and with
Total body water in the young adult is about 50 to 60 diminished smell often comes decreased enjoyment of foods
percent. There is a difference between males and females and decreased consumption.23 Research continues to evolve
because of the difference in the number of fat cells. Most concerning taste discrimination in older adults. More recent
water in the young adult is intracellular, with only about 20 studies support limited changes in taste associated with
percent of fluid being extracellular. Growth is essentially aging when healthy, nonmedicated adults are sampled. The
finished by this developmental age. impact of medications, poor oral hygiene, or cigarette smok-
ing may cause older adults to complain of an unpleasant
ADULT taste in their mouth called dysgeusia.24
Changes in olfaction and decreased salivation second-
Ptyalin has sharply decreased by age 60 as well as other
ary to disease or medications can influence the taste of food.
digestive enzymes. Total body water is now about 47 to 54.7
When compounded by gum disease, poor teeth, or dentures,
percent. Diet and activity indirectly influence the amount of
problems with food intake can occur. The number of older
body water by directly altering the amount of adipose tissue.
adults who are edentulous (without teeth) is gradually
The basal metabolic rate gradually decreases along with a
declining and is estimated to be approximately 37 percent of
reduced demand for calories. Caloric intake should be
adults 70 years of age or older.21 Caries, especially occur-
adjusted for age and activity level.
ring on the crowns of the tooth, occur in more than 95 per-
Tissues of the integumentary system maintain a
cent of the elderly population.21 Older adults are especially
healthy, intact, glowing appearance until age 50 to 55 if the
vulnerable to oral carcinomas.25
individual is receiving adequate vitamins, minerals, other
Total body water of the older adult is about 45 to 50
nutrients, and fluids and maintains good personal hygiene.
percent. Older adults have problems tolerating extremes of
Wrinkles do become more noticeable, however, and body
temperature. Aging results in skin changes such as dryness
water (from integumentary tissues) decreases, leading to
and wrinkling. Skin assessment for alterations in fluid vol-
thinner, drier skin that bruises much more easily. Fat
ume must be carefully interpreted. Skin turgor assessment
increases, leading to skin that is not as elastic and will not
should be done on the abdomen, sternum, or the forehead.
recede with weight loss, so bags develop readily under the
Skin turgor is not a reliable indicator of hydration status in
eyes.8 Also, skin wounds heal more slowly because of
older adults. Assessment should focus on tongue dryness,
decreased cell regeneration.
furrows in the tongue, confusion, dry mucous membranes,
“sunken” appearance of the eyes, or difficulty with speech.26
OLDER ADULT
Older adults also have a diminished thirst sensation second-
The nutritional status of the older adult is receiving ary to changes in brain osmoreceptors; thus thirst is not
increased scrutiny by health-care professionals because of readily triggered in older adults.25 Changes in blood volume
the impact poor nutrition has on health status and quality of are minimal. Serum protein (albumin) production is
life.17,18 Since the early 1990s, many states and organiza- decreased, but globulin is increased.
tions working with older adults have begun nutritional Aging changes do bring about changes in nephrotic
screening to identify those at high risk for poor nutrition. tubular function, which affects removal of water, urine con-
The Nutrition Screening Initiative (NSI) program encour- centration, and dilution. This leads to a decrease in specific
ages use of a 10-item checklist entitled “DETERMINE” to gravity and urine osmolarity. There is a decrease in bladder
identify at-risk elders. The checklist is easily administered capacity, often leading to nocturia. With the change in blad-
and results in a score ranging from 0 (lowest risk) to 21 der capacity, older adults may limit fluid in the evenings to
(highest risk).19 Scores of 4 or more on the checklist usually offset nocturia, but limiting fluids may lead to nocturnal
indicate that the older adult should undergo further nutri- dehydration. Sodium and chloride levels remain constant,
tional evaluation. Many older adults experience aging but potassium decreases.
changes that can affect nutritional status. Older adults also Many changes occur in the GI tract, such as decreased
experience risk factors, such as polypharmacy, social isola- enzyme secretion, gastric irritation, decreased nutrient and
tion, low income, altered functional status, loneliness, and drug absorption, decreased hydrochloric acid secretion,
chronic and acute diseases, that impact nutritional status.20 decreased peristalsis and elimination, and decreased sphinc-
Older adults may experience changes in the mouth ter muscle tone, making nutrition a primary concern. Older
that can affect nutrition. Tooth decay, tooth loss, degenera- adults need decreased and nutrient-dense calories. Adequate
tion of the jaw bone, progressive gum regression, and intake of vitamins and trace elements along with adequate
increased reabsorption of the dental arch can make chewing protein, fat, carbohydrates, bulk, and electrolytes is impor-
and eating a difficult task for the older adult if good dental tant. The decreased intake of milk and fresh fruits, com-
health has not been maintained.21 Reduced chewing ability, monly found in older populations, is a source of concern
problems associated with poorly fitting dentures, and a because of the continuing need for calcium, fiber, and vita-
decrease in salivation, secondary to disease or medication, min intake.27
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Developmental Considerations • 127
Integumentary changes result in skin that is drier and blood flow make older adults more sensitive to cooler
thinner, and skin lesions or discolorations, and scaliness conditions. Older adults may wear sweaters or additional
(keratosis) may appear. Wrinkling occurs in areas com- layers of clothing when the external temperature feels
monly exposed to the sun, such as the face and hands. comfortable or warm to younger individuals. Melanocyte
Fatty layers lost in the trunk, face, and extremities leads to decreases lead to pale skin color and gray hair. Hair
the appearance of increased joint size throughout the body. loss is common. Older women, with imbalances in andro-
The skin becomes less elastic with aging and may lose gen–estrogen hormones, may have noticeable increases in
water to the air in low-humidity situations, leading to skin facial and chin hairs. Aging changes to the skin can result
chapping. in tactile changes, and therefore, the ability to perceive
The older adult has difficulty tolerating temperature temperature, touch, pain, and pressure is diminished.23
extremes. Body temperature may increase because of a Decreased tactile ability may lead to thermal, chemical,
decrease in the size, number, and function of the sweat and mechanical injury that is not readily detected by the
glands. Decreased fat cells and changes in peripheral older adult.
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128 • Nutritional–Metabolic Pattern
T A B L E 3 . 1 NANDA, NIC, and NOC Taxonomy Linkages (continued from page 127)
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Developmental Considerations • 129
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130 • Nutritional–Metabolic Pattern
T A B L E 3 . 1 NANDA, NIC, and NOC Taxonomy Linkages (continued from page 129)
Risk for
Knowledge: Diet
Nutritional Status
Nutritional Status: Food & Fluid Intake;
Nutrient Intake
Risk Control
Risk Detection
Stress Level
Weight: Body Mass
Weight Control
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Adult Failure to Thrive • 131
Risk for
Pressure Management
Pressure Ulcer
Prevention
Skin Surveillance
Risk for
Allergic Response: Localized
Child Development: Adolescence
Fluid Overload Severity
Hemodialysis Access
Immobility Consequences:
Physiological
Infection Severity
Infection Severity: Newborn
Nutritional Status
Nutritional Status: Biochemical
Measures
APPLICABLE NURSING DIAGNOSES 5. Weight loss (decreased body mass from baseline
weight—5 percent unintentional weight loss in 1 month,
10 percent unintentional weight loss in 6 months)
ADULT FAILURE TO THRIVE 6. Physical decline (decline in body function)
DEFINITION28 7. Evidence of fatigue, dehydration, and incontinence of
bowel and bladder
A progressive functional deterioration of a physical and cog-
8. Frequent exacerbations of chronic health problems
nitive nature; the individual’s ability to live with multisys-
such as pneumonia or urinary tract infections
tem diseases, cope with ensuing problems, and manage his
9. Cognitive decline (decline in mental processing) as
or her care is remarkably diminished.30
evidenced by problems with responding appropriately
to environmental stimuli, demonstrates difficulty in
DEFINING CHARACTERISTICS28 reasoning, decision making, judgment, memory, and
1. Anorexia—does not eat meals when offered concentration, and decreased perception
2. States does not have an appetite, not hungry, or “I don’t 10. Decreased social skills or social withdrawal—notice-
want to eat” able decrease from usual past behavior in attempts to
3. Inadequate nutritional intake—eating less than body form or participate in cooperative and independent
requirements relationships (e.g., decreased verbal communication
4. Consumes minimal to no food at most meals (i.e., con- with staff, family, and friends)
sumes less than 75 percent of normal requirements at 11. Decreased participation in activities of daily living that
each or most meals) the older person once enjoyed
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132 • Nutritional–Metabolic Pattern
RELATED FACTORS28
EXPECTED OUTCOME
1. Depression
2. Apathy Will gain [number] pounds of weight by [date].
3. Fatigue Makes [number] of decisions related to care by [date].
TARGET DATES
RELATED CLINICAL CONCERNS
Adult Failure to Thrive will require long-term intervention.
1. Any terminal diagnosis (e.g., cancer, AIDS, or multiple Target dates should initially be stated in terms of weeks.
sclerosis) After improvement is shown, target dates can be expressed
2. Chronic clinical depression in terms of months.
3. Any chronic disease
4. Cerebrovascular accident or paralytic conditions
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Adult Failure to Thrive • 133
ACTIONS/INTERVENTIONS R AT I O N A L E S
Schedule periods of rest and activity.
Develop contract with patient to assume increasing
responsibility ADLs. [Note patient’s contract here.]
Do not force feed. Risk for aspiration pneumonia.
Collaborate with: Provides basic resources and information needed; pro-
motes holistic approach to treatment.
• Psychiatric nurse clinician To address underlying emotional and cognitive problems.
• Nutritionist/dietician Formulate appropriate nutrient intake to support health
restoration.
• Physical/occupational therapist To preserve and improve physical abilities to assume
responsibility of ADLs.
Child Health
This diagnosis would not be used with infants or children.
Women’s Health
Nursing actions for this diagnosis are the same as those for Adult Health, Mental Health, and Gerontic Health.
Mental Health
● N O T E : For clients with severe or life-threatening compromised physiologic status,
refer to Adult Health for interventions. When the client is psychologically unstable, refer
to the following plan of care. The adult and psychiatric interventions can be combined
based on client need. Monitor client for suicidal ideation. If this is determined to be an
issue, appropriate interventions should be implemented utilizing the Risk for Suicide
diagnosis. Also utilize plans for Ineffective Individual Coping and Disturbed Thought
Process as appropriate.
ACTIONS/INTERVENTIONS R AT I O N A L E S
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Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide foods that meet the client’s preferences, are of Meeting basic health needs improves stamina.33
high nutritional value, and require little energy to eat.
[Note client’s preferences here.]
Sit with the client during meals and provide positive ver- Fatigue may limit the client’s physical energy.33
bal reinforcement. [Note here client-specific rein-
forcers.]
When the client’s mental status improves, spend [number This demonstrates acceptance of the client and facilitates
of] minutes each shift with the client discussing issues problem solving.31
and concerns. [Note here those issues important for the
client to discuss.]
Provide prescribed medications and monitor for effects.
When the client’s mental status improves, engage the Decreases sense of loneliness and isolation, increases self-
client in [number of] therapeutic groups per day. [Note understanding, increases social support, and facilitates
here the groups the client will attend.] the development of relationship and coping skills.31,32
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review the older adult’s medication list for possible Adverse reactions to medications such as antidepressants,
medication-induced failure to thrive. beta-blockers, neuroleptics, anticholinergics, benzodi-
azepines, potent diuretic combination drugs, and anti-
convulsants and polypharmacy (more than four to six
prescription drugs) can lead to cognition changes,
anorexia, dehydration, or electrolyte problems and
result in failure to thrive.34
Monitor weight loss pattern according to care setting pol- In older adults, a percentage weight loss over a 6- to
icy or client contact opportunities. Maintain weight 12-month time period is associated with increased risk
information in an easily retrievable place to allow of disease, disability, and mortality.35
quick access and ease in comparison of weights.
Review nutritional pattern with the client and/or care- Poor nutrition can lead to adverse clinical outcomes for
giver to determine whether adequate nutritional sup- older adults.35
port is present.
Arrange for psychological supports for the older client, The therapies listed promote self-worth, decrease
such as validation therapy, reminiscing, life review, stress, focus on the client’s strengths, and provide
or cognitive therapy. the opportunity for resolution of prior unfinished
conflicts.36
Refer the older client for evaluation of depression. Depression is frequently underdiagnosed in the older
adult and is often associated with unintentional weight
loss in the older population.35
Review the social support system available to the client. Social isolation is considered a significant feature in
depression, malnutrition, and decreased function in
older adults.37
Encourage the client to participate in a regular program Exercise can prevent further loss of muscle mass often
of exercise. found with failure to thrive and improve strength and
energy.25
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Aspiration, Risk For • 135
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136 • Nutritional–Metabolic Pattern
✔ Have You Selected the Correct Diagnosis? tract because of some of the same related factors as
are found with Risk for Aspiration. However, in
Impaired Swallowing Ineffective Airway Clearance, the defining characteris-
Swallowing means that when food or fluids are present tics (abnormal breath sounds, cough, change in rate
in the mouth, the brain signals both the epiglottis and or depth of respirations, etc.) are associated directly
the true vocal cords to move together to close off the with respiratory function, whereas the defining char-
trachea so that the food and fluids can pass into the acteristics of Risk for Aspiration are directly or indi-
esophagus and thus into the stomach. Impaired rectly related to the oropharyngeal mechanisms that
Swallowing implies that there is a mechanical or physi- protect the tracheobronchial passages from the
ologic obstruction between the oropharynx and the entrance of foreign substances.
esophagus that prevents food or fluids from passing
into the esophagus. In Risk for Aspiration there may or
may not be an obstruction between the oropharynx
and the esophagus. The major pathophysiologic dys- EXPECTED OUTCOME
function that occurs in Risk for Aspiration is the inabil-
ity of the epiglottis and true vocal cords to move to
Will describe [number] of strategies to decrease risk for
close off the trachea. This inability to close off the tra- aspiration by [date].
chea may occur because of pathophysiologic changes
in the structures themselves, or because messages to TARGET DATES
the brain are absent, decreased, or impaired.
Aspiration is life threatening. Initial target dates should
Ineffective Airway Clearance be stated in hours. After the number of risk factors has
In Ineffective Airway Clearance, the patient is unable
been reduced, the target dates can be moved to 2- to 4-day
to effectively clear secretions from the respiratory
intervals.
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Aspiration, Risk For • 137
ACTIONS/INTERVENTIONS R AT I O N A L E S
In preparation for discharge:
• Teach the patient to eat when calm and in a relaxed,
nonstimulating atmosphere.
• Teach the patient and family the Heimlich maneuver Would assist in episodes of choking, and allow the patient
and have them return-demonstrate at least daily for 3 and family to feel comfortable with level of expertise
days before discharge. before going home.
• Teach the patient and family suctioning technique as
needed, including appropriate ordering of supplies.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine best position for the patient as determined by Natural upper airway patency is facilitated by upright
underlying risk factors (e.g., head of bed elevated 30 position. Turning to right side decreases likelihood of
degrees with the infant propped on right side after drainage into trachea rather than esophagus in the
feeding). event of choking.
• Confirm need for special positioning with pediatrician
or primary health-care provider as this constitutes a
deviation from the BACK TO SLEEP protocol to pre-
vent risk for SIDS, especially in infants from birth to
6 months of age.
Check bilateral breath sounds every 30 minutes or with In the event of aspiration, increased gurgling and rales
any change in respiratory status. with correlated respiratory difficulty (from mild to
severe) will be noted.
Measure amount of residual, immediately before feeding, Monitors the speed of digestion and indicates the
in nasogastric tube and report any excess beyond 10 to patient’s ability to tolerate the feeding.
20 percent of volume or as specified.
Note and record the presence of any facial trauma or sur- Monitoring for these risk factors assists in preventing
gery of face, head, or neck with associated drainage. unexpected or undetected aspiration.
Monitor for risk factors that would promote aspiration An increased stimulation or sensitivity to the gag reflex
(e.g., increased intracranial pressure, Reye’s syndrome, increases the likelihood of choking and possible
nausea associated with medications, cerebral palsy, or aspiration.
neurologic damage).
Assist the patient and family to identify factors that help
prevent aspiration (e.g., avoiding self-stimulation of
gag reflex, avoiding deep oral or pharyngeal suction-
ing, and chewing food thoroughly).
Provide opportunities for the patient and family to ask Allows an opportunity to decrease anxiety, provides time
questions or ventilate regarding risk for aspiration by for teaching, and allows individualized home care
scheduling at least 30 minutes twice a day at [times] planning.
for discussing concerns.
Teach the family and patient (if old enough) age- Basic safety measures for dangers of aspiration.
appropriate cardiopulmonary resuscitation (CPR),
first aid, and Heimlich maneuver.
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Women’s Health
● N O T E : The following actions pertain to the newborn infant if meconium is present
in amniotic fluid.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Alert obstetrician and pediatrician of the presence of Presence of meconium alerts health-care providers to
meconium in amniotic fluid. possible complications.
Assemble equipment and be prepared for resuscitation Basic emergency preparedness.
of the newborn at the time of delivery.
Be prepared to suction the infant’s nasopharynx and
oropharynx while head of the infant is still on the
perineum.
Immediately evaluate and record the respiratory status of
the newborn infant.
Assist pediatrician in viewing the vocal cords of
the infant (have various sizes of pediatric laryn-
goscopes available). If meconium is present, be
prepared to insert endotracheal tube for further
suctioning.
Continue to evaluate and record the infant’s respiratory There is no designated time frame for observation;
status. however, the nurse needs to continue to evaluate
the infant for at least 12 to 24 hours for respiratory
distress and the complications of pulmonary intersti-
tial emphysema, pneumomediastinum, pneumotho-
rax, persistent pulmonary hypertension, central
nervous system (CNS) dysfunction, and renal failure.
These infants should be placed in a level 2 or 3
nursery.
Reassure the parents by keeping them informed of actions. Reduces anxiety.
Allow opportunities for the parents to verbalize fears and Reduces anxiety and provides teaching opportunity.
ask questions.
Mental Health
● N O T E : Clients receiving electroconvulsive therapy (ECT) are at risk for this
diagnosis.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Remain with the client who has had ECT until gag reflex Basic safety measures until the client can demonstrate
and swallowing have returned to normal. Monitor gag control.
reflex and swallowing every [number] minutes until
return to normal.
Place the client who has had ECT on right side until Lessens the probability of aspiration through the influ-
reactive. ence of gravity on stomach contents.
Clients in four-point restraint should be placed on right side Lessens probability of aspiration due to difficulty in swal-
or stomach. Elevate the client’s head to eat, and remove lowing tablets or pills that might cause gagging.
restraints one at a time to facilitate eating. Request that
oral medications be changed to liquid forms.
Observe clients receiving antipsychotic agents for possi- One side effect of these medications is suppression of the
ble suppression of cough reflex. cough reflex. Loss of this reflex promotes the likeli-
hood of aspiration.38
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Body Temperature, Imbalanced, Risk For • 139
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Older adults may develop a decreased gag reflex. To Establishes baseline data to use for comparison after the
reduce the risk of aspiration: procedure is completed.
• Monitor gag reflex before any procedures involv-
ing anesthesia such as bronchoscopy, esophagogas-
troduodenoscopy (EGD), or general surgery.
Monitor gag reflex post procedure before giving fluids Ensuring return of gag reflex decreases risk of aspiration
or solids. once oral intake is resumed.
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140 • Nutritional–Metabolic Pattern
✔ Have You Selected the Correct Diagnosis? is unable to dissipate the heat normally. Both heat
production and heat dissipation are potentially non-
Risk for Imbalanced Body Temperature functional in Risk for Imbalanced Body Temperature.
Risk for imbalanced body temperature needs to be As with Hypothermia, a temperature measurement
differentiated from Hypothermia, Hyperthermia, and shows an abnormal measurement.
Ineffective Thermoregulation.
Ineffective Thermoregulation
Hypothermia Ineffective Thermoregulation means that a person’s
Hypothermia is the condition in which a person main- temperature fluctuates between being too high and
tains a temperature lower than normal for him or her. too low. There is nothing wrong, generally, with heat
This means that the body is probably dissipating heat production or heat dissipation; however, the ther-
normally but is unable to produce heat normally. In moregulatory systems in the hypothalamus or the thy-
Risk for Imbalanced Body Temperature both heat pro- roid are dysfunctional. Again, a temperature
duction and heat dissipation are potentially nonfunc- measurement shows an abnormality.
tional. In Hypothermia, a lower than normal body
temperature can be measured. In Risk for Imbalanced
Body Temperature, temperature measurement may EXPECTED OUTCOME
not show an abnormality until the condition has
changed to Hyperthermia or Hypothermia. Will have no alteration in body temperature by [date].
Hyperthermia
Hyperthermia is the condition in which a person main- TARGET DATES
tains a temperature higher than normal. This means Initial target dates would be stated in hours. After stabiliza-
that the body is probably producing heat normally but
tion, target dates could be extended to 2 to 3 days.
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Body Temperature, Imbalanced, Risk For • 141
ACTIONS/INTERVENTIONS R AT I O N A L E S
Avoid sedatives and tranquilizers that depress cerebral Risk factors for this diagnosis.
function and circulation.
Assist the patient to learn to assess biorhythms. Generally, early morning is the period of lowest body
metabolic activity. Add extra clothes until food and
physical movement stimulate increased cellular metab-
olism and circulation. Helps determine peak and trough
of temperature variations.
Teach patient to balance physical and sedentary activity. Assists in maintaining consistency in metabolic
functioning.
Refer to nursing diagnoses Hypothermia or Hyperthermia
for interventions related to these situations once the
alteration has occurred.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor temperature at least every hour. The young infant and child may lack mature thermoregu-
latory capacity. Temperatures that are either too high
(102⬚F or above) or too low (below 97⬚F) may bring
about spiraling metabolic disruption of acid–base
status. Seizures and shock may follow.
If temperature is less than 97⬚F rectally (or parameters Young infants and children may not be able to initiate
defined by physician), take appropriate measures for compensatory regulation of temperature, especially in
maintaining temperature: premature and altered CNS/immune conditions. These
basic measures must be taken to safeguard a return to
the homeostatic condition.
• Infants: Radiant warmer or isolette Best method of warming newborn infant is to place infant
on mother’s chest skin to skin and cover both with
warm blanket. Sometimes infants placed under warm-
ers or in isolettes can become dehydrated if not moni-
tored adequately.
• Older child: Thermoblanket
• Administer medications as ordered.
Be cautious to not overdose in a 24-hour period. Abide Using caution in dosage calculation and abiding by
by recommended dosage schedule every 8 hours or appropriate guidelines minimize inadvertent overdos-
pediatric medication recommendations. ing and subsequent untoward effects of medication.
If temperature is above 101⬚F, take appropriate measures Young infants and children may have febrile seizures due
to bring temperature back to normal range (or at least to immature thermoregulatory mechanisms and must
98 to 100⬚F): be appropriately safeguarded against further sequelae.
• Administer Tylenol, antibiotics, or other medications as
ordered.
• Monitor and document related symptoms with specific
regard for potential febrile seizures.
• Monitor for the development of febrile seizures, and
check for history of febrile seizures.
• If the infant or child has reduced threshold for seizures Anticipatory planning promotes optimal resuscitation
during times of fever, be prepared to treat seizures with efforts.
anticonvulsants, maintain airway, and provide for
safety from injury.
• Provide appropriate teaching to the child and parents Self-care empowers and fosters long-term confidence as
related to hyperthermia and hypothermia (e.g., temper- well as reduces anxiety.
(care plan continued on page 142)
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142 • Nutritional–Metabolic Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
ature measurement, wearing of proper clothing, use of
Tylenol instead of aspirin, consuming adequate
amounts of food and fluid, and use of tepid baths).
• Be cautious and do not overtax the infant or child with Increased metabolic demands in the presence of an already
congestive heart failure or pulmonary problems by taxed cardiopulmonary status can become severe, result-
allowing a temperature elevation to develop. ing in life-threatening conditions if left untreated.
• Avoid use of aspirin and aspirin products. Standards of care per the American Academy of Pediatrics
to decrease the potential for Reye’s syndrome.
• Avoid use of tympanic membranous thermometer in Studies indicate that tympanic thermometers are inaccu-
infants age 6 months or younger. rate in infants, especially those younger than 3 months
of age.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient in identifying lifestyle adjustments nec- So-called hot flashes related to changes in the body’s core
essary to maintain body temperature within normal temperature can be somewhat controlled in women via
range during various life phases (e.g., perimenopause estrogen replacement therapy; however, as hormone
or menopause). levels fluctuate with the aging process, some hot
flashes will occur. These can be helped by adjusting
the environment (e.g., room temperature, amount of
clothing, or temperature of fluids consumed).
Maintain house at a consistent temperature level of 70
to 72⬚F.
Keep bedroom cooler at night and layer blankets or
covers that can be discarded or added as necessary.
Have the patient drink cool fluids (e.g., iced tea or cold
soda).
Have the patient wear clothing that is layered so that
jackets, etc., can be discarded or added as necessary.
In collaboration with physician, assist the patient in Individuals have unique, different requirements as to the
understanding role of estrogen and the amount of amount of estrogen necessary to maintain appropriate
estrogen replacement necessary during perimenopause hormone levels. It is of prime importance that each
and menopause. patient can recognize what her body’s needs are and
communicate this information to the health-care
provider.39
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Observe clients receiving neuroleptic drugs for signs and Neuroleptic drugs may decrease the ability to sweat, and
symptoms of hyperthermia. Teach clients these symp- therefore make it difficult for the client to reduce body
toms and caution them to decrease their activities in temperature.38,40
the warmest part of the day and to maintain adequate
hydration, especially if they are receiving lithium car-
bonate with these drugs.
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Body Temperature, Imbalanced, Risk For • 143
ACTIONS/INTERVENTIONS R AT I O N A L E S
Observe clients receiving antipsychotics and antidepres- Antipsychotics and antidepressants can cause a loss
sants for loss of thermoregulation. Elderly client, espe- of thermoregulation. The client’s learned avoidance
cially, should be monitored for this side effect. Provide behavior can be altered and consciousness can be
the client with extra clothing and blankets to maintain clouded as a result of medications. Hypothermia is
comfort. Protect this client from contact with uncon- more common that hyperthermia.38,40
trolled hot objects such as space heaters and radiators.
Heating pads and electric blankets can be used with
supervision.
Do not provide electric heating devices to the client who Basic safety measure.
is on suicide precautions or who has alterations in
thought processes.
Notify physician if the client receiving antipsychotic Antipsychotics, especially chlorpromazine and thiori-
agents has an elevation in temperature or flu-like dazine, can cause agranulocytosis. This risk is greatest
symptoms. 3 to 8 weeks after therapy has begun.38,40 Clients who
have experienced this side effect in the past should not
receive the drug again because a repeat episode is
highly possible.
Review the client’s complete blood count (CBC) before Basic monitoring for agranulocytosis.
drug is started, and report any abnormalities on subse-
quent CBCs to the physician.
Clients receiving phenothiazines should be monitored for These medications can produce hyperthermia, which can
hot, dry skin, CNS depression, and rectal temperature be fatal. This hyperthermia is due to a peripheral auto-
elevations (can be as high as 108⬚F). Monitor the nomic effect.38,40
client’s temperature three times a day while awake at
[times]. Notify physician of alterations.
Monitor clients receiving tricyclic antidepressants (TCAs) The side effect of a hyperpyretic crisis can be produced
and the monoamine oxidase inhibitors (MAOIs) for in clients receiving these medications.38,40
alterations in temperature three times a day while
awake. [Note times here.] Notify physician of any
alterations.
Gerontic Health
● N O T E : Normal changes of aging can contribute to altered thermoregulation. Age-
related changes that may be associated with altered thermoregulation are a decrease in
febrile response, inefficient vasoconstriction, decreased cardiac output, decreased subcu-
taneous tissue, diminished shivering, diminished temperature sensory perception, and
diminished thirst perception. Thus, older clients are at high risk for alterations in ther-
moregulation, both hyperthermia and hypothermia.
In addition to the interventions for Adult Health the following can be utilized with the older adult client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Check on older adults often who are at risk: Primary preventive measure.
• During heat alerts
• During cold weather
• In homes without air conditioning or heating
• During electrical outages or electrical service
interruptions
Instruct/assist client to select proper clothing: Primary preventive measure
• Layers during cold weather and lighter garments during
warmer weather
(care plan continued on page 144)
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144 • Nutritional–Metabolic Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor and record the temperature of older clients often Tracks client norms and provides a mechanism for early
and regularly during high-risk times: identification of changes.
• Intra- and postoperative period
• When infection is present
• When fluid imbalance is present
Use warmed IV solutions in older clients in the intra-/ Prevent episodes of hypothermia.
postoperative period unless hyperthermia is present.
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Breastfeeding, Effective • 145
Child Health
While the infant and mother typically have established effective breastfeeding within the first week or so of life there are
instances when a need for intervention does occur on the child health-care unit. Obviously the reason for hospitalization
is considered in the plan for effective breastfeeding, especially when surgical intervention is a part of the plan of care. In
such instances mothers are encouraged to pump during times when the infant is NPO or unable to breastfeed, and freeze
the expressed milk in individual bottles labeled for future use. Please see nursing actions under Women’s Health for addi-
tional interventions.
Women’s Health
● N O T E : If the diagnosis of Effective Breastfeeding has been made, the most appropri-
ate nursing action is continued support for the diagnosis. Successful lactation can be
established in any woman who does not have structural anomalies of the milk ducts and
who exhibits a desire to breastfeed. Adoptive mothers can breastfeed as well as birth-
mothers. The following actions serve to facilitate the development of Effective
Breastfeeding.
(care plan continued on page 146)
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146 • Nutritional–Metabolic Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review the mother’s knowledge base regarding breast- Success or failure to breastfeed is strongly influenced by
feeding prior to the initial breastfeeding of the infant. family and community, their values and beliefs. Sisters,
Information on benefits of breastfeeding must be given aunts, mothers, and grandmothers play a large role in
to the patient’s extended family as well as the patient. breastfeeding success. Determining the basis for assis-
The nutritional merit of breastfeeding must be tance and teaching is essential to avoid nonessential
embraced by the extended family. Social, emotional, repetition and confusion for the mother.41–43
and spiritual aspects of breastfeeding must be Confidence is gained through knowledge. Research has
addressed. Education must be tailored culturally and to shown that providing pregnant women with accurate
each community’s beliefs. breastfeeding information increases breastfeeding initi-
ation rates.44
The baby is kept with the mother immediately after birth Research has shown that not separating the mother and
so that breastfeeding can be initiated at the time the baby after birth leads to higher success rates with
newborn is most receptive (within the first hour after breastfeeding.41–49
birth).
Demonstrate and assist the mother and significant other Successful lactation depends on understanding the basic
with correct breastfeeding techniques (e.g., positioning how-to’s and correct techniques for the actual feeding
and latch-on). act. Women who attend prenatal breastfeeding skills
education and a breastfeeding class before discharge
increased breastfeeding knowledge. These women had
a significantly higher rate of breastfeeding at 6 months
postpartum.44,49
Teach the mother and significant other basic information Informing the family about how they can support and
related to successful breastfeeding (e.g., milk supply, help the new mother increases the success rate of
diet, rest, breast care, breast engorgement, infant breastfeeding after return home. Small things such as
hunger cues, and parameters of a healthy infant). fixing a cup of tea (hydration for the mother), running
a bath, minding the older siblings, or making a quick
trip to the grocery store, gives the new mother time to
breastfeed.5,41
Assess the mother’s breasts for graspable nipples, surgi- Provides the assessment base for diagnosing of potential
cal scars, skin integrity, and abnormalities prior to the problems as well as the base for developing strategies
initial breastfeeding of the infant. for success.
Assess the infant for ability to breastfeed prior to
breastfeeding (e.g., state of awareness or physical
abnormalities).
Place the infant to breast within the first hour after birth. It is important to work with the infant’s sleep–wake cycle
in establishing breastfeeding. If the infant can success-
fully suckle immediately after birth, a successful and
encouraging pattern is usually established for both the
mother and the infant.
To initiate or maintain lactation when the mother is This assists in establishing and maintaining the milk
unable to breastfeed the infant, encourage the mother supply. The hospital-grade electric pump with a double
to express breast milk either manually or by using a collecting kit is essential equipment in helping mothers
breast pump at least every 3 hours. maintain milk supply when the infant cannot suckle at
a breast. This is an important part of the success of this
mother to provide nutrition and emotional support as
well as nutritional support to the infant who cannot
breastfeed because of prematurity or illness.50,51
● N O T E : Always use a hospital-grade electric pump with a double collecting kit when
assisting mothers of babies in neonatal units to pump.
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Breastfeeding, Effective • 147
ACTIONS/INTERVENTIONS R AT I O N A L E S
Observe the infant at breast, noting behavior, position, Using a written scale is an excellent method of measuring
latch-on, and sucking technique with the initial breast- the self-efficacy of mothers who are breastfeeding, as
feeding and then as necessary. Document these obser- well as identifying high-risk mothers, build confidence
vations in the mother’s and infant’s charts. in breastfeeding mothers, assess breastfeeding behav-
iors, and evaluate the effectiveness of interventions.52
Encourage the mother and significant other to identify The majority of women who are successfully breast-
support systems to assist her with meeting her physical feeding when leaving the hospital quit as soon as
and psychosocial needs at home. they are home for 2 weeks. Support systems are
a critical component in the maintenance of suc-
cessful lactation.41–43,52
Encourage the mother to drink at least 2000 mL of fluids
a day, or 8 ounces of fluids every hour.
To provide sufficient amounts of calcium, proteins, and Breastfeeding mothers should increase their caloric intake
calories, encourage the mother to eat a wide variety of to 2000 to 2500 calories/day in order to maintain suc-
foods from the Food Pyramid.5 cessful lactation.5
Encourage the mother to breastfeed at least every 2 to 3 Newborns need frequent feeding to satisfy their hunger
hours to establish milk supply, then regulate feeding and to establish their feeding patterns. It is important
according to infant’s demands (feed effectively at least that the mother understand that the infant’s suckling
8 times per day). will determine the supply and demand of breast milk.
Monitor the infant’s output for number of wet diapers. Helps determine intake, hydration, and nutritional status
Document the number of diapers and the color of of infant.
urine. A well hydrated infant will have six to eight wet
diapers and at least three bowel movements every 24
hours after day 4.5
Weigh the infant at least every third day and record.
Assist the mother in planning a day’s activities when breast- Helps the new mother establish a schedule that is benefi-
feeding to ensure that the mother gets sufficient rest. cial for both the mother and infant.41
Encourage advanced planning for the working mother if
she intends to continue to breastfeed after returning to
work.
Involve the father or significant other in breastfeeding by The breastfeeding mother requires a great deal of support
encouraging the “provider–protector” role. and encouragement. Fathers can supply this by provid-
ing her with time for rest and assistance with infant
care. For example, the father can bring the infant to the
mother at night rather than the mother having to get up
each time for the feeding. Fathers can intervene with
family and friends to provide nursing mothers with pri-
vacy and a quiet environment.
Mental Health
This diagnosis will not be applicable in a mental health setting.
Gerontic Health
This diagnosis is not applicable in gerontic health.
Home Health
The Home Health nursing actions for this diagnosis are the same as those for Women’s Health.
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148 • Nutritional–Metabolic Pattern
BREASTFEEDING, INEFFECTIVE
✔ Have You Selected the Correct Diagnosis?
DEFINITION28
Ineffective Breastfeeding
The state in which a mother, infant, or child experiences dis- Ineffective Breastfeeding should be differentiated from
satisfaction or difficulty with the breastfeeding process. the patient’s concern over whether she wants to
breastfeed or not. Although a mother who does not
want to breastfeed will more than likely be ineffective
DEFINING CHARACTERISTICS28 in her breastfeeding attempts, ineffective breastfeed-
1. Unsatisfactory breastfeeding process ing can be related to problems other than just unwill-
2. Nonsustained sucking at the breast ingness to breastfeed. Other diagnoses that need to
be differentiated include:
3. Resisting latching on
4. Unresponsiveness to other comfort measures Anxiety
5. Persistence of sore nipples beyond the first week of Anxiety is defined as a vague, uneasy feeling, the
breastfeeding source of which is often nonspecific or unknown to
6. Observable signs of inadequate infant intake the individual. If an expression of perceived threat to
self-concept, health status, socioeconomic status,
7. Insufficient emptying of each breast per feeding
role functioning, or interaction patterns is made, this
8. Inability of infant to attach onto maternal breast
would constitute the diagnosis of Anxiety.
correctly
9. Infant arching and crying at the breast Impaired Parenting
10. Infant exhibiting fussiness and crying within the first Impaired Parenting is defined as the inability of the
nurturing figures to create an environment that pro-
hour after breastfeeding
motes optimum growth and development of another
11. Actual or perceived inadequate milk supply
human being. Adjustment to parenting, in general, is
12. No observable signs of oxytocin release a normal maturation process following the birth of a
13. Insufficient opportunity for sucking at the breast child.
Delayed Growth and Development:
RELATED FACTORS28 Self-Care Skills
1. Nonsupportive partner or family This diagnosis is defined according to a demonstrated
deviation from age group norms for self-care.
2. Previous breast surgery
Inadequate caretaking would be defined according to
3. Infant receiving supplemental feedings with artificial
specific behavior and attitudes of the individual
nipple mother or infant.
4. Prematurity
5. Previous history of breastfeeding failure Ineffective Individual Coping
This diagnosis is defined as the inability of the indi-
6. Poor infant sucking reflex
vidual to deal with situations that require coping or
7. Maternal breast anomaly
adaptation to meet life’s demands and roles. All the
8. Maternal anxiety or ambivalence changes secondary to the birth of a new baby could
9. Interruption in breastfeeding result in this diagnosis.
10. Infant anomaly
11. Knowledge deficit
EXPECTED OUTCOME
RELATED CLINICAL CONCERNS Infant will require no supplemental feedings by [date].
1. Any diseases of the breast
TARGET DATES
2. Cleft lip; cleft palate
3. Failure to thrive Because Ineffective Breastfeeding can be physically detri-
4. Prematurity mental to the infant as well as emotionally detrimental to the
5. Child abuse mother, an initial target date of 3 days is best.
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Breastfeeding, Ineffective • 149
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for factors contributing to the infant’s ability Assessment of the infant’s ability to suck assists in meet-
to suck: ing goals for effective breastfeeding.
• Structural abnormalities (e.g., cleft lip or palate)
• Altered level of consciousness, seizures, or CNS
damage
• Mechanical barriers to sucking (e.g., endotracheal tube
or ventilator)
• Pain or underlying altered comfort or medication
• Prematurity with diminished sucking ability
Determine the effect the altered or impaired breastfeeding The maternal–infant responses provide the essential data-
has on the mother and infant by providing at least one base in determining how serious the breastfeeding
30-minute period per day for talking with the mother. issues are. This information dictates how to approach
Monitor maternal feelings expressed, maternal–infant the problem and promote realistic follow-up.
behaviors observed, and excessive crying or unrelent-
ing fussiness in the infant.
To the degree possible, provide emotional support for the Before attempting any formula feedings try various artifi-
infant in instances of temporary inability to breastfeed cial feeding techniques using the mother’s own milk
(e.g., gavage feedings with appropriate cuddling). for the infant.51 Provides temporary substitutions for
Include the parents in care. Allow the infant to suck breastfeeding that promote trust and sense of security
on pacifier if possible. for the infant. Also, bonding with the mother is still
possible.50,51,53,54
Coordinate the parents’ visitation with the infant to best
facilitate successful breastfeeding in such areas as rest,
natural hunger cycles, and comfort of all involved.
Assist with plan to manage impaired breastfeeding to best Maintain the mother’s confidence in breastfeeding.
provide support to all involved (e.g., breast-pumping Supporting her choice for alternative feeding demon-
for period of time with support for this effort until nor- strates valuing of her beliefs.50,51,53,54
mal breastfeeding can be resumed). Breast milk may
be frozen or even given in gavage feeding. Support the
mother’s choice for whatever alternatives are chosen.
Provide appropriate resources that may include local lac-
tation specialist or in house assistance, plus those avail-
able via the Internet, library, and book stores.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ascertain the mother’s desire to breastfeed the infant Provides intervention base for nursing actions. Allows
through careful interviewing and reviewing of the planning of support, teaching, and evaluation of
mother’s knowledge of breastfeeding. motives and desires to breastfeed.
List the advantages and disadvantages of breastfeeding Assists the mother to make an informed decision about
for the mother. breastfeeding.5,44,52
Obtain a breastfeeding and bottle-feeding history from
the mother (e.g., did she breastfeed before, and if so,
was it successful or unsuccessful)?
Allow for uninterrupted breastfeeding periods. Providing the mother and infant with uninterrupted
breastfeeding times allows them to become acquainted
with each other and allows time for learning different
breastfeeding techniques.
(care plan continued on page 150)
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150 • Nutritional–Metabolic Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collaborate with physician, lactation consultant, perinatal Assists the mother who has strong desire to breastfeed to
clinical nurse specialist, etc. to determine ways to be successful.
make abnormal breast structure amenable for breast-
feeding.
Observe the mother with the infant during breastfeeding. Provides basic information and visible support to assist
Explain and demonstrate methods to increase infant with successful breastfeeding.
sucking reflex. Demonstrate to the mother various
positions for breastfeeding and how to alternate posi-
tions with each feeding to prevent nipple soreness
(e.g., sitting up, lying down, using football hold, hold-
ing the baby “tummy to tummy,” using pillows for the
mother’s comfort, or using pillows for supporting the
baby).
Ascertain the mother’s need for privacy during breast- Promotes the mother’s comfort with the physical act of
feeding. breastfeeding.
Monitor for poor or dysfunctional sucking by checking: Proper positioning facilitates satisfaction with breastfeed-
• Position the mother is using to hold the baby ing for both the mother and baby.
• Baby’s mouth position on areola and nipple
• Position of the baby’s head (e.g., inappropriate hyper-
extension)
Ascertain the mother’s support for breastfeeding from Support from others is essential for attaining successful
others (e.g., husband or significant other, patient’s breastfeeding. Success or failure to breastfeed is
female family members, obstetrician, pediatrician, strongly influenced by family and community, their
and nurses on postpartum unit). values and beliefs. Sisters, aunts, mothers, and grand-
mothers play a large role in breastfeeding success. To
determine the basis for assistance and teaching is
essential in order to avoid nonessential repetition and
confusion for the mother.41–43
Discuss the infant’s needs and frequency of feedings. Provides basic information and visible support to assist
with successful breastfeeding.
Assist the mother in planning a day’s activities when Provides information necessary for the mother to plan the
breastfeeding, ensuring that the mother gets plenty basics of her self-care.
of rest.
Teach the patient:
• The proper diet for the breastfeeding mother, listing The breastfeeding woman can generally meet her nutri-
important food groups and necessary calories to ade- tional needs and those of her infant through adequate
quately maintain milk production. dietary intake of food and fluids; however, because the
• The idea of advanced planning for the working mother energy demand is greater during lactation, RDA stan-
who plans to breastfeed dards recommend an additional 200 to 500 extra calo-
• That it takes time to establish breastfeeding (usually a ries per day to be added to the diet to provide adequate
month) nutrients for both mother and infant without catabolism
• The use of various hand pumps, battery-operated of the mother’s lean tissue.5
pumps, and electric pumps
• How to hand-express breast milk
• How to store expressed breast milk properly
Schedule specific times for consultation and support for
the mother. Plan at least 30 minutes per shift (while
awake) for talking with the mother.
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Breastfeeding, Ineffective • 151
ACTIONS/INTERVENTIONS R AT I O N A L E S
If the baby is separated from the mother, such as in
neonatal intensive care unit (NICU), involve the baby’s
nurses in planning with the mother routines and times
for breastfeeding the infant.50,51
Refer the mother to breastfeeding support groups. Provides basic information and visible support to assist
with successful breastfeeding.
For the mother who has had a cesarean section, place a Assists in keeping pressure off the incision line while
pillow over the abdomen before putting the infant to breastfeeding.
the breast.
Breastfeeding after breast surgery: Research has shown that breast surgery may not have an
• Prenatal nipple and breast assessment along with his- impact on a women’s ability to breastfeed as much as
tory and description of breast surgery the support around her.41,55
• Teach appropriate interventions for mother’s use.
• Supplemental methods of feeding (using a supplemen-
tal nursing system)
• Ensure that mothers know how to assess for infant
dehydration.
• Sunken anterior fontanel
• Weak, high-pitched cry and insufficient and infrequent
wet diapers (early days—one or two wet diapers per day;
after days 3 and 4—six to eight wet diapers per day)
• Availability of galactogogues (increase milk supply).
Should be taken only when a low milk supply is docu-
mented by the mother.55
Assist the mother of a premature baby to pump breast See effective breastfeeding diagnosis for correct pump
routinely to initiate milk production. setup for these mothers.
Demonstrate proper storage and transportation of breast Basic teaching to ensure safe nutrition for infant.
milk for the premature baby.
Assist the mother who has to wean a premature baby Provides needed support during this process.
from tube feedings to breastfeeding by:
• Teaching the mother to place the infant at the breast
several times a day and during tube feeding
• Encouraging the mother to hold, cuddle, and interact
with the infant during tube feedings
• Allowing the mother and infant privacy to begin
interaction with breastfeeding
• Being available to assist with the infant during
breastfeeding interaction
• Reassuring the mother that it might take several
attempts before the baby begins to breastfeed
Give breastfeeding mothers copies of educational Provides a readily available information source.
materials.
If breastfeeding is not possible because of an infant phys- Allows the mother the option of breastfeeding in the
ical deformity, teach the mother how to pump breasts event that the deformity can be surgically corrected.
and how to feed the infant breast milk in bottles with
special nipples.
Encourage maternal attachment behavior by not separat- Assists the mother in adjustment to parenting and effec-
ing mother and baby after birth. tive caretaking of the infant.
Mental Health
Refer to Women’s Health nursing actions for interventions related to this diagnosis.
(care plan continued on page 152)
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Gerontic Health
This diagnosis is not appropriate for gerontic health.
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Breastfeeding, Interrupted • 153
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for infant’s ability to suck. Encourage sucking Provides basic data critical to success. In times of non-
on a regular basis, especially if gavage feedings are a breastfeeding, it is beneficial to encourage sucking to
part of the therapeutic regimen. reinforce the feeding time as pleasurable and to
enhance digestion, unless contraindicated by a surgical
or medical condition (e.g., cleft repair of lip or palate,
prolonged NPO [nothing by mouth] status with con-
cerns for air swallowing).
Provide support for the mother–infant dyad to facilitate Feedback may provide essential valuing during times of
breastfeeding satisfaction. stress.
Monitor infant cues suggesting satisfaction: The fact that the infant’s satisfaction and input are valued
• Weight gain appropriate for status provides a critical component in the entire process of
• Ability to sleep at intervals breastfeeding.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide appropriate information on why breastfeeding Assists breastfeeding families in establishing and main-
needs to be interrupted. Be specific about length of taining breastfeeding capabilities when it is inadvis-
time (i.e., days, weeks, or months), and offer options able or impossible to put the baby to the breast for
for maintaining breast milk until able to resume breast- feeding.
feeding.49-51,53
Describe routine for pumping, expressing, and storing of
breast milk during emergency period.
Contact lactation consultant and/or perinatal nurse who
can assist with plan of nursing care and with mainte-
nance of breast milk during mother’s illness (e.g.,
emergency surgery, medical regimen [medications] that
contradict breastfeeding, or injury requiring hospital-
ization of mother).45,46
Provide the mother with appropriate information about
breast pumps and how to obtain one (rent or buy) to
aid in expression of breast milk (i.e., semiautomatic
breast pump, automatic breast pump, battery-operated
breast pump, or manual breast pump).
Demonstrate and have the mother return-demonstrate
proper assembly and use of breast pump.
Assist the mother in learning manual expression of breast
milk.46
• Good handwashing technique before expressing milk
• Correct positioning of hand and fingers so as not to
damage breast tissue
(care plan continued on page 154)
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Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Sterile wide-mouth funnel and bottle for storage of
breast milk
Discuss options for maintaining breastfeeding with the
mother who is returning to work. Provide assistance to
help the mother establish feeding schedule with work
schedule (e.g., breastfeed a.m. and p.m., pumping at
noon, etc.)45,46,56
Provide resources (e.g., printed materials or consultant) to
assist the mother when negotiating with her employer
for time and place to pump or breastfeed during work-
ing hours.46
Assist the mother and family to arrange schedule to bring
the infant to her during working hours.
Encourage the mother and significant other to verbalize
their frustrations and concerns about establishing and
maintaining lactation when the infant is ill or prema-
ture.47,50,51,53
Refer to lactation consultant/clinical nurse specialist who Provides basic information that assists in promoting
can support the parents and assist the nurse in develop- effective breastfeeding.
ing a program of breastfeeding or supplementing of the
infant with the mother’s breast milk.53–55
Mental Health
● N O T E : This diagnosis will not, in all likelihood, be applicable in a mental health
setting. Should a mother be admitted with a mental health–related diagnosis, the physi-
cian would probably suggest changing the infant to bottle-feedings. Should the physician
agree that breastfeeding could continue, the Women’s Health actions would be applica-
ble for the mental health client.
Gerontic Health
This diagnosis is not appropriate for gerontic health.
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Dentition, Impaired • 155
ACTIONS/INTERVENTIONS R AT I O N A L E S
Recognize cultural variations in feeding practices when Feeding patterns vary according to cultural norms.
assessing effectiveness of breastfeeding.
Provide additional education or referrals as requested or Community-based support is ongoing; early intervention
as the situation changes. as the situation changes increases the potential for con-
tinued effectiveness. Support from others is essential in
attaining successful breastfeeding. Success or failure to
breastfeed is strongly influenced by family and commu-
nity, their values and beliefs. Sisters, aunts, mothers,
and grandmothers play a large role in breastfeeding
success. Determining the basis for assistance and teach-
ing is essential in order to avoid nonessential repetition
and confusion for the mother.41–43
DENTITION, IMPAIRED 12. Chronic use of tobacco, coffee, tea, or red wine
13. Lack of knowledge regarding dental health
DEFINITION28 14. Excessive use of abrasive cleaning agents
Disruption in tooth development, eruption patterns, or struc- 15. Bruxism
tural integrity of individual teeth.30
RELATED CLINICAL CONCERNS
DEFINING CHARACTERISTICS28 1. Dental surgery
1. Excessive plaque 2. Elderly wearing dentures
2. Crown or root caries 3. Facial trauma
3. Halitosis 4. Anorexia or bulimia
4. Tooth enamel discoloration 5. Malnutrition
5. Toothache
6. Loose teeth ✔ Have You Selected the Correct Diagnosis?
7. Excessive calculus
8. Incomplete eruption for age (may be primary or perma- Imbalanced Nutrition, Less Than Body
nent teeth) Requirements
9. Malocclusion or tooth misalignment Impaired Dentition might be a primary factor in the
10. Premature loss of primary teeth development of Imbalanced Nutrition, Less Than Body
11. Worn down or abraded teeth Requirements. Impaired Dentition is a very specific
12. Tooth fractures diagnosis related only to the teeth and would require
intervention before working on the broader diagnosis
13. Missing teeth or incomplete absence
of Imbalanced Nutrition, Less Than Body
14. Erosion of enamel
Requirements.
15. Asymmetric facial expression
Adult Failure to Thrive
RELATED FACTORS28 Again, Impaired Dentition might contribute to the
development of Adult Failure to Thrive. This means
1. Ineffective oral hygiene Impaired Dentition would need to be resolved before
2. Sensitivity to heat or cold the broader definition of Adult Failure to Thrive.
3. Barriers to self-care
4. Access or economic barriers to professional care
5. Nutritional deficits EXPECTED OUTCOME
6. Dietary habits
7. Genetic predisposition Will return-demonstrate complete oral hygiene by [date].
8. Selected prescription medications
TARGET DATES
9. Premature loss of primary teeth
10. Excessive intake of fluoride One week would be an appropriate time period to check ini-
11. Chronic vomiting tial progress toward resolving this problem area.
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Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for all possible contributing factors to include, Consideration of all possible etiologies best helps identify
but not limited to, organic, genetic, familial, medical, treatment modalities.
prenatal, or neonatal factors; prematurity; jaundice;
significant injuries or exposures; and nutritional possi-
bilities.
Determine whether there are coexistent congenital anom- Primary deficits may exist in isolation or in combination
alies or risk factors. with other deficits.
• Risk for caries increased by the infant or toddler being
given fruit juices or high corn syrup/fructose content
beverages, especially in a bottle.
Identify current dental hygiene for the client (expecta- Preventive maintenance knowledge offers a baseline for
tions according to age norms; e.g., 6 months—gentle hygiene routines and reduction of risk factors for age.
cleansing of gums with soft cotton cloth).
• Teach the child and significant others practices that
increase the risk of caries.
Monitor the mouth fully for status of gums and teeth, if Actual observation assists in accuracy of diagnosis and
present, type and location, condition of enamel, and treatment.
alignment or malocclusion.
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Dentition, Impaired • 157
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine pattern of tooth appearance and correlation to Expected norms assist in identification of deviations.
norms for primary and secondary teeth.
Determine patterns of tooth loss according to norms for Expected norms assist in identification of deviations.
primary and secondary teeth.
Make appropriate recommendations for maintenance, Appropriate referral to specialists offers maximum poten-
prophylactic, and restorative care of the client’s teeth tial for long-term maintenance of dentition health.
and gums.
Offer appropriate education for safeguarding permanent Anticipatory planning assists in dentition health main-
teeth for the client and family, to include indications tenance.
for mouth guards during contact sports, ways to mini-
mize risk of injury, and importance of seeking immedi-
ate attention of dentist in event of accidental loss of
tooth.
Ascertain client and parental knowledge regarding med- Validation of actual knowledge or care issues affords
ications, dietary factors, special orthodontia, or other optimum likelihood of adherence to regimen for the
related maintenance issues. individual client.
Provide information for local support groups when appli- Support groups foster shared experience with validation
cable (e.g., Dental Association). of peer input.
Determine resources for continued maintenance, includ- Resources help provide appropriate care as situation
ing financial, as determined on an individual basis. permits.
• Refer to community resources to facilitate continued
maintenance of dental health.
Women’s Health
Nursing interventions for Women’s Health are the same as those for Adult Health.
● N O T E : It is important to practice good dental health during pregnancy. A pregnant
woman needs approximately 1.2 g of calcium and phosphorus daily during pregnancy to
help maintain bony stores.
Mental Health
The nursing actions for this diagnosis in the mental health client are the same as those for Adult Health.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine the client and/or caregiver’s ability to perform Physical aging changes associated with chronic disease
oral hygiene measures. such as arthritis may limit the ability to perform oral
care.56
Review and/or teach the client strategies for good oral Many older adults have not been taught how to ade-
hygiene as necessary (i.e., daily flossing, brushing after quately clean their teeth by brushing and flossing.56
meals, and using correct equipment [soft-bristled tooth
brush]).54
Refer the client to an occupational therapist, if needed, Older adults may experience problems with gripping
for assistive equipment and techniques to enhance oral toothbrushes or using dental floss, and thus adequate
hygiene practices.57 oral care is inhibited.57
Advocate for clients to ensure access to dental services. Many older adults are reluctant to use dental services
because of cost concerns.58
(care plan continued on page 158)
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158 • Nutritional–Metabolic Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
If dentures are present, monitor for appropriate fit, bed- There is continuous resorption of ridges beneath dentures
time removal of dentures, and presence of food trap- over time, causing a slow change in how well dentures
ping under dentures after meals. fit. Failure to remove dentures at bedtime may result in
oral trauma or breathing problems if the dentures are
loose. Food trapping can lead to mucosal inflammation
from organisms trapped under dentures.56
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Fluid Balance, Readiness For Enhanced • 159
Child Health
Oral rehydration offers a realistic treatment option for mild and moderate dehydration and often is suited to home as
opposed to hospital management.58
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for all contributory patterns to provide a basis Provides fullest database for considering plan for
for fluid and electrolyte needs, especially prior 24-hour success.
intake and output, losses per stool, surgical losses, and
post-op drainage.
Offer fluids according to plan-see that fluids and elec- Appropriate fluid amount and composition will best sat-
trolytes are offered according to hydration needs* isfy rehydration needs according to dehydration risk.*
(based on metabolic requisites for size by surface area
calculations). Clarify with pediatrician, nurse practi-
tioner, or primary care physician. May also consult
(care plan continued on page 160)
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Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Harriet Lane handbook with a desired urinary output
of 2 mL/kg minimally.59 [Note those fluids preferred
by the child here.]
Teach the family to have appropriate fluid and electrolyte Provides guidance for future situations.
solutions including Pedialyte, Infalyte, Resol, Lytren,
Nutrilyte, and others, on hand.
Avoid simple sugars, such as soft drinks or Kool-Aid. Osmotic effects may worsen diarrhea.
Monitor for tolerance of fluid and avoid overfeeding— Lessens likelihood of increased intolerance during initial
small feedings regularly are better tolerated. rehydration phase.
Reassess for hydration status with a focus on urinary out-
put of 2 mL/kg, minimally, level of consciousness, skin
turgor, and anterior fontanel status for infants.
Maintain strict intake and output for the duration of the Offers a record for evaluation of effectiveness of plan.
rehydration experience.
Reassess the caregiver’s knowledge for need for rehydra- Provides anticipatory guidance.59
tion. [Note teaching needs and plan here.]
Women’s Health
The nursing actions for the women’s health client with this diagnosis are the same as those for the adult health clients and
gerontic health clients. For breastfeeding women, see Effective Breastfeeding diagnosis.
Mental Health
The nursing actions for the mental health client with this diagnosis are the same as those for the Adult Health client.
Gerontic Health
● N O T E : Dehydration has been reported to be the most common fluid and electrolyte
imbalance in older people. Hospitalized elders with dehydration have mortality rates as
high as 46 percent. Elders are particularly susceptible to dehydration because of age-
related changes such as decreased renal perfusion and sensitivity to antidiuretic hor-
mone (ADH), decreased sense of thirst, decreased mobility, and confusion. In addition,
some pathological conditions; such as hypertension and heart and renal disease, make
elders highly susceptible to fluid and electrolyte imbalances.60
In addition to the interventions for Adult Health, the following may be utilized for the aging client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Facilitate client receiving at least 1500 cc/day of oral Less than this can lead to rapid dehydration.
intake.
Regularly and frequently monitor dependent and semide- Preventive practice.
pendent clients for adequate fluid intake. These clients
should be considered for a restorative fluid program.
Utilize a fluid intake sheet to monitor daily fluid intake. Tracks oral intake and allows for early identification of
less than optimal intake.
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Fluid Volume, Deficient, Risk For and Actual • 161
ACTIONS/INTERVENTIONS R AT I O N A L E S
Regularly and frequently present fluids to bedridden Facilitates maintenance of adequate hydration status.
clients. [Note the client’s preferred fluids here.]
Utilize medication time to encourage increased fluid intake. Medication time can be an important source of fluids.60
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162 • Nutritional–Metabolic Pattern
Have You Selected the Correct Diagnosis? (box infant or young child is not able to obtain the fluid he
continued from page 161) or she wants and must depend on others. If the par-
ents are unable to recognize or meet these needs,
client just may not be ingesting enough food from then the infant or young child may have a Risk for or
which the body can absorb fluids. Actual Deficient Fluid Volume. Even in an adult, the
Bowel Incontinence, Diarrhea, primary nursing diagnosis may be Self-Care Deficit.
or Urinary Incontinence Again, if the adult is unable to obtain the fluid he or
These diagnoses may be causing an extreme loss of she requires because of some pathophysiologic prob-
fluid before it can be absorbed and used by the body. lem, then he or she may have a Risk for or Actual
Deficient Fluid Volume.
Impaired Skin Integrity
This diagnosis could be the primary problem. For
example, the patient who has been burned has
grossly impaired skin integrity. The skin is supposed EXPECTED OUTCOME
to regulate the amount of fluid lost from it. If there is
relatively little intact skin, the skin is unable to perform Intake and output will balance within 200 mL by [date].
its regulatory function and there is significant loss of
fluid and electrolytes. TARGET DATES
Self-Care Deficit or Impaired Parenting Normally, intake and output will approximately balance
In the infant or young child, the problem may primarily
only every 72 hours; thus, an appropriate target date would
be a Self-Care Deficit or Impaired Parenting. The
be 3 days.
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Fluid Volume, Deficient, Risk For and Actual • 163
ACTIONS/INTERVENTIONS R AT I O N A L E S
Force fluids to a minimum of 2000 mL daily: Offer small
amount of fluid (4 to 5 ounces) at least every hour
while awake and at every awakening during night.
[Note client’s fluid preferences here.]
• Interspace fluids with high-fluid-content foods (e.g.,
popsicles, gelatin, pudding, ice cream, or watermelon).
Avoid beverages with diuretic effects.
Collaborate with health-care team to determine medica-
tions that address source of fluid loss (e.g., antidiar-
rheals or antiemetics).
Assist the patient to eat and drink as necessary. Provide Prevents dehydration and easily replaces fluid loss with-
positive verbal support for the patient’s consuming out resorting to IVs. Frequent fluids improve hydra-
fluid. tion; variation in fluids is helpful to encourage the
patient to increase intake.
Monitor and address insensible fluid losses.
Monitor gastric tubes to suction for large amounts of
gastric drainage. Initiate replacements if necessary.
Teach the patient, prior to discharge, to increase fluid
intake at home during:
• Elevated temperature episodes
• Periods when infection and elevated temperatures are
present
• Periods of exercise
• Hot weather
Measures to ensure adequate hydration: Support the patient’s self-care by pointing out measures
• Need to drink fluids before feeling of thirst is experi- he or she can use to control fluid imbalance. Adequate
enced intake and early intervention will prevent undesirable
• Recognizing signs and symptoms of dehydration such outcomes.
as dry skin, dry lips, excessive sweating, dry tongue,
and decreased skin turgor
• How to measure, record, and evaluate intake and output
Refer to other health-care professionals as necessary. Provides support and fosters collaboration through use of
readily available resources.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Measure and record total intake every shift and note 24- A 24-hour fluid assessment is meaningful for diagnosing
hour totals: deficits and also provides a basis for replacement
• Check intake and output hourly (may require weighing needs.
diapers or insertion of a Foley catheter [infants may
require use of a 5 or 8 feeding tube if size 10 Foley is
too large]).
• Check urine specific gravity every 2 hours on [odd/even] Specific gravity is a good indicator of degree of
hour or every voiding or as otherwise ordered. hydration.
Force fluids to a minimum appropriate for size (will be Prompt replacement and maintenance of appropriate
closely related to electrolyte needs and cardiac, respira- fluids prevents further circulatory or systemic prob-
tory, and renal status). [Note fluids preferred by child lems. Specific attention is also required with respect
here.] to sodium, potassium, and caloric intake. Infants are
• Infants: 70 to 100 mL/kg in 24 hours subject to fluid volume depletion because of their rela-
• Toddler: 55 to 70 mL/kg in 24 hours tively greater surface area, higher metabolic rate, and
• School-age child: 20 to 50 mL/kg in 24 hours immature renal function.61
(care plan continued on page 164)
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Weigh the patient daily at the same time of day, on the Accuracy of weight cannot be overstressed. The weight
same scale, and in the same clothing (weigh infants often serves as a major indicator of the effectiveness of
without diaper). the treatment regimen. Iatrogenic problems are more
likely to occur with inaccuracies.
Assist in individualizing oral intake to best suit the When options exist, honoring them facilitates better com-
patient’s needs and preferences. Include parents in pliance with goals and helps the patient and family to
designing this plan. feel valued.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient to identify lifestyle factors that could be Provides basis for treatment of symptoms and basis for
contributing to symptoms of nausea and vomiting dur- teaching and support strategies.
ing early pregnancy. There are homeopathy methods of controlling nausea and
• Eat small, frequent meals. vomiting of pregnancy including yoga, acupuncture,
• Eat dry toast or crackers before arising. and rearranging eating patterns during the first 3 to
• Avoid foods with bothersome smells. 4 months of pregnancy.5,62,63
• Avoid rich, fatty foods, spicy foods, and greasy foods.
• Drink fluids separately from meals.
• Drink herbal teas (raspberry leaf or peppermint).
• Suck on a cinnamon stick.
Identify the patient’s support system.
Monitor the patient’s feelings (positive or negative) about
pregnancy.
Evaluate social, economic, and cultural conditions.
Involve significant others in discussion and problem-
solving activities regarding physiologic changes of
pregnancy that are affecting work habits and interper-
sonal relationships (e.g., nausea and vomiting).
Teach the patient measures that can help alleviate patho-
physiologic changes of pregnancy.
In collaboration with the dietitian:
• Obtain dietary history.
• Assist the patient in planning diet that will provide
adequate nutrition for her and her fetus’s needs.
Teach methods of coping with gastric upset, nausea, and Provides information, education, and support for self-care
vomiting: during pregnancy. There are homeopathy methods of
• Eat bland, low-fat foods (no fried foods or spicy controlling nausea and vomiting of pregnancy includ-
foods). ing yoga, acupuncture, and rearranging eating patterns
• Increase carbohydrate intake. during the first 3 to 4 months of pregnancy.5,62,63
• Eat small amounts of food every 2 hours (avoid empty
stomach).
• Eat dry crackers or toast before getting up in the
morning.
• Take vitamins and iron with night meal before going to
bed (vitamin B, 50 mg, can be taken twice a day but
never on an empty stomach).
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Fluid Volume, Deficient, Risk For and Actual • 165
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Drink high-protein liquids (e.g., soups or eggnog).5,62,63
• Avoid foods with bothersome smells.
• Avoid rich, fatty foods, spicy foods, and greasy foods.
• Drink fluids separately from meals
• Drink herbal teas (raspberry leaf or peppermint).
• Suck on a cinnamon stick.5,62,63
Monitor the patient for: Provides basis for therapeutic intervention if necessary as
• Variances in appetite well as support of that patient, which can decrease fear
• Vomiting between 12 and 16 weeks of pregnancy and feelings of helplessness.
• Weight loss
• Intractable nausea and vomiting
Collaborate with physician regarding monitoring for: Provides support and information to increase self-
Dehydration awareness and self-care.
• Electrolyte imbalance: hemoconcentration, ketosis with
ketonuria, hyponatremia, hypokalemia
● N O T E : “During pregnancy, gastric acid secretion normally is reduced because of
increased estrogen stimulation. This places the women at risk for alkalosis, rather than
the acidosis that usually occurs in an advanced stage of dehydration.”64
• Hydration (approximately 3000 milliliters/24 hours)
and providing vitamin supplements
• Restriction of oral intake and providing parental
administration of fluids and vitamins.
● N O T E : “Vitamin B6 has been found effective and safe for use in nausea and vomiting
of pregnancy.”5
Allow expression of feelings and encourage verbalization
of fears and questions by scheduling at least 30 min-
utes with the patient at least once per shift.
Provide the patient and family with diet information for Provides information that allows for successful lactation
the breastfeeding mother to prevent dehydration: and healthy recovery from childbirth.
• Increase daily fluid intake.
• Drink at least 2000 mL of fluid daily.
• Extra fluid can be taken just before each breastfeeding
(e.g., water, fruit juices, decaffeinated tea, or milk).
• Eat well-balanced meals to include the basic food groups.
Teach the parents fluid intake needs of the newborn. Feeding behavior is important not only for fluid but also
for food. The caloric need of the infant for the first 3
months is 110 kcal/kg per day, from 3 to 6 months 100
kcal/kg per day, and from 6 to 9 months 95 kcal/kg per
day.5 Breast milk contains adequate nutrients and vita-
mins for 6 months of life. The American Academy of
Pediatrics recommends breastfeeding exclusively for
the first 6 months of life and continue breastfeeding
with other food induction for at least 12 months.5
Monitor the newborn for fluid deficit, and teach the par- Provides information and support for healthy growth and
ents to monitor via the following factors: development of the newborn.
• “Fussy baby,” especially immediately after feeding
• Constipation (remember, breastfed babies have fewer
stools than formula-fed babies)
• Weight loss or slow weight gain
Evaluate the baby, mother, and nursing routine:
• Is the baby getting empty calories (e.g., a lot of water
between feedings)?
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Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Monitor the baby for nipple confusion from switching
the baby from breast to bottle and vice versa many
times.
• Count the number of diapers per day (should have six
to eight very wet diapers per day).
• Monitor the infant for intolerance to the mother’s milk
or bottle formula.
Monitor the baby for illness or lactose intolerances.
Monitor how often the mother is nursing the infant (infre-
quent nursing can cause dehydration and slow weight
gain).
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
If the client is confused or is unable to interpret signs of Medications and/or clouded consciousness may affect the
thirst, place on intake and output measurement, and client’s ability to recognize need for fluids.
record this information every shift.
Evaluate potential for fluid deficit resulting from medica- Estimated daily requirement for adults is 1500 to
tion or medication interaction (e.g., lithium and diuret- 3000 mL/day.65
ics). If this presents a risk, place the client on intake
and output measurement every shift.
Evaluate mental status every shift at [times]. Basic monitoring to determine the client’s ability to inde-
If the client’s values and beliefs influence intake: pendently take fluids.
• Alter environment as necessary to facilitate fluid
intake, and note alterations here (e.g., if the client
thinks fluids from cafeteria are poisonous, have the
client assist in making drink on unit).
• Provide positive attention to the client at additional
times to avoid not drinking as a way of obtaining
negative attention.
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized for the aging client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage the patient to drink at least 8 ounces of fluid Older adults may not experience thirst sensation in
every hour while awake. response to fluid deprivation. Older clients may not
feel thirst or dry mouth, even when dehydrated. When
given free access to fluids, older adults tend to drink
less than their younger counterparts. Older clients,
unprompted, may fail to drink enough fluids to stay
adequately hydrated. Thus, frequent offering of fluids
to the older adult is essential.
Be sure fluids are within reach of the patient confined For those confined to bed or with restricted movement,
to bed. this action is a simple, basic measure to promote fluid
intake.
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Fluid Volume, Excess • 167
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168 • Nutritional–Metabolic Pattern
TARGET DATES
ADDITIONAL INFORMATION
In a healthy person, intake and output reach an approximate
Excess fluid volume can occur as a result of water excess, balance over a span of 72 hours. An acceptable target date
sodium excess, or water and sodium excess.58 Careful would then logically be the third day after admission.
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Fluid Volume, Excess • 169
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the patient to monitor his or her own intake and Supports the patient’s self-care by pointing out measures
output at home. he or she can use to control fluid imbalance. Adequate
intake and early intervention will prevent undesirable
outcomes.
In collaboration with dietitian: Cost-effective use of readily available resources. Pro-
• Obtain nutritional history. motes interdisciplinary care and thus better care for
the patient.
Refer to other health-care professionals, as appropriate.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Measure and record total intake, output, blood pressure, A strict assessment of intake and output serves to guide
and pulse every shift: treatment for indication of hydration status. The spe-
• Check intake and output hourly, and weigh diapers. cific gravity assists in determining cardiac, renal, and
• Monitor specific gravity at least every 2 hours or as respiratory function and electrolyte status.
specified.
Reposition as tolerated every half-hour. Prevents stasis of fluids in any one part of body. Assists
in circulation of fluid and in preventing skin integrity
problems.
Weigh daily at the same time under the same conditions Accuracy of weight is critical; it serves as a major indica-
of dress (infants without clothes, children in under- tor for treatment effectiveness, and is an ongoing
wear). parameter for treatment.
Administer medications as ordered with attention to Potassium and sodium alterations may be present and
appropriate dosage and potential effect on electrolytes. must be addressed to prevent further fluid or electrolyte
imbalance.
Anticipate potential for respiratory distress and monitor Fluid overload and fluid and electrolyte deviations may
appropriately by cautious checking of breath sounds, lead to respiratory and/or cardiac arrest if undetected
respiratory effort, and level of consciousness. or untreated.
Administer fluids per IV with appropriate equipment; i.e., Likelihood of iatrogenic fluid overdose is lessened with
when using Buretrol clamp off main supply of fluids appropriate safeguards.
even while on IV pump. Place enough fluid for 2 hours
at a time in the Buretrol, and use medium infusion
pumps for medications. In young infants, 1 hour of
fluid may be used.
Women’s Health
● N O T E : Pregnancy-induced hypertension (PIH), often called the “disease of
theories,” has been documented for the last 200 years. Numerous causes have
been proposed but never substantiated; however, data collected during this time
do support the following:
1. Chorionic villi must be present in the uterus for a diagnosis of PIH to be made.
2. Women exposed for the first time to chorionic villi are at increased risk for developing PIH.
3. Women exposed to an increased amount of chorionic villi (e.g., multiple gestation or hydatidiform mole) are at greater
risk for developing PIH.
4. Women with a history of PIH in a previous pregnancy are at increased risk for developing PIH.
5. Women who change partners are more likely to develop PIH in a subsequent pregnancy.
6. There is a genetic predisposition for the development of PIH, which may be a single gene or multifactorial.
7. Vascular disease places the patient at greater risk for developing superimposed PIH.64
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170 • Nutritional–Metabolic Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review the client’s history for factors associated with Basic database required to assess for potential of PIH.
pregnancy-induced hypertension (PIH):
• Family and personal history such as diabetes or multi-
ple gestation
• Rh incompatibility or hypertensive disorder
• Chronic blood pressure 140/90 mm Hg or greater prior
to pregnancy, or in the absence of a hydatidiform mole,
that persists for 42 days postpartum
During current pregnancy, observe for the following char- Increased knowledge for the patient will assist the patient
acteristics of PIH: with earlier help-seeking behaviors.
• Nulliparous women younger than 20 or older than 35
years of age
• Multipara with multiple gestation or renal or vascular
disease
• Presence of hydatidiform mole
Monitor the patient for chronic hypertension65:
• Increase in systolic blood pressure of 30 mm Hg or
diastolic blood pressure of at least 15 mm Hg above
baseline on two occasions at least 2 hours apart
• Development of proteinuria
Monitor and teach the patient to immediately report the Increased knowledge for the patient will assist the patient
following signs of PIH: with earlier help-seeking behaviors.
• Increase of 30 mm Hg in blood pressure or 140/90
blood pressure and above
• Edema: Weight gain of 5 pounds or greater in 1 week
• Proteinuria: 1 g/L or greater of protein in a 24-hour
urine collection (2⫹ by dipstick)
• Visual disturbances: blurring of vision or headaches
• Epigastric pain
Observe closely for signs of severe preeclampsia in any Knowledge of the complexity and multisystem nature of
patient who presents with64: the disease assists with early detection and treatment.
• Blood pressure greater than or equal to 160 mm Hg
systolic, or greater than or equal to 110 mm Hg dias-
tolic, on at least two occasions 6 hours apart with the
patient on bedrest
• Proteinuria greater than or equal to 5 g in 24 hours or
3⫹ to 4⫹ on qualitative assessment
• Oliguria: less than 400 mL in 24 hours
• Cerebral or visual disturbances
• Epigastric pain
• Pulmonary edema or cyanosis
• Impaired liver function of unclear etiology
• Thrombocytopenia
Monitor, at least once per shift, for edema. Teach the Basic safety measures.
patient to:
• Monitor swelling of hands, face, legs, or feet.
(Caution: May need to remove rings.)
• Be aware of a possible need to wear loose shoes or a
bigger shoe size.
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Fluid Volume, Excess • 171
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Schedule rest breaks during day and to elevate feet.
• When lying down, to lie on left side to promote placen-
tal perfusion and prevent compression of vena cava.
In collaboration with the dietitian:
• Obtain nutritional history.
• Place the patient on high-protein diet (80 to 100 g of
protein).
• Place the patient on reduced sodium intake (not more
than 6 g daily or less than 2.5 g daily).
Monitor:
• Intake and output: urinary output not less than 30 mL/h
or 120 mL/4 h
• Effect of magnesium sulfate (MgSO4) and hydralazine
hydrochloride (Apresoline) therapy (have antidote for
MgSO4 [calcium gluconate] available at all times dur-
ing MgSO4 therapy)
• Deep tendon reflexes (DTR) at least every 4 hours
[state times here]
• Respiratory rate, pulse, and blood pressure at least
every 2 hours on the [odd/even] hour
• Fetal heart rate and well-being at least every 2 hours on
the [odd/even] hour
Institute seizure precautions.
Ensure bedrest and reduction of noise level in the Decreases sensory stimuli that might increase the likeli-
patient’s environment. hood of a seizure.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Observe chronic psychiatric clients and clients with pre- A pattern of extreme polydipsia and polyuria can develop
existing alcoholism66 for signs and symptoms of poly- in clients with psychiatric disorders. This may be
dipsia and/or water intoxication. The observations related to dopamine central nervous system activity
include66–68: and dysfunction in antidiuretic hormone activity in
• Frequent trips to sources of fluid and excessive con- combination with psychosocial factors. The sense of
sumption of fluids thirst can also be increased by certain medications.67,68
• Client stating, “I feel as if I have to drink water all of
the time,” or a similar statement
• Fluid-seeking behavior
• Dramatic or rapid fluctuations in weight
• Polyuria
• Incontinence
• Carrying large cups
• Urine specific gravity of 1.008 or less66
• Decreases in serum sodium
Discuss the client’s explanations for excessive drinking to Determining exact reason for polydipsia allows for more
determine causes of excessive fluid intake. If it is deter- effective intervention.
mined that drinking is a diversionary activity or an
attempt to avoid interaction, implement nursing actions
for Social Isolation and/or Deficient Diversional
Activity, as appropriate. If it is determined that fluid
intake is related to testing concern of staff or testing
limits, refer to nursing actions for Powerlessness or
Self-Esteem disturbances.
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172 • Nutritional–Metabolic Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
If it is determined that the client is at risk for water intox- Water intoxication can be life-threatening.66
ication, implement the following actions:
• Monitor and document fluid intake and output and
weight fluctuations on a daily basis.
• Restrict fluids as ordered by physician.
Provide small medicine cup (30 mL) for the client to
obtain fluids.
Provide fluids such as chipped ice on a schedule. [Note
schedule here.]
Instruct the client in need for reducing nicotine consump- Nicotine increases release of antidiuretic hormone
tion. If the client cannot do this, it may be necessary to (ADH), a water-conserving hormone.66
initiate a “rationing” plan. If so, note plan here.
Provide the client with sugarless gum and/or hard candy
to decrease dry mouth. [Note the client’s preference.]
Identify with the client those activities that would be
most helpful in diverting attention from fluid restric-
tion. [Note specific activities here with schedule for
use.]
Refer to occupational and recreational therapists.
If the client continues to have difficulty restricting fluids,
provide increased supervision by limiting the client to
day area or other group activity rooms where he or she
can be observed. Note restrictions here. If necessary,
place the client on one-to-one observation.
Talk with the client about feelings engendered by restric-
tions for 15 minutes per shift. [Note times here.]
Discuss the client’s restriction in a community meeting if:
• Restrictions are impacting others on the unit.
• Support from peers would facilitate client’s maintain-
ing restrictions.
Provide positive verbal support for the client’s maintain- Promotes the client’s self-esteem and provides motivation
ing restriction(s). for continued efforts.
Identify with the client appropriate rewards for maintain- Promotes the client’s self-esteem and sense of control and
ing restrictions and reaching goals. Describe rewards provides motivation for continuing his or her efforts.
and behaviors necessary to obtain rewards here.
Gerontic Health
Nursing actions for the gerontic health patient with this nursing diagnosis are the same as those for Adult Health and Home
Health.
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Fluid Volume, Imbalanced, Risk For • 173
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Practice proper body alignment.
• Use pillows, pads, etc. to relieve pressure on dependent
parts.
• Avoid shearing force when moving in bed or chair.
• Alter position at least every 2 hours.
Assist the client and family to set criteria to help them Planned decision making to prepare for potential crisis.
determine when a physician or other intervention is
required.
Assist the client and family in identifying risk factors per- Identification of risk factors and understanding of rela-
tinent to the situation (e.g., heart disease, kidney dis- tionship to fluid excess provide for intervention to
ease, diabetes mellitus, diabetes insipidus, liver reduce or prevent negative outcomes.
disease, pregnancy, or immobility).
Teach signs and symptoms of fluid excess: Early recognition of signs and symptoms provides data
• Peripheral and dependent edema for early intervention.
• Shortness of breath
• Taut and shiny skin
Assist the client and family in identifying lifestyle Knowledge and support provide motivation for change
changes that may be required: and increase potential for positive outcome.
• Avoid standing or sitting for long periods of time; ele-
vate edematous limbs.
• Avoid crossing legs.
• Avoid constrictive clothing (girdles, garters, knee-high
stockings, rubber bands to hold up stocking, etc.).
• Consider wearing antiembolism stockings.
• Avoid excess salt. Teach the patient and family to read
labels for sodium content. Avoid canned and fast foods.
• Use spices other than salt in cooking.
• Avoid lying in one position for longer than 2 hours.
• Raise head of bed or sit in chair if having difficulty
breathing.
• Restriction of fluid intake as necessary (e.g., usual in
kidney and liver disease).
• Weigh at the same time every day wearing the same
clothes and using the same scale.
Teach purposes and side effects of medication (e.g., Appropriate use of medication and reduction of side
diuretics or cardiac medications). effects.
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Fluid Volume, Imbalanced, Risk For • 175
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor at-risk populations, especially those infants and Greater likelihood exists for fluid volume imbalances
children scheduled for surgery or procedures in which with infants or children who undergo surgery during
NPO status is necessary for fluid inbalances. which fluids may be lost or gained in a short period
of time.
Determine preoperatively or prior to onset of procedures Anticipatory planning provides appropriate focus on risk
the ongoing fluid plan for the client with specifications for deficit or overload for vulnerable infants and chil-
for: dren in advance of actual occurrence.
• Type of fluid and status of oral feedings
• Rate of administration of IV fluid
• Electrolyte status and additives to be administered
• Accurate weight
• Accurate 24-hour intake and output
• Recent essential preoperative laboratory tests with
abnormal results addressed
• Allowance for special drainage or physiologic demands
• Past 24-hour specific gravity record
Identify appropriate parameters to be addressed by all Pre-identification of coordination of multidisciplinary
members of the health-care team during and after sur- specialists assists in appropriate fluid maintenance.
gery or procedure to include cardiac, renal, neurologic,
metabolic, and related physiologic alterations.
Maintain the patient’s temperature during and after sur- Metabolic demands are lessened in the absence of cold
gery or procedure. stress or hyperthermia.
Women’s Health
● N O T E : Bleeding can occur rapidly during pregnancy, delivery, and postpartum.
There is potential for maternal exsanguination within 8 to 10 minutes because of the
large amount of blood flowing to the uterus and placenta during pregnancy.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the patients presenting to labor and delivery for
signs and symptoms of:
• Severe abruptio-persistent uterine contractions Abruptio placentae accounts for approximately 15 per-
• Shock out of proportion to blood loss cent of all perinatal deaths.
• Rigid, tender, localized uterine pain, and tetanic con-
tractions
• Bright red bleeding without pain Placenta previa occurs in 0.005 percent of pregnancies
but has a reoccurrence rate of 4 to 8 percent.
Carefully monitor for uterine involution and signs and Subinvolution, retained products of conception, uterine
symptoms of bleeding during delivery and postpartum. atony, and lacerations of the birth canal are the leading
causes of postpartum hemorrhage.
Mental Health
The nursing actions for this diagnosis in the mental health client are the same as those for Adult Health.
(care plan continued on page 176)
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176 • Nutritional–Metabolic Pattern
Gerontic Health
● N O T E : See interventions for Adult Health. Older adults are at risk for this diagnosis
as a result of aging changes that affect the ability to respond to volume changes. Renal
system changes make responses to volume overload or depletion difficult. Older adults
experience a delayed response to a decrease in sodium and are at higher risk for volume
depletion. A delay in the ability to excrete salt and water leads to an increased risk for
fluid overload and hyponatremia. Postoperatively, the older adult may have excessive or
prolonged aldosterone/ADH responses, causing difficulty eliminating excess fluids.
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Hyperthermia • 177
3. Hyperthyroidism
or until administration of medications such as Tylenol
4. Any disease leading to dehydration (e.g., diarrhea, vom- and aspirin show a definitive effect on the elevation.
iting, hemorrhage)
5. Any condition causing pressure on the brainstem Hypothermia
6. Heat stroke Hypothermia means the patient’s body temperature is
subnormal. This indicates the exact opposite meas-
✔ Have You Selected the Correct Diagnosis? urement from Hyperthermia.
Ineffective Thermoregulation
Ineffective Thermoregulation indicates that the TARGET DATES
patient’s body temperature is fluctuating between Because hyperthermia can be life-threatening, initial target
being elevated and being subnormal. In Hyperthermia, dates should be in terms of hours. After the patient has
the temperature does not fluctuate; it remains elevated
demonstrated some stability toward a normal range, the tar-
until the underlying cause of the elevation is negated
get date can be increased to 2 to 4 days.
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178 • Nutritional–Metabolic Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide health-care teaching, beginning on admission, Relieves anxiety and allows the patient and family to par-
regarding: ticipate in care. Initiates home care planning.
• Need for frequent temperature checks
• Related medical or nursing care
• Safety needs when using ice packs or electric cooling
blanket
• How family can assist in care
• Importance of hydration
• Possible fear or altered comfort of patient with fever
because of discomfort, fast heart rate, dizziness, and
general feeling of illness
• Possible seizure activity
Carry out appropriate infection control process, in the Prevents spread of infection.
event or potential event of infectious disease, according
to actual or suspected organisms.
Assist in obtaining specimens for culture. Assists in identifying potential causative source.
Assist in promoting a quiet environment. Allows for essential sleep and rest.
Hyperthermia causes increased metabolic rate.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor temperature every 30 minutes until temperature Frequent assessment per tympanic (aural) thermometer or
stabilizes. as specified provides cues to evaluate efficacy of treat-
• In malignant hyperthermia secondary to response to ment and monitors underlying pathology.
anesthetic agent such as halothane, prevention includes
pre-operative assessment for family history, but risk is
still present with each successive surgery.
Administer antipyretic, antiseizure, or antibiotic medica- Unique components for each individual patient must be
tions as ordered with precaution for: considered within usual treatment modalities to help
• In diagnosed malignant hyperthermia, dantrolene or bring safe and timely return of temperature while
similar agent will be given. avoiding iatrogenic complications.
• Maintenance of IV line
• Drug safe range for the child’s age and weight
• Potential untoward response
• IV compatibility
• The infant’s or child’s renal, hepatic, GI status and risk
for cardiac arrhythmias secondary to tachycardia
Provide padding to siderails of crib or bed to prevent Protection from injury in likelihood of uncontrolled sud-
injury in event of possible seizures. den bodily movement serves to protect the patient from
further problems. Uses universal seizure precautions.
Ensure that airway maintenance is addressed by appropri- As a part of seizure activity, there is always the potential
ate suctioning and airway equipment according to age. of loss of consciousness with respiratory involvement.
During acute phase of treatment, as applicable, recogniz- Regular and timely informative updates alleviate fears
ing need for cooling blanket, gastric lavage, and possi- and assist family in coping.
ble cardiopulmonary bypass, assist in explaining
procedures to family and provide updates on child’s
status on a regular basis.
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Hyperthermia • 179
Women’s Health
● N O T E : Women’s Health will have the same nursing actions and rationales as Adult
Health, Gerontic Health, and Psychiatric Health, except for the following: (Newborn is
included with Women’s Health because newborn care is administered by nurses in
mother-baby units.)
ACTIONS/INTERVENTIONS R AT I O N A L E S
When under heat source or bililights, monitor the infant Provides safe environment for the infant.
every hour for increased redness and sweating. Check
heat source at least every 30 minutes (overhead, iso-
lettes, or bililights).
Monitor the infant’s temperature, skin turgor, and Provides essential information as to the infant’s current
fontanels (bulging or sunken) for signs and symptoms status and promotes a safe environment for the infant.
of dehydration every 30 minutes while under heat
source. First temperature measurement should be rec-
tal; thereafter can be axillary.
Check for urination; the infant should wet at least six dia- Basic monitoring of the infant’s physiologic functioning.
pers every 24 hours.
Replace lost fluids by offering the infant breast, water, or Decreases insensible fluid loss and maintains body tem-
formula at least every 2 hours on [odd/even] hour. perature within normal range. This action decreases the
infant’s needs for IV glucose.
Pregnancy: Provides safe environment for the mother and prevents
• Teach the patient to avoid use of hot tubs or saunas. injury to the fetus.
• During first trimester: Concerns about possible CNS
defects in fetus and failure of neural tube closure.69
• During second and third trimesters: Concerns about
cardiac load for mother.69
• Provide cooling fans for mothers during labor and for
patients on MgSO4 therapy.
• Keep the labor room cool for the mother’s comfort.
Mental Health
Adult Health plan of care provides the foundation care of the mental health client with the following considerations:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor clients receiving neuroleptic drugs for decreased Clients who are receiving neuroleptic medications are at
ability to sweat by observing for decreased perspiration risk for developing neuroleptic malignant syndrome,
and an increase in body temperature with activity, which can be life-threatening.65
especially in warm weather. Monitor these clients for
hyperpyrexia (up to 107⬚F). Notify physician of alter-
ations in temperature. Note alteration in the client’s
plan of care and initiate the following actions:
• The client should not go outside in the warmest part of
the day during warm weather.
• Maintain the client’s fluid intake up to 3000 mL every
24 hours by (this is especially important for clients
who are also receiving lithium carbonate; lithium levels
should be carefully evaluated):
• Having client’s favorite fluids on the unit.
• Having the client drink 240 mL (8-ounce) glass of
fluids every hour while awake, and 240 mL with each
meal. If necessary, the nurse will sit with the client
while the fluid is consumed.
(care plan continued on page 180)
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180 • Nutritional–Metabolic Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Maintaining record of the client’s intake and output.
• Dress the client in light, loose clothing.
• If the client is disoriented or confused, provide one-to- High fevers can alter mental status and thus decrease the
one observation. client’s ability to make proper judgments.
Decrease the client’s activity level by: Increased physical activity increases body temperature,
• Decreasing stimuli and the decreased ability to sweat, secondary to med-
• Sitting with the client and talking quietly, or involving ications, inhibits the body’s normal adaptive
the client in a table game or activity that requires little response.65
large muscle movement. [Note activities that that client
enjoys here.]
• Assigning room near nurse’s station and dayroom areas
Monitor the client’s mental status every hour.
Do not provide clients with alteration in mental status
with small electrical cooling devices unless they
receive constant supervision.
Give the client as much information as possible about his
or her condition and measures that are implemented to
decrease temperature.
Teach the client and family measures to decrease or elim-
inate risk for hyperthermia. (See Home Health for
teaching information.)
Consult with appropriate assistive resources as indicated.
Gerontic Health
● N O T E : Normal changes of aging may alter the older client’s experience of hyperther-
mia. Older clients may exhibit diminished sweating and a diminished sensory perception
of heat. Thus, careful assessment is essential in older clients.
In addition to the interventions for Adult Health, the following may be utilized for the aging client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Facilitate the client’s maintenance of adequate hydration, Primary prevention.
especially during periods of infection, activity, or heat.
Teach the client symptoms of heat cramps: Allows for early recognition and prevents complications.
• Painful musculoskeletal cramps and spasms
• Tender muscles
• Moist skin
• Normal or slightly elevated body temperature
For clients with heat cramps, provide oral saline solution, Prevents complications.
and rest in a cool place.
Teach the client symptoms of heat syncope: Allows for early recognition and prevents complications.
• Sudden episode of unconsciousness
• Weak pulse
• Cool and moist skin
For clients with heat syncope, place the client in a recum- Prevents complications.
bent position, provide oral or IV fluids, and allow for
rest in a cool place.
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Hyperthermia • 181
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach clients symptoms of heat exhaustion: Allows for early recognition and prevents complications.
• Thirst
• Fatigue
• Nausea
• Reduced urine output
• Giddiness or delirium
For clients with heat exhaustion, allow for rest in a cool Prevents complications.
environment, and replace fluids with saline solution
(oral or IV).
Teach clients/caregivers signs of heat stroke: Signifies the need for emergency interventions.
• Absence of sweating
• Loss of consciousness
For clients with heat stroke, access emergency services Prevents further complications.
immediately, remove excess clothing, and cool the
client rapidly (cold water immersion, ice packs, tepid
water spray, fans) without inducing shivering.
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182 • Nutritional–Metabolic Pattern
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Copyright © 2007 by F. A. Davis. •
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Hypothermia • 183
ACTIONS/INTERVENTIONS R AT I O N A L E S
Address skin protective needs by frequent monitoring for Hypothermia causes peripheral vasoconstriction, which
breakdown or altered circulation. leads to a risk for impaired skin integrity.
Monitor respiratory rate, depth, and breath sounds every Hypothermia and its related factors promote the develop-
hour. Provide for airway suctioning and positioning as ment of respiratory complications.
needed.
Bathe with appropriate protection and covering. Prevents heat loss.
Devote appropriate attention to prevention of major com- Awareness of the complications of hypothermia will help
plications such as shock, cardiac failure, tissue necro- prevent the complication.
sis, infection, fluid and electrolyte imbalance,
convulsions or loss of consciousness, respiratory fail-
ure, and renal failure.
Administer medications as prescribed.
Monitor effects of medication, and record within 30 min- Assists in monitoring effectiveness of therapy.
utes after administration.
Obtain a detailed history regarding:
• Onset
• Related trauma and causative factors
• Duration of hypothermia
Provide opportunities for the patient and family to ask Decreases anxiety and facilitates home care teaching.
questions and relay concerns by including 30 minutes
for this every shift. [Note times here.]
Allow for appropriate attention to resolution of psycho- Helps in reducing patient’s anxiety, and facilitates
logical trauma, especially in instances of severe expo- patient’s resolving lingering effects of trauma.
sure to cold at least once per shift. [Note times here.]
Teach the patient and family measures to decrease or Permits the patient to participate in self-care, and pro-
eliminate the risk for hypothermia, to include: motes compliance to prevent future episodes.
• Wearing appropriate clothing when outdoors
• Maintaining room temperature at minimum of 65⬚F
• Wearing clothing in layers
• Covering the head, hands, and feet when outdoors
(especially the head)
• Removing wet clothing
Teach the patient about the kinds of behavior that
increase the risk for hypothermia:
• Drug and alcohol abuse
• Working, living, or playing outdoors
• Poor nutrition, especially when body fat is reduced
below normal levels as in anorexia nervosa
Teach the patient and family signs and symptoms of early
hypothermia:
• Confusion, disorientation
• Slurred speech
• Low blood pressure
• Difficulty in awakening
• Weak pulse
• Cold stomach
• Impaired coordination
Make appropriate arrangements for follow-up after dis- Fosters resources for long-term management in terms of
charge from hospital. Identify support groups in the adequate housing, financial resources, and social
community for the patient and family. habits.
Consult with appropriate assistive resources as indicated: Promotes effective long-term management and prevention
of future episode.
(care plan continued on page 184)
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184 • Nutritional–Metabolic Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Obtain an energy audit by public service company to
identify possible sources of heat loss.
• Refer the patient to social services to provide informa-
tion on emergency shelters, clothing, and food banks.
• Recommend financial counseling if heating the home is
financially difficult.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for level of involvement according to history and Treatment is determined by level of involvement with
contributing factors, and address client’s initial stabi- anticipatory planning to restore normal homeostasis.
lization as appropriate.
• During the immediate treatment phase, the infant or
child may require intensive care to include assisted
ventilation and cardiac and renal monitoring as stabi-
lization is achieved.
Provide for maintenance of body temperature by hat Heat loss is greatest via the head in young infants, as well
(stockinette for infant) and using open radiant warmer, as by convection and evaporation. Suitable mainte-
isolette, or heating blanket. nance of temperature by appropriate equipment helps
maintain neutral body core temperature.
Incorporate other health-care team members to address Provision of support for long-term follow-up places value
collaborative needs. on the need for care and the importance of compliance.
Assists in reducing anxiety.
Monitor for knowledge needs and provide teaching to Serves to establish foundation of trust, and provides
address unknown and necessary information for the essential basis for follow-up care.
child and family in developmentally appropriate terms
(e.g., temperature measurement).
Anticipate safety needs according to the patient’s age and Each opportunity for reinforcing the importance of safety
development status. [Note adaptations necessary to as a part of well-child follow-up should not be over-
meet safety needs here.] looked. Emphasize caution with rectal thermometer to
prevent trauma to anal sphincter and tissue, and cau-
tion the family regarding the use of mercury-glass ther-
mometer and breakage. If electronic equipment is used,
emphasize the importance of protection to skin, con-
stant surveillance, and unique safety needs per manu-
facturer.
Teach caregiver(s) preventive measures to decrease likeli- Assists in ensuring careful consideration of dangers of
hood of recurrence, especially related to minimizing cold exposure for infants and children.
cold exposure with use of clothing appropriate to the
season such as suitable bunting and snowsuits in cold
climates.
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Hypothermia • 185
Women’s Health
Newborn
● N O T E : This nursing diagnosis pertains to the woman the same as to any other man.
The reader is referred to the other sections for specific nursing actions pertaining to
women and hypothermia. Infants control their body temperature with nonshivering ther-
mogenesis; this process is accompanied by an increase in oxygen and calorie consump-
tion. Therefore, use of a radiant warmer or prewarmed mattress for initial care provides
environmental heat giving rather than heat losing. However, it is important to note that
hypothermia and cold stress in the neonate are related to the amount of oxygen needed
by the infant to control apnea and acid–base balance. It is estimated that to replace a
heat loss during a temperature drop of 6.3⬚F, the infant requires a 100 percent increase
in oxygen consumption for more than 11/2 hours. Metabolic acidosis can occur quickly if
the infant becomes hypothermic.5
ACTIONS/INTERVENTIONS R AT I O N A L E S
To prevent hypothermia in the newborn: Prevention of heat loss in the infant reduces oxygen and
• Dry the new infant thoroughly. calorie consumption and prevents metabolic acidosis.
• Cover with blanket.
• Lay next to the mother (cover the mother and the infant Skin-to-skin contact with the mother is absolutely the
by placing the blanket over them). best method of producing and maintaining the infant’s
• Place the infant under a radiant heat source. thermal balance.
• Keep the infant and mother out of drafts.
Observe the infant for hypothermia. Check temperature
every hour until stable, then every 4 hours times 4,
then once a shift in the hospital. Do not use rectal ther-
mometers; take newborn temperatures by axilla or skin
probe (continuous probe).
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the client’s mental status every 2 hours [note Antipsychotic and antidepressant medications can alter
times here]; report alterations to the physician. thermoregulation, which results in hypothermia.65
If the client is receiving antipsychotics or antidepressants,
report this to the physician when the alteration is first
noted.
Protect the client from contact with uncontrolled hot
objects such as space heaters and radiators by teaching
clients and family to remove these from the environment.
Allow the client to use heating pads and electric blankets Basic safety measures.
only with supervision.
Teach the client the potential for medication to affect
body temperature regulation, especially in the elderly.
Gerontic Health
● N O T E : Aging clients may experience a diminished sensory perception of tempera-
tures. Other normal changes of aging such as inefficient vasoconstriction, decreased car-
diac output, decreased subcutaneous tissue, and decreased shivering may contribute to
the development of hypothermia in the aging client.
(care plan continued on page 186)
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186 • Nutritional–Metabolic Pattern
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized for the aging client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach caregivers to recognize the stages of hypothermia: Older clients may not verbalize typical symptoms of
Early—no feeling of cold, temperature lower than usual hypothermia owing to a decreased sensory perception
baseline of temperatures. Regular and frequent assessment of
Mid—impaired mental functioning, slurred speech, client status during high-risk times is essential.
slowed or irregular pulse, diminished tendon reflexes,
slow and shallow respirations
Late—rapid progression of hypothermia, muscular rigid-
ity, diminished urinary output, stupor, coma, cool and
pink skin
Monitor temperature frequently and regularly. Establishes a baseline and allows for early identification
of changes.
Use warming blankets with caution. Warming blankets may be effective but should be moni-
tored closely, as clients may not verbalize or experi-
ence possible hyperthermia that may result.
Utilize warmed IV solutions as appropriate. Prevention of complications or further hypothermia.
Utilize cardiac monitoring in high-risk clients. Older clients may experience dysrythmias secondary to
hypothermia.
For late-stage hypothermia, consider core rewarming Prevention of further complications.
techniques such as cardiac bypass.
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Infant Feeding Pattern, Ineffective • 187
3. Thrush
Imbalanced Nutrition, Less
4. Hydrocephalus Than Body Requirements
5. Any condition that would require major surgery immedi- Certainly this diagnosis could be the result of Ineffective
ately after birth Infant Feeding Pattern if the feeding problem is not
remedied. However, correction of the primary problems
✔ Have You Selected the Correct Diagnosis? would prevent the development of this diagnosis.
Ineffective Breastfeeding
With this diagnosis, the infant is able to suckle and EXPECTED OUTCOME
swallow, but there is dissatisfaction or difficulty
with the breastfeeding process. The key difference Will demonstrate normal ability to suck-swallow by [date].
would be based on the defining characteristics of
Ineffective Breastfeeding versus Ineffective Infant TARGET DATES
Feeding Pattern. If the infant demonstrates prob- This diagnosis would be life-threatening; therefore, progress
lems with initiating, sustaining, or coordinating
should initially be evaluated every few hours. After the infant
sucking, swallowing, and breathing, then Ineffec-
tive Infant Feeding Pattern is the most appropriate
has begun to exhibit at least some sucking-swallowing, then
diagnosis. the target date can be moved to every 2 days, as improvement
is made.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for all possible contributory factors: A thorough assessment and monitoring serves as the criti-
• Actual physiologic sucking potential cal basis for appropriately individualizing and prioritiz-
• Other objective concerns (e.g., swallowing or respira- ing a plan of health care.
tory)
• Objective history data (e.g., prematurity or congenital
anomalies)
• Maternal or infant reciprocity and degree to which
the mother tunes in to infant’s cues for readiness
for feeding
• Subjective data from the caregivers or parents
Provide anticipatory support to the infant for respira- Airway maintenance is a basic safety precaution for this
tory difficulties that could increase the probability infant. Airway and suctioning equipment are standard.
of aspiration. (See nursing actions for Risk for Aspiration.)
Ascertain the most appropriate feeding protocol for the A realistic yet holistic approach provides a foundation for
infant with attention to: multidisciplinary management with best likelihood for
success.
• Nutritional needs according to desired weight gain Specific criteria provide measurable progress parameters.
• Actual feeding mode (i.e., modified nipple, larger hole
nipple, syringe adapted for feeding, position for feed-
ing, or gastric tube)
(care plan continued on page 188)
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188 • Nutritional–Metabolic Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Health status and prognosis
• Compliance factors
• Socioeconomic factors
• Maternal–infant concerns
Explore the feelings the caregivers or parents have related Often the expression of feelings reduces anxiety and may
to the Ineffective Feeding Pattern. allow further potential alterations to be minimized by
early intervention.
Strictly monitor and calculate intake, output, and caloric Caloric intake and hydration status are indirectly and
count on each shift, and total each 24 hours. directly used to monitor the infant’s progress in toler-
ance of feeding and feeding efficacy.
Weigh the infant daily or more often as indicated. Weight gain would serve as a major indicator of effective
feeding and assist in assessment of hydration.
Collaborate with other health-care professionals to better A multidisciplinary approach is most effective in level
meet the infant’s needs. and cost of care.
Allow for appropriate time to prepare the infant for feed- A nonhurried, nonstressful milieu promotes the infant’s
ing, and provide a calm, soothing milieu. relaxation and allows the infant to perceive feeding as
a pleasant experience.
Facilitate family to participation in feeding and plans for Inclusion of the family empowers the family and aug-
feeding. ments their self-confidence and coping.
Provide teaching based on an assessment of parental Knowledge provides a means of decreasing anxiety.
knowledge needs and/or deficits. [Note teaching plan When based on assessed needs, it will reflect the indi-
here.] vidualized needs and more likely meet the parents’
learning needs.
Allow for time to clarify feeding protocols, questions, Appropriate attention to questions and concerns the par-
and discharge planning. Schedule follow-up with lacta- ents may have assists in reducing anxiety, thereby
tion specialist as needed. allowing for learning and a greater likelihood of adher-
ence to the therapeutic regimen.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide support and information to the mother and signif- The basic rationale for all the nursing actions in this diag-
icant other. Explain the infant’s inability to suck, and nosis is to provide nutrition to the infant in the most
provide suggestions and options (based on etiology of appropriate, cost-effective, and successful manner.
sucking problem) to correct or reduce the prob-
lem.50,53,70–73
Describe the anatomy and physiology of sucking to the Assists in decreasing anxiety, provides a base for teach-
mother. ing, and permits long-range planning.
Explain importance of positioning for both bottle- and Encourages proper suckling by the infant.
breastfeeding.71–73
Provide support and supervision to assist the mother in
encouraging the infant to suck properly.
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Nausea • 189
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the mother and family to assess appropriate intake Ensures that the infant is getting enough nutrition and is
by observing the infant for at least six to eight wet dia- not becoming dehydrated.50,53,71
pers in 24 hours (after milk has come in).
If necessary, provide supplemental nutrition system while Pays attention to basic nutrition while also attending to
teaching the infant to suck (e.g., dropper, syringe, problem with sucking.
spoon, cup, or supplementation device).74,75
Refer the mother to lactation consultant or clinical nurse
specialist for assistance and support in teaching the
infant to suck.
Assist the mother and significant others to choose feeding Provides basic support to encourage essential nutrition.
system for the infant (breast, bottle, cup, or tube) that
will supply best nutrition.
Mental Health
This diagnosis would not be used in Mental Health.
Gerontic Health
This diagnosis is not appropriate for the aging patient.
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190 • Nutritional–Metabolic Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for all possible contributory factors including: A thorough assessment provides the most appropriate
• Actual physiologic components (electrolyte imbal- base of data for individualized care.
ances, history of cancer, altered metabolic status,
bilirubin elevations, increased intracranial pressure,
gastrointestinal irritation/deviations, etc.)
• Potential pharmacologic agents (chemotherapy agents,
medications, or allergens)
• Emotional concerns of the client and family or signifi-
cant others
• Subjective data from all who have influence in the care
of the client
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Nausea • 191
ACTIONS/INTERVENTIONS R AT I O N A L E S
Identify the pattern of nausea, including known precedent A thorough assessment of the pattern assists in individu-
auras or sensations, triggering stimuli, correlation of alization of care with the intent of remaining open to
stimuli to perception of nausea or suggestion of nau- ongoing priorities, as well as the identification of other
sea, physical signs and symptoms noted, length of nursing problems.
duration of symptoms, factors noted to ameliorate per-
ceived nausea, and ongoing effects nausea exerts.
Develop a plan for dealing with nausea with an element of An individualized plan of care with specific needs
ongoing monitoring every 1 hour, or more often as addressed will best afford successful management
needed, for goal of lessening of perceptions or suggested of nausea.
nausea if the client is unable to express sensations.
• Note signs and symptoms suggestive of nausea.
• Correlate signs and symptoms with other sensations,
stimuli, or events.
• Identify measures to alleviate perceived sensation of
nausea, such as cold cloth on forehead, administration
of antiemetics, or other specific antinausea medications.
• Provide a therapeutic milieu to promote rest. Eliminate
noxious stimuli of noise, odors, and light. Maintain
room temperature at a comfortable and steady level.
• Determine the need for presence of the parent or signif-
icant other to provide a sense of security for the infant
or child. [Note client-specific management plan here.]
Collaborate with other health professionals as needed to A multidisciplinary approach offers the most inclusive
best address needs for the client and family. and cost-effective approach for care.
Offer developmentally appropriate coping mechanisms to Appropriate developmental approach is critical to success
enhance the child’s sense of self-worth and likelihood in creating the best effort for self-worth of the infant or
of cooperation. child and the parent.
Women’s Health
The nursing actions for this diagnosis are the same as for Adult Health.
Mental Health
The nursing actions for this diagnosis in the mental health client are the same as those in Adult Health.
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized for the aging client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Carefully assess fluid and volume status frequently and Nausea, even in the absence of vomiting, may lead to
regularly. fluid and electrolyte imbalances as the client may avoid
any oral intake when nauseated. Older clients are at
increased risk for fluid and volume status imbalances.
Consider dietary modifications as appropriate to include: Reduces exposure to factors that may contribute to
• Small frequent meals nausea.
• Reduced fat content
• Avoidance of indigestible or partially indigestible
materials
• Avoiding carbonated beverages
(care plan continued on page 192)
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192 • Nutritional–Metabolic Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Consider antiemetic agents or prokinetic agents as appro- Pharmacologic therapy, when given as prescribed, can
priate. alleviate existing nausea and prevent further episodes.
Review the older adult’s medications to determine Many drugs taken by older adults, such as opioids, anti-
whether GI problems are noted as a side effect.23 depressants, and anticholinergics, have nausea as a side
effect.84
Determine whether the older adult is using herbs (aloe, Using large amounts of herbal laxatives may cause
senna, cascara) to alleviate problems with constipation. nausea.85
Discuss with the client, if noted, stress effects on the GI Stress can lead to reductions in peristalsis and digestive
system, and assist the client with relaxation strategies enzymes and cause nausea, anorexia, abdominal dis-
as needed to reduce stress. tention, or vomiting.57
Monitor the infusion rate of tube feeding, if present, to Rapid feeding rates can produce nausea.86
prevent rapid feeding.
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Nutrition, Readiness for Enhanced • 193
TARGET DATES
RELATED CLINICAL CONCERNS
Client education and support are key interventions for
1. New diagnoses that would necessitate nutritional alter- Readiness for Enhanced Nutrition. Since the client is
ations, such as Diabetes. already demonstrating positive behaviors, it is recom-
2. Treatments that require alterations in nutrition mended that target dates be no further than 3 days from the
3. Developmental change in nutritional needs. date of initial diagnosis.
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Copyright © 2007 •by F. A. Davis.
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194 • Nutritional–Metabolic Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for all contributory factors, especially reasons for Offers the fullest database for consideration of a plan that
disruption in usual nutrition pattern, such as surgery, is individualized.
illness, or other.
Determine the ability of the caregiver to provide feedings Offers anticipatory guidance for prevention of inability to
as determined by schedule and type, especially if for- follow regimen.
mula is difficult to obtain or costly.
Refer to community resources for nutritional assistance, Provides resources for the essential plan.
i.e., WIC. [Note referral information here.]
Teach the caregiver when and how to weigh infant or Provides anticipatory support to boost the confidence of
young child, and when to notify primary care physician the caregiver.
or pediatrician.
Teach the caregiver about the importance of a calm envi- Assists in creation of a stress-free environment to facili-
ronment during feedings and about providing adequate tate normal digestive processes.
rest periods.
Women’s Health
Nursing actions for this diagnosis are the same as those for Adult Health.
Mental Health
Nursing actions for this diagnosis are the same as those for Adult Health.
Gerontic Health
Nursing actions for this diagnosis are essentially the same as those for Adult Health and Home Health.
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Nutrition, Imbalanced, Less Than Body Requirements • 195
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Copyright © 2007 •by F. A. Davis.
•
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196 • Nutritional–Metabolic Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Administer appropriate medications 30 minutes before
meals (e.g., analgesics or antiemetics); record effects of
medications within 30 minutes of administration.
Provide a rest period of at least 30 minutes prior to meal. Conserves energy for feeding self and digestion.
Provide an environment that entices the patient to eat and
facilitates the patient’s eating:
• Reduce noxious stimuli.
• Open all food containers and release odors outside the
patient’s room.
• Raise the head of bed.
• Open carton and packages.
• Cut food into small, bite-size pieces.
• Provide assistive devices (e.g., large-handled spoon or
fork, all-in-one utensil, or plate guard).
Offer small, frequent feedings every 2 to 3 hours rather Three large meals a day give a sense of fullness, and the
than just three meals per day. Allow the patient to size of servings may be overwhelming to the patient.
assist with food choices and feeding schedules. Smaller meals facilitate gastric emptying, thus promot-
ing a larger food intake overall.
Offer between-meal supplements. Focus on high-protein Provides additional caloric intake. Providing high-protein
diet and liquids. foods and fluids helps prevent muscle-tissue loss.
Encourage significant others to bring special food from Familiar food promotes appetite and empowers the
home. patient and family in regard to the diet. Allows an
opportunity for teaching diet.
Maintain calorie count with every meal. Review daily Monitors goal attainment or identifies areas for improve-
intake. ment.
As goal weight is achieved, allow patient to increase Stimulates appetite.
physical activity. Coordinate with physical/occupa-
tional therapy.
Monitor: Allows early detection of complications, and assists in
• Vital signs every 4 hours while awake at [state times monitoring effectiveness of therapy.
here] and as required based on measurement results
• Airway, sensorium, chest sounds, bowel sounds, skin
turgor, mucous membranes, bowel function, urine spe-
cific gravity, and glucose level at least once per shift
• Laboratory values (e.g., electrolyte levels, hematocrit,
hemoglobin, blood glucose, serum albumin, and total
protein)
Make sure intake and output is balancing at least every Ensures that weight gain is not due to fluid retention.
72 hours.
Weigh daily at [state time] and in same-weight clothing. Assesses effectiveness of therapy and interventions.
Have the patient empty bladder before weighing. Teach Promotes the patient’s control of weight after dis-
the patient this routine for continued weighing at charge.
home.
Provide frequent positive reinforcement for:
• Weight gain
• Increased intake
• Using consistent approach
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Nutrition, Imbalanced, Less Than Body Requirements • 197
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the patient and significant others: Provides essential information needed to prevent future
• Balanced diet based on the dietary recommendations episodes.
• Role of diet in health (e.g., healing, energy, and normal
body functioning)
• How to keep food diary with calorie count
• Adding spices to food to improve taste and aroma
• Use of exchange lists
• Relaxation techniques
Teach patient strategies that lend to success of goal:
• Encourage the patient to eat slowly. Facilitates the digestion process.
• Avoid gas-producing foods and carbonated beverages. Gas-producing foods promote nausea and a feeling of
fullness.
• Allow rest periods of at least 30 minutes after feeding. Facilitates digestion and reduces stress.
Educate the patient on consuming nutrient-dense foods.
Refer, as necessary, to other health-care providers. Provides ongoing support for long-term care.
ADDITIONAL INFORMATION tube feedings or total parenteral nutrition will become nec-
essary. In addition to the nursing actions for the overall nurs-
There will be situations in which the patient’s nutritional ing diagnosis of Imbalanced Nutrition, Less Than Body
condition has progressed or clinical situation warrants that Requirements, the following actions should be added:
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Copyright © 2007 •by F. A. Davis.
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198 • Nutritional–Metabolic Pattern
Child Health
● N O T E : This diagnosis represents a long-term care issue. Therefore, a series of sub-
goals of smaller amounts of weight to be gained in a lesser period of time may be neces-
sary. Long-term goals are still to be formulated and revised as the patient’s status
demands. Also, there will undoubtedly be instances in which overlap may exist for other
nursing diagnoses. Specifically, as an example, in the instance of an alteration in nutri-
tion related to actual failure to thrive, one must refer to appropriate role performance on
the part of the mother with consideration for holistic nursing management. It would be
most critical to include a few specific nursing process components to reflect the critical
needs for the mother–infant dyad.
Adult health interventions can be utilized as indicated with the following considerations:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine all contributory factors, especially underlying Variable degrees of involvement will demand appropriate
malabsorptive conditions secondary to congenital anom- follow-up to consider the fullest needs for nursing
alies. intervention.
*Short bowel syndrome may constitute a long term need
for treatment with in-depth teaching needs.
Feed the infant on a regular schedule that offers nutrients The stomach capacity and digestive concerns for each
appropriate to metabolic needs. For example, an infant patient must be considered to realistically plan for
of less than 5 pounds will eat more often, but in lesser weight gain over a slow, steady, incremental time
amounts (2 to 3 ounces every 2 to 3 hours) than an frame.
infant of 15 pounds (4 to 5 ounces every 3 to 4 hours).
Assist or feed the patient: Appropriate attention to aesthetic, physical, and emo-
tional details related to feeding helps provide the opti-
mal potential for pleasant, long-lasting eating patterns.
The limitation of psychological and emotional duress
cannot be overemphasized, and must be considered in
each parent–child unit.
• Elevate the head of bed, or place the infant in infant Facilitates digestion and provides interactive times for
seat, and older infant or toddler in high chair with caregiver(s) and infant or young child.
safety belt in place. If necessary, hold the infant. (This
will be dictated in part by the patient’s status and pres-
ence of various tubes and equipment.)
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Help the patient wash hands. For infants and toddlers, Prevents risk of infection.
administer diaper change as needed.
• Warm foods and formula as needed, and test on wrist Safety for potential hyperthermic injury.
before feeding the infant or child.
• Provide aids appropriate for age and physical capacity Favors self-care according to developmental capacity.
as needed, such as two-handed cups for toddlers,
favorite spoon, or Velcro strap for utensils for child
with cerebral palsy.
• Offer small, age-appropriate feedings with input from Offers the family input to best meet the child’s need and
family members regarding the child’s preferences. likelihood for adequate nutrition.
• Encourage the patient to eat slowly and to chew food Assists in tolerance of feeding.
thoroughly. For infant, bubble before, during, and after
feeding.
Role-model for parents, in a nonthreatening, nonjudg- Nonthreatening role-modeling and personal encourage-
mental manner, feeding an infant or child. ment foster compliance and lessen anxiety.
Weigh the patient on same scale and at same time [state Weight gain serves as a critical indicator of efficacy of
time here] daily. Weigh infants without clothes, older treatment. Maintaining consistency in weighing lessens
children in underwear. the number of potential intervening variables that
would result in an inaccurate weight.
Teach the patient and family:
• Balanced diet appropriate for age using basic food
groups
• Role of diet in health (e.g., healing, energy, and normal
body functioning). If the infant is medically diagnosed
as Failure to Thrive, offer appropriate emotional sup-
port and allow at least 30 minutes three times a day
[state times here] for exploring dyad relationships
• How to use spices and child-oriented approach in
encouraging the child to eat (e.g., peach fruit salad,
with peach as a face, garnished with cherries and raisins
for eyes and nose, half of a pineapple round for mouth)
• Monitoring for possible food allergies, especially in
toddlers with history of allergies
• How to weigh self appropriately, if applicable, or for
parents to weigh the child
Provide positive reinforcement as often as appropriate for Reinforcement of desired behaviors fosters long-term
the parents and child, demonstrating critical behavior. compliance, thereby empowering the family with satis-
faction and confidence for ultimate self-care manage-
ment with minimal intervention by others.
Women’s Health
● N O T E : Poverty and substance abuse are often associated with nutritional deficits.
Remember that underweight women who are pregnant will exhibit a different pattern of
weight gain than normal-weight women. This difference exhibits a rapid weight gain at
the beginning of the first trimester of about 1 pound per week by 20 weeks. In the under-
weight woman, weight gain can be as much as 18 to 20 pounds. Remember to teach the
parents signs and symptoms of weight loss in the neonate.49
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collaborate with the dietitian in planning and teaching Gives baseline from which to plan better nutrition.
diet:
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200 • Nutritional–Metabolic Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Emphasize high-quality calories (cottage cheese, lean
meats, fish, tofu, whole grains, fruits, and vegetables).
• Avoid excess intake of fats and sugar.
• Assist the patient in identifying methods to keep
caloric intake within the recommended limit.
Verify pre-pregnant weight. Assist in planning realistic diet changes within the
patient’s means and according to the patient’s particu-
lar needs and habits.
Determine whether weight loss during first trimester is
due to nausea and vomiting.
Check activity level against daily dietary intake.
Check for food intolerances.
Check environmental influences:
• Hot weather
• Cultural practices
• Pica eating
• Economic situation
• Ascertain economic status and ability to buy food
• Monitor woman’s emotional response to the pregnancy
and to additional weight gain
● N O T E : Dieting is never recommended during pregnancy because it deprives the
mother and fetus of nutrients needed for tissue growth, and because weight loss is
accompanied by maternal ketosis, a direct threat to fetal well-being.5,62
Identify additional caloric needs and sources of those
calories for the nursing mother.89,90
• An additional 500 calories/day above normal dietary
intake is needed to produce adequate milk (depending
on the individual, a total of 2500 to 3000 calories/day).
• Additional fluids are necessary to produce adequate
milk.
Collaborate with nutritionist to provide a health dietary Provides basis for ensuring good nutrition, and assists in
pattern for the lactating mother. successful breastfeeding.
Monitor the mother’s energy levels and health mainte-
nance:
• Does she complain of fatigue?
• Does she have sufficient energy to complete her daily
activities?
• Does the dietary assessment show irregular dietary
intake?
• Is she more than 10 percent below the ideal weight for
her body stature?
For breastfeeding the newborn or neonate during the first
6 months, teach the mother:
• The major source of nourishment is human milk.
• Vitamin supplements can be used as recommended by
physician:
• Vitamin D
• Fluoride
• If indicated, iron
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ACTIONS/INTERVENTIONS R AT I O N A L E S
The infant should be taking in approximately 420 mL Provides for good nutritional status of the newborn.
daily soon after birth and building to 1200 mL daily at
the end of 3 months.
Monitor for fluid deficit at least daily: Allows early intervention for this problem.
• “Fussy baby,” especially if immediately after feeding
• Constipation (remember breastfed babies have fewer
stools than formula-fed babies)
Weight loss or slow weight gain: Closely monitor the
baby, the mother, and nursing routine:
• Is the baby getting empty calories (e.g., a lot of water
between feedings)?
• Avoid nipple confusion, which results from switching the
baby from breast to bottle and vice versa many times.
• Instruct the mother in “cup feeding” of nursing infant Provides the infant with nutrition, while supporting the
to ensure adequate fluid intake and avoid nipple confu- breastfeeding mother.63
sion.50,54,59
• Count the number of diapers per day (should have six
to eight very wet diapers per day).
• Is there intolerance to mother’s milk or bottle formula?
• Is there illness or lactose intolerance?
• Infrequent nursing can cause slow weight gain.
Mental Health
● N O T E : Because of long-term care requirements for these clients, target dates should
be determined in weeks or months, not hours or days.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Do not attempt teaching or long-term goal setting with Starvation can affect cognitive functioning.91
the client until concentration has improved (symptom
of starvation).
Establish contract with the client to remain on prescribed Provides the client with a sense of control, and clearly
diet and not to perform maladaptive behavior (e.g., establishes the consequences and rewards for behavior.
vomiting or use of laxatives). State specific behavior Weight gain of 2 to 3 pounds/week for inpatient care
and rewards for the client here. and 0.5 to 1 pound/week is reasonable.92
• Plan gradual refeeding with incremental progression
Provide vitamin and mineral supplements as prescribed.
Place the client on 24-hour constant observation (this will Provides consistency and structure during the stressful
be discontinued when the client ends maladaptive early period of treatment.
behavior, or at specific times that nursing staff assess
are low risk).
Place the client on constant observation during meals and Provides support for the client during stressful period.
at high-risk times for maladaptive behavior (such as
1 hour after meals or while using the bathroom). This
action will take effect when the preceding one is dis-
continued.
Do not allow the client to discuss weight or calories. Decreases the client’s abnormal focus on food and pro-
Excessive discussion of food is also discouraged. motes normal eating patterns. This behavior is more
indicative of starvation than an eating disorder.91
Require the client to eat prescribed diet (all food on tray Promotes the client’s sense of control and participation in
each meal except for those three or four foods the decision-making within appropriate limits.
client was allowed to omit in the admission contract).
List the client’s omitted food here.
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202 • Nutritional–Metabolic Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Sit with the client during meals, and provide positive sup- Provides a positive, supportive context for the client.91
port and encouragement for the feelings and concerns
the client may have.
Do not threaten the client with punishment (tube feeding
or IVs).
Report all maladaptive behavior to the client’s primary
nurse or physician for confrontation in individual ther-
apy sessions.
Spend [number] minutes with the client every [number]
minutes to establish relationship.
Respond to queries related to fears of being required to
gain too much weight with reassurance that the goal of
treatment is to return the client to health, and that he or
she will not be allowed to become overweight. Also
reinforce the risks of eating disorder.
Provide the client with information on bingeing and purg- Provides the client with increased information about his
ing and the impact they have on dieting and the body. or her behaviors. Does not impact calorie loss and
destroys the tissue of the upper GI tract.93
If the client vomits, have him or her assist with the Provides natural consequences for behavior.
cleanup, and require him or her to drink an equal
amount of a nutritional replacement drink.
Schedule the client for group therapy (specific encourag- Provides support from peers and a source of honest feed-
ing behavior should be listed here, such as assisting the back.91
client to complete morning care on time or other inter-
ventions that are useful for this client).
Encourage the client’s family by [list specific encourag- Provides support for the family and an opportunity for the
ing behaviors for this family] to attend family therapy family to work through their concerns together.91
sessions.
Assist the client with clothing selection. Clothes should Altered body image makes it difficult for clients to make
not be too loose, hiding weight loss, or too tight, assist- appropriate choices; honest feedback and support from
ing the client to feel overweight even though appropri- the nursing staff makes the transition to “healthy”
ate weight is achieved. choices easier.
Have the client develop a daily food diary that records Assists clients in linking thoughts with behaviors.93
time of day, amount and type of food, and binge or
purge behavior with feelings and thoughts.
When maintenance weight is achieved, assist the client As symptoms of starvation are resolved, the client is bet-
with selection of appropriate foods from hospital ter able to make appropriate choices, and gradual
menu. returning of control prepares the client to accept
responsibility at discharge.91
When maintenance weight is achieved, refer to the
dietitian for teaching about balanced diet and home
maintenance.
When maintenance weight is achieved, refer to occupa-
tional therapist for practice with menu planning,
trips to grocery stores to purchase food, and meal
preparation.
When maintenance weight is achieved, plan passes with Provides further information to the client to assist in
the client for trips to restaurants for meals. maintaining desired weight. Provides visible reward
for weight maintenance.
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Nutrition, Imbalanced, Less Than Body Requirements • 203
ACTIONS/INTERVENTIONS R AT I O N A L E S
Allow the client to exercise [number] minutes [number]
times per day while supervised (this will be altered as
the client reaches maintenance weight).
Allow the client to do the following exercises during the
exercise period. (These are graded to the client’s physi-
cal condition. Consultation with the occupational thera-
pist is useful.)
Allow the client [number] of [number] minute walks on Assists the client in developing realistic goals for exercise
hospital grounds with a staff member each day. according to age and ability.
Meet with family/significant others [number] minutes Family support, education, and therapy improve out-
[number] times per week to discuss positive family comes of eating disorder treatment.92
interactions and support for client. In this meeting
model appropriate communication and develop plan for
responding to the client’s eating patterns. Refer to
nursing actions for Family Processes, Interrupted for
more in depth plan to address family interaction issues.
• Facilitate the development of a specific plan for ongo-
ing care and support after discharge. [Note that plan
here with the names of contact persons.]
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized with the aging client.
● N O T E : National Clinical Guidelines recommend in cases of clients with weight loss
problems, that the client or their proxy have a full discussion of their health-care wishes
with a health-care professional. A discussion of the treatment goals and the resident’s
ongoing quality of life, should be initiated. The decision they make should be docu-
mented. Certain causes of malnutrition may be irreversible.94
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor and record client’s weight each week. Establishes a baseline and allows for early identification
of changes.
Monitor and record client’s hydration status regularly. Establishes a baseline and allows for early identification
Elders should ingest between 1500 and 2000 mL of changes.
per day.94
Ensure environmental conditions at mealtime are con-
ducive to adequate intake:
• Palatable, minimally restrictive diet
• Pleasant, well lit, unhurried mealtimes
• Social environment at mealtime94
For clients with dependency in eating, establish and Recognition of feeding problems and proper feeding tech-
adhere to restorative feeding program.94 niques may improve weight loss in nursing homes.94
Involve family with visits or assistance with feeding at
mealtimes.94
Use calorie-dense foods whenever possible.94
Initiate or maintain an exercise program when appro- Exercise may increase dietary intake.94
priate.94
Offer nutritional supplements between meals and not to To increase dietary intake.94
substitute for calorie intake at meals.94
Evaluate the client for possible depression and treat Depression may be a reversible cause of decreased
accordingly.94 dietary intake.94
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204 • Nutritional–Metabolic Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Consult with a pharmacist to determine drugs that might Drugs have been found to be a cause of weight loss in
be producing anorexia.94 long term care residents.94
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Nutrition, Imbalanced, More Than Body Requirements, Risk For and Actual • 205
3. Reported or observed obesity in one or both parents 5. Any disorder resulting in prolonged immobility
4. Reported or observed higher baseline weight at 6. Metabolic syndrome
beginning of each pregnancy
5. Rapid transition across growth percentiles in infants ✔ Have You Selected the Correct Diagnosis?
or children
6. Pairing food with other activities Deficient Knowledge
7. Observed use of food as reward or comfort measure The patient, because of his or her cultural back-
8. Eating in response to internal cues other than ground, may not know the appropriate food groups
hunger, such as anxiety and the nutritional value of the foods. In addition, the
9. Eating in response to external cues such as time of cultural beliefs held by a patient may not value thin-
day or social situation ness. Therefore, the people of a particular culture may
actually promote obesity.
10. Dysfunctional eating patterns
B. More Than Body Requirements Ineffective Health Maintenance
1. Triceps skin fold greater than 15 mm in men, or 25 Because of other problems, the patient may not be
mm in women able or willing to modify nutritional intake even though
2. Weight 20 percent more than ideal for height and he or she has information about good nutritional pat-
frame terns.
3. Eating in response to external cues such as time of Other Possible Diagnoses
day or social situation Several diagnoses from the psychosocial realm may
4. Eating in response to internal cues other than hunger be the underlying problem that has resulted in Risk for
(e.g., anxiety) or More Than Body Requirements. Powerlessness,
5. Reported or observed dysfunctional eating pattern Self-Esteem Disturbance, Social Isolation, Disturbed
(e.g., pairing food with other activities) Body Image, or Ineffective Individual Coping may also
6. Sedentary activity level need to be dealt with in the patient who is at risk for
7. Concentrating food intake at end of day or actually has Imbalanced Nutrition, More Than Body
Requirements.
RELATED FACTORS28
1. Risk for: The risk factors also serve as the related fac- EXPECTED OUTCOME
tors.
Will lose [number] pounds by [date].
2. More Than Body Requirements: Excessive intake in
Will verbalize plan for healthy weight loss by [date].
relation to metabolic needs.
Will identify [number] behaviors that facilitate weight
loss by [date].
RELATED CLINICAL CONCERNS
TARGET DATES
1. Alzheimer’s disease
2. Morbid obesity Because this diagnosis reflects long-term care in terms of
3. Hypothyroidism both cause and correction, a target date of 5 days or more
4. Disorders requiring medicating with corticosteroids would not be unreasonable.
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206 • Nutritional–Metabolic Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss with the patient past attempts at weight loss and Provides increased individualization and continuity of
factors that contributed to their success or failure. care, which facilitates the development of a therapeutic
relationship.95
Weigh the patient daily at [state time]. Teach the patient Provides a visible means of ascertaining weight-loss
to weigh self at the same time each morning in same progress.
clothing. Help the patient to establish a graphic to
allow visualization of progress (e.g., bar chart, chart
with gold star for each weight-loss day).
Limit the patient’s intake to number of calories recom- Reduces calories to promote weight loss yet maintain
mended by the physician and/or nutritionist. body’s nutritional status.
Have the patient design own weight-loss plan at least 3 Allows the patient to assume control for long-term ther-
days prior to discharge to allow practice and revision apy. The more the patient is involved in planning care,
as necessary: the higher the probability for compliance.
• Maintain accurate calorie count every shift. Review Monitors progress toward goals. Gives tangible feedback
every 24 hours. to patient.
Collaborate with physical therapist in establishing an Exercise burns calories and tones muscles. Assists in nar-
exercise program. rowing the range between calories consumed and calo-
Assist the patient in selecting an exercise program by ries burned. Facilitates development of adaptive coping
providing the patient with a broad range of options, behaviors.
and have the client select one he or she will enjoy.
[Note client’s plan for exercise here.]
Assist the patient to establish a food diary, during first Helps the patient to identify real intake and to identify
day of hospitalization, which should be maintained behavioral and emotional antecedents to dysfunctional
until weight has stabilized to desired goal. The diary eating behavior.32,33,96
should include specific details of eating habits includ-
ing the foods, where consumed, when consumed, and
specific factors surrounding consumption and physical
activity.
Teach the patient the principles of a balanced diet, or Provides basic knowledge needed to control weight at
refer to dietitian for instructions, at least 3 days before home. Promotes self-care. Promotes the patient’s per-
discharge. ception of control.
Review pros and cons of alternate weight-loss options Promotes safety in weight-loss plan. Avoids serious com-
with the patient: plications such as heart failure due to questionable
• Fad diets weight-loss ideas.
• Enrollment in weight loss programs
• Surgery
Demonstrate adaptations in eating that could promote Assists in behavior modification needed to lose weight.
weight loss:
• Smaller plate
• One-half of usual serving
• No second servings
Suggest that the patient contract with a significant other Provides added reinforcement and support for continued
or home health nurse prior to discharge. Consult with weight loss. Involves others in supporting the patient in
the family and visitors regarding importance of the weight-loss effort.
patient’s adhering to diet. Caution against bringing
food, etc., from home.
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Nutrition, Imbalanced, More Than Body Requirements, Risk For and Actual • 207
ACTIONS/INTERVENTIONS R AT I O N A L E S
Refer to community resources at least 3 days before dis- Provides long-range support for continued success with
charge from hospital. Refer the patient and family to weight loss.
psychiatric nurse practitioner for appropriate tech-
niques to use at home, as well as assistance with guilt,
anxiety, etc. over being obese.
Child Health
Orders are the same as for the adult. Make actions specific to the child according to the child’s developmental level.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Verify the pre-pregnancy weight. Provides basis for planning diet with the patient.
Obtain a 24-hour diet history. Ask the patient to select a
typical day.
Calculate the woman’s calorie and protein intake.
Rule out excessive edema and hypertension. Measure
ankles and abdominal girth and record. Remeasure
each day. Measure blood pressure every 4 hours while
the patient is awake at [state times here].
Encourage the client to increase her activity by: Joining Assists in maintaining desired weight gain; improves
exercise groups for pregnancy (usually found in child- muscle tone and circulation.
birth classes in community):
• Joining swim exercise groups for pregnancy (usually
found at YWCAs or community centers)
Refer to appropriate support groups for assistance in
exercise programs for the pregnant woman (e.g., physi-
cal therapist, local groups that have swimming classes
for pregnant women, and childbirth classes).
If recommended intake is 2400 calories/day but 24-hour Basic measures and teaching factors to assist in weight
diet recall reveals a higher caloric intake: control.
• Recommend reduction of fat in diet (e.g., decrease
amount of cooking oil used, use less salad dressing and
margarine, cut excess fat off meat, and take skin off
chicken before preparing).
• Monitor size of food portions.
• Stress appetite control with high-quality sources of
energy and protein.
Assist mothers with cultural or economic restrictions to
introduce more variety into their diets.
Stress that weight gain is the only way the fetus can be
supplied with nourishment.
Point out that added body fat will be burned and will pro-
vide necessary energy during lactation (breastfeeding).
Assist pregnant adolescents within 3 years of menarche to Diet has to be planned to meet the growth needs of the
plan diets that have needed additional nutrients. adolescent as well as those of the fetus.
Discourage any attempts at weight reduction or dieting. Dieting is never recommended during pregnancy because it
deprives the mother and the fetus of nutrients needed for
tissue growth, and because weight loss is accompanied
by maternal ketosis, a direct threat to fetal well-being.70
(care plan continued on page 208)
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208 • Nutritional–Metabolic Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
A satisfactory pattern of weight gain for the average Over the course of the pregnancy, a total weight gain of
woman is: 25 to 35 pounds is recommended for both nonobese
• 0 weeks of gestation 650 g (approximately 1.5 lb) and obese pregnant women. During the second and
• 20 weeks of gestation 4000 g (approximately 9.0 lb) third trimesters, a gain of about 1 pound/week is con-
• 30 weeks of gestation 8500 g (approximately 19.0 lb) sidered desirable.5
• 40 weeks of gestation 12,500 g (approximately 27.5 lb)5
Mental Health
Nursing actions for the Mental Health client with this diagnosis are the same as those actions in Adult Health with the fol-
lowing considerations:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor client’s taking psychotropic (especially atypical Atypical antipsychotics are associated with greater meta-
antipsychotics) medications for increased weight, blood bolic dysfunction, including weight gain, changes in
pressure, fasting plasma glucose, and lipid profile. serum triglycerides, and glycemic control.96
If the client shows weight gain of 5 percent or more from Modest weight loss can have a significant impact on risk
baseline, consult with physician to prescribe a more factors. Metabolically neutral medications have been
weight/metabolic neutral medication. demonstrated to improve weight and other metabolic
measures.96
Teach the patient about this side effect of the medica- Increases the client’s sense of control.
tions, and the need to monitor his or her weight, blood
sugars, and lipids.
Spend [number] minutes per day discussing client’s per- Change depends on the client’s perception of the prob-
ception of his or her weight and nutrition needs. lem.97
Spend [number] minutes per day planning weight man- Successful weight management plans have been behav-
agement program with client that is based on the ioral and included diet and exercise.96
client’s perceptions of need and goals. Plan needs to
include diet alterations and exercise. [Note plan here
with nursing actions needed to support the plan.]
• Develop, with the client, specific behavioral rewards Positive reinforcement increases behavior.
for meeting diet and exercise goals. Note these rewards
and goals with weight management plan.
Consult with the nutritionist to develop a diet plan and to
provide nutritional education. [Note schedule for meet-
ings with nutritionist here, and client’s plan with the
assistance needed from nursing to implement the plan.]
Consult with physical, recreational, and occupational Developing a plan that includes activities the client
therapy to assist client in developing an exercise and enjoys increases potential for continuing the activity.
recreational activity plan.
Refer client to community support systems for diet and
exercise. Note those resources here. Provide client with
phone numbers and names of contact persons.
Meet with client’s support system to review current
dietary needs and to develop a plan that can be imple-
mented in the home.
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Swallowing, Impaired • 209
Gerontic Health
Nursing actions for the gerontic patient with this diagnosis are the same as those actions in Adult Health and Home Health.
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210 • Nutritional–Metabolic Pattern
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Swallowing, Impaired • 211
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for contributory factors, especially palate forma- A thorough assessment will best identify those patients
tion, possible tracheoesophageal fistula, or other con- who have greater-than-usual likelihood of swallowing
genital anomalies. difficulties due to structural, acquired, or circumstantial
conditions.
Maintain the infant in upright position after feedings for An upright position favors, by gravity, the digestion and
at least 11/2 hours. absorption of nutrients, thereby decreasing the likeli-
hood of reflux and resultant potential for choking.
Address anticipatory safety needs for possible choking: Usual anticipatory airway management is appropriate in
• Have appropriate suctioning equipment available. long-term patient management. Education and teaching
• Teach the parents CPR. concerns can be addressed in a supportive environ-
• Provide parenting support for CPR and suctioning. ment, thereby reducing anxiety in event of cardiopul-
monary arrest secondary to impaired swallowing.
• Assist the family to identify ways to cope with swal- Appropriate individualization fosters input and respect for
lowing disorder (e.g., the need for extra help in feed- how to best meet needs of client in a way the family
ing). Refer to health-care specialists to facilitate this, can relate.
especially occupational therapist.
Administer medications as ordered. Avoid powder or pill Pills or powders may increase the likelihood of impaired
forms. Use elixirs or mix as needed. swallowing in young children and infants. Appropriate
mixing with fruit syrups or using manufacturer’s elixir
or suspension form of the drug lessens the likelihood
of impaired swallowing.
(care plan continued on page 212)
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212 • Nutritional–Metabolic Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
If training is in conjunction with tracheostomy removal, Provides the most realistic and holistic plan of care.
involve all the health team members to appropriately
coordinate plan. [Note client’s plan here with assis-
tance needed by nursing to facilitate plan.]
Women’s Health
The nursing actions for a woman with the nursing diagnosis of Impaired Swallowing are the same as those for Adult
Health.
Mental Health
● N O T E : The following nursing actions are specific considerations for the mental
health client who has Impaired Swallowing that is caused or increased by anxiety. Refer
to Mental Health nursing actions for the diagnosis of Anxiety for interventions related to
decreasing and resolving the client’s anxiety. If swallowing problems are related to an
eating disorder, refer to Mental Health nursing actions for Imbalanced Nutrition, Less
Than Body Requirements, for additional nursing actions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide a quiet, relaxed environment during meals by dis- Promotes the client’s control and facilitates relaxation
cussing with the client the situations that increase anxi- response, thus inhibiting the sympathetic nervous
ety and excluding those factors from the situation. system response.27,95
Provide things such as favorite music and friends or
family that increase relaxation. [Note information pro-
vided by the client here, especially those things that
need to be provided by the nursing staff.]
Provide medications in liquid or injectable form. [Note Liquids are easier to swallow than tablets. Providing
any special preference the client may have in presenta- medications by injection would prevent any swallow-
tion of medications here.] ing problems.
Teach the client deep muscle relaxation. (Refer to the Promotes client control and inhibits the sympathetic
Mental Health nursing actions for Anxiety for actions nervous system response.
related to decreasing anxiety.)
Discuss with the client foods that are the easiest and the Promotes client control.
most difficult to swallow. [Note information from this
discussion here. Also note time and person responsible
for this discussion.]
Plan the client’s most nutritious meals for the time of day
he or she is most relaxed, and note that time here.
Provide the client with high-energy snacks several times Provides additional calories in frequent small amounts.
during the day. [Note snacks preferred by the client
and time they are to be offered here.]
Assign primary nurse to sit with the client 30 minutes Provides increased individualization and continuity of
(this can be increased to an hour as the client tolerates care, facilitating the development of a therapeutic rela-
interaction time better) 2 times a day to discuss con- tionship. The nursing process requires that a trusting
cerns related to swallowing. (This can be included in and functional relationship exist between nurse and
the time described under the nursing actions for client.95 Change depends on the client’s perception of
Anxiety.) As the nurse–client relationship moves to a the problem.97
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working phase, discussion can include factors that pre-
cipitated the client’s focus on swallowing. These fac-
tors could be a trauma directly related to swallowing,
such as an attack in which the client was choked or in
which oral sex was forced.
Teach the client and client’s support system nutrition fac- Promotes long-term support for assistance with problem.
tors that will improve swallowing and maintain adequate
nutrition. [Note here the names of persons the client
would like included in this teaching. Also note time
arranged and person responsible for this teaching here.]
Gerontic Health
Nursing actions for the gerontic patient with this diagnosis are the same as those for Adult Health and Psychiatric Health.
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Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Protect the child from excessive chilling during bathing Evaporation and significant change of temperature for
or procedures. even short periods of time contribute to heat loss for
the young child or infant, especially during illness.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist in answering the parent’s or child’s questions Appropriate teaching fosters compliance and reduces
regarding temperature-monitoring procedures or anxiety.
administration of medications.
Assist the parents in dealing with anxiety in times of Because the emphasis on monitoring and treating altered
unknown causes or prognosis by allowing [number] thermoregulation is so great, it can be easy to overlook
minutes per shift for venting anxiety. [State times the parents and their concerns. Specific attention must
here.] Interview the parents specifically to ascertain be given to ascertaining how the patient and family are
anxiety. feeling about all the many concerns generated.
Involve the parents and family in the child’s care when- Parental involvement fosters empowerment and regaining
ever appropriate, especially for comforting the child. of self-care, thereby reestablishing the likelihood for
effective family coping.
Women’s Health
This nursing diagnosis will pertain to women the same as it would for any other adult. The reader is referred to the Adult
Health and Home Health nursing actions for this diagnosis.
Mental Health
The nursing actions for this diagnosis in the mental health client are the same as those in Adult Health.
Gerontic Health
● N O T E : Normal changes of aging can contribute to altered thermoregulation. Age-
related changes that may be associated with altered thermoregulation are a decrease in
febrile response, inefficient vasoconstriction, decreased cardiac output, decreased subcu-
taneous tissue, diminished shivering, diminished temperature sensory perception, and
diminished thirst perception. Thus, older clients are at high risk for alterations in ther-
moregulation, both hyperthermia and hypothermia.
In addition to the interventions for Adult Health the following can be utilized with the older adult client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Check on older adults often who are at risk: Primary preventive measure.
• During heat alerts
• During cold weather
• In homes without air conditioning or heating
• During electrical outages or electrical service interrup-
tions.
Instruct/assist the client to select proper clothing: Primary preventive measure.
• Layers during cold weather and lighter garments during
warmer weather.
Monitor and record the temperature of older clients often Tracks client norms and provides a mechanism for early
and regularly during high risk times: identification of changes.
• Intra- and postoperative period
• When infection is present
• When fluid imbalance is present
Use warmed IV solutions in older clients in the intra-/ Prevent episodes of hypothermia.
postoperative period unless hyperthermia is present.
(care plan continued on page 216)
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for factors contributing to Ineffective Allows early recognition and early implementation of
Thermoregulation (illness, trauma, immaturity, aging, therapy.
or fluctuating environmental temperature).
Involve the client and family in planning, implementing, Personal involvement and input increases likelihood of
and promoting reduction or elimination of Ineffective maintenance of plan.
Thermoregulation.
Teach the client and family early signs and symptoms of
Ineffective Thermoregulation (see Hyperthermia and
Hypothermia).
Teach the client and family measures to decrease or elim-
inate Ineffective Thermoregulation (see Hyperthermia
and Hypothermia).
Assist the client and family to identify lifestyle changes Provides basic information and planning to successfully
that may be required (see Hyperthermia and manage condition at home.
Hypothermia).
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• If the patient has dentures, cleanse with equal parts of
hydrogen peroxide and water.
• Apply lubricant to lips at least every 2 hours on
[odd/even] hour.
Maintain good body hygiene. Be sure the patient has at
least a sponge bath every day unless skin is too dry.
Monitor for signs of infection at least daily. Infection, through production of toxins, wastes, and so
on, increases the probability of tissue damage.
Keep room temperature and humidity constant. Room Keeps skin cool and dry to prevent perspiration.
temperature should be kept close to 72⬚F and humidity
at a low level unless otherwise ordered.
Teach the patient the impact of smoking on tissues. Highly irritating to mucous membranes.
• Provide information on smoking cessation programs.
• Consult with physician to provide nicotine patches and/
or gum as indicated.
If lesions develop, cleanse area daily at [time] according
to prescribed regimen.
Protect open surface with such products as:
• Karaya powder
• Skin gel
• Wafer barrier
• Other commercial skin preparations
Collaborate with an enterostomal therapist and physician
regarding care specific to the patient (list individual-
ized care procedures here).
Change dressings when needed using aseptic techniques.
Collaborate with health-care team regarding dressing
type and use of topical agents. [Note procedure to be
used for client here.]
Teach the patient and significant others care of the wound Basic care measures for impaired skin integrity.
prior to discharge.
Avoid use of adhesive tape. If tape must be applied, use
nonallergenic tape.
Avoid use of doughnut ring.
Use mild, unscented soap (or soap substitute) and cool or
lukewarm water.
Avoid vigorous rubbing, but do massage gently using a
lanolin-based unscented lotion.
Pat area dry.
Monitor: These measures would allow early detection of any com-
• Skin surface and pressure areas at least every 4 hours at plications.
[state times here] for blanching, erythematic, tempera-
ture difference (e.g., increased warmth), or moisture.
• Fluid and electrolyte balance. Collaborate with health-
care team regarding frequency of measurement of elec-
trolyte levels.
Watch for signs or symptoms of edema.
Caution the patient and assist to avoid scratching irritated Avoids further irritation of already damaged tissue.
areas:
• Apply cool compresses.
Collaborate with health-care team regarding medicated
baths (e.g., oatmeal) and topical ointments.
(care plan continued on page 220)
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Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collaborate with health-care team regarding adjunct ther-
apies (e.g., therapeutic beds, wound closure systems, or
barrier lotions).
Involve physical/occupational therapy in plan of care.
Refer to community health agencies and other health-care Provides on-going support and cost-effective use of avail-
providers as appropriate. able resources.
Child Health
Utilize adult health interventions with appropriate developmental adaptations with the following considerations.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Handle the infant gently; especially caution paramedical The epidermis of infants and young children is thin and
personnel regarding need for gentle handling. lacking in subcutaneous depth. Others, such as x-ray
technicians, may not realize the fragile nature of skin
as they carry out necessary procedures.
Place the patient on flotation pad, or if the parents Alternating surface contact and position favors circula-
choose, allow the infant or child to be held frequently tory return to central venous system.
(avoid placement of infant on any soft surface that
presents a risk for SIDS).
Caution the patient and parents to avoid scratching irri- Anticipate potential injury of delicate epidermis, espe-
tated area: cially when irritation may prompt itching.
• Trim nails with appropriate scissors; receive parental
permission if necessary.
• Make small mitts if necessary from cotton stockinette
used for precasting.
Monitor perineal area for possible allergy to diapers. Various synthetics in diapers may evoke allergenic
responses and either cause or worsen existent skin irri-
tation.
Encourage fluids: Adequate hydration assists in normal homeostatic mecha-
• Infants: 250 to 300 mL/24 h nisms that affect the skin’s integrity.
• Toddler: 1150 to 1300 mL/24 h
• Preschooler: 1600 mL/24 h
(These are approximate ranges. The physician may order
specific amounts according to the child’s age and con-
dition.)
Provide protection such as bandage or padding to tissue Anticipation and protection from injury serves to limit
site involved. the depth and/or degree of impaired skin integrity.
Monitor and document circulation to affected tissue via: These factors represent basic appropriate criteria for cir-
• Peripheral arterial pulses culatory checks. They may be added to in instances of
• Blanching or capillary refill specific concerns such as compartment syndrome asso-
• Tissue color ciated with hand trauma.
• Sensation to touch or temperature
• Tissue general condition (e.g., bruising or lacerations)
• Drainage (e.g., amount, odor, or color)
• OM limitations
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Administer oral hygiene according to needs and status: Appropriate oral hygiene decreases the likelihood of
• Special orders for postoperative cleft palate or cleft lip altered integrity of surrounding tissues and is critical
repair for care of associated oral disorders.
Teach the parents to limit time the infant sucks bottle in Evidence suggests that bottle mouth syndrome is pre-
reclining position to prevent bottle mouth syndrome vented by not having the infant go to sleep with bottle.
and decayed teeth. Completion of feeding and removal of bottle is sug-
gested before placing the infant in crib.
Protect the altered tissue site as needed during movement Provision of support and usual use of body parts favor
by providing support to the limb. adequate circulation and prevent further injury.
Provide ROM and ambulation as permitted to encourage
vascular return. [Note specific plan for this client here.]
Position the patient while in bed so that the head of the Appropriate venous return is favored by resultant gravity
bed is elevated slightly and involved limb is elevated with limb higher than heart.
approximately 20 degrees.
Address ineffective thermoregulation, and especially pro- In severe instances of ineffective thermoregulation or
tect the patient from chilling or shock due to dehydra- related pathology, there may not be the usual manifes-
tion or sepsis. Refer to care plans related to tations of derivations from normal. It may also be diffi-
thermoregulation for detailed interventions. cult to assess sensation in the young infant because of
the infant’s inability to provide verbal feedback.
Use restraints judiciously for involved limb or body site. Any undue constriction or threat to circulation must be
weighed appropriately in making decisions whether or
not to restrain the child.
Monitor intravenous infusion and administration of med- This is usual protocol for IV therapy and must be consid-
ications cautiously. Avoid use of sites in close proxim- ered paramount as IV medications or solutions pose
ity to area of impaired tissue integrity. serious threats to the veins and surrounding tissues.
Allow the patient and family time to express concerns by Reduces anxiety because their concerns can be made
providing at least [number] minutes per shift for family known and their feelings valued.
counseling. [State times here.]
Teach the patient and family: [Note specific teaching plan Appropriate education serves to build self-confidence and
for client here.] effects long-term compliance with treatment and health
• Need for follow-up care management.
• Signs and symptoms to be reported:
• Increased temperature (101⬚F or higher)
• Foul odors or drainage
• Delayed healing or increase in damage site size
• Loss of sensation or pulsation in limb or site
• Any increase in pain
• Use of prosthetic device if indicated
• Use of aids in mobility, such as crutches or walker
• Need to avoid constrictive clothing
• Appropriate dietary needs
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor perineum and rectum after childbirth for injury Assesses basic physical condition as a basis for providing
or healing at least once per shift at [state times here]. care and preventing complications.
Monitor episiotomy site for redness, edema, or
hematomas each 15 minutes immediately after delivery
for 1 hour, then once each shift thereafter.
Collaborate with physician regarding: Provides comfort and promotes healing.
(care plan continued on page 222)
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Applying ice packs or cold pads to perineum for the
first 8 to 12 hours after delivery to reduce edema and
increase comfort
• Warm baths twice a day at [state times here] and as
necessary for pain and discomfort
• Analgesics and topical anesthetics as necessary for pain
and discomfort
Teach good perineal hygiene and self-care: Promotes healing and encourages self-care.
• Rinse perineal area with warm water after each
voiding.
• Pat dry gently from front to back to prevent con-
tamination.
• Apply perineal pad from front to back to prevent
contamination.
• Change pads frequently to prevent infection and
irritation.
Provide factual information on resumption of sexual Provides basic information to promote safe self-care.
activities after childbirth:
• First intercourse should be after adequate healing
period (usually 3 to 4 weeks).
• Intercourse should be slow and easy (woman on top
can better control angle, depth, and penetration).
Teach postmenopausal women the signs and symptoms Provides basic information that promotes self-care and
of atrophic vaginitis: health maintenance.
• Watery discharge
• Burning and itching of vagina or vulva
Encourage examinations (Pap smears) for estrogen levels
at least annually.
In collaboration with physician, encourage use as
needed of:
• Estrogen replacement creams or vaginal suppositories
• Extra lubrication during intercourse
Teach breastfeeding mothers about breast care. Provides basic information that assists in preventing skin
• Inspect for cracks or fissures in nipples. breakdown and promotes self-care and successful lac-
• Wear supportive bra (breast binder to relieve engorge- tation.
ment).
• Shower daily; do not use soap on breast; allow to
air dry.
• Use lanolin-based cream (vitamin E cream, Massé
Breast cream, or A and D cream) to prevent drying
and cracking of nipples.
Enhance let-down reflex: Promotes let-down reflex and successful breastfeeding.
• Nurse early and frequently. Ten minutes on each side
is easier on sore nipples than nursing less frequently.
• Nurse at both breasts each feeding. Switch sides to
begin nursing each time (e.g., if the baby nursed first
on left side at last feeding, begin on right side this
time). A safety pin or small ribbon on bra strap will
remind the mother which side she used first last time.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Change positions from one feeding to next (distributes
sucking pressure).
• Check the baby’s position on breast. Be certain areola
is in mouth, not just nipple.
• Begin nursing on least sore side first, if possible, then
switch the baby to other side.
• Apply ice to nipple just before nursing to decrease pain
(fold squares, put them in the freezer and apply as
needed).
Collaborate with the physician regarding analgesics as
needed. Caution the patient to not take over-the-
counter medication because some medications are
passed to the baby via breast milk.
● N O T E : Between the third and sixth months of pregnancy, the process of tooth calci-
fication (hardening) begins in the fetus. What the mother consumes in her diet will
affect the development of the unborn child’s teeth. A well-balanced diet usually pro-
vides correct amounts of nutrients for both the mother and the child.
Teach the patient to practice good oral hygiene at least Promotes sense of well-being. Assists in promoting
twice a day as well as PRN: proper growth and development of the fetus, and
• Each time the patient eats and, if nauseated and vomit- encourages health maintenance.
ing, vomits, the patient should clean gums and teeth.
• If the smell of toothpaste or mouth rinse makes the
patient nauseated, the patient should use baking soda.
Reduce the number of times sugar-rich foods are eaten
between meals.
Teach the patient to snack on fruits, vegetables, cheese, Provides basic information to the patient that promotes
cottage cheese, whole grains, or milk. health maintenance and increases awareness of need
for self-care.
Have the patient increase daily calcium intake to at least
a total of 1.2 g of calcium per day.
Collaborate with obstetrician and dentist to plan needed
dental care during pregnancy.
Assist in planning best time in pregnancy for dental
visits:
• Not during the first 3 months if:
• Previous obstetric history includes miscarriage
• Threatened miscarriage
• Other medical indications
• Hypersensitive to gagging (will increase nausea and
vomiting)
• Not during the last 3 months if:
• Not able to sit in dental chair for long periods of time
• Obstetric history of premature labor
Instruct the patient to have X-ray examinations only Prevents X-ray exposure to the fetus.
when it is absolutely necessary. Caution the patient to
request a lead apron when having X-ray examinations.
ADDITIONAL INFORMATION
Nursing actions for newborn health immediately follow
the Women’s Health nursing actions. As previously
mentioned, newborn actions are included in this sec-
tion because newborn care is most often administered
(care plan continued on page 224)
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ACTIONS/INTERVENTIONS R AT I O N A L E S
by nurses in the obstetric or women’s health area.
Focus needs to be made on the newborn simply
because the newborn’s oral mucous membrane prob-
lems can be easily overlooked.
In collaboration with dentist, teach the parents the oral
and dental needs of the neonate:
• Use of fluoride
• Proper use of pacifiers
• Do not use homemade pacifiers
• Use pacifiers recommended by dentist
• Allowing the infant who is teething to chew on soft
toothbrush (will encourage later brushing of teeth
because it allows the infant to become familiar with
toothbrush in mouth)
• Holding on to brush
• Giving brush to the infant only when an adult is present
Teach the parents how to administer oral hygiene:
• Massage and rub the infant’s gums with finger daily.
• Inspect oral cavity daily for hygiene and problems.
Take the infant for first dental visit between 18 months
and 2 years of age.
Dental caries (decay) can be a result of prolonged nursing Promotes good health and provides information as a basis
or delayed weaning: for parental care of the infant. Assists in preventing
• Do not allow the infant to nurse at breast or bottle infection.
beyond the required feeding time.
• Do not allow the infant to sleep habitually at the breast
or with a bottle or pacifier in the mouth.
• Teach the neonate’s parents to:
• Avoid giving sweet liquids (soft drinks) or fruit juices
in bottle.
• Wean the child from bottle to cup soon after first
birthday.
• When continuing to nurse the infant, give water in a
cup soon after the first birthday.
• Use good handwashing techniques to prevent infec-
tion with, or reinfection of, thrush.
• Not place the infant on sheets where the mother has
been sitting.
• Thoroughly clean breast or bottle-feeding equipment.
Mental Health
Plan for adult health can provide the foundation for care with the following considerations:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Refer to Chapter 8 for stress-reduction measures and
interventions for the stressors that produce psy-
chogenic skin reactions.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
If the client is placed in restraints, monitor the integrity
of skin under restraints every hour.
Apply lanolin-based lotion and cornstarch or powder to Lubricates skin and decreases risk for breakdown.
area under restraint at least every 2 hours on
[odd/even] hour and PRN.
Pad restraints with nonabrasive materials such as sheep- Decreases mechanical friction against the skin, and
skin. decreases risk for breakdown.
Keep the area of restraint next to the skin clean and dry.
Release restraints one at a time every 2 hours on
[odd/even] hour and PRN. Remove restraints as soon
as the client will tolerate one-to-one care without risk
to self or others.
Maintain proper movement and alignment of affected Decreases mechanical friction on specific areas for long
body parts. periods of time, thus decreasing risk for breakdown.
• Change the client’s position every 2 hours on
[odd/even] hour.
• Offer the client fluids every 15 minutes. [List preferred
fluids here.]
• While the client is very agitated and physically active, Hydration improves skin condition.
provide constant one-to-one observation.
• While the limb is out of restraints, have the client move Promotes circulation and assists in preventing the conse-
the limb through ROM. quences of immobility.
• If the client is in four-point restraints, place him or her Client safety is of primary importance. This positioning
on side or stomach and change this position every 2 prevents aspiration by facilitating drainage of fluids
hours on [odd/even] hour. away from the airway.
• Monitor skin condition of pressure areas.
• If the client is in four-point restraints, provide one-on- Provides supportive environment to the client.
one observation.
• Continually remind the client of reason for restraint
and conditions for having the restraints removed.
• Talk with the client in a calm, quiet voice and use the
client’s name.
• Use restraints that are wide and have padding. Make
sure padding is kept clean and dry and free of wrinkles.
If Impaired Tissue Integrity is the result of self-harm, Client safety is of primary importance. Provides ongoing
place the client on one-to-one observation until the risk supervision to inhibit impulsive behavior, and encour-
of future harm has diminished. ages use of alternative coping behaviors.
Monitor self-inflicted injuries hourly for the first 24 hours Early identification and treatment of infection can prevent
for signs of infection can prevent more of infection and more serious damage.
further damage. Note information on a flow sheet.
After the first 24 hours, monitor on a daily basis.
Provide equipment and time for the client to practice oral Removes debris and food particles, thus reducing the risk
hygiene at least after each meal. of tissue injury.
Discuss with the client lifestyle changes to improve con- Alerts the client to lifestyle patterns that increase risk for
dition of mucous membranes, including nutritional injury to oral mucous membranes. If risk factors are
habits, use of tobacco product, use of alcohol, mainte- present, frequent assessment and increased attention to
nance of proper hydration, and effects of frequent oral hygiene can decrease the risk of membrane break-
vomiting. down.
Discuss with the client side effects of medications, such
as antibiotics, antihistamines, phenytoin, antidepres-
sants, and antipsychotics that contribute to alterations
in oral mucous membranes.
(care plan continued on page 226)
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client to use nonsucrose candy or gum to stim- Maintains hydration of membranes and decreases chance
ulate flow of saliva. of breakdown.
Teach the client to avoid excessive wind and sun expo- These medications can cause photosensitivity.38
sure, especially with antipsychotic drugs.
If the client is taking antipsychotic drugs, suggest the use
of a sunscreen containing PABA.
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized with the aging client
ACTIONS/INTERVENTIONS R AT I O N A L E S
Nursing actions for this diagnosis in the gerontic patient The incidence of dry skin in the older adult is increased
are essentially the same as those for Adult Health and as a result of decreased production of natural skin oils.
Home Health with the following special notations: Use
only superfatted, nonperfumed, mild, nondetergent, and
hexachlorophene-free soap in bathing the patient.98
When drying the skin after bathing, pat the skin dry Increases the moisture level of the patient’s skin. Careful
rather than rubbing, and apply lubricating lotion while attention to dry skin conditions in the older adult assists
the skin is still damp. in maintaining tissue integrity for the older adult.
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Tissue Integrity, Impaired • 227
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach measures to promote tissue integrity: Provides knowledge and skills that will prevent or mini-
• Use mild laundry detergent on clothes. Double-rinse mize skin breakdown.
clothes, linens, and diapers if skin is sensitive.
• Use sunscreen to prevent sun damage.
• Avoid excessive wind and sun exposure.
• Wear properly fitting shoes.
R E F E R E N C E S 27. Gaston, NW, et al: A focus on nutrition for the elderly: It’s time to
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3. McGraw-Hill, New York, 1981. 30. Oakley, LD, and Kane, J: Personal and social illness demands related
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8. Schuster, CS, and Ashburn, SS: The Process of Human Develop- 34. Verdery, RB: Clinical evaluation of failure to thrive in older people.
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Nursing Care, ed 4. CV Mosby, St. Louis, 1986. 36. Kimball, MJ, and Williams-Burgess, C: Failure to thrive: The silent
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Through the Life Cycle. Appleton-Century-Crofts, East Norwalk, CT, tice. Saunders Elsevier Science, St. Louis, 2003.
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and screens. J Am Diet Assoc 95:647, 1995. breastfeeding confidence and infant feeding plans: Effects on actual
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disability and depressive symptoms among high-risk older adults. J 45. Lawrence, RA: Breastfeeding: A Guide for the Medical Profession, ed
Am Geriat Soc 47:995, 1999. 5. CV Mosby, St. Louis, 1999.
21. Ettinger, RL: The unique oral health needs of an aging population. 46. Riordan, J, and Auerback, KG: Breast Feeding and Human Lactation,
Dent Clin North Am 41:633, 1997. ed 2. Jones and Bartlett, Sudbury, MA, 1999.
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1999. preterm infants’ sleep-wake patterns. JOGNN J Obstet Gynecol
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26. Miller, CA: Nursing Care of Older Adults: Theory and Practice, ed 3. sive care unit. JOGNN J Obstet Gynecol Neonatal Nurs 22:4,
Lippincott, Philadelphia, 1999. 338–347, 1993.
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51. Meier, PP, Engstrom, JC, Mingolelli, SS, Miracle, DG, and Kiesling, 74. Kavanaugh, K, et al: The rewards outweigh the efforts: Breastfeeding
S: The Rush mothers’ milk club: Breastfeeding interventions for outcomes for mothers of preterm infants. J Hum Lactat 13:51, 1997.
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Neonatal Nurs 33(2):164, 2004. replacements and formula samples on women employed outside the
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assessment of the short form. JOGNN J Obstet Gynecol Neonatal 76. Capili, B, and Anastasi, JK: A symptoms review: Nausea and vomit-
Nurs 32(6):734, 2003. ing in HIV. J Assoc Nurses AIDS Care 9:47, 1998.
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mothers and low birthweight infants. Nurs Clin North Am 31:351, panel finds. Wall Street Journal, November 6, 1997, p B8.
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54. Author: When the Care Plan includes breastfeeding and/or Kangaroo liative care. Br Med J 315:1148, 1997.
Care, the mother and father can experience…, March of Dimes- 79. Henderson, CW: New guidelines for nausea and vomiting in cancer.
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Dent Clin North Am 41:651, 1997. 82. Voelker, R: NIH panel says more study is needed to assess mari-
57. Wold, GH: Basic Geriatric Nursing, ed 2. CV Mosby, St. Louis, 1999. juana’s medical use. JAMA 277:867, 1997.
58. Miller, CA: Nursing Care of Older Adults: Theory and Practice, ed 3. 83. Wolfe, YL, and Chillot, R: Curb queasiness: Surprising cure for
Lippincott, Philadelphia, 1999. chronic nausea. Prevention 49:148, 1997.
59. Nechyba, C, and Gunn, V: The Harriet Love Handbook, ed 16. CV 84. Woods, A Spralla, G, and Medical Economics Company: PDR
Mosby, St. Louis, 2003. Nurses’ Handbook, Montvale, NJ, 1999.
60. Larsen, CE: Safety and efficacy of oral rehydration therapy for the 85. Eliopoulos, C: Gerontological Nursing. Lippincott, Philadelphia,
treatment of diarrhea and gastroenteritis in pediatrics, Pediatr Nurs 1997.
26:177, 2000. 86. Staab, AS, and Hodges, AC: Essentials of Gerontological Nursing:
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ple. Best Practice 5:1, 2001. 87. Metheney, N, et al: Detection of inadvertent respiratory placement of
62. Wong, DL, and Perry, SE: Maternal Child Nursing Care. CV Mosby, small-bore feeding tubes. Heart Lung 19:631, 1990.
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63. Teschendorf, M: Women during the reproductive years. In Breslin, ET feeding tube location. Nurs Res 39:266, 1990.
and Lucas, VA, Women’s Health Nursing: Toward Evidence-Based 89. American Dietetic Association: Position of the American Dietetic
Practice. Saunders Elsevier Science, St. Louis, 2003. Association: Promotion of breastfeeding. J Am Diet Assoc 97:626,
64. Huebscher, R: Natural, alternative and complementary health care. 1997.
In Breslin, ET, and Lucas, VA, Women’s Health Nursing: Toward 90. Grams, M: Breastfeeding Source Book. Achievement Press, Sheridan,
Evidence-Based Practice. Saunders Elsevier Science, St. Louis, WY, 1990.
2003. 91. Garner, D, and Garfinkel, P (eds): Handbook of Treatment for Eating
65. Mandeville, LK, and Troiano, N: NH: High Risk Intrapartum Nursing. Disorders, ed 2. Guilford Press, New York, 1999.
JB Lippincott, Philadelphia, 1992. 92. Author: Practice guideline for the treatment of patients with eating
66. Beland, I, and Passos, J: Clinical Nursing: Pathophysiological and disorders, American Psychiatric Association Workgroup on Eating
Psychosocial Approaches, ed 4. Macmillan, New York, 1981. Disorders. Am J Psychiatr 157:1, 2000.
67. Cosgray, RE, et al: The water-intoxicated patient. Arch Psychiatr Nurs 93. White, J: The development and clinical testing of an outpatient pro-
5:308, 1990. gram for women with bulimia nervosa. Arch Psychiatr Nurs 13:179,
68. Lapierre, E, et al: Polydipsia and hyponatremia in psychiatric 1999.
patients: Challenge to creative nursing care. Arch Psychiatr Nurs 94. Folkedahl, BA, and Frantz, R: Treatment of pressure ulcers. Univer-
5:87, 1990. sity of lowa Gerontological Nursing Interventions Research Center,
69. Boyd, MA: Polydipsia in the chronically mentally ill: A review. Arch Research Dissemination Core, lowa City, IA, 2002, www.guidelines.
Psychiatr Nurs 5:166, 1990. gov.
70. Nichols, FH, and Zwelling, E: Maternal-Newborn Nursing: Theory 95. Erickson, HC, and Kinney, C: Modeling and Role-Modeling: Theory,
and Practice. Churchill-Livingstone, New York, 1997. Research, and Practice. Author, Austin, TX, 1990.
71. Orr, E: Breast feeding after a cesarean. Int J Childbirth Educ 9:26, 96. Meyer, J: Expert interview: Schizophrenia and the metabolic syn-
1994. drome. Medscape Psychiatr Ment Health 10:2005.
72. Niefert, MR, and Secat, JM: Milk yield and prolacting rise with 97. Wright, L, and Leahey, M: Nurses and families, ed 4. FA Davis,
simultaneous breast pump. Ambulatory Pediatric Association Meeting Philadelphia,2005.
Abstracts, Washington, DC, May, 1985. 98. Maas, M, Buckealter, K, and Hardy, M: Nursing Diagnoses and
73. Neifert, MR, and Secat, JM: Lactation insufficiency: A rational Interventions for the Elderly. Addison-Wesley Nursing, Fort Collins,
approach. Birth 16:182, 1989. CO, 1991.
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4
1. BOWEL INCONTINENCE 236
2. CONSTIPATION, RISK FOR, ACTUAL, AND PERCEIVED 240
3. DIARRHEA 248
4. READINESS FOR ENHANCED URINARY ELIMINATION 252
5. URINARY INCONTINENCE 254
A. Actual
B. Functional
C. Reflex
D. Stress
E. Total
F. Urge
G. Risk for Urge
6. URINARY RETENTION 263
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Conceptual Information • 231
nation, but to discuss elimination is considered rude.1 fluids upon morning waking potentiate the gastrocolic
Therefore, obtaining a reliable, complete elimination pattern reflex. If the fluids are warm or contain caffeine, they will
assessment may be difficult. Added to this difficulty is the also stimulate peristalsis.1,2
fact that each person has his or her own normal elimination The secretions of the gastrointestinal tract assist with
habits and acceptable verbiage around elimination. Elimina- food passage and further digestion. The passage rate of the
tion is highly individualized and can be influenced by age, contents through the intestines helps determine the absorp-
circadian rhythms, culture, diet, activity, stress, and a num- tion amount. The small intestine is responsible for about 90
ber of other factors. Elimination has elements of both percent of the absorption of amino acids, sodium, calcium
involuntary and voluntary control. The mechanisms that chloride, fatty acids, bile salts, and water. Potassium and
control the production of waste materials and the neural sig- bicarbonate are excreted. The usual amount of time for
nals that the bladder or bowel needs to be emptied are pri- chyme to move from the stomach to the ileocecal valve
marily involuntary. However, each person can usually varies from 3 to 10 hours. It takes approximately 12 hours
control both the timing of bowel and bladder evacuation, as for feces to travel from the ileocecal valve to the rectum.
well as the use of abdominal and perineal muscles to assist One bowel movement may be the result of meals eaten over
in evacuation. the past 3 to 4 days, but most of the food residue from any
Food and fluid intake are extremely important in elim- particular meal will have been excreted within 4 days.
ination. A fluid intake of 2000 mL per day and a food intake Passage of contents is influenced primarily by the amount of
of high-fiber foods would, in the majority of instances, residue and the motility rate. Feces are normally evacuated
ensure an adequate elimination pattern.3,4 Alteration in elim- on a moderately regular schedule, but it will vary from three
ination may cause psychosocial problems, such as social times daily to once per week depending on the individual.
isolation due to embarrassment, as well as physiologic prob- When proper absorption does not occur, necessary
lems, such as fluid and/or electrolyte imbalance. nutrients and electrolytes are lost for subsequent body use.
Small bowel loss can cause metabolic acidosis and
hypokalemia. Large bowel loss can lead to dehydration and
BOWEL ELIMINATION
hyponatremia.
The lower gastrointestinal tract includes the small and large The squatting, leaning forward position is the most
intestines. The small bowel includes the duodenum, jejunum, supportive position for defecation because it increases intra-
and ileum, and is approximately 20 feet in length and 1 inch abdominal pressure and promotes easier abdominal and per-
in diameter. The large bowel includes the cecum, colon, and ineal muscle contraction and relaxation. Beside positioning,
rectum and terminates at the anus. The large bowel is diet, and fluid intake, other aids to elimination include ene-
approximately 5 feet long and 21/2 inches in diameter. The mas and laxatives.
small bowel and large bowel connect at the ileocecal valve.2 Enemas assist in evacuation through promotion of
The intestines receive partially digested food from the peristalsis, chemical irritation, or lubrication. Volume ene-
stomach and move the food element through the lower tract, mas—500 to 1000 mL of fluid—cause distention, which
thus assisting in proper absorption of water, nutrients, and increases peristalsis. The addition of heat and soapsuds, for
electrolytes. The intestines also provide secretory and stor- example, adds chemical irritation and increases peristalsis.
age functions. They secrete mucus, potassium, bicarbonate, Straight tap-water enemas should be used cautiously,
and enzymes. because they are hypotonic and may disturb electrolyte bal-
The chyme (small intestine contents) is moved by ance. Electrolyte enemas are usually prepackaged and are
peristalsis, and the feces (large intestine contents) are pro- hypertonic. Hypertonic enemas increase fluid amounts in
pelled by mass movements that are stimulated by the gas- the bowel through osmosis, thus slightly increasing disten-
trocolic reflex. The gastrocolic reflex occurs in response to tion and providing a relatively mild chemical irritation. Both
food entering the stomach and causing distention, so mass the distention and irritation also result in increased peristal-
movement occurs only a few times a day. The gastrocolic sis. Oil enemas are usually small-volume enemas (100 to
reflex occurs within 30 minutes after eating and is predomi- 200 mL) providing lubrication as well as stool softening.1,5
nant after the first meal of the day. Therefore, the time after Laxatives assist elimination by producing bulk, pro-
the first meal of the day is the most frequent occurrence viding lubrication, causing chemical irritation, or softening
bowel elimination. Other reflexes involved in elimination stool. The action of laxatives ranges from harsh to mild.
are the duodenocolic reflex and the defecation reflex. The Both laxatives and enemas can be abused. Persistent
duodenocolic reflex is stimulated by the distention of the use of either will diminish normal reflexes so that the indi-
duodenum as food passes from the stomach to the duode- vidual will begin to require more and more aid. The individ-
num. The gastrocolic and duodenocolic reflexes stimulate ual then establishes an aid-dependent habit just as a drug
rectal contraction and, usually, a desire to defecate. The abuser does.
defecation reflex occurs in response to feces entering the Although constipation and diarrhea are the two most
rectum. This reflex promotes relaxation of the internal anal common problems with bowel elimination, flatulence may
sphincter, thus also promoting a desire to defecate. Extra be an associated problem. Flatus (intestinal gas) is normal.
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232 • Elimination Pattern
A problem arises when the individual cannot pass the gas within normal limits to void 5 to 10 times per day. Common
or when abnormally large amounts of gas are produced. times for urination are on arising and before retiring. Other
Flatus is produced by swallowed air, diffusion of gases times will vary with habits and correspond with work breaks
from the bloodstream to the gastrointestinal tract, carbon and availability of toilet facilities.1,2
dioxide formed by the action of bicarbonate with hydrochlo- Urine volume varies according to the individual and
ric acid or fatty acids, and bacterial decomposition of food depends on normal kidney functioning, amount of fluid and
residue. Common causes of gas problems include gas- food intake, environmental temperature, fluid requirements
producing foods, highly irritating foods, constipating med- of other organs, presence of open wounds, output by other
ications such as opioids, and inactivity. The problems relate areas (skin, bowel, or respiration), and medications such as
directly to the amount of gas produced and decreased motil- diuretics. The amount of solutes in the urine, an intact neu-
ity. Increased flatus causes distention that, in turn, can cause romuscular system, and the action of the antidiuretic hor-
pain, respiratory difficulty, and further problems with intes- mone also influence output. A significant impact on urinary
tinal motility.1 output is the opportunity to void at socially acceptable times
As previously mentioned, any bowel elimination prob- in private.1
lem can ultimately be life-threatening. Any bowel elimina- Inadequate urinary output may arise from either the
tion problem, whether constipation, diarrhea, or flatulence, kidney not producing urine (suppression) or blockage of
that lasts more than 1 to 2 weeks in an adult, or more than 2 urine flow (retention) somewhere between the kidney and
to 3 days for an infant or elderly person, requires immediate external urinary meatus. Suppression may result from dis-
health care intervention. ease of the kidneys or other body structures and inadequate
fluid intake. Retention may be either mechanical or func-
tional in nature. Mechanical retention is due to anatomic
URINARY ELIMINATION
blockage, such as a stricture or a calculus. Functional reten-
The lower urinary tract is composed of the ureters, bladder, tion refers to any retention that is not mechanical and
and urethra, which serve as storage and excretory pathways includes such areas as neurogenic problems.2
for the waste secreted by the kidneys. The ureters extend Urinary control relates to the integrity and strength of
from the kidney pelvis to the trigone area in the bladder. The the urinary sphincters and perineal musculature. Inability to
ureters are small tubes composed of smooth muscle that control urinary output often leads to social isolation due to
propels urine by peristalsis from the kidney to the bladder. embarrassment over control and odor. Urinary incontinence
The bladder stores the urine until it is excreted through the is more common than most health-care professionals realize.
urethra. Between the base of the bladder and the top of the Studies indicate that urinary incontinence is quite common
urethra is the urethral sphincter. The sphincter opens under among healthy premenopausal middle-aged women.6,7,16
learned voluntary control. Opening the urethral sphincter These studies found no relationship between continence sta-
allows the urine to pass through the urethra and meatus for tus, number of children, history of gynecologic surgery,
elimination. The female urethra is approximately 3 to 5 cen- smoking, physical activity, or intake of alcohol and caffeine.
timeters long, and the male urethra is approximately 20 cen- The studies found also that very few of these women sought
timeters long.2 treatment for this incontinence.
In adults, the desire to void occurs when the bladder Bladder-retraining programs may vary according to
has reached a capacity of 250 to 450 mL of urine. As urine individual hospitals and physicians. Consultation with a
collects to the bladder capacity, the stretch receptors in the rehabilitation nurse clinician provides the most current and
bladder muscle are activated. This stretching stimulates the reliable information regarding a quality bladder-retraining
voiding reflex center in the spinal cord (sacral levels two, program.8 Two measures that may assist with incontinence
three, and four), which sends signals to the midbrain and the are Credé’s maneuver and the Valsalva maneuver. Credé’s
pons. These stimuli result in inhibition of the spinal reflex maneuver involves placing the fingertips together at the mid-
center and pudendal nerve, which allows relaxation of the line of the pelvic crest, then massaging deeply and smoothly
external sphincter and contraction of the bladder, and void- down to the pubic bone. Check with the physician first,
ing occurs. The bladder is under parasympathetic control, because there are contraindications, such as ureteral reflux.5
with the learned voluntary control being guided by the cor- The Valsalva maneuver involves asking the client to simu-
tex, midbrain, and medulla.1,2 late having a bowel movement. Have the client take a deep
The anatomically correct positions for voiding are sit- breath, hold it, and then bear down as if expelling feces.
ting for the female and standing for the male. It is important Check with the physician first, because there are contraindi-
to note that in some cultural groups the correct voiding posi- cations, such as glaucoma, eye surgery, and impaired circu-
tion for the male is squatting. Either standing or squatting is lation.4,5
anatomically correct. Difficulties arise if the male is lying Urine is a waste product formed as a part of body
down, for example, in traction or a body cast. An individual metabolism. Urine is normally produced at a rate of 30 to 50
generally voids 200 to 450 mL each voiding time, and it is mL per hour. Under normal circumstances, output will bal-
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Developmental Considerations • 233
ance with intake approximately every 72 hours. An hourly lent peristaltic waves and increased gas pressure in the rec-
output of less than 30 mL, a 24-hour output of 500 mL or tum.9 The cause is unknown but may have to do with the
less, or an intake–output imbalance lasting longer than 72 simple (rather than the complex) digestive enzymes of the
hours requires immediate intervention.1,3 infant or a decreased amount of vitamins A, K, or E. Most
authorities agree that colic disappears as digestive enzymes
become more complex and when normal bacterial flora
DEVELOPMENTAL CONSIDERATIONS accumulate.9
Elimination depends on the interrelatedness of fluid intake,
muscle tone, regularity of habits, culture, state of health, and TODDLER AND PRESCHOOLER
adequate nutrition.2
By the time the child is 2 years of age, the kidneys are able
to conserve water and to concentrate urine almost on an
INFANT
adult level, except under stress. The bladder increases in size
Kidney function does not reach adult levels until 6 months and is able to hold approximately 88 mL of urine.
to 1 year of life. Nervous system control is inadequate, and Nervous system and gastrointestinal maturation has
renal function does not reach a mature status until approxi- occurred during infancy and the beginning of the toddler
mately 1 year of life.2 Voiding is stimulated by cold air. An years. By the time children are 2 to 3 years of age, they are
infant usually voids 15 to 60 mL at each voiding during the ready to control bowel and bladder functioning. Bowel elim-
first 24 hours of life and may void reflexively at birth. If the ination control is usually attained first; daytime bladder con-
infant has not voided by 12 hours after birth, there is cause trol is second; and nighttime bladder control is third. The
for concern. By the third day, the infant may void 8 to 10 child must be able to walk a few steps, control the sphincter,
times during each 24 hours, equaling about 100 to 400 mL. recognize and interpret that the bladder is full, and be able
Urinary output is affected by the amount of fluid consumed, to indicate that he or she wants to go to the bathroom. The
the amount of activity (increased activity equals less urine), child must also value dryness. He or she must recognize that
and the environmental temperature (increased temperature it is more socially acceptable to be dry than to be wet.
equals less urine).9 Uric acid crystals may be found in con- Parents should not attempt toilet training, even if the
centrated urine, causing a rusty discoloration to the diaper.9 child is ready, if there are family or environmental stressors.
The muscles and elastic tissues of an infant’s intestines Regression is normal during toilet training and, coupled with
are poorly developed, and nervous system control is inade- undue stress, could cause physical or psychosocial problems.
quate. Water and electrolyte absorption is functional but Bladder training takes time to accomplish. Both the
immature. The intestines are proportionately longer than in parent and the child must have patience and not get unduly
an adult. Although some digestive enzymes are present, they upset when accidents occur. In fact, nighttime bladder con-
can break down only simple foods. These digestive enzymes trol may not be attained until age 5 to 8 years. Doctors
are unable to break down complex carbohydrates or protein. and researchers disagree on the age at which nighttime bed-
Meconium is the first waste material that is eliminated wetting (enuresis) becomes a problem.9 Parents should limit
by the bowel, usually during the first 24 hours of an infant’s fluids at night, have the child void before going to bed, and
life. After 24 hours, the characteristics of the bowel move- get the child up at least once during the night to assist in
ment change as it mixes with milk. The characteristics of the attaining nighttime control.
stool depend on whether an infant is breastfed or bottle-fed. To toilet train, the parent should watch for patterns of
The breastfed infant has soft, semiliquid stools that are yel- defecation. Eating stimulates peristaltic activity and evacua-
low or golden in color. The bottle-fed infant has a more tion. The child can then be taken to the toilet at the expected
formed stool that is light yellow to brown in color. time after eating. The child should be told what is expected
An infant may have four to eight soft bowel move- while on the toilet. Give the child enough time to evacuate
ments a day during the first 4 weeks of life. Flatus often the bowel, but do not have the child sit on the toilet too long,
accompanies the passage of stool, and there may be a sour as both the child and the parent may become frustrated.
odor to the bowel movement. By the fourth week of life, the Children at this age like to please their parents. Evac-
number of bowel movements has decreased to two to four uation of the bowel is a natural process and should not be
per day. By 4 months, there is a predictable interval between approached as a dirty or unnatural one. The child should
bowel movements. be rewarded when able to defecate, but should not be pun-
It is common for an infant to push or strain at stool. ished if unable to have a bowel movement. Children should
However, if the stools are very hard or dry, the infant should feel proud of their accomplishments, and should not be pun-
be assessed for constipation. The bottle-fed infant is more ished or made to feel ashamed for not producing expected
prone to constipation than the breastfed infant is. results.
Infants sometimes suffer from what is known as colic, Children usually do not need enemas or laxatives to
described as daily periods of distress caused by rapid, vio- make them regular. In fact, the artificial aids may be dan-
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234 • Elimination Pattern
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Developmental Considerations • 235
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Copyright © 2007 •by F. A. Davis.
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236 • Elimination Pattern
T A B L E 4 . 1 NANDA, NIC, and NOC Taxonomy Linkages (continued from page 235)
GORDON’S
FUNCTIONAL NANDA NURSING NIC PRIORITY
HEALTH PATTERN DIAGNOSIS INTERVENTIONS NOC EVALUATIONS
Urinary Incontinence: Urinary Incontinence Care Tissue Integrity: Skin & Mucous
Total Membrane
Urinary Continence
Urinary Elimination
Urinary Incontinence: Urinary Habit Training Self-Care: Toileting
Urge Urinary Incontinence Care Urinary Continence
Urinary Elimination
Urinary Incontinence: Urinary Habit Training Infection Severity
Urge, Risk for Knowledge: Medication; Treatment
Regimen
Medication Response
Neurological Status: Autonomic
Risk Control
Risk Detection
Stress Level
Urinary Continence
Urinary Elimination
Urinary Retention Urinary Catheterization Urinary Continence
Urinary Retention Care Urinary Elimination
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Copyright © 2007 by F. A. Davis. •
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Bowel Incontinence • 237
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Copyright © 2007 •by F. A. Davis.
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238 • Elimination Pattern
Child Health
Nursing actions for bowel incontinence in the child are essentially the same as those for Adult Health, plus the following.
Modifications need to be made for child’s age and size (e.g., medication dosage and fluid amounts). Encopresis is the term
noted in the literature, with a prerequisite factor identified to be that the event must occur at least once a month for at least
3 months, and the chronological or developmental age of the child must be at least 4 years.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for contributory factors, especially environmental Allows for fullest consideration of possible etiology for
change such as a new home, birth of sibling, or change the problem of bowel incontinence.
in bathrooming environment.
Note related abnormalities of the digestive tract including Allows for fullest consideration of possible etiology for
leakage secondary to bowel obstruction in infants or the problem of bowel incontinence.
Hirschsprung’s syndrome of mega-colon or related
bowel obstruction with leakage.
Assess for related medical conditions such as Ensures consideration for fullest possible etiology of
myelomeningocele, cerebral palsy, or hypothyroidism. problem of bowel incontinence.
For instances of pattern of fear–pain cycles of encopresis, Emotional factors may contribute to the pattern.
assess for possible disturbance in the mother–child
relationship.
Assess for stressors in the family or child’s daily routine. Stress contributes to altered bowel pattern.
Obtain a full history in order to individualize the plan of Offers individualized plan of care with attention to pri-
care. Identify related circumstantial factors and encour- mary factors.
age the parents to share their thoughts regarding the
problem.
Maintain a nonjudgmental attitude throughout. Fosters open communication.
Allow for embarrassment according to age when child is Communicates caring and nonjudging of behaviors.
expected to be self-toileting.
Provide appropriate emotional support for child and Offers validation of the importance of being accepted by
family. others and how this is threatened.
Women’s Health
Nursing actions and interventions in bowel incontinence in Women’s Health are the same as in Adult Health, except for
the following:
As women age and estrogen levels decrease, the perineal Encourage women to discuss with the health care
floor sometimes loses elasticity, which can lead to con- provider any problems with changes in bowel habits.
stipation and/or bowel incontinence if proper diet and Many women will not discuss these problems because
exercise are not practiced. of embarrassment.16
Many women who have suffered uterine prolapse and
pelvic relaxation with displacement of pelvic organs
can be relieved only by surgical repair.15
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
If a pattern forms around specific events, develop plan to: Promotes the client’s perceived control, and increases
• Remind the person to use the bathroom before the potential for the client’s involvement in treatment
event. Add positive reinforcers as they remember on plan.17
their own. [Note reinforcers to be used here.]
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Bowel Incontinence • 239
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Alter the manner in which a specific task is performed
to prevent stress. [Note alterations here.]
• Discuss with the client alternative ways of coping
with stress. (Refer to Chapter 8 for specific nursing
actions related to reduction of anxiety, and Chapter
11 for specific nursing actions related to ineffective
coping.)
If assessment suggests secondary gains associated with Provides negative consequences for inappropriate coping
episodes, decrease these by: behavior.18
• Withdrawing social contact after an episode
• Having the client clean him- or herself
• Providing social contact or interactions with the client
at times when no incontinence is experienced
If not related to secondary gain, spend [number] minutes Verbalization of feelings in a nonthreatening environment
with the client after each episode to allow expression models acceptance of feelings and positive coping
of feelings. behavior.18
Discuss with the client the effects this problem has on his Increases the client’s awareness of impact inappropriate
or her lifestyle. coping behaviors have on lifestyle. Provides data for
development of alternative coping, promoting the
client’s perceived control.19
Gerontic Health
l N O T E : Incontinence is not a normal part of aging. When older adults experience
incontinence, efforts should be made to both determine the cause of the incontinence and
return the client to a continent state.
In addition to the interventions for Adult Health, the following may be utilized for the aging client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Record events associated with incontinent episode. Assists in determining the pattern of incontinence. Older
adults may have difficulty in reaching the commode or
bathroom easily.
Monitor medication intake for potential to result in bowel Medications with a sedative effect may decrease the abil-
incontinence. ity of the client to reach toilet facilities in a timely
manner.
Teach toileting skills to caregivers of cognitively Depending on the stage of the disease, a person with
impaired older adults. In early dementia, labeling the dementia may forget to toilet or have difficulty finding
bathroom and reminding the individual to toilet may a bathroom that is not readily identified.
result in continence.
Home Health
Nursing actions for incontinence in the Home Health setting are the same as those for Adult Health, with the following
additions:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client/family in identifying factors that may be Diarrhea is a common cause of bowel incontinence.
contributing to the problem: Promotes understanding of the condition and may lead
to solutions.
(care plan continued on page 240)
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240 • Elimination Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Diarrhea
• Diet
• Medications
• Environmental issues
• Fatigue
• Difficulty removing clothes
Modify the home environment as needed to facilitate con-
tinence as appropriate:
• Clear the path to the bathroom.
• Provide bedside commodes as needed.
Educate the client/family on the correct use of antidiar- Diarrhea is a common cause of bowel incontinence.
rheal agents as needed to reduce the frequency of
bowel movements.
Monitor skin integrity for skin breakdown. These measures prevent secondary problems from occur-
ring as a result of the existing problem.
Educate the client/family regarding the need to keep bed These measures prevent secondary problems from
linens and clothing clean and dry occurring as a result of the existing problem.
Assess the client/family need for adult diapers, linens. These measures prevent secondary problems from occur-
Make referrals for obtaining these supplies as ring as a result of the existing problem.
appropriate.
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Constipation, Risk for, Actual, and Perceived • 241
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242 • Elimination Pattern
j. Rectocele
Deficient Fluid Volume
k. Rectal prolapse This diagnosis might also be the primary problem. The
l. Neurologic impairment feces need adequate lubrication to pass through the
m. Hemorrhoids gastrointestinal tract. If there is a Deficient Fluid
n. Obesity Volume, the feces is harder, more solid, and unable to
B. Risk for Constipation move through the system.
The risk factors are also the related factors.
C. Perceived Constipation Diarrhea or Bowel Incontinence
1. Impaired thought processes Constipation can be misdiagnosed as Diarrhea or
2. Faulty appraisal Bowel Incontinence. Diarrhea or incontinence may
3. Cultural or family health belief be a secondary condition to constipation, as semi-
liquid feces may pass around the area of constipa-
RELATED CLINICAL CONCERNS tion.
4 Have You Selected the Correct Diagnosis? ated. Both of these psychosocial diagnoses initiate
stress as an autonomic response, and the parasympa-
Imbalanced Nutrition, Less or thetic system stimuli (which control motility of the
More Than Body Requirements gastrointestinal tract) are reduced. This reduced motil-
This might be the primary nursing diagnosis. Either of ity may lead to constipation.
these diagnoses influences the amount and consis-
tency of the feces.
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Constipation, Risk for, Actual, and Perceived • 243
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Attempt digital removal using gloves and lubrication.
• Administer oil retention enema of small volume.
Have the client retain for at least 1 hour.5
• Use small-volume saline enema if oil retention does
not relieve impaction.
Collaborate with appropriate members of health-care
team regarding additional pharmacological strategies
(e.g., stool softeners, laxatives, etc.).
Measure and total intake and output every shift. Allows monitoring of adequate fluid intake to increase
water content of feces.
Force fluids, of client’s choice, to at least 2000 mL daily. Increases moisture and water content of feces for easier
Provide 8 ounces of fluid every 2 hours on [odd/even] movement through intestines and anus.
hour beginning at awakening each morning. [Note
client’s preferred fluids here.]
Increase the client’s activity to extent possible through Activity promotes stimulation of the bowel and assists in
ambulation at least three times per day while awake. elimination.
[Note schedule here.]
Assist the client with implementation of stress reduction Promotes relaxation and can increase feces passage
techniques at least once per shift. [Note technique to be through the intestines.
used and schedule here.]
Digitally stimulate the anal sphincter at scheduled times Stimulates defecation reflex and urge.
(usually after meals) [State times here].
Provide privacy and sufficient time for bowel elimination. Decreases stress and promotes relaxation, which
increases likelihood of bowel movement.
Help the client assume positions that facilitate bowel Promotes effective use of abdominal muscles, and allows
movements (e.g., a forward leaning position while sit- gravity to assist in defecation.
ting, or a semi-Fowler’s position if on a bedpan).20
Monitor anal skin integrity at least once per shift. Straining at stool can cause splits and tears of the anal
tissue.
Teach the client, starting as soon after admission as Promotes understanding of self-care needs prior to dis-
possible: charge.21
• Pelvic floor muscle exercises Strengthens pelvic floor and abdominal muscles.
• The importance of a bowel routine and the need to
respond to the urge to defecate as soon as possible
• To stimulate gastrocolic reflex through drinking prune
juice or hot liquid on arising
• To allow sufficient time for bowel movement and plan
time for elimination
• To include high-fiber foods and adequate liquid in
daily diet
• To avoid prolonged use of elimination aids such as
laxatives and enemas
• To avoid straining
• To use proper perineal hygiene
• To describe the relationship of diet and activity to
bowel elimination
Collaborate (as deemed necessary), with the following as Provides basic resources and information needed; pro-
soon as possible after admission: motes holistic approach to treatment.
• With the dietitian, regarding a high-fiber, high-
roughage diet (the more food a client eats, the less lax-
atives the client will require)
• With the physical therapist, regarding exercise program
(care plan continued on page 244)
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244 • Elimination Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• With the health-care provider, regarding mild anal-
gesics and ointments for control of pain associated with
bowel movements
• With the health-care provider, regarding use of stool
softeners, laxatives, suppositories, and enemas
• With the enterostomal therapist, regarding ostomy care
(i.e., irrigations, stoma and skin care, and appliances)
• With the psychiatric nurse clinician, regarding counsel-
ing for the client and family about possible underlying
emotional components
• With the home health nurse, regarding follow-up plan-
ning for home and usual daily activities of living with
emphasis on stress, etc.
Child Health
Nursing actions for constipation in the child are essentially the same as those for Adult Health. Modifications would
be made for child’s age and size, for example, medication dosage and fluid amounts. For the diagnosis of Risk for
Constipation, the following actions would be appropriate:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for all possible contributory factors including: Appropriate identification of cause of constipation in
• Hirschsprung’s disease (congenital aganglionic case of Hirschsprung’s disease will offer appropriate
megacolon) treatment.
• Neonatal period:
• Failure to pass meconium in first 24 to 48 hours after
birth
• Reluctance to ingest fluids
• Bile-stained vomitus
• Abdominal distention
• Intestinal obstruction
• Infancy:
• Inadequate weight gain
• History of constipation
• Abdominal distention
• Episodic diarrhea and vomiting
• Bloody diarrhea
• Fever
• Severe lethargy
• Childhood:
• Constipation
• Ribbon-like, foul-smelling stools
• Abdominal distention
• Palpable fecal masses
• History of poor appetite, poor growth
Monitor for contributing factors according to likelihood Developmentally appropriate factors will assist in
of potential for age, diet, known medical status, and identification of likely essential issues.
developmental crisis (e.g., iron in infant formula, vita-
mins, known hypothyroidism, self-toileting, etc.).
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Constipation, Risk for, Actual, and Perceived • 245
Women’s Health
Nursing actions for constipation in women are essentially the same as those for Adult Health, except for the following con-
siderations during pregnancy:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client in identifying lifestyle adjustments that Provides information needed as basis for planning care
may be needed because of changes in physiologic and health maintenance.
function, or needs during experiential phases of life
(e.g., during pregnancy, postpartum, and following
gynecologic surgery).
Teach the client changes that occur during pregnancy that Provides basic information for self-care during preg-
contribute to decreased gastric motility and potential nancy, birthing process, and postpartum.22
constipation:
• Fluid intake may decrease because of nausea and vom-
iting of early pregnancy.
• Increased use of mother’s body fluid intake to pro-
duce lactation can lead to decrease in fluid intake
overall.
• Supplemental iron during pregnancy can lead to severe
constipation.
• Fear of injury or pain upon defecation after birth can
lead to constipation.
Teach anatomic shifting of abdominal contents because Provides information as a basis for nutrition plan during
of fetal growth. pregnancy. Promotes self-care.
Teach hormonal influences (e.g., increased progesterone)
on bodily functions:
• Decreased stomach emptying time
• Decreased peristalsis
• Increase in water reabsorption
• Decrease in exercise
• Relaxation of abdominal muscles
• Increase in flatulence
Teach the effects of the increase in oral iron or calcium Provides basis for teaching the client plan of self-care
supplements on the gastrointestinal tract (e.g., consti- at home, and promotes healing process.
pation).
Describe the physical changes present in the imme-
diate postpartum period that affect the gastrointesti-
nal tract:
• Lax abdominal muscles
• Fluid loss (perspiration, urine, lochia, or dehydration
during labor and delivery)
• Hunger
Assist the client in planning diet that will promote heal- Promotes successful lactation, good self-care, and good
ing, replace lost fluids, and help with return to normal nutrition, and provides basis for teaching care.
bowel evacuation.
Instruct in the use of ointments, anesthetic sprays, sitz
baths, and witch hazel compresses to relieve epi-
siotomy pain and reduce hemorrhoids.
Instruct in pelvic floor exercises (Kegel exercises) to
assist healing and reduction of pain.
Teach nursing mothers alternate methods of assistance
with bowel evacuation other than cathartics (cathartics
are expressed in breast milk).
(care plan continued on page 246)
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246 • Elimination Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Prune juice
• Hot liquids
• High-fiber, high-roughage diet
• Daily exercise
Describe the physical changes present in the imme- Provides basis for teaching and planning of care.
diate postoperative period (cesarean section and Promotes and encourages self-care.
gynecologic surgery) that affect the gastrointestinal
tract:
• Fluid loss (blood loss or dehydration as a result of
NPO [nothing by mouth] status and surgery)
• Decreased peristalsis
• Bowel manipulation during surgery
• Increased use of analgesics and anesthesia
During pregnancy: Gastrointestinal tract motility slows because of hormones
(particularly progesterone) and increased growth of
uterus. Greater absorption of water causes drying of
stool.
• Encourage women to drink sufficient fluids (at least Constipation can be avoided by increasing fluids and fiber
eight glasses per day). in the diet and regular exercise.16
• Establish regular schedule for bowel movements.
• Encourage a balanced diet with appropriate amounts of
fiber, fruits, and vegetables.
During pregnancy the bowel is misplaced by the growing Education and nutritional counseling should focus
uterus and this can lead to changes in bowel elimina- on dietary advice to ensure the new mother is drink-
tion and function. ing sufficient fluids and including roughage in her
diet.22
During the postpartum period the combination of medica- The above is especially true during the postpartum period
tions used in labor and delivery, a hectic schedule, lack and when breastfeeding.22
of sleep, as well as preoccupation with a new baby,
lead to changes in elimination patterns.
Mental Health
Clients taking antipsychotics, antianxiety agents, and antidepressants are at risk for this diagnosis.23 The nursing actions
for Mental Health are the same as those for Adult Health. Please refer to those recommended actions.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review medication record for drugs that may have consti- Older adults receiving opioid analgesics, antidepressants,
pation as a side effect. anticholinergics, or certain antacids may experience
constipation due to the drug-delayed motility of waste
matter through the intestine. Older adults are more
likely to be on multiple medications that can result in
constipation.
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Constipation, Risk for, Actual, and Perceived • 247
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collaborate with the physician regarding changes in med-
ication to avoid the side effect of constipation.
Collaborate with the client to increase their mobility as Lack of exercise is associated with slowed bowel motility.
appropriate through:
• Consultation with physical therapy
• Chair exercises
Collaborate with client and caregivers to increase fluid Increased fluid and fiber prevent constipation. Increased
and fiber intake. Caution should be taken to increase fiber in the absence of adequate fluid consumption can
fiber only when fluids are tolerated well. lead to increased incidence of fecal impaction, particu-
larly in immobile clients.
Use bulking agents with care in the aging client. Increased fiber in the absence of adequate fluid consump-
tion can lead to increased incidence of fecal impaction,
particularly in immobile clients.
Encourage the client to establish effective bowel habits: These habits minimize the risk of constipation.11
• Taking advantage of the gastro-colic reflex but toileting
after meals
• Toileting at a regular time each day
• Ensuring that the toilet is the correct height, using seat
raisers as needed.
Assist the client to maintain adequate toileting facilities: These habits minimize the risk of delayed emptying
• Privacy during toileting which leads to constipation.11
• Toilet at the correct height
• Assistance with mobility as needed
• Facilities to call for assistance to access toilet
Home Health
l N O T E : Nursing actions for constipation in the Home Health setting are the same as
those for Adult Health. The locus of control shifts from the nurse to the client, family,
and/or caregiver.
ACTIONS/INTERVENTIONS R AT I O N A L E S
The nurse will teach others to complete activities. The client and members of the family may have different
ideas regarding appropriate elimination patterns.
Teach the client and family the definition of constipation. Nursing interventions for physiologic definition are out-
Determine whether the problem is perceived by the lined in the Adult Health nursing action. Nursing inter-
client and family because of incorrect definition or is ventions for varying definitions require family
based on physiologic dysfunction. involvement.
Assist the client and family in identifying lifestyle Home-based care requires involvement of the family.
changes that may be required: Bowel elimination problems may require adjustments
• Establishment of a regular elimination routine based on in family activities.
cultural and individual variations
• Stress management techniques
• Decrease in concentrated, refined foods
• Identification of any food intolerances or allergies and
avoidance of those foods
• Appropriate use and frequency of use of prescribed and
over-the-counter medications
• Physiologic parameters of constipation
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Diarrhea • 249
ACTIONS/INTERVENTIONS R AT I O N A L E S
Measure and total intake and output every shift. Monitors hydration status.
Provide oral intake of fluids and bland food. Fluid intake will assist in maintaining adequate fluid bal-
ance. Bland foods will avoid bowel stimulation.
Ensure the client can easily access bathroom facilities or Helps prevent accidents and prevent embarrassment for
bedside commode. the client.
Administer antidiarrheal medications as prescribed and Documents effectiveness of medication.
document results within 1 hour after administration.
For example, diarrhea decreased from one stool every
30 minutes to one stool every 2 hours.25
Increase fluid intake to at least 2500 mL per day. Maintains hydration status.
Offer fluids high in potassium and sodium at least once Replaces or maintains electrolytes lost with diarrhea.
per hour (e.g., sports drinks).
Serve fluids at tepid temperature (avoid temperature Fluids at temperature extremes can stimulate the bowel.
extremes).
List the client’s fluid likes and dislikes here.
Provide perineal skin care after each bowel movement. Dries moisture, prevents skin breakdown, and prevents
Inspect perianal skin integrity after each bowel perineal infection. Monitors for skin breakdown.
movement.
If tube feedings are a causal factor, collaborate with the Modification may decrease incidence of diarrhea.
appropriate health-care provider regarding optimal
enteral therapy.
Assist the client with stress reduction exercises at least Promotes relaxation and decreases stimulation of bowel.
once per shift; provide quiet, restful atmosphere. [Note
exercises to be used and schedule here.]
Collaborate with the dietitian regarding low-fiber, low- Helps identify foods that stimulate bowel and exacerbate
residue, soft diet. diarrhea.
List here those foods that the client has described as
being irritating.
Teach the client: Increases the client’s knowledge of causes, treatment, and
• Diet: avoiding irritating foods, including basic food complications of diarrhea. Promotes self-care.
pyramid groups, influence of high-fiber foods, and
influence of fruits.
• Fluids: maintaining intake and output balance, influ-
ence of environmental temperature, influence of activ-
ity, and influence of caffeine and milk.
• Medications: caution with over-the-counter medica-
tions, those that are antidiarrheal, and those that poten-
tiate diarrhea (e.g., antacids and antibiotics).
Child Health
The treatment of diarrhea is obviously dictated by its severity, and the resultant effect on hydration and electrolyte bal-
ance, and is managed according to individual factors such as age, possible etiology, and status of the infant/child. As a
rule, the younger the child, the more severe the effects of diarrhea. Children experiencing malnutrition, or with a com-
promised immune status, are typically affected more than others. Additional factors include overcrowding and potential
contamination of milk.
(care plan continued on page 250)
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250 • Elimination Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Weigh diapers for urine and stools; assess specific gravity A strict assessment of intake and output serves as a basis
after each voiding. for monitoring the efficacy of the treatment and may
provide a database for treatment protocol. Hydration
is monitored via specific gravity as an indication of
the renal ability to adjust to fluid and electrolyte
imbalance.
Monitor for signs and symptoms of dehydration: Dehydration is extremely dangerous for the infant and
• Depressed anterior fontanel in infants requires close monitoring to offset the effects of dehy-
• Poor skin turgor dration.
• Decreased urinary output
Monitor signs and symptoms associated with Associated signs and symptoms serve as supportive data
bowel movement, including cramping, flatus, and to follow the altered bowel function, with an emphasis
crying. on related pain or discomfort.
Provide prompt and gentle cleansing after each diaper Skin breakdown occurs in a short period of time because
change. For older children, offer warm soaks after each of frequent bowel movements and the resultant skin
diarrheal episode. irritation.
• Collaborate with the physician regarding: These nursing measures constitute routine measures to
• Frequent stooling (more than three times per shift) monitor diarrhea and its related problems. Prompt
• Excessive vomiting reporting and intervention decrease the likelihood of
• Possible dietary alterations for specific formula more serious complications.
or diet Oral rehydration therapy is favored when acute diarrhea
• Monitoring electrolytes and renal function occurs.
• Maintenance of intravenous (IV) fluids
• Antidiarrheal medications free of opioids.
Women’s Health
l N O T E : Some women experience diarrhea 1 or 2 days before labor begins. It is not
certain why this occurs, but it is thought to be due to the irritation of the bowel by the
contracting uterus and the decrease in hormonal levels (estrogen and progesterone) in
late pregnancy. For diarrhea that is a precursor to labor, the following action applies.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Offer oral electrolyte solutions such as: Provides nutrition, electrolytes, and minerals that support
• Gatorade® a successful labor process. Recent research has shown
• Classic Coca-Cola® that women can safely eat light foods or drink fluids
• Jell-O® during labor to maintain energy and fluid balance,
• Pedialyte® without harm. There was no increased vomiting in the
later stages of labor than has been historically reported.
However, because of other multiple variables present in
the acute care setting, the authors could not provide
convincing evidence to change practice.26
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Diarrhea • 251
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor lithium levels when these clients present with Diarrhea can be a normal side effect with the initiation of
diarrhea. Li therapy. It is more common in toxicity. Fluid and
electrolyte imbalance caused by diarrhea fluid loss can
increase the risk of Li toxicity.23
Discuss with the client the role stress and anxiety play in Diarrhea can be related to autonomic nervous system
this problem. response to emotions.27
Develop with the client a stress reduction plan and prac- Promotes the client’s adaptive response to stress, and pro-
tice specific interventions three times a day at [list motes the client’s sense of control.
times here].
Refer to Chapter 8 for specific nursing actions related to
the diagnosis of anxiety.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor medication intake to assess for potential side The older adult may be having diarrhea as a result of
effect of diarrhea. antibiotic therapy, use of drugs with a laxative effect,
such as magnesium-based antacids, or as a sign of drug
toxicity secondary to antiarrhythmics, such as digitalis,
quinidine, or propranolol.
Collaborate with the physician regarding possible alter-
ations in medications to decrease the problem of diar-
rhea.
Frequently offer electrolyte-rich fluids of choice to pre- Provides nutrition, electrolytes, and minerals to offset or
vent dehydration. prevent dehydration.
Carefully monitor the client for early symptoms of dehy-
dration.
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252 • Elimination Pattern
READINESS FOR ENHANCED 5. The patient positions him- or herself for emptying of
URINARY ELIMINATION bladder.
6. Fluid intake is adequate for daily needs.
DEFINITION13
A pattern of urinary functions that is sufficient for meeting
eliminatory needs and that can be strengthened. EXPECTED OUTCOME
Will maintain or improve current state of urinary elimina-
DEFINING CHARACTERISTICS13 tion patterns by [date].
1. The patient expresses willingness to enhance urinary
elimination.
TARGET DATES
2. Urine is straw colored with no odor.
3. Specific gravity is within normal limits. As this is a positive diagnosis with predominantly teaching
4. The amount of output is within normal limits for age interventions, appropriate target dates can be as long as 7 to
and other factors. 10 days with intermittent reassessment weekly.
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Readiness for Enhanced Urinary Elimination • 253
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist patient in identifying appropriate bladder training
program:
• Pelvic muscle training program
• Biofeedback
• Scheduled voiding
Follow up weekly [list dates here]. Monitors progress and allows for appropriate revision
of plan.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for all possible contributory factors to consider, Provides the most inclusive base for care.
especially cultural influences.
Offer a child-oriented approach.
Validate readiness for the toddler: Appropriately validates realistic expectations for the
• Physical child.29,30
• Ability to hold urine for 2 hours or more
• Gross motor skills of sitting, walking, and squatting
• Fine motor skills for self-removal of clothing
• Mental
• Recognizes cues for need to urinate
• Cognitive capacity to role model others in toileting
behaviors
• Psychological
• Expresses willingness to please parent
• Capacity to self-identify wet diaper and desire to be dry
Validate readiness for the caregiver(s):
• Recognizes toddler’s cues for readiness.
• Verbalizes willingness to invest time for assisting with
the urination pattern.
• Verbalizes absences of major family stressors that
would interfere with success of pattern (divorce, move,
addition of new sibling).
Acknowledges readiness to approximate 18 months of Validates realistic expectations.
age with pattern for girls to exhibit earlier patterns than
boys.
Acknowledge cultural aspects for family. Sensitivity to family values creates respect and pro-
vides a likelihood of success in follow-through of
pattern.
Consider use of free-standing potty chair and/or transi- Provides a sense of security for child.
tional portable seat attached to toilet.
Practice sessions should be limited to no more than Ensures safety and allows for natural elimination of
10 minutes with parent in presence of toddler. urine.
Praise the child for cooperative behaviors. Offers reinforcement of learning.
Use dolls, books, or other materials for learning that are Provides nonstressful learning at an appropriate level
appropriate for the toddler or child. with greater likelihood for success.
Assist the caregiver(s) and child to identify related Satisfies individual needs to increase likelihood of safety
assistance necessary to carry out plan, especially and success in dealing with the pattern.30,31
modified equipment to augment stability of potty
chair or toilet.
(care plan continued on page 254)
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Women’s Health
Interventions for Adult Health apply to women, along with the following considerations:
ACTIONS/INTERVENTIONS R AT I O N A L E S
A thorough assessment and physical exam to determine Age-related changes of aging contribute to urinary incon-
the extent of the problem should be performed. Include tinence in older women. Lack of care and assessment,
in the assessment physical problems, patient’s mobility, as well as the patient’s inability or reluctance to dis-
and environment. cuss problems with her health-care provider results in
approximately 40 percent of the admissions to nursing
homes.16
Engage the patient in bladder training: Learning different techniques can result in a 50 percent
• Postpone voiding. reduction of incontinence in some women. “Control
• Urinate at timed intervals by developing a schedule of requires intact cognitive, neurologic and physical
urination. parameters as well as motivational and environmental
• Biofeedback factors.”30
• Medication
Mental Health
Nursing interventions for this diagnosis are the same as those for Adult Health.
Gerontic Health
In addition to the interventions for Adult Health, the following may apply to the aging client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Maintain fluid intake: Ensures sufficient fluid intake, but restricts fluid when
activity decreases. Assists in preventing nocturia.
• Encourage fluids to at least 2000 mL per day. Dilute urine discourages bacterial growth.
Increase client activity if client is sedentary. Strengthens muscles and promotes kidney and bladder
functioning.
Beginning on day of admission, teach the client the fol- Strengthens pelvic floor muscles.
lowing exercises:
• Bent-knee sit-ups
• Bent-leg lifts
• Contracting posterior perineal muscles as if trying to
stop a bowel movement
• Contracting anterior perineal muscles as if trying to
stop voiding
• Starting and stopping urine stream
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Urinary Incontinence • 255
Urge Urinary Incontinence The state in which an 5. Voiding in small amounts (less than 100 mL)
individual experiences involuntary passage of urine occur- 6. Nocturia (more than two times per night)
ring soon after a strong sense of urgency to void. 7. Inability to reach toilet in time
Risk for Urge Urinary Incontinence Risk for invol- G. Risk for Urge Urinary Incontinence
untary loss of urine associated with a sudden, strong sensa- 1. Effects of medication, caffeine, alcohol
tion or urinary urgency. 2. Detrusor hyperreflexia from cystitis, urethritis, tumor,
renal calculi, and central nervous system disorders
DEFINING CHARACTERISTICS13 above pontine micturition center
3. Detrusor muscle instability with impaired con-
A. Urinary Incontinence
tractibility
1. Incontinence
4. Involuntary sphincter relaxation
2. Urgency
5. Ineffective toileting habits
3. Nocturia
6. Small bladder capacity
4. Hesitancy
5. Frequency
RELATED FACTORS13
6. Dysuria
7. Retention A. Urinary Incontinence
B. Functional Urinary Incontinence 1. Urinary tract infection
1. May only be incontinent in early morning 2. Anatomic obstruction
2. Senses need to void 3. Multiple causality
3. Amount of time required to reach toilet exceeds 4. Sensory motor impairment
length of time between sensing urge and uncontrolled B. Functional Urinary Incontinence
voiding 1. Psychological factors
4. Loss of urine before reaching toilet 2. Impaired vision
5. Able to empty bladder completely 3. Impaired cognition
C. Reflex Urinary Incontinence 4. Neuromuscular limitations
1. No sensation of urge to void 5. Altered environmental factors
2. Complete emptying with lesion above pontine mic- 6. Weakened supporting pelvic structures
turition center C. Reflex Urinary Incontinence
3. Incomplete emptying with lesion above sacral mic- 1. Tissue damage from radiation, cystitis, inflammatory
turition center bladder conditions, or radical pelvic surgery
4. No sensation of bladder fullness 2. Neurologic impairment above level of sacral micturi-
5. Sensations associated with full bladder such as tion center or pontine micturition center
sweating, restlessness, and abdominal discomfort D. Stress Urinary Incontinence
6. Unable to cognitively inhibit or initiate voiding 1. Weak pelvic muscles and structural supports
7. No sensation of voiding 2. Overdistention between voidings
8. Predictable pattern of voiding 3. Incompetent bladder outlet
9. Sensation of urgency without voluntary inhibition of 4. Degenerative changes in pelvic muscles and struc-
bladder contraction tural supports associated with increased age
D. Stress Urinary Incontinence 5. High intra-abdominal pressure (e.g., obesity, gravid
1. Reported or observed dribbling with increased uterus)
abdominal pressure E. Total Urinary Incontinence
2. Urinary frequency (more often than every 2 hours) 1. Neuropathy preventing transmission of reflex indicat-
3. Urinary urgency ing bladder fullness
E. Total Urinary Incontinence 2. Trauma or disease affecting spinal cord nerves
1. Constant flow of urine occurring at unpredictable 3. Anatomic (fistula)
times without distention, or uninhibited bladder con- 4. Independent contraction of detrusor reflex due to sur-
tractions or spasms gery
2. Unsuccessful incontinence refractory treatments 5. Neurologic dysfunction causing triggering of micturi-
3. Nocturia tion at unpredictable times
4. Lack of perineal or bladder-filling awareness F. Urge Urinary Incontinence
5. Unawareness of incontinence 1. Alcohol
F. Urge Urinary Incontinence 2. Caffeine
1. Urinary urgency 3. Decreased bladder capacity (e.g., history of pelvic
2. Bladder contracture or spasm inflammatory disease, abdominal surgeries, or
3. Frequency (voiding more often than every 2 hours) indwelling urinary catheter)
4. Voiding in large amounts (more than 550 mL) 4. Increased fluids
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Urinary Incontinence • 257
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Perineal skin integrity at least once per shift
• For bladder distention at least every 2 hours on
[odd/even] hour
Schedule fluid intake: Assists in predicting times of voiding. Decreases urge to
• Avoid fluids containing caffeine and other fluids that void at unscheduled times.
produce a diuretic effect (e.g., coffee, grapefruit juice,
and alcohol).
• Offer 8 ounces of fluid every 2 hours on [odd/even]
hour during the day.
• Limit fluids after 6 p.m.
Maintain bowel elimination. Monitor bowel movements, Fullness in bowel may exert pressure on bladder, causing
and record at least once each shift. bladder incontinence.
Beginning on day of admission, teach and have the Prevents skin irritation, infection, and odor.
patient return-demonstrate perineal skin care.
Respond immediately to the patient’s request for voiding. Immediate response may prevent an incontinent episode.
Implement scheduled voiding regimens which may Voiding at scheduled intervals prevents overdistention
include: and helps establish a voiding pattern.
• Schedule toileting every 2 hours on [odd/even] hour
during the day.
• Schedule toileting at least 30 minutes before foresee-
able incontinence times.
• Awaken the patient once during the night for voiding.
• Verbally prompting the patient to void every 2 hours on
[odd/even] hour. Praise the patient for appropriate toi-
leting.
Stimulate voiding at scheduled time by:
• Assisting the patient to maintain normal anatomic posi- A normal anatomical position facilitates voiding.
tion for voiding.
• Teach trigger techniques to stimulate voiding (e.g.,
gently tapping over bladder or having the patient listen
to dripping water).21
• Using Credé’s or Valsalva maneuver
• Providing privacy
• Providing night light and clear path to bathroom
Implement bladder training, including gradually increas- Extending time between voiding will increase volume
ing time between voiding [Note schedule here.] of urine in bladder and will stretch bladder.
Implement strategies to strengthen pelvic floor muscle Strengthens pelvic floor and abdominal muscles.
exercises, including Kegel exercises, biofeedback tech-
niques, or vaginal weight training.
Consult with the physician about the use of occlusive
devices that mechanically block the leakage of urine by
supporting the urethrovesical junction or occluding the
urethral meatus.
Assist the patient with stress reduction and relaxation Promotes relaxation and self-control of voiding.
techniques at least once per shift.
Collaborate with the physician regarding intermittent Prevents complications related to bladder overdistention.
catheterization and obtaining postvoid residual volumes.
Collaborate with the rehabilitation nurse clinician to Allows establishment of a program that is current in con-
establish a bladder-retraining program. tent and procedures.
(care plan continued on page 258)
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258 • Elimination Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the patient exercises to strengthen pelvic floor Strengthens pelvic floor muscles to better control
muscles. Exercise should consist of 10 repetitions at voiding.31
least three times per day, three to four times a week.
[Record date and times exercises are performed here.]
Teach the patient the importance of maintaining a daily Helps establish urinary elimination pattern, and prevents
routine: overdistention of bladder.
• Voiding upon arising
• Awakening self once during the night
• Voiding immediately before retiring
• Not postponing voiding unnecessarily
Discuss possibilities of client regaining continence. Helps preserve self-concept and body image. Promotes
Include discussion about techniques to facilitate social- compliance.
ization:
• Wearing street clothes with protective pads in under-
garments
• Maintaining bladder-retraining program
• Responding as soon as possible to voiding urge
Consult with physician regarding pharmacological
therapy.
Monitor for side effects of pharmacological therapy:
• Dry mouth
• Constipation
• Blurred vision
• Dizziness
Refer to home health care agency for follow-up. Provides continuity of care and support system for ongo-
ing care at home.
Child Health
Nursing actions for the child with incontinence are the same as for Adult Health, with attention to the developmental,
anatomic, and physiologic parameters for age and with attention to organic potentials, including congenital malformations.
Special allowance for urinary reflux or recurrent potential urinary tract infections should be made in all ages.
The definition is offered for primary enuresis as bedwetting in children who have never been dry for extended period
of time, and secondary enuresis as the onset of wetting after a period of established urinary continence. Nocturnal enure-
sis occurs only at nighttime while diurnal enuresis occurs during both day and night. Nocturnal enuresis is more common.
Although most children with enuresis do not experience coexisting psychopathology, some children also experience
developmental disorders, learning problems, or difficulties in behavior. Self-esteem is influenced according to the parental
response and especially is vulnerable in harsh or punitive instances. Severe punishment for unrealistic expectations or
inappropriate management of enuresis can serve as a trigger for child abuse.29
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for all possible contributing factors, including rul- Offers the fullest consideration of causes to best uncover
ing out urinary tract infection, structural disorders, all factors.32
neurologic deficits as with myelomeningocele, and
conditions with increased urinary output (diabetes mel-
litus or diabetes insipidus).
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Offer psychiatric intervention as the cues arise for need Offers the fullest consideration to provide holism.32
for same—may be related to sexual abuse or other psy-
chological factors.
Obtain history of wetting behavior in a nonjudgmental Creates a basis for open consideration of problem.32
manner including information of toilet training and
usual attempts for dealing with the behavior.
Initiate or instruct caregiver(s) and child (as appropriate) Provides baseline data to determine the extent of the
on how to do a baseline record of enuresis. problem and assists in monitoring treatment.32
Provide assistance in chosen therapy: Fosters support to child and family.32
• Conditioning therapy includes a stimulus response con-
ditioning often with a pad and buzzer alarm when
moisture is sensed-used with a success rate of approxi-
mately 60 to 90 percent.
• Retention control training is offered for enhancement
of bedwetters whose functional bladder capacity was
reduced.
• The waking schedule training includes awakening the Safeguards child from potential side effects.
child during the night at intervals. This method is suc-
cessful in reducing, but not eliminating incidents.
Drug therapy is used more and more and may include Ensures reduction of risk from overdosage.32
anticholinergic agents, vasopressin analog desmo-
pressin as a nasal spray, and other individualized com-
binations of modified doses for these and tricyclic
antidepressants or antispasmodics. In these instances,
the caregiver(s) must monitor for side effects and safe-
guard medications from potential overdose by other
siblings.
Support child and family within a non-punitive frame- Lessens sense of lost self-esteem and offers positive rein-
work during time of treatment. forcement without conditional acceptance of child.32
Women’s Health
l N O T E : The same nursing interventions pertains to Women’s Health as to Adult
Health. During pregnancy, the woman may occasionally experience uncontrolled void-
ing before reaching the toilet. This is usually caused by the overexpansion of the uterus
or the pressure and weight of the baby and uterus on the bladder. This usually resolves
after the delivery of the baby. Many women experience uncontrollable leakage of urine
due to injury during pregnancy and childbirth. However, certain medications, such as
diuretics, muscle relaxants, sedatives, and antidepressants, can contribute to urinary
incontinence.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client in identifying lifestyle adjustments that Bladder capacity is reduced because of enlarging uterus,
may be needed to accommodate changing bladder displacement of abdominal contents by enlarged
capacity caused by anatomic changes of pregnancy. uterus, and pressure on bladder by enlarged uterus.
• Teach the client to recognize symptoms of urinary tract
infection (urgency, burning, or dysuria).
• Teach the client how to take temperature (make sure
the client knows how to read thermometer).
• Instruct the client to seek immediate medical care if
symptoms of urinary tract infection appear.
(care plan continued on page 260)
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260 • Elimination Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach women Kegel exercises and pelvic floor muscula- Strengthening of pelvic floor muscles helps reduce the
ture retraining. urge to void and prevents leakage of urine.
Encourage good hygiene and cleansing of the perineum,
wiping from front to back to prevent urinary tract
infections.
Discuss the physiological changes women experience as Loss of estrogen after menopause contributes to weaken-
they age that affect the bladder and can lead to inconti- ing of pelvic muscle fibers. Bladder training, educa-
nence. tion, biofeedback along with medications including
• Ability of bladder to expand decreases. oral or vaginal estrogen can help alleviate some of the
• Involuntary bladder contraction increase. symptoms of incontinence.30
• Bladder outlet loses strength and resistance of pelvic
floor muscles resulting in being unable to close.
• Urethra shortens and weakens.
• Ability to postpone voiding decreases.
• Postvoiding residual volume increases.
Provide a nonjudgmental, relaxed atmosphere that will
encourage the woman to ask questions without embar-
rassment.
Mental Health
l N O T E : If the alteration is related to psychosocial issues and has no physiologic com-
ponent, initiate the nursing actions that follow. (Refer to Adult Health for physiologically-
produced problems.)
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor times, places, persons present, and emotional cli- Identifies target behaviors, and establishes a baseline
mate around inappropriate voiding episodes. measurement of behavior with possible reinforcers
for inappropriate behavior.18
Remind the client to void before a high-risk situation or Removes positive reinforcement for inappropriate
remove secondary gain process from situation. behavior.18
Provide the client with supplies necessary to facilitate Appropriate behavior cannot be implemented without
appropriate voiding behavior (e.g., urinal for the client the appropriate equipment.18
in locked seclusion area).
Inform the client of acceptable times and places for void- Negative reinforcement eliminates or decreases
ing and of consequences for inappropriate voiding. behavior.18
[Note consequences here.]
Have the client assist with cleaning up any voiding that Provides a negative consequence for inappropriate
has occurred in an inappropriate place. behavior.18
Provide as little interaction with the client as possible Lack of social response acts as negative reinforcement.18
during cleanup.
Provide the client with positive reinforcement for voiding Positive reinforcement encourages appropriate behavior.18
in appropriate place and time. [List specific reinforcers
for the client here.]
Spend [number] minutes with the client every hour in an Interaction with the nurse can provide positive reinforce-
activity the client has identified as enjoyable; do not ment. Withdrawing attention for inappropriate behavior
provide this time, or discontinue time, if the client provides negative reinforcement.18
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Urinary Incontinence • 261
ACTIONS/INTERVENTIONS R AT I O N A L E S
inappropriately voids during the specified time. [List
identified activities here.]
If the client voids inappropriately [number] during a shift, Negative consequences decrease or eliminate undesirable
he or she will spend [number] minutes (no more than behavior.18
30) in time-out. Each inappropriate voiding in time-out
adds 5 minutes to this time.
As behavior improves, add rewards for accumulated Intermittent reinforcement can render a response more
times of appropriate voiding (e.g., award a 2-hour pass resistant to extinction once it has been established.18
for 1 day of appropriate voiding). [Record these
rewards here.]
l N O T E : Refer to Chapters 8 and 11 for interventions related to the specific alterations
that would promote this coping pattern.
Gerontic Health
Incontinence is not a normal part of aging. When older adults experience incontinence efforts should be made to both
determine the cause of the incontinence and return the client to a continent state.
In addition to the interventions for Adult Health, the following may be utilized for the aging client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review medication record for drugs such as sedatives, Sedatives and hypnotics may result in a delayed response
hypnotics, or diuretics that may contribute to urinary to the urge to void. Diuretic therapy, depending on
incontinence. dosage and time of administration, may result in an
inability to reach the bathroom in a timely manner.
Assist the client/caregiver to establish a schedule for Promotes bladder tone, helps prevent accidents from
voiding. decreased sense of urge to void.
Modify the environment to facilitate continence: Prevents urgency incontinence due to environmental
• Call bells within reach barriers.
• Bedside commode, urinal, bedpan as appropriate in
reach
• Clear, unobstructed path to toileting facilities
• Well lit toileting facilities
Modify the client’s garments as appropriate to facilitate Prevents urgency incontinence due to difficulty removing
continence: garments.
• Elastic waist pants rather than zippers or buttons
• Pants rather than one-piece garments such as coveralls
• Knee high hose rather than panty hose
Home Health
l N O T E : If this nursing diagnosis is made, it is imperative that a physician referral
also be made. If referred to home care under a physician’s care, it is important to main-
tain and evaluate response to prescribed treatments.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client and family in identifying lifestyle Basic measures to prevent recurrence.
changes that may be required:
• Using proper perineal hygiene
• Taking showers instead of tub baths
• Drinking fluids to cause voiding every 2 to 3 hours to
flush out bacteria
• Scheduling fluid intake
(care plan continued on page 262)
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262 • Elimination Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Voiding after intercourse
• Avoiding bubble baths, perfumed soaps, toilet paper,
or feminine hygiene sprays
• Wearing cotton underwear
• Using proper handwashing techniques
• Following a daily routine of voiding (see Adult Health
actions)
• Establishing a bladder-retraining program
• Doing exercises to strengthen pelvic floor muscles
Providing an environment conducive to continence:
• Clear path to the bathroom
• A light in the bathroom
• Bedside commode as needed
• Clothes that are easily removed
• Wearing street clothes and protective underwear
• Using an air purifier
• Performing activities as tolerated
• Providing unobstructed access to bathroom
• Avoiding fluids that produce diuretic effect (e.g.,
caffeine, alcohol, or teas)
Teach the client and family to dilute and acidify the urine Dilute urine and acidic urine discourage bacterial growth.
by:
• Increasing fluids
• Introducing cranberry juice, poultry, etc., to increase
acid ash
Teach the client and family to monitor and maintain skin Prevents or minimizes problems secondary to inconti-
integrity: nence.
• Keep skin clean and dry.
• Keep bed linens and clothing clean and dry.
• Use proper perineal hygiene.
Assist the client and family to set criteria to help them Assists in preventing or minimizing further physiologic
determine when a physician or other intervention is damage.
required (e.g., hematuria, fever, or skin breakdown).
Monitor and teach the importance of appropriate medica-
tions and treatments ordered by physician.
Refer to appropriate assistive resources as indicated. Additional resources may be needed based on the under-
lying problem.
Educate the client about the importance of urinating on a Empties the bladder before stretching or distention
regular basis, prior to urge. occurs.
Assist the client in obtaining necessary personal hygiene Provides a sense of security.
supplies as needed (e.g., pads, diapers, linens).
Educate the client about prescribed medications and their Promotes sense of accountability and improves compli-
possible side effects. ance.
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264 • Elimination Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Teach the client to assist bladder contraction:
• Credé’s maneuver
• Valsalva maneuver
• Abdominal muscle contraction
• Pelvic floor muscle exercises, alternating contraction Strengthens the pelvic floor and abdominal muscles.
and relaxation of perineal muscles while sitting in a
chair and with feet placed apart on floor.
Collaborate with physician regarding: Relieves bladder distention, assists in scheduling voiding,
• Intermittent catheterization and prevents infection.
• Pharmacological agents
• Medications (e.g., urinary antiseptics or analgesics)
Refer to home health agency as appropriate at least Provides continuity of care and a support system for
2 days prior to discharge for continued monitoring. ongoing home care.
Child Health
l N O T E : For infants and children less than 20 pounds, it would be necessary to calcu-
late exact intake and output and fluid requisites according to the etiologic factors pres-
ent. Attention must be paid to the child’s physiologic developmental level regarding
urinary control.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide opportunities for the child and parents to verbal- Assists in reducing anxiety, and attaches value to the
ize concerns or views about body image disturbances client’s and parents’ feelings. Promotes the develop-
related to urinary control and retention. Spend at least ment of a therapeutic relationship.29
30 minutes per shift in privacy with the child and par-
ents to permit this verbalization.
Monitor parental (client as applicable) knowledge of pre- Parental knowledge will assist in the reduction of anxiety
ventive health care for the client: and will provide a greater likelihood for compliance
• Teaching and observation of urinary catheterization with the desired plan of care.29
• Maintenance of catheters and supplies
• How to obtain supplies
• How to obtain a sterile culture specimen
• Appropriate restraint of the infant
• Potential regarding urinary control
Provide opportunities for parental participation in the Appropriate parental involvement provides opportunities
care of the infant or child: for trial care and allows the parents to practice care in
• Feedings a safe, supportive environment before the time of more
• Bathing total self-care.29
• Monitoring intake and output. Caution for removal of Helps to monitor for other factors to be addressed and
too much urine* and for reporting of excessive pattern prevents hypovolemia, secondary to excessive removal
of urinary production as with diabetes insipidus. of urine according to age/size of child.29
• Planning for care to include individual preferences
when possible
• Assisting with procedures when appropriate
• Provision of safety needs
• Cautious handwashing to prevent infection33
• Appropriate emotional support
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Appropriate diversional activity and relaxation
• Need for pain medication
Collaborate with other health-care professionals as
needed.
Assist the family to identify support groups represented Identification of support for the family will best assist
in the community for future needs. them to comply with the desired plan of care while
reducing anxiety and promoting self-care.29,33
*Varies by size and age–get norms
Women’s Health
Actions and rationales are the same for Adult Health except in the following situation.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collaborate with the physician regarding intermittent It is not easy to catheterize a woman postpartum, nor is
catheterization. it desirable to introduce an added risk of infection, so
every effort and support should be directed toward
helping the woman to void on her own. If, however,
she is unable to void or to empty her bladder, an
indwelling catheter may be placed for 24 to 48 hours
to rest the bladder and allow it to heal, edema to sub-
side, and bladder and urethral tone to return.22
Mental Health
l N O T E : Clients receiving antipsychotic and antidepressant drugs are at increased
risk for this diagnosis.23 Refer to Adult Health for general actions related to this dia-
gnosis.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Place clients receiving antipsychotic or antidepressant Early intervention and treatment ensures better out-
medication on a daily assessment for this diagnosis. come.23
Elderly clients should be evaluated more frequently if
their physical status indicates.
Monitor the bladder for distention at least every 4 hours at
[times] if verbal reports are unreliable or if they indi-
cate a voiding frequency greater than every 4 hours.
Increase the client’s activity by: Activity maintains muscle strength necessary for mainte-
• Walking with the client [number] minimum of three nance of normal voiding patterns. (See Adult Health
times per day at [list times here] for specific exercises to strengthen pelvic floor mus-
• Collaborating with the physical therapist regarding an cles.)
exercise program. Note the plan developed with the
physical therapist here.
• Placing the client in a room distant from the day area, Anxiety can increase muscle tension and therefore con-
nursing stations, and other activity if condition does not tribute to urinary retention.18
contraindicate this
• Providing physical activities that the client indicates are
of interest. [List those here with the time for each.]
Teach deep muscle relaxation, and spend 30 minutes Anxiety can increase muscle tension and therefore con-
twice a day at [list times here] practicing this with the tribute to urinary retention.18
(care plan continued on page 266)
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266 • Elimination Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
client. Associate relaxation with breathing so that the
client can eventually relax with deep breathing while
attempting to void.
Collaborate with the physician regarding catheterization Catheterization increases the risk for infection, so every
and medication adjustments. effort and support should be directed toward helping
the client to void on his or her own.
Gerontic Health
l N O T E : Obstructive voiding symptoms secondary to prostate disease include hesi-
tancy, decreased force of stream, terminal dribbling, postvoid fullness, and double void-
ing. Benign prostatic hypertrophy (BPH) is the most common cause of prostatic
enlargement requiring intervention. Seventy-five percent of men older than 80 years of
age experience BPH and the resulting urinary symptoms.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collect a thorough and comprehensive history of the Assist the client and physician in determining the cause
client’s symptoms. of retention.
Review the medication record for use of anticholinergic, The use of anticholinergic, antidepressant, and antipsy-
antidepressant, and antipsychotic medications. chotic medication can result in urinary retention as a
side effect.
Home Health
l N O T E : If this nursing diagnosis is made, it is imperative that physician referral be
made. Vigorous intervention is required to prevent damage or systemic infection. If
referred to home care under a physician’s care, it is important to maintain and evaluate
the patient’s response to prescribed treatments.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client and family in lifestyle changes that may Similar to Adult Health. Locus of control now is with the
be required: family and client.
• Monitor bladder for distention.
• Record intake and output.
• Stimulate micturition reflex. (See Adult Health.)
• Institute bladder-retraining program.
• Perform exercises to strengthen pelvic floor muscles.
• Use proper position for voiding.
• Maintain fluid intake.
• Maintain physical activity as tolerated.
• Use straight catheterization.
Assist the client and family to set criteria to help them Knowledge will assist the client and family to seek timely
determine when a physician or other intervention is interventions.
required (e.g., specified intake and output limit, pain,
or bladder distention).
Assess the client/caregiver understanding of prescribed Facilitates self-care.
medications. Provide teaching as needed.
Refer to appropriate assistive resources as indicated. Additional support may be required to help the client and
family maintain care at home.
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Urinary Retention • 267
ACTIVITY–EXERCISE
5
PATTERN
1. ACTIVITY INTOLERANCE, RISK FOR 14. HOME MAINTENANCE, IMPAIRED 360
AND ACTUAL 283 15. INFANT BEHAVIOR, DISORGANIZED,
2. AIRWAY CLEARANCE, INEFFECTIVE RISK FOR AND ACTUAL, AND
292 READINESS FOR ENHANCED
3. AUTONOMIC DYSREFLEXIA, RISK FOR ORGANIZED 365
AND ACTUAL 299 16. PERIPHERAL NEUROVASCULAR
DYSFUNCTION, RISK FOR 370
4. BED MOBILITY, IMPAIRED 304
17. PHYSICAL MOBILITY, IMPAIRED 373
5. BREATHING PATTERN, INEFFECTIVE
307 18. SEDENTARY LIFESTYLE 381
6. CARDIAC OUTPUT, DECREASED 313 19. SELF-CARE DEFICIT (FEEDING,
BATHING-HYGIENE, DRESSING-
7. DISUSE SYNDROME, RISK FOR 321
GROOMING, TOILETING) 386
8. DIVERSIONAL ACTIVITY, DEFICIENT 20. SPONTANEOUS VENTILATION,
327 IMPAIRED 393
9. DYSFUNCTIONAL VENTILATORY 21. TISSUE PERFUSION, INEFFECTIVE
WEANING RESPONSE (DVWR) 331 (SPECIFY TYPE: RENAL, CEREBRAL,
10. FALLS, RISK FOR 336 CARDIOPULMONARY, GASTRO-
INTESTINAL, PERIPHERAL) 396
11. FATIGUE 340
22. TRANSFER ABILITY, IMPAIRED 406
12. GAS EXCHANGE, IMPAIRED 346
23. WALKING, IMPAIRED 408
13. GROWTH AND DEVELOPMENT,
DELAYED; DISPROPORTIONATE 24. WANDERING 411
GROWTH, RISK FOR; DELAYED 25. WHEELCHAIR MOBILITY, IMPAIRED
DEVELOPMENT, RISK FOR 353 415
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270 • Activity—Exercise Pattern
PATTERN DESCRIPTION 10. Does the family need help with home maintenance
after the patient goes home?
This pattern focuses on the activities of daily living (ADLs) a. Yes (Impaired Home Maintenance)
and the amount of energy the individual has available to b. No
support these activities. The ADLs include all aspects 11. Does the patient have health insurance?
of maintaining self-care and incorporate leisure time as a. Yes
well. Because the individual’s energy level and mobility b. No (Impaired Home Maintenance)
for ADLs are affected by the proper functioning of the 12. Is the patient within height and weight norm for age?
neuromuscular, cardiovascular, and respiratory systems, a. Yes
nursing diagnoses related to dysfunctions in these systems b. No (Delayed Growth and Development)
are included. 13. Can the patient perform developmental skills appropri-
As with the other patterns, a problem in the activ- ate for age level?
ity–exercise pattern may be the primary reason for the a. Yes
patient entering the health-care system or may arise second- b. No (Delayed Growth and Development)
ary to problems in another functional pattern. Any admis- 14. Are there any abnormal movements?
sion to a hospital may promote the development of problems a. Yes (Disorganized Infant Behavior)
in this area because of the therapeutics required for the med- b. No
ical diagnosis (e.g., bed rest) or because of agency rules and 15. If the patient is an infant, does he or she respond
regulations (e.g., limited visiting hours). appropriately to stimuli?
a. Yes
b. No (Disorganized Infant Behavior)
PATTERN ASSESSMENT 16. Does the patient’s cardiogram indicate arrhythmias?
1. Does the patient’s heart rate or blood pressure increase a. Yes (Decreased Cardiac Output)
abnormally in response to activity? b. No
a. Yes (Activity Intolerance) 17. Is the patient’s jugular vein distended?
b. No a. Yes (Decreased Cardiac Output)
2. Does the patient have dyspnea after activity? b. No
a. Yes (Activity Intolerance) 18. Are the patient’s peripheral pulses within normal
b. No limits?
3. Does the patient have a medical diagnosis related to the a. Yes
cardiovascular or respiratory system? b. No (Decreased Cardiac Output, Ineffective Tissue
a. Yes (Risk for Activity Intolerance) Perfusion, or Risk for Peripheral Neurovascular
b. No Dysfunction)
4. Does the patient have a history of Activity Intolerance? 19. Are the patient’s extremities cold?
a. Yes (Risk for Activity Intolerance, Sedentary a. Yes (Ineffective Tissue Perfusion or Risk for
Lifestyle) Peripheral Neurovascular Dysfunction)
b. No b. No
5. Does the patient complain of fatigue, weakness, or lack 20. Does the patient have claudication?
of energy? a. Yes (Ineffective Tissue Perfusion or Risk for
a. Yes (Activity Intolerance or Fatigue) Peripheral Neurovascular Dysfunction)
b. No b. No
6. Is the patient unable to maintain his or her usual rou- 21. Does the patient have full range of motion?
tines? a. Yes
a. Yes (Fatigue or Self-Care Deficit) b. No (Impaired Physical Mobility or Impaired
b. No Walking)
7. Does the patient report difficulty in concentrating? 22. Does the patient have problems moving self
a. Yes (Fatigue) in bed?
b. No a. Yes (Impaired Bed Mobility)
8. Review self-care chart. Does the patient have any self- b. No
care deficits? 23. Does the patient have problems ambulating?
a. Yes (Self-Care Deficit [specify which area]) a. Yes (Impaired Physical Mobility or Impaired
b. No Walking)
9. Can the patient engage in a usual hobby while in b. No
hospital? 24. Is the patient paralyzed?
a. Yes a. Yes (Risk for Disuse Syndrome)
b. No (Deficient Diversional Activity) b. No
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Conceptual Information • 271
25. Is the patient immobilized by casts or traction? 39. Can the patient independently transfer him- or herself
a. Yes (Risk for Disuse Syndrome or Risk for from site to site?
Peripheral Neurovascular Dysfunction) a. Yes
b. No b. No (Impaired Transfer Ability)
26. Does the patient have a spinal cord injury at T7 or
above?
a. Yes (Risk for Autonomic Dysreflexia) CONCEPTUAL INFORMATION
b. No
27. Does the patient have a spinal cord injury at T7 or Several nursing diagnoses are included in this pattern that, at
above and paroxysmal hypertension? first glance, seem to have little relationship with each other.
a. Yes (Autonomic Dysreflexia) However, closer investigation demonstrates that there is
b. No one concept common to all of the diagnoses: immobility.
28. Does the patient have a spinal cord injury at T7 or Immobility, or the impulses that control and coordinate
above and bradycardia or tachycardia? mobility, can contribute to the development of any of these
a. Yes (Autonomic Dysreflexia) diagnoses, or any of these diagnoses can ultimately lead to
b. No the development of immobility.
29. Review the mental status examination. Is the patient Mobility and immobility are end points on a contin-
exhibiting confusion or drowsiness? uum with many degrees of impaired mobility or partial
a. Yes (Impaired Gas Exchange) mobility between the two points.1 Immobility is usually dis-
b. No tinguished from impaired mobility by the permanence of the
30. Review blood gas levels. Does the patient demonstrate limitation. A person who is quadriplegic has immobility,
hypercapnia? because it is permanent; a person with a long cast on the left
a. Yes (Impaired Gas Exchange or Impaired leg has impaired mobility, because it is temporary.2
Spontaneous Ventilation) Mobility is defined as the ability to move freely and
b. No is one of the major means by which we define and express
31. Were rales (crackles) or rhonchi (wheezes) present on ourselves. The central nervous system integrates the stim-
chest auscultation? uli from sensory receptor nerves of the peripheral nerv-
a. Yes (Ineffective Airway Clearance) ous system and projection tracts of the central nervous
b. No system to respond to the internal or external environment
32. Is respiratory rate increased above the normal range? of the individual. This integration allows for movement
a. Yes (Ineffective Airway Clearance or Ineffective and expressions. A problem with mobility can be a measure
Breathing Pattern) of the degree of the illness or health problem of an indi-
b. No vidual.3
33. Is the patient on a ventilator? If yes, does the patient Patients with self-care deficits are most often those
have restlessness or an increase from baseline of blood who are experiencing some type of mobility problem.2
pressure, pulse, or respiration when weaning is Mobility problems require greater energy expenditure,
attempted? which leads to activity intolerance, deficient diversional
a. Yes (Dysfunctional Ventilatory Weaning Response) activity, and impaired home maintenance simply because of
b. No the lack of energy or nervous system response to engage in
34. Does the patient have dyspnea and shortness of breath? these activities.
a. Yes (Ineffective Breathing Pattern, Impaired Problems with mobility and nervous system response
Spontaneous Ventilation, or Activity Intolerance) also lead to other physical problems. When a person has
b. No impaired mobility or immobility, bed rest is quite often pre-
35. Is the patient exhibiting pursed-lip breathing? scribed or is voluntarily sought in an effort to conserve
a. Yes (Ineffective Breathing Pattern) energy. Several authors3–5 describe the physical problems
b. No that can occur secondary to prolonged bed rest:
36. Does the patient have a history of falling?
a. Yes (Risk for Falls) 1. Respiratory: Decreased chest and lung expansion
b. No causes slower and more shallow respiration. Pooling of
37. Does the patient have diminished mental status? secretions occurs secondary to decreased respiratory
a. Yes (Risk for Falls) effort and the effects of gravity. The cough reflex is
b. No decreased as a result of decreased respiratory effort,
38. Does the patient have difficulty in manipulating his or gravity, and decreased muscle strength. Acid–base bal-
her wheelchair? ance is shifted, causing a retention of carbon dioxide.
a. Yes (Impaired Wheelchair Mobility) Respiratory acidosis causes changes in mentation:
b. No vasodilatation of cerebrovascular blood vessels and
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272 • Activity—Exercise Pattern
increased cerebral blood flow, headache, mental However, the concept of immobility does serve to point out
cloudiness, disorientation, dizziness, generalized weak- the interrelatedness of the diagnoses.
ness, convulsions, and unconsciousness. In addition, Because fatigue plays a major role in determining the
because of the buildup of carbon dioxide in the lungs, quality and amount of musculoskeletal activity undertaken,
adequate oxygen cannot be inspired, leading to tissue consideration of the factors that influence fatigue is an
hypoxia. essential part of nursing assessment for the activity–exercise
2. Cardiovascular: Circulatory stasis is caused by vasodi- pattern. Fatigue might be considered in two general cate-
latation and impaired venous return. Muscular inactivity gories: experiential and muscular. The degree to which the
leads to vein dilation in dependent parts. Gravity effects individual participates in activity is significant in determin-
also occur. Decreased respiratory effort and gravity lead ing the fatigue experienced. Activities that the individual
to decreased thoracic and abdominal pressures that usu- enjoys are less likely to produce fatigue than are those not
ally assist in promoting blood return to the heart. Quite enjoyed. Preferences should be considered within the frame-
often patients have increased use of the Valsalva maneu- work of capacity and needs. Obviously, other factors that
ver, which leads to increases in preload and afterload of must be considered include the physical and medical condi-
cardiac output and, ultimately, a decreased cardiac out- tion of the person and his or her emotional state, level of
put. Continued limitation of activity leads to decreased growth and development, and state of health in general.
cardiac rate, slower circulatory volume, and arterial Oxygenation needs and extrinsic factors also need to be
pressure as a result of redistribution of body fluids. addressed. If there is overstimulation, such as with noise,
Venous stasis contributes to the potential for deep extremes of temperature, or interruption of routines, a
venous thrombosis and pulmonary embolus. After pro- greater amount of fatigue or disorganized behavior can be
longed bed rest, the normal neurovascular mechanism of expected. Sensory understimulation with resultant boredom
the cardiovascular system that prevents large shifts in can also contribute to fatigue.
blood volume does not function adequately. When the Fatigue can develop as a result of too much waste
individual who has experienced extended bed rest material accumulating and too little nourishment going to
attempts to assume an upright position, gravity pulls an the muscles. Muscle fatigue usually is attributed to the accu-
excessive amount of blood volume to the feet and legs, mulation of too much lactic acid in the muscles. Certain
depriving the brain of adequate oxygen. As a result, the metabolic conditions, such as congestive heart failure, place
individual experiences orthostatic hypotension.4 a person at greater risk for fatigue.
3. Musculoskeletal: Inactivity causes decreased bone
stress and decreased muscle tension. Osteoblastic and
osteoclastic activities become imbalanced, leading to
calcium and phosphorus loss. Decreased muscle use
DEVELOPMENTAL CONSIDERATIONS
leads to decreased muscle mass and strength as a result Diet, musculoskeletal factors, and respiratory and cardio-
of infrequent muscle contractions and protein loss. vascular mechanisms influence activity. Developmental con-
4. Metabolic: Basal metabolic rate and oxygen consump- siderations for diet are addressed in Chapter 3. The
tion decrease, leading to decreased efficiency in using developmental considerations discussed here specifically
nutrients to build new tissues. Normally, body tissues relate to musculoskeletal, respiratory, and cardiovascular
break down nitrogen, but apparently muscle mass loss factors.
with accompanying protein loss leads to nitrogen loss
and a negative nitrogen balance. Changes in tissue
INFANT
metabolism lead to increased potassium and calcium
excretion. Decreased energy use and decreased basal Many things, including genetic, biologic, and cultural fac-
metabolic rate (BMR) lead to appetite loss, which leads tors, influence physical and motor abilities. Nutrition, matu-
to a decrease in the nutrient intake necessary to offset ration of the central nervous system, skeletal formation, and
losses. overall physical health status, as well as amount of stimula-
5. Skin: The negative nitrogen balance previously dis- tion, environmental conditions, and consistent loving care
cussed, coupled with continuous pressure on bony also play a part in physical and motor abilities.6 Girls usu-
prominences, leads to a greatly increased potential for ally develop more rapidly than do boys, although boys have
skin breakdown. a higher activity level.6
All muscular tissue is formed at birth, but growth
Immobility is not the sole causative factor of the nurs- occurs as the infant uses the various muscle groups. This use
ing diagnoses in this pattern. Many of the diagnoses can be stimulates increased strength and function.
related to specific medical diagnoses, such as congestive The infant engages in various types of play activity at
heart failure, or may occur as a result of diagnoses in this various times in infancy because of developing skills and
pattern, for example, Delayed Growth and Development. changing needs. The infant needs the stimulation of parents
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Developmental Considerations • 273
in this play activity to develop fully. However, parents In the lungs, the alveoli are functioning, but not all
should be aware of the dangers of overstimulation. Fatigue, alveoli may be expanded. Therefore, there is a large amount
inattention, and injury to the infant may result.6 of dead space in the lungs. The infant has to work harder to
Interruptions in the normal developmental sequence exchange enough oxygen and carbon dioxide to meet body
of play activities due to illness or hospitalization, for exam- demands. The elevated respiratory rate of the infant (30 to
ple, can have a detrimental effect on the future development 60 per minute) reflects this increased work. In addition, arte-
of the infant or child. An understanding of the normal rial blood gases of the infant may show an acid–base imbal-
sequence of play development is important so that therapeu- ance. The rate and rhythm of respiration in the infant is
tic interventions can be designed to approximate the devel- somewhat irregular, and it is not unusual for the infant to use
opmental needs of the individual. accessory muscles of respiration. Retractions with respira-
The structural description of play development tion are common.
focuses on the Piagetian concepts of the increasing cognitive The alveoli of the infant increase in number and com-
complexity of play activities. Elementary sensorimotor- plexity very rapidly. By 1 year of age, the alveoli and the lin-
based games emerge first, with the gradual development of ing of the air passages have matured considerably.
advanced social games in adulthood.7 Respiratory tract obstructions are common in this age
Play activities assist in the child’s development of psy- group because of the short trachea and the almost straight-
chomotor skills and cognitive development. Socialization line position of the right main stem bronchus. In addition,
skills are learned and practiced via the interaction with oth- the epiglottis does not effectively close over the trachea
ers during play. As the child begins to learn more about his during swallowing. Thus, foreign objects are aspirated into
or her body during play, he or she will incorporate more the lungs.
complicated gross and fine motor skills. Play is extremely In terms of cardiovascular development, the foramen
valuable in the development of language and other commu- ovale closes during the first 24 hours, and the ductus arte-
nication skills. Play helps the individual establish control riosus closes after several days. The neonate can survive
over self and the environment and provides a sense of mild oxygen deprivation longer than an adult can. The
accomplishment. Through play activities, the infant learns to Apgar scoring system is used to measure the physical status
trust the environment. Play also affords the child the oppor- of the newborn and includes heart rate, color, and respira-
tunity to express emotions that would be unacceptable in tion. There is no day–night rhythm to the neonate’s heart
other normal social situations. rate, but from the sixth week on, the rate is lower at night
Practice games begin during the sensorimotor level of than during the day. Axillary temperature readings and age-
cognitive development at 1 to 4 months of age, and continue sized blood pressure cuffs should be used to assess vital
with increasing complexity throughout childhood. These signs. The pulse is 120 to 150 beats per minute; respiration
games include skills that are performed for the pleasure of ranges from 35 to 50 per minute; and blood pressure ranges
functioning, that is, for the pleasure of practice. from 40 to 90 mm Hg systolic and 6 to 20 mm Hg diastolic.
Symbolic games appear later during the sensorimotor Vital signs become more stable over the first year. Listening
period than do practice games—at about age 12 to 18 for murmurs should be done over the base of the heart rather
months. Make-believe is now added to the practice game. than at the apex. Breath sounds are bronchovesicular. The
Other objects represent elements of absent objects or per- neonate has limited ability to respond to environmental tem-
sons. As previously stated, activity is influenced by respira- perature changes and loses heat rapidly. This leads to an
tory and cardiovascular mechanisms. increased basal metabolic rate (BMR) and an increased
The respiratory mechanisms, or air-conducting pas- workload on the heart. Until patients reach age 7, the apex is
sages (nose, pharynx, larynx, trachea, bronchi, bronchioles, palpated at the fourth interspace just to the left of the mid-
and alveoli) and lungs, of the infant are small, delicate, and clavicular line.
immature. The air that enters the nose is cool, dry, and unfil-
tered. The nose is unable to filter the air, and the mucous TODDLER AND PRESCHOOLER
membranes of the upper respiratory tract are unable to pro-
duce enough mucus to humidify or warm the inhaled air. By this age, the child is walking, running, climbing, and
Therefore, the infant is more susceptible to respiratory tract jumping. The toddler is very active and curious. He or she
infections.7 gets into everything. This helps the toddler organize his or
In addition, the infant is a nose breather. When upper her world and develop spatial and sensory perception.6 It is
respiratory tract infections do occur, the infant is unable to during this period that the child begins to see him- or herself
clear the airways appropriately and may get into some diffi- as a person separate from his or her parents and the envi-
culty until he or she learns to breathe through his or her ronment. This increasing level of autonomy also presents a
mouth (at about 3 to 4 months of age). The cough of the challenge for the caregivers. The child alternates between
infant is not very effective, and the infant quickly becomes the security of the parents and the exciting exploration of the
fatigued with the effort.7 environment.
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274 • Activity—Exercise Pattern
The toddler is fairly clumsy, but gross and fine motor the task. Delays or regressions in the tasks of self-feeding
coordination is improving. Neuromuscular maturation and may reflect issues other than a self-care deficit, for example,
repetition of movements help the child further develop discipline, family coping, and role-relationships.
skills.6 Muscles grow faster than bones during these years.
Physiology
Safety is a major concern for children of this age. The tod-
During the preschool years, the child seems to have an
dler, especially, wants to do many things for him- or herself,
unlimited supply of energy. However, he or she does not
thus testing control of self and the environment.
know when to stop and may continue activities past the point
Bathing and Hygiene of exhaustion. Parents should provide a variety of activities
By the age of 3, the child can wash and dry his or her hands for these age groups, as the attention span is short.
with some wetting of clothes and can brush his or her teeth, The lung size and volume of the toddler have now
but requires assistance to perform the task adequately. By increased, and thus the oxygen capacity of the toddler has
the fourth birthday, the child may bathe him- or herself with increased. The toddler is still susceptible to respiratory tract
assistance. The child will be able to bathe him or herself infections but not to the same extent as the infant. The rate
without assistance by the age of 5. Both parents and nurses and rhythm of respiration have decreased, and respirations
must keep in mind the safety issues involved in bathing; the average 25 to 35 per minute. Accessory muscles of respira-
child requires supervision in selection of water temperature tion are used infrequently now, and respiration is primarily
and in the prevention of drowning. diaphragmatic.
The respiratory structures (trachea and bronchi) are
Dressing and Grooming
positioned farther down in the chest now, and the epiglottis
At age 18 to 20 months, the child has the fine motor skills
is effective in closing off the trachea during swallowing.
required to unzip a large zipper. By 24 to 48 months, the
Thus, aspiration and airway obstruction are reduced in this
child can unbutton large buttons. The child can put on a
age group.
coat with assistance by age 2; the child can undress him- or
The respiratory rate of the preschooler is about 30 per
herself in most situations and can put on his or her own
minute. The preschooler is still susceptible to upper respira-
coat without assistance by age 3. At 31/2 years the child
tory tract infections. The lymphatic tissues of the tonsils and
can unbutton small buttons, and by 4 years can button small
adenoids are involved in these respiratory tract infections.
buttons. Dressing without assistance and a beginning ability
Tonsillectomies and adenoidectomies are no longer per-
to lace shoes are accomplishments of the 5-year-old. The
formed “routinely.” These tissues serve to protect the respi-
development of fine motor skills is required for most of
ratory tract, and valid reasons must be presented to warrant
the tasks of dressing. It is important that the child’s cloth-
their removal.
ing have fasteners that are appropriate for the motor skill
The temperature of the toddler ranges around 99⬚F ⫾
development. The child will require assistance with decid-
1⬚ (orally); pulse ranges around 105 beats per minute ⫾ 35;
ing the appropriateness of clothing selected; seasonal vari-
respirations range from 20 to 35 per minute; and blood pres-
ations in weather and culturally accepted norms regarding
sure ranges from 80 to 100 mm Hg systolic and 60 to 64 mm
dressing and grooming are learned by the child with assis-
Hg diastolic. The size of the vascular bed increases in the
tance.
toddler, thus reducing resistance to flow. The capillary bed
Feeding has increased ability to respond to environmental tempera-
The child can drink from a cup without much spilling by 18 ture changes. Lung volume increases. Breath sounds are
months. The child will have frequent spills while trying to more intense and more bronchial, and expiration is more
get the contents of a spoon into his or her mouth at this age. pronounced. The toddler’s chest should be examined with
By 2 years of age, the child can drink from a cup; use of a the child in an erect position, then recumbent, and then
spoon has improved at this age, but the child will still spill turned to the left side. Arrhythmias and extrasystoles are not
liquids (soup) from a spoon when eating. The child can eat uncommon but should be recorded.
from a spoon without spilling by 31/2 years. Accomplished The temperature of the preschooler is 98.6⬚ F ⫾ 1⬚
use of a fork occurs at 5 years. (orally); pulse ranges from 80 to 100 beats per minute; res-
piration is 30 per minute ⫾ 5; and blood pressure is 90/60
Toileting
mm Hg ⫾ 15. There is continued increase of the vascular
By age 3, the child can go to the toilet without assistance;
bed, lung volume, and so on, in keeping with physical
the child can pull pants up and down for toileting without
growth.
assistance at this stage as well. The development of food
preferences, preferred eating schedules and environment,
and toileting behavior are imparted to the child by learning. SCHOOL-AGE CHILD
Toileting, food, and the eating experience may also include Whereas the muscles were growing faster than the bones
pleasures, control issues, and learning tasks in addition to during the toddler and preschool years, the skeletal system
the development of the motor skills required to accomplish is growing rapidly during these years—faster than the mus-
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Developmental Considerations • 275
cles are growing. Children may experience “growing pains” needs, the child should be advised against sustained physical
because of the growth of the long bones. There is a gradual activity and be watched for tiring. After age 7, the apex of the
increase in muscle mass and strength, and the body takes on heart lies at the interspace of the fifth rib at the midclavicu-
a leaner appearance. The child loses his or her “baby fat,” lar line. Circulatory functions reach adult capacity. The child
muscle tone increases, and loose movements disappear. will still have some vasomotor instability with rapid vasodi-
Adequate exercise is needed to maintain strength, flexibility, lation. A third heart sound and sinus arrhythmias are fairly
and balance and to encourage muscular development.7 common but, again, should be recorded.
Males have a greater number of muscle cells than females.
Posture becomes more upright and straighter but is not nec- ADOLESCENT
essarily influenced by exercise. Posture is a function of the
strength of the back muscles and the general state of health Growth in skeletal size, muscle mass, adipose tissue, and
of the child. Poor posture may be reflective of fatigue as well skin is significant in adolescence. The skeletal system grows
as skeletal defects,7 with fatigue being exhibited by such faster than the muscles; thus, stress fractures may result. The
behaviors as quarrelsomeness, crying, or lack of interest in large muscles grow faster than the smaller muscles, with the
eating. Skeletal defects such as scoliosis begin to appear occasional result of poor posture and decreased coordina-
during this period. tion. Boys are clumsier than girls. Muscle growth continues
Neuromuscular coordination is sufficient to permit in boys during late adolescence because of androgen pro-
the school-age child to learn most skills6; however, care duction.6
should be taken to prevent muscle injuries. Hands and Physical activities provide a way for adolescents to
fingers manipulate things well. Although children age 7 enjoy the stimulation of conflict in a socially acceptable
have a high energy level, they also have an increased atten- way. Some form of physical activity should be encouraged
tion span and cognitive skills. Therefore, they tend to engage to promote physical development, prevent overweight, for-
in quiet games as well as active ones. Seven-year-olds mulate a realistic body image, and promote peer acceptance.
tend to be more directed in their range of activities. Games The respiratory rate of the adolescent is 16 to 20 per
with rules develop as the child engages in more social minute. Parts of the body grow at various rates, but the res-
contacts. These games characteristically emerge during piratory system does not grow proportionately. Therefore,
the operational phase of cognitive development in the school the adolescent may have inadequate oxygenation and
age child. These rule games may also be practice or sym- become more fatigued. The lung capacity correlates with the
bolic in nature, but now the child attaches social signif- adolescent’s structural form. Boys have a larger lung capac-
icance and order to the play by imposing the structure ity than girls because of greater shoulder width and chest
of rules. size. Boys have greater respiratory volume, greater vital
Eight-year-olds have grace and balance. Nine-year- capacity, and a slower respiratory rate. The boy’s lung
olds move with less restlessness, their strength and capacity matures later than the girl’s. Girls’ lungs mature at
endurance increase, and their hand–eye coordination is age 17 or 18.
good.6 Competition among peers is important to test out The heart continues to grow during adolescence but
their strength, agility, and coordination. Although 10- to 12- more slowly than the rest of the body, contributing to the
year-old children are better able to control and direct their common problems of inadequate oxygenation and fatigue.
high energy level, they do have energetic, active, restless The heart continues to enlarge until age 17 or 18. Systolic
movements with tension release through finger drumming, pulse pressure increases, and the temperature is the same as
foot tapping, or leg swinging. in an adult. The pulse ranges from 50 to 68 beats per minute;
The respiratory rate of the school-age child slows to 18 respiration ranges from 18 to 20 per minute; and blood pre-
to 22 per minute. The respiratory tissues reach adult matu- ssure is 100 to 120/50 to 70 mm Hg. Adolescent girls
rity, lung volume increases, and the lung capacity is propor- have slightly higher pulse rates and basal body temperature
tionate to body size. The school-age child is still susceptible and lower systolic pressures than boys. Hypertension inci-
to respiratory tract infections. The frontal sinuses are fairly dence increases. Essential hypertension incidence is approx-
well developed by this age, and all the mucous membranes imately equal between races for this age group.
are very vulnerable to congestion and inflammation. The Athletes have slower pulse rates than peers. Heart
temperature, pulse, and respiration of the school-age child sounds are heard readily at the fifth left intercostal space.
are gradually approaching adult norms, with temperature Functional murmurs should be outgrown by this time. Chest
ranging from 98 to 98.6⬚F, pulse (resting) 60 to 70 beats per pain may arise from musculoskeletal changes, but cardio-
minute, and respiration from 18 to 20 per minute. Systolic vascular pain should always be investigated. Cardiovascular
blood pressure ranges from 94 to 112 mm Hg, and diastolic problems are the fifth leading cause of death in adolescents.
from 56 to 60 mm Hg. The heart grows more slowly during More rest and sleep are needed now than earlier. The
this period and is smaller in relation to the rest of the body. teenager is expending large amounts of energy and func-
Because the heart must continue to supply the metabolic tioning with an inadequate oxygen supply; both these fac-
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276 • Activity—Exercise Pattern
tors contribute to fatigue and lead to the need for additional leisure-time pursuits. The young adult should learn to bal-
rest. Parents may need to set limits. Rest does not necessar- ance his or her work with leisure-time activities. Getting
ily mean sleep and can also include quiet activities.6 started in a career can be very stressful and can lead to
Because of the very rapid growth during this period, burnout if an appropriate balance is not found. Physical fit-
the adolescent may not have sufficient energy left for stren- ness reflects ability to work for a sustained period with vigor
uous activities. He or she tires easily and may frequently and pleasure, without undue fatigue, and with energy left
complain of needing to sit down. Gradually the adolescent is over for enjoying hobbies and recreational activities and for
able to increase both speed and stamina during exercise. An meeting emergencies.6
increase in muscular and skeletal strength, as well as the Basic to fitness are regular physical exercise, pro-
increased ability of the lungs and heart to provide adequate per nutrition, adequate rest and relaxation, conscientious
oxygen to the tissue, facilitates maintenance of hemody- health practices, and good medical and dental care. Regular
namics and rate of recovery after exercise. The body reaches physical fitness is a natural tranquilizer releasing the body’s
its peak of physiologic resilience during late adolescence own endorphins, which reduce anxiety and muscular
and young adulthood. Regular physical training and an indi- tension.
vidualized conditioning program can increase both strength The respiratory system of the young adult has com-
and tolerance to strenuous activity. pletely matured. Oxygen demand is based on exercise and
Faulty nutrition is another major cause of fatigue in activity now but gradually decreases between age 20 and 40.
the adolescent. Poor eating habits established during the The body’s ability to use oxygen efficiently is dependent
school-age years, combined with the typical quick-service, on the cardiovascular system and the needs of the skeletal
quick-energy food consumption patterns of adolescents, fre- muscles.
quently lead to anemia, which in itself can lead to activity The respiratory and cardiovascular systems change
intolerance.7 gradually with age, but the rate of change is highly depend-
The adolescent may be given responsibility for assist- ent on the individual’s diet and exercise pattern. Generally,
ing with the maintenance of the family home, or may be contraction of the myocardium decreases. Maximum car-
responsible for his or her own home if living independent diac output is reached between the age of 20 and 30. The
from the family of origin. The role exploration characteris- arteries become less elastic. The maximum breathing capac-
tic of adolescence may lead to temporary changes in ity decreases between ages 20 and 40. Cardiac and respira-
hygiene practices. tory function can be improved with regular exercise.
Recreational activities in adolescence often take the Hypertension (blood pressure 140/90 mm Hg or higher) and
form of organized sports and other competitive activities. mitral valve prolapse syndrome are the most common car-
Social relationships are developed and enhanced, specific diovascular medical diagnoses of the young adult.
motor and cognitive skills related to a specific sport are
refined, and a sense of mastery can be developed. Group ADULT
activities and peer approval and acceptance are important.
The adolescent responds to peer activities and experiments Basal metabolism rate gradually decreases. Although there
with different roles and lifestyles. The nurse must distin- is a general and gradual decline in quickness and level
guish self-care practices that are acceptable to the peer of activity, people who were most active among their age
group from those that indicate a self-care deficit. group during adolescence and young adulthood tend to be
the most active during middle and old age. In women, there
YOUNG ADULT is frequently a menopausal rise in energy and activity.8
Growth of the skeletal system is essentially complete by age Judicious exercise balanced with rest and sleep modify and
25. Muscular efficiency is at its peak between 20 and 30. retard the aging process. Exercise stimulates circulation to
Energy level and control of energy are high. Thereafter, all parts of the body, thereby improving body functions.
muscular strength declines with the rate of muscle aging, Exercise can also be an outlet for emotional tension. If the
depending on the specific muscle group, the activity of the person is beginning exercises after being sedentary, certain
person, and the adequacy of his or her diet. precautions should be taken, such as increasing exercise
Regular exercise is helpful in controlling weight and gradually to a moderate level, exercising consistently, and
maintaining a state of high-level wellness. Muscle tone, avoiding overexertion. Research indicates that cardiovascu-
strength, and circulation are enhanced by exercise. Problems lar risk factors can be reduced in women by low-intensity
arise especially when sedentary lifestyles decrease the walking.9
amount of exercise available with daily activities. Caloric The adult is beginning to have a decrease in bone mass
intake and exercise should be balanced. and a loss of skeletal height. Muscle strength and mass are
Adequate sleep is important for good physical and directly related to active muscle use. The adult needs to
mental health. Lack of sleep results in progressive sluggish- maintain the patterns of activity and exercise of young adult-
ness of both physical and cognitive functions. The major hood and not become sedentary. Otherwise, muscles lose
activities of individuals in this age group are work and mass structure and strength more rapidly.
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Developmental Considerations • 277
Temperature for the adult ranges from 97 to 99.6⬚F; Age-related changes to the respiratory system may
pulse ranges from 50 to 100 beats per minute; respiration include a decrease in lung elasticity, chest wall stiffness,
ranges from 16 to 20 per minute; and blood pressure is diminished cough reflex, increased physiologic dead space
120/80 mm Hg ⫾ 15. Cardiac output gradually decreases, secondary to air trapping, and nonuniform alveolar ventila-
and the decreasing elasticity of the blood vessels causes tion.15 Alveolar enlargement and thinning of alveolar walls
more susceptibility to hypertension and cardiovascular dis- mean less alveolar surface is available for gas exchange.16
eases. After menopause women become as prone to coro- The older adult may experience decreases in PaO2 and
nary disease as men, so estrogen appears to be a protective increases in PaCO2 because of age-related changes in the res-
agent. The BMR generally decreases. Essential and second- piratory system.
ary hypertension and angina occur more frequently in this Cardiovascular diseases remain the primary cause of
age group. death in the older population.17 With aging, the cardiovascu-
The lung tissue becomes thicker and less elastic with lar system undergoes changes in structure and function. Left
age. The lungs cannot expand as they once did, and breath- ventricular, aortic, and mitral valve thickening have an
ing capacity is reduced. The respiratory rate may increase to impact on cardiac contractility and systolic blood flow.
compensate for the reduced breathing capacity. Increased arterial thickness and arterial stiffening may lead
The normal adult should be able to perform activ- to a decrease in the effectiveness of baroreceptors.
ities of daily living without assistance. The need for close Diminished baroreceptor response has an effect on the
relationships and the intimacy of adulthood can be initi- body’s ability to control blood pressure with postural
ated by leisure activities with identified partners or a small changes. Pacemaker cells in the sinoatrial node decrease
group of close friends (e.g., hiking, tennis, golf, or attend- with aging. Calcification may occur along the conduction
ing concerts or theaters, etc.). The middle-age adult is system of the heart. Myocardial irritability leads to the
often interested in the personal satisfaction of diversional potential for increased cardiac arrhythmias.16 The ability of
activities. the cardiovascular system to respond to increased demands
The adult will most likely be responsible for home becomes reduced, and the older adult experiences a decrease
maintenance as well as outside employment. Role strain or in physiologic reserves.16 These changes can have serious
overtaxation of the adult is possible. Illness or injury to the consequences when the older adult experiences physical
adults in the household will significantly affect the ability of or psychological stress. It becomes increasingly difficult
the family unit to maintain the home. for the older adult to have rapid and efficient blood pressure
and heart rate changes. Vital sign ranges for older adults
OLDER ADULT are similar to those for middle-age adults. There may be a
slight increase in respiratory rate,13 and blood pressure
Older adults face a gradual decline in function through the increases, especially systolic changes, are often present.
years. Age-related changes in the cardiovascular, respira- Healthy older men, from age 50 onward, may experience
tory, and musculoskeletal systems vary from person to per- a 5 to 8 mm Hg increase in systolic blood pressure per
son. Studies attempting to describe age-related system decade. Healthy older women, from age 40 onward, may
changes have faced problems in determining what changes have similar systolic changes.18 Diastolic changes are usu-
may be age-related versus disease-induced.11 ally minimal.
Changes in the older musculoskeletal system typically With the potential age-related changes just described,
include decreases in bone volume and strength, decreases in some older adults may experience changes in function.
skeletal muscle quality and mass, and reductions in muscle Many of the changes combined can lead to problems with
contractility.11 After the age of 40 to 50, an incremental energy available to cells, organs, and systems to accomplish
process of bone absorption without successful new bone for- desired activities. Health promotion efforts should focus on
mation leads to gradual bone loss.12 This loss is greater in activity and exercise and their impact on the older adult’s
women, but occurs in both men and women. Tendon and lig- sense of well-being. Research in the 1990s has shown the
ament strength decrease with aging, and collagen stiffness benefits to older adults when weight training and exercise
and cross-linking occur. The tendon and ligament changes are a part of their lifestyle.19 Older clients may need prompt-
can result in joint range-of-motion losses of 20 to 25 per- ing and reminders to pace their activities to compensate for
cent.11 Changes in older adults vestibular and nervous sys- aging changes. The increase in leisure time associated with
tems present a challenge to older adults attempting to retirement and a lessening of occupational and child-rearing
maintain balance, prevent falls, and have a smooth gait.13 responsibilities create the opportunity for exploring other
Vestibular changes can impede spatial orientation. The activity options.
vestibular and nervous system changes in conjunction with The older adult has the developmental challenge of
a slowed reaction time, increased postural sway, decreased finding meaning in the course of the life they have lived
stride, decreased toe-floor clearance, decreased arm swing, and feeling comfort with the results of their actions and
and knee and hip rotation all may impact the mobility level choices.20 Strategies to support this task may take on the
of older adults.14 form of life review with the older client, promoting remi-
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278 • Activity—Exercise Pattern
niscing, and other opportunities for the older adult to changes cited in this section are not universal and inevitable
acknowledge and experience self-worth.21 for all older adults. Health-care providers need to be wary of
Because of the diversity of our older population, indi- stereotyping clients based on age. There are many independ-
vidualized assessment is a high priority. The age-related ent older adults in our society, and the number is increasing.
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280 • Activity—Exercise Pattern
T A B L E 5 . 1 NANDA, NIC, and NOC Taxonomy Linkages (continued from page 279)
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Developmental Considerations • 281
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282 • Activity—Exercise Pattern
T A B L E 5 . 1 NANDA, NIC, and NOC Taxonomy Linkages (continued from page 281)
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Activity Intolerance, Risk For and Actual • 283
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284 • Activity—Exercise Pattern
✔ Have You Selected the Correct Diagnosis? Activity Intolerance, on the other hand, implies that
the person is willing and able to participate in activ-
Impaired Physical Mobility ities but is unable to endure or adapt to the increased
This diagnosis implies that an individual would be energy or oxygen demands made by the movement
able to move independently if something were not lim- or activity.
iting the motion. Activity Intolerance implies that the
individual is freely able to move but cannot endure or
adapt to the increased energy or oxygen demands EXPECTED OUTCOME
made by the movement or activity.
Will participate in increased self-care activities by [date].
Self-Care Deficit (Specify which self-care activities, that is, bathing, feeding,
Self-Care Deficit indicates that the patient has some
dressing, or ambulation, and the frequency, duration, or
dependence on another person. Activity Intolerance
intensity of the activity.)
implies that the patient is independent but is unable
to perform activities because the body is unable to EXAMPLE
adapt to the increased energy and oxygen demands
made. A person may have a self-care deficit as a Will increase walking by at least 1 block each week for
result of activity intolerance. 8 weeks.
Ineffective Individual Coping
Persons with the diagnosis of Ineffective Individual
TARGET DATES
Coping may be unable to participate in their usual Appropriate target dates will have to be individualized
roles or in their usual self-care because they feel according to the degree of activity intolerance. An appropri-
they lack control or the motivation to do so. ate range would be 3 to 5 days.
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Activity Intolerance, Risk For and Actual • 285
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage progressive activity and increased self-care Gradually increases tolerance for activities.
as tolerated. Schedule moderate increase in activities
on a daily basis (e.g., will walk 10 feet farther each
day).
Assist the patient with self-care activities as needed. Let Allows the patient to have some control and choice in
the patient determine how much assistance is needed. plan; helps the patient to gradually decrease the
amount of activity intolerance.
Collaborate with health-care providers regarding oxygen Oxygen may be needed for shortness of breath associated
therapy. with increased activity.
Collaborate with a physical therapist in establishing an Provides most appropriate activities for the patient.
appropriate exercise plan.
Provide for a quiet, nonstimulating environment. Limit Determine various methods to motivate behavior.
number of visitors and length of their stay.
Assure adequate dietary input, consider the patient’s food Provides adequate nutrition to meet metabolic demands.
preferences and consult with dietitian.
Assist the patient in weight reduction as required. Decreased weight requires less energy.
Teach the patient relationship between nutrition and Assists the patient to learn alternate methods to conserve
exercise tolerance, and assist in developing a diet that energy in ADLs.
is appropriate for nutritional and metabolic needs.
(See Chapter 3 for further information.)
Instruct the patient in energy-saving techniques of daily
care (e.g., preparing meals sitting on a high stool rather
than standing).
Initiate physical therapy and/or occupational therapy Will deter muscle wasting and development of disuse
early in admission. syndrome.
Child Health
May include applicable, according to age/developmental status, the generic components of Adult Health care plan plus the
following:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor factors that are contributing to this problem. Provides foundation for comprehensive approach to
problem-solving.
Address relevant pre-existing issues to include issues for A holistic approach offers the greatest likelihood for
timing of activity, previous level of activity, current meeting the client’s desired goal in the safest way
medical status and how the desired level of activity is possible.
to be attained.
*May include the pediatrician and occupational or physi-
cal therapist.
Develop, with the child and parents, an activity plan. Emphasizes the role each will have for fostering the suc-
[Note that plan here.] cess of the plan.
Provide learning modules and practice sessions with Developmentally appropriate materials enhance learning
materials suitable for the child’s age and develop- and maintain the child’s attention.
mental capacity (e.g., dolls, videos, or pictures).
Provide for continuity in care by assigning the same Continuity of caregivers fosters trust in the nurse–patient
nurses for care during critical times for teaching and relationship, which enhances learning.
implementation.
(care plan continued on page 286)
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286 • Activity—Exercise Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Modify expected behavior to incorporate appropriate Valuing of the patient’s developmental needs fosters self-
developmental needs (e.g., allow for shared cards, esteem and serves as a reward for efforts.
messages, or visitors to lobby if possible for adoles-
cent patients).
Reinforce adherence to regimen with stickers or other Extrinsic rewards may help symbolize concrete progress
appropriate measures to document progress. and assist in reinforcing appropriate behaviors for
achieving goals.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Premature Rupture of Membranes23–25
● N O T E : Approach to treatment is controversial and depends on practice in your
particular area.
Carefully monitor fetal heart rate to detect cord compres-
sion and/or cord prolapse.
Carefully monitor for signs and symptoms of amnionitis.
• Check maternal temperature every 4 h.
• Evaluate for uterine tenderness at least twice a day.
• Check daily leukocyte counts.
• Avoid vaginal examinations.
Keep the patient and partner informed, and encourage
their participation in management decisions.
Explain and provide answers to questions regarding: Assists in reducing fears of expectant parents and increas-
• Possible preterm delivery ing the likelihood of a good outcome for the pregnancy.
• Fetal lung maturity and possible use of corticosteroids
to accelerate fetal lung maturity
Provide comfort measures to decrease intolerance of bed
rest:
• Back or body massage
• Diversional activities, such as television, reading, or
handicrafts
• Bedside commode (if acceptable to treatment plan)
Preterm Labor24–28
● N O T E : Although there is disagreement on the definition, the most widely used defini-
tion of preterm labor is six to eight contractions per hour or 4 contractions in 20 min-
utes associated with cervical change.25
Thoroughly explain to the patient and partner the process
of preterm labor.
Discuss options of activity allowed. Provides the parents with information, increases motiva-
tion to continue with reduced activity, and allows
informed choices
● N O T E : This varies, and there is controversy in the literature on the value of bed
rest for preterm labor; therefore, look at practice in your area.
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Activity Intolerance, Risk For and Actual • 287
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss various treatment possibilities:
• Prolonged bed rest or at least a marked reduction in
activity
• Intravenous volume expansion (IV therapy)
• Tocolytic therapy (IV, oral, or pump)
• Use of magnesium sulfate
• Use of prostaglandin synthesis inhibitors such as
indomethacin
• Use of calcium channel blockers
Carefully monitor those patients receiving tocolytic
therapy for:
• Pulmonary edema
• Hypokalemia
• Hyperglycemia
• Shortness of breath
• Chest pain
• Cardiac dysrhythmia
• Electrocardiographic “ischemia” changes
• Hypotension
Carefully monitor uterine contractions (strength, quality,
frequency, and duration).
Monitor fetal heart rate in association with contractions.
Provide diversional activities for patients on bed rest.
Refer for home monitoring and evaluation if appropriate: Increases compliance, decreases cost, and decreases
• Assess the patient’s ability to identify contractions. maternal stress when she can achieve treatment
• Evaluate the patient’s support system at home. at home instead of in an acute care setting.
• Assess the patient’s access to health-care provider.
Pregnancy-Induced Hypertension (PIH)29–32
Explain the various screening procedures for PIH to the
patient and partner:
• Blood pressure measurement
• Urine checked for protein
• Assessment of total and interval weight gain
• Signs and symptoms of sudden edema of hands and
face, sudden 5-pound weight gain in 24 to 48 hours,
epigastric pain, or spots before eyes or blurred vision
Discuss treatment plan with the patient and partner:
• Bed rest on either side (right or left)
• Magnesium sulfate therapy
• Reduction in noise, visual stimuli, and stress
• Careful monitoring of fetal heart rate
• Possible sonogram to determine intrauterine growth
rate (IUGR)
• Good nutrition with a maximum recommended
daily allowance (RDA) sodium intake of 110 to
3300 mg/day
Assess the patient’s support system to determine whether
the patient can be treated at home.29–32
Assist the family in planning for needed caretaking and
housekeeping activities if the patient is at home.29–32
(care plan continued on page 288)
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Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Consult with perinatalogist and visiting nurse to imple-
ment collaborative care plan.
Ensure that the family knows procedure for obtaining
emergency service.
Uncomplicated Pregnancy
● N O T E : Even though there are often no complications in pregnancy, it is not unusual,
particularly during the last 4 to 6 weeks, to have activities restricted because of edema,
bouts with false labor, and fatigue. This fatigue continues after the birth, when the
mother and father become responsible for the care of a newborn infant 24 hours a day.
Discuss with the expectant parents methods of conserving
energy while continuing their daily activities during the
last weeks of pregnancy.
Assist the expectant mother in developing a plan whereby Provides opportunity to rest throughout the day and
she can take frequent (two in the morning, two in the therefore the ability to maintain as many routine activi-
afternoon), short breaks during the work day to: ties as possible. Increases oxygen flow to the uterus
• Retain energy and reduce fatigue. and the fetus, thereby reducing the possibility of
• Reduce the incident of false labor. preterm labor and severe fatigue.
• Increase circulation and thus reduce dependent lower
limb edema and increase oxygen to the placenta and
fetus.
Assist the expectant parents to plan for the possibility of
reducing the number of hours the woman works during
the week. Look at the work schedule and talk with the
employer about the possibilities of:
• Working every other day
• Working only half-day each day
• Working 3 days in the middle of the week, i.e.,
Tuesday, Wednesday, and Thursday, thus, having a
4-day weekend to rest
• Job sharing
After Delivery
Instruct the patient in energy-saving activities of daily A common problem with a new baby is overwhelming
care: fatigue on the part of the mother. These measures will
• Take care of self and baby only. assist in decreasing the fatigue.
• Let the partner and others take care of housework and
other children.
• Let the partner and others take care of the baby for a
prearranged time during the day so the mother can
spend quality time with the other children.
• Learn to sleep when the baby sleeps.
• Turn off the telephone or turn on the answering
machine.
• Have specific times set for visiting of friends or rela-
tives.
• If breastfeeding, partner can change the infant and
bring the infant to the mother at night. (The mother
does not always have to get up and go to the infant.)
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Activity Intolerance, Risk For and Actual • 289
ACTIONS/INTERVENTIONS R AT I O N A L E S
Consider taking the baby to bed with the parent. Newest research shows that taking the baby to bed with the
mother and father at night for the first few weeks25,31:
• Allows the mother, father, and infant to get more rest.
• Provides more time for the baby to nurse, and baby
begins to sleep longer more quickly.
• Possibly reduces the incidence of sudden infant death
syndrome (SIDS) because the baby mimics the breath-
ing patterns of the mother and father.
• Promotes positive learning and acquaintance activities for
the new parents. Allows the infant to feel more secure,
and therefore increases infant-to-parent attachment.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss with the client his or her perceptions of activity Provides an understanding of the client’s worldview so
appropriate to his or her current capabilities. that care can be individualized and interventions devel-
oped that are acceptable to both the nurse and the
client.33
If the client estimates a routine that far exceeds current
capabilities (as with eating disorder clients or clients
experiencing elated mood):
• Establish appropriate limits on exercise. (The limits Negative reinforcement eliminates or decreases behav-
and consequences for not maintaining limits estab- ior.34 Because of the high energy level, elated clients
lished should be listed here. If the excessive exercise need some large motor activity that will discharge
pattern is related to an elated mood, set limits in a energy but does not present a risk for physical harm.35
manner that allows the client some activity while not
greatly exceeding metabolic needs until psychological
status is improved.)
• Begin the client slowly (e.g., with stretching exercise Goals need to be achievable to promote the sense of
for 15 minutes twice a day). accomplishment and positive self feelings, which will
• Note client’s goals here. in turn increase motivation.33
• As physical condition improves, gradually increase A regimen that provides positive cardiovascular fitness
exercise to 30 minutes of aerobic exercise once without risk of overexertion.37
per day.
• Discuss with the client appropriate levels of exer- Overexertion can decrease benefits of exercise by increas-
cise considering his or her age and metabolic ing risk for injury.36
pattern.
• Discuss with the client the hazards of overexercise.
• Establish a reward system for clients who maintain the Positive reinforcement encourages appropriate behavior.34
established exercise schedule (the schedule for the
client should be listed here with the reinforcers that are
to be used).
• Stay with the client while he or she is engaged in Interaction with the nurse can provide positive
appropriate exercise. reinforcement.34
• Develop a schedule for the client to be involved in an Promotes accurate perception of body size, nutrition, and
occupational therapy program to assist the client in exercise needs.
identifying alternative forms of activity other than aer-
obic exercise.
(care plan continued on page 290)
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Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Limit number of walks off the unit to accommodate
client’s weight, level of exercise on the unit, and physi-
ology (the frequency and length of the walk should be
listed here).
For further information related to eating disorder clients,
see Imbalanced Nutrition, Less Than Body
Requirements (Chapter 3).
If the client’s expectations are much less than current Goals need to be achievable to promote sense of accom-
capabilities (as with a depressed or poorly motivated plishment and positive self feelings, which will in turn
client), implement the following actions: increase motivation.33
• Establish very limited goals that the client can accom-
plish (e.g., a 5-minute walk in a hallway once a day or
walking in the client’s room for 5 minutes). The goal
established should be listed here.
• Establish a reward system for achievement of goals Positive reinforcement encourages appropriate behavior.34
(the reward program should be listed here with a list of
items the client finds rewarding).
• Develop a schedule for the client to be involved in an Provides the client with opportunity to improve self-help
occupational therapy program (note schedule here). skills while engaged in a variety of activities.
• Establish limits on the amount of time the client can Exercise raises levels of endorphins in the brain, which
spend in bed or in his or her room during waking has a positive effect on depression and general feeling
hours (establish limits the client can achieve, and of well-being.35,37
note limits here).
• Stay with the client during exercise periods and time Interaction with the nurse can provide positive
out of the room until the client is performing these reinforcement.34
tasks without prompting.
• Provide the client with firm support for initiating the Attention from the nurse can provide positive reinforce-
activity. ment and increase the client’s motivation to accomplish
goal.
• Place a record of goal achievement where the client can Provides concrete evidence of goal attainment and moti-
see it, and mark each step toward the goal with a vation to continue these activities that will promote
reward marker. well-being.
• Provide positive verbal reinforcement for goal achieve-
ment and progress.
For further information about clients with depressed
mood, refer to Ineffective Individual Coping
(Chapter 11).
Monitor effects current medications may have on activity Psychotropic medications may cause postural hypoten-
tolerance, and teach the client necessary adjustments. sion, and the client should be instructed to change
position slowly.
Schedule time to discuss plans and special concerns with Recognizes the reciprocity between the client’s illness
the client and the client’s support system. This could and the family context.38
include teaching and answering questions. Schedule
daily during initial days of hospitalization and one
longer time just before discharge. Note schedule times
and person responsible for this.
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Activity Intolerance, Risk For and Actual • 291
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized with aging clients.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collaborate with the client to determine factors that con- Individualizes care.
tribute to activity intolerance (pain, shortness of breath).
Address those factors specifically as appropriate.
Determine, with the assistance of the patient, particular Maximizes potential to participate in or complete care
time periods of highest energy, and plan care requirements successfully.
accordingly.
Teach the patient to monitor pulse before, during, and Promotes self-monitoring and provides means of deter-
after activity. mining progress across care settings.
Refer the patient to occupational therapy and physical Collaboration ensures a plan that will result in activity for
therapy for determination of a progressive activity maximum effect.
program.
Establish goals that can be met in a short time frame Provides motivation to continue program.37
(daily or weekly).
Use positive feedback for incremental successes. Reinforces the older adult’s potential to have efforts
produce positive outcomes. Enhances sense of self-
efficacy.40
Monitor for signs of potential complications related to Older adults are highly susceptible to the negative
decreased activity level, such as problems with skin physiologic and psychological consequences of
integrity, elimination complications, and respiratory immobility.40
problems.
Home Health
● N O T E : Interventions for Adult Health apply with the addition of the following
interventions:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the safety of the home environment for a client Promotes safety.
with activity intolerance. Educate client/caregiver of
possible environmental modifications needed to
include:
• Wider doors
• Lever style door handles instead of doorknobs
• Bathroom rails
• Removal of clutter
• Functional arrangement of furniture
• Flooring that facilitates use of mobility assistive devices
• Phones that are readily accessible
Teach the client and family appropriate monitoring of Provides baseline for prevention and/or early inter-
causes, signs, and symptoms of risk for or actual activ- vention.
ity intolerance:
• Prolonged bed rest
• Circulatory or respiratory problems
• New activity
• Fatigue
• Dyspnea
• Pain
(care plan continued on page 292)
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Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Vital signs (before and after activity)
• Malnutrition
• Previous inactivity
• Weakness
• Confusion
Assist the client and family in identifying lifestyle Lifestyle changes require sufficient support to achieve.
changes that may be required:
• Progressive exercise to increase endurance
• Range of motion (ROM) and flexibility exercises
• Treatments for underlying conditions (cardiac, respira-
tory, musculoskeletal, circulatory, etc.)
• Motivation
• Assistive devices as required (walkers, canes, crutches,
wheelchairs, exercise equipment, etc.)
• Adequate nutrition
• Adequate fluids
• Stress management
• Pain relief
• Prevention of hazards of immobility
• Changes in occupations or family or social roles
• Changes in living conditions
• Economic concerns
Assist the client and family to set criteria to help them Provides additional support for the client.
determine when calling a physician or other interven-
tion is required.
Monitor the client need for resources and refer appropri- Provides additional support for the client.
ately. Consider possible needs such as:
• Assistive devices
• Mobility devices
• Security devices
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Airway Clearance, Ineffective • 293
Tidal volume (TV) 500 Amount of air inhaled or exhaled with each breath
Inspiratory reserve volume (IRV) 3100 Amount of air that can be forcefully inhaled after a
normal tidal volume inhalation
Expiratory reserve volume (ERV) 1200 Amount of air that can be forcefully exhaled after
a normal tidal volume exhalation
Residual volume (RV) 1200 Amount of air left in the lungs after a forced
exhalation
Total lung capacity (TLC) 6000 Maximum amount of air that can be contained in
the lungs after a maximum inspiration: TLC ⫽
TV ⫹ IRV ⫹ ERV ⫹ RV
(table continued on page 294)
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Vital capacity (VC) 4800 Maximum amount of air that can be expired after
a maximum inspiration: VC ⫽ TV ⫹ IRV ⫹ ERV
Should be 80% of TLC
Inspiratory capacity (IC) 3600 Maximum amount of air that can be inspired after
a normal expiration: IC ⫽ TV ⫹ IRV
Functional residual capacity (FRC) 2400 Volume of air remaining in the lungs after a normal
tidal volume expiration: FRC ⫽ ERV ⫹ RV
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Airway Clearance, Ineffective • 295
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient with clearing secretions from mouth Removes tenacious secretions from airways.
or nose by:
• Providing tissues
• Using gentle suctioning if necessary
Assist the patient with oral hygiene at least every 4 hours Oral hygiene clears away dried secretions and freshens
while awake at [times]: the mouth. Oil-based products may obstruct breathing
• Lubricate lips with a moisturizing agent. passages.
• Do not allow the use of oil-based products around
the nose.
Discuss with the patient the importance of maintaining Facilitates expansion of the diaphragm; decreases proba-
proper position to include: bility of aspiration.
• Side-lying position while in bed
Promote rest and relaxation by scheduling treatments and Avoids overexertion and worsening of condition.
activities with appropriate rest periods.
Confer with appropriate consultations as needed (e.g., Promotes cost-effective use of resources, and promotes
respiratory therapy or physical therapy). follow-up care.
Provide for appropriate follow-up by scheduling appoint-
ments before dismissal.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor patient factors that relate to ineffective airway Provides an individualized data baseline that facilitates
clearance, including: individualized care planning.
• Feeding tolerance or intolerance
• Allergens
• Emotional aspects
• Stressors of recent or past activities
• Congenital anomalies
• Parental anxieties
• Infant or child temperament
• Abdominal distention
• Related vital signs, especially heart rate
• Diaphragmatic excursion
• Retraction in respiratory effort
• Choking, coughing
• Flaring of nares
• Appropriate functioning of respiratory equipment
Provide appropriate attention to suctioning and related Ensures basic maintenance of airway and respiratory
respiratory maintenance: function. Gives priority attention to the child’s status
• Appropriate size for catheter as needed and developmental level.
• Appropriate administration of humidified oxygen as
ordered by physician
• Appropriate follow-up of blood gases
• Documentation of oxygen administration, characteris-
tics of secretions obtained by suctioning, and vital
signs during suctioning, reporting apical pulse less than
70 or more than 149 beats per minute for an infant or
less than 90 or more than 120 beats per minute for a
young child.
(care plan continued on page 296)
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296 • Activity—Exercise Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage the parent’s input in planning care for the Promotes family empowerment, and thus promotes the
patient, with attention to individual preferences when likelihood of more effective management of therapeutic
possible. regimen after discharge.
Provide health teaching as needed based on assessment Allows timely home care planning, family time to ask
and the child’s situation. questions, practicing of techniques, etc. before dis-
charge. Assists in reducing anxiety, and promotes con-
tinuance of the therapeutic regimen.
Plan for appropriate follow-up with health team Provides for long-term support and effective management
members. of the therapeutic regimen.
Reduce apprehension by providing comforting behavior Sensitivity to individual feelings and needs builds trust in
and meeting developmental needs of the patient and the nurse–patient–family relationship.
family.
Allow for diversional activities to approximate tolerance Realistic opportunities for diversion will be chosen based
of the child. on what the patient is capable of doing and what will
leave the patient feeling refreshed and renewed for
having participated.
Encourage the family members to assist in care of the Return-demonstration provides feedback to evaluate
patient, with use of return-demonstration opportunities skills and serves to provide reinforcement in a support-
for teaching required skills. ive environment. Involvement of the parents also
satisfies the emotional needs of both the parents and
the child.
Provide for appropriate safety maintenance, especially Appropriate safety measures must be taken with the use
with oxygen administration (no smoking), and of combustible potentials whose use outside of pre-
appropriate precautions for age and developmental scribed parameters may be toxic.
level.
Allow ample time for parental mastery of skills identified Greater success in compliance and confidence is
in care of the child. afforded by providing ample time for skills that
require mastery.
Women’s Health
● N O T E : The following nursing actions pertain to the newborn infant in the delivery
room immediately following delivery. See Adult Health and Home Health for actions
related to the mother.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Evaluate and record the respiratory status of the newborn Basic measures to clear the newborn’s airway. Deep suc-
infant: tioning would stimulate reflexes that could result in
• Suction and clear mouth and pharynx with bulb syringe. aspiration.
• Avoid deep suctioning if possible.
Continue to evaluate the infant’s respiratory status, and act Basic protocol for the infant who has difficulty immedi-
if necessary to resuscitate. Depending on the infant’s ately after birth.
response, the following nursing measures can be taken:
• Administer warm, humid oxygen with a face mask.
• If no improvement, administer oxygen with bag and
mask.
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Airway Clearance, Ineffective • 297
ACTIONS/INTERVENTIONS R AT I O N A L E S
• If no improvement, be prepared for:
• Endotracheal intubation
• Ventilation with positive pressure
• Cardiac massage
• Transport to neonatal intensive care unit
Mental Health
Care plan for Adult Health can be utilized as a foundation with the following considerations for psychiatric clients:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collaborate with the physician for possible use of saline These commonly used medications can cause blood
gargles or anesthetic lozenges for sore throats (report dyscrasias that present with the symptoms of sore
all sore throats to the physician, especially if the client throat, fever, malaise, unusual bleeding, and easy bruis-
is receiving antipsychotic drugs and in the absence of ing. Early intervention is important for patient safety.41
other flu or cold symptoms).
Remind the client to chew food well, and sit with the Provides safety for the client with alterations of mental
client during mealtime if cognitive functioning indi- status.
cates a need for close observation. [Note any special
adaptations here (e.g., soft foods, observation during
meals, etc.)]
Gerontic Health
● N O T E : Aging adults tend to decrease their fluid intake, which can contribute to the
development of ineffective airway clearance. Consider this issue as a part of initial and
ongoing assessment.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach and facilitate pulmonary hygiene measures with Basic pulmonary hygiene prevents further airway
the client and caregivers: problems.
• Coughing and deep-breathing exercises every 2 hours
on [odd/even] hour
• Ensuring adequate hydration (monitor intake and
output)
• Clearing the bronchial tree by controlled coughing
• Decreasing viscosity of secretions via humidity and
fluid balance
• Postural drainage
• Learning stress management
• Ensuring adequate nutritional intake
• Learning diaphragmatic breathing
• Administering pain relief
• Beginning progressive ambulation (avoiding fatigue)
• Maintaining position so that danger of aspiration is
decreased
• Maintaining body position to minimize work of breath-
ing and cleaning airway
• Ensuring adequate oral hygiene
• Clearing secretions from throat
• Suctioning as needed
(care plan continued on page 298)
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298 • Activity—Exercise Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Keeping area free of dust and potential allergens or
irritants
Provide small, frequent feedings during periods of Conserves energy and promotes ventilation efforts.
dyspnea.
Instruct the patient regarding early signs of respiratory Early recognition of signs of infection promotes early
infections (e.g., increased amount or thickness of intervention and avoidance of severe infection.
secretions, increased cough, or changes in color of
sputum produced).
Facilitate increased mobility, as tolerated, on a daily Mobility helps increase rate and depth of respiration as
basis. [Note plan for this client here.] well as decreasing pooling of secretions.
Teach the patient to complete prescribed course of antibi- Because of economic factors, patients commonly stop
otic therapy. therapy before the designated time frame, “saving” the
medication for possible future episodes.
Monitor for the use of sedative medications that can These medications can decrease the level of alertness and
decrease the level of alertness and respiratory effort. respiratory effort.
Collaborate with the physician regarding the use of cough Decreases episodes of persistent, nonproductive
suppressants and mucolytics. coughing.
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Autonomic Dysreflexia, Risk For and Actual • 299
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Ensuring adequate nutritional intake
• Learning diaphragmatic breathing
• Administering pain relief
• Beginning progressive ambulation (avoiding fatigue)
• Maintaining position so that danger of aspiration is
decreased
• Maintaining body position to minimize work of breath-
ing and cleaning airway
• Ensuring adequate oral hygiene
• Clearing secretions from throat
• Suctioning as needed
• Keeping area free of dust and potential allergens or irri-
tants
• Ensuring adequate hydration (monitor intake and
output)
Teach the client and family purposes, side effects, and
proper administration techniques of medications.
Assist the client and family to set criteria to help them Locus of control shifts from nurse to the client and fam-
determine when calling a physician or other interven- ily, thus promoting self-care.
tion is required.
Teach the family basic cardiopulmonary resuscitation
(CPR).
Consult with or refer to appropriate assistive resources Provides additional support for the client and family,
as indicated. and uses already available resources in a cost-effective
manner.
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300 • Activity—Exercise Pattern
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Autonomic Dysreflexia, Risk For and Actual • 301
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302 • Activity—Exercise Pattern
Child Health
● N O T E : Recognizing the pattern is critical as encephalopathy and shock will
often ensue.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for contributing factors, esp. bladder distention Offers anticipatory guidance for plan with definitive
and provide intervention as needed. action for most likely cause.
*Drain the bladder slowly to avoid sudden change in
pressure.
Administer medications as required to help control Assists in preventing seizures, and provides appropriate
the blood pressure at appropriate levels for age and intervention to maintain pressure within desired
weight ranges.49
*Antihypertensives are administered IV initially and
then PO when stabilization is reached for main-
tenance. Antispasmodics may also be admin-
istered.
Monitor the pulse as needed and blood pressure every Basic monitoring for initial indications of problem devel-
5 minutes until stable. Determine parameters for the opment.
patient according to the norms for age, site, and
condition.
Monitor the family’s understanding and perception of Assists in preventing misunderstandings and in identify-
dysreflexia. Ensure that proper attention is paid to ing learning needs.
the family’s needs for support during this emergency
phase.
Teach the patient, to the extent he or she is capable, Education enhances care and provides an opportunity
and the family routine for care, including the pre- for care to be practiced in a supportive environment.
vention of infection (particularly urinary and integu-
mentary).
Monitor for latex allergy risk because of multiple Frequent catheterization with latex supplies increases
urinary catheterizations. the risk for allergy.49
Women’s Health
● N O T E : The same nursing diagnosis pertains to Women’s Health as to Adult Health.
The following precautions should be taken when the victim is pregnant.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Position the patient to prevent supine hypotension by: Keeps the weight of the uterus off the inferior vena cava.
• Placing the patient on her left side if possible.
• Using a pillow or folded towel under the right hip to
tip to left.
• If neck injury is suspected, placing the patient on a
back board and then tipping the board to the left.
Start an intravenous line for replacement of lost fluid The pregnant woman has 50 percent more blood
volume. volume and her vital signs may not change until
there is a 30 percent reduction in circulating blood
volume.
Monitor fetal status continuously. Monitor for uterine Basic data needed to ensure positive outcome.
contractions at least once per hour.
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Autonomic Dysreflexia, Risk For and Actual • 303
Mental Health
The expected outcomes and nursing actions for the mental health client are the same as those for the adult patient.
Gerontic Health
The nursing actions for the gerontic patient are the same as those for Adult Health.
Home Health
● N O T E : The interventions listed for autonomic dysreflexia are preventive in nature.
Should this condition develop in the home setting, emergency health care should be
sought immediately.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client, family, and potential caregivers meas- Basic care techniques that can assist in preventing the
ures to prevent Autonomic Dysreflexia47–49: occurrence of dysreflexia. Promotes sense of control
• Bowel and bladder routines and autonomy.
• Prevention of skin breakdown (e.g., turning, transfer,
or prevention of incontinence)
• Use and care of indwelling urinary catheter
• Prevention of infection
Assist the client and family in identifying signs and Provides for early recognition and intervention for prob-
symptoms of Autonomic Dysreflexia47: lem.
• Teach the family how to monitor vital signs and how
to recognize tachycardia, bradycardia, and paroxysmal
hypertension.
• Assist the client and family in identifying emergency Occurrence of this diagnosis is an emergency. This infor-
referrals: mation provides the family with a sense of security by
• Physician providing routes to and numbers of readily available
• Emergency room emergency assistance.
• Emergency medical system
• Educate the client, family members, and potential care- Other treatments will not be effective until the stimulus
givers about immediate elimination of the precipitating is removed.
stimuli.
• When an episode occurs, instruct the family and care- Decreases blood pressure and promotes cerebral venous
givers to place the head of the patient’s bed to an return.
upright position.
• Assist the client in obtaining necessary equipment to Allows for immediate removal of precipitating stimulus.
drain the bladder or remove impactions at home.
• Educate clients at risk for dysreflexia to be alert for
signs and symptoms of Autonomic Dysreflexia during
sexual encounters. Preparation for sexual intercourse
should include a bowel and bladder check and discon-
necting urinary drainage systems.
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304 • Activity—Exercise Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the patient and family appropriate uses and side Locus of control shifts from nurse to the client and fam-
effects of medications as well as proper administration ily, thus promoting self-care.
of the medications.
Obtain available wallet-sized card that briefly outlines
effective treatments in an emergency situation.50 Have
the client carry this card with him or her at all times.
Family members must be familiar with content and
location of card.
● N O T E : Labeled a Treatment Card, this card contains information related to patho-
physiology, common signs and symptoms, stimuli that trigger Autonomic Dysreflexia,
problems, and recommended treatment.
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Bed Mobility, Impaired • 305
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for contributing factors within the client’s devel- A complete ongoing assessment provides the primary
opmental capacity. database for individualization of care.
Identify priorities of basic physiologic functions to be Stabilization of basic physiologic status must be consid-
stabilized and considered as related to movement: ered for tolerance and safety.
• Respiratory
• Cardiovascular
• Neurologic
• Orthopedic
• Urologic
• Integumentary
Determine need for assistive devices. Realistic support may depend on orthotics, braces,
splints, or other mechanical devices for safety.
Determine teaching needs regarding mobility for Appropriate planning will offer greater likelihood of safe
the client, family, or staff assisting with mobility and consistent efforts.
activities.
Coordinate efforts for other health team members. The nurse is best suited to provide consistent and safe
planning of care with all health team members.
Determine the need for restraints of the client, and seek Appropriate attention to safety is paramount.
appropriate orders if indicated.
Provide ongoing assessment with documentation of the Ongoing timely assessment ensures safety and prevents
client’s tolerance of mobility activities as often as the injury.
patient’s status dictates.
Provide developmentally appropriate diversional Engagement in preferred activities enhances the likeli-
activities. hood of cooperation by the client.
Safeguard areas of vulnerability while movement Caution to entire body will best help prevent further
occurs, such as burns, traumatized limb, or surgical injury.
site.
Honor the child’s ability to safely carry out activities as Supports autonomy.49
appropriate.
Women’s Health
The nursing actions for Women’s Health are the same as those for Adult Health.
(care plan continued on page 306)
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306 • Activity—Exercise Pattern
Mental Health
Refer to Adult Health for interventions and rationales related to this diagnosis.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Consult with occupational therapist and physical therapist Facilitates mobility efforts the client may be able to sup-
for adaptive equipment to support the client while in port.51
bed (such as trapeze, transfer enabler, and foam sup-
port blocks).
Ensure that adaptive equipment is maintained in proper Ensures that safety needs are met.
functioning order.
Implement pressure-reducing devices, such as therapeutic Older adults are at high risk for pressure ulcers because
mattresses or mattresses with removable sections, to of skin fragility, changes in sensation, and altered
prevent problems with skin integrity. nutrition.52
Schedule turning and position changes according to the Depending on the individual client’s health status, turning
client’s tolerance to pressure. (Determined for each at the usually prescribed interval of q 2 h may not be
individual based on general condition and risk for sufficient to reduce risk for pressure ulcers.52
pressure ulcer development.)
Initiate ROM interventions (active or passive) on a daily Maintains joint mobility and prevents contractures.53
basis.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client in obtaining necessary durable medical
equipment to facilitate independent movement and
assisted movement (e.g., over-bed trapeze, hospital bed
with siderails, and sliding board).
Educate the client, family, and caregivers in the correct
use of equipment to facilitate independent movement
and assisted movement (e.g., over-bed trapeze, hospital
bed with siderails, and sliding board).
Instruct the caregivers in the proper use of draw sheets Minimizes risk of injury to both the client and caregiver.
to reposition the client rather than dragging the client
or using poor body mechanics to assist in reposi-
tioning.
Assist the client in obtaining necessary supplies to pre- Prevents deep vein thrombosis.
vent thrombus formation due to immobility, such as
thromboembolic stockings or pneumatic devices.
Encourage ROM exercises to promote strength. Improves circulation and motor tone.
Teach the client regarding proper body mechanics. Prevents further injury.
As the client begins to progress in his or her efforts Promotes independence while protecting from further
toward independent mobility, the nurse provides mini- injury.
mal assistance from the weak side, supporting the
unaffected side.
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Breathing Pattern, Ineffective • 307
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308 • Activity—Exercise Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Maintain appropriate attention to relief of pain and anxi-
ety via positioning and administration of medications
as prescribed.
Raise head of bed 30 degrees or more if not contraindi- Allows gravity to assist in lowering the diaphragm, and
cated. provides greater chest expansion.
Instruct in diaphragmatic deep breathing and pursed-lip Promotes lung expansion and slightly increases pressure
breathing. in the airways, allowing them to remain open longer.
Reduce pain, fear, and anxiety. These can cause altered breathing patterns (e.g., hyper-
ventilation).
Exercise caution with use of drugs that cause respiratory
depression.
Position patient in semi-Fowler’s position. Promotes lung expansion.
Encourage the patient’s mobility as tolerated (see Promotes tolerance for activities and helps with lung
Impaired Physical Mobility). expansion and ventilation.
Instruct the patient in effects of smoking, air pollution, Knowledge will assist the patient to avoid harmful envi-
etc., prior to discharge, on breathing pattern. ronments and to protect him- or herself from the
effects from such activities.
Provide teaching based on needs of the patient and family Reduces anxiety; starts appropriate home care planning;
regarding: assists the family in dealing with health-care system.
• Illness
• Procedures and related nursing care
• Implications for rest and relief of anxiety secondary to
respiratory failure
• Advocacy role
Child Health
The adult health-care plan can be implemented as developmentally appropriate with the following considerations:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine possible contributing factors. Facilitates comprehensive care planning.
Maintain appropriate emergency equipment in an accessi- Standard accountability for emergency equipment and
ble place. (Specify actual size of endotracheal tube for treatment is basic to patient care and especially so
the infant, child, or adolescent, tracheotomy set size, when risk factors are increased.
and suctioning catheters or chest tube for size of the
patient.)
Allow at least 5 to 15 minutes per shift for the parents Appropriate time for venting may be hard to determine,
and child to verbalize concerns related to illness. but efforts to do so demonstrate valuing of patient and
family needs and serve to reduce anxiety.
Determine perception of illness by the patient and parents. How the parents and child see (perceive) the patient’s
problem provides meaningful data that serve to
ensure sensitivity in care and provides information
regarding teaching needs. Provides cues to ques-
tions regarding continued implementation of
therapeutic regimen.
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Breathing Pattern, Ineffective • 309
ACTIONS/INTERVENTIONS R AT I O N A L E S
Include the parents in the care of the child as appropriate, Parental involvement is critical in maintaining emotional
to include comfort measures, assisting with feeding, bonds with the child. Also augments sense of con-
and the like. tributing to the child’s care, with opportunities for mas-
tering the skills in a supportive environment.
Collaborate with appropriate health team members as Appropriate coordination of services will best meet the
needed. patient’s needs with attention to the patient’s individ-
uality.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient and significant other in identifying Increased cardiovascular fitness supports increased respi-
lifestyle changes that may be required to prevent ratory effectiveness.
Ineffective Breathing Pattern during pregnancy (e.g.,
stopping smoking or avoiding crowds during influenza
epidemics).
Develop exercise plan for cardiovascular fitness during
pregnancy.
Teach the patient to avoid wearing constrictive clothing Any constriction contributes to further breathing difficul-
during pregnancy. ties, and breathing becomes more difficult as the
expanding uterus and abdominal contents press against
the diaphragm.54
Teach and encourage the patient to practice correct Assists in preventing hyperventilation.
breathing techniques for labor.
During the latter stages of pregnancy, encourage the During this stage, the chest cavity has less room to
patient to: expand because of the enlarging uterus.55
• Walk up stairs slowly.
• Lie on left or right side, to get more oxygen to the fetus.
• Position herself in bed with pillows for optimum com- Often edema of the latter stage of pregnancy causes
fort and adequate air exchange. “stuffy” noses and full sinuses.
• Take frequent rest breaks during the workday.
Carefully monitor maternal respiration during the labor- Analgesics and anesthesia can cause maternal hypoxia
ing process. and reduce fetal oxygen.
If prolonged decrease in fetal heart tone (FHT) immedi-
ately prior to delivery, administer pure oxygen (10 to
12 L/min) to the mother before delivery and until ces-
sation of pulsation in cord.
Evaluate and record the respiratory status of the newborn Basic care measures to ensure effective respiration in the
infant: newborn infant.
• Determine the 1-minute Apgar score.
• Suction and clear mouth and pharynx with bulb syringe.
• Avoid deep suctioning if possible.
Dry excess moisture off the infant with towel or blanket. Helps stimulate the infant; prevents evaporative heat loss.
Stimulate (if necessary), using firm but gentle tactile
stimulation:
• Rubbing up and down spine
• Flicking heel
(care plan continued on page 310)
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310 • Activity—Exercise Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Place the infant in warm environment:
• Place the infant under radiant heat warmer.
• Place the infant next to the mother’s skin
• Cover the infant’s head with a stocking cap.
• Cover both the mother and infant with a warm blanket.
Determine and record the 5-minute Apgar score.
Continue to evaluate the infant’s respiratory status and be Basic protocol to care for the newborn who has respira-
prepared to act if necessary to resuscitate. Depending tory problems.
on the infant’s response, the following nursing meas-
ures can be taken:
• Administer warm, humid oxygen with face mask.
• If no improvement, administer oxygen with bag and
mask.
• If no improvement, be prepared for:
• Endotracheal intubation
• Ventilation with positive pressure
• Cardiac massage
• Transport to neonatal intensive care unit
Mental Health
● N O T E : The following orders are for Ineffective Breathing Pattern Related to Anxiety.
When the diagnosis is related to physiologic problems, refer to Adult Health nursing actions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor causative factors. Provides information on the client’s current status so
interventions can be adapted appropriately.
Place the client in a calm, supportive environment. Anxiety is contagious, as is calm. A calm, reassuring
environment can communicate indirectly to the client
that the situation is safe and that the nurse can assist
him or her in mobilizing their internal resources, thus
facilitating the client’s sense of control.
Maintain a calm, supportive attitude, reassuring the client
that you will assist him or her in maintaining control.
Give the client clear, concise directions. Anxiety can decrease the client’s ability to focus on and
understand a complex presentation of information.
Have the client maintain direct eye contact with nurse. Communicates interest in the client, and assists the client
Modulate based on the client’s ability to tolerate eye in tuning out extraneous stimuli.
contact. Should not be done in a manner that appears
to “stare the client down.”
Instruct the client to take slow, deep breaths. Demonstrate Helps stimulate relaxation response.
breaths to the client, and practice with the client.
Provide the client with constant, positive reinforcement
for appropriate breathing patterns.
Remain with the client until the episode is resolved. Reassures the client of safety and security.
If the client does not respond to the attempts to control Rebreathing air with higher carbon dioxide (CO2) content
breathing, have the client breathe into a paper bag. slows the respiratory rate.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Distract the client from focus on breathing by beginning Interrupts pattern of thought that reinforces anxiety
a deep muscle relaxation exercise that starts at the and therefore increases breathing difficulties.
client’s feet.
Use successful resolution of a problematic breathing Promotes the client’s self-esteem and perceived control;
episode as an opportunity to teach the client that he or also provides positive reinforcement for adaptive cop-
she can gain conscious control over breathing and that ing behaviors.
these episodes are not out of his or her control.
Teach the client and significant others proper breathing Promotes perceived control and adaptive coping behav-
techniques, to include: iors. Provides information that will facilitate positive
• Maintaining proper body alignment reinforcement from the support system, increasing the
• Using diaphragmatic breathing (see Ineffective Airway probability for the success of the behavior change.56
Clearance for information on this technique)
• Use of deep muscle relaxation before the onset of inef-
fective breathing pattern begins
Practice with the client diaphragmatic breathing twice a Enhances relaxation response.
day for 30 minutes. [Note practice times here.]
Develop a plan with the client for initiating slow, deep Early recognition of problematic situations facilitates
breathing when an ineffective breathing pattern begins. the client’s ability to gain control and utilize adaptive
coping behaviors.
Identify with the client the situations that are most fre- Positive imagery promotes positive psychophysiologic
quently associated with the development of ineffective responses and enhances self-esteem, which promotes
breathing patterns, and assist him or her in practicing the possibility for a positive outcome.36
relaxation in response to these situations 1 time a day
for 30 minutes. [NOTE time of practice session here.]
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor respiratory rate, depth, effort, and lung sounds Minimum database needed for this diagnosis.
every 4 hours around the clock.
Because of age-related “air trapping,” have the patient Decreased alveoli and decreased elasticity lead to air
focus on improving expiratory effort. Instruct the trapping, which results in hyperinflation of lungs.
patient to inhale to the count of 1 and exhale for 3
counts.57
Collaborate with occupational therapy and respiratory Occupational therapist can teach the patient less energy-
therapy regarding other measures to enhance respira- expanding means to complete activities of daily living.
tory function. Respiratory therapist can assist the patient and family in
learning how to perform pulmonary toileting at home.
In the event of a chronic Ineffective Breathing Pattern, Provides long-term support for coping with problems;
refer the patient to a support group such as those spon- provides updated information; provides role modeling
sored by the American Lung Association. from other group members.
Instruct in relaxation techniques (e.g., guided imagery May assist in decreasing the episodes of acute breathing
or progressive muscle relaxation, to reduce stress). problems in those with chronic Ineffective Breathing
Pattern.
Where applicable, monitor for knowledge of proper Maximum benefit may be derived from proper drug
medication use, especially if inhalers are a part of administration and usage. Inhalers may be difficult to
the therapy. operate because of physical problems and lack of
information regarding proper usage.
(care plan continued on page 312)
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Home Health
● N O T E : If this diagnosis is suspected when caring for a patient in the home, it is
imperative that a physician referral be obtained immediately. If the patient has been
referred to home health care by a physician, the nurse will collaborate with the physi-
cian in the treatment of the patient.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family appropriate monitoring Provides for early recognition and intervention for
of signs and symptoms of Ineffective Breathing problem.
Pattern:
• Cough
• Sputum production
• Fatigue
• Respiratory status: cyanosis, dyspnea, rate
• Lack of diaphragmatic breathing
• Nasal flaring
• Anxiety or restlessness
• Impaired speech
Assist the client and family in identifying lifestyle Provides basic information for the client and family that
changes that may be required in assisting to prevent promotes necessary lifestyle changes.
ineffective breathing pattern:
• Stopping smoking
• Prevention and early treatment of lung infections
• Avoidance of known irritants and allergies
• Practicing pulmonary hygiene:
• Clearing bronchial tree by controlled coughing
• Decreasing viscosity of secretions via humidity and
fluid balance
• Clearing postural drainage
• Treatment of fear, anxiety, anger, depression, thorax
trauma, or narcotic overdoses
• Adequate nutritional intake
• Stress management
• Adequate hydration
• Breathing techniques (diaphragmatic, pursed lips)
• Progressive ambulation
• Pain relief
• Preventing hazards of immobility
• Appropriate use of oxygen (dosage, route, and safety
factors)
Teach the patient and family purposes, side effects, and
proper administration techniques of medication.
Assist the client and family to set criteria to help them Locus of control shifts from nurse to the client and fam-
determine when calling a physician or other interven- ily, thus promoting self-care.
tion is required.
Teach the family basic CPR.
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314 • Activity—Exercise Pattern
tole) increases. This allows for an increase in the preload or by administration of such substances as calcium and
and a subsequent increase in stroke volume. If the stroke epinephrine.
volume falls, the heart rate increases to compensate. Afterload is the amount of tension developed by the
Preload, contractility, and afterload affect stroke volume. ventricle during contraction. The amount of peripheral
Preload refers to the amount of stretching of the resistance predominantly determines the amount of tension.
myocardial fibers. The fibers stretch as a result of the An excessive increase in the afterload reduces stroke volume
increase in the volume of blood delivered to the ventricles and cardiac output.
during diastole. The degree of myocardial stretch before The heart rate is predominantly influenced by the
contraction is preload. Preload is determined by the venous autonomic nervous system, through both the sympathetic
return and ejection fraction (amount of blood left in the ven- and parasympathetic nervous systems. The sympathetic
tricle at the end of systole). Prolonged excessive stretching fibers can increase both rate and force, whereas the parasym-
leads to a decrease in cardiac output. pathetic fibers act in an opposite direction. Other factors
Contractility is a function of the intensity of the such as the central nervous system pressoreceptor reflexes,
actinomycin linkages. Increased contractility increases ven- cerebral cortex impulses, body temperature, electrolytes,
tricular emptying and results in increased stroke volume. and hormones also affect the heart rate, but the autonomic
Contractility can be increased by sympathetic stimulation nervous system keeps the entire system in balance.58
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Cardiac Output, Decreased • 315
Child Health
This pattern represents a life-threatening status, which demands immediate attention.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for all possible contributing factors, especially Provides realistic basis for plan of care.
known underlying cardiac anomaly.
Provide in-depth monitoring and documentation related These factors constitute the basic measures utilized in
to the following: monitoring for decompensation of cardiac status.
• Ventilator, if applicable: Closely related are respiratory function, hydration
• If continuous positive airway pressure (CPAP), adjust status, and hemodynamic status.
setting according to the physician order
• Peak pressure as ordered
• O2 percentage desired as ordered
• Intake and output hourly and as ordered. Notify the
physician if below 10 mL/h or as specified for size of
the infant or child
• Excessive bleeding. If in postoperative status,
notify the physician if more than 50 mL/h or as
specified.
• Tolerance of feedings
• Notify the physician for:
• Premature ventricular contractions (PVCs) or other
arrhythmias
• Limits of pulse, respiratory rate, output criteria as
specified for the individual patient
• Use caution in the administration of medications as
ordered, especially digoxin:
• Have another RN check the dose and medication
order.
• Validate and document the heart rate to be greater
than the specified lower limit parameter (e.g., 100 for
an infant) or as ordered per pediatric cardiologist or
intensivist before administering.
• Document if the medication is withheld because of
heart rate.
• Monitor for signs and symptoms of toxicity (e.g.,
vomiting).
• Ensure potassium maintenance. Collaborate with the
physician regarding frequency of serum potassium
measurement, and immediately report results.
• Maintain digitalizing protocol.
• Make sure that the parents understand the patient’s sta-
tus and treatment.
• Monitor the patient’s response to suctioning, x-ray
exam, or other procedures.
Ensure availability of a crash cart and emergency equip- Standard nursing care includes availability and appropri-
ment as needed, to include: ate use of equipment and medications in event of car-
• Cardiac or emergency drugs diac arrest. Anticipation for need of equipment with a
• Defibrillator child in high-risk status is required.
• Ambu bag (pediatric or infant size)
• Appropriate suctioning equipment
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316 • Activity—Exercise Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Allow time for the parents to voice concern on a regular Verbalization of concerns helps reduce anxiety.
basis. Set aside 10 to 15 minutes per shift for this Attempting to set aside time for this verbalization
purpose. demonstrates the value it holds for the patient’s care.
Encourage parental input in care, such as with feeding, Parental input assists in meeting the emotional needs of
positioning, and monitoring intake and output as both the parents and child, and supports the care given
appropriate. by health care personnel. This action also allows for
learning essential skills in a supportive environment.
Encourage the patient, as applicable, to participate in care. Self-care enhances sense of autonomy and empowerment.
Allow for sensitivity to time in understanding of diagno- Abstract aspects of an illness often prove more difficult to
sis. The seemingly abstract nature of underlying car- grasp. Congenital cardiac anomalies are often complex
diac physiology, especially in noncyanotic heart in nature, which requires health-care personnel to use
disease, can be confusing. consistent terms and offer appropriate aids to depict
key issues of anatomy.
Support the parents in usual appropriate coping mecha- Emotional security may be afforded by encouragement of
nisms. usual coping mechanisms for age and developmental
status.
Maintain appropriate technique in dressing change (asep- Standard care requires universal precautions, which mini-
sis and cautious handwashing). mize risk factors for infection.
Limit visitors in immediate postoperative status as Visitation may prove overwhelming to all when unlimited
applicable. in immediate postoperative period. Remember that
numerous nursing–medical therapies must be attended
to during this time also.
Help reduce patient and parental anxiety by touching and Comforting allows the parent and child to feel more
allowing the patient to be held and comforted. secure and decreases feelings of intimidation the par-
ents might experience from seeing numerous pieces of
equipment and activity. Human caring helps offset per-
ceptions of impersonal high tech.
Provide teaching with sensitivity to patient and parental Individualized teaching with appropriate aids will most
needs regarding equipment, procedures, or routines likely serve to reinforce desired learning and enlist the
(e.g., use a doll for demonstration with a toddler). patient’s cooperation.
Encourage the parents to meet other parents of similarly Sharing with similarly involved clientele or families
involved cardiac patients. affords a sense of unity, hope, and affirmation of the
future far beyond what nurses or others may offer.
Address the need for the parents to continue with ADLs Aim should be for normalcy within parameters dictated
with confidence regarding knowledge of restrictions in by the child’s condition. Strive to refrain the family
the child’s status. from labeling the child or encouraging the child to
become a “cardiac cripple.”
Women’s Health
● N O T E : Caution the patient never to begin a new vigorous exercise plan while preg-
nant. Teach the patient to exercise slowly, in moderation, and according to the individ-
ual’s ability. A good rule of thumb is to use moderation and, with the consent of the
physician, continue with the pre-pregnant established exercise plan. Most professionals
discourage aerobics and hot tubs or spas because of the heat. It is not known at this time
if overheating by the mother is harmful to the fetus.
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Cardiac Output, Decreased • 317
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient with relaxation techniques. Assists in stress reduction.
Assist in developing an exercise plan for cardiovas- Assists in increasing cardiovascular fitness during preg-
cular fitness during pregnancy. Some good exer- nancy.
cises are:
• Swimming
• Walking
• Bicycling
• Jogging (If the patient has done this before and is
used to it, jogging is probably not harmful, but rem-
ember that during pregnancy joints and muscles are
more susceptible to strain. If the patient feels pain,
fatigue, or overheating, she should slow down or
stop exercise.)
Refer the patient to support groups that understand
the physiology of pregnancy and have developed
exercise programs based on this physiology, such as
swimming classes for pregnant women at the local
YWCA, childbirth education classes, or exercise
videotapes specifically directed and produced for
use during pregnancy.
Teach the patient and significant others how to avoid The expanded uterus causes pressure on the large blood
“supine hypotension” during pregnancy (particularly vessels.
the later stages).
Prior to the start of labor, encourage the patient to attend
childbirth education classes to learn how to work with
her body during labor.
During the second stage of labor59–61:
• Allow the patient to assume whatever position aids her
in the second stage of labor (i.e., upright, squatting,
kneeling position, the use of birth balls, etc.).
• Provide the patient with proper physical support
during the second stage of labor. This support might
include allowing the partner or support person to sit
or stand beside her and support her head or shoulders,
or behind her supporting her with his or her body.
The partner might also stand in front of her, allowing
her to lean on his or her neck. The patient may also
use a birthing bed or chair, pillows, over-the-bed
table, or bars.
Do not urge the woman to “push, push” or to hold Avoids straining and the Valsalva maneuver.62
breath during the second stage of labor. Allow the
woman to bear down with her contractions at her
own pace:
• Encourage spontaneous bearing down only if fetal head
has not descended low enough to stimulate Ferguson’s
reflex.
• Encourage the mother to push when she feels the urge
and to rest between contractions.62
(care plan continued on page 318)
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318 • Activity—Exercise Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Discourage prolonged maternal breath-holding (longer Breath-holding involves the Valsalva maneuver. Increased
than 6 to 8 seconds) during pushing. intrathoracic pressure due to a closed glottis causes a
• Assist the mother to accomplish four or more pushing decrease in cardiac output and blood pressure. The fall
efforts per contraction. in pressure causes a decrease in placental perfusion,
• Support the mother’s efforts in pushing, and validate causing fetal hypoxia.54,62,63
the normalcy of sensations and sounds the mother is
verbalizing. (These sounds may include grunting,
groaning, and exhaling during the push or breath-
holding less than 6 seconds.)
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor risk factors: Early identification and intervention helps ensure better
• Medications outcome.
• Past history of cardiac problems
• Age
• Current condition of the cardiovascular system
• Weight
• Exercise patterns
• Nutritional patterns
• Psychosocial stressors
Monitor every [number] hours (depends on level or risk, Basic database for further intervention.
can be anywhere from 2 to 8 hours) the client’s cardiac
functioning. [list times to observe here]:
• Vital signs
• Chest sounds
• Apical–radial pulse deficit
• Mental status
Report alterations to the physician.
If acute situation develops, notify the physician and
implement adult health nursing actions.
If the client’s condition or other factors necessitate the
client’s remaining in the mental health area beyond the
acute stage, refer to adult health nursing actions for care
on an ongoing basis. This is not recommended because
of the lack of equipment and properly trained staff to
care for this situation on most specialized care units.
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
If the client is placed on the unit while in the rehabilita- Promotes the client’s perceived control and supports self-
tion stage of this diagnosis, implement the following care activities.
nursing actions: (Discuss with the client and other
health-care providers current rehabilitation schedule,
and record special consideration here.)
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Cardiac Output, Decreased • 319
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide appropriate rest periods following activity. Prevents excessive stress on the cardiovascular system,
This varies according to the client’s stage in rehabil- and prevents fatigue.
itation. Most common times of needed rest are after
meals and after any activity. [Note specific limits
here.]
Assist the client with implementation of exercise Promotes cardiovascular strength and well-being.
program. List types of activity, time spent in
activity, and times of activity here. Also list special
motivators the client may need, such as a com-
panion to walk for 30 minutes three times a day
at [times].
Provide diet restrictions (e.g., low-sodium, low-calorie, Decreases dietary contributions to increased risk factors.
low-fat, low-cholesterol, or fluid restrictions).
Monitor intake and output each shift. Medications can affect fluid balance, and excessive
fluid can increase demands on the cardiovascular
system.
Monitor for and teach the client to assess for: Increases the client’s perceived control, and promotes
• Potassium loss (muscle cramps) early recognition and treatment of problem.
• Chest pain
• Dyspnea
• Sudden weight gain
• Decreased urine output
• Increased fatigue
Monitor risk factors, and assist the client in developing a Increases the client’s perceived control, and decreases
plan to reduce these (e.g., smoking, obesity, or stress). risk for further damage to the cardiovascular system.
Refer to appropriate nursing diagnosis for assistance in
developing interventions.
Spend 30 minutes twice a day teaching the client deep Relaxation decreases stress on the cardiovascular system.
muscle relaxation and practicing this process. [List
times here.]
Discuss with the patient’s support system the lifestyle
alterations that may be required.
Develop stress reduction program with the client, and Enhances possibility for continuation of behavior
provide necessary environment for implementation. change.56
This could include massage therapy, meditation,
aerobic exercise as tolerated, hobbies, or music.
[Note specific plan here.]
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized in aging clients.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the older adult for atypical signs of pain, such Older adults may experience physiologic and psychologi-
as alterations in mental status, anxiety, or decreasing cal alterations that affect their response to pain.64
functional capacity.
(care plan continued on page 320)
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320 • Activity—Exercise Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for possible side effects of diuretic therapy. Older adults may have excessive diuresis on normal
diuretic dosage.
Review the health history for liver or kidney disease in To avoid complications, dosages of diuretics may need to
patients on diuretic therapy. be adjusted in those with pre-existing kidney or hepatic
disease.
Whenever possible, give diuretics in the morning. Decreases problems with nocturia and consequent
distributed sleep–rest pattern or risk for injury from
falls.
Teach proper medication usage (e.g., dosage, side Basic safety for medication administration.
effects, dangers related to missed doses, and food/drug
interactions).
Teach patients who are on potassium-wasting diuretics:
• The need for potassium replacement
• Foods that are high in potassium (e.g., bananas)
• Signs and symptoms of potassium depletion
Assist the patient and/or family to determine environmen- Assists in conservation of energy and balancing oxygen
tal conditions that may need to be adapted to promote demands with resources.
energy.
Home Health
● N O T E : If this diagnosis is suspected when caring for a client in the home, it is imper-
ative that a physician referral be obtained immediately. If the client has been referred to
home health care by a physician, the nurse will collaborate with the physician in the
treatment of the client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the patient and significant others: Provides for early recognition and intervention for
• Risk factors (e.g., smoking, hypertension, or obesity) problem.
• Medication regimen (e.g., toxicity or effects)
• Need to balance rest and activity
• Monitoring of:
• Weight daily
• Vital signs
• Intake and output
• When to contact health-care personnel:
• Chest pain
• Dyspnea
• Sudden weight gain
• Decreased urine output
• Increased fatigue
• Dietary adaptations, as necessary:
• Low sodium
• Low cholesterol
• Caloric restriction
• Soft foods
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Disuse Syndrome, Risk For • 321
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient and family in identifying lifestyle Provides basic information for the client and family that
changes that may be required: promotes necessary lifestyle changes.
• Eliminating smoking
• Cardiac rehabilitation program
• Stress management
• Weight control
• Dietary restrictions
• Decreased alcohol
• Relaxation techniques
• Bowel regimen to avoid straining and constipation
• Maintenance of fluid and electrolyte balance
• Changes in role functions in the family
• Concerns regarding sexual activity
• Monitoring activity and responses to activity.
● N O T E : Level of damage to left ventricle should be determined before exercise pro-
gram is initiated.66
• Providing diversional activities when physical activity
is restricted. (See Deficient Diversional Activity.)
• Pain control
Teach the family basic CPR. Locus of control shifts from nurse to the client and fam-
ily, thus promoting self-care.
Teach the client and family purposes and side effects
of medications and proper administration tech-
niques.
Teach the client and family to refrain from activities that
increase the demands on the heart (e.g., snow shovel-
ing, lifting, or Valsalva maneuver).
Assist the client and family to set criteria to help them
determine when calling a physician or other interven-
tion is required.
Consult with or refer to appropriate assistive resources Provides additional support for the client and family,
as indicated. and uses already available resources in a cost-effective
manner.
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322 • Activity—Exercise Pattern
✔ Have You Selected the Correct Diagnosis? well be a predisposing factor to Risk for Disuse
Syndrome.
Activity Intolerance
This diagnosis implies that the individual is freely able
EXPECTED OUTCOME
to move but cannot endure or adapt to the increased
energy or oxygen demands made by the movement Will exhibit no signs or symptoms of disuse syndrome by
or activity. [date].
Impaired Physical Mobility TARGET DATES
With this diagnosis, the individual could move
Disuse syndrome can develop rapidly after the onset of
independently if something was not limiting the
immobilization. The initial target date, therefore, should be
motion. Impaired Physical Mobility could very
no more than 2 days.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the family in development of an individualized The family is the best source for individual preferences
plan of care to best meet the child’s potential. and needs as related to what daily living for the child
involves.
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Disuse Syndrome, Risk For • 323
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the family in identification of factors that will Identifies learning needs and reduces anxiety. Fosters a
facilitate progress as well as those factors that may hin- plan that can be adhered to if all involved participate in
der progress in meeting the child’s potentials. List its development. Empowers the family.
those factors here, and assist the family in planning
how to offset factors that hinder progress and encour-
age factors that facilitate progress.
Facilitate both patient and family ventilation of feel- Ventilation of feelings assists in reducing anxiety and
ings that may relate to disuse problem by scheduling promotes learning about condition.
of 15 to 20 minutes each nursing shift for this
activity.
Assist the family in identification of the support system Promotes coordination of care and cost-effective use
for best possible follow-up care. of already available resources.
Women’s Health
This nursing diagnosis will pertain to women the same as to adults. Refer to nursing actions for Risk for Activity
Intolerance to meet the needs of women with the diagnosis of Risk for Disuse Syndrome.
Mental Health
● N O T E : The nursing actions in this section reflect the Risk for Disuse Syndrome
related to mental health, including use of restraints and seclusion. If the inactivity is
related to a physiologic or physical problem, refer to the Adult Health nursing actions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Attempt all other interventions before considering immo- Promotes the client’s perceived control and self-esteem.65
bilizing the client. (See Risk for Violence in Chapter
9 for appropriate actions.)
Carefully monitor the client for appropriate level of Client safety is of primary importance while maintaining,
restraint necessary. Immobilize the client as little as much as possible, the client’s perceived control and
as possible while still protecting the client and self-esteem.
others.
Obtain necessary medical orders to initiate methods Provides protection of the client’s rights. This should
that limit the client’s physical mobility. be done in congruence with the state’s legal require-
ments.
Carefully explain to the client, in brief, concise lan- High levels of anxiety interfere with the client’s ability to
guage, reasons for initiating the intervention and process complex information. Maintains relationship
what behavior must be present for the intervention and promotes the client’s perceived control.
to be terminated.
Attempt to gain the client’s voluntary compliance with Communicates to the client that staff has the ability to
the intervention by explaining to the client what is maintain control over the situation, and provides the
needed and with a “show of force” (having the neces- client with an opportunity to maintain perceived con-
sary number of staff available to force compliance if trol and self-esteem.
the client does not respond to the request).
Initiate forced compliance only if there is an adequate Staff and client safety are of primary importance.
number of staff to complete the action safely. (See
Risk for Violence in Chapter 9 for a detailed descrip-
tion of intervention with forced compliance.)
(care plan continued on page 324)
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324 • Activity—Exercise Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Secure the environment the client will be in by removing Provides a safe environment by removing objects the
harmful objects such as accessible light bulbs, sharp client could use to impulsively harm self.
objects, glass objects, tight clothing, metal objects,
or shower curtain rods.
If the client is placed in four-point restraints, maintain Promotes client safety and communicates maintenance of
one-to-one supervision. relationship while meeting security needs.
If the client is in seclusion or in bilateral restraints, Ensures client safety.
observe the client at least every 15 minutes, or more
frequently if he or she is agitated. [List observation
schedule here.]
Leave a urinal in the room with the client or offer toilet- Meets the client’s physiologic needs and communicates
ing every hour. respect for the individual.
Offer the client fluids every 15 minutes while he or she is
awake.
Discuss with the client his or her feelings about the initia- Promotes the client’s regaining control, and clearly pro-
tion of immobility, and review at least twice a day the vides the client with alternative behaviors for coping.
kinds of behavior necessary to have immobility discon-
tinued. [Note behaviors here.]
When checking the client, let him or her know you Promotes a sense of security, and provides information
are checking by calling him or her by name and orient- about the client’s mental status that will provide infor-
ing him or her to day and time. Inquire about the mation for further interventions.
client’s feelings, and implement necessary reality
orientation.
Provide meals at regular intervals in paper containers, Meets physiologic needs while maintaining client safety.
providing necessary assistance. [Amount and type of
assistance required should be listed here.]
If the client is in restraints, remove restraints at least Maintains adequate blood flow to the skin and prevents
every 2 hours, one limb at a time. Have the client move breakdown. Maintains joint mobility and prevents con-
limbs through a full ROM and inspect for signs of tractures and muscle atrophy.
injury. Apply lubricants such as lotion to area under
restraint to protect from injury.
Pad the area of the restraint that is next to the skin with Protects skin from mechanical irritation from the
sheepskin or other nonirritating material. restraint.
Check circulation in restrained limbs in the area below Early assessment and intervention prevent long-term
the restraint by observing skin color, warmth, and damage.
swelling. The restraint should not interfere with
circulation.
Change the client’s position in bed every 2 hours on Protects skin from ischemic and shearing pressure dam-
[odd/even] hour. Have the client cough and deep age. Promotes normal clearing of airway secretions.
breathe during this time.
Place the body in proper alignment to prevent complica-
tions and injury. Use pillows for support if the client’s
condition allows.
If the client is in four-point restraints, place him or her on Prevents aspiration or choking.
the stomach or side or elevate the head of the bed.
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Disuse Syndrome, Risk For • 325
ACTIONS/INTERVENTIONS R AT I O N A L E S
Place the client on intake and output monitoring to ensure Promotes normal hydration, which prevents thickening of
that adequate fluid balance is maintained. airway secretions and thrombus formation.66
Have the client in seclusion move around the room at Assesses the client’s risk for the development of orthosta-
least every 2 hours on [odd/even] hour. During this tic hypotension.
time, initiate active ROM and have the client cough
and take deep breaths.
Administer medications as ordered for agitation.
Monitor blood pressure before administering antipsy-
chotic medications.
Have the client change position slowly, especially from The combination of immobility and antipsychotic med-
lying to standing. ications can place the client at risk for the development
of orthostatic hypotension. Slowing position change
allows time for blood pressure to adjust and prevents
dizziness and fainting.
Assist the client with daily personal hygiene. Gives the client a sense of control.
Have the environment cleaned on a daily basis. Communicates respect for the client.
Remove the client from seclusion as soon as the con- Promotes the client’s perception of control, and provides
tracted behavior is observed for the required amount positive reinforcement for appropriate behavior.
of time. (Both of these should be very specific and
listed here. See Risk for Violence in Chapter 9 for
detailed information on behavior change and
contracting specifics.)
Schedule a time to discuss this intervention with the Promotes family understanding, and optimizes potential
client and his or her support system. Inform the for positive client response.56
support system of the need for the intervention and
about special considerations related to visiting with
the client. This information must be provided with
consideration of the support system before and after
each visit.
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized for the aging client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for iatrogenesis, especially in the case of institu- Although the regulations of the Omnibus Bill Reconcilia-
tionalized elderly. tion Act (OBRA) require the least-restrictive measures
and ideally restraint-free care, older adults in long-
term care may be placed at risk for disuse syndrome
secondary to geri-chairs, use of wheelchairs, and lack
of properly functioning or fitted adaptive equipment.
In addition, there may be reluctance to prescribe
occupational therapy or physical therapy because
of costs.
Advocate for older adults to ensure that inactivity is Health-care providers may be reluctant to ensure early
not based on ageist perspectives. mobilization in older patients, especially the old-old
clientele.
In the event of impaired cognitive function, remind the Prompting may encourage increased activity and
patient of need for and assist the patient (or caregiver) decreased risk for disuse.
in mobilizing efforts.
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326 • Activity—Exercise Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family appropriate monitoring of Provides for early recognition and intervention for
causes, signs, and symptoms of Risk for Disuse problem.
Syndrome:
• Prolonged bed rest
• Circulatory or respiratory problems
• New activity
• Fatigue
• Dyspnea
• Pain
• Vital signs (before and after activity)
• Malnutrition
• Previous inactivity
• Weakness
• Confusion
• Fracture
• Paralysis
Assist the client and family in identifying lifestyle Provides basic information for the client and family that
changes that may be required: promotes necessary lifestyle changes.
• Progressive exercise to increase endurance
• ROM and flexibility exercise
• Treatments for underlying conditions (cardiac,
respiratory, musculoskeletal, circulatory, neuro-
logic, etc.)
• Motivation
• Assistive devices as required (walkers, canes, crutches,
wheelchairs, ramps, wheelchair access, etc.)
• Adequate nutrition
• Adequate fluids
• Stress management
• Pain relief
• Prevention of hazards of immobility (e.g., antiem-
bolism stockings, ROM exercises, position changes)
• Changes in occupations, family, or social roles
• Changes in living conditions
• Economic concerns
• Proper transfer techniques
• Bowel and bladder regulation
Teach the client and family the purposes and side effects The locus of control shifts from the nurse to the client
of medications and proper administration techniques and family, thus promoting self-care.
(e.g., anticoagulants or analgesics).
Assist the client and family to set criteria to help them
determine when calling a physician or other interven-
tions are required.
Consult with, or refer to, appropriate resources as Provides additional support for the client and family, and
indicated. uses already available resources in a cost-effective
manner.
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Diversional Activity, Deficient • 327
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328 • Activity—Exercise Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage significant others to assist in increasing diver- Reinforces “normal” lifestyle, and encourages feelings
sional activity by: of self-worth.
• Bringing books, games, or hobby materials
• Visiting more frequently
• Encouraging other visitors
Provide for appropriate adaptations in equipment or posi-
tioning to facilitate desired diversional activity.
Provide for scheduling of diversional activity at a time
when the patient is rested and without multiple inter-
ruptions.
Consider alternate therapies (e.g., pet therapy).
Refer the patient to individual health-care practitioners
who can best assist with problem.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the patient’s potential for activity or diversion Provides essential database for planning desired and
according to: achievable diversion.
• Attention span
• Physical limitations and tolerance
• Cognitive, sensory, and perceptual deficits
• Preferences for gender, age, and interests
• Available resources
• Safety needs
• Pain
Facilitate parental input in planning and implementing Helps ensure that the plan is attentive to the child’s inter-
desired diversional activity plan. ests, thus increasing the likelihood of the child’s partic-
ipation.
Allow for peer interaction when appropriate through Involvement of peers serves to foster self-esteem and
diversional activity. meets developmental socialization needs.
Consult with the play therapist and plan for introduction Specialists facilitate the development of client-specific
of play therapy here. plans of care in complex situations.49
Women’s Health
● N O T E : The following refers to women placed on restrictive activities because of
threatened abortions, premature labor, multiple pregnancy, or pregnancy-induced
hypertension.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage the family and significant others to participate Promotes socialization, empowers the family, and pro-
in the plan of care for the patient. vides opportunities for teaching.
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Diversional Activity, Deficient • 329
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage the patient to list lifestyle adjustments that Basic problem-solving technique that encourages the
need to be made as well as ways to accomplish these patient to participate in his or her care. Will increase
adjustments. understanding of the current condition.
Teach the patient relaxation skills and coping mecha-
nisms.
Maintain proper body alignment with use of positioning
and pillows.
Provide diversional activities: Provides a variety of options to offset deficit.
• Hobbies (e.g., needlework, reading, painting, or
television)
• Job-related activities as tolerated (that can be
done in bed) (e.g., reading, writing, or telephone
conferences)
• Activities with children (e.g., reading to the child,
painting or coloring with the child, allowing the child
to “help” the mother such as bringing water to the
mother or assisting in fixing meals for mother)
• Encourage help and visits from friends and relatives
(e.g., visit in person, telephone visit, help with child-
care, or help with housework).
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine the source of deficient diversional activity. Recognizes the impact of physical space on the client’s
Is the nursing unit appropriately stimulating for the mood.
level or type of clients, or is the problem the client’s
perceptions?
Nursing Unit–Related Problems
Develop a milieu therapy program: Promotes here-and-now orientation and interpersonal
interactions.
• Include seasonal activities for clients, such as parties, Role models for clients skills in developing and initiating
special meals, outings, or games. Post schedule of diversional activities.
activities in client care areas. Enlist clients in activity
planning.
• Alter the unit environment by changing pictures, Enhances the aesthetics of the environment and has a
adding appropriate seasonal decorations, updating bul- positive effect on the client’s mood.35
letin boards, and cleaning and updating furniture.
• Alter the mood of the unit with bright colors, seasonal Colors and sounds affect the client’s mood.33
flowers, or appropriate music.
• Develop group activities for clients, such as team Provides opportunities to build social skills, explore dif-
sports; Ping-Pong; bingo games; and activity planning, ferent types of activities, and learn alternative methods
meal planning, meal preparation, current events discus- of coping.
sion, book discussion, exercise, or craft groups.
• Decrease emphasis on television as a primary unit Television does not provide opportunities for learning
activity. alternative coping skills and decreases physical
activity.
• Provide books, newspapers, records, tapes, and craft These resources assist the client in meeting belonging
materials. needs by facilitating interaction with others on the unit
and the world around him or her.
(care plan continued on page 330)
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330 • Activity—Exercise Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Use community service organizations to provide Provides varied sensory stimulation.
programs for clients.
Collaborate with the occupational therapist for ideas
regarding activities and supplies. Note schedule for
these activities here.
Collaborate with the physical therapist regarding physical
exercise program.
Client Perception–Related Problems
Discuss with the client past activities, reviewing those Promotes the client’s sense of control.
that have been enjoyed and those that have been tried
and not enjoyed.
List activities that the client has enjoyed in the past, with
information about what keeps the client from doing
them at this time.
Monitor the client’s energy level, and develop an activ- Promotes development of alternative coping behaviors by
ity that corresponds to the client’s energy level and assisting the client in choosing appropriate activities.
physiologic needs. For example, a manic client
may be bored with playing cards, and yet physio-
logic needs require less physical activity than the
client may desire, so an appropriate activity would
address both these needs. [Note client’s activity
plan here.]
Develop with the client a plan for reinitiating a previ- Promotes the client’s sense of control.
ously enjoyed activity. [Note that plan here.]
Develop time in the daily schedule for that activity.
[Note that time here.]
Relate activity to enjoyable time, such as a time for inter- Interaction can provide positive reinforcement for engag-
action with the nurse alone or interaction with other ing in the activity.
clients in a group area.
Provide positive verbal feedback to the client about his or Positive verbal reinforcement encourages appropriate
her efforts at the activity. coping behaviors.
Assist the client in obtaining necessary items to imple- Facilitates appropriate coping behaviors.
ment activity, and list necessary items here.
Develop a plan with the client to attempt one new Promotes the client’s perceived control, and provides pos-
activity—one that has been interesting for him or itive reinforcement for the behavior.
her but that he or she has not had time or direction to
pursue.
[Note plan and rewards for accomplishing goals here.]
Have the client set realistic goals for activity involve- Promotes the client’s strengths and self-esteem.
ment (e.g., one cannot paint like a professional in the
beginning).
Discuss feelings of frustration, anger, and discom- Verbalization of feelings and thoughts provides opportu-
fort that may occur as the client attempts a new nities for developing alternative coping strategies.
activity.
Frame mistakes as positive tools of learning new Promotes the client’s strengths.
behavior.
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Dysfunctional Ventilatory Weaning Response (DVWR) • 331
Gerontic Health
In addition to the interventions for Adult Health, the following can be utilized for the aging client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess the client’s level of activity prior to illness/hospi- Establishes a baseline and allows for realistic goal setting
talization. and intervention.
Provide at least 10 to 15 minutes per shift, while the Increases self-esteem, and focuses on strengths the
patient is awake, to engage in reminiscing with the patient has developed over his or her lifetime.67
patient.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor factors contributing to deficient diversional Provides database for prevention and/or early
activity. intervention.
Involve the client and family in planning, implement- Involvement improves motivation and improves the out-
ing, and promoting an increase in diversional come.
activity via:
• Family conference
• Mutual goal setting
• Communication
Assist the client and family in lifestyle adjustments that Provides basic information for the client and family that
may be required: promotes necessary lifestyle changes.
• Time management
• Work, family, social, and personal goals and priorities
• Rehabilitation
• Learning new skills or games
• Development of support systems
• Stress management techniques
• Drug and alcohol use issues
Refer the patient to appropriate assistive resources Provides additional support for the client and family, and
as indicated. uses already available resources in a cost-effective
manner.
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332 • Activity—Exercise Pattern
d. Pale, slight cyanosis ative events in the room, low nurse–patient ratio,
e. Slight respiratory accessory muscle use extended nurse absence from bedside, or unfamiliar
f. Inability to respond to coaching nursing staff)
g. Inability to cooperate c. History of multiple unsuccessful weaning attempts
h. Apprehension d. History of ventilator dependence ⬎1 week
i. Color changes e. Inappropriate pacing of diminished ventilator support
j. Decreased air entry on auscultation f. Inadequate social support
k. Diaphoresis
l. Eye widening, “wide-eyed look”
RELATED CLINICAL CONCERNS
m. Hypervigilence to activities
3. Severe DVWR 1. Closed head injury
a. Deterioration in arterial blood gases from current 2. Coronary bypass
baseline 3. Respiratory arrest
b. Respiratory rate increases significantly from baseline 4. Cardiac arrest
c. Increase from baseline blood pressure ⬎20 mm Hg 5. Cardiac transplant
d. Agitation
e. Increase from baseline heart rate ⬎20 beats per ✔ Have You Selected the Correct Diagnosis?
minute
Ineffective Breathing Pattern
f. Paradoxical abdominal breathing
In this diagnosis, the patient’s respiratory effort is
g. Adventitious breath sounds insufficient to maintain the cellular oxygen supply.
h. Cyanosis This diagnosis would contribute to the patient’s being
i. Decreased level of consciousness placed on ventilatory assistance; however, DVWR
j. Full respiratory accessory muscle use occurs after the patient has been placed on a ventila-
k. Shallow, gasping breaths tor and efforts are being made to re-establish a regu-
l. Profuse diaphoresis lar respiratory pattern. The key difference is whether
m. Discoordinated breathing with the ventilator or not a ventilator has been involved in the patient’s
n. Audible airway secretion therapy.
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Dysfunctional Ventilatory Weaning Response (DVWR) • 333
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for contributing factors68: Provides a database that will assist in generating the most
• Pathophysiologic health concerns (e.g., infections, ane- individualized plan of care.
mia, fever, or pain)
• Previous respiratory history, especially risk indicators of
reactive airway disease and bronchopulmonary dysplasia
• Previous cardiovascular history, especially risk indica-
tors such as increased or decreased pulmonary blood
flow associated with congenital deficits
• Previous neurologic status
• Recent surgical procedures
• Current medication regimen
• Psychological and emotional stability of the parents as
well as the child
(care plan continued on page 334)
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334 • Activity—Exercise Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collaborate with the physician, respiratory therapist, and Specific ventilator-related criteria offer the best decision-
other health-care team members to determine respira- making support for determining the best plan of
tory parameters that suggest readiness to begin the ventilator weaning.
weaning process69:
• Spontaneous respirations for age (e.g., rate or depth)
• Oxygen saturations in normal range for condition (e.g.,
spontaneous tidal volume of 5 mL/kg body weight,
vital capacity per Wright) Respirometer of 10 mL/kg
body weight, effective oxygenation with positive end-
expiratory pressure (PEEP) of 4 to 6 centimeters of
H2O. An exception to the norms would exist if the
infant has transposition of the great vessels.
• Blood gases in normal range
• Stable vital signs
• Parental or patient anxiety regarding respirator
• Patient’s facial expression and ability to rest
• Resolution of the precipitating cause for intubation and
mechanical support
• Tolerance of suctioning and use of Ambu bag
• Central nervous system and cardiovascular stability
• Nutritional status, muscle strength, pain, drug-induced
respiratory expression, or sleep deprivation
● N O T E : Oxygen saturation, blood gases, and vital signs may be abnormal secondary
to chronic lung damage with accompanying hypoxemia and hypercapnia, but the pH
may be normal with metabolic compensation for chronic respiratory acidosis. In this
instance, acceptable ranges would be defined.
Provide constant one-to-one attention to the patient, and Hierarchy of needs for oxygenation must be met for all
focus primarily on cardiorespiratory needs. Have vital functions to be effective in homeostasis.
CPR backup equipment readily available. Anticipatory safety for a patient on a ventilator
demands backup equipment in case of failure of the
current equipment.
Monitor the anxiety levels of the patient and family Expression of feelings will assist in monitoring family
at least once per shift. concerns and help reduce anxiety.
Monitor patient-specific parameters during actual Assists in further planning for weaning.
attempts at weaning:
• Arterial blood gases
• Vital signs
• Chest sounds
• Pulse oximetry
• Chest X-ray exam
• Hematocrit
Provide teaching as appropriate for the patient and fam- Assessment and individualized learning needs allow
ily, with emphasis on the often slow pace of weaning. appropriate focus on the patient. Explanation regard-
ing the slow pace encourages a feeling of success
rather than failure when each session does not meet
the same time limits as the previous session.
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Dysfunctional Ventilatory Weaning Response (DVWR) • 335
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide attention to rising related emotional problems With the need to implement intubation and ventilation,
secondary to the association of ventilators with termi- there can arise a myriad of concerns regarding the
nal life support. patient’s prognosis.
Refer the patient for long-term follow-up as needed. Fosters long-term support and coping with care at home.
Administer medications as ordered with appropriate The best chance for successful weaning includes appro-
attention to preparation for weaning (e.g., careful use priate consciousness, no respiratory depression, and
of paralytic agents or narcotics). adequate neuromuscular strength. Special caution must
be taken in positioning the patient receiving neuromus-
cular blocking agents so that dislocation of joints does
not occur.70
Maintain a neutral thermal environment. Altered oxygenation and metabolic needs occur in
instances of hyperthermia and hypothermia.
Provide the parents the option to participate in care Family input offers emotional input and security for the
as permitted. child in times of great stress, thereby allowing for
growth in parental–child coping behaviors.
Communicate with the infant or child using age-appropri- Effective communication serves to allow for expression
ate methods (e.g., an infant will enjoy soft music or a of or reception of messages of cares or concerns,
familiar voice, whereas an older child may be able to thereby acknowledging the value of the patient.
use a small magic slate or point to key terms).
Women’s Health
The nursing actions for Women’s Health clients with this diagnosis are the same as those for Adult Health.
Mental Health
This diagnosis is not appropriate for the mental health care unit.
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized for the aging client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the patient for presence of factors that make These factors can significantly contribute to a delay in the
weaning difficult, such as71: weaning process.
• Poor nutritional status
• Infection
• Sleep disturbances
• Pain
• Poor positioning
• Large amounts of secretions
• Bowel problems
Ensure that communication efforts are enhanced by the Effective communication is critical to the success of
proper use of sensory aids such as eyeglasses, hearing weaning efforts. Lack of information or misinterpreted
aids, or adequate light, decreased noise level in room, information may result in increased anxiety and
speaking in a low-pitched tone of voice, and facing the decreased weaning success.
patient when speaking. If written instructions are used,
make sure they are brief, jargon-free, printed or written
in dark ink, and printed or written in large letters.
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336 • Activity—Exercise Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Maintain same staff assignments whenever possible.72 Facilitates communication, and decreases anxiety and
fear caused by unfamiliarity with caregivers.
Contract with the patient for short-term and long-term
weaning goals, providing reinforcements and rewards
for progress. Use wall chart or diary to record progress.
Home Health
Clients are discharged to the home health setting with ventilators; however, the nursing care required is the same as those
actions covered in Adult Health and Gerontic Health.
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Falls, Risk For • 337
RELATED FACTORS22 injury, but making the specific diagnosis of Risk for
Falls as a primary problem allows more specific focus
The risk factors also serve as related factors. on prevention.
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Copyright © 2007 •by F. A. Davis.
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338 • Activity—Exercise Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Identify all contributing factors, including: A holistic approach provides a thorough database to pro-
• Neurologic vide individualized care.
• Musculoskeletal
• Cardiovascular
• Cognitive
• Developmental
• Environmental
• Situational
• Pharmacologic
• Medical
Ensure safety in the environment on an ongoing basis. Risk is reduced by anticipatory safety measures.
Provide teaching to the client, family, and health team Standardization and shared plan will afford the best
members based on specific content per plan. chance for attainment of goal with empowerment of
others to provide appropriate assistance.
Provide transfer of principles of prevention to alternate Offers validation of the importance of principles of safety
settings as required per daily activities of living (e.g., that can be applied in the future as needed.
playroom, dining area, etc.).
Maintain ongoing surveillance for potential changes. Constant anticipatory safety needs are mandatory.
Determine the need for post-hospitalization teaching Provides appropriate time for questions or concerns prior
regarding preventive or related data. to dismissal.
Administer medications, treatments, or related care in a Clustering of care and appropriate attention to timing of
manner that permits the best likelihood for noninterfer- medications or treatments will best afford safety and
ence in usual mobility. lessen risk.
Ensure adequate lighting on a 24-hour basis. Safety needs include appropriate lighting, especially at
night or in times of darkness.
Ensure availability of assistive devices as required per Appropriate augmentation as needed will prevent likeli-
client (e.g., corrective lenses, braces, helmet, etc.). hood of falls.
Women’s Health
The nursing interventions for this diagnosis in Women’s Health are the same as those for Adult Health and Gerontic
Health.
Mental Health
The nursing interventions for this diagnosis in Mental Health are the same as those for Adult Health and Gerontic Health.
Gerontic Health
● N O T E : Aging adults are at high risk for falls due to the prevalence of common fall
risk factors among this age group. Common risk factors for falls include muscle weak-
ness, history of falls, gait or balance deficits, use of assistive devices, visual deficits,
arthritis, impaired activities of daily living, depression, cognitive impairment, and age
older than 80 years. (National Guidelines Clearinghouse, http://www.guidelines.gov)
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Falls, Risk For • 339
ACTIONS/INTERVENTIONS R AT I O N A L E S
Perform fall risk assessment on all older clients, appropri- Risk factors for falls in older clients are multifactorial
ate to the caregiving site. and site-specific assessment tools help target factors
(such as equipment, structures, furnishings, personnel
issues) that may increase fall potential.
All older persons should be asked at least once a year
about falls.
All older persons who report a single fall should be
observed as they stand up from a chair without
using their arms, walk several paces, and return
(Get Up and Go Test). Those demonstrating no
difficulty or unsteadiness need no further assessment.
Persons with difficulty or demonstrated unsteadiness
performing this test require further assessment.
(National Guidelines Clearinghouse, http://www.
guidelines.gov)
Older persons who have recurrent falls or risk for falls Promotes strength and balance needed to prevent falls.
should be offered long-term exercise and balance train-
ing. (National Guideline Clearinghouse,
http://www.guidelines.gov)
Persons who have fallen should have their medications Removes a potential risk factor for future falls.
reviewed and altered or stopped as appropriate.
Particular attention should be given to persons taking
four or more medications and those taking psy-
chotropic medications. (National Guidelines
Clearinghouse, http://www.guidelines.gov)
Instruct client to use assistive devices as a part of a com- Assistive devices alone are not adequate to prevent falls.
prehensive program for falls prevention.73
Carefully monitor the client’s cardiovascular status and Falls that have a cardiac cause may be amenable to treat-
address issues such as syncope and dysrhythmias.73 ment of the cardiac condition (pacing, medication
changes).
Carefully assess the client’s visual system and collaborate Visual changes are associated with a higher rate of falls.
with the health-care team to address any remediable
visual abnormalities.73
Avoid the use of restraints as a falls prevention method. The use of restraints has not been demonstrated to
prevent falls and may contribute to client
injury.73
Ensure that any sensory adaptive equipment is available Visual and auditory deficits can affect balance.14
and properly functioning. [Note equipment needed for
client here.]
Consult with occupational therapist and physical therapist The factors listed have been identified as having an
for balance, gait, transfer, and strength assessment and impact on the potential for falls in older adults.19
training as needed.
Review drug list to evaluate any medication-associated These medications have been shown to increase the
risks, such as diuretics, antihypertensives, sedatives, incidence of falls in older adults.76
psychotropics, and hypoglycemic drugs.
Develop a teaching plan for the client and/or caregiver to Raises awareness of fall potential and strategies needed to
reduce fall potential based on risk factors present. reduce risks.
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340 • Activity—Exercise Pattern
FATIGUE 4. Tired
5. Inability to maintain usual routines
DEFINITION 6. Verbalization of an unremitting and overwhelming lack
An overwhelming sustained sense of exhaustion and of energy
decreased capacity for physical and mental work at usual 7. Lethargic or listless
level.22 8. Perceived need for additional energy to accomplish
routine tasks
DEFINING CHARACTERISTICS22 9. Increase in physical complaints
1. Inability to restore energy even after sleep 10. Compromised concentration
2. Lack of energy or inability to maintain usual level of 11. Disinterest in surroundings, introspection
physical activity 12. Decreased performance
3. Increase in rest requirements 13. Compromised libido
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Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Instruct the patient in stress reduction techniques. Have Mental and physical stress contribute greatly to a sense of
the patient return-demonstrate at least once a day fatigue.
through the day of discharge.
Provide frequent rest periods. Schedule at least 30 min- Allows the patient to gradually increase strength and tol-
utes of rest after any strenuous activity. erance for activities.
Assist the patient with self-care as needed. Plan gradual
increase in activities over several days.
Promote rest at night:
• Warm bath at bedtime
• Warm milk at bedtime
• Back massage
Avoid sensory overload or sensory deprivation. Provide Sensory stimulation can deplete energy stores; diversional
diversional activities. activities help prevent overload or deprivation by
focusing the patient’s concentration on an activity he or
she personally enjoys.
Limit visitation as necessary.
Address issues that will interfere with sleep, including
pain.
Educate the patient to avoid activities that will
interfere with sleep or reduce quality of sleep
(consumption of alcohol or stimulants, or exercising
close to bedtime).
Refer to local exercise center for assistance with regular Regular exercise decreases fatigue.
exercise plan.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Develop, with patient and parents, a plan to best address Parents are best able to describe objective behaviors that
contributory factors as determined by verbalized per- offer cues to fatigue factors, especially when the
ceptions of fatigue (may be related to parents’ percep- patient cannot speak or describe his or her feelings.
tions). [Note plan here.] When the plan is developed in collaboration with
the client and family there is a greater probability
of success.49
Provide daily feedback and positive reinforcement Because of the ever-changing fatigue factors, close atten-
regarding progress, and reassess the child’s and the tion to progress will aid in a sense of mastery and
family’s perception of fatigue. [Note those things objectify concerns.
that are reinforcing to the child here.]
Ensure safety needs according to the child or infant’s age Standard accountability is to provide for safety needs
and developmental capacity. with special attention to the child’s age, developmental
capacity, parental education, compliance, etc.
Collaborate with other members of the health-care team Offers input from team members to safeguard the client’s
as indicated, especially pediatrician, pediatric cardiolo- progress.
gist, dietician, and physical therapist.
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Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
During pregnancy, schedule rest periods during the Realistic planning to offer brief rest periods during the
day. day.
Find restful area, and get away from the work area to
rest 5 to 10 minutes with feet propped above the
abdomen, once in the morning and once in the
afternoon.
During lunch, leave the work area to rest 10 to 15 min-
utes lying on the left side or with feet propped above
the abdomen.
Have the patient research the possibility of split time or
job sharing at work during pregnancy.
Teach the patient relaxation techniques. Techniques induce a restful state and can be used for
short periods of rest as well as more extended periods
of rest.
Teach the patient to use music of preference during rest Assists with relaxation.
periods.
Plan for at least 6 to 8 hours of sleep during the night.
(See Disturbed Sleep Pattern, Chapter 6, for nursing
actions to promote sleep.)
Involve significant others in discussion and problem- The family can assume more responsibilities to assist in
solving activities regarding lifestyle changes needed increasing rest time for the patient.
to reduce fatigue.
After delivery, identify a support system that can assist Assists in alleviating fatigue related to trying to manage
the patient with infant care and household duties. household as always as well as trying to care for a new
baby.
Learn to rest and sleep when the infant sleeps. Conserves energy and increases amount of time available
for rest.
Plan daily activities to alleviate unnecessary steps and to
allow for frequent rest periods.
• If bottle-feeding, prepare formula for 24 hours at a
time.
• If breastfeeding, let spouse get up at night and bring
the baby to the mother.
• If breastfeeding, sleep with the baby in bed. The baby begins to feed for longer periods and begins to
sleep longer more quickly. Both the mother and infant
get more rest.
• Prepare extra when cooking meals for the family, and
freeze extra for future meals (e.g., prepare big batch of
stew or spaghetti on one day, and freeze portions for
future meals).
Plan return to work on a gradual basis (e.g., work part- Provides gradual return to activities, and decreases likeli-
time for the first 2 weeks, gradually increasing time at hood of fatigue.
work until full-time by end of 4 weeks).
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Mental Health
● N O T E : All goals established for the nursing actions should be achievable
and adjusted as the client’s condition changes.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Schedule time by which the client must be out of bed Provides goal the client can achieve, and enhances self-
and dressed. [Note time here.] Initially this goal may esteem.
be limited to the client getting out of bed without
dressing.
Assist the client with grooming activities. [Note here the Promotes the client’s sense of control, and enhances self-
degree of assistance needed as well as any special esteem.
items needed.]
While assisting the client with grooming activities, teach Promotes the client’s control by providing increased
performance of tasks in energy-efficient ways (e.g., opportunity for self-care.
placing all necessary items in one place before groom-
ing is begun).
Provide the client with appropriate rewards for accom- Positive reinforcement encourages appropriate behavior.
plishing established goals (Note special goals here with
the reward for achievement of goal). Establish rewards
with client input.
Establish time for the client to rest during the day. Meets physiologic need for rest. Also provides the client
Initially this will be more frequent and diminish as the with an opportunity for perceived control in determin-
client’s condition changes. [Note times and duration of ing when these rest periods should be provided.
rest periods here.]
Walk with the client on unit [number] minutes [number] Promotes cardiorespiratory fitness, and promotes self-
times a day. esteem by providing a goal the client can meet.
Interaction with the nurse can provide positive rein-
forcement for this activity.
Have the client identify pleasurable activities that cannot Promotes positive orientation by connecting the client
be performed because of fatigue. with images of past pleasures, and provides material
for developing positive imaging.
Identify one pleasurable activity, and develop a gradually Promotes positive orientation by providing the client with
escalating plan for client involvement in this activity. positive goal to work toward. This will increase moti-
Provide rewards for accomplishment of each step in vation. Positive reinforcement encourages behavior.
this plan.
Provide the client with foods that are high in nutritional Meets physiologic needs for nutrition in a manner that
value and are easy to consume. conserves energy.
Talk with the client 30 minutes twice a day. Topics for Promotes the client’s sense of control by providing time
this discussion should include: for his or her input into the plan of care on a daily
• Client’s perception of the problem basis; also provides positive reinforcement through
• Identification of thoughts that support the feeling of social interaction with the nurse and verbal feedback
fatigue about accomplishments.
• Identification of thoughts that decrease feelings of
fatigue
• Identification of unrealistic goals
• Client’s evaluation of and attitudes toward self
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Identification of circumstances in the client’s environ-
ment that support continuing feelings of fatigue (e.g.,
family stressors or secondary gain from fatigue)
• Identification of the client’s accomplishments
After the client has verbalized the effects negative Cognitive maps impact feelings and behavior. When cog-
thoughts have on feelings and behavior, teach the client nitive maps are used inappropriately, they can promote
how to stop negative thoughts and replace them with maladaptive thinking, behaving, and feeling.
positive thoughts. Recognition of dysfunctional maps provides the client
with the opportunity for developing positive orientation
and adaptive cognitive maps.37
Reward the client for positive self-statements with Positive reinforcement encourages appropriate behavior.
informative positive verbal reinforcement.
Assign the client tasks on the unit, and provide positive
reinforcement for task accomplishment. [Note task
assigned and reward established here.]
Involve the client in group activity with other clients for Interaction with peers provides opportunities to increase
[number] minutes [number] times a day. social network, learn problem-solving strategies,
and test perceptions of self and experiences with
peers.
Meet with the client and client’s family to evaluate inter- Family support enhances probability of behavior changes
action patterns and provide information that would being maintained after discharge.
assist them in assisting the client.
Have the client identify those factors that will maintain Reinforces behavior change and new coping skills, while
a feeling of well-being after discharge, and develop a providing positive feedback and enhancing self-
specific behavioral plan for implementing them. [Note esteem.37
plan here.]
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review medications for side effects or possible drug Many medications can contribute to the sensation of
interactions. fatigue, particularly cardiac and antihypertensive med-
ications, high-dose or replacement corticosteroids,
antivirals, antifungals, and immune therapy.73
Collaborate with the health-care team in assessing the Depression is often underreported and undertreated in
patient for depression. older adults.
Collaborate with the health-care team in assessing thyroid Alterations in thyroid function and hormone levels can
function and hormone levels. lead to fatigue.
Monitor for activities that interrupt the patient’s sleep pat- Environmental noises and inattention to the patient’s
tern, such as taking vital signs, daily weights, or treat- usual sleep pattern may result in sleep fragmentation.
ments.
Carefully assess sleep patterns and sleep hygiene and Sleep deprivation can lead to fatigue.
make recommendations for improvement as needed.
Avoid bedrest when possible. Bedrest and sedentary lifestyle can contribute to fatigue.
Collaborate with the health-care team to provide graded Graded aerobic activity offers benefit in cases of
aerobic exercise. fatigue.73
Plan care activities around periods of least fatigue. Gives attention to the patient’s circadian rhythm.
(care plan continued on page 346)
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348 • Activity—Exercise Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide for periods of activity and rest. Conserves energy needed for breathing and decreased
oxygen consumption.
Discuss with the patient the effects smoking has on the Smoking, or passive smoke for the nonsmoker, greatly
respiratory system, and refer the patient to a stop increases the risk for development of respiratory and
smoking group if the patient is motivated to stop smok- cardiovascular diseases. Smoking immediately before
ing. If the patient is not motivated to stop smoking, eating or exercise causes vasoconstriction, leading
instruct the patient not to smoke 15 minutes before to decreased gas exchange, and compounding the
meals and physical activity. condition.
Review the patient’s resources and home situation regard- Initiates appropriate home care planning and long-range
ing long-term management of Impaired Gas Exchange support for the patient and family.
before discharge. Refer to appropriate community
resources.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor contributing factors, especially current medical
status and respiratory demands.
Ensure availability of emergency equipment as appro- Basic emergency preparedness.
priate:
• Ambu bag
• Endotracheal tube appropriate for age and size of infant
(3.5)
• Suctioning unit and catheters: infant, 5 or 8 Fr; child, 8
or 10 Fr
• Crash cart with appropriate drugs
• Defibrillation unit with guidelines
• O2 tank (check amount of oxygen left)
• Tracheostomy sterile set
• Sterile chest tube tray
Provide for parental input in planning and implementing Parental involvement provides emotional security for the
care (e.g., comfort measures, assisting with feedings, child’s parents; offers empowerment and allows prac-
and daily hygienic measures). ticing of care techniques in a supportive environment.
Allow at least 10 to 15 minutes per shift for the family to Assists in reducing anxiety, and provides teaching oppor-
verbalize concerns regarding the child’s status and tunity.
changes. Encourage the parents to ask questions as
often as needed.
Collaborate with related health-care team members as Promotes coordination of care without undue duplication
needed. and fragmentation of care.
While the child is still in the hospital, provide opportuni- Learning of essential skills is enhanced when opportuni-
ties for the parents and child to master essential skills ties for practice are allowed in a safe, secure environ-
necessary for long-term care, such as suctioning. ment. Compliance is also fostered.
Schedule parents and family for CPR training well before Anticipatory need for CPR should better prepare parents
dismissal from hospital. [Note time and responsible and other family members in the event of pulmonary
person here.] arrest. Having this basic knowledge will assist in
reducing anxiety regarding home care.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Facilitate the parents’ use of the support system to aid in Reliance on others should afford the parents some degree
coping with illness and hospitalization. of relief from constant worry based on the likelihood
of primary needs with a chronically ill child.
Allow for sibling visitation as applicable within institu- Sibling visitation enhances the opportunity for family
tion or specific situation. coping and growth. Provides moral support to both
siblings.
Administer medications that are ordered. Monitor for Provides anticipatory guidance with safe administration
variable response in child especially antibiotics, corti- of medications.
costeroids (inhaled and IV).
Teach the child and family about needs for follow-up care Reinforces need for realistic plan of follow-up and antic-
and protection from triggering events, including expo- ipatory prevention.
sure to respiratory infections.
Refer to appropriate community agencies for support Offers support to child and family.
after discharge. [Note those referral agencies here.]
Women’s Health
● N O T E : This nursing diagnosis will pertain to women the same as in any other adult.
The following nursing actions focus only on the fetal–placental unit during pregnancy.
Placental function is totally dependent on maternal circulation; therefore, any process
that interferes with maternal circulation will affect the oxygen consumption of the pla-
centa and, in turn, the fetus.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient in developing an exercise plan during Increases cardiovascular fitness, and therefore increases
pregnancy. oxygenation and nutrition to placenta and fetus.
Teach the patient and significant others how to avoid
“supine hypotension” during pregnancy (particularly
during the later stages):
• Lying on right or left side to reduce pressure on vena
cava
• Taking frequent rest breaks during the day
Assist the patient in identifying lifestyle adjustments that
may be needed because of changes in physiologic
function or needs during pregnancy:
• Stop smoking.
• Reduce exposure to secondhand smoke.
• Avoid lying in the supine position.
• Take no drugs unless advised to do so by physician.
Identify underlying maternal diseases that will affect the These disorders have direct impact on the gas exchange
fetal–placental unit during pregnancy: in the fetal–placental unit.
• Maternal origin:
• Maternal hypertension
• Drug addiction
• Diabetes mellitus with vascular involvement
• Sickle cell anemia
• Maternal infections
• Maternal smoking
• Hemorrhage (abruptio placentae or placenta previa)
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Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Fetal origin:
• Premature or prolonged rupture of membranes
• Intrauterine infection
• RH disease
• Multiple pregnancy
Mental Health
In addition to the nursing interventions for Adult Health, the following interventions apply
to specific Mental Health situations:
ACTIONS/INTERVENTIONS R AT I O N A L E S
If the client is demonstrating alterations in mental status, The central nervous system is particularly sensitive to
assess for increased hypoxia. impaired gas exchange because of its reliance on sim-
ple sugar metabolism for energy production.66
Observe the client for signs of respiratory infection. Infection will increase mucus production, which
decreases airway clearance.66
Protect the client from respiratory infection by: Prevents further injury to a system that is stressed, and
• Maintaining proper humidity in the environment. promotes airway patency.
• Observe the client closely for signs and symptoms of
respiratory infection. If infection is present, and the
client is sharing a room, move the roommate to another
room.
• Arrange staff assignments so that staff who care for
clients with infections are not also caring for clients
who are free of infection.
• Keeping the client away from crowds.
• Assisting the client in obtaining appropriate immuniza-
tions against influenza.
• Having the client inform staff of signs or symptoms of
respiratory infection when the earliest symptoms
appear.
• Keeping environment as free of respiratory irritants as
possible (e.g., dust, allergens, or pollution).
• Provide the client with equipment required to maintain
adequate oxygenation. [Note that equipment and spe-
cial adaptations here.]
• Collaborate with respiratory therapy to provide client
education about proper use of the equipment.
Discuss with the client the effects of alcohol and other The sedative effects of some drugs decrease airway clear-
depressant drugs on the respiratory system. Refer to a ance, increasing the risk for the development of infec-
drug-abuse recovery program as necessary. tion. Diffusion is also decreased with chronic
alcoholism.77
Collaborate with physician regarding supplemental vita- Thiamine is essential for the conversion of glucose to
mins, especially thiamine, if the impaired gas exchange metabolically useful forms. Nerve cell function
is secondary to alcohol abuse. depends on this glucose. This compensates for the
nutritional deficits that result when nutritional calories
are replaced by alcohol.78
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Gas Exchange, Impaired • 351
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend [number] minutes [number] times a day with the Promotes the client’s sense of control by facilitating
client discussing feelings and reactions to current sit- understanding of factors that contribute to maladaptive
uation. As feelings are expressed, begin to explore coping behaviors.
lifestyle changes with the client. Refer to Ineffective
Individual Coping (Chapter 11) and Powerlessness
(Chapter 8) for specific care plans related to coping
styles.
Develop with the client a plan for gradually increasing Improves cardiorespiratory functioning, thus improving
physical activity. (See Activity Intolerance for specific gas exchange.
behavioral interventions.)
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ensure that oxygen delivery system is properly function- Basic care standards.
ing and fits well. Avoid face mask if the patient is ema-
ciated. Check proper positioning of nasal cannula
(prongs turned inward), and ensure that all oxygen is
humidified.
Monitor skin color, mental status, and vital signs every
2 hours on [odd/even] hour.
Check oxygen flow and amount every 4 hours around the The patient may increase the liter flow during acute
clock at [times]. episodes of impaired gas exchange and cause res-
piratory system depression with retention of carbon
dioxide.
Monitor for potential carbon dioxide narcosis (e.g.,
changes in level of consciousness, changes in oxygen
and carbon dioxide blood gas levels, flushing,
decreased respiratory rate, and headaches). This is
especially important for a patient on long-term oxygen
therapy.58
Teach the patient and family the signs and symptoms of Decreases potential for carbon dioxide narcosis.
carbon dioxide narcosis, especially those on long-term
oxygen therapy.
Home Health
● N O T E : If this diagnosis is suspected when caring for a client in the home, it is
imperative that a physician referral be obtained immediately. If a physician has referred
the client to home health care, the nurse will collaborate with the physician in the treat-
ment of the client. Preliminary research77 indicates that women with chronic bronchitis
or chronic obstructive pulmonary disease (COPD) cannot walk as far as men. Activity
should be planned according to tolerance, keeping in mind gender differences. There is
no doubt that better control of dyspnea is a pressing need, with research79 indicating
that a client’s subjective report of health status is a better predictor of level of function-
ing than is objective measure of the lung function.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family appropriate monitoring of Provides for early recognition and intervention for
signs and symptoms of Impaired Gas Exchange: problem.
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Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Pursed-lip breathing
• Respiratory status: cyanosis, rate, dyspnea, or
orthopnea
• Fatigue
• Use of accessory muscles
• Cough
• Sputum production or change in sputum production
• Edema
• Decreased urinary output
• Gasping
Assist the client and family in identifying lifestyle Provides basic information for the client and family that
changes that may be required: promotes necessary lifestyle changes.
Prevention of Impaired Gas Exchange: Stopping smok-
ing, prevention or early treatment of lung infections,
avoidance of known irritants and allergens, obtaining
annual influenza and pneumonia immunizations.
• Pulmonary hygiene: clearing bronchial tree by con-
trolled coughing, decreasing viscosity of secretions via
humidity and fluid balance, and postural drainage
• Daily activity as tolerated (remove physical barriers to
mobility/activity)
• Breathing techniques to decrease work of breathing
(diaphragmatic, pursed lips, or sitting forward)
• Adequate nutrition intake
• Appropriate use of oxygen (dosage, route of adminis-
tration, safety factors). Ensure that the patient and care-
giver understand the risks associated with smoking in
the presence of supplemental oxygen.
• Stress management
• Limiting exposure to upper respiratory infections
• Avoiding extreme hot or cold temperatures
• Keeping area free of animal hair and dander or dust
• Assistive devices required (oxygen, nasal cannula, suc-
tion, ventilator, etc.)
• Adequate hydration (monitor intake and output)
Teach the client and family purposes, side effects, and To promote adequate self-care and to prevent complica-
proper administration technique of medications. tions from untoward medication side effects.
Assist the client and family to set criteria to help them To promote adequate self-care and facilitate timely acqui-
determine when calling a physician or other interven- sition of professional health care as needed.
tion is required (e.g., change in skin color, increased
difficulty with breathing, increase or change in sputum
production, or fever).
Teach the family basic CPR. Basic safety measure.
Assess the client/family need for additional resources and Provides additional support for the client and family, and
refer to community resources, as appropriate. uses already available resources in a cost-effective
manner.
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Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor and teach the parents to monitor the child’s As a rule, single assessments are not as revealing in
growth and development status. Determine what alter- growth and development parameters as are serial, lon-
ations there are (i.e., delays or precocity). gitudinal patterns. Parental involvement offers a more
thorough monitoring, fosters their involvement with the
child, and empowers the family.
Determine what other primary health-care needs exist, In instances of brain damage or retardation, it is often dif-
especially brain damage or residuals of brain damage. ficult to get an accurate assessment of cognitive capa-
bility. The general health of the patient will often influ-
ence, to a major degree, what alteration in cognitive
functioning exists (e.g., sickle cell anemia with result-
ant infarcts to major organs such as the brain).
Identify, with the child or the parents, realistic goals for A plan of care based on individual needs, with parental
growth and development. input, better reflects holistic care and increases proba-
bility of effective home management of problem.
Collaborate with related health-care team members as Collaboration is required for meeting the special long-
necessary. [Note those providers involved here with a term needs for activities of daily living.
plan for their involvement.]
Identify anticipatory safety for the child related to These children may be large physically because of
Delayed Growth and Development (e.g., ingestion of chronologic age, and there is a possibility of overlook-
objects, falls, or use of wheelchair). [Note special ing the developmental or mental age.
safety adaptations that are needed for this child here.]
Teach parents special diet necessitated by a metabolic Appropriate diet can assist in preventing further deterio-
disorder (e.g., various enzymes lacking). ration or be essential to replace lacking vitamins,
enzymes, or other nutrients.
Refer the child and parents to appropriate community Offering early intervention assists in fostering develop-
resources to assist in fostering growth and develop- ment, while preventing tertiary delays.
ment, such as the early childhood intervention services.
Assist the parents to provide for learning needs related to Appropriate match of services to needs enhances the
future development, including identification of schools child’s development to the highest level possible.
for developmentally delayed children.
Refer the child and parents to state and national support Support groups assist in empowerment and advocacy at
groups such as National Cerebral Palsy Association. local, state, and national levels.
Provide the patient and family with long-term follow-up Promotes implementation of management regimen, and
appointments before discharge. provides anticipatory resources and checkpoint for the
patient and family.
Women’s Health
● N O T E : The same nursing diagnosis pertains to Women’s Health as to Adult Health.
The following nursing actions pertain only to women with reproductive anatomic abnor-
malities. The mother does need to be aware of the normal growth patterns in order to
assess the health and development of her child. See Child Health.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Obtain a thorough sexual and obstetric history, especially Provides a basic database for determining therapy needs.
noting recurrent miscarriages in the first 3 months of
pregnancy.
Collaborate with the physician regarding assessment for
infertility.
(care plan continued on page 356)
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Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Refer to a gynecologist for further testing if primary
amenorrhea is present.
Encourage the patient to verbalize her concerns and fears. Decreases anxiety. Allows an opportunity for teaching,
and allows correction of any misinformation.
Encourage communication with significant others to iden- Provides a base for teaching and long-range counseling.
tify concerns and explore options available.
Mental Health
● N O T E : If anorexia nervosa is the underlying cause for growth risk, refer to the
Mental Health care plan for the diagnosis Imbalanced Nutrition, Less Than Body
Requirements, for the appropriate intervention.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide a quiet, nonstimulating environment, or an envi- Too little or too much sensory input can result in a sense
ronment that does not place additional stress on an of disorganization and confusion and result in dysfunc-
already overwhelmed coping ability. tional coping behaviors.35
Sit with the client [number] minutes [number] times per Attention from the nurse can enhance self-esteem.
day at [list specific times] to discuss current concerns Expression of feelings can facilitate identification and
and feelings. resolutions of problematic coping behaviors.
Provide the client with familiar or needed objects. These Promotes the client’s sense of control by providing an
should be noted here. environment in which the client feels safe and secure.
Discuss with the client perceptions of self, others, and the Provides positive orientation, which improves self-esteem
current situation. This should include the client’s per- and provides hope for the future.
ceptions of harm, loss, or threat. Assist the client in
altering perception of these situations so they can be
seen as challenges or opportunities for growth rather
than threats.
Provide the client with an environment that will optimize Appropriate levels of sensory input promote contact with
sensory input. This could include hearing aids, the reality of the environment, which facilitates appro-
eyeglasses, pencil and paper, decreased noise in con- priate coping.
versation areas, and appropriate lighting. These inter-
ventions should indicate an awareness of sensory
deficit as well a sensory overload, and the specific
interventions for the client should be noted here (e.g.,
place hearing aid in when the client awakens, and
remove before bedtime).
Provide the client with achievable tasks, activities, and Provides positive reinforcement, which enhances self-
goals (these should be listed here). These activities esteem and provides motivation for working toward the
should be provided with increasing complexity to give next goal.
the client an increasing sense of accomplishment and
mastery.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Communicate to the client an understanding that all cop- Promotes positive orientation, which enhances self-
ing behavior to this point has been his or her best effort esteem and promotes hope.
and asking for assistance at this time is not failure.
Explain that a complex problem often requires some
outside assistance in resolution. (This will assist the
client in maintaining self-esteem and diminish feelings
of failure.)
Provide the client with opportunities to make appropriate Promotes the client’s perception of control, which pro-
decisions related to care at his or her level of ability. motes self-esteem.
This may begin as a choice between two options and
then evolve into more complex decision making. It is
important that this be at the client’s level of function-
ing so confidence can be built with successful decision-
making experiences.
Provide constructive confrontation for the client about Provides opportunities for the client to question aspects
problematic coping behavior. (See Wilson and Kneisl32 of behavior that can promote a desire to change.
for guidelines on constructive confrontation.) The
kinds of behavior identified by the treatment team as
problematic should be listed here.
Provide the client with opportunities to practice new Provides opportunities to practice new behavior in a safe
kinds of behavior either by role playing or by applying environment where the nurse can provide positive feed-
them to graded real-life experiences. back for gradual improvement of coping strategies.
This increases the probability for the success of the
new behavior in real-life situations, which in turn
serves as positive reinforcement for behavior change.
Provide positive social reinforcement and other behav- Positive reinforcement encourages appropriate behavior.
ioral rewards for demonstration of adaptive behavior.
(Those things that the client finds rewarding should be
listed here with a schedule for use. The kinds of behav-
ior that are to be rewarded should also be listed.)
Assist the client in identifying support systems and in Support systems can provide positive reinforcement for
developing a plan for their use. behavior change, increasing the opportunities for the
client’s success enhancing self-esteem.
Assist the client with setting appropriate limits on aggres- Excessive environmental stimuli can increase a sense of
sive behavior by (see Risk for Violence, Chapter 9, disorganization and confusion.
for detailed nursing actions if this is an appropriate
diagnosis):
• Decreasing environmental stimulation as appropriate.
(This might include a secluded environment.)
• Providing the client with appropriate alternative outlets Promotes a sense of control, and teaches constructive
for physical tension. (This should be stated specifically ways to cope with stressors.
and could include walking, running, talking with a staff
member, using a punching bag, listening to music, or
doing a deep muscle relaxation sequence. These outlets
should be selected with the client’s input.)
Meet with the client and support system to provide infor- Enhances opportunities for success of the treatment plan.
mation on the client’s situation and to develop a plan
that will involve the support system in making changes
that will facilitate the client’s movement to age-appro-
priate behavior. [Note this plan here.]
Refer to appropriate assistive resources as indicated.
(care plan continued on page 358)
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358 • Activity—Exercise Pattern
Gerontic Health
Nursing interventions provided in the Adult Health and Home Health sections for this diagnosis may be enhanced for the
older client with the addition of the following actions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide opportunities for clients to reflect on their Promotes ability to obtain perspective on life
strengths and life accomplishments through activities experiences.80 Provides potential for enhancing life sat-
such as life review, reminiscing, and oral or written isfaction.80
autobiographies.
Consult with the physician for potential assessment and Depression often goes undetected in older adults and may
treatment of depression. negatively impact their ability to effectively cope with
losses and to positively appraise their current
situation.80
Ask older clients what tasks of aging they have defined Promotes discussion of the older adult’s expectations.81
for themselves.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for factors contributing to Delayed Growth and Provides a database for prevention and/or early interven-
Development. tion.
Involve the client and family in planning, implementing, Involvement improves motivation and improves the out-
and promoting reduction or correction of the delay in come.
growth and development:
• Family conference
• Mutual goal setting
• Communication
Teach the client and family measures to prevent or Locus of control shifts from nurse to the client and fam-
decrease delays in growth and development: ily, thus promoting self-care.
• Explain expected norms of growth and development
with anticipatory guidance. If the caretakers realize, for
example, that the newborn begins to roll over by 2 to 4
months or that the 2-year-old can follow simple direc-
tions, then appropriate environmental and learning con-
ditions can be provided to protect the child and to
promote optimal development.
• Alert the parents to signs and symptoms of alterations
in growth and development that may require profes-
sional evaluation (e.g., delay in language skills, delay
in crawling or walking, or delay in growth below
50 percent on growth chart).
• Teach parents how to recognize developmental mile-
stones and their expected/associated behaviors and
how to discipline effectively without violence.
• Provide guidance on developmentally appropriate nutri-
tion (e.g., how to introduce finger foods to toddlers,
how to monitor calorie intake for expected develop-
mental stage, and how to ensure a balanced diet).
Assist the client and family to identify lifestyle changes Provides basic information for the client and family that
that may be required: promotes necessary lifestyle changes.
• Care for handicaps (e.g., blindness, deafness, or mus-
culoskeletal or cognitive deficit)
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Proper use of assistive equipment
• Adapting to need for assistance or assistive equipment
• Determining criteria for monitoring the client’s ability
to function unassisted
• Time management
• Stress management
• Development of support systems
• Learning new skills
• Work, family, social, and personal goals and priorities
• Coping with disability or dependency
• Development of consistent routine
• Mechanism for alerting family members to the need for
assistance
• Providing appropriate balance of dependence and inde-
pendence
Assess the client/caregiver need for assistive equipment Assistive equipment improves function and increases the
or supplies and assist the client and family to obtain possibilities for self-care.
assistive equipment as required (depending on alter-
ation present and its severity):
• Adaptive equipment for eating utensils, combs,
brushes, etc.
• Straw and straw holder
• Wheelchair, walker, motorized cart, or cane
• Bedside commode or incontinence undergarments
• Hearing aid
• Corrective lenses
• Dressing aids: dressing stick, zipper pull, button hook,
long-handled shoehorn, shoe fasteners, or Velcro closures
• Bars and attachments and benches for shower or tub
• Handheld shower device
• Medication organizers
• Magnifying glass
• Raised toilet seat
Assess the client/family need for in home assistance Provides additional support for the client and family, and
(daily hygiene, housework, meal delivery services) and uses already available resources in a cost-effective
refer to community resources as appropriate. manner.
Assist the client or caregivers in obtaining prescribed Promotes adherence to the therapeutic regimen.
medications, and ensure that they understand doses,
administration times, therapeutic effects, and possible
side effects.
If the client is a child, the nurse can serve as a liaison Provides continuity of care.
between the school nurse, family, and primary physi-
cian to monitor effectiveness of therapy and to provide
anticipatory guidance for family members.
Instruct the client as appropriate and the caregivers to Consistency can promote success and focus on the
maintain a consistent home environment (e.g., sched- strengths of the client.
ules, parenting, and goal setting). The home environ-
ment should be free of distractions when it is necessary
for the client to perform tasks.
Refer clients and family members for counseling, special Helps develop healthier self-esteem and positive coping
training (e.g., parenting classes), or support groups as strategies.
necessary.
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360 • Activity—Exercise Pattern
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Home Maintenance, Impaired • 361
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor risk factors of or contributing factors to Impaired Provides primary database for intervention.
Home Maintenance, to include:
• Addition of a family member (e.g., birth)
• Increased burden of care as a result of the child’s ill-
ness or hospitalization
• Lack of sufficient finances
• Loss of family member (e.g., death)
• Hygienic practices
• History of repeated infections or poor health manage-
ment
• Offensive odors
Identify ways to deal with home maintenance alterations Coordinated activities will be required to meet the entire
with assistance of applicable health team members. range of needs related to improving problems with
home maintenance.
Allow for individual patient and parental input in plan for Parental input offers empowerment and attaches value to
addressing home maintenance issues. family preferences. This in turn increases the likeli-
hood of compliance.
Monitor educational needs related to illness and the Monitoring of educational needs balanced with the home
demands of the situation (e.g., mother who must attend situation will best provide a base for intervention.
to a handicapped child and six other children with vari-
ous school appointments, health care appointments, etc.)
Provide health teaching with sensitivity to the patient and Teaching to address identified needs reduces anxiety and
family situation (e.g., seeming inability to manage with promotes self-confidence in ability to manage.
overwhelming demands of the child’s need for care,
such as a premature infant or a child with cerebral
palsy who has feeding difficulties).
Provide 10 to 15 minutes each 8-hour shift as a time for Setting aside times for discussion shows respect and
discussion of patient and family feelings and concerns assigns value to the patient and family.
related to health management.
Provide the patient and family with information about Support groups empower and facilitate family coping.
support groups in the community. Arrange contact with
groups that would provide the most support before
discharge.
If the infant is at risk for sudden infant death syndrome When risk factors for pulmonary arrest are present as, for
(SIDS) by nature of prematurity or history of previous example, for a SIDS infant, family members will be less
death in family, assist parents in learning about alarms anxious if they are taught CPR techniques and given
and monitoring respiration, and institute CPR teaching. opportunities to rehearse and master these techniques.
Refer to community and primary care providers for Follow-up plans provide a means of further evaluation for
follow-up after discharge from the hospital. progress in coping with home maintenance. Ideally,
actual home visitation allows the best opportunity for
monitoring goal achievement.
(care plan continued on page 362)
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362 • Activity—Exercise Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client to describe her perception or understand- Provides a database needed to plan changes that will
ing of home maintenance as it relates to her lifestyle increase ability in home maintenance.
and lifestyle decisions. Include stress-related problems
and effects of environment:
• Allow the patient time to describe work situation.
• Allow the patient time to describe the home situation.
• Encourage the patient to describe how she manages her
responsibilities as a mother and a working woman.
• Encourage the patient to describe her assets and deficits
as she perceives them.
• Encourage the patient to list lifestyle adjustments that
need to be made.
• Monitor identified possible solutions, modifications,
etc., designed to cope with each adjustment.
• Teach the client relaxation skills and coping
mechanisms.
Consider the patient’s social network and significant
others:
• Identify significant others in the patient’s social
network.
• Involve significant others if so desired by the patient in
discussion and problem-solving activities regarding
lifestyle adjustments.
Encourage the patient to get adequate rest: Fatigue can be a major contributor to impaired home
• Take care of self and baby only. maintenance.
• Let significant others take care of the housework and
other children.
• Learn to sleep when the baby sleeps.
• Have specific, set times for friends or relatives to visit.
• If breastfeeding, significant other can change the infant Both the parents and infant get more rest. The baby
and bring the infant to the mother at night so that the begins to nurse longer and sleep for longer periods
mother does not always have to get up for the infant. of time.
Or the mother can sleep with the infant.
• Cook several meals at one time for the family and
freeze them for later use.
• Prepare baby formula for a 24-hour period and refriger-
ate for later use.
• Freeze breast milk, emptying the breast after the baby
eats; significant other can then feed the infant one time
at night so the mother can get adequate, uninterrupted
sleep.
• Put breast milk into a bottle and directly into the
freezer:
• Milk can be added each time breasts are pumped until
the needed amount is obtained.
• Milk can be frozen for 6 weeks if needed.
• To use, milk should be removed from the freezer and
allowed to thaw to room temperature.
• Once thawed, must be used within a 12- to 24-hour
period. Do not refreeze.
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Home Maintenance, Impaired • 363
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss with the client his or her concerns about return- Promotes the client’s sense of control, which enhances
ing home. self-esteem.
Develop with the client and significant others a list of Promotes the client’s and support system’s sense of con-
potential home maintenance problems. trol, which increases the willingness of the client to
work on goals.
Teach the client and family tasks that are necessary for Provides opportunities for positive reinforcement of
home care. [NOTE tasks and teaching plan here.] approximation of goal achievement.
Provide time to practice home maintenance skills, at least
30 minutes once a day. Medication administration
could be evaluated with each dose by allowing the
client to administer own medications. The times and
types of skills to be practiced should be listed here.
If financial difficulties prevent home maintenance, refer
to social services or a financial counselor.
If the client has not learned skills necessary to cook or Provides opportunities to practice new skills in a safe
clean home, arrange a time with occupational therapist environment and to receive positive reinforcement for
to assess for ability and to teach these skills. Support approximation of goal achievement.
this learning on unit by [check all that apply]:
• Having the client maintain own living area.
• Having the client assist with the maintenance of the
unit (state specifically those chores the client is respon-
sible for).
• Having the client assist with the planning and prepara-
tion of unit meals when this is a milieu activity.
• Having the client clean and iron own clothing.
If special aids are necessary for the client to maintain self
successfully, refer to social services for assistance in
obtaining these items.
If the client needs periodic assistance in organizing self to
maintain home, refer to homemaker service or other
community agency.
If meal preparation is a problem, refer to community
agency for Meals-on-Wheels, or assist the family with
preparing several meals ahead of time or exploring
nutritious, easy ways to prepare meals.
Determine with the client a list of rewards for meeting Positive reinforcement encourages the maintenance of
the established goals for achievement of home mainte- new behavior.
nance, and then develop a schedule for the rewards.
[Note the reward schedule here.]
Assess the environment for impairments to home mainte-
nance, and develop with the client and family a plan
for resolving these difficulties (e.g., recipes that are
simplified and written in large print to make them
easier to follow).
Provide appropriate positive verbal reinforcers for accom- Positive reinforcement encourages maintenance of new
plishment of goals or steps toward the goals. behaviors.
Utilize group therapy once a day to provide:
• Positive role models
• Peer support
• Realistic assessment of goals
(care plan continued on page 364)
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364 • Activity—Exercise Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Exposure to a variety of problem solutions
• Socialization and learning of social skills
Refer to a home health agency for continued support after
discharge.
• Provide the client and family with contact information This will increase the potential for community follow-up
for the agency so that a relationship can be established after discharge.
before discharge.
Gerontic Health
Nursing actions for Adult and Home Health are appropriate for the older adult. The nurse may provide information on
resources that target the elderly, such as the area Agency on Aging; local support groups for people with chronic illnesses;
and city, county, or state resources for the elderly.
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Infant Behavior, Disorganized, Risk For and Actual, and Readiness For Enhanced Organized • 365
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Proper food preparation and storage—teach the
client/family safety measures for food preparation and
storage, assist client to obtain materials to facilitate
safe food handling when indicated.
Assess the client/family’s need for additional assistive Provides additional support for the client and family, and
resources and refer to appropriate community agencies uses already available resources in a cost-effective
as indicated. manner.
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366 • Activity—Exercise Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for all possible contributing factors related to the Inclusion of all contributing factors will result in an indi-
infant’s status, including: vidualized plan of care.
• Prenatal course
• Birth history and Apgar scores
• Known medical diagnoses
• All genetically relevant data
• Actual description of problem/triggering cues
• Treatment modalities (monitors, medications, special
equipment, and/or special care related)
Determine both the mother’s and father’s (parental) per- Ultimate responsibility will be better assumed by the
ception of the infant’s status. caregiver if planning is long term and considers
parental input.
Spend [number] minutes per shift with parents discussing Opportunities to express concerns and gain knowledge
their concerns and feelings about infants status will enhance coping.
Identify specific parameters (according to etiologic or Treatment of condition will be enhanced with a specific,
known cause of problem) for appropriate management individualized plan of care. Inclusion of early child-
of infant; i.e., laboratory ranges (arterial blood gases) hood developmental specialist, occupational therapist,
and respiratory rate, as applicable. [Note client specific physical therapist, dietitian, home health nurse, and
plan for management of these parameters here.] others as required will offer essential specialized care.
Evaluate parental capacity to assume caregiving role of Anticipatory planning will enhance likelihood of ade-
the infant by: quate timing and gradual relinquishment of care to the
• Asking the parent to verbalize special care the infant parents or, when necessary, other primary caregivers.
requires
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Infant Behavior, Disorganized, Risk For and Actual, and Readiness For Enhanced Organized • 367
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Observing the parent in care behaviors while still in
hospital setting for appropriateness (e.g., feeding,
handling, or as necessary, giving medications, suc-
tioning, etc.)
• Assessing problem-solving skills related to the infant’s
care (i.e., when to call for assistance)
• Risk factor analysis of total 24-hour care of the infant
• Ability to identify the infant’s cues
• Ability to respond to the infant’s cues
• Ability to handle, emotionally and otherwise, demands
of the infant’s status
• Verbalization of expected prognosis or developmental
potential
• Evidence of realistic planning for respite care backup
after discharge from hospital
Spend [number] minutes per shift discussing a plan of
care with parents. Note status of plan development here
and update as planning progresses, noting assistance
needed from staff to facilitate the implementation.
Provide anticipatory care, including positioning, in plan- Appropriate anticipation of possible cardiac or respiratory
ning for feedings, if necessary, with safety-mindedness arrest and/or related dysfunction of vital functions will
as dictated by the infant’s status, including possibility best identify degree of physiologic support required to
of cardiac or respiratory arrest. sustain the infant.
Provide stimulation only as tolerated by the infant, to Protection of the infant from undue environmental stres-
include minimal gentle touching, decreased sound, sors during acute phase will decrease the possibility of
decreased light, decreased strong chemical odors, and increased levels or length of time when disorganized
gentle suctioning of oropharynx as necessary. [Note behavior is present.
special adaptations for this client.]
Support the infant in basic physiologic needs as required, Support of adaptive potentials may help restore patterns
including: of organized behavior or at least maintain a more
• Dietary needs (by mouth [p.o.]), gastrostomy tube, enhanced organized behavior pattern with individual-
hyperalimentation, etc.) ized allowances as a basis for determining effective
• Respiratory functioning or maintenance (O2, tra- care.
cheotomy, endotracheal ⫹ ventilation ⫹ pulmonary
toileting)
• Urinary/elimination (self-toileting, diapering, Foley
catheter)
• Cardiac homeostasis (self-regulatory, medication, pace-
maker, monitoring)
• Neuromuscular requisites (positioning in alignment,
protection from injury in event of seizure, use of
splints, special equipment for adaptive needs, adminis-
tration of seizure medications if needed)
• Communication augmentation (close and continuous
observation, interpretation of cues, adaptive aids rang-
ing from musical toys to developmentally appropriate
interactive toys)
• Tolerance of stimulation (satisfactory oxygen satura-
tion, ability to rest at intervals, etc.)
(care plan continued on page 368)
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368 • Activity—Exercise Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Readiness for Enhanced Organized Infant Behavior
Monitor for all factors contributing to disorganized Inclusion of all contributing factors will most likely offer
behavior that can be controlled (e.g., sounds, sights, potential to influence the infant’s behavior on an indi-
and other stimuli). Note client-specific factors here. vidualized basis.
Develop a plan for identifying adaptation behaviors for Ongoing evaluation will serve the purpose of substantia-
evaluating effectiveness of current treatment and redef- tion of progress and thereby define enhancement
inition. behaviors and patterns.
Once enhancement behaviors are identified, redefine plan
of care to best incorporate client goals.
● N O T E : Case management becomes an issue of paramount importance with a need
to keep the family updated as changes occur. Also, in event of compromise and/or
ultimate death, there should be consideration for:
• Spiritual Distress, Risk For
• Anticipatory Grieving
• Parent, Infant, Child Attachment, Impaired, Risk for
Also, it could be that this infant requires long-term care
with allowance for acute exacerbations made worse by
underlying disorganized infant behavior.
Women’s Health
● N O T E : This diagnosis will relate to the delivery room and the immediate postpartum
period (48 to 72 hours). For further clarification beyond this period, see Child Health.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the infant’s cardiovascular and respiratory system Apgar score is an indicator of the infant’s condition at
by use of Apgar score, at 1 and 5 minutes after birth. birth and provides a baseline for determining the need
for appropriate interventions and neonatal resuscitation.
Prepare for neonatal resuscitation by having all equip- If there is a compromised infant, then it is appropriate
ment and supplies ready. Be prepared to support for the nurse in the delivery room to support and assist
neonatal staff, if available, and/or pediatrician. Support the neonatal staff in stabilizing the infant. If no neona-
and reassure the parents by keeping them informed of tal staff is available, the labor–delivery staff needs
the infant’s condition. to be well versed in neonatal stabilization and resusci-
tation.
Support the parents of the ill neonate by being available Parents often need to verbalize what they have been told
to listen and answer questions. by the neonatologist and the NICU staff. This helps
them cope and can provide clarification of any infor-
mation they have been given. The nurse who listens
can correct inaccurate perceptions and keep NICU
staff informed of the parents’ understanding so they
can better understand and provide support where the
mother and family are physically and emotionally
stressed.
Act as a liaison between neonatal intensive care unit
(NICU) and the parents, assisting both parties by
clarifying and explaining.
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Infant Behavior, Disorganized, Risk For and Actual, and Readiness For Enhanced Organized • 369
ACTIONS/INTERVENTIONS R AT I O N A L E S
Accompany and/or transport the patient to NICU the first
time, to provide guidance and support, as well as intro-
ducing him or her to the NICU staff.
If the infant is transported to another hospital, keep the
mother informed by establishing contact with the
NICU staff.
Obtain pictures of the infant and telephone numbers so
the mother can call and talk with NICU staff.
Monitor and document the infant’s physiologic parame- Utilizing every opportunity to teach new parents about
ters during periods of reactivity: their newborn increases confidence and infant caretak-
• Assist new parents in utilizing the normal periods of ing activities.
reactivity in the neonate to begin breastfeeding and the
parent–infant attachment process.
• Perform a complete physical assessment of the new-
born, documenting findings in an organized manner
(usually head to toe).
• Note and inform the parents of aspects of normal new-
born appearance, especially noting such items as milia,
normal newborn rash, or “stork bites.”
• Explain the importance of thermoregulation, voiding
patterns, and neurologic adaptations during the imme-
diate newborn period.
• Practice good handwashing techniques before touching
the newborn, and explain to the parents the importance
of this in preventing infection.
• Monitor the infant for ability to feed (breast or bottle),
intake, output, and weight loss or gain.
• Encourage parent participation in the care and observa-
tion of the infant.
• Be available to answer questions and demonstrate tech-
niques of baby care to new parents.
Prevent heat loss by immediately drying the infant and Drying decreases the incidence of iatrogenic hypothermia
laying him or her on a warmed surface (best place is in the newborn. (Infant’s temperature can drop as much
skin-to-skin with the mother). as 4.7⬚F in the delivery room.)82
Immediate Postpartum Period
Perform a gestational age assessment, and compare the Gestational age and the size (AGA, SGA, LGA) of the
infant’s gestational age and weight. Based upon this infant can affect the transition to extrauterine life.
examination, determine whether infant is83:
• Average for gestational age (AGA)
• Small for gestational age (SGA)
• Large for gestational age (LGA)
Review the mother’s prenatal and labor–delivery The use of drugs during labor or prenatally, and maternal
histories for factors that would interfere with the diseases such as diabetes may inhibit the thermoregula-
normal transitional physiologic process by the tory and cardiovascular responses or respiratory
neonate, such as metabolic disorders (diabetes, etc.) effort.83
and/or use of medications, both therapeutic and
abusive.
Continue to monitor the infant’s vital signs frequently.
(care plan continued on page 370)
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370 • Activity—Exercise Pattern
Mental Health
● N O T E : Mental health interventions for this diagnosis would focus on family support.
Refer to the following diagnoses for care plans:
Management of Therapeutic Regimen (Family), Ineffective
Caregiver Role Strain
Family Coping, Compromised or Disabled
Family Coping, Readiness for Enhanced
Parenting, Impaired or Risk for
The practitioner should review the definition and defining characteristics of these diag-
noses to determine which one relates to those characteristics being demonstrated by the
infant’s family and/or support system.
Gerontic Health
This diagnosis would probably not be used in Gerontic Health.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client and family in lifestyle changes that may Home-based care requires involvement of the family.
be required. Provide for: Disorganized infant behavior can disrupt family sched-
• Supportive environment ules. Adjustment in family activities may be required.
• Consistent care provider
• Appropriate stimulation
• Control of pain—teach the caregiver to recognize signs
of pain, and appropriate pain management actions, to
include safe use of prescribed analgesics.
• Understanding of normal growth and development—
teach the caregiver normal developmental milestones
and their associated behaviors.
Assist the family to set criteria to help them determine Provides the family with background knowledge to seek
when additional intervention is required (e.g., change appropriate assistance as need arises.
in baseline physiologic measures).
Assess the client/caregiver need for assistive resources Additional assistance may be required for the family to
and refer to appropriate community agencies. care for the infant. Use of readily available resources is
cost effective.
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Peripheral Neurovascular Dysfunction, Risk For • 371
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine exact parameters to be used in monitoring risk Specific parameters for assessment of neurodeficits can
concerns (e.g., if the patient is without sensation in guide caregivers in choosing the best precautionary
specific levels of anatomy, document what the known treatment.49
deficits are: High level of myelomeningocele, lumbar
4, with apparent sensation in peroneal site). [Note
client specific adaptations here.]
(care plan continued on page 372)
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372 • Activity—Exercise Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Carry out treatments with attention to the neurologic Common safety measure.
deficits (e.g., using warm pads for a child unable to
perceive heat would require constant attention for signs
or symptoms of burns).
Provide teaching according to the patient and family Appropriate assessment will best foster learning and help
needs, especially with regard to safety. [Note client prevent injury.49
specific teaching plan here.]
Include the family in care and use of equipment (e.g., Family involvement assuages the child’s emotional needs
braces, etc.). and empowers the parents.
Refer to appropriate community agencies for follow-up.49 Long-term follow-up validates the need for rechecking
and offers a time to reassess progress in goal attain-
ment or altered patterns.
Teach the patient (as developmentally appropriate) and Provides anticipatory guidance in safe administration
family administration of medications especially antico- of medications.49
agulation agents as low-dose heparin.49
Women’s Health
● N O T E : Women are at risk for thrombosis in the lower extremities during pregnancy
and the early postpartum period. Because of decreased venous return from the legs,
compression of large vessels supplying the legs during pregnancy, and during pushing
in the second stage of labor, patients need to be continuously assessed for this prob-
lem.84
ACTIONS/INTERVENTIONS R AT I O N A L E S
Closely monitor the patient at each visit and teach patient Knowledge of the problem and its causative factors can
to self-monitor size, shape, symmetry, color, edema, assist in planning and carrying out good health habits
and varicosities in the legs. during pregnancy. This knowledge can assist in pre-
venting thrombotic complications during pregnancy.
Encourage the patient to walk daily during the pregnancy
and to wear supportive hosiery.
Assist the patient to plan a day’s schedule during preg-
nancy that will allow her time to rest. The schedule
should also include several times during the day for her
to elevate her legs.
Encourage the patient to use a small stool when sitting
(e.g., at desk to keep feet elevated and less compres-
sion on upper thighs and knees).
In the event thrombophlebitis develops: Basic assessment for early detection of complications.
• Monitor legs for stiffness, pain, paleness, and swelling
in the calf or thigh every 4 hours around the clock.
• Place the patient on strict bedrest with the affected leg Basic safety measure to avoid dislodging of clots.
elevated.
Provide analgesics as ordered for pain relief, and assess
for effectiveness within 30 minutes of administration.
Place a bed cradle on the bed. Keeps pressure of bed linens off the affected leg.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Administer and monitor the effects of anticoagulant ther-
apy as ordered. Collaborate with the physician regard-
ing the frequency of laboratory examinations to
monitor clotting factors.
● N O T E : Breastfeeding mothers who are taking heparin can continue to breastfeed.
Breastfeeding mothers who are taking dicumarol should stop breastfeeding, because it
is passed to the infant in breast milk.
Do not rub, massage, or bump affected leg. Handle with Basic safety measures to avoid dislodging clots.
care when changing linens or giving bath.
Assist the family to plan for care of the infant; include Assist the patient and family in coping with illness.
the mother in planning process. Promotes effective implementation of home care.
Provides support and teaching opportunity.
Encourage verbalizations of fears and discouragement
by the mother and family.
Mental Health
The mental health client with this diagnosis requires the same type of nursing care as the adult client. A review of the
nursing actions for Activity Intolerance, Impaired Physical Mobility, and Ineffective Tissue Perfusion would also be of
assistance.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Avoid the use of restraints if at all possible. Restraint use in older adults can lead to physical and
mental deterioration, injury, and death.85
Monitor restraints, if used, at least every 2 hours on Frequent monitoring decreases the injury risk.
[odd/even] hour. Release restraints, and perform ROM
exercises before reapplying.
Home Health
Nursing actions for the home health client with this diagnosis are the same as those for the Adult Health client.
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374 • Activity—Exercise Pattern
TARGET DATES
✔ Have You Selected the Correct Diagnosis? These dates may be short term or long term, based on the
Activity Intolerance etiology of the diagnosis. An acceptable first target date
This diagnosis implies that the individual is freely able would be 5 days.
to move but cannot endure or adapt to the increased *Suggested Functional Level Classification
energy or oxygen demands made by the movement or
activity. Impaired Physical Mobility indicates that an
0 ⫽ Completely independent
individual would be able to move independently if 1 ⫽ Requires use of equipment or device
something were not limiting the motion. 2 ⫽ Requires help from another person, for assis-
tance, supervision, or teaching
Impaired Physical Mobility 3 ⫽ Requires help from another person and equip-
This diagnosis also needs to be differentiated from the ment service
respiratory (Impaired Gas Exchange and Ineffective
4 ⫽ Dependent, does not participate in activity
Breathing Pattern) and cardiovascular (Decreased
(Code adapted by NANDA.) 106
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Physical Mobility, Impaired • 375
ACTIONS/INTERVENTIONS R AT I O N A L E S
Medicate for pain as needed, especially before activity. Pain interferes with ability to ambulate by inhibiting mus-
Exercise caution with medications that effect senso- cle movement.
rium.
Perform ROM exercises (passive, active, and functional) Increases circulation, maintains muscle tone, and prevents
every 2 hours on [odd/even] hour. joint contractures.
Maintain proper body alignment at all times; support Prevents flexion contractures and progression of compli-
extremities with pillows, blankets, towel rolls, or sand- cations.
bags.
Implement measures to prevent falls, such as keeping bed Basic safety measures.
in low position, wearing appropriately fitting shoes or
nonskid slippers.
Devise strategies for strength training.
Maintain adequate nutrition. Provides nutrients for energy, and prevents protein loss
due to immobility.
Observe for complications of immobility (e.g., constipa- Allows early detection and prevention of complications.
tion, muscle atrophy, decubitus ulcers).
Include the patient and family or significant other in car- Allows time for practice under supervision. Increases
rying out plan of care. likelihood of effective management of therapeutic
regimen.
Initiate physical therapy and/or occupational therapy as
soon as feasible.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor alteration in mobility each 8-hour shift according Provides the primary database for an individualized plan
to: of care.
• Actual movement noted and tolerance for the move-
ment
• Factors related to movement (e.g., braces used,
progress in use)
• Situational factors (e.g., previous status, current health
needs, or movement permitted)
• Pain
• Circulation check to affected limb
• Change in appearance of affected limb or joint
Include related health team members in care of the The nurse is in the prime position to coordinate health
patient as needed. [Note plan for their involvement team members to best match needs and resources.
here.]
Consider patient and family preferences in planning to Consideration of preferences increases likelihood of plan
meet desired mobility goals. [Note special adaptations success.
needed to incorporate family/patient preferences
here.]49
Facilitate participation of family members, especially the Involving the family in care serves to enhance their skills
parents, in care of the patient according to needs and in care required at home.
situation (feeding, comfort measures). [Note
patient/family specific adaptations here.]
(care plan continued on page 376)
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376 • Activity—Exercise Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide diversional activities appropriate for age and Diversional activity, when appropriately planned, serves
developmental level. [Note those activities preferred by to refresh and relax the patient
client here.]
Maintain appropriate safety guidelines according to age Basic requirements for maintaining standards of care.
and developmental guidelines.
Monitor traction or related equipment in use (e.g., Ensures therapeutic effectiveness of equipment, and pro-
weights hanging free or rope knots tight). vides for safety issues related to these interventions.
Monitor patient and family needs for education regarding Allows timely planning for home care, and allows prac-
the patient’s situation and any future implications. tice of care in a supportive environment.
[Note plan for family education here.]
Monitor intake and output to ensure adequate fluid bal- Strict intake and output will assist in monitoring hydra-
ance for each 24-hour period. tion status, which is crucial for healing and circulatory
adequacy.
Address related health issues appropriate for the patient Appropriate attention to related health issues fosters
and family. holistic care (e.g., the child may need braces, but may
also have need for healing, or speech followup second-
ary to meningitis, and developmental delays).49
Women’s Health
● N O T E : The following nursing actions apply to those women placed on restrictive
activities because of threatened abortions, premature labor, multiple pregnancy, or
pregnancy-induced hypertension.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Facilitate the participation of the family and significant
others in the plan of care for the patient.
When resting in bed, have the patient rest in the left lat- Prevents supine hypotension, and allows adequate renal
eral position as much as possible. and uterine perfusion.
Encourage the patient to list lifestyle adjustments that
will need to be made.
Teach the patient relaxation skills and coping mecha- Decreases anxiety and muscle tension.
nisms.
Facilitate adequate protein intake. [Note special needs Replaces protein lost because of decreasing muscle con-
here.] traction during immobility.
Maintain proper body alignment with use of positioning
and pillow.
Provide diversionary activities (e.g., hobbies, job-related Decreases anxiety and reduces muscle tension. Provides
activities that can be done in bed, or activities with appropriate amounts of activity without danger to
children). pregnancy.
Facilitate help and visits from friends and relatives:
• Visit in person
• Telephone visit
• Help with child care
• Help with housework
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Physical Mobility, Impaired • 377
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
● N O T E : The following actions and interventions are related to imposed restrictions.
This includes seclusion and restraint.
Attempt all other interventions before considering immo- Promotes the client’s sense of control and supports self-
bilizing the client as an intervention. (See Risk for esteem.
Violence, Chapter 9, for appropriate nursing actions.)
Carefully monitor the client for appropriate level of
restraint necessary. Immobilize the client as little as
possible while still protecting the client and others.
Obtain necessary medical orders to initiate methods that
limit the client’s physical mobility.
Carefully explain to the client in brief, concise language Excessive stimuli can increase confusion. Provides the
reasons for initiating this intervention, and what behav- client with sense of control.
ior must be present for the intervention to be termi-
nated.
Attempt to gain the client’s voluntary compliance with Promotes the client’s sense of control and safety, which
the intervention by explaining to the client what is promotes self-esteem.
needed and with a “show of force” (have the necessary
number of staff available to force compliance).
Initiate forced compliance only if there is an adequate Client and staff safety are of primary concern.
number of staff to complete the action safely. (See
Risk for Violence, Chapter 9, for a detailed description
of intervention with forced compliance.)
Secure the environment the client will be in by removing Prevents injury by protecting the client from impulsive
harmful objects such as accessible light bulbs, sharp actions of self-harm.
objects, glass objects, tight clothing, and metal objects
such as clothes hangers or shower curtain rods.
If the client is placed in four-point restraints, maintain Client safety is primary concern.
one-to-one supervision.
If the client is in seclusion or bilateral restraints, observe
the client at least every 15 minutes, more frequently if
agitated [List observation schedule here.]
Leave the urinal in room with the client, or offer toileting
every hour.
Offer the client fluids every 15 minutes. Maintains adequate hydration.
Discuss with the client his or her feelings about the initia- Exploration of feelings in an accepting environment helps
tion of immobility, and review with him or her again, the client identify and explore maladaptive coping
at least twice a day, the behavior necessary to have behaviors. Promotes the client’s sense of perceived
immobility discontinued. control.
When checking the client, let him or her know you are Promotes perceived control and promotes an environment
checking by calling him or her by name and orienting of trust.
him or her to day and time. Inquire about the client’s
feelings, and implement necessary reality orientation.
Provide meals at regular intervals on paper containers, Meets biophysical needs while providing consistency in a
providing necessary assistance. [Amount and type of respectful manner, which promotes self-esteem and
assistance required should be listed here.] trust.
(care plan continued on page 378)
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378 • Activity—Exercise Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
If the client is in restraints, remove restraints at least Promotes normal circulation and motion, which prevents
every 2 hours, one limb at a time. Have the client move injury to the limb.
limb through a full ROM and inspect for signs of
injury. Apply lubricants such as lotion to area under
restraint to protect from injury.
Pad the area of the restraint that is next to the skin with Protects skin from mechanical irritation.
sheepskin or other nonirritating material.
Check circulation in restrained limbs in the area below Early assessment and intervention prevents serious injury.
the restraint by observing skin color, warmth, and
swelling. Restraint should not interfere with circulation.
Change the client’s position in the bed every 2 hours on Prevents disuse syndrome.
[odd/even] hour.
Place body in proper alignment. Use pillows for support Prevents complications and injury.
if the client’s condition allows.
If the client is in four-point restraints, place him or her on Prevents aspiration or choking.
stomach or side.
Place the client on intake and output monitoring. Ensures that adequate fluid balance is maintained.
Have the client in seclusion move around the room at Prevents complications of immobility.
least every 2 hours on [odd/even] hour, and during this
time initiate active ROM.
Administer medications as ordered for agitation. Medications reduce anxiety and facilitate interaction with
others.
Monitor blood pressure before administering antipsy- Psychotropic medications can cause orthostatic hypoten-
chotic medications. sion.
Assist the client with daily personal hygiene (record time Communicates positive regard for the client by the nurse,
for this here). which facilitates the development of positive self-
esteem.
Have environment cleaned on a daily basis. Promotes sanitary conditions and provides an orderly
environment, which can decrease the client’s disorgani-
zation and confusion.
Review with the client the purpose for restraint or seclu- Promotes the client’s sense of control by providing him
sion as required, and discuss alternative kinds of or her with behavioral alternatives and establishing
behavior that will express feelings without threatening clear limits.
self or others.
Remove the client from seclusion as soon as the con- Provides positive reinforcement for appropriate coping
tracted behavior is observed for the required amount of behavior, and promotes the client’s sense of control.
time (both of these should be very specific and listed
here). (See Risk for Violence, Chapter 9, for detailed
information on behavior change and contracting
specifics.)
Schedule time to discuss this intervention with the client Support system understanding and support of treatment
and his or her support system. Inform support system goals has a positive effect on client outcome.
of the need for the intervention and about special con-
siderations related to visiting with the client. This
information must be provided with consideration of
client confidentiality. Plan to spend at least 5 minutes
with the members of the support system before and
after each visit.
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Physical Mobility, Impaired • 379
ACTIONS/INTERVENTIONS R AT I O N A L E S
Arrange consultations with appropriate resources after the Facilitates the development of trust as well as respect for
client is released from mobility limitations to assist the the client, which can have a positive effect on the
client with developing alternative coping behavior. This client’s self-esteem.
could include a physical therapist, an occupational
therapist, or a social worker.
● N O T E : The following interventions are related to restrictions due to psychogenic
causes.
• If restrictions are due to anxiety, refer to Chapter 8 and
the diagnosis of Anxiety.
• If restrictions are due to depressed mood, implement
the following interventions:
• Sit with the client for [number] minutes [number]
times per shift. Initially these times will be brief but
frequent (e.g., 5 minutes per hour).
• Establish clear expectations for these interactions Communicates respect for the client, and facilitates the
(e.g., the client is not expected to talk, it is okay for client’s perception of control.
these times to be spent in silence).
Explain to the client in simple concrete terms the positive Physical activity can stimulate endorphin production,
effects of physical activity on mood. [Note person which has a positive effect on mood.
responsible for this teaching here.]
Talk with the client about activities they have enjoyed in Promotes a positive expectational set based on past posi-
the past. tive experiences.
Develop with the client a program for increasing physical Promotes the client’s sense of control. Positive reinforce-
activity. Note that contact here. Also note rewards for ment encourages behavior and enhances self-esteem.
accomplishing goals (e.g., will walk from bed to door
once per hour). If accomplished, the client can remain
in bed during visiting hours. Activities can increase as
the client masters each step.
Provide positive verbal reinforcement for accomplishing Positive recognition from significant others enhances
tasks. self-esteem.
Recognize the client’s perceptions about the difficulty of Communicates acceptance of the client, and facilitates the
physical activity in the initial stages of recovery. development of a trusting relationship.
Pair physical activity with situations the client finds Promotes positive expectational set by pairing physical
rewarding. Note these situations here (e.g., walking exercise with a positive stimulus.
with the client to get a cup of coffee. This pairs walk-
ing with two things the client finds rewarding: time
with the nurse and coffee).
Have the client identify perceived barriers to increased Promotes the client’s sense of control and increases the
physical activity. Note those here and develop client’s commitment to the plan because he or she has
with the client plan for reducing these. [Note plan contributed to the plan.
here.]
Teach support system importance of the client’s increas- Support system involvement increases the probability for
ing physical activity, and have them identify ways positive outcome.
they could assist with this. Note here the person
responsible for this, and record the plan when it is
developed.
(care plan continued on page 380)
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380 • Activity—Exercise Pattern
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized with the aging client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for complications of immobility such as: Normal aging changes in combination with immobility
• Orthostatic hypotension can leave the older adult at increased risk for com-
• Thrombosis plications.86
• Urinary tract infections
• Constipation
Assess the client for depression and treat appropriately. Depression can contribute to sedentary lifestyle and
resulting immobility.
Observe the patient for Valsalva maneuver (increased Valsalva maneuver can produce increased pulse rate and
intrathoracic pressure induced by forceful exhalation increased blood pressure. This adversely affects
against a closed glottis) when he or she is changing patients with cardiovascular disorders, which may
position, pushing a wheelchair, or toileting. lead to their choosing not to engage in physical
activity.86
Monitor for behavioral changes that may result from Psychological changes not addressed may increase prob-
decreased sensory stimulation or decreased socializa- lems of physical mobility and lead to prolonged peri-
tion (e.g., depression, hostility, confusion, or anxiety). ods of immobility.
Observe when increasing mobility, transferring, or during Older adults may be at risk for falls secondary to ortho-
early ambulation stage for the risk for falls. static blood pressure changes or problems with bal-
ance, especially after prolonged periods of immobility.
Teach the client to perform isometric muscle contraction Isometric contraction helps maintain muscle strength,
(i.e., tightening of muscle group as hard as possible which can decrease with immobility as much as 5 per-
and then relaxing the muscle). cent per day.86
Collaborate with health-care team to provide supervised Maintain muscle strength.
flexibility and range of motion exercises for client.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient and family in identifying risk factors Locus of control shifts from nurse to the client and fam-
pertinent to the situation: ily, thus promoting self-care.
• Immobility
• Malnourishment
• Confusion or lethargy
• Physical barriers
• Neuromuscular deficit
• Musculoskeletal deficit
• Trauma
• Pain
• Medications that affect coordination and level of
arousal
• Debilitating disease (cancer, stroke, diabetes, muscular
dystrophy, multiple sclerosis, arthritis, etc.)
• Depression
• Lack of or improper use of assistive devices
• Casts, slings, traction, IVs, etc.
• Weather hazards
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Sedentary Lifestyle • 381
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family measures to promote physical
activity:
• Use of assistive devices (wheelchairs, crutches, canes,
walkers, prostheses, adaptive eating utensils, devices to
assist with activities of daily living, etc.)
• Providing safe environment (reducing barriers to activ-
ity such as throw rugs, furniture in pathway, electric
cords on floor, doors, or steps)
• Maintaining skin integrity
• Use of safety devices (ramps, lift bars, tub rails, tub or
shower seat)
• Proper transfer techniques
Assist the patient and family in identifying lifestyle Provides basic information for the client and family that
changes that may be required: promotes necessary lifestyle changes.
• Alteration in living space (ramps, assistive devices,
etc.)
• Changes in role functions
• Range of motion exercises
• Positioning and transferring techniques
• Pain control
• Progressive activity
• Use of assistive devices
• Prevention of injury
• Maintenance of skin integrity
• Assistance with activities of daily living
• Special transportation needs
• Financial concerns
Assess the client/family need for assistance with obtain- Provides additional support for the client and family, and
ing assistive devices, or in home assistance with ADLs, uses already available resources in a cost-effective
cooking, and housework. Refer to community agencies manner.
providing needed services.
1. The risk factors also serve as the related factors for this
TARGET DATES
diagnosis.
2. Deficient knowledge of health benefits of physical exer- Appropriate target dates will have to be individualized
cise according to the degree of deconditioning. An appropriate
3. Lack of training for accomplishment of physical exercise range would be 3 to 5 days.
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382 • Activity—Exercise Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for contributing factors, especially current med- Provides a realistic basis for plan of care.
ical status and potential limitations imposed.
Develop, with the client and family, specific goals for Creates a measurable goal.
activity.
Identify strategies to attain the goal. Provides a realistic plan.
Involve other health team members as appropriate, Offers safe and appropriate plan to match the child’s
including pediatrician, pediatric cardiologist, or other potential.
primary care provider, nutritionist, occupational or
physical therapist, and child life specialist.
Establish need for supervision and equipment essential in Provides anticipatory planning in the event of an unto-
event of untoward response to exercise or activity ward response during activity.
*May include halter monitoring or peak flow meter
assessment.
Determine a mutually satisfactory way to reward the Satisfies reinforcement with likelihood for continued suc-
child for participation. [Note that plan here.] cess with plan.
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Sedentary Lifestyle • 383
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss with child and family values related to increased Allows for likelihood of exploring lifelong values to
activity vs. rationale for not remaining sedentary. assist in maintenance of health.
Develop peer activities mutually agreed upon by child Allows for child’s input within parental framework to
and parents to assist in support of desired activities. consider peer interaction with resultant likelihood to
continue activity.
Women’s Health
● N O T E : Women’s lifestyles will be the same as for Adult Health with the following
notations:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Living—A Five-Step Program (American College of Statistics show that 55% of American adults have been
Sports Medicine: 1998); classified as obese, and 58 million Americans are diag-
1. Get moving, quantity of cardiovascular exercise nosed as “clinically obese.” This factor, along with
2. Get in the zone–quality of cardiovascular exercise stress and a sedentary lifestyle is leading to millions of
3. Strength Training Assessment (excellent to prevent Americans becoming progressively disabled, losing
bone loss) their ability to perform such basic functions as getting
4. Nutrition and Exercise104 in and out of a car or chair.104
Assist the client to plan, start, and maintain an exercise Women go through five stages of change as they adopt an
program that fits their life-stage. Be certain that when exercise regimen: (1) precontemplation, (2) contempla-
planning an exercise program, you (1) consider the tion, (3) preparation, (4) action, and (5) maintenance.
woman’s experiences, (2) make no assumptions based When most women reach the maintenance stage and
on popular literature, and (3) look at what is meaning- exercise has become a routine part of their life, they
ful interaction for the woman.104 feel a sense of empowerment and well-being.104
Poverty remains one of the major factors affecting Lifestyle choices such as nutritious diet, regular exercise,
women’s health. Sixty percent of chronic diseases are and avoidance of smoking will help prevent the major-
preventable, and exercise is becoming known as having ity of chronic diseases.87
the greatest benefit to prevent chronic diseases.
Biological changes in cardiovascular, respiratory, and Researchers report that 30 to 60 percent of the general
musculoskeletal systems plus inactivity place women population does not do any physical activity, and 42
at risk for disability.88 percent of those who are 65 and older state they lead
sedentary lives.88
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend [number] minutes discussing with client his or her Helps determine aspects of the client’s cognitive appraisal
perception of lifestyle and experiences with increased that could impact learning.34
activity and exercise. Identify what he or she thinks is
most important about the current situation.
Determine the client’s current physical abilities. This can
be done in collaboration with his or her primary care
provider.
Provide feedback to the client about discrepancies in cur- Presents an opportunity to review with the client how
rent behavior and stated values/goals. behavior change will facilitate goal achievement.89
Provide the client with arguments for and against change. If the client is resistant to change, this places the nurse in
a neutral position and prevents the client pushing back
in non-growth-promoting directions.89
(care plan continued on page 384)
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384 • Activity—Exercise Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Contribute positive outcomes and successes to the client. Promotes self-efficacy. Builds confidence in ability to
• Use these successes to demonstrate to the client that he change.89
or she has the resources to change their behavior.
Include the client in decisions about change and progress Promotes self-efficacy.89
toward changes.
Develop, with the client, a specific plan for change. [Note
that plan here and the support needed from staff to
implement the plan.]
Provide positive, informative verbal reinforcement for Positive reinforcement promotes behavior change.34
goal attainment.
Develop, with the client, a specific plan for maintaining
these changes after discharge.
• Provide the client with a written plan to take with him
or her.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor current potential for activities, including: Provides baseline for planning activities and increase in
• Activities of interest activities.
• Physical limitations
• Realistic expectations for goal achievement
• Objective criteria by which specific progress may be
measured (e.g., distance, time)
• Previous activities the patient enjoyed
Assess community resources for exercise (e.g., walking Assists the client in utilizing existing resources.
tracks, indoor pools, and church activity centers) and
refer the client to facilities that are nearby or that
match the client’s interests.
Teach client about various ways to increase activity: Assists the client in making informed decisions.
• Walking
• Graduated Walking
• Bicycling
• Swimming
Include education about safety with each type of activity.
Teach the client safety measures to consider when Promotes safety.
increasing activity:
• Always check with a physician before starting an exer-
cise program.
• Stop and consult a health-care professional if pain or
unusual symptoms occur (e.g., chest pain, palpitations,
irregular heart beat, dizziness, light headedness, nau-
sea, vomiting, extreme fatigue, pale or splotchy skin,
“cold sweat”)
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Sedentary Lifestyle • 385
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Start in small increments and increase as tolerated
• Avoid exercising for 2 hours after a large meal and
do not eat for 1 hour after exercising.
• Include warmup and cool down exercises.
• Use proper equipment and clothing
• Wear comfortable rubber soled shoes and loose
clothing.
• Avoid exercising in extreme heat or cold.90
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386 • Activity—Exercise Pattern
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Self-Care Deficit (Feeding, Bathing-Hygiene, Dressing-Grooming, Toileting) • 387
energy or oxygen demands made by the movement or regarding inability to cope also require looking at
activity. Activity Intolerance can be a contributing fac- these diagnoses.
tor to the development of self-care deficits.
Interrupted Family Processes
Impaired Physical Mobility Through observing family interactions and communi-
This diagnosis is quite often a contributing factor to cation, the nurse may assess that Interrupted Family
the development of Self-Care Deficit. It is probable Processes should be considered. Poorly communi-
that any time a patient has Impaired Physical Mobility, cated messages, rigidity of family functions and roles,
he or she will also have some degree of Self-Care and failure to accomplish expected family develop-
Deficit. mental tasks are a few observations to alert the nurse
Disturbed Thought Process to this possible diagnosis.
If the patient is exhibiting impaired attention span;
impaired ability to recall information; impaired percep-
tion, judgment, and decision making; or impaired
conceptual and reasoning ability, the most proper diag- EXPECTED OUTCOME
nosis would be Disturbed Thought Process. Most likely, Will return-demonstrate, with 100 percent accuracy, [spec-
Self-Care Deficit would be a companion diagnosis.
ify] self-care by [date].
Ineffective Individual Coping or Compromised
or Disabled Family Coping
Suspect one of these diagnoses if there are major dif- TARGET DATES
ferences between reports by the patient and the fam- Overcoming a self-care deficit will take a significant invest-
ily of health status, health perception, and health care
ment of time; however, 7 days from the date of diagnosis
behavior. Verbalizations by the patient or the family
would be appropriate to check for progress.
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388 • Activity—Exercise Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide positive reinforcement for each self-care accom- Increases self-esteem and motivation.
plishment.
Perform ROM exercises, or assist the patient with every 4 Maintains muscle tone and joint mobility.
hours while the patient is awake at [times].
Assist the patient and significant others in planning meas- Promotes timely home care planning and encourages par-
ures to overcome or adapt to self-care deficits: ticipation in care.
• Gradual increments in self-care responsibility (e.g.,
getting up in chair independently before ambulating to
bathroom by self)
• Self-care assistive devices (e.g., helping hand)
Place a visual aid in the room to help document progress. Visually documents success.
Monitor: Allows evaluation of progress and assist in determining
• Vital signs every 4 hours while the patient is awake at physiologic impact of progress.
[times].
• Ambulation: Increase, to extent possible.
Monitor bowel and bladder elimination at least once daily Baseline data that assist in determining bowel functioning
at [time]. pattern.
Establish bowel- and bladder-retraining programs as nec- Provides basic education, practice, and reinforcement that
essary. (See Bowel Incontinence and Urinary facilitate the patient’s control of these functions.
Incontinence, Chapter 4.)
Collaborate with dietitian regarding diet (e.g., foods to Promotes self-care, and provides motivation to continue
facilitate self-feeding). striving for improvement.
Refer the patient to community support services. Provides for long-term support.
Make a home health referral to assist significant others to Provides time to adapt home for basic safety measures.
adapt home environment, as soon as feasible:
• Nonskid rugs
• Ramps
• Handrails
• Safety strips in tub and shower
Child Health
Adult Health care plan can provide the foundation for care of children with the following adaptations/considerations:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the patient’s and parents’ potential for self-care Provides a database for an individualized plan of care.
measures appropriate to age and developmental factors.
Allow the patient and parents to participate in planning Enhances satisfaction, and increases the likelihood that
for care when possible to help ensure best compliance. care will be continued after discharge from hospital.
[Note plan for including the family here.]
Teach the appropriate skills necessary for self-care in the Individualized teaching best affords reinforcement of
child’s terms, with sensitivity to developmental needs learning. Sensitivity to special need attaches value to
for practice, repetition, or reluctance. [Note client- the patient and family’s needs.
specific plan here.]
Provide opportunities that will enhance the child’s confi- Confidence in self-care will enhance self-esteem.
dence in performing self-care. [Note plan for this client
here.]
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Self-Care Deficit (Feeding, Bathing-Hygiene, Dressing-Grooming, Toileting) • 389
Women’s Health
● N O T E : These activities relate to the new mother, their self care, and care of infant
during the first postpartum days. Other activities will apply to women the same as
Adult Health, Gerontic Health, and Home Health.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage the patient to list lifestyle adjustments that Promotes gradual assumption of self-care while avoiding
need to be made. overwhelming the patient with activities that must be
accomplished.
Encourage progressive activity and increased self-care as
tolerated:
• Ambulation
• Bathing
• Body image and early postpartum exercises
• Bowel care
• Breast care
• Perineal care
Encourage the patient to get adequate rest:
• Take care of self and baby only.
• Let significant other take care of the housework and
other children.
• Learn to sleep when the baby sleeps.
• Have specific, set times for friends or relatives to visit.
• If breastfeeding, significant other can bring the infant
to the mother at night (the mother doesn’t have to get
up every time for the infant).
Provide quiet, supportive atmosphere for interaction with Promotes attachment.
the infant.
Instruct the patient in infant care, and have her return- Basic teaching measures for care of newborn.
demonstrate:
• Bathing
• Never leave the infant or small child alone in bath.
• Bathe the infant in a small area (the kitchen sink is
good) for the first few weeks.
• Use a warm area in the house.
• Use an area convenient for the mother.
• Be sure the area is not drafty.
• Never run water directly from the faucet onto the
infant; always test with a forearm before placing the
infant in water (water should be warm, but not too
hot).
• Cord care
• Clean the cord with alcohol and cotton swabs when
changing diapers.
• Clean around the base of the cord.
• Leave the cord alone until it drops off.
• Alert the mother that there will be a small amount of
spotting (bleeding) at the cord site when it drops off.
• Clothing
• To determine whether the infant is warm enough, feel
the infant’s chest or back with hand; never judge the
infant’s body temperature by feeling the infant’s
hands or feet.
(care plan continued on page 390)
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390 • Activity—Exercise Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Use a mild detergent when laundering the infant’s
clothing
• Diapering
• Cloth diapers
• Disposable diapers
• Cleaning of the infant when changing diapers
• Circumcision care—Yellen clamp (metal clamp)
• Gently wash the penis with water to remove urine and
feces.
• Reapply fresh, sterile Vaseline gauze around glans.
• It is best to use cloth diapers until completely healed
(approximately 7 to 10 days).
• Circumcision care—plastic bell
• Gently wash the penis with water to remove urine and
feces.
• Do not apply petrolatum gauze.
• Leave the plastic circle on the penis alone until tissue
heals and circle falls off.
• Taking the baby’s temperature and reading a ther-
mometer:
• Axillary Promotes attachment.
• Rectal
Explain infant alert and rest states and how the caretaker
can best use these states to interact with the infant.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine the client’s optimum level of functioning and This information assists in establishing realistic goals.
note here.
Develop behavioral short-term goals by: Goal accomplishment provides positive reinforcement
• Listing those activities the client can assume and enhances self-esteem.
• Breaking these activities into their component parts
• Determining how much of each activity the client could
successfully complete, and listing achievable activities
here with goal achievement dates
• Discussing expectations with the client
Keep instructions simple. Inappropriate levels of sensory stimuli can contribute to
the client’s sense of disorganization and confusion.
Provide support to the client during tasks by: Interaction with the nurse can be a source of positive
• Spending time with the client while he or she is com- reinforcement.
pleting the task.
• Having all items necessary to achieve task readily Increases the possibility for the client to complete the
available. task successfully.
• Assisting the client in focusing on the task at hand.
• Providing positive verbal feedback as each step of the Positive feedback encourages behavior.
task is achieved.
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Self-Care Deficit (Feeding, Bathing-Hygiene, Dressing-Grooming, Toileting) • 391
ACTIONS/INTERVENTIONS R AT I O N A L E S
Keep the environment uncluttered, presenting only those Inappropriate levels of sensory stimuli can contribute to
items necessary to complete the task in the order needed. the client’s sense of disorganization and confusion.
Develop a reward schedule for achievement of goals. Promotes the client’s sense of control. Positive feedback
Discuss possible rewards with the client, and list the encourages behavior.
things the client finds rewarding here with the goal to
be achieved to gain the reward.
Schedule adequate time for the client to accomplish task Communicates acceptance of the client, which facilitates
(depressed client may need 2 hours to bathe and dress). the development of trust and self-esteem.
[Note the client’s schedule here.]
Decrease environmental stimuli to the degree necessary Promotes the client’s sense of control.
to assist the client in focusing on task. [Note the
client’s adaptations here.]
Present ADLs on a regular schedule and note that sched-
ule here. This schedule should be developed in consul-
tation with the client.
Spend [number] minutes with the client twice a day dis- Expression of feelings in a safe environment can facilitate
cussing feelings and reactions to current progress and problem identification and the development of coping
expectations. Times for this and person responsible for strategies.
this activity should be listed here.
Allow the client to perform activities even though it Communicates trust, and promotes the client’s sense of
might be easier at times for staff to complete the task control.
for the client.
Communicate expectations and goals to all staff mem- Promotes consistency in the treatment, and communicates
bers. respect for the client.
Discuss with the family and other support systems and Increases potential for success of treatment plan.
the client the plan and goals. Spend at least 5 minutes
with the family after each visit to answer questions and
explain treatment plan.
Have members of support system identify how they can
assist the client in achieving established goals.
Spend time with the client discussing alternative ways Promotes the client’s sense of control when encountering
of coping with the frustration that may occur while these difficulties. Successful coping will promote posi-
attempting to reach established goals. tive self-esteem.
Collaborate with the occupational therapist or physical
therapist regarding special adaptations needed to assist
the client with task accomplishment (e.g., exercises to
increase muscle strength when muscles have not been
used for a period of time).
Monitor effects medications might have on goal achieve-
ment, and collaborate with the physician regarding
problematic areas.
Develop goals and schedules with the client, communi-
cating that he or she does have responsibility and con-
trol in issues related to care.
Discuss with the client and significant others the things Facilitates the development of positive coping strategies,
that will facilitate continuance of self-care at home, and increases potential for success when the client
and develop a plan that will assist the client in obtain- returns home. Successful accomplishment of this tran-
ing necessary items. sition promotes positive self-esteem.
Refer to community resources as necessary for continued
support.
(care plan continued on page 392)
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392 • Activity—Exercise Pattern
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized with the aging client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach self-monitoring skills such as maintaining a journal Encourages the patient to identify areas that may need
or diary to record what factors may increase the self- improvement or changes in lifestyle.91
care deficit.
Contract with the patient for achievement of specific Enhances motivation to increase self-care.
incremental goals, and provide rewards or reinforce-
ments when goals are met.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor factors contributing to self-care deficit of Provides a database for prevention and/or early inter-
[specify]. This includes items in the related factors vention.
section.
Involve the client and family in planning, implementing, Involvement improves motivation and improves the out-
and promoting reduction of the specific self-care come.
deficit:
• Family conference
• Mutual goal setting
• Communication
Assist the client and family to obtain assistive equipment Assistive equipment improves function and increases the
as required: possibilities for self-care.
• Raised toilet seat
• Adaptive equipment for eating utensils, combs,
brushes, etc.
• Rocker knife
• Suction device under plate or bowl
• Wrist or hand splints
• Blender, crock pot, or microwave
• Long-handled reacher (helping hand)
• Box on seat of chair
• Raised ledge on utility board
• Straw and straw holder
• Washcloth with soap
• Wheelchair, walker, motorized cart, or cane
• Bedside commode, incontinence undergarments
• Bars and attachments and benches for shower or tub
• Hand-held shower device
• Long-handled sponge
• Shaver holder
• Medication organizers and magnifying glass
• Diet supplements
• Hearing aid
• Corrective lenses
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Spontaneous Ventilation, Impaired • 393
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Dressing aids: dressing stick, zipper pull, buttonhook,
long-handled shoehorn, shoe fasteners, or Velcro clo-
sures
Teach the client and family signs and symptoms of Planning activities around physical capabilities prevents
overexertion: further reduction in self-care capacity.
• Pain
• Fatigue
• Confusion
• Decrease or excessive increase in vital signs
• Injury
Assist the client and family in lifestyle adjustments that Provides basic information for the client and family that
may be required: promotes necessary lifestyle changes.
• Proper use of assistive equipment
• Adapting to need for assistance or assistive equipment
• Determining criteria for monitoring the client’s ability
to function unassisted
• Time management
• Stress management
• Development of support systems
• Learning new skills
• Work, family, social, and personal goals and priorities
• Coping with disability or dependency
• Providing environment conducive to self-care privacy,
pain relief, social contact, and familiar and favorite sur-
roundings and foods
• Prevention of injury (falls, aspiration, burns, etc.)
• Monitoring of skin integrity
• Development of consistent routine
• Mechanism for alerting family members to need for
assistance
Refer the patient to appropriate assistive resources as Provides additional support for the client and family,
indicated. and uses already available resources in a cost-effective
manner.
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394 • Activity—Exercise Pattern
✔ Have You Selected the Correct Diagnosis? Ventilation demonstrate this characteristic, but
Impaired Spontaneous Ventilation is of a more critical
Ineffective Breathing Pattern nature than impairment.
In this diagnosis, the patient’s respiratory effort is
insufficient to maintain the cellular oxygen supply.
Both diagnoses would contribute to the patient being
placed on ventilatory assistance; however, Impaired EXPECTED OUTCOME
Spontaneous Ventilation is a more life-threatening,
critical diagnosis than just an Ineffective Breathing
Blood gases will return to normal range by [date].
Pattern. The major difference would be the critical-
ness of the patient’s condition. TARGET DATES
Impaired Gas Exchange Because of the life-threatening potential of this diagnosis,
This diagnosis refers to the exchange of oxygen and initial target dates will need to be stated in terms of hours.
carbon dioxide in the lungs or at the cellular level.
After the patient’s condition has improved and stabilized,
Both this diagnosis and Impaired Spontaneous
the target date can be increased in increments of 1 to 3 days.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine parameters for respiratory status: A specific respiratory assessment will help individualize
• Range of acceptable rate, rhythm, and quality of respi- the need plan of care.
ration
• Limits for apnea monitor setting.92 The settings should
be set for a range of safety according to age-related
norms:
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Spontaneous Ventilation, Impaired • 395
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Neonates: 30–60
• Infants: 25–60
• Toddlers: 24–40
• Preschoolers: 22–34
• Adolescents: 12–16
• Arterial blood gases
• Oxygen saturation levels
• Respiratory testing (e.g., pneumogram)
• Other indicators of respiratory function (e.g., cyanosis,
mottling, diminished pulses, listless behavior, poor
feeding, or vital signs)
Provide one-to-one care for infants and children at risk In high-risk respiratory patients, the possibility of arrest
for apnea or pulmonary arrest. should be planned for. Identification of the actual arrest
is a major factor in successful resuscitation.
Keep emergency medications and equipment (Ambu bag, Success in appropriate treatment of pulmonary arrest
airway, suctioning equipment, crash cart, ventilator, requires anticipatory planning with standard treatment
and oxygen) in close proximity. modalities according to the American Heart
Association guidelines and Pediatric Advanced Life
Support guidelines.
Administer medication as ordered, being careful in Anticipatory planning for the possibility of respiratory
administration of medications that might affect respira- depression or arrest will lessen the likelihood of actual-
tions (e.g., narcotics, bronchodilators, or vasoconstric- ity in many instances and serve to allow for more suc-
tors). Monitor blood levels for therapeutic parameters cess in treatment of these problems. If neuromuscular
of aminophylline–theophylline. Report levels above or blocking agents are utilized, exercise caution in posi-
below the desired range. tioning because of the possibility of dislocation.70,93
Spend [number] minutes per shift with the family. During Verbalization of concerns helps reduce anxiety and pro-
this time, focus on their concerns about the patient’s vides subjective data for assessment and an opportunity
respiratory status. for teaching.
Allow parental input as an option when it is realistic. Parental involvement provides emotional security for the
child and reinforces parental coping.
Carry out teaching according to inquiries by the patient Individualized learning is facilitated when it is directed
or family. [Note special teaching needs here.] toward stated needs.
Check level of consciousness (responsiveness) at least Decreased responsiveness is indicative of onset of respi-
every 30 minutes. ratory failure.
Monitor and document episodes of crying that result in Breath-holding or crying may seem to cause hypoxia, but
apnea or loss of usual color for prolonged periods (15 often there are underlying causes. Attention to underly-
seconds or more). ing cause can be carried out, but vigilance for possible
arrest is necessary.
Exercise caution in feeding or offering fluids. Possible aspiration is likely if the infant is apneic, unable
to suck well, or has problems swallowing.
Monitor for contributing factors to problem: Alteration in any aspect of respiratory anatomy will affect
• Central nervous system status adequate ventilation.
• Airway
• Chest wall
• Respiratory muscles
• Lung tissue
ADDITIONAL INFORMATION: Be aware of the major
nursing considerations involved in the legal regulations
related to brain death determination in children in the
event of a decision to withhold or cease use of the venti-
lator for the purpose of determining brain death.
(care plan continued on page 396)
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396 • Activity—Exercise Pattern
Women’s Health
The nursing actions for Women’s Health are the same as those for Adult Health.
Mental Health
● N O T E : If the client develops this diagnosis while being cared for in a mental health
unit, he or she should immediately be transferred to an intensive care unit or adult
health unit. A mental health unit is not equipped to handle this type of emergency.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for iatrogenic reactions to medications. Medication reactions may decrease respiratory drive and
effort.
Observe for signs and symptoms of sleep-pattern dis- Decreased rest secondary to sleep-pattern disturbances
turbance. further diminishes physiologic reserves in older
patients.94
Home Health
N O T E : Should the home health client develop this diagnosis, the nurse should immedi-
ately have the client transferred to an acute care setting for the proper care.
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Tissue Perfusion, Ineffective (Specify Type: Renal, Cerebral, Cardiopulmonary, Gastrointestinal, Peripheral) • 397
•
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Copyright © 2007 •by F. A. Davis.
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398 • Activity—Exercise Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Address and remove any physical or chemical factors that
interfere with circulation.
Implement measures to optimize adequate cerebral per- Maintains cerebral perfusion.
fusion:
• Avoid undue elevations of ICP, maintain cerebral perfu-
sion pressure
• Implement actions to avoid vasospasm including
administration of appropriate medications and HHH
therapy as prescribed by the health-care team
• Maintain blood pressure within prescribed therapeutic
range as determined by health-care team
Collaborate with the health-care team regarding medica-
tions that can improve perfusion such as vasopressors
and positive inotropes.
Implement strategies that decrease myocardial oxygen
consumption (e.g., negative chronotropes).
Maintain euthermia.
Assure that areas susceptible to pressure are addressed
(e.g., casts, endotracheal tube pilot balloon).
Assess circulation to sites distal to temporary equipment To monitor for adverse effects of large venous devices.
(e.g., venous access devices, IABP).
Interpret data including lab work, hemodynamic moni- Determines efficacy of therapy and need for alternation
toring, ICP of plan of care.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Perform appropriate monitoring and documentation for Provides basic database to ascertain progress and to indi-
contributory factors to include: vidualize plan of care.
• Circulatory monitoring of anatomic site or general
signs and symptoms related to peripheral pulses
• Apical pulse, blood pressure, temperature, and respira-
tion (monitor at least every hour or as ordered, and
check cardiac monitor if applicable)
• Intake and output every hour
• Nausea or vomiting
• Constipation or diarrhea
• Tolerance of feeding
• Pain or discomfort
• Skin color and temperature; any integrity problems
• Circulatory pattern: Notify the physician for any
change in the pattern that suggests lack of oxygenation
(e.g., cyanosis, arterial blood gas results, or decreased
pulses).
• Appropriate functioning of equipment, such as ventila-
tor, arterial line, or intravenous pump
• Maintenance of intravenous line for administration of
fluids
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Tissue Perfusion, Ineffective (Specify Type: Renal, Cerebral, Cardiopulmonary, Gastrointestinal, Peripheral) • 399
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Positional demands
• Pain or discomfort
• Sensory input appropriate for age and developmental
status
• Fluid and electrolytes
Collaborate with other health-care providers as needed. Coordination and implementation of plan of care may
[Note special needs of collaboration here.] involve numerous professionals according to the cause
of alteration and the treatment modalities available.
Provide for appropriate availability of resuscitative equip- Basic emergency preparedness.
ment, including:
• Ambu bag
• Crash cart for pediatrics with drugs and defibrillator
• Appropriate respiratory intubation equipment
Allow for parental and child health teaching needs by Verbalization of health-related concerns may serve as
allowing 10 to 15 minutes per 8-hour shift for verbal- cues for teaching needs and also serves to reduce
ization of concerns. [Note special teaching needs here.] anxiety.
Allow for parental participation in care of the child at Parental involvement in care puts the child at ease and
appropriate level (e.g., giving comfort measures or provides self-esteem and empowerment for the parents.
assisting with feeding).
Provide rest by scheduling procedures together with Appropriate attention to rest needs helps prevent further
ample time between activities. Note the routine for this metabolic demands on already less than ideal home-
client here. ostasis scenario. Consistency increases the sense of
security.
Allow patient and parental preferences in plan of care. Individualization shows value attached to parents’ input.
Note those preferences here.
Deal with appropriate related factors associated with inef- All efforts to lessen workload on heart and respiratory
fective tissue perfusion (e.g., minimizing crying by system will assist in preventing further decompensa-
anticipating needs). tion.
Provide appropriate safety for age (e.g., keeping siderails Safety is a standard part of care and ought to be planned
up or positioning as ordered). for according to health status, age, and development.
Maintain proper use of equipment, such as Clinitron bed, Assists circulation.
or special K-pads.
Provide for appropriate follow-up via scheduled appoint- Encourages consistency in long-range care. Demonstrates
ments after hospitalization. [Note follow-up plan here.] how to schedule appointments, and provides support
for parents.
Provide the patient with teaching appropriate to needs of Assists in reducing anxiety, and facilitates home manage-
illness and family (e.g., if activities and daily care are ment of care.
to be modified, consider use of pulse oximeter to moni-
tor perfusion, and explain how to do circulatory checks
after cast application). [Note teaching plan here.]
Ensure that the parents have been certified in CPR before Basic need for home care when perfusion problem is
the child is dismissed from hospital. present.
● N O T E : A major effort will be that of follow-up with appropriate special-
ized care to include pediatric cardiology and, as needed, other expertise to
anticipate a long course of therapy. Care is focused on early diagnosis,
especially in instances of congenital cardiac anomaly (e.g., simple coro-
nary artery malformation versus that associated with other related physio-
logic malformation of the heart and vasculature). A specific concern is
Kawasaki’s disease, with a residual concern of coronary artery aneurysm.
Periodic echocardiography is mandated for those individuals.
(care plan continued on page 400)
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400 • Activity—Exercise Pattern
Women’s Health
● N O T E : In instances of decreased coronary tissue perfusion, the women’s health
client should immediately be transferred to a coronary care unit.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient in identifying lifestyle adjustments that Decreases factors that could lead to decreased perfusion
may be needed because of changes in physiologic of oxygen to uterus, placenta, and fetus.
function or needs during experiential phases of life
(e.g., pregnancy, birth, postpartum and related to gyne-
cology):
• Avoid prolonged sitting, sitting with crossed legs, or
standing.
• Develop exercise plan for cardiovascular fitness during
pregnancy.
• Avoid wearing constrictive clothing.
• Maintain a balanced diet with adequate hydration.
• Avoid constipation and bearing down to prevent hemor-
rhoids.
Monitor the patient for signs of pregnancy-induced Allows early intervention to avoid perfusion problems
hypertension (PIH): and development of complications.
• Prenatal weight
• Blood pressure
• Presence of edema
• Proteinuria
• Pre-eclampsia
• Headaches
• Visual changes such as blurred vision
• Increased edema of face and pitting edema of extremi-
ties
• Oliguria
• Hyperreflexia
• Nausea or vomiting
• Epigastric pain
• Eclampsia
• Convulsions
• Coma
Monitor for edema: Provides early warning of perfusion problems, and pro-
• Swelling of hands, face, legs, or feet. motes early intervention.
• Caution: The patient may have to remove rings.
• The patient may need to wear loose shoes or a bigger
shoe size.
• Schedule rest breaks during day when the patient can
elevate legs.
• When the patient is lying down, he or she should lie on
the left side to promote placental perfusion and prevent
compression of vena cava.
In collaboration with physician (as appropriate):
• Check intake and output (urinary output not less than
30 mL/h or 120 mL/4 h).
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Use magnesium sulfate (MgSO4) and hydralazine
hydrochloride (Apresoline) therapy according to physi-
cian order. Have antidote for MgSO4 (calcium glu-
conate) available at all times during MgSO4 therapy.
• Assess deep tendon reflexes (DTR).
• Check respiratory rate, pulse, and blood pressure at
least every 2 hours on [odd/even] hour.
• Evaluate for possibility of seizures.
• Limit the amount of noise in the patient’s environment.
• Monitor fetal heart rate and well-being.
Provide quiet, nonstimulating environment for the patient. Reduces anxiety and promotes rest. Both measures will
assist in maintaining peripheral circulation by avoiding
vasoconstriction.
Provide the patient and family factual information and Reduces anxiety and provides teaching opportunity.
support as needed.
Monitor and teach the patient to monitor and report any Allows early detection of problem and more rapid inter-
signs of PIH immediately: vention.
• Rapid rise in blood pressure
• Rapid weight gain
• Marked hyperreflexia, especially transient or sustained
ankle clonus
• Severe headache
• Visual disturbances
• Epigastric pain
• Increase in proteinuria
• Oliguria, with urine output of less than 30 mL/h
• Drowsiness
In collaboration with dietitian: Dietary measures that assist in controlling blood pressure.
• Obtain nutritional history.
• Provide a high-protein diet (80–100 grams of protein).
• Provide low-sodium diet (not more than 6 grams daily
or less than 2.5 grams daily).
Oral Contraceptive Therapy
Monitor for factors that contraindicate use of oral birth These factors promote side effects and untoward effects
control. from birth control pills.
• Family history of stroke, diabetes, or reproductive
cancer
• History of thromboembolic disease or vascular prob-
lems, hypertension, hepatic disease, and smoking
• Presence of any breast disease, nodule, or fibrocystic
disease
Mental Health
● N O T E : The nursing actions in this section reflect alteration in tissue perfusion
related to the cerebral and peripheral vascular systems, because these are the systems
most commonly affected in the mental health setting.
(care plan continued on page 402)
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402 • Activity—Exercise Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Check on orthostatic hypotension by taking blood pres- Psychotropic medications can predispose the client to
sure while the client is lying down, then taking blood orthostatic hypotension.
pressure just after the client stands or sits up (provide
support for the client to prevent injury from a fall).
Monitor the client’s mental status. If compromised, pro-
vide information in a clear, concise manner.
Discuss with the client causes of decreased cerebral Assists in explaining reasons for therapies to the client.
blood flow.
Have the client get out of bed slowly by: Allows time for cardiovascular system to adapt, thus pre-
• Sitting up venting fainting or dizziness due to orthostatic
• Swinging legs over edge of bed hypotension.
• Resting in this position for at least 2 minutes
• Standing up slowly
• Walking slowly
Teach the client to avoid situations in which he or she
changes position quickly (e.g., bending over to pick
something up off the floor or standing quickly from a
sitting position).
Have the client supported while changing positions that
cause vertigo until problem is resolved.
Assist the client in getting in and out of the bathtub.
Collaborate with physician regarding alterations in med- Promotes changing to a medication that would not inter-
ications. fere with perfusion.
If situation persists, have the client: Provides external support for venous system.
• Sleep sitting up or with head elevated.
• Use elastic stockings that are waist high.
• Apply stockings while the client is still in bed.
• Have the client raise legs for several minutes.
• Apply stockings slowly and evenly.
• Remove stockings after the client is lying down at least
every 8 hours.
Develop with the client a plan for daily exercise that is Improves cardiovascular strength. Assists in maintaining
very modest (e.g., walking the length of the hall for muscle tone, which assists in supporting the venous
15 minutes twice a day for 3 days, then increasing dis- circulation.
tance and time gradually until the client is walking for
30 minutes twice a day). [Note the client’s exercise
regimen here.]
Develop with the client a reward schedule for implement-
ing exercise plan. [List rewards and the reward sched-
ule here.]
Provide the client with positive verbal support for goal
accomplishment.
Do not allow the client to participate in unit activities that Basic safety measures.
could produce injury until the condition is resolved
(e.g., cooking or using sharp objects while standing).
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss with the client the effects of alcohol and smoking
on blood flow, and assist him or her to develop alterna-
tive coping behavior if necessary. [Note plan for this
here.]
Provide decaffeinated beverages for the client. Consult
with the dietary department about this adaptation.
Increase the client’s fluid intake during times of increased
loss, such as exercise or periods of anxiety. Instruct the
client in the need for this.
Observe the client carefully after injecting medications Basic measure to offset the possibility of falling second-
that have a high potential for producing hypotension. ary to orthostatic hypotension.
This is especially true for clients who are very agitated
and physically active.
Inform the client of need to change position slowly after
injecting medication.
Teach the client and support system about over-the-
counter medications that alter blood flow (e.g., cold
medications, antihistamines, or diet pills).
Monitor peripheral pulses on affected limbs every 8 hours
at [times].
Avoid, and teach the client to avoid, pressure in points on Avoids compromising circulation by pressure or constric-
affected limbs to include: tion.
• Changing position frequently when sitting or lying
down
• Avoiding pressure in the area behind the knee
• Not crossing legs while sitting
• Making sure shoes fit properly and do not rub feet
• Elevating feet when sitting to reduce pressure on backs
of legs
Keep feet clean and dry, and teach the client to do the Avoids lower extremity skin integrity problems and possi-
same by assessing foot condition once a day at [time]. ble infection with the resultant impact on circulation.
This assessment should include:
• Washing feet
• Checking for sores, reddened areas, and blisters
• Keeping toenails trimmed and caring for ingrown nails
• Applying lotion to feet
• Rubbing reddened areas if the client does not have a
history of emboli
• Applying clean, dry socks
• Teaching significant others to assist with foot care of
the elderly client
• Keeping limbs warm (but do not use external heating
sources such as heating pads or hot-water bottles)
Develop with the client an exercise program, and note Promotes normal venous return.
that program here. Begin slowly, and gradually
increase time and distance (e.g., walk for 15 minutes 2
times per day for 1 week). This should be increased
until the client is walking 1 mile in 30 to 45 minutes
three times a week.
(care plan continued on page 404)
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404 • Activity—Exercise Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Instruct the client to discontinue exercise if: Client safety is of primary importance.
• Pulse does not return to resting rate within 3 minutes
after exercise.
• Shortness of breath continues for more than 10 minutes
after stopping exercise.
• Fatigue is excessive.
• Muscles are painful.
• The client experiences dizziness, pain in the chest,
lightheadedness, loss of muscle control, or nausea.
Encourage the client’s exercise by:
• Walking with him or her
• Determining things that the client would find rewarding
and supplying these as goals are achieved
• Providing positive verbal support as goals are
achieved [Note the client’s specific reward system
here.]
Monitor the client’s nutritional status, and refer to nutri-
tionist for teaching if necessary.
Discuss with the client the effects of smoking on periph- Nicotine causes vasospasm and vasoconstriction.
eral blood flow, and assist him or her in decreasing or
eliminating this by:
• Referring the client to a stop-smoking group
• Encouraging him or her not to smoke before meals or
exercise
• Decreasing amount smoked per day
Discuss special needs with the client and support system Increases probability of the client’s behavior change
before discharge. being maintained after discharge.
Refer the client to community agencies to provide ongo-
ing care as needed.
Gerontic Health
In addition to the interventions for adults, the following may be utilized for aging clients.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for signs of dyspnea, chronic fatigue, behav- Older clients with decreased cardiac perfusion often pres-
ioral changes, or evidence of acute cerebral insuffi- ent with these symptoms.
ciency.
Plan physical activities, such as hygiene, meals, and Decreases cardiac workload.
ambulation, with rest periods.
Instruct in use of oxygen, if prescribed. Supplemental oxygen may be prescribed to help decrease
cardiac workload.
Teach the client relaxation methods to help decrease Decreasing anxiety helps decrease the release of cate-
anxiety. cholamines. An increase in catecholamines results in
increased cardiac workload.
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Tissue Perfusion, Ineffective (Specify Type: Renal, Cerebral, Cardiopulmonary, Gastrointestinal, Peripheral) • 405
Home Health
● N O T E : If this diagnosis is suspected when caring for a client in the home, it is imper-
ative that a physician referral be obtained immediately. If a physician has referred the
client to home health care, the nurse will collaborate with the physician in the treatment
of the client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family appropriate monitoring of Provides database for prevention and/or early inter-
signs and symptoms of alteration in tissue perfusion: vention.
• Pulse (lying, sitting, and standing)
• Skin temperature and turgor
• Edema
• Motor status
• Sensory status
• Blood pressure (lying, sitting, standing, and pulse pres-
sure)
• Respiratory status (dyspnea, cyanosis, and rate)
• Weight fluctuations
• Urinary output
• Leg pain with walking
Assist the client and family in identifying lifestyle Provides basic information for the client and family that
changes that may be required: promotes necessary lifestyle changes.
• Eliminating smoking
• Decreasing caffeine
• Decreasing alcohol
• Avoiding over-the-counter medications
• Protecting skin and extremities from injury due to
decreased sensation (burns, frostbite, etc.)
• Protecting skin from pressure injury (making frequent
position changes and using sheepskin for pressure areas
and foot cradle)
• Improving arterial blood flow (keeping extremities
warm, elevating head and chest, avoiding crossing legs
or sitting for long periods of time, wiggling fingers and
toes every hour, and performing ROM exercises)
• Performing exercise program as tolerated
• Improving venous blood flow (elevating extremity,
using antiembolus stockings, and avoiding pressure
behind knees)
• Performing skin and foot care
• Decreasing cholesterol and saturated fat intake
• Performing diversional activities as needed
• Practicing stress management
Teach the family basic CPR. Basic safety measure.
Teach the client and family purposes, side effects, and Promotes safe adherence to the therapeutic regimen.
proper administration technique of medications.
Assist the client and family to set criteria to help them Locus of control shifts from nurse to the client and fam-
determine when a physician or other intervention is ily, thus promoting self-care.
required.
Assess the client/family need for assistive resources and Provides additional support for the client and family, and
refer to community agencies that provide such uses already available resources in a cost-effective
resources. manner.
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Transfer Ability, Impaired • 407
ACTIONS/INTERVENTIONS R AT I O N A L E S
Educate the patient about working with limitations and Gives patient realistic purview of progress through plan
gradually increasing activity as physical ability allows. of care.
Refer to rehabilitation facility as appropriate and as soon
as feasible.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine all contributing factors, to include: All possible factors are considered in providing a holistic
• Neuromuscular database for individualization.
• Cardiovascular
• Pulmonary
• Cognitive
• Developmental
• Situational
Determine augmentative devices, personnel, or environ- Appropriate support ensures safety.
mental needs and have these available before transfer.
[Note the client’s special needs here.]
Determine the client’s level of proprioception. Prerequisite for each maneuver to increase likelihood of
success.
Determine strength and ability to coordinate body move- Pre-assessment helps ensure safety needs are met.
ments well in advance of attempted maneuver.
Schedule transfer activities in a timely manner when pos- Time to adjust and slowly incorporate concept of transfer
sible. [Note the time needed for the client to perform will be best afforded in a leisure vs. crisis time frame.
activity here.]
Determine readiness for taking on task of transfer. Validation of readiness offers empowerment and a sense
of control in attempt.
Determine need for teaching the client, family, or other Teaching with focus on learner’s needs will most likely
caregivers how to assist in transfer activities. [Note ease anxiety and afford consistency in safe manner.
teaching plan here.]
Determine a reward system to fit developmental status of Provides reinforcement of desired behavior.
the client for appropriate attainment of goal. [Note
those rewards and situations to be rewarded here.]
Schedule group teaching of transfer activities. [Note Group behavior offers peer support.
schedule here.]
Determine need for adaptations related to the patient’s Principles of safety may be altered yet upheld for
changing status and environmental needs. (Home and changes that occur.
school vs. hospital)
Allow sufficient time for teaching and mastery of transfer Early teaching with plan for dismissal results in greater
if discharge may occur within short period of time. likelihood of attainment and may be reason to keep
[Note teaching plan and schedule here.] patient until satisfied.
Women’s Health
The nursing actions for Women’s Health are the same as those for Adult Health.
(care plan continued on page 408)
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408 • Activity—Exercise Pattern
Mental Health
The nursing actions for the mental health client are the same as those for Adult Health.
Gerontic Health
The nursing actions for Gerontic Health are the same as those for Adult Health.
WALKING, IMPAIRED
✔ Have You Selected the Correct Diagnosis?
DEFINITION22
Impaired Physical Mobility
Limitation of independent movement within the environ- Impaired walking could be considered to be a subset
ment on foot.21 of Impaired Physical Mobility and is a more specific
diagnosis. If the patient is having difficulty only with
DEFINING CHARACTERISTICS22 walking and not other aspects of mobility, such as
moving in bed and getting up and down in sitting,
1. Impaired ability to climb stairs then Impaired Walking is the most correct diagnosis.
2. Impaired ability to walk required distances
Activity Intolerance
3. Impaired ability to walk on an incline or decline
This diagnosis relates more to feeling fatigued or
4. Impaired ability to walk on uneven surfaces weakness while performing activities. Again, Activity
5. Impaired ability to navigate curbs Intolerance is a broader diagnosis than Impaired
Walking.
RELATED FACTORS22
To be developed.
EXPECTED OUTCOME
RELATED CLINICAL CONCERNS Will independently walk by [date].
1. Arthritis
TARGET DATES
2. Chronic obstructive pulmonary disease
3. Cerebrovascular accident Activities to facilitate walking with ease require weeks. An
4. Neuromuscular disorders appropriate evaluation target date would be 1 to 2 weeks
5. Amputation involving lower extremities from the day of admission.
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Walking, Impaired • 409
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for all contributing factors including: A complete assessment provides primary database for
• Orthopedic individualization.
• Neurologic
• Developmental
• Situational
Monitor readiness for weight-bearing. Note exact limits Validation of status of limbs and their capacity for
of activity with reliance on limbs, both lower and weight-bearing is critical for safety and non-injury
upper. before ambulation is considered.
Assess for need for assistive devices or personnel for Appropriate augmentive aids help ensure safe activity.
walking activity.
Determine teaching needs for the client, family, or related Specific data for safety and likelihood of success is para-
assistants. [Note teaching plan here.] mount for all involved to feel empowered.
Provide posture-appropriate alignment during walking Lessens likelihood of related injury to spine or limbs.
activities.
Provide appropriate cautionary information when assis- Ensures likelihood of safe walking with appropriate atten-
tance is required for the patient’s walking. State when, tion to limit setting to reinforce importance of plan.
what must be done, and with whom to meet prerequi-
site walking behaviors.
Coordinate health-care team members and scheduling of The nurse is in the best position to provide safe and con-
walking activities. [Note collaboration plan here as sistent care with total patient needs in mind.
well as assistance needed from nursing staff to imple-
ment plan.]
(care plan continued on page 410)
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410 • Activity—Exercise Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide safe environment, free of clutter or equipment, to Lessens the likelihood for barriers or obstacles to free
degree possible. path.
Schedule medications to enhance success in walking According to nature of medication, onset of action, half-
activities. [Note schedule here.] life, side effects, or untoward effects, the best likeli-
hood for walking without undesired effects is upheld.
Seek assistance from Occupational and/or Physical Periodic regular assessment with appropriate health team
Therapy to facilitate progress in walking activities. members provides appropriate validation for safe
walking.
Determine an appropriate reward system according to the Reinforces desired behavior.
patient’s developmental capacity. [Note plan here.]
Provide opportunities for group teaching of walking Peer pressure and interaction offers diversionary stimulus
activity as appropriate for the child’s developmental to perform desired activity.
level.
If equipment is required, offer artistic opportunities for Self-expression provides a sense of identity for the client.
the client to decorate same per developmental interest.
Determine need for discharge planning well before actual Prior planning permits sufficient time to safely master
event. [Note plan and person responsible for coordinat- walking protocol in a supportive environment.
ing this activity here.]
Discuss with the child and family a plan for adapting Anticipation of usual events of daily living to be reincor-
mobility needs to school or other regular activities. porated in advance will lessen likelihood of unsafe or
unsuccessful attempts to adapt lifestyle.
Women’s Health
The nursing actions for Women’s Health are the same as those for Adult Health.
Mental Health
The nursing actions for the mental health client are the same as those for Adult Health.
Gerontic Health
In addition to the interventions for Adult Health, the following may be utilized with the aging client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collaborate with the physical therapist for assessment Physical therapists are health-care professionals specializ-
and treatment plan to improve walking ability. ing in problems related to the lower extremities and
ambulation skills.
Ensure that any adaptive or assistive equipment (such as Reduces potential for injuries when the client is walking.
braces, footwear, or eyeglasses) fit correctly and are
properly functioning.
Promote interdisciplinary team member communication Ensures continuity of care across disciplines and care set-
to ensure that plan of care is consistently applied. tings.
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Wandering • 411
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor and report symptoms as needed from medica- Older adults may require medication adjustments to
tions (e.g., antihypertensives, diuretics, or psychotrop- decrease side effects that have a deleterious effect on
ics) with side effects such as lightheadedness, or ambulation ability and safety.96,97
orthostatic blood pressure changes that may affect the
client’s ambulatory ability.
Encourage client participation in a walking program, if Promotes the client’s physical and psychological well-
available in care setting. being.
Teach the client and/or caregivers to check for environ- Emphasizes safety focus prior to onset of activity.
mental aids (e.g., handrails) or barriers (poorly fitting
shoes, shiny floor surfaces, or cluttered pathways) to
walking.
Promote use of activity programs, if available, that sup- Provides increased opportunities for older adults to prac-
port the goal of increasing walking ability in clients tice skills to enhance walking ability.
(e.g., Senior Olympic activities, exercises to promote
lower extremity strengthening, or enhanced trunk con-
trol and balance abilities).97
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Educate the client, family, and potential caregivers about
the following:
• Using proper body mechanics to avoid injury
• Maintaining a clear walking path
• Installation of rails in the home to assist the client as he
or she ambulates
• Eliminating throw rugs and cords that cross walking
paths, because they increase the risk of falls
• The correct use of assistive devices
• Ensuring that all assistive devices are set to the correct
height
Assist the client in obtaining necessary durable medical
equipment (e.g., crutches or walkers).
Refer the client for a home physical therapy consult to
help maximize his or her ability to safely ambulate at
home and to have assistive devices appropriate for the
home environment.
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Wandering • 413
Child Health
This diagnosis, according to its definition and defining characteristics, would not be appropriate for Child Health.
Women’s Health
Interventions for a Women’s Health client with this diagnosis would be the same as the interventions given in Adult Health
and Gerontic Health.
Mental Health
The mental health client with this diagnosis would require the same interventions as those given in Adult Health and
Gerontic Health.
Gerontic Health
● N O T E : Wandering, a behavior noted in clients with dementia, remains a perplexing
activity for study and nursing interventions. Current research is attempting to describe
and design assessments and nursing interventions for various types of wandering behav-
ior.94 With this need for further investigation in mind, the following actions are based on
keeping clients safe, providing an outlet for stress and anxiety reduction, and providing
environmental cues for clients. Nursing interventions should be adapted to meet the
needs of the individual client who wanders. Some clients may favorably respond to inter-
ventions such as touch or music, whereas others may not. All clients should be thor-
oughly assessed for possible underlying cognitive dysfunction using the Folstein Mini
Mental State Exam (MMSE) or a similar tool. In addition, a thorough assessment of
the client’s functional status should be conducted to establish a baseline and safety
precautions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine the pattern of wandering and share observa- Knowledge of patterns can prompt caregivers to antici-
tions with caregivers95 (e.g., the client wanders at pate need for activities or personal attention.
certain times of day or evening, or after visits from
family or friends).
Monitor for possible causes of wandering and address
them as appropriate.Wandering can be caused by envi-
ronmental stimuli or a lack of stimuli, feelings of lone-
liness or separation, situational insecurity, boredom or
fear, sleep disorder, anxiety, or unmet physical needs
such as hunger or pain.
Monitor for expression of intent “I’m going home now”
and expression of the loss of a valued adult role, “The
children need me now.”
Modify the environment to provide adequate rest, safety, Eliminate possible precipitators of wandering.
and sleep for the client.
Evaluate the patient’s response to medications and collab- Some medications may increase the risk for falls in the
orate with the health-care team to adapt the medication client who wanders.
regimen as needed.
Provide the patient with essential sensory aids (glasses, Prevents possible sensory confusion that can lead to wan-
hearing aids). dering and prevents falls when wandering occurs.
(care plan continued on page 414)
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414 • Activity—Exercise Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Avoid physical and chemical restraints. These do not stop the urge to wander and may exacerbate
the urge to wander. These measures may contribute to
client injury.
Schedule and maintain a regular toileting schedule. [Note Eliminate possible precipitators of wandering.
the client’s schedule here.]
Provide information to all staff that a patient is a wan- Prevention of injury related to wandering.
derer. Develop a mechanism for identification, and a
plan to follow if a wanderer is missing. [Note that plan
here.]
Use grid like markings in front of doorways. May prevent the client from exiting due to a change in
visual cues.
Ensure that the client has ID bracelet or necklace listing Provides means of identification if the client becomes
his or her name and an emergency telephone number.98 lost.
Monitor the environment for possible safety hazards (e.g., Decreases environmental injury risk.
toxic solutions or plants, electrical hazards, fire risks,
or firearms).99
Have poison control number available in the event of Decreased cognition may result in the client ingesting
ingestion of unsafe products. toxic substances.
Encourage community-dwelling caregivers to enroll the Provides organized response if the client becomes lost.
client in the Alzheimer’s Association Safe Return
Program.
Ensure that there is an updated client photograph avail- Assists in identification efforts. As dementia progresses,
able. there may be marked changes in the client’s appear-
ance.
Discourage access to exits by using electronic keypad Provides audible alarm if door is opened without using
alarm systems on doors. the correct code.
Depending on care setting, promote group walking activ- Offers outlet for socializing and meeting the client’s
ity in early afternoon or after evening meals.100 activity and exercise needs.
Based on client preference, use music for 20 to 30 min- Music has been shown to reduce or eliminate agitation in
utes before periods when the client is known to some clients affected with dementia.101
become increasingly agitated.
Incorporate slow-stroke massage for brief periods (10 to Slow-stroke massage has been helpful with some demen-
20 minutes) to the client’s neck, shoulders, and back in tia clients in reducing the frequency and severity of
early morning or late afternoon. agitation and the onset of aggressive behaviors.102
Use familiar items, pictures, and furniture in the client’s Familiar objects may provide a sense of comfort for the
surroundings. client.
Use distractions such as preferred activities, food, or flu- Clients may not be able to recognize onset of fatigue
ids to provide rest periods for the client. when wandering.
Remove items from environment, such as coats, hats, or Decreases stimulus for leaving the site.
keys, that may trigger wandering.
Disguise doors by painting them the same color as the Difficult for the client to identify as an exit area.
wall surface.
Place fabric strips attached to door frames or stop signs Signs or fabric strips often serve as deterrents to clients
on doors to prevent the client from entering areas that who wander.
are “off limits.”
Use pictures and universal symbols for bathrooms, dining Wanderers may no longer have ability to read and inter-
areas, or room identification. pret signs for these areas.
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Wheelchair Mobility, Impaired • 415
ACTIONS/INTERVENTIONS R AT I O N A L E S
Arrange furniture areas where clients wander, to encour- Provides cues to clients for rest periods.
age resting spots.
Arrange repetitive activities for the client, such as linen The client has opportunity for repetitive movement with
folding, rocking, or paper work, if the client is engaged less energy expended.
in “lapping type wandering” and showing signs of
fatigue.101
Consider offering food, fluids, toileting, or pain medica- Clients with decreased or absent verbal communication
tion when the client initiates wandering episodes, if skills may be unable to articulate these basic needs to
this seems to be a need pattern for the client.103 caregivers.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Consult with and/or refer the patient to assistive resources Utilization of existing services is an efficient use of
such as caregiver support groups, as needed. resources.
When wandering is related to inappropriate responses to May help prevent episodes of wandering and subsequent
cues, adapt the environment to change the cues: injury.
• Cover doorknobs.
• Remove keys that are in a visible location.
• Remove knobs from the oven and stove.
Ensure that the environment is as safe as possible when To prevent injury in the event of wandering by the client.
wandering occurs:
• Remove knobs from the oven and stove.
• Alert neighbors that the client may wander, and inform
them about actions to take when the client is found
wandering.
Provide the client with an ID bracelet indicating numbers To minimize the time the client is away from caregivers
where caregivers can be reached. in the event of wandering.
Assist the client and caregiver in obtaining alarm systems To alert the caregiver if the client begins to wander.
to indicate when doors have been opened.
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416 • Activity—Exercise Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine contributing factors to best consider child’s A full assessment of contributing factors offers the most
assistive needs that would facilitate their reaching holistic approach to determining the degree of assis-
highest potential of functioning. tance needed.
Identify priorities of basic functions (e.g., breathing, air- Basic physiologic functioning must be provided for if the
way maintenance, cardiovascular endurance, tolerance movement is to be successful and not bring about alter-
of positioning, proprioception, and neuromuscular ations to basic functions.
coordination).
Define limitations of tolerance for positioning, move- Critical thresholds will assist in defining reasonable like-
ment, and ideal plan for mobility. lihood for success.
Determine equipment or assistive equipment needed. Stabilization and use of appropriate assistive devices offer
likelihood of success without injury.
Anticipate safety needs and environmental considerations Anticipatory safety is inherent in all mobility endeavors
related to safety needs. and serves to prevent injury.
According to maternal and infant or maternal and child Caregiver input serves to put the infant or child at ease
dyad or caregiver status, decide who will assist in with likelihood of success, plus provides an important
mobility activities. opportunity for sense of input by the patient.
Assess for medication implications for movement timing The best likelihood for desired effects will be related to
and best potential for desired effects in relation to appropriate medication correlation, with related mobil-
mobility, freedom of undesired effects, or contraindica- ity or position.
tion of related treatments.
Establish a plan for each 8-hour period to include the Regular scheduled movement with attention to prescribed
maneuvers to be carried out, equipment or personnel assessments, documentation, and awareness of thresh-
needed, and critical thresholds to be attended to as dic- olds assists in maintaining the client’s stable status.
tated per patient’s status (i.e., pulse oximeter level
above [specify], pulse range [specify], etc). [Note
child’s plan here.]
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Wheelchair Mobility, Impaired • 417
ACTIONS/INTERVENTIONS R AT I O N A L E S
Document critical thresholds and report to the physician Ongoing assessment and appropriate reporting of critical
as ordered. thresholds will maintain desired stability of the client
and provide basis for setting limits or increasing limits.
Determine outcomes according to previous baseline or If it takes a period of time more than 3 to 4 days, sub-
desired level of activity. (May require sub-goals over a goals will better reflect the incremental change or grad-
longer period of time.) [Note child’s goals here.] ual attainment of a greater goal.
Coordinate mobility activities as necessary with appropri- Each person’s input is best utilized in a manner of patient-
ate health team members, to include physical therapy, centered planning to afford optimum likelihood of suc-
occupational therapy, child life specialist, etc. cess and not tire the patient, vs. fragmented, duplicated,
or less than individualized efforts for mobility.
Schedule meetings between child/family and others who Role modeling significantly enhances learning.
are successfully managing mobility issues (as develop-
mentally appropriate).
Refer to community agencies and groups that can con- Role modeling enhances learning, and community sup-
tinue support for client and family. If use of a wheel- port enhances self-esteem and decreases sense of
chair will be long term, this could include wheelchair isolation.
sports teams, and adults in the community who are
successfully living with similar mobility concerns.
Women’s Health
The nursing actions for Women’s Health are the same as those for Adult Health.
Mental Health
The nursing actions for the mental health client are the same as those for Adult Health.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Obtain consultation with occupational and physical thera- Occupational and physical therapists are health-care pro-
pists to determine treatment plan for the client. fessionals best suited to evaluate the client and design
treatment regimen.
Check wheelchair for proper fit for the client (adequate Proper fit enhances the client’s ability to control wheel-
seat width, appropriate armrest height, and level of chair.
footrests).
Provide positive feedback when the client correctly Positive feedback encourages the desired behavior.
manipulates wheelchair.
Ensure environment where the client is active is accessi- Adapted environment supports wheelchair use.
ble by wheelchair (e.g., width of door frames, table
height, ramps, and curb cuts present in walkways).
Promote interdisciplinary communication to ensure that Clearly described and communicated treatment goals
treatment plan is followed. assist caregivers in providing care and feedback.
Review with the client and/or caregiver teaching plan for Provides opportunities to evaluate learning and address
wheelchair use. any questions related to wheelchair use.
(care plan continued on page 418)
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418 • Activity—Exercise Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Educate the client, family, and potential caregivers about
the following:
• Using proper body mechanics to avoid injury
• Maintaining a clear wheelchair path
Assist the client in developing a schedule for range of To maintain and build muscle strength.
motion exercises.
Refer the client for a home physical therapy consult. To help maximize his or her ability to safely use a wheel-
chair at home and to have assistive devices appropriate
for the home environment.
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Wheelchair Mobility, Impaired • 419
45. Earnhardt, J, and Frye, B: Understanding dysreflexia. Rehabil Nurs 78. Black, JM: Medical-Surgical Nursing: Clinical Management for
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SLEEP–REST PATTERN
6
1. SLEEP DEPRIVATION 425
2. SLEEP PATTERN, DISTURBED 431
3. SLEEP, READINESS FOR ENHANCED 437
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422 • Sleep–Rest Pattern
PATTERN DESCRIPTION the reticular activating system in the brain stem, spinal
cord, and cerebral cortex and the bulbar synchronizing por-
The sleep–rest pattern includes relaxation in addition to tion in the medulla. These two systems function intermit-
sleep and rest. The pattern is based on a 24-hour day and tently by activating and suppressing the higher centers of the
looks specifically at how an individual rates or judges the brain.2
adequacy of his or her sleep, rest, and relaxation in terms of After falling asleep, a person passes through a series
both quantity and quality. The pattern also looks at the of stages that afford rest and recuperation physically, men-
patient’s energy level in relation to the amount of sleep, rest, tally, and emotionally. In stage 1, the individual is in a
and relaxation described by the patient as well as any sleep relaxed, dreamy state, and is aware of his or her surround-
aids the patient uses. ings. In stages 2 and 3, there is progression to deeper levels
of sleep in which the individual becomes unaware of his or
her surroundings but wakens easily. In stage 4, there is pro-
PATTERN ASSESSMENT found sleep characterized by little body movement and dif-
1. Does the patient report a problem falling asleep? ficult arousal. Stage 4 restores and allows the body to rest.
a. Yes (Disturbed Sleep Pattern) Stages 1 through 4 are known as non–rapid eye movement
b. No (Readiness for Enhanced Sleep) (NREM) sleep. NREM sleep accounts for 75 percent of an
2. Does the patient report interrupted sleep? 8-hour night’s sleep. Stage 5 is called rapid eye move-
a. Yes (Disturbed Sleep Pattern) ment (REM) sleep. REM sleep accounts for 25 percent of an
b. No (Readiness for Enhanced Sleep) 8-hour night’s sleep and is the stage in which dreaming
3. Does the patient report long periods without sleep, occurs. Other characteristics of REM sleep are irregular
resulting in daytime malaise? pulse, variable blood pressure, muscular twitching, pro-
a. Yes (Sleep Deprivation Pattern) found muscular relaxation, and an increase in gastric secre-
b. No (Readiness for Enhanced Sleep) tions.2,3 After REM sleep, the individual progresses back
through stages 1, 2, and 3 again.
Sleep patterns and characteristics vary and change
over the life cycle. A person’s age, general health status, cul-
CONCEPTUAL INFORMATION ture, and emotional well-being dictate the amount of sleep
A person at rest feels mentally relaxed, free from anxiety, he or she requires. On the whole, older persons require less
and physically calm. Rest need not imply inactivity, and sleep, whereas young infants require the most sleep. As the
inactivity does not necessarily afford rest. Rest is a reduction nurse assesses the patient’s needs for sleep and rest, he or
in bodily work that results in the person’s feeling refreshed she makes every effort to individualize the care according to
and with a sense of readiness to perform activities of daily this sleep–rest cycle. A major emphasis is to provide patient
living (ADLs). education regarding the influence of disease process on
Sleep is a state of rest that occurs for sustained peri- sleep–rest patterns.
ods at a deeper level of consciousness. The reduced con- Reports of the occurrence of excessive and pathologic
sciousness during sleep provides time for essential repair sleep most commonly relate to narcolepsy and hypersom-
and recovery of body systems. Sleep is as essential to nia.2,3 Narcolepsy is characterized by an attack of irresistible
our bodies as good nutrition and exercise. Sleep is consid- sleep of brief duration with “auxiliary” symptoms. In sleep
ered one of the major components to our health, perform- paralysis, the narcoleptic patient is unable to speak or move
ance, safety, and quality of life.1 A person who sleeps and breathes in a shallow manner. Auditory or visual hypn-
has temporarily reduced interaction with the environment. agogic hallucinations may occur. Cataplexy, a brief form of
Sleep restores a person’s energy and sense of well-being and narcolepsy, is an abrupt and reversible decrease or loss of
lets him or her function in a safe, efficient, and effective muscle tone and is most often elicited by emotion. The
manner. attacks may last several seconds and almost go undetected,
Studies have confirmed that sleep is a cyclical phe- or they may last as long as 30 minutes with muscular weak-
nomenon. The most common sleep cycle is the 24-hour ness being evident. In the initial stage of the attack, con-
day–night cycle. This 24-hour cycle is also referred to as sciousness remains intact.2,3
the Circadian Biological Clock, which regulates the timing Hypersomnia, in contrast, is characterized by daytime
of sleep and wakefulness.1,2 In general, light and darkness sleepiness and sleep states that are less imperative and of
govern the 24-hour circadian rhythm. Additional factors longer duration than those in narcolepsy. Often, a deepening
that influence the sleep–wake cycle of the individual are and lengthening of night sleep is also noted. Sleep apnea and
biologic, such as hormonal and thermoregulation cycles. the Kleine–Levin syndrome are two examples of the hyper-
Most individuals attempt to synchronize activity with somnia disorders.2,3
the demands of modern society. The two specialized areas Sleep apnea may occur in patients with a damaged
of the brain that control the cyclical nature of sleep are respiratory center in the brain, brain stem infarction, drug
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Developmental Considerations • 423
intoxication (barbiturates, tranquilizers, etc.), bilateral cor- a landmark, for it is at this time that the behavioral states in
dotomy, and/or Ondine’s curse syndrome. Patients with the the fetus and preterm infant begin to take on a more mature
typical pickwickian syndrome show marked obesity and character. The joining of physiologic variables results in
associated alveolar hypoventilation, sleep apnea, and hyper- identification of recurrent behavioral states with various
somnia. Several forms of this condition may exist without parameters. Term birth leads to a number of profound
obesity. One such syndrome is Ondine’s curse syndrome, changes, especially in respiratory regulation, but more evi-
which involves the loss of the automaticity of breathing and dence suggests that continuity of development, rather than
manifests during sleep as a recurrent apnea. Another is the discontinuity, prevails.7
Kleine–Levin syndrome, which is associated with periods of The newborn begins life with a regular schedule of
hypersomnia accompanied by bulimia or polyphagia and sleep and activity that is evident during periods of reactivity.
mental disturbances. A cyclic hypersomnia is also reported For the first hour, infants born of unmedicated mothers
that is related to the premenstrual periods. The typical syn- spend 60 percent of the time in the quiet, alert state and only
drome—pickwickian—is rare, whereas the atypical variants 10 percent of the time in the irritable, crying states. Six dis-
seem more common.3 tinct sleep–activity states for the infant have been noted: (1)
Various factors influence a person’s capability to deep sleep, (2) light sleep, (3) drowsiness, (4) quiet alert, (5)
gain adequate rest and sleep.4,5 For the home setting, it is active alert, and (6) crying.7,8
appropriate for the nurse to assist the patient in developing After 1 month of age, sleep and wakefulness change
behavior conducive to rest and relaxation. In a health- dramatically, as do a large number of physiologic variables.
care setting, the nurse must be able to provide ways of pro- This period of central nervous system (CNS) reorganization
moting rest and relaxation in a stressful environment. Loss (with a likely increased vulnerability) is immediately fol-
of privacy, unfamiliar noises, frequent examinations, tiring lowed by a short transient interval at 3 months of age in
procedures, and a general upset in daily routines culmi- which play and wakefulness—and, within it, the basic
nate in a threat to the client’s achievement of essential rest rest–activity cycle–show excessive regularity. This regular-
and sleep. ity may carry its own risk.
The study of mobility has proved worthwhile in
detecting the origin of the basic rest–activity cycle in the
DEVELOPMENTAL CONSIDERATIONS fetus. Neonatologists, who deal with the immature infant,
often use mobility in prognosis.
In general, as age increases, the amount of sleep per night Apneas during sleep are common in normal infants
decreases. The length of each sleep cycle—active (REM) and occur most often during the newborn period, with a
and quiet (NREM)—changes with age. For adults, there is marked decrease in the first 6 months of life. Long apneas,
no particular change in the actual number of hours slept, but lasting longer than 15 seconds, are not usually observed dur-
there is a change in the amount of deep sleep and light sleep. ing sleep in laboratory conditions. Obstructive apneas of 6
As a person ages, the amount of deep sleep decreases and to 10 seconds are also rarely observed. However, in labora-
the amount of light sleep increases. This helps explain why tory studies, paradoxical breathing is observed in neonates,
the older patient wakens more easily and spends time in and periodic breathing is associated with REM sleep in nor-
sleep throughout the day and night. REM sleep decreases in mal infants.7,9
amount from the time of infancy (50 percent) to late adult- Infants found not breathing by parents are usually
hood (15 percent). The changes in sleep pattern with age rushed to the hospital. Causes for life-threatening apnea to
development are7: be investigated include congenital conditions, especially
Infant: Awake 7 hours; NREM sleep, 8.5 hours; REM cardiac disease or arrhythmias; cranial, facial, or other con-
sleep, 8.5 hours ditions affecting the anatomy of the airway; infections such
Age 1: Awake 13 hours; NREM sleep, 7 hours; REM as sepsis, meningitis, pneumonia, botulism, and pertussis;
sleep, 4 hours viral infections such as respiratory syncytial virus; meta-
Age 10: Awake 15 hours; NREM sleep, 6 hours; REM bolic abnormalities; administration of sedatives; seizures;
sleep, 3 hours and chronic hypoxia. If these causes are ruled out, the infant
Age 20: Awake 17 hours; NREM sleep, 5 hours; REM is diagnosed as having “apnea of infancy.” Sleep studies,
sleep, 2 hours with polygraph recordings, are required. The term near-miss
Age 75: Awake 17 hours; NREM sleep, 6 hours; REM sudden infant death syndrome (near-miss SIDS) implies the
sleep, 1 hour child is found limp, cyanotic, and not breathing and would
have died had caretakers not intervened. Because the rela-
tionship of the near miss SIDS event to SIDS is speculative,
INFANT
apnea of infancy is the preferred term.9,10
The development of sleep and wakefulness can be traced to Obstructive and central apnea identification, hypop-
intrauterine life. A gestational age of 36 weeks seems to be nea, prolonged expiration, apnea and reflux, and apnea and
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424 • Sleep–Rest Pattern
cardiac arrhythmia are the current issues being studied great extent how much sleep the child at this age requires.
in trying to solve this problem. For any infant-related Permission to stay up late must be weighed against the
apnea, hospitalization, with special observation for all pos- potential upset to routine and demands of the next day.
sible contributing factors and close monitoring of cardiac When bedtime is assigned a status, peer pressure and power
and respiratory function, is recommended. Attention must issues may ensue.
be given to parents for the extreme anxiety this problem When the school-age child alters the usual routines of
creates. sleep and rest, fatigue may result. Attempts should be made
The newborn and young infant spends more time in to maintain usual routines even when school is not in session
REM sleep than adults do. As the infant’s nervous system to best maintain the usual sleep–rest pattern.
develops, the infant will have longer periods of sleep and
wakefulness that become more regular. At approximately ADOLESCENT
8 months of age, the infant goes through the stage of sepa-
ration anxiety with potentially altered sleep patterns. Irregular sleep patterns seem to be the norm for the adoles-
Teething, ear infections, or other disorders affect sleep pat- cent as a result of high activity levels and usual peer-related
terns. Respirations are quiet, with minimal activity noted activities. There may be a tendency to overexertion, which is
during deep sleep. The infant sleeps an average of 12 to 16 made more pronounced by the numerous physiologic
hours per day. changes that create increased demands on the body. Fatigue
may occur during this time. On average, the adolescent
sleeps approximately 8 to 10 hours per day, with REM sleep
TODDLER AND PRESCHOOLER
comprising 20 percent.
The toddler needs approximately 10 to 12 hours of sleep at Rest may be necessary to supplement sleep. Supple-
night, with an approximate 2-hour nap in the afternoon. The menting sleep with rest serves to assist in preventing illness
percentage of REM sleep is 25 percent. Rituals for prepara- or the risk of illness. Extracurricular activities may also need
tion for sleep are important, with bedtime associated as sep- to be prioritized.
aration from family and fun. Quiet time to gradually
unwind, a favorite object for security, and a relatively con-
ADULT
sistent bedtime are suggested. Nightmares may begin to
occur because of magical thinking. An adult sleeps approximately 8 hours per day, with REM
The preschooler sleeps approximately 10 to 12 hours sleep comprising 22 percent. Sleep patterns may be subject
per day. Dreams and nightmares may occur at this time, to the demands of young infants or children in the household
and resistance to bedtime rituals is also common. Unwind- or after-hours professional and social activities.
ing or slowing down from the many activities of the day The adult may be at high risk for fatigue because of
is recommended to lessen sleep disturbances. Actual increasing role expectations, especially in caring for a new
attempts to foster relaxation by mental imaging at this age baby. Sleep deprivation can adversely affect the ability to
have proved successful. The percentage of REM sleep is 20 cope with the many expectations the adult may feel.
percent. Research has shown that women of all ages have
Special needs may be prompted for the toddler during higher rates of sleep disturbance than men do. Some specu-
hospitalization. When at all possible, a parent’s presence lation has occurred that relates this to the reproductive
should be encouraged throughout nighttime to lessen fears. lives of women and hormonal changes. It is well docu-
Limit-setting with safety in mind is also necessary for the mented that the psychosocial and hormonal changes that
toddler because of his or her surplus of energy and the desire accompany pregnancy lead to sleep disturbances.6 That
for constant activity. The preschooler may be at risk for sleep deprivation occurs during the postpartum period is
fatigue. Sleep may not be necessary at naptime, but rest a well-known fact. A new baby does not allow a mother
without disturbance is recommended to supplement night uninterrupted sleep for approximately 4 to 6 weeks after
sleep and to prevent fatigue. birth.8,11,12
Sleep disturbance seen in women who are experienc-
ing perimenopausal and menopausal symptoms is often
SCHOOL-AGE CHILD
related to declining estrogen levels. “Disrupted sleep is one
The school-age child seems to do well without a nap and of the earliest effects on the brain of decreasing levels of
requires approximately 10 hours of sleep per day, with estrogen.”11 Sometimes these sleep changes begin as early
REM sleep being approximately 18.5 percent. Individual- as 8 to 10 years before menses cease, and research has
ized rest needs are developed by this age, with a reliable proved that sleep deprivation not only causes suppression of
source being the child who can express his or her feelings the immune system but is also a major factor in causing per-
about rest or sleep. Health status would also determine to a sistent fatigue.
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Sleep Deprivation • 425
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426 • Sleep–Rest Pattern
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Sleep Deprivation • 427
ACTIONS/INTERVENTIONS R AT I O N A L E S
Consider herbal solutions such as valerian. However, Reduces the time it takes to get to sleep but does not
watch for side effects such as headaches, nausea, seem to reduce the number of times people wake in the
blurred vision, heart palpitations, and paradoxically, night.
excitability and restlessness. Do not take concurrently
with other sleep aids or alcohol.
Assess the patient’s mattress and pillow. Is it too hard or The mattress is an important component of restful sleep.
soft? Does it offer enough support?
Check for mild iron deficiency. Vitamin E may also help Even a low–normal iron level may cause restless leg syn-
with restless leg syndrome. drome.
Teach the patient to try relaxation techniques such as
meditation, counting your breaths, slowly tensing and
relaxing muscles, guided imagery, etc. just before
bedtime.
Encourage the patient to exercise earlier in the day rather Exercise stimulates the body.
than at night.
Counsel the patient to not “take problems to bed.” He or Helps clear the patient’s mind, order his or her problems,
she should sit quietly in a chair for a few minutes and set his or her plans for the next day.20
before going to bed and think about all those things
that have worried him or her during the day.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine all possible contributing factors that may Provides a database for individualization of care.
impact sleep deprivation (including situational,
environmental, or those related to another medical
condition).
Stabilize factors that can be stabilized to minimize con- Affords a better picture of actual causative factors for
tributing factors*: sleep deprivation with attention to anticipatory needs.
• Clustering activities to not disturb unnecessarily.
• Providing as near to normal routine for sleep for the
client, with attention to developmental needs (as noted
in under Conceptual Information).
Consider reassessment on an ongoing basis for disruptive In a short period of time there may be significant changes
contributing factors. to consider for accurate sleep assessment.
Based on assessments, develop a restructured plan for Restructuring may afford sleep and awake cycles to recur.
sleep allowance by eliminating, to degree possible, all
factors identified to be barriers to sleep.
Determine teaching needs of the client, parents, and/or Specific knowledge regarding sleeping and waking cycles
caregivers. facilitates individualized match of needs for clients and
caregivers.7,8
Reevaluate measures to define the optimum likelihood for Possible growth and developmental phases may be
sleep to occur as desired. required for appropriate reestablishment of cycles.
Implement appropriate nursing measures as noted for Once major factors are stabilized, basic maneuvers to
sleep disturbance as applicable. encourage sleep may be afforded per prior successful
plan with allowance for updated developmental needs.
Monitor for caregiver frustration in attempts to deal with Parents will often be subject to sleep deprivation of the
sleep deprivation secondary to caregiver role strain. infant or child.
(care plan continued on page 428)
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Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the parents in identification of ways to deal with Empowerment for possible solutions offers growth poten-
sleep deprivation of the infant or child. tial as parents and acknowledges potential need of
caregiver.7,24
Reassure the parents or, if applicable, the child, of the Ability to cope with problem is increased when individu-
likelihood for regular sleep pattern to be reestablished als believe problem is manageable.
with sufficient time and allowance for recycling.
Determine effect sleep deprivation may have over time, Related physiologic alterations often ensue related to
monitoring every 8 hours to note related alterations, sleep deprivation.
with attention to basic physiologic parameters as indi-
cated per the client’s condition and needs.
Monitor for mental and cognitive capacity, with attention Identification of related onset of interference in usual
to subjective or behavioral changes. mental or behavioral domain will help minimize
greater disturbance of the client’s status.
Ensure safety needs are met at all times. Altered sleep and wake cycles may alter usual proprio-
ception or cognitive ability.7,24
*In
instances of nightmares, offer safety and reassurance to child.
Women’s Health
Nursing actions for the Women’s Health client with this diagnosis are the same as those actions for Adult Health with the
following exceptions:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess the client for feelings of sleepiness or drowsiness Disruptive sleep patterns can lead to problems with
during the day. memory and are associated with daytime drowsiness,
fatigue, feeling “foggy” mentally along with distur-
bances in memory, concentration, and libido.
If the client is reporting perimenopausal symptoms and As estrogen levels drop, the brain responds with bursts of
disturbances in memory at any age, but particularly in adrenalin-type chemicals that arouse one from sleep.
the 30s, 40s, and 50s, refer to the physician for hor- Prolonged periods of sleep disruption can be a cause
monal evaluation.12 of biochemical changes, which can lead to chronic
fatigue and depression.11,12
Provide the patient/client with suggestions to adapt to the Research has shown that the most critical period for sleep
newborn infant’s sleep–wake cycle during the first 2 to disturbance is the first 2 to 6 weeks postpartum. If the
4 weeks postpartum: new mother does not experience some relief and assis-
• Turn off pagers and phones during sleep times. tance, it could very easily lead to sleep deprivation,
• Rest and/or sleep when the baby sleeps. chronic fatigue, and depression.8,25
Plan with the partner to take turns during the night to get
the baby (partner can bring the baby to the mother for
breastfeeding, which helps the mother to fall asleep
again faster).
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collaborate with the physician and pharmacist to assess Sleep disorders, such as sleep apnea, and certain medical
for physiologic and pharmacologic factors that con- conditions can contribute to sleep deprivation by dis-
tribute to wakefulness. ruption of normal sleep patterns.26–28
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Sleep Deprivation • 429
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess the client’s use of caffeine, alcohol, tobacco, and Use of certain chemicals can contribute to sleep distur-
other substances. (This can be accomplished with a bance by increasing central nervous system stimula-
sleep journal.) tion.28
Assess the client for changes in normal activity patterns. Changes in environmental conditions can contribute to
(This can be accomplished with a sleep journal.) sleep disturbance. Exercise close to bedtime can cause
stimulation and make it difficult to begin sleep.
Irregular daily cycles can interfere with sleep patterns.
Also, the client’s perceived sleep time may differ from
the actual time.28
Sit with the client for [number] minutes each shift to dis- Emotional stressors can increase anxiety and decrease the
cuss current stressors. client’s ability to relax sufficiently to sleep normally.27
Spend 30 minutes each shift in the first 24 hours to Understanding the client’s perception of the situation of
review with the client the strategies he or she has used past solutions facilitates change. Decreases feelings of
to improve sleep. Validate and normalize the client’s isolation and creates the perception of a manageable
responses. [Note persons responsible for this here.] problem.20,21
Develop with the client a plan to limit caffeine-containing Caffeine and nicotine stimulate the central nervous sys-
beverages and nicotine 4 hours before bedtime. [Note tem.28
that plan here.]
Develop with the client a plan for positive reinforcement Positive reinforcement strengthens desired behaviors.28
for accomplishing the goals established. [Note the
behaviors to reward and the rewards here.]
Develop an exercise schedule. [Note schedule and type of Exercise promotes normal daytime fatigue and facilitates
exercise here.] Arrange schedule so the client is not normal sleep patterns.
exercising just before bedtime.
Spend [number] minutes [times a day] assisting the client Concerns not addressed in a constructive manner can
with problem solving at least 2 hours before bedtime. contribute to nighttime wakefulness. Stress before
bedtime can inhibit normal sleep.31
Establish a bedtime routine with the client. [Note the Routine promotes relaxation.28
client’s routine here.]
Provide a light, high-carbohydrate snack before bedtime. Hunger can interfere with normal sleep patterns. Carbo-
[Note the client’s preference here.] hydrates increase tryptophan, which facilitates the
development of serotonin. Serotonin promotes sleep.28
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the older adult or caregiver to maintain his or her Avoid further changes in circadian rhythm.
daily schedule of rising, resting, and sleeping.
Encourage the older adult to use progressive muscle Progressive muscle relaxation has been found to be an
relaxation as a strategy to promote sleep. effective nonpharmacologic intervention to improve
sleep onset and quality in older adults.32
Provide caregivers with information on community re- Assists caregivers in reducing sense of isolation and
sources, stress management, and ways to reduce disrup- stress.18
tive behaviors when caring for people with dementia.
Consult with the physician for possible evaluation of Because sleep problems are assumed to be normal aging
sleep disorder. by elderly and health-care professionals, sleep disor-
ders are often not evaluated or treated.13
(care plan continued on page 430)
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Sleep Pattern, Disturbed • 431
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client/family in developing an activity plan to To facilitate effective sleep patterns
facilitate effective sleep patterns:
• Exercise 2 or more hours before bedtime.
• Engage in enjoyable exercise.
• Avoid excess fatigue.
• Avoid excess sleep on weekends or holidays to prevent
alterations in the normal sleep cycle.
Assist the client/family in developing an eating/diet plan To facilitate effective sleep patterns
to facilitate effective sleep patterns:
• Avoid large, heavy meals at night.
• Avoid caffeine in the evening.
• Identify food allergies and avoid allergens.
• Maintain a normal, healthy body weight.
Encourage self-care, exercise, and activity, as appropriate, Sleep and rest patterns are stabilized by a balance
based on medical diagnosis and client condition. of activity and exercise.
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Sleep Pattern, Disturbed • 433
ACTIONS/INTERVENTIONS R AT I O N A L E S
Once the patient is sleeping, place a “do not disturb” sign Promotes uninterrupted sleep.
on the door.
Increase exercise and activity during day as appropriate Promotes a regular diurnal rhythm.
for the patient’s condition.
When appropriate, discuss reasons for the sleep pattern Promotes adaptation that can increase sleep.
disturbance and teach appropriate coping mechanisms.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Give a warm bath 30 minutes to 1 hour before scheduled Promotes relaxation, and provides quiet time as a part of
sleep time. the sleep routine.
Feed formula, or a snack of protein and simple carbohy- In young infants and small children, a sense of fullness
drate (no fats), 15 to 30 minutes before scheduled and satiety, without difficulty in digestion, promotes
sleep time. sleep without the likelihood of upset or disturbances.
Implement usual bedtime routine: A structured approach to setting limits while honoring
• Rocking individual preference. Provides security and promotes
• Patting sleep.
• Child cuddling with favorite stuffed animal
• Using special blanket
Read a calm, quiet story to the child immediately after Reading allows a passive, meaningful enjoyment that
putting to bed. occupies the attention of the young child while creat-
ing a bond between the caretaker and child.
Serendipitous relaxation often follows.
Provide environment conducive to sleep, such as: Lack of unpleasant stimuli will provide sensory rest,
• Room temperature of 74 to 78⬚F as well as a chance to tune out need for cognitive–
• Soft, relaxing music perceptual activity.
• Night light
Restrict loud physical activity at least 2 to 3 hours before Overstimulating physical activity may signal the central
scheduled sleep time. nervous system to activate bodily functions.
Schedule therapeutics around sleep needs. Complete all The nurse’s valuing of the sleep schedule will convey resp-
therapeutics at least 1 hour before scheduled sleep time. ect for the importance of sleep to the patient and family.
Assist the parents with defining and standardizing a Parents will be able to cope better with developmental
general waking and sleeping schedule. issues given the knowledge and opportunity to inquire
about sleep-related issues. It is reported that limit set-
ting with confidence by parents is the most effective
way to develop healthy patterns of sleep when no
related health problems exist.
Teach the parents and child appropriate, age-related Improves parents’ coping skills in dealing with common
relaxation techniques (e.g., imagination of the “most developmental issues that affect sleep.
quiet place game” and other imaging techniques).
Discuss with the parents the difference between inability
to sleep and fears related to developmental crises:
• Infant and toddler—Separation anxiety
• Preschooler—Fantasy versus reality
• School-age—Ability to perform at expected levels
• Adolescent—Role identity versus role diffusion
Ensure the child’s safety according to developmental and Basic safety standards for infants and children.
psychomotor abilities (e.g., infant placed on side or
back; no plastic, loose-fitting sheets; and bedrails to
prevent falling out of bed).
(care plan continued on page 434)
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434 • Sleep–Rest Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient in scheduling rest breaks throughout Knowledge and proper planning can help the patient
day. reduce fatigue during pregnancy and the immediate
postpartum period.8,34
Review daily schedule with the patient, and assist the Knowledge of life changes can help in planning and
patient to adjust her sleep schedule to coincide with the implementing mechanisms to reduce fatigue and sleep
infant’s sleep pattern. disturbance.
Identify a support system that can assist the patient in
alleviating fatigue.
Assist the patient in identifying lifestyle adjustments that During the immediate postpartum period, 2 to 4 weeks
may be needed because of changes in physiologic after birth, it is important for the mother to adjust her
function or needs during experiential phases of life sleep cycle to the infant’s if at all possible, in order to
(e.g., pregnancy, postpartum, or menopause): get enough rest and sleep.8
• Possible lowering of room temperature During perimenopause and menopause try such things as
• Layering of blankets or covers that can be discarded or avoiding caffeine, alcohol, and nicotine; and exercis-
added as necessary ing, but not too close to bedtime. About an hour before
• Practicing relaxation immediately before scheduled going to bed engage in a relaxing, nonalerting activity,
sleep time do not drink or eat too much, and maintain a quiet,
• Establishing a bedtime routine (e.g., bath, food, fluids, dark, and preferably cool but comfortable, sleep envi-
or activity) ronment.1,12
Involve significant others in discussion and problem-
solving activities regarding life-cycle changes that are
affecting work habits and interpersonal relationships
(e.g., hot flashes, pregnancy, or postpartum fatigue).
Teach the patient to experiment with restful activities
when she cannot sleep at night rather than lying in bed
and thinking about not sleeping.
Discuss with women the following to assess sleep pattern
disturbance:
• Do they have an irregular sleep–wake pattern?
• Do they have problems falling asleep at night?
• Do they regularly wake up several times at night and
have difficulty falling back asleep?
• Do they feel sleepy or drowsy during the day?
Assess for snoring, jerky movements during sleep, or
stoppage of breathing during sleep. (Can assess in
sleep lab or question the client’s sleeping partner.)
Collaborate with the woman’s physician, and recommend For women in midlife, restless sleep with several awaken-
an evaluation of hormone levels and/or further evalua- ings may be one of the earliest indicators of declining
tion of sleep disorders. estrogen. Sleep apnea can lead to sexual dysfunction,
major depression, high blood pressure, chronic fatigue,
problems with memory and concentration during the
day, and potentially a heart attack.11,12
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Sleep Pattern, Disturbed • 435
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide only decaffeinated drinks during all 24 hours. Caffeine stimulates the central nervous system.
Spend [amount] minutes with the client in activity of the Increases mental alertness and activity during daytime
client’s choice at least twice a day. hours.
Provide appropriate positive reinforcement for achieve- Positive reinforcement encourages behavior.
ment of steps toward reaching a normal sleep pattern.
Talk the client through deep muscle relaxation exercise Facilitates relaxation and disengagement from the activi-
for 30 minutes at 9 P.M. ties and thoughts of the day to prepare the client both
physically and mentally for sleep.
Sit with the client for [amount] minutes three times a day Positive reinforcement encourages calm behavior and
in a quiet environment, and provide positive reinforce- enhances self-esteem.
ment for the client’s accomplishments.
● N O T E : This is for clients with increased activity.
Go to the client’s room and walk with him or her to the Stimulates wakefulness during daytime hours, and facili-
group three times a day. tates the area development of a trusting relationship.
Spend time out of the room with the client until he or she Stimulates wakefulness during daytime hours.
demonstrates ability to tolerate 30 minutes of interac-
tion with others.35
● N O T E : This is for clients with depressed mood.
Spend 30 minutes with the client discussing concerns Facilitates problem-solving during daytime hours at
2 hours before bedtime. a time when normal sleep patterns will not be
disturbed.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collaborate with the physician and pharmacist, if a This ensures that the older adult has as natural a sleep
sleeping medication is prescribed, to ensure that the pattern as possible.
drug is one that minimally interferes with the normal
sleep cycle.
Assess for the presence of physical causes of interrupted
sleep and provide referrals as needed:
• Prostatic hypertrophy leading to nocturia.
• Prescription medications that may interrupt normal
sleep patterns (beta-blockers are commonly used in eld-
erly clients and can cause nightmares and insomnia).
• Recent losses or grief can lead to altered sleep patterns.
• Some cardiac disorders can lead to orthopnea.
Monitor for the presence of pain prior to bedtime and Untreated pain may prevent the onset of sleep and inter-
if the patient is found awake frequently during the rupt the individual’s usual sleep pattern.
night.
Monitor for symptoms of depression,36 especially if the Depression is frequently underreported and undertreated
older adult reports waking very early in the morning in older adults.
with an inability to fall back to sleep, and is experienc-
ing feelings of anxiety on awakening.
(care plan continued on page 436)
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Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client and family in planning, implementing, Household involvement is important to ensure the envi-
and promoting restful environment and sleep routine: ronment is conducive for sleep and rest.
• Coordinate family activities and the client’s sleep needs
to maximize both schedules.
• Request that visits and calls be at specified times so
that sleep time is not interrupted.
• Provide favorite music, pillows, bedclothes, teddy
bears, etc.
• Support usual bedtime routine as much as possible in
relation to medical diagnosis and the client’s condition.
• Assist the client with maintaining a consistent bedtime
routine as necessary.
Provide client/family teaching about medications that
may disrupt normal sleep patterns:
• Hypnotics
• Diuretics
• Antidepressants and stimulants
• Alcohol
• Caffeine
• Beta-adrenergic blockers
• Benzodiazepines
• Narcotics
• Anticonvulsants
Assist the client/family in modifying the home environ-
ment to facilitate effective sleep patterns:
• Good ventilation
• Quality mattress
• Quiet sleep environment or soft “white” noise, if
preferred
• Dark sleep environment with soft night lights, if preferred
• Where possible the bedroom should be used for sleep-
ing only. Work, television viewing, studying, and other
activities should be done in other rooms.
• Unplug telephone in room, or adjust volume control
on bell.
Assist the client/family in developing an activity plan to
facilitate effective sleep patterns:
• Exercise 2 or more hours before bedtime.
• Engage in enjoyable exercise.
• Avoid excess fatigue.
• Avoid excess sleep on weekends or holidays to prevent
alterations in the normal sleep cycle.
Assist the client/family in developing an eating/diet plan
to facilitate effective sleep patterns:
• Avoid large, heavy meals at night.
• Avoid caffeine in the evening.
• Identify food allergies and avoid allergens.
• Maintain a normal, healthy body weight.
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Readiness For Enhanced Sleep • 437
ACTIONS/INTERVENTIONS R AT I O N A L E S
Maintain pain control via appropriate medications, body Pain disturbs or prevents sleep and rest.
positioning, and relaxation. Narcotics can suppress
REM sleep and lead to increased daytime sleepiness.
Encourage self-care, exercise, and activity as appropriate Sleep–rest patterns are stabilized by a balance of activity
and based on medical diagnosis and client condition. and exercise.
SLEEP, READINESS FOR ENHANCED culty in maintaining his or her usual activities.
However, assessment documents that this
DEFINITION19
fatigue exists regardless of the amount
A pattern of natural, periodic suspension of consciousness of sleep.
that provides adequate rest, sustains a desired lifestyle, and
Health-Seeking Behaviors
can be strengthened.
The patient will tell the health-care provider that
DEFINING CHARACTERISTICS19 they need assistance with sleep, whether with medi-
cation or a change in environment, when in actuality
1. Expresses willingness to enhance sleep. the patient documents adequate sleep for age and
2. Amount of sleep and REM sleep is congruent with life cycle.
developmental needs.
3. Expresses a feeling of being rested after sleep. Ineffective Coping
4. Follows sleep routines that promote sleep habits. Patient complains of inability to cope related to lack
of sleep, when in reality, there is another factor of
5. Occasional or infrequent use of medications to induce
worry, fear, or lifestyle which is interfering with
sleep. patient’s sleep patterns.
RELATED CLINICAL CONCERNS
1. Long work hours or shift in work hours
2. Environmental impacts of modern living EXPECTED OUTCOME
3. Jet lag
4. Driving while fatigued The client will sleep at least (number) hours in 24 hours by
5. Life changes that affect one’s sleep patterns and/or (date).
characteristics The client will demonstrate effective sleep habits by
(date).
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438 • Sleep–Rest Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for all contributory factors, especially evidence for Provides realistic base for plan.
pattern of sleep, which are appropriate for develop-
mental age and status.
Foster current daily regimen with specific attention to Values current need for sleep and success in attainment
continuing plan for sleep routine. of desired plan for adequate rest.
Provide opportunity for development of mutually agree- Provides anticipatory guidance for plan.
able ongoing guidelines for caregiver(s) and/or child,
as appropriate, to continue to monitor sleep patterns
with best practice to attain desired sleep.37
Offer instructions according to caregiver(s) baseline Provides a realistic basis for teaching and likelihood of
knowledge of sleep, especially regarding aids to sleep, follow-up for plan.
need for maintenance of schedule, and routine for sleep.
Offer resources according to infant or child’s age/devel- Provides appropriate anticipatory guidance for realistic
opmental status. expectations.
Warn caregiver(s) of dangers of co-sleeping and of risk Offers safe anticipatory guidance.7,37
for SIDS for young infants.37 Childcare programs outlines what should be included in
the safe sleep policy (http://www.healthychildcare.org/
pdf/SIDSchildcaresafesleep.pdf)
Women’s Health
Women’s Health will follow the same interventions and rationales as does Adult Health, Home Health, and Gerontic
Health, except for the following:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess sleeping arrangements of childbearing couples, A through assessment of sleeping arrangements, cultural
particularly after the birth of the new baby. influences, sleeping habits of the parents, presence of
Be sensitive to cultural diversity and family sleeping pets in the household, and any additional lifestyle
habits. changes that have occurred since the arrival of the new
Assess lifestyle changes that the addition of a new baby baby will allow the health care provider to make sug-
brings to the household gestions and help the couple plan. This planning will
help the couple to maintain their sleep patterns and
promote enhanced readiness for sleep.7,8,25
Assist women who are approaching midlife and experi- Women who are aware of their life-cycles and know what
encing perimenopause and menopause plan and learn to expect can better plan and implement changes in
methods of continuing to maintain healthy sleep pat- their environment that will help them maintain good
terns. Some tips to share are: sleeping habits. That will prevent sleep problems and
• Avoid shift work if possible, especially switching shifts promote optimal sleep and show enhanced readiness
at work on a routine basis. for sleep.1,11,12,14–16
• Avoid caffeine, alcohol, and nicotine.
• Exercise, but not too close to bedtime.
• Avoid naps.
• About an hour before going to bed:
• Engage in a relaxing, nonalerting activity.
• Do not drink or eat too much.
• Maintain a quiet, dark, and preferably cool, but com-
fortable sleep environment.
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Readiness For Enhanced Sleep • 439
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Keep a sleep diary to identify your sleep habits and
patterns.
• Layer blankets, so that you can take them off or put
them on if you are experiencing “hot flashes.”
• Keep the bedroom cool and use only for sleep (do not
watch television in bed).
Mental Health
Spend [number] minutes [number] times a day discussing Change is dependent on the client’s perception of the
with client his or her perceptions of current sleep pat- problem.37
terns. [Note the schedule of these meetings here.]
Develop, with the client, a plan for addressing his or her
needs for sleep enhancement.
• Utilize information about sleep hygiene to guide client
in plan development (See information on sleep hygiene
in Sleep Deprivation care plan).
[Note the client’s plan here with information about the
assistance needed from nursing for goal achievement.]
Develop, with the client, a plan for rewarding positive Positive reinforcement encourages behavior change.29,37
behavior change.
[Note the plan for rewarding behavior here.]
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440 • Sleep–Rest Pattern
COGNITIVE–
7
PERCEPTUAL PATTERN
1. ADAPTIVE CAPACITY, INTRACRANIAL, DECREASED 450
2. CONFUSION, ACUTE AND CHRONIC 454
3. DECISIONAL CONFLICT (SPECIFY) 463
4. ENVIRONMENTAL INTERPRETATION SYNDROME,
IMPAIRED 469
5. KNOWLEDGE, DEFICIENT (SPECIFY) 474
6. KNOWLEDGE, READINESS FOR ENHANCED 479
7. MEMORY, IMPAIRED 482
8. PAIN, ACUTE AND CHRONIC 486
9. SENSORY PERCEPTION, DISTURBED (SPECIFY:
VISUAL, AUDITORY, KINESTHETIC, GUSTATORY,
TACTILE, OLFACTORY) 497
10. THOUGHT PROCESS, DISTURBED 506
11. UNILATERAL NEGLECT 514
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442 • Cognitive–Perceptual Pattern
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Developmental Considerations • 443
usual activities of daily living in the fullest level of func- behavior by the individual. Perceptual processes enhance
tioning. All these functions rely on a healthy nervous system this behavior as well.
containing receptors to detect input accurately, a brain that Perception is the process of extracting information in
can interpret the information correctly, and transmitters that such a way that the individual transforms sensory input into
can transport decoded information. Bodily response is also meaning. The senses, which serve as the origin of perceptual
a basic requisite to respond to the sensory and perceptual stimuli, are as follows:
demands of the individual.
1. Exteroceptors (distance sensors)
Cognition is the process of obtaining and using knowl-
a. Visual
edge about one’s world through the use of perceptual abili-
b. Auditory
ties, symbols, and reasoning. For this reason, it includes the
2. Proprioceptors (near sensors)
use of human sensory capabilities to receive input about the
a. Cutaneous (skin senses that detect and communicate,
environment. Cognition usually leads to perception, which is
or transducer, changes in touch, e.g., pressure, tem-
the process of extracting information in such a way that the
perature, and pain)
individual transforms sensory input into meaning. Cognition
b. Chemical sense of taste
incorporates knowledge and the process used in its acquisi-
c. Chemical sense of smell
tion; therefore, ideas (concepts of mind symbols) and lan-
3. Interoceptors (deep sensors)
guage (verbal symbols) are two tools of cognition. Learning
a. Kinesthetic sense that senses changes in position of
may be considered the dynamic process in which perceptual
the body and motions of the muscles, tendons, and
processing of sensory input leads to concept formation
joints
and change in behavior. Cognitive development is highly
b. Static or vestibular sense that senses changes related
dependent on adequate, predictable sensory input.
to maintaining position in space and the regulation of
There are two general approaches to contemporary
organic functions such as metabolism, fluid balance,
cognitive theory. The information-processing approach
and sensual stimulation
attempts to understand human thought and reasoning
processes by comparing the mind with a sophisticated com- It is important to note that because perceptual skill
puter system that is designed to acquire, process, store, and processing is an internal event, its presence and develop-
use information according to various programs or designs. ment are inferred by changes in overt behavior. For full
The second approach is based on the work of the Swiss appreciation of the cognitive–perceptual pattern, it is also
psychologist Jean Piaget, who considered cognitive adapta- necessary to understand the normal physiology of the nerv-
tion in terms of two basic processes: assimilation and accom- ous system.
modation. Assimilation is the process by which the person
integrates new perceptual data or stimulus events into exist-
ing schemata or existing patterns of behavior. In other words, DEVELOPMENTAL CONSIDERATIONS
in assimilation, a person interprets reality in terms of his or
INFANT
her own model of the world based on previous experience.
Accommodation is the process of changing the model the The full-term newborn has several sensory capacities. The
individual has of the world by developing the mechanisms to neonate should have a pupillary reflex in response to light
adjust to reality. Piaget believed that representational thought and a corneal reflex in response to touch. At birth, the sen-
originates not in a social language but in unique symbols that sory myelination is best developed for hearing, taste, and
provide a foundation later for language acquisition.1 smell.
American psychologist Jerome Bruner broadened
Vision. Structurally, the eye is not completely differentiated
Piaget’s concept by suggesting that the cognitive process is
from the macula. The newborn has the capacity to fixate
affected by three modes. The enactive mode involves repre-
momentarily on a bright or moving object held within
sentation through action, the iconic mode uses visual and
8 inches and in the midline of the visual field. By approxi-
mental images, and the symbolic mode uses language.1
mately 4 months of age, the infant is capable of 20/200
Cognitive dissonance is the mental conflict that takes
visual acuity. Binocular fixation and convergence to near
place when beliefs or assumptions are challenged or contra-
objects is possible by approximately 4 months of age. In a
dicted by new information. The unease or tension the indi-
supine position, the infant can follow a dangling toy from
vidual may experience as a result of cognitive dissonance
the side to past midline.
usually results in the person’s resorting to defense mecha-
nisms in an attempt to maintain stability in his or her con- Hearing. The neonate is capable of detecting a loud sound
ception of the world and self. of approximately 90 decibels and reacts with a startle. At
In a broad sense, thinking activities may be considered birth, all the structural components of the ear are fully devel-
internally adaptive responses to intrinsic and extrinsic stim- oped. However, the lack of cortical integration and full
uli. The thought processes serve to express inner impulses, myelination of the neural pathways prevents specific
but they also serve to generate appropriate goal-seeking response to sound. The infant will usually search to locate
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444 • Cognitive–Perceptual Pattern
sounds. By approximately 15 months of age, the infant is a horizontal prone position and suddenly thrust downward,
beginning to acquire eye–hand coordination and is capable will place hands and fingers forward as an attempt to protect
of accommodation to near objects. Of concern at this age him- or herself from falling. This reflex appears at approxi-
would be any abnormalities noted in any of these tasks plus mately 7 months and persists indefinitely.
rubbing of eyes, self-rocking, or other self-stimulating The neonate responds with total body reaction to a
behavior. By approximately 2 months, the infant will turn to painful stimulus. The primitive reflexes demonstrate this,
the appropriate side when a sound is made at ear level. By especially the Moro, or startle, response to sudden loss of
approximately 20 months, the infant will localize sounds support or loud noises. The neonate is dependent on others
made below the ear. A cause for concern might be failure to for protection from pain. The mother of a newborn is most
be awakened by loud noises or abnormal findings in any of often the person who assumes this task, along with the father
the previously mentioned responses. Speech or the uttering and other primary caregivers. For this reason, management
of sounds by age 6 to 8 months would also be a component. of pain must also include the parents. Distraction, for exam-
ple, a pacifier, is useful in dealing with painful stimuli.
Smell. Smell seems to be a factor in breastfed infants’
The infant gradually offers localized reaction in
response to the mother’s engorgement and leaking.
response to pain at approximately 6 to 9 months of age. Still,
Newborns will turn away from strong odors such as vinegar
the cognitive abilities of the infant remain limited with
and alcohol. By approximately 6 to 9 months, the infant
respect to pain. Often a physical tugging of the painful body
associates smell with different foods and familiar people of
part proves to be the clue of pain for the infant, as with an
his or her circle of activity. The infant also avoids strong,
earache. The infant is incapable of offering cooperation in
unpleasant odors.
procedures and must be physically restrained, because he or
Taste. The newborn responds to various solutions with the she is largely incapable of resisting painful stimuli. Crying
following facial reflexes: and irritability may also be manifestations of pain, particu-
larly when the nurse is certain other basic needs have been
1. A tasteless solution elicits no facial expression.
attended to.
2. A sweet solution elicits an eager suck and look of satis-
If chronic pain comes to be a way of life for the infant
faction.
soon after birth or before much development has occurred,
3. A bitter liquid produces an angry, upset expression.
there may be alterations in any subsequent development. In
By 1 year of age, the infant shows marked prefer- some instances, infants adapt and develop high tolerances
ences, with similar responses to different flavors, as did the for pain.
young neonate. The neonate is dependent on others for appropriate
care and health maintenance. Values for health care are
Touch. At birth, the neonate is capable of perception of
being formed through this provision of care by others. The
touch, and the mouth, hands, and soles of the feet are the
infant will gradually continue to learn values of health care.
most sensitive. There is increasing support for the notion
Safety becomes an ongoing concern, as has been previously
that touch and motion are essential to normal growth and
acknowledged. Parents or primary caregivers assume this
development.
responsibility. The infant is capable of object permanence
By 1 year of age, the infant has a preference for soft
but cannot be expected to remember abstract notions.
textures over rough, grainy textures. The infant relies on the
The neonate subjected to hypoxia in the perinatal
sense of touch for comforting. Over-response or under-
period is at risk for possible future developmental delays.
response to stimuli, for example pain, is a cause for concern.
Apgar scores are typically used as criteria, in addition to
Proprioception. At birth, the infant is limited in perceiv- neurologic reflexes. Seizures during the neonatal period
ing itself in space, because this requires deep myelination must also be followed up. In a general sense, the premature
and total integration of cortical activity. There is momentary infant of less than 37 weeks’ gestation should also be con-
head control. In general, referral to more exacting neurologic sidered at risk for developmental delays. It is paramount that
reflexes of the neonate will provide in-depth supplementary close examination be performed for basic primitive reflexes
data. In essence, primitive reflexes, which are protective in and general neonatal status as well as identification of any
nature, serve to assist the neonate in adjustment to extrauter- genetic syndromes or congenital anomalies.
ine life and identification of congenital anomalies. A critical The infant gradually incorporates symbols and inter-
appreciation of organic and operational synergy for the cen- acts with the world through primary caregivers. Any major
tral nervous system is necessary as sensory deficits are con- delays in development should be cause for further close
sidered. follow-up. Sensory-perceptual deficiencies may indeed
By approximately 3 months of age, the infant will, bring about impaired thought processes.
when suspended in a horizontal prone position with the head
flexed against the trunk, reflexively draw up the legs. This is
TODDLER AND PRESCHOOLER
known as the Landau reflex. It remains present until approx-
imately 12 to 24 months of age. Another related reflex is the Binocular vision is well established by now. The toddler can
parachute reflex, in which the infant, on being suspended in distinguish geometric shapes and can demonstrate begin-
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Developmental Considerations • 445
ning depth perception. Marked strabismus should be treated pitalization. If a deficit exists, parents should be encouraged
at this time to prevent amblyopia. The toddler can begin to to continue appropriate follow-up and intervention.
name colors. The preschooler may be aware of how he or she is
Smell, taste, and touch all become more related as the different from peers, although egocentrism continues. Of
toddler initially sees an object and handles it while enjoying, importance is the mastery of separation from parents for
via all the senses, what it is to “know.” Regression to previ- increasing periods of time. The likelihood of sibling inte-
ous tactile behavior for comfort is common in this group, as gration should be considered also. At this time, a known
exemplified by a preference for being patted and rocked to neglect of one side of the body may be problematic, as the
sleep during times of stress, such as illness. Concerns by this child may rebel and fail to comply with desired therapy.
time would be for secondary deficits in development that The toddler gradually learns to care for him- or herself
may arise. There is also a great concern for the toddler who and is strongly influenced by the family’s value system.
shows greater response to movement than to sound or who There is capacity for expression of beginning thoughts.
avoids social interaction with other children. By this time, The preschooler has a capacity for magical thinking
speech should be sufficiently developed to validate a basic and enjoys role-play of the parent of the same sex. At this
sense of the toddler’s ability to use symbols. Proprioception age, beginning resistance to parental authority is common,
is not perfected, but “toddling” represents a major milestone. and the child is still egocentric in thought. This makes it dif-
Falls are common at this age. ficult to apply universal understanding of use of language
There is an even greater incorporation of sensory and symbols for children of this age; for example, death may
activity in sequencing for the preschooler, in whom major be perceived as “sleep.”
myelination for the most part is fully developed. There is By this age, there should be a general notion of the
refinement of eye–hand coordination, and reading readiness cognitive capacity of the child. The child explores the world
is apparent. Visual acuity begins to approach 20/20, and the in a meaningful fashion and still relies closely on primary
preschooler will know colors. Before age 5, the child should caregivers. If there are marked delays, they should be mon-
be screened for amblyopia; after age 5, there is minimal itored with a focus on maintaining optimum functioning
potential for development of amblyopia. Language becomes with developmental sequencing.
more sophisticated and serves to provide social interaction. The preschooler will enjoy activity and is beginning to
By this age, the child will remember and exercise caution enjoy learning colors, using words in sentences, and gradu-
regarding potential dangers, such as hot objects. ally forming relationships with persons outside the immedi-
The toddler may regress to previous behavior levels ate family. If there are delays, they should continue to be
with physical resistance in response to painful stimuli. This monitored. By now, major deficits in cognition become
will be especially true with invasive procedures. On occa- more obvious.
sion, a toddler may demonstrate tolerance for painful proce-
dures on the basis of understanding benefits offered, for
SCHOOL-AGE CHILD
example, young children with a medical diagnosis of
leukemia. This is not the usual case, however. Temper The school-age child has a significant ability to perform log-
tantrums, outbursts, and avoidance of painful stimuli ical operations. More complete myelination and maturation
describe the usual behavior of the toddler. When the toddler enhance the basic physiologic functioning of the central
must deal with chronic pain, he or she may regress to previ- nervous system. Generally, the school-age child can estab-
ous behavior as a means of coping. lish and follow simple rules. There is self-motivation with a
The preschooler views any invasive procedure as gradual grasp of time in a more abstract nature. The concept
mutilation and attempts to withdraw in response to pain. of death is recognized as permanent.
The preschooler cries out in pain and will express feel- The school-age child begins to interpret the experi-
ings in his or her own terms as descriptors of pain. The inter- ence of pain with a cognitive component—the cause or
pretation of pain is influenced greatly by the parental and source of pain, as well as implications for possible recur-
familial value systems. In severe pain, the potential for rence. The child in this developmental category will attempt
regression to previous behavior is high. The nurse should be to hold still as needed, with an appearance of bravery.
aware that fears of abandonment, death, or the unknown Expression of the experience of pain is to be expected
would be brought out by pain for this age group. Also, the by a school-age child. If the school-age child is particularly
effect the pain has on others may serve to further frighten shy, special attempts should be made to establish a trusting
the child. relationship to best manage pain. A major fear is loss of
Play is an ideal noninvasive means of assessment. control. The nurse must consider the need to completely
Difficulties in gait, balance, or the use of upper limbs in evaluate chronic pain. In some instances, it may signal
symmetry with lower limbs should be noted, as well as other altered patterns, especially a distressed family or
related holistic developmental components including inability to cope. Lower performance in school can be
speech, motor, cognitive, perceptual, and social compo- an indicator of chronic pain. Also, the nurse should be
nents. Allowance should be made for regression to prior aware of the increased complexity required for activities of
patterns as needed in times of stress, such as illness and hos- daily living (ADLs). The child of this age may feel negative
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446 • Cognitive–Perceptual Pattern
about him- or herself if he or she is unable to perform as ADULT AND OLDER ADULT
peers do. The importance of group activities cannot be over-
stressed. Vision. The adult is capable of 20/20 vision with a gradual
The school-age child will blossom with a sense of decline in acuity and accommodation after approximately
accomplishment. When school does not bring success, frus- 40 years of age. There is a tendency toward farsightedness.
tration follows. It is mandatory that caution be exercised in Color discrimination decreases in later ages, with green and
assessing for deficits versus behavioral manifestations of not blue being the major hues affected. Depending on the cause,
liking school. there is a great potential for the use of corrective aids. In
examples of degenerative processes, such is not the case, as
with macular degeneration. Eventually depth perception and
ADOLESCENT peripheral vision are also affected. There may also be sensi-
Vision. Acuity of 20/20 is reached by now. Squinting tivity to light, as with cataract formation. The nurse should
should be investigated, as should any symptoms of pro- be alert for all etiologic components, especially the retinopa-
longed eyestrain. thy associated with diabetic alterations.
Hearing. Further investigation should be done on any ado- Hearing. The adult has sensitivity to accurately discrimi-
lescent who speaks loudly or who fails to respond to loud nate 1600 different frequencies. There should be equal sen-
noises. sation of sounds for the left and right ear. The Rinne test
may be done to validate air and bone conduction via a tun-
Touch. Over- or under-reaction to painful stimuli is a cause ing fork. The Weber test may be used to assess lateralization.
for further investigation. Equilibrium assessment provides data regarding the vestibu-
Taste. The adolescent may prefer food fads for a length of lar branch.
time, but concern is appropriate if the adolescent overuses With time, the acuity of what is heard gradually
spices, especially salt or sugar, or complains of foods not diminishes, with detection of high-pitched frequencies espe-
“tasting as they used to.” cially affected. The nurse should be concerned with a lack of
response to loud noises and increased volume of speech, and
Smell. The adolescent should distinguish a full range of should be alert to cues of decreased hearing, such as cupping
odors. The nurse should be concerned if the adolescent is of the hand on the “better” ear or leaning sideways to catch
unresponsive to noxious stimuli. the conversation on the “better” side.
Proprioception. There may be temporary clumsiness Smell. There may be a gradual deterioration in sensitivity
associated with growth spurts. The nurse should be con- for smell after approximately age 60, although for the most
cerned if he or she observes patterns of deteriorating gross part the sense of smell remains functional in the absence of
and fine motor coordination and ataxia. organic disease. There may be altered gastrointestinal
By now the adolescent is capable of formal opera- enzyme production, which ultimately interferes with usual
tional thought and is able to move beyond the world of con- perception of smells.
crete reality to abstract possibilities and ideas. Problem Taste. The ability to taste is well differentiated in adult-
solving is evident with inductive and deductive capacity. hood. Sweet and sour can be detected bilaterally. Concern
There is an interest in values, with a tendency toward ideal- may be raised if the client states the sense of taste has dimin-
ism. Attention must be given to the adolescent’s sensitivity ished or changed. There is a gradual loss of acuity in taste as
to others and potential for rejection if body image is altered. aging occurs in later life. This is due in part to decreased
Of particular importance at this time are sports and peer- enzymatic production and utilization in digestive processes.
related activities. As feelings are explored more cautiously, Over-salting or -spicing of foods may serve as a clue to this
there is a tendency to draw into oneself at this stage. There loss of taste sensation. The use of dentures may also affect
may be major conflicts over independence when self-care is the sensation of taste and enjoyment of food.
not possible.
The adolescent fears mutilation and attempts to deal Touch. The adult is able to discriminate on a wide range of
with pain as an adult might. Self-control is strived for, with tactile stimuli, including pressure, temperature, texture, and
allowance for capitalization on gains from pain. Sexuality pain or noxious components. With aging, there is a decrease
factors of role performance enter into this group as pain in subcutaneous fat, loss of skin turgor, increase in capillary
occurs. As with the adult, an attempt to discover the cause fragility, and a decrease in conduction of impulses. All these
and implication of the pain is made. The adolescent experi- changes influence the sense of touch, with a loss of acuity in
encing chronic pain will be at risk for abnormal peer inter- aging.
action and may potentially endure altered self-perception. Proprioception. The adult is well coordinated and has a
The adolescent will most often remain steady in cog- keen sense of perception of his or her body in space. There
nitive functioning if there are no major emotional or sensory are multiple protective mechanisms that aid in maintaining
problems. Of concern at this age would be substance abuse balance. Typically, even with eyes closed, the individual is
that could impair thought processes. able to stand and maintain balance.
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Developmental Considerations • 447
By now the tolerance and threshold one has for pain is is carried out, focus should be on risk factors such as chronic
well established. The individual has learned various ways to illness, financial deficits, resolution of ego integrity versus
cope with pain, and thus may be equipped with a more sta- despair, and obvious etiologic components. The nurse should
ble base from which to respond. Paradoxically, the adult may assist the patient to maintain self-care, as the patient desires.
experience unresolved conflicts of previous development With aging, there is a gradual loss of balance, perhaps
levels as well. For this reason, the required change may be most related to the concurrent vascular changes. For this rea-
subject to associated changes as pain and its response affect son proprioceptive data may provide an immediate basis for
the multiple demands of daily living by the adult. safety needs of the geriatric client.
The adult is equipped to solve problems and apply In the absence of adversity, the adult enjoys the daily
principles to everyday living. There is emphasis on seeking challenges of living. If coping is altered for whatever reason,
a lifetime mate who is able to satisfy basic companionship a risk for impaired thought process exists. With aging there
needs. There may be difficulties in accepting life’s chal- are potential risks for impaired thought processes. In addi-
lenges as parents or as adults juggling the many necessary tion, there may be potential risks for some regarding degen-
roles. There is, in later life, a gradual decline in problem- erative brain and central nervous system disorders, which
solving capacity, which may be exaggerated by illness. also include impaired thought processes. Two concerns for
Allowing for potential decrease in bodily perception older adults related to altered thought processes are demen-
and functioning with age must be considered. As assessment tia and delirium or acute confusional states.
Chronic Chronic
Dementia Management Cognition
Dementia Management: Cognitive Orientation
Bathing Decision-Making
Mood Management Distorted Thought Self-
Control
Identity
Information Processing
Memory
Neurological Status:
Consciousness
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448 • Cognitive–Perceptual Pattern
T A B L E 7 . 1 NANDA, NIC, and NOC Taxonomic Linkages (continued from page 447)
GORDON’S FUNCTIONAL
HEALTH PATTERN NANDA NURSING DIAGNOSIS NIC PRIORITY INTERVENTIONS NOC EVALUATIONS
*Still
Knowledge (Specify), in Development Knowledge: Body Mechanics;
Readiness for Breastfeeding; Cardiac Disease
Enhanced Management; Child Physical
Safety; Conception Prevention;
Diabetes Management; Diet;
Disease Process; Energy
Conservation; Fall Prevention;
Fertility Promotion; Health
Behavior; Health Promotion;
Health Resources; Illness Care;
Infant Care; Infection Control;
Labor and Delivery; Medication;
Ostomy Care; Parenting;
Personal Safety; Postpartum
Maternal Health; Preconception
Maternal Health; Pregnancy;
Prescribed Activity; Sexual
Functioning; Substance Use
Control; Treatment Procedure(s);
Treatment Regimen
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Developmental Considerations • 449
GORDON’S FUNCTIONAL
HEALTH PATTERN NANDA NURSING DIAGNOSIS NIC PRIORITY INTERVENTIONS NOC EVALUATIONS
Gustatory Gustatory
Nausea Management Appetite
Nutrition Management Nutritional Status: Food & Fluid
Intake
Sensory Function: Taste & Smell
Tactile Tactile
Lower Extremity Monitoring Sensory Function: Cutaneous
Peripheral Sensation
Management
Teaching: Foot Care
Olfactory Olfactory
Environmental Management Appetite
Nutrition Management Nutritional Status: Food & Fluid
Intake
Sensory Function: Taste & Smell
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450 • Cognitive–Perceptual Pattern
T A B L E 7 . 1 NANDA, NIC, and NOC Taxonomic Linkages (continued from page 449)
GORDON’S FUNCTIONAL
HEALTH PATTERN NANDA NURSING DIAGNOSIS NIC PRIORITY INTERVENTIONS NOC EVALUATIONS
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Adaptive Capacity, Intracranial, Decreased • 451
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for factors contributing to altered intracranial Thorough evaluation for contributing factors allows for
pressure including medical/physiologic deviation and early detection of complications.
related issues, especially positioning, treatments, med-
ications, suctioning, ventilation, etc.
Carry out thorough neurologic assessment according to Deviations from norms will assist in differential workup
the degree of stimulation and movement permitted per and expedite treatment plan.
the infant’s or child’s status.
(care plan continued on page 452)
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452 • Cognitive–Perceptual Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Maintain the head of bed at greater than 30 degrees, with Neutral body alignment will assist in stabilizing the
the head in line with the body, and, ideally, not posi- intracranial adaptation.
tioned from side to side unless specified. (Avoid use of
pillows under the patient’s head.) Recheck every 1 to
2 hours.
Offer a calm, supportive environment with attention Few stimuli will enhance the infant’s or child’s likelihood
to safety of airway maintenance, side rails up with of rest during acute phase, while anticipatory safe-
padding, and availability of emergency equipment guarding will minimize further injury.
according to the infant’s or child’s needs.
Develop a daily plan of care that best matches the devel- Previous skills may not be able to be remastered, or
opmental capacity of the infant or child, yet allows for altered temporarily because of illness in the pediatric
possible regression. [Note plan here.] client.
Incorporate parental input in the daily plan of care as Family will feel valued, and their input will assist in pro-
appropriate. [Note parent preferences here.] viding some familiarity to the infant or child and lessen
effects of multiple caregivers.
Offer time (30 minutes each shift and as needed) for Assists in reducing anxiety, and offers cues regarding
parents to ventilate feelings regarding the infant’s or parental concerns.
child’s status.
Assess caregiver(s) knowledge level for care of the infant Provides a realistic base for teaching needs.
or child.
Provide appropriate teaching regarding equipment, proce- Knowledge allows for acceptance.
dures, surgery, etc. [Note teaching plan here.]
Offer gentle massage, and monitor carefully skin integrity Likelihood of skin breakdown increases when reposition-
and tissue perfusion, especially when the condition ing is limited.
lasts more than 2 days.
Check for potential untoward effects of medications, Likelihood of interaction increases with three or more
and exercise caution in appropriate dilution for IV medications, and inappropriate administration may
administration. likewise cause side effects.
Maintain ongoing communication with the family to offer Trust in caregivers will be enhanced if the family can be
updates on the infant’s or child’s condition. kept abreast of activities on an ongoing basis.
Encourage the parents to bring the infant’s or child’s Familiar favored objects offer a sense of security in an
favorite blanket, small toy, or security object if possible. otherwise foreign setting, thereby reducing stress.
Arrange for appropriate follow-up, including home Appropriate referral will foster long-term continued
health, physical therapy, or neurology, especially when regimen and offer goals over time.10,11
there may be a ventricular peritoneal (V–P) shunt. For
example, including when to notify primary care
provider for possible infection or malfunction.
Women’s Health
For Women’s Health, see Adult Health, except for the following interventions:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Hypertensive Disorders of Pregnancy Gestational hypertensive disorders, including pre-eclamp-
sia and eclampsia, and chronic hypertension compli-
cate pregnancy.13
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Adaptive Capacity, Intracranial, Decreased • 453
ACTIONS/INTERVENTIONS R AT I O N A L E S
Place on continuous intensive monitoring (cardiac and The reason for difficulty in diagnosing hypertension has
fetal). Observe blood pressure, urine output, reflexes, been a lack of standardization in blood pressure meas-
headache, visual problems, irritability/changes in urement. It is important for the health care provider to
affect, and epigastric pain.7,8 establish a baseline and monitor throughout the preg-
nancy.12,13
Progression from pre-eclampsia to severe pre-eclampsia Monitor maternal parameters:
to eclampsia can occur. Pre-eclampsia—usually occurs after the 20th week of
pregnancy, gestational hypertension plus presence of
proteinuria.
Severe pre-eclampsia—systolic 160 mmHg
Diastolic blood pressure 110 mmHg, plus proteinuria,
plus oliguria, cerebral or visual disturbances, hepatic
involvement, thrombocytopenia and pulmonary or
cardiac involvement.
Eclampsia—onset of seizure activity or coma with no his-
tory of existing pathology.13
To prevent progression to eclampsia: Reduction of external stimuli can reduce or prevent con-
• Place in a darkened, quiet environment, to decrease vulsions in these patients. They need the reduction of
external stimuli. light to lessen eye pain and headache.
• Constantly monitor signs and symptoms of progression
of disease.
Place padded tongue blade at head of bed. Seizure precautions and medications close at hand to use
Suction equipment and oxygen should be available, and quickly. As this disease can progress quickly, even
emergency medication tray and emergency birth pack when every precaution is taken.13
should be accessible.
Carefully monitor magnesium sulfate (MgSO4) levels, if Often lethargy and confusion are the result of MgSO4
appropriate, for therapeutic dose and/or toxicity. therapy for eclampsia.
Monitor fetal heart tone (FHT).
Assist the patient in orientation to time and place.
Do not allow the patient to ambulate alone. Provide assis- These patients feel out of control, lethargic, and confused
tance. Provide a bedside commode. and cannot remember what has just been said to them
as a result of both the convulsion and the medication.
They need specific direction and a lot of support and
understanding.
HELLP Syndrome: laboratory diagnosis for variant of Associated with increased risk for both mother and fetus,
severe preeclampsia that involves hepatic dysfunction: as well as adverse outcomes. Increased risk for pla-
Hemolysis (H) centa abruption, renal failure, preterm birth and fetal
Elevated liver enzymes (EL) or maternal death.13,14
Low platelets (LP)
Newborn
Carefully assess the newborn for cranial injury.
Carefully examine the infant’s skull. Note the anterior
and posterior fontanels. Be especially alert for a
bulging anterior fontanel indicative of:
• Increased intracranial pressure
• Major hemorrhage
• Hydrocephalus
(care plan continued on page 454)
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454 • Cognitive–Perceptual Pattern
Mental Health
The nursing actions for Mental Health for this diagnosis are the same as the actions presented in the Adult Health section.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Maintain the head in a neutral position, even while the Prevents increases in pressure from flexion or extension
patient is side-lying. of the head.
● N O T E : Nursing interventions found in the Adult Health section are appropriate to
this age group. Caution must be used because of the potential for problems regarding
hydration, hypothermia, pupillary reaction, deficits related to eye surgery, and risk for
sensory deprivation with decreased activity.
Home Health
See Adult Health care plan. If the patient with this diagnosis is living in the home, professional home care will be required.
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Confusion, Acute and Chronic • 455
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Copyright © 2007 •by F. A. Davis.
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456 • Cognitive–Perceptual Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the family about the patient’s condition and how to Assists the family in understanding changes in the
interact more effectively with the patient; i.e., provide patient’s orientation, cognition, and behavior. Increases
ongoing orientation to surroundings and happenings the family’s sense of competency in relating to the
within the family. patient.
Recognize family responses to the patient’s condition, Family members often feel anxious and helpless
and teach about reasons for condition and how to about the patient’s behavior. Teaching reasons for
respond during acute episodes. the patient’s condition and how to respond decreases
anxiety and may help decrease the patient’s confu-
sion.
Refer to psychiatric-mental health clinical nurse specialist The psychiatric-mental health CNS has the expertise to
(CNS). Make other referrals to community agencies as collaborate with the adult health nurse to plan nursing
needed, i.e., Alzheimer’s support group, adult day care, interventions for the patient that will help the patient
Meals-on-Wheels, etc. and nursing staff deal with chronic confusion in the
acute care setting.
Child Health11,16
Although intended for the population older than 60 years of age, confusion may occur in younger people as well, as a
result of similar causes. Uncertainty may be greater regarding potential for recovery because of age, exact cause of prob-
lem, and so on.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Acute
Monitor for potential contributory factors, especially as A thorough assessment offers the best basis for identifica-
applicable: tion and treatment of confusion.
• Prenatal influences, i.e., drugs, sepsis
• Previous health status
• Known conditions, whether or not requiring treatment
• Triggering event, trauma, surgery, emotional event
• Daily routine or alterations
Determine with the parents previous patterns of develop- Parents are best able to provide previous development
ment, and develop daily plan of care within capacity capacity cues within level of comfort for the infant or
offered by the infant’s or child’s status. child, thus enhancing likelihood of sense of security
for all.
Identify current plan of care to best suit the infant’s or Best holistic plan of care reflects expertise of all which
child’s capacities with input from all members of the best know and interact with the infant or child.
health-care team, especially the parents.
Offer treatment within developmentally appropriate In all situations there is greater likelihood of success in
framework of the infant or child. care when the infant or child is approached from devel-
opmentally appropriate stance to afford a sense of
security.
Provide a safe and calm environment with stimuli best An environment that is safe and developmentally appro-
suited to the infant’s or child’s needs. priate provides freedom from injury while allowing the
infant or child to recover.
Offer the parents realistic plans for the infant or child Parents will better be able to trust and accept the infant’s
with frequent updates. or child’s status and caregivers when trusting relation-
ships are based on communication that is honest and
forthright.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide 30 minutes each shift for the parents to ventilate Helps reduce anxiety, and offers cues to parental con-
feelings about the infant or child. cerns.
Identify discharge and follow-up needs with attention to Support for the parents upon the family’s return to home
all members of the health-care team. will help maintain plan for care and thereby attain ther-
apeutic goals.
Chronic
Offer resources for support groups and advocacy interest Specific support groups will assist the parents in dealing
opportunities. with situation represented by the infant’s or child’s
status.
Explore specific patterns of daily care needs and how best Realistic demands will best direct care according to time
to offer care within domain of resources available. and constraints.
Note risk for caregiver role strain due to demands
over time.
Women’s Health
See nursing actions for Adult Health.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Acute
● N O T E : Mental health clients at risk for this diagnosis include:
Patients taking the following substances: lithium, Compendium of psychotropic drugs-fast reference for
antianxiety agents, anticholinergics, phenothiazine, health-care provider.17
barbiturates, methyldopa, disulfiram, alcohol, cocaine,
amphetamines, opiates, and hallucinogenics.
Patients experiencing drug withdrawal, electroconvulsive
therapy (ECT) treatments, dementia, dissociative disor-
ders, mood disorders, and thought disorders, and eld-
erly clients with acute infections such as urinary tract
infections.
Place the client in an environment with appropriate stim- Increases patient safety and promotes orientation.18,19
uli. Note level of stimulation and alterations in envi-
ronmental stimuli here. For example, specific objects in
the environment that stimulate illusions should be
removed; appropriate lighting, clocks and calendars,
and holiday decorations should be used. Refer to day,
date, and other orienting information during each inter-
action with the client.
Assign the client a room that provides opportunities for Promotes client safety and decreases environmental stim-
careful observation but is not a chaotic environment. uli. High levels of stimuli can increase confusion and
hyperactivity.17,20,21
Place identifying information on the patient and the Promotes safety and orientation.
patient’s room. Utilize the patient’s preferred name in
each interaction. [Note that name here.]
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Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Remove harmful objects from the environment. This Protects the client from falls and accidental injury.
could include objects in walkways, cords, belts, and Clients attempting to free themselves can fall or be
raised bedrails or other restraining devices. During injured on the restraints.18 Promotes client safety.
periods of increased agitation, one-to-one observation
should be instituted.
Assign primary care nurse each shift. [Note those persons Promotes client orientation by providing familiar environ-
here.] ment.19,20
Communicate with the client using a moderate rate Decreases ambiguity, prevents information overload, and
of speech and simple sentences without many ques- provides the time necessary for the client to process
tions. Allow time for responding, and avoid indefinite information, which preserves self-esteem, decreases
pronouns. anxiety, and improves orientation.22
Observe every [number] minutes. Inform the client of this Promotes client safety. Provides opportunities to reorient
schedule, and provide the client with written informa- the client to here and now and to ensure client
tion as necessary. Provide this schedule in written comfort.21 Promotes the client’s sense of control.
form, i.e., written on a white board in the client’s
room. [Note information necessary for the client here.]
Replace the use of physical restraints with one-to-one Promotes safety and the client’s self-esteem by maintain-
observation, comfort measures, recliners, appropriate ing personal control and dignity. Frequent use of
physical activity, visual barriers, secure unit, lower bed restraints can encourage clients to assume a passive
or bed on floor. [Note here those interventions specific approach to avoid further restraint or as an adaptation
to this client.]18 to daily use of restraints. At times, physical restraints
may increase agitation.18,21,23
If physical restraints are used, check circulation at least Promotes client safety, sense of personal control, and
every 15 minutes, remove restraint from one limb self-esteem.19,24 Promotes physical comfort, which
at a time at least every 2 hours, and provide ROM, decreases agitation.
opportunities to void, nourishment, brief clear expla-
nations about the purpose of the restraint, and infor-
mation about when they will be removed during each
interaction.
Utilize touch as appropriate to the client. [Note the Clients’ touch preferences are very personal. Some clients
client’s preferences here.] may find it comforting, whereas others may perceive it
as an intrusion and respond with increased agitation.21
Administer antipsychotic medication only if neurologic Antipsychotic medications can increase confusion. These
status indicates that this will not increase confusion. medications can also produce orthostatic hypotension,
increasing the client’s fall risk.17,18
Provide daily routine that closely resembles the client’s Promotes orientation; increases the client’s sense of per-
normal schedule. [Note that schedule here.] sonal control.
Provide whatever aids the client needs to adequately per- Promotes orientation to the environment and sense of per-
ceive the environment (hearing or vision). [Note neces- sonal control.
sary aids here and location for storing when not in use
by the client.]
Assess mental status through normal interactions with the Repeated questioning can increase the client’s confusion,
client. Do not use formal mental status examinations and inability to answer questions may have negative
unless absolutely necessary. [Note method and sched- impact on self-esteem.19,24
ule for assessment here.]
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Confusion, Acute and Chronic • 459
ACTIONS/INTERVENTIONS R AT I O N A L E S
Limit the client’s choices, and provide information or Increases orientation while preserving the client’s self-
direction in brief, simple sentences. Note the level of esteem. Large amounts of information provided at one
the client’s ability to process information here (e.g., the time can increase confusion and agitation.19,21
client can choose between two items). Support optimal
cognitive functioning by: [Note here those interven-
tions to be used with this client.]
• Responding to the client’s confused verbalizations Increased anxiety can increase confusion and
(delusions, hallucinations, confabulations, illusions, agitation.19,21
etc.) in a calm manner
• Utilizing refocusing and/or responding to the feelings Maintains self-esteem, relieves anxiety, and orients to
underlying the content to respond to confused verbal- present reality.25
izations
• Utilizing “I” messages rather than arguments to reori- Meets the client’s esteem needs by communicating
ent when necessary. respect while providing orientation.19,24,25 Promotes
here-and-now orientation.19
• Providing clothing that is appropriate to time of day
and situation (e.g., night clothes at night and street
clothes during the day)
• Scheduling participation in groups that provide oppor- Promotes here-and-now orientation. Provides opportuni-
tunities to remember, review current events, discuss ties to maintain current cognitive skills.19,25
seasonal activities, and socialize. [Note here the sched-
ule and appropriate groups for this client.]
• Providing measures that promote rest and sleep. [Note Inadequate sleep can increase confusion and disori-
here those measures that are specific for this client with entation.19
schedule for implementation.]
Provide clear feedback on appropriate behavior. Refer to Positive reinforcement encourages behavior. Realistic
Risk for Violence if the client is at risk for violent goals increase opportunities for success, providing pos-
behavior toward self or others. Assess expectations for itive reinforcement and enhancing self-esteem.
being realistic with the client’s abilities. [Note limits to
be set here with specific consequences for unwanted
behaviors and specific reinforcers for desired behaviors.]
Provide support system with information about the client Provides support system with positive coping strategies
and how to best approach the client. Note here the that enhance the client’s functioning.
information to be provided and responsible person.
Chronic
● N O T E : Mental health clients at risk for this diagnosis include those with Alzheimer’s
disease, Korsakoff’s psychosis, and AIDS dementia. In addition to those interventions for
acute confusion, the following interventions are included. It is important to remember
that the primary difference between these two diagnoses is the irreversibility of the cog-
nitive deficits in this diagnosis. It is also important to assess the client for depression,
because depression can appear as those illnesses that are related to this diagnosis, espe-
cially in elderly clients.
Maintain familiar environment:
• Provide objects from the client’s home environment, to Promotes orientation while promoting sense of safety and
include pictures, personal bedding, personal clothing, security.22
music, and other special objects with personal meaning.
Note those objects important to the client here, with the
nursing actions necessary to maintain the objects.
• Label room with name in large letters and a familiar Maintains orientation while promoting a sense of per-
picture or item. sonal control by maintaining independence.19,24
(care plan continued on page 460)
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460 • Cognitive–Perceptual Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Provide the same room for the entire hospital stay. Maintains orientation by providing continuity of sur-
Assign primary care personnel. [Note those persons roundings and staff familiar with the client’s needs,
here.] perspective, and treatment plan. Excessive stimulation
can exacerbate cognitive or behavioral problems.
• Provide structured daily routines, and note the client’s Promotes orientation by providing familiarity.18,26
routine here. This should parallel prehospital routine as
much as possible.
Provide opportunities for the client to be involved in rem- Provide opportunities for clients to interact using current
iniscence, remotivation, current events, socialization, cognitive skills, which helps decrease anxiety, maintain
and other groups as appropriate by providing the client dignity, and prevent further deterioration and with-
with assistance needed to get to the groups. [Note the drawal.25
client’s group schedule here, with the assistance
needed from nursing staff.]
Spend [number] minutes [number] times a day discussing Promotes positive reorientation, maintains the client’s
the client’s past experiences. This activity can be facili- dignity, and promotes positive self-esteem. It is impor-
tated with music, family photographs, and other items tant to note that some clients may have a great deal of
that elicit memories. Note the client’s response to this difficulty coping with past experiences. If this process
activity, and if it appears to increase stress, discon- increases anxiety, the activity should be discontinued,
tinue. The process of this interaction is to provide posi- because high levels of anxiety can increase confusion.
tive cognitive reframes of past experiences.
Identify and control underlying causes or triggers of Preserves the client’s dignity and sense of control.26 Each
increased cognitive and behavioral problems. This of these factors can decrease the client’s ability to
could include limiting visitors or certain topics of con- cope.
versation, increasing rest or providing rest periods dur-
ing the day, and ensuring adequate hydration. [Note the
special adaptations here.]
Utilize nonconfrontational approaches for dealing with Maintains the client’s dignity, and recognizes the limita-
behavior extremes. This could include changing the tions of cognitive abilities.26
client’s context, responding to the feelings being
expressed, or meeting comfort needs. [Note here those
responses that are most effective for the client.]
Spend [number] minutes [number] times a day with the Positive environmental cues from staff have been shown
client doing activities (this should be some activity to decrease problematic behaviors in these clients.27
the client enjoys and that provides an opportunity for
success).
Spend [number] minutes [number] times a day involved Increased physical activity decreases wandering behavior
in [type] exercise with the client. (Choose an exercise and improves the client’s rest.23,27
the client enjoys and that involves large motor activity
if at all possible.)
Retrieve and divert the client when wandering behavior Decreases the client’s wandering behaviors.27
presents risk or takes her or him into unobserved areas.
Schedule meetings with the primary care provider before Facilitates support for caregivers and prevents caregiver
discharge to teach effective behavior management tech- “burnout”.19
niques and develop a plan for care at home. This
should include respite for the caregiver. [Note plan
here.]
Refer to community agencies that will facilitate ongoing
care. [Note agencies here.]
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Confusion, Acute and Chronic • 461
Gerontic Health
● N O T E : Aging clients may experience age-related changes in memory to include for-
getting specific details but remembering them later, ability to learn new information with
some difficulty in information retrieval, a general awareness of memory impairment, and
memory impairment that does not affect daily life. Causes of confusion should be ruled
out upon identification of new onset confusion. Causes may include metabolic diseases,
infection, neoplasm, drug side effects, nutritional deficiencies, and cerebrovascular
injury. Alzheimer dementia is possible with new onset confusion and should be ruled out
as well.
Goals for clients with confusion may not necessarily need to include reversal of
confusion. Rather, assisting the confused client and caregiver to feel safe, comfortable
and in control is a worthy goal.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review pertinent laboratory work for possible Acute confusion may be related to changes in elec-
imbalances. trolytes, glucose, or drug levels.
Obtain medication list from the client or family of all pre- Medications are a frequent precipitant for acute confu-
scribed and over-the-counter (OTC) medications used sion, especially in the very young or old.
by the client.
Decrease extraneous audible–visual input. Provide low- Decreases sensory overload and need to cope with a
stimuli environment. complex and noisy environment.
Provide orienting cues to the physical layout of the care Promotes independence.
site (such as universal symbols for the bathroom, eat-
ing area, and the client’s room).
Provide personalized surroundings (familiar pictures, Promotes identification with self.
clothing, or mementos).
Use a client photograph to identify personal space. Increases connectedness with self. Provides sense of
belonging.
Address the client by preferred name at each contact. Reinforces sense of self.
Introduce self by name at each contact. Provides sense of the familiar.
Arrange for the family or significant others to be avail- Provides for familiar person in the care setting.
able during periods of increased anxiety or agitation.
Use name and orienting cues in conversations. Enhances sense of self and connectedness.
Provide physical contact and/or comfort along with Decreases anxiety generated when trying to cope with
verbal interactions. threatening environment. Assists the client in sorting
out environment and setting.
Explore and explain briefly equipment used in care. Decreases fearfulness.
Use familiar objects for activities such as glasses or cups Decreases complexity of coping with the unfamiliar.
for fluids rather than styrofoam cups or paper or plastic
cartons.
Assign consistent caregivers. Provides sense of security.
Limit choices to two in situations where the client must Decreases stress of too many choices.
make decisions such as dressing or eating.
Provide positive feedback for independent function. Promotes self-esteem.
Ensure quiet time or rest periods during the day. Decreases stress.
Approach and work with the client in an unhurried Sense of urgency associated with speed perceived as
manner. threatening.
Provide information in simple sentences, and allow time Decreases complexity.
for the client to process information.
(care plan continued on page 462)
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462 • Cognitive–Perceptual Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
If repetition is needed, repeat information in the exact Allows for processing of information.
manner as originally stated.
Encourage participation in failure-free activities such as Enhances self-esteem.
singing, exercise, or uncomplicated crafts.
Monitor mental status for changes at least daily and every
shift in acute care setting.
Monitor for increased confusion related to new medica-
tion usage.
Chronic (Often Alzheimer dementia)
Retrieve and divert the client when wandering behavior Decreases the client’s wandering behaviors.27
presents risk or takes her or him into unobserved areas.
Assess for expression of intent, “I’m going home now,”
and the expression of loss of a valued adult role, “The
children need me now.”28
Modify the environment to provide adequate rest, safety, Eliminate possible preciptators of confusion.
and sleep for the client.28
Provide client with essential sensory aides such as Prevents possible sensory confusion.28
glasses, dentures, and hearing aids.
Avoid chemical and physical restraints. These can increase confusion and agitation. These do not
stop the urge to wander and may exacerbate the urge to
wander by decreasing the client’s perception of safety.
These measures may contribute to client injury.28
Schedule and maintain a regular toileting schedule. [Note Eliminate possible precipitators of confusion and
schedule here.] wandering.
Provide information to all staff that a client is a wanderer. Prevention of injury related to wandering.
Develop a mechanism for identification and a plan to
follow if a wandering client is missing.28
Use grid-like markings in front of doorways. May prevent a client from exiting due to a change in
visual cues.28
Home Health
● N O T E : Onset of acute confusion may be an emergency requiring immediate referral
for care.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Rule out possible causes of confusion: Understanding the cause of confusion determines the best
• Drugs intervention.
• Hypoxia
• Pain or discomfort
• Full bladder or urinary tract infection
• Bowel impaction
• Infection (particularly pulmonary or urinary). Keep in
mind that elder clients may not exhibit typical signs of
infection.
• Alcohol or benzodiazepine withdrawal
• Extreme anxiety
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Decisional Conflict (Specify) • 463
ACTIONS/INTERVENTIONS R AT I O N A L E S
Offer explanation and support to the family members and Confusion is difficult to cope with at home and can be
caregivers. distressing to family members.
Encourage the family members and caregivers to maxi- Some effective communication can still occur if the client
mize communication with the client during lucid inter- experiences lucid intervals.
vals. Critical information should be exchanged during
these times.
Help the family members and caregivers identify and Understanding the cause of confusion determines the best
cope with impending death if confusion is occurring in intervention.
the last hours of life. Terminal confusion, a condition
common to impending death, is best treated with mor-
phine, chlorpromazine, and scopolamine.29
Assist the client and family in identifying lifestyle Home-based care requires involvement of the family.
changes that may be required: Acute confusion disrupts family schedules and role
• Treatment or prevention of underlying problem (sub- relationships. Adjustments in family activities and roles
stance abuse, infection, pain, or nutritional deficits) may be required.
• Providing for rest periods
• Providing safe environment
• Providing environmental cues to orient the patient (e.g.,
clocks, calendars, photos, familiar objects).
• Provide assistive resources as required to include: Decreased vision or hearing acuity may contribute to con-
• Glasses fusion.
• Hearing aids
• Clocks with large numbers
• Family response to changing behavior and mental sta-
tus of the affected person
Assist the family to set criteria to help them determine Provides the family with background knowledge to seek
when additional intervention is required, for example, appropriate assistance as need arises.
change in baseline behavior.
Refer the patient to appropriate assistive resources as Additional assistance may be required for the family to
indicated. care for the acutely confused person. Use of readily
available resources is cost-effective.
DECISIONAL CONFLICT (SPECIFY) 8. Questioning personal values and beliefs while attempt-
ing a decision
DEFINITION2
The state of uncertainty about course of action to be taken RELATED FACTORS2
when choice among competing actions involves risk, loss, or
challenge to personal life values.2 1. Support system deficit
2. Perceived threat to value system
DEFINING CHARACTERISTICS2 3. Multiple or divergent sources of information
4. Lack of relevant information
1. Verbalization of undesired consequences of alternative 5. Unclear personal values or beliefs
actions being considered 6. Lack of experience or presence of interference with
2. Verbalized uncertainty about choices decision making
3. Vacillation between alternative choices
4. Delayed decision making
RELATED CLINICAL CONCERNS
5. Verbalized feeling of distress while attempting a
decision 1. Any surgery causing body image change
6. Self-focusing 2. Any illness carrying a potential terminal prognosis
7. Physical signs of distress or tension (e.g., increased 3. Any chronic disease
heart rate, increased muscle tension, restlessness) 4. Dementia
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Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine who will intervene on behalf of the infant or For legal and ethical reasons, it is essential to clarify
child: parents or appointed legal guardian. [Note that when the parent(s) are unable to assume the parental
person here.] role and obligations and to make this fact known to all
involved in the child’s care. It is likewise essential for
all caregivers to know who is the legal guardian or
spokesperson.
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Decisional Conflict (Specify) • 465
ACTIONS/INTERVENTIONS R AT I O N A L E S
In instances of conflicting decision makers, ensure that Irrespective of conflicts in decision making, the infant or
the child’s rights are protected according to legal child is entitled to appropriate care. In extreme cases of
statutes. conflict, a state or local judge may appoint guardians
or foster parents to assume decision making regarding
health matters. In other instances (e.g., withholding
suggested treatment because of religious beliefs), indi-
vidual statutes, and precedents must be sought by the
parties involved.
Ensure that appropriate documentation is carried out Legal documentation according to health care decisions
according to situational needs. and related matters is to be carried out as standard
care, with attention to the mandates of the institution
regarding appropriate paper forms to complete.
Although the child may be ill equipped or unable to par- Early involvement in decision making fosters safe support
ticipate fully in decision-making, facilitate develop- for the child, thereby increasing the likelihood of learn-
mentally appropriate involvement of the child in ing effective coping behaviors. Will also empower the
decision-making. In these interactions, teach the child child and foster a positive self-image.
decision-making skills.
Be certain that choices or options indeed exist when the Preferences and individualization will be realistically val-
child is allowed to exercise decision-making. ued when there is choice or options in the care plan. It
is unethical to indicate there are choices when none
exist (e.g., medication cannot be given by any other
route but intramuscular).
Provide behavioral reinforcement that best fosters learn- Appropriate reinforcement will serve to enhance learning
ing with appropriate follow-up when the child is and assist the patient in growth in decision-making.
involved in decisional conflict. [Note behaviors to be
reinforced and reinforcers here.]
Explore with the child and support system potential long- Decision making often has far-reaching effects (e.g., in
term residual effects related to specific decisional con- early childhood, values of a lifetime are formulated).
flict for the child or family. Appropriate regard to this fact should guide all
involved in this aspect of child-rearing and supportive
aspects of health care.30
Women’s Health
Unwanted Pregnancy
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide an atmosphere that encourages the patient to Provides information that allows the patient to make an
view her options in the event of an unwanted preg- informed choice.45
nancy. Assure the patient of confidentiality.
Give clear, concise, complete information to the patient,
describing the choices available to her:
• Carrying the pregnancy and keeping the infant
• Adoption of the infant
• Abortion
Discuss the advantages and disadvantages of each option
with the patient.
Encourage the patient to discuss beliefs and practices in a
nonthreatening atmosphere, and include significant oth-
ers in the conversation and decision as the patient
desires.
(care plan continued on page 466)
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466 • Cognitive–Perceptual Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Refer the patient to the proper agency for guidance and
treatment.
Discuss and review with the patient the different methods Provides information and support to assist the patient in
of birth control. planning future pregnancies.31
Assess the patient’s ability to correctly use the different
methods of birth control.
Provide factual information, listing the advantages and
disadvantages of each method.
Provide the patient information on obtaining her method
of choice.
Explore with the patient and significant other their views
on children and family.
Women’s Health
Less-Than-Perfect Infant
● N O T E : Families faced with the birth of a child with congenital anomalies or devel-
opmental defects experience decisional conflict and great confusion about choices that
need to be made. Often there is a sense of urgency, because decisions need to be made
quickly to save the life of the infant. Many times the infant was delivered by cesarean
section, and it is the mother’s partner who, alone, must often make crucial decisions that
could affect the family and the life of the infant. Parents experience not only confusion,
fear, guilt, and helplessness, but also feelings of inadequacy as parents.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide accurate information to the parents as soon as Provides information and supportive environment that
possible. helps the parents make decisions.32,33
Stillborn or Fetal Demise
Let the parents see and hold the infant if at all possible. Promotes bonding and provides comfort for both the par-
ents and infant.
Support the parents in their grieving process for the loss
of the perfect infant, and perhaps the death of the
infant.34,35
Keep the parents informed continuously, and encourage
the health-care team to talk to them often.
Contact significant persons, of the parents’ choice, who
can come and be of support to them.36
Give the parents a private place to be with their support
persons.
Encourage the parents to visit the infant in the neonatal
intensive care unit (NICU) as often as possible.
Collaborate with NICU staff to plan activities that allow
the mother and infant to spend as much time together
as much as possible.
Refer to support groups and agencies as needed for Support is essential in resolving decisional conflict.
follow-up care when leaving hospital.37,38
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Decisional Conflict (Specify) • 467
Mental Health
● N O T E : The client who is experiencing a decisional conflict is faced with confusion
about alternative solutions. When assisting these clients, the nurse should be careful not
to connote the client’s confusion negatively. Various authors 39–41 have supported the
positive role confusion plays in the change process. Erickson39 frequently encouraged
confusion as a way to distract the conscious mind and allow the unconscious to develop
solutions. It is from this theoretical base that the following interventions are developed.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assure the client that the difficulty he or she is experienc- Promotes positive orientation, self-worth, and hope.
ing in decision-making is positive in that it has placed
him or her in a position to look for new creative solu-
tions. If he or she were not experiencing this difficulty,
he or she might be tempted to remain in the same old
problem solution set.
Assist the client in reducing the pressure of time on mak-
ing a decision.
Have the client explain the time he or she has given him- Provides time to develop alternative problem solutions,
or herself to make a decision. Asking the client the fol- and decreases stress on the client.
lowing question may assist in this process: “What is
the worst that will happen if a decision is not made
right now?”
Sit with the client for [number] minutes twice per day to Aids in understanding the client’s perception of the
discuss the information and perceptions she or he has situation.
regarding the current situation and possible solutions.
As the client explores the situation, the remaining
interventions can be added to these discussions.
Have the client explore feelings related to the choices and The client’s cognitive style and feelings about the situa-
the information related to the choices. This process tion affect his or her appraisal of both the situation and
may extend over several days. The client may be reluc- possible solutions.42
tant to verbalize negative feelings related to certain
choices if a trusting relationship has not yet been
developed with the nurse.
Have the client discuss how significant others think and Support system involvement increases the probability of
feel about the various choices. Have the client evaluate positive outcomes.
the impact of the feelings of significant others on his or
her decision-making process.
Have the client fantasize an ideal choice. Accesses creative problem solutions that bypass the
client’s self-imposed limits.
Have the client construct a list of solutions (at least 20)
that would produce the ideal choice. (These solutions
are not to be evaluated at this time.) Encourage the
client to develop some unrealistic solutions. This may
be promoted by asking the client what he or she might
tell a friend to do in this situation or by having the
client generate three magic-wish solutions (e.g., “If
you had a magic wand, what would you do to resolve
this situation?”)
Sort through developed list with the client generating solu-
tions from the ones listed. At this time, the client can
begin to combine and eliminate ideas after evaluation.
Carefully evaluate each solution before it is eliminated.
What appears to be a bizarre solution can become useful
when altered or combined with another idea.
(care plan continued on page 468)
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Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
As each idea is evaluated, provide all information neces- Aids in assessing the client’s commitment to each possi-
sary to evaluate the idea. ble solution.
Explore the client’s thoughts and feelings about each idea.
Remind the client that there are no perfect answers and Promotes positive orientation, self-worth, and hope for
that each of us makes the best choice that can be made the future.
at the time.
Remind the client that if a choice that is made does Promotes positive orientation.
not resolve the problem, alternative solutions can
then be tried.
Remind the client that a solution that does not work
provides more information about the problem that
can be used in developing future solutions.
Meet with the client and support system to allow the Support system involvement increases the probability of
support system to be a part of the decision-making positive outcome.
process, if appropriate.
Discuss with the client and support system any secondary Assesses for positive reinforcement for not resolving
gains from not making a decision. problem.
Once a decision is made, have the client develop a behav- Having a plan to cope with the anticipated situations pro-
ioral plan for implementation. [Note that plan here.] motes a perception of greater control over future situa-
tions and increases the probability of the client’s
enacting new coping behaviors.
Gerontic Health
In addition to the following interventions, the interventions for Adult Health can be applied to the aging client. Decision-
making capacity is defined as possessing a set of values and goals, being able to communicate and understand informa-
tion, and having the ability to reason and deliberate about one’s choices.43 The mere presence of aging should not imply
impaired decision-making capacity. In the absence of dementia, older adults are usually capable of adequate decision-
making independently or with assistance.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss with the patient prior examples of Decisional Emphasizes ability to problem solve, and reinforces
Conflict and their outcomes. successes.
Assess for the presence of dementia May affect the client’s ability to make sound decisions.
Assess for the presence of legal documents granting Surrogate decision makers may already be in place.
durable power of attorney for health care in new
clients.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family measures to decrease Appropriate knowledge and values clarification between
Decisional Conflict: the client and family will reduce conflict.
• Providing appropriate health information
• Joining a support group
• Clarifying values
• Performing stress reduction activities
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Seeking spiritual or legal assistance as needed
• Identifying useful sources of information
Assist the client and family in identifying risk factors Early identification of risk factors provides opportunity
pertinent to the situation: for early intervention.
• Lack of knowledge
• Developmental or situational crisis
• Role confusion
• Excess stress
• Excess stimuli
Answer questions about a terminal diagnosis and progno- Develops trusting relationship, and helps clients make
sis with honesty and sensitivity. well-informed decisions.
Consult with or refer the patient to appropriate assistive Use of the network of existing community services pro-
resources as indicated. vides for effective utilization of resources.
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470 • Cognitive–Perceptual Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Identify self and the patient by name at each interaction. Short-term memory loss necessitates frequent orientation
to person, time, and environment.
Speak slowly and clearly in short, simple words and sen- Allows time for information processing, and avoids use
tences. of complex statements and abstract ideas.
When the patient is delusional, focus on underlying feel- Recognizing and acknowledging feelings may decrease
ings and reinforce reality (have clocks, calendars, etc. the client’s anxiety and give a sense of being under-
on the wall). Do not argue with the patient. stood. Arguing may increase the patient’s anxiety and
reinforce intensity delusions.44
If the patient becomes aggressive, focus on underlying Focusing on feelings increases the patient’s feelings of
feelings and attempt to refocus interaction on topics being understood, and discussing nonthreatening topics
more acceptable and/or less threatening to the patient. increases the patient’s sense of competency and self-
esteem.
Keep the patient’s room well lighted. Maintain a calm Decreases possibility of environmental sensory misrepre-
environment. sentations, and helps meet patient safety needs.
Teach the family about the patient’s condition and how to Assists the family in understanding changes in the
interact more effectively with the patient; i.e., provide patient’s orientation, cognition, and behavior. Increases
ongoing orientation to surroundings and happenings the family’s sense of competency in relating to the
within the family. patient.
Refer to psychiatric–mental health CNS. Make other The psychiatric-mental health CNS has the expertise to
referrals to community agencies as needed, i.e., collaborate with the adult health nurse to plan nursing
Alzheimer’s support group, adult day care, Meals-on- interventions for the patient that will help the patient
Wheels, etc. and nursing staff deal with chronic confusion in the
acute care setting.
Child Health
This diagnosis may present in children also. If so, the same basic plan of care as that of adults should be implemented,
with attention to safe, developmentally appropriate interventions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for parental–infant reciprocity to determine Reciprocity will offer cues as to what match does or does
nature of parent–infant or parent–child relationship. not exist in the relationship.
When there may be a genetic concern, offer appropriate When a genetic component exists, there is an obligation
counseling. for present and futuristic planning by all involved.
Offer [number] minutes each shift for the parents to ven- Offers reduction in anxiety, plus an opportunity to note
tilate specific concerns regarding the infant or child. parental concerns.
Explore all contributing factors, especially underlying Provides a comprehensive base for plan.
medical status or deviation in behavior.
Provided environmental adaptations to protect from self- Provides anticipatory safety.
injury. [Note those adaptations necessary here.]
Provide routine of care with attention to caregiver(s) Values parental input.
input.
Seek assistance from primary care health team members, Satisfies need for special care.
especially pediatric psychiatrist, child life specialist,
and pediatrician, as appropriate.
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Environmental Interpretation Syndrome, Impaired • 471
Women’s Health
See Adult Health nursing actions.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the client’s level of anxiety and refer to Anxiety Increased anxiety can negatively impact memory and ori-
(Chapter 8) for detailed interventions related to this entation and contribute to further deficits.
diagnosis.
Place the client in an environment with appropriate stim- Increases patient safety and promotes orientation.
uli. Note level of stimulation and alterations in envi-
ronmental stimuli here; i.e., specific objects in the
environment that stimulate illusions should be
removed, and appropriate lighting, clocks, calendars,
and holiday decorations should be provided. Refer to
day, date, and other orientating information during
each interaction with the client.
Place identifying information on the patient and the Provides safety and promotes orientation.
patient’s room. Utilize the client’s preferred name in
each interaction. [Note that name here.]
Remove harmful objects from the environment. This Protects the client from falls and accidental injury.
could include objects in walkways, cords, belts, and
raised bedrails or other restraining devices. Note here
special precautions for this client.
Assign primary care nurse each shift. Note those persons Promotes client orientation by providing familiar
here. environment.
Observe every [number] minutes. Inform the client of this Promotes client safety. Provides opportunities to reorient
schedule, and provide the client with written informa- the client to here and now and to ensure client comfort.
tion as necessary. Note information necessary for the Promotes the client’s sense of control.
client here. If the client is depressed, this observation
may be increased because of increased risk for self-
harm. Refer to Risk for Violence (Chapter 9) for spe-
cific interventions.
Provide daily routine that closely resembles the client’s Promotes orientation, and increases the client’s sense of
normal schedule. [Note that schedule here.] personal control and orientation.
Assess mental status through normal interactions with the Repeated questioning can increase the client’s confusion,
client. Do not use formal mental status examinations and inability to answer questions may have negative
unless absolutely necessary. [Note here method and impact on self-esteem.
schedule for assessment.]
Limit the client’s choices, and provide information or High levels of stimulation can increase confusion, and
direction in brief, simple sentences. [Note here the inability to make choices may have negative impact on
level of the client’s ability to process information (e.g., the client’s self-esteem.
the client can choose between two items).]
Keep initial interactions short but frequent. Speak to the Too much information can increase the client’s confusion
client in brief, clear sentences. [Note frequency and and disorganization.
length of interactions here.]
Utilize “I” messages, rather than argument, to reorient Meets the client’s esteem needs by communicating
when necessary. respect while providing orientation. Promotes here-
and-now orientation.
Respond to confused verbalizations by responding to the Maintains self-esteem, relieves anxiety, and orients to
feelings being expressed. present reality.
(care plan continued on page 472)
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472 • Cognitive–Perceptual Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
When the client’s ability to tolerate more complex situa- Promotes here-and-now orientation. Provides opportuni-
tions increases, schedule his or her participation in ties to maintain current cognitive skills.
groups that provide opportunities to remember, review
current events, discuss seasonal activities, and social-
ize. [Note here the schedule and appropriate groups for
this client.]
Provide clear feedback on appropriate behavior. Set Positive reinforcement encourages behavior. Realistic
behavior goals that the client can achieve. [Note here goals increase opportunities for success, providing pos-
the behaviors that are to be rewarded and the rewards itive reinforcement and enhancing self-esteem.
that are to be given.]
Spend [number] minutes [number] times a day involved Improves rest and increases natural endorphins.
in exercise with the client. (Choose exercise the client
enjoys and that involves large motor activity if at all
possible.) [Note the specific activity here.]
Spend [number] minutes [number] times per week pro- Family and client involvement enhances effectiveness of
viding information to the client’s support system. Note intervention and promotes community support.
specific information to be provided and person respon-
sible for this activity here.
Refer to community agencies that will provide ongoing
monitoring of client’s condition and support for care-
givers.
Gerontic Health
In addition to the following interventions, the interventions for Adult Health can be applied to the aging client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review mental status examination to identify areas of Depending on examination used, may indicate the client’s
strengths and needs. ability to read, interpret symbols, or process simple
versus complex instructions.
Survey current environment for potential unsafe areas. Correcting unsafe areas decreases potential for client
injury.
Adapt the environment to decrease risk for injury (e.g.,
access to exits, thermal injury potential, or ingestion of
harmful substances).
Instruct the caregiver in environmental adaptations to pro-
vide protective environment.
Use labeling or pictorial symbols to indicate specific Assists the client to interpret environment.
areas or conveniences (such as universal symbols for
food or restrooms or pictures to indicate the client’s
room).
Ensure identification of the client (ID bracelet or Provides means of identification in the event the client
necklace). leaves the care setting.
Provide conversational cues to person, place, and time. Presents information in a nonthreatening manner.
Retrieve and divert the client when wandering behavior Decreases the client’s wandering behaviors.27
presents risk or takes her or him into unobserved areas.
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Environmental Interpretation Syndrome, Impaired • 473
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for expression of intent, “I’m going home now,”
and the expression of loss of a valued adult role, “The
children need me now.”28
Modify the environment to provide adequate rest, safety, Eliminate possible preciptators of confusion.
and sleep for the client.28
Provide client with essential sensory aides such as Prevents possible sensory confusion.28
glasses, dentures, and hearing aids.
Avoid chemical and physical restraints. These can increase confusion and agitation. These do not
stop the urge to wander and may exacerbate the urge to
wander by decreasing the client’s perception of safety.
These measures may contribute to client injury.28
Schedule and maintain a regular toileting schedule. [Note Eliminate possible precipitators of confusion and
schedule here.] wandering.
Provide information to all staff that a client is a wanderer. Prevention of injury related to wandering.
Develop a mechanism for identification and a plan to
follow if a wandering client is missing.28
Use grid like markings in front of doorways. May prevent a client from exiting due to a change in
visual cues.28
Home Health
In addition to the following interventions, the interventions for Adult Health can be applied with the home health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client and family in identifying lifestyle Home-based care requires involvement of the family.
changes that may be required: Impaired interpretation of the environment disrupts
• Provide a consistent care provider. family schedules and role relationships. Adjustments in
• Provide for consistent daily schedule with structured family activities and roles may be required.
activities.
• Have the client wear identification bracelet; put name
in clothing.
• Provide safe environment.
• Provide environmental cues to orient the patient (e.g.,
clocks or calendars).
• Provide assistive resources as required. Decreased vision or hearing acuity may contribute to con-
fusion.
• Monitor family response to changing behavior and
mental status of the affected person.
Assist the family to set criteria to help them determine Provides the family with background knowledge to seek
when additional intervention is required; for example, appropriate assistance as need arises.
help them to recognize signals indicating a change in
their ability to maintain a safe environment.
Offer support to the caregivers and family members: Promotes adaptive coping.
• Teaching about management of behavior
• Self-care strategies
• Community resources
Refer to appropriate assistive resources as indicated. Additional assistance may be required for the family
to care for the family member with Impaired Environ-
mental Interpretive Syndrome.
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Knowledge Deficient (specify) • 475
ACTIONS/INTERVENTIONS R AT I O N A L E S
Explain each procedure as it is being done, and give the Incorporates another teaching method; reduces anxiety,
rationale for procedure and the patient’s role. thus promoting learning.
Provide positive reinforcement as often as possible for Reinforces learning achieved and promotes positive ori-
the patient’s progress. entation.
Have the patient restate, in his or her own words, cogni- Repeated practice of a behavior internalizes and personal-
tive materials during teaching session. Have repeat on izes the behavior.44
each subsequent day until discharge.
Ensure that basic needs are taken care of before and Prevents distractions during teaching session due to basic
immediately after teaching sessions. needs not being met.
Pace teaching according to the patient’s rate of learning Considers the patient’s learning style and ability to
and preference during teaching session. process new information.
Provide the patient with ample opportunity to ask
questions.
Collaborate with and refer the patient to appropriate Coordinates team approach to health and provides means
assistive resources. to follow up and reinforce learning.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine whether there are ambiguities in the minds of Clarification and verification will ensure a greater likeli-
the parents or child. hood of understanding and valuing aspects critical to
patient teaching.
Identify the learning capacity for the patient and family. Realistic capacity for learning should be a primary factor
in patient teaching, because it serves as one major
parameter in expectations of learning.
Determine the scope and appropriate presentation for the Developmental needs of all involved will best serve as an
patient and family based on previous actions, plus essential framework for teaching the patient and fam-
developmental crises for each. Do not overwhelm the ily. Potentials and capacity for use of all the sensory-
patient. [Note adaptations needed based on client perceptual aspects of cognition should be explored
need.] and used to ensure the best opportunity for effective
teaching.
Evaluate the effectiveness of the teaching-learning experi- Evaluation is an indicator of both teaching effectiveness
ence by: and learning. It serves as another essential aspect of
• Brief verbal discourse to provide concrete data patient teaching, with the appropriate focus on individ-
• Brief written examination to show progress ualization, by pointing out areas needing reteaching.
• Observation of skills critical for care (e.g., change of
dressing according to sterile technique)
• Allowing the child to perform skills in general fashion
with use of dolls
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach normal physiologic changes the new mother can Provides information to assist new mothers in postpartum
expect postpartum: adaptation and transition to motherhood.46,47
• Lochia flow
• Breast changes
(care plan continued on page 476)
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476 • Cognitive–Perceptual Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Breastfeeding: Engorgement, comfort measures, Stress during the postpartum period is physical, intraper-
clothing, positions for mother and infant comfort and sonal and interpersonal, research suggests that breast-
hygiene (see actions for the Nutrition diagnoses in feeding can reduce stress by protecting the mother
Chapter 3). from environmental stimuli.48
• Non-breastfeeding: Suppression of lactation (medica- Breast binding should be discontinued as a means of lac-
tions, clothing such as tight-fitting bra, and comfort tation suppression as research shows that supportive
measures); importance of holding the baby while bot- bras are more effective.49
tle-feeding (NEVER prop bottle and do burp the baby
often); formulas (different kinds and preparation).
• Perineum and rectum: episiotomy, hemorrhoids,
hygiene, medications, and comfort measures
Demonstrate infant care to new parents: Assists new parents in adapting to parenting role. Allows
• Bathing the parents to practice new skills in a nonthreatening
• Feeding environment and seek clarification from an informed
• Cord care source.50–54
• Holding, carrying, etc.
• Safety
• Sleep–wake states of the infant
Provide quiet, supportive atmosphere for interaction with Promotes positive learning experience for the mother,
the infant to allow the parent to: father, and baby.50–54
• Become acquainted with infant
• Practice caretaking activities such as breastfeeding or
formula feeding
• Begin integration of the infant into the family
Discuss infant care, taking into consideration age and cul-
tural differences of the parents:
• Teenagers: Involve significant others. Have the mother
return-demonstrate infant care. Refer to support sys-
tems such as Young Parent Services and church groups.
• First-time older mothers: Allow verbalization of fears.
Involve significant others. Provide encouragement.
Adjust teaching to take into consideration different cul-
tural caretaking activities, such as preventing the evil
eye in the Hispanic culture, or the mother not holding
the baby for several days immediately after birth in
some Far Eastern Indian cultures.
Demonstrate newborn skills to the parents. Utilize differ-
ent assessment skills to teach the parents about their
newborn’s capabilities—gestational age assessment,
physical examination of newborn, or Brazelton
Neonatal Assessment Scale (sleep–wake states).
Encourage the parents to hold and talk to the newborn. Helps the parents gain confidence when caring for the
newborn. Provides opportunity for nurse to teach and
reinforce teaching.50–54
Discuss different methods of birth control and the advan- Informs the new mother (parents) of choices in birth con-
tages and disadvantages of each method: trol methods, and gives them the opportunity to ask
questions.
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Knowledge, Deficient (Specify) • 477
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Chemical: spermicides and pills
• Mechanical: condom, diaphragm, intrauterine device
(IUD)
• Behavioral: abstinence, temperature-ovulation-cervical
mucus (Billing’s method), or coitus interruptus
• Sterilization: vasectomy, tubal ligation, or hysterec-
tomy
Discuss signs and symptoms of perimenopausal and Clients who are informed and active participants in their
menopausal changes with the woman: hot flashes, per- own health decisions, in collaboration with the health
spiration, and/or chilly sensations; numbness or tin- care provider who can provide a screening of hormone
gling of skin; insomnia or restlessness; interrupted levels, can relieve some of the symptoms of
sleep; feelings of irritability, anxiety, or apprehension; menopause.
feeling depressed or unhappy; sensations of dizziness
or swimming in the head; feeling of weariness of mind
and body associated with desire for rest; joint or mus-
cle pain; headaches; quickening or acceleration of
heartbeat; and sensation of “crawly skin” (feels like
insects creeping over skin).55–57
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ask the client about previous learning experiences in Helps determine aspects of the client’s cognitive appraisal
general and about those related to the current area of that could impact learning.
concern (e.g., has the client learned that he or she is a
poor learner, that he or she does not have the intellec-
tual ability to learn the type of information that is cur-
rently required, or that the smallest mistake in the
activity to be learned could be fatal?)
Monitor the client’s current level of anxiety. If level of Severe anxiety and impaired cognitive functioning can
anxiety will inhibit learning, assist the client with anxi- decrease the client’s ability to attend to the environ-
ety reduction. (Refer to Anxiety in Chapter 8 for ment in a manner that facilitates learning.
detailed interventions.)
Determine what the client thinks is most important in the The client’s cognitive appraisal can impact his or her
current situation. willingness to attend to the information. This is espe-
cially true of adult learners. Change is dependant on
the client’s perception of the problem.58
Assist the client in meeting those needs that represent Promotes attention to learning. Reduces anxiety.
lower-level needs on Maslow’s hierarchy so attention
can be focused on the area of learning to be addressed
(e.g., if the client is concerned that children are not
being cared for while he or she is hospitalized, he or
she may not be able to focus on learning). [List the
needs to be met here.]
Sit with the client for [number] minutes 2 times each day Facilitates client change and understanding by addressing
to discuss the following (each discussion point can be the client’s perceptions of need. When information is
added as appropriate to the client’s situation): presented when the client is ready in a way that is
meaningful for the client, it has greater impact.58,59
• Have the client describe those issues that are most Change is dependant on client’s perception of the
important for them to address. problem.58
(care plan continued on page 478)
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Provide all information in a format that is meaningful
to the client. This includes careful selection of lan-
guage and of the information provided.
• Provide successive information based on client’s
response to previous information presented.
Provide positive, informative verbal reinforcement for the Positive reinforcement increases behavior.
client’s efforts to learn. [Note here those statements
that are reinforcing for this client.]
Establish learning goals with the client that ensure suc- Success provides positive reinforcement and promotes
cess. [Note those goals here.] continued learning efforts.
Establish time to include significant others in the learning A change in one part of the system affects the whole sys-
experiences. During this interaction, address the con- tem. If the intervention is developed with the input of
cerns of these support systems. [Note schedule here significant others, then it has meaning to this support
and those to be included.] system.58,59
Include the client in group learning experiences (e.g., Provides the client with opportunity to learn from
medication groups). others and to discuss new coping behaviors in a
safe environment.
Refer client and support system to community agencies
that will provide ongoing support for learning. [Note
those agencies here.]
Gerontic Health
In addition to the following interventions, the interventions for Adult Health can be applied to the aging client.
● N O T E : Aging clients are able to learn new material readily but may experience
difficulty with information retrieval. This should be considered when teaching elderly
clients.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine current knowledge base by interviewing the Provides a stepping-stone to pieces of information that
patient and have the patient state current knowledge may be incorrect or lacking.
regarding condition.
Ensure that glasses and hearing aids, if needed, are func- Enhances communication process.
tioning and used.
Encourage the patient to set the pace of the teaching Assists in keeping sessions focused on the patient’s abil-
sessions.59 ity to acquire new information.
Monitor for fatigue. Fatigue interferes with concentration and thus decreases
learning.
Present small pieces of information in each session. Avoids overwhelming the patient. Promotes learning.
Use examples that can be related to the individual’s life Adds realism to information, and makes transferring of
and lifestyle. information easier.
Determine whether there is increased anxiety during Anxiety decreases concentration and ability to learn.
teaching sessions (e.g., watch body language). If so,
use relaxation techniques prior to session.
Use audiovisual aids that are appropriate for the individual Promotes visual and sensory input according to the indi-
in regard to print size, colors, volume, and tone pitch. vidual’s needs.
Use repetition with positive feedback for correct Reinforces learning and allows evaluation of learning.
responses.
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Knowledge, Readiness For Enhanced • 479
Home Health
● N O T E : Many of the interactions between clients, families, and the nurse during the
course of home health care are related to health education. Proper assessment by the
nurse of the potential for or actual knowledge deficit is imperative. The nurse should use
techniques based on learning theory to design teaching interventions that will be appro-
priate to the situation at hand. These techniques include, but are not limited to, using
teaching materials that match the readiness of the participant, repeating the material
using several senses, reinforcing the learner’s progress, using a positive and enthusias-
tic approach, and decreasing barriers to learning, for example, language, pain, or phys-
ical illness.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family measures to reduce knowl- Conditions that support learning will decrease deficit.
edge deficit by seeking the following information and Provides the client and family with necessary
learning conditions: information.
• Information regarding disease process
• Rationale for treatment interventions
• Techniques for improving learning situation [motiva-
tion, teaching materials that match cognitive level of
participants, reduction of discomfort (e.g., control of
pain and use of familiar surroundings)]
• Enhancement of self-care capabilities
• Written materials to supplement oral teaching (i.e.,
written materials that are appropriate to cognitive level
and to self-care management)
• Addressing client and family questions
Coordinate the teaching activities of other health care pro- Coordination reduces duplication and enhances planning.
fessionals who may be involved. Reinforce the teaching Provides an opportunity for health care professionals to
of ROM by the physical therapist, for example. clarify any conflicting information before sharing it
with the client.
Involve the client and family in planning, implementing, Involvement improves motivation and improves the out-
and promoting reduction in knowledge deficit: come.
• Family conference
• Mutual goal setting
• Communication
• Family members responsible for specific tasks or infor-
mation
Consult with or refer to assistive resources as indicated. Use of the network of existing community services pro-
vides for effective utilization of resources.
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480 • Cognitive–Perceptual Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine learning needs and focus on developmentally Ensures realistic approach for child and parents.
appropriate method. [Note method to be used for this
child here.]
Determine goals for health-related requisite knowledge Sets relevant focus for learning.
with inclusion of parents.
Provide appropriate tools and models for teaching. For Offers realistic opportunity for practice in supportive
example, flow meter for asthmatic training, or insulin, environment
syringes, and guidelines for plan for diabetes client and
family.
Monitor for follow-up. Use appropriate technique to Validates appropriate knowledge and application.
accurately ascertain required information. For example,
how to perform peak flow meter demo or administer
accurate dosage of insulin subcutaneously with aseptic
technique.
Teach the patient and family when to seek assistance or Offers anticipatory guidance.
to report to primary care pediatrician.
Facilitate adaptation of plan for long-term needs with Provides realistic planning of health plan.
specific attention to possible school nursing assistance
or a setting other than home.
Provide opportunities to meet with other children experi- Engenders a sense of peer support to afford a sense of
encing similar health-care needs. shared affiliation.
Assist in identification of how the usual daily routine may Provides realistic anticipatory planning.
be maintained with incorporation of essential health-
care regimen.
Provide reinforcement for success in meeting goals and Values and enhances learning with empowerment for
compliance with the expected health-care regimen. future success.
[Note reinforcement plan for this client here.]
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Knowledge, Readiness For Enhanced • 481
Women’s Health
These would be the same as for Adult Health except for the following:
ACTIONS/INTERVENTIONS R AT I O N A L E
Women teach other women, and have been viewed as Research has shown that women are more open to alter-
healers throughout history. native methods of health and healing.60
Provide women with information about tests and screen- Women will seek out information and care for their
ings that will prevent health-care problems. health-care needs.61
Mental Health
Refer to nursing interventions for Knowledge, Deficient, Mental Health to assist client in addressing knowledge needs.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine the client’s priorities and preferred learning Allow the nurse to focus on what is relevant to client and
style. provide teaching that is best received by the client.
Monitor physical changes that may impact learning This allows the nurse to make needed accommodations
(visual changes, hearing loss, memory impairment). when teaching.
Assist the patient in setting realistic goals for learning. Client will not become discouraged by unrealistic goals.
Provide an environment conducive to learning: Maximizes the effectiveness of teaching and learning.
• Maintain a comfortable temperature.
• Ensure the client is not hungry, in pain, or sleepy.
• Have a family member present if desired or needed.
• Use real equipment when possible to facilitate under-
standing.
• Keep the session short, factual, and to the point.
• Use common vocabulary and avoid the use of medical
jargon.
Provide referral as needed to include: Use of the interdisciplinary team facilitates most compre-
• Enterostomal therapist hensive and accurate information and assistance for the
• Dietician client.
• Physical therapy
• Occupational therapy
Utilize adult teaching principles during educational Maximizes the effectiveness of teaching and learning.
sessions:
• Focus on information that is important to the client.
• Use teaching materials that appeal to many types of
learners (visual, auditory, kinesthetic).
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Memory, Impaired • 483
Child Health
Same as Adult Health within developmental capacity for infant or child, and safety-mindedness in all aspects.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine all who may need to be involved to best sup- Ambiguous unknowns present frustration for all involved,
port the infant or child in situations where actual so it is best to establish most complete team to manage
known level of involvement may not be clear. care to foster holistic approach.
Offer 30 minutes each shift and as needed for the parents Reduces anxiety and offers insight into parental concerns.
to express concerns.
Offer appropriate advocacy on behalf of the infant or child Child advocacy will best protect the child’s interests
when the parents are unable to offer this component. when the parents cannot.
Women’s Health
Same as Adult Health except for magnesium sulfate therapy specific to pregnancy-induced hypertension. For midlife
women, the actions and interventions are the same as those given for perimenopausal and menopausal life periods in
Deficient Knowledge, Sleep Deprivation, and Disturbed Sleep Pattern.
(care plan continued on page 484)
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484 • Cognitive–Perceptual Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the client’s level of anxiety, and refer to Anxiety Anxiety can increase the client’s confusion and disorgani-
(Chapter 8) for detailed interventions related to this zation.
diagnosis.
Speak to the client in brief, clear sentences. Too much information can increase the client’s confusion
and disorganization, increasing memory problems.
Interact with the client for [number] minutes every [num- Time of interaction should be guided by the client’s atten-
ber] minutes. Begin with 5-minute interactions and tion span.
gradually increase the length of interactions.
Be consistent in all interactions with the client. Facilitates the development of a trusting relationship, and
meets the client’s safety needs.
Initially, place the client in an area with little stimulation. Inappropriate levels of sensory stimuli can contribute to
the client’s sense of disorganization and confusion,
increasing memory problems.
Orient the client to the environment, and assign someone Promotes the client’s safety needs while promoting the
to provide one-to-one interaction while the client ori- development of a trusting relationship.
ents to unit.
Do not argue with the client about inaccurate memory of Communicates acceptance of the client and promotes
situations (e.g., the client insisting he or she has not self-esteem.
eaten when he or she has just finished a meal). Inform
the client in a matter-of-fact manner that this is not
your experience of the situation.
Provide orientation information to the client as needed. Facilitates maintenance of self-esteem and memory.
Specify here what information this client needs (e.g.,
name on room, calendar, clock, written daily schedule,
or information provided in written form in a notebook
or on a white board).
Utilize reflection of the last statement made by the client Facilitates memory within conversation.
in conversations.
Establish a daily schedule for the client, and provide a Decreases anxiety and promotes consistency.
written copy to him or her or post a copy of the daily
schedule in an obvious location in the milieu. [Note the
client’s specific schedule here.]
Spend [number] minutes [number] times a day reviewing Associating information from various senses enhances
with the client concerns about memory and developing memory by providing meaningful links. Written mate-
memory techniques. These could include visual rial provides prompts.
imagery, mnemonic devices, memory games, associa-
tion techniques, making lists, rehearsing information,
or keeping a journal about activities.
Practice memory techniques with the client [number] Practice improves performance and integrates behavior
minutes 2 times a day. [Note specific techniques to be into the client’s coping strategies.
practiced.]
Spend [number] minutes following an activity discussing Opportunities to use memory enhance memory.
the activity to provide the client with an opportunity to
practice remembering.
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Memory, Impaired • 485
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide positive verbal reinforcement to the client for Positive feedback encourages behavior.
accomplishing task progress.
Sit with the client each morning and develop a list of the Provides practice with memory techniques.
day’s activities. Review this list each evening.
Schedule the client for groups that provide opportunities Provides opportunities for the client to practice using
to utilize memory. These could be current event groups, memory, which enhances memory.
reminiscence groups, or life review groups. Note the
client’s group schedule(s) here, as well as the assistance
needed from staff to get the client to the group(s).
Spend [number] minutes each week discussing the Support system reactions impact the client.
client’s coping strategies with support system. Note
here person responsible and time for this discussion.
Gerontic Health
In addition to the following interventions, the interventions for Adult Health can be applied to the aging client.
● N O T E : Aging clients may experience age related changes in memory to include for-
getting specific details but remembering them later, ability to learn new information with
some difficulty in information retrieval, a general awareness of memory impairment, and
memory impairment that does not affect daily life.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Introduce self with each client contact. Promotes comfort for the client to identify caregiver.
Use the client’s preferred name in course of conversations. Provides orienting cue to the client’s identity.
Request photographs and names of significant others Provides information about the client and point of refer-
from the family or caregiver. ence while providing care.
Maintain consistency in environment. Decreases need to cope with change on a frequent basis.
Document any appliances client requires (prostheses, eye- Provides a record of needed equipment that the client
glasses, hearing aids, cane, or walker). may not be able to recall.
Ensure permanent identification of all appliances required Assists in keeping equipment available to the client, and
by the client. eliminates potential of using incorrect assistive devices.
Maintain consistent routine of care. Provides sense of the familiar.
Avoid arguments over forgetful behavior. Promotes client self-esteem, and decreases potential for
escalating anxiety related to the memory loss.
Omit statements or questions that emphasize memory Promotes client self-esteem, and decreases potential for
loss such as “Don’t you remember eating breakfast?” escalating anxiety related to the memory loss.
or “Do you know who came to see you this morning?”
In congregate social or living situations, introduce clients Fosters social skills and interactions.
prior to group activities.
Monitor solid and liquid intake on a daily basis. Memory loss may prevent the client from obtaining ade-
quate nutrition or fluid intake.
Document responses to medications, and note any Some medications may have side effects that in the older
changes in memory associated with medications. client promote amnesia. This problem can occur espe-
cially with long-acting benzodiazepines and hypnotics.
Administer mental status examination on a semiannual Monitors memory function and may assist in identifying
basis unless the client is receiving medication to changing strengths. Increased frequency recommended
enhance memory. if the client is taking memory-improving medication.
Monitor for changes in activities of daily living If memory loss is progressive, ADL skills will decrease
(ADLs) ability and for performance of ADLs over time and increased assistance will be needed.
without prompting.
(care plan continued on page 486)
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486 • Cognitive–Perceptual Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Use distraction techniques if the memory-impaired Distraction can allow time for the client to forget cause of
client becomes increasingly agitated or aggressive agitation.
in the care setting.
Educate the caregiver to recognize signs of personal Decreases potential for caregiver burnout.
stress when caring for the client with impaired
memory.
Provide the caregiver information on available respite Decreases potential for caregiver burnout.
services.
Monitor the patient for changes in elimination patterns. The memory-impaired client may not be able to report
changes in bowel or bladder function.
Home Health
● N O T E : If this is an acute development, immediate referral is required.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client and family in lifestyle adjustments that Home-based care requires involvement of the family.
may be necessary: Impaired memory can disrupt family schedules and
• Provide a safe environment. role relationships. Adjustments in family activities and
• Structure teaching methods and interventions to the roles may be required.
person’s ability.
• Explain to the family the changes from their usual roles
required in caring for the patient.
Assist the family to set criteria to help them determine Provides the family with background knowledge to seek
when additional intervention is required (e.g., explain appropriate assistance as need arises.
how to recognize change in baseline behavior).
Refer to appropriate assistive resources as indicated. Additional assistance may be required for the family to
• Support groups for caregivers care for the person with impaired memory. Use of
• Support groups for persons with similar problems readily available resources is cost-effective.
• Home care assistance
Teach the client and family memory involvement tasks, Structured memory tasks can increase the client’s func-
such as reminiscence and memory practice exercises. tional ability.
Teach the client and family compensation strategies (e.g., Compensation strategies can increase the client’s func-
daily planner or checklists). tional ability.
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Pain, Acute and Chronic • 487
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Copyright © 2007•by F. A. Davis.
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488 • Cognitive–Perceptual Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Administer pain medication as prescribed. Reassess and Response to pain and pain medication is unique to each
document amount of pain relief within 30 minutes after patient.
administration. Devise alternate methods for pain relief
in conjunction with other health-care team members if
pain is not relieved. [Note that plan here.]
Consider continuous dosing (e.g., continuous drip or PCA Avoids a roller coaster effect in pain relief.
for patients with consistent pain).
Consider alternative methods including massage, biofeed-
back, progressive relaxation, or guided imagery. [Note
methods to be used with client here.]
Turn at least every 2 hours on [odd/even] hour. Maintain Helps stimulate circulation. Alignment helps prevent pain
anatomic alignment with pillows or other padded from malposition and enhances comfort.
support.
Provide calm, quiet environment. Promotes action and effect of medication by providing
decreased stimuli.
Monitor vital signs at least every 4 hours while awake at Detects early changes that might indicate pain.
[times].
Monitor the sleep–rest pattern. Promote rest periods Fatigue may contribute to an increased pain response, or
during day and at least 8 hours sleep each night. pain can contribute to interrupted sleep.
(See nursing actions for Disturbed Sleep Pattern,
Chapter 6.)
Check bowel elimination at least once per shift. Immobility caused by pain may decrease the parasympa-
thetic stimulation to the bowel. Many analgesics have
constipation as a side effect.
Allow time for the patient to discuss fears and anxieties Just as pain is unique to the individual, so is the pain con-
related to pain by scheduling at least 15 minutes once trol intervention. Discussions with the patient provide
per shift to visit with the patient on one-to-one basis. collaboration and increase the patient’s compliance.
Decreases feeling of powerlessness, and initiates basic
teaching regarding control of pain.
Collaborate with health-care team regarding use of tran- Collaboration promotes the best approach to pain man-
scutaneous electrical nerve stimulation (TENS). agement.
Teach the patient and significant others: Knowledge assists the patient in feeling like an active
• Cause of pain participant on the health team. Decreases sense of
• Common and expected side effects of analgesics powerlessness. Promotes effective pain management.
• The low rate of addiction when narcotics are used
for pain
• The importance of maintaining round-the-clock
dosing for continuous pain and preventive dosing
for expected pain
• Avoiding and minimizing pain
• Splinting
• Gradual increase in activities
• Use of alternative noninvasive techniques (See previous
nursing action.)
• Combining techniques (e.g., medication with relaxation
technique)
Refer the patient to or collaborate with other health-care Collaboration promotes the best long-range plan for man-
professionals. agement of pain.
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Pain, Acute and Chronic • 489
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for contributory factors to pain at least every 1 to Provides the essential database for planning and modifi-
2 hours, or according to need. cation of planning.
• Physical injury or surgical incision
• Stressors
• Fears
• Knowledge deficit
• Anxieties
• Fatigue
• Description of exact nature of pain, whether per the
McGill, Elkind or faces by Wong pain assessment tool
• Vital signs—many consider pain to be a fifth vital sign.
• Response to medication
• Meaning of pain to the child and family
Provide appropriate support in management of pain for Validation and support of the patient and family will
the patient and significant others by: serve to show value and respect for the individual’s
• Validation of the pain health need. Maintains basic standards of care.
• Maintaining self-control to extent feasible Ventilation reduces anxiety, and parental involvement
• Providing education to deal with pain and assist the enhances coping skills.
patient and family to talk about the pain experience by
allowing at least [number] minutes per shift for such
ventilation and education at [times]. [Note topics to be
addressed for this client here.]
• Allowing the parents to be present and participate in
comforting of the patient; assisting the child and par-
ents to develop a plan of care that addresses individual
needs and is likely to result in a better coping pattern
(particularly for chronic pain). [Note client’s plan
here.]
• Appropriate diversional activities for age and develop-
mental level
*Collaborate with child life specialist to identify appro-
priate activities.
• Attention to controlling external stimuli such as noise
and light
• Use of relaxation techniques appropriate for the child’s
capacity. (This could include visual imagery of favorite
places or comforting situations.)
• Appropriate follow-up of pain tolerance and response
to medication as ordered.
Facilitate provision of pain medication by least invasive Utilize least invasive and most individually safe, effective
and most effective. Insist on appropriate and prompt and appropriate mode of pain relief for child.
mode for relief of pain.
(care plan continued on page 490)
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490 • Cognitive–Perceptual Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
If IV route is utilized, monitor for respiratory and blood
pressure depression every 10 minutes ⫻ 6 at [times].
Monitor intake and output for decrease as a result of
hypomotility or spasm.
Give appropriate emotional support during painful proce-
dures or experiences:
• Provide explanations at the child’s level of openness
and honesty.
• Use puppets to demonstrate the procedure.
• Explain to the parents that even if the child cries exces-
sively, their presence is encouraged.
• Comfort child before, during, and after procedure.
• Reward the child for positive behavior according to
developmental need (e.g., stars on a chart). [Note
rewards to be used here.]
• Facilitate parents and child sharing feelings about the
painful experience while providing care.
Collaborate with or refer the patient to appropriate
health-care team members.
Teach the patient and family ways to follow up at home
or school with needed pain regimen:
• Appropriate timing of medication
• Appropriate administration of medication
• Not to substitute acetaminophen for aspirin in arthritis
• Contact the school nurse with the plan of care
Monitor for side effects of medications such as decreased
peristalsis, GI bleed, and respiratory depression.
Develop daily plans for pain management that meet the
child’s individual needs. [Note that plan here.]
Develop several contingency pain control plans. Note
plans for this client here.
● N O T E : Chronic pain is going to recur; therefore, there is a need for long-term
follow-up. This follow-up is especially critical because chronic pain places the patient
at risk for developmental delays and altered quality of life.
Women’s Health
Gynecologic Pain
● N O T E : A significant amount of the pain experienced by women is associated with the
pelvic area and the reproductive organs. Determining the origin of the pain is one of the
most difficult tasks facing nurses dealing with the gynecologic patient. An organic expla-
nation for pain is never found in approximately 25 percent of women. Because of the
close association with the reproductive organs, gynecologic pain can be extremely
frightening, can connote social stigma, affect the perception of the feminine role, cause
anger and guilt, and totally dominate the woman’s existence. “Pain is culturally more
acceptable in certain parts of the body and may elicit more sympathy than pain in other
sites.”31,62
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Pain, Acute and Chronic • 491
ACTIONS/INTERVENTIONS R AT I O N A L E S
Identify factors in the patient’s lifestyle that could be Provides the database to adequately assess pain and deter-
contributing to pain. mine the underlying cause.
Record accurate menstrual cycle and obstetric, gyneco-
logic, and sexual history, being certain to note prob-
lems, previous pregnancies, descriptions of previous
labors, previous infections or gynecologic problems,
and any infections as a result of sexual activities.
Assist the client to describe her perception of pain as it
relates to her.
Include dysmenorrhea pain pattern, being certain to deter-
mine whether the pain occurs before, during, or after
menstruation.
Monitor disturbance of the client’s daily routine as a
result of pain. Have the patient describe the location of
the pain (e.g., lower abdomen, legs, breast, or back).
Have the patient describe any edema, especially “bloat-
ing” at specific times during the month.
Have the patient describe the onset and character of the
pain (e.g., mild or severe cramping).
Ascertain whether the pain is associated with nausea,
vomiting, or diarrhea.
Identify any precipitating factors associated with pain This information can assist in pinpointing source of pain
(e.g., emotional upsets, exercise, or medication). and devising a plan of care.
Assist the patient in identifying various methods of pain Individualizes pain control and provides options for the
relief, including exercise (pelvic rock), biofeedback, patient.
relaxation, and medication (analgesics and
antiprostaglandins).
Women’s Health
Labor Pain and Nursing
ACTIONS/INTERVENTIONS R AT I O N A L E S
Labor
Encourage the patient to describe her perception of labor Providing information about the laboring process helps
pain related to her previous laboring experiences. the patient cope with the pain of labor.13,31,63
Provide factual information about the laboring process.
Refer the patient to childbirth preparation group (e.g.,
Lamaze groups).
Describe methods of coping with labor pain (e.g., relax-
ation, imaging, breathing, medication, hydrotherapy, or
ambulation).
Provide support during labor.
Encourage involvement of significant others as support
during labor process.
Postpartum
Encourage the patient to describe her perception of pain
associated with the postpartum period.
(care plan continued on page 492)
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492 • Cognitive–Perceptual Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide information for pain relief (e.g., Kegel exercises,
sitz baths, or medications).
Explain etiology of “afterbirth pains” to involution of Knowing the source of pain increases the patient’s sense
uterus. of control.
Explain the relationship of breastfeeding to involution
and uterine contractions.
Assist the patient in putting on a supportive bra.
Encourage early, frequent breastfeedings to enhance let-
down reflex.
Support the patient and provide information on correct Knowledge of how to lessen discomfort during breast-
breastfeeding techniques, such as changing positions feeding contributes to successful or effective breast-
from one feeding to next to distribute sucking pressure feeding.
and prevent sore nipples.
Check the baby’s position on the breast; be certain the
areola is in mouth and not just the nipple.
Provide warm, moist heat for relief of engorged breasts. Demonstrates to the patient various pain relief methods.
Provide analgesics for discomfort of engorged breasts.
Pump after the infant nurses until the breast is emptied.
Encourage the patient to nurse on least sore side first to
encourage let-down reflex.
Apply ice to nipple just before nursing to decrease pain.
Mental Health
● N O T E : Pain in the mental health client should be carefully assessed for physiologic
causes. The following interventions are for pain associated with psychological factors or
chronic pain. For chronic pain, they are used in conjunction with physiologic interven-
tions. Refer to Adult Health nursing actions for physiologic pain management strategies.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the nurse’s response to the client’s perception of The nurse’s response to the client can be communicated
pain. If the nurse has difficulty understanding or cop- and have an effect on the client’s level of anxiety,
ing with the client’s expression of pain, he or she which can then affect the pain response.
should discuss these feelings with a colleague in an
attempt to resolve the concerns.
Note any recurring patterns in the pain experience, such Initiates the client’s awareness of this pattern, and allows
as time of day, recent social interactions, or physical the nurse to assess the client’s perception of this obser-
activity. If a pattern is present, begin a discussion of vation.
this observation with the client.
Determine effects pain has had on the client’s life, includ- Assesses meaning of pain to the client’s amount of anxi-
ing role responsibilities, financial impact, cognitive and ety associated with the pain and possible benefits of
emotional functioning, and family interactions. pain in the client’s life. Change depends on the client’s
perception of the problem.58
Review the client’s beliefs and attitudes about the role If pain is assuming an important role, then it might be
pain is assuming in the client’s life. If pain is very difficult for the client to “give up” all of the pain, and
important to the client’s definition of self, assure the this should be considered in all further interven-
client that you are not requiring him or her to give up tions.49,50
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ACTIONS/INTERVENTIONS R AT I O N A L E S
the pain by indicating that you are only interested in
that pain that causes undue discomfort or by indicating
that this client’s pain is special and that it would be dif-
ficult, if not impossible, for the health care team to get
rid of it.
Spend brief, goal-directed time with the client when he or Decreases positive reinforcement for the client’s focus on
she is focusing conversation on pain or pain-related pain and diminishes secondary gain for pain.
activities.
Schedule a time with the client when he or she is not Provides positive feedback to the client about an aspect
complaining about pain. List this schedule here. Focus of himself or herself that is not pain related.
on special activities in which the client is involved or
follow-up on a non–pain-related conversation the client
seemed to enjoy.
Find at least one non–pain-related activity the client Reinforcement encourages a positive behavior and
enjoys that can be the source of positive interaction improves self-esteem.
between the client and others, and encourage client
participation in this activity with positive reinforce-
ment (list client-specific positive reinforcers here along
with the activity).
Discuss with the client alternatives for meeting personal
need currently being met by pain. You may need to
refer the client to another, more specialized care
provider if this is a problem of long standing or if the
client demonstrates difficulty in discussing these con-
cerns. Refer to the self-esteem diagnoses (Chapter 8)
for specific interventions related to perceptions of self.
Develop with the client a plan to alter those factors that The social milieu can change the basic quality of the pain
intensify the pain experience. For example, if the pain experience.
increases at 4 P.M. each day and the client associates
this with his boss’s daily visit at 5 P.M., then the plan
might include limiting the visits from the boss or hav-
ing another person present when the boss visits. [List
specific interventions here.]
Develop with the client plan for learning relaxation tech- These techniques decrease anxiety.
niques, and have the client practice technique 30 min-
utes two times a day at [times]. Remain with the client
during practice session to provide verbal cues and
encouragement as necessary. These techniques can
include:
• Meditation
• Progressive deep muscle relaxation
• Visualization techniques that require the client to visu-
alize scenes that enhance the relaxation response (such
as being on the beach or having the sun warm the
body)
• Biofeedback
• Prayer
• Autogenic training
Monitor interaction of analgesic with other medications These medications may potentiate one another.
the client is receiving, especially antianxiety, antipsy-
chotic, and hypnotic drugs. Collaborate with pharma-
cist and physician to maintain adequate pain control.
(care plan continued on page 494)
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494 • Cognitive–Perceptual Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review the client’s history for indication of illicit drug The client may have developed a cross-tolerance for these
use and the effects this may have on the client’s toler- drugs.
ance to analgesics.
If the client is to be withdrawn from the analgesic, dis- Promotes perception of control, and decreases anxiety.
cuss the alternative coping methods and how they will
assist the client with the process. Assure the client that
support will be provided during this process. Help the
client identify those situations that will be most diffi-
cult, and schedule one-to-one time with the client dur-
ing these times.
• Develop plan with client for management of pain with-
out analgesics. [Note patients plan here.]
If the client demonstrates altered mood, refer to Ineffec-
tive Individual Coping (Chapter 11) for interventions.
Consult with occupational therapy to assist the client in Decreases conscious awareness of pain, thus decreasing
developing diversional activities. [Note time for these the pain experience.
activities here as well as a list of special equipment
that may be necessary for the activity.]
Consult with physical therapy to develop exercise rou-
tines that will facilitate pain management. [Note sup-
port needed from nursing to facilitate exercise plan.]
Involve the client in group activities by sitting with him Alters the client’s perception of the pain.
or her during a group activity, such as a game, or
assign the client a responsibility for preparing one part
of a unit meal. Begin with activities that require little
concentration, and then gradually increase the task
complexity.
Consult with physician for possible referral for use of
hypnosis in pain management.
Sit with the client and the family during at least two visits
to assess family interactions with the client and the
role pain plays in family interaction.
Discuss with the client the role of distraction in pain Provides other pain relief options for the client.
management, and develop a list of those activities the
client finds distracting and enjoyable. These could
include listening to music, watching television or spe-
cial movies, or physical activity. Develop with the
client a plan for including these activities in the pain
management program, and list that plan here.
Discuss with the client the role that exercise can play in Exercise encourages release of natural endorphins.
pain management, and develop an exercise program
with the client. This should begin at or below the
client’s capabilities and could include a 15-minute
walk twice a day or 10 minutes on a stationary bicycle.
[Note the plan here, with the type of activity, length of
time, and time of day it is to be implemented.]
Provide positive reinforcement to the client for imple- Positive reinforcement encourages repeating the behavior
menting the exercise program by spending time with and enhances self-esteem.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
the client during the exercise, providing verbal feed-
back, and allowing the client the rewards that have
been developed. These rewards are developed with the
client. [Note reward schedule to be used here.]
Monitor family and support system understanding of the Assists the family in normalizing and in moving away
pain and perceptions of the client. If they demonstrate from a pain-focused identity.
the attitude that interaction with the client is closely
linked with the pain, then develop a plan to include
them in the experiences described here. List that plan
here. Consider referral to a clinical specialist in mental
health nursing or a family therapist to assist the family
in developing non–pain-related interaction patterns.
Provide ongoing feedback to the client or support system
about progress.
Refer to outpatient support systems, and assist with Long-term support enhances the likelihood of effective
arranging for the client to contact these systems before home management.
discharge.
Gerontic Health
In addition to the following interventions, the interventions for Adult Health can be applied to the aging client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Acute Pain
Ask the client about the presence of pain using a 0 to 10 Pain is often underreported or minimized. Asking and
scale, word descriptor scale, faces scale, or pain ther- using a scale facilitates reporting and understanding of
mometer at least every 2 hours. pain intensity.
For clients with cognitive impairment, assessment of Early identification of pain facilitates effective treat-
behaviors and family or caregiver observations should ment.64
be used to assess for pain.
Abstain from the use of placebos. The use of placebos is unethical and impairs the trust
relationship between client and nurse.64
Opioids for episodic pain (non-recurring) should be pre- Prevention of overuse.
scribed as needed, rather than round the clock. (NGC,
Retrieved February 8, 2006 from http:// www.guide-
lines.gov)
Assess the client often and regularly for breakthrough Maintain adequate pain control.
pain:
• End of dose failure
• Incident pain
• Spontaneous, unpredictable pain and titrate dose
accordingly
Titrate medications in the older client carefully, consider- Pharmocokinetics and pharmacodynamics are affected by
ing the propensity for drug accumulation, drug interac- the aging process.
tions, and side effects.64
Assess clients taking opioid analgesics regularly and Opioid analgesics consistently cause slowing in bowel
often for alterations in bowel function and treat consti- motility and subsequent constipation.
pation as needed. Anticipate slowed bowel motility
when starting an opioid analgesic and begin preventive
stool softeners concurrently.64
(care plan continued on page 496)
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496 • Cognitive–Perceptual Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Medicate every 4 to 6 hours rather than on an as needed Enhances pain control, and thus promotes early mobility,
(PRN) basis for the first 48 to 72 hours, especially which decreases the potential for postoperative compli-
postoperatively.65 cations.
Collaborate with physician to prescribe medications other These medications are more likely to cause side effects
than meperidine, talwin, methadone, and darvon, if a such as confusion and psychotic behavior when given
narcotic analgesic is required. to the older adult.66
When beginning a new medication for pain, start with the Older adults often respond differently to pain medications
lowest dose and increase slowly as needed.66 than younger adults.
Investigate the patient’s beliefs regarding pain. Does he May be a barrier to seeking pain relief.
or she consider pain a punishment? Does he or she
think that having to take pain medication signals severe
illness or a potential for dying?67
Teach the patient to report pain as soon as it occurs, espe- Pain is more easily controlled when treated early. Patient
cially if medication order is PRN. may not realize that medication won’t be given on a
scheduled basis.
Avoid presenting self in a hurried manner. Older adults are less likely to report pain if caregiver is
rushed.67
Chronic Pain
Explore with the patient how he or she has managed Assists in determining what measures were of significant
chronic pain in the past. or of little help.
Determine use of distraction in helping the patient cope Music, humor, and relaxation techniques can provide
with chronic pain.65 temporary respite from discomfort.
Monitor skin status when thermal interventions are used, Changes in sensation may result in thermal injury if not
such as ice or heat packs. closely monitored.
In the presence of chronic pain, depression may also Chronic pain is exhausting physically and mentally.
exist. Screen for depression.64
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family measures to promote comfort: Involvement of the client and family promotes comfort
• Proper positioning and decreases self-reported pain and analgesic use.65
• Appropriate use of medications (e.g., narcotics as
ordered, nonnarcotic analgesics, anti-inflammatories)
• Knowledge regarding source of pain or of disease
process
• Self-management of pain and of care as much as is
appropriate
• Relaxation techniques
• Therapeutic touch
• Massage (if not contraindicated)
• Distraction
• Breathing techniques
• Heat or cold treatments (if not contraindicated)
• Regular activity and exercise
• Planning and goal setting
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Biofeedback
• Yoga or tai chi
• Imagery or hypnosis
• Group or family therapy
Teach the client and family factors that decrease tolerance Reducing these factors can increase the tolerance to
to pain and methods for decreasing these factors: pain.66
• Lack of knowledge regarding disease process or pain
control methods
• Lack of support from significant others regarding the
severity of the pain
• Fear of addiction or fear of loss of control. Addiction occurs very infrequently in clients medicated
• Fatigue for legitimate pain.64
• Boredom
• Improper positioning
Involve the client and family in planning, implementing, Involvement improves motivation and improves outcome.
and promoting reduction in pain:
• Family conference
• Mutual goal setting
• Communication
• Support for the caregiver
Assist the client and family in lifestyle adjustments that Lifestyle changes require changes in behavior.
may be required:
• Occupational changes
• Family role alterations
• Comfort measures for chronic pain
• Financial situation
• Responses to pain (mood, concentration, or ability to
complete activities of daily living)
• Coping with disability or dependency
• Mechanism for altering need for assistance
• Providing appropriate balance of dependence and inde-
pendence
• Stress management
• Time management
• Obtaining and using assistive equipment (e.g., for
arthritis)
• Regular, rather than as-needed, schedule of pain med-
ication
Teach the client and family purposes, side effects, and Provides necessary information for safe self-care.
proper administration techniques of medications.
Consult with or refer to appropriate assistive resources as Use of the existing community services network provides
indicated. effective utilization of resources.
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Sensory Perception, Disturbed (Specify: Visual, Auditory, Kinesthetic, Gustatory, Tactile, Olfactory) • 499
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Keep clock and calendar in room.
• Touch the patient frequently.
• Check orientation to person, time, and place at least
once per shift.
• Listen carefully.
Collaborate with occupational therapist regarding appro- Provides stimuli.
priate diversionary activity. [Note recommendations
here with support needed for implementation.]
Auditory Deficit
Enhance communication by speaking in low tones when Allows for alteration in hearing high-frequency sounds.
interacting with the patient. High-frequency tones are lost first.
• Do not shout when talking with the client. Shouting accentuates vowel sounds while decreasing con-
sonant sounds.
• Decrease background noise as much as possible when Avoids confusion, and increases the patient’s ability to
talking with the client. localize sounds.
• Stand where the client can watch your lips when you
are speaking to him or her.
Allow the patient extended time to respond to verbal Allows for understanding and interpretation of message.
messages.
Use visual cues as much as possible to enhance verbal Utilizes alternative communication methods.
messages.
• Provide message board to use with the patient.
Teach the patient and family proper maintenance of hear- Promotes proper functioning of hearing aid.
ing aid.
• Replace batteries in hearing aids and clean earwax for
ear mold of hearing aid as necessary
Visual Deficit
Assure that glasses or other visual aids are available and Facilitates the patient’s use of equipment, and assists in
placed proximal to patient. preventing damage or loss of equipment.
Provide written information in large-print or audio
recorded format.
Provide telephone dials and other equipment necessary
that have large numbers on nonglare surfaces. List here
special equipment that is necessary for this patient and
when the patient may need it so it can be provided at
appropriate times.
Identify the patient’s room with large numbers or the
patient’s name in large print.
Provide large-screen television and pictures with large, Larger images are easier for the patient to interpret.
colorful images.
Provide nonglare work surfaces.
Identify stairs and door frames with contrasting tape or Increases visual acuity. Basic safety measure.
paint.
Verbally address the patient when entering the patient’s Makes the patient aware of presence.
proximity, and approach the patient from the front.
Do not alter the patient’s physical environment without Promotes consistency in environment, which improves
telling him or her of the changes. safety.
Teach the patient and family proper maintenance of eye- Ensures proper functioning and prevents scratching of
glasses and other prosthesis. lenses.
(care plan continued on page 500)
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500 • Cognitive–Perceptual Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the patient and family methods to improve environ-
mental safety.
Assist the patient with activities of daily living (ADLs) as Allows the patient to be as independent as possible.
necessary. List the activities that require assistance
here, along with the type of assistance that is needed
(e.g., assisting the patient to eat to extent necessary
[feed totally or cut up food and open packages]).
Touch and Kinesthesia Deficit
Provide safe environment: Basic safety measures.
• Remove sharp objects from the patient’s environment.
• Protect the patient from exposure to excessive heat and Basic safety measures to prevent accidental burns.
cold.
Teach patient to utilize visualization as a method to
assess for injury and method for compensation for
decrease in tactile response.
Have the patient change position every 2 hours on Promotes circulation, and relieves pressure on bony
[even/odd] hour. prominences.
Monitor condition of skin every 4 hours at [times]. Note Guards against skin breakdown.
any alteration in integrity. Teach the patient to visually
inspect skin on a daily basis.
Assist the patient in determining whether clothing is fit-
ting properly without abrading the skin.
Perform and teach adequate foot care on a daily basis to
include: [Note schedule here and teaching plan.]
• Bathing feet in warm water
• Applying moisturizing lotion
• Trimming nails as needed
• Checking skin for abrasions or reddened areas
Assist the patient with care of affected body parts. Prevents unilateral neglect, and provides cues for the
patient.
Assist the patient with ADLs (note type and amount of Promotes self-care through demonstrating care to the
assistance needed here). patient.
Refer the patient to occupational therapy for assisting
with learning new self-care behavior.
Olfactory Deficit
Teach patient to utilize other senses to adapt to deficit
including visualization, color and texture assessments.
Determine effect the smell deficit has on the patient’s Assists to compensate for loss of smell.
appetite, and work with dietitian to make meals visu-
ally appealing.
Provide for appropriate follow-up appointments before Providing specific appointments lessens the confusion
dismissal. [Note referral plan here.] about the specifics of appointments and increases the
likelihood of subsequent follow-through.
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Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine how the parent and child perceive the deficit Appropriate attention to both subjective as well as objec-
addressed by setting aside adequate time (30 minutes) tive data is required to best plan care.
each shift for discussion and listening.
Facilitate follow-up evaluation for any suspected sensory Preventing or minimizing secondary and tertiary deficits
deficits of infants and young children. [Note plan for is enhanced by appropriate attention to sensory percep-
follow-up here.] tion follow-up.
Provide safe environment according to sensory deficit and Sensory deficits and developmental capacity increase the
the child’s developmental capacity. [Note special adap- risk of accidents.
tations for client here.]
Initiate plans for discharge immediately to provide time Adequate practice time in a nonjudgmental situation
for building confidence in the performance of necessary allows positive feedback and corrective action. Lessens
self-care tasks. anxiety and performance pressures. Increases confi-
dence in giving care at home.
Provide attention to family coping as it may relate to the A child with sensory perception problems and the inter-
deficit: ventions necessary to deal with these problems place
• Monitoring of usual dynamics strain on the family. Promoting coping will lessen the
• Identification of impact on the parents and siblings strain on the family while increasing the likelihood that
• Presence of mental deficits the child’s needs are met.
• Values regarding the deficit
• Support systems
Review for appropriate immunization, especially rubella, In the event of early deficits, the likelihood exists for the
mumps, and measles. need to modify the schedule of immunization. This is
too often overlooked and will then place the infant or
child at unnecessary risk for infectious diseases.
In the presence of ear infections, exercise caution regard- Treatment for chronic infections with antibiotics by sev-
ing use of ototoxic medications. eral practitioners must be carried out with precaution
to prevent potential side effects.
Correlate medical history for potential risk factors such as Contributory factors to the pattern of health must be pur-
chronic middle ear infections, upper respiratory infec- sued with openness to all possible causes.
tions, or allergies.
Provide appropriate sensory stimulation for age, begin- Appropriate sensory stimulation will favor gradual
ning slowly so as not to overload child. [Note special progress in development.
adaptations for this client here.]
Deal with other contributory factors such as nutrition, Related factors must be considered in total health of the
illness, or effects from behavioral disorders or infant or child with altered sensory–perceptual pattern.
medications.
Include the parents in plans for rehabilitation whenever Inclusion of the parents provides an opportunity for learn-
possible by: ing essential skills and enhances security of the infant
• Using basic plan for care or child. All efforts contribute to empowerment and
• Adapting intervention as required for the child potential growth of the family unit.
• Supporting them in their role
• Pointing out opportune times for interaction
• Informing them of appropriate safety precautions for
the child’s age and situation
• Encouraging gentle handling and comforting of the
infant
Provide continuity in staffing for nursing care of the child Continuity provides trust and opportunities for reinforce-
and family. ment of learning.
(care plan continued on page 502)
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502 • Cognitive–Perceptual Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
In instances of a handicapped child, provide appropriate Appropriate introduction of new skills or reinforcement
attention to developing sequencing to best actualize of existent patterns will favor progress.
potential offered.
Especially note, on follow-up, the home environment for The home to which the infant or child will go may require
nurturing aspects and support systems. reasonable adaptation to foster appropriate resources.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Vision
Monitor the patient for signs of pregnancy-induced Knowledge of signs of visual disturbances associated with
hypertension (PIH). PIH can assist the patient in seeking early treatment.13,14
Monitor for signs and symptoms of preeclampsia (e.g.,
headaches, visual changes such as blurred vision,
increased edema of face, oliguria, hyperreflexia, nausea
or vomiting, and epigastric pain).13,14
Teach the patient the importance of reporting these signs
and symptoms, because they can be precursors to
eclampsia.
Smell
Be aware of the patient’s tendency during early preg-
nancy to experience morning sickness, i.e., nausea and
vomiting.
In collaboration with dietitian:
• Obtain dietary history.
• Assist the patient in planning diet that will provide ade-
quate nutrition for her and her fetus’s needs.
Teach methods for coping with gastric upset, nausea, and Knowledge can assist the patient in planning actions to
vomiting: decrease incidences of nausea and vomiting and assist
• Eating bland, low-fat foods in preventing dehydration and possibly hospitalization.
• Increasing carbohydrate intake
• Eating small, frequent meals
• Having dry crackers or toast before getting out of bed
• Taking vitamins and iron with snack before going to
bed
• Supplementing diet with high-protein liquids (e.g.,
soups or eggnog)
Touch During Pregnancy
Be aware of the expectant mother’s sensitivity to extrane- Assists the mother to know that her feelings are normal.
ous touching:
• Shyness
• Protectiveness of unborn child
• Uterine sensitivity during pregnancy and particularly
during labor
Maternal Touch
Encourage visual and tactile contact between the mother Provides time for beginning attachment process between
and infant as soon as possible. the mother and infant.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide an atmosphere conducive to continual
mother–infant contact.
Delay newborn eye treatment for 1 hour, so that the baby
can see the mother’s face.
Kinesthesia
Be aware of the expectant mother’s increased vulnerabil- Reassures mothers that this is a temporary state.
ity related to physical size of body in third trimester:
• Protectiveness of unborn child
• Heavy movement
• Possible slowed reflexes
• Tires easily
Assist in and out of furniture that is too low and difficult
to get up from.
Encourage correct body mechanics when lying down or
sitting up.
Encourage to wear seat belt when traveling in automo- Provides for safety measures for the mother and fetus.
bile. (Shoulder belts are best.)
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the client’s neurologic status as indicated by cur- Client safety is of primary importance. Early recognition
rent condition and history of deficit (e.g., if deficit is and intervention can prevent serious alterations.
recent, assessment would be conducted on a schedule
that could range from every 15 minutes to every 8
hours). Note the frequency and times of checks here. If
checks are to be very frequent, then it might be useful
to keep a record of these checks on a flow sheet.
If deficit is determined to result from a psychological Client safety is of primary importance.
rather than a physiologic dysfunction, refer to
Ineffective Individual Coping, Disturbed Body Image,
Anxiety, and Chronic Low or Situational Low Self-
Esteem for detailed nursing actions.
● N O T E : A comprehensive physical examination and other diagnostic evaluations
should be completed before this determination is made. Each of these deficits can be
symptoms of severe physiologic or neurologic dysfunction and should be approached
with this understanding, especially in a mental health environment where the clients
may be assigned without careful assessment. This is a great risk for the client who has
a history of mental health problems.
If deficit is related to a physiologic dysfunction, attend to Provides positive reinforcement for adaptive coping
needs resulting from the identified sensory deficit in a behaviors.
matter-of-fact manner, providing basic care and having
the client do the majority of the care. (See Adult
Health interventions for additional care.)
If deficit is related to a psychological dysfunction, spend Promotes the client’s sense of control, and increases self-
[number] minutes every hour with the client in an esteem. Provides positive reinforcement for positive
activity that is not related to the sensory deficit. If coping behaviors and removes social reinforcement for
the client begins to focus on the deficit, terminate the negative coping behaviors.19
interaction.
(care plan continued on page 504)
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504 • Cognitive–Perceptual Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend [number] minutes twice a day discussing with the
client the effects the deficit will have on his or her life
and developing alternative coping behavior. Note times
for conversations here. If the family is involved in the
client’s care, they should be included on a planned
number of these interactions.
Refer to appropriate mental health professional if the
client is going to require long-term assistance in adapt-
ing to the deficit or if current emotional adaptation
becomes complicated.
Discuss with the client and support system the necessary Promotes the client’s sense of control.
alterations that may be necessary in the home environ-
ment to facilitate daily living activities.
Auditory or Visual Alterations68–71
Observe for signs of hallucinations (intent listening for no Interrupts patterns of hallucinations.
apparent reason, talking to someone when no one is
present, muttering to self, stopping in mid-sentence, or
unusual posturing). When these symptoms are noted,
engage the client in here-and-now, reality-oriented con-
versation or involve the client in here-and-now activity.
Initiate touch only after warning the client that you are The client may perceive touch as a threat and respond in
going to touch him or her. an aggressive manner.
Communicate acceptance to the client to encourage the Provides information on the content of the hallucination
sharing of the content of the hallucination. so early intervention can be initiated when content sug-
gests harm to the client or others.
If hallucinations place the client at risk for self-harm or Client and staff safety are of primary importance.
harm to others, place the client on one-to-one observa-
tion or in seclusion.
If the client is placed in seclusion, interact with the client Provides reality orientation, and assists the client in con-
at least every 15 minutes. trolling the hallucinations.
Have the client tell staff when hallucinations are present Early intervention promotes the client’s sense of safety
or when they are interfering with the client’s ability to and control.
interact with others.
Maintain environment in a manner that does not enhance High levels of environmental stimuli can increase the
hallucinations (e.g., television programs that validate client’s disorganization and confusion.
the client’s hallucinations, abstract art on the walls,
wallpaper with abstract designs, or designs that
enhance imagination).
Teach the client to control hallucinations by: Promotes the client’s sense of control, and enhances self-
• Checking ideas out with trusted others esteem. Provides control of auditory alterations.72
• Practicing thought stopping by singing to self, telling
the voices to go away (This can be done quietly to self,
or by asking the voices to come back later, but not to
talk now.)
• Telling the voices to go away, using headphones to
listen to music, watching TV, or wearing ear plug in
one ear.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
When the client is not constantly experiencing alterations, Facilitates interaction, self-management, and monitoring
engage him or her in a group that addresses manage- of symptoms, and instills hope.72
ment of these alterations.
When the client is responding to hallucinations, respond
to the feelings expressed in the client’s communication.
Respond to the client with “I” statements (“I do not see Provides indirect confrontation of their experience.
or hear that”) when they request validation of halluci- Preserves self-esteem while indicating that nurse does
nations. Do not argue with client’s experience. not experience the same stimuli.73
Talk with the client about ways to distract him- or herself
from the hallucinations, such as physical exercise,
playing a game or a craft that takes a great deal of con-
centration. [Note those activities preferred by the client
here.]
When signs of the client’s hallucinating are present, assist Reinforces new coping behaviors, and increases the
the client in initiating those activities or other control client’s perceived control.
behaviors that have been identified by the client as
useful.
As the client’s condition improves, primary nurse will Facilitates the development of alternative coping
assist the client to identify onset of hallucinations and behaviors.
situations that facilitate their onset.
As difficult situations are identified, primary nurse can Promotes the client’s sense of control and self-esteem.
begin working with the client on alternative ways of
coping with these situations. (Note alternative coping
behaviors selected by the client here.) Use relaxation
techniques to manage anxiety that focus on concrete
directions and do not include open-ended visualiza-
tions for clients who are currently experiencing sensory
perceptual alterations.
Refer the client and support system to appropriate sup- Establishes continuity of responses and support for the
port systems in the community (e.g., Compeer). client after discharge.
[Contact local mental health association for programs
in your community.]
Arrange time with significant others to provide education Client outcomes are improved when support systems are
about sensory–perceptual alterations and appropriate provided education and included in discharge
responses to them. planning.14,28
Gerontic Health
The nursing actions for the gerontic patient with this diagnosis are the same as those for the Adult Health patient.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family measures to prevent sensory Family and client involvement in basic safety measures
deficit: enhances the effectiveness of preventive measures.
• Use of protective gear (e.g., goggles, sunglasses,
earplugs, or special clothing in hazardous conditions to
prevent radiation, sun, or chemical burns)
(care plan continued on page 506)
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506 • Cognitive–Perceptual Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Prevention of injuries to eyes, ears, skin, nose, and
tongue
• Prevention of nutritional deficiencies
• Close monitoring of medications that may be toxic to
the eighth cranial nerve
• Correct use of contact lenses
• Prevention of fluid and electrolyte imbalances
Involve the client and family in planning, implementing, Involvement improves motivation. Communication and
and promoting correction or compensation for sensory mutual goals increase the probability of positive out-
deficit [specify] by [date]: comes.
• Family conference
• Mutual goal setting
• Communication (e.g., use of memorabilia and audio-
tapes or videotapes provided by family members to
stimulate in cases of impaired communication)72
Assist the patient and family in lifestyle adjustments that Lifestyle changes require change in behavior. Self-
may be required: evaluation and support facilitate these changes.
• Assistance with activities of daily living
• Adjustment to and usage of assistive devices (e.g.,
hearing aid, corrective lenses, or magnifying glass)
• Providing safe environment (e.g., protect kinestheti-
cally impaired individuals from burns)
• Stopping substance abuse
• Changes in family and work role relationships
• Techniques of communicating with the individual with
auditory or visual impairment
• Providing meaningful stimulation
• Special transportation needs
• Special education needs
Consult with or refer to appropriate assistive resources as Use of existing community services provides for effective
indicated. utilization of resources.
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Thought Process, Disturbed • 507
11. Delirium
this case, Disturbed Thought Process and Ineffective
12. Eating disorders Health Maintenance would be companion diagnoses.
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508 • Cognitive–Perceptual Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Facilitate self-care to the extent possible. [Note patient’s Increases self-esteem, forces reality check, decreases
abilities here.] powerlessness, and provides a means of evaluating the
patient’s status.
Involve significant others in care, and include in teaching Provides social support and consistency in management.
sessions. [Note teaching plan here.]
Refer to and collaborate with appropriate assistive Provides for long-term support and a more holistic
resources. approach to care.
Collaborate with psychiatric nurse clinician and rehabili- Collaboration provides the best plan of care.
tation nurse specialist.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor cognitive capacity according to age and develop- Basic data needed to plan individualized care.
mental capacity.
Note discrepancies in chronologic age and mastery of
developmental milestones.
Provide ongoing reality orientation by encouraging the As the patient attempts to reorient, it is helpful that date,
family to visit, and by emphasizing time, personal time, and specific concrete planning, hour by hour, are
awareness, and gradual resumption of daily routine to offered. The infant should be reintroduced to data, in a
degree possible. calm manner, that will assist in regaining some control
over the environment and in regaining the previous
functioning level so that he or she can continue to
progress.
Provide safety based on developmental needs. [Note Disturbed Thought Process serves as a high-risk factor
client specific adaptations here.] for all involved. It would be a reasonable standard of
care to increase all anticipatory safety efforts.
Facilitate family member’s expressions of concerns for Promotes ventilation, which helps reduce anxiety and
the child’s condition by allowing [number] minutes offers insight into thoughts about the patient’s condi-
each shift for discussion. tion.
Provide for primary health needs, including administra- Attention to regular health needs must also be considered
tion of medications, comfort measures, and control of as the whole person is considered.
environment to aid in the child’s adaptation.
Structure the room in a manner that befits the child’s Keeping the environment adapted to personal needs will
needs. facilitate care, minimize the chance for accidents, and
*Keep room free of clutter with clear path for special demonstrate the needed structure.
needs.
Allow for ample rest and sleep periods according to Rest is a key and essential consideration to provide opti-
developmentally appropriate guidelines. Note specific mal potential for cognitive–perceptual functioning.
adaptations for this client here.
Monitor for altered coping and role performance. All contributing factors must be explored to ensure meet-
ing the patient’s needs.
Assist the family with discharge plans with referral to Improves family adjustment and coping by assisting in
community resources. preparing for home needs. Empowerment then permits
them the opportunity for growth in coping skills and
parenting.
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Thought Process, Disturbed • 509
ACTIONS/INTERVENTIONS R AT I O N A L E S
If institutionalization is required, assist the family in Planning provides the means for coping and adjusting to
learning about related issues, such as visitation, med- the move with an opportunity for clarification.
ical records maintenance, prognosis, and risk factors. Provides advocacy for the patient and family.
Allow for culturally unique aspects in management of Increases individuation and satisfaction with care. Shows
care (e.g., respect for visitation on religious holidays, respect for the family’s values. Enhances nurse–patient
family wishes for diet, and bathing). relationship.
Provide for appropriate follow-up by making appoint- Follow-up arrangements for clinic visits enhance the like-
ments for next clinic visits. lihood of follow-up and demonstrate the importance of
this follow-up care.
Allow the family members opportunities for learning nec- Anticipating learning needs serves to minimize crises
essary care and mastery of content for long-term needs, related to the child’s condition.
such as resolution of conflicts related to institutional-
ization or respite care and prognosis.
Women’s Health
This nursing diagnosis will pertain to the woman the same as any other adult, with the following exception. For midlife
women, the nursing actions and interventions are the same as those given in Deficient Knowledge, Sleep Deprivation, and
Disturbed Sleep Pattern under the headings perimenopausal and menopausal life periods.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the client’s level of anxiety, and refer to Anxiety Too much information can increase the client’s confusion
(Chapter 8) for detailed interventions related to this and disorganization. The amount of time devoted to
diagnosis. interaction should be guided by the client’s attention
span.73
Speak to the client in brief, clear sentences.
Keep initial interactions short but frequent. Interact with Facilitates the development of a trusting relationship.
client for [number] minutes every 30 minutes. Begin
with 5-minute interactions and gradually increase the
times of interactions.
Assign the client a primary care nurse on each shift to Facilitates the development of a trusting relationship.
assume responsibility for gaining a relationship of trust
with the client.
Be consistent in all interactions with the client. Facilitates the development of a trusting relationship, and
meets the client’s safety needs.
Set limits on inappropriate behavior that increases the Client and staff safety are of primary importance.
risk of the client or others being harmed. [Note the
limits here as well as revisions to the limits.]
Initially place the client in an area with little stimulation. Inappropriate levels of sensory stimuli can contribute to
client’s sense of disorganization and confusion.
Orient the client to the environment, and assign someone Promotes the client’s safety needs while facilitating the
to provide one-to-one interaction while the client ori- development of a trusting relationship.
ents to unit.
Do not make promises that cannot be kept. Facilitates the development of a trusting relationship.
Inform the client of your availability to talk with him or Communicates acceptance of the client, which facilitates
her; do not pry or ask many questions. the development of trust and self-esteem.
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510 • Cognitive–Perceptual Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Do not argue with the client about delusions; inform the Argument may reinforce the client’s need to maintain the
client in a matter-of-fact way that this is not your expe- delusional system and interferes with the development
rience of the situation (e.g., “I do not think I am angry of a trusting relationship.
with you.”)
Recognize and support the client’s feelings (e.g., “You Focuses on the client’s real feelings and concerns.
sound frightened.”)
Respond to the feelings being expressed in delusions or
hallucinations.
Initially have the client involved in one-to-one activities; High levels of environmental stimuli may increase confu-
as condition improves, gradually increase the size of sion and disorganization.
the interaction group. [Note current level of function-
ing here.]
Have the client clarify those thoughts you do not under- Facilitates the development of a trusting relationship, and
stand. Do not pretend to understand that which you do prevents inadvertent support of the delusional thinking.
not.
Do not attempt to change delusional thinking with This may encourage the client to cling to these thoughts.
rational explanations.
After listening to delusion once, do not engage in conver- Decreases the possibility of supporting or reinforcing the
sations related to this material or focus conversations delusion.
on this material.
Focus conversations on here-and-now content related to Facilitates the client’s contact with reality.69
real things in the environment or to activities on the
unit.
Do not belittle or be judgmental about the client’s delu- Protects the client’s self-esteem.
sional beliefs.
Avoid nonverbal behavior that indicates agreeing with Decreases the possibility of supporting or reinforcing the
delusional beliefs. delusion.
When the client’s behavior and anxiety level indicate Provides feedback about delusional beliefs from peers.
readiness, place the client in small-group situations.
Do not put clients who are actively hallucinating
in groups. The client will spend [number] minutes
in group activities [number] times a day.
(Time and frequency will increase as the client’s ability
to cope with these situations improves.)
Develop a daily schedule for the client that encourages Facilitates the client’s contact with reality. Promotes posi-
focus on “here and now” and is adapted to the client’s tive self-image.
level of functioning so that success can be experienced.
Note daily schedule here.
Assign the client meaningful roles in unit activities. Facilitates the client’s contact with reality. Promotes posi-
Provide roles that can be easily accomplished by the tive self-image.
client to provide successful experiences. [Note client
responsibilities here.]
Primary nurse will spend [number] minutes with the Assists in the development of alternative coping
client twice a day to discuss the client’s feelings and behaviors.
the effects of the delusions on the client’s life.
(Number of minutes and the degree of exploration of
the client’s feelings will increase as the client develops
relationship with nurse.)
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide rewards to the client for accomplishing task Positive feedback encourages productive behavior.
progress on the daily schedule. These rewards should
be ones the client finds rewarding.
Spend [number] minutes twice a day walking with the Facilitates the development of a trusting relationship.
client. This should start at 10-minute intervals and Social interaction provides positive reinforcement.
gradually increase. This can be replaced by any physi- Helps increase daytime wakefulness, promoting a nor-
cal activity the client finds enjoyable. A staff member mal sleep–wake cycle.
should be with the client during this activity to provide
social reinforcement to the client for accomplishing the
activity.
Arrange a consultation with the occupational therapist to Increases daytime wakefulness, maintaining a normal
assist the client in developing or continuing special sleep-rest cycle.
interests.
Monitor delusional beliefs for potential of harming self or Patient and staff safety are of primary concern.
others.
Note any change in behavior that would indicate a change Patient and staff safety are of primary concern.
in the delusional beliefs that could indicate a potential
for violence.
If the client is placed in seclusion, interact with the client Provides reality orientation, and assists the client with
at least every 15 minutes. controlling hallucinations and delusions.
Maintain environment that does not stimulate the client’s Excessive environmental stimuli can increase confusion
delusions (e.g., if the client has delusions related to and disorganization.
religion, limit discussions of religion and religious
activity on unit to very concrete terms). Limit interac-
tion with persons who stimulate delusional thinking.
The primary nurse will assist the client in identifying Promotes the client’s sense of control, and enhances self-
signs and symptoms of increasing thought disorganiza- esteem.
tion and in developing a plan to cope with these situa-
tions before they get out of control. This will be done
in the regularly scheduled interaction times between
the primary nurse and the client.
As the client’s condition improves, primary nurse will Facilitates the client’s developing alternative coping
assist the client to identify onset delusions with periods behaviors.
of increasing anxiety.
As connection is made between thought disorder and Promotes the client’s sense of control, and enhances self-
anxiety, the client will be assisted to identify specific esteem.
anxiety-producing situations and learn alternative cop-
ing behaviors. See Anxiety (Chapter 8) for specific
interventions.
Teach client strategies to manage the thoughts that pre-
cede increases in anxiety by:
• Linking increase in anxiety to dysfunctional thinking
• Thought stopping techniques (wearing rubber band on
wrist and snapping it when negative thoughts occur)
• Rehearse changes in self-talk that would decrease anxi-
ety (replace words like should, never, and always with
more reality based thinking). Refer to resources on
Cognitive therapy for more techniques.19
Refer the client to outpatient support systems, and assist Facilitates the client’s reintegration into the community.
with making arrangements for the client to contact
these before discharge.
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512 • Cognitive–Perceptual Pattern
Gerontic Health
● N O T E : Problems related to Disturbed Thought Process with older adults may pres-
ent themselves in various ways. Two conditions, dementia and delirium, are considered
here. Irreversible dementia, such as Alzheimer’s or multi-infarct dementia, is usually
progressive, gradual in onset, of long duration, and has a steady downward course.
Delirium, or acute confusional state, presents with acute onset, is of short duration, and
has a fluctuating course and is often reversible with treatment.74 Nursing interventions
vary depending on the cause of the Disturbed Thought Process.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Dementia
Conduct a thorough assessment and collaborate with the To facilitate treatment of the primary problem.
health-care team to treat possible etiologies of demen-
tia: metabolic diseases, toxin exposure, infection, neo-
plasm, drug side effects, nutritional deficiencies,
degenerative neurologic disease, cerebral vascular
injury.
Offer immediate attention with supportive and sympto- Prevent further disturbed thought processes.
matic care.
Assure continuity of care personnel. Facilitates feelings of safety by client, allows for early
identification of changes in client mental status.
Support sensory function in all stages of dementia by Minimizes sensory sources of disturbed thought
using assistive devices such as glasses, hearing aids, processes.
and dentures.
Maintain safe environment. Avoid leaving solutions, Basic preventive measure.
equipment, or medications near the patient that could
result in injury through misuse or ingestion.
Provide a consistent environment and schedule but Prevents exacerbation of disturbed thought processes.
remain flexible.
Communicate with the client using verbal or nonverbal Clients with middle stage Alzheimer disease often have
strategies as appropriate for the stage of dementia. difficulty understanding or expressing verbally. Late-
stage Alzheimer’s clients often lose their ability to
communicate verbally.
Monitor environment to prevent overstimulating the With dementia, the patient has a reduced threshold for
patient with light, sounds, and frequent activity. stress.
Support sensory function in all stages of dementia by
using assistive devices such as glasses, hearing aids,
and dentures.
Provide appropriate environmental cues and limit inap-
propriate environmental cues.
For example, when preparing a client to bathe, place tow-
els and clean clothing in a visible location. This pro-
vides an environmental cue for the activity of bathing.
• Limit the client’s exposure to cues such as keys, oven
knobs, or cooking utensils if they stimulate the client to
engage in activities that are not appropriate or safe.
Schedule activities that are of short duration (usually 20- Prevents stresses on an individual already suffering from
minute sessions). [Note client’s schedule here.] attention deficits and anxiety.
Use short sentences and clear directions when communi- Allows processing of basic information without
cating with the patient. distraction.
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Thought Process, Disturbed • 513
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine self-care abilities that are intact, and encour- Provides stimulation and sense of pride. Promotes physi-
age continued participation in these activities. cal activity.
Monitor food and fluid intake to determine that nutri-
tional status is adequate.
Provide consistent staff. Reduces anxiety.
Refer the family to local Alzheimer’s and related disease Provides long-term support.
support groups.
Delirium
Monitor for conditions that can induce delirium. Certain factors such as electrolyte imbalance, preopera-
tive dehydration, unanticipated surgery, intraoperative
hypotension, postoperative hypothermia, and a large
number of medications have been found to be associ-
ated with acute confusional states in older adults.75,76
Provide orienting information to the patient as often as Provides information to the patient about the current situ-
necessary. ation, and assists in reducing anxiety and confusion.
Provide sensory stimulation such as bathing, touching, Assists in restoring the patient’s sense of body image.77
and back massages.
Home Health
In addition to the following interventions, the interventions for Adult Health can be applied to the home health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family to monitor for signs and Basic monitoring that allows for early intervention.
symptoms of Disturbed Thought Process:
• Poor hygiene
• Poor decision making or judgment
• Regression in behavior
• Delusions
• Hallucinations
• Changes in interpersonal relationship
• Distractibility
Involve the client and family in planning, implementing, Involvement improves cooperation and motivation,
and promoting appropriate thought processing: thereby increasing the probability of an improved
• Family conference outcome.
• Mutual goal setting
• Communication
Assist the client and family in lifestyle adjustments that
may be necessary:
• Providing safety and prevention of injury
• Frequent orientation to person, place, and time
• Providing reality testing and patient verification
• Assisting in working through alterations in role func-
tions in family or at work
• Stopping substance abuse
• Facilitating family communication
• Setting limits
• Learning new skills
• Decreasing risk for violence
• Preventing suicide
• Explaining possible chronicity of disorder
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514 • Cognitive–Perceptual Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Referring the client to community resources for finan-
cial assistance
• Reducing sensory overload
• Teaching stress management
• Teaching relaxation techniques
• Referring the client and family to support groups
Assist the client and family to set criteria to help them Early identification of issues requiring professional evalu-
determine when professional intervention is required. ation will increase the probability of successful inter-
ventions.
Teach the client and family purposes, side effects, and Provides necessary information for the client and family
proper administration techniques for medications. that promotes safe self-care.
Consult with or refer to appropriate assistive resources as Efficient and cost-effective use of community resources.
required.
DEFINING CHARACTERISTICS2
1. Consistent inattention to stimuli on an affected side
✔ Have You Selected the Correct Diagnosis?
2. Does not look toward affected side Disturbed Sensory Perception
This diagnosis refers to a problem with receiving sen-
3. Positioning and/or safety precautions in regard to the
sory input and interpretation of this input. Unilateral
affected side
Neglect could be, as indicated by the related factors,
4. Inadequate self-care an outcome of this disturbance in sensory input
5. Leaves food on plate on the affected side and/or perception of this input.
RELATED FACTORS2
1. Effects of disturbed perceptual abilities, for example, EXPECTED OUTCOME
hemianopsia
2. Neurologic illness or trauma Performs self-care of all body parts by [date].
3. One-sided blindness Verbalizes plan to address self-care deficits by [date].
Identifies [number] of needs for assistance by [date].
RELATED CLINICAL CONCERNS
TARGET DATES
1. Cerebrovascular accident
2. Glaucoma A target date between 5 and 7 days would be appropriate to
3. Blindness secondary to diabetes mellitus evaluate initial progress.
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Unilateral Neglect • 515
ACTIONS/INTERVENTIONS R AT I O N A L E S
Frequently remind the patient to attend to both sides of Repetition improves brain processing.
his or her body.
Consult with physical and occupational therapy to facili- Increases brain’s awareness of neglected side.
tate patient’s awareness of and articulate sensations on
neglected side. [Note support from nursing needed
here.]
Assist the patient with ROM exercises to neglected side Increases brain’s awareness of neglected side, and main-
of body every 4 hours while awake at [times]. Teach tains muscle tone and joint mobility.
the extent of movement of each joint on the neglected
side of body.
Help the patient position neglected side of body in a simi-
lar way as attended side of body whenever position is
changed.
Refer to rehabilitation nurse clinician. Collaboration provides a more holistic plan of care, and
rehabilitation nurse will have most up-to-date knowl-
edge regarding this diagnosis.
Child Health
See nursing actions under Disturbed Sensory Perception in addition to those listed here.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Allow 30 minutes every shift for the patient and family to Ventilation of feelings is paramount in understanding the
express how they perceive the unilateral neglect. effect the problem has on the patient and the family; it
is also critical as a means of evaluating needs.
Determine how the unilateral neglect affects the usual Previous and/or current developmental capacity may be
expected behavior or development for the child. affected by the unilateral neglect depending on the
degree of severity. To be able to judge the best means
of therapy requires these data to be considered (e.g.,
does the child use the affected hand as a helper, or not
try to use it at all?)
Monitor for presence of secondary or tertiary deficits. Identification of primary deficits should alert all to moni-
tor for possible secondary and tertiary deficits to mini-
mize further sequelae, which can be treated early.
Establish, with family input, appropriate anticipatory Safety needs and measures must reflect the developmen-
safety guidelines that are based on the unilateral neg- tal capacity of the child and slightly beyond it. There is
lect and the developmental capacity of the child. a special need to structure the environment to allow for
appropriate exploratory behavior while maintaining
safety without overprotection.
Stress appropriate follow-up prior to dismissal from hos- Arrangement for follow-up increases the likelihood of
pital with appropriate time frame for the family. compliance and shows the importance of follow-up.
Women’s Health
This nursing diagnosis will pertain to women the same as any other adult.
Mental Health
Nursing interventions for this diagnosis are those described in Adult Health.
(care plan continued on page 516)
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516 • Cognitive–Perceptual Pattern
Gerontic Health
The interventions for Adult Health can be applied to the aging client.
Home Health
In addition to the following interventions, the interventions for Adult Health can be applied to the home health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for factors contributing to Unilateral Neglect This action provides the database needed to identify inter-
(e.g., disturbed perceptual abilities, neurologic disease, ventions that will prevent or diminish Unilateral
or trauma). Neglect.
Involve the client and family in planning, implementing, Family involvement is important to ensure success.
and promoting reduction in effects of Unilateral Communication and mutual goals improve the
Neglect: outcome.
• Schedule family conferences (e.g., to discuss concerns
family members have).
• Encourage the family’s ideas for addressing the
concern.
• Set mutual goals (e.g., establish two measures to offset
the effect of unilateral neglect). Be sure roles for the
participants are identified.
• Maintain communication.
• Provide support for the caregiver (e.g., plan respite
time for the primary caregiver). Alternate caregivers are
identified and trained.
Teach the client and family measures to decrease effects These actions diminish the negative effects of Unilateral
of Unilateral Neglect: Neglect.
• Active and passive ROM exercises
• Ambulation with assistive devices (canes, walkers, or
crutches)
• Objects placed within field of vision and reach
• Assistive eating utensils
• Assistive dressing equipment
• Safe environment (e.g., objects removed from area out-
side field of vision)
Assist the family and client to identify lifestyle changes Lifestyle changes require changes in behavior. Self-
that may be required: evaluation and support facilitate these changes.
• Change in role functions
• Coping with disability or dependency
• Obtaining and using assistive equipment
• Coping with assistive equipment
• Maintaining safe environment
Consult with appropriate assistive resources as indicated. Appropriate use of existing community services is effec-
tive use of resources.
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Unilateral Neglect • 517
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66. Ferrell, B, and Ferrell, B: Easing the pain. Geriatric Nursing 11:175, 72. Buccheri, R, et al: Auditory hallucinations in schizophrenia. Journal
1990. Psychosocial Nursing 34:12, 1996.
67. Hofland, S: Elder beliefs: Blocks to pain management. J Gerontol 73. Dochtermann, McCloskey, J, and Bulechek, G: Nursing Interventions
Nurs 18:19, 1992. Classification, ed 4. Mosby–Year Book, St. Louis, 2004.
68. Haber, J, et al: Comprehensive Psychiatric Nursing, ed 5. Mosby–Year 74. Gomez, G, and Gomez, E: Dementia? Or delirium? Geriatr Nurs
Book, St. Louis, 1997. 11:136, 1989.
69. Puskar, KR, et al: Psychiatric nursing management of medication-free 75. Foreman, M: Complexities of acute confusion. Geriatric Nurs 11:136,
psychotic patients. Arch Psychiatri Nurs 4:78, 1990. 1990.
70. Townsend, M: Nursing Diagnosis in Psychiatric Nursing, ed 5. FA 76. Bowman, AM: The relationship of anxiety to development of post
Davis, Philadelphia, 2001. operative delirium. J Gerontol Nurs 18:24, 1992.
71. Schwartz, MS, and Shockley, EL: The Nurse and the Mental Patient. 77. Faraday, K, and Berry, M: The nurse’s role in managing reversible
Russell Sage Foundation, New York, 1956. confusion. J Gerontol Nurs 15:17, 1989.
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SELF-PERCEPTION
8
AND SELF-CONCEPT
PATTERN
1. ANXIETY 530
2. BODY IMAGE, DISTURBED 541
3. DEATH ANXIETY 548
4. FEAR 553
5. HOPELESSNESS 562
6. LONELINESS, RISK FOR 569
7. PERSONAL IDENTITY, DISTURBED 575
8. POWERLESSNESS, RISK FOR AND ACTUAL 579
9. SELF-CONCEPT, READINESS FOR ENHANCED 586
10. SELF-ESTEEM: CHRONIC LOW, SITUATIONAL LOW,
AND RISK FOR SITUATIONAL LOW 590
11. SELF-MUTILATION, RISK FOR AND ACTUAL 598
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PATTERN DESCRIPTION 11. Does the patient appear passive or verbalize passivity?
a. Yes (Hopelessness)
As the nurse interacts with the client, the most important b. No
knowledge the client contributes is self-knowledge. It is this 12. Does the patient demonstrate decreased verbalization
understanding, most often labeled “self-concept,” that deter- and/or flat affect?
mines the individual’s manner of interaction with others. a. Yes (Hopelessness)
One’s self-concept is composed of beliefs and attitudes b. No
about the self, including perception of abilities (cognitive, 13. Does the patient have a problem with physical or social
affective, or physical), body image, identity, self-esteem, isolation?
and general emotional pattern.1 An individual’s behavior is a. Yes (Risk for Loneliness)
affected not only by experiences prior to interactions with b. No (Readiness for Enhanced Self-Concept)
the health-care system, but also by interactions with the 14. Has the patient recently suffered the loss of a signifi-
health-care system. cant other?
a. Yes (Risk for Loneliness)
b. No
15. Does the patient verbalize lack of control?
PATTERN ASSESSMENT a. Yes (Powerlessness)
1. Does the patient express concern the regarding current b. No
situation? 16. Is the patient participating in care and decision making
a. Yes (Anxiety or Fear) regarding care?
b. No a. Yes (Readiness for Enhanced Self-Concept)
2. Can the patient identify the source of concern? b. No (Powerlessness)
a. Yes (Fear)
b. No (Anxiety)
CONCEPTUAL INFORMATION
3. As a result of this admission, will the patient going
have a change in body structure or function? Definition of the self and of a self-concept has been an issue
a. Yes (Disturbed Body Image) of debate in philosophy, sociology, and psychology for
b. No many years, and many publications are available on this
4. Does the patient verbalize a change in lifestyle as a topic.2 The complexity of the problem of defining self is
result of this admission? compounded by the knowledge that external observation
a. Yes (Disturbed Body Image) provides only a superficial glimpse of the self, and intro-
b. No spection requires that the “knower” knows himself or herself
5. Does the patient express fear about dying? so that information actually gained is self-referential. In
a. Yes (Death Anxiety) spite of these problems, the concept continues to be perva-
b. No sive in the literature and in the universal experience of “self”
6. Does the patient express worries about the impact of or “not self.” Intuitively one would say, of course, “There is
his or her death on his or her family and/or friends? a self because I have experiences separate from those around
a. Yes (Death Anxiety) me; I know where I end and they begin.” The importance
b. No of self is also emphasized by the language in the multitude
7. Does the patient verbalize a negative view of self? of self-referential terms such as self-actualization, self-
a. Yes (Situational Low Self-Esteem) affirmation, ego-involvement, and self-concept.
b. No (Readiness for Enhanced Self-Concept) Cognitive neuroscientists have utilized brain imaging
8. Does the patient believe he or she can deal with the during various self-referential tasks to understand the
current problem that led to this admission? process of experiencing the self. This research has linked
a. Yes specific areas of the brain with activities of self-reference.3
b. No (Situational Low Self-Esteem) The medial prefrontal cortex is one area that demonstrates
9. Does the patient or his or her family indicate that the the most activity when thinking about the self. It is hypoth-
self-negating impression is a long-standing (several esized that this area links multiple self-knowledge systems
years) problem? in the brain.3 Clearly, the neurological response is different
a. Yes (Chronic Low Self-Esteem) when one is thinking of the self, and this process changes as
b. No (Situational Low Self-Esteem) we develop a better self-concept.4 The understandings
10. Does the patient question who he or she is or verbalize evolving from cognitive neuroscience provide a map to the
lack of an understanding regarding his or her role in intricacies of self-knowledge, which can inform client care.
life? Some of the basic neuroscience understandings with
a. Yes (Disturbed Personal Identity) implications for intervening with human responses related
b. No (Readiness for Enhanced Self-Concept) to self-perception are related to the awareness of one’s own
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Conceptual Information • 521
body. This is the foundational understanding of the self, to foundation for the self in this theoretical model. James out-
know where the physical self begins and ends. The process lines the internal working of the self with his concepts of “I”
of knowing this occurs when the neuro command to move a and “Me.” “I” is the thinker or the state of consciousness.
body part is issued. At this point two signals are sent, one to “Me” is what the “I” is conscious of, and includes all of
the body part that needs to be moved, and one to the part of what people consider theirs. This “Me” contains three
the brain that monitors movement. The monitoring process aspects: the “material me,” the “social me,” and the “spiri-
predicts the action experience. If the prediction does not tual me.”6 The self-construction outlined by Mead8 indicates
match what is experienced, and the difference cannot be rec- that there is the “knower” part of the self and that which the
onciled, then the brain processes this as not caused by the “knower” knows. Mead conceptualizes the thoughts them-
self.4 Difficulties in making this link could result in a dis- selves as the “knower” to resolve the metaphysical problem
turbed body image or delusional thinking. The client, in of who the “I” is. In Mead’s writings, the consciousness of
search of an explanation for his or her experience, could self is a stream of thought in which the “I” can remember
conclude that someone or something outside of him- or her- what came before and continues to know what was known.
self is controlling his or her actions. Continued research in Mead8 expressly addresses the development of these memo-
cognitive neuroscience will increase understanding about ries and how they affect one’s behavior.
how to facilitate the development of self-knowledge links Mead8 describes the self-concept as evolving out of
and assist in refining nursing interventions. interactions with others in social contexts. This process
Neuroscientists recognize that humans have devel- begins at the moment of birth and continues throughout a
oped a uniquely complex sense of self. The evolution of this lifetime. The definition of self can occur only in social inter-
complexity may have been a response to living in complex actions, for one’s own self exists only in relation to other
social networks.4 This connection between the brain and selves. The individual is continually processing the reac-
social networks reflects the circular causal model of sys- tions of others to his or her actions and reactions. This pro-
tems/cybernetics that provides the theoretical foundation for cessing is taking place in a highly personalized manner, for
the research.3 In that circular wholistic perspective, the soci- the information is experienced through the individual’s
ological understandings of the development of the self must selective attention, which is guided by the current needs that
also be considered. are struggling to be expressed. This results in an environ-
Turner5 addresses society’s need for the individual to ment that is constructed by one’s perceptions. Mead’s con-
conceptualize the self-as-object. Recognizing the self-as- ceptualization leads to an interesting feedback process in
object allows society to place responsibility, which becomes that we can only perceive self as we perceive others perceive
a very valuable asset in maintaining social control and social us. This continues to reinforce the idea that the self-concept
order. This returns us to the initial problem of what the self is is highly personalized.
and how we can understand others’ selves and ourselves.6 In Many authors5,7,8 have addressed the process of devel-
this section, the assumption is made that self-concept refers oping a concept of self. The model developed by Harry
to the individual’s subjective cognitions and evaluations of Stack Sullivan9 is presented here because it is consistent
self; thus, it is a highly personal experience. This indicates with the information presented in the symbolic interaction
that the self is a personal construct and not a fact or hard real- literature, and is used as the theoretical base in much of the
ity. It is further assumed that the individual will act, as stated nursing literature.
earlier, in congruence with the self-concept. This conceptual- Sullivan9 describes the self-concept as developing in
ization is consistent with the authors who will be discussed, interactions with significant others. Sullivan sees develop-
and with the assumptions utilized in psychological research.6 ment of the self-concept as a dynamic process resulting
It is also important to recognize that language assists in from interpersonal interactions that are directed toward
developing a concept. This becomes crucial when thinking meeting physiologic needs. This process has its most obvi-
about the concept of self in English, because the English lan- ous beginnings with the infant and becomes more complex
guage comes from a tradition of Cartesian dualism that does as the individual develops. This increasing complexity
not express integrated concepts well. Often it will appear that results from the layering of experiences that occurs in the
the information presented is separating the individual into developing individual. The biologic processes become less
various parts, when, in fact, an integrated whole is being and less important in directing the individual the further
addressed. For example, James7 talks about an “I” and a away from birth one is and as the importance of interper-
“Me.” If these terms were taken at face value, it would appear sonal interaction increases. The initial interpersonal interac-
that the individual is being divided into multiple parts, when, tion is between the infant and the primary caregivers. An
in fact, an integrated whole is being discussed. The words infant expresses discomfort with a cry and the “parenting
describe patterns of the whole person. Unless otherwise one” responds. This response, whether tender or harsh,
stated, it can be assumed that the concepts presented in this begins to influence the infant’s beliefs about herself or him-
book reflect on the individual as an integrated whole. self, as well as the world in general. If the interaction does
Symbolic interaction theory provides a basis for not provide the infant with a feeling of security, anxiety
understanding the self. James7 and Mead8 developed the results and interferes with the progress toward other life
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522 • Self-Perception and Self-Concept Pattern
goals. Sullivan makes a distinction between the inner expe- lation of interventions focused on improving perceptions of
rience and the outer event and describes three modes of self. Five facets that contribute to a positive perception of
understanding experience. self emerged from Stake’s15 research: task accomplishment,
The first developmental experience is the prototaxic power, giftedness, likeability, and morality. The characteris-
mode. In this mode, the small child experiences self and the tics of task accomplishment include perceptions of having
universe as an undifferentiated whole. At 3 to 4 months, the good work habits and the ability to manage and complete
child moves into the parataxic mode. The parataxic mode tasks efficiently. Perceptions of personal power include hav-
presents experiences as separated but without recognition of ing strength, toughness, and the ability to influence others.
a connectedness or logical sequence. Finally, the individual Perceiving oneself as having special natural aptitudes and
enters the syntaxic mode, in which consensual validation is talents provides the foundation for the facet of giftedness.
possible. This allows for events and experiences to be com- Seeing oneself as pleasant and enjoyable to be with consti-
pared with others’ experiences and for establishment of tutes the characteristic of likeability. Morality is made up of
mutually understandable communication instead of the autis- factors that indicate the individual perceives himself or her-
tic thinking that has characterized the previous stages.10,11 self as having qualities valued as good and virtuous.
As one experiences the environment through these Additional facets have been added to these basic founda-
three modes of thought, the self-system or self-concept is tions.16,17 These factors include perceptions about physical
developed. Sullivan conceptualized three parts of the self. appearance, behavioral conduct and job, and athletic and
The part of the self that is associated with security and scholastic competence.
approval becomes the “good me,” whereas that which is Integration of theory and research related to self-
within one’s awareness, but is disapproved of, becomes the concept indicates that positive self-perceptions evolve in a
“bad me.” The “bad me” could include those feelings, needs, positive nurturing environment. Factors that contribute to
or desires that stimulate anxiety. Those feelings and under- the success of this environment include positive support for
standings that are out of awareness are experienced as “not decision making; warm acceptance; positive, informative
me.” These “not me” experiences are not nonexistent but are praise; promotion of self-efficacy; a sense of belonging and
expressed in indirect ways that can interfere with the con- purpose; and the development of positive social skills.18
duct of the individual’s life.9,10 The complex interaction of facets that evolve into
As the social sciences adopted a cybernetic world- the self-concept is an ongoing process occurring throughout
view, this theoretical perspective has been applied to devel- the individual’s life. This process can be impacted by
oping a concept of self. Glasersfeld12 spoke of the self as a life events, including illness,19,20 that impinge on any of the
relational entity that is given life through the continuity of identified factors, whether positively or negatively.
relating. This relating provides the intuitive knowledge that The Search Institute21 has developed, as a result of
our experience is truly ours. It reflects the perspective of their research, a list of 40 assets that support the development
knowing presented at the beginning of this section. of young people. If these assets are compared with the facets
Watts13 describes what many authors feel is the self, as necessary to build a positive self-concept, many parallels can
it can be understood through a cybernetic worldview. Self is be identified. The 40 assets are divided into internal and
the whole, for it is part of the energy that is the universe and external. The four general external asset categories are sup-
cannot be separated. “At this level of existence ‘I’ am imme- port, empowerment, boundaries and expectations, and con-
asurably old; my forms are infinite and their comings and structive use of time. The internal asset categories include
goings are simply the pulses or vibrations of a single and commitment to learning, positive values, social competen-
eternal flow of energy.” In this view, an individual is con- cies, and positive identity. These eight general categories are
nected to every other living being in the universe. This further divided into assets that are more specific. The assets
places the self in a unique position of responsibility. The self of positive identity, empowerment, positive values, and
then becomes responsible to everything because it is every- social competencies are similar to the concepts of likeability,
thing. This conceptual model resolves the issue of responsi- power, and morality discussed in the self-concept literature.
bility to society without relying on an individual self to The Search Institute21 has found that the more assets
whom responsibility is assigned. the young person has, the fewer his or her high-risk behav-
Although the conceptual model represented here by iors. Specific behaviors for nurturing the development of
Watts13 fits with current theoretical models being utilized in each asset have been identified. These asset development
nursing and the social sciences, it is not congruent with the guidelines provide concrete direction facilitating the devel-
experience of most persons in Western society. This limits opment of self-concept-enhancing experiences in the young
its usefulness when working with clients in a clinical setting. person’s life. Specific asset-building behaviors are discussed
It is presented here to provide practitioners with an alterna- in the next section under each developmental age to provide
tive model for themselves. practitioners with direction in supporting the development
Stake14,15 developed an instrument to measure self- of positive perceptions of self.
perception. Knowledge of the factors contributing to the Sidney Jourard22 provides direction for interventions
development of the self-perception can assist in the formu- related to an individual’s self-concept. The healthy self-
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Developmental Considerations • 523
concept allows individuals to play roles they have satisfac- orders, failure to thrive syndrome, and constipation with
torily played while gaining personal satisfaction from this early toilet training. Stranger anxiety and separation anxiety
role enactment. This person also continues to develop and may be demonstrated with screaming, attempting to with-
maintain a high level of physical wellness. This high level of draw, and refusing to cooperate. Both stranger anxiety and
wellness is achieved by gaining knowledge of oneself separation anxiety are normal developmental responses, and
through a process of self-disclosure. Jourard22 states that, “If should not be considered pathologic as long as they are not
self-disclosure is one of the means by which healthy per- severe or prolonged, and if the parental response is appro-
sonality is both achieved and maintained, we can also note priately supportive of the infant’s needs.
that such activities as loving, psychotherapy, counseling, Fear is a normal protective response to external threats
teaching and nursing, all are impossible—without the dis- and will be present at all ages. It becomes dysfunctional at
closure of the client.” the point that it is attached to situations that do not present a
Elaboration of this thought reveals that for the nurse to threat, or when it prevents the individual from responding
effectively meet the needs of the client, an understanding of appropriately to a situation. Thus, it is important that chil-
the client’s self must be achieved. This understanding must dren have certain fears to protect them from harm. The hot
go beyond the interpretation of overt behavior, which is an stove, for example, should produce a fear response to the
indirect method of understanding, and access the client’s degree that it prevents the child from touching the stove and
understanding of self through the process of self-disclosure. being injured. Fear is a learned response to situations, and
Dufault and Martocchio23 present a conceptual model children learn this response from their caregivers. Thus, it
for hope that also provides a useful perspective for nursing becomes the caregivers’ responsibility to model and teach
intervention. Hope is defined as multidimensional and appropriate fear. If a mother cannot tolerate being left alone
process-oriented. Hopelessness is not the absence of hope in the house at night with her children, her children will
but is the product of an environment that does not activate learn to fear being in this situation. When this home is
the process of hoping. Vaillot24 supports the view presented located in a low-crime area with supportive neighbors and
by Dufault and Martocchio with the existential philosophi- appropriate locks, fear becomes an inappropriate response,
cal perspective that hope arises from relationships and the and the children may be affected by it for a lifetime.
beliefs about these relationships. One believes that help can Various developmental stages have characteristic fears
come from the outside of oneself when all internal resources associated with them. In the mind of the child, these charac-
are exhausted. Hopelessness arises in an environment where teristic fears present threats, so the fears can be seen both
hope is not communicated. This model supports nursing as a source of fear and as a source of anxiety. The charac-
interventions from a systems theory perspective, because it teristic fears result from strong or noxious environmental
validates the ever-interacting system, the whole. In this per- stimuli such as loud noises, bright lights, or sharp objects
spective, the nurse, as well as the client, contributes to the against the skin. The response to fears produces physiologic
“hopelessness,” and thus the responsibility of nurturing hope symptoms. The most immediate and obvious response of the
is shared.23–27 child is crying and pulling away from the stressful object or
situation.
Erickson28 indicated that he thought hope evolved out
DEVELOPMENTAL CONSIDERATIONS of the successful resolution of this first developmental stage,
basic trust versus mistrust. Hope was perceived by Erickson
INFANT
to be a basic human virtue. The type of environment that has
In general, the sources of anxiety begin in a very narrow been identified as promoting the development of this basic
scope with the infant and broaden out as he or she matures. trust is warm and loving, where there is respect and accept-
Initially the relationship with the primary caregiver is the ance for personal interests, ideas, needs, and talents.25
source of gratification for the infant, and disruptions in Several environmental conditions have been associated with
this relationship result in anxiety. As one matures, needs are early childhood and are seen as increasing the perceptions
met from multiple sources, and therefore the sources of anx- consistent with hopelessness. These conditions are economic
iety expand. Specific developmental considerations are des- deprivation, poor physical health, being raised in a broken
cribed in the paragraphs that follow. home or a home where parents have a high degree of conflict,
The primary source of anxiety for the infant appears having a negative perception of parents, or having parents
to be a sense of “being left.” This response begins at about who are not mentally healthy. From an existential perspec-
3 months. Sullivan,9 as indicated earlier, would contend that tive, Lynch29 identified five areas of human existence that can
the infant could experience anxiety even earlier with any produce hopelessness. If these areas are not acknowledged in
disruption in having needs met by the primary caregiver. At the developmental process, the individual is at greater risk of
age 8 to 10 months, separation anxiety peaks for the first frustration and hopelessness because hope is being intermin-
time. At 5 to 6 months, the infant begins to demonstrate gled with a known area of hopelessness. The five areas that
stranger anxiety. Primary symptoms include disruptions in Lynch identified are death, personal imperfections, imperfect
physiologic functioning and could include colic, sleep dis- emotional control, inability to trust all people, and personal
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524 • Self-Perception and Self-Concept Pattern
areas of incompetence. This supports Erickson’s contention appears to be wrong,” and also can produce a perception
that hope evolves out of the first developmental stage, of powerlessness. They are “damned if they do and damned
because these basic areas of hopelessness are issues related if they don’t.” If the individual cannot influence this system
primarily to the resolution of trust and mistrust. It should be in a direct manner, again, indirect behavior patterns are cho-
remembered that previously resolved or unresolved develop- sen. Bateson30 proposes that this is the process behind the
mental issues must be renegotiated throughout life. symptom cluster identified as schizophrenia. This suggests
Each developmental stage has a set of specific etiolo- that if the child is continually placed in the position of
gies and symptom clusters related to hopelessness. Because being wrong no matter what he or she has done, the child
the relationship between self-concept strength and degree of could develop the perception that his or her position is one
hopefulness is seen as a positive link, many of the etiologies of powerlessness and carry this attitude with him or her
and symptoms of hopelessness at the various developmental throughout life.
stages are similar to those of self-esteem disturbances.30 Infants have a need for consistent response to having
As conceptualized by Erickson,28 infancy is the pri- physiologic needs met, and the most important relationship
mary age for developing a hopeful attitude about life. If the becomes that with the “parenting one.” If this relationship is
infant does not experience a situation in which trust in disrupted and needs are not met, symptoms related to infant
another can be developed, then the base of hopelessness has depression or failure to thrive could communicate a percep-
begun. Thus, if the infant experiences frequent change in tion related to powerlessness.
caregivers, or has a caregiver who does not meet the basic It is important to remember that self-concept, includ-
needs in a consistent and warm manner, the infant will ing body image, is developed throughout life. For the infant,
become hopeless. Research29 has indicated that children the primary source of developing self-concept and body
who have been raised in an environment of despair are image is physical interaction with the environment. This
at greater risk for experiencing hopelessness. Symptoms includes both the environment’s response to physical needs
of hopelessness in infants resemble infant depression or fail- and the body’s response to environmental stimuli.
ure to thrive. Because symptoms in infants are a general Some behaviors that build assets in the infant and tod-
response, the diagnosis of Hopelessness must be considered dler include playing with the child at eye level; exposing the
equally with other diagnoses that produce similar symptom child to positive values by modeling sharing and being nice
clusters, such as Powerlessness and Ineffective Coping. to others; reading to the child; providing a safe, caring, stim-
One’s perceptions of place in the larger system and of ulating environment; and communicating to the child that he
influence in this system begin at birth. These perceptions are or she is important by spending time with him or her.31
developed through interactions with those in the immediate These behaviors have the strongest impact on the
environment and continue throughout life with each new infant when they are provided in an environment of consis-
interaction in each new experience. Thus, the child learns tent relationships and respect. Consideration of the child’s
from primary caregivers that his or her expressions of need preferences and abilities nurtures positive self-knowledge.32
may or may not have an effect on those around him or her
and also learns what must be done to have an effect. If the
TODDLER AND PRESCHOOLER
caregiver responds to the earliest cries of the infant, a sense
of personal influence has begun. The two areas that consis- The basic sources of anxiety remain the same as for the
tently influence one’s perceptions of influence are discipline infant. Separation anxiety appears to peak again at 18 to 24
and communication styles. months, and stranger anxiety peaks again at 12 to 18 months.
Implementation of discipline in a manner that pro- Loss of significant others is the primary source of anxiety at
vides the child with a sense of control over the environment this age. In addition to the physiologic responses already
while teaching appropriate behavior can produce a percep- mentioned, the child may demonstrate anxiety by motor rest-
tion of mutual system influence. Harsh, over-controlling lessness and regressive behavior. The preschooler can begin
methods can produce the perception that the child does not to tolerate longer periods away from the parenting one and
have any influence in the system if acting in a direct manner. enjoys having the opportunity to test his or her new abilities.
This produces an indirect influencing style. An example of Lack of opportunity to practice independent skills can
indirect influence is the child who always becomes ill just increase the discomfort of this age group. Increased anxiety
before his parents leave for an evening on the town. The par- can be seen in regressive behavior, motor restlessness, and
ents, out of concern for the child, decide to remain at home physiologic response.
and thus never have time together as a couple. Authoritarian Sources of anxiety can include concerns about the
styles of interaction can also produce perceptions of power- body and body mutilation, death, and loss of self-control.
lessness in adults in unfamiliar environments. If the hospital These concerns can be expressed in the ways previously dis-
staff acts in an authoritarian manner, the client may develop cussed, as well as with language and dramatic play, as lan-
perceptions of powerlessness. guage abilities increase. This could include playing out
Double-bind communication can place the individual anxiety-producing situations with dolls or other toys. This
in a position of feeling that “no matter what action I take, it play can assume a very aggressive nature. The anxieties of
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Developmental Considerations • 525
the day can also be expressed in dreams and result in night- concept. Peers begin to assume greater importance in self-
mares or other sleep disturbance. perceptions. Physical integrity continues to be important,
In this age group, fears evolve from real environmen- and physical difference can have a profound effect on the
tal stimuli and from imagined situations. Typical fears of preschool child.
specific age groups are fear of sudden loud noise (2 years), Actions that build assets in the preschooler include
fear of animals (3 to 4 years), fear of the dark (4 to 5 years), playing and talking to them on eye level; asking them to talk
and fear of the dark and of being lost (6 years). Symptoms with you about things they have seen; working with them to
of fears include regressive behavior, physical and verbal cru- use words to express themselves; reading to them; taking
elty, restlessness, irritability, sleep disturbance, dramatic them to community events, museums, and cultural events;
play around issues related to the fear, and increased physical modeling for them how to behave; providing a supportive
closeness to the caregiver. family life; providing clear rules and consequences; involv-
Alterations to the body or its functioning place a child ing child in creative activities; modeling expectation that
at this age at the greatest risk of experiencing hopelessness. others will do things well; valuing expressions of caring;
If the child experiences a difference between self and other assisting the child to learn the difference between truth and
or is ashamed about body functioning, in a nonsupportive lying; assisting the child to make simple choices and deci-
environment, hopelessness can develop. A specific issue sions; and helping the child to learn how to deal nonvio-
encountered at this stage is toilet training. If the child is lently with challenges and frustrations.27 With growing
placed in a position of being required to gain control over sense of self independent of others, positive responses to
bowel and bladder functions before the ability to physically their increased competencies facilitates the development of
master these functions has developed, the child can experi- a positive perception of self.32
ence hopelessness in that he or she truly cannot make his or
her body function in the required manner. Peer interactions
SCHOOL-AGE CHILD
are also important at this time because they foster the begin-
nings of trust in someone other than the “mothering” one, Typically, fears are aroused by strange noises such as ghosts
thus understanding that hope can be gained elsewhere. and imagined phantoms; natural elements such as fire,
Struggle between self-control and control by others water, or thunder (6 years); not being liked or being late for
becomes the primary psychosocial issue. If appropriate school (7 years); and personal failure or inadequacy (8 to 10
expansion of self-control is encouraged, the child will years). Symptoms of these fears include physical symptoms
develop perceptions related to mutual systemic influence. of autonomic stimulation, increased verbalization, with-
This appropriate support is crucial if the child is to develop drawal, aggression, sleep disturbance, or needing to repeat a
a perception of a personal role in the social system. If this specific task many times.
struggle for self-control is thwarted, the child can express Concerns about imagined future events produce the
themes of over control in play or become overly dependent anxieties of the school-age child. The specific concern
on the primary caregiver and withdraw completely from new varies with the developmental age. Young school-age
situations and learning. children demonstrate concerns related to the unknowns in
For the preschooler, there is a continuation and refine- their environment, such as dark rooms, and natural ele-
ment of a sense of personal influence. Varying approaches ments, such as fire or tornadoes. Older school-age chil-
are explored, and a greater sense of what can be achieved is dren have anxieties related to personal inadequacies.
developed. One of the primary sources of anxiety during this Preadolescence brings increasing concerns about the valua-
stage is loss of self-control. Symptoms of difficulties in this tion of peers and concerns about the acceptance of peers.
area include playing out situations with personal influence Expression of anxiety can occur in the ways discussed in the
as a theme and aggressive play. previous level, with the addition of increased verbalization
Sources of the self-concept perceptions are the and compulsive behavior such as repeating a specific task
responses of significant others to exploration of new physi- many times.
cal abilities and to the toddler’s place in these relationships. Peers’ perceptions of the individual assume a role in
The primary concept of self is related to physical qualities, the development of attitudes related to personal hopefulness
motor skills, sex type, and age. A concept of physical dif- and influence within the larger social system. This is built on
ferences and of physical integrity is developed. Thus, situa- the perceptions achieved during earlier stages of develop-
tions that threaten the toddler’s perception of physical ment. The sense of a strong peer group can produce percep-
wholeness can pose a threat. This would include physical tions of help coming from the outside as long as the child
injury. Toilet training poses a potential threat to the success- thinks and believes along with the group, but can produce
ful development of a positive self-concept or body image. perceptions of exaggerated personal influence. Problems at
Failure at training could produce feelings of personal this developmental stage can be demonstrated by with-
incompetence or of the body being shameful. drawal, daydreaming, increased verbalizations of helpless-
In the preschooler, physical qualities, motor skills, sex ness and hopelessness, angry outbursts, aggressive behavior,
type, and age continue to be the primary components of self- irritability, and frustration.
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Developmental Considerations • 527
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T A B L E 8 . 1 NANDA, NIC, and NOC Taxonomic Linkages (continued from page 527)
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Developmental Considerations • 529
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530 • Self-Perception and Self-Concept Pattern
T A B L E 8 . 1 NANDA, NIC, and NOC Taxonomic Linkages (continued from page 529)
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Anxiety • 531
z. Nausea (parasympathetic)
in which Fear would be an appropriate diagnosis is:
aa. Urinary urgency (parasympathetic) After being released from jail, the prisoner threatened
bb. Faintness (parasympathetic) to kill the judge who placed him or her in jail. The
cc. Respiratory difficulties (sympathetic) judge, if experiencing psychological stress due to this
dd. Increased blood pressure (sympathetic) threat and knowing the prisoner was out of jail, would
ee. Trembling/hand tremors receive the diagnosis of Fear.
ff. Shakiness
Disturbed Personal Identity
4. Cognitive
This diagnosis is the most appropriate diagnosis if the
a. Blocking of thought individual’s symptoms are related to a general distur-
b. Confusion bance in the perception of self. Anxiety would be used
c. Preoccupation when the discomfort was related to other areas.
d. Forgetfulness
e. Rumination Dysfunctional Grieving
This would be considered an appropriate diagnosis if
f. Impaired attention
the loss was real, whereas the diagnosis of Anxiety
g. Decreased perceptual field
would be used when the loss is a threat that is not
h. Fear of unspecified consequences necessarily real, such as a perceived loss of esteem
i. Tendency to blame others from others.
j. Difficulty concentrating
k. Diminished ability to problem solve and learn Ineffective Individual Coping
l. Awareness of physiologic symptoms This would be the appropriate diagnosis if the individ-
ual is not making the necessary adaptations to deal
with daily life. This may or may not occur with Anxiety
RELATED FACTORS40 as a companion diagnosis.
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532 • Self-Perception and Self-Concept Pattern
awareness. This level enhances learning and usually is anxiety. Objective symptoms include Headaches, dizzi-
not perceived as stressful. ness, nausea, trembling, insomnia, palpitations, tachy-
Moderate: Reduction of perceptual field, reduced alertness cardia, hyperventilation, urinary frequency, diarrhea.
to environment. Learning can occur at a reduced level Panic: Inability to focus on any details with mispercep-
with decreased attention span and ability to concentrate. tions of the environment. Learning, concentration,
Objective symptoms include increased restlessness, heart and/or comprehension of simple directions cannot occur.
rate, respirations, perspiration, muscular tension, altered Client experiences a sense of impending doom and/or
speech (rate, volume, pitch increased). terror. Objective symptoms include dilated pupils,
Severe: Perceptual field greatly diminished, focus on labored breathing, severe trembling sleeplessness, palpi-
details or fixation on a single detail. Very limited atten- tations, diaphoresis, pallor, muscular incoordination,
tion span and great difficulty with concentration or prob- immobility or purposeless hyperactivity, bizarre behav-
lem-solving. Focus is on the self and desire to decrease ior, hallucinations, delusions.
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Anxiety • 533
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide at least 20 to 30 minutes every 4 hours while the Provides an opportunity to practice the technique and
patient is awake for focus on anxiety reduction. [List express anxiety-provoking experiences.
times here.]
• Encourage the client to express feelings verbally and
through activity.
• Answer questions truthfully.
• Offer realistic reassurance and positive feedback.
Administer anti-anxiety medications as prescribed. The effectiveness of medication is determined so modifi-
Monitor and document effects of medication within cation can be provided if needed. Medication helps
30 minutes of administration. reduce anxiety to a manageable level.
Collaborate with the psychiatric nurse clinician regarding Collaboration helps provide holistic care. The specialist
care (see Mental Health nursing actions). may help discover underlying events for anxiety and
assist in designing an alternate plan of care.
Refer the patient to, and collaborate with, appropriate Support groups can provide ongoing assistance after
community resources. discharge.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for possible causes of anxiety to include situa- Provides a realistic basis for plan of care.
tion, recent event, trauma, or medications.
Review, with the child and parents, coping measures used The identification of coping strategies provides essential
for daily changes and crises. information to deal with anxiety. Once they are identi-
fied, the nurse can begin to evaluate the strategies that
are effective.
Identify ways the parents can assist the child to cope with A major starting point is to describe the feelings and
anxiety (e.g., set realistic explanations or demands, and attempt to create a sense of control, which is more
avoid bribing or not telling the truth). likely in patients of a certain developmental capacity
(e.g., those capable of abstract thinking). In younger
infants, rocking can provide soothing repetitious notion
when all other measures seem not to have calmed the
infant.
Adapt the routine to best help the child regain control Allowing the child to plan for meals or snacks with
(e.g., use of speech according to situation, and simple choices when possible or structuring the room to offer
but firm speech pattern). a sense of self is conducive to empowerment.
Modify procedures, as possible, to help reduce anxiety Unnecessary pain or invasive procedures make over-
(e.g., do not use intramuscular injection when an oral whelming demands on the already stressed hospitalized
route is possible). child with anticipatory safety addressed.
*Exercise safe dosage administration of medications,
especially amnesiacs and sedatives, with appropriate
attention to back-up resuscitation equipment and staff.
Use the child’s developmental needs as a basis for care, The developmental level of the patient serves to guide the
especially for ventilation of anxiety (e.g., use of toys). nurse in care. A holistic approach is more likely to
meet holistic health needs.
Allow the child and parents adequate time and opportuni- Appropriate time in preparation offers structure and
ties to handle required care issues and thus reduce anx- allows focused attention, which empowers and helps
iety (e.g., when painful treatments must be done, reduce anxiety as efforts are directed to what is known.
prepare all involved according to an agreed-upon plan.
*Use a child life specialist when available to assist in pre-
procedural planning.
(care plan continued on page 534)
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534 • Self-Perception and Self-Concept Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Facilitate family involvement with care as appropriate, Family involvement provides a sense of empowerment
including feeding, comfort measures, and stories. and growth in coping, thereby reducing anxiety and
promoting a sense of security in the child.
Offer sufficient opportunities for rest according to age Proper attention to rest for each individual child will fos-
and sleep requirements. ter coping capacities by conserving energy for coping.
Identify knowledge needs, and address these by having Provides a teaching opportunity that increases the
the family explain what they understand about treat- patient’s and family’s knowledge about the situation,
ments, procedures, needs, etc. which assists in reducing anxiety.
Point out and reinforce successes in conquering anxiety. Positive reinforcement that assists in learning.
Assist the patient and family to apply coping in future Allows practice in a non-anxiety-producing environment.
potential anxiety-producing situations by presenting Increases skill in using coping strategy. Empowers the
possible scenarios that would call for utilization of the patient and family.
new skills (e.g., reviewing use of new coping behaviors
before surgery).
Discuss with the client and family alternative methods for Assists in an minimizing anxiety response to a more
coping with anxiety in the future. manageable degree.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Acute Anxiety Attack
Provide a realistic, tranquil atmosphere (e.g., close door, Provides an atmosphere that assists in calming the patient
sit with the patient, remind the patient you are there to and promotes the initiation of coping by the patient.
help).
• Do not leave the patient alone.
• Speak softly using short, simple commands.
• Be firm but kind.
• Be prepared to make decisions for the patient.
• Decrease external stimuli and provide a “safe” atmos-
phere.
Administer anti-anxiety medication as ordered, and Medication is best taken in moderation and only under
monitor effectiveness of medication within 30 minutes the guidance of a physician. Today there are many nat-
to 1 hour of administration. ural and herbal remedies on the market. While some of
these therapies can minimize the side effects of strong
medications, they must be used with caution and guid-
ance from those who understand and have utilized
them in their practices. Practitioners of natural, alterna-
tive, or complementary heath care are becoming more
well known in this country. Some of the terms used are
alternative, complementary, natural, nonallopathic, and
non-Western medicine.41
Mild or Moderate Anxiety
Guide the patient through problem-solving related to the
anxiety:
• Assist the patient to verbalize and describe what she
thinks is going to happen.
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Anxiety • 535
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Describe to the patient what will happen (to the best of
your ability), and compare with her expectations.
• Assist the patient in describing ways she can more
clearly express her needs.
Assist the patient in changing unrealistic expectations by By providing factual information, clarification of miscon-
explaining procedures (e.g., labor process or sensations ceptions, and emotional support, it is possible to
during a pelvic examination). enhance the patient’s coping.42,43
Encourage the patient to participate in assertiveness train-
ing and/or to join an appropriate support group.41
Pregnancy and Childbirth
Provide the patient and significant others with factual
information about the physical and emotional changes
experienced during pregnancy.
Review the daily schedule with the patient and significant Helps reduce anxiety about financial concerns due to hav-
other. Assist them to identify lifestyle adjustments that ing to quit work. Good planning and working with the
may be needed for coping with pregnancy. patient and partner to establish a realistic work sched-
• Practicing relaxation techniques when stress begins to ule to present to the employer can assist the patient to
build reduce edema and fatigue and thus remain on the job
• Establishing a routine for relaxing after work longer.
• Developing a plan to provide frequent rest breaks
throughout the day (particularly in the last trimester)
Refer to a support group (e.g., childbirth education
classes or maternal–child health (MCH) nurses in the
community).
Provide the patient and significant other with factual Factual information provides the family with the essential
information about sexual changes during pregnancy: knowledge needed in planning for the pregnancy,
• Answer questions promptly and factually. accomplishing the task of pregnancy, and adapting to a
• Introduce them to people who have had similar experi- new infant.44
ences.
• Discuss fears about sexual changes.
• Discuss aspects of sexuality and intercourse during
pregnancy:
• Positions for intercourse during different stages of
pregnancy
• Frequency of intercourse
• Effect of intercourse on pregnancy or fetus
• Describe the healing process postpartum and timing of
resumption of intercourse.
Provide the patient support during the birthing process Assists in reducing anxiety. Increases coping.
(e.g., Montrice, doula, or other support person or
coach).
Provide support for significant others(s) during this Support of significant others leads to more support for the
process: patient.
• Encourage verbalization of fears.
• Answer questions factually.
• Demonstrate equipment.
• Explain procedures.
Postpartum
Provide support for new parents during the first few days Provides support and information from an “expert,”
of the postpartum period. Provide new parents with helping to reduce the anxiety of being new parents.
telephone number to call with questions and concerns.
Call new parents 36 to 48 hours after discharge:
(care plan continued on page 536)
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Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Formulate questions to receive simple one- or two-
word answers.
• Allow new parents time to ask questions and voice
concerns.
Before discharge from the hospital, give the new Provides a continuity of services and support and educa-
mother an appointment to return to follow-up clinic, tion for the new family during time between discharge
or schedule home visit by nurse for herself and her and follow-up visit to the primary health-care provider.
infant.
Assess the mother and baby for appropriate physical
recovery from the birth:
• Maternal: episiotomy, cesarean section incision, breasts
(lactating and nonlactating), involution of uterus, lochia
flow, fatigue level, etc.
• Infant: Number of wet diapers in 24-hour period, num- Check with your individual state as to the laws governing
ber of stools in 24-hour period, color and consistency newborn screening (comprehensive blood testing) and
of stools, feeding patterns, bilirubin check, follow-up newborn hearing screening.
on newborn screening and hearing screening as man-
dated by most state law.
Discuss with the mother and partner, or family, the psy- Research has shown that postpartum depression can begin
chosocial aspects of being new parents. Be alert to during pregnancy, in the postpartum period, or in the
cues or signs and symptoms of depression in the weeks and months after the delivery of the baby. A par-
mother. Pay special attention to any sleeping/eating ticularly vulnerable group are adolescents, with depres-
disturbances, anxiety/insecurity, emotional labiality, sion rates as high as 47 percent.45–47
mental confusion, loss of self, guilt/shame or suicidal
thoughts, ignoring the infant’s cues, and actual neglect
of the infant.45
Assist in developing and planning coping skills for new
roles.
Provide appropriate education. (May have to repeat all Readiness for learning for new mothers does not always
education done during stay in hospital on postpartum occur during the hospital stay and requires follow-up.
unit.) Research has shown that the most important learning
needs immediately postpartum were “stitches, epi-
siotomy, and complications,” followed by feeding
and illness.48,49
Monitor the infant and parents for attachment behaviors.
Refer the parents to appropriate resources for support and
further follow-up:
• Lactation consultants
• Primary care provider (obstetrician, pediatrician, certi-
fied nurse midwife, family practitioner, or nurse practi-
tioner)
• Public health nurse
• Visiting nursing services
Provide documentation of follow-up to the patient’s
primary care provider.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Midlife Women
Provide information about hormone influences on sleep Research has shown that hormone influences create
disorders, cardiac and mental functioning (forgetful- symptoms that many women report during the mid-life
ness), lack of energy, irritability, weight gain, and per- cycle, usually beginning with perimenopause. The
ceptions of anxiety.50,51,53 health-care provider should address the concerns of
these affective and cognitive disturbances in these
women and refer them to appropriate resources.50–54
Refer the client to appropriate resources for support and Some resources are:
further follow-up: National Women’s Health Network
• Physicians well versed in women’s health 514 10th Street NW, Suite 400
• Women’s health centers Washington, DC 20004
• Alternative health centers (202) 347-1140
http://www.Womenshealthnetwork.org
• Menopause and midlife centers The North American Menopause Society
P.O. Box 94527
Cleveland, Ohio 44101
(440) 442-7550
http://www.menopause.org
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Approach the client in a calm, reassuring manner, assess- Anxiety is contagious and can be communicated from the
ing the caregiver’s level of anxiety and keeping this to social network to the client.55
a minimum.
Provide a quiet, nonstimulating environment that the Inappropriate levels of sensory stimuli can contribute to
client perceives as safe. For the client experiencing the client’s sense of disorganization and confusion.38,55
severe or panic anxiety, this may be a quiet room set-
ting. This may include providing objects that symbol-
ize safety to the client. (Note here the special
environmental adaptations necessary for this client.)
Provide frequent, brief interactions that assist the client Appropriate levels of sensory stimuli promote the client’s
with orientation. Verbal information should be pro- sense of control.28
vided at a level that the client can process based on his
or her anxiety level. Note the client’s anxiety level, fre-
quency, and focus of interactions here. (See Additional
Information for assistance in determining the client’s
anxiety level.)
If the client is experiencing severe or panic anxiety, pro- Communicates acceptance of the client, which facilitates
vide support in a non-demanding atmosphere. [Note the development of trust and self-esteem.
client-specific adaptations here.]
If the client is experiencing severe or panic anxiety, pro- High levels of anxiety decrease the client’s ability to
vide a here-and-now focus. process information.
• Provide the client with a simple repetitive activity until High levels of anxiety decrease the client’s ability to
anxiety decreases to the level at which learning can problem solve. Promotes the client’s sense of control.
begin. Note client specific activity here.
If the client is hyperventilating, guide in taking slow, Re-establishes a normal breathing pattern, and promotes
deep breaths. If necessary, breathe along with the the client’s sense of control.
client, and provide ongoing, positive verbal rein-
forcement.
(care plan continued on page 538)
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538 • Self-Perception and Self-Concept Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide a constant, one-to-one interaction for the client Presence of a calm, trusted individual can promote a
experiencing severe or panic anxiety. This should pre- sense of control and calm in the client. Protects a
clude use of physical restraints, which tend to increase client’s right to the least restrictive environment.38
the client’s anxiety.
Provide the client with alternative outlets for physical Promotes the client’s sense of control, and begins the
tension. Note techniques to be used by client here. development of alternative, more adaptive coping
These could include walking, running, talking with a behaviors.56
staff member, using a punching bag, listening to music,
doing a deep muscle relaxation sequence [number]
times per day at [state specific times]. The outlet
should be selected with the client’s input.
Discuss relaxation techniques with the client (visual These techniques promote physiologic relaxation and
imagery, deep muscle relaxation, massage, meditation, shift the client to a state of parasympathetic nervous
or music). Have the client select one activity he or she system recuperation.37 Repeated practice of a behavior
would like to incorporate into his or her coping behav- internalizes and personalizes the behavior.56
iors. Schedule 30 minutes per day to practice this
activity with the client. [Note here activity and practice
time.]
Sit with the client [number] times per day at [times] for Identification of precipitating factors is the first step in
[number] minutes to discuss feelings and complaints. developing alternative coping behaviors and promoting
As the client expresses these openly, the nurse can then the client’s sense of control.56,57
explore the onset of the anxiety with the purpose of
identifying the sources of the anxiety.
• After the source of the anxiety has been identified, the Promotes the client’s sense of control.
time set aside can be utilized to assist the client in
developing alternative coping styles.
Provide [number] times per day to discuss interests in the Provides positive reinforcement through the nurse’s atten-
external environment with the client (especially with tion for improved coping behaviors.38
clients who tend to focus strongly on nonspecific phys-
ical complaints).
Talk with the client about the advantages and disadvan- Identification of contributing factors is the first step in
tages of the current condition. (Help the client to iden- developing alternative coping behaviors.56
tify secondary gain from the symptoms.) This would
be done in the individual discussion sessions or in
group therapy when a trusting relationship has been
developed.
• During the interaction point out dysfunctional thinking Thoughts can influence feelings. Cognitive interventions
patterns. These could include overgeneralization, mag- have been demonstrated to have a positive impact on
nification, dichotomous thinking, catastrophic thinking, the long-term resolution of anxiety-related disor-
and minimization ders.38,56
• When these thought patterns are identified (one of the Alters distorted thought patterns.58
following responses can be implemented):
• Discuss alternative ways of viewing the situation
• Make a statement or ask a question that challenges
the perception
• Examine the evidence for and against the thought
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide the client with feedback on how his or her behav- Assists the client with consensual validation.
ior affects others (this could be done in an individual Specific positive reinforcement encourages behavior and
or group situation). [The target behavior and goals enhances self-esteem.38
should be listed here with appropriate informative posi-
tive reinforcers.]
Provide positive specific informative feedback as appro- Positive feedback encourages behavior and enhances self-
priate on changed behavior. (The target behavior and esteem.38,56
goals should be listed here.) [Note positive feedback to
be used with this client here.]
Provide appropriate behavioral limits to control the Client and milieu safety is of primary importance.38
expression of aggression or anger. These limits should
be specific to the client and listed here on the care plan
(e.g., the client will be asked to go to a private room
for 15 minutes when he raises his voice to another
client). The client should be informed of these limits,
and the limits should not exceed the client’s capability.
The client should be informed of the time frame of
the limits (e.g., the time limit for raising his voice is
15 minutes). No limit should be set for an indefinite
time. All staff should be aware of the limits so they can
be enforced consistently with consistent consequences.
• Provide the client with an opportunity to discuss the Assists the client with an opportunity to review behav-
situation after the consequences have been met. ioral limits and provides the staff with an opportunity
to communicate to the client that limit setting is not a
punishment.
Interact with the client in social activities [number] times Promotes the development of a trusting relationship.
per day for [number] minutes. This will provide the Provides social reinforcers for pro-social behaviors.
client with staff time other than that which is used to
set limits. The activities selected should be done with
the client’s input and stated here in the care plan.
Provide medication as ordered, and observe for appro- Antidepressants are the most commonly prescribed and
priate effects and side effects (these should be are supported as the primary pharmacological treat-
listed here). ment for most anxiety disorders.38,56,59
Inform the client of community resources that provide Promotes the client’s sense of control and self-esteem.
assistance with crisis situations, and provide a tele-
phone number before the client leaves the unit.
Develop a list of alternative coping strategies that the Repeated practice of a behavior internalizes and personal-
client can use at home, and have the client practice izes the behavior.55,59
them before leaving the unit. (Note strategies to be
practiced and practice schedule here. This could
include role playing those situations the client identi-
fies as the most difficult to manage.)
When signs of increasing anxiety are observed, talk the Repeated practice of a behavior internalizes and personal-
client through one of the coping strategies they have izes the behavior.
identified. [Note here the client’s symptoms of anxiety
that are to be addressed and the identified coping
strategy.]
Provide the client with a written list of appointments that Provides visible documentation of the importance of
have been scheduled for outpatient follow-up. follow-up. Increases the likelihood that appointments
will be kept.
(care plan continued on page 540)
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540 • Self-Perception and Self-Concept Pattern
Gerontic Health
In addition to the following interventions, the interventions for Adult Health can be applied to the aging client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor daily for side effects of anxiolytic medications The potential for side effects and drug interactions is
agents if prescribed. increased with older adults because of the decreased
metabolism of drugs.
Assure consistent caregivers to the extent possible Decreases anxiety and facilitates trust.
Identify environmental factors that may increase anxiety, The environmental factors mentioned, if not addressed,
such as noise level, harsh lighting, and high traffic induce more stress in the older individual.
flow.
Provide direct, basic information on usual routines and May help decrease autonomic nervous system activity
procedures. and feelings of anxiety.
Home Health
In addition to the following interventions, the interventions for Adult Health can be applied to the home health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family appropriate monitoring of Provides baseline data for early recognition and inter-
signs and symptoms of anxiety: vention.
• Increased pulse
• Sleep disturbance
• Fatigue
• Restlessness
• Increased respiratory rate
• Inability to concentrate
• Short attention span
• Feeling of dread
• Faintness
• Forgetfulness
Involve the client and family in planning and implement- Family and client involvement enhances effectiveness
ing strategies to reduce and cope with anxiety: of intervention.
• Family conference: Identification of sources of anxiety
and interventions designed to decrease anxiety
• Mutual goal setting: Specific ways to decrease anxiety,
and identification of role of each family member
• Communication
Assist the client and family in lifestyle adjustments that Lifestyle changes require changes in behavior. Self-
may be required: evaluation and support facilitate these changes.
• Relaxation techniques (e.g., yoga, biofeedback, hypno-
sis, breathing techniques, or imagery)
• Problem-solving techniques
• Crisis intervention
• Maintaining the treatment plan of health-care profes-
sionals who are guiding the therapy
• Redirecting energy to meaningful or productive activi-
ties (e.g., active games and hobbies, walking, or sports)
• Decreasing sensory stimulation
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Body Image, Disturbed • 541
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client and family to set criteria to help them Early identification of issues requiring professional evalu-
determine when the intervention of a health-care pro- ation will increase the probability of successful inter-
fessional is required (e.g., inability to perform activi- ventions.
ties of daily living or threat to self or others).
Teach the client and family purposes, side effects, and Provides necessary information for self-care.
proper administration techniques of medications.
Consult with or refer to assistive resources as indicated: Use of existing community services; provides for effec-
• Caregiver support groups tive utilization of resources.
• Disease-specific support groups
• Counseling services
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542 • Self-Perception and Self-Concept Pattern
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Body Image, Disturbed • 543
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Physical therapy
• Rehabilitation services
Collaborate with the psychiatric nurse clinician regarding Collaboration promotes a holistic care plan and hastens
care as needed. (See Mental Health nursing actions.) solving of the patient’s problem.
Refer to and collaborate with community resources. Provides long-term support. Cost-effective use of already
available support.
Child Health
According to age/developmental status, some components of Adult, Women’s, or Mental Health also apply, in addition to
the following:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for contributory factors for Disturbed Body Provides database needed to plan interventions more
Image (e.g., disfigurement or perceived disfigurement) accurately.
in addition to relationship issues. (The family may per-
ceive such on behalf of the young infant or child.)
Utilize developmentally appropriate communication to Developmental capacity has to guide the interaction to
assess and determine exact expression of Disturbed gain accurate information.
Body Image (e.g., use puppet play or constructive dia-
logue with the toddler).
Provide factual information to assist in dealing with Knowledge serves to reduce anxiety and assists the
Disturbed Body Image (e.g., availability of assistive patient to cope. Provides options to assist in decision
devices or surgery). making.
Include other specialists, such as dietitian, occupational, Promotes a more accurate and developmentally appropri-
physical, and speech therapist, and child life specialist ate holistic plan of care.
as required.
Monitor, on a daily basis, for attitude toward body. Allows daily evaluation, which promotes changes in plan
of care to best meet the patient’s current status.
Refer patient and family to community support groups as Offers support by peers.
appropriate. Note specific support group information
here.
l N O T E : In some instances, such as an infant or child with an anomaly or a condi-
tion offering no hope of resolution, this alteration may accompany other disturbances
such as self-esteem, parental coping, and loss.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Body Image: Surgery
Assist the patient to identify lifestyle adjustments that Initiate discharge planning, and assist the health-care
may be needed (e.g., recuperation time or prosthesis as provider and patient identify needed resources before
necessary [mastectomy]). surgery, allowing resources to be available to the
patient and family when needed.
Monitor the patient’s anxiety level and discuss preoper-
atively:
• Discuss routines related to surgery (e.g., anesthesia,
pain, length of surgery, postoperative care, and
resources available to patient after discharge home).
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544 • Self-Perception and Self-Concept Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Physical changes (e.g., cessation of menstruation or Regardless of how menopause occurs, it is the signal of
menopausal symptoms related to surgical or natural life-cycle change and many women mourn the loss of
menopause). the ability to bear children. Research has shown that
while many women morn the loss of reproductive abil-
ities, other women begin to feel both liberated and
often begin to direct their energies toward the world
outside of the home.50,51,53
Allow the patient to grieve loss of body image (e.g., no
longer able to have children), and provide an empa-
thetic atmosphere that will allow the patient to venti-
late concerns about appearance or reaction of
significant other.
Dispel “old wives’ tales” (usually connected to hysterec- Provides factual information, allowing the patient to ask
tomy) such as: further questions and be realistic about her status and
• You will no longer feel like a woman. (Reassure the goals.
patient that although there will be no more pregnancies
or menstruation, hysterectomy does not affect sexual
performance, enjoyment, or response.)
• There will be masculinization. (There is no basis for
this belief.)
• There will be weight gain. (Weight gain will not occur
if the patient participates in health living, including an
exercise routine and proper diet.)
Involve significant others in discussion and problem- Provides basic information, and allows early intervention
solving activities regarding life cycle changes that for anxiety. Provides an opportunity for teaching and
might affect self-esteem and interpersonal relationships clarification of misinformation.50,51,53
(e.g., hot flashes, appearance, sexual relationships, or
ability to have children).
In collaboration with other health-care providers, provide Assists the patient in making decision regarding use or
factual information on hormone replacement therapy. nonuse of estrogen therapy. Recent research has shown
that some hormone replacement therapy does not sup-
port cardiac health and can lead to dementia in older
women when not carefully watched. Many physicians
and compounding pharmacists are working together to
provide patients with individualized hormone replace-
ment therapies, as well as natural sources of
hormones.41,50,51
Body Image: Pregnancy
Assist the patient in identifying lifestyle adjustments due Knowledge that body changes in pregnancy are normal
to physiologic, physical, and emotional changes that and temporary encourages the patient to follow through
will occur throughout pregnancy and postpartum. on care. Assists the patient to cope with the pregnancy
Review with the patient the body changes that occur dur- and adapt to the changing images.
ing pregnancy and the effect on body image (particu-
larly for teenagers):
• Weight gain
• Breast tenderness and enlargement
• Enlargement of abdomen
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Body Image, Disturbed • 545
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Change in gait
• Chlosama (mask of pregnancy)
• Striations (stretch marks) from pregnancy
Consider the patient’s age and preparation for pregnancy, Continued home care planning that encourages the
including (particularly for teenagers): patient to better apply good health practices and thus
increase maternal and fetal well-being.
• Stress weight loss after delivery usually takes up to It is important that the new mother not resort to fad diets
4 to 6 weeks. to speed weight loss, especially if breastfeeding. She
• Discuss physical development. will lose the pregnancy weight by following a good
• Evaluate the patient’s attitude toward health-care diet and exercise program.
providers.
• Discuss self-esteem.
• Provide emotional support.
• Prepare the patient for lifestyle interruptions.
• Encourage the patient to bring an attractive, loose-
fitting dress to wear home.
• Caution breastfeeding women against purposeful
weight loss while lactating.
• Encourage non-breastfeeding mothers to follow low-
calorie, high-protein diet for weight loss.
• Encourage exercise (begin slowly and work up to
desired plan).
• Caution the patient to avoid fatigue.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend [number] minutes with the client at [times] dis- Promotes the client’s sense of control, and provides infor-
cussing their perception of the situation. After a thera- mation that can be utilized in developing a plan of care
peutic relationship has been established this discussion that will fit within the client’s perception of self.
can be expanded to include: Perceptions influence change.61
• Discuss with the client meaning of loss or change from Expression of feelings in an accepting environment can
a personal, religious and cultural perspective. This dis- facilitate the client’s problem solving. Cognitive maps
cussion should also consider the impact of race, gender, influence the change process.61
and age.
• Discuss with the client the difference between the Helps promote reality orientation by contrasting real with
cultural ideal of physical appearance and the popu- ideal, and confronts irrational goals.
lation norm based on the realities of physiology.
This activity should be done by the primary care
nurse who has developed a relationship with the
client.
• Discuss with the client his or her significant others’ Support system understanding and support can facilitate
reaction to loss or change. the client’s adjustment.
Set an appointment to discuss with the client and signifi- Expression of feelings and concerns in an accepting envi-
cant others effects of the loss or change on their rela- ronment can facilitate problem solving. Social support
tionships. (Time and date of appointment and all enhances coping.62,63
follow-up appointments should be listed here.)
Spend [number] minutes with the client each day to focus Cognitive maps influence behavior.64
on values, thoughts, and feelings that perpetuate body
image problems. During this discussion:
(care plan continued on page 546)
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546 • Self-Perception and Self-Concept Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Point out dysfunctional thinking patterns. These could Thoughts can influence feelings. Cognitive interventions
include overgeneralization, magnification, dichotomous have been demonstrated to have a positive impact on
thinking, catastrophic thinking, and minimization the long-term resolution of anxiety-related disor-
• When these thought patterns are identified (one of the ders.38,56 Alters distorted thought patterns.58
following responses can be implemented):
• Discuss alternative ways of viewing the situation
• Make a statement or ask a question that challenges
the perception
• Examine the evidence for and against the thought
• Discrepancies between current behavior and client Client-centered interaction facilitates change.65
goals/values
• Have client explore perspectives for and against accept-
ance of change
• Utilize goals established by client and credit client with
any progress toward their goals
Spend [number] minutes each day to discuss assertive Assists in developing appropriate interpersonal bound-
communication skills and practice these with the client. aries.66
[Note specific behaviors to be practiced here.]
Schedule time with the client’s significant other to assess Support assists with the development of lifestyle
his or her perception of the client and provide him or changes. Positive support has a positive impact on
her with the necessary information to support the body image.63 The support system’s response to
client’s change. [Note here the time and person respon- change can impact the client’s perception of self.62
sible for this meeting.]
Spend [number] minutes with the client at [times] to Promotes the client’s sense of control, and enhances self-
assist with efforts to enhance appearance. esteem.
Discuss with the client role exercise plays in health, and Provides the client with the information necessary to
develop an appropriate exercise plan. [Note here the make healthy lifestyle choices. Exercise has a positive
plan for this client.] impact on self-esteem and assists with the client devel-
oping comfort with changes.
Provide physical activities two times per day at [times] Assists the client in developing a new perception of his or
that provide the client opportunities to define bound- her body.
aries of body. These activities should be ones the client
identifies as enjoyable and that are easily accomplished
by the client. Those activities that are selected should
be listed here. If this diagnosis is in conjunction with
an eating disorder, adjust exercise to appropriate levels
for the client.
Have the client draw a picture of self before and after Assists the client in contrasting and externalizing his or
body change, and discuss this with him or her. This her perceptions of self to facilitate development of con-
activity can also be done with clay models constructed gruence between real and ideal.
by the client. This activity should be done by the pri-
mary care nurse who has developed a relationship with
the client.
When the client has begun to discuss issues related to Facilitates the development of congruence between real
body change with the primary care nurse, the client can and perceived self.
then be asked to discuss reactions to image of self in a
mirror. One hour should be allowed for this activity.
This activity should be done by the primary care nurse
who has developed a relationship with the client.
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Body Image, Disturbed • 547
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss with the client the mental images held of what Discussion of concerns in a safe environment facilitates
the altered body is like and what life will be like. One the development of strategies of coping.
hour should be allowed for this activity, and it should
be implemented by the primary care nurse after a rela-
tionship has been established. Note the schedule for
this activity here.
Collaborate with physical and occupational therapy to Group membership provides role models for life skills
schedule a time for client to attend group with others necessary for adaptation and the opportunity for
experiencing similar loss or change and that fit with the upward comparison.60,63,67 In addition, groups instill
client’s comparison targets. This could include support hope, and enhance self-esteem.38,55,63
groups, activity groups, or specialty sports teams (e.g.,
wheelchair basketball team). [Note group schedule
here.]
For clients with eating disorders evidence based practice Disturbances related to perceptions of self are more com-
supports using a more comprehensive self-esteem prehensive than those related to body image, and effec-
intervention. (See Have You Selected the Correct tive care addresses these broader concerns.60
Diagnosis.) In addition, the following interventions
related specifically to body image can be considered:
• Monitor the client for suicidal thoughts or depression Change in body shape can negatively impact self-esteem
related to weight gain. and increase feelings of depression.64
• Have the eating disorder client draw a life-size picture Assists the client in confronting the difference between
of self on paper hung on the wall; then have the client his or her perception of his or her body and the real
stand against the picture and trace the real outline, and body size and shape.
discuss the differences. This activity should be done by
the primary care nurse who has developed a relation-
ship with the client.
Collaborate with social services to develop a discharge
plan that includes building community support for the
client and family.
Gerontic Health
The interventions for Adult Health can be applied to the aging client.
Home Health
In addition to the following interventions, the interventions for Adult Health can be applied to the home health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client and family in planning and implement- Family involvement enhances effectiveness of inter-
ing strategies to reduce and cope with disturbance in ventions.
body image:
• Family conference: Discuss meaning of loss or change
from family perspective and from the perspective of
individual members. Discuss the effects of the loss on
family relationship roles.
• Mutual goal setting: Establish realistic goals, and iden-
tify specific activities for each family member (e.g.,
assisting with activities as required or attending support
groups as needed).
(care plan continued on page 548)
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548 • Self-Perception and Self-Concept Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Communication: Clarify responses to Disturbed Body
Image.
Assist the client and family in lifestyle adjustments that Rehabilitation is a long-term process. Permanent changes
may be required: in behavior and family roles require evaluation and
• Obtaining and providing accurate information regard- support.
ing specific Disturbed Body Image and potential for
rehabilitation.
• Maintaining safe environment.
• Encouraging appropriate self-care without encouraging
dependence or expecting unrealistic independence.
• Maintaining the treatment plan of the health-care pro-
fessionals guiding therapy.
• Altering family roles as required.
Consult with, or refer to, assistive resources as indicated. Utilization of existing services is efficient use of
• Support groups resources. Rehabilitation therapists and support groups
• Counseling services can enhance the treatment plan.
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Death Anxiety • 549
Child Health
l N O T E : Review developmental conceptual considerations with a keen appreciation
of unique needs per each client plus, as applicable, those orders for Adult Health.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for all possible contributing factors to include, as A holistic assessment provides the most thorough data-
applicable, the client’s verbalization of feelings, family base for individualized care.
or caregiver perceptions, related family interactions or
stressors, and risk indices, with attempt to identify anx-
iety to be mild, moderate, or acute.
Once determined, provide appropriate factual information There will be a difference in how mild, moderate, or
to assist in how best to deal with anxiety. acute anxiety is dealt with.
Determine previous effective coping strategies. Successful coping strategies will assist in establishing
possible ways to augment current needs with modifica-
tion to offer a sense of empowerment.
(care plan continued on page 550)
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550 • Self-Perception and Self-Concept Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Identify ways to assist the child in coping with appropri- Feelings of empowerment will result when attempts are
ate incorporation of these strategies in daily care, with made to adhere to a regimen that values previously
identification of additional coping strategies. successful coping strategies on which new strategies
may then be more readily accepted.
Provide a calm atmosphere with limitation of excessive Enhancement of coping is likely when the surrounding
noise, interruptions, or numbers of caregivers. atmosphere does not add more stress.
Provide all health-care team members updates, and seek The nurse is in the best position to offer coordination of
information as needed to coordinate care on a daily care while maintaining continuity and affording trust.
basis.
*Ideally the same primary care nurses ought to care for
this child and family during this time.
Facilitate appropriate involvement of all members of the Child specialists are most appropriately suited to assist in
health care team, especially the child life specialist, anxiety reduction strategies.
psychiatrist, or psychologist.
Provide anti-anxiety medications as appropriate to Provides augmentation of the therapeutic regimen and
provide adequate pain relief. offers relief from disturbing symptoms related to anxi-
ety and pain.
Provide opportunities for the child and family to share Creating a sense of safe haven for all fears and thoughts
thoughts of death-related anxiety issues or related feel- to be shared demonstrates a valuing of open communi-
ings on an ongoing basis, with a sensitivity to unex- cation and the worth of the individual, thereby reduc-
pected potential for same. ing anxiety.
Provide developmentally appropriate tools to assist Age-appropriate expression of anxiety is fostered by pref-
patient with expression of feelings such as puppets, erences of the child per developmental capacity.
video viewing, art, or story telling. Note the items that
are most useful for this client here.
Provide opportunities for the utilization of family’s cul- Individualized sensitivity to culture provides valuing of
tural practices. [Note special family needs here.] the person and the importance he or she places on
food, beliefs, or specific ways to cope.
Identify with the child and family ways to cope with When anxieties are diminished, actual engagement with
dying and meaning of death. dying can be realistically approached.
Offer assistance in obtaining or notifying clergyman, Anxiety may be further reduced with assistance from
counselors, or other supportive personnel as needed. those who are experts in death and dying.
Provide reassurance according to personal family beliefs Anxiety may be further reduced when the child’s fears of
about an afterlife or beliefs of same according to age- being alone or separated can be alleviated, while also
appropriate concerns of the child. supporting valued family beliefs.
Women’s Health
The interventions for this diagnosis in Women’s Health are the same as those given in Adult Health and Gerontic Health.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide a quiet, nonstimulating environment. (Note spe- Inappropriate levels of sensory stimuli can contribute to
cific adaptations to the environment that promote the the client’s sense of anxiety.
client’s relaxation, i.e., music, scents, lighting, etc.)
[Note the behaviors that facilitate the development of a
relationship with this client here.]
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Death Anxiety • 551
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend [number] minutes per shift talking with the client Assists the client in establishing the link between the
about concerns and feelings. Include perceptions of feelings of anxiety and thoughts, which facilitates
death and life. development of coping behaviors.70 An expression of
feeling helps reduce intense emotion that can block
problem solving.71 Frank discussion of fears and con-
cerns can decrease anxiety.72
Provide support necessary to meet identified client’s spir-
itual needs. Note any special adaptations needed for
this support here (e.g., time for special prayers, medita-
tion, reading, or contact with members of the client’s
faith community).58
After concerns are identified, validate and normalize the Validation of affect can decrease feelings of isolation and
emotional response. assist the client to connect with others, including the
family.71
When concerns involve the family and/or support system, Assists the support system in bringing forth their own
schedule [number] minutes each day to bring the fam- resources and strengths to support one another and
ily together and facilitate discussion of the issues and problem solve. Decreases the feeling of isolation in
concerns. members of the support system who are coping with
• Develop a list of issues that client/support system iden- the impending death.71
tify as important.
• Explore beliefs/feelings that facilitate/hinder resolution
of concerns.
• Develop, with the client and support system, actions
that are needed to resolve issues and concerns. This
could include resolution of past misunderstandings and
forgiveness.
• During interactions with client and support system
model positive communication skills and facilitate pos-
itive interactions between the client and support sys-
tem.
Spend [number] minutes [number] times per day with the Empowers the client and facilitates growth-promoting
client identifying alternative ways of responding to change.71
concerns that decrease anxiety.
• Once a relationship has been established these discus- Assists the client in identifying strengths and past coping
sions can also include opportunities for life review and mechanisms.72
making appropriate future plans. Note those topics to
be discussed with this client here.
Discuss with the support system their need to provide Provides the support system with a sense of helpfulness
care, and provide them the necessary information and and control.71
equipment to accomplish this at the level they feel
comfortable. (Note the assistance needed to accomplish
this care.)
Monitor the support system’s need for respite, and Assists the family in coping with guilt about their need to
talk with them about taking breaks to increase their take a break to enhance their coping resources.71
ability to support the client. (Note the family’s need
here.)
Provide the client with information about his or her Empowers the client and decreases concerns about the
care. unknown.
(care plan continued on page 552)
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552 • Self-Perception and Self-Concept Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend [number] minutes [number] times each day assist- Shifts the physiologic state from sympathetic nervous
ing the client with a relaxation sequence he or she has system arousal to a state of parasympathetic recu-
identified as helpful. This could be deep muscle relax- peration.73
ation, visual imagery, meditation, or deep breathing
exercises. (Note the method identified by the client
here.)
Provide massage for [number] minutes as needed to Promotes physical and psychological relaxation.74
reduce anxiety. (Note the client’s preference for mas-
sage here.)
Identify support systems in the community, and provide Provides visual documentation of the importance of
the client with a connection to these systems before follow-up and community support, increasing the like-
discharge. (Note those identified for this client here.) lihood that these referrals will be utilized.
Gerontic Health
l N O T E : Research on the presence of death anxiety in older adults is slowly evolving,
with no clear predictors of which older adults are at risk for experiencing death anxiety.
Generally, elders with increased physical and psychological problems, and decreased
ego integrity, are more likely to have death anxiety. Which physical and/or psychologi-
cal problems have an impact on death anxiety are not yet clearly identified. In addition
to selecting interventions from the adult health and mental health section, nurses caring
for older adults may find the following actions to be effective.75–77
ACTIONS/INTERVENTIONS R AT I O N A L E S
Consult as needed with social services, mental health pro- Enables clients to discuss and address issues that may be
fessionals, and/or religious counselors as signs of death contributing to distress.
anxiety are noted.
Administer anxiolytics cautiously as needed. Treatment of anxiety.
Assist the client in completing advanced directives. Death anxiety decreases in clients who have advanced
directives.75
When consistent with the nurse’s personal values and Prayer is an important source of coping with death anxi-
beliefs, pray with the patient as requested by the ety in older clients.76
patient.
Monitor older adults for signs of decreased ego integrity, Decreased ego integrity is a contributor to death anxiety
such as statements of regret related to past life experi- noted in older adults.
ences, unresolved relational problems, and expressions
of despair.
Assist and encourage the older adult in life review Provides an opportunity to review prior successes, effec-
process. tive and ineffective coping strategies, personal
strengths, sense of life satisfaction, and psychological
well-being.
Refer the client to hospice services if the client meets The hospice care team is prepared to address needs sur-
admission criteria for hospice care. rounding death and dying.
Home Health
In addition to the following interventions, the interventions for Adult Health and Mental Health can be applied to the home
health client.
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Fear • 553
ACTIONS/INTERVENTIONS R AT I O N A L E S
Manage the client’s pain and other troubling symptoms, Physical symptoms often contribute to anxiety.
such as nausea.
Encourage the family to become involved in the care of A sense of purpose and usefulness can replace anxiety.
the client as much as they are able.
Help the client to talk about his or her anxiety and its Makes the client, the nurse, and the family more aware of
source. issues that need discussing or problems that need to be
addressed.
Listen to client and family concerns, and answer all ques- Understanding helps promote a sense of control and
tions truthfully. Tell the client and family as much as order.
you can about the dying process and disease process to
decrease the number of “surprises” they may experi-
ence with the dying process.77
Acknowledge all fears, feelings, and perceived threats as All client fears are valid to the client, whether they are
valid to the client. realistic or not.
Reassure the client that even though the dying process Fear of abandonment is an almost universal fear of dying
cannot be stopped, someone will be with them and persons.77
they will not be left alone. Then ensure that a family
member or caregiver is with the patient at all times.
Administer anxiolytics as ordered, and educate the family Promotes a sense of well-being.
or caregivers about prescribed medications, their
effects, side effects, and scheduling.77
FEAR 4. Physiologic
a. Increased pulse
DEFINITION40 b. Anorexia
Response to perceived threat that is consciously recognized c. Nausea
as danger. d. Vomiting
e. Diarrhea
DEFINING CHARACTERISTICS40 f. Muscle tightness
g. Fatigue
1. Report of:
h. Increased respiratory rate and shortness of breath
a. Apprehension
i. Pallor
b. Increased tension
j. Increased perspiration
c. Decreased self-assurance
k. Increased systolic blood pressure
d. Excitement
l. Pupil dilation
e. Scared
m. Dry mouth
f. Jitteriness
g. Dread
RELATED FACTORS40
h. Alarm
i. Terror 1. Natural or innate origin, for example, sudden noise,
j. Panic height, pain, or loss of physical support
2. Cognitive 2. Learned response, for example, conditioning or model-
a. Identifies object of fear ing from or identification with others
b. Stimulus believed to be a threat 3. Separation from support system in a potentially threaten-
c. Diminished productivity, problem solving ability, ing situation, for example, hospitalizations, or proce-
learning ability dures
3. Behaviors 4. Unfamiliarity with environment experience(s)
a. Increased alertness 5. Language barriers
b. Avoidance or attack behaviors 6. Sensory impairment
c. Impulsiveness 7. Phobic stimulus
d. Narrowed focus on “it” (i.e., the focus of the fear) 8. Innate releasers (neurotransmitters)
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554 • Self-Perception and Self-Concept Pattern
RELATED CLINICAL CONCERNS cipline at home, the parent tells the child that if he or
1. Any hospitalization she does not behave, the nurse or doctor will give him
2. Any threat to loss of a body part, loss of functioning, or or her a shot. In this situation, the parent’s inappropri-
loss of life ate use of the threat of the injection produced a fear
in the child.
3. Perceived or Impending Death
Deficient Knowledge
4 Have You Selected the Correct Diagnosis? If the patient indicates that he or she is afraid of not
being able to care for himself or herself, then the most
Anxiety appropriate diagnosis would be Deficient Knowledge.
Anxiety is a vague uneasy feeling combined with an Providing the patient with information, teaching, and
autonomic response to a source that is usually non- reinforcement of self-care ability will overcome this
specific or unknown. Fear is the anxiety that is a diagnosis.
response to recognized and realistic danger. The
response to meeting a bear in the woods or the antici-
pation of this would be fear. A threat that cannot be EXPECTED OUTCOME
identified or linked to a specific situation would be Will be able to identify specific source of fear by [date].
anxiety. Will demonstrate normalization of physiological
Impaired Parenting signs/symptoms [note specific signs to monitored for this
This diagnosis should be considered as the appropri- client here] by [date].37
ate diagnosis when the child’s fears result from the Will identify [number] of strategies for coping with
parent’s modeling or reinforcing of a child’s fear or fear by [date].
when the parent is not providing the appropriate sup-
port for the developmental fears. An example might TARGET DATES
be the child who becomes uncontrollable in the clinic
A target date of 2 to 3 days would be acceptable, because the
each time an injection is indicated. During the assess-
ment, the nurse discovers that, as a reinforcer to dis-
sooner the fear can be reduced, the sooner other problems
can be resolved.
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Fear • 555
ACTIONS/INTERVENTIONS R AT I O N A L E S
Support active participation in activities of daily living. Helps restore sense of being in control.
Allow for preferences in day-to-day decisions (e.g.,
establishing a bath time).
Refer to psychiatric nurse clinician as needed. Collaboration promotes a more holistic and complete
(See Mental Health nursing actions.) plan of care.
Identify religious, cultural, or community support groups Support groups can provide advocacy for the patient and
prior to discharge. Provide appointments for follow-up. continued monitoring and support of the patient after
discharge from the hospital.
Child Health
Depending on gender and age/developmental status, some content of Adult, Women’s, and Mental Health may also apply.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Offer brief interactions that assist the patient and family Brief explanations and factual information serve to
with orientation (e.g., hospital unit, procedures, and empower the patient and family as the unknown is
aspects of care). made known. The patient and family can then focus
on dealing with the identified fear rather than with
added fears.
In instances of severe fear: Avoids overwhelming the patient. Promotes a sense
• Provide support in a nondemanding atmosphere. of trust.
• Provide a here-and-now focus.
• Provide one-to-one care.
• Offer simple, direct, repetitive tasks.
Provide the patient and family with ways to assist and Providing such outlets promotes release of tension.
alternative outlets for physical tension. These outlets
should be stated specifically and could include walk-
ing, talking, etc., at least [number] times per day at
[times]. These outlets should be designed with input
from the patient.
Sit with the patient and parents [number] times per day at As the patient or parents express these factors openly, the
[times] for [number] minutes to discuss feelings and nurse can explore the possible onset of fear with the
complaints. purpose of individualizing the plan according to the
*The same primary care nurses would ideally participate patient’s needs. The subjective verbalization of fears
in this process. helps reduce the preoccupation of the patient with the
fear in the trusting relationship of nurse–patient/family.
Monitor patient and parents to for changes in feelings Reflection on an ongoing basis demonstrates a sensitivity
about fears. Discuss these changes with the patient and to need.
parents.
Provide appropriate behavioral limits to control the Structured rules regarding behavioral consequences create
expression of aggression or anger. These limits should a sense of limits, which provides security for the child.
be specific in time, expected behavior, and conse-
quences. Note the plan for this client here.
Provide the patient and parents with opportunities to dis- Rediscussion and clarification of events serves to update
cuss the behavior after consequences have been met. needs and provides feedback for evaluation. Valuing
of the patient is also shown.
Provide opportunities for socialization appropriate for the Socialization is vital as the individual or family assumes
patient and family. Note patient and family preferences coping behaviors and learns new coping skills.
here.
(care plan continued on page 556)
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Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Develop a list of alternative coping strategies to be prac- Allows practice in a nonthreatening environment.
ticed by the patient and family before dismissal (e.g., Increases skills.
communication or progressive relaxation). Note tech-
niques to be used by patient here.
Ensure follow-up appointments by scheduling them for Follow-up appointments help ensure follow-up care.
the patient before dismissal.
Assist the patient and family to view situation represented Validation of success in coping provides a sense of
as something that can be managed. Model positive empowerment.
reinforcement of desired behavior patterns.
Consult with child mental health specialists for unre- Provides appropriate anticipatory guidance and offers a
solved issues related to fear. Make necessary referrals greater likelihood of resolution or coping with fears.
as appropriate.
Women’s Health
l N O T E : Phobias affect approximately 2 to 3 percent of the adult population, and 80
percent of the affected group are female. The most common phobias among women are
agoraphobia, fear of animals, and fear of social situations.78,79
ACTIONS/INTERVENTIONS R AT I O N A L E S
Obtain a detailed history of the patient’s fears: Provides an essential database for planning appropriate
• Encourage the patient to discuss signs and symptoms interventions.
or precipitating event.
• Ascertain how often problem occurs.
• Have the patient describe her reaction.
• Identify coping mechanisms that have previously
helped.
• Identify those factors or coping mechanisms that do not
help.
Domestic Violence
Provide a nonjudgmental, safe environment for all Domestic violence against women cuts across all socioe-
women patients to verbalize their fears. Obtain a good conomic, age, religious, and ethnic strata of the popu-
history that can identify high-risk families and high- lation. Physical abuse usually concerns control and
risk situations. Be alert to subtle clues in the patient’s power issues. Domestic violence is not necessarily
history or physical examination that hint at physical physical; it refers to violence in any form, both physi-
abuse. cal and verbal.51,80–84
Patiently explain all procedures and their purpose to the Be sensitive to cultural norms in dealing with pregnant
patient before performing them. Be aware that proce- women. It is important to be able to speak the patient’s
dures in labor and delivery can trigger unpleasant fears language if the health-care provider is to establish the
and anxieties in the patient, with possible flashbacks to needed rapport to care for the patient. Often immigrant
an abusive situation or rape. Perform necessary proce- women suffer more severe and repeated abuse before
dures as quickly as possible and with empathy, allow- they are aware that they are being abused.84 Women
ing the patient to direct as much of the care as often delay care during pregnancy because of an abu-
possible. Encourage the patient to verbalize her fears sive situation.83
and verbally relive the birth experience in a nonjudg-
mental environment.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Screen for abuse at every opportunity, during the hospital
stay and on postpartum follow-up visits.80–83
Educate women about resources available to them
and how you, the health-care provider, can assist
them.80,83
Provide written educational material. Although this material can be displayed in waiting rooms
and public areas, it is best to duplicate the display in
bathrooms where only the woman can go. Resources
and “help lines” need to be on small cards that can be
concealed easily by the woman.80–83
Inform patients of services and shelters for the battered It is important to provide information about resources to
woman. Post telephone numbers in conspicuous places. these women in an unobtrusive manner, so they can
Post telephone numbers in the women’s bathroom access the resources when they are ready.
(unavailable to men, so they cannot see the partner get-
ting the number). Tell women to memorize the number
and never write it down.
Birthing Process
Provide a comfortable, nonjudging atmosphere to encour- Assists in decreasing fear through promotion of verbal-
age the patient and her significant other to verbalize ization.
their fears of:
• The unknown
• Safety for herself and her baby
• Pain during the birthing process
• Mutilation during the birthing process
• “Losing control” during the birthing process
Refer the patient to appropriate support groups for infor- Provides effective use of existing resources and long-
mation: range support.
• Childbirth education classes in the community
• Special national organizations
Monitor the patient’s level of confidence using prepared Use of relaxation techniques and provision of information
childbirth techniques during labor: regarding progress facilitate the labor process by eas-
• Encourage use of relaxation and prepared childbirth ing anxiety and promoting comfort.44
techniques during labor.
• Provide ongoing and accurate information, during the
labor and birth process, to both the patient and her sig-
nificant other.
• Assist the patient in using “imagery” to overcome fears
during the birthing process.
Provide continuity of care by remaining with and provid- Encourages involvement in the process, which enhances
ing comfort for the laboring woman throughout the coping.
birthing process:
• Provide clear answers to the patient’s questions.
• Keep the patient informed of her progress in the
birthing process.
Provide the patient and significant others with as many
opportunities as possible to make decisions about her
care during the birthing process.
(care plan continued on page 558)
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Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide a quiet, nonstimulating environment for the Inappropriate levels of environmental stimuli can increase
client. This would include removing persons and disorientation and confusion. Manipulation of the envi-
objects that the person perceives as threatening. If the ronment can eliminate the fear response.43
person is experiencing a thought disorder with delu-
sions and hallucinations, attention should be paid to
the details of the environment that could be misinter-
preted. At times a same-sex caregiver can increase fear
in the client.
Obtain the client’s understanding of the threat. Use sim- Facilitates the development of interventions that directly
ple concrete questions to obtain information (e.g., address the client’s concerns. High levels of anxiety
“What do you need right now?”) decrease the client’s ability to process complex
information.38
Provide a one-to-one relationship for the client with a Promotes a trusting relationship, and enhances the client’s
member of the nursing staff. This should be maintained self-esteem. After the relationship is developed, pro-
until the symptoms return to normal levels. Remain vides a sense of security in unfamiliar situations
with the client in unfamiliar situations.
Provide clear answers to the client’s questions. Inappropriate amounts of sensory stimuli can increase the
client’s confusion and disorganization.
Carry on conversations in the client’s presence or vision Meets safety needs of the client by eliminating stimuli
in a voice that the client can hear. that could be misinterpreted in a personalized manner.
Inform the client of plans related to care before the plans Promotes the client’s sense of control and enhances self-
are implemented. If possible, discuss these with the esteem.
client (e.g., if it is necessary to move the client to
another room or institution, the client should be
informed of this change before it takes place).
Orient the client to the environment. Promotes safety needs by increasing the client’s familiar-
ity with the environment in the accompaniment of a
trusted individual.
Maintain a consistent environment and routine. Record Promotes the client’s sense of safety and trust by main-
the client’s daily routine here, along with notes about taining consistency in the environment.
client’s special reactions to visitors and staff members.
Provide a primary care nurse for the client on each shift. Promotes the development of a trusting relationship.
Sit with the client [number] minutes [number] times per Promotes the development of a trusting relationship.
shift. (Initially the times should reflect short, frequent Interaction with the nurse can provide positive rein-
contact. This can change with the client’s needs.) forcement and enhance self-esteem.
Provide the client with objects in the environment that Meets the need for affiliation by providing meaningful
promote security. These may be symbolic items from objects to which the client is attached.43
home or religious objects. List significant items here.
Note the client’s desired personal space, and respect these Communicates respect for the client, while decreasing the
limits (the general guidelines should be stated here). client’s anxiety by maintaining a comfortable personal
space.
Assist the client with sorting out the fearful situation by: Communicates respect for the client, while encouraging
• Recognizing that the experience is real for the client reality testing.
even though it may not be your experience of the situa-
tion: “I can see that you are very upset. I can under-
stand how those thoughts could make you fearful.”
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Providing feedback about distorted thoughts: “No, I am
not going to punish you. I am here to talk with you
about your concerns.”
• Talking about client’s perceptions specific terms and
not vague generalizations: “When you say your family
is out to get you, who and what do you mean?”
• Focusing conversations on the here and now; this
includes information about the effects of the client’s
behavior on those around him or her, your experience
of the client, and your perceptions of the environment.
• Not arguing about the client’s perceptions; instead, pro-
vide feedback in the here and now with your percep-
tions of the situation. The client tells you that you must
be angry with him or her because of the look you had
on your face while reviewing the client’s chart. Your
response is, “I am not angry with you, when I was
looking at your chart, I was thinking about the conver-
sation we had this morning about your job.”
Provide the client with as many opportunities as possible Promotes the client’s sense of control, and enhances
to make decisions about his or her care and the current self-esteem.
situation.
Develop, with the client, a list of potential solutions to Teaches the client problem-solving skills, while promot-
the threatening situation. ing the client’s sense of control and strengths.
Review the developed list of solutions with the client, and Facilitates the client’s decision-making process.
assist him or her in evaluating the benefits and costs of
each solution.
Rehearse with the client, if necessary, the solution Behavioral rehearsal helps facilitate the client’s learning
selected, or have the client practice a new response to new skills through the use of feedback and modeling
the threatening situation. Note times and frequency of by the nurse.43
this practice here.
Provide positive informative verbal feedback to the client Positive feedback encourages behavior and enhances self-
about efforts to resolve the threatening situation. esteem.43
Spend [number] minutes [number] times each day with Planned coping strategies facilitate the enactment of new
the client to develop alternative outlets for the feelings behaviors when the client is experiencing stress.
generated by the threatening situation, and provide the
opportunity for the use of these outlets. These would
be noted in the written care plan so other staff mem-
bers would be aware of them and could talk the client
through their use when they notice the client’s discom-
fort increasing.
Provide the client feedback that identifies early behav- Early recognition and intervention enhances the opportu-
ioral cues indicating fear or that he or she is entering a nities for new coping behaviors to be effective.
fearful situation.
Support the client in using alternative coping strategies Promotes the client’s perception of control. Positive rein-
developed by: forcement encourages behavior.
• Providing the necessary environment
• Providing the appropriate equipment
• Spending time with the client doing the activity
• Providing positive reinforcement for the use of the
strategy (this could be verbal as well as with special
privileges) [Note the special adaptations needed here.]
(care plan continued on page 560)
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560 • Self-Perception and Self-Concept Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
If fear is related to a specific object or situation, teach the The relaxation response inhibits the activation of the
client to use deep muscle relaxation, and then teach autonomic nervous system’s fight-or-flight response.
this along with progressively real mental images of
the threatening situation. This is for those situations
that will not cause the client harm if he or she is
approached, such as riding in elevators. This could
also include other methods of relaxation such as
music, deep breathing, thought stopping, fantasy,
assertiveness training, audiotapes with relaxation
images or sequences, yoga, hypnosis, and
meditation.
Note techniques to be taught with teaching schedule here.
Explore with the client ways to increase the feeling of
control in threatening situations; e.g., a fear of eleva-
tors could be altered by the client only riding in eleva-
tors with emergency telephones and only riding when
he or she could stand near the telephone. The fear may
also indicate that the client is feeling out of control in
an unrelated area of his or her life. If this is suspected,
this should be explored and ways of increasing control
should be explored (e.g., a woman’s fear of driving
could indicate that she feels out of control in her mar-
riage, and increased assertive behavior with her hus-
band removes the fear). [Note schedule for this
discussion here.]
When the client shows signs and symptoms of fear (note Shifts physiologic state from sympathetic nervous system
those signs and symptoms unique to this client here), arousal to a state of parasympathetic recuperation.73
talk him or her through the coping and/or relaxation Behavioral rehearsal helps facilitate mastery of new
strategies that have been identified as useful to him or behavior through the use of feedback and modeling by
her. Note the client’s specific coping strategies to be the nurse.43 Promotes a sense of control.70 Contextual
used here. This may include removing the client from stimuli can elicit the fear response.43
the fear-producing context.
Provide positive reinforcement for the client’s implemen- Positive reinforcement encourages behavior.
tation of the new coping behaviors. Note those things
that are to be used to reinforce this client here.
If the method to increase control involves interactions Promotes the client’s sense of control, and enhances self-
with the health-care team, these should be noted in esteem.
specific terms on the client’s chart.
Assist the client in developing strategies to be used in Behavioral rehearsal provides opportunities for feedback
the community after discharge, and role-play various and modeling from the nurse.
situations with the client [number] times for [number]
minutes.
Collaborate with other members of the health-care team Gamma-aminobutyric acid (GABA) agonists inhibit the
to provide clients with pharmacologic agents to be amygdala, which is the location of the fear response.43
administered before exposure to a context that elicits
fear. Monitor for side effects of these medications and
provide appropriate client education.
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Fear • 561
Gerontic Health
In addition to the following interventions, the interventions for Adult Health and Mental Health can be applied to the aging
client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient in discussing the source of fear (e.g., Addressing the source of fear enables the patient to
pain, death, or loss of function) by scheduling at least develop a specific plan of action to reduce the fear.
30 minutes twice a day at [times] to confer with the
patient about the fear.
During the interview, observe behaviors of the patient. Elder abuse is not new, but it receives little attention as
Patients will not readily offer information of abuse. the elderly in this country seem to be “the invisible
You may observe: population.”87
• The patient is unable to provide information without
the caregiver present.87
• The caregiver demonstrates aggressive behavior toward
patient.87
• The patient seems to be controlled by the caregiver and
the caregiver shows no affection or seems indifferent to
situation.87
Identify which coping strategies that the client has previ- This helps the client identify effective strategies while
ously used have been effective and which have not. reinforcing that he or she can cope with his or her fear.
Discuss ways that effective strategies can be used to
cope with future fearful events.
Assist the patient in determining what resources are avail- Knowledge and use of appropriate resources aid in reduc-
able to enhance his or her coping skills. ing fear-provoking experiences by increasing the
patient’s inventory of skills to deal with fear.
Home Health
In addition to the following interventions, the interventions for Adult Health and Mental Health can be applied to the home
health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ask the client to describe the precipitating event. Assists the nurse in understanding the client’s perception
of the fear.
Determine the client’s perception of the fear. Assists the nurse in understanding the client’s perception
of the fear.
Assess sources of support, resources, and usual coping Assists the nurse in understanding the client’s perception
methods. of the fear.
Identify which coping strategies that the client has previ- This helps the client identify effective strategies while
ously used have been effective and which have not. reinforcing that he or she can cope with his or her fear.
Discuss ways that effective strategies can be used to
cope with future fearful events.
Help the client to talk about his or her fear and its source. Makes the client, the nurse, and the family more aware of
issues that need discussing or problems that need to be
addressed.
Listen to the client’s and family’s concerns, and answer Understanding helps promote a sense of control and
all questions truthfully. Tell the client and family as order.
much as you can to decrease the number of “surprises”
they may experience with the fear-producing event.
(care plan continued on page 562)
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Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Acknowledge all fears, feelings, and perceived threats as All client fears are valid to the client, whether they are
valid to the client. realistic or not.
Administer anxiolytics as ordered, and educate the family Promotes a sense of well-being.
or caregivers about prescribed medications, their side
effects, and scheduling.
Consult with and/or refer the patient to assistive resources Utilization of existing services is an efficient use of
as needed. resources.
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Hopelessness • 563
Child Health
Depending on the age and developmental status of the child, some components of Adult and Mental Health will also apply
in addition to the following:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for the etiologic components contributing to Provides a database that results in a more accurate and
hopelessness pattern. complete plan of care.
Facilitate with patient and parents discussions of feelings Verbalization helps reduce anxiety and assigns value to
about current status, with 30 minutes set aside each the patient’s concerns. Allows ongoing assessment.
shift at [times] for this purpose.
Assist the patient and family to explore growth potential Opportunity for growth may be overlooked in times of
afforded by this specific experience. crisis.
(care plan continued on page 564)
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564 • Self-Perception and Self-Concept Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Allow opportunities for the child to “play out” feelings Play and the acting out of feelings provide insight into
under appropriate supervision and guidance of child coping and perceptions of the child in a noninvasive
life specialist: mode. Provides valuable data to monitor feelings, con-
• Play with dolls for toddler cerns, etc.
• Art and puppets for preschooler
• Peer discussions for adolescents
Refer, as appropriate, to child mental health specialist. Provides actual and anticipatory guidance for resolution
of the acute phase.
Women’s Health
l N O T E : The following nursing actions are for the couple (husband or wife) who has
been unable to conceive a child, after testing and treatment. See Chapter 10 for detailed
information on infertility. Provide a nonjudgmental atmosphere to allow the infertile
couple to express their feelings such as anger, denial, inadequacy, guilt, depression,
or grief.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Infertility
Support and allow the couple to work through the Provision of support for and encouragement of discussion
grieving process for loss of fertility, loss of children, regarding emotions allows the couple to begin to deal
loss of idealized lifestyle, and loss of feminine life with emotions and lays the groundwork for future deci-
experiences such as pregnancy, birth, and breast- sion making.44
feeding.
Encourage the couple to talk honestly with one another Most adults assume they will have children; finding they
about feelings. cannot conceive often leads to feelings of inferiority,
doubts about their sexuality, and guilt or blame.44
Encourage the couple to seek professional help if neces-
sary to deal with feelings related to sexual relationship,
conflicts, anxieties, parenting, and coping mechanisms
used for dealing with loss of fertility (their expecta-
tions, relatives’ expectations, and society’s expecta-
tions).
Be alert for signs of depression, anger, frustration, and Allows early intervention and avoidance of complica-
impending crisis. tions.44
Provide the infertile couple with accurate information on Adoption choices in this country are limited because
adoption and living without children. many single mothers are keeping their babies and
because of the availability of birth control and abor-
tion. Often couples in the United States look to
foreign countries to adopt.44
Postpartum Depression
l N O T E : The majority of patients who experience hopelessness that leads to postpar-
tum depression have been found to have underlying psychiatric disorders, or life expe-
riences other than pregnancy, that accounted for the depression.80
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide factual information to the patient and partner on Give the patient and partner realistic guidelines for when
postpartum depression. Describe the difference they might need to seek professional help for depres-
between “baby blues” and depression. Identify sion beyond “baby blues.”80
potential psychosocial triggers in the patient’s
environment that could lead to postpartum
depression, such as:
• Feelings of ambivalence
• Feelings of inadequacy
• Marital discord
• Guilt and irritability
Domestic Violence80–84,88
Provide a nonjudgmental atmosphere that allows the
patient to express anger, fears, and feelings of hope-
lessness. Refer the patient to an appropriate agency for
assistance to find shelter and psychological counseling.
Assist the patient in developing a plan of action in the
event of a situation that could threaten her or her chil-
dren’s safety.
Place telephone numbers for assistance in the women’s Provides resources and information to patients without
bathroom and other places women can see and putting them or their children in further danger.
memorize it without fear of reprisal from their
partner.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the health-care team’s interactions with the client Negative attitudes from the staff can be communicated to
for behavior (verbal and nonverbal) that would encour- the client.
age the client not to be hopeful (e.g., using an example
of a less that optimal outcome of a disease process
such as “I am a diabetic and am currently waiting for
my kidney transplant,” or referring to adult incontinent
underwear as diapers). If situations are identified, they
should be noted here, and the team should discuss
alternative ways of behaving in the situation. The
actions needed to support the client’s hope should be
noted on the client’s chart.
Sit with the client [number] times per day at [times] Promotes positive orientation by assisting the client in
for 30 minutes to discuss feelings and perceptions the remembering past successes and important aspects
client has about the identified situation. These times of life that make it important that he or she succeed
should also include discussions about the client’s sig- this time.89,90
nificant others, times the client has enjoyed with these
persons, the projects or activities the client was plan-
ning with or for these persons that have not been
accomplished, the client’s values and beliefs about
health and illness, and the attitudes about the current
situation.
(care plan continued on page 566)
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566 • Self-Perception and Self-Concept Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Identify with the client’s significant others times that they Negative expectations from the support system can be
can talk with the staff about the current situation. communicated to the client.
Themes that should be explored during this interaction
should be their thoughts and feelings about the current
situation, ways in which they can support the client,
the importance of their support for the client, questions
they may have about the client’s situation, and possible
outcomes. (Note the time for this interaction here as
well as the name of the person who will be talking
with the significant others.)
Note the times when significant others will be visiting, Assists the client in maintaining connections with the
and schedule this time so there will be a private time support systems, and increases the awareness of contri-
for them to interact with the client. (Note these times butions the client has made in the past and can make in
here, and designate those times that are scheduled as the future to this system.
private visitation times.) Inform the client and signifi-
cant others of places on the unit where they can have
privacy to visit.
Identify with the client preferences for the daily routine, Promotes the client’s sense of control.
and place this information on the chart to be imple-
mented by the staff. It is vital to this client to have the
information shared with all staff so that it will not
appear that the time spent in providing information was
wasted.
Provide answers to questions in an open, direct manner. Promotes the client’s sense of control, while building a
trusting relationship.
Provide information on all procedures at a time when the
client can ask questions and think about the situation.
Allow the client to participate in decision making at the Promotes the client’s sense of control in a manner that
level to which he or she is capable of doing so. A client increases the opportunities for success. This success
who has never made an independent decision would be serves as positive reinforcement.
overwhelmed by the complexity of the decisions made
daily by a corporation executive. If necessary, offer
decision situations in portions that the client can mas-
ter successfully (the amount of information that the
client can handle should be noted here as well as a list
of decisions that have been presented to the client).
Provide positive reinforcement for behavior changed and Positive reinforcement encourages behavior while
decisions made. The actions that are reinforcing for this enhancing self-esteem.
client should be listed here along with the reward sys-
tem that has been established with the client (e.g., play
one game of cards with the client when a decision about
ways to cope with a specific problem has been made).
Provide verbal informative social reinforcements along Promotes the development of a trusting relationship.
with behavioral reinforcements. Enhances self-esteem.89
Keep promises (specific promises should be listed on the
chart so that all staff will be aware of this information).
Accept the client’s decision if the decision was given to Promotes the client’s sense of control, while enhancing
the client to make. These decisions should be noted on self-esteem.
the chart.
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide ongoing, informative, positive feedback to the Provides positive reinforcement for accomplishments.89
client on progress.
Spend 30 minutes a day talking with the client about cur- Interaction with the nurse can provide positive reinforce-
rent coping strategies and exploring alternative coping ment. Behavioral rehearsal provides opportunities for
methods. Note the time for this discussion here as well feedback and modeling of new behaviors from the
as the person responsible for this interaction. When nurse.
alternative coping styles have been identified, this time
should be used to assist the client with necessary prac-
tice. The alternative styles that the client has selected
should be noted on the chart, and the staff should assist
the client in implementing the strategy when appropri-
ate. These could include deep muscle relaxation, visual
imagery, prayer, or talking about alternative ways of
coping with stressful events.
Allow the client to express anger, and assist with discov- Promotes the development of a positive orientation.
ering constructive ways of expressing this feeling (e.g.,
talking about this feeling, using a punching bag, play-
ing Ping-Pong, or throwing or hitting a pillow). Talk
with the client about signs of progress, and assist him
or her in recognizing these as they occur with verbal
reminders or by keeping a record of steps taken toward
progress.
Assist the client in establishing realistic goals and realis- Goals that are achieved serve as positive reinforcement
tic expectations for situations. The goals should be for behavior change and enhance self-esteem and a
short term and stated in measurable behavioral terms. positive expectational set.
Usually, dividing the goal set by the client in half pro-
vides an achievable goal. This could involve dividing
one goal into several smaller goals. [Note goals and
evaluation dates here.]
Determine times with the client to evaluate progress Provides positive reinforcement for movement toward the
toward these goals and to discuss his or her observa- goal, and provides an opportunity for the nurse to pro-
tions about this progress. These specific times should vide positive verbal reinforcement.
be listed here with the name of the person responsible
for this activity. Initially this may need to be done on a
daily basis until the client develops competency in
making realistic assessments.
Assist the client in developing a list of contingencies for Provides direction for the client, with an opportunity to
possible blocks to the goals. These would be “what-if” mentally rehearse situations that could require alter-
and “if-then” discussions. This would be done in the ation of goals. This protects the client from all-or-none
goal-setting session, and a record of the alternatives situations.
discussed would be made in the chart for future
reference.
Discuss with the client values and beliefs about life, and Spirituality can provide hope-giving experiences.
assess the importance of formal religion in the client’s
life. If the client requires contact with a person of his
or her belief system, arrange this, and note necessary
information for contacting this person here. Provide the
client with the time necessary to perform religious ritu-
als that are important to him or her. Note the rituals
here with the times scheduled and any assistance that is
required from the nursing staff.
(care plan continued on page 568)
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568 • Self-Perception and Self-Concept Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide the client with opportunities to enjoy aesthetic Promotes the client’s interest in the positive aspect of life,
experiences that have been identified as important, promoting a positive orientation.
such as listening to favorite music, having favorite pic-
tures placed in the room, enjoying favorite foods, or
having special flowers in the room. Spend 5 minutes
three times a day discussing these experiences and
assisting the client in becoming involved in the enjoy-
ment of them. Note here activities that have been iden-
tified by the client as important and times when they
will be discussed with the client.
Assist the client in developing an awareness and an Provides the client with an opportunity to access past
appreciation for the here and now by helping him or positive experiences in the present, thus promoting a
her focus attention in the present by pointing out to positive orientation.
him or her the beauty in the flowers in the room, the
warmth of the sunshine as it comes through the win-
dow, the calmness or vitality of a piece of music, the
taste and smell of a special food item, the odor of flow-
ers, etc.
Establish a time to talk with the client about maximizing Promotes the client’s sense of control, enhancing self-
potential at his or her current level of functioning. Note esteem.
date and time for this discussion here. This may need
to be done in several stages during more than one time,
depending on the client’s level of denial. Note here the
person responsible for these discussions.
Gerontic Health
The nursing actions for the older adult with this diagnosis are the same as for the Adult Health and Mental Health patient.
Home Health
In addition to the following interventions, the interventions for Adult Health and Mental Health can be applied to the home
health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for factors contributing to the hopelessness (e.g., Provides a database for early recognition and inter-
psychological, social, economic, spiritual, or environ- vention.
mental factors).
Involve the client and family in planning, implementing, Clarifies roles. Personal involvement in planning, etc.
and promoting reduction or elimination of hope- Increases the likelihood of success in resolving the
lessness: problem.
• Family conference: To identify and discuss factors con-
tributing to hopelessness
• Mutual goal setting: Setting goals with roles of each
family member identified
• Communication
• Support for the caregiver
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Loneliness, Risk For • 569
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client and family in making lifestyle adjust- Lifestyle changes require significant behavior change.
ments that may be required: Self-evaluation and support can assist in ensuring that
• Use relaxation techniques: yoga, biofeedback, hypno- changes are not transient.
sis, breathing techniques, or imagery.
• Provide assertiveness training.
• Provide opportunities for individual to exert control
over the situation. Offer choice when possible; support
and encourage self-care efforts.
• Provide a sense of mastery; set accomplishable and
meaningful goals in secure environment.
• Look for meaning in the situation (e.g., what can be
learned from the situation).
• Provide treatment for the physiologic condition.
• Provide grief counseling.
• Provide spiritual counseling.
Consult with, or refer to, assistive resources as indicated. Effective use of existing community resources.
LONELINESS, RISK FOR Loneliness is a risk diagnosis and is the client’s per-
DEFINITION 40 ception of his or her situation. Social Isolation is a risk
factor for the diagnosis of Loneliness.
At risk of experiencing vague dysphoria.
Impaired Social Interaction
RISK FACTORS40 This diagnosis is also an actual diagnosis. In Impaired
1. Affectional deprivation Social Interaction, the problem can be insufficient or
2. Social isolation excessive social activity. If a person is experiencing
3. Cathectic deprivation impaired social interaction, he or she could be at risk
for loneliness.
4. Physical isolation
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570 • Self-Perception and Self-Concept Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Include and facilitate child visitation as appropriate.
Initiate family involvement in care through providing
explanations of patient status, teaching about proce-
dures, and performing aspects of care.
Facilitate family involvement by identifying accommoda-
tions for visitation (e.g., family house, local hotels, etc.)
Evaluate whether strategies are meeting needs. Enables monitoring of progress and allows for altering
the plan of care.
Identify alternative social interactions including outreach
groups or pet therapy.
Assist the patient to find alternate support systems, even Patients perceive that nurses can offer psychological
short, quality interactions with the nurse. support with even short visits.61
If expected outcomes are not met, see interactions for
Social Isolation and Impaired Social Interaction.
Child Health
Same as for Adult Health, with attention to developmentally appropriate approach for all interventions. When other diag-
noses (e.g., Grief or Loss, Parent–Infant Separation, Coping) also contribute to this pattern, seek follow-up with concur-
rent plan for loneliness as well.
ACTIONS/INTERVENTIONS R AT I O N A L E S
If anaclitic depression is to be considered, stage appropri- In separation anxiety, the infant or child may have differ-
ately for current/ongoing status (i.e., protest, despair, ent needs, but all will help direct caregivers to support
or withdrawal). client regain bonding with others.
Determine how to support the infant, child, or adolescent Holistic planning according to realistic capacity of the
coping with loneliness as applicable infant, child, or adolescent will provide an appropriate
[Note the methods most appropriate for this patient here.]: chance to reestablish a sense of belonging.
• Play therapy or counseling
• Consideration of developmental capacity
• Access to activities within the local community
• Monitor physical or emotional readiness, for both the
individual and the family
• Allowance for regression due to illness
• Support services, foster grandparents, volunteers, Child
Protective Services (CPS), or college interest groups
Involve all who have input in establishing consistent Often underlying dynamics may require long-range
long-term goals. planning.
When necessary, advocate for the infant or child. Loneliness may be related to abuse on the part of the par-
ents and must be considered appropriately.
Schedule a time for counseling that provides appropriate Loneliness will undermine family dynamics if left unrec-
valuing of family needs. Note schedule and special ognized.
accommodations for this here.
Offer 30 minutes each shift for the patient or parents to Frequent verbalization will offer cues to suggest insight
ventilate feelings about loneliness. into how loneliness is being perceived and provide the
basis for the most appropriate treatment.
Determine the need for follow-up counseling or referral Provides actual or anticipatory guidance for resolution
to child mental health specialist. of related issues.
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Loneliness, Risk For • 571
Women’s Health
l N O T E : The heath-care provider will see this diagnosis in many more females than in
male clients as a result of women outliving men. This is one of the most frequent diag-
noses in geriatric women.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Postpartum
Provide the patient with access to support by the provid- Provides new parents support and guidance during the
ing telephone number and name of available support first days of the postpartum period, and assists in the
person she can call with questions. transition to parenthood.
Encourage new parents to attend parenting support
groups and participate in parent education programs in
the acute care setting and in the community after dis-
charge. Suggest to parents:
• YWCA
• Churches
• Neighborhood groups
• Friends who have had babies
• State-funded follow-up programs
Single Parents
Assist the new mother to develop a plan for coordinating
activities of daily living with the new infant.
Assist the patient in identifying available resources:
• Family
• Significant others
• Community agencies
• Peer groups
Assist the patient in identifying and developing intraper-
sonal skills.
Encourage attendance at parenting classes or support
groups.
• Learn about baby cues and how to provide for psycho-
logical needs of new infant.
• Identify others with similar concerns and needs.
• Identify new sources of support and contact opportuni-
ties for developing new friendships.
Encourage the patient to identify friends or acquaintances Provides support and guidance during the transition to
who have recently had new babies and to begin: parenthood, as well as provides additional resources
• Discussing similar concerns and problems with caring specific to assisting the single parent.
for a new baby
• Sharing babysitting activities to reduce costs and
increase opportunities for the new mom to get away
occasionally
Divorce and Widowhood
Provide a relaxed atmosphere that will encourage the
patient to express feelings, identify concerns, and allow
for grieving.
Evaluate need for professional assistance and/or family
support.
Identify and clarify with the patient feelings of abandon-
ment, anger, and loss of previous lifestyle.
(care plan continued on page 572)
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572 • Self-Perception and Self-Concept Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient in identifying new opportunities for
involvement with others, i.e., church groups, commu-
nity volunteer groups, social groups (ski club, travel
clubs, etc.) for people with similar interests, returning
to college, cultural events, etc.
Provide opportunities for new interactions in a supportive
atmosphere (e.g., identify friend to accompany the
patient to social events or identify friend she can
talk to).
Provide referrals to appropriate professional resources for Provides support and guidance during a time of crisis
assistance if necessary. for the patient. Assists the client to find and utilize
available resources.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend [number] minutes [number] times a day discussing Assists in understanding the client’s worldview, which
with the client his or her perception of the source of facilitates the development of client-specific interven-
the loneliness and how they have tried to resolve the tions. Increases the client’s sense of involvement and
situation. empowerment.90
Have the client list the persons in the environment who Facilitates the client’s reality testing of perception of
are considered family, friends, and acquaintances. Then being alone.
have the client note how many interactions per week
occur with each person. Have the client identify what
interferes with feeling connected with these persons.
Note here the person responsible and schedule for this
interaction.
When contributing factors have been identified, develop a Facilitates the development of alternative coping behav-
plan to alter them. This could include: iors, and improves social skills, which improves role
• Assertiveness training performance and social confidence.
• Role-playing difficult situations
• Teaching the client relaxation techniques to reduce
anxiety in social situations
• Providing the client with aids to compensate for sen-
sory deficits
• Providing the client with special clothing or prosthetic
devices to enhance physical appearance
• Teaching the client personal hygiene necessary to
maintain aesthetic appearance (ostomy care, inconti-
nence care, or wound care)
Note here the specific interventions, and schedule neces-
sary for this client with person responsible for the
activity. For example, the primary care nurse will inter-
act with the client 30 minutes 2 times a day to teach
assertive skills, or the client will attend social skills
group at [time].
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Loneliness, Risk For • 573
ACTIONS/INTERVENTIONS R AT I O N A L E S
Develop a list of things the client finds rewarding, and Positive reinforcement encourages behavior and enhances
provide these rewards as the client successfully com- self-esteem. Increases the client’s competence, and
pletes progressive steps in the treatment plan. This thus enhances role performance and self-esteem.
schedule should be developed with the client. Note
here the schedule for rewards and the kinds of behavior
to be rewarded.
Consult with the occupational therapist if the client needs
to learn specific skills to facilitate social interactions,
such as cooking skills so friends can be invited to din-
ner, craft skills, or dancing so the client can join others
in these social activities.
Include the client in groups on the unit. Assign the client Successful accomplishment of a valued task can provide
activities that can be accomplished easily and that will positive reinforcement, which encourages social behav-
provide positive social reinforcement from other per- ior. Provides opportunities for the client to practice
sons involved in the activities. Note here the group and social interaction skills in a context where feedback
activity schedule. can be obtained.37,38
If lack of activities contributes to the loneliness, refer to Decreased activities can increase the sense of time pass-
Deficient Diversional Activity in Chapter 5 for detailed ing slowly, which perceptually increases the time spent
interventions. alone, increasing the sense of loneliness.90
Consult with social services if transportation or financial Decreased mobility can decrease social interaction and
resource problems contribute to social isolation. sense of aloneness.
Discuss with clients those times it would be appropriate Promotes the client’s sense of control, while facilitating
to be alone, and develop a plan for coping with these the development of alternative coping behaviors.
times in a positive manner. For example, the client will
develop a list of books to read and music to listen to,
or call a friend.91
When the client is demonstrating socially inappropriate Lack of positive reinforcement decreases a behavior.
behavior, keep interactions to a minimum, inform the
client that the behavior is inappropriate, and escort him
or her to a place away from group activities. Note here
the target behaviors for this client.
When inappropriate behaviors stop, discuss the behavior Promotes the client’s sense of control, while promoting
with the client, and develop a list of alternative kinds the development of alternative coping behaviors.
of behavior for the client to use in situations in which
the inappropriate behavior is elicited. Note here the
behaviors that are considered problematic, with the
action to be taken if they are demonstrated. For exam-
ple, the client will spend time out in seclusion or sleep-
ing area.
The primary care nurse will spend 30 minutes once a day Provides positive reinforcement for appropriate problem
with the client at [time] discussing the client’s reac- solving.
tions to social interactions and assisting the client with
reality testing of social interactions, for example, what
others might mean by silence, or various nonverbal and
common verbal expressions. This time can also be used
to discuss role relationships and the client’s specific
concerns about relationships.
Assign the client a room near areas with high activity. Facilitates the client’s participation in unit activities.
Assign one staff person to the client each shift, and have Decreases the client’s opportunities for socially isolating
this person interact with the client every 30 minutes him- or herself.
while the client is awake.
(care plan continued on page 574)
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574 • Self-Perception and Self-Concept Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Have the client identify activities in the community that
are of interest and would provide opportunities for
interactions with others. List the client’s interests here.
Develop with the client a plan for making contact with Promotes the client’s sense of control, and begins the
the identified community activities before discharge. development of adaptive coping behaviors.
Arrange at least 1 hour a week for the client to interact Support system understanding facilitates the maintenance
with his or her support system in the presence of the of new behaviors after discharge.
primary care nurse. This will allow the nurse to assess
and facilitate these interactions. [Note here the sched-
ule and responsible person.]
Discuss with the support system ways in which they can
facilitate client interaction (e.g., frequent telephone
calls, teaching the client to use public transportation,
Meals-on-Wheels, or community telephone call check-
in services).
Model for the support system and for the client the kinds Provides opportunities for the client to practice new role
of behavior that facilitate communication. behaviors in a safe, supportive environment.
Limit the amount of time the client can spend alone in
room. This should be a gradual alteration and should
be done in steps that can easily be accomplished by the
client. Note the specific schedule for the client here.
For example, the client will spend 5 minutes per hour
in the day area. Have the staff person remain with the
client during these times until the client demonstrates
an ability to interact with others.90
Provide a guest book in the client’s room for visitors to This intervention assists with situations in which the
sign. This should include a space for visitor’s name, client’s perception of visitation is not congruent with
date, and time of visit. A space for a summary of the actual contact with support systems. Provides the client
discussion could also be included. and staff with documentation of visits to aid with real-
ity testing.
Refer the client to appropriate community agencies.
Gerontic Health
See actions and interventions under Mental Health. The older adult who is experiencing losses associated with aging, such
as loss of a spouse, decline in physical health, and changes in role, is especially vulnerable to loneliness.
Home Health
In addition to the following interventions, the interventions for Adult Health and Mental Health can be applied to the home
health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family to identify and prevent risk Early recognition and intervention can interrupt develop-
factors of loneliness: ment of loneliness.
• Physical and social isolation
• Deprivation
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Personal Identity, Disturbed • 575
ACTIONS/INTERVENTIONS R AT I O N A L E S
A terminal diagnosis can result in less outside interaction. Reestablishes previous social contacts.
If friends stop visiting, assist the family and client to
understand possible reasons:
• It is difficult for others to face their own mortality.
• Others may fear that the client is too sick for visitors.
The client and family should speak frankly with friends
and family about these issues and their wishes regard-
ing visitors.
Assist the client and family in lifestyle adjustments that Home-based care requires involvement of the family.
may be necessary: Loneliness can disrupt family schedules and role rela-
• Develop a plan for increased involvement (e.g., begin tionships. Adjustments in family activities and roles
with social contacts that are least threatening). may be required.
• Provide for personal hygiene.
• Provide a supportive environment.
Assist the family to set criteria to help them determine Provides the family with background knowledge to seek
when additional intervention is required (e.g., inability appropriate assistance as the need arises.
of the client or family to care for the client).
Refer to appropriate assistive resources as indicated. Additional assistance may be required for the family
to care for the family member with loneliness.
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576 • Self-Perception and Self-Concept Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for contributing factors that might predispose the Provides the database needed to more accurately and
development of Disturbed Personal Identity: completely plan care.
• Altered maternal–infant attachment (e.g., parents’ over-
protection or ignoring of the infant)
• Altered development norms related to independent
functioning (e.g., following commands; check for
organic or sensory–perceptual deficits.)
• Preference for solitary play
• Display of self-stimulation and/or self-mutilation
behaviors
• History of altered identity problems in the family
Provide basic care for other needs with prioritization for In anticipatory safety planning, standards must be in
safety needs. Close observation is mandatory. accord with both the known and the unknown self-
injury potential of the patient.
Administer medications as ordered, with attention to The patient is prone to dehydration and malnutrition due
hydration and nutritional concerns. to inability to rely on usual thirst or appetite regulators.
Provide appropriate follow-up and collaboration with the Appropriate use of specialists will offer a more individu-
family. [Note special adaptations needed here.] alized plan of care with greater likelihood of meeting
needs.
Assist the family in decision making regarding long-term Assistance and support in identification of options assists
care (e.g., institutionalization versus day care). in decision making, reducing stress, and empowering
the family.
Women’s Health
The nursing actions for the woman with this nursing diagnosis are the same as those for the Mental Health client. Also see
Risk for Loneliness and Anxiety.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assign the primary care nurse to establish trusting Establishes boundaries so changes can be immediately
nurse–client relationship. processed.90
Monitor the client for mental status changes. Alterations in mental status that result in identity confu-
sion can be related to a delirium related to a general
medical condition or substance withdrawal. These situ-
ations can be life threatening and need to be addressed
with immediate consultation with client’s primary care
provider to determine contributing factors.38,58
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Personal Identity, Disturbed • 577
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide the client with information about unit structure, Assists the client in establishing clear interpersonal
policies, expectations, and requirements. boundaries.
Provide a quiet, nonstimulating environment. Inappropriate levels of sensory stimuli can increase con-
fusion and sense of disorganization.
Provide frequent interactions that assist the client with Promotes the development of a trusting relationship
orientation. within the client’s attention span.
Provide environmental cues to enhance orientation. These Clients who have experienced alterations in personal
could include calendar with day and date marked, identity still respond to basic personality characteristics
schedule board, personal items of attachment, and the and familiar objects.92,93
client’s name or object that they connect with on door
of room.
Verbal information should be provided in simple, brief Interactions with others also assist in reestablishing weak
sentences. ego boundaries.
Sit with the client [number] minutes [number] times per Promotes the development of a trusting relationship.
day at [times] to provide the client with an opportunity Provides positive reinforcement for the client, meeting
to discuss feelings and thoughts. needs in a more constructive way.
Provide the client with honest, direct feedback in all Promotes the development of a trusting relationship.
interactions.
Utilize constructive confrontation if necessary, to include: Assists the client in establishing ego boundaries, while
• “I” statements supporting self-esteem.
• Relationship statements that reflect the nurse’s reaction
to the interaction
• Responses that will assist the client in understanding,
such as paraphrasing and validation of perceptions
Develop, with the health-care team, a clear set of bound- Firm limits facilitate the client’s focusing on feelings
aries and a list of expectations and the consequences rather than moving away from them.93,94 Prevents staff
for inappropriate behaviors. Schedule frequent team splits, which are detrimental to clients who have iden-
meetings to review the client’s behavior and to make tity and splitting problems.93,94
revisions in care. Note times of meetings here.
Discuss with the client the source of the threat. Assists the client in developing more adaptive coping
behaviors.
Develop with the client alternative coping strategies. Promotes the client’s sense of control and positive expec-
Activities, items, or verbal responses that are rewarding tational set by providing a concrete plan for responding
for the client should be listed here. to stressful situations.
When the client is presented with a threat, assist with Behavioral rehearsal provides opportunities for feedback
progressing through one of the alternative coping and modeling from the nurse.
methods, or practice with the client the alternative
coping methods [number] minutes twice a day.
Provide the client with anchors developed to assist him or Grounding reconnects the client to the here and now and
her with reality orientation (stuffed animal, verbal increases his or her sense of control over the traumatic
phrase, article of clothing, etc.) when the client demon- situation.95
strates signs of dissociation or impending dissociation.
Note the anchor to be used here.
If there is not a predetermined anchor, use the five senses
to connect person in the present. This is done in a calm
and supportive manner.
Develop achievable goals with the client. (The goals that Goal achievement enhances self-esteem and promotes a
are appropriate for this client should be listed here.) positive expectational set, which motivates the client to
move on to more complex goals and behavior change.
(care plan continued on page 578)
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578 • Self-Perception and Self-Concept Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
As the client masters the first set of goals, develop Moves the client toward health goals in a manner that
increasingly complex goals and problems. promotes self-esteem.
Provide positive reinforcement for accomplishments at Positive reinforcement encourages behavior while
any level. (Activities, items, or verbal responses that enhancing self-esteem.
are rewarding for the client should be listed here.)
Do not argue with a client who is experiencing an alter- Arguing with the belief interferes with the development
ation in thought process. (See Chapter 7 for nursing of a trusting relationship and does not serve to change
actions related to Disturbed Thought Process.) the perceptions.
Monitor the client’s mental status before attempting Alterations in mental status can interfere with the client’s
learning or confrontation. If the client is disoriented, ability to process information, and teaching at this
orient to reality as needed. point could increase stimuli to a level that would only
increase the client’s confusion and disorganization.
For clients with Dissociative Identity Disorder:
• Do not ask for alter personalities. Does not further dissociation.73,94 Discourages dissocia-
tion and encourages integration.
• Remind alters they are part of the host personality. Discourages dissociation, while encouraging integration.
• Discuss the feelings that have been dissociated, rather Encourages integration.
than asking for alters.
• Emphasize the normalcy of having a range of feelings.
Point out that one day the host will be able to tolerate
all feelings.
• Do not assure calm alters that they will be protected Prevents the strengthening of angry alters and disso-
from hostile alters. ciation.
If disorientation is present related to organic brain Short-term memory loss will assist with changing the
dysfunction, distract the client from disorientations that client’s orientation without getting into a strong con-
are not correct with a brief, simple explanation. frontation.
Gerontic Health
l N O T E : In the event the patient is unable to distinguish between self and nonself, it is
necessary to contact a mental health clinician to further assess and devise the plan of
care. Please see Mental Health nursing actions.
Home Health
l N O T E : Should the patient develop this nursing diagnosis in a home health setting,
referral should be made immediately to a mental health nurse clinician. (See nursing
actions under Mental Health.) If the patient is in the home setting after stabilization of
the condition, the interventions for Adult Health and Mental Health can be applied to
the home health client. In addition, the following interventions may be used:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client and family in planning and implement- Family involvement enhances effectiveness of inter-
ing strategies to reduce and cope with disturbance in ventions.
personal identity:
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Powerlessness, Risk For and Actual • 579
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Family conference: Discuss feelings related to distur-
bance in personal identity of the client.
• Mutual goal setting: Establish realistic goals, and
identify the roles of each family member (e.g., pro-
vide a quiet environment and provide the client with
honest and direct feedback).
• Communication: Clear and honest communication
among family members is essential. If organic brain
dysfunction is present, the nurse may need to use dis-
traction techniques.
Assist the client and family in lifestyle adjustments that Disturbed Personal Identity can be a chronic condition
may be required: that alters family relationships. Permanent changes
• Maintaining a safe environment in behavior and family roles require evaluation and
• Altering roles as necessary support.
• Maintaining the treatment plan of the health-care
professionals guiding therapy
Consult with or refer to assistive resources as indicated. Utilization of existing services is efficient use of
resources. Psychiatric nurse clinicians and support
groups can enhance the treatment plan.
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580 • Self-Perception and Self-Concept Pattern
3. Severe
entiation is based on the predominant symptom
a. Verbal expressions of having no control or influ- sequence.
ence over the situation, outcome, or self-care
b. Depression over physical deterioration that occurs Deficient Knowledge
despite patient compliance with regimens If the client lacks sufficient knowledge about a situa-
c. Apathy tion, a perception of Powerlessness may result. There-
fore, Deficient Knowledge would be the primary
diagnosis.
RELATED FACTORS40
A. Risk for Powerlessness
The defining characteristics serve also as the risk factors. EXPECTED OUTCOME37
B. Powerlessness
1. Health-care environment Will describe at least [number] areas of control over self by
2. Interpersonal interaction [date].
3. Illness-related regimen Verbalize plan to participate in health-care decisions
4. Lifestyle of helplessness by [date].
Initiates [number] of activities to obtain more infor-
mation about current situation by [date].
RELATED CLINICAL CONCERNS Verbalizes [number] of personal preferences related to
1. Any diagnosis that is unexpected or new to the patient care by [date].
2. Any diagnosis resulting from a sudden, traumatic
event TARGET DATES
3. Any diagnosis of a chronic nature
4. Any diagnosis with a terminal prognosis A target date of 3 days is realistic to check for progress
5. Hospitalization toward reduced feeling of powerlessness.
6. Enmeshed family pattern
ADDITIONAL INFORMATION
4 Have You Selected the Correct Diagnosis? The paradox of the metaphor of power has been presented in
the literature. Systems theorists and cyberneticians have pre-
Anxiety sented the most useful information when one is planning
Anxiety may have as a component a perception of
intervention strategies. Keeney presents a summary of the
Powerlessness, which would evolve into a situation in
debate over the power metaphor.97 In sum, most cyberneti-
which the anxious client does not attempt to resolve
the situation. Powerlessness can also have Anxiety as cians find this to be an invalid metaphor when discussing
a component. Deciding on the primary diagnosis is systems of interaction. The process of a system involves
based on the clinical judgment of the nurse about mutual interactions, and within a system each member exerts
which symptoms predominate. influence over the other members. Therefore, the individual
who acts as if he or she is powerless is exerting “power” over
Ineffective Individual Coping
the other parts of the system to act in a manner that would
A perception of Powerlessness can produce Ineffec-
increase this “lost” personal power. The “powerless” one is
tive Individual Coping because if one perceives that
one’s own actions cannot influence a situation, then actually exercising power to motivate other parts of the
appropriate actions may not be taken. If Ineffective system to act in certain ways. Understanding this conceptual
Individual Coping is determined to result from a per- model provides the client with an opportunity to know how
ceived lack of influence, then Powerlessness would one’s behavior affects the situation and provides nurses with
be the primary diagnosis. an opportunity to understand their reactions to and feelings
toward the client with the diagnosis of Powerlessness. If the
Disturbed Thought Process
power metaphor is not accepted, this affects the concept of
This diagnosis can produce a sense of Powerlessness
because of the individual’s inability to assess the situ- internal versus external locus of control. The concepts of
ation accurately. Thus, the most appropriate diagnosis internal and external loci of control become metaphors for
would be Disturbed Thought Process. how a person perceives personal influence within an interac-
tional system. Persons with an external locus of control do
Fear not understand their influence on the system, whereas per-
Fear can produce a sense of Powerlessness,
sons with an internal locus of control have an understanding
just as Powerlessness can produce Fear. Differ-
of personal influence.
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Powerlessness, Risk For and Actual • 581
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Perform a thorough assessment appropriate for the Developmentally appropriate assessment will provide
patient’s developmental needs to identify specific fac- cues and reveal data to generate a more accurate and
tors that are causing powerlessness. Collaborate with complete plan of care.
the child life specialist, especially for infants and
young children.
• Use of art
• Use of puppetry
• Use of group therapy
Facilitate the family’s participation in care as they are Family participation provides security to the child and
able and choose to. [Note adaptations needed to empowerment for the parents, with increased growth in
accomplish this process here.] coping skills.
Include the child and family by providing opportunities Valuing individual preferences is demonstrated by fre-
for them to voice preferences whenever appropriate. quent encouragement to express choices. Promotes a
sense of control.
(care plan continued on page 582)
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582 • Self-Perception and Self-Concept Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Identify and address educational needs that might be con- Misinformation and inadequate knowledge are contribut-
tributing to powerlessness. Note necessary adaptations ing factors that can be easily overcome by teaching.
here.
Refer to the patient by preferred name or nickname. List Promotes personalized communication. Points out indi-
that name here. viduality, and serves to empower the patient.
Allow for privacy and need to withdraw to the family as Demonstrates appropriate respect for the family. Attaches
a unit. value to the family unit.
Keep the patient and family informed as changes occur. Frequent updates and provision of information help clar-
ify actions and reduce anxiety, which results in a
greater sense of control.
Provide opportunities for the child and parents to demon- Allows practice in a nonthreatening environment, which
strate appropriate care before dismissal from the increases sense of control.
hospital.
Consider referral to a child mental health specialist for Offers anticipatory guidance for prevention of secondary
unresolved issues. issues.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide the prospective parents with factual information Provides basic information that assists the family in deci-
about the type of choices available for birth, and assist sion making, thus promoting empowerment of the fam-
them to identify their preference: ily unit.44,49
• Traditional obstetric services
• Family-centered maternity care units
• Single-room maternity care
• Mother–baby care
• Birthing center
Provide answers to questions in an open, direct manner.
Provide information on all procedures so the patient can
make informed choices:
• Assist the patient and significant others in establishing
realistic goals (list goals with evaluation dates here).
• Allow the patient and significant others to participate
in decision making.
Allow the patient maximum control over the environ- Decreases perception of powerlessness and assists in tran-
ment. This could include the husband’s staying in the sition to parenthood.
postpartum room to assist with infant care, keeping the
newborn with the mother at all times, using different
positions for birth (e.g., squatting or hand–knee posi-
tion), having grandparents and siblings in the room
with the mother and newborn.
Provide positive reinforcement for parenting tasks.
Assist the patient in identifying infant behavior patterns
and understanding how they allow her infant to com-
municate with her.
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Powerlessness, Risk For and Actual • 583
ACTIONS/INTERVENTIONS R AT I O N A L E S
Support the patient’s decisions (e.g., to breastfeed or not
to breastfeed, or who she wants as significant others
during the birthing process).
Reassure the new mother that it takes time to become
acquainted with her infant.
Support and reassure the mother in learning infant care
(e.g., breastfeeding, bathing, changing, holding a new-
born, cord care, or bottle-feeding).
Allow the parents to verbalize fears and insecure feelings Promotes decision making, and leaves decisions up to
about their new roles as parents. family by providing the guidance and support that is
needed.
Assist the parents in identifying lifestyle adjustments that
may be needed because of the incorporation of a new-
born into the family structure.
Involve significant others in discussion and problem- Involvement enhances motivation to stay with plan,
solving activities regarding role changes within the thus reinforcing decision-making capacity of new
family. parents.96
Domestic Violence (See also Hopelessness)
Provide the patient with support, and assist in identifying
actions the patient can take to begin helping herself.
Recognize that leaving the abuser is not necessarily the
best option at all times and that leaving is a process
that may take time for a client.
Provide a safe atmosphere for identifying needs and
making decisions.
Provide information in an honest, clear manner to help
with the decision-making process. Do not attempt to
“convince” the client of the correct course of action.
Tell the client that there are options, that no one
deserves to be beaten, and that she can stop the cycle
of violence with outside help.
Assist the patient in identifying resources available to
her and her children.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Sit with the client [number] times per day at [times] for Promotes the development of a trusting relationship, and
30 minutes to discuss feelings and perceptions the assists the client in identifying factors contributing to
client has about the identified situation. the feelings of powerlessness.
Identify client preferences for daily routine, and place It is vital to this client to have the information shared
this information on the chart to be implemented by with all staff so that it will not appear that the time
the staff. spent in providing information was wasted. Promotes
the client’s perception of control.
Provide information to questions in an open, direct Facilitates the development of a trusting relationship.
manner.
Provide information on all procedures at a time when the Facilitates the development of a trusting relationship, and
client can ask questions and think about the situation. promotes the client’s sense of control.
(care plan continued on page 584)
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584 • Self-Perception and Self-Concept Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Allow the client to participate in decision making at the The client who has never made an independent decision
level to which he or she is capable. If necessary, offer would be overwhelmed by the complexity of the deci-
decision situations in portions that the client can mas- sions made daily by a corporation executive. Promotes
ter successfully. (The amount of information that the the client’s sense of control.
client can handle should be noted here as well as a list
of decisions the client has been presented with.)
Identify the client’s needs and how these are currently Assertive direct communication increases the opportunity
being met. If these involve indirect methods of influ- for the client’s needs being met. When the client is
ence, discuss alternative direct methods of meeting successful in getting needs met in a direct manner, his
these needs. (The client who requests medication for or her sense of control and self-esteem will increase.
headache every 15 minutes may be requesting attention
and is encouraged to approach the nurse and ask to talk
when the need for attention arises.)
Provide positive reinforcement for behavior changed and Positive reinforcement encourages behavior while
decisions made. Things that are reinforcing for this enhancing self-esteem.
client should be listed here along with the reward sys-
tem that has been established with the client (e.g., play
one game of cards with the client when a decision
about what to eat for dinner is made, or walk with the
client on hospital grounds when a decision in made
about grooming).
Provide verbal social reinforcements along with behav- Promotes the development of a trusting relationship.
ioral reinforcements.
Keep promises (specific promises should be listed here so
that all staff will be aware of this information).
Assist the client in identifying current methods of influ- Promotes positive orientation by assisting the client
ence and in understanding that influence is always in identifying ways in which he or she is already
there by providing feedback on how the influence is “powerful.”98
being used in the client’s interactions with the nurse.
Accept the client’s decisions if the decisions were given Promotes the client’s sense of control and enhances
to the client to be made (e.g., if the decision to take or self-esteem.
not take medication was left with the client, the deci-
sion not to take the medication should be respected).
Allow the client maximum control over the environment. Promotes the client’s sense of control.
This could include where clothes are kept, how the
room is arranged, and times for various activities.
[Note preferences here.]
Spend 30 minutes two times per day at [times] allowing Promotes the client’s sense of control in a manner that
the client to role-play interactions that are identified as increases opportunities for success. This success serves
problematic. (The specific situations as well as new as positive reinforcement.
behavior should be noted here.)
Provide opportunities for significant others to be involved Provides opportunities for the support system and the
in care as appropriate. Careful assessment of the inter- client to practice new ways of interacting while in a
actions between the client and significant others must situation where they can receive feedback from the
be made to determine the best balance of influencing health-care team.
behavior between the client and support system.
Specific situations should be listed here.
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Powerlessness, Risk For and Actual • 585
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the health-care team’s interactions with the client The role of the nurse in the therapeutic milieu is to
for behavior patterns that would encourage the client to promote healthy interpersonal interactions.
choose indirect methods of influence. This could
include interactions that encourage the adult client to
assume a childlike role. If situations are identified, they
should be noted here.
Provide ongoing feedback to the client on progress. Positive reinforcement encourages behavior.
Assist the client in establishing realistic goals. List goals Realistic goals increase the client’s opportunities for suc-
with evaluation dates here. Usually dividing the goal cess, providing positive reinforcement and enhancing
set by the client in half provides an achievable goal; self-esteem.
this could also involve dividing one goal into several
smaller goals.
Schedule meetings with the client’s identified support A change in one member of a system has impact on the
system when the client verbalizes the need. Facilitate whole system.61
communication between the client and support system
about decision making and communication of needs.
Note schedule for this meeting here.
Refer the client to outpatient support systems, and assist Provides the client with support for continuing new
him or her with making arrangements to contact these behaviors in the community after discharge.
before discharge. These could be systems that would
assist the client in maintaining a perception of influ-
encing ability and could include assertiveness training
groups, battered persons’ programs, and legal aid.
Gerontic Health
In addition to the following interventions, the interventions for Adult Health and Mental Health can be applied to the aging
client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ensure the client has easy access to call light, telephone, Increases the patient’s ability to take control of some
personal care items, and television control.39 aspects of care.
Advocate for the patient, ensuring that health care Decision-making capacity does not necessarily diminish
professionals are including client in decision making. with age.
Home Health
In addition to the following interventions, the interventions for Adult Health and Mental Health can be applied to the home
health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client and family in planning and implement- Personal involvement and goal setting according to
ing strategies to reduce Powerlessness: personal wishes enhance the likelihood of success
• Family conference: Identify and discuss strategies. in resolving problem.
• Mutual goal setting: Agree on goals to reduce
Powerlessness. Identify roles of all participants.
• Discuss effective communication techniques.
Assist the client and family in lifestyle adjustments that Lifestyle adjustments require permanent changes in
may be required: behavior. Self-evaluation and support facilitate the
success of these lifestyle changes.
(care plan continued on page 586)
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586 • Self-Perception and Self-Concept Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Relaxation techniques: Yoga, biofeedback, hypnosis,
breathing techniques, imagery
• Providing opportunities for the individual to exert con-
trol over situation, giving choices when possible, sup-
porting and encouraging self-care efforts
• Problem solving and goal setting
• Providing sense of mastery and accomplishable goals
in secure environment
• Maintaining the treatment plan of the health-care pro-
fessionals guiding therapy
• Obtaining and providing accurate information regard-
ing condition
Consult with or refer to assistive resources as indicated. Use of existing community resources provides for effec-
tive use of resources.
Assist the client and family to set criteria to help them Early identification of issues requiring professional evalu-
determine when the intervention of a health-care pro- ation will increase the probability of successful inter-
fessional is required (e.g., inability to perform activi- vention.
ties of daily living, or condition has declined rapidly).
SELF-CONCEPT, READINESS
FOR ENHANCED 4 Have You Selected the Correct Diagnosis?
Self-Esteem: Chronic Low, Situational Low
DEFINITION40 Address situations in which the client is demon-
A pattern of perceptions of ideas about the self that is suffi- strating alterations in self-perceptions and nega-
cient for well-being and can be strengthened. tive self-evaluation.
Self-Esteem: Risk for Situational Low
would be the appropriate diagnosis when the client is
DEFINING CHARACTERISTICS40 experiencing a situation that could have a negative
impact on self-esteem.
1. Expresses willingness to enhance self-concept.
Self-Concept: Readiness for Enhanced
2. Expresses satisfaction with thoughts about self, sense of
is the appropriate diagnosis for situations where the
worthiness, role performance, body image, and personal client is expressing positive self-statements and
identity. expresses a desire to enhance this self-perception.
3. Actions are congruent with expressed feelings and
thoughts.
4. Expresses confidence in abilities. EXPECTED OUTCOME
5. Accepts strengths and limitations. Will identify [number] goals for self improvement by [date].
Will demonstrate achievement of personal goals by
[date].
RELATED FACTORS40 Will verbalize satisfaction with role performance by
None listed [date].
TARGET DATES
RELATED CLINICAL CONCERNS
Self-improvement can be a life-long process. The enhance-
1. History of abuse ment of self-concept, as used here, should focus on spe-
2. Physical disability cific goals that can be measured with in a reasonable time.
3. Adolescence This could include short-term goals with target dates meas-
4. Situations that require significant role changes ured in days and long-term goals that could be measured in
5. Amputations or surgeries that alter body image weeks.
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Self-Concept, Readiness For Enhanced • 587
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Seek input from all members of the health-care Engenders a collaborative effort to be of best support for
team, including child life specialist, family or facilitating goals for the individual child and family.
child counselor/psychologist, and clinical nurse
specialist.
Assist the child and family in identifying strategies to Specific identified goals offer structure with likelihood of
foster desired plan, especially daily routine, personal marking aspired levels of manageable achieve-
diary, feedback, or goal setting sessions with follow-up ment.106–108
progress sessions.
Offer basic and then incrementally more challenging Scaffolding provides likelihood of learning and reinforce-
daily routine management. Develop goals that are ment for success as opposed to overwhelming the
achievable by the child. [Note the specific plan for the learner. When the child can successfully reach goals
client and family here.] self-esteem is enhanced.106–108
Provide feedback in a timely manner according to devel- Offers reinforcement that is suitable and able to encour-
opmental level and appropriate nature of plan. Note age greater goal achievement.
feedback to be used with this client here.
Determine barriers to plan for care, especially how to Anticipatory guidance alleviates crises and affords facili-
modify the desired plan in light of equipment, treat- tative progress.
ments, or necessary interruptions. If school issues are
to be considered, relate with teachers and the school
nurse as appropriate.
Assist the child and family to identify resources that will Provides support to value efforts.
foster continued success in self-concept enhancement.
[Note specific plan to facilitate this here.]106–108
Teach the family and client appropriate use of prostheses Anticipatory guidance alleviates secondary and tertiary
or equipment. events that are preventable.
Schedule a time for the client and family to be involved Facilitates the reception of positive feedback. Positive
in support groups. self reflection from others enhances self-esteem.
Teach parents how to develop behavioral reward systems Positive reflections of self from others enhance self-
and provide positive meaningful verbal feedback.106–108 esteem.106–108
(care plan continued on page 588)
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588 • Self-Perception and Self-Concept Pattern
Women’s Health
Note most of the interventions and rationales for women will be the same as for Adult Health and Mental Health, with the
following additions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client in making responsible choices to care for Enhanced self-concept comes with feeling good about
themselves within their various life-cycles.99 Spend yourself and choosing to do what is good for your
time discussing how to achieve selected goals for life- physical, emotional, and spiritual health. The health-
style choices such as nutritious diet, regular exercise, care provider must guide and offer information on
no smoking, and mind–spirit awareness.99–101 many choices women can make, including
natural/alternative/complementary health care (NAC)
options.101
Offer information so that client can make informed
choices. Provide the client with:
• List of women’s health tests from adolescence through Understanding which tests women should be participating
elderly cycles of a woman’s life. in and at what age and frequency will assist women in
monitoring and maintaining their health. Tests such as
screening for Osteoporosis (Bone Density Test),
Cholesterol, Blood Glucose, Blood Pressure,
Colorectal Exams, Breast Cancer Screenings, Dental
Checkup, Pap Test, and Pelvic Exam are just a few.102
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend [number] minutes [number] times per day dis- Change depends on the client’s perception of the prob-
cussing the client’s understanding of his or her con- lem.61
cerns and personal goals. Establish a nurse–client Enhances the client’s sense of control and self-
relationship based on warm positive regard and empa- esteem/self-efficacy.89,98
thy for the client.
Develop with the client a list of goals that are specific Goal attainment increases the client’s sense of self-
and behavioral. Establish goals that will move client to efficacy.
their larger personal goals and that are going to be
achievable by the client. [Note client specific goals
here.]
• Develop a list of positive reinforces for goal achieve- Positive reinforcement increases behavior.38,65
ment. (Note reinforcers and schedule for reinforcement
here.)
• Spend [number] minutes [number] times each day Informative praise that is specific and provides clear
reviewing client’s progress towards goals. Provide direction about which behavior is being rewarded
specific informative praise for steps toward goal enhances self-esteem. (This is in contrast to bland
achievement. praise such as using the word “good” without a
behavioral reference.)89
Spend [number] minutes once a day exploring with client Positive social support and the sense of belonging to a
their interests and achievements. From this interaction group enhance self-concept. Recognition of past
develop a list of community or other groups that would achievements increases self-efficacy and therefore
promote client’s interests. self-concept.63,89
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Self-Concept, Readiness for Enhanced • 589
ACTIONS/INTERVENTIONS R AT I O N A L E S
Identify the steps client can take to establish a relation- Specific, concrete, incremental steps increase the client’s
ship with one or two of these groups or begin engage- perceptions of the possibility of goal attainment.
ment with an activity. Note the groups selected and the
steps to be taken here.
Schedule client’s attendance at [number] groups that pro- Positive social support and the sense of belonging to a
vide the opportunity for positive social support per day group enhance self-concept.63,89
that reflect client’s goals. Note the group times here. Groups that provide a variety of role models and/or
Walk the client to the group and introduce him or her enhance social skills demonstrate positive effects on
to other members. Note specific interventions needed self-concept. It is important that the client be allowed
to assist the client with group attendance here. to make his or her own comparisons.62
Collaborate with the client to establish an exercise rou- Exercise and good health have a positive impact on self-
tine. Note specific exercises and times here. If the concept.104,105
client has not done regular exercises, establish moder-
ate goals and activities.
Provide the client with information on assertive skills Positive social skills enhance self-concept.
training.
• If the client identifies this as a need, schedule the client
for assertiveness training group. Note the schedule for
group here.
• Role-play social interactions the client has identified as
difficult.
• Provide positive verbal reinforcement for achieve-
ments.
Meet with the client and his or her social support system Positive social support and a sense of belonging enhance
to discuss methods of continuing social support after self-concept.
discharge. Note the schedule for meetings here. Client involvement in goal setting enhances sense of
During the meeting: self-efficacy and in turn self-concept is enhanced.
• Model assertive communication and other positive
communication skills.
• Model positive informative praise.
Develop a specific plan for achieving the goals that
evolved from this meeting. Note specific goals and
plan for achieving goals here. Provide members of the
social support system with written copies of this plan.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient in setting realistic goals for strengthen- Client will not become discouraged by unrealistic goals.
ing a sense of well-being and self concept.
Provide an environment conducive to improved self- Maximizes the effectiveness of planning and maintaining
concept: a program for improvement.
• Client is not hungry, in pain, or sleepy.
• Have a family member present if desired or needed.
• Maximize the client’s control of the environment.
Provide referral as needed to include: Use of the interdisciplinary team facilitates the client’s
• Physical therapy ability to control his or her environment and determine
• Occupational therapy strategies for maintaining a positive self-concept.
• Pastoral care
• Social work
(care plan continued on page 590)
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590 • Self-Perception and Self-Concept Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient in setting realistic goals for Client will not become discouraged by unrealistic goals.
strengthening his or her sense of well-being and
self-concept.
Provide an environment conducive to improved self- Maximizes the effectiveness of planning and maintaining
concept: a program for improvement.
• Client is not hungry, in pain, or sleepy.
• Have a family member present if desired or needed.
• Maximize the client’s control of the environment.
Provide referral as needed to include: Use of the interdisciplinary team facilitates the client’s
• Physical therapy ability to control his or her environment and determine
• Occupational therapy strategies for maintaining a positive self-concept.
• Pastoral care
• Social work
Refer the client to community resources as appropriate: Utilizing existing resources facilitates success and is time
• Support groups for clients and families and cost efficient.
• Educational Web resources
•
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Copyright © 2007 by F. A. Davis. •
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Self-Esteem, Chronic Low, Situational Low, and Risk for Situational Low • 591
C. Risk for Situational Low Self-Esteem (Risk Factors) body structure or function. If interviewing reveals the
1. Developmental changes (specify) patient perceives a potential change in body structure
2. Body image disturbance or function, then Disturbed Body Image is the most
3. Functional impairment (specify) appropriate diagnosis.
4. Loss (specify)
5. Social role changes (specify) Disturbed Personal Identity
When the patient cannot differentiate self from non-
6. History of learned helplessness
self, some self-esteem problems probably exist; how-
7. History of abuse, neglect, or abandonment ever, the primary diagnosis would be Disturbed
8. Unrealistic self-expectations Personal Identity. Working with the Disturbed Personal
9. Behavior inconsistent with values Identity will address the self-esteem problem.
10. Lack of recognition or rewards
11. Failures or rejections Ineffective Individual Coping
12. Decreased power or control over environment This diagnosis results from the client’s inability to
cope with stress appropriately. If the client demon-
13. Physical illness (specify)
strates a decreased ability to cope appropriately, he
or she may also have some defining characteristics
RELATED CLINICAL CONCERNS27 related to self-esteem disturbance. Teaching and sup-
porting coping will also assist in correcting the self-
1. Pervasive developmental disorders esteem problem.
2. Disruptive behavior disorders
3. Eating disorders Self-Concept, Readiness for Enhanced
4. Organic mental disorders This diagnosis reflects a perception of self that is pos-
itive and supports well-being. If the client is express-
5. Substance use or dependence or abuse disorders
ing negative self perceptions then the diagnosis would
6. Mood disorders be one of the compromised self-esteem diagnoses.
7. Adjustment disorders
8. Personality disorders
9. Trauma
10. Surgery EXPECTED OUTCOME
11. Medical problems that contribute to the loss of body
Will list at least [number] positive aspects about self by
functions
[date].
12. Pregnancy
Will verbalize [number] of situations where success
13. Chronic diseases
was experienced by [date].
14. Dysfunctional family processes
Will demonstrate assertive behavior in [describe situ-
ation] by [date].
4 Have You Selected the Correct Diagnosis?
Disturbed Body Image TARGET DATES
This diagnosis relates to alterations in the perception A target date of 3 to 5 days is acceptable to begin monitor-
of self when there is an actual or perceived change in
ing progress.
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592 • Self-Perception and Self-Concept Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Reinforce assertive behavior in interacting with the Helps the patient avoid vacillating from one behavior to
patient. Assist the patient to review passive and aggres- another. Promotes self-control and a “win–win” situa-
sive behavior. tion, which increases self-esteem.
Allow the patient to progress at his or her own rate. Start Helps the patient have a sense of mastering of tasks, and
with simple, concrete tasks. Reward success. promotes self-esteem.
In interactions with the patient:
• Be honest with the patient.
• Point out and limit self-negating statements.
• Do not support denial.
• Focus on reality and adaptation (not necessarily accept-
ance).
• Set limits on maladaptive behavior.
• Focus on realistic goals.
• Be aware of own nonverbal communication and
behavior.
• Avoid moral value judgments.
• Encourage the patient to try to note differences in
situations and events.
Use routine interactions as an opportunity to have the Assists in self-understanding and facilitates self-
patient verbalize feelings. acceptance.
Help the patient to ascertain why he or she can maintain
self-esteem in one situation and not in another.
Build on coping mechanisms or interpretations that main- Supports adaptive coping, and helps broaden the inven-
tain or increase self-esteem. Assist to find alternative tory of coping strategies.
coping mechanisms.
Refer to and collaborate with community resources. Provides ongoing and long-term support.
Collaborate with the psychiatric nurse clinician regarding Collaboration promotes a more holistic and total plan
care. (See Mental Health nursing actions.) of care.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for contributory factors related to poor self- Generates the database needed to plan care more accu-
esteem, including: rately and completely.
• Family crisis
• Lack of adequate parenting
• Lack of sensory stimulation
• Physical scars, malformations, or disfigurement
• Altered role performance
• Social isolation
• Developmental crisis
Identify ways the patient can formulate or reestablish a Developmental norms serve as the conceptual framework
positive self-esteem according to developmental needs. for assisting the child to increase self-esteem.
Note the methods best for this patient here.
• Coping skills
• Communication skills
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Role expectations
• Self-care
• Activities of daily living
• Basic physiologic needs; primary health care
• Expression of self
• Peer and social relationships
• Feelings of self-worth
• Decision making
• Validation of self (e.g., setting developmentally appro-
priate expectations)
Praise and reinforce positive behavior. [Note reinforcers Reinforcement of desired behavior serves to enhance the
that are most important for this patient here.] permanence of the behavior.
Explore value conflicts and their resolution. Values must be clarified as one strives to find one’s iden-
tity. A healthy sense of self contributes to a positive
self-image.
Collaborate with other health-care team members as Collaboration promotes a more holistic plan of care.
needed.
Meet primary health needs in an expedient manner. Conserves energy, minimizes stress, and enhances trust.
Provide appropriate attention to other alterations, espe- Related issues must be considered as contributing factors
cially those directly affecting this diagnosis such as to the diagnosis. Inattention to these factors means res-
Risk for Violence or Impaired Parenting. olution of the problem will not occur.
Provide for follow-up before the child is dismissed from Attaches value to follow-up, and promotes likelihood of
hospital. compliance.
Use developmentally appropriate strategies in the care of Developmentally based strategies are most likely to not
these children: frighten the child or parent unnecessarily.
• Infant and toddlers: Play therapy or puppets
• Preschoolers: Art
• School-agers: Art or role-playing
• Adolescents: Discussion or role-playing
Teaching parents and child about appropriate health Personal hygiene and self-care will enhance a positive
maintenance. This could include ways of dealing with self-esteem as the patient copes with daily living.
crisis, or enhanced communication skills. [Note teach-
ing plan here.]
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Postpartum and Parenting Roles
Allow the patient to “relive” the birthing experience Promotes ventilation of feelings, and provides a database
by listening quietly to her perception of the birthing for intervention.
experience.
Encourage the patient to express her concerns about her
physical appearance.
List here the activities in which the patient can engage to
gain positive feelings about herself.
Join friends or an exercise group with the same goals as Provides a support system that demonstrates adaptive
the patient. behaviors.
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594 • Self-Perception and Self-Concept Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage participation in activities outside of the home Support and positive activities assist in adaptation to new
as appropriate (e.g., parenting support groups or parental role and increase sense of self-worth.
women’s groups).
Encourage networking with other women with similar
interests.
Encourage the patient to “do something for herself”:
• Buy a new dress.
• Fix her hair differently.
• Find some time for herself during the day.
• Take a walk.
• Take a long bath.
• Rest quietly.
• Do a favorite activity (e.g., reading, sewing, or some
other hobby)
• Spend time with spouse, without the children
Encourage the patient to engage in positive thinking.
Encourage the patient to engage in assertiveness training.
l N O T E : Pregnant teenagers, single mothers, and battered women have similar needs
in building or rebuilding their self-esteem.
Provide a safe, nonjudgmental atmosphere that will
encourage the patient to verbalize her needs and con-
cerns.
Assist the patient in identifying support groups with simi-
lar concerns and available community resources.
Encourage teen mothers to take advantage of opportuni-
ties provided by various school systems to finish their
education.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Sit with the client [number] minutes [number] times per Expression of feelings and concerns in an accepting envi-
shift to discuss the client’s feelings about self. ronment can facilitate problem solving.
Answer questions honestly. Promotes the development of a trusting relationship.
Provide feedback to the client about the nurse’s percep- Assists the client with reality testing in a safe, trusting
tions of the client’s abilities and appearance by: relationship.
• Using “I” statements
• Using references related to the nurse’s relationship to
the client
• Describing the client’s behavior in situations
• Describing the nurse’s feelings in relationship
Provide positive informative reinforcement. List here the Positive reinforcement encourages behavior.
things that are reinforcing for the client and when they
are to be used. Also list here the things that have been
identified as nonreinforcers for this client, and include
social rewards.
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Self-Esteem, Chronic Low, Situational Low, and Risk for Situational Low • 595
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide group interaction with [number] persons [num- Disconfirms the client’s sense of aloneness, and assists
ber] minutes three times a day at [times]. This activity the client to experience personal importance to others
should be gradual and within the client’s ability (e.g., while enhancing interpersonal relationship skills.
on admission the client may tolerate one person for 5 Increasing these competencies can enhance self-
minutes). If the interactions are brief, the frequency esteem and promote positive orientation. Group
should be high (i.e., 5-minute interactions should occur interaction provides opportunities for social com-
at 30-minute intervals). parison which can have a positive impact on self-
esteem.62
Monitor the client during each interaction for thoughts Client safety is of primary concern. Low self-esteem can
of self-harm. If thoughts are present protect the client be related to thoughts of self-harm.
from harm by: (See Chapter 8, Self-Mutilation
and Chapter 9, Violence, Self-Directed for comprehen-
sive care plans on this behavior if present.)
• Removing all sharp objects from the environment
• Removing belts and strings from the environment
• Providing a one-to-one constant interaction if risk for
self-harm is high
• Checking on the client’s whereabouts every 15 min-
utes or providing constant visual supervision if the
risk is high. Note the level of observation needed
here.
• Removing glass objects from the environment
• Removing locks from the room and bathroom doors
• Providing a shower curtain that will not support
weight
• Checking to see whether the client swallows medi-
cations
• Removing any items in the environment that would
facilitate the client implementing his or her plan for
self-harm
In a supportive attitude and manner, reflect back to the Increases the client’s awareness of negative evaluations of
client negative self-statements he or she makes. self.
Set achievable goals for the client. [Note goals and Goals that can be accomplished increase the client’s per-
support necessary to achieve ceptions of power and enhance self-esteem.
goals here.]
Provide activities that the client can accomplish and that Activities the client finds demeaning could reinforce the
the client values. client’s negative self-evaluation. Accomplishment of
valued tasks provides positive reinforcement and
enhances self-esteem.38,58
Provide positive informative verbal reinforcement for Positive reinforcement encourages behavior while
achievement of steps toward a goal. enhancing self-esteem.89
Have the client develop a list of strengths and potentials. Promotes positive orientation and hope.28
Define the client’s lack of goal achievement or failures as Promotes positive orientation.28
simple mistakes that are bound to occur when one
attempts something new (e.g., learning comes with
mistakes, or if one does not make mistakes one does
not learn).
(care plan continued on page 596)
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596 • Self-Perception and Self-Concept Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Make necessary items available for the client to groom Physical grooming can facilitate positive self-esteem by
self. encouraging positive feedback from others.
Spend [number] minutes at [time] assisting the client Presence of the nurse can serve as a positive reinforce-
with grooming, providing necessary assistance, and ment. Positive reinforcement encourages behavior
providing positive informative reinforcement for while enhancing self-esteem.
accomplishments. Note special accommodations here.
Reflect back to the client the statements that discount the Raises the client’s awareness of this behavior, which
positive evaluations of others. facilitates change. Self-concept development is facili-
tated by reflections of others about the self.32,98
Focus the client’s attention on the here and now. Past happenings are difficult for the nurse to provide
feedback on.
Present the client with opportunities to make decisions Promotes the clent’s sense of control which enhance
about care, and record these decisions in the chart. self-esteem.
Develop with the client alternative coping strategies. Link Promotes the client’s sense of control, and enhances
these to client’s past successes. opportunities for positive outcome when stressful
events are encountered. This supports client’s
competencies and provides a positive orientation of
self.28,61
Practice new coping behaviors with the client [number] Behavioral rehearsal provides opportunities for feedback
minutes at [times]. and modeling of new behaviors from the nurse.
Place the client in a therapy group for [number] minutes Facilitates the client’s awareness of others’ thoughts
once a day where the focus is mutual sharing of feel- about themselves and him or her.
ings and support of each other.
Identify with the client the situations that are perceived as Facilitates developing alternative coping behavior.
most threatening to self-esteem.
Assist the client in identifying alternative methods of Increases the client’s opportunities for success, and each
coping with the identified situations. These should be success enhances self-esteem.
developed by the client and listed here.
Role-play with the client once per day for 45 minutes the Behavioral rehearsal provides opportunities for feedback
high-risk situations that were identified and the alterna- and modeling of new behaviors from the nurse.
tive coping methods.
Establish an appointment with the client and significant Support system understanding facilitates the maintenance
others to discuss their perceptions of the client’s situa- of new behaviors after discharge.110
tion. (The time of this and follow-up appointments
should be listed here.)
• During the sessions model positive communication and
recognizing each other’s accomplishments.
• Teach the support system to provide positive informa-
tive verbal feedback.
Discuss with the client current behavior and reactions of Provides opportunities for feedback on new behaviors in
others to this behavior. a safe, trusting environment.
Provide the client with [number] minutes of assertive Teaches clients they have a right to their feelings, beliefs,
skills training [number] times per week. This could be and opinions, and provides them with the skills to
provided in a group or individual context. express themselves effectively.73
Practice with the client [number] minutes twice a day Promotes the development of a positive orientation.
making positive “I” statements.
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Self-Esteem, Chronic Low, Situational Low, and Risk for Situational Low • 597
Gerontic Health
In addition to the following interventions, the interventions for Adult Health and Mental Health can be applied to the aging
client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient in developing self-care skills needed for Enhances perception of control over the situation.
managing the current illness.111
Assist the patient in identifying his or her unique abili- Increases recognition of successes that come from the use
ties, and relate the benefits you as a nurse receive from of personal strengths with the patient.111
your interactions.
Review the patient’s current abilities and how they may Increases perception of functional ability in preferred life
require role modification.111 roles.
Assist with personal grooming needs, such as removal Attention to personal appearance can have a positive
of excess facial hair and use of cosmetics, where influence on self-esteem and thus perception of the
applicable.112 individual.
Home Health
In addition to the following interventions, the interventions for Adult Health and Mental Health can be applied to the home
health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client and family in planning and implement- Family involvement improves effectiveness of imple-
ing strategies to reduce and cope with disturbance in mentation.
self-esteem:
• Family conference: Discuss perceptions of the client’s
situations and identify realistic strategies.
• Mutual goal setting: Establish goals and identify roles
of each family member (e.g., provide safe environment,
assist with grooming, or focus on here and now).
• Communication.
Assist the client and family in lifestyle adjustments that Lifestyle changes require long-term changes in behavior.
may be required.113 Such changes in behavior require support.
• Obtaining and providing accurate information
• Clarifying misconceptions
• Maintaining a safe environment
• Encouraging appropriate self-care without encouraging
dependence or expecting unrealistic independence
• Providing an opportunity for expressing feelings
• Realistic goal-setting
• Providing a sense of mastery and accomplishable goals
in a secure environment
• Maintaining the treatment plan of the health-care pro-
fessionals guiding therapy
• Relaxation techniques: Yoga, biofeedback, hypnosis,
breathing techniques, or imagery
• Altering roles
Consult with or refer to assistive resources as indicated. Utilization of existing services is efficient use of
resources. Psychiatric nurse clinician and support
groups can enhance the treatment plan.
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Self-Mutilation, Risk For and Actual • 599
Child Health
l N O T E : Refer the patient to a mental health practitioner. (See Mental Health nursing
actions related to this diagnosis.)
Women’s Health
The nursing actions for the woman with this diagnosis are the same as those given for Mental Health.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Sit with the client [number] minutes [number] times per Promotes the development of a trusting relationship, and
shift at [times] to assess the client’s mood, distress, an opportunity to monitor risk for self harm, in a non-
needs, and feelings. intrusive manner.114 Also communicates to client that
their emotional needs will be respected and attempts
will be made to understand their behavior.115
(care plan continued on page 600)
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600 • Self-Perception and Self-Concept Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Place the client on a frequent observation schedule. Note Client safety is of primary importance. Increased atten-
that schedule here. This observation should take place tion may inadvertently reinforce injury if it occurs in
in a nonintrusive manner. relation to self-injury episodes.114
Remove from the environment any object that the patient Client safety is of primary importance.
could use to harm him- or herself. Note the items most
preferred by this client here.
Use one-to-one observation to protect the client during Physical and chemical restraints have been demonstrated
periods of risk for self-harming behavior. to escalate behavior. At times clients may escalate their
behavior to be placed in restraints.116
Develop a baseline assessment of the self-injury patterns. Provides baseline information on which to base criteria
This should include frequency of behavior, type of for behavioral change. Provides positive reinforcement.
behavior, factors related to self-harm, and effects of
self-harm on the client and other clients. Note this
information here.
Answer the client’s questions honestly. Maintain an envi- Promotes the development of a trusting relationship.115
ronment of reassurance and respect.
Develop a no self-harm contract with the client. Provides client with clear understanding of behavioral
expectations.58
Reframe the client’s self-harming behavior as a habitual Promotes a positive orientation, and supports the client’s
behavior that can be changed, like any habit. While strengths.117
doing this, do not diminish the client’s experience of
emotional pain and discomfort.
Identify, with the client, goals that are reasonable. Note Assists the client in gaining internal control of problem-
the goals here (e.g., the client will contact staff when atic behaviors.117 Achieving goals provides reinforce-
feeling need to harm self). ment of positive behavior and enhances self-esteem.
Provide positive verbal reinforcement for positive behav- Positive reinforcement encourages behavior and enhances
ior change. self-esteem.
Have the client develop a list of “feel-good” reinforcers. Promotes the client’s sense of control, while supporting a
[Note those reinforcers here.]114 positive orientation.
Provide feel-good reinforcers according to the rein- Provides consistency in behavioral rewards. Positive
forcement plan developed. Note the plan here. reinforcement encourages behavior and enhances
self-esteem.
Identify with the client situations and feelings that trigger Promotes the client’s perception of control by pairing
self-injury.114 self-injurious behavior to specific situations and
decreasing cognitive exaggerations.118
Identify with the client strategies that can be utilized to Promotes the client’s sense of control, and assists the
cope with these situations. [Note the identified strate- client with cognitive preparation for coping with these
gies here.] situations.118
Assists with the development of emotional self-
regulation.115,119
Select one identified strategy and spend 30 minutes a day Behavioral rehearsal provides opportunities for feedback
at [times] practicing this with the client. This could be and modeling from the nurse.
in the form of a role-play. Note here the person respon-
sible for this practice.
Meet with the client just prior to and after trigger situa- Promotes the client’s sense of control, and provides an
tions to assist with planning coping strategies and pro- opportunity for the nurse to provide positive reinforce-
cessing outcome to revise plans for future situations.116 ment for adaptive coping mechanisms.
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Self-Mutilation, Risk For and Actual • 601
ACTIONS/INTERVENTIONS R AT I O N A L E S
Initiate the client’s coping strategy or provide distraction, Provides opportunity for the client to practice new behav-
such as physical activity, when the client identifies that iors in a supportive environment where positive feed-
the urge to harm him- or herself is strong. back can be provided. Promotes the client’s sense of
Acknowledge that the distraction will not increase control, and enhances self-esteem. Promotes positive
comfort as much as self-harm would at the present orientation.
time, but the feelings of mastery will be satisfying.117
Identify, with the client, areas of social skill deficits, and Enhances interpersonal skills by providing the client with
develop a plan for improving these areas. This could more adaptive ways of achieving interpersonal goals.
include assertiveness training, communication skills
training, and/or relaxation training to reduce anxiety in
trigger situations. Note plan and schedule for imple-
mentation here. This should be a progressive plan with
rewards for accomplishment of each step.116–118
Develop a schedule for the client to attend group thera- Provides an opportunity for the client to practice interper-
pies. Note this schedule here. sonal skills in a supportive environment and to observe
peers modeling interpersonal skills.
Administer medications as appropriate. Assist with stabilizing mood and decreasing anxiety.58
Monitor for side effects of medication and desired out-
comes.
Meet with the client and the client’s support system to Facilitates support system understanding of the behav-
plan coping strategies that can be used at home. Assist ior and facilitates appropriate response in the
system in obtaining resources necessary to implement community.115
this plan.
In the event that self-mutilation does occur, provide the Prevents loss of function and further injury.
necessary first aid in a matter-of-fact manner. If the Assists in developing self-responsibility for the conse-
injury does not require medical attention, provide the quences of behavior.58
client with the tools to do self-care and instructions
that can be used to provide this self-care in the future.
• Avoid elaborate focusing on the injury. Prevents the development of secondary gains from self-
injury.120
• Sit with the client for [number] minutes to discuss the Supports the development of appropriate methods of
feelings that preceded the act. coping with feelings.
Gerontic Health
The nursing actions for the gerontic patient with this diagnosis are the same as those given for the Mental Health patient.
Home Health
Should the patient develop this nursing diagnosis on an adult health care unit, referral should be made immediately to a
mental health nurse clinician. (See nursing actions under Mental Health.)
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for factors contributing to risk for self- Provides database for early recognition and intervention.
mutilation. Family involvement enhances effectiveness of interven-
Involve the client and family in planning, implementing, tions.
and promoting reduction or elimination of risk for self-
mutilation:
• Family conference: Discuss the perspective of each
family member.
(care plan continued on page 602)
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602 • Self-Perception and Self-Concept Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Mutual goal setting: Develop short- and long-term
goals with evaluative criteria. Tasks and roles of each
family member should be specified.
• Communication: Open, direct, reality-oriented commu-
nication.
Assist the client and family in lifestyle adjustments that Adjustments in lifestyle require long-term behavioral
may be required: changes. Such changes are enhanced by education and
• Development and use of support networks support.
• Provision of safe environment
• Protection of client from harm
• Necessity for long-term care
Consult with or refer to assistive resources such as care- Utilization of existing services is efficient use of
giver support groups as needed. resources. A psychiatric nurse clinician, support group,
and mental health–mental retardation expert can
enhance the treatment plan.
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Self-Mutilation, Risk For and Actual • 603
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55. Kneisl, C, Wilson, H, and Trigoboff, E: Contemporary Psychiatric- 85. Beck, C, Reynolds, M, and Rutowski, P: Maternity blues and postpar-
Mental Health Nursing. Upper Saddle River, NJ, Pearson Education, tum depression. JOGNN J Obstet Gynecol Neonat Nurs 21(4):287,
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56. National Guideline Clearinghouse. Anxiety disorders. Agency for 86. National Guideline Clearinghouse. Anxiety disorders. Agency for
Healthcare Research and Quality (AHRQ). 1–8, 2005. Washington, Healthcare Research and Quality (AHRQ). 1–8, 2005. Washington,
DC, US Department of Health and Human Services. DC, US Department of Health and Human Services.
57. Ossman, SS: Clinical consult. Motivational interviewing: A process to 87. Sellers, JB: Health care for older women. In Breslin, ET, and Lucas,
encourage behavioral change. Nephrol Nurs J 31:346, 2004. VA (eds): Women’s Health Nursing: Toward Evidence-Based Practice.
58. McCloskey Dochterman J, and Bulechek, G: Nursing Interventions Saunders, St. Louis, 2003.
Classification. CV Mosby, St. Louis, 2004. 88. Gantt, L, and Bickford, A: Screening for domestic violence: How one
59. National Guideline Clearinghouse. Stress related conditions and other hospital network started asking about abuse. Lifelines 3:36, 1999.
mental disorders. Agency for Health Care Research and Quality 89. Colwell, J, and O’Connor, T: Understanding nurturing practices : A
(AHRQ), 2006, Washington DC, US Department of Health and comparison of the use of strategies likely to enhance self-esteem in
Human Services. http://www.guidelines.gov. nurture groups and normal classrooms. Br J Spec Educ 30:119, 2003.
60. Stein, KF, and Corte, C: Reconceptualizing causative factors and 90. Drew, N: Combating the social isolation of chronic mental illness.
intervention strategies in the eating disorders: A shift from body J Psychosoc Nurs Ment Health Serv 29:14, 1991.
image to self-concept impairments. Arch Psychiatr Nurs 17:57, 2003. 91. Hoeffer, B: A causal model of loneliness among older single women.
61. Wright L, and Leahey, M: Nurses and Families: A Guide to Family Arch Psychiatr Nurs 1:366, 1987.
Assessment and Intervention. FA Davis, Philadelphia, 2005. 92. Liberman, MD, and Disenberger, NI: Conflict and habit: A social cog-
62. Dewar, A: Boosting strategies: Enhancing the self-esteem of individu- nitive neuroscience approach to the self. In Tesser A, Wood JV, and
als with catastrophic illnesses and injuries. J Psychosoc Nurs Ment Staple DA (eds): On Building, Defending and Regulating the Self: A
Health Serv 41:24, 2003. Psychobiological Perspective. Psychology Press, New York, 2004, pp.
63. McEvey, GL, and Davis, R: A program to promote positive body 77–102.
image: A 1-year follow-up evaluation. J Early Adolesc 22:96, 2002. 93. Zimmer, C: The neurobiology of the self. Sci Am 293:92, 2005.
64. Conant, M: The client with an eating disorder. In Lego, S (ed): 94. Lego, S: The client with dissociative identity disorder. In Lego, S (ed):
Psychiatric Nursing: A Comprehensive Reference. Lippincott, Psychiatric Nursing: A Comprehensive Reference. Lippincott,
Philadelphia, 1996. Philadelphia, 1996.
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95. McAllister, M, Higson, D, McIntosh, W, et al: Dissociative identity 107. DeMoulin, DF: Reconceptualizing the self-efficacy paradigm:
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An action research study. Aust N Z J Ment Health Nurs 10:20, 2001. 108. DeMoulin, DF: Enhancing self-concept development of kindergart-
96. Tulman, L, and Fawcett, J: Return of functional ability after child- ners through a personalized reading program. Natl Forum Appl Educ
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97. Keeney, BP: Aesthetics of Change. Guilford, New York, 1983. 109. Dossey, BM, Keegan, L, and Guzzetta, CE: Holistic Nursing:
98. Kahng, SK, and Mowbray, CT: What affects self-esteem of persons A Handbook for Practice, ed 3. Aspen, Gaithersburg, MD,
with psychiatric disabilities: the role of causal attributions of mental 2000.
illnesses. Psychiatr Rehabil J 28:354, 2005. 110. Gilliss, C, et al: Toward a Science of Family Nursing. Addison-
99. Breslin, E: Women’s health: Challenges and opportunities. In Wesley, Menlo Park, CA, 1989.
Breslin, ET, and Lucas, VA (eds): Women’s Health Nursing: Toward 111. Miller, JF: Coping with Chronic Illness: Overcoming Powerlessness.
Evidenced Based Practice. Saunders, St. Louis, 2003. FA Davis, Philadelphia, 2000.
100. Upvall, MJ: Women and culture. In Breslin, ET, and Lucas, VA 112. Burnside, IM: Nursing and the Aged: A Self-Care Approach, ed 3.
(eds): Women’s Health Nursing: Toward Evidenced Based Practice. McGraw-Hill, New York, 1988.
Saunders, St. Louis, 2003. 113. Norris, J: Nursing intervention for self-esteem disturbances. Nurs
101. Huebscher, R: Natural, alternative and complementary health care. In Diagn 3:48, 1992.
Breslin, ET, and Lucas, VA (eds): Women’s Health Nursing: Toward 114. King, KS, Dimond, M, and McCance, KL: Coping with relocation.
Evidenced Based Practice. Saunders, St. Louis, 2003. Geriatr Nurs 8:258, 1987.
102. Burns, M: Screening and diagnostic tests. In Breslin, ET, and Lucas, 115. Starr, D: Understanding those who self-mutilate. J Psychosoc Nurs
VA (eds): Women’s Health Nursing: Toward Evidenced Based Ment Health Serv 42:33, 2004.
Practice. Saunders, St. Louis, 2003. 116. Valente, S: Deliberate self-injury: Management in a psychiatric
103. Bernhard, LA: Patriarchy, feminism, and women’s health. In Breslin, setting. J Psychosoc Nurs Ment Health Serv 29:19, 1991.
ET, and Lucas, VA (eds): Women’s Health Nursing: Toward 117. Gallop, R: Self-destructive and impulsive behavior in the patient
Evidenced Based Practice. with a borderline personality disorder: Rethinking hospital treatment
104. Ekeland, E, Heian F, Hagen, KB, et al: Exercise to improve self- and management. Arch Psychiatr Nurs 6:178, 1992.
esteem in children and young people. Cochrane Library 2006. 118. Reeder, D: Cognitive therapy of anger management: Theoretical and
105. Reitzes, DC, and Mutran, EJ: Self and health: Factors that encourage practical considerations. Arch Psychiatr Nurs 5:147, 1991.
self-esteem and functional health. J Gerontol B Psychol Sci Soc Sci 119. Swales, M, Heard, HL, and Williams, MG: Linehan’s Dialectical
61B:S44, 2006. Behavior Therapy (DBT) for borderline personality disorder:
106. DeMoulin, DF: I like me! Enhancing self concept in kindergarten Overview and adaptation. J Ment Health 9:7, 2000.
age children through active school/business partnerships. Natl 120. Lego, S: The client with borderline personality disorder. In Lego, S
Assoc School Psychol 27:8 (accessed March 20, 2006, http:// (ed): Psychiatric Nursing: A Comprehensive Reference. Lippincott,
www.likeme.org/article2.html). Philadelphia, 1996.
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ROLE-RELATIONSHIP
9
PATTERN
1. CAREGIVER ROLE STRAIN, RISK FOR AND ACTUAL 618
2. COMMUNICATION, IMPAIRED VERBAL AND READINESS
FOR ENHANCED 626
3. FAMILY PROCESSES, INTERRUPTED, AND FAMILY
PROCESSES, DYSFUNCTIONAL: ALCOHOLISM AND
READINESS FOR ENHANCED 635
4. GRIEVING, ANTICIPATORY 646
5. GRIEVING, DYSFUNCTIONAL, RISK FOR AND ACTUAL 654
6. PARENT, INFANT, AND CHILD ATTACHMENT, IMPAIRED,
RISK FOR 659
7. PARENTING, IMPAIRED, RISK FOR AND ACTUAL,
READINESS FOR ENHANCED AND PARENTAL ROLE
CONFLICT 662
8. RELOCATION STRESS SYNDROME, RISK FOR AND
ACTUAL 673
9. ROLE PERFORMANCE, INEFFECTIVE 678
10. SOCIAL INTERACTION, IMPAIRED 684
11. SOCIAL ISOLATION 688
12. SORROW, CHRONIC 695
13. VIOLENCE, SELF-DIRECTED AND OTHER-DIRECTED,
RISK FOR 700
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606 • Role-Relationship Pattern
PATTERN DESCRIPTION 13. Does the patient have family or significant others
visiting or calling?
The role-relationship pattern is concerned with how a per- a. Yes
son feels he or she is performing the expected behavior b. No (Social Isolation)
delineated by the self and others. Each of us has several 14. Is the patient uncommunicative, withdrawn, or not
roles in family, work, and social relationships during our making eye contact?
daily lives, with the related responsibilities. Disruption in a. Yes (Social Isolation)
these roles, relationships, and responsibilities can lead b. No
a patient to seek assistance from the health-care system. 15. Does the client indicate that admission might impact
Likewise, satisfaction with these is a patient strength role (family, work, or leisure)?
that can be used in planning care for other health problem a. Yes (Ineffective Role Performance)
areas. b. No
16. Does the family or do significant others verbalize that
admission might impact the patient’s role (family,
PATTERN ASSESSMENT work, or leisure)?
1. Is the client exhibiting distress over a potential loss? a. Yes (Ineffective Role Performance)
a. Yes (Anticipatory Grieving) b. No
b. No 17. Does the child show signs or symptoms of physical or
2. Is the client denying a potential loss? emotional abuse?
a. Yes (Risk for Dysfunctional Grieving) a. Yes (Impaired Parenting)
b. No b. No
3. Is the client exhibiting distress over an actual loss? 18. Do the parents indicate difficulty in controlling the
a. Yes (Most people exhibit distress over an actual loss; child?
that is not dysfunctional) a. Yes (Impaired Parenting)
b. No b. No
4. Is the client displaying extended grief symptoms that 19. Do the parents demonstrate attachment behaviors?
are not improving? a. Yes
a. Yes (Dysfunctional Grieving) b. No (Risk for Impaired Parenting, Risk for Impaired
b. No Parent, Infant, and Child Attachment)
5. Does the client have risk factors for dysfunctional grief 20. Do the parents make negative comments about the
following a loss? child?
a. Yes (Risk for Dysfunctional Grieving) a. Yes (Risk for Impaired Parenting)
b. No b. No
6. Is the client denying an actual loss? 21. Does the family demonstrate a capability to meet the
a. Yes (Dysfunctional Grieving) child’s physical needs?
b. No a. Yes
7. Is the client making verbal threats against others? b. No (Interrupted Family Processes)
a. Yes (Risk for Violence) 22. Does the family demonstrate a capability to meet the
b. No child’s emotional needs?
8. Is the client exhibiting increased motor activity? a. Yes
a. Yes (Risk for Violence) b. No (Interrupted Family Processes)
b. No 23. Does a family member exhibit signs and symptoms of
9. Can the patient speak English? alcoholism?
a. Yes (Readiness for Enhanced Communication) a. Yes (Dysfunctional Family Processes: Alcoholism)
b. No (Impaired Verbal Communication) b. No
10. Does the patient demonstrate any difficulty in 24. Do the parents express concern about the ability to
talking? meet the child’s physical or emotional needs?
a. Yes (Impaired Verbal Communication) a. Yes (Parental Role Conflict)
b. No (Readiness for Enhanced Communication) b. No
11. Does the client verbalize difficulty with social situa- 25. Are the parents frequently questioning decisions about
tions? the child’s care?
a. Yes (Impaired Social Interaction) a. Yes (Parental Role Conflict)
b. No b. No
12. Does the client indicate strained relationships with his 26. Was the infant premature?
or her family or others? a. Yes (Risk for Impaired Parent, Infant, and Child
a. Yes (Impaired Social Interaction) Attachment)
b. No b. No
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Conceptual Information • 607
27. Do the parents express anxiety regarding the parental Because our roles are such an integral part of our lives,
role? we seldom analyze them until they become a problem to our
a. Yes (Risk for Impaired Parent, Infant, and Child internal or external adaptation to life’s demands. Roles that
Attachment) are often associated with stages of development serve as
b. No society’s guides for meaningful and satisfying relationships
28. Has the patient recently received a diagnosis related to in life by facilitating an orderly method for transferring
a chronic physical or mental condition? knowledge, responsibility, and authority from one genera-
a. Yes (Chronic Sorrow) tion to the next.
b. No During the childhood years, an individual will have
29. Is the patient verbally expressing prolonged sadness? numerous contacts with different individuals having differ-
a. Yes (Chronic Sorrow) ent sets of values. The child learns to internalize the values
b. No of those significant in his or her life as personal goals are
30. Is the patient in the role of primary caregiver for actualized. When the goals are realistic, consistent, and
another person? attainable, the individual is assisted in developing a sense of
a. Yes (Risk for Caregiver Role Strain, Caregiver Role self-esteem as these various roles are mastered. Each new
Strain) role carries with it the potential for gratification and
b. No increased ego identity if the role is acquired. If the role is
31. Does the patient verbally express difficulty in or con- not mastered, poor self-esteem and role confusion may
cerns about caregiving role? ensue. The potential for successful role mastery is dimin-
a. Yes (Caregiver Role Stress) ished with multiple role demands and the absence of suit-
b. No able role models. In addition, role acquisition depends on
32. Has the patient recently moved from one living site to adequate patterns of cognitive–perceptual ability and a
another? healthy sense of self.1
a. Yes (Risk for Relocation Stress Syndrome) Although all roles are learned within the context of
b. No one’s culture, specific roles are delineated in two ways:
33. Does the patient appear depressed following a change acquired and achieved. Acquired roles have variables over
in living environments? which the individual has no choice, such as gender or race.
a. Yes (Risk for Relocation Stress Syndrome) Role achievement allows for some choice by the individual,
b. No with the result of purposefully earning a role, such as choos-
34. Does the patient facing a change in a living environ- ing to become a professional nurse.
ment have a good support system? Many roles are not clearly defined as being either
a. Yes acquired or achieved but rather are a combination of the two.
b. No (Risk for Relocation Stress Syndrome) Roles are not mutually exclusive, but interdependent. The
35. Does the patient express concern over his or her recent roles an individual assumes usually blend well; however,
move? those that a person achieves or acquires may not always
a. Yes (Risk for Relocation Stress Syndrome) make for a harmonious blend. Role conflicts can occur
b. No from the most internalized personal level to a generalized
societal level.
Roles may be influenced by a multitude of factors,
CONCEPTUAL INFORMATION including economics, family dynamics, changing roles of
The social connotation for role performance and relation- institutions, and gender role expectations. Roles can be
ships is a major premise for the intended use of this pattern. mediated through role-playing skills and self-conceptions. It
A role is a comprehensive pattern of behavior that is socially is hoped that with the increased demands on the individual,
recognized and that provides a means of identifying and society will continue to value human dignity with respect for
placing an individual in a society. Role is the interaction life itself. Roles should allow for self-actualization.
point between the individual and society. It also serves as a One of the more recent eclectic theories of personality
means of coping with recurrent situations. The term “role” development encompassing role theory is that of symbolic
is a borrowed theatrical noun that emphasizes the distinction interaction. In this orientation, social interaction has sym-
of the actor and the part. A role remains relatively stable bolic meaning to the participants in relation to the roles
even though different persons may be occupying the posi- assigned by society. (For further related conceptual infor-
tion or role; however, the expectations of the script, other mation, refer to Chapter 8.)
players, and audience all influence role enaction.1 The Symbolic interaction encompasses the roles assumed
importance of each of these factors varies with the context by humans in their constant interaction with other humans,
of each interaction. In our personal roles, the script is equiv- communicating symbolically in almost all they do. This
alent to the societal “norms,” and our audience can be real interaction has meaning to both the giver and the receiver of
or imagined. Uniqueness of style may exist within the the action, thus requiring both persons to interact symboli-
boundaries of the role as determined by society. cally with themselves as they interact with each other.
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608 • Role-Relationship Pattern
Symbolic interaction involves interpretation, that is, ascer- rights with respect to property, divorce, and spheres of
taining the meaning of the actions or remarks of the other authority
person, and definition, that is, conveying indication to Father and son Economic cooperation in masculine
another person as to how he or she is to act. Human associ- activities under leadership of the father; obligation of
ation consists of just such a process of interpretation and material support vested in the father during childhood
definition. It is through this process that participants fit their of the son and in the son during the old age of father;
own acts to the ongoing acts of one another, and, in doing responsibility of father for instruction and discipline
so, guide others.2 of son; duty of obedience and respect on the part of
To explore further how relationships develop, a brief the son; tempered by some measure of comradeship
overview of kinship is offered. A kinship system is a struc- Mother and daughter Relationship parallel to that
tured system of relationships in which individuals are bound between father and son, but with more emphasis on
one to another by complex, interlocking relationships. These child care and economic cooperation, and less on author-
relationships are commonly referred to as families. It is not ity and material support (However, strong relationships
so much the family form in which one lives as how the fam- in the development of mothering skills and parenting
ily form functions that defines whether or not there is a techniques lead to obligations of emotional support and
cohesive family structure.3 An ideal family environment caretaking activities vested in the mother during the
consists of a family that has many routines and traditions, childhood of the daughter and in the daughter during
provides for quality time between adults and children, has old age of mother.)
regular contact with relatives and neighbors, lives in a sup- Father and daughter Responsibility of the father
portive and safe neighborhood, has contact with the work for protection and material support before marriage
world, and has adult members who model a harmonious and of the daughter; economic cooperation, instruction,
problem-solving relationship.3 and discipline appreciably less prominent than in
The 1980s saw great change in family structures with father–son relationship; playfulness common in
an explosion of individualized living arrangements and infancy of daughter, but normally yields to a meas-
lifestyles requiring new definitions of the “family.”3–6 Fewer ure of reserve with the development of a strong
nuclear families consisting of husband, wife, and children incest taboo
exist today. There are in today’s society many different Mother and son Relationship parallel to that of mother
acceptable family forms that do not fit the definition of a and daughter, but with more emphasis on financial and
nuclear family. The following are some of the different fam- emotional support in later life of mother
ily forms identified in today’s society.3–6 Elder and younger brother Relationship of playmates,
developing into that of comrades; economic cooperation
Nuclear family Husband, wife, and children living in a under leadership of elder; moderate responsibility of
common household, sanctioned by marriage elder for instruction and discipline of younger
Nuclear dyad Husband and wife alone; childless or chil- Elder and younger sister Relationship parallel to that
dren have left home between elder and younger brother, but with more
Single-parent family One head of household, mother or emphasis on physical care of the younger sister
father, as a result of divorce, abandonment, or separation Brother and sister Early relationship of playmates, vary-
Single adult alone Either by choice, divorce, or death of ing with relative age; gradual development of an incest
a spouse taboo, commonly coupled with some measure of reserve;
Three-generation family Three or more generations in a moderate economic cooperation; partial assumption of
single household parental role, especially by the elder sibling
Kin network Nuclear households or unmarried members
The nurse must exercise great caution in maintaining
living in close geographic proximity
sensitivity to the individual meaning attached to various
Institutional family Children in orphanages or residen-
roles, and the way in which these roles are perceived and
tial schools
assumed. With the current societal and economic changes,
Homosexual family Homosexual couples with or with-
the individual’s roles are being impacted on a daily basis,
out children
even without the added stress of a health problem.
Despite the differences in family forms and cultural
differences, primary relationships within various family
structures reveal markedly similar characteristics in
all societies. These relationships were described7 in DEVELOPMENTAL CONSIDERATIONS
1949, and still exist in the various family forms cited
NEONATE AND INFANT
today:
Husband and wife Economic specialization and coopera- The newborn period is especially critical for the develop-
tion, sexual cohabitation; joint responsibility for support, ment of the first attachment that is so vital for all future
care, and upbringing of children; well-defined reciprocal human relationships. Attachment behavior includes crying,
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Developmental Considerations • 609
smiling, clinging, following, and cuddling. The infant is marked periods of time, there is a potential for developmen-
dependent on his or her mother and father for basic needs of tal delays secondary to the lack of appropriate social stimu-
survival. This is often demanding and requires parents to lation.
place self-needs secondary to the needs of the infant, mak- The newborn period is especially critical for the devel-
ing for a potential role-relationship alteration. opment of the neonate’s first attachment for future human
Although dependent on others, the infant is an active relationships. During this period, the infant must depend on
participant in role-relationship pattern development from others for his or her care and basic needs. This is often a
conception on. The infant is capable of influencing the inter- demanding situation for parents, who must sacrifice their
actions of those caring for him or her. Reciprocal interactions own needs to best meet the needs of the infant.8
also influence the maternal–paternal–infant relationship. The infant is dependent on others for care, ranging
Positive interactions will be greatly influenced by infant- from required food for physical growth to appropriate sen-
initiated behavior, as well as maternal–paternal responses sory and social stimulation. In the absence of the stability
and the reciprocal interaction of all involved. The state of the usually afforded by the family in its usual functioning pat-
infant as well as that of the parent interacting with the infant tern, the infant may be at risk for failure to thrive or devel-
must be considered as critical. opmental delay. Ultimately, rather than developing a sense
It is important to note that any alteration in health sta- of trust and a feeling that the world is a place in which one’s
tus of the mother, the neonate, or both has the potential of needs are met, the infant will doubt and mistrust others. This
interfering with the establishment of the maternal–infant in turn places the infant at risk for an abnormal pattern of
relationship. This may not necessarily be the case, but it is development.
often critical that the potential risk be acknowledged early Crying serves as primitive verbal communication for
so that residual, secondary problems can be prevented with the neonate and infant. As the infant begins to understand
appropriate nursing intervention. It is also important to keep and respond to the spoken word, the world should be sym-
in mind that the infant is taking in all situational experi- bolized as comforting and safe. With time, basic attempts at
ences, and that as learning occurs through interaction with verbalization are noted in imitation of what is heard. There
the environment, a gradual evolution of role-relationship is a correlation between parental speech stimulation and the
patterns occurs. actual development of speech in young children, suggesting
By approximately 12 months of age, the infant shows a positive effect for early stimulation. Echolalia (the often
fear of being left alone, and will search for the parents with pathologic repetition of what is said by other people as if
his or her eyes. The infant will avoid and reject strangers. echoing them) and attempts at making speech are most crit-
There is an obvious increasing interest in pleasing the par- ical to note during this time.
ent. In protest, the infant cries, screams, and searches for the The infant may be the recipient of violent behavior,
parent. In despair, the infant is listless, withdrawn, and dis- and, all too often, it is because of crying. The attempt to
interested with the environment. In detachment or resigna- quiet the infant can take the form of lashing out for those
tion, a superficial “adjustment” occurs in which the infant individuals unable to deal with the usual role-relationship
appears happy, friendly, and interested in surroundings for patterns. The infant is unable to defend him- or herself, and
short periods of time. The infant is emotionally changeable, therefore is to be protected by reporting of any suspected
from crying to laughing, with a beginning awareness of sep- abusive or negligent behavior. At particular risk are infants
aration from the environment. Still, the infant uses the with feeding or digestive disorders, premature or small-for-
mother as a safe haven from which to explore the world. The gestational-age infants who require feedings every 2 hours,
infant will have a favorite toy, blanket, or other object that or others perceived as “demanding” or “irritable.” Also at
serves to comfort him or her in times of stress. (Sucking risk are infants who are born with congenital anomalies or
behavior may also serve to calm the infant, and eventually disfigurements.8
he or she will develop self-initiated ways of dealing with the
stressors of life, such as thumb sucking versus the actual
TODDLER AND PRESCHOOLER
taking of formula or milk.)
The infant receives cues from significant others and The toddler has an increasing sense of identity and is aware
primary caregivers regarding grief responses such as crying, of him- or herself as a separate person. The toddler treats
with a preference for the mother. Depending on age and sit- other children as if they were objects and gradually becomes
uational status, the infant may protest by crying for the involved in parallel play, which then leads to more interac-
mother. In a weakened state, the infant may make little tive play with peers. The sharing of possessions is not yet to
response of preference for caregivers.8 be expected with toddlers. The toddler begins to formulate a
According to family structure, the neonate or infant sense of right and wrong, with the ability to conform to
will adapt to usual socialization routines within reasonable some social demand, as exemplified by the capacity for self-
limits. Actual isolation for the infant would perhaps occur if toileting. It is reasonable that a toddler would begin to work
the primary caregiver could not exercise usual role-taking through problems of family relationships with other children
behavior for socialization. If this behavior is arrested for while playing.
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610 • Role-Relationship Pattern
The preschool child talks and plays with an imaginary blame him- or herself for the change or crisis, or who may
playmate as a projection. What is offered may be what the think magically and have fears that may be unrelated to the
child views as bad in him- or herself. The preschooler may situation. Subsequent development may be altered by family
have some friends of the same sex, and opportunities for process dysfunction, with regression often occurring.
socialization serve critical functions. The preschool child At this age, it is important to stress the need for ritu-
lives in the “here and now” and is capable of internalizing alistic behavior as a means of mastering the environment
more and more of society’s norms. By this age, there is a with adequate anticipatory safety. This period allows for
sense or morality and conscience. A strong sense of family knowing “self” as a separate entity. The toddler is capable of
exists for the preschooler. attempting to conform to social demands but lacks the abil-
The toddler may be unusually dependent on the ity of self-control.
mother, objects of security, and routines.8 He or she is capa- The importance of setting limits must be stressed with
ble of magical thinking and may believe in animation of regard to safety and disciplinary management. At this age,
inanimate objects, such as believing an X-ray machine is the child begins to resist parental authority. Methods of deal-
really a mean monster. Toddlers may be fearful of seeing ing with differences or rules from one setting to another
blood. These fears may be unrelated to actual situations. must be simple and appropriate to the situation.
The preschooler may be critical of him- or herself and For the toddler, this time can prove frustrating, with a
may blame him- or herself for a situation, with some attempt need to be understood despite a limited vocabulary. Jargon
at viewing the current situation as punishment for previous and gestures may be misinterpreted, with resultant frustra-
behavior or thoughts. He or she will tolerate brief separation tion for both the child and the parent. Patience and under-
from parents in usual functioning. Play or puppet therapy, standing go far with a child of this age. Pictures and the
which is appropriate to the situation, will help the pre- telling of stories serve as means of enhancing speech as well
schooler in expressing feelings. as instilling an appreciation for reading and speech. Feelings
The toddler must have room to explore safely, with a come to be expressed by the spoken word also. The child is
sense of autonomy evolving in the ideal situation. If social able to refer to him- or herself as “I,” “me,” or by name.
isolation limits these opportunities, the toddler will be lim- By preschool age, the child is able to count to 10,
ited in role-relationship exposure. This will often result in define at least one word, and may name four or five colors.
either social isolation or a form of forced precocious role- Speech now serves as a part of socialization in play with
taking in which the toddler is perceived as being able to sat- peers. Wants should be expressed freely as the child broad-
isfy the companionship needs of adults. The toddler may ens his or her contact with persons other than primary family
misinterpret socialization opportunities as abandonment or members. The preschooler enjoys stories and television pro-
punishment, so short intervals of parallel play with one peer, grams and attempts to tell stories of his or her own creation.
to begin with, would be appropriate. Toddlers who are If the toddler is unable to fulfill the expectations of
denied opportunities for peer interaction are at risk for role- parents or caregivers who demand unrealistic behavior, there
relationship problems.8 is a risk of abuse. Especially noteworthy would be a desire
The child of the preschool age group may experience for the young toddler to be capable of self-toileting behav-
alteration in socialization attempts if overpowered by peers, ior when in fact such is not possible. This places the toddler
if there are too many rigid or unrealistic rules, or if the situ- in a target population for abuse also. At this age, the toddler
ation places the child in a situation that presents values may be unable to express hostility or anger verbally, and so
greatly different from those of the child and his or her fam- a common occurrence may be temper tantrums. At risk for
ily. If the child at this age experiences prolonged social iso- violence would be the toddler who resists parental authority
lation or rejection, there could be marked potential for in discipline, and cannot meet demands of the parents.
difficulty in forming future relationships. If things do not go
well in his or her socialization, the child at this age may
SCHOOL-AGE CHILD
blame him- or herself.
The toddler will seek out opportunities to explore and Learning social roles as male or female is a major task for
interact with the environment, provided there is a safe haven the school-age child, with a preference for spending time
to return to as represented by the family.8 When this facili- with friends of the same sex rather than with the family. The
tative factor is not present, the toddler may regress and school-ager is capable of role-taking and values cooperation
become dependent on primary caregivers or others, or may and fair play. There may be a strict moralism that is “black
manifest frustration via extremes in demanding behavior. and white,” with no gray areas noted. The school-ager
The child’s subsequent development may also be affected by enjoys simple household chores, likes a reward system, and
family process alteration. has the capacity for expressing feelings. Fear of disability
The preschool child is able to verbalize concerns and concern for missing school are typical concerns for this
regarding changes in family process but is unable to com- age group.
prehend dynamics. It is critical to attempt to view the altered Illness may impose separation from the peer group.
process through the eyes of the preschooler, who could Although independent of parents in health, the school-
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Developmental Considerations • 611
ager may require close parental relationship in illness or The adolescent will be constantly weighing self-
crisis. Loss of control and fear of mutilation and death are identity versus perceived identity expressed via peers. He or
real concerns. The school-age child may fear disgracing she may be fearful of expressing true feelings or concern for
parents if loss of control, such as crying, occurs. He or she fear of rejection by peers, parents, or significant others.
is aware of the severity of his or her prognosis and may even Isolation from peers places the adolescent at risk for altered
deal with reality better than parents or adults might. The self-identity as well as altered role-relationship patterns.
school-age child may use art as a means of expressing his or The adolescent is able to assist within the family dur-
her feelings. ing times of altered process. It is important to stress that in
This child is at risk of social isolation if a situation is more and more dual-career or single-parent families, young
different from previous socialization opportunities. He or she adolescents spend more and more time alone. Nonetheless,
may experience value conflict and question the rules. He or adolescents should still have opportunities for peer interac-
she may also be afraid to express desires or concerns regard- tion and socialization according to the family’s needs.
ing socialization needs for fear of punishment. Peer involve- There may be marked vacillations, as the adolescent
ment is a most vital component of assisting the school-ager strives to find self-identity, with dependence and independ-
to formulate views of acceptable social behavior. ence issues. Even more marked rebellion against parental
The school-ager may try to assume the role of a par- wishes may be manifest at this time as peer approval is
ent if the dysfunction of the family relates to the parent sought.
of the same sex. This may be healthy with appropriate Any factors that may interfere with usual speech pat-
acknowledgment of limitations. At this age, the child is con- terns may prove especially difficult for the adolescent.
cerned with what other friends may think about the family, Bracing of teeth may be common, with the potential for self-
with some stigma attached in certain cultures to divorce, image alteration. Also, the eruption of 12-year molars could
homosexuality, and alternate lifestyles. To best endure the prove painful, as might the possible impaction of wisdom
altered family process, it is critical for the school-ager to teeth later. Expressed wit is valued in this age group, as
have a close friend who might share the cultural views of his might be special colloquial expressions to qualify group or
or her own family. peer identity. Difficulty in expression of self may be a major
Allowance for increasing interests outside the home problem for this individual. Respect for times of reflection
should be made with sensitivity to parental approval or dis- and estrangement should be maintained.
approval. The child may rebel against parental authority in The adolescent may be caught in the crossfire of strife
an attempt to be like peers. for independence versus dependence. For this group, it
Confidence in self and a general sense of well-being is paramount that self-control be attained to develop the
will promote adequacy in communication development. The meaningful relationships so critical for appropriate role-
child of this age continues to learn vocabulary and takes relationship patterns. Often adolescents who have not
pride in his or her ability to demonstrate appropriate use of acquired appropriate socialization skills resort to drugs or
words. At this age, jokes and riddles serve as a means of alcohol as a means of feeling better and escaping the reality
encouraging peer interaction with speech. Reading is a of life. This may also foster loss of control, as reality is dis-
leisure activity for the school-age child. torted. In many instances, there may be related juvenile
The child will usually enjoy school and consider peer delinquency, with resultant records of lawbreaking.
interaction an enjoyable part of life. In instances in which In addition, any adolescent who is assuming a role that
the child feels inferior, there may be a risk for violence or stresses or negates the usual development of self-identity is
abusive behavior as a cover-up for poor self-image or low at risk for violence as a means of coping. An example of this
self-esteem. Often there will be related role-relationship would be two young teenagers attempting to parent when
alterations as well. The family serves as a means of valuing they themselves still require parenting.
the interaction, which should foster the appropriate enjoy-
ment of friendships. At risk are children with learning dis-
YOUNG ADULT
abilities or handicaps, parental conflicts, or related
role-relationship alteration. Although biophysical and cognitive skills reach their peak
during the adult years, the young adult is still in a period of
growth and development. Striving for achievement of an edu-
ADOLESCENT
cation, job security, meaningful intimate relationships with
Vacillation between dependence and independence is com- others, and establishment of a family are the primary focuses
mon for the adolescent who is attempting to establish a of the young adult. Although young adults usually have
sense of identity. The adolescent questions traditional val- achieved independence, they find themselves learning
ues, especially those of parents. There is a gradual trend to socially relevant behavior and settling into specific acquired
independent functioning that allows the adolescent to roles within a chosen profession or occupation. They begin to
assume roles of adulthood, including the development of adopt some of the values of the group to which they belong,
intensive relationships with members of the opposite gender. and to assume assured roles such as marriage and parenting.
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612 • Role-Relationship Pattern
Cognitively, young adults have reached their peak reproductive capabilities. These biologic and physical
level of intellectual efficiency, and they are able to think changes can affect sexual lifestyles either positively or neg-
abstractly and to synthesize and integrate their ideas, expe- atively, depending on the perception and orientation of the
riences, and knowledge. For the adult, thinking usually individual.
involves reasoning, taking into consideration past experi- Most middle-age adults function well and learn to
ences, education, and the possible outcomes of a situa- gradually accept the changes of aging, and with proper
tion more realistically and less egocentrically than the nutrition, exercise, and a healthy lifestyle, they can experi-
adolescent. ence excellent health and a productive middlescence.
Young adulthood is still a time of great adjustment. Middle-age people usually begin to face more accidents, ill-
The individual is expected to look at the self in relation to ness, and death; they begin to deal with their own aging
society, learning how to deal with personal needs and process and death, as well as that of their parents. There is
desires as opposed to the needs and desires of others, and often a role reversal, with the middle-age adult assuming the
managing the economic and physical needs of life. Sexual role of parent.
activity focuses toward the development of a single intimate, This is the time of life when individuals usually
meaningful relationship and the establishment of a family. review their goals and aspirations, sometimes to find that
In developing the role of parenting, the young adult often they did not reach the potential they once dreamed. Most
falls back on the parenting patterns and behavior of his or middle-age adults begin to feel that there is not enough time
her own parents. to accomplish all they want to accomplish, and they begin
The young adult begins to assume the responsibility of to adjust to the fact that they may not reach all the goals
providing for a family. Most young adults are members of they set in their youth. This can result in a loss of self-
dual-career families, and thus face the stresses of multiple esteem, or it can be a motivation to develop previously
roles. Many of these young adults become single parents, untapped reservoirs, which can lead to self-actualization and
and the stresses of multiple responsibilities and roles personal satisfaction.
are greater both at home and at work. Just as during ado-
lescence, the negation of development of self-identity can OLDER ADULT
lead to crises, role strain, conflict, and often failure in the
With aging, individuals may have fewer demands placed on
young adult.
them, thus leaving more time, and fewer potential opportu-
As the adult acquires full role responsibility, there
nities, for role performance. This may also be a time when
may be difficulties related to role diffusion, role confusion,
one is able to fulfill volunteer roles and roles of choice ver-
role strain, or related assumption of appropriate roles. Also,
sus those of demand. A critical factor may be the freedom
the ultimate developmental need for assumption of account-
one feels as basic needs are met. If health is satisfactory and
ability for self may be unresolved. There may be a greater
one has children or grandchildren to enjoy, financial stabil-
likelihood for the various demands of society on male and
ity, and the ability to pursue fulfillment via role engagement,
female roles to be experienced at this time as women assume
this experience would be self-actualizing. On the other hand,
the multiple roles of wife, mother, worker, housekeeper, and
if one’s health fails, few meaningful family supports exist,
so on, just as men also have assumed more and more roles
and financial needs arise, self-actualizing role performance
that were formerly assumed by females. This challenge
is potentially threatened.
also brings the potential for growth and fulfillment in self-
The older adult must deal with decreasing function
actualizing individuals.
with resultant decreasing socialization potential. This is a
time for retrospection and pondering the past, with sincere
MIDDLE-AGE ADULT
concerns regarding the future and death. In some instances,
Middle age, or middlescence, is often considered the most full functional level is possible, whereas for others life is
productive years of an individual. Persons in this age group lived vicariously. Elder role-modeling opportunities, with
are usually secure in a profession or career, are in the mid- respect for those who have lived life, still exist in many cul-
dle of raising a family, and often must assume responsibility tures. For these individuals, the aging process is welcomed
for aging parents. and enjoyed as the fullest potential is actualized for
As biophysical changes occur, there is a concurrent role-relationship patterning, namely the generation of values
adaptation of the cognitive and physical activities of the to the young in society. In instances in which aging is
individual. The body ages in varying stages or degrees, and accompanied by loss in whatever form, the potential exists
young middle-age adults usually retain the body structure for the individual to become dependent. This dependency
and activity level they established as young adults. Middle- may range from a minor to a major form of total dependence
age adults with more sedentary lifestyles must establish on others. The onset of dependency may be gradual or sud-
exercise programs to retain their youthful figures. The great- den. In either instance, the nurse must recognize the impact
est changes facing both men and women during this time of the loss for the patient according to the values of the
are those associated with the climacteric and the loss of patient and family.
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614 • Role-Relationship Pattern
T A B L E 9 . 1 NANDA, NIC, and NOC Taxonomic Linkages (continued from page 613)
Family Processes, *
Still in development Family Coping
Readiness for Family Functioning
Enhanced Family Resiliency
Family Social Climate
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Developmental Considerations • 615
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616 • Role-Relationship Pattern
T A B L E 9 . 1 NANDA, NIC, and NOC Taxonomic Linkages (continued from page 615)
Psychosocial Adjustment:
Live Change
Role Performance
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Developmental Considerations • 617
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618 • Role-Relationship Pattern
T A B L E 9 . 1 NANDA, NIC, and NOC Taxonomic Linkages (continued from page 617)
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Caregiver Role Strain, Risk For and Actual • 619
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Copyright © 2007 •by F. A. Davis.
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620 • Role-Relationship Pattern
Have You Selected the Correct Diagnosis? (box both Compromised or Disabled Family Coping and
continued from page 619) Caregiver Role Strain are likely to develop.
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Caregiver Role Strain, Risk For and Actual • 621
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for contributing factors with a focus on high-risk Unrealistic demands of parenting or care provision
populations: increase the likelihood of role strain.
• Excessive demands exist secondary to a child requiring
extensive care (e.g., several small children in family
with one child requiring extensive assistance with
physical or mental problems). This can be compounded
when depression is a coexisting factor.
• A patient who has a total self-care deficit
• Caregiver indicates inability to carry out usual routines
Schedule a daily conference with the caregiver of at least Allows identification of current perception of role strain
30 minutes to focus on: by encouraging ventilation of feelings. Provides a
teaching opportunity. Assists in identification of refer-
rals that are needed.
• Exploring with the parent or caregiver options available Support from others serves as a means of preventing fur-
to assist with the demands of the situation. ther demise of desired role taking while also allowing
• Encourage the caregiver to provide time for self on a for long-term needs. Time for self will enhance coping
daily basis through such means as seeking outside help abilities and, ultimately, self-esteem.
(e.g., visiting nurse, housekeeping assistance, respite
care, institutionalization such as temporary per day or,
if appropriate and desired, permanent).
• Identifying community resources that are available, Provides long-term support and information. Encourages
especially parenting support groups. sharing of concerns with others in the same situation.
• Assisting the caregiver and significant other(s) to ex- Expectations may be unrealistic. Clarification of expecta-
plore inevitabilities and realities associated with the care tions and reality assists in problem solving.
Schedule a family conference, as needed, to focus on the Assists in delineating roles for each family member.
family’s willingness to provide assistance in caregiving. Assists in providing relief for the primary caregiver on
a more regular basis.
Monitor for any unresolved guilt regarding role demands, Unresolved conflict increases the likelihood of little
“less-than-perfect child,” or related aspects of situation change in behavior.
(See Dysfunctional Grieving).
Preserve the effective functioning of the caregiver The likelihood of secondary and tertiary alterations for
through teaching and support during all interactions. the caregiver increases when primary needs of rest and
[Note specific ongoing support the caregivers might own physical self are not met.
need here.]
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
New Mother or Parent Role
Assist the new mother in developing realistic plans for Provides time for assessment and planning for home care.
infant care at home. Have the mother review plans for Affords an opportunity to teach and give realistic feed-
self-care and plans for care of the infant in the home. back regarding the impact a newborn makes on the for-
mer lifestyle.
Include the significant other in plans for care of the new
mother and infant after discharge from the hospital.
Encourage discussion by the mother and significant
other of various role changes in the family that will
occur with the new infant’s being incorporated into the
household (e.g., sibling’s, wife’s, husband’s, or grand-
parent’s role).10
(care plan continued on page 622)
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622 • Role-Relationship Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage discussion of the “new” role of being a mother
and father, as well as being husband and wife.
Assist with development of plan to save time, such as Assists in reducing fatigue, which is a significant contrib-
learning to sleep when the infant sleeps, turning tele- utor to the development of caregiver role strain.
phone off when trying to rest, or putting sign on front Provides long-term support and a source of information.13
door when sleeping.11
Identify areas in which the significant other can assist the
new mother and help reduce fatigue. For example, if
breastfeeding, let dad get the infant, change the diaper,
and bring the infant to the mother for feeding during
the night.11,12
Plan, cook, and freeze meals for the family before leaving
for the hospital, so that they can be prepared easily
during the first few weeks at home.11
Teen Parenting
● N O T E : The nursing actions for the teenage parent will be the same as those in the
previous section with the following additions:
Refer the young couple or teenager to young parents’
groups in the community for social and personal support.
Give the young couple telephone hot lines they can call
for assistance and support (e.g., hospital nursery,
young parent services, or the YWCA). Check with
individual community agencies for what is available in
your community.
Assist the young parent to get into or stay in school by Promotes long-range planning and reduces the likelihood
giving references for childcare. of strain for the young parent.
Encourage the young couple to express their feelings
about the new responsibilities they face.
Parent to Your Parents
● N O T E : Approximately 80 percent of women will become the primary care providers
for their elderly parents. These interventions and rationales can also apply to spouse
and/or other family members.14
• Identify specific concerns and needs. Sharing responsibilities for elderly parents assists the
• Explore the inevitabilities and realities of the situation. entire family to lead better lives. Many women have
• Identify possible resources in the community (financial the entire burden of caring for elderly parents while
assistance, personal support, social work, or day care). trying to maintain jobs and their own families. Often
• Identify methods by which the family members and they will not speak of this; therefore, the nurse must
siblings can share responsibilities. patiently interview the women.14
• Establish ties from the primary caretaker to other fam-
ily members to provide relief for each other.
• Identify methods of sharing expenses associated with
housing (keeping parent[s] in own home, nursing home
or extended care, or assisted living).
• Assist with development of plan to provide supervision
for parent while working (neighbors of parents, family
members, day care, or home aide assistant).
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Caregiver Role Strain, Risk For and Actual • 623
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide instructions to both the woman and spouse Ensures that both parties have the same instructions or
(significant other) about provision of needed care. information about care needed.
Provide telephone number where the caregiver can reach Provides a resource to answer questions and give reas-
clinical, professional assistance, day or night. surance.
Discuss with the caregiver possible lifestyle changes that Most caregivers are not professional health-care providers
will occur: and have to understand the need to plan their daily
• Sleeplessness (worried about hearing if needed) schedules to incorporate the time required to provide
• Arranging time needed for work and other family needed care.13,14
members’ needs
● N O T E : Abundant resources for caregivers exist in bookstores and on the Internet.
In addition, most local hospitals and outpatient facilities host support group meetings
for caregivers. Here’s a short list of resources to help nurses, patients, and caregivers
alike sharpen their skills:
• Alzheimer’s Association, (800) 677-1116, has a great
World Wide Web site at http://www.alz.org, with a host
of resources for caregivers.
• Caregiver Network, Inc., is a Canadian resource
dedicated to making caregivers’ lives easier and hosts
extensive caregiver links to other World Wide Web
sites, including “Ask a Professional” link at http://
www.caregiver.on.ca/.
• Eldercare Locator (800) 677-1116
• Senior Net has a library of caregiving resources at:
http://www.seniornet.com/.
• Today’s Caregiver, (800) 829-2734, a magazine writ-
ten by and for caregivers, features a caregiver’s bill of
rights among other useful resources at http://www.
caregiver.com/.
Mental Health
● N O T E : For information related to the caregivers of clients with a medical diagnosis
of dementia, refer to Gerontic Health. As used in this discussion, “caregiver” can mean
one person or an extended family system.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend [number] minutes [number] times per week inter- Promotes the development of a trusting relationship.
acting with the primary caregiver.
Provide a role model for effective communication by: Family problem solving is improved when the family
• Seeking clarification members can effectively communicate with one
• Demonstrating respect for individual family members another and the health-care team.15
and the family system
• Listening to expression of thoughts and feelings
• Setting clear limits
• Being consistent
Include the caregiver in weekly treatment planning meet- Assists in providing information to the caregiving system
ings with the client. [Note here the time for this meeting so they can better cope with the uncertainty of a psy-
and persons responsible for providing the information.] chiatric diagnosis.15,16
Provide the family with opportunities to provide the care Provides the family with a sense of helpfulness and
and support they identify as important. [Note here the control.16
care the family is going to provide, with the assistance
they need to complete these activities.]
(care plan continued on page 624)
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624 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend [number] minutes [number] times per week edu- Provides the caregiver with an increased understanding of
cating the primary caregiver about the client’s diagno- the diagnosis, and assists in the development of a home
sis. Provide both written and verbal information. care plan. When anxiety is high, caregivers may have
difficulty remembering information provided only in
verbal form. Increases the stability in the living envi-
ronment by decreasing the caregiver’s anxiety.
Communicate understanding of the difficulty of the care- Promotes the development of a trusting relationship, and
giver role by: assists the caregiver in the process of working through
• Answering questions honestly feelings related to the client.
• Providing time to interact with the caregiver when he
or she visits
• Inquiring about the caregiver’s self-care activities
• Encouraging the caregiver to use the time the client is
in the hospital to rest and meet personal needs
• Providing time for the caregiver to express feelings
related to the client and the hospitalization
• Commend the family on their competencies and Provides caregivers an opportunity to change their self-
strengths. For example, comment on what the caregiver view, which opens them up to viewing the problem dif-
has said or done that is effective and useful. ferently, and move toward solutions that are more
effective.17
Normalize the caregiver’s feelings of guilt and/or ambiva- Promotes a positive orientation, and enhances self-
lence by informing him or her that these are normal esteem.
feelings for anyone who assumes the level of responsi-
bility that he or she has assumed.
Have the caregiver identify areas where he or she feels a Promotes the caregiver’s sense of control, and provides
need for support on a daily basis, and assist him or her positive reinforcement when he or she can accomplish
in networking community resources to meet these the task, which enhances self-esteem.
needs. This should be a process that allows the nurse to
teach the caregiver the skills necessary to accomplish
this networking on his or her own after discharge.
Spend [number] minutes [number] times per week dis- Gives permission to the caregiver to care for self.
cussing his or her self-care activities. This could Promotes the caregiver’s strengths.
include planning time away from the client, inviting
friends to visit, going for a walk, or arranging to get
uninterrupted sleep. Inform the caregiver that if he or
she does not care for him- or herself, he or she will
eventually not have the energy to care for the client.
A specific plan should be developed and noted here.
Before the client is discharged, meet with the client and Anxiety can decrease an individual’s ability to process
caregiver to: information during hospitalization. A specific coping
• Review information about the diagnosis and hospital plan provides direction during times of crisis, and pre-
course. vents reliance on ineffective patterns of coping. These
• Review special treatments the client is to receive. actions increase the caregiver’s repertoire of strategies
• Explain the client’s medications. to deal with the problems.18
• Anticipate problems that may arise after discharge.
A specific plan should be developed for coping with
anticipated problems. This plan should be written
down and given to both the client and the caregiver.
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Caregiver Role Strain, Risk For and Actual • 625
Gerontic Health
● N O T E : One of the twenty-first century trends in the United States is the increased
number of multigenerational families, which is a direct result of the number of people
who survive well into old age. The trend has increased the probability that older adults
will ultimately be caregivers for an aging parent, an aging spouse, or perhaps younger
family members with chronic illnesses. In come cases, these roles may exist concur-
rently, magnifying the stress of caregiving.19 In addition to the following interventions,
the interventions for Mental Health and Adult Health may also apply to the aging adult.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for signs of increasing strain in the caregiver, The stresses of caregiving have a negative effect on the
such as an increase in episodes of illness. caregiver’s immune system.20
Assess the quality and type of the prior relationship Dyads with previously tense or troubled relationships are
between the caregiver and patient.19 at greater risk for caregiver role strain, violence, and
illness.19
Assist the caregiver in discussing feelings about caregiv- Provides an opportunity for ventilation of feelings about
ing. For example, encourage sharing by use of state- caregiving, which assists in reducing stress.
ments such as “Often people in your situation say they
feel angry, helpless, guilty, or depressed.”
Determine the caregiver’s knowledge of support services Assists in identifying actual or potential resources based
in the community, such as adult daycare, respite serv- on the individual’s current knowledge of services.
ices, or family support groups. Expands options available to the caregiver.
Discuss with the caregiver stress management techniques
such as imagery, deep breathing, or exercise. What has
been tried? How helpful was it?
Encourage the caregiver to use a journal to evaluate Provides a database to use in planning interventions to
stresses, prioritizing stresses and noting his or her reduce stress.
usual response. Are there specific times, days, or cir-
cumstances when stress is especially high?
If needed, consult with social services for increased sup- Highlights attention to the caregiver. Realistic planning
port in home care. serves to reduce stress.
Discuss with the caregiver, before patient discharge,
his or her plan for maintaining self-health and coping
abilities.21
Home Health
In addition to the following interventions, the interventions for Mental Health and Adult Health may also apply to the
home health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Consult with and/or refer the patient to assistive resources Utilization of existing services is an efficient use of
as needed, to include: resources.
• Caregiver support groups
• Assistance with client activities of daily living
• Assistance with home maintenance (cleaning)
• Financial assistance
Provide respite care for the client to allow the caregiver To allow the caregiver physical and emotional rest, which
rest as finances allow. promotes the best possible care for the client.
(care plan continued on page 626)
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626 • Role-Relationship Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Educate all family members about critical care issues for Knowledge helps promote a sense of control and order, as
the client, and encourage the primary caregiver to dele- well as more appropriate delegation of tasks. Delega-
gate caregiving responsibilities as appropriate. tion promotes caregiver physical and emotional rest,
which enhances client care.
Help the caregiver identify positive outcomes related to Positive feelings can balance negative feelings and pro-
caregiving (e.g., increased relationship intimacy and vide a sense of purpose.
feeling valued in the relationship) to balance negative
feelings.
Provide written documentation of caregiving responsibili- To assist the caregiver in obtaining time away from work
ties as needed for the caregiver’s employers. if needed to provide care.
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Communication, Impaired Verbal and Readiness for Enhanced • 627
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628 • Role-Relationship Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Inform the family, significant others, and other health- Promotes effective communication. Avoids frustration
care personnel of the effective ways the patient com- for the patient.
municates.
Answer call bell promptly rather than using the intercom Decreases stress for the patient by not straining commu-
system. nication resources.
Assure the patient that parenteral therapy does not inter- Decreases anxiety.
fere with the patient’s ability to write.
Initiate referral to speech therapist if appropriate. Initial teaching regarding speech may need interventions
by specialist.
Initiate referrals to support agencies such as Lost Chord Groups that experienced the same problems can assist in
Club or New Voice Club as appropriate. rehabilitation and decrease social isolation. Promotes
the patient’s comfort.
Discuss use of electronic voice box and esophageal Reduces anxiety and increases self-confidence.
speech before discharge. Have the patient practice
using device.
Encourage the patient to have recordings made for reach- Promotes safety, increases comfort, and decreases
ing police, fire department, doctor, or emergency med- anxiety.
ical service if impaired verbal communication is a
long-term condition.
Readiness for Enhanced
Assist the patient in identifying factors that enhance or Identifying limiting factors can enhance efforts for com-
inhibit open communication (e.g., environment, per- munication.
sonal feelings, self-image) and address accordingly by:
• Assisting patient in crafting message that clearly articu- Assists patient in clearly communicating these areas.
lates needs, perceptions, or feelings.
• Instructing patient in appropriate and acceptable meth-
ods for communication that do not alienate other
parties.
• Assisting patient in developing appropriate coping
mechanisms to manage differences in opinion, such as
using assertive communication techniques.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Impaired Verbal Provides a database needed to plan more complete and
Monitor the patient’s potential for speech according to accurate interventions.
subjective and objective components, to include:
• Reported or documented previous speech capacity or
potential
• Health history for evidence of cognitive, sensory, per-
ceptual, or neurologic dysfunction
• Actual auditory documentation of speech potential
• Assessment by a speech specialist
• Patterns of speech of parents and significant others
• Cultural meaning attached to speech or silence of
children
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Communication, Impaired Verbal and Readiness for Enhanced • 629
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Any related trauma or pathophysiology
• Parental perception of the child’s status, especially in
instances of congenital anomaly such as cleft lip or
palate
• Identification of dominant language and secondary lan-
guages heard or spoken in the family
Assist the patient and parents to understand needed expla- Provides a teaching opportunity. Decreases anxiety,
nations for procedures, treatments, and equipment to which can interfere with communication.
be used in nursing care.
Encourage feelings to be expressed by taking time to Alternate methods of communication and sensitivity to
understand possible attempts at speech. For young chil- attempts at communication attach value to the patient
dren, use pictures if necessary. and serve to reinforce future attempts at communica-
tion.
Encourage family participation in the care of the patient Family input provides an opportunity for communication
as situation allows. and fosters the parent–child relationship.
Assist the family to identify community support groups. Provides long-term support for coping.
Assist the patient and family in determining the impact Family functioning relies heavily on communication.
Impaired Verbal Communication may have for family
functioning.
Provide information for long-term medical follow-up Knowledge helps prepare the family for long-term needs
as indicated, especially for congenital anomalies. and helps reduce anxiety about unknowns.
Assist in identification of appropriate financial support if Funding by third-party payment may be available,
the child is able to qualify for help according to state depending on the patient’s medical status.
and federal legislation.
Monitor for potential for related alterations in role- Alterations in communication can affect the role-
relationship patterns as a result of Impaired Verbal relationship pattern.
Communication.
Monitor the potential for related alterations in self- Alterations in communication may impact self-esteem
concept or coping patterns as a result of Impaired and should be considered as a risk factor.
Verbal Communication.
Provide appropriate patient and family teaching for care Basic standards of care for the patient with a tra-
of the patient if permanent tracheostomy or related cheostomy.
prosthetic is to be used, to include:
• Appropriate number or size of tracheostomy tube
• Appropriate duplication of size of tracheostomy tube in
place in event of accidental dislodging or loss
• Appropriate administration of oxygen via tracheostomy
adapter
• Appropriate suctioning technique, sterile and nonsterile
• Appropriate list of supplies and how to procure them
• Resources for actual care in emergency, with list of
numbers including ambulance and nearest hospital
• Appropriate indications for notification of physician.
● N O T E : These may vary slightly according to physician’s plan or actual patient
status.
• Bleeding from tracheostomy
• Coughing out or dislodging of tracheostomy
• Difficulty in passing catheter to suction tracheostomy
• Fever higher than 101⬚F
(care plan continued on page 630)
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630 • Role-Relationship Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Appropriate daily hygiene of tracheostomy
• Caution regarding use of regular gauze or other sub-
stances that might be inhaled or ingested through tra-
cheostomy
• Need for humidification of tracheostomy
Readiness for Enhanced
Determine need for aids or instruments to assist in com- Provides support for effective communication.
munication (e.g., hearing aid or other augmentation).
Facilitate child’s expression of thoughts and feelings Fosters the likelihood of success in communication.
regarding desired issues related to communication with
attention to:
• Getting down to eye level of child.
• Providing environment free of distractions.
• Offering active listening.
• Facilitating nonstressful and open engagement.
• Avoiding interruptions.
• Allowing the child to maintain control of the conversa-
tion as situations allows.
Offer positive reinforcement with encouraging feedback Positive reinforcement encourages behavior.
for efforts in communicating. [Note specific reinforce-
ment plan here.]
Women’s Health
This nursing diagnosis pertain to women the same as for all adults. The reader is referred to the other sections—Adult
Health, Mental Health, and Home Health.
Mental Health
● N O T E : If impaired communication is related to alterations in physiology or surgical
alterations, refer to Adult Health nursing actions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Impaired Verbal
Establish a calm, reassuring environment. Inappropriate levels of sensory stimuli can increase con-
fusion and disorganization.
If communication difficulties are related to disorientation
to person, place, or time, provide appropriate environ-
mental cues to support orientation. These can include:
• Calendars
• Orientation boards
• Seasonal decorations and conversations
• Clocks with large numbers
• Name signs on doors
• Current event groups
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Communication, Impaired Verbal and Readiness for Enhanced • 631
ACTIONS/INTERVENTIONS R AT I O N A L E S
Note items that are necessary for this client with the fre-
quency of exposure needed to support the client’s ori-
entation. If disorientation is related to delusions, refer
to Disturbed Thought Process in Chapter 7 for addi-
tional interventions.
Provide the client with a private environment if experi- High levels of anxiety decrease the client’s ability to
encing high levels of anxiety, to assist him or her in process information.
focusing on relevant stimuli.
Communicate with the client in clear, concise language. Inappropriate levels of sensory stimuli can increase con-
• Speak slowly to the client. fusion and disorganization. When verbal and nonverbal
• Do not shout. behavior is not in agreement, a double-bind or incon-
• Face the client when talking to him or her; make sure gruent message may be sent. These incongruent mes-
lips are visible by wearing lipstick or trimming beards. sages place the receiver in a “darned if you do, darned
• Role-model agreement between verbal and nonverbal if you don’t” situation and promote interpersonal inef-
behavior. fectiveness.
• Use “I” messages to request clarification from client
when you do not understand what is being communi-
cated (e.g., “I want to understand what you are saying,
could you please repeat that?”)
Spend 30 minutes twice a day at [times] with the client Promotes the development of a trusting relationship,
discussing communication patterns. As the client pro- while providing the client a safe environment in which
gresses, this time could also include: to practice new behaviors. Behavioral rehearsal helps
• Constructive confrontation about the effects of the dys- facilitate the client’s learning new skills through the
functional communication pattern on relationships use of feedback and modeling by the nurse.
• Role-playing appropriate communication patterns
• Pointing out to the client the lack of agreement
between verbal and nonverbal behavior and context
• Helping the client understand purpose of dysfunctional
communication patterns
• Developing alternative ways for the client to have
needs met
Develop, with the client’s assistance, a reward program Reinforcement encourages positive behavior while
for appropriate communication patterns and for enhancing self-esteem.
progress on goals. [Note here the kinds of behavior to
be rewarded and schedule for reward.]
Instruct the client in assertive communication techniques, Assertiveness improves the individual’s ability to act
and practice these in daily interactions with the client. appropriately and effectively in a manner that maxi-
Note here those assertive skills the client is to practice mizes coping resources.22
and how these are to be practiced (e.g., each medica-
tion is to be requested by the client in an assertive
manner).
Provide the client with positive verbal rewards for appro- Reinforcement encourages positive behavior.
priate communication.
Sit with the client while another client is asked for feed- The nurse’s presence provides support while the client
back about an interaction. can receive feedback on interpersonal skills from a
peer.
Keep interactions brief and goal directed when the client Inappropriate levels of sensory stimuli can increase con-
is communicating in dysfunctional manner. fusion and disorganization.
Spend an extra 5 minutes in interactions in which the Time with the nurse can provide positive reinforcement.
client is communicating clearly, and inform the client
of this reward of time.
(care plan continued on page 632)
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632 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Reward improvement in the client’s listening behavior. Improved attending skills improve the client’s ability to
This can be evaluated by having the client repeat what understand communication from others and to clarify
has just been heard. Provide clarification for the differ- unclear portions of communication.
ences between what was heard and what was said.
Have the support system participate in one interaction per Behavioral rehearsal provides opportunities for feedback
week with the client in the presence of a staff member. and modeling from the nurse. Support system under-
The staff member will facilitate communication standing facilitates the maintenance of new behaviors
between the client and the support system. [Note time after discharge.
for these interactions here, with the name of the staff
person responsible for this process.]
Arrange for the client to participate in a therapeutic Provides an opportunity for the client to receive feedback
group. [Note schedule for these groups here.] on communication from peers and to observe the inter-
actions of peers so that he or she may increase the req-
uisite variety of responses in social situation.
Request that the client clarify unclear statements or com- Models appropriate communication skills for the client.
munications in private language.
Teach the client to request clarification on confusing Repeated practice of a behavior internalizes and personal-
communications. This may be practiced with role-play. izes the behavior.
Include the client in unit activities, and assign appropriate Provides opportunities for the client to practice new
tasks to the client. These should require a level of com- behaviors in a supportive environment.
munication the client can easily achieve so that a posi-
tive learning experience can occur. [Note level of
activity appropriate for the client here.]
If communication problems evolve from a language dif- Decreases the client’s sense of isolation and anxiety.
ference, have someone who understands the language
orient the client to the unit as soon as possible and
answer any questions the client might have.
Use nonverbal communication to interact with the client Decreases the client’s sense of social isolation, and pro-
when no one is available to translate. motes the development of a trusting relationship.
Obtain information about nonverbal communication in Decreases the possibilities for misunderstanding to
the client’s culture and about appropriate psychosocial develop.
behavior. Alter interactions and expectations to fit these
beliefs as they fit the client. [Note here information
that is important in providing daily care for this client.]
Determine whether the client understands any English Promotes the development of a trusting relationship.
and, if so, how it is best understood (i.e., written or
spoken).
If the client does not understand English, determine Communication facilitates social interaction and
whether a language other than the one from the culture increases the client’s sense of control.
of origin is spoken. Perhaps a common language for
staff and the client can be found. For example, few
people other than Navajos speak Navajo, but some
older Navajos also speak Spanish.
Do not shout when talking with someone who speaks Inappropriate levels of sensory stimulation can increase
another language. Speak slowly and concisely. confusion and disorganization.
Use pictures to enhance nonverbal communication. Pictures facilitate communication when the caregiver
and client do not share the same language.
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Communication, Impaired Verbal and Readiness for Enhanced • 633
ACTIONS/INTERVENTIONS R AT I O N A L E S
If a staff member does not speak the client’s language, Promotes the client’s sense of control, and decreases
arrange for a translator to visit with the client at least social isolation.
once a day to answer questions and provide informa-
tion. Have a schedule for the next day available so this
can be reviewed with the client and information can be
provided about complex procedures. Have a staff mem-
ber remain with the client during these interactions to
serve as a resource person for the translator. Allow
time for the client to ask questions and express feel-
ings. Note schedule for these visits here, with the
name of the translator.
Readiness for Enhanced
Spend [number] minutes with client [number] times per Change is dependent on the client’s perception of the
day to discuss what client understands about communi- problem.23
cation and clarifying what they want to learn. [Note
client’s goals here with education plan.]
Introduce the client to assertive communication skills and Assertive communications enhance the ability to express
provide opportunities to practice these skills in the one’s needs.24
areas clients find difficult. [Note client learning needs
here and schedule for practice.]
Provide positive verbal reinforcement for client goal Positive reinforcement increases behavior.24
achievement.
Refer the client to community resources that can assist
him or her with continued communication skill
enhancement. [Note those resources here and arrange
contact with the client before discharge.]
Gerontic Health
Impaired Verbal
The nursing actions for a gerontic patient with this diagnosis are the same as those given in Adult Health and Mental
Health.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Readiness for Enhanced
Collaborate with the client, family, and/or caregiver to
determine appropriate goals for enhanced communica-
tion and preferred methods of communication.
Collaborate with the client, family, and/or caregiver to
determine previously effective modes or methods of
communication and determine how those methods
might be strengthened in the current situation.
Assess client strengths in communication (written or ver-
bal communication) and facilitate the use of the
stronger modes of communication for the client:
• Discuss ways to communicate in writing for the client
with strong written communication skills to include e-
mail, journaling, letters, poetry.
• Discuss ways to strengthen the verbal communication of
the person who prefers verbal communication to include
brainstorming, reflecting, or telephone conferencing.
(care plan continued on page 634)
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634 • Role-Relationship Pattern
Home Health
In addition to the interventions for Adult Health, Mental Health, and Gerontic Health, the following may be applied in the
home setting.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Impaired Verbal
Involve the client and family in planning and implement- Family involvement enhances effectiveness of interven-
ing strategies to decrease, prevent, or cope with tions.
Impaired Verbal Communication:
• Family conference: Discuss each member’s perspective
of the situation.
• Mutual goal setting: Set short-term accomplishable
goals with evaluation criteria; specify tasks for each
member.
• Communication: Identify ways to communicate with
the client.
Teach the client and family appropriate information Knowledge bases are required to interact with the family
regarding the care of a person with Impaired Verbal member who is verbally impaired.
Communication:
• Use of pencil and paper, alphabet letters, hand signals,
sign language, pictures, flash cards, or computer
• Use of repetition
• Facing the person when communicating
• Using simple, one-step commands
• Allowing time for the person to respond
• Use of drawing, painting, coloring, singing, or
exercising
• Identifying tasks the person with Impaired Verbal
Communication can do well
• Decreasing external noise
Assist the patient and family in lifestyle adjustments that Lifestyle changes require long-term behavioral changes.
may be required: Support enhances permanent changes in behavior.
• Stress management
• Changing role functions and relationships
• Learning a foreign language
• Acknowledging and coping with frustration with com-
munication efforts
• Obtaining necessary supportive equipment (e.g., hear-
ing aid, special telephone, or artificial larynx)
Consult with, or refer to, appropriate assistive resources Self-help groups and rehabilitation services can enhance
as required. the treatment plans.
Readiness for Enhanced
Collaborate with the client, family, and/or caregiver
to determine appropriate goals for enhanced com-
munication and preferred methods of communi-
cation.
Assist the client in obtaining resources to enhance
communication to include telephones, e-mail,
journals.
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636 • Role-Relationship Pattern
ll. Failure to accomplish current or past devel- 6. Family roles are flexible and appropriate for devel-
opmental tasks, or difficulty with life cycle opmental stages.
transitions 7. Respect for family members is evident.
mm. Family special occasions are alcohol-centered 8. Family adapts to change.
nn. Controlling communications or power struggles 9. Boundaries of family members are maintained.
oo. Self-blaming 10. Energy level of family supports activities of daily
pp. Stress-related physical illnesses living.
qq. Substance abuse other than alcohol 11. Family resilience is evident.
rr. Unresolved grief 12. Balance exists between autonomy and cohesiveness.
ss. Verbal abuse of spouse or parent
3. Feelings
RELATED FACTORS9
a. Insecurity
b. Lingering resentment A. Interrupted Family Processes
c. Mistrust 1. Power shift of family members
d. Rejection 2. Family role shifts
e. Feelings of responsibility for the alcoholic’s 3. Shift in health status of a family member
behavior 4. Developmental transition and/or crisis
f. Shame or embarrassment 5. Situation transition and/or crisis
g. Unhappiness 6. Informal or formal interaction with community
h. Powerlessness 7. Modification in family social status
i. Anger or suppressed rage 8. Modification in family finances
j. Anxiety, tension, or distress B. Dysfunctional Family Processes: Alcoholism
k. Emotional isolation or loneliness 1. Abuse of alcohol
l. Frustration 2. Genetic predisposition
m.Guilt 3. Lack of problem-solving skills
n. Hopelessness 4. Inadequate coping skills
o. Hurt 5. Family history of alcoholism, resistance to treatment
p. Decreased self-esteem or feelings of worthless- 6. Biochemical influences
ness 7. Addictive personality
q. Repressed emotions C. Family Processes, Readiness for Enhanced
r. Vulnerability Related factors are not provided for wellness diagnoses.
s. Hostility
t. Lack of identity
RELATED CLINICAL CONCERNS
u. Fear
v. Loss 1. Surgery
w. Emotional control by others 2. Trauma
x. Misunderstood 3. Mental retardation
y. Moodiness 4. Chronic illness
z. Abandonment 5. Alcoholism
aa. Being different from other people 6. Chemical abuse
bb. Being unloved
cc. Confused love and pity
dd. Confusion ✔ Have You Selected the Correct Diagnosis?
ee. Failure Compromised or Disabled Family Coping
ff. Depression This diagnosis has a history of destructive patterns
gg. Dissatisfaction of behavior. For the diagnosis of Interrupted Family
C. Family Processes, Readiness for Enhanced Processes to be applicable, there would be evidence
1. Expresses willingness to enhance family dynamics. that the usual adequacy in coping is altered in relation
2. Family functioning meets physical, social, and psy- to a specific crisis.
chological needs of family members.
3. Activities support the safety and growth of family
members.
EXPECTED OUTCOME
4. Communication is adequate.
5. Relationships are generally positive; interdependent Will describe specific plan to cope with [specific stressor]
with community; family tasks are accomplished. by [date].
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Copyright © 2007 •by F. A. Davis.
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638 • Role-Relationship Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Family Process, Readiness for Enhanced
Assist the patient in identifying appropriate adaptation to Maintains realistic expectations of the evolving role.
life changes. [Note specific assistance needed here.]
Help the patient in identifying areas of family dynamics Strengthens interactions among family members.
that can be enhanced through discussions during the
provision of care.
Support the patient’s efforts to organize family activities. Promotes cohesiveness.
[Note specific assistance needed here.]
Facilitate efforts toward enhanced communication by
modeling appropriate communication and providing
time for the family to interact.
Child Health
● N O T E : Depending on the age of the infant or child, a range of possible needs may be
represented in the context of the family—all interventions should be developmentally
appropriate. Include all children in family counseling as applicable. Refer to Mental
Health for Readiness for Enhanced Family Processes.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Promote sibling participation in the patient’s hospitaliza- Inclusion of sibling(s) fosters a sense of family concern,
tion and plans for discharge (e.g., allowing visitation and the need for support is met for all involved. Undue
during game time). prolonged separations increase stress for the sibling(s)
and family relationships.
Provide for cultural preferences when possible, including Attention to preferences demonstrates valuing and sensi-
diet, religious needs, and plans for health care. tivity for the family.
Provide reinforcement to appropriately value caretaking Reinforcement of desired behaviors serves to offer posi-
behavior. tive learning, with increased likelihood of compliance.
Advocate on the infant’s or child’s behalf to best offer The infant, child, or adolescent may be unable to look
management of alcohol or substance abuse impact on after self-interests, and when this is so, it is legally and
current or future development. morally mandated that the client have an advocate.
Determine the child’s or adolescent’s feelings of the Assists in anxiety reduction, and values input of all indi-
family per ventilation about same for 30 minutes vidual family members. Also, data may be known for
each shift. best treatment.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
New Parents
Assist the patient and significant others in establishing Assist the family with role changes during a normal, but
realistic goals related to changes in role due to new- often unexpected, amount of role change event.
born (e.g., sharing of tasks or parenting skills). Provides basis for planning necessary changes.
Provide positive reinforcement for parenting tasks. Provides motivation and enhances likelihood of effective
parenting.
Assist the parents in identifying infant behavior patterns Assists in reducing stress and promotes positive
and understanding how they allow the infant to com- parenting.
municate with them (e.g., crying or fussing).
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient in verbalizing her perceptions of the Provides a database that allows more effective teaching
infant’s growth and development, individual and family and planning for effective parenting.
needs, and the stresses of being a new parent.
Identify support groups (e.g., formal groups, such as Promotes planning and allows early intervention for
Mother’s Day Out, and informal groups, such as par- potential stress areas.
enting groups, family, or friends).
Encourage open communication between the mother
and father about household tasks, discipline, fears,
and anxieties (e.g., less-than-perfect baby).
Help develop a plan for sharing household tasks and child Reduces stress-provoking events.
caretaking activities:
• Bathing
• Feeding
• Care of siblings
• Quality time with older children
Allow older children to assist with newborn care (even
the smallest child can do this with parental supervi-
sion):
• Bringing a diaper to the parent
• Pushing the baby in the stroller
• Holding the baby (while sitting on couch is best)
Follow up with home visits after discharge from hospital Provides long-term support.
to physically monitor the infant, monitor family inter-
actions, provide support, and provide referrals to the
proper agencies.
Teach and reinforce methods of caring for, and coping Provides measures and preplanning to cope with potential
with, the emotional and physiologic needs of the stressful events.
infant, siblings, parents, and other relatives, such as
grandparents.
Parent to Your Parents
Assist the client and family to establish realistic goals
related to increasing responsibilities in caring for eld-
erly parents, e.g., sharing of tasks, time, and resources
(financial and emotional).
Assist in identifying resources in the community:
• Daycare for the elderly
• Church groups
• YWCAs
• Professional help in the home, such as home health
aides
Assist in exploring and identifying need for care of eld-
erly parent outside of home (e.g., assisted living or
skilled nursing care).
Alcoholism
● N O T E : Interventions under Adult Health and Mental Health will apply here,
in addition to the following:
Perinatal
Check your state’s laws. Because of the widespread drug
use in this country, some states have mandatory screen-
ing for drug use during the perinatal period.26,27
(care plan continued on page 640)
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640 • Role-Relationship Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Screen clients for chemical use during pregnancy by
means of interview at first visit. Provide a relaxed,
secure atmosphere for the client when trying to obtain
a substance-abuse history. Include the following in
your questions:
• Use of nonprescription drugs
• Use of coffee
• Use of cigarettes
• Use of alcohol
• Use of prescription drugs
• Use of recreational drugs, such as marijuana
• Use of multiple drugs
• Problems encountered in trying to abstain from drug use
Assure the client of acceptance of her and her family, but
not of self-destructive behaviors.28
Support and praise the client for health-seeking behav-
iors.28
Thoroughly assess the woman and the fetus who present
with complications related to substance abuse in order
to provide the best physiologic support for her and her
fetal well-being.
Obtain a sample for toxicology screening:
• Maternal or neonatal urine toxicology screen
• Meconium and maternal or neonatal hair samples Because of slow growth of hair and meconium produced
by the second trimester, these methods provide the best
analysis of long-term data on drug use.28
Collaborate with the physician to provide appropriate Women with narcotic dependency problems have a high
pain control during labor. tolerance to analgesics and usually have a low pain
Notify neonatal personnel of the patient’s labor and his- threshold.28
tory of substance abuse.
Support and guide maternal–infant interactions in order
to encourage maternal–infant attachment.
● N O T E : For the addicted infant, see Child Health.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide a role model for effective communication by: Communication skills provide a framework for effective
• Seeking clarification problem solving.
• Demonstrating respect for individual family members
and the family system
• Listening to expression of thoughts and feelings
• Setting clear limits
• Being consistent
• Communicating with the individual being addressed in
a clear manner
• Encouraging sharing of information among appropriate
system subgroups
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Demonstrate an understanding of the complexity of sys- Outcome improves when psychosocial problems are
tem problems by: treated from a systems perspective.17
• Not taking sides in family disagreements
• Providing alternative explanations of behavior that rec-
ognize the contributions of all persons involved with the
problem, including health-care providers, as appropriate
• Requesting the perspective of multiple family members
on a problem or stressor
Include all family members in the first interview. Provides an opportunity to assess all family members’
perception of the problem, and in identification of
problem-solving strategies that are acceptable to more
family members.
Have each member provide his or her perspective to the Assists the family in defining a problem that can be
current difficulties. resolved. For example, rather than defining the prob-
lem as “We don’t love each other any more,” the prob-
lem can be defined as “We do not spend time together
in family activities.” This definition evolves from the
family’s description of what they mean by the more
general problem description.
Assist the family in developing behavioral short-term Setting achievable goals increases the opportunities for
goals by: success, which increases the motivation to continue to
• Asking what they would see happening in the family if work toward problem resolution.
the situation improved
• Having them break the problem into several parts that
combine to form the identified stressor
• Asking them what they could do in a week to improve
the situation (should include a response from each fam-
ily member)
Maintain the nurse’s role of facilitator of family commu- Maintains a context that enhances and supports the fam-
nication by: ily’s problem-solving skills.
• Having family members discuss possible solutions
among themselves
• Having each family member talk about how he or she
might contribute to both the problem and the problem’s
resolution
Provide the family with the information necessary for
appropriate problem solving.
During each meeting with the family, provide posi- Promotes the family’s positive opinions of themselves,
tive comments about the family’s strengths and which opens them up to viewing the problem differ-
competencies. ently and developing more effective problem solving.17
Answer all questions in an open, direct manner. Promotes a trusting relationship.
Support the expression of affect by: Promotes communication among family members, while
• Having family members share feelings with one another developing a positive expectational set.
• Normalizing the expression of emotion (e.g., “Most
persons experience anger after they have experienced a
loss.”)
• Providing a private environment for this expression
Maintain and support a functional family role For exam- Provides positive reinforcement for functional interac-
ple, allow the parents private time alone, allow the tions, and serves to encourage this behavior while
children to visit parents, and encourage the presenting enhancing self-esteem.
of problems to the “family leader.”
(care plan continued on page 642)
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642 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Schedule a time with the family to discuss how the cur-
rent situation affects family roles and possible changes
that may be necessary.
Have the family identify the systems in the community Promotes and develops the family’s strengths.
that could support them during this time, and assist the
family in contacting these systems. Note here the sys-
tems to be contacted as well as how they will assist the
family.
Provide positive verbal reinforcement for the family’s Positive reinforcement encourages behavior and enhances
accomplishments. self-esteem.
Assist the family in identifying patterns of interaction Facilitates the development of more appropriate coping
that interfere with successful problem resolution. For behaviors.
example, the husband frequently asks his wife closed-
ended questions, which discourages her from sharing
her ideas; the children interrupt the parents when their
level of conflict increases to a certain level; or the wife
walks out of the room when the husband brings up
issues related to finances.
Assist the family in planning fun activities together. This Families in crisis often limit their emotional experience.
could include time to play or exercise together, or
engage in a shared project.
Teach the family methods of anxiety reduction; establish Relaxation response inhibits the activation of the auto-
a practice schedule and a schedule for discussing how nomic nervous system’s fight-or-flight response.
this method could be used on a daily basis in the fam- Repeated practice of a behavior internalizes and per-
ily. The selected method, along with the schedule for sonalizes the behavior.
discussion and practice, should be listed here.
Include the family in discussions related to planning care Support system involvement in problem solving increases
and sharing information about the client’s condition. the opportunities for a more positive outcome.
Assist the family in developing a specific plan when the Promotes the client’s sense of control. Planned coping
client is scheduled for a pass or discharge. Note that strategies facilitate the enactment of new behaviors
plan here, with the assistance needed from the nursing when stress is experienced. This increases the opportu-
staff for implementation. nities for successful coping and enhances self-esteem.
Alcohol
Promote a trusting therapeutic relationship during interac- Provides comfort and aids in the development of a con-
tion with the client and family by being empathetic, text that supports expressions of emotions and risking
listening actively, accepting feelings and attitudes, and change.29
being nonjudgmental.
Spend time in the initial interactions with the family dis- Assists the family in viewing the problem as outside
cussing the influence the problem or illness has on of themselves, objectifying the problem rather than the
their lives and the influence they have on the problem. person, thus making it easier for the family to see
the problem as something they can influence. Assists
the family in developing a different perspective of the
problem.17
Establish a therapeutic relationship with whatever part of Working with the nonalcoholic spouse and family mem-
the family system initiates treatment. bers can facilitate the entry of the alcoholic family
member into treatment.30
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ACTIONS/INTERVENTIONS R AT I O N A L E S
Promote open, honest communications among family Promotes verbalization of feelings and shared under-
members by facilitating group interaction. Promote the standing of problems. Assists the family to acknowl-
expression of feelings regarding current family process edge and accept the problem. Promotes a common
by spending [specific time] each shift, while the patient definition of the problem and assists in identifying
is awake, for this purpose. ways to cope.
Schedule the family for psychoeducational groups that Family involvement in early treatment improves the
explore basic information, family responses to alco- outcome.30
holism, family roles in intervention, and codependence.
Included topics should be:
• Basic disease concepts
• Family control behaviors
• Anger
• Threats
• Covering up for or enabling the alcoholic
• Personal responsibility
• Self-care
• Healthy communication
Provide a role model for effective communication by: Communication skills provide a framework for effective
• Seeking clarification problem solving.
• Demonstrating respect for individual family members
and the family system
• Listening to expression of thoughts and feelings
• Setting clear limits
• Being consistent
• Communicating clearly with the individual being
addressed
Demonstrate an understanding for the complexity of Outcome improves when family communication prob-
system problems by: lems are addressed.30
• Not taking sides in family disagreements
• Providing alternative explanations of behavior that rec-
ognize the contributions of all persons involved with
the problem
• Requesting the perspective of multiple family members
on a problem or stressor
Assist the family in defining a problem that can be
resolved. For example, rather than defining the prob-
lem as “I want him to be more responsible around the
house,” try “I would like him to take responsibility for
paying the bills by the first of the month.”
Assist the family in developing behavioral short-term Setting achievable goals increases the opportunities for
goals by: success, which increases the motivation to continue to
• Asking what they would see happening in the family if work toward problem resolution.
the situation improved
• Having them break the problem into several parts that
can bring to fore the identified stressor
• Asking them what they could do in a week to improve
the situation
Maintain the nurse’s role of facilitator of family commu- Maintains a context that enhances and supports the fam-
nication by: ily’s problem-solving skills.
• Having family members discuss possible solutions
among themselves
• Having each family member take responsibility for his or
her own actions and not accept responsibility for others
(care plan continued on page 644)
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644 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Support the expression of affect: Expression of affect is one of the most difficult areas for
• Have family members share feelings with one another. these families. Promotes learning positive ways of
• Normalize the expressions of emotion, for example, communicating among family members, while devel-
“Most families experience anger as part of the recovery oping a positive expectational set.31
process.”
• Provide a private environment for this expression.
Schedule a time with the family to discuss how the cur-
rent situation affects family roles, and possible changes
that may be necessary. [Note that schedule here with
responsible person.]
Maintain and support functional family roles; for exam- Provides positive reinforcement for functional interac-
ple, allow the parents private time alone, or allow the tions and serves to encourage this behavior while
children to visit parents. enhancing self-esteem.
Have the family identify those systems in the community Promotes and develops the family’s strengths and pro-
that could support them in recovery, and assist them in vides support systems for behavior changes.
contacting these systems (Alcoholics Anonymous, Al-
Anon, Al-Ateen). [Note here the systems to be con-
tacted and person responsible for this activity.]
Provide positive verbal reinforcement for the family’s Positive reinforcement encourages behavior and enhances
accomplishments. self-esteem.
Assist the family in planning fun activities together. This Families in crisis often limit emotional experiences.
could include time to play together, exercise together,
or engage in a shared project.
Teach the family methods of anxiety reduction; establish The relaxation response inhibits the activation of the
a practice schedule and a schedule for discussing how autonomic nervous system’s fight-or-flight response.
this method could be used on a daily basis in the fam- Repeated practice of a behavior internalizes and per-
ily. The selected method along with the schedule for sonalizes the behavior.
discussion and practice should be listed here.
Assist the family in developing a specific plan when the Promotes the client’s sense of control. Planned coping
client is scheduled for a pass or discharge. [Note that strategies facilitate the enactment of new behaviors
plan here, including the assistance needed from the when stress is experienced. This increases the opportu-
nursing staff for implementation.] nities foe successful coping and enhances self-esteem.
Readiness for Enhanced
Spend [number] minutes with family identifying their Change is dependent on the client’s perception of the
areas of concern and develop plan that will facilitate problem.23,24
their meeting goals. [Note that plan here.]
Refer the family to community programs that focus on
positive skill building such as Couples Communication
and Parent Effectiveness Training, Developmental
Assets programs (Search Institute).
Spend [number] minutes with family identifying positive Promotes positive family affect and enhances the focus
family activities and establishing a schedule for partici- on family strengths.23
pation.
Identify with family community organizations that share
their values and can assist with their ongoing develop-
ment (e.g., faith communities, youth groups,
Developmental Assets Programs).
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Family Processes, Interrupted, & Family Processes, Dysfunctional: Alcoholism & Readiness for Enhanced • 645
Gerontic Health
● N O T E : The nursing actions for the gerontic patient with these diagnoses would be
the same as those given in Adult Health and Mental Health. The prevalence of alco-
holism in older adults is reportedly lower than in the general population; however, this
may be due to the lack of age-specific screening instruments.32 In older adults, there may
be late-onset alcoholism due to an increase in the stresses associated with aging, such
as loss of a spouse, changes in health, and retirement.33 Some researchers advocate
programs that are connected to aging service programs, such as senior programs, to
assist the older alcoholic and his or her family in dealing with aging issues as well as
alcoholism.34
Home Health
See Mental Health nursing actions for detailed psychosocial interventions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family appropriate information Basic knowledge that contributes to successful family
regarding the care of family members: functioning.
• Discipline strategies appropriate for developmental
level
• Normal growth and development
• Expected family life cycles (e.g., childrearing or grand-
parenting)
• Coping strategies for family growth
• Care of health deviations
• Developing and using support networks
• Safe environment for family members
• Anticipatory guidance regarding growth and develop-
ment, discipline, family functioning, responses to ill-
ness, role changes, etc.
Involve the client and family in planning and implement- Family involvement enhances effectiveness of the inter-
ing strategies to decrease or prevent alterations in fam- vention.
ily process:
• Family conference to ascertain perspective of members
on current situation and to identify strategies to
improve situation
• Mutual goal setting to identify realistic goals with eval-
uation criteria and specific activities for each family
member
• Encouragement of clear, consistent, and honest com-
munication with positive feedback
• Distribution of family tasks so that all members are
involved in maintaining the family based on develop-
mental capacity
Assist the client and family in lifestyle adjustments that Permanent changes in behavior and family roles require
may be required: support.
• Separation or divorce
• Temporary stay in community shelter
• Family therapy
• Communication of feelings
• Stress reduction
• Identification of potential for violence
(care plan continued on page 646)
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646 • Role-Relationship Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Providing safe environment
• Therapeutic use of anger
• Seeking and providing support for family members
• Coping with catastrophic or chronic illness
• Requirements for redistributing family tasks
• Changing role functions and relationships
• Financial concerns
Consult with or refer to assistive resources as required. Utilization of existing services is efficient use of
resources. Support groups, psychiatric nurse clinicians,
and teachers can enhance the treatment plan.
GRIEVING, ANTICIPATORY 5. Any diagnosis that the family has been told has a termi-
nal prognosis
DEFINITION9
Intellectual and emotional responses and behaviors by which ✔ Have You Selected the Correct Diagnosis?
individuals, families, or communities work through the pro-
Disturbed Sensory Perception
cess of modifying self-concept based on the perception of
The diagnosis of Disturbed Sensory Perception is
potential loss. identified according to the patient’s change in capac-
ity to exercise judgment or think critically with appro-
DEFINING CHARACTERISTICS9 priate sensory–perceptual functioning. This may well
be related to Anticipatory Grieving.
1. Expression of distress at potential loss
2. Sorrow Anxiety or Fear
3. Guilt Anxiety is the response the individual has to a threat
4. Denial of potential loss that is for the most part unidentified. Fear is the
5. Anger response of an individual to an identified threat. When
6. Altered communication patterns the patient is faced with the thought of death, loss of
7. Potential loss of significant object (e.g., people, posses- a limb, loss of functioning, loss of a loved one, and so
on, Anxiety and Fear may arise as parallel diagnoses
sions, job, status, home, ideals, and parts and processes
with Anticipatory Grieving.
of the body)
8. Denial of the significance of the loss Ineffective Individual Coping
9. Bargaining Ineffective Individual Coping is the appropriate diag-
10. Alterations in: nosis if the individual is not making the necessary
a. Eating habits adaptations to deal with the threatened loss. This
b. Sleep patterns diagnosis can be a companion diagnosis to
Anticipatory Grieving.
c. Dream patterns
d. Activity level Spiritual Distress
e. Libido When faced with a devastating loss, the client may
11. Difficulty taking on new or different roles well express Spiritual Distress. This quite often is a
12. Resolution of grief prior to the reality of loss companion diagnosis to Anticipatory Grieving.
RELATED FACTORS9
EXPECTED OUTCOME
To be developed.
Will identify at least two support systems by [date].
RELATED CLINICAL CONCERNS
TARGET DATES
1. Cancer
2. Amputation A target date ranging from 2 to 4 days would be appropriate
3. Spinal cord injury in evaluating progress toward achievement of the expected
4. Birth defects outcome.
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Grieving, Anticipatory • 647
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend at least 30 minutes every 8 hours (or as the situa- A structured discussion places value on the importance
tion dictates) to address specific anticipated loss by: of grieving and provides critical data for the plan of
• Facilitating the patient’s and family’s expression of care.
perceptions of current situation (may be facilitated by
age and developmentally appropriate intervention such
as drawing, play, or puppet therapy)
• Providing active listening in a quiet, private environ-
ment
• Offering clarification of procedures, treatment, or plans
for the patient and family
• Revising plan of care to honor preferences when
possible
• Discussing and identifying impact of anticipated loss
Collaborate with appropriate health-care professional Appropriate collaboration and coordination of efforts
members to meet needs of the patient and family in results in more holistic, versus fragmented, care at a
realistically anticipating loss. time of special need. A sense of support remains long
after the event itself.
Encourage the patient and family to realistically develop Fostering coping strategies provides an opportunity for
coping strategies to best prepare for anticipated loss growth with minimal support from others, thereby
through: increasing empowerment for the family.
• Engaging in diversional activities of choice
• Reminiscing of times spent with loved one or associ-
ated with anticipated loss
• Identification of support groups
Facilitate optimal functioning for as long as possible, Participation in usual daily activities provides a sense of
with identification of need for proper attention to rest, normalcy despite impending loss and provides valida-
diet, and health of all family members at this time of tion of life.
stress.
Promote parental and sibling participation in care of the Maintenance of family input and participation in care
infant or child according to situation: offers continuation of the family unit at a time when
• Feedings and selection of menu unity can serve to positively influence daily coping
• Comfort measures such as holding the child or giving for all.
backrubs
• Diversional activities, quiet games, or stories
• Decisions regarding life-support measures and resusci-
tation
Reassure the infant or child that he or she is loved and Reassurance lessens the likelihood of guilt, while demon-
cared for, with ample opportunities to answer questions strating there is no need for assignment of blame to
regarding specific anticipated loss, whether related to any member of the family.
self or others. According to age and developmental sta-
tus, provide reassurance that the cause of the situation
is not the patient’s own doing.
(care plan continued on page 648)
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648 • Role-Relationship Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Remember that hearing is one of the last of the senses to Speaking can serve to reassure the child of worth; urge
remain functional. Exercise opportunities for loved caution in conversations that indicate the child cannot
ones and staff to continue to address the patient even hear.
though the patient may be unable to answer or respond.
Provide for appropriate safety and maintenance related to Standard practice requires safety maintenance. Special
physiologic care of the patient. attention is required when the infant or child is coma-
tose or cannot respond regarding sensations, especially
for pressure areas, heat, or cold.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Obtain a thorough obstetric history, including previous Provides an essential database needed to plan for effec-
occurrences of fetal demise. tive interventions.
Ascertain whether there were any problems conceiving
this pregnancy or any attempts to terminate this preg-
nancy.
Assess and record the mother’s perception of cessation of
fetal movements.
Monitor and record fetal activity or lack of activity.
Inform the mother and significant others of antepartal
testing and why it is being ordered, and explain results:
• Nonstress testing
• Oxytocin (Pitocin) challenge test
• Ultrasound
Be considerate and honest in keeping the patient and sig- Promotes a trusting relationship and provides support
nificant other(s) informed. Share information as soon during a very difficult time.
as it becomes available.
Allow the mother and family to express feelings and Provides support and care to the patient and family, who
begin the grieving process. are unable to begin real grieving because death is not
yet real to them while they are going through a “nor-
mal” birthing process.
With the collaboration of the physician, facilitate neces-
sary laboratory tests and procedures (e.g., blood tests
such as complete blood count, type, and crossmatch;
disseminated intravascular coagulation [DIC] screening
and coagulation studies; real-time or obstetric ultra-
sound; or amniotomy).
Provide emotional support for the couple during labor
and the birth process.
Closely monitor the physiologic process of labor.
Explain the procedure of induction of labor and the use In instances where fetal death has been ascertained, labor
of Pitocin, IVs, and the uterine contraction pattern. is induced to prevent further complications.
Watch for nausea, vomiting, and diarrhea.
Provide comfort measures: analgesics, tranquilizers, and
medications for side effects, or prostaglandins as ordered
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Grieving, Anticipatory • 649
ACTIONS/INTERVENTIONS R AT I O N A L E S
Change the patient’s position at least every 2 hours on
[odd/even] hour.
Observe for full bladder. Record intake and output every
8 hours.
Provide ice chips for dry mouth, and lip balm or petro-
leum jelly for dry lips.
Monitor vital signs every 2 to 4 hours at [times].
Utilize breathing and relaxation techniques with the
patient for comfort.
Inform the physician of the mother’s wishes for use of
anesthetic for birth (e.g., awake and aware, sedated, or
asleep).
Prepare the infant for viewing by the mother and signifi- Initiates the grieving process in a supportive environment.
cant others: Demonstrates respect for and understanding of the
• Clean the infant as much as possible. family’s emotional state.
• Use clothing to hide gross defects, such as a hat for
head defects and a T-shirt or diapers for trunk defects.
• Wrap in a soft, clean baby blanket (allow the mother to
unwrap the infant if she desires).
Provide a private, quiet place and time for the parents and Provides essential support for the family during time of
family to: grief. Provides reality by letting the parents hold the
• See and hold the infant infant.
• Take pictures
Provide a certificate with footprints, handprints, lock of
hair, armbands, date and time of birth, weight of the
infant, and name of the infant.
Ask the client whether she has a faith community. Asking about a faith community is less threatening than
using the term religion. The client is more likely to
respond.
Contact the religious or cultural leader as requested by
the mother or significant other. Provide for religious
practices such as baptism.
Provide references to supportive groups within commu-
nity, such as Resolve with Sharing or Parents of
Miscarried Children.
Explain the need for autopsy or genetic testing of the
infant.
In instances of infertility, assist in realistic planning for Provides a database that can be used in assisting the cou-
the future: ple to cope with situation and initiate realistic planning
• Possible extensive testing for the future.
• Fear
• Economics
• Uncertainty
• Embarrassment
• Surgical procedures
• Feelings of inadequacy
• Life without children
• Adoption
(care plan continued on page 650)
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650 • Role-Relationship Pattern
Mental Health
● N O T E : It may take clients anywhere from 6 months to a year or more to grieve a
loss. This should be taken into consideration when developing evaluation dates. In a
short-stay hospitalization, a reasonable set of goals would be to assist the client system
in beginning a healthy grieving process. It is also important to note the anniversary date
because grief reaction can be experienced past the 1-year period noted here.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assign the client a primary care nurse, and inform client Promotes the development of a trusting relationship.
of this decision. This nurse must have a degree of com-
fort in discussing issues related to loss and grief.
The primary care nurse will spend 30 minutes once a Promotes the development of a trusting relationship and
shift with the client discussing his or her perceptions of provides a supportive environment for the expression
the current situation. These discussions could include: of feelings, which facilitates a healthy resolution of
• His or her perceptions of the loss the loss.
• His or her values or beliefs about the lost “object”
• Client’s past experiences with loss and how these were
resolved
• The client’s perceptions of the support system and pos-
sible support system responses to the loss
The primary care nurse will schedule 30-minute interac-
tions with the client and support system to assist them
in discussing issues related to the loss and answering
any questions they might have. [Note time and date of
this interaction here.]
The primary care nurse will discuss with the client and Anticipatory planning facilitates adaptation.
family role adjustments and other anticipated changes
related to the loss.
If necessary after the first interaction, the primary care
nurse will schedule follow-up visits with the client and
his or her support system. [Note schedule for these
interactions here.]
Spend [number] minutes (this should begin as 5-minute Promotes the development of a trusting relationship
sessions, and can increase to 10 minutes as the client and the client’s sense of control.
needs and unit staffing permit) with the client each
hour. If the client does not desire to talk during this
time, it can be used to give a massage (backrub) or sit
with the client in silence. Inform the client of these
times, and let him or her know if for some reason this
schedule has to be altered, and develop a new time for
the visit. Inform the client that the purpose of this time
is for him or her to use as he or she sees fit. The nurse
should be seated during this time if he or she is not
providing a massage.
Provide positive verbal and nonverbal reinforcement to Positive reinforcement encourages the behavior and
expressions of grief from both the client and the sup- enhances self-esteem.
port system. This would include remaining with the
client when he or she is expressing strong emotions.
Once the client and the support system are discussing the Facilitates healthy resolution of the loss.
loss, assist them in scheduling a time when they can be
alone with the client.
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Grieving, Anticipatory • 651
ACTIONS/INTERVENTIONS R AT I O N A L E S
Answer questions in an open, honest manner. Promotes the development of a trusting relationship and
the client’s sense of control.
If the client expresses anger toward the staff, and this Expression of anger is a normal part of the grieving
anger appears to be unrelated to the situation, accept it process, and it is “safer” to be angry with members of
as part of the grieving process and support the client in the health-care team than with the family.
its expression by:
• Not responding in a defensive manner
• Recognizing the feelings that are being expressed (e.g.,
“It sounds like you are very angry right now,” or “It
can be very frustrating to be in a situation where you
feel you have little control.”)
Recognize that the stages of grief progress at individual Supports the client’s perception of control and strengths.
rates and in various patterns. Do not “force” a client
through stages or express expectations about what the
“normal” next step should be.
If the client is in denial related to the loss, allow this to Serves as a way for the client to protect him- or herself
happen, and provide the client with information about from information he or she is not ready to cope with.
the loss at the client’s pace. If the client does not As coping behaviors are strengthened, the client will
remember information given before, simply provide the be able to accept and respond to this information.
information again.
Allow the client and the support system to participate in Promotes the client’s sense of control and enhances his or
decisions related to nursing care. Areas in which client her strengths.
decision making is to be encouraged should be noted
here along with the client’s decisions.
Normalize the client’s and support system’s experience of Promotes the client’s sense of control and promotes a
grief by telling the client that his or her experience is positive orientation, which enhances self-esteem.
normal, and by discussing with him or her potential
future responses to loss.
Recognize that this is an emotionally painful time for the Encourages expression of feelings and facilitates progres-
client and the support system, and share this under- sion through the grieving process.
standing with the client system.
Assist the client in obtaining the spiritual support needed.
Monitor the use of sedatives and tranquilizers. Consult Extensive use of these medications may delay the griev-
with the primary care provider if overuse is suspected. ing process.
Monitor the client system’s use of alcohol and nonpre- These are symptoms of ineffective coping and interfere
scription drugs as a coping method. (Refer to Ineffec- with the normal grieving process.
tive Individual Coping in Chapter 11 if this is
identified as a problem.)
Have the client and the support system develop a list of Promotes the client’s strengths.
concerns and problems, and assist them in determining
those they have the ability to change and those they
do not.
When they have a list of workable problems, have the Facilitates creative problem solving by assisting the
client system list all of the solutions they can think of family to break the “more-of-the-same” problem-
for a problem; encourage them to include those solu- solving set.
tions they think are impossible or just fantasy solu-
tions. Do this one problem at a time.
After solutions have been generated, assist the client in Promotes the development of creative problem solutions.
evaluating solutions generated. Solutions can be com-
bined, eliminated, or altered. From this list the best
solution is selected. It is important that the solution
selected is the client’s solution.
(care plan continued on page 652)
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652 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client in developing a plan for implementing Planned coping strategies facilitate the enactment of new
this solution. [Note here any assistance needed from behaviors when the client is experiencing stress.
the nursing staff.]
Monitor the client for signs and symptoms of dysfunc- Early intervention promotes a positive outcome.
tional grieving.
Monitor the client’s nutritional pattern, and refer to Nutritional status impacts the individual’s ability to cope.
appropriate nursing diagnoses if a problem is
identified.
Develop an exercise plan for the client. Consult with the Exercise increases the production of endorphins, which
physical therapist as needed. Develop a reward sched- contribute to feelings of well-being.
ule for the accomplishment of this plan. Note the
schedule for the plan here. This can also include the
support system.
Provide assistance for the support system by: Support system reactions can impact the client.
• Having them develop a schedule for rest periods
• Providing snacks for them and scheduling periods of
high nursing involvement with the client at a time
when support persons can obtain meals. (This can reas-
sure the support person that the client will not be alone
while he or she is gone.)
• Assisting the support system in finding cafeteria and
transportation
• Suggesting that support persons rest or walk outside or
around hospital while the client is napping
• Helping support persons discuss their feelings with the
client
• Facilitating interaction with client’s/significant other’s
faith community if they feel this will be supportive in
coping with the loss.
Gerontic Health
In addition to the interventions for Adult Health and Mental Health, the following may be utilized with the aging client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide information to the patient regarding what is This intervention is viewed by survivors as especially
occurring, and expected or anticipated changes. helpful during the dying process.35
Discuss, with the individual, the grieving process, what Provides information on common responses to loss and
can be anticipated, and how each person grieves in his what emotions are commonly experienced by grieving
or her own way. people. Promotes the grieving process and reassures
the survivor that he or she is coping well.
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Grieving, Anticipatory • 653
Home Health
See Mental Health nursing actions for detailed interventions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family appropriate monitoring of Provides a database for early recognition and inter-
signs and symptoms of anticipatory grief: vention.
• Crying, sadness
• Alterations in eating and sleeping patterns
• Developmental regression
• Alterations in concentration
• Expressions of distress at loss
• Denial of loss
• Expressions of guilt
• Labile affect
• Grieving beyond expected time
• Preoccupation with loss
• Hallucinations
• Violence toward self or others
• Delusions
• Prolonged isolation
Involve the client and family in planning and implement- Family involvement in planning enhances the effective-
ing strategies to reduce or cope with anticipatory ness of the plan.
grieving:
• Family conference: Develop list of concerns and prob-
lems; identify those concerns that family can control.
• Mutual goal setting: Set short-term realistic goals and
evaluation criteria. Specify the role of each member.
• Communication: Discuss the loss in a supportive envi-
ronment.
Assist the client and family in lifestyle adjustments that Permanent changes in behavior and lifestyle are facili-
may be required: tated by knowledge and support.
• Providing realistic hope
• Identifying expected grief pattern in response to loss
• Recognizing a variety of accepted expressions of grief
• Developing and using support networks
• Communicating feelings
• Providing a safe environment
• Therapeutic use of denial
• Identifying suicidal potential or potential for violence
• Therapeutic use of anger
• Exploring meaning of situation
• Stress reduction
• Promoting expression of grief
• Decision making for the future
• Promoting family cohesiveness
Assist the client and family to set criteria to help them Provides data for early intervention.
determine when intervention of a health-care profes-
sional is required (e.g., if the client is threat to self or
others, or if the client is unable to perform activities of
daily living).
Consult and/or refer to assistive resources as indicated. Utilization of existing services is efficient use of resources.
Self-help groups, a religious counselor, or a psychiatric
nurse clinician can enhance the treatment plan.
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654 • Role-Relationship Pattern
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Grieving, Dysfunctional, Risk For and Actual • 655
Child Health
● N O T E : It is difficult to make general assumptions as to how each child views death,
but according to previous patterns of behavior, including communication, it would be
necessary to allow for developmental patterns previously attained. In young children,
there may be manifestations of obsessive, ritualistic behavior related to the loss or activ-
ities surrounding the loss. For example, if a loved one died, young children may think
that if they fall asleep they may also die. In the event of grieving, regardless of the pre-
cipitating event, the child must be allowed to respond in keeping with developmental
capacity. At times when the child is in danger of self-injury or injuring others, the risk
for violence must be considered.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide opportunities for expression of feelings related to Expression of feelings helps the client deal with the sense
loss or grief according to developmental capacity (e.g., of loss and provides a database for intervention.
puppets or play therapy for toddlers). Expression of grief reduces uncontrolled outbursts.
In the event of a family member’s death, offer support in Provides a database for more accurate intervention in
understanding the deceased family member’s relation- dealing with the loss.
ship to the patient, and status for the family, with spe-
cial attention to siblings and their reactions. Identify
the impact the grief has for family dynamics via moni-
toring of family dynamics.
Allow for cultural and religious input in the plan of care, Demonstrates valuing of these beliefs to the family, and
especially related to care of the dying patient and care decreases stress for the family.
of the patient at the time of death.
Collaborate with professionals and paraprofessionals to Collaboration offers the most comprehensive plan of care
aid in resolution of grief according to family prefer- and avoids fragmentation of care.
ences.
Identify support groups to assist in resolution of grief, Support groups offer validation of feelings and a sense of
such as Compassionate Friends Organization. hope as similar concerns are shared.
Assist the family members in identification of coping Provides for support during the adjustments that are
strategies needed for resultant role-relationship required because of the loss of a loved one.
changes.
Assist the family members to resolve feelings of loss via Reminiscing and valuing past experiences will offer an
reminiscing about loved one, positive aspects of situa- opportunity to project the impact for the present and
tion, or personal growth potential presented. Remember future.
that behavior often serves as the most effective commu-
nication for the child or young toddler.
Allow the family members time and space to face the Time and readiness promote the willingness to discuss
reality of the situation and ponder the meaning of the feelings after the major emotional shock has dimin-
loss for self and the family. ished.
Direct the family to appropriate resources regarding posi- A sense of fulfillment may be derived from the sharing of
tive methods of acknowledging the loved one through time, talent, or money in honor of the loved one. This
memorials or related processes. affords some sense of resolve of the guilt or emptiness
associated with the loss.
Assist in referral to appropriate resources for funeral In times of emotional duress, objective decisions may be
planning and arrangements if needed. difficult. Providing assistance will offer empowerment
and a sense of coping.
In the event of SIDS, provide an opportunity, through a
scheduled conference, for verbalization of:
• How the infant’s death occurred
• Police investigation
• Sense of guilt
(care plan continued on page 656)
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656 • Role-Relationship Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Feelings of powerlessness
• Questions
• Anger
• Disbelief
• Fears for future pregnancies and birth
Identify the impact the death or grief has on other family Provides the essential database that can assist in planning
members, the relationship of the couple, and the cou- that will offset the development of dysfunctional
ple’s attitude toward having other children. grieving.
Make referrals, as appropriate, to psychiatrist, psycholo- Anticipatory guidance lessens likelihood of unresolved
gist, mental health nurse clinician, or counselor. grief.
Dysfunctional Grieving, Risk for
Assess for contributory factors, especially precipitating Provides a relevant base for the plan.
loss of significant family member, friend, or situational
move/catastrophic event.
Determine previous coping capacity with input from reli- Helps establish a realistic baseline.
able informants (e.g., the caregiver).
Seek input from all primary paraprofessionals including Offers continuity with greater likelihood of trust in the
child psychiatrist, psychologist, child life specialist, and team.
nursing specialists during the time of greatest need.
Institute the plan for assisting with those factors that are Provides anticipatory planning, thereby reducing stress
modifiable with truth and honesty as soon as possible: with the likelihood of acceptance of the plan with a
• Determine actual response versus usual expected sense of control.
response according to all factors surrounding the prob-
lem based on previous data, especially the meaning for
the anticipated loss in the life of this child.
• Set aside time for planning an approach to the problem.
• Identify with the child, family, and team strategies for
reduction of stress related to anticipated loss.
Honor cultural wishes, especially religious and cultural Demonstrates cultural sensitivity and increases the likeli-
rituals that enhance positive coping capacity. hood of reduction of sense of loss.
Provide information for the child and family about sup- Offers realistic oneness for similar populations, thereby
port groups in the community. affording hope for acceptance of/dealing with antici-
pated loss.
Establish a plan for ongoing counseling or assistance Offers anticipatory guidance to reduce secondary risk.
after the current episode.
Reinforce plan of coping with realistic expectations for Reinforces learning.
success using appropriate feedback. For example, for
very young children use stickers or some other form of
immediate reward.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Schedule a 30-minute daily conference with the couple Initiates expression of emotions that allows gradual trans-
and focus on: ference through the grief process. Allows clarification
• Expression of grief, anger, guilt, or frustration of issues related to a pregnancy that has not resulted in
a healthy infant.
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Grieving, Dysfunctional, Risk For and Actual • 657
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Exploring expectations regarding children (e.g., the
couple’s, relatives’, and society’s expectations)
• Providing factual information (on whichever diagnosis
is appropriate) regarding SIDS, stillbirth, or abortion
• Encouraging the couple to honestly share feelings with
each other
During the conference, encourage the couple to ask ques-
tions through open-ended questions, reflection, etc.
Monitor, during hospitalization, for signs and symptoms Provides the database necessary to permit early interven-
of depression, anger, frustration, and impending crisis. tion and prevention of more serious problems during
this crisis.
Encourage the couple to seek professional help, as neces- Fetal demise, SIDS, the decision to have an abortion, and
sary, to deal with continued concerns, such as their the like all have long-term effects; therefore, long-term
sexual relationship, conflicts, anxieties, parenting, and support will be required.
coping mechanisms that can be used to deal with the
loss of fertility.
Assist the couple, through teaching and provision of writ- Avoids unrealistic expectations regarding grief resolution.
ten information, to realize that grief may not be
resolved for more than a year.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the source of the interference with the grieving Early recognition and intervention can facilitate the griev-
process. ing process.
Monitor the client’s use of medications and the effects Sedatives and tranquilizers may delay the grieving
this may have on the grieving process. Consult with the process.
physician regarding necessary alterations in this area.
Assign a primary care nurse to the client. Facilitates the development of a trusting relationship.
Provide a calm, reassuring environment. Excessive environmental stimuli can increase the client’s
confusion and disorganization.
When the client is demonstrating an emotional response Encourages appropriate expression of feelings.
to the grief, provide privacy and remain with the client
during this time.
The primary care nurse will spend 15 minutes twice a Facilitates the development of a trusting relationship.
day with the client at [times]. These interactions should Rituals are most helpful in situations where there is
begin as nonconfrontational interactions with the confusion because of incompatible demands.16
client. The goal is to develop a trusting relationship so
the client can later discuss issues related to the grieving
process. If the client and support system do not iden-
tify rituals that would facilitate the grieving process,
assist them in developing rituals as appropriate. [Note
here the rituals and any assistance needed in complet-
ing the ritual.]
Monitor the level of dysfunction, and assist the client Facilitates the development of a trusting relationship.
with activities of daily living as necessary. [Note type
and amount of assistance here.]
Monitor nutritional status, and refer to Imbalanced Alterations in nutrition can impact coping abilities, or
Nutrition in Chapter 3 for detailed care plan. diminished coping abilities can lead to alterations in
nutrition.
(care plan continued on page 658)
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658 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor significant others’ response to the client, and have Support system understanding facilitates the maintenance
the primary care nurse set a schedule to meet with them of new behaviors after discharge.
and the client every other day to answer questions and
facilitate discussion between the client and the support
system. [Note schedule for these meetings here.]
Provide the spiritual/cultural support that the client indi- Clients may find answers to their questions about life and
cates is necessary. Note here the type of assistance loss through spiritual/cultural expression.
needed from the nursing staff. (Refer to Chapter 12
for clients needing in depth spiritual support.)
Allow the client to express anger, and assure him or her Violent behavior can evolve from unexpressed anger.
that you will not allow harm to come to anyone during Appropriate expression of anger promotes the client’s
this expression. sense of control and enhances self-esteem.
Provide the client with punching bags and other physical Assists the client in developing appropriate coping behav-
activity that assists with the expression of anger. [Note iors that enhance self-esteem.
tools preferred by this client here. Note the specific
activities that assist this client with this expression here.]
Remind the staff and support system that the client’s Support system understanding facilitates the maintenance
expressions of anger at this point should not be taken of new behaviors after discharge.
personally, even though they may be directed at these
persons.
Answer questions directly and honestly. Promotes the development of a trusting relationship.
Provide the time and opportunity for the client to partici- Rituals provide clarity and direction for the grieving
pate in appropriate religious rituals. [Note here assis- process.
tance needed from nursing staff.]
Sit with the client and listen attentively while he or she is The presence of the nurse provides positive reinforce-
talking about the lost object. ment, which encourages the behavior.
When the client’s verbal interactions increase with the Provides opportunities for peer feedback and peer assis-
primary care nurse to the level that group interactions tance with problem solving.
are possible, schedule the client to participate in a
group that allows expression of feelings and feedback
from peers. [Note the schedule of the group here.]
Assign the client appropriate tasks in unit activities. Note Successful accomplishment of tasks enhances self-
type of tasks assigned here. These should be based on esteem.
the client’s level of functioning and should be at a level
that the client can accomplish. [Note type of tasks to
be assigned to the client here.]
If delusions, hallucinations, phobias, or depression are
present, refer to Ineffective Individual Coping in
Chapter 11, and Disturbed Thought Process in Chapter
7. Some persons in active functional grief may experi-
ence hallucinations of the lost person. Tell them that
this is common and subsides as their grief is resolved.
The primary care nurse will engage the client and the Planned coping strategies facilitate the enactment of new
support system in planning for lifestyle changes that behaviors when the client is experiencing stress, which
might result from the loss. [Note the schedule for these enhances self-esteem.
interactions here, along with the specific goals.]
Refer the client and family to community resources that These resources will provide ongoing support when the
support grieving individuals (e.g., hospice, faith com- client is discharged.
munities, and grief centers).
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Parent, Infant, and Child Attachment, Impaired, Risk For • 659
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Carefully assess the client for risk of self-harm. Should a Prevention of complications.
risk for self harm be determined, please move directly
to Violence: Risk for Self-Harm interventions.
Listen to the client when they are ready to talk; avoid the Listening is an essential source of support.36
temptation to offer advice or opinions and focus on lis-
tening.
Access additional resources as appropriate to the client to Collaboration with the interdisciplinary team provides
include: the most comprehensive client care.36
• Chaplain
• Psychiatrist
• Physician
• Social services
• Palliative clinical nurse specialist
Avoid artificial positivism. Accept the client’s negative Individualizes care and acknowledges the client’s
feelings. feelings.37
PARENT, INFANT, AND CHILD effectively initiate parental contact as a result of altered
ATTACHMENT, IMPAIRED, RISK FOR behavioral organization
5. Lack of privacy
DEFINITION9 6. Inability of parents to meet personal needs
Disruption of the interactive process between parent, or sig- 7. Separation
nificant other, and infant that fosters the development of a
protective and nurturing reciprocal relationship. RELATED FACTORS9
The risk factors also serve as the related factors.
RISK FACTORS9
1. Physical barriers RELATED CLINICAL CONCERNS
2. Anxiety associated with the parent role 1. Premature infant
3. Substance abuse 2. Chronically ill child
4. Premature infant, ill infant, or child who is unable to 3. Chronically ill parent
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660 • Role-Relationship Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for factors regarding the infant that contribute to A thorough assessment of reciprocal behaviors will serve
or influence maternal or paternal or parent or infant as a guide to specific needs of parent–infant dyad.
reciprocity:
• Inability to send cues for needs
• Inability of the mother or father to attend to cues Provides major concepts of maternal sensitivity that are
appropriately and in a timely manner. antecedents to infant attachment.39
• Inability of the mother or father to comfort the infant
• Mismatch of temperament of the infant to the mother
or father
• Parental verbalization of feelings about the infant less
than ideal for appropriate bonding
Explore actual parent–infant interactions and note
strengths and deficits.
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Parent, Infant, and Child Attachment, Impaired, Risk For • 661
ACTIONS/INTERVENTIONS R AT I O N A L E S
Identify behaviors so unsafe as to suggest the need for Safety and legal needs will help protect the infant in an
separation of the infant from the parent, that is, physi- unsafe relationship.
cal or emotional abuse. (Involve Child Protective
Services according to protocols for location; a hotline
is available nationally.)
Offer role modeling and parenting teaching modules at Often new parenting roles must be acquired as there may
readiness of the parents and when deemed suitable to be no suitable role modeling in the parent’s own child-
do so: hood.40
• Normal growth and development
• Special care for the infant
When the parents must be absent, maintain communica- Trust and sincerity will support the parents in this
tion that is consistent, ideally with the same few indi- demanding role.
viduals, to maintain long-term relationship.
Involve appropriate support services as indicated in a Support during the time of need will enable the parents to
timely manner (e.g., Ronald McDonald House for be near the infant as much as possible.
lodging, and local social services agencies).
Ensure appropriate counseling and follow-up for all Long-term goals are best established during the acute
members as may be deemed essential. phase of the crisis.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Pregnancy
Encourage the expectant parents to discuss their percep- Allows expectant parents to progress through pregnancy
tions and expectations of the pregnancy. in a satisfactory and satisfying manner. Provides a
Provide a nonthreatening atmosphere to encourage the knowledge base, and helps the parents know that what
parents to discuss their fears and concerns. they are experiencing is normal.39,40
Assist the parents to dispel myths about birth, the post-
partum period, and early parenthood.
Assist the parents to plan for changes in financial require-
ments of pregnancy, birth, and early parenthood.
Encourage the parents to talk to the fetus, spend time
together feeling the fetus move, etc.
Encourage attendance in various classes that can assist in
the transition to parenthood.
Assist the parents in identifying community resources
available to expectant and new parents.
Parenthood39–42
Encourage the new parents to touch, talk to, and observe Allows time for new parents to become acquainted with
the newborn as soon as possible (immediately is best). their newborn, learn the infant’s cues, and begin to
Encourage comparison of newborn characteristics to respond to the needs of the infant.40,41
those of the fantasized newborn.
Mental Health
Nursing actions for this diagnosis can be found in Child Health and Women’s Health care plans.
(care plan continued on page 662)
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662 • Role-Relationship Pattern
Gerontic Health
This diagnosis is not appropriate to use with gerontic clients.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client and family in planning and implement- Family involvement enhances the effectiveness of the
ing strategies to decrease or prevent alterations in intervention.
attachment:
• Identify family strengths and weaknesses.
• Design strategies to support strengths and correct
weaknesses.
• Provide a safe environment.
Teach parenting strategies and techniques to enhance Parenting is learned behavior.
parent–child interactions.
• Appropriate stimulation for the child
• Consistent approach to parenting
Consult with or refer to community resources as required. Provides efficient use of existing resources.
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Parenting, Impaired, Risk For and Actual, Readiness for Enhanced and Parental Role Conflict • 663
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664 • Role-Relationship Pattern
•
•
Copyright © 2007 by F. A. Davis. •
•
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Parenting, Impaired, Risk For and Actual, Readiness for Enhanced and Parental Role Conflict • 665
•
•
Copyright © 2007 •by F. A. Davis.
•
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666 • Role-Relationship Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss with the patient strategies to meet Their emo- Self-care is an essential foundation for being supportive
tional needs. [Note that plan here with the assistance to others.
needed from the health care team to implement.]
Explore the patient’s feelings regarding the parenting
role. Address any areas of concern. [Note plan for
addressing these concerns here.]
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review current level of knowledge regarding parenting of Provides a database needed to accurately plan care.
the infant or child to include:
• Parental perception of the infant or child
• Parental views of expected development of the infant or
child
• Health status of the infant or child
• Current needs of the infant or child
• Infant or child communication (remember, behaviors
reveal much about feelings)
• Infant’s or child’s usual responsiveness
• Family dynamics (e.g., who offers support for emo-
tional needs or the child’s view of mother and father)
Determine needs for specific health or developmental Needs may be identified with assistance from experts in
intervention from other health-care providers as multidisciplinary domains. Collaboration is essential to
needed. avoid fragmentation of care.
Observe parental readiness, and encourage caretaking in a Provides data needed to plan teaching and to provide
supportive atmosphere in the following ways, as appli- individualization of the plan of care.
cable:
• Feeding
• Bathing
• Anticipatory safety measures
• Clarification of medical or health maintenance regimen
• Play and developmental stimulations for age and
capacity
• Handling and carriage of the infant or child
• Diapering and dressing of the infant or child
• Social interaction appropriate for age and capacity
• Other specific measures according to the patient’s sta-
tus and needs
Schedule a daily conference of at least 1 hour with the Provides a teaching opportunity. Verbalization reveals
parents, and encourage the parents to verbalize per- thoughts and data needed to more accurately plan care.
ceived parenting role, both current and desired.
Allow the parents to gradually assume total care of the Provides an opportunity for practice of needed skills or
infant within the hospital setting at least 48 hours before roles; fosters growth and confidence in parenting.
dismissal. If more time is required to validate appropri-
ate parenting success, collaborate with the pediatrician
regarding extending the child’s stay for 24 hours.
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Parenting, Impaired, Risk For and Actual, Readiness for Enhanced and Parental Role Conflict • 667
ACTIONS/INTERVENTIONS R AT I O N A L E S
Readiness for Enhanced This is a wellness concept and, as such, the health-care
provider should be a resource and support for the par-
ents, providing them with correct information and
helping them sort out the appropriate information
about parenting.
Provide parents with resources for information and sup-
port in the early days of parenting.
• Parenting classes
• Parenting support groups
• Being available to help translate and sort out informa-
tion if needed.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient, through monthly conferences, in com- Acceptance of pregnancy and working through the tasks
pleting the tasks of pregnancy by encouraging verbal- of pregnancy provide a strong basis for positive parent-
ization of: hood and appropriate attachment and bonding.39–42
• Fears
• The mother’s perception of marriage
• The mother’s perception of the “child within” her
• The mother’s perception of the changes in her life as a
result of this birth:
• Relationship with the partner
• Relationship with other children
• Effects on career
• Effects on family
Allow the mother to question the pregnancy: “Now” and
“Who, me?”42
Assist the mother in realizing the existence of the child Provides a basis for appropriate attachment behaviors and
by encouraging the mother to: coping skills for transition to the maternal role.
• Note when the infant moves.
• Listen to fetal heart tones during the visit to the clinic.
• Discuss body changes and their relationship to the
infant.
• Verbalize any questions she may have.
Assist in preparation for birth by:
• Encouraging attendance at childbirth education classes
• Providing factual information regarding the birthing
experience
• Involving significant others in preparation for birthing
process
Assist the patient in preparing for role transition to
parenthood by encouraging:
• Economic planning (e.g., physician, hospital, or prena-
tal testing fees)
• Social planning (e.g., changes in lifestyle)
Assist the patient in identifying needs related to the fam- Assists in identifying patients at high risk for the devel-
ily’s acceptance of the newborn: opment of this diagnosis.
• Mother’s perceived level of support from family
members
(care plan continued on page 668)
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668 • Role-Relationship Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Stressors present in the family (e.g., economics, hous-
ing, or level of knowledge regarding parenting)
Monitor for the following behaviors:
• Refuses to plan for the infant
• No interest in pregnancy or fetal progress
• Overly concerned with own weight and appearance
• Refuses to gain weight (diets during pregnancy)
• Negative comments about “What this baby is doing
to me!”
Postpartum
Assist the patient and significant others in establishing
realistic goals for integration of the baby into the
family.
Provide positive reinforcement for parenting tasks: Promotes realistic planning for the new baby as well as
• Encourage use of birthing room: labor, delivery, and bonding and attachment.39–42
recovery (LDR) room and labor, delivery, recovery, and
postpartum (LDRP) rooms—for birth to allow active
participation in birth process by both parents.
• Allow the mother and partner time with the infant (do
not remove to nursery if stable) after delivery.
• Provide mother–baby care to allow maximum continu-
ity of mother–infant contact and nursing care.
Assist the parents in identifying different kinds of infant Provides the parents with essential information they need
behavior and understanding how they allow the infant to care for the infant.
to communicate with them:
• Perform gestational age assessment with the parents,
and explain the significance of the findings.
• Perform Brazelton neonatal assessment with the par- Teaches parents to recognize their infant’s cues and how
ents, and explain the significance of the findings. to respond to them. This interaction between parent
• Demonstrate how to hold the infant for maximum com- and infant is a major factor in the brain development of
munication. the infant.
• Explain infant reflexes (e.g., rooting or Moro) and the
importance of understanding them.
Assist the parents in identifying support systems:
• Friends from childbirth classes
• Parents and parents-in-law
• Siblings
• Nurse specialists
Encourage the parents to reminisce about the birthing
experience.
Assist the patient in identifying needs related to family Provides the database needed for planning to offset fac-
functioning: tors that would result in ineffective parenting.39–42
Identify negative maternal behavior:
• No interest in the new baby
• Talks excessively to friends on the telephone
• Is more interested in TV than in feeding the infant
• Refuses to listen to infant teaching
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ACTIONS/INTERVENTIONS R AT I O N A L E S
• Asks no questions
• Extraordinary interest in self-appearance:
• Severe dieting to gain pre-pregnancy figure
• Overutilization of exercise to gain pre-pregnancy
figure
• Crying, moodiness
• Lack of interest in the family and other children
• Failure to perform physical care for the infant
• Noncompliance: Breaks appointments with health-care
providers for self and the infant
Identify negative paternal behavior:
• Refusal to support wife by:
• Not assisting in child care
• Not sharing household tasks
• Keeping “his” social contacts and going out while
the wife remains at home with the child
• Not providing financial support
• Abandonment
Assist the patient in identifying methods of coping with Provides long-term support.
stress of the newborn in the family:
• Seek professional help from the nurse specialist, physi-
cian (obstetrician or pediatrician), or psychiatrist
• Identify the support system in the family or among
friends
• Refer to appropriate community or private agencies
Readiness for Enhanced This is a wellness concept and as such the health-care
provider should be a resource and support for the par-
ents, providing them with correct information and
helping them sort out the appropriate information
about parenting.
Provide parents with resources for information and sup-
port in the early days of parenting.
• Parenting classes
• Parenting support groups
• Being available to help translate and sort out informa-
tion if needed.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the degree to which drugs and alcohol interfere Early intervention and treatment increase the likelihood
with the parenting process. If this is a factor, discuss a of a positive outcome.
treatment program with the client.
Ask the client who is caring for the children while he or Early intervention and treatment increase the likelihood
she is hospitalized, and assess his or her level of com- of a positive outcome.
fort with this arrangement. If a satisfactory arrange-
ment is not present, refer to social services so
arrangements can be made.
Discuss with the client expectations and problem Promotes the client’s sense of control.
perception.
(care plan continued on page 670)
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670 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Have the client identify support systems, and gain per- Support system understanding facilitates the maintenance
mission to include these persons in the treatment plan of behaviors after discharge.
as necessary. This could include spouse, parents, close
friends, etc.
If the client desires to maintain parenting role, arrange to A continuous relationship between the parent and the
have the children visit during hospitalization. Assign a child is necessary for the normal development of the
staff member to remain with the client during these child.43
visits. The staff person can serve as a role model for
the client and facilitate communication between the
child and the client. [Note schedule for these visits
here and the staff person responsible for the supervi-
sion of these interactions.]
Answer the client’s questions in a clear, direct manner. Promotes the development of a trusting relationship.
Spend 15 minutes twice a day at [times] with the client Promotes the development of a trusting relationship, and
discussing his or her perception of the parenting role provides information abut the client’s worldview that
and his or her expectations for self and the children. can be utilized in constructing interventions.
Arrange 30 minutes a day for interaction between the Supports the maintenance of these relationships, and pro-
client and one member of the support system. A staff vides opportunities for the nurse to do positive role
member is to be present during these interactions to modeling.
facilitate communication and focus the discussion on
parenting issues.
Provide the client with information on normal growth and Provides information that will assist the client in making
development and normal feelings of the parents. appropriate parenting decisions, enhancing self-esteem.
Provide the client with concrete information about Provides parents with specific strategies for affirmation
building age-appropriate developmental assets. This of parent and child interactions that support positive
could include setting appropriate boundaries, providing child development.
appropriate support, and constructive use of time.44
Assist the client in developing a plan for disciplining the Facilitates the development of positive coping behaviors
children. This plan should be based on behavioral and promotes a positive expectational set.
interventions, and the primary focus should be on posi-
tive social rewards.44
Teach the client ways of interacting with the child that Promotes positive orientation and enhances self-esteem.
reduce levels of conflict (e.g., providing the child with
limited choices, spending scheduled time with the
child, and listening carefully to the child).
Encourage the client to maintain telephone contact with Assists in maintaining these important relationships to
the children by providing a telephone and establishing make the transition home easier.
a regular time for the client to call home, or have the
children call the hospital.
Encourage the support system to continue to include the Assists in maintaining the client’s role functioning, thus
client in decisions related to the children by having enhancing self-esteem.
them bring up these issues in daily visits, and by assist-
ing the client and the support system to engage in col-
laborative decision making regarding these issues.
Have the client identify parenting models, and discuss
the effect these persons had on their current
parenting style.
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Parenting, Impaired, Risk For and Actual, Readiness for Enhanced and Parental Role Conflict • 671
ACTIONS/INTERVENTIONS R AT I O N A L E S
Observe the interaction between the parents to assess for Children can be triangled into parental conflicts in an
problems in the husband–wife relationship that may be unconscious effort to preserve the marital relation-
expressed in the parenting relationship. If this appears ship.22,45
to be happening, refer the parents to family therapy.
Have the client develop a list of problem behavior pat- Promotes the client’s sense of control and begins the
terns, and then assist him or her in developing a list of development of alternative, more adaptive coping
alternative behavior patterns. For example, Current: behaviors.
When I get frustrated with my child, I spank him with
a belt. New: When I get frustrated with my child, I
arrange to send him to the neighbors for 30 minutes
while I take a walk around the block to calm down.
Role-play with the client situations that are identified as Behavioral rehearsal provides opportunities for feedback
being most difficult, and provide opportunities to prac- and modeling of new behaviors by the nurse.
tice more appropriate behavior. This should be done
daily in 30-minute time periods. Note the schedule for
this activity here, list time periods, and list situations
that are to be practiced. It would be useful to include
the spouse.
Have the client attend group sessions where feelings and Assists the client to experience personal importance to
thoughts can be expressed to peers and the thoughts others, while enhancing interpersonal relationship
and feelings of peers can be heard. [Note the schedule skills. Increasing these competencies can enhance self-
for the group here.] esteem and promote positive orientation.
Assist the client in identifying personal needs and in Assists the parents to develop strategies for coping with
developing a plan for meeting these needs at home. For role strain.
example, the parents will exchange babysitting time
with neighbors so they can have an evening out once
a month. [Note this plan here.]
Monitor staff attitudes toward the client, and allow them Negative attitudes of staff can be communicated to the
to express feelings, especially if child abuse is an issue client, decreasing the client’s self-esteem and increas-
with this client. ing the client’s defensiveness.
Assist the client with grieving separation from the child,
and refer to Anticipatory Grieving for detailed nursing
actions.
Provide the client with positive verbal support for posi- Positive reinforcement encourages behavior and enhances
tive parenting behavior and for progress on behavior self-esteem.
change goal. For example, “You demonstrate a great
deal of concern for your child’s welfare,” or “You have
taught your child to be very sensitive.” Make sure these
comments are honest and fit the client’s awareness of
the situation.
Assist the client in developing stress reduction skills by:
• Teaching deep muscle relaxation and practicing this
with the client 30 minutes a day at [time].
• Discussing with the client the role physical exercise
plays in stress reduction and developing a plan for
exercise. [Note plan and type of exercise here.] Have
the staff member remain with the client during these
exercise periods. [Note time for these periods here.]
When the client’s level of tension or anxiety is rising on
the unit, remind him or her of the exercise or relax-
ation technique, and work through one of these with
him or her.
(care plan continued on page 672)
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672 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Observe the interaction between the parents to monitor Conflict in one part of the family system can impact
for problems in the parental dyad that may be interactions in other parts of the system.
expressed in the parenting relationship with the chil-
dren. If this appears to be happening, refer the patient
to family therapy.
Readiness for Enhanced
Spend time with the client identifying areas they want to Change is dependent on client’s perception of the
enhance and develop a plan to meet these needs. [Note problem.
that plan here.]
Refer to community programs that focus on positive skill
building such as Couples Communication and Parent
Effectiveness Training, Developmental Assets pro-
grams (Search Institute).
Spend [number] minutes with parents identifying positive Promotes positive family affect and enhances focus on
family activities and establishing a schedule for partici- family strengths.23
pation.
Identify with parents community organizations that share
their values and can assist with their ongoing develop-
ment (e.g., faith communities, youth groups,
Developmental Assets Programs)
Refer to community programs that focus on positive skill
building such as Couples Communication and Parent
Effectiveness Training, and Developmental Assets pro-
grams (Search Institute).
Gerontic Health
● N O T E : This would be an unusual diagnosis for the gerontic patient, but might
develop if the grandparents had to take grandchildren into their home as a result of a
family crisis. In that instance, the nursing actions would be the same as those given in
Adult Health and Child Health.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Act as role model through use of positive behaviors when Role modeling provides an example for parenting skills.
interacting with the child and parents.
Report child abuse and neglect to the appropriate Meets legal requirements and provides for intervention.
authorities.
Teach the client and family appropriate information Knowledge is necessary to provide appropriate child care.
regarding the care and discipline of children:
• Cultural norms
• Normal growth and development
• Anticipatory guidance regarding psychosocial, cogni-
tive, and physical needs for children and parents
• Expected family life cycles
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Relocation Stress Syndrome, Risk For and Actual • 673
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Development and use of support networks
• Safe environment for family members
• Nurturing environment for family members
• Special needs of the child requiring invasive or restric-
tive treatments
Involve the client and family in planning and implement- Involvement of the family in planning enhances the effec-
ing strategies to decrease or prevent alterations (risk tiveness of the interventions.
for or actual) in parenting:
• Family conference: Identify each member’s perspective
of the situation.
• Mutual goal setting: Develop short-term, realistic goals
with evaluation criteria.
• Communication: Use open, honest communication with
positive feedback.
• Distribution of family tasks: Tasks are performed by all
family members as developmentally and physically
appropriate.
• Promoting the parent’s self-esteem: Provide positive
support of existing positive parenting skills.
Assist the client and family in lifestyle adjustments that Long-term behavioral changes require support.
may be required:
• Development of parenting skills
• Use of support network
• Establishment of realistic expectations of the children
and spouse
Refer to appropriate assistive resources. Support groups, family therapist, school nurse, and teach-
ers can enhance the treatment plan.
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674 • Role-Relationship Pattern
RELATED FACTORS9
✔ Have You Selected the Correct Diagnosis?
A. Risk for Relocation Stress Syndrome (Risk Factors)
Ineffective Individual Coping
The risk factors also serve as the related factors.
Ineffective Individual Coping and Relocation Stress
B. Relocation Stress Syndrome Syndrome do sound similar in some ways; however,
1. Unpredictability of experiences the differentiating factor is whether or not the individ-
2. Temporary or permanent move ual is being or recently has been involved in a transfer
3. Voluntary or involuntary move from one care setting to another. If such a transfer is
4. Past, concurrent, or recent losses being considered or has occurred, initial interventions
5. Feelings of powerlessness should be directed toward resolving the problems
6. Lack of adequate support system or group associated with relocation of the patient.
7. Lack of predeparture counseling Impaired Adjustment
8. Passive coping Certainly any move, whether for an ill or healthy indi-
9. Impaired psychosocial health vidual, would require some adjustment. However, this
10. Decreased health status diagnosis relates to an individual’s adjusting to his or
11. Isolation from family and/or friends her own illness or health problem, not adjustment to a
12. Language barrier change in the health-care setting.
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Relocation Stress Syndrome, Risk For and Actual • 675
ACTIONS/INTERVENTIONS R AT I O N A L E S
Consult with other health-care professionals as necessary. Collaboration promotes care that incorporates physiologic
and psychosocial interventions that may be needed as a
result of relocation stress.
Help the patient maintain former relationships by provid- Decreases feelings of isolation and depression.
ing letter-writing materials or a telephone.
Provide the patient with a list of organizations and com- Assists the patient to develop new relationship and may
munity services available for newcomers (e.g., hasten adjustment.
Welcome Wagon, senior citizens’ groups, churches, or
singles’ groups).
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess, to the degree possible, the emotional stability of Adaptability to change is determined to a large degree by
the patient and family. (Can use Chess-Thomas temperament and previous coping.
Temperament Scale.)46
Schedule a family conference of at least 1 hour daily and Provides support to cope with changes caused by reloca-
focus on: tion.
• Feelings of the patient and family regarding move
• Aspects of relocation that are problematic (e.g., school
or friends)
• Identification of potential benefits and growth the relo-
cation might offer
Facilitate plans for maintaining desired relationships
despite physical move (e.g., letter, telephone calls,
or visits).
Facilitate expression of feelings with referral to mental Provides anticipatory or actual guidance for control of
health nurse clinician, psychiatrist, psychologist, or risk for unresolved issues.
counselor.
Women’s Health
The nursing actions for a woman with this nursing diagnosis are the same as those found in Adult Health, Mental Health,
and Gerontic Health.
Mental Health
In addition to those interventions identified under Adult Health and Gerontic Health, the following interventions apply:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the client’s cognitive resources. Nursing interventions should be adapted to the client’s
cognitive abilities.47
Arrange to have objects familiar to the client in the envi- Familiar objects decrease anxiety and increase the sense
ronment. This could include photographs, clothing, fur- of control while helping to reestablish personal space.
niture, or other significant personal items.
Provide the client with a sense of personal space by label- Facilitates the reestablishment of a personal space.
ing the room, having him or her seated at the same
place at mealtimes, and assisting him or her in the pro-
tection of this space and his or her belongings. [Note
those adaptations here.]
(care plan continued on page 676)
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676 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client in the decision to change location. This Promotes a sense of personal control and facilitates the
is adjusted to fit the client’s cognitive abilities, and the psychological and emotional preparation for the move.
degree to which the client is involved should be noted
here.
Sit with the client [number] minutes each day to discuss Facilitates adjustment to the new milieu.22
the move and memories of the former home. Having a
picture of the former residence may facilitate this.
[Note the person responsible for this discussion here.]
Provide sensory adaptive devices such as hearing aids Facilitates orientation to the environment and promotes
and eyeglasses. [Note the devices needed by this a sense of control. Promotes safety in the new environ-
client here.] ment.
Gerontic Health
● N O T E : This diagnosis is appropriate for clients who have already experienced relo-
cation. The reader is encouraged to view the Web site http://www.guidelines.gov before
relocation to facilitate effective planning of relocation Post-relocation, all interventions
should be tailored to meet the individual values, culture, and needs of the elder.48
ACTIONS/INTERVENTIONS R AT I O N A L E S
Offer choices such as where and when to move, room Involvement in decision making increases control.48
choice, where to locate items in the room, a daily
schedule, and activities.
Assist the client with unpacking his or her own Promotes personal sense of control and mastery.48
belongings.
Provide opportunities to see old friends, make new Provides social support and activities.48
friends, volunteer, or continue meaningful roles and
activities.48
Facilitate support from, and interaction with, family, Provides social support and activities.48
friends, and new neighbors by introducing neighbors,
extending invitations to social gatherings, and schedul-
ing visits.48
Facilitate the development of relationships with others Provides social support and activities.48
(peers and staff), especially if there are no former
friends in the new environment.48
Establish a buddy system between the new resident and a Provides social support and activities.48
person living in the new environment.
Make available animal visits and visits with children if Provides social support and activities.48
desired.48
Assess preferences and opportunities for being alone in Individualizes care.48
addition to meeting the need for social support.48
Promote coping with the relocation: Addresses the feelings of loss.48
• Assist with grieving processes, providing more intense
support in the first month.
• Listen and allow the client to talk about feelings
regarding the move.
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Relocation Stress Syndrome, Risk For and Actual • 677
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Encourage activities/rituals to say goodbye to the old
residence and welcome the new space.
• Discuss usual coping strategies with the client.
• Assist the client in identifying positive aspects of the
move (increased physical safety, fewer household
responsibilities).79
Orient the client to the new environment: A planned approach to relocation promotes adjustment.48
• Welcome the client.
• Promote communication among residents, family,
and staff.
• Establish a trusting relationship with the client.
• Orient the client to the physical environment and rou-
tines.
• Provide adequate lighting and mark the room so it is
easy to find.48
Maintain stability or continuity of care: Promotes coping with relocation.48
• Develop and adhere to a plan of care.
• Assist the client as needed to ensure continuity in tak-
ing medications, keeping physician appointments.
• Maintain continuity in daily patterns of living
• Maintain consistency in the physical environment by
keeping favorite items readily available (i.e., chair,
afghan, photos).48
Ensure meeting of physical and psychosocial needs: Promotes coping with relocation.48
• Support the client’s highest level and functioning, thus
his or her autonomy.
• Refer to social support services as needed.
• Ensure adequate assistance with personal care.
• Maintain appropriate use of assistive devices (glasses,
hearing aids, walkers).48
Identify whether the patient is at risk for relocation syn- Early identification of patients at risk can mean earlier
drome. In older adults, this may include those with no intervention and a possible decrease in the negative
confidant (social support), those who perceive them- consequences of relocation.
selves as worriers, those in poor health, and those with
low self-esteem.49
Assist the patient in realistic perception of event: what May assist in accepting the need for relocation.
has occurred, reasons for transfer based on physical
needs, changed health status.
Discuss possible occurrence of the syndrome with signifi- Provides anticipatory information that avoids undue stress
cant others. on the family.
If not returning to prehospitalization location, discuss Allows time for ventilation of feelings related to the relo-
with the patient his or her proposed plans, reasons for cation.
transfer, and the patient’s response to the proposal.
Home Health
See Gerontic and Mental Health for additional interventions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client or caregiver to make the new environment Enhances the client’s sense of security and comfort.
as much like the previous environment as possible:
(care plan continued on page 678)
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678 • Role-Relationship Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Similar schedules and routines
• Decorations from previous environment
• Significant items such as blankets, artwork, and music
• Foods served should be as familiar as possible.
Educate the client or caregiver as far in advance as possi- Promotes a sense of control and avoids unpleasant sur-
ble of necessary changes in location, and tell them prises.
what to expect.
When the change in location involves separation from Enhances the client’s sense of security and comfort.
significant others, help the client or caregiver to obtain
items that may increase the client’s comfort:
• Photographs of loved ones
• Letters and cards from loved ones
• Videotapes and/or audiotapes of loved ones
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Copyright © 2007 by F. A. Davis. •
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Role Performance, Ineffective • 679
3. Physiologic
problems, chooses to be alone or perceives that he or
a. Inadequate or inappropriate linkage with the health- she is alone and therefore isolated from society. This
care system diagnosis deals mainly with the individual who cannot
b. Substance abuse or will not perform any role.
c. Mental illness
d. Body image alteration Interrupted Family Processes
Interrupted Family Processes refers to an entire family
e. Physical illness
that must in one way or another alter the processes
f. Cognitive defects
that go on within the family. Many times this will
g. Health alterations (e.g., physical health, body image, involve altered role performances of the individual
self-esteem, mental health, psychosocial health, cog- family members; however, the overall focus is on the
nition, learning style, or neurologic health) alteration within the family and not with the individual
h. Depression members of the family.
i. Low self-esteem
j. Pain
k. Fatigue EXPECTED OUTCOME
RELATED CLINICAL CONCERNS Will describe role changes necessitated by life change [note
specific change here] by [date].
1. Any major surgery Will describe plan to adapt to role changes by [date].
2. Any chronic disease Will demonstrate [number] new role behavior by
3. Any condition resulting in hemiplegia, paraplegia, or [date].
quadriplegia Will verbalize satisfaction with new role performance
4. Chemical abuse by [date].
5. Cancer
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Copyright © 2007 •by F. A. Davis.
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680 • Role-Relationship Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Determine how the child and parent perceive the expected Provides the essential database necessary to plan care.
role for the child.
Identify confusion or diffusion of role according to the Problem identification serves to establish common areas
child’s and parent’s expectations versus the actual role. to be further explored in role performance.
Determine the value the child has in the family. The value a child has for each family is critical to expec-
tations for all involved.
Determine the child’s self-perception. One’s self-perception provides insight into how one eval-
uates his or her own performance.
Identify ways to alleviate role performance alteration Alleviation of one or more role performance alterations
according to the actual cause. If the child is temporar- may prevent further deterioration in role functioning,
ily unable to participate in certain physical activities, with a greater appreciation for the value of all roles.
explore other nonphysical ways the child can partici-
pate.
Allow for ventilation of feelings by the child via pup- Feelings are most critical in exploring one’s role perform-
petry, art, or other age-appropriate methods. Schedule ance. Appropriate aids in communication serve to fos-
at least 30 minutes during each 8-hour shift, while the ter focused play or behaviors to reveal thoughts of the
patient is awake, for this activity. [Note times here.] child who is unable to express him- or herself.
Provide the patient and parents with options to best facili- Vicarious involvement allows for shared activities and the
tate needs for future implications of compromised role sense of maintaining closeness with the desired groups
performance (e.g., shared experiences with peers who or person.
have temporarily had to forsake physical activities
because of illness. How did they keep up with the
team?)
Allow for family time and support for choices to uphold Shared time of family and friends is important, especially
role needs (e.g., visitation by peers). in times of role stress, to maintain the value of self.
Provide for safety needs of the child and family. Standard care includes safety. The tendency is to relax
concerns in times of less stressful activity.
Assist in follow-up plans with appropriate appointments Arrangements for follow-up promote valuing of follow-
for psychiatric or pediatric care. up and increase the likelihood for compliance.
Provide support in identification of risk to normal actual- Early identification of primary or secondary risks may
ization of potential of the child. Refer to the child or prevent or minimize tertiary risks for the child and
family mental health practitioner as appropriate. family.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Allow the patient to describe her perception of her role as Provides a database to initiate care planning.
a mother, wife, and working woman.
Identify sources of role stress and strain that contribute to
role conflict and fatigue.
Assist in developing a schedule that manages time well,
both at home and at work.
Involve significant others in planning methods of reduc- Encourages the patient to identify various roles she is
ing role stress and strain at home by: currently fulfilling, and provides support that allows
• Assisting with child care planning of coping strategies and techniques.
• Assisting with household duties
• Sharing carpooling and children’s activities
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Role Performance, Ineffective • 681
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage the patient to use time at work for “work
activities” and time at home for “home activities,” i.e.,
do not take work home.
Look at possibility of job sharing or part-time employ-
ment while the children are at home.
Plan home activities in advance, such as shopping for and
cooking meals in advance, and freezing them for later
use.
Encourage division of workload by exchanging childcare
activities with friends or other families in the neighbor-
hood.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Sit with the client [number] minutes [number] times per Provides information about the client’s perceptions and
day to discuss the client’s feelings about self and role expectations that can be utilized in developing specific
performance. interventions.
Answer questions honestly. Promotes the development of a trusting relationship.
Provide feedback to the client about nurse’s perceptions Assists the client in realistically evaluating his or her per-
of the client’s abilities and appearance by: ceptions.
• Using “I” statements
• Using references related to the nurse’s relationship to
the client
• Describing the nurse’s feelings in relationship
Provide positive reinforcement. List here those things, Reinforcement encourages positive behavior and
including social rewards, that are reinforcing for the enhances self-esteem.
client and when they are to be used. Also list those things
that have been identified as nonreinforcers for this client.
Provide group interaction with [number] persons [num- Assists the client to experience personal importance to
ber] minutes three times a day at [times]. This activity others, while enhancing interpersonal relationship
should be gradual within the client’s ability. For exam- skills. Increasing these role competences can enhance
ple, on admission the client may tolerate one person self-esteem and promote a positive orientation.
for 5 minutes. If the interactions are brief, the fre-
quency should be high, e.g., 5-minute interactions
should occur at 30-minute intervals.
Reflect back to the client negative self-statements. This This will increase the client’s awareness of these state-
should be done with a supportive attitude in a manner ments and facilitate the development of alternative cog-
that will increase the client’s awareness of these nega- nitive patterns.
tive evaluations of self.
Set achievable goals for the client. Achievement of goals provides positive reinforcement
that encourages the behavior and enhances self-esteem.
Provide activities that the client can accomplish and that Accomplishment of valued tasks provides positive rein-
the client values. Care should be taken not to provide forcement that encourages behavior and enhances self-
tasks that the client finds demeaning, which could rein- esteem.
force the client’s negative self-evaluation.
Provide verbal reinforcement for the achievement of steps Promotes a positive orientation.
toward a goal.
Have the client develop a list of his or her strengths and
potentials.
(care plan continued on page 682)
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682 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Define the client’s lack of goal achievement or failures as Promotes a positive orientation.
simple mistakes that are bound to occur when one
attempts something new. For example, learning comes
with mistakes; if one does not make mistakes, one does
not learn.
Define past failures as the client’s best attempts to solve a
problem; for example, if the client had known a better
solution, he or she would have used it; one does not set
out to fail.
Make necessary items available for the client to groom Appropriate grooming improves the client’s self-
self. evaluation.
Spend [number] minutes at [time] assisting the client The nurse’s presence can provide positive reinforcement,
with grooming, providing necessary assistance and and reinforcement encourages positive behavior.
positive reinforcement for accomplishments.
Focus the client’s attention on the here and now. It is difficult for the nurse to provide feedback on past
happenings.
Present the client with opportunities to make decisions Promotes the client’s sense of control, and enhances self-
about care, and record these decisions on the chart. esteem.
Develop with the client alternative coping strategies. Promotes the development of more adaptive coping
behaviors and increases the client’s role competence.
Practice new coping behavior with the client [number] Repeated practice of a behavior internalizes and personal-
minutes at [time]. izes the behavior.
Discuss with the client ideal versus current perceptions of Assists the client in a cognitive appraisal of perceptions
role performance. to eliminate unrealistic or irrational beliefs.
Discuss with the client the factors that are perceived to be Assists the client in cognitive evaluation of perception of
interfering with role performance. role performance.
Have the client develop a list of alternatives for resolving Facilitates the development of alternative coping
interfering factors. [This list should be noted here.] behaviors.
Establish an appointment with significant others to dis- Assists in establishing agreement on the performance of
cuss their perceptions of the client’s role performance role pairs to decrease role conflict and strain. This is of
and their perceptions of the various roles involved in primary importance because roles occur in interactions.
the identified situations. [Date and time of this meeting
should be written here.]
Discuss with the client and significant others alterations
in role that will facilitate successful performance.
[Date and time of this meeting should be written here.]
Develop a specific list of necessary changes, and provide
the client system with a written copy.
Role-play altered role situations with the client system Repeated practice of a behavior internalizes and personal-
for 1 hour once a day at [time]. This would include izes the behavior.
opportunities for clients to practice the areas of role
performance that may be new or unique.
If the client and client system cannot achieve agreement Interactions with the health-care system involve role pairs
on the problematic role, refer to: with the role expectations that are present in any social
• Psychiatric mental health clinical nurse specialist situation. As in any interaction, there can be differing
• Family therapist expectations about role performance, which can lead to
• Social worker role conflict and strain.
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Role Performance, Ineffective • 683
ACTIONS/INTERVENTIONS R AT I O N A L E S
If problematic roles involve interactions between the
client and members of the health-care team (nurses,
physicians, etc.), request consultation with psychiatric
mental health clinical nurse specialist or mental health
specialist with experience in the area of resolving sys-
tem problems (i.e., family therapists or social workers).
Refer the client and significant others to community
resources that will continue to support role develop-
ment (e.g., family therapist, occupational therapist,
rehabilitation counseling).
Gerontic Health
In addition to the interventions for Adult Health and Mental Health, the following may be utilized with the aging client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss with the patient how he or she perceives his or Provides an opportunity to gain the patient’s exact per-
her role performance has altered. spective on the situation. Provides database needed for
most effective planning.
Discuss with the patient potential role modifications or Depending on the patient’s interests and abilities, these
substitutions, such as foster grandparenting, friendly measures would provide an alternate method to achieve
visitor at a long-term-care facility, participant in inter- role satisfaction.
generational programs, or telephone reassurance visitor
or caller.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for factors contributing to disturbed role per- Provides a database for early recognition and interven-
formance. tion.
Involve the client and family in planning, implementing, Family involvement in planning increases the likelihood
and promoting reduction or elimination of disturbance of effective intervention.
in role function:
• Family conference: Clarify expected role performance
of all family members.
• Mutual goal setting: Set realistic goals and evaluation
criteria. Identify tasks for each family member.
• Communication: Use open, direct communication and
provide positive feedback.
Assist the client and family in lifestyle adjustments that Long-term behavioral changes require support.
may be required:
• Treatment of physical or emotional disability
• Stress management
• Adjustment to changing role functions and relation-
ships
• Development and use of support networks
• Requirements for redistribution of family tasks
Consult with assistive resources as indicated. Utilization of existing services is efficient use of
resources. Psychiatric nurse clinician, occupational and
physical therapists, and support groups can enhance the
treatment plan.
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684 • Role-Relationship Pattern
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Copyright © 2007 by F. A. Davis. •
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Social Interaction, Impaired • 685
ACTIONS/INTERVENTIONS R AT I O N A L E S
Help the patient participate in group interactions. [Note Increases social skills by providing social contact.
assistance the patient needs to accomplish this here.]
Involve the patient in daily care. Help the patient make Improves self-concepts. Increases motivation. Decreases
decisions about own care. feeling of powerlessness.
If the patient is in isolation, spend at least 10 minutes for Avoids feeling of total isolation for the patient.
each routine patient interaction.
Initiate referrals to support groups before discharge. Puts the patient in contact with community groups to
interact with the patient to decrease social isolation.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for contributory factors to altered social interac- Provides a database needed to plan appropriate care.
tion pattern (e.g., role-play with puppets).
Determine the effect the altered social interaction has on Provides a database needed to accurately plan
the child, parent, family, and school. intervention.
Develop a plan of care to best meet the child’s potential Individual family values will dictate the way in which
for succeeding with appropriate social interaction—this they deal with social interaction.
will be impacted by social class and values.
Determine whether conflict exists between the parent’s Conflict may prevent appropriate attention to actual social
and the child’s desired social interaction. interaction, but must be dealt with as it will remain a
critical component. This may be true particularly at
times of authority issues (e.g., adolescence).
If conflict exists regarding social interaction, deal with Values and beliefs may be in conflict, and some resolu-
this as needed in values or beliefs pattern. tion of the problem is essential to prevent further long-
term effects.
Assist the child, parents, and family in ventilation of feel- Ventilation of feelings and the opportunity to do so serve
ings regarding social interaction impairment, including to value the importance for the patient to help reduce
actual consequences of the impairment. anxiety and initiate problem resolution.
*Best facilitated with same primary care nurse.
Make referrals as appropriate to professionals best able to Referral serves to best deal with problems according to a
assist in dealing with problem (e.g., psychiatric nurse match of needs and resources.
clinical specialist, play therapist, or family therapist).
Identify local support groups to appropriately match Resource groups provide vital support through provision
needs (e.g., parent–child support groups for the handi- of a common, shared sense of concern, coping, and
capped, United Cerebral Palsy Association, or Spina empowerment.
Bifida Association).
If impaired social interaction also relates to the school, Valuing the importance of school and the need to provide
include the teacher and essential school personnel in the best for the child and family in the development of
plans for resolving the impairment and for best positive social interaction is showing respect for the
follow-up. patient and family.
Identify follow-up appointment needs and ways to moni- Provides reinforcement and attaches value to follow-up.
tor progress for the child and family (e.g., stickers as
incentives to reinforce desired behavior).
Anticipate discrepant or unrealistic parental expectations Unrealistic demands or expectations are risk indicators
of the child. Monitor for potential abuse of the child for abuse.
according to pattern for this.
(care plan continued on page 686)
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686 • Role-Relationship Pattern
Women’s Health
This nursing diagnosis pertains to women the same as to any other adult. The reader is referred to the other sections—
Adult Health, Child Health, Mental Health, Gerontic Health, and Home Health—for specific nursing actions.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
If delusions or hallucinations are present, refer to Dis-
turbed Sensory Perception for detailed interventions.
Assign a primary care nurse to the client. Promotes the development of a trusting relationship.
The primary care nurse will spend [number] minutes Promotes the development of a trusting relationship and
twice a day at [times] with the client. The focus of this provides opportunities for the client to observe the
interaction will change as a relationship is developed. nurse in appropriate interpersonal interactions.
Initially, the nurse should model for the client how to
develop a relationship through his or her behavior in
developing a relationship with the client. This model-
ing should include demonstrating respect for the client;
consistency in interaction; congruence between
thoughts, feelings, and actions; and empathy.
Have the client identify the persons who are considered Assists the client in reality testing of the belief that he or
family, friends, and acquaintances. Then have the client she is having difficulty with interpersonal relationships.
note how many interactions per week occur with each
person. Have the client identify his or her thoughts,
feelings, and behavior about these interactions.
Provide appropriate confrontation with the client about Assists the client in developing alternative coping behav-
his or her behavior patterns that inhibit interaction in iors that are adaptive.
relationships with the nurse.16
Observe the client in interactions with others on the unit, Facilitates the provision of feedback to the client on
and identify patterns of behavior that inhibit social methods he or she could use to improve interpersonal
interaction. effectiveness.
Develop a list of things the client finds rewarding, and Positive reinforcement encourages behavior.
provide these rewards as the client successfully com-
pletes progressive steps in treatment plan.
When the client is demonstrating socially inappropriate Continuing the interaction could provide positive rein-
behavior, keep interactions to a minimum and escort forcement and encourage inappropriate behavior.
the client to a place away from activities.
When the inappropriate behavior stops, discuss the Promotes the client’s sense of control and begins the
behavior with the client and develop a list of alterna- development of alternative, more adaptive coping
tive kinds of behavior for the client to use in situations behaviors. Social isolation assists in decreasing
where the inappropriate behavior is elicited. [Note here behaviors.
the kinds of behavior that are identified as problematic,
with the action to be taken if they are demonstrated;
e.g., the client will spend time out in seclusion and
away from group activity.]
Develop a schedule for gradually increasing time of the Social interaction can provide positive reinforcement and
client in group activities. For example, the client will opportunities for the client to practice new behaviors in
spend [number] minutes in the group dining hall dur- a supportive environment.
ing mealtimes, or will spend [number] minutes in a
group game. [Note the client’s specific activities here.]
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Social Interaction, Impaired • 687
ACTIONS/INTERVENTIONS R AT I O N A L E S
Primary nurse will spend 30 minutes a day with the client
exploring thoughts and feelings about social interac-
tions and assisting with reality testing of social interac-
tion (e.g., what others might mean by silence and other
nonverbal responses).
Identify with the client areas of social skill deficit, and Promotes the client’s sense of control and begins the
develop a plan for improving these areas. This could development of alternative, more adaptive coping
include: behaviors by increasing role competence.
• Assertiveness training
• Role-playing difficult situations
• Teaching the client relaxation techniques to reduce
anxiety in social situations. [Note here the plan and
schedule for implementation. This should be a pro-
gressive plan with rewards for accomplishment of
each step.]
Consult with the occupational therapist if the client needs Increasing behavioral repertoire increases role compe-
to learn specific skills to facilitate social interactions tence, which enhances self-esteem.1
(e.g., cooking skills so friends can be invited to dinner,
or craft skills so the client can join others in social
interactions around these activities).
Include the client in group activities on the unit, and Reinforcement encourages positive behavior and
assign the client activities that can be easily accom- enhances self-esteem.
plished, and that will provide positive social reinforce-
ment from other persons involved in the activities.
When the client demonstrates tolerance for group interac- Disconfirms the client’s sense of aloneness, and assists
tions, schedule a time for the client to participate in a the client to experience personal importance to others,
group therapy that provides opportunities for feedback while enhancing interpersonal relationship skills.
about relationship behavior from peers, and for listen- Increasing these competencies can enhance self-esteem
ing to the thoughts and feelings of peers. and promote positive orientation.
Discuss with the support system ways in which they can Support system understanding facilitates the maintenance
facilitate client interaction. of new behaviors after discharge.
Have the client identify the activities in the community Increases the client’s ability to perform these roles suc-
that are of interest and would provide opportunities for cessfully, which provides positive reinforcement,
interaction. List the activities here, and develop a plan thereby encouraging the behavior and enhancing self-
for the client to develop necessary skills to ensure esteem.
opportunities for interactional success during these
activities (e.g., practice a card game or tennis while
in the hospital).
When the client reports problems in an interaction, Assists the client with reality testing of his or her
review his or her perceptions of the interaction and an perceptions.
evaluation of when the problems began.
Limit the amount of time the client can spend alone in Successful accomplishment of a task provides positive
room. This should be a gradual alteration and done in reinforcement and promotes a positive orientation.
steps that can easily be accomplished by the client.
Note specific schedule for the client here. Have a staff
person remain with the client during these times until
client demonstrates an ability to interact with others.
Have the referral source make contact with the client Promotes the development of a trusting relationship while
before discharge and schedule a post-discharge the client is in a safe environment.
meeting.
(care plan continued on page 688)
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688 • Role-Relationship Pattern
Gerontic Health
The nursing actions for the gerontic patient with this diagnosis are the same as those given in Adult Health and Mental
Health.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for factors contributing to the impaired social Provides database for early recognition and intervention.
interaction (e.g., psychological, physical, economic, or
spiritual).
Involve the client and family in planning, implementing, Family involvement enhances the effectiveness of the
and promoting reduction or elimination of Impaired interventions.
Social Interaction:
• Family conference: Identify the perspective of each
member. Establish consistent rules for behaviors.
• Mutual goal setting: Set consistent rules for behavior
and provide support for care providers. Identify tasks
for each member.
Assist the patient and family in lifestyle adjustments that Permanent changes in behavior and family roles require
may be required: support.
• Providing a safe environment
• Development and use of support networks
• Change in role functions
• Prescribed treatments (e.g., medications or behavioral
interventions)
• Assistance with self-care activities
• Possible hospitalization or placement in halfway house
• Treatment of drug or alcohol abuse
• Development and practice of social skills
• Independent living skills
• Finances
• Stress management
• Suicide prevention
Assist the client and family to develop criteria to deter- Provides a database for early recognition and interven-
mine when a crisis exists and professional intervention tion.
is necessary:
• Violence
• Sudden change in ability to care for self
• Hallucinations or delusions
Consult with or refer to assistive resources as indicated. Utilization of existing services is efficient use of
resources. Respite care and support groups can
enhance the treatment plan.
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Copyright © 2007 by F. A. Davis. •
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Social Isolation • 689
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Copyright © 2007 •by F. A. Davis.
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690 • Role-Relationship Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Facilitate visits from the family, friends, and significant Increases social contacts and interactional skills.
others daily. If appropriate, arrange for family to room-
in. Involve in patient care to the extent feasible.
Facilitate the patient’s involvement in diversional Increases social contacts and interactional skills, espe-
activities. cially those involving groups, daily.
Encourage the patient to identify and use community sup- Increases social contacts. Promotes assistance with short-
port systems and groups before discharge. term and long-term goals.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide opportunities for expression of feelings about Ventilation of feelings allows for insight into the patient’s
desired social activity by spending 15 to 20 minutes thinking and assists in reducing anxiety.
per shift, during waking hours, at [times] with the
patient and family.
Determine what obstacles are perceived by the patient Directed inquiry into obstacles that prevent the patient
and family in pursuit of desired social activities by ask- from engaging in desired social interaction increases
ing both direct and open-ended questions; for example, the likelihood of a more complete database that will
“What do you think prevents you from doing what you allow more individualized planning.
want to?”
Identify what realistic patterns for socialization are appli- Realistic goals are more likely to bring about the desired
cable for the patient and family in collaboration with changes for more effective social interaction.
the patient and family.
Collaborate with other health-care professionals to meet Appropriate use of resource personnel ensures optimal
realistic goals for patient and family socialization. likelihood for goal attainment.
Monitor for contributory related factors to best consider All factors must be considered to provide a holistic plan
the social activity pattern. of care.
Identify support groups to assist in realization of desired Support groups provide a sense of sharing and empower-
social activities. ment.
Monitor the patient’s and family’s perceptions of the Roles are closely impacted by patterns of social
effect desired social activities might have on the cur- interaction.
rent role-relationship pattern.
Provide appropriate opportunities for assessment of the The child’s view of him- or herself in relationship to
young child’s perceptions of situational needs and how social patterns is vital to planning the most effective
he or she views self. interventions.
Assist the patient to develop a schedule for consideration Appropriate planning serves to increase success with
of desired social activities at least 2 days before dis- desired activities.
missal from hospital.
Provide for appropriate follow-up appointment as needed Follow-up plans attach value to long-term care for the
before dismissal from the hospital. patient.
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Social Isolation • 691
Women’s Health
● N O T E : When women experience social isolation, it is especially important to assess
for the presence of domestic violence. Social isolation may be one of the methods by
which an abuser controls his or her partner. The following nursing actions apply to the
social isolation experienced by the patient who has sexually transmitted diseases such as
herpes genitalis, syphilis, chlamydia, gonorrhea, and AIDS.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assure the patient of confidentiality. Promotes sharing of information by the patient.
Refer for counseling and/or treatment to: Provides long-term support and care for the patient.
• Support groups
• Professionals (e.g., public health clinic, nurse special-
ists, or physician)
Provide a nonjudgmental atmosphere50 to encourage Provides the database needed to provide appropriate care
verbalization of concerns: and teaching.
• Recurrent nature of disease, especially herpes and
Chlamydia
• Lack of cure for disease (AIDS)
• Economics in treating the disease
• Social stigma associated with the disease
• Opportunity for entrance into the health-care system
Encourage honesty in answers to such question as:
• Multiple sexual partners (identify contacts)
• Describing sexual behavior
Encourage honest communication with sexual partners. Sexual partners will also need to seek health care.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
If delusions and/or hallucinations are present, refer to Assists in understanding the client’s worldview, which
Disturbed Sensory Perception for detailed interven- facilitates the development of client-specific interven-
tions. tions.
If social isolation is related to the client’s feelings of
powerlessness, refer to Powerlessness in Chapter 8 for
detailed interventions.
Discuss with the client his or her perception of the source Change is dependent on the client’s perception of the
of the social isolation, and have him or her list those problem.23
things he or she has tried to resolve the situation.
Have the client list the persons who are considered fam- Facilitates the client’s reality testing of his or her percep-
ily, friends, and acquaintances. Then have the client tion of being socially isolated.
note how many interactions per week occur with each
person. Have the client identify what interferes with
feeling connected with these persons. This activity
should be implemented by the primary care nurse.
[Note schedule for this interaction here.]
When contributing factors have been identified, develop a Facilitates the development of alternative coping behav-
plan to alter these factors. This could include: iors that enhance role performance.
• Assertiveness training
• Role-playing difficult situations
• Teaching the client relaxation techniques to reduce
anxiety in social situations [Note plan and schedule for
implementation here.]
(care plan continued on page 692)
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692 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Develop a list of things the client finds rewarding, and Reinforcement encourages positive behavior and
provide the rewards as the client successfully com- enhances self-esteem.
pletes progressive steps in the treatment plan. This
schedule should be developed with the client. [Note
here the schedule for rewards and the kinds of behavior
to be rewarded.]
Consult with the occupational therapist if the client needs Increases the client’s competencies, which enhances role
to learn specific skills to facilitate social interactions performance and self-esteem.
(e.g., cooking skills so friends can be invited to dinner,
craft skills so the client can join others in social inter-
actions around these activities, or dancing).
Provide the client with the prostheses necessary to facili-
tate social interactions, (e.g., hearing aids or eye-
glasses). [Note here the assistance needed from nursing
staff in providing these to the client. Also note where
they are to be stored while not in use.]
Include the client in group activities on the unit. Assign Successful accomplishment of a valued task can provide
the client activities that can be easily accomplished and positive reinforcement, which encourages behavior.
that will provide positive social reinforcement from
other persons involved in the activities. This could
include things like having the client assume responsi-
bility for preparing a part of a group meal, or for serv-
ing a portion of a meal.
Role-play with the client the social interactions identified Repeated practice of a behavior internalizes and personal-
as most difficult. This will be done by primary nurse. izes the behavior.
[Note schedule for this activity here.]
Discuss with the client the times it would be appropriate Promotes the client’s sense of control, while facilitating
to be alone, and develop a plan for coping with these the development of alternative coping behaviors.
times in a positive manner (e.g., the client will develop
a list of books to read, music to listen to, or commu-
nity activities to attend).
When the client is demonstrating socially inappropriate Lack of positive reinforcement decreases a behavior.
behavior, keep interactions to a minimum, and escort
to a place way from group activities.
When inappropriate behavior stops, discuss the behavior Promotes the client’s sense of control, while facilitating
with the client, and develop a list of alternative kinds the development of alternative coping behaviors.
of behavior for the client to use in situations where the
inappropriate behavior is elicited. [Note here the kinds
of behavior that are identified as problematic, with the
action to be taken if they are demonstrated, e.g., the
client will spend a time-out in seclusion or a sleeping
area.]
Develop a schedule of gradually increasing time for the Provides the client with opportunities to practice new
client in group activities. For example, the client will behaviors in a safe, supportive environment.
spend [number] minutes in the group dining hall dur-
ing mealtimes or will spend [number] minutes in a
group game twice a day. [Note specific goals for the
client here.]
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Social Isolation • 693
ACTIONS/INTERVENTIONS R AT I O N A L E S
The primary care nurse will spend 30 minutes once a day
with the client at [time] discussing the client’s reac-
tions to social interactions and assisting the client with
reality testing social interactions (e.g., what others
might mean by silence or various nonverbal and com-
mon verbal expressions). This time can also be used to
discuss relationship roles and the client’s specific con-
cerns about relationships.
Assign the client a room near areas with high activity. Facilitates the client’s participation in unit activities.
Assign one staff person to the client each shift, and have Decreases the client’s opportunities for socially isolating
this person interact with the client every 30 minutes self.
while the client is awake.
Be open and direct with the client in interactions, and Promotes a trusting relationship.
avoid verbal and nonverbal behavior that requires inter-
pretation from the client.
Have the client tell staff his or her interpretation of inter- Assists the client in reality testing his or her perceptions
actions. that might inhibit social interactions.
Have the client identify the activities in the community Promotes the client’s sense of control.
that are of interest and would provide opportunities
for interactions with others. List the client’s interests
here.
Develop, with the client, a plan for making contact with Promotes the client’s sense of control and begins the
the identified community activities before discharge. development of adaptive coping behaviors.
When the client demonstrates tolerance for group interac- Disconfirms the client’s sense of aloneness and assists the
tions, schedule a time for the client to participate in a client to experience personal importance to others,
therapy group that provides opportunities for feedback while enhancing interpersonal relationship skills.
about relationship behavior from peers and for listen- Increasing these competencies can enhance self-esteem
ing to the thoughts and feelings of peers. and promote positive orientation.
Arrange at least 1 hour a week for the client to interact Support system understanding facilitates the maintenance
with his or her support system in the presence of the of new behaviors after discharge.
primary nurse. This will allow the nurse to assess and
facilitate these interactions.
Discuss with the support system ways in which they can
facilitate client interaction.
Model for the support system and for the client those
kinds of behavior that facilitate communication.40
Limit the amount of time the client can spend alone in Provides opportunities for the client to practice new role
the room. This should be a gradual alteration and behaviors in a safe, supportive environment.
should be done in steps that can easily be accom-
plished by the client. Note specific schedule for
the client here; for example, the client will spend
5 minutes per hour in day area. Have staff person
remain with the client during these times until the
client demonstrates an ability to interact with
others.
Refer the client to appropriate community agencies.
(care plan continued on page 694)
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694 • Role-Relationship Pattern
Gerontic Health
In addition to the interventions for Adult Health and Mental Health, the following may be utilized with the aging client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss with the patient what efforts he or she has made Assists in determining what interventions may result in
to increase social contacts and what results have been positive outcomes.
obtained.
Ask the patient to identify hobbies and activities that Provides information on preferred activities and guides
have been a part of his or her adult life. the nurse in seeking resources that match the patient’s
interests.
Ask the patient to identify barriers to continuing with the Barriers may be indicators of need for use of specific
hobbies and activities he or she enjoyed. resources such as adaptive equipment or transportation.
Assist the patient in identifying and contacting commu- In many areas, initial contact with support services can
nity support services. entail numerous telephone calls to reach the appropri-
ate resource.
Home Health
See Mental Health nursing actions for detailed interventions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client and family in planning and implement- Family involvement in planning enhances the effective-
ing strategies to reduce social isolation: ness of interventions.
• Family conference: Discuss perceptions of source of
social isolation, and list possible solutions.
• Mutual goal setting: Set realistic goals with evaluation
criteria. List specific tasks for each family member.
• Communication: Provide positive feedback.
Assist the family and patient with lifestyle adjustments Permanent changes in behavior and family roles require
that may be required: support.
• Promote social interaction.
• Provide transportation.
• Provide activities to keep busy during lonely times.
• Provide communication alternatives for those with sen-
sory deficits.
• Assist with disfiguring illness (e.g., refer the patient to
enterostomal therapist or prosthesis manufacturer).
• Control incontinence, or provide absorbent undergar-
ments when socializing.
• Promote self-worth.
• Promote self-care.
• Develop and utilize support groups.
• Use pets.
• Establish regular telephone contact.
• Inform of volunteer programs in the community that
person could work for.
Consult with or refer to assistive resources as indicated. Utilization of existing services is efficient use of
resources. Self-help groups, occupational therapists, or
home-bound programs can enhance the treatment plan.
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Sorrow, Chronic • 695
•
•
Copyright © 2007 •by F. A. Davis.
•
•
696 • Role-Relationship Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Take time to listen, empathize, and support the patient. Listening conveys respect, compassion, and a nonjudg-
mental position.
Have the patient participate in his or her own care Helps the patient feel control over own life.
and maintain involvement in personal interests and
activities.41
Provide opportunities for the patient to interact with oth- Helps the patient to see that he or she is not alone in the
ers who have experienced the same type of loss. grief process.
Refer to the Mental Health nursing actions for additional
information.
Child Health
● N O T E : Identify developmentally appropriate approach, with incorporation of appro-
priate nursing interventions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for all possible contributing factors to chronic Provides the most holistic database to offer appropriate
sorrow, including history, family, child, or others as individualization.
feasible.
Facilitate the child’s and family members’ verbalization Expression of feelings helps reduce anxiety and offers
of feelings about sorrow. clues to related issues.
Identify preferences of the child to further express feel- Free and creative expression provides a noninvasive
ings per age-appropriate play, art, discussion, or, when insight to monitor feelings on an ongoing basis.
appropriate, support groups.
Help the child and family to identify the meaning the Significance of sorrow is often the key to acceptance and
chronic sorrow provides. reducing negative effects of sorrow.
Identify ways to cope with factors that contributed or Growth is enhanced when coping strategies familiar to
contribute to chronic sorrow by determining previously the client are valued.
successful coping patterns.
Introduce additional coping strategies according to the Reinforcement is best timed when the client is success-
child’s and family’s readiness. fully dealing with demands and is more likely to
accept additional modes.
Determine the effect chronic sorrow has on basic daily Sorrow may be interfering with basic daily activities.
functioning.
Support the child’s and family’s daily progress in expres- Ongoing assessment and expression foster trust and open
sion of feelings and ways to cope with sorrow. communication.
Identify the need for other pediatric specialists as needed Experts will best be able to deal with the child’s and fam-
(e.g., play therapist, child psychologist, and psychiatrist). ily’s long-range needs.
Determine a support group for long-term follow-up. Peer support is valued, with the likelihood of bonding
and reduction of feelings of isolated sorrow.
Provide sensitive inquiry as related to anniversaries or Valuing of the importance of events for the child and fam-
events that may hold significance for the child or family. ily provides respect and facilitates sharing to foster trust.
Identify, with the child’s and family’s input, ways to cope Actual resolution of chronic sorrow is possible with an
effectively with chronic sorrow. individualized plan known to be effective and familiar
to the client, thereby lessening the likelihood of recur-
rence.
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Women’s Health
For this diagnosis, the Women’s Health nursing actions are similar to Adult Health, Child Health, Gerontic Health, and
Mental Health, except for the following:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Fetal Demise or Stillborn
The following are important first steps to help the parents Initiates the grieving process in a supportive environment,
cope with chronic sorrow: as well as providing a database that can be used by the
• Allow the parents to express feelings and participate in family and therapist when dealing with chronic sorrow.
needed decision making.
• Prepare the infant for viewing by the parents and sig-
nificant others.
• Provide a private, quiet place and time for the parents
and family to see and hold the infant.
• Take pictures, and complete a “memory box” for the
parents.
• Contact faith-based or cultural leader as requested by
the parents for desired ceremonies for the infant.
• Provide references to supportive groups within commu-
nity, such as Resolve with Sharing or other parents who
have lost infants.
Obtain from the client or other family members informa- Some deaths of babies are a relief to the parents, such as
tion about the cause of sorrow that could help with in the case of congenital abnormalities or a long, diffi-
understanding and therefore planning actions to sup- cult illness of a child. This does not mean they do not
port the client. love their babies, and could result in experiencing feel-
• Determine, if possible, the cause of death and the ges- ings of guilt because of the feeling of relief. Many
tational age of fetus and/or infant at the time of death. family members and relatives do not know what to say
• Determine the nature of attachment of the parents to or do, and therefore ignore the subject, believing this is
the infant. better for the parents so they can forget sooner.
• Discuss past unresolved grief.
• Determine social support of parents. (Beware of a
“conspiracy of silence.”)51,52
Discuss with the parents the aspect of anniversaries, Such dates often become an anticlimax; they have
birthdays, or holidays. Give suggestions of how to dreaded the date and find it either easy or very diffi-
observe the child’s memory, such as: cult. Acknowledgment tells the parents that you share
• Have a small ceremony with the family and friends at their pain without becoming intrusive. Holidays are
gravesite, home, or place of worship. very difficult, particularly when other children are cele-
• Plant a tree or flowers in the child’s memory. brating. It often becomes a reminder that they will
• Encourage the family and friends to acknowledge never be able to do these things with their child.
awareness of special day to the parent.
Mental Health
● N O T E : Because this is a normal response, clients most likely to have this diagnosis
will be seen as outpatients. Inpatient clients may experience this response if a trigger
event occurs during hospitalization.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide the client with the information he or she requests Assists with decision making and promotes a sense of
related to illness and the disease process. control.53,54
Sit with the client [number] minutes [number] times a Assists with coping, and promotes a sense of control.53
day to explore and provide specific information he or
she may need to cope with the identified situation.
(care plan continued on page 698)
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Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide information that indicates to the client that his or Alleviates feelings of “difference” or isolation, and
her reaction is normal. This information should be pro- increases sense of control. Assists the client in making
vided in a manner that does not diminish the individ- room for grief, as a normal process, in his or her
ual’s personal experience. life.16,54
Discuss with the client the situations that might con- Promotes client understanding of the experience, and
tribute to the increase or recurrence of grief feelings. assists with the normalizing of the experience, while
These situations could include comparisons with providing anticipatory guidance.55 Facilitates the devel-
norms, management crises, anniversaries, unending opment of the belief that grief is a life process and not
caregiving, and awareness of role changes. [Note here something that is “dealt with” or ended.54
the person responsible for this discussion.]
Sit with the client [number] minutes [number] times per Validates the client’s experience, and legitimizes the
day to provide an opportunity for him or her to tell his emotions.16,56
or her story with the effect of the experience.
Discuss with the client his or her beliefs about grief and Understanding the client’s perceptions provides the foun-
how it affects his or her life. dation for necessary change.54
Discuss with the client previous strategies utilized to cope Supports strengths and assists with the development of
with loss, and the extent to which these were success- client-specific coping strategies.16,52
ful. [Note here the person responsible for this discus-
sion and ongoing follow-up.]
Provide the client with necessary supports to utilize iden- Facilitates the use of coping strategies.53
tified coping strategies. Note here the supports, specific
for this client, needed from staff. This could include
referrals to community support groups, arrangements
for respite care, supporting the use of humor and play
as a coping strategy, arrangements to interact with spir-
itual leader, and providing opportunities for physical
activity.
Schedule a meeting with the support system to explore Something that affects one member of the support system
their beliefs and experiences related to loss. [Note here affects other members.54
the time for this meeting and the person responsible.]
Meetings with support systems should also include:
• Normalization of the support system emotions. Normalizes the experience and increases the sense of
• Provide stories of the successes of other support sys- control, while providing a context that supports posi-
tems. tive coping.54
• Sit with them as they express their thoughts and feel-
ings related to the situation.
• Support strengths of this system.
• Modeling of good communication.
• Include open, honest communication about the issues Addressing both the perceived positive and negative
the system finds most difficult to discuss. aspects of a situation opens communication and
decreases guilt.54
• Provide information the system needs about the situa- Promotes a sense of control, and facilitates decision
tion and disease process. making.
• Refer the support system to community support groups. Normalizes the experience and provides a source for
information on coping.
• Discuss opportunities for respite from caregiving Decreases guilt related to the need to withdraw from the
responsibilities. caregiving role.16
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Sorrow, Chronic • 699
Gerontic Health
In addition to the nursing actions provided here, the nurse is referred to the Mental Health section for this diagnosis.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide the client and/or caregiver with information that Assists the client and/or caregiver to have a sense of con-
is understandable and focused on the specific informa- trol in meeting care needs.
tion needed for the situation, and practical.
Encourage use of community, facility, or Web site support Gives the client or caregiver access to information and
services dealing with the specific disability or chronic resources that may help meet the challenges of their
illness involved.57 condition.
Promote use of available respite services as needed. Provides a means of positive coping for the individual.
Advise the older adult to maintain personal interests and Identified in research as a means of coping and maintain-
activities as much as possible. ing control.57,58
Use empathetic presence (listening, offering support and Helps the client or caregiver feel supported by profes-
encouragement and validation of feelings). sionals involved in care needs.
Discuss with the client or caregiver milestones and events Presents opportunities for anticipatory guidance.
that may trigger episodes of feeling sorrow, such as
anniversaries, birthdays, or celebrations that contrast
what could have been with what is.55
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Actively listen to the client’s story, helping him or her to There is an almost universal need to describe the feelings
put events in sequence, increasing his or her recall of and events of a death or major diagnosis.
details, and separating what is real from what is not.59
Teach the client and significant others the importance of Removes impediments to healthy expression of sadness.
expressing and accepting sadness59:
• Avoid platitudes.
• Avoid quiet suffering and suppression of grief.
• Change settings as necessary to allow expressions of
grief.
Assist the client to acknowledge and express feelings of This is the first step in resolution of feelings of guilt.
guilt.
If the chronic sorrow is related to death, assist the client Talking about the relationship is an important element of
in reviewing his or her relationship with the healing.
deceased59:
• Exploring the early days of the relationship, covering
negative aspects as well as positive aspects
• Exploring what might have been had the death not
occurred
Consult with and/or refer the patient to assistive resources Utilization of existing services is an efficient use of
as needed. resources.
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Violence, Self-Directed and Other-Directed, Risk For • 701
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Copyright © 2007 •by F. A. Davis.
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702 • Role-Relationship Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient and family to describe usual patterns of Insight into role-relationships is basic in determining the
role-relationship activities. risk for violence.
Monitor for precipitating or triggering events that seem to Risk indicators can be identified as assessment for
recur as the pattern for violence is explored. repeated violence is considered.
Assist the patient and family to describe their perception Insight of the patient or parents reveals basic data about
of the actual or potential violence pattern. the violence pattern, which assists in accurate interven-
tion.
Provide opportunities for expression of emotions related Expression of thoughts and feelings in a directive age-
to the violence appropriate for age and developmental appropriate manner helps the child understand the
capacity (e.g., a toddler could use dolls, puppets, or impact of the violence and assists in reducing his or
other noninvasive methods). her anxiety.
Provide appropriate collaboration for long-term follow-up Valuing long-term follow-up fosters compliance and
regarding appropriate intervention. shows sensitivity to the patient’s needs for long-term
support. Safety is also at risk. In many instances, legal
mandates dictate the exact protocols to be enforced.
Provide for role-taking by parents in a supportive manner Supportive role-modeling provides a safe and nonjudg-
when possible. mental milieu for the parents to practice parenting
and appropriate behaviors with the child. It also allows
for observation of behaviors to follow reciprocity of
parent–infant dyad or triad.
Provide consistency in caregivers to best develop a trust Consistency increases trust in caregivers.
for the nursing staff during hospitalization.
Provide for confidentiality and privacy. These standards are too often overlooked.
Ensure that discussions regarding the child and family are Objective dialogues are less threatening for all involved.
carried out with objectivity.
Address appropriate authorities as needed for protection Appropriate child protective measures must be taken.
of the child and family members, to include security or
police members according to institutional policy.
Provide support in determining usual coping patterns and Support in coping and dealing with violence will help
how these may be enhanced to deal with altered role- reduce the likelihood of increasing violence and assist
relationship pattern of violence. in reducing anxiety.
Assist in plans for placement, transitional placement, or Appropriate planning for changes in care and the environ-
dismissal to return home for the family. ment lessens the emotional trauma of these changes.
Assist in identification of specific resources for long-term Follow-up ensures attention to long-term needs and
planning as appropriate. attaches value to follow-up care.
Maintain objectivity in documentation of parent–child
interactions.
Women’s Health
● N O T E : These actions relate specifically to the abused, battered woman.60–63
ACTIONS/INTERVENTIONS R AT I O N A L E S
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Violence, Self-Directed and Other-Directed, Risk For • 703
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Are you afraid of your partner or significant other?
• Has your partner or significant other ever made you
feel afraid, inadequate, or worthless?
Be alert for cues that might indicate battering, such as: Provides the database necessary to accurately assess the
• Hesitancy in providing detailed information about true causative factor.
injury and how it occurred
• Explanation for injuries that are inconsistent with the
injury (e.g., trunk injury not consistent with a fall)
• Inappropriate affect for the situation
• Delayed reporting of symptoms
• Types and sites of injuries, such as bruises to head,
throat, chest, breast, or genitals
• Inappropriate explanations
• Increased anxiety in the presence of the batterer
• Injuries that are proximal, rather than distal, may indi-
cate a battering injury.
• Injuries that are in various stages of healing (e.g., old
bruises along with new bruises)
• Vague somatic symptoms with no visible cause
Provide a quiet, secure atmosphere to facilitate verbaliza- Provides emotional support to the patient. Fosters secu-
tion of fears, anger, rage, guilt, and shame. All discus- rity for the patient so that she will realize that she is
sions about violence should be initiated and conducted not alone, or not the only person to have had this expe-
with the patient isolated away from the partner. rience.
Provide information on options available to the patient Provides basic information needed by the patient for
(e.g., women’s shelters and legal aid societies). future planning.
Assist the patient in raising her self-esteem by:
• Asking permission to do nursing tasks
• Involving the patient in decision making
• Providing the patient with choices
• Encouraging the patient to ask questions
• Assuring the patient of confidentiality
• Listening to her concerns and choices without judging
Assist the patient in reviewing and understanding family
dynamics.
Facilitate the patient’s planning for economic and finan- Provides the information, long-range support, and essen-
cial needs, such as housing, job, child care, food, cloth- tials for resolving the problem.
ing, schooling for the children, and legal assistance.
Refer the patient to social services or battered women’s
support programs for immediate financial assistance
for shelter, food, clothing, and child care.
Assist the patient in identifying lifestyle adjustments that
each decision could entail.
Encourage development of community and social net-
work systems.
The nurse should monitor his or her own biases about Biases negatively impact appropriate nursing interven-
victims of domestic violence: tions.
• Belief that they deserve the abuse because they choose
to stay with the abuser
• Belief that the patient is powerless to change the (Refer to Rape Trauma Syndrome in Chapter 10.)
situation
(care plan continued on page 704)
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704 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Introduce self to the client, and call the client by name. Conditions that make people feel anonymous facilitate
aggressive behavior.64
If aggressive behavior is resulting from toxic substances, Staff and client safety is of primary concern.
consult with the primary care provider for medication
and detoxification procedure.
Observe the client every 15 minutes during detoxification, Client safety is of primary concern.
assessing vital signs and mental status, until the condi-
tion is stable.
Place the client in a quiet environment for detoxification. Inappropriate levels of sensory stimuli can increase con-
fusion and disorganization.
Eliminate environmental stimuli that affect the client in a Inappropriate levels of sensory stimuli can increase con-
negative manner. This could include staff, family, and fusion and disorganization, increasing the risk for vio-
other clients. Establish a balance between being in con- lent behavior.
trol and being controlling.
Provide a calm, reassuring environment. Respect the
client’s requests for quiet, alone time.
Protect the client from harm by: Provides basic client safety.
• Removing sharp objects from environment
• Removing belts and strings from the environment
• Providing a one-to-one constant interaction if risk for
self-harm is high
• Checking on the client’s whereabouts every 15 minutes
• Removing glass objects from environment
• Removing locks from room and bathroom doors
• Providing a shower curtain that will not support weight
• Checking to see whether the client swallows medica-
tion
Observe the client’s use of physical space, and do not Encroachment of the client’s personal space may be per-
invade client’s personal space. ceived as a threat.65
If it is necessary to have physical contact with the client, Clarifies the role of the staff to the client so that the intent
explain this need to the client in brief, simple terms of these interactions is framed in a positive manner.
before approaching.
Remove unnecessary clutter and excess stimuli from the Inappropriate levels of sensory stimuli can increase the
environment. client’s confusion and disorganization, thus increasing
the risk for violent behavior.
Talk with the client in a calm, reassuring voice.
Do not make sudden moves.
Remove persons who irritate the client from the environ- The best intervention for violent behavior is prevention.
ment. Observe the client carefully for signs of increas-
ing anxiety and tension.
Do not assume physical postures that are perceived as
threatening to the client.
If an increase in tension is noted, talk with the client Assists the client in developing coping behaviors.
about his or her feelings.
Help the client attach feelings to appropriate persons and Assists the client in developing coping behaviors that are
situations; for example, “Your boss really made you appropriate to the situation. Promotes the client’s sense
angry this time.” of control.65
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Violence, Self-Directed and Other-Directed, Risk For • 705
ACTIONS/INTERVENTIONS R AT I O N A L E S
Suggest to the client alternative behavior for releasing Assists the client in releasing physical tension associated
tension, for example, “You really seem tense right now. with high levels of anger.
Let’s go to the gym so you can use the punching bag.”
Or, “Let’s go for a walk.”
Provide medication as ordered, and observe the client for Provides the least restrictive way of assisting the client to
signs of side effects, especially orthostatic hypotension. control behavior.
Answer questions in an open, direct manner. Promotes the development of a trusting relationship, and
promotes consistency in interventions.65
Orient the client to reality in interactions. Use methods of Direct confrontations could be perceived as a threat to the
indirect confrontation that do not pose a personal threat client and precipitate violent behavior.66
to the client. Do not agree with delusions, for example,
“I do not hear voices other than yours or mine,” or
“This is the mental health unit at [name] Hospital.”
Refer to Disturbed Thought Process in Chapter 7 for Promotes the development of a trusting relationship. In
detailed interventions for delusions and hallucinations. crisis, clients are more likely to respond positively to
someone with whom they have a trusting relationship.
Increases consistency in interventions.65
Assign one staff member to be primary caregiver to the
client to facilitate the development of a therapeutic
relationship.
Inform the client before any attempts to make physical Clients who are prone to violence need increased per-
contact are made in the process of normal provision of sonal space. Intrusions could provoke violent
care. For example, explain to the client you would like behavior.65
to assist him or her with dressing, and would this be all
right?
Assist the client in identifying potential problem behavior Promotes the client’s sense of control, which decreases
with feedback about his or her behavior. the risk for violent behavior.65
Have the client talk about angry feelings toward self and Assists the client to understand the reasons for the anger,
others. which can defuse the situation.65
Contract with the client to talk with staff member when Promotes the client’s sense of control by assuring the
he or she feels an increase in internal tension or anger. client that if he or she can no longer maintain control,
the staff has a specific plan to assist him or her.65
Set limits on inappropriate behavior, and discuss these
limits with the client. Note these limits here, as well as
the consequences for these kinds of behaviors. This
information should be very specific so that the inter-
vention is consistent from shift to shift. Present these
limits as choices.
If conflict occurs between the client and someone else, sit Staff presence can reinforce using appropriate problem-
with them as they resolve the conflict in an appropriate solving skills as the client practices these new behav-
manner. The nurse will serve as a facilitator during this iors.
interaction.
Discuss tension-reduction techniques with the client, and Promotes the client’s sense of control. Repeated prac-
develop a plan for the client to learn these techniques tice of a behavior internalizes and personalizes the
and apply them in difficult situations. [Note the plan behavior.
here.]
Develop with the client a reward system for appropriate Positive reinforcement encourages behavior.
behavior. [Note reward system here.]
Talk with the client about the differences between feel- Promotes the client’s sense of control by establishing limits
ings and behavior. Role-play with the client, attaching around feelings in the cognitive realm. Repeated practice
different kinds of behavior to feelings of anger. of a behavior internalizes and personalizes the behavior.
(care plan continued on page 706)
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706 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Help the client in determining whether the feeling being Placing other names on the feeling may open new behav-
experienced is really anger. Explain that at times of ior possibilities to the client, while promoting a posi-
high stress we can misinterpret feelings and must be tive orientation. For example, if this were anger,
very careful not to express the wrong feeling. What we lashing out would be appropriate, but because it is anx-
are expressing as anger may actually be, for example, iety, it is more appropriate to relax.
anxiety or frustration.
When the client is capable, assign him or her to group in Promotes the client’s sense of control by providing role
which feelings can be expressed and feedback can be models for alternative ways of coping with feelings.
obtained from peers. [Note the schedule for group
activity here.]
Review with the client consequences of inappropriate Assesses the possibility for secondary gain for inappro-
behavior, and assess the gains of this behavior over the priate behavior.
costs.
Accept all threats of aggressive behavior as serious. Client and staff safety are of primary importance.
Remind the staff to not take aggressive acts personally, As the nurse’s level of arousal increases, judgment
even if they appear to be directed at one staff member. decreases, making the nurse less effective when work-
ing with the client who is experiencing difficulty.65
Provide the client with positive verbal feedback about Positive feedback encourages behavior.
positive behavior changes.
Do not place the client in frustrating experiences without Frustration can increase the risk for aggression.64
a staff member to support the client during the experi-
ence.
If the client is suicidal, place him or her in a room with Decreases the amount of time the client is alone.
another client.
Provide the client with opportunities to regain self-control Promotes the client’s perception of control while support-
without aggressive interventions by giving the client ing self-esteem.
choices that will facilitate control; for example,
“Would you like to take some medication now or
spend some time with a staff member in your room?”
Or “We can help you into seclusion, or you can walk
there on your own.”
Provide the client with opportunities to maintain his or
her dignity.
Assure the client that you will not allow him or her to
harm self or someone else.
Reinforce this by having more staff in attendance than Client and staff safety are of primary concern.
necessary to physically control the client if necessary.
Persons from other areas of the institution may be
needed in these situations. If others are used, they
should be trained in proper procedures.
If potential for physical aggression is high65,66:
• Place one staff member in charge of the situation. Promotes consistency in intervention and decreases inap-
propriate levels of sensory stimulation.
• As the primary care person attempts to “talk the client Client and staff safety are of primary concern.
down,” other staff member should remove other clients
and visitors from the situation.
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Violence, Self-Directed and Other-Directed, Risk For • 707
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Other staff members should remove potential weapons Assists in reducing levels of emotion.
from the environment in an unobtrusive manner. This
could include pool cues and balls, chairs, flower vases,
or books.
• Avoid sudden movements.
• Never turn your back on the client.
• Maintain eye contact (this should not be direct, for this Assists in assessing the client’s intentions without appear-
can be perceived as threatening to the client), and ing threatening.
watch the client’s eyes for cues about potential targets
of attack.
• Do not attempt to subdue the client without adequate Client and staff safety are of primary concern.
assistance.
• Put an increased distance between the client and self. Clients who have a potential for violent behavior need
more personal space.
• Tell the client of the concern in brief, concise terms. Maintains appropriate levels of sensory stimuli.
• Suggest alternative behavior. Promotes the client’s sense of control.
• Help the client focus aggression away from the staff. May prevent the need for more restrictive interventions.
• Encourage the client to discuss concerns. Assists in reducing levels of emotion and de-escalation of
behavior.
If talking does not resolve the situation:
• Have additional assistance prepared for action (at least Client and staff safety are of primary concern.
four persons should be present).
• Have those who are going to be involved in the inter-
vention remove any personal items that could harm
client or self (e.g., eyeglasses, guns, long earrings,
necklaces, or bracelets).
• Have seclusion/restraints ready for the client, remove Prevents sensory overload while providing reassurance to
glass objects and sharp objects, and open doors for the client.
easy entry.
• Briefly explain to client what is going to happen and
why.
• Use method practiced by intervention team to place the Client and staff safety and coordination are of primary
client in seclusion or restraints. concern.
• Protect self with blankets, arms bent in front of the Contains the client’s body and blocks the client’s vision if
body to protect the head and neck. it is necessary to disarm the client.66
• Be prepared to leave the situation, and be aware of Client and staff safety is of primary concern.
location of exits.
See Impaired Physical Mobility, Chapter 5, for care of the
client in seclusion or restraints.
Discuss the violent episode with the client when control Debriefing diminishes the emotional impact of the inter-
has been regained. Answer questions the client has vention, and provides an opportunity to clarify the cir-
about the situation, and provide the client with oppor- cumstances for the intervention, offer mutual feedback,
tunities to express thoughts and feelings about the and promote the client’s self-esteem.67
episode.
Inform the client of the behavior that is necessary to be Promotes the client’s sense of control and enhances self-
released from seclusion or restraints. esteem.
Process the situation with the client after incident and
explore alternative coping strategies for future situa-
tions.
Assess the milieu for “organizational provocation.”
If the client has a history of violent acts: Provides offenders with the opportunity to rebuild their
relationship style.68
(care plan continued on page 708)
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708 • Role-Relationship Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Provide the client with individual or group opportuni-
ties to:
• Take responsibility for the violent act.
• Develop empathy for the victim.
• In some way, develop an apology to the victim. (This
method may be indirect if it would not be in the best
interest of the victim to receive a direct apology.)
• Explore the interactions of thoughts, feelings, and
behaviors in their violent acts.
• Develop a plan for alternative ways of responding to
the identified thoughts and feelings.
• Note persons responsible for facilitating this process
here, along with the meeting schedule.
• If partner or family violence is an issue, arrange con- Provides partners with an opportunity to develop alterna-
joint, solution-oriented treatment. This should include a tive ways of communicating and problem solving.69,70
no-violence contract between the partners.
Educate the client about personal behaviors that could Client’s may not be aware of the risks involved in these
result in self-harm or are high risk (e.g., autoerotic behaviors.
asphyxia, failure to use personal protective sports
equipment).
Gerontic Health
● N O T E : Suicide or attempted suicide is a serious functional consequence of depres-
sion in elders. Particularly at risk are elderly clients who are: males; Protestant with
rare church attendance; Caucasian; widowed or divorced; living alone or living in an
urban environment; recently relocated; retired or unemployed; depressed; alcoholic or
dependent on other substances; experiencing low self-esteem, decreased life satisfaction,
or hopelessness; or has a family history of suicide or mental illness. Elders who attempt
suicide are typically successful on the first attempt. If there is a failed attempt, the elder
should be considered high risk for further attempts.71 Remember that for the client who
has intent to end their life the correct nursing diagnosis would be Suicide, Risk for.
Psychoses and agitation are common in clients with dementia. In cases of agita-
tion, it is critical to consider the safety of the patient and that of those around him or
her. The health-care team should carefully evaluate the medical, psychiatric, or psy-
chosocial problems that underlie the disturbance and tend to those in an effort to resolve
the problem.72
ACTIONS/INTERVENTIONS R AT I O N A L E S
Risk for Self-Directed Violence
Carefully conduct an assessment of verbal, behavioral, These are warning signs that may signal suicidal
situational, or syndromatic warning signs that may sig- ideology.71
nal suicidal ideology:
• Stockpiling medications
• Purchasing a gun
• Making or changing a will
• Putting personal affairs in order
• Giving money or possessions away
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Violence, Self-Directed and Other-Directed, Risk For • 709
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Donating one’s body to science
• Sudden interest or disinterest in religion
• Self-neglect
• Difficulty in performing household or social tasks
• Deterioration of relationship behaviors
• A general downturn in health status
• Failure to thrive
• Scheduling an appointment with a physician for vague
symptoms
• Recent move
• Death of a spouse, child, or friend
• Diagnosis of a terminal illness
• Depression accompanied by anxiety
• Tension, agitation, guilt, and dependency
• Rigidity, impulsiveness, and isolation
• Changes in sleeping and eating habits
• Sudden recovery from a deep depression
Carefully assess the client for the presence of protective These are important resources that the nurse can draw
factors and draw upon these when working with the upon when working with a suicidal elder.71
client:
• The potential for understanding, relating, benefiting
from experience, benefiting from knowledge, accept-
ance of help
• The capacity for loving, wisdom, sense of humor,
social interest
• Possession of a sense of purpose or meaning in life
• A history of successful transitions, coping independ-
ently, acquisition of life skills, the ability to reminisce
(especially about life successes)
• The presence of a caring and available family and sup-
portive community network
• The presence of a caring, available, and knowledgeable
nurse or health-care provider and health network
• Membership in a religious community, particularly
Catholic or Jewish
• Commitment to personal values and ideals, people,
groups, creative work, and/or social, political, or intel-
lectual causes
Determine the agency’s suicide policy/protocol and
adhere to it.71
Risk for Other-Directed Violence
When bathing the client with a tendency toward
violence73:
• Keep the bathing area warm.
• If the sound of running water agitates the client, run the
water before the client enters the bathing area.
• Avoid rushing; task-oriented behavior by the caregiver
is associated with agitated behavior.
• Use “rescuing” if necessary to reduce agitation; a nega-
tive response to one caregiver can be “solved” by the
second caregiver.
(care plan continued on page 710)
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710 • Role-Relationship Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Assess early signs of agitation; back off for a few min-
utes until the client calms.
• Remove dentures in clients who tend to bite.
• Offer gum or other foods or engage the client in
singing if he or she tends to bite.
For clients who “grab,” offer distraction or something for
them to hold. Ensure that an adequate number of care-
givers are present for lifting and transferring so the
client feels safe.74
In cases of dementia, discuss with the caregiver whether Awareness of violence triggers provides guidelines to
there is a usual pattern of violence. For example, does adjust environment and staff behaviors.
startling or speaking in loud tones, or having several
people speaking at once, usually result in a violent out-
burst by the patient?
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the client and family appropriate monitoring of Provides a database for early recognition and
signs and symptoms of the risk for violence: intervention.
• Substance abuse
• Increased stress
• Social isolation
• Hostility
• Increased motor activity
• Disorientation to person, place, and time
• Disconnected thoughts
• Clenched fists
• Throwing objects
• Verbalizations of threats to self or others
Assist the client and family in lifestyle adjustments that Permanent changes in behavior require support.
may be required:
• Recognition of feelings of anger or hostility
• Developing coping strategies to express anger and hos-
tility in acceptable manner, such as exercise, sports, art,
music, etc.
• Prevention of harm to self and others
• Treatment of substance abuse
• Management of debilitating disease
• Coping with loss
• Stress management
• Decreasing sensory stimulation
• Provision of a safe environment
• Removal of weapons, toxic drugs, etc.
• Development and use of a support network
• Restriction of access to weapons, especially
handguns75,76
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Violence, Self-Directed and Other-Directed, Risk For • 711
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss workplace issues related to violence.77 Homicide is a leading cause of occupational death.
Prevention is needed.
Develop anticipatory guidance materials for violence pre- Age-appropriate prevention strategies provide support for
vention.77,78 change.
Involve the patient and family in planning and imple- Provides for early intervention.
menting strategies to reduce the risk for violence:
• Family conference
• Mutual goal setting
• Communication
Assist the client and family to set criteria to help them
determine when intervention of law enforcement offi-
cials or health professionals is required (e.g., if the
patient becomes threat to self or others).
Consult with or refer to assistive resources as appropriate. Utilization of existing services is efficient use of
resources. The psychiatric nurse clinician and support
groups can enhance the treatment plan.
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Copyright © 2007 •by F. A. Davis.
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712 • Role-Relationship Pattern
39. Lowdermilk, DL, and Perry, SE: Maternity & Women’s Health Care, 60. Phillips, DSH: Culture and systems of oppression in abused women’s
ed 8. CV Mosby, St. Louis, 2004. lives. JOGNN J Obstet Gynecol Neonatal Nurs 27:678, 1998.
40. Teschendorf, M: Women during the reproductive years. In Breslin, 61. Parker, B, and McFarlane, J: Identifying and helping battered pregnant
ET, and Lucas, VA (eds): Women’s Health Nursing: Toward women. MCN Am J Matern Child Nurs 16:161, 1991.
Evidenced-Based Practice. WB Saunders, St. Louis, 2003. 62. Sampselle, CM: The role in preventing violence against women.
41. Pridham, KF, et al: Early postpartum transition: Progress in maternal JOGNN J Obstet Gynecol Neonatal Nurs 20:481, 1991.
identity and role attainment. Res Nurs Health 14:21, 1991. 63. Farley, M, and Keaney, JC: Physical symptoms, somatization, and dis-
42. Condon, J, and Corkindale, C: The correlates of antenatal attachment sociation in women survivors of childhood sexual assault. Women’s
in pregnant women. Br J Med Psychol 70:359, 1997. Health 25:33, 1997.
43. Gilliss, C, et al: Toward a Science of Family Nursing. Addison- 64. Zimbardo, P: In review. In Evans, R: The Making of Psychology.
Wesley, Menlo Park, CA, 1989. Alfred Knopf, New York, 1976.
44. Roehlkepartain, E: You Can Make a Difference for Kids. Search 65. Stevenson, S: Heading off violence with verbal de-escalation.
Institute, Minneapolis, MN, 1999. J Psychosoc Nurs Ment Health Serv 29:6, 1991.
45. Patterson, G: Families. Research Press, Champaign, IL, 1971. 66. Morton, P: Staff roles and responsibilities in incidents of patient vio-
46. Wong, DL: Whaley and Wong’s Nursing Care of Infants and Children, lence. Arch Psychiatr Nurs 1:280, 1987.
ed 6. CV Mosby, St. Louis, 1999. 67. Norris, M, and Kennedy, C: The view from within: How patients per-
47. Abraham, IL, and Reel, S: Cognitive nursing interventions with long- ceive the seclusion process. J Psychosoc Nurs Ment Health Serv 30:7,
term care residents: Effects on neurocognitive dimensions. Arch 1992.
Psychiatr Nurs VI:356, 1992. 68. Sheela, RA: A nurse’s experiences working with sex offenders.
48. National Guide Clearinghouse: National guidelines for management J Psychosoc Nurs 37:25, 1999.
of relocation in cognitively intact older adults. http://www.guideline. 69. Stith, S: Domestic violence. Clin Update 2000 1:1, 2000.
gov, 2006. 70. Robinson, C, Wright, L, and Watson, WA: A nontraditional approach
49. King, KS, Dimond, M, and McCance, KL: Coping with relocation. to family violence. Arch Psychiatr Nurs 8:30, 1994.
Geriatr Nurs 8:258, 1987. 71. National Guideline Clearinghouse: Evidenced-based protocol: Elderly
50. Flake, KJ: HIV testing during pregnancy: Building the case for volun- suicide, secondary prevention. http://www.guideline.gov, 2006.
tary testing. Lifelines 4:13, 2000. 72. National Guideline Clearinghouse: Guideline for the treatment of
51. Stewart, A, and Dent, A: At a Loss: Bereavement Care When a Baby patients with Alzheimer’s disease and other dementias of late life.
Dies. Bailliere Tindall, London, 1994. http://www.guideline.gov, 2006.
52. Cote-Arsenault, C, and Mahlangu, N: Impact of perinatal loss on 73. National Guideline Clearinghouse: Prevention of violence.
the subsequent pregnancy and self: Women’s experiences. JOGNN http://www.guideline.gov, 2006.
J Obstet Gynecol Neonatal Nurs 28:274, 1999. 74. National Guideline Clearinghouse: Bathing persons with dementia.
53. Hainsworth, M: Helping spouses with chronic sorrow related to multi- http://www.guideline.gov, 2006.
ple sclerosis. J Psychosoc Nurs 34:36, 1996. 75. Loftin, C, et al: Effects of restrictive licensing of handguns and
54. Moules, N: Legitimizing grief: Challenging beliefs that constrain. homicide and suicide in the District of Columbia. N Engl J Med
J Fam Nurs 4:142, 1998. 325:1615, 1991.
55. Burke, M, Eakes, G, and Hainsworth, M: Milestone of chronic sor- 76. Kellerman, A, et al: Suicide in the home in relation to gun ownership.
row: Perspectives of chronically ill and bereaved persons and family N Engl J Med 327:467, 1992.
caregivers. J Fam Nurs 5:374, 1999. 77. Centers for Disease Control/National Institute of Occupational Safety
56. Eakes, G: Chronic sorrow: The lived experience of parents of chroni- and Health: Homicide in US Workplaces: A Strategy for Prevention
cally mentally ill individuals. Arch Psychiatr Nurs 9:77, 1995. and Research. US Department of Health and Human Services,
57. Lindgre, CL, and Connely, CT: Grief in spouse and children care- Morgantown, WV, 1992.
givers of dementia patients. West J Nurs Res 21:521, 1999. 78. Roberts, C, and Quillian, J: Preventing violence through primary care
58. Lindgren, CL: Chronic sorrow in persons with Parkinson’s and their intervention. Nurse Pract 17:62, 1992.
spouses. Scholast Inquiry Nurse Pract 10:351, 1996. 79. National Guidelines for Management of Relocation in Cognitively
59. Kemp, C: Terminal Illness: A Guide to Nursing Care, ed 2. Lippincott, Intact Older Adults, http://www.guidelines.gov (accessed February 8,
Williams & Wilkins, Philadelphia, 1999. 2006).
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SEXUALITY–
10
REPRODUCTIVE
PATTERN
1. RAPE-TRAUMA SYNDROME: COMPOUND
REACTION AND SILENT REACTION 717
2. SEXUAL DYSFUNCTION 725
3. SEXUALITY PATTERNS, INEFFECTIVE 731
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714 • Sexuality–Reproductive Pattern
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Copyright © 2007 by F. A. Davis. •
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Developmental Considerations • 715
As in gender identity, researchers have noticed gender turing and providing care-taking activities allows the infant
role-play in children as young as 13 months. Schoolchildren to begin experiencing various pleasures and physical sensa-
are particularly exposed and pressured into gender role tions, such as warmth, pleasure, security, and trust,1 and it is
stereotyping by parents, teachers, and peers, who demand through these acts of nurturing that the infant begins to
expected, rigid behavior patterns according to the sex of the develop a sense of masculinity or femininity (gender iden-
child. Molding into gender roles is often accomplished by tity). The infant is further molded by the parents’ percep-
handling girls and boys differently. Little girls are usually tions of sex-appropriate behavior through reward and
handled gently as infants, and adults fuss with their baby’s punishment. Female infants tend to be less aggressive and
hair and tell her how pretty she is; little boys are usually develop more sensitivity because girls are usually rewarded
roughhoused and are told “What a big boy you are.” Sex for “being good,” and male infants develop more aggres-
directional training is also accomplished by such verbaliza- sively and learn to be independent because boys are told that
tions as “Where’s Daddy’s girl?” and “Big boys don’t cry; “big boys don’t cry” and they learn to comfort themselves.
be a man.”5 By the age of 13 months, sexual behavior patterns and dif-
North American society is moving toward a blending ferences are in place,1,4 and core gender identity is theorized
of male and female roles; however, stereotyping still exists. to be formed by 18 months.7 “These early behaviors are so
According to Schuster and Ashburn,4 stereotyping is not all critical to one’s core gender-identity that children who expe-
bad, as it can help “reduce anxiety arising from gender dif- rience gender reassignment after the age of 2 years are high-
ferences and may aid in the process of psychic separation risk candidates for psychotic disorders.”4
from one’s parents.” Therefore, they conclude that stereo- The infant who is sexually abused is usually physically
types can provide structure and facilitate development as traumatized and, many times, dies. Developmental delays
well as restrict development and become too rigid, thus can be recognized in these children by failure to thrive, low
interfering with a child’s potential. weight or no weight gain, lethargy, and flat affect.
One’s sexuality is a continuing lifetime evolution,
changing as one matures and progresses through the life TODDLER AND PRESCHOOLER
cycle. It is impossible to separate an individual’s sexuality Neuromuscular control allows toddlers to explore their envi-
from his or her development, as sexuality combines the ronment, interact with their peers,1,4 and develop autonomy
interaction of the biophysical and psychosocial elements of and independence.7 Genital organs continue to increase in
the individual. size but not in function. The toddler’s vocabulary increases;
According to a national research study,8 “Rape in he or she distinguishes between male and female by recog-
America,” rape occurs far more often than previously recog- nizing clothing and body parts; and he or she develops pride
nized. This study found that 683,000 American women were in his or her own body, especially the genital area, as he or
raped in 1990, which is a far higher number than had been she becomes aware of elimination or excretory functions.
estimated. Almost 62 percent of these women stated they They need guidance and require parents to set limits as they
were minors when they were raped, and about 29 percent learn to “hold on” or “let go” in order to achieve a sense of
stated they were younger than 11 when the rape occurred. autonomy.4 By the age of 3, they have perfected verbal terms
This indicates rape is most definitely a traumatic event for for the sexes, understand the meaning of gender terms and
our young in America. Of the rapists, 75 percent were known the roles associated with those terms (e.g., girl is sister or
by the victim, and included such persons as neighbors, mother, and boy is brother or father),1 and receive pleasure
friends, relatives, boyfriends, ex-boyfriends, husbands, or from kissing and hugging.7
ex-husbands. Only 22 percent of the rapists were strangers to The preschooler is busy developing a sense of social-
the victim. In 28 percent of the cases, injuries to the victim, ization and purpose. Learning suitable behavior for girls and
beyond the rape itself, occurred. Sadly, only 16 percent of the boys or sex role behavior is the major task during the pre-
victims told police about the attack, with the victims being school years. Preschoolers will often identify with the par-
concerned about the family finding out, being blamed by oth- ent of the same sex while forming an attachment to the
ers for the attack, and others knowing about the attack. These parent of the opposite sex. They are inquisitive about sex
concerns have decreased in victims raped in the past 5 years. and are often occupied in exploration of their own bodies
Nonetheless, in this group there were increased concerns and friends’ bodies, which will often be exhibited in group
about having their name become public, getting AIDS and games such as “doctor–nurse,” urinating “outside,” or mas-
other sexually transmitted diseases, and becoming pregnant. turbating.7 The toddlers’ concept of their bodies, not as a
Confidentiality of identity is a high priority for these victims. whole but as individual parts, changes when as preschoolers
they begin to develop “an awareness of themselves as indi-
DEVELOPMENTAL CONSIDERATIONS viduals, and become more concerned about body integrity
and intactness.”4
INFANT
It is important to note that 6-year-olds are the age
Erickson defines the major task of infancy as the develop- group most subjected to sexual abuse.8 How a child handles
ment of trust versus mistrust.4 The act of the parents’ nur- this experience, and his or her future developmental and
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716 • Sexuality–Reproductive Pattern
psychological growth, depend largely on the reactions and from exploring behavior to intercourse, sometimes with
actions of the significant adult in the child’s life.7 Rape that the result of teenage pregnancy. Exploring behavior can be
occurs during early childhood may simply be acknowledged either with the opposite sex (foreplay and intercourse), the
by the child as part of the experience of growing up and may same sex (homosexuality), or self (masturbation). How
have no long-term effects if not repeated. Usually counsel- the teenager views him- or herself sexually will depend on
ing during this developmental age has great effect. All the reassurance and guidance he or she receives from a sig-
claims of abuse by a child should be investigated and should nificant adult in his or her life. The greatest misunderstand-
be handled through someone who has the experience and ings of teenagers involve homosexuality, masturbation, and
knowledge to deal with the child and his or her parents in a conception and contraception. How these subjects are
professional and understanding manner. approached, taught, and supported can influence their adult
sexuality.1,7
SCHOOL-AGE CHILD It is during adolescence, when new experiences of
sexual maturity begin, that questions about maleness or
Play is the most important work of children—it allows them femaleness are asked by the individual and concerns arise
to be curious and investigate social, sexual, and adult behav- about “who one is within the peer group.”1 Adolescents must
ior. “Through play children learn how to get their needs met evaluate their masculinity and femininity and question and
and how to meet the needs of others.”4 Different socializa- then decide on their gender identity, gender orientation, and
tion of boys and girls tends to become apparent in play dur- gender preference. The adolescent not only deals with phys-
ing the school years, with boys engaging in aggressive team ical changes, but also integrates past experiences and role
play and girls in milder play and forming individual friend- models with new experiences and new role models into his
ships. These activities can lead to stereotyping and exagger- or her own gender identity.
ation of gender difference. Violent sexual occurrences during this period of life
Going to school allows children to begin to be can devastate a person for the rest of his or her life.
more independent and form peer groups of the same sex. Adolescents are dealing with sexual confusion and identifi-
Although the peer group becomes very important to them, cation; rape can stop or slow or change this process. Fear
they need adult direction in learning socially acceptable and loss of self-esteem can dictate actions and influence the
forms of sexual behavior and when they may engage in sexual identity and gender expression.
them. If they do not receive the information they are
seeking, negative feelings and apprehension about sexuality
YOUNG ADULT
may develop.1
Great trauma can occur when rape occurs during these This period of an individual’s life (usually 20s and early
years. It is very damaging to the value systems that are being 30s) is concerned with selecting a vocation, obtaining an
formed. Sexual identity can be disturbed, and sexual confu- education, military service, choosing a partner, building a
sion can occur. career, and establishing an intimate relationship. This is a
period of maximal sexual self-consciousness, commitment
ADOLESCENT to a relationship, and social legitimization of sexual experi-
ences.1,4,7 There is a concern with parenting and establish-
Puberty, “the period of maturation of the reproductive sys- ment of the marital relationship.
tem,”4 causes profound changes in the individual’s sexual Rape can slow or stop normal sexual relationships
anatomy and physiology and is a major developmental cri- during the adult years. Fear can become the greater part
sis for the adolescent. Secondary sex characteristics of life for the victim. These years are ones for forming
appear—breasts, pubic hair, and menstruation in girls; tes- lasting relations with a sexual partner, marrying, and begin-
ticular enlargement, penile enlargement, pubic hair, ejacula- ning families. Rape can cause withdrawal from any interac-
tion, and growth of muscle mass in boys. The configuration, tion with a sexual partner; relationships can break up,
contour, and function of the body changes rapidly and dra- not only because of the reaction of the victim of rape, but
matically point out sexual differences and the onset of adult- also because of the reactions of the family and partner of
hood. These changes bring new feelings that create role the victim.
confusion and increase awareness of sexual feelings. “The
major task of adolescence is the establishment of identity in
ADULT
the fact of role confusion.”1
Peer groups have an important influence on the young Demands placed on adults by their careers and raising chil-
adolescent (12 to 15 years), but during late adolescence (16 dren may interfere with their sexual interest and activity.1
to 19 years) the peer group influence lessens and more inti- The major task of this period of life is to accent one’s own
mate relationships with the opposite sex develop.7 These lifestyle and decisions rather than feeling frustrated and dis-
relationships can involve a wide range of sexual behavior appointed. “Social pressures and expectations, feedback
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Rape-Trauma Syndrome: Compound Reaction and Silent Reaction • 717
from significant others and, finally, self-perception all influ- sent. The trauma syndrome that develops from this attack, or
ence how one evaluates the success of one’s life.”1 attempted attack, includes an acute phase of disorganization
Although the adult is at the peak of his or her career of the victim’s lifestyle and a long-term process of reorgan-
or profession, physiologic changes begin to influence the ization of lifestyle.
adult’s lifestyle. The aging process, illnesses, and
menopause (male and female) cause changes in lifestyles DEFINING CHARACTERISTICS10
and everyday activities. Changes in sexual activities can
occur because of these physical and physiologic changes; A. Rape-Trauma Syndrome
however, the adult who lives a healthy lifestyle, has good 1. Disorganization
nutrition, exercises, and has an optimistic outlook usually 2. Change in relationships
feels good and functions well sexually. Often middle-age 3. Physical trauma (e.g., bruising and tissue irritation)
adults, just as they have finished raising their children, are 4. Suicide attempts
faced with the task of caring for their elderly parents. 5. Denial
6. Guilt
7. Paranoia
OLDER ADULT 8. Humiliation
9. Embarrassment
As in adolescence, dramatic body changes begin in late
10. Aggression
adulthood and continue into old age. There is no reason that
11. Muscle tension and/or spasms
healthy men and women cannot continue to enjoy their sex-
12. Mood swings
uality into old age. Women must deal with menopause and
13. Dependence
postmenopause, and men must often deal with impotence;
14. Powerlessness
however, with an interested sexual partner, good healthy
15. Nightmares and sleep disturbance
sexuality can continue.
16. Sexual dysfunction
Older women are viewed by rapists as easy victims.
17. Revenge
Slowing of physical reactions and disabilities of old age
18. Phobias
(impaired seeing or hearing, or slow gait) keep them from
19. Loss of self-esteem
being alert to danger and from reacting quickly. More
20. Inability to make decisions
important, the older woman often views herself as inferior,
21. Dissociative disorders
and this contributes to her own victimization.9 Because most
22. Self-blame
women outlive men and face changes in lifestyles and eco-
23. Hyperalertness
nomic status, they are reluctant, and often cannot afford, to
24. Vulnerability
leave familiar older parts of cities that often change and
25. Substance abuse
deteriorate. This may expose them to the accompanying
26. Depression
increase in crime rate.9
27. Helplessness
28. Anger
29. Anxiety
APPLICABLE NURSING DIAGNOSES 30. Agitation
31. Shame
RAPE-TRAUMA SYNDROME: 32. Shock
COMPOUND REACTION AND 33. Fear
SILENT REACTION B. Rape-Trauma Syndrome: Compound Reaction
1. Change in lifestyle, for example, changes in resi-
DEFINITIONS10
dence, dealing with repetitive nightmares and pho-
Rape-Trauma Syndrome Sustained maladaptive response bias, seeking family support, or seeking social
to a forced, violent sexual penetration against the victim’s network support in long-term phase
will and consent. 2. Emotional reaction, for example, anger, embarrass-
Rape-Trauma Syndrome: Compound Reaction ment, fear of physical violence and death, humilia-
Forced, violent sexual penetration against the victim’s will tion, revenge, or self-blame in acute phase
and consent. The trauma syndrome that develops from this 3. Multiple physical symptoms (e.g., gastrointestinal
attack or attempted attack includes an acute phase of disor- irritability, genitourinary discomfort, muscle tension,
ganization of the victim’s lifestyle, and a long-term process or sleep pattern disturbance in acute phase)
of reorganization of lifestyle. 4. Reactivated symptoms of previous conditions, that is,
Rape-Trauma Syndrome: Silent Reaction Forced, physical illness or psychiatric illness in acute phase
violent sexual penetration against the victim’s will and con- 5. Reliance on alcohol and/or drugs (acute phase)
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718 • Sexuality–Reproductive Pattern
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Copyright © 2007 by F. A. Davis. •
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Rape-Trauma Syndrome: Compound Reaction and Silent Reaction • 719
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide for appropriate privacy and health teaching as Avoids perpetuating the survivor’s fear as a result of
care is administered. Allow the survivor to see her own necessity of examination and treatment in the same
anatomy if this seems appropriate as part of health body area involved in the rape. Could promote a sensa-
teaching. tion of rape recurrence.
Assist the survivor in activities of daily living (ADLs) Promotes a slight sense of return to normalcy. Emotional
after examination. shock may render the survivor temporarily unable to
perform basic ADLs.
Determine to what degree or extent symptoms of physical Basic database needed to plan for long-term effects of
reactions exist, such as: rape.
• Pain or body soreness
• Disturbances in sleep
• Altered eating patterns
• Anger
• Self-blame
• Mood swings
• Feelings of helplessness
Administer medications as ordered to alleviate pain, anxi- Allows time for the survivor to process event in a way
ety, or inability to sleep, and teach the survivor how to that maintains self-integrity and self-esteem.
safely take such medications.
When interacting with the survivor, recognize that she
will proceed at her own rate in resolving rape trauma.
Do not rush or force the survivor.
Identify available support systems (e.g., rape crisis center, Support systems that know signs and symptoms of rape-
and involve the significant other as appropriate). trauma syndrome can provide help for both short-term
and long-term interventions. Promotes effective coping
for the survivor.
Monitor coping in the survivor and significant other until Monitors for adaptive and maladaptive coping strategies.
discharge from the hospital. Provides an opportunity to assist the survivor and sig-
nificant other to practice alternative coping strategies.
Assist the survivor to identify own strengths in dealing Helps build the survivor’s self-esteem and overcome self-
with the rape. blame.
Provide anticipatory guidance about the long-term effects Helps prepare for expected and unexpected reactions in
of rape. Promote self-confidence and self-esteem self, friends, and significant others.
through positive feedback regarding strengths, plans,
and reality.
Provide for appropriate epidemiologic follow-up in cases Required by law.
of venereal disease.
Collaborate with other health-care professionals as Promotes a holistic approach and more complete plan of
needed. care.
Arrange for appropriate long-term follow-up before dis- Provides for long-term support.
charge from the hospital (e.g., counseling).
Male Rape Victim
Provide the same considerations as with a female sur- The act of rape is an act of violence regardless of the
vivor. (Usually these are the result of homosexual rela- gender of the patient, and requires the same type of
tionships. Most reported cases are children and early care and concern.
adolescents.)
Refer the patient to a trained male counselor (rape crisis
center).
(care plan continued on page 720)
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720 • Sexuality–Reproductive Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage collaboration among health-care professionals A specialist will be required to deal with the unique
to best address the patient’s needs. needs of the young child enduring rape. The likelihood
exists for incest or a closely related individual’s being
identified as the one who committed the act.
Try to establish trust as dictated by age and circum-
stances related to rape trauma (with nurse being same
sex as the patient). Do not leave the child alone. Be
gentle and patient.
• Infants and toddlers: Ensure continuity of caregivers.
Explain procedures with dolls and puppets.
• Preschoolers: Ensure continuity of caregivers. Allow
the patient to perform self-care behavior as ability
allows. Use art and methods that deal with the general
view of what happened, singling out the child as not
being the “cause” of this incident.
• School-agers: Maintain continuity of caregivers. Assist
the patient to express concerns related to incident. Use
appropriate techniques in interviewing to determine the
extent of sexual dysfunction or potential threat to
future functioning.
• Adolescents: Maintain continuity of caregivers.
Encourage the patient to express how this experience
affects own self-identity and future sexual activities.
Encourage psychiatric assistance in resolving this crisis
for any patients of this age group. Look for signs of
growth of secondary sex characteristics.
Follow up with appropriate documentation and coordina- Appropriate protocols for documentation and reporting of
tion of child protective service needs. Assist the par- rape or incest must be followed according to state and
ents or guardians in signing proper release forms. federal guidelines.
Determine whether the situation involves incest.
Assist the patient to deal with residual feelings such Resolution of unresolved guilt or feelings about the event
as guilt for revealing or identifying assailant (in must be dealt with as soon as the client’s condition
young children this often must be dealt with within permits.
the family or extended-family situations) by allowing
at least 30 minutes per shift (while the patient is
awake) at [times]. Use simple language when dealing
with the child.
Encourage the family members to assist in care and Risk behaviors serve as cues to alert the family or care-
follow-up of the patient’s reorganization plans: giver to monitor the child’s progress in resolving the
• Be alert for signs of distress such as refusing to go to crisis.
school, dreams, nightmares, or verbalized concerns.
• Identify ways to gradually resume normal daily
schedule.
• Assist the family to identify how best to resolve and
express feelings about the incident.
Carry out appropriate health teaching regarding normal Normalcy is afforded as attempts are realistically made to
sexual physiology and functioning according to age resolve any aspects of rape trauma.
and developmental capacity.
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Rape-Trauma Syndrome: Compound Reaction and Silent Reaction • 721
ACTIONS/INTERVENTIONS R AT I O N A L E S
Incest
Monitor for inappropriate sexual behavior among family Provides a database needed to accurately assess for
members. incest.
Monitor for children who know more about the actual
mechanics of sexual intercourse than their develop-
mental age indicates they would.
Monitor for girls who seem to have taken over the
mother’s role in the home.
Monitor for mothers who have withdrawn from the home,
either emotionally or physically.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the survivor through the procedures for provision Provides a database necessary for intervention. Secures
of necessary health care treatment. Explain each phase chain-of-evidence procedure, and assists in reducing
of examination to the survivor. Remain with the sur- anxiety for the client.
vivor at all times.
Obtain history:
• List of previous venereal diseases
• List of previous pelvic infections
• Any injuries that were present before attack
• Obstetric and menstrual history
Assist in gathering information to provide proper health
and legal care.
Secure the survivor’s description of any objects used in
the attack and how these objects were used in the
attack.
Maintain sequencing and collection of evidence (chain of
evidence):
• Label each specimen with:
• Survivor’s name and hospital number
• Date and time of collection
• Area from which specimen was collected
• Collector’s name
• Ensure proper storage and packaging of specimens:
• Clothing and items that are wet (e.g., with blood or Plastic bags will cause molding of wet items.
semen) should be put in paper bags, not plastic.
• Specimens obtained on microscopic slides or swabs
need to be air dried before packaging.
• Comb pubic hair for traces of the attacker’s pubic hair
or other evidence:
• Submit paper towel placed under the victim to catch
combings, as well as the comb used, along with pubic
hair.
• Pluck (do not cut) two or three pubic hairs from the
patient, and label properly. These are used for com-
parison.
(care plan continued on page 722)
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722 • Sexuality–Reproductive Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• When custody of evidence is transferred to police, be
certain written evidence of transfer is properly
recorded:
• Signatures of individuals involved in transfer
• Name of person to whom the evidence is being trans-
ferred
• Date and time
• Take photographs of injuries or torn clothing.
• Have the survivor sign forms for release of information
to authorities.
• Provide medical treatment and follow-up for:
• Injuries
• Sexually transmitted disease: AIDS, gonorrhea, or
syphilis
• Pregnancy
Report to proper authorities any suspicion of family vio- Initiates long-range support for the patient.
lence.
Evaluate for increased rate of changing residences, Provides a database that allows accurate interpretation of
repeated nightmares, and sleep pattern disturbance. the long-range impact. Provides information needed to
plan long-term care.
Encourage the patient to discuss phobias, frustrations,
and fears.
Be available and allow the patient to express difficulties Provides long-term essential support.
in establishing normal ADLs and redescribe the attack
as needed.
Assist the patient in developing a plan of reorganization Promotes realistic planning for problem while avoiding
of ADLs. continued denial of problem.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assign a primary care nurse to the client. This nurse Promotes the development of a trusting relationship.
should be of the sex the client demonstrates most com-
fort with at the current time.
The primary care nurse will remain with the client during Promotes the development of a trusting relationship.
the orientation to the unit.
Limit visitors, as the client feels necessary. Promotes the client’s sense of control, while meeting
security needs.
Answer the client’s questions openly and honestly. Promotes the development of a trusting relationship.
The primary care nurse will be present to provide support Promotes the development of a trusting relationship,
for the client during medical or legal examinations if while meeting the client’s security needs.
the client has not identified another person.
Assist the client in identifying a support person, and Promotes the client’s sense of control, while meeting
arrange for this person to remain with the client as security needs.
much as necessary. [Note the name of this person
here.]
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Rape-Trauma Syndrome: Compound Reaction and Silent Reaction • 723
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide information to the client’s support system as the Support system understanding enhances their ability to
client indicates is needed. support the client in a constructive manner.
Allow the client to talk about the incident as much as is Facilitates the confrontation of the memories of the event
desired. Sit with client during these times, and encour- and attachment of meaning to the situation, which will
age expression of feelings. promote a sense of control.11
Communicate to the client that his or her response is nor- Normalization of the client’s feelings, without diminish-
mal. This could include expressions of anger, fear, and ing his or her experience, enhances self-esteem and
discomfort with persons of the opposite sex, discom- helps him or her move from a position of victim to that
fort with sexuality, or personal blame. of a survivor.12
Inform the client that rape is a physical assault rather than Promotes the client’s resolution of guilt and feelings of
a sexual act and that rapists choose victims without responsibility.
regard for age, physical appearance, or manner of dress.
Assist the client in developing a plan to return to ADLs. Promotes the client’s sense of control, and inhibits the
The plan should begin with steps that are easily accom- tendency toward social isolation.12
plished so that the client can regain a sense of personal
control and power. [Note the steps of the plan here.]
Provide positive social rewards for the client’s accomplish- Positive reinforcement encourages behavior while
ment of established goals. [Note here the kinds of behav- enhancing self-esteem.
ior that are to be rewarded and the rewards to be used.]
Provide the client with opportunities to express anger at Assists the client in moving from the powerless position
the assailant in a constructive manner, e.g., talking of victim to a position of survivor.
about fantasies of revenge, use of punching bag or pil-
low, or physical activity.
When the client can interact with small groups, arrange Provides the client opportunities to resolve his or her feel-
for the client’s involvement in a therapeutic group that ings of being different, while decreasing social isolation.
provides interaction with peers. [Note time of group Promotes consensual validation of the experience with
meetings here.] others from similar situations, which enhances self-
esteem and emotional resources available for coping.12
Involve the client in unit activities. Assign the client Prevents social isolation. Accomplished tasks enhance
activities that can be easily accomplished. [Note the self-esteem with positive reinforcement. Also provides
client’s level of functioning here along with those tasks opportunities to reality test self-perceptions against
that are to be assigned to the client.] those of peers on the unit.
Primary nurse will spend [number] minutes with the Promotes reality testing of feelings related to the rape,
client twice a day at [times] to focus on expression of and inhibits the development of self-blame and guilt,
feelings related to the rape. Encourage the client not to which often occur in survivors.
close these feelings off too quickly. Assist the client in
reducing stress in other life situations while healing
emotionally from the rape experience. Begin to facili-
tate the client’s use of cognitive coping resources by
logically assessing various aspects of the situation.
Assist the client in developing a plan to reduce life stres- Promotes the client’s sense of control and provides a pos-
sors so emotional healing can continue. [Note this plan itive orientation.
here, with the support needed from the nursing staff in
implementing this plan.]
The primary care nurse will meet with the client andpri- Support system understanding and acceptance facilitate
mary support person once per day to facilitate their the client’s coping and the maintenance of these rela-
discussion of the rape. If the client is involved in an tionships.
ongoing relationship, such as a marriage, this interaction
is very important. The support person should be encour-
aged to express his or her thoughts and feelings in a con-
structive manner. If it is assessed that the rape has resulted
in potential long-term relationship difficulties such as
rejection or sexual problems, refer to couple therapy.
(care plan continued on page 724)
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724 • Sexuality–Reproductive Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Refer the client to appropriate community support Promotes the client’s reintegration into the community,
groups, and assist him or her with contacting these and inhibits the isolating behavior often exhibited by
before discharge. these clients.12
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
In the event of the rape being secondary to elder abuse, Provides a resource for the older adult to explore options
refer the patient to adult protective services. and prevent recurrence of problem.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
During the acute phase, be sure that appropriate assess- Early and accurate intervention decreases sequelae and
ment, law enforcement involvement, and treatment of provides documentation for any legal action.
physical injuries or sexually transmitted diseases are
provided.
Assist the client and family in lifestyle changes that may Provides support and enhances recovery.
be needed:
• Treatment for physical injuries or sexually transmitted
disease
• Testimony in court
• Protection
• Coping with terror, nightmares, or fear
• Coping with alterations in sexual response to signifi-
cant others
• Development and use of support networks
• Stress management
• Changing telephone number or moving
• Traveling with companion
• Strategies for prevention of rape
Assist the client and family in planning and implementing Crimes of violence upset the family equilibrium and
strategies for resolution of Rape-Trauma Syndrome: require support to correct.
• Communication (e.g., discussion of feelings among
family members)
• Mutual sharing and trust Involvement of the client and significant others is impor-
• Problem solving (e.g., providing support for the family tant to ensure successful resolution.
members and client; strategies to reduce possibility of
future attacks)
Consult with, or refer the patient to, assistive resources as Use of existing resources and expertise provides high-
appropriate. quality care and is effective use of already available
resources.
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Sexual Dysfunction • 725
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Copyright © 2007 •by F. A. Davis.
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726 • Sexuality–Reproductive Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Be nonjudgmental in your attitudes. Sexuality is a highly personal experience. Nonjudgmental
attitudes reduce anxiety and open the way for thera-
peutic communication.
Respect the patient’s values and attitudes about sexuality Sexual behavior is intimately linked to the value-belief
and sexual functioning. system. Demeaning these values and beliefs will cause
anxiety in the patient.
Provide accurate information on effects of medical diag- Clarifies misconceptions. Provide information on changes
nosis or treatment on sexual functioning. or modifications in sexual activities that may need to
occur as a result of disease process.
Implement measures to improve self-concept (e.g., posi- How one feels about self is important in self-perception
tive self-talk, assertiveness, new hairdo, new clothes, or of sexuality.
new social surroundings).
Provide privacy for expressing sexuality (e.g., masturba- Sexuality expression may be inhibited by hospitalization,
tion, sexual intercourse), particularly when the patient but the need still exists.
has been hospitalized for a significant length of time,
or has been separated from his or her significant other
for a significant length of time.
Teach the patient the importance of adequate rest before Sexual activity increases basal metabolic rate and initiates
and after sexual activity. the sympathetic nervous system, creating a high level
of stress.
If dyspareunia is a problem, teach the patient and signifi- Increases comfort and reduces trauma. Eases dryness and
cant other to: avoids irritation.
• Use adequate amounts of water-soluble lubricant.
• Use vaginal steroid cream.
• Take sitz baths.
If impotence is a problem, advise the patient to: Discover the underlying causes of impotence. Provides an
• Consult with a physician regarding a complete physical alternative method of penile erection to find satisfac-
examination. tion in intercourse.
• Consult with a sex therapist.
• Consider a penile prosthesis.
Child Health
This diagnosis is not appropriate for a child.
Women’s Health
l N O T E : Very little information is found in the literature on Sexual Dysfunction of les-
bian women, as they often conceal their sexual orientation when they receive health care
and some choose not to receive health care if there is a danger of exposure.14 The follow-
ing actions refer to those who have a heterosexual relationship.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Obtain a detailed sexual history. Provides a database needed to plan accurate intervention.
Determine who the patient is:
• Female
• Male
• Couple or partners
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Sexual Dysfunction • 727
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review communication skills between partners.
Ascertain the couple’s knowledge of:
• Sexual performance
• Female and male anatomy and physiology
• Female and male orgasm
• Anticipatory performance anxiety
• Unrealistic romantic ideas
• Rigid religious conformity
• Negative conditioning in formative years
• Erection and ejaculation
• Stimulation
• Arousal
• Sexual anxiety
• Fear of failure
• Demand for performance
• Fear of rejection
Dispel sexual myths and fallacies or misinformation Provides basic information and support that can assist the
about sexuality by: patient in long-term care.
• Allowing the patient to talk about beliefs and practices
in a nonthreatening atmosphere
• Providing correct information
• Answering questions in an honest manner
• Referring to the appropriate agencies or health-care
providers
Obtain description of current problem: Provides an essential database to permit narrowing of
• Psychological focus for intervention.
• Physical
• Social
Determine the type of sexual dysfunction:
• General
• Lack of erotic feeling
• Lack of sexual responses
• No pleasure in the sexual act
• Consider it an ordeal
• Avoidance
• Frustration
• Disappointment
• Fear
• Disgust
• Orgasmic difficulties
If the client is sexually responsive but cannot complete
the sexual response cycle, determine whether this is:
• Situational: Client is inhibited, disappointed, or disin-
terested.
• Physiologic: Interruption results from lack of lubrica-
tion, impotence, or interference with the sexual
response cycle.
• Psychological: Ambivalence, guilt, or fear is present.
• If vaginismus (tight closing of vaginal muscle with any
attempt at penetration) is present, determine whether
this results from:
• Fear of vaginal penetration
• Spasm of vaginal muscle
(care plan continued on page 728)
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728 • Sexuality–Reproductive Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Frustration
• Fear of inadequacy
• Guilt
• Pain
• Prior sexual trauma
• Strict religious code
• Rape
• Dyspareunia
Discuss consequences of sexual acts and situations in an Initiates intervention in a supportive environment.
honest and nonthreatening manner.
Collaborate with appropriate therapists. Provides the long-term care and support that is needed to
resolve the basic problem
Mental Health
l N O T E : If sexual dysfunction is related to physiologic limitations, loss of body part,
or impotence, refer to Adult Health care plan. If dysfunction is related to ineffective cop-
ing or poor social skills, initiate the following actions:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Set limits on the inappropriate expression of sexual Promotes the client’s sense of control, while maintaining
needs. Note the kinds of behavior to be limited and the the safety of the milieu.
consequences for inappropriate behavior here; for
example, when the client approaches staff member
with sexually provocative remarks, the staff member
will use constructive confrontation and discontinue the
interaction).15 Inform the client of these limits.
Assign a primary care nurse to the client on each shift. Promotes the development of a trusting relationship.
The primary care nurse will spend 15 minutes with the
client twice per shift at [times] to develop a relation-
ship, and then begin to explore with the client the
effects this behavior has on others and the needs that
are being met by the behavior.
Assist the client in identifying environmental stimuli that
provoke sexual behavior and in developing alternative
responses to these stimuli in inappropriate situations.
Develop with the client a list of alternative kinds of Promotes the client’s sense of control.
behavior to meet the need currently being met by the
sexual behavior. [Note alternative behavior patterns
here with plan for implementing them.]
Provide the client with information about appropriate sex- Facilitates the development of appropriate coping
ual behavior—for example, what are “normal” sexual behaviors.
expressions, what are appropriate ways to meet sexual
needs (intercourse with appropriate person or mastur-
bation at suitable time in an appropriate place).
Role-play with the client social situations that have been Behavioral rehearsal provides opportunities for feedback
identified as problematic. These could include setting and modeling of new behaviors by the nurse.
limits on other’s inappropriate behavior toward the
client, or situations in which the client needs to prac-
tice appropriate social responses.
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Sexual Dysfunction • 729
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client in appropriate labeling of feelings and Promotes the client’s sense of control, and facilitates the
needs. For example, anxiety may be inappropriately development of adaptive coping behaviors.
labeled as “sexual tension.”
Plan a private time and place for the client. Inform the
client that this can be used for appropriate sexual
expression. [Note this plan here.]
If the client begins inappropriate sexual behavior while Social isolation inhibits inappropriate behavior by remov-
involved in group activities, remove the client from ing social rewards.
group to a private place and explain to the client pur-
pose of this. Inform the client that he or she may return
to the group when (the limit set by the care team will
be noted here).
If sexual behavior results from anxiety, refer to Anxiety
(Chapter 8) for detailed care plan.
Assign the client tasks in unit activities that are appropri- Promotes the development of adaptive interpersonal skills
ate for the client’s level of comfort with group interac- in an environment that provides supportive feedback
tion. For example, if the client is uncomfortable with from peers.
persons of opposite sex, assign a task that requires
involvement with a same-sex group, or involvement
with an opposite-sex staff member who can begin a
relationship.
Recognize and support the client’s feelings; for example, Promotes the development of a trusting relationship.
“You sound confused.” Models for the client appropriate expressions of feel-
ings in a supportive environment. Helps the client learn
to talk about feelings rather than act on them.
Engage the client in a socialization group once a day at Decreases social isolation, and provides the client with an
[time]. This should provide the client with an opportu- opportunity to practice interpersonal skills in a sup-
nity to interact with peers in an environment that pro- portive environment.
vides feedback to the client in a supportive manner.
Arrange a consultation with occupational therapist to Increases the client’s interpersonal competence and
assist the client in developing needed social skills enhances self-esteem.
(e.g., cooking skills or skills at games that require
socialization).
Provide an environment that does not stimulate inappro- Promotes an environment that increases the opportunities
priate sexual behavior; for example, a staff member for the client to succeed with new behaviors. This suc-
indirectly encourages the client’s behavior with dress cess serves as reinforcement that encourages positive
or verbal comments, or other clients interact with the behavior and enhances self-esteem.
client in a sexual manner.
Sit with the client [number] minutes once a shift at [time] Nurses’ interactions can provide social reinforcement for
to discuss non-sexual-related information. the client’s appropriate interactions. Provides an oppor-
tunity for the client to practice new behaviors in a sup-
portive environment. Success in this situation provides
reinforcement that encourages positive behavior and
enhances self-esteem.
Provide positive social rewards for appropriate behavior Reinforcement encourages positive behavior and
(the rewards, as well as the kinds of behavior to be enhances self-esteem.
rewarded, should be noted here).
Evaluate the effects of the client’s current medication on Basic monitoring of medication efficiency.
sexual behavior, and consult with the physician as
needed for necessary alterations.
(care plan continued on page 730)
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730 • Sexuality–Reproductive Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Develop a structured daily activity schedule for the client, Assists the client in focusing away from issues of sexual-
and provide the client with this information. ity and engage in socially appropriate activity.
Schedule a time for the client to engage in physical activ- Physical activity decreases anxiety and increases the pro-
ity. This activity should be developed with the client’s duction of endorphins, which increase the client’s feel-
assistance and could include walking, jogging, basket- ings of well-being.16 Provides opportunities for the
ball, cycling, dancing, “soft” aerobics, etc. A staff client to learn alternative ways of coping with anxiety
member should participate with the client in these in a supportive environment.
activities to provide positive social reinforcement.
[Note schedule and type of activity here.]
If the client’s concerns are related to his or her relation-
ship with his or her significant other, initiate the fol-
lowing actions:
• Assess the role current medications and nonprescrip- Medications and nonprescription drugs can have a nega-
tion drug use may have on sexual functioning. Note tive impact on sexual functioning. These can include
here the person responsible for this assessment. If the antidepressants, antihypertensives, and alcohol.17
medications could have a negative impact on sexual
functioning, assist the client in discussing a medication
change with the primary care provider. For example, an
antidepressant with fewer sexual side effects, such as
bupropion, could be prescribed.
• Explore with the client, and his or her significant other, Poor understanding of the normal sexual response cycle
their understanding of normal sexual functioning. can have a negative impact on sexual functioning.18,19
Provide information as appropriate. This could include
referring clients to appropriate references. [Note here
information and follow-up needed.]
• Provide the client system with opportunities to discuss Assists clients with developing skills to communicate
concerns while modeling communication skills. Note about their sexual relationship.
here the person responsible for this interaction.
• If providing basic information does not resolve client Sex therapy requires advanced preparation.
concerns, arrange a referral to a health-care provider
with expertise in addressing issues related to sexual
functioning. [Note here the name of referral source and
appointment time.]
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for use of medications that may induce sexual Identifies correctable source of impotency.
dysfunction. Male impotency may be related to antihy-
pertensive medications.
Determine the individual patient’s knowledge of facts and Knowledge of expected aging changes may encourage the
myths regarding sexual changes in aging. individual to discuss changes experienced and seek
treatment for dysfunction.
Identify resources for assistance with sexual dysfunction, Provides an information source and support for individu-
such as Impotents Anonymous groups.20 als with a common problem. Impotence, regardless of
etiology, shows marked increase beyond age 65.
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Sexuality Patterns, Ineffective • 731
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide resources for patients with chronic illnesses, such
as chronic obstructive pulmonary disease (COPD) or
arthritis, that address and assist in problem solving
regarding disease-related sexual difficulties.21
Provide uninterrupted time for couples, particularly in Assists patients in maintaining sexuality as long as
long-term-care settings, where it may be difficult to possible.
maintain or attain privacy.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client and significant other in planning and Sexual dysfunction affects and is affected by relation-
implementing strategies for reducing sexual dysfunc- ships. Involvement of significant people in strategies
tion and enhancing sexual relationship: is vital to enhance the potential for success.
• Communication (e.g., discussion of concerns and ideas
for intervention)
• Mutual sharing and trust
• Problem solving (e.g., identification of specific strate-
gies with roles defined, such as second honeymoon or
specific sexual arousal exercises)
Assist the patient and significant other with lifestyle Lifestyle changes require permanent behavior changes.
adjustments that may be required by: Support and self-evaluation can improve the probabil-
• Providing accurate and appropriate information regard- ity of successful change.
ing contraception
• Teaching stress management
• Providing information regarding sexuality and clarify-
ing myths regarding sexuality
• Exploring strategies for coping with disabling injury or
disease
• Using massage
• Using touch
• Treating substance abuse
• Exercising regularly
• Coping with changes in role functions and role rela-
tionships
• Using water-soluble lubricants
• Obtaining treatment for physical problems (e.g., vagi-
nal infections or penile discharge)
• Teaching changes accompanying pregnancy
• Teaching side effects of medication
Consult with, or refer to, assistive resources as indicated. Use of existing resources provides for high-quality care
and effective use of services.
•
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Copyright © 2007 •by F. A. Davis.
•
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732 • Sexuality–Reproductive Pattern
EXPECTED OUTCOME
4 Have You Selected the Correct Diagnosis? Will identify at least [number] factors contributing to inef-
Sexual Dysfunction fective sexual pattern by [date].
Sexual Dysfunction indicates there are problems in
sexual functioning. Ineffective Sexuality Patterns TARGET DATES
refers to concerns about sexuality but does not nec-
essarily mean an overwhelming problem. In some Because of the extremely personal nature of sexuality, the
instances, this diagnosis may involve a lifestyle differ- patient may be reluctant to express needs or problems in this
ent from heterosexual norms. area. For this reason, a target date of 5 to 7 days would be
acceptable.
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Sexuality Patterns, Ineffective • 733
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage the child and family to verbalize perception of Provides the database necessary to accurately plan inter-
altered sexual functioning (e.g., undescended testicle). vention.
Assist the patient and family to identify how the desired Specific plans for goals of sexual function desired will
sexual function may be attained. assist in how the client will be treated (e.g., surgeries
for future procreation).
Include appropriate collaboration with other health-care Specialist may best meet the unique needs represented
team members as needed. with ineffective sexual functioning.
Provide attention to developmentally appropriate role Opportunities appropriate for age with role models serve
modeling for age and situation. as valuable learning modes.
Encourage peer support during hospitalization as appro- Peer support fosters sense of self, which is also a com-
priate. posite of sexuality.
Plan for potential long-term nursing follow-up. The chronic nature of many physiologic components will
necessitate serial rechecks and treatment over time as
the child grows and matures.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient to describe her sexuality and under- Provides database needed to plan for successful inter-
standing of sexual functioning as it relates to her ventions.
lifestyle and lifestyle decisions.
Allow the patient time to discuss sexuality and sex-
related problems in a nonthreatening atmosphere.
Obtain a complete sexual history, including current
emotional state.
Assist the patient in listing lifestyle adjustments that need
to be made, e.g., different methods of achieving sexual
satisfaction in the presence of mutilating surgery.
Identify significant others in the patient’s life and involve
them, if so desired by the patient, in discussion and
problem-solving activities regarding sexual adjust-
ments.
Provide an atmosphere that allows the patient to discuss Assists the patient in planning coping strategies to vari-
freely: ous life situations, and provides information the patient
• Partner choice needs to achieve the planning.
• Sexual orientation
• Sexual roles
Assist the patient in identifying lifestyle adjustments to
each different cycle of reproductive life:
• Puberty
• Pregnancy
• Menopause
• Postmenopause
Discuss pregnancy and the changes that will occur during Provides essential information needed by the patient to
pregnancy and the postpartum period: offset concerns regarding maintaining sexuality during
• Sexuality and after pregnancy.
• Mood swing
(care plan continued on page 734)
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Copyright © 2007 •by F. A. Davis.
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734 • Sexuality–Reproductive Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss aspects of sexuality and intercourse during preg-
nancy. Answer questions promptly and factually:
• Positions
• Frequency
• Effects on fetus
• Effects on pregnancy
• Fears about sexual changes
Discuss the postpartum healing process, and timing of
resumption of intercourse.
Assist the patient facing surgery or body structure
changes in identifying lifestyle adjustments that may
be needed (e.g., ileostomy, colostomy, mastectomy, or
hysterectomy).
Allow the patient to grieve loss of body image.
Reassure the patient that she can still participate in sexual Provides support to the patient who is questioning contin-
activities. uance of sexuality.
Ensure confidentiality for the patient with sexually trans- Promotes sharing of information necessary to plan care.
mitted diseases.
Encourage verbalization of concerns with sexually trans- Provides the database needed to most accurately plan
mitted diseases: care.
• Recurrent nature of disease, especially herpes and
Chlamydia
• Lack of cure for the disease (AIDS)
• Economics of treating the disease
• Social stigma associated with disease
Encourage honesty in answers to such questions as:
• Multiple sex partners
• Describing sexual behavior
Encourage honest communication with sexual partners(s). Sexual partner will require health care.
• Discuss the impact of the male partner’s prostate sur-
gery and possible impotence.
• Discuss the impact on either partner of medication that
may affect libido.
• Discuss means of satisfying sexual desires other than
intercourse:
• Cuddling
• Massaging, stroking, or touching partner
• Masturbation
Mental Health
l N O T E : If alteration is related to altered body function or structure or illness, refer to
Adult Health nursing actions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assign a primary care nurse who is comfortable dis- Promotes the development of a trusting relationship.
cussing related material with the client.
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Sexuality Patterns, Ineffective • 735
ACTIONS/INTERVENTIONS R AT I O N A L E S
The primary care nurse will spend [number] minutes
[number] times a day with the client discussing
issues related to diagnosis. These discussions will
include:
• Client’s use of prescription and nonprescription med- Prescription and nonprescription medications can have a
ications. If current medications could have a negative negative impact on sexual functioning.
impact on sexual functioning, assist the client in dis-
cussing possible medication changes with the primary
health-care provider.
• Client’s current physiologic health Disease states can have a negative impact on sexual func-
tioning. This can include cardiovascular disease and
diabetes.
• Client’s thoughts and feelings about alteration Expression of feelings and perceptions in a supportive
environment facilitates the development of alternative
coping behaviors.
• Other stressors and concerns in the client’s life that
could affect sexual patterns
• Client’s perceptions of partner’s responses
• Client’s perceptions of self as a sexual person without a
partner
• Client’s perceptions of social or cultural expectations
• Client’s thoughts and feelings about sexuality
If alteration is related to lack of information, develop a Provides a guide to ensure that the client gets accurate
teaching plan. [Note teaching plan here.] and consistent information.
When the client identifies specific difficulties that con- Promotes the client’s sense of control and enhances self-
tribute to the concern, develop a specific action plan to esteem.
cope with these and note the plan here.
If the alteration is related to problems with the signifi- Provides an opportunity for the nurse to facilitate com-
cant other, arrange a meeting with the client and signif- munication between the partners and for the partners to
icant other to discuss the perceptions each has about communicate their relationship needs as well as per-
the problem. If these difficulties are related to a lack sonal needs in a nonthreatening environment.
of information, develop a teaching plan and note it
here. If alteration is related to a long-term relationship
or if alteration is only one of several problems, refer
to a marriage and family therapist or clinical nurse
specialist.
Arrange a private time for the client and partner to Provides recognition and support for this relationship.
discuss relationship issues, including sexuality.
[Note time and place arranged for this discussion
here.]
During interactions with the client and significant Promotes the development of a positive expectational set.
other, have them express feelings about their rela- Positive feelings enhance self-esteem and enhance per-
tionship. These should be both positive and negative sonal psychological resources for coping with the diffi-
feelings. cult aspects of the relationship.
Gerontic Health
The nursing actions for the older adult with this diagnosis are the same as for the Adult Health patient.
(care plan continued on page 736)
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•
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Copyright © 2007 •by F. A. Davis.
•
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736 • Sexuality–Reproductive Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for factors contributing to Ineffective Sexuality Provides a database for early identification and interven-
Patterns by [date]. tion.
Involve appropriate family members (e.g., significant oth- Sexual behavior can affect the entire family. Involvement
ers or parents of child) in planning, implementing, and of the family in problem identification and intervention
promoting reduction or elimination of Ineffective enhances the probability of successful intervention.
Sexuality Patterns:
• Communication (e.g., discussion of values and sexual
mores)
• Mutual sharing and trust
• Problem solving (e.g., identification of strategies
acceptable to all involved with the role of each person
identified)
• Sex education (e.g., clarify any misconceptions regard-
ing sexual behavior and sexuality)
Assist the client and family with lifestyle adjustments Provides knowledge and support necessary for permanent
that may be required: behavioral change.
Providing accurate and appropriate information regarding
sexuality and contraception.
Providing time and privacy for development and improve-
ment of sexual relationship:
• Teaching stress management
• Coping with loss of sexual partner
• Providing accurate and appropriate information regard-
ing sexually transmitted diseases
• Providing accurate and appropriate information regard-
ing sexual orientation (e.g., homosexuality, heterosexu-
ality, or transsexuality)
• Coping with physical disability
• Explaining side effects of medical treatment
Consult with assistive resources as indicated. Specialized counseling may be indicated. Effective use
of existing resources provides continuity.
R E F E R E N C E S 9. Molcan, KL, and Fickley, BS: Sexuality and the Life Cycle. In
Poorman, SG (ed): Human Sexuality and the Nursing Process.
1. Gordon, M: Manual of Nursing Diagnosis. McGraw-Hill, New York, Appleton & Lange, Norwalk, CT, 1988.
2002. 10. Ames, LB, and Ilg, FL: Child Behavior. Dell, New York, 1976.
2. Fogel, CI: Female sexuality. In Breslin, ET, and Lucas, VA (eds): 11. Warner, CG: Rape and Sexual Assault: Management and Intervention.
Women’s Health: Toward-Based Practice. WB Saunders, St. Louis Aspen Systems, Germantown, MD, 1980.
2003. 12. NANDA: Nursing Diagnosis: Definitions and Classification,
3. Youngkin, EQ, and Davis, MS: Woman’s Health: A Primary Care 2005–2006. North American Nursing Diagnosis Association,
Clinical Guide. Appleton & Lange, Norwalk, CT, 1994. Philadelphia, 2005.
4. Speroff, L, Glass, RH, and Kase, NG: Clinical Gynecologic 13. Ben-David, S, and Schneider, O: Rape perceptions, gender role atti-
Endocrinology and Infertility, ed 6. Lippincott, Williams & Wilkins, tudes and victim-perpetrator acquaintance. Sex Roles J Res 53(5-
Philadelphia, 1999, p 321. 6):385, 2005.
5. Fogel, CI, and Woods, NF: Health Care of Women: A Nursing 14. Associated Press: Shock Rape Survey: Asking for It. The Mirror,
Perspective. CV Mosby, St. Louis, 1981. London, November 21, 2005.
6. Schuster, CS, and Ashburn, SS: The Process of Human Development: 15. Erickson, EH: Childhood and Society. Triad/Paladin, St. Albans,
A Holistic Life-Span Approach, ed 3. JB Lippincott, Philadelphia, England, 1978.
1992. 16. Scott, LD: Sexuality & older women: Exploring issues while promot-
7. Biddle, BJ, and Thomas, EJ: Role Theory: Concepts and Research. ing health. Lifelines 6(6):520, 2003.
Robert E. Drieger, Huntington, NY, 1979. 17. American Academy of Pediatrics: The evaluation of sexual abuse in
8. Associated Press: Study finds greater number of rape victims than sup- children. Kellogg and the Committee on Child Abuse and Neglect
posed. Lubbock Avalanche J 70:A-11, April 24, 1992. 116(2):506 American Academy of Pediatrics Policy, 2005.
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Sexuality Patterns, Ineffective • 737
18. American Academy of Pediatrics: Guidelines for the Evaluation of 31. Teschendorf, M: Women during the reproductive years. In Breslin, ET,
Sexual Abuse of children: Subject Review—Committee on Child and Lucas, VA (eds): Women’s Health Nursing: Toward Evidence-
Abuse and Neglect 103:1, 186, American Academy of Pediatrics Based Practice. WB Saunders, St. Louis, 2003.
Policy, 1999. 32. Sellers, JB: Health care for older women. In Breslin, ET, and Lucas,
19. Hockenberry, MJ: Wong’s Essentials of Pediatric Nursing, ed 7. CV VA (eds): Women’s Health Nursing: Toward Evidence-Based Practice.
Mosby, St. Louis, 2006. WB Saunders, St. Louis, 2003.
20. Muram, D: Child sexual abuse: Relationship between sexual acts and 33. Maxmen, J, and Ward, N: Psychotropic Drugs Fact Facts. WW
genital findings. Child. (http://aappolicy.aappublications.org). Norton, New York, 2002.
21. Dienemann, J, Campbell, J, Wiederhorn, N, Laughon, K, and 34. Dossey, B, Keegan, L, and Guzzetta, CE: Holistic Nursing: A
Jordan, E: A critical pathway for intimate partner violence across Handbook for Practice, ed 3. Aspen, Gaithersburg, MD, 2000.
the continuum of care. JOGNN J Obstet Gynecol Neonatal Nurs 35. Love, P: What is this thing called love? Family Therapy Network
32(5):594, 2003. 23:34, 2000.
22. Anderson, C: Battered & pregnant: A nursing challenge. Lifelines 36. Butler, K: The evolution of modern sex therapy. Family Therapy
6(2):95, 2002. Network 23:28, 1999.
23. Hartman, SJ: Battered woman in a small town: Encountering violence 37. Wright, L, and Leahey, M: Nurses and Families: A Guide to
through the story of one woman. Lifelines 4(4):35, 2000. Family Assessment and Intervention. F.A. Davis, Philadelphia,
24. Lutz, KF: Abused pregnant women’s interactions with health care 2005.
providers during the childbearing year, JOGNN J Obstet Gynecol 38. Buczny, B: Impotence in older men: A newly recognized problem. J
Neonatal Nurs 34(2):151, 2005. Gerontol Nurs 18:25, 1992.
25. Haggerty, LA, Kelly, R, Hawkins, J, Pearce, C, and Kearney, MH: 39. Eliopoulos, C: Manual of Gerontological Nursing, ed 2. CV Mosby,
Pregnant women’s perceptions of abuse. JOGNN J Obstet Gynecol St. Louis, 1999.
Neonatal Nurs 30(3):283, 2001. 40. Lightfoot-Klain, H, and Shaw, E: Special needs of ritually circum-
26. McCloskey Dochterman, J, and Bulecheck, G: Nursing Interventions cised women patients. JOGNN J Obstet Gynecol Neonatal Nurs
Classification. CV Mosby, St. Louis, 2004. 20:102, 1991.
27. Haber, J, et al: Comprehensive Psychiatric Nursing, ed 5. CV Mosby, 41. Northrup, C: The Wisdom of Menopause: Creating Physical and
St. Louis, 1997. Emotional Health and Healing During the Change. Random House,
28. McArthur, M: Reality therapy with rape victims. Arch Psychiatr Nurs New York, 2003.
4:360, 1990. 42. Berg, JA: Dimensions of sexuality in the perimenopausal transition:
29. Townsend, M: Psychiatric Mental Health Nursing: Concepts of Care A model for practice, JOGNN J Obstet Gynecol Neonatal Nurs
in Evidence-Based Practice, ed 5. FA Davis, 2006. 30(4):421, 2001.
30. Brown, K, Streubert, G, and Burgess, A: Effectively detect and manage 43. Katz, A: Sexuality after hysterectomy. JOGNN J Obstet Gynecol
elder abuse. Nurse Pract Am J Primary Health Care 29(8):22, 2005. Neonatal Nurs 31:256, 2001.
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COPING–STRESS
11
TOLERANCE PATTERN
1. ADJUSTMENT, IMPAIRED 747
2. COMMUNITY COPING, INEFFECTIVE AND READINESS FOR
ENHANCED 756
3. FAMILY COPING, COMPROMISED AND DISABLED 760
4. FAMILY COPING, READINESS FOR ENHANCED 767
5. COPING, INEFFECTIVE AND READINESS FOR
ENHANCED 771
A. COPING, DEFENSIVE
B. DENIAL, INEFFECTIVE
6. POST-TRAUMA SYNDROME, RISK FOR AND ACTUAL 785
7. SUICIDE, RISK FOR 791
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740 • Coping–Stress Tolerance Pattern
•
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Copyright © 2007 by F. A. Davis. •
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Conceptual Information • 741
be related to major health problems if inappropriate coping process, it is important to understand those factors that can
is present.1,4 influence the system’s ability to respond to stress. Stress can
Stress has been defined as the body’s nonspecific arise from biophysical, chemical, psychosocial, and cultural
response to any demand placed on it.1 These demands can be sources. The basic health of the affected system improves
any situation that would require the system to adapt. For the the ability to respond to these stressors. Response to the
individual, this could include anything from getting out of biophysical–chemical stressors can be improved by improv-
bed in the morning to experiencing the loss resulting from a ing the condition of the biologic system, including proper
major environmental disaster. Stress is life. nutrition, appropriate amounts of rest, appropriate levels
The body’s physiologic response to stress involves of exercise, and reduced exposure of the system to toxic
activation of the autonomic nervous system. The symptoms chemicals.1
of this activation can include sweating, tachycardia, tachyp- The literature1 indicates that a great deal of psychoso-
nea, nausea, and tremors. This process has been labeled the cial–cultural stress evolves from a philosophy of life that is
general-adaptation syndrome (GAS)5 and occurs in three impossible to fulfill. This would indicate that a great deal of
stages: alarm reaction, resistance, and exhaustion. The alarm stress arises from the perception of events, not from the
stage mobilizes the system’s defense forces by initiating the events themselves. This is compounded by the social and cul-
autonomic nervous system response. The system is prepared tural influences on the system. The sociocultural influences
for “fight or flight.” In the resistance stage, the system fights could include the cultural attitudes about age, body appear-
back and adapts, and normal functioning returns. If the ance, and family roles and the social approaches to assistance
stress continues and all attempts of the system to adapt fail, for working mothers, advancement in employment status,
exhaustion occurs, and the system is at risk for experiencing and so on. The system’s beliefs about these sociocultural
major disorganization. stressors can affect the degree to which the stressors affect
Four levels of psychophysiologic stress responses the system. If the stressor is perceived as unnatural or impos-
have been described.5 The first level comprises the day-to- sible to adapt to, the system’s stress level will be increased.
day stressors that all systems experience as a part of living. Response to the psychosocial–cultural stressors can be
This stress calls on the self-regulating processes of the sys- improved with attitude assessment and interventions that
tem for adaptation. Intersystem coping mechanisms are reduce the physiologic response to psychosocial stressors.
used, and the system does not require assistance from out- Coping has been defined as behavior (conscious and
side sources to adapt. Level 2 responds to less routine or unconscious) that a system uses to change a situation for the
new experiences encountered by the system. The system better or to manage the stress-resultant emotions.6 These
experiences a mild alarm reaction that is not prolonged. The kinds of behavior can occur on the biologic, psychological,
individual system might experience a mild increase in heart and social levels. Effective coping uses biologic, psycholog-
rate, sensations of bladder fullness and increased frequency ical, and social resources in attempts to manage the situation.
of urination, temporary insomnia, tachypnea, anxiety, fear, A coping model has been developed3 that addresses
guilt, shame, or frustration. Some outside assistance may be the biologic, psychological, and sociocultural aspects of this
necessary to facilitate adaptation. This assistance could be in process. The model indicates that systems have generalized
the form of identifying stressors and strengths or encourag- resistance resources (GRRs) to facilitate coping. GRRs are
ing the individual to solve problems. Level 3 consists of the those characteristics of the system that can facilitate effec-
moderate amount of stress that occurs when a persistent tive tension management. Genetic characteristics that pro-
stress is encountered or when a new situation is perceived as vide increased resistance to the effects of stressors are
threatening. Emergency adaptation processes are activated. considered physical and biochemical GRRs. These GRRs
The individual experiences tachycardia, palpitations, can include levels of immunity, nutritional status, and the
tremors, weakness, cool pale skin, headache, oliguria, vom- adaptability of the neurologic system. Valuative and attitudi-
iting, constipation, and increased susceptibility to infec- nal GRRs describe consistent features of the system’s cop-
tions. This level of stress usually requires assistance from a ing behavior, which could include personality characteristics
professional helper and can include identifying problems and the system’s perception of the stressor. The more flexi-
and coping strengths, teaching, performing tasks for the ble, rational, and long term these are, the more effective they
client, or altering the environment to facilitate coping. When are as GRRs. Interpersonal–relational GRRs include social
the system cannot adapt to a stressful situation with assis- support systems and can provide an important resource in
tance, a severe degree of stress is experienced, which is managing stress. Finally, those cultural supports that facili-
labeled Level 4. This occurs when all coping strategies are tate coping are referred to a macrosociocultural GRRs.
exhausted. Intervention at this level requires the assistance Macrosociocultural GRRs could include religions, rites of
of professionals who have the skills to assist with the devel- passage, and governmental structures.
opment of unique coping strategies. In 1979, Kobasa introduced the concept of hardiness
Because stress is life itself, adaptation to reduce the to the literature on coping.7,8 She described the hardy indi-
effects of stress on the system is imperative. To begin this vidual as having three characteristics that provide him or her
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742 • Coping–Stress Tolerance Pattern
with the ability to cope effectively with stress. The first char- in environments that provide children with a loving, warm
acteristic is commitment, or a purpose and involvement in environment; respect and acceptance for personal interests,
life. Challenge is the second characteristic of the hardy indi- ideas, needs, and talents; stable role models; challenges that
vidual. Challenge is the belief that the changes in life can be foster development of competence and responsibility;
meaningful opportunities for personal growth. The third opportunities to explore all of their feelings; a variety of
characteristic is control. Control has three components: cog- experiences; opportunities for age-appropriate problem
nitive control, decisional control, and a repertoire of coping solving and the knowledge that they must live with the con-
skills. Kobasa and other authors proposed that the hardy sequences of their decisions; opportunities to develop com-
individual would remain healthier and experience less dis- mitments to others; and encouragement in the development
abling psychological stress. of their own standards, values, and goals.10
An understanding of the concept of hardiness can According to developmental stages, there are some
facilitate the nurse’s assessment of the client’s potential abil- specific etiologies and symptom clusters.
ity to cope with life’s stresses. Based on this assessment, the
nurse can then develop interventions that support or develop INFANT
commitment, challenge, and control for the client. These
interventions might include providing the client with as Interactions with significant others are the primary source
much control as possible in the situation, facilitating his or of the infant’s response to trauma or stress. If the significant
her positive orientation with reframes, and assisting in the other is supportive and consistent, the effects of the event
development of a variety of coping strategies.8 on the infant are minimized. Events that separate infants
Wagnild and Young9 have questioned the validity of from their significant others also pose a threat to this age
hardiness as a concept. The concern of these authors evolves group. Primary symptoms are disruptions in physiologic
from their observation that the tools utilized to measure the responses.
various components of hardiness do not provide clear dis- Chronic diseases place this age group at special risk.
tinctions between the identified concepts and other influ- Because the development of coping behavior is limited at this
encing variables. Wagnild and Young conclude that it is age, the primary caregivers (usually the parents) provide the
important to continue the research related to a hardiness child with the support to cope. If the caregivers cannot pro-
concept, and, until a more precise understanding of what vide the proper supports, then the child is affected. Chronic
constitutes this concept is developed, it will be difficult to illness in a child places an extreme stress on the family and
apply it to therapeutic interventions.9 From a clinical per- can result in divorce. Support for the parents is crucial in sup-
spective, hardiness is a useful concept to consider when porting the child’s coping.
interacting with the client system, for it both provides a
model for understanding client response and presents fertile TODDLER AND PRESCHOOLER
content for clinical nursing research related to psychosocial Responses of significant others are still the primary supports
aspects of coping. for the child in this age group. Thus, as for the infant, the
Effective coping can occur when the system has a response of significant others or separation from these per-
strong physiologic base combined with adequate psychoso- sons can have an effect on the toddler and preschooler. In
ciocultural support. This implies that any intervention that addition, threats to body integrity pose a special threat to
addresses coping behavior should address each of these this age group. Traumatic events that inflict physical damage
areas. Interventions that have been applied to this process on these children place the child at greatest risk. Regression
include therapeutic touch, kinesiology, meditation, relax- is the primary symptom and coping behavior. This can be
ation training, hypnosis, family therapy, nutritional counsel- frustrating to caregivers who expect the child to assist in a
ing, massage, and physical exercise. time of crisis with age-appropriate developmental behavior
when the child may regress to a very dependent stage. Other
DEVELOPMENTAL CONSIDERATIONS methods used by young children in coping include denial,
repression, and projection. Coping may be more difficult
The number of resources available to the system greatly because adults may not recognize that young children can
affects its ability to cope with stressors. Thus, there is a need experience crisis and will, therefore, not provide assistance
to maximize physical, cognitive, and psychosocial develop- with the coping process.11
ment. Cross-cultural research has identified the characteris-
tics that are common to individuals who are perceived as
SCHOOL-AGE CHILD
mature and capable of coping effectively. These characteris-
tics include an ability to anticipate consequences; calm, Symptoms include problems with school performance,
clear thinking; potential fulfillment; problem solving that is withdrawal from family and peers, behavioral regression,
orderly and organized; predictability; purposefulness; realis- physical problems related to anxiety, and aggressive behav-
ticness; reflectiveness; strong convictions; and implacabil- ior to self or others. Coping behavior includes that used
ity.9 The development of these characteristics is maximized by the younger child, only in a more effective manner. This
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Developmental Considerations • 743
age group may find a great deal of support from siblings ADULT
during a crisis. Situations that can precipitate crisis in this
age group include school entry, threats to body image, peer Coping resources have broadened for this age group as a
problems, and family stress such as divorce or death of a result of past successful coping experiences and the possible
loved one.11 addition of adult children as supports during crisis.
Chronic disease or disability also affects the adjust- Symptoms of difficulties with coping are similar to those of
ment of this age group. Again, the primary support for adap- the young adult. Age-related stressors include loss, such as
tation comes from the primary caregivers, usually the significant others and physical functioning; role changes,
parents. such as job loss and the leaving of adult children; aging par-
ents; career pressures; and cultural role expectations.11
ADOLESCENT
OLDER ADULT
The adolescent demonstrates more adult-like coping behav-
ior. Symptoms of stress include anxiety; increased physical Older adults face many psychosocial challenges; loss of
activity, daydreaming, and apathy; change in mood cycles; autonomy, ageist stereotypes, retirement, chronic illness,
alteration in sleeping patterns; aggressive behavior directed relocation, and death of friends and spouses. Symptoms of
at self or others; and physical symptoms associated with extreme stress in this age group may be overlooked and
anxiety. Crisis-producing situations can include role attributed to senility. These symptoms include withdrawal,
changes, peer difficulties, threats to body integrity, rapidly decreased functioning, increased physical complaints, and
changing body functioning, conflict with parents, personal aggressive behavior. Decreased function of hearing, vision,
failures, sexual awareness, and school demands.11 and mobility, as well as loss of support systems and other
Response to traumatic events is similar to that of resources, affects coping behavior. These problems can be
adults. Etiologies of crisis-producing events, for this age balanced by life experience that has provided the individual
group, are also similar to those for adults. Specific events with many situations of successful coping to fall back on
that place this age group at greater risk are those that affect during stressful times.
the peer group and could have effects on body image or sex- The effects of multiple losses related to alteration in
ual functioning. Coping behavior is adult-like. This age health status and the loss of support systems place the older
group may find support from peers especially useful in facil- adult at risk for impaired adjustment. In the absence of ill-
itating coping. Coping may also be affected by limited life ness affecting cognitive functioning, the older adult can
experience and impulsive behavior. assume responsibility for making decisions related to alter-
Illnesses that threaten body image could result in dif- ations in health status. This ability, combined with life expe-
ficulties in adjustment. Peers again provide a primary sup- rience, can facilitate creative problem solving with the
port system and can have a great impact on the adolescent’s support of health-care personnel.12
acceptance. Educating significant peers about the client’s
situation could facilitate their acceptance of the client, and FAMILY LIFE CYCLE
in turn facilitate the client’s adjustment to the change in
The following is a presentation of the developmental frame-
health status. Adjustment could also be facilitated by involv-
work of the family life cycle as described by Carter and
ing the client in a support group composed of peers with
McGoldrick.13
similar alterations.
Between Families. The unattached young adult: The
YOUNG ADULT process of this level is accepting parent–child separation.
The individual must separate from his or her family of ori-
Symptoms of problems with coping include changes in per-
gin and develop intimate peer relationships and a career.
formance of roles at home and at work, aggressive behavior
directed at self or others, and physical symptoms associated Joining of Families Through Marriage. The newly
with anxiety and denial. Changes in role performance might married couple: The process of this level involves commit-
include loss of interest in sexual relationships or withdrawal ment to a new system. The individuals form a marital sys-
from the community. Situations that might tax the coping tem and realign relationships with extended families and
abilities of the young adult include balancing increasing role friends to include spouse.
responsibilities, dealing with threats to the self or to body
Family with Young Children. The task faced is to
integrity, leaving home, and making career choices.11
accept a new generation of members into the system. The
Alterations in health status that affect the ability of
marital system adjusts to make space for the child(ren) and
role performance place this age group at risk for impaired
assumes parental roles. Additional realignment takes place
adjustment. This could include loss of ability to function in
to include parenting and grandparenting roles.
job responsibilities. Behavior can include regression, but
this does not necessarily indicate that the client is experi- Family with Adolescents. The family task is to increase
encing impaired adjustment. flexibility of family boundaries to include children’s inde-
11Newfield (F)-11 3/31/07 6:45 PM Page 744
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744 • Coping–Stress Tolerance Pattern
pendence. The parent–child relationships shift to allow the boundaries must be opened to accept the child. Unsuccessful
adolescents to move in and out of the system. The parents resolution of this stage could result in physical or emotional
refocus on midlife marital and career issues, and there is a abuse of the child. If there is a developmental delay in the
beginning shift toward concerns for the older generation. parents and they are not ready to assume the responsibilities
that accompany parenthood, family dysfunction can occur.
Family in Later Life. Accepting the shifting of genera-
A family with adolescents is faced with the task of
tional roles is the task of this stage. The system maintains
increasing flexibility to include children’s independence.
individual and couple functioning and interests in conjunc-
This may require a major shift in family rules. This is also
tion with physiologic decline. There is an exploration of new
influenced by the parents’ perception of the adolescent and
role options with more support for a more central role for the
the environment. If the adolescent is seen as being compe-
middle generation. The system also makes room for the wis-
tent, and the environment that the adolescent interacts in is
dom and experience of the elderly and to support the older
seen as safe, then it will be much easier for the family to pro-
generation without overprotecting them. This stage will also
vide the necessary shifts in relationships. When this stage is
include coping with the deaths of significant others and
not resolved successfully, the adolescent may enhance
preparation for death.
behavior that highlights his or her differences with the fam-
Specific problems can arise in family coping when the
ily to force separation, or the frequency and intensity of
family developmental cycle or expectations do not corre-
family conflict may increase. Unsuccessful resolution of this
spond with the developmental tasks of individual family
stage may indicate that the family has overly rigid bound-
members. There are three stages that are nodal points in
aries to the external world and individual boundaries that are
family development.
overly permeable.
The joining of families through marriage requires a
Application of the concept of coping at the aggregate
commitment to a new system. If the separation from the
or community level is in the process of development.
parents is not successful, then the new family does not have
Additional research is needed to identify and validate com-
an opportunity to form its own identity by combining the
munity-based diagnoses. Successful communities are
experiences both bring into this new relationship. Symptoms
healthy communities.13–15
of unsuccessful resolution of this stage could result in the
marital partners returning home to their parents when con- l N O T E : For the individual diagnoses in this chapter, the
flict arises or an ongoing struggle over loyalties to families psychiatric health nursing actions serve as the generic
of origin. nursing actions, because the nature of the diagnoses in this
The second major shift occurs when children enter the chapter calls for the skills, knowledge, and expertise of a
system. The new role of parent is assumed, and the couple psychiatric–mental health nursing specialist.
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Copyright © 2007 by F. A. Davis. •
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Developmental Considerations • 745
Disabled Disabled
Family Support Caregiver–Patient Relationship
Family Therapy Caregiver Performance: Direct Care;
Indirect Care
Caregiver Well-Being
Caregiving Endurance Potential
Family Coping
Family Normalization
Ineffective Ineffective
Coping Enhancement Acceptance: Health Status
Decision-Making Support Adaptation to Physical Disability
Child Adaptation to Hospitalization
Coping
Decision Making
Impulse Self-Control
Knowledge: Health Resources
Psychosocial Adjustment: Life
Change
Role Performance
Stress Level
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Copyright © 2007 •by F. A. Davis.
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746 • Coping–Stress Tolerance Pattern
T A B L E 1 1 . 1 NANDA, NIC, and NOC Taxonomic Linkages (continued from page 745)
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Copyright © 2007 by F. A. Davis. •
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Adjustment, Impaired • 747
Pain Control
Personal Well-Being
Psychomotor Energy
Risk Control
Risk Control: Alcohol Use; Drug Use
Risk Detection
Social Interaction Skills
Social Support
Stress Level
Substance Addiction Consequences
Suicide Self-Restraint
Will to Live
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Copyright © 2007 •by F. A. Davis.
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748 • Coping–Stress Tolerance Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for all possible etiologic factors via active listen- Provides the database needed to most accurately plan
ing by asking questions that are appropriate for the care.
child (who, what, where, and when) regarding first
feeling of not being able to adjust.
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Adjustment, Impaired • 749
ACTIONS/INTERVENTIONS R AT I O N A L E S
Help the child realize it is normal to need some time and Realistic planning increases the likelihood of compliance
assistance in adjusting to changes (e.g., the child need- and increases the sense of success.
ing assistance with ambulating following surgery).
Explore the child’s and family’s previous coping strate- Previous coping strategies serve as critical information in
gies. developing interventions for the current status.
Identify ways the child can feel better about coping with Effective coping can empower the child and family and
the needed adjustment, including reinforcement of thereby afford a positive adjustment.
desired behavior.
Assist the child and family in creating realistic goals for Realistic goals enhance success.
coping.
Collaborate with related health-care team members as Collaborations with specialists serve to meet the unique
needed. needs of the patient and family.
Provide clear and simple explanations for procedures. Simple and clear instructions promote the child’s func-
tioning while he or she is in a stressful situation.
Address educational needs related to health care. Knowledge serves to empower and provide guidelines for
compliance with the expected behavior.
Deal with other primary care needs promptly. Basic primary needs require prompt attention to offer the
best likelihood of minimizing adjustment difficulty.
Provide for posthospitalization follow-up with home care Follow-up affords long-term resolution of adjustment.
as needed.
Assist the patient and family in identification of commu- Identification of resources before discharge will encour-
nity resources that can offer support. age the patient and family to use the resources as
needed and will help them cope with the changes in
their lifestyle.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Couvade Syndrome
When counseling with expectant fathers, be alert for Provides a database that allows early intervention.
characteristics for Couvade Syndrome.17
• The syndrome affects males only.
• Wives are pregnant and usually in the third or ninth
month of gestation.
• Symptoms are confined to the gastrointestinal (GI) or
genitourinary (GU) system; notable exceptions are
toothache and skin growths.
• Anxiety and affective disturbances are common (e.g.,
constant worrying about labor events, “I can’t do this”
or “I just know I will faint,”) and/or over-managing
arrangements for the new baby (e.g., painting the nurs-
ery three times).
• Physical findings are minimal.
• Laboratory and X-ray testing yields normal results.
• Patient makes no connection between his symptoms
and his wife’s pregnancy.
Provide a nonjudgmental atmosphere to allow the patient Encourages the patient to talk about feelings, and allows
(in this instance, a man with the medical diagnosis of planning of how to channel feelings into activities that
Couvade Syndrome)17 to express concerns of: will assist in preparing for fatherhood.
• Self-image as a father
• Relationship with his father
(care plan continued on page 750)
11Newfield (F)-11 3/31/07 6:45 PM Page 750
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Copyright © 2007 •by F. A. Davis.
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750 • Coping–Stress Tolerance Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Self-responsibility
• Feelings about the wife’s or partner’s pregnancy
• Concerns about the safety of the wife or partner
Accurately record physical symptoms described by the Allows more effective interventions and planning.
expectant father:
• Fatigue
• Weight gain
• Nausea or vomiting
• Headaches
• Backaches
• Food cravings
Support and guide the expectant father through the
changes being experienced.
Assure the expectant couple that: Emphasizes that this is not necessarily unusual behavior.
• Expectant fathers can suffer physical symptoms during Assists with positive actions that support both partners,
partner’s pregnancy. and allows the man to view the pregnancy
• Pregnancy affects both partners. realistically.17
• Fathers also have emotional needs during pregnancy.
Postpartum Affective Disorders
Postpartum Blues
This affects approximately 50 to 85 percent of all deliver-
ing women, is viewed as part of the adaptation process
to childbirth, and usually resolves with normal support
of the family. Therefore, it is not considered an impair-
ment and is not discussed here.
Postpartum Depression
Described as postpartum major affective disorder in psy- The following tools assist health-care personnel in check-
chiatric literature (usually occurs 2 weeks to 3 months ing for postpartum depression:
postpartum). PDPI—Postpartum Depression Prediction Inventory
PDSS—Postpartum Depression Screening Scale
EPDS—Edinburgh Postnatal Depression Scale19,20
Encourage the client to express fears about a less-than- Research has shown that not one factor alone creates an
perfect infant. This can include: environment that makes the woman vulnerable to post-
• Low-birth-weight infant partum depression.19–22
• Different sex than desired by parents
• Fussy infant
• Premature infant
• Unwanted infant (the infant could be the result of an
unwanted pregnancy or of rape).
Continually assess the new mother’s mood, observing for Nursing observations can be critical in getting these
signs of: patients the professional help they need. Too often
• Continuous crying women feel this is just part of being a new mother and
• Insomnia not related to care of the infant that they have no one who will listen. Often these signs
• Mood swings and symptoms go unreported and unrecognized by
• Loss of appetite family members.18–20
• Withdrawal
• Irritability
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Adjustment, Impaired • 751
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Guilt feelings
• Feeling of inability to care for self or the infant or
function in roles of wife and mother
• Impaired memory
• Lowered self-image
Provide nonjudgmental atmosphere for the patient to dis- Encourages the patient to discuss feelings and verbalize
cuss problematic situations. Issues may include: disappointments or problems, so that plans for coping
• Partner’s lack of sexual interest with reality of birth experience can be initiated.21,22
• Any illness or problems with older children
• Marital status
• Disappointment in experience (Unwanted cesarean sec-
tion, medications administered during labor, or any
unexpected occurrences.)
• Isolation during the postpartum period (Unable to
return to work immediately, no adults available to talk
to during day, unable to complete daily activities owing
to fatigue, demands of infant, uncooperative partner,
lack of support system, and so on.)
Postpartum Psychosis
The incidence of postpartum psychosis is approximately
1 in 1000 deliveries. Onset is acute and abrupt.18
Obtain a complete patient and family history, particularly
regarding previous depressive or psychotic episodes.
(Usually has familial and/or genetic basis.)
Collaborate with family members to never leave the
patient alone, particularly with the infant.
Arrange for the family to take and care for the infant.
If needed, arrange for community resources for care of
the infant.
Obtain immediate assistance from mental health col- This diagnosis needs professional assistance immediately
leagues for the mother. and is beyond the scope of practice for perinatal nurs-
ing. The main duty of the perinatal nurse is to see that
no harm comes to the mother or infant until mental
health colleagues can assume care of the mother.
Explain to family the likelihood of repetition of psychosis
with subsequent pregnancies.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Call the client by the name he or she has identified as the Promotes a positive orientation, while enhancing self-
preferred name with each interaction. [Note this name esteem.
on the chart.]
Discuss with the client his or her perception of the cur- Communicates respect for the client and his or her expe-
rent alteration in health status. This should include rience of the stressor, which promotes the development
information about the coping strategies that have been of a trusting relationship. Provides information about
attempted and his or her assessment of what has made the client’s strengths that can be utilized to promote
them ineffective in promoting adaptation. coping, and provides the nurse with an opportunity to
support these strengths in a manner that promotes a
positive orientation.
(care plan continued on page 752)
11Newfield (F)-11 3/31/07 6:45 PM Page 752
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Copyright © 2007 •by F. A. Davis.
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752 • Coping–Stress Tolerance Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide the client with clocks and calendars to promote Maintains the client’s cognitive strengths in a manner that
orientation and involvement in the environment. will facilitate the development of coping strategies.7
Give the client information about the care that is to be Promotes the client’s sense of control.
provided, including times for treatments, medicines,
group, and other therapy.
Assign the client appropriate tasks during unit activities. Accomplishment of tasks provides the positive reinforce-
These should be at a level that can easily be accom- ment that enhances self-esteem and motivates behavior.
plished. Provide the client with positive verbal support Also assists the client to develop a positive expecta-
for completing the task. Gradually increase the diffi- tional set.
culty of the tasks as the client’s abilities increase.
Sit with the client [number] minutes [number] times per Communicates concern for the client, and facilitates the
day at [times] to discuss current concerns and feelings. development of a trusting relationship. Promotes the
client’s sense of control by communicating that his or
her ideas and concerns are important.
Provide the client with familiar needed objects. These Promotes the client’s sense of control, while meeting
should be noted here. These should assist the client in safety and security needs.
identifying a personal space over which he or she feels
some control. This space is to be respected by the staff,
and the client’s permission should be obtained before
altering this environment.
Provide the client with an environment that will optimize Appropriate levels of sensory input decrease confusion
sensory input. This could include hearing aids, eye- and disorganization, maximizing the client’s coping
glasses, pencil and paper, decreased noise in conversa- abilities.
tion areas, and appropriate lighting. (These actions
should indicate an awareness of sensory deficit as well
as sensory overload, and the specific interventions for
this client should be noted here—e.g., place hearing
aid in when client awakens and remove before bedtime
(9:00 P.M.)
Communicate to the client an understanding that all cop-
ing behavior to this point has been his or her best effort
and asking for assistance at this time is not failure—a
complex problem often requires some outside assis-
tance to resolve.
Have the client dress in “street clothing.” This should be Promotes positive orientation and the client’s sense
items of clothing that have been brought from home of control by supporting normal daily routine and
and in which the client feels comfortable. activities.
Provide the client with opportunities to make appropriate Promotes the client’s sense of control, and enhances self-
decisions related to care at his or her level of ability. esteem when appropriate decisions are made.
This may begin as a choice between two options and
then evolve into more complex decision making. It is
important that this be at the client’s level of function-
ing so that confidence can be built with successful
decision-making experiences. [Note here those deci-
sions that the client has made.]
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Adjustment, Impaired • 753
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide the client with a primary care nurse on each shift. Promotes the development of a trusting relationship,
Nurse will spend 30 minutes once per shift at [time] while promoting the client’s sense of control with
developing a relationship with the client. This time knowledge about the environment.
could be spent answering the client’s questions about
the hospital, daily routines, etc., or providing the client
with a backrub.
Identify with the client methods of anxiety reduction. The High levels of anxiety interfere with decision making.
specific method selected by the client should be noted Increased control over anxiety promotes the client’s
here. For the first 3 days, the staff should remain with sense of control. The presence of the nurse can provide
the client during a 30-minute practice of the selected positive reinforcement, which encourages behavior.
method. The method should be practiced 30 minutes, Behavioral rehearsal internalizes and personalizes the
three times a day at [times]. (See Anxiety in Chapter behavior.
8 for specific instructions about anxiety reduction
methods.)
Provide positive social reinforcement and other behav- Reinforcement encourages positive behavior and
ioral rewards for demonstration of adaptation. The enhances self-esteem.
things that the client finds rewarding should be listed
here with a schedule for use. The kinds of behavior
that the team is to be rewarding should also be listed
with the appropriate reward.
Assist the client in identifying support systems and in Support systems can facilitate the client’s coping strate-
developing a plan for their use. The support systems gies.23
identified should be noted along with the plan for
their use.
Schedule a meeting with members of the identified sup- Promotes the development of a trusting relationship, and
port system to assist them in understanding alterations provides the support system with the information they
in the client’s health. Provide time to answer any ques- can utilize to provide more effective support.
tions they may have. [Note the time for this meeting
here and the person responsible for this meeting.]
Provide the client with group interaction with [number] Disconfirms the client’s sense of aloneness, and assists
persons, [number] minutes, [number] times per day at the client to experience personal importance to others
[times]. This activity should be graded with the client’s while enhancing interpersonal relationship skills.
ability. For example, on admission, the client may tol- Increasing these competencies can enhance self-esteem
erate one person for 5 minutes. If the interactions are and promote a positive orientation.24
brief, the frequency should be high; for example, 5-
minute interactions should occur at 30-minute inter-
vals. If the client is meeting with a large client group,
this may occur only once a day. The larger groups
should include persons who are more advanced in
adapting to their alterations and persons who may be
less advanced.
Make available items necessary for the client to groom Appropriate grooming enhances self-esteem.
him- or herself. Have these items adapted as necessary Reinforcement encourages positive behavior while
to facilitate client use. List the items that are necessary enhancing self-esteem.24
here, along with any assistance that is needed from the
nursing staff. Assign one person per day to be respon-
sible for this assistance. Provide positive social rein-
forcement for the client’s accomplishments in this area.
Set an appointment to discuss with the client and signifi- Promotes communication in the system that can serve as
cant others effects of the loss or change on their rela- the basis for developing coping strategies.25,26
tionship (time and date of appointment and all
follow-up appointments should be listed here). [Note
the person responsible for these meetings.]
(care plan continued on page 754)
11Newfield (F)-11 3/31/07 6:45 PM Page 754
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Copyright © 2007 •by F. A. Davis.
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754 • Coping–Stress Tolerance Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor the nurse’s nonverbal reactions to loss or change, Promotes the development of a trusting relationship and
and provide the client with verbal information when the development of a positive orientation.
necessary to establish the nurse’s acceptance of the
change.
If the nursing staff is having difficulty coping with the Staff thoughts and feelings can be indirectly communi-
client’s alterations, schedule a staff meeting where cated to the client, which could have a negative effect
these issues can be discussed. An outside clinical nurse on the client’s developing a positive orientation.
specialist may be useful in facilitating these meetings.
Schedule ongoing support meetings as necessary.
Utilize constructive confrontation if necessary to include Models appropriate communication skills, while provid-
“I” statements, relationship statements that reflect ing the client with information that facilitates consen-
nurse’s reaction to the interaction, and responses that sual validation.
will assist the client in understanding, such as para-
phrasing and validation of perceptions.
When a relationship has been developed, the primary care Promotes the development of adaptive coping strategies.
nurse will spend 30 minutes twice a day at [time] with
the client discussing thoughts and feelings related to the
alteration in health status. These discussions could
include memories that have been activated by this alter-
ation, the client’s fears and concerns for the future, the
client’s plans for the future before the alteration in health
status, the client’s perceptions of how this alteration will
affect daily life, and the client’s perceptions of how this
alteration will affect the lives of significant others.
Provide the client with information about care and treat- Promotes the client’s sense of control. Inappropriate lev-
ment. Give information in concise terms appropriate to els of sensory input can increase the client’s confusion
the client’s level of understanding. Note here those and disorganization.
areas for which the client needs the most information,
and include a plan for providing this information.
Do not argue with the client while he or she is experienc- Arguing with these perceptions decreases the client’s self-
ing an alteration in thought process. (Refer to esteem and increases his or her needs to enlist dysfunc-
Disturbed Thought Process in Chapter 7 for related tional coping behavior.
nursing actions.)
Develop with the client a very specific behavioral plan for Achievement of a specific plan provides positive rein-
adapting to the alteration in health status. Note that forcement and enhances self-esteem, which motivates
plan here. It should include achievable goals so the positive behavior.
client will not become frustrated.
Refer the client to occupational therapy to develop the Successful adaptation to the occupational role enhances
necessary adaptations to the occupational role. [Note self-esteem.27
times for these meetings here.]
Schedule a time for the client and his or her support sys- Provides opportunities for the support system to maintain
tem to be together without interruptions. The times for normal relationships while the client is hospitalized.
these interactions should be noted here.
If the client is disoriented, orient to reality as needed and Enhances the client’s cognitive functioning, improving
before attempting any teaching activity. Provide the his or her ability to problem solve and to cope.
client with clocks and calendars, and refer to day, date,
and time in each interaction with this client.
Refer the client to appropriate assistive resources as indi- Establishes the client’s support system in the community.
cated. [Note here those referrals made and the name of Social support enhances coping.
the contact person.]
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Adjustment, Impaired • 755
Gerontic Health
In addition to the following, the nursing actions for the Adult Health and Mental Health patient may also be used.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Communicate your own positive views about aging, and Promotes positive anticipatory coping.
the client’s ability to cope, to the client and caregivers.
Avoid ageist remarks such as “You look so good for Promotes positive self-esteem.
someone who is 90 years old.”
Assist the client to maintain functional abilities or make Self-esteem and coping are closely related with physical
referrals for Occupational Therapy or Physical Therapy health and functional ability.
to assist the client to improve his or her functional
abilities.
Discuss the client’s roles in life (grandparent, parent, Persons with greater numbers of role identities have
roommate) and the associated responsibilities with the improved perceptions of self worth.
roles.
Utilize reminiscence therapy, either in a group or individ- Reminiscence therapy assists the client in identifying unre-
ually, with the client. solved conflicts and focusing on their achievements.
Promote a sense of control for the client: Older clients who feel a sense of control are better able to
• Include the client in the decision-making process. cope.
• Speak to the client rather than about him or her.
• Show respect for the client’s privacy (knock before
entering his or her room, keep the curtains drawn, be
careful with personal possessions).
• Promote physical fitness in clients able to participate in
activities.
Home Health
In addition to the interventions for Adult Health and Mental Health, the following may be used for the home health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for factors contributing to impaired adjustment Provides a database for intervention.
(e.g., psychological, social, economic, spiritual, or
environmental factors).
Involve the client and family in planning, implementing, Family involvement enhances the effectiveness of inter-
and promoting reduction or elimination of impaired ventions.
adjustment:
• Family conference: Discuss feelings and altered roles,
and identify coping strategies that have worked in the
past.
• Mutual goal sharing: Establish realistic goals and spec-
ify role of each family member; for example, provide a
safe environment and support self-care.
• Communication: Clear and honest communication
should be promoted among family members. If sensory
impairments exist, corrective interventions are needed
(e.g., eyeglasses or a hearing aid).
Assist the client and family in lifestyle adjustments that Family relationships can be altered by impaired adjust-
may be required: ment. Permanent changes in behavior and family roles
• Stress management require evaluation and support.
• Development and use of support networks
• Treatment for disability
(care plan continued on page 756)
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756 • Coping–Stress Tolerance Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Appropriate balance of dependence and independence
• Grief counseling
• Change in role functions
• Treatment for cognitive impairment
• Provision of comfortable and safe environment
• Activities to increase self-esteem
Consult with or refer to appropriate assistive resources as Utilization of existing services is efficient use of
indicated. resources. Resources such as an occupational therapist,
a psychiatric nurse clinician, and support groups can
enhance the treatment plan.
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Copyright © 2007 by F. A. Davis. •
•
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Community Coping, Ineffective and Readiness for Enhanced • 757
Child Health
Same as for Adult Health, with acknowledgement of parents and caregivers assuming the advocacy role. Use develop-
mentally appropriate approach. May be dependent on funding or interest of local potential supporters.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ineffective Community Coping
l N O T E : It has been noted that with early discharge of the new mother and baby, many
communities are ineffective in having in place follow-up programs to assist these new
mothers and their infants in the first critical postpartum days. Even with states’ mandat-
ing “48-hour stays,” there still exists a great need to support new mothers and their new-
borns after discharge from the hospital.
Investigate what programs are available to the new Provides a coordinated flow of care for the patient.
mother and her infant in the community. Different Allows for more equal distribution of scarce resources,
communities have different programs, such as: which can eliminate duplication of services to some
• Well-baby clinics30,31 while others have none.28–31
• Public health department programs
• Nursing centers (usually at schools of nursing in uni-
versity settings)
• State and federal programs such as First Steps, First
Start, and maternity support programs
Network with nursing colleagues in the community to
assess how you can assist one another in providing con-
tinuity of care for these mothers and their newborns.
Readiness for Enhanced Community Coping
l N O T E : Many private nursing agencies and acute care hospitals have or are putting
into place follow-up programs to deal with the issue of early discharge of the new
mother and her infant. These programs include telephone follow-up, postpartum after-
care centers, and home visits.28–31
Telephone Follow-up
Call the discharged mother within 36 to 48 hours after Provides follow-up contact with the new mother and her
discharge. Allow the mother time to answer questions family. This contact can provide important information
and expand on her answers if necessary. (Sometimes and monitoring, reinforcement of previous education,
this takes some leading and directed questioning by emotional and professional support to new parents, and
the nurse.) referral to appropriate professional services, if needed.
(care plan continued on page 758)
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758 • Coping–Stress Tolerance Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide a nonjudgmental atmosphere that allows the new
mother and/or father to verbalize concerns and needs.
Ask for descriptions of the infant’s color, cord, circumci-
sion (if appropriate), feeding patterns, stool patterns,
and number of wet diapers.
Ask the mother to describe feeding sessions. If breast-
feeding:
• How often and how long does the infant nurse?
• Does the infant nurse on both sides?
• How do her breasts look (cracks, bleeding, or sore)?
• Does the infant latch on correctly?
• What does the infant’s stool look like, and how many
wet diapers are there in a 24-hour period?
If formula feeding:
• How often does the infant feed?
• How many ounces does the infant take?
• Is the infant tolerating formula (not spitting excessively
or having projectile vomiting)?
• What is the color of the stool and pattern? How many
wet diapers?
Discuss potential for injury to the infant, covering the fol-
lowing topics:
• Use of approved car seat
• Smoking in the presence of the infant or in home
where the infant is
• Use of proper bedding and proper positioning of the
infant in bed (on back or side)
• Environmental safety (“childproofing” the house)
Ask the mother how she is feeling (tired, overwhelmed,
out of sorts, etc.). Inquire about her physical well-
being:
• Episiotomy
• Incision (if cesarean section)
• Any alterations in involution (lochia—rubra, serosa, or
alba)
• Breasts
• Stools (diarrhea or constipation)
• Any signs and symptoms of infection (increased tem-
perature, increased tenderness of uterus [abdomen],
foul-smelling lochia)
Instruct the mother and/or father to call primary health-
care provider if any signs or symptoms of infection are
noted.
If concerns are noted, make arrangements for the mother, Provides a creative solution to the early discharge of new
father, and infant to return to postpartum follow-up mothers and their infants from the acute care system
center or clinic, and/or schedule a home visit by a after birth. Allows for continuation of quality nursing
nurse. If concerns are urgent, recommend that the care and monitoring of the postpartum progress of the
mother, father, and infant go to emergency room and/or mother and her infant.28–31
their primary health care provider immediately.
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Community Coping, Ineffective and Readiness for Enhanced • 759
ACTIONS/INTERVENTIONS R AT I O N A L E S
Follow-up Clinic and/or Home Visit
Assess interaction between the parents and the parents
with the newborn. If siblings are present, assess inter-
action with the parents and the new baby.
Assess the mother for physical and psychological well-
being. (See previous interventions for physical well-
being. See also Impaired Adjustment for psychological
well-being.)
Assess the home for social economic needs and referrals,
such as:
• Enough to eat
• Cleanliness
• Whether the new mother have help in home
• Transportation
Assess the infant for physical well-being. (See previous
interventions.)
Document findings, and place them in the mother’s and
infant’s charts when returning to hospital. Send a copy
of the documentation to primary health-care provider
for both the mother and infant.
Mental Health
Refer to Home Health actions and interventions for these care plans.
Gerontic Health
l N O T E : This diagnosis covers community as a whole, and affects all areas
of health care.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ineffective Community Coping
Discuss examples of ineffective coping in order to begin Increases awareness of problems in the community and
problem solving. stimulates interest.
Clarify questions related to coping that arise from Helps identify strategies that may increase coping skills.
problem-solving sessions.
Identify fiscal resources available to the community for Local, regional, state, or federal programs may have
problem solving. funds dedicated to addressing problems related to
aging.
Identify local leaders (formal as well as informal) who
have power within the community, and gain their per-
spective.
Facilitate use of community services to network for Conserves money. Also increases likelihood of reaching
problem solving, such as radio or television stations the target audience in the community.
that offer to air public service announcements, news-
papers to publish letters to the editor, or libraries
to make available access to community internets.
(care plan continued on page 760)
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760 • Coping–Stress Tolerance Pattern
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Readiness for Enhanced Community Coping
Facilitate participation in community activities. Older adults are more likely to be involved in organized
activities, such as senior citizens’ groups. They are also
more likely to vote and actively support or campaign
for governmental candidates.
Enlist older adults in community setting in problem-solv- Can provide historical perspective on the community and
ing meetings. its growth pattern and needs.
Consult with organized community resources such Provides a wealth of life experiences for problem solving
as RSVP or American Association of Retired Persons within the community.
(AARP) groups for problem solving and future
planning.
Consider use of telephone trees, computer connections, or Time is an important factor in community growth and
letter writing for older adults with decreased mobility planning, and older adults may have more time to assist
who can still add to community life and growth. the community. Activities such as those mentioned may
be possible even for those with limited mobility.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve community groups in problem identification and Involvement at the local level enhances community devel-
program development: opment and communication.
• Identify local needs for addressing problems or stres-
sors.
• Facilitate participation in the community process.
Identify community strengths and weaknesses. Community recognition of strengths, weaknesses, and
• Develop strategies to enhance strengths and correct resources enhances the potential.
weaknesses.
• Identify resources needed and resources available.
Develop collaborative relationships within the community Supportive relationships enhance the success of the plan.
to promote development of the community.
Utilize strategies identified for enhanced community cop-
ing to identify factors leading to Ineffective
Community Coping:
• Develop strategies to correct the deficits.
• Develop a plan with community involvement to correct
deficits.
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762 • Coping–Stress Tolerance Pattern
Child Health
Obvious concern is for safety of child; when necessary, child protective services will be involved. Many nursing actions
are related to those of women’s health and psychiatric nursing. A developmentally appropriate basis for care is paramount.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage the child and family to express feelings and Expression of concerns provides insight into views about
fears by allotting 30 minutes per shift, while the client problem and the values of the patient and family.
is awake, for this purpose.
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Family Coping, Compromised and Disabled • 763
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review family dynamics in place before the crisis. Family dynamics in usual times is paramount in under-
standing coping dynamics during times of stress.
Facilitate family member participation in the child’s care, Family and patient input ensures individualized plan of
as appropriate, including bathing, feeding, comfort, care. Provides a teaching opportunity and increases the
and diversional activity. child’s security.
Provide education to all family members regarding the Reduces anxiety, increases likelihood of compliance, and
child’s illness, prognosis, and special needs as appro- empowers the family.
priate.
Involve health-care team members in collaboration for Increases the likelihood of a holistic plan of care for both
care with focus on role modeling desired behaviors. short-term and long-term goals.
Provide referral to appropriate community resources for Provides for long-term follow-up and support.
support purposes.
Provide for home discharge planning at least 5 days Allows time for teaching, practice, and return-
before discharge. demonstration.
Make referral for home health care and other community Provides for long-term follow-up and support.32
resources as needed (e.g., parenting support groups).
Women’s Health
l N O T E : This diagnosis would be most likely to relate to the single mother in the area
of Women’s Health.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Review the physical, mental, social, and economic status Provides a database that can be used to plan appropriate
of the single mother, taking into account whether she is interventions and locate support systems for the
widowed; divorced; single, and a parent by choice; or patient.
single, and a parent not by choice. (See Impaired
Adjustment.)
Identify support system available to the single mother
(e.g., family, friends, co-workers, or formal support
groups such as church or community organizations).
Review the patient’s perception of employment status Assists the patient to realistically plan for fiscal needs
(e.g., educational level and skills, job opportunities, and of herself and her infant. Allows identification of
opportunity for improvement of employment status). resources that could assist in improving income status.
Identify child care requirements considering the age of
children, who has legal custody of children, and child
support (financial and emotional).
Suggest strategies for exposing the children to male role Provides for male role modeling in the absence of a
models.32 father figure.
• Assign to classes with male teachers.
• Ask for assistance from brothers or grandparents.
• Involve the children in sports. (Coaches are usually
male.)
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Role-model effective communication by: Models for the family effective communication that can
• Seeking clarification enhance their problem-solving abilities.
(care plan continued on page 764)
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764 • Coping–Stress Tolerance Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Demonstrating respect for individual family members
and the family system
• Listening to expression of thoughts and feelings
• Setting clear limits
• Being consistent
• Communicating with the individual being addressed in
a clear manner
• Encouraging sharing of information among appropriate
system subgroups
At each meeting with the family, provide positive verbal Promotes hope, and helps the family develop a positive
reinforcement related to the observed strengths. view of themselves and their abilities, promoting an
environment for change. Supports the development
of a positive therapeutic relationship.32
Demonstrate an understanding of the complexity of sys- Promotes the development of a trusting relationship,
tem problems by: while developing a positive orientation.
• Not taking sides in family disagreements
• Providing alternative explanations of behavior patterns
that recognize the contributions of all persons involved
in the problem, including health care providers, if
appropriate
• Requesting the perspective of multiple family members
on a problem or stressor
Determine the risk for physical harm, and refer to appro- Client safety is of primary concern.
priate authorities if the risk is high (child protective
services, battered women’s centers, or police).
Assist the family in developing behavioral short-term Accomplishments of goals provide reinforcement, which
goals by: motivates continued positive behavior and enhances
• Asking what changes they would expect to see when self-esteem.
the problem is improved
• Having them break the problem into several parts that
combine to form the identified stressor or crisis
• Setting a time limit of 1 week to accomplish a taskl for
example, “What could you do this week to improve the
current situation?”
Develop a priority list with the family. Promotes the family’s sense of control and promotes the
development of a trusting relationship by communicat-
ing respect for the client system.
Begin work with the presenting problem, and enlist the Promotes the development of a trusting relationship,
system’s assistance in resolving concerns. while enhancing the client system’s sense of control.
Include assessment data in determining how to work on
the presenting problem. For example, if behavioral
controls for a child are requested, the nurse can
develop a plan for teaching and implementing them in
the home that includes both parents.
Support communication between family members by: Assists the family in developing problem-solving skills
• Having the family members discuss alternatives to the that will serve them in future situations.
problem in the presence of the nurse
• Having each family member indicate how he or she
might help resolve the problem
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Family Coping, Compromised and Disabled • 765
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Having each family member indicate how he or she
contributes to the maintenance of the problem, or how
he or she does not help the identified patient change
behavior
• Spending time having the family members give each
other positive feedback
Discuss with the family the need for taking breaks from Provides the family with balance between illness
the focus on the health challenge. Options to accom- demands and the need for self-care activities.32 Assists
plish this might include: the family in discovering positive aspects of their rela-
• Arranging for respite care tionships.
• Planning a family vacation
• Planning a family play day
Note here the family plan and support needed from the
staff.
Support the development of appropriate subgroups by: Promotes healthy family functioning.
• Presenting problems to the appropriate subsystems for
discussion—for example, if the problem involves a dis-
cussion of how the sexual functioning of the marital
couple will change as a result of illness, this issue
should be discussed with the husband and wife
• Providing an opportunity for the children to discuss
their concerns with their parents
• Supporting appropriate generational boundaries—for
example, parent’s attempts to exclude children from
parental roles
Develop direct interventions that instruct a family to do Provides information on the family’s ability to change
something different or not to do something. If direct at this point in time, while promoting a positive orien-
interventions are not successful and reassessment indi- tation.
cates they were presented appropriately, this may indi-
cate the family system is having unusual problems with
the change process and should be referred to an
advanced practitioner for further care.
Provide experiences for the family to learn how they can Promotes a positive orientation, while assisting the family
think differently about the problem, for example, a job in developing problem-solving skills.
loss can be seen as an opportunity to reevaluate family
goals, focus on interpersonal closeness, and enhance
family problem-solving skills.
Provide opportunities for the expression of a range of Validates the family members’ emotions, and helps iden-
affect; this can mean laughing and crying together. tify the appropriateness of their affective responses.
This may require that the nurse “push” the family to
express feelings with the skills of confrontation or pro-
viding feedback.32,33
Develop a teaching plan to provide the family with infor-
mation that will enhance their problem solving. (This
could include information about the disease process
and skills necessary for self-care.) [Note that teaching
plan here.]
Assist the family with interactions with other systems by: Facilitates the development of support networks in the
• Providing information about the system community that can be called on in future situations.
• Maintaining open communication between nurse and
other agencies or systems
(care plan continued on page 766)
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766 • Coping–Stress Tolerance Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Having the family identify what their relationship
is with the system, and how they could best achieve
the goals they have for their interactions with this
system
Provide constructive confrontation to the family about Facilitates the development of functional coping behav-
problematic coping behavior.33 Those kinds of behavior iors in a warm, supportive environment.
identified by the treatment team as problematic should
be listed here.
Teach the family methods to reduce anxiety, and prac- High levels of anxiety can interfere with adaptive coping
tice and discuss the use of these methods with the behaviors. Repeated practice of a behavior internalizes
family [number] times per week. This should be and personalizes the behavior.
done at least once a week until family members are
using this as a coping method. This could include
deep muscle relaxation, physical exercise, family
games that require physical activity, or cycling.
Those methods selected by the family should be
listed here, with the time schedule for implementa-
tion. The family should be given “homework” related
to the practice of these techniques at home on a
daily basis.
Provide the family with the information about proper Proper nutrition promotes physical well-being, which
nutrition that was indicated as missing on the assess- facilitates adaptive coping. Successful accomplishment
ment. This should include time spent on discuss- of goals provides positive reinforcement and motivates
ing how proper nutrition can fit the family lifestyle. behavior, while enhancing self-esteem.
This teaching plan should be listed here. A “home-
work” assignment related to the necessary pattern
change should be given. This should involve all
the family members. Make an assignment that has
high potential for successful completion by the
family.
If a homework assignment is not completed, do not Promotes positive orientation.
chastise the family. Indicate that the nurse misjudged
the complexity of the task, and assess what made it
difficult for the family to complete the task. Develop
a new, less complex task based on this information. If
a family continues not to complete tasks, they may
need to be referred to an advanced practitioner for con-
tinued care.
Monitor the family’s desire for spiritual counseling,
and refer to appropriate resources. The name of the
resource person should be listed here.
Assist the family in identifying support systems and in
developing a plan for their use. This plan should be
recorded here.
Refer the family to community resources as necessary for Provides resources that can provide support in the com-
continued support. munity.
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Family Coping, Readiness for Enhanced • 767
Gerontic Health
In addition to the interventions for Adult Health and Mental Health, the following may be used for the older client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Refer to adult protective services if risk of physical harm Provides means for monitoring the patient and family.
is high. Effective use of resources to reduce risk of harm for
the patient.
Home Health
In addition to the interventions for Adult Health and Mental Health, the following may be used for the home health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client and family in planning and implement- Family involvement and clarification of roles are neces-
ing strategies to improve family coping: sary to enhance interventions.
• Crisis management: Identify actions to identify crisis and
intervene (e.g., removing individuals from situation).
• Mutual goal setting: Identify realistic goals and specify
activities for each family member.
• Communication: Provide realistic feedback in positive
manner.
• Family conference: Each member identifies how he or
she is involved, and possible interventions are consid-
ered.
• Support for the caregiver.
Assist the family and client in lifestyle adjustments that Changes in family roles and behaviors require long-term
may be required: behavioral changes. Support is required to facilitate
• Stress management these lifestyle changes.
• Altering past ineffective coping strategies
• Treatment for substance abuse
• Treatment for physical illness
• Appropriate use of denial
• Avoiding scapegoating
• Activities of daily family living
• Financial concerns
• Change in geographic or sociocultural location
• Potential for violence
• Identify family strengths
• Obtain temporary assistance (e.g., housekeeper, sitter, or
temporary placement outside the home)
Consult with and refer to assistive resources as appropriate. Utilization of existing services is efficient use of
resources. Such resources as a family therapist, protec-
tive services, a psychiatric nurse clinician, and commu-
nity support groups can enhance the treatment plan.
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768 • Coping–Stress Tolerance Pattern
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Family Coping, Readiness for Enhanced • 769
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Identify how the child views the current crisis by using The impact of the crisis on the child is basic data needed
play, puppetry, etc. for planning care.
Identify the family’s and the child’s previous and current Family coping behaviors serve as reference data to under-
coping patterns. stand the child’s response and behavior. Will also pro-
vide needs assessment data for planning of teaching.
Assist the child in identifying ways the current crisis or Viewing current situation for beneficial outcomes can
situation can enhance his or her coping for future assist in a positive outcome.
needs.
Identify appropriate health members who can assist in Specialists may best assist the patient in positive resolu-
providing support for growth potential. tion of crisis.
Offer educational instruction to meet the patient’s and Knowledge serves to empower the patient and family and
family’s needs related to health care. reduces anxiety.
Allow for sufficient time while in hospital to reinforce Learning in a supportive environment provides reinforce-
necessary skills for care (e.g., range of motion (ROM) ment of desired content.
exercises).
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage participation of significant others in prepara- Enhances the support system for the patient, and pro-
tion for birth (e.g., spouse, boyfriend, partner, children, motes positive anticipation of birth.
in-laws, grandparents, and others who are important to
the individual).
Discuss childbirth and the changes that will occur in the
family unit.
Encourage the patient to list family lifestyle adjustments Provides directions for anticipation of birth, and allows
that need to be made. Involve significant others in dis- more long-range planning that can prevent crises.
cussion and problem-solving activities regarding fam-
ily adjustments to the newborn (e.g., child care,
working, household responsibilities, social network, or
support groups).
Encourage the woman and partner (significant other) to Provides basic information that assists in easing labor
attend childbirth education or parenting classes in experience. Promotes a more positive birth experience
preparation for the birthing experience. and reduces anxiety.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Talk with the family to identify their goals and concerns. Promotes development of a trusting relationship by com-
municating respect and concern for the family.
Assist the family in identifying strengths. Promotes a positive orientation.
Commend family strengths at each meeting with the Promotes hope and helps the family develop a positive
family. view of themselves and their abilities, promoting an
environment for change. Supports the development of a
positive therapeutic relationship.32
Refer the family to appropriate community support Parents and families with social supports demonstrate
groups. enhanced relationships and coping.23
(care plan continued on page 770)
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770 • Coping–Stress Tolerance Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Teach the family the skills necessary to provide care to an Provides the family with an increased repertoire of
ill member. behavior that they can use to effectively cope with the
situation.
Talk with the family about the role flexibility necessary to Assists the family in anticipatory planning for the neces-
cope with an ill member and how this may be affecting sary adjustments that could evolve from the present sit-
their family. uation. Anticipatory planning increases their
opportunities for successful coping, which enhances
self-esteem.
Provide the family with information about normal devel- Promotes a sense of control and increases opportunities
opmental stages and anticipatory guidance related to for successful coping.
these stages.
Discuss with the family normal adaptive responses to an Promotes the family’s strengths.
ill family member, and relate this to their current func-
tioning.
Support appropriate family boundaries by providing Promotes healthy family functioning.
information to the appropriate family subgroup.
Model effective communication skills for the family by Effective communication improves problem-solving
using active listening skills, “I” messages, problem- abilities.
solving skills, and open communication without
secrets.
Spend [number] minutes with the family per [day or Behavioral rehearsal provides opportunities for feedback
week] providing them with the opportunity to practice and modeling of new behaviors by the nurse.
communication skills and to share feelings (if this is an
identified goal). [Note the schedule for these meetings
here.]
Arrange [number] minute appointments with the family Provides opportunities for the nurse to give positive rein-
[weekly or daily] for [number] times to assess progress forcement and promotes positive orientation.
on the established goals. The need for continued
follow-up can be decided at the end of the last
scheduled visit.
Accept the family’s decisions about goals for care. Promotes the family’s sense of control.
Discuss with the family the role nutrition has in health Nutrition impacts coping abilities.
maintenance, and develop a family nutritional plan.
Consult with nutritionist as necessary.
Discuss with the family the role exercise has in improv- Exercise improves physical stamina and increases the
ing ability to cope with stress, and assist in the devel- production of endorphins.
opment of a family exercise plan. Consult with
physical therapist as necessary.
Gerontic Health
In addition to the interventions for Adult Health and Mental Health, the following may be used for the older client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Communicate your own positive views about aging and Promotes positive anticipatory coping.
the client’s ability to cope to the client and caregivers.
Avoid ageist remarks. For example, “You look so good Promotes positive self-esteem.
for someone who is 90 years old.”
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Coping, Ineffective and Readiness for Enhanced • 771
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client to maintain functional abilities or make Self-esteem and coping are closely related with physical
referrals for Occupational Therapy or Physical Therapy health and functional ability.
to assist the client to improve their functional abilities.
Discuss the client’s roles in life (grandparent, parent, room Persons with greater numbers of role identities have
mate) and the associated responsibilities with the roles. improved perceptions of self-worth.
Utilize reminiscence therapy, either in a group or individ- Reminiscence therapy assists the client in identifying unre-
ually, with the client. solved conflicts and focusing on their achievements.
Promote a sense of control for the client: Older clients who feel a sense of control are better able
• Include the client in the decision making process. to cope.
• Speak to the client rather than about him or her.
• Show respect for the client’s privacy (knock before
entering their room, keep the curtains drawn, be careful
with personal possessions).
• Promote physical fitness in clients able to participate in
activities.
Home Health
In addition to interventions for Adult Health and Mental Health, the following may be used for the home health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Involve the client and family in planning and implement- Family involvement in planning enhances growth and
ing strategies to enhance health and growth: implementation of the plan.
• Family conference: Identify family strengths.
• Mutual goal setting: Establish family goals, and iden-
tify specific activities for each family member.
• Communication: Enhance family discussions and
support.
Assist the family and client in lifestyle adjustments that Support enhances permanent behavioral changes.
may be required:
• Provide information related to health promotion.
• Provide information related to expected growth and
development milestones, both individual and family.
• Assist in development and use of support networks.
Consult with and refer to assistive resources as Community services provide a wealth of resources to
appropriate. enhance growth (e.g., service organizations such as
Lion’s Club, Altrusa, etc., colleges and universities, or
recreational facilities).
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Coping, Ineffective and Readiness for Enhanced • 773
•
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Copyright © 2007 •by F. A. Davis.
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774 • Coping–Stress Tolerance Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient to identify and use available support Broadens the support network to reach short-term and
systems before discharge from hospital. long-term goals.
Initiate referral to psychiatric clinical nurse specialist as Specialized skills may be needed to intervene in signifi-
needed. cant problem areas.
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ineffective Coping
Establish a trusting relationship with the child and Promotes communication and allows gathering of data
respective family by allowing time (30 minutes) per that enhance care planning.
shift, while the patient is awake, for verbalization of
concerns and their perception of the situation.
Identify the need for collaboration with related health Specialist (e.g., mental health, may best be able to deal
team members. with the problem).
Reinforce appropriate behavior of choosing or coping by Positive reinforcement will enhance learning of coping
verbal praise. mechanisms.
Assist the patient and family in setting realistic goals. Realistic goals enhance success, which increases coping
ability.
Provide appropriate attention to primary nursing needs. Meeting of primary care needs allows the patient to focus
energy on coping.
Offer education to provide clarification of information as Provides basic knowledge needed to avoid future crises.
needed, regarding any health-related needs. Increases options for coping choices.
Determine appropriate developmental baseline behavior Baseline data will provide valuable information for com-
versus actual coping behavior. parative follow-up.
Administer medications as ordered, including sedatives. Relaxation assists in decreasing anxiety. Conserves
energy to deal with crisis.
Set aside time each shift [specify] to deal with how the Acting out or expression of feelings provides valuable
child and parents feel about the defensive behavior. data that increase the likelihood of a successful plan of
This may require art, puppetry, or related expressive care.
dynamics.
Provide feedback with support for progress. When Feedback serves to clarify and allows for reviewing the
progress is not occurring, provide reflective referral specific coping activity with reteaching as needed.
back to the child and parent as applicable.
Provide ongoing information regarding the child’s health Factors related to coping may well be influenced by
status, which could affect defensive behavior by the residual effects from illness. Misinformation or lack of
child or parents. information can also be detrimental to positive coping.
Throughout defensive coping period, monitor and ensure Basic standard of care.
the child’s safety.
Determine disciplinary plans for all to abide by with Structured limit setting will provide security and safety.
safety in mind.
Provide appropriate reality confrontation according to Reality confrontation helps keep perspective on here and
readiness of the child and parents. now and is a useful approach to initiate coping with
current situation.
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Coping, Ineffective and Readiness for Enhanced • 775
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide for discharge planning with reinforcement of Attaching value to follow-up increases the likelihood of
importance of follow-up appointments as needed. satisfactory attendance for appointments and other
follow-up activities.
Identify, along with the patient and family, resources to Support groups provide empowerment and a sense of
assist in coping, including support groups. shared concern.
Readiness for Enhanced34
Monitor for defining characteristic for enhanced coping Provides a relevant base.
readiness plan.
Facilitate health-care team paraprofessionals, especially Provides the likelihood of addressing child and family’s
child life specialist, provision of developmentally needs within a realistic scope.
appropriate coping strategies.
Assist the child and family to generate ways to incorpo- Offers a realistic approach.
rate the plan into daily routine with allowance for alter-
ations of role, time, activity, or related aspects,
including school and extracurricular activities.
Offer opportunities for discussion in group or with child Offers a sense of input for each member.
alone regarding the desired level of change the coping
offers.
Promote ongoing evaluation and reinforcement of small Enhances and empowers the child to see effects of behav-
changes related to application of enhanced coping. ior changes.
Refer, as appropriate, for counseling to promote enhanced Provides anticipatory guidance with likelihood of contin-
coping. ued success.
Assist the child and family to communicate to relevant Offers continuity of plan for daily routine.
persons how to best assist in maintenance of plan,
especially school teacher and nurse, as applicable.
Women’s Health
l N O T E : Women’s health will be the same as Adult Health, Mental Health, and
Gerontic Health for these diagnoses, in addition to the following:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ineffective Coping
Identify groups at risk for ineffective individual coping Provides a database that allows for early recognition,
(e.g., single parents, minority women, women with planning, and action.35–37
“superwoman” syndrome, and lesbians).
Identify situations that place patients at risk for ineffec-
tive individual coping, e.g., unwanted or unplanned
pregnancy, unhappy home situation (marriage),
demands at work, or demands of children or spouse.
(See Impaired Adjustment for Postpartum Depression.)
Assist the patient in identifying typical stressful times
(e.g., at home, at work, in social situations, or during
an average day).
Assist the patient in identifying lifestyle adjustments that Supports the patient in identification and planning
may be made to lower stress levels (e.g., planning for of strategies to reduce stress.35–37
divorce or planning for job change, either part-time or
unemployment for a period of time).
(care plan continued on page 776)
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776 • Coping–Stress Tolerance Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the patient in identifying factors that contribute to Identification of factors that contribute to the situation is
ineffective coping, for example, depression, guilt the first step in learning positive rather than negative
(blaming self), assuming helplessness, passive accept- skills.
ance of traditional feminine role, anger toward self and
others (aggressive behavior, suicide threats, or sub-
stance abuse), and failure to make time for self (relax-
ation, pleasure, or self-care).
Assist the patient in developing problem-solving skills to Assists the patient in planning positive actions and in
modify stressors, for example, using 12-step plan (as communicating her needs to others.
developed by Alcoholics Anonymous), or planning
time for self-rewarding activities such as exercise or
long quiet baths.
Assist the patient in identifying negative and positive
responses to stressors (e.g., pressures at work such as
being constantly interrupted or become defensive when
challenged).
Assist the patient in developing an individual plan of
stress management (e.g., relaxation techniques or
assertiveness training).
Involve significant others in discussion and problem-
solving activities.
Provide a nonjudgmental atmosphere that allows the
patient to discuss her feelings about the pregnancy,
including such areas as lifestyle, children, or support
systems.
Explore the patient’s use of what she perceives are con- Provides a basis for planning lifestyle options.35–37
traceptives38 (e.g., pills, intrauterine devices,
diaphragm, withdrawal, feminine hygiene products,
douching, spermicide foams, or rhythm).
Explore the patient’s lack of contraceptive use39 due to Provides health-care personnel information to plan care
ignorance (“It won’t happen to me” syndrome), guilt that enhances likelihood of successful compliance.
(“If I use the pill, then I am not good”), spontaneity,
excitement due to risk, loneliness, crisis or pressure, or
uncertainty in sex role relationships or self-image.
Readiness for Enhanced Coping
Refer clients to natural resources and activities to Self-care practices are practices an individual can pursue
enhance their coping skills, such as the following: on their own to assist in coping, comforting, and heal-
• Bibliotherapy—readings that help clients through diffi- ing activities.66
cult times
• Journaling, writing, storytelling, creativity, arts—writ-
ings of personal thoughts, memories, and/or experi-
ences kindles introspection and meaning
• Affirmations—positive personal statements in present
tense that express a desirable outcome
• Presence, deep breathing, centering—presence with all
senses focused
• Relaxation, imagery, visualization
• Prayer, religion, spirituality, meditation
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Coping, Ineffective and Readiness for Enhanced • 777
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Music therapy—application of pleasant sounds to pro-
duce desired changes
• Color therapy—display of colors for healing
• Light therapy—for those with seasonal affective disor-
der.
• Hydrotherapy—water used in healing process
• Nutrition/herbs, etc.
• Health-care provider assistance.66
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ineffective Coping
Determine the client’s functional abilities and developmen- Cognitive abilities can impact the client’s ability to
tal level for the adaptation of all future interventions. develop appropriate coping behaviors.
The results of this assessment should be noted here.
Discuss with the client his or her perception of the cur- Promotes the development of a trusting relationship
rent crisis and stressors. This should include informa- by communicating respect for the client.
tion about the coping strategies that the client has
attempted and his or her assessment of what has made
them ineffective in resolving this stressor or crisis.
Assist the client in developing an appropriate time frame “De-catastrophizes” the client’s perceptions of the
for the resolution of the situation. (Often when experi- situation.44
encing a crisis, the individual has the perception that
resolution must take place immediately.) This could
include, as appropriate to the client’s situation:
• Informing the client that any difficulty that has taxed
his or her resources as much as this one has will take an
extended time to resolve because it must be complex.
• Informing the client that a situation that is as important
as this one is to the individual’s future deserves a well-
thought-out answer and that a decision should not be
made hastily.
• Assisting the client in determining the source of the time
pressure and the appropriateness of this time frame.
• Assisting the client in developing an appropriate per-
spective on the time frame. (One question that could be
useful is “What would be the worst that could happen
if this problem is not resolved by [put client’s stated
time frame here]?”)
• Assist the client in understanding that goals should be Provides an opportunity for client success in achieving
modest. Complex change should be taken slowly. change while enhancing self-esteem.
Provide a quiet, nonstimulating environment or an envi- Inappropriate levels of sensory stimuli can increase con-
ronment that does not add additional stress to an fusion and disorganization.
already overwhelmed coping ability. (Potential envi-
ronmental stressors for this client should be listed here
with the plan for reducing them in this environment.)
Sit with the client [number] minutes [number] times per Communication of concerns in a supportive environment
day at [specify times here] to discuss current concerns can facilitate the development of adaptive coping
and feelings. behaviors. Continues the development of a trusting
relationship.
(care plan continued on page 778)
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778 • Coping–Stress Tolerance Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client with setting appropriate limits on aggres- Inappropriate levels of environmental stimuli can increase
sive behavior. (See Risk for Violence in Chapter 9 for disorganization and confusion, increasing the risk for
more detailed nursing actions if this diagnosis develops.) acting-out behavior.
Decrease environmental stimulation as appropriate. (This
might include a secluded environment.)
Provide the client with appropriate alternative outlets for Physical activity decreases the tension that is related to
physical tension. (This should be stated specifically anxiety. Appropriate control of behavior promotes the
and could include walking, running, talking with a staff client’s sense of control and enhances self-esteem.
member, using a punching bag, listening to music, or
doing a deep muscle relaxation sequence.) Strategies
should be used [number] times per day at [times] or
when increased tension is observed. These outlets
should be selected with the client’s input.
Orient the client to date, time, and place. Provide clocks, Orientation enhances the client’s coping abilities.
calendars, and bulletin boards. Make references to this
information in daily interactions with the client. The
frequency needed for this client should be noted here
(e.g., every 2 hours, every day, or three times a day).
Provide the client with familiar or needed objects. These Promotes the client’s sense of control, while meeting
should be noted here. security needs.
Provide the client with an environment that will optimize Inappropriate levels of sensory stimuli can increase con-
sensory input. This could include hearing aids, eye- fusion and disorganization.
glasses, pencil and paper, decreased noise in conversa-
tion areas, or appropriate lighting. (These interventions
should indicate an awareness of sensory deficit as well
as sensory overload.) The specific interventions for this
client should be noted here, for example, place hearing
aid in when client awakens and remove before bedtime
(9:00 P.M.).
Provide the client with achievable tasks, activities, and Accomplishment of these goals provides reinforcement
goals (these should be listed here). These activities and encourages positive behavior, while enhancing
should be provided with increasing complexity to give self-esteem.
the client an increasing sense of accomplishment and
mastery.
Communicate to the client an understanding that all cop- Assists the client to maintain self-esteem, diminishes
ing behavior to this point has been his or her best effort feelings of failure, and promotes a positive orientation.
and that asking for assistance at this time is not failure.
A complex problem often requires some outside assis-
tance to resolve.
Provide the client with opportunities to make appropriate
decisions related to care at his or her level of ability.
This may begin as a choice between two options and
then evolve into more complex decision making.
It is important that decision making be at the client’s Promotes the client’s sense of control.
level of functioning so that confidence can be built
with successful decision-making experience.
Provide the client with a primary care nurse on each shift. Promotes the development of a trusting relationship.
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Coping, Ineffective and Readiness for Enhanced • 779
ACTIONS/INTERVENTIONS R AT I O N A L E S
When a relationship has been developed with primary Promotes development of a trusting relationship. Discus-
care nurse, this person will sit with the client [number] sion of concerns in a supportive environment promotes
minutes per shift to discuss concerns about sexual the development of alternative coping behaviors.
issues, fears, and anxieties (begin with 30 minutes and
increase as the client’s ability to concentrate improves).
Provide constructive confrontation for the client about Assists the client in reality testing of coping behaviors.
problematic coping behavior.33 Those kinds of behavior
identified by the treatment team should be listed here.
Provide the client with information about care and treat- Promotes the client’s sense of control. Inappropriate lev-
ment. Give information in concise terms appropriate to els of sensory stimuli increase confusion and disorgani-
the client’s level of understanding. zation.
Identify with the client methods for anxiety reduction. High levels of anxiety decrease the client’s coping abili-
Those specific methods selected should be listed here. ties and interfere with the learning of new behaviors.
Assist the client with practice of anxiety reduction tech- Repeated practice of a behavior internalizes and personal-
niques, and remind him or her to implement these tech- izes the behavior.
niques when level of anxiety is increasing.
Provide the client with opportunities to test problem solu- Behavioral rehearsal helps facilitate the client’s learning
tions either by role-playing or by applying them to new skills through the use of feedback and modeling
graded real-life experiences. by the nurse.
Assist the client to revise problem solutions if they are Promotes positive orientation and enhances the client’s
not effective. (This will assist the patient to learn that self-esteem by turning disadvantages into advantages.44
no solution is perfect or final and that problem solving
is a process of applying various alternatives and revis-
ing them as necessary.)
Allow the client to discover and develop solutions that Promotes the client’s sense of control, and development
best fit his or her concerns. The nurse’s role is to pro- of new behaviors enhances the client’s problem-solving
vide assistance and feedback and to encourage creative behaviors and improves self-esteem.
approaches to problem behavior.
Teach the client skills that facilitate problem solving, Increases repertoire of coping behaviors, decreasing all-
such as assertive behavior, goal setting, relaxation, or-none thinking.44
evaluation, information gathering, requesting assis-
tance, and early identification of problem behavior.
Those skills that are identified by the treatment team as
being necessary should be listed here with the teaching
plan. This should include a schedule of the information
to be provided and identification of the person respon-
sible for providing the information.
Spend [number] minutes two times per day at [times] with Repeated practice of a behavior internalizes and personal-
the client role-playing and practicing problem solving izes the behavior.
and implementation of developed solutions. This will
be the responsibility of the primary care nurse.
Assist the client in identifying those problems he or she Increases the client’s opportunities for success in early
cannot control or resolve and in developing coping problem-solving attempts. This success provides rein-
strategies for these situations. This may involve alter- forcement, which motivates positive behavior and
ation of the client’s perception of the problem. enhances self-esteem.
Monitor the client’s desire for spiritual counseling, and Increases the resources available to the client.
refer to appropriate resources.
Provide positive social reinforcement and other behavioral Reinforcement encourages positive behavior and
rewards for demonstration of adaptive problem solving. enhances self-esteem.
(Those things that the client finds rewarding should be
listed here with a schedule for use. The kinds of behav-
ior that are to be rewarded should also be listed).
(care plan continued on page 780)
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780 • Coping–Stress Tolerance Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client in identifying support systems and in Decreases the client’s sense of social isolation.
developing a plan for their use.
The following interventions relate to the client who is
experiencing problems related to organic brain dys-
function:
• Maintain a consistent environment; do not move furni- Inappropriate levels of sensory stimuli increase confusion
ture or personal belongings. and disorganization.
• Remove hazardous objects from the environment, such Client safety is of primary concern.
as loose rugs or small items on the floor.
• Provide environmental cues to assist the client in locat-
ing important places such as the bathroom, own room,
or the dining room.
• Do not argue with the client about details of the recent The client cannot remember this information, and arguing
past. increases the client’s levels of frustration, which can
precipitate aggressive behavior.
• Avoid situations that result in aggressive behavior by Prevention provides the safest approach to aggression.
redirecting the client’s attention.
• Provide a constant daily routine and a homelike atmos- Appropriate levels of sensory stimuli can increase orien-
phere, to include personal belongings, music, and tation and organization.
social mealtimes with assistance with meal preparation.
This can often provide appetite cues to the client and
stimulate memories.
• Provide group experiences that explore current events, Promotes the client’s orientation, and maximizes cogni-
seasonal changes, reminiscence, and organizing life tive abilities.
experiences.
The following interventions related to the client who is
experiencing Defensive Coping:
• Approach the client in a positive, nonjudgmental manner. Promotes the development of a trusting relationship.
• Focus any feedback on the client’s behavior. Communicates acceptance of the client, while providing
information on coping behaviors that create problems.
• Provide an opportunity for the client to share his or her Promotes the development of a trusting relationship by
perspectives and feelings. communicating acceptance of the individual. This rela-
tionship will decrease the need for defensive coping.
• Use “I” statements, e.g., “I feel angry when I see you Provides modeling of more effective coping behaviors.
breaking the window.”
• Develop a trusting relationship with the client before Trusting relationship decreases need for defensive coping
using confrontation or requesting major changes in and increases the client’s ability to respond to this
behavior.45,46 information constructively.
• Provide positive reinforcement for the client when Reinforcement encourages positive behavior while
issues are addressed. (Things that are reinforcing for enhancing self-esteem.
this client should be noted here.)
• When the client’s defenses increase, reduce anxiety in Anxiety increases the client’s use of familiar coping
situation. (See Anxiety in Chapter 8 for precise infor- behaviors and makes it difficult to practice new behav-
mation on anxiety control.) iors.
• Determine the kinds of behavior by staff members that Provides an environment that is supportive of the client’s
increase the client’s defensive coping, and note them learning new coping behaviors.
here with a plan to decrease them.
• Be clear and direct with the client. Inappropriate levels of sensory stimuli can increase con-
fusion and disorganization.
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Coping, Ineffective and Readiness for Enhanced • 781
ACTIONS/INTERVENTIONS R AT I O N A L E S
• If defensive coping is related to alteration in self-
concept, refer to the appropriate nursing diagnosis
for interventions.
• Reduce or eliminate environmental stressors or threats.
• Arrange a time for the client to be involved in activity Promotes positive orientation.
that he or she enjoys, and that provides him or her with
positive emotional experiences. [Note activity and time
for this activity here.]
The following interventions are for the client experienc- High levels of anxiety increase the client’s use of familiar
ing Denial: coping behaviors and make it difficult to practice new
• Determine whether current use of denial is appropriate behaviors.
in the current situations. (Facilitates coping with situa-
tion in a manner that does not compromise normal
functioning)
• If denial is determined to be non-health promotive, ini- Communicates acceptance of the client, promoting the
tiate the following interventions: development of a trusting relationship.
• Provide a safe, secure environment.
• Allow the client time to express feelings.
• Provide a positive, nonjudgmental environment. Promotes positive orientation.
• Develop a trusting relationship with the client before A trusting relationship decreases the client’s need to
presenting threatening information. enlist dysfunctional coping behaviors.
• Present information in a clear, concise manner. Inappropriate levels of sensory stimuli can increase the
client’s confusion and disorganization.
• Determine which kinds of staff behavior reinforce Models appropriate coping behavior, while decreasing
denial, and note them here with alternative behavior. direct threats to the client’s self-system.
• Utilize “I” messages, and reflect on the client’s behav-
ior.32
• Present the client with information that demonstrates Places in question the client’s current coping behaviors,
inconsistencies between thoughts and feelings, between and facilitates the examining of options and alterna-
thoughts and behavior, and between thoughts about tives.44
others and their perceptions of the situation.
• Arrange for the client to participate in a group that will Assists the client to experience personal importance to
provide feedback from peers regarding the stressful sit- others, while enhancing interpersonal relationship
uation. skills. Increasing the client’s competencies can enhance
self-esteem and promote positive orientation.
• Present the client with differences between his or her Assists the client in questioning the evidence that he or
perceptions and the nurse’s perceptions with “I” mes- she has been using to support ineffective coping behav-
sages. iors without directly challenging them. This decreases
the need for the client to use ineffective coping behav-
iors.44
• Do not agree with the client’s perceptions that are Would support and reinforce ineffective coping behaviors.
related to denial.
• Schedule a time for the client and support system to Support system understanding promotes the continuation
discuss issues related to the current problem. [Note this of new coping behaviors after discharge.
time here with the name of the staff person responsible
for this session.]
• Assist the support system in learning constructive ways
of coping with the client’s denial.
• Schedule time for the client to be involved in positive
esteem-building activity. (This activity should be
selected with client input.) [Note activity and times
here.]
(care plan continued on page 782)
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782 • Coping–Stress Tolerance Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Provide positive feedback for the client, addressing Feedback encourages positive behavior and enhances
concerns in a direct manner. [Note here those things self-esteem.
that are rewarding for the client.]
• Determine needs that are being met with denial.
Establish and present the client with alternative kinds
of behavior for meeting these needs. [Note alternatives
here.]
Readiness for Enhanced Coping
Talk with the client to identify their goals and concerns.
[Note client’s goals here.]
Assist the client in identifying strengths and purpose in
life.
Commend client’s strengths at each meeting.
Identify, with the client, the support needed from staff to
strengthen coping behaviors and build on strengths.
Note the support needed here (e.g., music, quiet time,
training in a specific relaxation technique).
• Collaborate with other health-care providers to provide
assistance needed in developing additional coping
strategies (e.g., physical therapy, music therapist, occu-
pational therapists, and leaders of the client’s faith
community). Note those providers involved here with
those supports needed to facilitate their work with the
client (meeting schedules, group times).
Spend [number] minutes [number] time(s) per day dis-
cussing client’s progress toward goals. Provide inform-
ative positive verbal reinforcement for goal attainment.
Provide client with the information necessary to facilitate
enhanced wellness. [Note the information needed
here.]
Before discharge, meet with the client’s support system
and client to develop a plan for addressing stressors.
[Note the time for this meeting here.]
Refer the client to appropriate community support
groups. [Note groups here with supports needed from
staff to facilitate the client’s connecting with these
groups.]
Gerontic Health
In addition to the interventions for Adult Health and Mental Health, the following may be used for the older client:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ineffective Coping
Discuss with the patient any recent life changes that may Recent or multiple losses may significantly impact usual
have affected his or her coping, such as loss of a loved coping skills.
one, relocation, loss of best friend, or loss of a pet.47
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Coping, Ineffective and Readiness for Enhanced • 783
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess the client for physical factors that may contribute Identifies factors that can be changed or addressed to
to impaired coping: facilitate coping.
• hearing impairment
• communication barriers
• chronic illness
• fatigue
• social isolation
• mobility limitations
Readiness for Enhanced
Communicate your own positive views about aging and Promotes positive anticipatory coping.
the client’s ability to cope to the client and caregivers.
Avoid ageist remarks such as, “You look so good for Promotes positive self-esteem.
someone who is 90 years old.”
Facilitate the client’s maintenance of functional abilities Self-esteem and coping are closely related with physical
or make referrals for Occupational Therapy or Physical health and functional ability.
Therapy to assist the client to improve his or her func-
tional abilities.
Discuss the client’s roles in life (grandparent, parent, Persons with greater numbers of role identities have
roommate) and the associated responsibilities with the improved perceptions of self worth.
roles.
Utilize reminiscence therapy, either in a group or individ- Reminiscence therapy assists the client in identifying unre-
ually, with the client. solved conflicts and focusing on their achievements.
Promote a sense of control for the client.
• Include the client in the decision-making process.
Speak to the client rather than about him or her.
• Show respect for the client’s privacy (knock before
entering their room, keep the curtains drawn, be careful
with personal possessions).
• Promote physical fitness in clients able to participate in
activities.
Home Health
In addition to the interventions for Adult Health and Mental Health, the following may be used for the home health client.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ineffective Coping
Involve the client and family in planning and implement- Family involvement enhances effectiveness of interven-
ing strategies to improve individual coping: tions.
• Family conference: Identification of problem and role
each family member plays.
• Mutual goal setting: Set realistic goals. Specify activi-
ties for each family member. Establish evaluation
criteria.
• Communication: Use accurate and honest feedback in a
positive manner.
Assist the family and client in lifestyle adjustments that
may be required:
• Stress management
• Development and use of support networks
• Alteration of past ineffective coping strategies
(care plan continued on page 784)
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784 • Coping–Stress Tolerance Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Treatment for substance abuse
• Treatment for physical illness
• Activities to increase self-esteem: Exercise or stress
management
• Temporary assistance: Babysitter, housekeeper, or sec-
retarial support
Identify signs and symptoms of illness. Permanent changes in behavior and family roles require
support and accurate information.
Point out hazards and benefits of home remedies, self-
diagnosis, and self-prescribing.
Consult with and refer the patient to assistive resources as Utilization of existing services is efficient use of
appropriate. resources. Resources such as a psychiatric nurse clini-
cian, a family therapist, and support groups can
enhance the treatment plan.
Readiness for Enhanced
Monitor for factors contributing to adaptive coping (psy- Provides a basis for continued improvement.
chological, social, economic, spiritual, or environmen-
tal factors).
Involve the client and family in planning, implementing, Family involvement enhances effectiveness of interven-
and promoting continued adaptive coping. tions.
• Family conference: Discuss feelings, roles, and identify
coping strategies that have worked in the past.
• Mutual goal sharing: Establish realistic goals and spec-
ify role of each family member (e.g., provide safe envi-
ronment and support self-care).
• Communication: Clear and honest communication
should be promoted among family members. If sensory
impairments exist, corrective interventions are needed
(e.g., eyeglasses or a hearing aid).
Assist the client and family in lifestyle adjustments that Family relationships can be altered by impaired adjust-
may be required: ment. Permanent changes in behavior and family roles
• Stress management require evaluation and support.
• Development and use of support networks
• Treatment for disability
• Appropriate balance of dependence and independence
• Grief counseling
• Change in role functions
• Treatment for cognitive impairment
• Provision of comfortable and safe environment
• Activities to increase self-esteem
Consult with or refer to appropriate assistive resources Utilization of existing services is efficient use of
as indicated. resources. Resources such as an occupational therapist,
a psychiatric nurse clinician, and support groups can
enhance the treatment plan.
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Post-Trauma Syndrome, Risk For and Actual • 785
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786 • Coping–Stress Tolerance Pattern
•
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Post-Trauma Syndrome, Risk For and Actual • 787
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for details surrounding the incident causing Post- Circumstances surrounding the event may provide clues
Trauma Syndrome. as to how the child may be internalizing people, places,
and objects as symbols or reminders.
Allow for developmental needs in encouraging the child Appropriate methods should help resolve the emotions
to express feelings about trauma: surrounding the incident and avoid further trauma-
• Play for infants tization.
• Puppets or dolls for toddlers
• Stories or play for preschoolers
Deal appropriately with other primary nursing needs Allows focusing of energy on dealing with the crisis.
(e.g., nutrition or rest).
Provide for one-to-one care and continuity of staff. Enhances trust.
Encourage the patient and family to note positive out- Potential for growth exists in crisis management.
comes of experience (e.g., being able to deal with
crisis).
Review previous coping skills. Coping may be enhanced by consideration of previous
skills within framework of current situation.
Address educational needs according to situation (e.g., Knowledge provides empowerment and enhances deci-
rights of the individual or related follow-up). sion making.
Allow for visitation by the family and significant others. Family visitation offers opportunity for reassurance and
promotes resuming daily routines and relationships.
Refer the patient appropriately for continuity and follow- Continuity and follow-up will foster likelihood of resolu-
up after discharge from hospital. tion of major conflicts.
Provide for diversional activity of the child’s choice. Promotes relaxation.
Allow for potential sleep disturbances. Provide favorite Recurrent nightmares may occur as a result of the trauma.
toy or security object. Offer adequate comforting, such
as holding the infant on waking.
Provide for follow-up for delayed Post-Trauma Syndrome Delayed response can be noted long after the initial event,
up to 2 years after the trauma. and must be included in the planning of care.49
Reassure the child that he or she is not being punished Depending on the cognitive level and coping ability, the
and is not responsible for trauma. child may associate the event as being caused by some-
thing “wrong” he or she did or said.
Women’s Health
This nursing diagnosis will pertain to the woman the same as to any other adult. The reader is referred to Rape-Trauma
Syndrome (see Chapter 10) and to the other nursing actions in this section (Adult Health, Mental Health).
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Risk for
Inform persons exposed to trauma of the signs and symp- Normalizes the response and provides them with the
toms of PTSD and indicate that this response is normal. knowledge to seek early assistance.50
• Emphasize strength of natural resilience (persons
before us have survived similar situations).
Discuss with client methods for coping with situation and
have them identify those coping strategies that would
be most useful.
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788 • Coping–Stress Tolerance Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Facilitate client’s connections with their support systems.
[Note type of assistance needed here.]
Develop, with client, plan for providing adequate nutri- Physiological well-being facilitates emotional well-
tion, sleep, and exercise. [Note client’s plan here.] being.50
Facilitate client’s maintenance of daily routine. Note Stability assists in reducing stress.50
client’s routines and type of assistance needed here.
Actual
Assign a primary care nurse to the client, and assign the Promotes the development of a trusting relationship and
same staff member to the client each day on each shift sense of safety.50
and establish a daily routine. [Note the client’s specific
routine there.]
Monitor for sleep disturbance and refer to Sleep pattern,
Disturbed for appropriate interventions.
Begin appropriate anxiety-reducing interventions if this is Provides the client with increased repertoire of coping
a significant problem for the client. (See Anxiety in behaviors to cope with intense emotional experiences.
Chapter 8 for detailed intervention strategies and
assessment criteria.)
Discuss with the client his or her perception of the cur- Promotes the client’s sense of control, while communicat-
rent situation and stressors. This should include infor- ing respect for the client’s experience.50
mation about the coping strategies that the client has
attempted, and his or her assessment of what has made
them ineffective in resolving this situation, and infor-
mation about PTSD symptoms.
If the client describes or demonstrates high levels of guilt, Clients with guilt related to the experience may view sui-
assess for suicide risk or risk for self-harm, and imple- cide as a way to end this guilt.33
ment appropriate precautions. Note here the actions to Clients experiencing high stress reactions can’t be at
be taken. (See Suicide, Risk for, or Self-Mutilation, greater risk for self-harm.50
Risk for, for detailed interventions.)
Monitor the client for risk for harming others. Refer to Clients experiencing stress reactions can be at increased
Other Directed Violence, Risk for, for appropriate risk for harming others.50
interventions if defining characteristics are present.
Monitor the client for signs and symptoms of substance Clients with acute stress reactions may utilized sub-
intoxication or withdrawal. stances as a coping strategy.50
Provide a quiet, nonstimulating environment, or an envi- Inappropriate levels of sensory stimuli can increase con-
ronment that does not add additional stress, to an fusion and disorganization and decrease sense of
already overwhelmed coping ability. [Potential envi- safety.50
ronmental stressors for this client should be listed here,
with the plan for reducing them in this environment.]
Provide the client with basic needs such as food, hygiene, Physiological stability facilitates recovery.50
sleep, fluids.
Sit with the client [number] minutes [number] times a Promotes the development of a trusting relationship,
day at [times] to discuss the traumatic event. This while providing the client with an opportunity to
should be directed by the client’s need to discuss vari- review and attach meaning to the client’s experi-
ous aspects of their experience and not forced. Person ence.45,50
responsible for this activity should be listed here. This
should be the nurse who has established a relationship
with the client.
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Post-Trauma Syndrome, Risk For and Actual • 789
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assist the client with setting appropriate limits on aggres-
sive behavior (see Risk for Violence in Chapter 9 for
nursing actions if this is an appropriate diagnosis) by:
• Decreasing environmental stimulation as appropriate. Inappropriate levels of sensory stimuli can increase con-
(This might include a secluded environment or a time- fusion and disorganization, which increases the risk for
out.) aggressive behavior.
• Providing the client with appropriate alternative outlets Physical activity decreases physical tension and increases
for physical tension. (This should be stated specifically, the production of endorphins, which can increase the
and could include walking, running, talking with staff feeling of well-being. This also provides the client with
member, using a punching bag, listening to music, opportunities to practice new coping behaviors in a
journaling, or doing a deep muscle relaxation sequence supportive environment.
[number] times per day at [times] or when increased
tension is observed.) These outlets should be selected
with the client’s input. Those outlets that the client
selects should be listed here.
• Talking with the client about past situations that Increases the client’s coping options, and assists with
resulted in loss of control, and discussing alternative cognitive appraisal of past coping behaviors.44
ways of coping with these situations. (Persons respon-
sible for this discussion should be noted here. This will
not be accomplished in one discussion; the time and
date for the initial discussion should be noted, with the
times and dates for follow-up discussions.)
Once the symptoms have been identified and linked to the Promotes the client’s positive orientation.
traumatic event, the primary nurse will sit with the
client [number] minutes (begin with 30 and increase as
the client’s ability to concentrate improves) per shift to
discuss the traumatic event These discussions should
include:
• The uniqueness of the situation, noting that one could
not plan for the behavior that might be needed to
endure the situation.
• Ways of evaluating behavior, noting that the usual Assists the client to evaluate and gain perspective on
moral and ethical standards may be inappropriate for behavior, while moving away from all-or-none think-
the unique situation of a traumatic event. ing.44
• Details of the event as the individual remembers them, Assists the client in attaching meaning to the experience.
and the thoughts and feelings that occur with these
memories.
• Meaning of life since the event, and the implications Promotes positive orientation, while assisting the client to
this has for the future. review cognitive distortions.27
• Client’s perceptions of the current actions of those Assists the client with reality testing his or her percep-
around them and information about the care provider’s tions of current situations and motivations of oth-
perceptions. This should include normalization of the ers.50,51
client’s responses. (Person is experiencing a normal
response to an abnormal situation).
Talk with client about thoughts rather than feelings about Inhibits automatic behavioral responses.44
the event if feelings become extreme, such as with rage
or despondency.
Provide constructive confrontation for the client about Assists the client to gain a perspective on the experience
problematic coping behavior.32 Those kinds of behavior and to label cognitive distortions that inhibit effective
identified by the treatment team as problematic should coping.44
be listed here with the selected method of confrontation.
Provide the client with information about care and treat- Promotes the client’s sense of control.
ment.
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790 • Coping–Stress Tolerance Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Provide the client with opportunities to make appropriate Success in this activity provides positive reinforcement
decisions related to care at his or her level of ability. and promotes the client’s utilizing alternative coping
This may begin as a choice between two options and behaviors, while enhancing self-esteem.
then evolve into more complex decision making. It is
important that this decision making be at the client’s
level of functioning so confidence can be built with
successful decision-making experiences. Those deci-
sions that the client has made should be noted.
Provide positive social reinforcement and other behav- Reinforcement encourages positive behavior and
ioral rewards for demonstration of adaptive problem enhances self-esteem.
solving and coping. Those things that the client finds
rewarding should be listed here, with a schedule for
use. Those kinds of behavior that are to be rewarded
should also be listed.
Assist the client in identifying support systems and in Support system understanding promotes their appropriate
developing a plan for their use. This plan should be support of the client.
noted here.
Inform significant others of the relationship between the Support system understanding promotes their appropriate
client’s behavior and the traumatic event. Discuss with support of the client.50
them their thoughts and feelings about the client’s
behavior. The person responsible for these discussions
should be noted here, along with the schedule for the
discussion times. This should also include information
about the importance of supporting the client in dis-
cussing the event and how this might be facilitated.
The concerns the significant others have about their
response to this sharing should be discussed as well as
planning for the types of information they might be
exposed to.
When the client develops a degree of comfort discussing Promotes the development of adaptive coping within the
the traumatic event, meetings between the client and support system.
significant others should be scheduled. Content of
these meetings should include:
• Opportunities for the client to share thoughts and feel-
ings about the event
• Opportunities for the significant others to share their
thoughts and feelings about the client’s behavior
• Sharing of thoughts and feelings related to other events
in the relationship as they surface as important topics
of discussion during the meetings
• Sharing of caring thoughts and feelings with each other
Arrange for the client to attend support group meetings Decreases the sense of social isolation, and decreases
with others who have experienced similar traumas. The feelings of deviance. Consensual validation from other
times and days for these meetings should be noted here group members enhances self-esteem, providing
with any special arrangements that are needed to facili- increased emotional resources for coping.50
tate the client’s attendance (e.g., transportation to
group meeting place). This could include veterans
groups, groups for survivors of natural disasters, and
victims’ groups.
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Suicide, Risk For • 791
ACTIONS/INTERVENTIONS R AT I O N A L E S
Schedule client involvement in unit activities. [Note here Decreases social isolation, and provides opportunity to
the client’s responsibilities in these activities, with practice new coping skills in a supportive environment.
times the client will be involved in the activity.]
Provide medications as ordered and monitor for therapeu- Medication may be utilized for clients who do not
tics response and side effects. respond to non-pharmacological treatment. These are
targeted to specific symptoms such as sleep disturbance
or excessive anxiety/panic attacks.50
Gerontic Health
The nursing actions for a gerontic patient with this diagnosis are the same as those given for the Adult Health and Mental
Health patient.
Home Health
See Mental Health nursing actions for detailed interventions. If family violence is involved, refer to Chapter 9.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ask the client to describe the precipitating event. Assists the nurse in understanding the client’s perception
of the crisis and its impact.
Determine the client’s perception of the stress.
Assess sources of support, resources, and usual coping
methods.
Identify which coping strategies that the client has previ- Crisis can produce growth if effective skills are applied in
ously used have been effective and which have not. future situations.
Discuss ways that effective strategies can be used to
cope with future crises.29
Assist the client in implementing adaptive coping mecha-
nisms.
Reinforce and encourage the use of healthy coping Assists the nurse in mobilizing resources and reinforcing
responses. adaptive actions.
Refer the client to existing community resources such as Utilizes existing resources to promote adaptive coping.
support groups.
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Copyright © 2007 •by F. A. Davis.
•
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792 • Coping–Stress Tolerance Pattern
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for all contributing factors, including the child’s A holistic and complete assessment will provide the most
or parental subjective data, objective data, primary and thorough database for individualized care.
secondary references. If a child is taking antidepres- Antidepressants have been associated with an increased
sants, monitor for side effects. risk of suicide in youth.52,53
Identify any threats or expression of related high-risk fac- Verbalization of ideation must be taken seriously.
tors suggesting low self-esteem or lack of self-worth.
Identify history of any past suicidal ideation. Tendency for recurrence is often noted with one suicide
ideation providing risk index.
Identify ways to enhance communication for the child and Communication will provide cues to how the client is
family to best express feelings on an ongoing basis. feeling, with an avenue for dialogue.
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Suicide, Risk For • 793
ACTIONS/INTERVENTIONS R AT I O N A L E S
Explore value conflicts and meaning these have for the Freedom to explore thoughts about values will assist in
client and family. noting uniqueness of each individual, while attempting
to also respect the family’s views.53–55
Identify ways to assist the child and family to identify Knowledge is enhanced with recognition of patterns per
cues suggestive of suicidal risk. individual and family.53–55
Provide appropriate attention to role of medications if Knowledge about drugs will assist in safe, effective com-
these are ordered, with focus on desired effect, appro- pliance with regimen.52,55
priate dosing and timing, importance of parent’s secur-
ing supply in a safe place, expected side effects,
possible toxicity, and ways to reduce toxicity vs.
importance of maintenance of blood levels.
Ensure environmental safety as noted per adult plus fre- Client safety is paramount.
quent surveillance every 10 minutes, or constant, as
may be required.
Identify appropriate peer support group activities, and The sense of isolation is reduced with peers who may be
encourage group activities. able to relate to similar feelings.
Collaborate with other members of health team, such as Expertise will best provide for needs of the child and
child life specialist, child psychologist, or psychiatrist. family.
Utilize developmentally appropriate strategies to encour- Expression of feelings may be facilitated through means
age ongoing expression of feelings and/or ways to cope other than verbalization and must be considered para-
with suicidal tendency. mount in the child with suicidal risk.
Identify with the child and family a plan to deal with the Input from the child and family will best reflect and
risk for suicide. demonstrate the need for anticipatory planning in event
of possible recurrence.
Identify a plan for gradual resumption of daily activities, Prior planning lessens anxiety and affords time to resume
such as school and extracurricular activities, well activities per individual coping strategies.
before actual dismissal.
Identify a plan for follow-up in advance of dismissal. Appropriate follow-up planning lessens likelihood of cri-
sis or recurrence before situational or precipitating fac-
tors can be controlled.
Women’s Health
The nursing interventions for a woman with this diagnosis are the same as those actions in Adult Health and Mental
Health.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Introduce self and call the client by name. Conditions that encourage feelings of anonymity facilitate
aggressive behavior.34
Frame suicide as one option or solution to the problem. Promotes a problem-solving approach without prompting
a power struggle between the staff and the client
around this option.
Inform the client about the limits of confidentiality. Honesty promotes the development of a trusting relation-
Plans to harm himself or herself or someone else must ship.
be shared with the treatment team and necessary
authorities.
(care plan continued on page 794)
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794 • Coping–Stress Tolerance Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Protect the client from harm by: Provides an environment that promotes client safety.
• Asking the client what in the environment could pose
harm for them
• Removing sharp objects from environment
• Removing belts and strings from environment
• Providing a one-to-one constant interaction if risk for
self-harm is high
• Checking on the client’s whereabouts every 15 minutes
if not on one-to-one observation
• Removing glass objects from environment
• Removing locks from room and bathroom doors
• Providing a shower curtain that will not support weight
• Providing staff to supervise client areas at times when
clients would normally expect less supervision, such as
change of shift
• Checking to see whether the client swallows medication
Sit with the client [number] minutes [number] times each
day. (Note person responsible for this here.) Use this
time to:
• Have the client tell his or her perspective of the situa- Facilitates the development of a trusting environment for
tion, including feelings. open expression of concerns.32 Communicates to the
client that his or her welfare is important to the staff.56
• Commend the client’s strengths. Increases the client’s awareness of strengths, which pro-
motes a context of change and alternative problem
solutions, while providing hope.32,39
• Explore the client’s past attempts to cope with concerns. Facilitates understanding of the client’s perception of the
problem. Change is dependent on problem perception.32
If suicidal behavior is influenced by intoxication, consult Intoxication with drugs and alcohol can have a negative
with the primary care provider for detoxification pro- impact on the client’s ability to make decisions.56
cedure.
If suicidal behavior is influenced by command hallucina- Command hallucinations place clients at high risk for
tions, provide one-to-one observation until the client self-harm.56
no longer describes these thoughts. Refer to Disturbed
Thought Process (see Chapter 7) for detailed interven-
tions for hallucinations.
Contract with the client to talk with staff member when Promotes the client’s sense of control by assuring the
he or she feels or thinks the risk for suicide is high. client that if he or she needs help controlling his or her
behavior, the staff has a specific plan to help. Assures
the client of staff availability.56,57
When the client is capable of group interactions, assign Facilitates the client’s development of social skills and
him or her to a support group. [Note schedule for social contacts.58
group interactions here.]
Schedule regular times with primary nurse for the client
to [Note times and person responsible for these interac-
tions here.]:
• Explore the need to carry out this problem solution at Removing the immediacy of this solution set can provide
this time. the client with time to develop alternative solutions.
• Explore past solutions. Assists in facilitating understanding of the client’s per-
ception of the problem.
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Suicide, Risk For • 795
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Explore solution sets that enlist creative problem solv- Facilitates the client’s learning new problem-solving
ing. These might include what the client would tell a strategies. Promotes the client’s sense of control.
friend to do, three wishes, generating a long list of
solutions that are not assessed for their practicality in
the initial problem-solving stages.
• When solutions are generated, note the support the
client needs from staff to implement these solutions
here.
• Develop with the client a plan to initiate new problem-
solving strategies when problems arise after discharge.
Provide the client with a written copy of this plan.
Develop with the client a system to reward the use of new Positive reinforcement encourages behavior.
problem-solving strategies. Note the behavior that is to
be rewarded and the reward system here.
Attend recreational activities with the client. Choose Provides the client with alternative outlets for anger or
activities that have a high potential for client success. aggression, while promoting a sense of belonging and
[Note activities here and person responsible for attend- self-worth.59
ing with the client.]
Develop with the client a list of support groups in the Social isolation increases the risk for suicide.58,59
community that will be utilized after discharge. [Note
the support groups here with names of contact persons.]
Arrange meeting with the client’s support system to pro- Promotes connection with support system, and facilitates
vide information about alternative coping strategies problem solving.58
and develop positive communication patterns. [Note
times and frequency of these meetings here.]
Gerontic Health
l N O T E : In the United States, the highest suicide rate is seen in the older, white male
population. Older adults rarely threaten to commit suicide. Usually they successfully
take action rather than discuss the possibility. With the “graying” of America comes a
need for health-care professionals to increase their own, and public, awareness of this
problem. The Mental Health section for this diagnosis provides information on nursing
actions that can be used in conjunction with the following interventions.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Obtain information regarding risk factors associated with A combination of these risk factors is frequently present
suicide in the elderly, such as loss of spouse in the past in older adults who commit suicide.
year, history of depression, social isolation, physical
decline, loss of independence, and terminal diagnosis.60
Refer to social support services for assistance in meeting Introduces means of dealing with changing life circum-
changing care needs.61 stances.
Refer for hospice support if the older adult has been diag- Provides interdisciplinary resources and support for the
nosed with a terminal illness and meets hospice admis- older client.
sion criteria.61,62
Question older adults about possible suicidal thoughts or Encourages the client to discuss feelings of possible sui-
plans.63–65 cidal intent.
Refer the client for psychiatric assessment and treatment Places the client in contact with necessary resources for
if risk for suicide is determined to be present.62,65 treatment.
(care plan continued on page 796)
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796 • Coping–Stress Tolerance Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Consult with and/or refer the patient to assistive resources Utilization of existing services is an efficient use of
such as caregiver support groups as needed. resources.
Monitor the client and family closely for warning signs or Understanding helps promote a sense of control and
risks for suicide. order.
Consider all threats seriously.
When a threat is made, do not leave the client alone for Minimizes risk of a suicide attempt.
any period of time.
Ask direct questions about intent: Helps determine the seriousness and lethality of the sui-
cide plan.
• Have you thought about killing yourself? Indicates to the client that you take him or her seriously
• Have you thought about how and when you might do and are willing to help.
this?
• What can I or we do to help you through this time?
Assist the family or caregivers in removing the most lethal Although it is not possible to remove all potentially
means of suicide, such as weapons and medications. destructive items, removal of the most lethal items
reduces the likelihood of an attempt or successful effort.
Develop a written “no-suicide contract” with the client; Allows time for intervention should the client decide to
that is, the client agrees that he or she will not hurt or attempt suicide. Provides the client with a sense of
kill himself or herself during a specific time period; responsibility to another and a sense that he or she is
that if such thoughts occur he or she will contact the important to others.
nurse or other involved person; and if the contact per-
son is not immediately available, the client will con-
tinue trying to reach him or her.
•
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Copyright © 2007 by F. A. Davis. •
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Suicide, Risk For • 797
27. Sang, KK, and Mowbray, CT: What affects self-esteem of persons 46. Stuart, GW, and Laraia, MT: Principles and Practice of Psychiatric
with psychiatric disabilities: The role of causal attributions of mental Nursing, ed 7. CV Mosby, St. Louis, 2001.
illnesses. Psychiatr Rehab J 28:354, 2005. 47. Matteson, MA, and McConnell, ES: Gerontological Nursing:
28. Evans, C: Personal interview. Swedish Medical Center, Seattle, WA, Concepts and Practices, ed 2. WB Saunders, Philadelphia, 1997.
November, 1995. 48. Laborde, JM: Torture: A nursing concern. Image 21:31, 1989.
29. Evans, C: Postpartum home care in the U.S. JOGNN J Obstet 49. Wong, DL: Whaley and Wong’s Nursing Care of Infants and Children,
Gynecol Neonatal Nurs 24:181, 1995. ed 6. CV Mosby, St. Louis, 1999.
30. Keppler, AB: Personal interview. Evergreen Hospital, Kirkland, WA, 50. US Department of Defense: Clinical Practice Guideline for the
December, 1995. Management of Post-Traumatic Stress. (Rep No Version 1.0).
31. Keppler, AB: Postpartum care center: Follow-up care in a hospital- Washington, DC: Veterans Health Administration, Department of
based clinic. JOGNN J Obstet Gynecol Neonatal Nurs 24:17, 1995. Defense, 2004.
32. Wright, LM, and Leahey, M: Nurses and Families: A Guide to Family 51. Symes, L: Post traumatic stress disorder: An evolving concept. Arch
Assessment and Intervention, ed 4. FA Davis, Philadelphia, 2005. Psychiatr Nurs 9:195, 1995.
33. Wilson, H, Kneisl, C, and Trigoboff, E: Contemporary Psychiatric- 52. Maxmen, J, and Ward, N: Psychotropic Drugs Fast Facts, ed. 3. WW
Mental Health Nursing. Pearson Education, Upper Saddle River, Norton, New York, 2002.
NJ, 2004. 53. American Academy of Pediatrics: Preventing youth suicide. Available
34. Hockenberry, MJ: Wong’s Essentials of Pediatric Nursing, ed 7. CV at http://www.keepkidshealthy.com, 2006.
Mosby, St. Louis, 2005. 54. American Academy of Pediatrics: About teen suicide. Available at
35. Blankenship, V: Psychosocial development of women. In Breslin, ET, http://www.kidshealth.org, 2006.
and Lucas, VA (eds): Women’s Health Nursing: Toward Evidence- 55. Pharmaceutical Drugs: Risk of suicide from children prescriptions.
Based Practice. WB Saunders, St. Louis, 2003. Available at http://www.hpakids.org, 2006.
36. Upvall, MJ: Women and culture. In Breslin, ET, and Lucas, VA (eds): 56. Egan, M, et al: The “No Suicide Contract”: Helpful or harmful? J
Women’s Health Nursing: Toward Evidence-Based Practice. WB Psychosoc Nurs 35:31, 1997.
Saunders, St. Louis, 2003. 57. Stevenson, S: Heading off violence with verbal de-escalation. J
37. Bernhard, LA: Patriarchy, feminism, and women’s health. In Breslin, Psychosoc Nurs 29:6, 1991.
ET, and Lucas, VA (eds): Women’s Health Nursing: Toward Evidence- 58. Editors News: Eight factors critical in evaluating suicide risk. J
Based Practice. WB Saunders, St. Louis, 2003. Psychosoc Nurs 38:7, 2000.
38. King, J: Helping patients choose an appropriate method of birth con- 59. Townsend, M: Psychiatric-Mental Health Nursing: Concepts of Care,
trol. MCN Am J Matern Child Nurs 17:91, 1992. ed 5. FA Davis, Philadelphia, 2006.
39. Lightfoot-Klain, H, and Shaw, E: Special needs of ritually circum- 60. Lambert, MT, and Fowler, DR: Suicide risk factors among veterans:
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20:102, 1992. Veterans Affairs. J Ment Health Admin 24:350, 1997.
40. Miller, JF: Coping with Chronic Illness, ed 3. FA Davis, Philadelphia, 61. Morrow-Howell, N, et al: Evaluating an intervention for the elderly at
2000. increased risk of suicide. Res Social Work Pract 8:29, 1998.
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2004. 63. Wattis, J, and Burns, E: What an old age psychiatrist does. BMJ
42. Ossman, SS: Clinical consult. Motivational interviewing: A process to 313:101, 1996.
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43. McCloskey Dochterman, J, and Bulechek, G: Nursing Interventions 1999.
Classification, ed 4. CV Mosby, St. Louis, 2004. 65. Butler, RN, and Lewis, MI: Late-life depression: When and how to
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Mosby–Year Book, St. Louis, 1997. Evidence-Based Practice. WB Saunders, St. Louis, 2003.
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VALUE–BELIEF
12
PATTERN
1. RELIGIOSITY, IMPAIRED 804
2. RELIGIOSITY, READINESS FOR ENHANCED 808
3. RELIGIOSITY, RISK FOR, IMPAIRED 811
4. SPIRITUAL DISTRESS 812
5. SPIRITUAL DISTRESS, RISK FOR 818
6. SPIRITUAL WELL-BEING, READINESS FOR ENHANCED 824
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800 • Value–Belief Pattern
PATTERN DESCRIPTION 2. Does the patient verbalize conflict about personal spiri-
tual beliefs?
The nurse may care for patients who, because of health alter- a. Yes (Risk for Spiritual Distress)
ations, experience disturbances in their individual value- b. No (Readiness for Enhanced Spiritual Well-Being)
belief systems. A person’s value-belief system is the core of 3. Does the patient indicate positive thoughts about spiritu-
his or her existence, his or her interconnectedness with his or ality?
her spiritual side as well as his or her interconnectedness a. Yes (Readiness for Enhanced Spiritual Well-Being)
with the environment. This value-belief system gives mean- b. No (Risk for Spiritual Distress)
ing and purpose to life. Some call this faith “Faith carries us 4. Does the patient indicate comfort with self and his or
forward when there is no longer reason to carry on. It her purpose in life and life stage?
enables us to exist during the in-between times: between a. Yes (Readiness for Enhanced Spiritual Well-Being)
meanings, amid dangers or radical discontinuity, even in the b. No (Risk for Spiritual Distress)
face of death. Faith is a sine qua non of life, a primal force 5. Is the patient unable to participate in rites and/or reli-
we cannot do without” Faith can be in many things–a supe- gious activities and services because of illness or life
rior being, the environment, self, family, or community. The circumstance?
nurse may care for patients who, because of their faith or a. Yes (Impaired Religiosity)
value-belief system, cope and even increase their spiritual b. No (Risk for Impaired Religiosity)
well-being when faced with health alterations. Other 6. Does the practice of religious rites bring the patient and
patients the nurse cares for may experience disturbances in family comfort and stronger feelings of well-being and
their individual value-belief system or faith because of strength?
health alterations. These alterations may take a form ranging a. Yes (Readiness for Enhanced Religiosity)
from being disturbed to being demolished. These distur- b. No (Risk for impaired religiosity)
bances can be manifested by the inability to practice formal
religious directions, such as attending church or following a
specific diet, to being totally unable to manage their own CONCEPTUAL INFORMATION
spiritual needs and live within a certain spiritual structure. According to several authors, spirituality and religiousness
Conversely, religion can affect physical or emotional well- are two very different concepts that are often used inter-
being if the practice of the religion results in spiritual dis- changeably.1 The nurse may care for patients who, because
tress. An individual’s value-belief system can contribute to of health alterations, experience disturbances in their indi-
alterations in health, just as alterations in health can con- vidual value–belief systems, as well as interruptions in their
tribute to disturbances in the individual’s values and beliefs. involvement in their religious community.1,2 A person’s
On the other hand alterations in health can strengthen value–belief system is the core of his or her existence. This
a person’s faith, values and beliefs.These patients are expe- belief system facilitates a connection with the spiritual self
riencing “enhanced spirituality” and often search for the by providing interconnectedness with the environment. This
greater meaning in their health alteration experience. Many system gives meaning and purpose to life. Some call this
times the nurse may encounter the patient who will refuse faith, and some call this spirituality. “Faith carries us for-
treatment and/or seek alternative methods of dealing with ward when there is no longer reason to carry on. It enables
illness. The nurse must individualize care to help enhance us to exist during the in-between times: between meanings,
and support faith while minimizing spiritual distress when amid dangers of radical discontinuity, even in the face of
meeting the specific needs of the individual patient within death. Faith is a sine qua non of life, a primal force we can-
his or her value-belief system. not do without.”3 An individual can have faith in many
The value-belief pattern looks not only at how the things—a Superior Being, the environment, self, family, or
individual retains faith and enhances his or her value-belief community. The nurse may care for patients who, because of
system in times of stress but at how physical illness can their faith or value–belief system, cope and even increase
interfere with the individual’s ability to practice religion and their spiritual well-being when faced with health alterations.
maintain beliefs, values, and spiritual life, as well as how a Other patients may experience disturbances in their individ-
person’s judgment and interpretation of the meaning of life ual value–belief system or faith because of health alterations
(faith) for himself or herself can affect or interfere with to themselves, their family, or friends. These alterations may
health care practices. range from being disturbed to being demolished and can be
manifested by the inability to exercise formal religious prac-
tices such as attending church or following a specific diet
PATTERN ASSESSMENT
(religiosity), to being totally unable to manage their own
1. Does the patient express anger toward a supreme being spiritual needs and live within a certain spiritual structure
regarding his or her current condition? (spiritual distress). Conversely, religion can enhance physi-
a. Yes (Spiritual Distress) cal or emotional well-being if the practice of the religion
b. No (Readiness for Enhanced Spiritual Well- results in stronger feelings of well-being and strength (readi-
Being) ness for enhanced religiosity). An individual’s value–belief
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Conceptual Information • 801
system can contribute to alterations in health, just as alter- Studies have shown that the value of specific rituals
ations in health can contribute to disturbances in the indi- such as prayer to the individuals who practice them is not
vidual’s values and beliefs. Nursing must individualize care affected by the fact that they can or cannot be proved scien-
to help enhance and support faith, while minimizing spiri- tifically. Longitudinal studies have found a protective link
tual distress when meeting the specific needs of the individ- between religious participation and increased chances for
ual patient within his or her value–belief system. living longer.7–10 The impact of values and beliefs is best
The value–belief pattern looks not only at how the described by the following quote, “When as much emphasis
individual retains faith and enhances his or her value–belief is placed on the symbolic and intuitive as is placed on the
system in times of stress, but also at how physical illness can analytical, consciousness develops more fully.”11 The expan-
interfere with the individual’s ability to practice religion and sion of consciousness is what life, and therefore health, is all
maintain beliefs. It also looks at how, when faced with stress about; health can coexist with illness and even encompass it
and/or alterations in health, an individual or family can as a meaningful aspect. This can be seen in those individuals
either maintain or lose the ability to discern meaning and who consider suffering, illness, and even death as having
purpose (faith) in life. How this is accomplished by the indi- “meaning in life” or as “God’s will.”7,11
vidual and/or family can affect or interfere with health-care Many individuals believe that the only value of life,
practices. and the source of strength and power, is the will of the indi-
It is important for the practitioner to be able to distin- vidual and that there is no need for assistance from the out-
guish between spirituality and religiousness. Spirituality is side. This focus has been described as “a person’s authority
defined by many authors as the manner in which people find within himself.”12 This focus may actually revolve around
meaning and purpose in life. This can be accomplished work, physical activity, or self—“I can do anything I want to
through relationships with others, art, music, literature, when I want to.”11,12 Three predominant indicators have
nature, and the ability to connect to a higher power through been listed that must be considered when judging the value
prayer, meditation, or thought.1,4 of continued life: mental capacity, physical capacity, and
Religiousness is how individuals or groups express pain.9 This would indicate that, in and of itself, life is not
their spirituality, and is more closely linked to culture and intrinsically valuable to the possessor of it. Rather, it is the
social subgroups. Religion is expressed and/or practiced by quality of conscious life that is important.
individuals in many different ways, and usually consists of a In one phenomenological study13 of spirituality, the
set of beliefs, rites, and rituals.1 constituents of spirituality, as reported by the study subjects,
The faith, belief, or value system of a person can be were described and included (1) realization of humanity of
described as the predominating force (spirituality) that pro- self or valued other; (2) event of nonhuman intervention; (3)
vides the vital direction to that person’s existence. This pre- receiving divine intervention; (4) visceral knowing; (5) will-
dominating force can be a faith in a supreme being or God, ingness to sacrifice; (6) physical sensations; (7) a personal
a belief in one’s self, or a belief in others.5 It is conceptual- experience; (8) a reality experience; (9) not easily explained;
ized that each person must find his or her place in the world, and (10) different from or more than daily experience.
nature, and in relationships with other beings. This faith, In 1981, Fowler3 described his faith development the-
belief, or value system is expressed by the individual in the ory, which was influenced by the work of Piaget and
form of organized religion, attitudes, and actions related to Kohlberg. Fowler describes faith as not always religious in
the individual’s sense of what is right, cultural beliefs, and its content or context, but “a person’s or group’s way of
the individual’s internal motivations. moving into the force field of life. It is our way of finding
All persons have some philosophical orientation to life coherence in and giving meaning to the multiple forces and
that assists in constructing their reality, regardless of whether relations that make up our lives.”3 Fowler described the
or not they practice a formal religion. Spirituality is inter- experience of spirituality in different stages of the life cycle.
woven into a person’s cultural background, beliefs, and indi- He states that one transitions from one stage to another,
vidual value system. This spirituality is what gives life some fast and some slow, and that it is not a simple change
meaning and allows the person to function in a more total of mind or even a conscious movement from one phase to
manner. These beliefs and values influence a person’s behav- another. He also states that it can be a long and painful
ior and attitudes toward what is right and what is wrong with process. Six states of faith are recognized by Fowler:
the lifestyle he or she practices. Many authors1,6,7 stress that
the nurse must not only take into consideration the patient’s 1. Intuitive–Projective. This stage is characterized by
beliefs and value system, but also must recognize his or her experiencing the world as a child, fluid and full of nov-
own beliefs and values. The nurse must know about, or elty, with a rudimentary awareness of self as the center
develop resources to assist with understanding, the different of the universe. Preoperational reasoning and judgment
beliefs and religious practices of individuals and groups are employed by people in this stage. There is no reason-
encountered in practice settings. Further understanding and ing or logic to thought; therefore, the capacity for taking
assessment of a patient’s beliefs can be ascertained by asking the role or perspective of others is extremely limited.
questions such as “Do you have a faith community?” or 2. Mythic–Literal. People in this stage can separate real
“Which beliefs and practices are important to you?”7 from unreal on the basis of experience, and therefore the
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802 • Value–Belief Pattern
world becomes more linear and orderly than in stage cannot be overemphasized in planning and providing high-
one. This is accompanied by a private world of specula- quality care for the patient.
tion, fantasy, and wonder. Bounds of the social world
widen, and the questioning of “good and evil” is begun. DEVELOPMENTAL CONSIDERATIONS
Often these thoughts, which can be reassuring, hopeful,
or full of terror and fear, are symbolized in dreams and The geographic, social, political, and home environment in
daydreams.3,14 which one lives has a major effect on how a person devel-
3. Synthetic–Conventional. One begins to structure the ops, how he or she will view health, and how spirituality,
world and the environment in interpersonal terms. The values, and beliefs are formulated. The values a person
individual constructs an image of self as seen by others holds influence all facets of life. How one perceives the
and becomes aware that others are performing the same world about him or her, as well as his or her basic philoso-
operations in their relationships. This is a conformist phy, guides all interactions with others and ultimately
stage, in which peers and their values become most reflects a person’s individuality.17
important. Influences from earlier stages are carried Fowler, in describing his developmental stages of
“within” as reference points by which beliefs and values faith, states he has found adults in all stages, regardless of
are valued, and actions are valued, validated, and sanc- their chronological age. Adolescents have been found in
tioned. stages two and three. However, persons are usually found in
4. Individuative–Reflexive. The individual begins to con- the various stages as shown in the parentheses at the end of
struct and maintain his or her own identity, autonomy, each developmental stage in the text that follows.3
and faith, without relying on others. The sense of self is
now reciprocal with a faith outlook or worldview that INFANT
negotiates between self and significant others. One The infant is totally dependent on the parents and those
knows he or she is different from others, and his or her about him or her and is busy building trust or mistrust.18
views and faith are vulnerable to challenge and change. Unable at this age to form values or distinguish spirituality,
5. Paradoxical–Consolidative. Many previous dimensions the infant is a mirror image of those about him or her. The
that were formally suppressed or ignored are integrated. parent’s method of interaction, communication, and fulfill-
One becomes open to the voices of one’s innermost self. ment of the emotional and physiologic needs of the infant
There is a coming to terms with one’s social uncon- forms the basis for value development. (Fowler’s Stage One)
sciousness: the myths, norms, ideal images, and preju-
dices that have, until now, formed one’s life. One can TODDLER AND PRESCHOOLER
see injustice because of an expanded awareness of the
demands of justice, and the implications of those The toddler imitates those about him or her, such as parents,
demands. siblings, and other adults. The toddler develops by mimick-
6. Universalizing. The individual at this stage becomes a ing observed behavior and receiving either positive or nega-
disciplined activist. He or she exhibits qualities that tive reinforcement. Values begin to form as the toddler starts
shake the usual criteria of normalcy. He or she leads and to become aware of others and to interact with those around
embraces strategies of nonviolent suffering and of ulti- him or her. Values become known to individuals through the
mate respect for life. “They often become martyrs to the process of social cognition, which begins in early childhood.
visions they incarnate.”7,16 This arises neither from objects, nor the subject, but from
the interaction between the subject and those objects.16
Other studies1,6,13,16 provide insights regarding the (Fowler’s Stage One)
interactive process of caring as it relates to spiritual needs.
Trust, meaningful support systems, and a respect for personal SCHOOL-AGE CHILD
beliefs were identified by participants as central to care. The school-age child begins to be influenced by peers out-
Because of the conscious, subconscious, and uncon- side the family structure, and also begins to question and
scious components of the value–belief system, nurses must make choices. The school-age child actively participates in
be continually alert for disruptions in the system. There is a his or her own moral development. Individual reasoning
need to be aware that every individual expresses disruptions develops through various stages, beginning in the school-
in spirituality differently.7,16 Some withdraw, some become age years.18,19 Play is the major mechanism of learning
more religious, and some become angry and defiant. Nurses throughout the school-age years. (Fowler’s Stage Two)
need to be cognizant of not only the patient’s spiritual
beliefs but also the stage of spiritual development in which
ADOLESCENT
both the patient and nurse are.1,6,13,16 This will affect and
determine not only the needs and concerns of the patients The adolescent searches for his or her own identity and
but how the nurse will approach the patient to care for those begins to practice values that are separate, and yet congruent
needs and concerns. This awareness of and respect for the with, his or her family unit. The adolescent is constantly
impact and influence values and beliefs have on the patient questioning, trying, and searching for the “truth of life”. This
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Developmental Considerations • 803
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804 • Value–Belief Pattern
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Copyright © 2007 by F. A. Davis. •
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Religiosity, Impaired • 805
Child Health
This pattern is primarily related to Adult Health, Women’s Health, and Mental Health aspects according to developmen-
tal stage and capacity, in addition to those noted for the school-aged child or older.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for all factors contributing to the alteration, espe- Provides a realistic base for plan.
cially those verbalized by the child. Be alert to poten-
tial circumstantial school related activities or perceived
barriers
Identify the effect the problem is having in the child’s Provides likelihood of fullest exploration of problem
world and how to intervene with assistance of family, within child’s realm.
child life specialist, religious clergy, or other identified
support persons. Involve the child and encourage their
engagement in the plan.
Assist the child, family, and relevant paraprofessionals in Allows for child’s regaining a sense of the right to
developing a plan that will satisfy the altered religios- express religiosity in appropriate manner and setting.
ity issue. Especially note ways to feel freedom of self-
expression of desired worship, while also remaining in
compliance with societal constraints.
*Issues may require legal or school-related input if con-
flicts are of these domains.
Provide a plan for follow-up to re-explore progress in Offers anticipatory guidance.
near future.
Refer to community resources with similar valued reli- Empowers and provides shared experiences for child
giosity, as faith-based centers. and family.
(care plan continued on page 806)
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806 • Value–Belief Pattern
Women’s Health
Women’s health will be the same as for Adult Health or Mental Health with the following additions:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Discuss a situation that is producing anxiety and strate- Research conducted at Arizona State University pin-
gize activities to reduce stress and increase religiosity. pointed specific traits associated with religion and
spirituality that positively affect health. One aspect
of religion and spirituality was linked to a specific
physiological response, and people who communicated
with a “higher-power” (prayer) throughout the day
were less reactive when exposed to an anxiety-
causing situation.20
Allow women to discuss fears related to role loss, declin- Older women cope and thrive in a variety of creative,
ing health, poor economic status, and widowhood. productive ways many of which involve participating
in their religion.21
Discuss the connection between spirituality, religion, and Religious practices and values are one way older women
productive activities. become involved.21
Facilitate bible reading, mediating, praying, and partici- Research shows these activities increase with age and
pation in religious activities. [Note client’s preferred engagement in these activities related to strong per-
practice here with support needed from nursing staff.] sonal spirituality.21
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Spend [number] minutes per [day/shift] with the client Communicates concern and acceptance. Clients report
and/or significant others identifying needs for religious wanting increased support for religious beliefs by
practice, and the influence it has on the client’s well- health-care providers. Religious practice that is predi-
being. cated on restrictive and punitive dogma may impede
the experience and healing potential of spirituality.22
Develop, with the client and/or significant others, plan for Familiar practices enhance emotional sense of well being
meeting needs of religious practice in a manner that and religious practice can facilitate healing and whole-
facilitates emotional well-being. [Note the client’s plan ness in times of stress.22
here with assistance needed from nursing staff for
implementation.]
Arrange religious accommodations that enhance client’s
sense of emotional well-being, for example, special
foods, schedule treatments around times for prayer,
meetings with religious leaders or members of their
faith community, recognition of special days of reli-
gious observance, religious texts, and religious healing
practices.
Demonstrate respect for client’s religious practices by:
• Providing special space to keep religious objects
• Maintaining safety of these objects (e.g., checking
gowns for medals before sending them to laundry).
Educate staff about religious practices and the support Enhances staff cultural competence and increases their
needed from staff to facilitate client’s plan. [Note plan ability to facilitate plan of care.
for this here.]
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Religiosity, Impaired • 807
ACTIONS/INTERVENTIONS R AT I O N A L E S
Collaborate with other health-care providers that have an The client’s well-being is enhanced when health-care
understanding of mental health issues and religious providers recognize the complex relationship between
practice (chaplain, parish nurse, dietary, etc.) to meet mental health issues and religious beliefs “Perceptions
the client’s needs. of mental illness as divine will or punishment may
cause increased distress when there is fear of displeas-
ing a punitive God or a sense of being unheard or
abandoned by a God of comfort.”22
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Engage in active listening with the client by: This assists the nurse in collecting data about client status
• Presence (creating a relationship with sincere commu- and establishing a trusting relationship with the client.
nication) Caring touch can improve a client’s self-esteem, sense
• Using therapeutic/caring touch as tolerated by client of well being, and faith.23
• Facilitating the client’s search for meaning
• Facilitating reminiscence
Assess which needs can be met in the client’s current cir- Assists the nurse in determining the client’s priorities and
cumstance, and which needs are most important to the preferences.
client. Assist the client in meeting those needs (pastoral
consult, visitors from church) as health status allows.
Encourage the client to seek forgiveness or to forgive Through forgiveness, older adults can discover new
others. meaning and continue the development of the spiritual
self.23
Offer to pray, meditate, or read spiritual text with the Supports the client’s existing spirituality.23
client, or arrange for another member of the health-
care team to do so while respecting the client’s time
for quietness and prayer.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Engage in active listening with the client by: This assists the nurse in collecting data about client status
• Presence (creating a relationship with sincere commu- and establishing a trusting relationship with the client.
nication) Caring touch can improve a client’s self-esteem, sense
• Using therapeutic/caring touch as tolerated by client of well-being, and faith.23
• Facilitating the client’s search for meaning
Assess which needs can be met in the client’s current cir- Assists the nurse in determining the client’s priorities and
cumstance, and which needs are most important to the preferences.
client. Assist the client in meeting those needs (pastoral
consult, visitors from church) as health status allows.
Encourage the client to seek forgiveness or forgive others. Through forgiveness, older adults can discover new
meaning and continue the development of the
spiritual self.23
Offer to pray, meditate, or read spiritual text with the Supports the client’s existing spirituality.23
client, or arrange for another member of the health-
care team to do so while respecting the client’s time
for quietness and prayer.
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808 • Value–Belief Pattern
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Copyright © 2007 by F. A. Davis. •
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Religiosity, Readiness for Enhanced • 809
Child Health
This pattern incorporates the applicable components of the adult and women’s components in a developmentally appro-
priate manner in addition to the following:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Monitor for cues to confirm readiness to engage in Offers a base for considering plan.
enhanced spirituality from child and/or parents:
• The child or family may verbalize willingness and
acceptance of current status.
Honor the practice of the desired plan within daily Continually practicing the plan models for the caregivers,
routine. so that they begin to value the plan.
• Allow for music, reading, or play as appropriate with
spiritual focus.
• Allow quiet time without undue interruptions.
• Respect privacy during times of spiritual expression or
participate according to the nurse’s and family’s mutual
comfort.
Determine the need for visitation or referral to clergy per- Provides anticipatory guidance.
sons or other support persons.
Assist the child and/or family in developing plan for con-
tinued practice of plan.24
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
When requested, describe for the client such therapies as: Support the client in exploring alternative practices if he
• Alternative medical systems or she desires. Many practices of self-care and alterna-
• Mind–body interventions tive health care reflect an inner focus, for instance,
• Biologically based therapies physical, mental, and spiritual, that sustains and sup-
• Manipulative and body-based methods ports when needed to enhance beliefs and values.25
• Energy therapies To some individuals, religiosity and spirituality has to do
with a “mystical feeling” or “a flowing dynamic qual-
ity of unity” rather than a formal religious practice.25
Discuss the situation that is producing anxiety and strate- Research conducted at Arizona State University pin-
gize activities to reduce stress and increase religiosity. pointed specific traits associated with religion and spir-
ituality that positively affect health. One aspect
identified was a specific physiological response, and
people who communicated with a “higher-power”
(prayer) throughout the day were less reactive when
exposed to an anxiety-causing situation.20
Allow women to discuss fears related to role loss, declin- Older women cope and thrive in a variety of creative,
ing health, poor economic status, and widowhood. productive ways many of which involve participating
in their religion.21
Discuss the connection between spirituality, religion, and Religious practices and values are one way older women
productive activities. become involved.21
Facilitate bible reading, mediating, praying and participa- Research shows these activities increase with age, and
tion in religious activities. [Note the client’s preferred engagement in these activities is related to strong per-
practice here with support needed from nursing staff.] sonal spirituality.21
(care plan continued on page 810)
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810 • Value–Belief Pattern
Mental Health
Refer to Mental Health nursing actions for Impaired Religiosity.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Engage in active listening with the client by: This assists the nurse in collecting data about client status
• Presence (creating a relationship with sincere commu- and establishing a trusting relationship with the client.
nication) Caring touch can improve a client’s self-esteem, sense
• Using therapeutic/caring touch as tolerated by client of well-being, and faith.23
• Facilitating the client’s search for meaning
• Facilitating reminiscence
Assess which needs can be met in the client’s current cir- Assists the nurse in determining the client’s priorities and
cumstance, and which needs are most important to the preferences.
client. Assist the client in meeting those needs (pastoral
consult, visitors from faith community) as health status
allows.
Encourage the client to seek forgiveness or forgive others. Through forgiveness, older adults can discover new mean-
ing and continue the development of the spiritual self.23
Offer to pray, meditate, or read spiritual text with the Supports the client’s existing spirituality.23
client, or arrange for another member of the health-
care team to do so while respecting the client’s time
for quietness and prayer.
•
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Copyright © 2007 by F. A. Davis. •
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Religiosity, Risk for Impaired • 811
RELATED FACTORS4 The patient and/or family will be able to express needs
concerning religious practices by [date].
A. Physical The patient and/or family will be able to accept an
1. Illness/hospitalization alternative plan for certain religious practices by [date].
2. Pain
B. Psychological TARGET DATES
1. Ineffective support/coping/caregiving
2. Depression A target date of 1 to 2 days is appropriate. The sooner the
3. Lack of security risk is addressed the sooner the patient and or family can
C. Sociocultural move on to enhanced religiosity.
1. Lack of social interaction
2. Cultural barrier to practicing religion 4 Have You Selected the Correct Diagnosis?
3. Social isolation
Impaired Religiosity
D. Spiritual Impaired Religiosity would be the correct diagnosis
Suffering if the patient and family has no interest in or is angry,
E. Environmental and refuses to discuss or practice any religious rites.
1. Lack of transportation
2. Environmental barriers to practicing religion Risk for Impaired Religiosity
F. Developmental Risk for Impaired Religiosity would be correct when a
patient or family comes into “harms way” and wishes
Life transitions
to still practice their religious rites. However, they can-
RELATED CLINICAL CONCERNS not achieve this without assistance or finding alterna-
tive methods for practicing, because of the mental,
1. Victims of disasters physical, or social situation they find themselves in.
2. Pain
Child Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Ensure quiet and time for worship as child or family
desire to degree possible.
Maintain the child’s room in a manner that permits pres-
ence of religious articles available in periphery vision
of the child.
(care plan continued on page 812)
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812 • Value–Belief Pattern
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Arrange for religious practices if requested and desired
(e.g., baptism or other rituals).
Contact a religious or cultural leader as requested by the
mother or family.
Provide support for the woman facing an unwanted Let the client express his or her anger; sometimes he or
pregnancy: she will refuse to practice religious rites or talk about
“faith issues.”26–29
Encourage questions and verbalization of the patient’s Provides information about choices and consequences
life expectations by providing at least 15 minutes of of each choice, which can assist with decision making.
one-to-one time at least twice a day at [times]. Gives long-term support by providing referrals.
Provide information on options available to the patient Not making judgments, but providing factual information
(e.g., adoption, abortion, or keeping the baby). can provide support for the client and help him or her
retain his or her faith and progress to enhanced reli-
giosity and enhanced spiritual well-being.28,30
Assist the patient in identifying lifestyle adjustments that
each decision could entail (e.g., dealing with guilt or
finances).
Involve significant others and include the patient’s reli-
gious or cultural leader, if so desired by the patient, in
discussion and problem-solving activities regarding
lifestyle adjustments.
Mental Health
Refer to Mental Health nursing actions for Impaired Religiosity.
Gerontic Health
Refer to Gerontic Health nursing actions for Impaired Religiosity.
•
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Copyright © 2007 by F. A. Davis. •
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Spiritual Distress • 813
•
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Copyright © 2007 •by F. A. Davis.
•
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814 • Value–Belief Pattern
Child Health
In addition to the following, this pattern is basically related to the Adult Health or Women’s Health pattern as noted, with
appropriate allowance for developmental capacity.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for situational related factors including: actual Offers a base for planning that allows support of the child
onset of life-limiting situation, barriers to usual spiri- or the parents (caregivers) of the child as needed.
tual enjoyment, or inability to express how the problem
is perceived.
Seek input from appropriate paraprofessionals including Provides a developmental approach to satisfy child’s
child life specialist, psychiatric nurse, clergy person, need.
ethicist and counselor, as well as the primary care nurse.
Provide input with child, family, and team for best ways Assists the family unit to value and learn how to make
to incorporate the plan into child’s daily routine in the plan a part of the child’s daily routine.
light of current health status.
Respect and honor the child’s wishes within realm of Offers respect for choice of expressed spirituality, with
what is possible. cues for availability of articles and environment suited
Establish ways to acknowledge the ways the plan can to enhanced potential for spirituality.
assist in acceptance of current situation.
Provide clear and honest communication to answer Promotes a trusting relationship.
child’s questions, while also honoring family’s values.
*It is ideal to have the same primary care nurses involved
in times of need for close communication and times of
distress.
12Newfield (F)-12 3/31/07 6:44 PM Page 815
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Copyright © 2007 by F. A. Davis. •
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Spiritual Distress • 815
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Allow the mother and family to express feelings about Allows the family to express their feelings and the health-
the less-than-perfect pregnancy outcomes.26,27 care provider to support and facilitate patient and fam-
ily coping with unexpected outcomes of pregnancy.
Guilt, loneliness, lack of emotions and an inability to
take interest in life, family and former values or beliefs
can be signs of spiritual distress and Postpartum
Depression.27
Stillborn or infant death:
• Provide time for the mother and family to see, hold,
and take pictures of the infant if so desired.
• Provide quiet, private place where the mother and fam- Contact religious or cultural leader as requested by the
ily can be with the infant. mother or family.
• Refer to appropriate support groups within the Positive spiritual perspectives has been shown to be
community. related to satisfaction with social support from others
• Do legacy building, for example, cap, bracelets, certifi- during pregnancy.28
cate of life (acknowledgement of baby), and
footprints.26
Less-than-perfect baby, for example, sick baby or infant
with anomaly26,27:
• Provide a quiet, private place for the mother and family
to visit with the infant.
• Encourage verbalization of fears and asking of any
question by providing time for one-to-one interactions
at least twice a day at [times].
• Encourage touching and holding of the infant by the
mother and family.
• Teach methods of caring for the infant (e.g., special
feeding techniques).
• Teach methods of coping with the stress connected
with caring for the infant (e.g., planned alone time for
relaxation techniques).
• Assign one staff member to care for both the mother Provides consistency and encourages the mother and
and infant. family to build trust with provider of care.
• Provide the patient with information and referrals to Provides support and information and assists with coping.
appropriate support groups and community agencies.
If requested, contact religious or cultural leader.
Assist the patient facing gynecologic surgery to express Provides support and give preoperative information,
her perceptions of lifestyle adjustments: which assists with postoperative recovery. Although
• Provide an explanation of the surgical procedure and sexuality is not changed due to hysterectomy or mas-
perioperative nursing care. tectomy, some women have problems that cannot be
• Provide factual information as to physiologic and psy- accounted for physically. Depression, fear of rejection,
chological reactions she may experience. and changed body image may occur and can result in
• Allow the patient to grieve the loss of body image (e.g., loss of sexual drive and spiritual distress.30
inability to have a child).
• Involve significant others in discussion and problem-
solving activities regarding life cycle changes that
could affect self-concept and interpersonal relation-
ships (e.g., hot flashes, sexual relationships, or ability
to have children).
(care plan continued on page 816)
12Newfield (F)-12 3/31/07 6:44 PM Page 816
•
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Copyright © 2007 •by F. A. Davis.
•
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816 • Value–Belief Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Remove items from the environment that increase prob- The environment will assist the client in demonstrating
lem behavior (list specific items for each client, e.g., appropriate coping behaviors, which increases opportu-
Bible or religious pictures). nities for succeeding with new coping behaviors.
Success provides reinforcement, which encourages
positive behavior and enhances self-esteem. Faith and
involvement in spiritual activities when practices are
not dogmatic and involvement is seen as a source of
solace and support.22
Restrict visitors who increase problem behavior for the Promotes the client’s sense of control.
client. Discuss with the family and other frequent visi-
tors the necessity of not discussing the problem ideas
with the client.
Request consultation from leader of client’s faith commu- Meets the client’s spiritual needs in a constructive man-
nity who has had education and experience in assisting ner. Spiritual messages that indicate mental illness is a
clients to cope with this type of spiritual distress. punishment or that one is being abandoned by a source
of spiritual power can increase spiritual distress.22
Do not discuss with the client belief systems that are These discussions only serve to reinforce the client’s mis-
related to problem behavior. (Specifically state what conceptions and decrease their spiritual well-being.
that content is here.)
Do not argue with the client about spiritual belief system This would reinforce the dysfunctional belief system that
or behaviors that evolve from this system. promotes the client’s distress.
Do not joke with the client about belief system or behav- Protects the client’s self-esteem at a time when it is most
ior that evolves from this system. vulnerable.
Spend time with the client when themes of conversation Presence of the nurse, at this time, provides reinforce-
are not related to the problem behavior. ment for this behavior, which encourages the positive
behavior and enhances self-esteem.
Limit topics of conversation to daily activities or situa- Environmental structure helps turn the client focus away
tions that do not include problematic spiritual beliefs. from problem areas, which supports his or her efforts
to enlist more appropriate coping behaviors.
Provide activities that decrease client time alone to reflect Provides the client with opportunities to practice alterna-
on the problem beliefs. Suggested activities include: tive coping behaviors in a supportive environment.
• Physical exercise such as walks, bicycle riding, swim-
ming, or exercise classes.
• Group activities such as board games, meal prepara-
tion, sports, or arts and crafts.
Facilitate positive spiritual connections by: Spirituality can support emotional healing when it is
expressed in the discovery of the true self, through car-
ing relationships, giving thanks, and embracing grace.
Higher levels of spirituality have been associated with
lower anxiety and lower risk of suicide.22
• Spending [number] minutes per [shift/day] discussing Being with the client can being the process of spiritual
client’s previously used strengths for solace and hope. connection and can mediate interventions at the spiri-
Elicit the client’s perceptions of what is needed, do not tual level. It is important for nurse to remain self-aware
suggest activities, beliefs. and neutral to diminish coercion and countertransfer-
ence. These interactions must be guided by the client’s
values and understandings, and not used as an opportu-
nity to share the nurse’s belief system. Seek supervi-
sion if having difficulty determining appropriate
boundaries for the therapeutic relationship.22
12Newfield (F)-12 3/31/07 6:44 PM Page 817
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Copyright © 2007 by F. A. Davis. •
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Spiritual Distress • 817
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Facilitating the client’s connections with faith commu- Can facilitate client’s movement from existential loneli-
nities he or she has found supportive in the past. ness when the connection is client focused. When spir-
itual experiences are viewed as a source of solace and
strength they can have a positive effect on mental
health.22
• Facilitating the client’s involvement in supportive rituals Positive spiritual involvement can contribute to emotional
that bring solace and hope. well-being.22
• Facilitating client-initiated and -led expressions of spiri- Before expression of spirituality is initiated, assess mean-
tuality by sitting with them during this process. This ing this has to client to validate that this will be a
could include prayer, meditation, guided imagery, and source of solace and hope. Client-initiated and led
other activities that connect persons to inner sources of prayer diminishes the risk of inadvertent provider coer-
solace and hope. cion.22 Use meditation and guided imagery cautiously
with clients who are experiencing sensory-perceptual
alternations, especially when this has negative content.
It may be difficult for the client to control the negative
content during these activities.
• Referring to health-care providers, or a member of the Provides ongoing support for client upon discharge.22
client’s spiritual network who specialize in spirituality
and have an understanding of mental health and spiritu-
ality, for in-depth spiritual counseling and community
support.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Establish a therapeutic relationship with the client A therapeutic relationship must be established for the
through active listening, nonjudgmental behaviors, and client to continue to share concerns.
offering as much time as is needed.
Discuss with the client the factors or events that are con- Assessment of the client’s concerns and priorities is the
tributing to spiritual distress and can be addressed first step toward resolution.
(anxiety, loneliness, pain, life changes).
Involve the client in addressing the factors contributing to Personal involvement in the process increases the likeli-
the distress than can be addressed. hood of successful resolution.
Tend to the client’s basic needs, particularly pain. Addresses one of the risk factors for the problem.
Offer social activities as appropriate for the client’s health Addresses one of the risk factors for the problem.
status.
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Copyright © 2007 •by F. A. Davis.
•
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818 • Value–Belief Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Support groups
• Visits from spiritual leaders
• scheduled time for the client to be outside
• Scheduled times for visitors
Consult with, or refer to, assistive services as indicated. Effective use of existing community resources.
SPIRITUAL DISTRESS, RISK FOR 4. Accident or injury that could potentially lead to change
in body image
DEFINITION4 5. Potential for less than perfect outcome for pregnancy
At risk for an impaired ability to experience and integrate 6. Divorce, loss of spouse or other life changing event(s)
meaning and purpose in life through a person’s connected-
ness with self, other persons, art, music, literature, nature, EXPECTED OUTCOMES
and/or a power greater than oneself Will describe at least [number] support systems to use when
spiritual conflict arises by [date].
DEFINING CHARACTERISTICS4 TARGET DATES
None given. Because of the largely subconscious nature of spiritual
beliefs and values, it is recommended the target date be at
RELATED RISK FACTORS4 least 5 days from the date of diagnosis.
A. Physical
1. Physical illness 4 Have You Selected the Correct Diagnosis?
2. Substance abuse/excessive drinking Ineffective Individual Coping
3. Chronic illness Many individuals use religion or beliefs as a means of
B. Psychosocial bargaining in unwanted life situations or denying their
1. Low self-esteem role in the situation by blaming it on a superior being.
2. Depression Others will find their source of strength and hope from
their beliefs in a superior being or God and are able to
3. Anxiety
live fully functional lives despite physical handicaps. If
4. Stress
the patient mentions any of the defining characteris-
5. Poor relationships tics of this diagnosis, then the primary diagnosis is
6. Separate from support systems Spiritual Distress, which must be attended to before
7. Blocks to experiencing love trying to intervene for Ineffective Individual Coping.
8. Inability to forgive
Impaired Religiosity
9. Loss
If patients and families are unable because of the situ-
10. Racial/cultural conflict
ation, disease, and/or treatment to practice religious
11. Change in religious rituals rites, such as participate in communion or follow a
12. Change in spiritual practices special diet (Kosher), and they seek help or verbalize
C. Developmental frustration with the situation. If they do not view this
1. Life change situation as a crisis or concern about finding meaning
2. Developmental life changes or purpose in life then risk for impaired religiosity is
D. Environmental the correct diagnosis.
1. Environmental changes Spiritual Distress
2. Natural disasters When a person or family learn about a terminal diag-
nosis or a permanent life change, question their faith
RELATED CLINICAL CONCERNS and beliefs and lose their purpose in life. The health
1. Potential diagnosis of terminal illness such as cancer care provider often hears questions such as , “What
2. Potential diagnosis of chronic illnesses did I do wrong?” or “Why me?” If the patient and/or
family refuse to be consoled or change their attitude,
3. Accident or injury that could potentially lead to change
then spiritual distress is the correct diagnosis.
in physical or mental status
12Newfield (F)-12 3/31/07 6:44 PM Page 819
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Copyright © 2007 by F. A. Davis. •
•
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Spiritual Distress, Risk For • 819
Child Health
In addition to the following, this pattern is basically related to the Adult Health or Women’s Health pattern as noted with
appropriate allowance for developmental capacity.
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for situational related factors including: actual Offers a base for planning.
onset of life limiting situation, barriers to usual spiri-
tual enjoyment, or inability to express how the problem
is perceived.
Seek input from appropriate paraprofessionals including Provides developmental approach to satisfy child’s need.
child life specialist, psychiatric nurse, clergy person,
counselor, and primary care nurse; if possible, ethicist
also advisable.
Provide input with the child, family, and health-care team Values how to make the plan a part of the child’s daily
for best ways to incorporate the plan into the child’s routine.
daily routine in light of current health status.
Respect and honor the child’s wishes within realm of Offers respect for choice of expressed spirituality with
what is possible. cues for availability of articles and environment suited
• Ensure quiet and time for worship as child or family to enhanced potential for spirituality.24
desire to the degree possible.
• Establish ways to acknowledge the ways the plan can
assist in acceptance of the current situation.
(care plan continued on page 820)
12Newfield (F)-12 3/31/07 6:44 PM Page 820
•
•
Copyright © 2007 •by F. A. Davis.
•
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820 • Value–Belief Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Maintain the child’s room in a manner that permits
presence of religious articles available in periphery of
the child.
Provide clear and honest communication to answer the Promotes a trusting relationship.24
child’s questions while also honoring family’s values.
*It is ideal to have the same primary care nurses
involved in times of need for close communication
and times of distress.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Allow the mother and family to express feelings at the Allows the family to receive religious and social support
less-than-perfect pregnancy outcome26,29: as a means of coping.
• Stillborn or infant death:
• Provide time for the mother and family to see, hold,
and take pictures of the infant if so desired.
• Provide quiet, private place where the mother and
family can be with the infant.
• Arrange for religious practices requested (e.g., bap-
tism or other rituals).
• Contact religious or cultural leader as requested by
the mother or family.
• Refer to appropriate support groups within the com-
munity.
• Do legacy building (e.g., cap, bracelets, certificate of
life, and footprints).26
• Spontaneous abortion:
• Provide the patient with factual information regarding Assists in reducing guilt, blame, etc.
the etiology of spontaneous abortion.
• Encourage verbal expressions of grief.
• Allow expression of feelings such as anger.
• Do legacy building (e.g., cap, bracelets, certificate of
life, and footprints).26
• Provide information on miscarriage and grief.
• Contact a religious or cultural leader as requested by
the patient.
• Provide referrals to appropriate support groups within Provides information and support for the family.
the community.
• Less-than-perfect baby (e.g., sick baby or infant with
anomaly)29:
• Provide a quiet, private place for the mother and fam-
ily to visit with the infant.
• Encourage verbalization of fears and asking of any
question by providing time for one-to-one interactions
at least twice a day at [times].
• Encourage touching and holding of the infant by the
mother and family.
• Teach methods of caring for the infant (e.g., special
feeding techniques).
12Newfield (F)-12 3/31/07 6:44 PM Page 821
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Copyright © 2007 by F. A. Davis. •
•
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Spiritual Distress, Risk For • 821
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Teach methods of coping with the stress connected
with caring for the infant (e.g., planned alone time for
relaxation techniques).
• Assign one staff member to care for both the mother
and infant.
• Contact religious or cultural leader as requested by Encourage religious rites if requested and appropriate.
the mother or family. For example, pin religious medal on baby’s clothing.
• Provide the patient with information and referrals to Provides support and information, and assists with
appropriate support groups and community agencies. coping.
Provide support for the woman facing an unwanted
pregnancy:
• Encourage questions and verbalization of the patient’s Provides information about choices and consequences of
life expectations by providing at least 15 minutes of each choice, which can assist with decision making.
one-to-one time at least twice a day at [times]. Gives long-term support by providing referrals.
• Provide information on options available to the patient
(e.g., adoption, abortion, or keeping the baby).
• Assist the patient in identifying lifestyle adjustments
that each decision could entail (e.g., dealing with guilt
or finances).
• Involve significant others and include the patient’s reli-
gious or cultural leader, if so desired by the patient, in
discussion and problem-solving activities regarding
lifestyle adjustments.
Assist the patient facing gynecologic surgery to express Provides support and gives preoperative information,
her perceptions of lifestyle adjustments: which assist with postoperative recovery.
• Provide explanation of surgical procedure and perioper-
ative nursing care.
• Provide factual information as to physiologic and psy-
chological reactions she may experience.
• Allow the patient to grieve loss of body image (e.g.,
inability to have a child).
• Involve significant others in discussion and problem-
solving activities regarding life cycle changes that
could affect self-concept and interpersonal relation-
ships (e.g., hot flashes, sexual relationships, or ability
to have children).
Participate with the patient in religious support activities Demonstrates visible support for the role these activities
(e.g., praying or reading religious literature aloud). play in the patient’s life.
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Remove items from the environment that increase prob- Environment will assist the client in demonstrating appro-
lem behavior (list specific items for each client, e.g., priate coping behaviors, which increases opportunities
Bible or religious pictures). for succeeding with new coping behaviors. Success
provides reinforcement, which encourages positive
behavior and enhances self-esteem.
Restrict visitors who increase problem behavior for the Promotes the client’s sense of control.
client. Discuss with the family and other frequent visi-
tors the necessity of not discussing the problem ideas
with the client.
(care plan continued on page 822)
12Newfield (F)-12 3/31/07 6:44 PM Page 822
•
•
Copyright © 2007 •by F. A. Davis.
•
•
822 • Value–Belief Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Request consultation from religious leader who has had
education and experience in assisting clients to cope
with this type of spiritual distress.
Do not discuss with the client belief systems that are Meets the client’s spiritual needs in a constructive
related to problem behavior. [Specifically state what manner.
that content is here.]
Do not argue with the client about religious belief system These discussions only serve to reinforce the client’s mis-
or behaviors that evolve from this system. conceptions.
Do not joke with the client about belief system or behav-
ior that evolves from this system. This would reinforce the dysfunctional belief system.
Spend time with the client when themes of conversation
are not related to the problem behavior. Protects the client’s self-esteem at a time when it is most
vulnerable.
Limit topics of conversation to daily activities or situa- Presence of the nurse, at this time, provides reinforce-
tions that do not include religious beliefs. ment for this behavior, which encourages the positive
behavior and enhances self-esteem.
Provide activities that decrease client time alone to reflect Environmental structure helps the client focus away from
on the problem beliefs. Suggested activities include: problem areas, which supports his or her efforts to
• Physical exercise such as walks, bicycle riding, swim- enlist more appropriate coping behaviors.
ming, or exercise classes Provides the client with opportunities to practice alterna-
• Group activities such as board games, meal prepara- tive coping behaviors in a supportive environment.
tion, sports, or arts and crafts
Facilitate positive spiritual connections by: Spirituality can support emotional healing when it is
expressed in the discovery of the true self, through car-
ing relationships, giving thanks, and embracing grace.
Higher levels of spirituality have been associated with
lower anxiety and lower risk of suicide.22
• Spending [number] minutes per [shift/day] discussing Being with the client can being the process of spiritual
client’s previously used strengths for solace and hope. connection and can mediate interventions at the spiri-
Elicit the client’s perceptions of what is needed; do not tual level. It is important for nurse to remain self-
suggest activities, beliefs. Note support from nursing aware and neutral to diminish coercion and counter-
needed to facilitate the client’s meeting spiritual needs. transference. These interactions must be guided by
client’s values and understandings and not used as an
opportunity to share the nurse’s belief system. Seek
supervision if having difficulty determining appropriate
boundaries for the therapeutic relationship.22
• Facilitate the client’s connections with faith communi- Can facilitate client’s movement from existential loneli-
ties he or she has found supportive in the past. ness when the connection is client focused. When spir-
itual experiences are viewed as a source of solace and
strength they can have a positive effect on mental
health.22
• Facilitate the client’s involvement in supportive rituals Positive spiritual involvement can contribute to emotional
that bring solace and hope well-being.22
12Newfield (F)-12 3/31/07 6:44 PM Page 823
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•
Copyright © 2007 by F. A. Davis. •
•
•
Spiritual Distress, Risk For • 823
ACTIONS/INTERVENTIONS R AT I O N A L E S
• Facilitate client-initiated and -led expressions of spiri- Before expression of spirituality is initiated assess
tuality by sitting with them during this process. This meaning this has to client to validate that this will
could include prayer, meditation, guided imagery, lis- be a source of solace and hope. Client initiated and led
tening to music and other activities that connect per- prayer diminishes the risk of inadvertent provider coer-
sons to inner sources of solace and hope. cion.39 Use meditation and guided imagery cautiously
with clients who are experiencing sensory-perceptual
alternations, especially when this has negative content.
It may be difficult for the client to control the negative
content during these activities.
• Refer to health-care providers or a member of the Provides ongoing support for the client upon discharge.22
client’s spiritual network who specialize in spirituality
and have an understanding of mental health and spiritu-
ality for in-depth spiritual counseling and community
support.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Engage in active listening with the client by: This assists the nurse in collecting data about client status
• Presence (creating a relationship with sincere commu- and establishing a trusting relationship with the client.
nication) Caring touch can improve a client’s self-esteem, sense
• Use of therapeutic/caring touch as tolerated by client of well-being, and faith.23
• Facilitating the client’s search for meaning
• Facilitating reminiscence
Assess which needs can be met in the client’s current cir- Assists the nurse in determining the client’s priorities
cumstance, and which needs are most important to the and preferences.
client. Assist the client in meeting those needs (pastoral
consult, visitors from church) as health status allows.
Encourage the client to seek forgiveness or to forgive Through forgiveness, older adults can discover new
others. meaning and continue the development of the spiritual
self.23
Offer to pray, meditate, or read spiritual text with the Supports the client’s existing spirituality.23
client or arrange for another member of the health-care
team to do so while respecting the client’s time for
quietness and prayer.
•
•
Copyright © 2007 •by F. A. Davis.
•
•
824 • Value–Belief Pattern
Mental Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Encourage the client to seek forgiveness or to forgive Through forgiveness, older adults can discover new
others. meaning and continue the development of the spiritual
self.23
Offer to pray, meditate, or read spiritual text with the Supports the client’s existing spirituality.23
client or arrange for another member of the health care
team to do so while respecting the client’s time for
quietness and prayer.
•
•
Copyright © 2007 by F. A. Davis. •
•
•
Spiritual Well-Being, Readiness for Enhanced • 825
Readiness for Enhanced Religiosity times have great meaning to the individual and their
Is the correct diagnosis in the case of the patient who ultimate connectiveness to the meaning and purpose
because of mental or physical illness cannot partici- of life. If the patient or family express any of the char-
pate in religious rites or practices; but does not acteristics of spirituality as central to their beliefs and
express spiritual concern or crisis and only wants faith and that they use religiosity to achieve peace,
assistance to be able to participate in religious rituals. harmony, and a sense of balance in life, then the diag-
Often the practice of or the ability to participate in reli- nosis is enhanced spiritual well-being.
gious rituals must be dealt with first as they some-
•
•
Copyright © 2007 •by F. A. Davis.
•
•
826 • Value–Belief Pattern
Adult Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Support family and friends’ expression of love and sup- Shows respect and support of the patient’s beliefs and
port for the patient values.33
Advocate for the patient’s spiritual beliefs with the health Significant symbols can be a source of consolation and
team. spiritual support.36
Consider the patient’s spiritual beliefs and values. When A patient’s spiritual needs are complex and individual.33
developing plan of care with the health-care team.29
Allow and support the patient’s to keeping significant Awareness of the nurse’s own feelings is helpful in guid-
symbols nearby. ing and/or controlling his or her actions.33
Inform the patient and family where chapel or prayer
room is located.
Determine own values and spirituality.
Child Health
This pattern would incorporate the applicable components of the adult and women’s components in a developmentally
appropriate manner in addition to the following:
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess for cues to confirm readiness to engage in Offers a base for considering a plan.
enhanced spirituality from child and/or parents:
• Child or family may verbalize willingness and accept-
ance of status.
• Honor the practice of desired plan within daily routine. Values the plan.
• Allow for music, reading, or play as appropriate with
spiritual focus.
• Allow quiet time without undue interruptions.
• Respect privacy during times of spiritual expression or
participate according to nurse’s and family’s mutual
comfort.
Determine need for visitation or referral to clergypersons Provides anticipatory guidance.24
or other support persons.
Help the child and/or family to determine how to con-
tinue to practice the plan.
Women’s Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Allow the woman and her family to direct the spiritual By allowing the patient to express her own beliefs and
care needed when possible. values, strengths, and relationships, great insight into
how health-care providers can provide high-quality
care to the whole person can emerge. This can form the
basis of care or support to patients.
Be available and willing to call whatever spiritual advisor
the woman and family wish.
Provide quiet, noninterruptive space for discussion,
prayer, or communication with spiritual advisor.
Allow the patient and family to participate in rituals as
requested when possible.
12Newfield (F)-12 3/31/07 6:44 PM Page 827
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•
Copyright © 2007 by F. A. Davis. •
•
•
Spiritual Well-Being, Readiness for Enhanced • 827
ACTIONS/INTERVENTIONS R AT I O N A L E S
Be open to spiritual awareness in both the patient’s life
and in the nurse’s own life. This could be accomplished
through being a participant in a dream-telling group.6,8,14
Assess how the patient views her “sense of fit” in her
world.7,9,37
Assess the patient’s sources of strength and relationships Life satisfaction in older women is related to their
that are important to her.7,8,38 engagement in social activities.21,32
Encourage the woman to give voice to her story.7,8,38
Encourage time for self-reflection and making connections.
Older women cope and thrive in a variety of creative and
productive ways. Research shows older women’s lives
are enhanced by volunteer activities and do-it-yourself
tasks.21,32
Mental Health
Refer to Mental Health interventions for Spiritual Distress, Risk for.
Gerontic Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Engage in active listening with the client by: This assists the nurse in collecting data about client status
• Presence (creating a relationship with sincere commu- and establishing a trusting relationship with the client.
nication) Caring touch can improve a client’s self-esteem, sense
• Use of therapeutic/caring touch as tolerated by client of well-being, and faith.23,39
• Facilitating the client’s search for meaning
• Facilitating reminiscence
Assess which needs can be met in the client’s current cir- Assists the nurse in determining the client’s priorities and
cumstance, and which needs are most important to the preferences.
client. Assist the client in meeting those needs (pastoral
consult, visitors from church) as health status allows.
Encourage the client to seek forgiveness or to forgive Through forgiveness, older adults can discover new
others. meaning and continue the development of the spiritual
self.23,40
Offer to pray, meditate, or read spiritual text with the Supports the client’s existing spirituality.23
client or arrange for another member of the health-care
team to do so while respecting the client’s time for
quietness and prayer.
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Engage in active listening with the client by: This assists the nurse in collecting data about client status
• Presence (creating a relationship with sincere commu- and establishing a trusting relationship with the client.
nication) Caring touch can improve a client’s self-esteem, sense
• Use of therapeutic/caring touch as tolerated by client of well-being, and faith.23,39
• Facilitating the client’s search for meaning
• Facilitating reminiscence
(care plan continued on page 828)
12Newfield (F)-12 3/31/07 6:44 PM Page 828
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828 • Value–Belief Pattern
Home Health
ACTIONS/INTERVENTIONS R AT I O N A L E S
Assess which needs can be met in the client’s current cir- Assists the nurse in determining the client’s priorities and
cumstance, and which needs are most important to the preferences.
client. Assist the client in meeting those needs (pastoral
consult, visitors from church) as health status allows.
Encourage the client to seek forgiveness or to forgive Through forgiveness, older adults can discover new mean-
others. ing and continue the development of the spiritual self.26
Offer to pray, meditate, or read spiritual text with the Supports the client’s existing spirituality23,39
client or arrange for another member of the health-care
team to do so while respecting the client’s time for
quietness and prayer.
NANDA’S AXES
A
DEFINITIONS*
AXIS 1 tain obligations toward others; related by blood and/or
choice
The diagnostic concept is the root of the diagnostic state- Group: A number of people with shared characteristics
ment. This statement may contain one or more nouns, each Community: A group of people living in the same locale
contributing a unique meaning (e.g., Infant Feeding Pattern). under the same governance. Examples include neigh-
This list contains the foundation for each diagnosis and is borhoods and cities.
not repeated here. Refer to NANDA Nursing Diagnosis: When the subject of the diagnosis is not stated, the default
Definitions and Classification, 2005–2006 for a complete subject is individual.
list.
AXIS 4: AGE
AXIS 2: TIME
This axis refers to the length of time the individual has been
Acute: Lasting less than 6 months living.
Chronic: Lasting more than 6 months
Intermittent: Stopping or starting again at intervals, peri- Fetus Adolescent
odic, cyclic Neonate Young adult
Continuous: Uninterrupted, going on without stop Infant Middle-age adult
Toddler Young old adult
Pre-school child Middle old adult
AXIS 3: SUBJECT OF DIAGNOSIS School-age child Old-old adult
This axis refers to the person for whom the diagnosis is
determined. AXIS 5: HEALTH STATUS
Individual: A single human being distinct from others, a This axis refers to the position or rank on the health contin-
person uum of wellness to illness (or death).
Family: Two or more people having continuous or
sustained relationships, perceiving reciprocal obli- Wellness: The quality or state of being healthy, especially
gations, sensing common meaning, and sharing cer- as a result of deliberate effort
Risk: Vulnerability, especially as a result of exposure to
*
From North American Nursing Diagnosis Association: NANDA Nursing factors that increase the chance of injury or loss
Diagnosis: Definitions and Classification, 2005–2006. NANDA, Actual: Existing in fact or reality, existing at the present
Philadelphia, 2005, pp 233–239, with permission. time
13Newfield (F)-App A 3/31/07 6:42 PM Page 830
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830 • Appendix A
ADMISSION
B
ASSESSMENT FORM
AND SAMPLE
ADMISSION ASSESSMENT FORM
DEMOGRAPHIC DATA
Date: _____________________________________________Time: __________________________________________
Name: ___________________________________________________________________________________________
Date of Birth: _________________________________Age:__________________________Sex:___________________
Primary Significant Other: __________________________________________Telephone #_______________________
Name of Primary Information
Source: __________________________________________________________________________________________
Admitting Medical Diagnosis: ________________________________________________________________________
VITAL SIGNS
Temperature: _______ F ______C _______ ; Oral _________ Rectal _________ Axillary ________ Tympanic _______
Pulse Rate: Radial ______________ Apical ______________ ; Regular _______________ Irregular _______________
Respiratory Rate: _____________________ Abdominal __________________ Diaphragmatic ____________________
Blood Pressure: Left arm _______ ; Right arm _________ ; Sitting _______Standing _________ Lying down ________
Weight: __________ pounds, _________ kilograms; Height: __________ feet __________ inches, ___________ meters
Do you have any allergies? No ___________ Yes ____________ What? _______________________________________
(Check reactions to medications, foods, cosmetics, insect bites, etc.)
Review admission CBC, urinalyses, and chest x-ray. Note any abnormalities here: ______________________________
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Copyright © 2007•by F. A. Davis.
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832 • Appendix B
5. Street drug use? No __________________ Yes __________________ What and how much?____________________
6. Any history of chronic diseases? No ______________Yes _______________ Describe. _______________________
______________________________________________________________________________________________
7. Immunization History: Tetanus __________; Pneumonia ___________; Influenza _____________; MMR ________;
Polio ________________________; Hepatitis B __________________________ ; Hib _______________________
8. Have you sought any health care assistance in the past year? No __________________ Yes ____________________
If yes, why? ___________________________________________________________________________________
9. Are you currently working? Yes ______________ No _____________How would you rate your working conditions
(e.g., safety, noise, space, heating, cooling, water, ventilation)?
Excellent ______________________ Good _______________ Fair __________________Poor _________________
Describe any problem areas _______________________________________________________________________
______________________________________________________________________________________________
10. How would you rate living conditions at home? Excellent ________ Good _______ Fair _________ Poor ________
Describe any problem areas _______________________________________________________________________
11. Do you have any difficulty securing any of the following services?
Grocery store? Yes ____________ No _______________ ; Pharmacy? Yes _______________ No _______________;
Health care facility? Yes _____________ No ____________ ; Transportation? Yes ____________ No ____________;
Telephone (for police, fire, ambulance, etc.)? Yes ___________________________ No ________________________
If any difficulties, note referral here _________________________________________________________________
12. Medications (over-the-counter and prescriptive)
NAME/DOSAGE AMT. TIMES/DAY REASON TAKING AS ORDERED
____________________________________________________________________________Yes ______No ______
____________________________________________________________________________Yes ______No ______
____________________________________________________________________________Yes ______No ______
____________________________________________________________________________Yes ______No ______
____________________________________________________________________________Yes ______No ______
____________________________________________________________________________Yes ______No ______
____________________________________________________________________________Yes ______No ______
____________________________________________________________________________Yes ______No ______
13. Have you followed the routine prescribed for you? Yes _____________________ No _________________________
Why not? ______________________________________________________________________________________
14. Did you think this prescribed routine was the best for you? Yes ____________________ No ___________________
What would be better? ___________________________________________________________________________
15. Have you had any accidents/injuries/falls in the past year? No _____________________ Yes ___________________
Describe. ______________________________________________________________________________________
16. Have you had any problems with cuts healing? No _________________________ Yes ________________________
Describe. ______________________________________________________________________________________
17. Do you exercise on a regular basis? No _____________ Yes ______________Type and Frequency ______________
______________________________________________________________________________________________
18. Have you experienced any ringing in the ears? Right ear: Yes ____________________ No _____________________
Left ear: Yes ___________________________________________ No _____________________________________
19. Have you experienced any vertigo? Yes __________ No _____________ How often and when? _________________
______________________________________________________________________________________________
20. Do you regularly use seat belts? Yes ______________________________ No _______________________________
21. For infants and children, are car seats used regularly? Yes _______________________ No _____________________
22. Do you have any suggestions or assistance requests for improving your health?
No _______Yes _________________________________________________________________________________
23. Do you do (breast/testicular) self-examination? No ____________________________ Yes _____________________
How often? ____________________________________________________________________________________
24. Were you or your family able to meet all your therapeutic needs? Yes __________________ No ________________
25. Are you scheduled for surgery? Yes _______________________________ No ______________________________
26. Have you recently had surgery? No ________________ Yes _________________ Date _______________________
Objective
1. Mental Status (Indicate assessment with an X)
a. Oriented __________________ Disoriented ____________________ Length of time _______________________
Time: Yes ____________________ No ______________________ Length of time _________________________
14Newfield (F)-App B 3/31/07 6:42 PM Page 833
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Admission Assessment Form • 833
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Copyright © 2007 •by F. A. Davis.
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834 • Appendix B
NUTRITIONAL–METABOLIC PATTERN
Subjective
1. Any weight gain in last 6 months? No _________ Yes ___________ Amount _______________________________
2. Any weight loss in last 6 months? No _________ Yes __________ Amount _________________________________
3. Would you describe your appetite as: Good ____________ Fair ______________ Poor ______________________
4. Do you have any food intolerances? No _________ Yes _________ Describe. _______________________________
_____________________________________________________________________________________________
5. Do you have any dietary restrictions? (Check for those that are a part of a prescribed regimen as well as those that
patient restricts voluntarily; for example, to prevent flatus.)
No ________ Yes ________ What __________________________________________________________________
6. Describe an average day’s food intake for you (meals and snacks).
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
7. Describe an average day’s fluid intake for you.________________________________________________________
______________________________________________________________________________________________
8. Describe food likes and dislikes. ___________________________________________________________________
______________________________________________________________________________________________
9. Would you like to: Gain weight? ________________ Lose weight? _______________ Neither _________________
10. Any problems with:
a. Nausea? No ________ Yes ________ Describe. ____________________________________________________
b. Vomiting? No ________ Yes _______ Describe. ____________________________________________________
c. Swallowing? No ______ Yes ________ Describe. ___________________________________________________
d. Chewing? No ________ Yes __________ Describe. _________________________________________________
e. Indigestion? No ___ Yes ___ Describe. _____________________________________________
11. Would you describe your usual lifestyle as: Active ________________________ Sedate ______________________
12. Do you have any chronic health problems? No ________ Yes _________ Describe. ___________________________
______________________________________________________________________________________________
For breastfeeding mothers only:
13. Do you have any concerns about breastfeeding? No ________________________ Yes ________________________
Describe. ______________________________________________________________________________________
14. Are you having any problems with breastfeeding? No ________________________ Yes _______________________
Describe._______________________________________________________________________________________
Objective
1. Skin Examination
a. Warm ________________ Cool _________________ Moist _____________________ Dry ___________________
b. Lesions? No ___________ Yes ________ Describe. ______________________________________
c. Rash? No ___________ Yes ________________ Describe. __________________________________
d. Turgor: Firm _____________ Supple ____________ Dehydrated _________________ Fragile ________________
e. Color: Pale _______ Pink _______ Dusky _______ Cyanotic ________ Jaundiced _________ Mottled _________
Other___________________________________________________________________________________________
2. Mucous Membranes
a. Mouth
14Newfield (F)-App B 3/31/07 6:42 PM Page 835
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Admission Assessment Form • 835
ELIMINATION PATTERN
Subjective
1. What is your usual frequency of bowel movements?
a. Have to strain to have bowel movement? No ________________________ Yes ___________________________
b. Same time each day? No ______________________________ Yes _____________________________________
2. Has the number of bowel movements changed in the past week? No ___________________ Yes ________________
Increased __________________ Decreased __________________________________________________________
3. Character of stool:
a. Consistency: Hard ____________________ Soft _____________________ Liquid ________________________
b. Color: Brown ______________ Black ______________ Yellow ____________ Clay colored_________________
c. Bleeding with bowel movements? No ____________________________ Yes _____________________________
4. History of constipation? No _____________ Yes ____________ How often?________________________________
Use bowel movement aids (laxatives, suppositories, diet)? No ________ Yes _________ Describe. ______________
______________________________________________________________________________________________
5. History of diarrhea? No ____________ Yes _____________ When________________________________________
6. History of incontinence? No ____________________________________ Yes _______________________________
Related to increased abdominal pressure (coughing, laughing, sneezing)? No _____________ Yes_______________
7. History of recent travel? No ________________ Yes ______________ Where?______________________________
8. Usual voiding pattern:
a. Frequency (times/day) ___________________ Decreased _______________ Increased ____________________
b. Change in awareness of need to void? No __________ Yes ________ Increased ________ Decreased _________
c. Change in urge to void? No _________ Yes ________ Increased _______________ Decreased ______________
d. Any change in amount? No __________ Yes __________ Decreased ______________ Increased ____________
e. Color: Yellow _____________________ Smoky _________________________ Dark ______________________
f. Incontinence? No _________Yes ___________ When________________________________________________
Difficulty holding voiding when urge to void develops? No _______________________ Yes _________________
14Newfield (F)-App B 3/31/07 6:42 PM Page 836
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Copyright © 2007 •by F. A. Davis.
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836 • Appendix B
ACTIVITY–EXERCISE PATTERN
Subjective
1. Using the following Functional Level Classification, have the patient rate each area of self-care.*
0 Completely independent
1 Requires use of equipment or device
2 Requires help from another person for assistance, supervision, or teaching
3 Requires help from another person and equipment or device
4 Dependent, does not participate in activity
Feeding _________________; Bathing/hygiene ___________________; Dressing/grooming ___________________;
Toileting _______________; Ambulation ____________; Care of home _____________; Shopping _____________;
Meal preparation _________________; Laundry ___________________; Transportation ______________________
2. Oxygen use at home? No ____________ Yes _______ Describe. __________________________________________
3. How many pillows do you use to sleep on? ___________________________________________________________
4. Do you frequently experience fatigue? No _____ Yes _______ Describe. ___________________________________
______________________________________________________________________________________________
5. How many stairs can you climb without experiencing any difficulty (can be individual number or number of flights)?
______________________________________________________________________________________________
6. How far can you walk without experiencing any difficulty? ______________________________________________
7. Any history of falls? No ___________ Yes ___________ How often?______________________________________
8. Has assistance at home for care of self and maintenance of home? No ________________ Yes _________________
Who__________________________________________________________________________________________
If no, would like to have or believes needs to have assistance? No _____________________ Yes ________________
With what activities?_____________________________________________________________________________
9. Occupation (if retired, former occupation)____________________________________________________________
10. Describe your usual leisure time activities/hobbies. ____________________________________________________
______________________________________________________________________________________________
11. Any complaints of weakness or lack of energy? No ________________________ Yes _________________________
Describe. ______________________________________________________________________________________
12. Any difficulties in maintaining activities of daily living? No _______________________ Yes ___________________
Describe. ______________________________________________________________________________________
*(Codeadapted by NANDA from Jones, E, et al: Patient Classification for Long-Term Care: Users’ Manual, HEW Publication No. HRA-74-3107.
November, 1974.)
14Newfield (F)-App B 3/31/07 6:42 PM Page 837
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Admission Assessment Form • 837
Objective
1. Cardiovascular
a. Cyanosis? No _____________ Yes _____________ Where? ___________________________________________
b. Pulses: Easily palpable?
Carotid: Yes ________ No _______; Jugular: Yes ________ No ________; Temporal: Yes _______ No ________;
Radial: Yes _________ No _______; Femoral: Yes ________ No _______; Popliteal: Yes _______ No _________;
Post-tibial: Yes _____________ No ______________; Dorsalis pedis: Yes _______________ No _____________
c. Extremities
(1) Temperature: Cold _____________ Cool ________________ Warm _______________ Hot ______________
(2) Capillary Refill: Normal _______________________________ Delayed ______________________________
(3) Color: Pink _____________ Pale _______________ Cyanotic __________________ Other _______________
Describe._____________________________________________________________________________________
(4) Homans’ sign? No _______________________________ Yes _______________________________________
(5) Nails: Normal _____________ Abnormal _____________ Describe. _________________________________
____________________________________________________________________________________________
(6) Hair Distribution: Normal _________ Abnormal __________ Describe._______________________________
____________________________________________________________________________________________
(7) Claudication? No _________ Yes __________ Describe. ___________________________________________
d. Heart: PMI Location
(1) Abnormal rhythm? No _______ Yes ______ Describe. _____________________________________________
____________________________________________________________________________________________
(2) Abnormal sounds? No _________ Yes _________ Describe.________________________________________
____________________________________________________________________________________________
2. Respiratory
a. Rate ________ ; Depth: Shallow ________ Deep ______ Abdominal ________ Diaphragmatic _______________
b. Have the patient cough. Any sputum? No __________ Yes __________ Describe. __________________________
____________________________________________________________________________________________
c. Fremitus? No _______________________________________ Yes ______________________________________
d. Any chest excursion? No ___________ Yes ____________ Equal _____________ Unequal __________________
e. Auscultate chest.
Any abnormal sounds (rales, rhonchi)? No _____________ Yes ________________ Describe.________________
____________________________________________________________________________________________
f. Have the patient walk in place for 3 minutes (if permissible):
(1) Any shortness of breath after activity? No __________________________ Yes _________________________
(2) Any dyspnea? No ______________________________________ Yes ________________________________
(3) BP after activity _____________________________________________________________ in (right/left) arm
(4) Respiratory rate after activity _________________________________________________________________
(5) Pulse rate after activity ______________________________________________________________________
3. Musculoskeletal
a. Range of motion: Normal ______ Limited ______ Describe. ___________________________________________
b. Gait: Normal _______ Abnormal _________ Describe. _______________________________________________
c. Balance: Normal ________ Abnormal ________ Describe. ____________________________________________
d. Muscle Mass/Strength: Normal _______________ Increased ________________ Decreased _________________
Describe. _______________________________________________________________
e. Hand Grasp: Right: Normal _________________________________ Decreased _______________________
Left: Normal _________________________________ Decreased ________________________
f. Toe Wiggle: Right: Normal ________________________ Decreased ________________________________
Left: Normal ____________________________ Decreased _____________________________
g. Posture: Normal ______________ Kyphosis ____________ Lordosis ___________________________________
14Newfield (F)-App B 3/31/07 6:42 PM Page 838
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Copyright © 2007 •by F. A. Davis.
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838 • Appendix B
COGNITIVE–PERCEPTUAL PATTERN
Subjective
1. Pain
a. Location (have the patient point to area) ____________________________________________
b. Intensity (have the patient rank on scale of 0–10) _________________________________________
c. Radiation? No _________ Yes ________ To where? _____________________________________
d. Timing (how often; related to any specific events) ______________________________________
______________________________________________________________________
e. Duration ________________________________________________________________
f. What do you do to relieve pain at home? ____________________________________________
g. When did pain begin? ________________________________________________________
2. Decision Making
a. Find decision making: Easy _______ Moderately easy _______ Moderately difficult ________ Difficult________
b. Inclined to make decisions: Rapidly ________________ Slowly _________________ Delay _________________
c. Difficulty choosing between options? Yes _________ No _________ Describe. ____________________________
________________________________________________________________________
3. Knowledge Level
a. Can define what current problem is? Yes ________________________ No ________________________
b. Can restate current therapeutic regimen? Yes __________________________ No __________________________
Objective
1. Review sensory and mental status completed in Health Perception–Health Management Pattern.
14Newfield (F)-App B 3/31/07 6:42 PM Page 839
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Copyright © 2007 by F. A. Davis. •
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Admission Assessment Form • 839
Objective
1. During assessment, the patient appears: Calm _____ Anxious _____ Irritable _____ Withdrawn _____ Restless ____
2. Did any physiologic parameters change: Face reddened? No _____________________ Yes ____________________
Voice volume changed? No ______________ Yes _____________ Louder ______________ Softer ______________
Voice quality changed? No___________ Yes_____________ Quavering _______________ Hesitation ___________
Other__________________________________________________________________________________________
3. Body language observed__________________________________________________________________________
4. Is current admission going to result in a body structure or function change for the patient?
No _______________________ Yes ________________________ Unsure at this time ________________________
5. Is the patient expressing any fears about dying? No ________________________ Yes ________________________
6. Is the patient expressing worries about the impact of his or her death on his or her family and/or friends?
No ___________________________ Yes ___________________________ N/A _____________________________
ROLE-RELATIONSHIP PATTERN
Subjective
1. Does the patient live alone? Yes ____________________ No _________________With whom__________________
2. Is the patient married? Yes ______ No ______ ; Children? No ______ Yes ______ ; # of children _______________
Age(s) of children _______________________________________________________________________________
Were any of the children premature? No _____________ Yes ______________ Describe. ______________________
3. How would you rate your parenting skills: Not applicable _______________________________________________
No difficulty with __________ Average ___________ Some difficulty with ___________ Describe. _____________
4. Any losses (physical, psychological, social) in past year? No ________ Yes ________ Describe. ________________
5. How is the patient handling this loss at this time? ______________________________________________________
6. Do you believe this admission will result in any type of loss? No _______ Yes ________ Describe. ______________
7. Has the patient recently received a diagnosis related to a chronic physical or mental illness? No _______ Yes ______
8. Is the patient verbally expressing sadness? No _________________________ Yes ____________________________
9. Ask both the patient and family: Do you think this admission will cause any significant changes in (the patient’s)
usual family role? No _____________________ Yes __________________ Describe._________________________
10. How would you rate your usual social activities? Very active ______ Active ______ Limited ______ None ________
11. How would you rate your comfort in social situations? Comfortable ______________ Uncomfortable ____________
12. What activities/jobs, etc., do you like to do? __________________________________________________________
13. What activities/jobs, etc., do you dislike doing? ________________________________________________________
14. Does the person use alcohol or drugs? No _____________ Yes _____________ Kind__________________________
Amount _______________________________________________________________________________________
15. Is the patient in the role of primary caregiver for another person? No ___________ Yes _______________________
14Newfield (F)-App B 3/31/07 6:42 PM Page 840
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840 • Appendix B
Objective
1. Speech Pattern
a. Is English the patient’s native language? Yes _________________________ No ____________________________
Native language is _______________________ ; Interpreter needed? No _______________ Yes _______________
b. During interview have you noted any speech problems? No __________ Yes __________ Describe. _________
2. Family Interaction
a. During interview have you observed any dysfunctional family interactions? No _____ Yes ______ Describe. _____
b. If the patient is a child, is there any physical or emotional evidence of physical or psychosocial abuse?
No ___________________ Yes _________________________ Describe. _________________________________
c. If the patient is a child, is there evidence of attachment behaviors between the parents and child?
Yes _______________________ No _______________________ Describe.________________________________
d. Any signs or symptoms of alcoholism? No ________________ Yes ____________ Describe. _____________
SEXUALITY–REPRODUCTIVE PATTERN
Subjective
Female
1. Date of LMP _________________ ; Any pregnancies? Para __________________ Gravida ____________________
Menopause? No ______________________ Yes ________________________ Year __________________________
2. Use birth control measures? No __________ N/A ____________ Yes ________________ Type _________________
3. Any history of vaginal discharge, bleeding, lesions? No ___________ Yes ___________ Description _____________
4. Pap smear annually? Yes ____________ No ________________ Date of last Pap smear _______________________
5. Date of last mammogram ___________________
6. History of STD (sexually transmitted disease)? No ___________ Yes __________ Describe. ___________________
If admission secondary to rape:
7. Is the patient describing numerous physical symptoms? No ____________ Yes __________ Describe. ___________
8. Is the patient exhibiting numerous emotional reactions? No _________ Yes __________ Describe. ______________
9. What has been your primary coping mechanism to handle this rape episode? ________________________________
10. Have you talked to persons from the rape crisis center? Yes ____________________ No ______________________
If no, does the patient want you to contact them for her? No ___________________ Yes ______________________
If yes, was this contact of assistance? No _______________________________ Yes __________________________
Male
1. Any history of prostate problems? No ________________ Yes ________________ Describe. ____________________
2. Any history of penile discharge, bleeding, lesions? No _____________ Yes ___________ Describe. ______________
3. Date of last prostate exam __________________________________________________________________________
4. History of STD (sexually transmitted disease)? No ______________ Yes ____________ Describe. _______________
Both
1. Are you experiencing any problems in sexual functioning? No __________ Yes _________ Describe. _____________
2. Are you satisfied with your sexual relationship? Yes ___________ No _________ Describe. ____________________
3. Do you believe this admission will have any impact on sexual functioning? No ______ Yes ______ Describe. ______
Objective
Review admission physical exam for results of pelvic and rectal exams. If results not documented, nurse should perform
exams. Check history to see whether admission resulted from a rape.
COPING–STRESS TOLERANCE PATTERN
Subjective
1. Have you experienced any stressful or traumatic events in the past year in addition to this admission?
No _________________________ Yes ______________________ Describe. _________________________________
2. How would you rate your usual handling of stress? Good ___________ Average _____________ Poor ____________
3. What is the primary way you deal with stress or problems? _______________________________________________
4. Have you or your family used any support or counseling groups in the past year?
No _________________ Yes ___________________ Group Name_________________________________________
Was support group helpful? Yes _______________ No ______________ Additional comments: __________________
5. What do you believe is the primary reason behind the need for this admission? _______________________________
6. How soon, after first noting symptoms, did you seek health care assistance? __________________________________
14Newfield (F)-App B 3/31/07 6:42 PM Page 841
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Admission Assessment Form • 841
7. Are you satisfied with the care you have been receiving at home? Yes ________ No _______ Comments: __________
8. Ask primary caregiver: What is your understanding of the care that will be needed when the patient goes home?
_______________________________________________________________________________________________
Objective
1. Observe behavior. Are there any overt signs of stress (e.g., crying, wringing of hands, clenched fists, etc.)?
Describe. _______________________________________________________________________________________
2. Ask the family or primary caregiver if the patient has threatened to kill himself or herself. No ________ Yes ________
3. Ask the family or primary caregiver if they have noticed any marked changes in the patient’s behavior, attitude, or
school performance? No ____________________________________ Yes ___________________________________
VALUE–BELIEF PATTERN
Subjective
1. Satisfied with the way your life has been developing? Yes __________ No ___________ Comments: _____________
2. Will this admission interfere with your plans for the future? No ___________ Yes ____________ How? ___________
3. Religion: Protestant _______ Catholic _______ Jewish _______ Islam _______ Buddhist _______ Other __________
4. Will this admission interfere with your spiritual or religious practices? No ________ Yes _________ How? _________
5. Any religious restrictions to care (diet, blood transfusions)? No __________ Yes ___________ Describe. __________
6. Would you like to have your (pastor, priest, rabbi, hospital chaplain) contacted to visit you?
No ____________________________ Yes ________________________ Who? _______________________________
7. Have your religious beliefs helped you deal with problems in the past? No ______ Yes _______ Comments: ________
Objective
1. Observe behavior. Is the patient exhibiting any signs of alterations in mood (e.g., anger, crying, withdrawal, etc.)?
No __________________________ Yes _________________________ Describe. _____________________________
GENERAL
1. Is there any information we need to have that I have not covered in this interview?
No ___________________________ Yes ___________________________ Comments: ________________________
2. Do you have any questions you need to ask me concerning your health, plan of care, or this agency?
No __________________________ Yes ________________________ Questions: _____________________________
________________________________________________________________________________________________
3. What is the first problem you would like to have assistance with? __________________________________________
CASE STUDY: MR. FRED CARSON Mr. Carson says he doesn’t pay any attention to his urine
tests—“They’re just a waste of time”—but, he adds, “I’ve
Mr. Fred Carson is a 63-year-old man who has been admit- been peeing a lot more the past few days. Does this mean
ted with a medical diagnosis of hyperglycemia secondary to I’m not behaving?” Mr. Carson states he was taught about
diabetes mellitus. He was first diagnosed as having adult his diabetes but thinks “They were just trying to scare me. I
onset diabetes 2 years ago. don’t think I really have diabetes. Kids develop that—not
On admission Mr. Carson’s vital signs are temper- old codgers like me. I only check in with the doctor when I
ature 101.4 F orally, pulse 98, respiration 20, blood pres- feel like it. He wants me to come in every other month, but
sure 98/70. Mr. Carson is 5 feet 9 inches tall and weighs I think he’s just trying to get more money.” When asked to
230 pounds. He states he has gained 20 pounds over the discuss what he was taught regarding his diabetes, Mr.
past 6 weeks. His fasting glucose is 200 mg/dL. His hemo- Carson relates a high level of understanding of his pre-
globin level is 20 g/dL, with a hematocrit of 56 vol/dL. scribed regimen.
Mr. Carson tells you he regulates his insulin according to You find out this is Mr. Carson’s fourth admission
what he eats and eats whatever he is hungry for. You find, in over the last 8 months. All of the admissions have been due
interviewing Mr. Carson, that he has been drinking three or to complications secondary to the diabetes. He exhibits
four “iced tea glasses” of water every hour stating, “I’m anger on each admission and refuses to have home health
always thirsty.” He has been voiding at least once an hour. nurses visit him.
His urine specimen is dilute and a very pale yellow. Mr. In examining Mr. Carson’s skin you find that his toe-
Carson’s urine glucose, as measured by a Clinitest, is 4. In nails and fingernails are dry, thick, and brittle. Both his skin
the past 2 hours Mr. Carson voided 1500 mL in addition and mucous membranes are dry in spite of the amount of
to the urine specimen, and his intake has been 500 mL. fluid Mr. Carson indicates he was drinking prior to admis-
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842 • Appendix B
sion. His extremities are shiny and cool to the touch, and his shin, and you can see that the lesion has begun to impact the
legs become cyanotic when they are kept in a dependent muscle tissue. Mr. Carson tells you he hit his leg on a table
position. When elevated, his legs become pale, and color is 3 weeks ago. You note three round scars with atrophied skin
very slow to return when his legs are returned to a neutral on his right leg and 1 similar scar on his left leg. Mr. Carson
position. His pedal pulses are difficult to locate and dimin- describes a sensation of “pins and needles when walking,
ished in volume. He has a 10 cm size lesion on his left but if I stop it goes away.”
VITAL SIGNS
Temperature 101.4_ F X____ C ________ Oral X____ Rectal _______ Axillary _______ Tympanic_________________
Pulse Rate: Radial 98______ Apical _________; Regular X_________________ Irregular ________________________
Respiratory Rate: 20___________ Abdominal _____________________________ Diaphragmatic X________________
Blood Pressure: Left arm 98/60_____ ; Right arm 100/64____ ; Sitting X_____ Standing ________ Lying down ______
Weight: 230 pounds, _____________ kilograms; Height: 5_ feet 9_ inches, ____________ meters
Do you have any allergies? No X_______ Yes _____________________ What?_________________________________
(Check reactions to medications, foods, cosmetics, insect bites, etc.)
Review admission CBC, urinalyses, and chest x-ray. Note any abnormalities here:
FASTING GLUCOSE 200 MG/DL; HGB 20 G/DL; HCT 56 VOL/DL________________________________________
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Sample Admission Assessment • 843
11. Do you have any difficulty securing any of the following services?
Grocery store? Yes _____________ No X____________ ; Pharmacy? Yes ______________ No X_______________;
Health care facility? Yes __________ No X___________ ; Transportation? Yes ____________ No X____________ ;
Telephone (for police, fire, ambulance, etc.)? Yes _________________________ No X________________________
If any difficulties, note referral here _________________________________________________________________
12. Medications (over-the-counter and prescriptive)
NAME DOSAGE AMT. TIMES/DAY REASON TAKING AS ORDERED
INSULIN REGULATES ACCORD. 1–3 TIMES DIABETES Yes ____ No ___X__
________________TO GLUCOSE METER READING ________________________________________________
________________________________________________________________ Yes ___________ No ____________
________________________________________________________________ Yes ___________ No ____________
________________________________________________________________ Yes ___________ No ____________
________________________________________________________________ Yes ___________ No ____________
________________________________________________________________ Yes ___________ No ____________
13. Have you followed the routine prescribed for you? Yes ______________________________ No X_______________
Why not? “I TAKE THE INSULIN, BUT I DON’T LIKE THE DIET.”
14. Did you think this prescribed routine was the best for you? Yes _______________________ No X_______________
What would be better? _____________“I EAT WHAT I WANT.”__________________________________________
15. Have you had any accidents/injuries/falls in the past year? No ______________________ Yes X_________________
Describe. “I HIT MY LEG ON THE TABLE A FEW WEEKS AGO.”______________________________________
16. Have you had any problems with cuts healing? No _______ Yes X_____ Describe. “THIS SORE HAS BEEN HERE
SINCE I HIT IT 3 WEEKS AGO (POINTS TO LT SHIN). THESE SCARS ARE FROM SORES THAT TOOK
AGES TO HEAL (POINTS TO RT LEG).”___________________________________________________________
17. Do you exercise on a regular basis? No X_______ Yes ________ Type and Frequency “I USED TO WALK EVERY
AFTERNOON, BUT SINCE I HAVE TO PEE SO MUCH I CAN’T LEAVE THE HOUSE.”___________________
18. Have you experienced any ringing in the ears? Right: Yes _______________ No X_______________________
Left: Yes _________________ No X______________________
19. Have you experienced any vertigo? Yes ______ No X_____ How often and when?___________________________
20. Do you regularly use seat belts? Yes ___________________________ No X________________________________
21. For infants and children, are car seats used regularly? Yes ______________________ No _____________________
22. Do you have any suggestions or assistance requests for improving your health? No ________ Yes X______ What?
“I WANT TO STOP PEEING SO MUCH.”___________________________________________________________
23. Do you do (breast/testicular) self-examination? No X_______________________ Yes ________________________
How often? ____________________________________________________________________________________
24. Were you or your family able to meet all your therapeutic needs? Yes X______________ No ___________________
25. Are you scheduled for surgery? Yes ______________________________ No X______________________________
26. Have you recently had surgery? No X__________________ Yes ___________________ Date___________________
Objective
1. Mental Status (Indicate assessment with an X)
a. Oriented X________________ Disoriented ______________________ Length of time_______________________
Time: Yes X__________________________ No ___________________ Length of time______________________
Place: Yes X___________________ No ______________________ Length of time__________________________
Person: Yes X_____________________ No ___________________ Length of time_________________________
b. Sensorium
Alert ______ ; Drowsy X_______ ; Lethargic _______ ; Stuporous ______; Comatose ______ ; Cooperative X___;
Combative ________ ; Delusions _________ ; Fluctuating levels of consciousness? Yes _________ No X_______
Appropriate response to stimuli? Yes X____________________________ No ______________________________
c. Memory
Recent? Yes X_______ No ________ ; Remote? Yes X______ No ______ ; Past 4 hours? Yes _______ No ______
d. Is there a disruption of the flow of energy surrounding the person? Yes X_____________ No _________________
Change in color? Yes ____ No X______ ; Change in temperature? Yes ___________ No X___________________ ;
Field? Yes ______ No X_______ ; Movement? Yes _______ No X_____; Sound? Yes _________ No X_________
e. Responds to simple directions? Yes X______________________________ No _____________________________
2. Vision
a. Visual Acuity: Both eyes 20/____________ Right 20/____________ Left 20/__________ Not assessed X_______
b. Pupil Size: Right: Normal X_____ Abnormal __________ ; Left: Normal X________ Abnormal ______________
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844 • Appendix B
Description of abnormalities_____________________________________________________________________
c. Pupil Reaction: Right: Normal X________ Abnormal ___________ ; Left: Normal X_____ Abnormal _________
Description of abnormalities NONE_______________________________________________________________
d. Wears glasses? Yes X_____________ No _________ ; Contact lenses? Yes ________________ No X__________
3. Hearing: Not assessed ____________________________________________________________________________
a. Right: WNL X__________________ Impaired _______________________ Deaf _________________________ ;
Left: WNL X_____________________ Impaired _______________________ Deaf ________________________
b. Hearing aid? Yes __________________________________________ No X_______________________________
4. Taste
a. Sweet: Normal _________________ Abnormal _____________ Describe. NOT EXAMINED________________
b. Sour: Normal _________________ Abnormal ______________ Describe. NOT EXAMINED________________
c. Tongue Movement: Normal X___________ Abnormal _______________ Describe. MIDLINE_______________
d. Tongue Appearance: Normal X___ Abnormal _______ Describe. PINK, NO LESIONS OR EXUDATE________
5. Touch
a. Blunt: Normal X______ Abnormal _________ Describe. RESPONDS TO TOUCH ON ALL EXTREMITIES
WITH FLAT TONGUE DEPRESSOR_____________________________________________________________
b. Sharp: Normal __________ Abnormal X______ Describe. DIMINISHED RESPONSE ON LT FOOT__________
c. Light Touch Sensation: Normal _____ Abnormal X__ Describe. HYPERESTHESIA LT ANKLE AND RT LEG__
d. Proprioception: Normal X________________ Abnormal __________________ Describe. ____________________
e. Heat: Normal _______ Abnormal X________ Describe. DIMINISHED RESPONSE LT FOOT_______________
f. Cold: Normal __________ Abnormal X_________ Describe. DIMINISHED RESPONSE LT FOOT___________
g. Any numbness? No _______ Yes X_______ Describe. BILATERALLY IN FEET WHEN WALKING__________
h. Any tingling? No ______ Yes X________ Describe. “PINS AND NEEDLES IN FEET” WHEN WALKING_____
6. Smell
a. Right Nostril: Normal X_______________ Abnormal __________________ Describe. _____________________
b. Left Nostril: Normal X________________ Abnormal __________________ Describe. _____________________
7. Assess Cranial Nerves: Normal X_____________________________ Abnormal _____________________________
Describe deviations _____________________________________________________________________________
8. Cerebellar Exam (Romberg, balance, gait, coordination, etc.): Normal ________________ Abnormal X___________
Describe. ROMBERG ABSENT, BALANCE GOOD, DOES NOT BEAR FULL WEIGHT ON LT FOOT_________
9. Assess Reflexes: Normal X_______ Abnormal ____________ Describe.____________________________________
10. Throat: Enlarged tonsils? No X_____________ Yes ___________ Location NORMAL________________________
Tenderness? No X_______ Yes _______ Exudate on tonsils? No X______ Yes _________ Color ________________
Uvula midline? No ____________________________________ Yes X_____________________________________
11. Neck: Any enlarged lymph nodes? No X__________ Yes ___________ Location and size _____________________
12. General Appearance
a. Hair BROWN, THINNING______________________________________________________________________
b. Skin PALE PINK, DRY, DECREASED TURGOR___________________________________________________
Eczema? No X__________________________ Yes __________________________________________________
c. Nails TOENAILS AND FINGERNAILS DRY, THICK, AND BRITTLE_________________________________
d. Body Odor NONE____________________________________________________________________________
13. History of multiple surgeries? No X_________ Yes _________; Reaction to latex? No X_____ Yes_______________
14. Incisions healing well? No _______________________ Yes _______________________ N/A X________________
NUTRITIONAL–METABOLIC PATTERN
Subjective
1. Any weight gain in last 6 months? No ____________ Yes X________ Amount 20 LBS IN LAST 6 WEEKS________
2. Any weight loss in last 6 months? No X_______ Yes ________ Amount_____________________________________
3. Would you describe your appetite as: Good X__________ Fair __________________ Poor ____________________
4. Do you have any food intolerances? No X_____ Yes _____________ Describe._______________________________
5. Do you have any dietary restrictions? (Check for those that are a part of a prescribed regimen as well as those that
patient restricts voluntarily; for example, to prevent flatus.)
No ___________ Yes X________ What “SPECIAL DIET MY WIFE FIXES ME FOR DIABETES.”______________
6. Describe an average day’s food intake for you (meals and snacks).
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Sample Admission Assessment • 845
BREAKFAST: 3 PANCAKES WITH LOW SUGAR SYRUP, JUICE, BLACK COFFEE, SAUSAGE; LUNCH:
SANDWICH, MILK OR SUGAR-FREE SOFT DRINK, POTATO CHIPS, FRUIT, “SOMETIMES A LITTLE CAKE
OR PIE”; DINNER: CASSEROLE, ICED TEA, ROLLS WITH BUTTER, VEGETABLES AND DESSERT (“SURE
DO LIKE MY ICE CREAM”). SNACKS: COOKIES AND JUICE________________________________________
7. Describe an average day’s fluid intake for you. “I DRINK ALL THE TIME,” AT LEAST 4 LARGE GLASSES PER
HOUR.________________________________________________________________________________________
8. Describe food likes and dislikes LIKES: MEAT, DESSERTS, AND POTATOES; DISLIKES: VEGETABLES AND
LOW SUGAR “STUFF”__________________________________________________________________________
9. Would you like to: Gain weight ____________________ Lose weight X______________ Neither _______________
10. Any problems with:
a. Nausea? No X_____________ Yes ___________________________ Describe.____________________________
b. Vomiting? No X____________ Yes ___________________________ Describe.____________________________
c. Swallowing? No X___________ Yes ___________________________ Describe.___________________________
d. Chewing? No X_____________ Yes ___________________________ Describe.___________________________
e. Indigestion? No X____________ Yes ___________________________ Describe.__________________________
11. Would you describe your usual lifestyle as: Active __________________________ Sedate X__________________
12. Any chronic health problems? No ___________ Yes X__________ Describe. DIABETES MELLITUS____________
For breastfeeding mothers only:
13. Do you have any concerns about breastfeeding? No ____________ Yes __________ Describe. __________________
14. Are you having any problems with breastfeeding? No ___________ Yes __________ Describe. _________________
Objective
1. Skin Examination
a. Warm ________________ Cool X____________ Moist ___________________________ Dry X_______________
b. Lesions? No _________ Yes X___________ Describe. 10 CM LT SHIN SEVERAL CM DEEP; RED 3 ROUND
SCARS WITH ATROPHIED SKIN ON RT LEG; 1 ON LT LEG_________________________________________
c. Rash? No X_________________ Yes ___________________ Describe. ___________________________________
d. Turgor: Firm __________ Supple ___________ Dehydrated X_____________ Fragile _______________________
e. Color: Pale ________ ; Pink ______ ; Dusky _______ ; Cyanotic _______ ; Jaundiced ______ ; Mottled ________ ;
Other PINK EXCEPT FOR LEGS. LEGS ARE CYANOTIC IN DEPENDENT POSITION; PALE WHEN ELE-
VATED.______________________________________________________________________________________
2. Mucous Membranes
a. Mouth
(1) Moist _________________________________________________ Dry X______________________________
(2) Lesions? No X____________________ Yes __________________ Describe.____________________________
(3) Color: Pale X_______________________ Pink ___________________________________________________
(4) Teeth: Normal X__________ Abnormal ___________ Describe.______________________________________
(5) Dentures? No _____________ Yes __________ Upper __________ Lower ____________ Partial X_________
(6) Gums: Normal X_____________ Abnormal __________________ Describe.___________________________
(7) Tongue: Normal X____________ Abnormal ________________ Describe._____________________________
b. Eyes
(1) Moist _________________________ Dry X______________________________________________________
(2) Color of conjunctivae: Pale ___________________ Pink X_________________ Jaundiced ________________
(3) Lesions? No X_______________________ Yes ___________________ Describe.________________________
3. Edema
a. General? No X____________________ Yes _____________ Describe.____________________________________
Abdominal Girth: ______________________________inches; Not measured X_____________________________
b. Periorbital? No X_____________ Yes ____________________ Describe.__________________________________
c. Dependent? No _______ Yes X________ Describe. BILATERAL ANKLES AND FEET WHEN DEPENDENT;
LEGS SHINY; NO PITTING._____________________________________________________________________
Ankle Girth: Right _____________inches; Left _______________inches; Not measured X____________________
4. Thyroid: Normal X___________ Abnormal ______________________ Describe.______________________________
5. Jugular vein distention? No X_____________________________ Yes ______________________________________
6. Gag Reflex: Present X_______________________ Absent ________________________________________________
7. Can the patient move self easily (turning, walking)? Yes ____________________ No X_________________________
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846 • Appendix B
Describe limitations DOES NOT BEAR FULL WEIGHT ON LEG; TURNING OK.__________________________
8. Upon admission was the patient dressed appropriately for the weather? Yes X____ No _______ Describe.__________
For breastfeeding mothers only:
9. Breast Exam: Normal _______________ Abnormal ____________________ Describe.________________________
10. Weigh the infant. Is the infant’s weight within normal limits? Yes _________________ No _____________________
ELIMINATION PATTERN
Subjective
1. What is your usual frequency of bowel movements? ABOUT 3 TIMES PER WEEK____________________________
a. Have to strain to have BM? No X______________________ Yes ________________________________________
b. Same time each day? No X_______________________ Yes ____________________________________________
2. Has the number of bowel movements changed in the past week? No X______________ Yes _____________________
Increased ___________________________ Decreased ___________________________________________________
3. Character of stool:
a. Consistency: Hard ______________ Soft X________________________ Liquid ___________________________
b. Color: Brown X__________ Black ___________ Yellow ________________ Clay colored ___________________
c. Bleeding with bowel movements? No X__________________ Yes _______________________________________
4. History of constipation? No X__________________ Yes _______________ How often_________________________
Use bowel movement aids (laxatives, suppositories, diet)? No X________ Yes __________ Describe.______________
5. History of diarrhea? No X_____________________ Yes _______________ When_____________________________
6. History of incontinence? No X______________________ Yes _____________________________________________
Related to increased abdominal pressure (coughing, laughing, sneezing)? No _______________Yes _______________
7. History of recent travel? No X___________________ Yes ____________________Where?______________________
8. Usual voiding pattern:
a. Frequency (times/day) FOR PAST 3 DAYS, 3–4/HOUR________________________________________________
Decreased __________________________ Increased X________________________________________________
b. Change in awareness of need to void? No ______________ Yes X________________________________________
Increased _____________ Decreased X_____________________________________________________________
c. Change in urge to void? No __________ Yes X___________ Increased X_________ Decreased _______________
d. Any change in amount? No __________ Yes X______ Decreased ___________ Increased X___________________
e. Color: Yellow VERY PALE______ Smoky ______________ Dark _______________________________________
f. Incontinence? No _________ Yes X________ When “IF TOO FAR FROM BATHROOM.”____________________
Difficulty holding voiding when urge to void develops? No _______________ Yes X_________________________
Have time to get to bathroom? Yes __________________ No X__________________________________________
How often does problem reaching bathroom occur? EVERY VOIDING____________________________________
g. Retention? No X_____________ Yes ______________ Describe.________________________________________
h. Pain or burning? No X___________ Yes ____________ Describe.________________________________________
i. Sensation of bladder spasms? No X______ Yes ___________ When?_____________________________________
Objective
1. Auscultate abdomen.
a. Bowel Sounds: Normal X________ Increased _________ Decreased __________ Absent ____________________
2. Palpate abdomen.
a. Tender? No X__________ Yes _______________ Where?______________________________________________
b. Soft? Yes X_________ No ____________; Firm? Yes ______________ No X______________________________
c. Masses? No X_____________ Yes _________________ Describe._______________________________________
d. Distention (include distended bladder)? No X_________ Yes ______________ Describe. _____________________
e. Overflow urine when bladder palpated? Yes ____________ No X_________________________________________
3. Rectal Exam
a. Sphincter tone: Describe. WITHIN NORMAL LIMITS________________________________________________
b. Hemorrhoids? No X_________ Yes ___________ Describe._____________________________________________
c. Stool in rectum? No _________ Yes X_____ Describe. HEME NEGATIVE________________________________
d. Impaction? No X_______ Yes ______________ Describe.______________________________________________
e. Occult blood? No X________ Yes _________________________________________________________________
4. Ostomy present? No X___________ Yes __________ Location____________________________________________
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Sample Admission Assessment • 847
ACTIVITY–EXERCISE PATTERN
Subjective
1. Using the following Functional Level Classification, have the patient rate each area of self-care. (Code adapted by
NANDA from Jones, E, et al: Patient Classification for Long-Term Care: Users’ Manual, HEW Publication No. HRA-
74-3107. November, 1974.)
0 Completely independent
1 Requires use of equipment or device
2 Requires help from another person, for assistance, supervision, or teaching
3 Requires help from another person and equipment or device
4 Dependent, does not participate in activity
Feeding 0_____________ ; Bathing-hygiene 0________ ; Dressing-grooming 0____________ ;
Toileting 0__________ ; Ambulation 0________ ; Care of home WIFE___________ ; Shopping WIFE___________;
Meal preparation WIFE_________ ; Laundry WIFE____________ ; Transportation 0_________________________.
2. Oxygen use at home? No X______________ Yes ____________ Describe.__________________________________
3. How many pillows do you use to sleep on? 1__________________________________________________________
4. Do you frequently experience fatigue? No _____ Yes X___ Describe. “I’M TIRED AFTER GOING TO THE______
BATHROOM SO MUCH.”________________________________________________________________________
5. How many stairs can you climb without experiencing any difficulty (can be individual number or number of flights)?
1 FLIGHT_____________________________________________________________________________________
6. How far can you walk without experiencing any difficulty? 1 BLOCK; “MY FOOT HURTS IF I TRY TO WALK
TOO FAR.”_____________________________________________________________________________________
7. Any history of falls? No X___________ Yes ___________ How often?_____________________________________
8. Has assistance at home for care of self and maintenance of home? No __________ Yes X______________________
Who WIFE_____________________________________________________________________________________
If no, would like to have or believes needs to have assistance? No ______________ Yes _______________________
With what activities?_____________________________________________________________________________
9. Occupation (if retired, former occupation) MAIL CARRIER_____________________________________________
10. Describe your usual leisure time activities-hobbies. GARDENING, FISHING, READING_____________________
11. Any complaints of weakness or lack of energy? No ________________ Yes X_______________________________
Describe. GOING TO THE BATHROOM SO MUCH “WEARS ME OUT.”_________________________________
12. Any difficulties in maintaining activities of daily living? No ____________ Yes X____________________________
Describe. “ALL I DO IS DRINK AND PEE.”_________________________________________________________
13. Any problems with concentration? No X_______ Yes _________ Describe._________________________________
14. If in wheelchair, do you have any problems manipulating the wheelchair? No ___Yes ___ N/A X__ Describe._____
15. Can you move yourself from site to site with no problems? No ____ Yes X______ Describe.___________________
Objective
1. Cardiovascular
a. Cyanosis? No _______ Yes X________ Where? LEGS WHEN DEPENDENT______________________________
b. Pulses: Easily palpable?
Carotid: Yes X____ No _____; Jugular: Yes X____ No _____; Temporal: Yes X_____ No ____________________;
Radial: Yes X_____ No ______; Femoral: Yes X______ No _____; Popliteal: Yes X_______ No ______________;
Post tibial: Yes________ No X______ ; Dorsalis pedis: Yes___________ No X_____________________________
c. Extremities:
(1) Temperature: Cold ________ Cool X________ Warm __________ Hot _______________________________
(2) Capillary Refill: Normal _____________ Delayed X_______________________________________________
(3) Color: Pink _________ Pale X________ Cyanotic X_________ Other ________________________________
Describe. PALE WHEN RAISED; CYANOTIC WHEN DEPENDENT________________________________
(4) Homans’ sign? No X_________ Yes ____________________________________________________________
(5) Nails: Normal ___ Abnormal X___ Describe. TOENAILS AND FINGERNAILS DRY, THICK, BRITTLE___
(6) Hair Distribution: Normal X______ Abnormal _________ Describe. __________________________________
(7) Claudication? No _______ Yes X_______ Describe. NUMBNESS AND TINGLING IN FEET_____________
d. Heart: PMI Location 4TH ICS LCL________________________________________________________________
(1) Abnormal rhythm? No X_________ Yes ___________ Describe. ____________________________________
(2) Abnormal sounds? No X______ Yes ______ Describe. _____________________________________________
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2. Respiratory
a. Rate 20/MIN________ ; Depth: Shallow _______ Deep X_____ Abdominal ______ Diaphragmatic X___________
b. Have the patient cough. Any sputum? No X__________ Yes __________ Describe. __________________________
c. Fremitus? No X___________ Yes __________________________________________________________________
d. Any chest excursion? No X__________ Yes __________ Equal ______________ Unequal ____________________
e. Auscultate chest:
Any abnormal sounds (rales, rhonchi)? No X________ Yes ____ Describe. ________________________
f. Have the patient walk in place for 3 minutes (if permissible):
(1) Any shortness of breath after activity? No X____________ Yes ______________________________________
(2) Any dyspnea? No X__________ Yes ____________________________________________________________
(3) BP after activity 108 / 74 in (right; left) arm
(4) Respiratory rate after activity 25____
(5) Pulse rate after activity 110_____
3. Musculoskeletal
a. Range of motion: Normal ______ Limited X_____ Describe. LIMITED IN LOWER EXTREMITIES__________
b. Gait: Normal ____ Abnormal X_____ Describe. DOES NOT BEAR FULL WEIGHT ON LEFT ANKLE_______
c. Balance: Normal X________ Abnormal ___________ Describe.________________________________________
d. Muscle Mass/Strength: Normal _______ Increased ________ Decreased X_____ Describe. ATROPHY IN BOTH
LEGS, ESPECIALLY IN AREA OF WOUNDS_____________________________________________________
e. Hand Grasp: Right: Normal X____ Decreased ______________________________________________________
Left: Normal X_____ Decreased ______________________________________________________
f. Toe Wiggle: Right: Normal X___ Decreased _______________________________________________________
Left: Normal X___ Decreased ________________________________________________________
g. Posture: Normal X_________ Kyphosis _____________ Lordosis ______________________________________
h. Deformities? No X_____________ Yes __________________ Describe._________________________________
i. Missing limbs? No X________ Yes __________ Where?______________________________________________
j. Uses mobility assistive devices (walker, crutches, etc.)? No X_____ Yes ________ Describe._________________
k. Tremors? No X_________ Yes _________ Describe._________________________________________________
l. Traction or casts present? No X________ Yes ________ Describe.______________________________________
m. Easily turns in bed? No ______ Yes X_____________________________________________________________
4. Spinal cord injury? No X______ Yes _________ Level__________________________________________________
5. Paralysis present? No X_________ Yes __________ Where?______________________________________________
6. Conduct developmental assessment. Normal ________ Abnormal _________ Describe. NOT DONE______________
7. Responds appropriately to stimuli? Yes X___________ No _____________ Describe.__________________________
8. Are there any abnormal movements? No X___________ Yes ________________ Describe._____________________
9. Frequent locomotion? Yes __________________ No X__________________________________________________
10. Episodes of trespassing or getting lost? Yes ________ No X______________________________________________
SLEEP–REST PATTERN
Subjective
1. Usual sleep habits: Hours/night 6 ; Naps? No __________ Yes X_______ A.M. ________ P.M. X__________________
Feel rested? Yes X_________ No ___________ Describe._________________________________________________
2. Any problems:
a. Difficulty going to sleep? No X__________ Yes_______________________________________________________
b. Awakening during night? No ______ Yes X (TO GO TO THE BATHROOM)_______________________________
c. Early awakening? No X____________ Yes___________________________________________________________
d. Insomnia? No X______ Yes __________ Describe.____________________________________________________
3. Methods used to promote sleep: Medication? No X___________ Yes ___________ Name_______________________
Warm fluids? No X_____________ Yes __________ What?_______________________________________________
Relaxation techniques? No X_____________ Yes _______________________________________________________
Objective
None
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Sample Admission Assessment • 849
COGNITIVE–PERCEPTUAL PATTERN
Subjective
1. Pain
a. Location (have the patient point to area) LEFT SHIN__________________________________________________
b. Intensity (have the patient rank on scale of 0–10) 5____________________________________________________
c. Radiation? No __________ Yes X_________ To where UP LEG_________________________________________
d. Timing (how often; related to any specific events) “ACHES ALL THE TIME”; INCREASED PAIN WITH WALK-
ING OR IF TOUCH WOUND_____________________________________________________________________
e. Duration AS ABOVE____________________________________________________________________________
f. What do you do to relieve pain at home? ELEVATE, TAKE AN ADVIL___________________________________
g. When did pain begin? “TWO WEEKS AGO”_________________________________________________________
2. Decision Making
a. Find decision making: Easy X______ Moderately easy ________ Moderately difficult _______ Difficult ________
b. Inclined to make decisions: Rapidly X______ Slowly ___________ Delay _________________________________
c. Difficulty choosing between options? Yes __________ No X____________ Describe.________________________
3. Knowledge level
a. Can define what current problem is? Yes X__________ No _____________________________________________
b. Can restate current therapeutic regimen? Yes X________ No ____________________________________________
Objective
1. Review sensory and mental status completed in Health Perception–Health Management Pattern.
2. Any overt signs of pain? No ___Yes X__ Describe. WINCES WHEN TRIES TO BEAR WEIGHT ON LEFT LEG___
3. Any fluctuations in intercranial pressure? Yes __________ No X____________________________________________
ROLE-RELATIONSHIP PATTERN
Subjective
1. Does the patient live alone? Yes _________ No X_________ Lives with: WIFE_______________________________
2. Is the patient married? Yes X__________ No _______; Children? No X_____ Yes ______; # of children___________
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850 • Appendix B
Age(s) of children________________________________________________________________________________
Were any of the children premature? No __________ Yes _____________ Describe. N/A_______________________
3. How would you rate your parenting skills: Not applicable X______________________________________________
No difficulty with __________ Average ___________ Some difficulty with ___________ Describe._______________
4. Any losses (physical, psychological, social) in past year? No _____________________ Yes X___________________
Describe. EARLY RETIREMENT___________________________________________________________________
5. How is the patient handling this loss at this time? “DOING FINE, JUST NEED TO GET FEET IN SHAPE SO I CAN
DO WHAT I WANT NOW THAT I HAVE THE TIME.”_________________________________________________
6. Do you believe this admission will result in any type of loss? No X_____ Yes _________ Describe. ______________
7. Has the patient recently received a diagnosis related to a chronic physical or mental illness? No X____ Yes________
8. Is the patient verbally expressing sadness? No X______ Yes ______________________________________________
9. Ask both the patient and family: Do you think this admission will cause any significant changes in (the patient’s) usual
family role? No X______ Yes _________ Describe._____________________________________________________
10. How would you rate your usual social activities? Very active _______ Active X____ Limited ________ None ______
11. How would you rate your comfort in social situations? Comfortable X_______ Uncomfortable __________________
12. What activities/jobs, etc., do you like to do? GARDENING, FISHING, PLAYING CARDS AND DOMINOES_____
13. What activities/jobs, etc., do you dislike doing? ANY HOUSEWORK OR COOKING AND HAVING TO PEE ALL
THE TIME_____________________________________________________________________________________
14. Does the person use alcohol or drugs? No X____________ Yes _______________ Kind________________________
Amount________________________________________________________________________________________
15. Is the patient in the role of primary caregiver for another person? No X___________ Yes ______________________
Objective
1. Speech Pattern
a. Is English the patient’s native language? Yes X__________ No __________________________________________
Native language is______________; Interpreter needed? No X___________ Yes ____________________________
b. During interview have you noted any speech problems? No X_______ Yes ________ Describe.________________
2. Family Interaction
a. During interview have you observed any dysfunctional family interactions? No X____ Yes _____ Describe._______
b. If the patient is a child, is there any physical or emotional evidence of physical or psychosocial abuse?
No ___________ Yes ______________ Describe._____________________________________________________
c. If the patient is a child, is there evidence of attachment behaviors between the parents and child?
Yes ____________ No _____________ Describe. N/A_________________________________________________
d. Any signs or symptoms of alcoholism? No X___________ Yes __________ Describe. _________________
SEXUALITY–REPRODUCTIVE PATTERN
Subjective
Female
1. Date of LMP______; Any pregnancies? Para______ Gravida______ Menopause? No _____ Yes _____ Year_______
2. Use birth control measures? No_____________ N/A _____________ Yes ____________ Type__________________
3. Any history of vaginal discharge, bleeding, lesions? No _________ Yes _____________ Describe._______________
4. Pap smear annually? Yes ___________ No ___________ Date of last pap smear______________________________
5. Date of last mammogram__________________________________________________________________________
6. History of STD (sexually transmitted disease)? No ____________ Yes ____________ Describe._________________
If admission secondary to rape:
7. Is the patient describing numerous physical symptoms? No __________ Yes ____________ Describe.____________
8. Is the patient exhibiting numerous emotional reactions? No ___________ Yes ___________ Describe.____________
9. What has been your primary coping mechanism to handle this rape episode?_________________________________
10. Have you talked to persons from the rape crisis center? Yes _______________ No ____________________________
If no, does the patient want you to contact them for her? No _________________ Yes _________________________
If yes, was this contact of assistance? No __________________ Yes _______________________________________
Male
1. Any history of prostate problems? No X________ Yes ___________ Describe.________________________________
2. Any history of penile discharge, bleeding, lesions? No X_______ Yes ________ Describe._______________________
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VALUE–BELIEF PATTERN
Subjective
1. Are you satisfied with the way your life has been developing? Yes ______________ No X______________________
Comments “WAS O.K. UNTIL THIS DIABETES DEVELOPED.”_________________________________________
2. Will this admission interfere with your plans for the future? No X_____________ Yes _________________________
How? __________________________________________________________________________________________
3. Religion: Protestant X_______ Catholic __________ Jewish __________ Islam __________ Buddhist ____________
4. Will this admission interfere with your spiritual or religious practices? No X___________ Yes __________________
How? __________________________________________________________________________________________
5. Any religious restrictions to care (diet, blood transfusions)? NO___________________________________________
6. Would you like to have your (pastor, priest, rabbi, hospital chaplain) contacted to visit you?
No X___________ Yes ______________ Which?_______________________________________________________
7. Have your religious beliefs helped you to deal with problems in the past? No _____________Yes X______________
Comments NONE________________________________________________________________________________
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852 • Appendix B
Objective
1. Observe behavior. Is the patient exhibiting any signs of alterations in mood (e.g., anger, crying, withdrawal, etc.)?
No _____________ Yes X_________ What CLENCHED FISTS___________________________________________
GENERAL
1. Is there any information we need to have that I have not covered in this interview?
No X_____________ Yes ______________ Comments__________________________________________________
2. Do you have any questions you need to ask me concerning your health, plan of care, or this agency?
No X____________ Yes ______________ Questions____________________________________________________
3. What is the first problem you would like to have assistance with? STOP ME FROM HAVING TO GO TO THE BATH-
ROOM ALL THE TIME___________________________________________________________________________
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Note: Page numbers followed by f indicate figures; page numbers followed by t indicate tables.
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Index • 855
defining characteristics, 139 defining characteristics, 148 tissue perfusion, ineffective, 397
definition, 139 definition, 148 nursing actions/interventions, 314–321
differential diagnosis, 140 differential diagnosis, 148 adult health, 314, 318–319
hyperthermia, 176–177 breastfeeding, interrupted, 152 child health, 315–316
hypothermia, 182 infant feeding pattern, ineffective, 187 expected outcome, 313
infection, risk for, 54 nursing actions/interventions, 148–152 gerontic health, 319–320
thermoregulation, ineffective, 214 child health, 149 home health, 320–321
nursing actions/interventions, 140–144 expected outcome, 148 mental health, 318–319
adult health, 140–141 home health/community health, 152 target dates, 313
child health, 141–142 target dates, 148 women’s health, 316–318
expected outcome, 140 women’s health, 149–151 related clinical concerns, 313
gerontic health, 143–144 related clinical concerns, 148 related factors, 313
home health/community health, 144 related factors, 148 taxonomy linkages, 279t
mental health, 142–143 taxonomy linkages, 128t Cardiovascular system
target dates, 140 Breastfeeding, interrupted, 129t, 152–155 adolescent, 275
women’s health, 142 defining characteristics, 152 bed rest effects, 272
related clinical concerns, 139 definition, 152 characteristics, 313–314
risk factors, 136, 139 differential diagnosis, 152 function, 397
taxonomy linkages, 128t nursing actions/interventions, 153–155 infant, 273
Body water child health, 153 older adult, 277
adolescent, 125 expected outcome, 152 school-age children, 275
adult, 126 home health/community health, 154–155 tissue perfusion. See Tissue perfusion, ineffec-
infant, 123 mental health, 154 tive
older adult, 126 target dates, 152 toddler and preschooler, 274
school-age child, 125 women’s health, 153–154 young adult, 276
toddler, 124–125 related clinical concerns, 152 Care plan, 5, 14, 22–23
young adult, 126 related factors, 152 Care planning, 3–5, 5f, 8–9, 22–23
Bone taxonomy linkages, 129t Caregiver
bed rest effects, 272 Breathing pattern, ineffective, 278t, 307–312 parent to your parent, 622–623
older adult, 277 defining characteristics, 307 resources, 623
Bottle mouth syndrome, 124 definition, 307 Caregiver Network, Inc, 623
Bowel elimination, 231–232. See also differential diagnosis, 307 Caregiver role strain, risk for and actual, 613t,
Constipation; Diarrhea airway clearance, ineffective, 293 618–626
Bowel incontinence, 235t, 236–240 dysfunctional ventilatory weaning response, defining characteristics, 618
defining characteristics, 236 332 definitions, 618
definition, 236 gas exchange, impaired, 346–347 differential diagnosis, 619–620
differential diagnosis, 237 ventilation, spontaneous, impaired, 394 nursing actions/interventions, 620–626
constipation, 242 nursing actions/interventions, 307–312 adult health, 620
fluid volume, deficient, risk for and actual, adult health, 307–308 child health, 621
162 child health, 308–309 expected outcome, 620
nursing actions/interventions, 237–240 expected outcome, 307 gerontic health, 625
adult health, 237–238 gerontic health, 311 home health, 625–626
child health, 238 home health, 312 mental health, 623–624
expected outcome, 236 mental health, 310–311 target dates, 620
gerontic health, 239–240 target dates, 307 women’s health, 621–623
home health, 240–241 women’s health, 309–310 related clinical concerns, 619
mental health, 239 related clinical concerns, 307 related factors, 618–619
target dates, 236–237 related factors, 307 taxonomy linkages, 613t
women’s health, 238–239 taxonomy linkages, 278t Cataplexy, 422
related clinical concerns, 236 Brown adipose tissue, 124 Cerebral blood flow, inadequate. See Tissue per-
related factors, 236 Bulbar synchronizing portion of medulla, 422 fusion, ineffective
taxonomy linkages, 235t Charting by exception, 13
Breastfeeding, 121–122 C Childbirth. See also Postpartum period;
Breastfeeding, effective, 128t, 144–147 Cardiac output, 313–314 Pregnancy
defining characteristics, 144–145 bed rest effects, 272 nursing actions/interventions
definition, 144 Cardiac output, decreased, 279t, 313–321 anxiety, 535
differential diagnosis, 145 additional information, 313–314 fear, 557
nursing actions/interventions, 145–147 defining characteristics, 313 Children. See Infant; Preschooler; School-age
expected outcome, 145 definition, 313 child; Toddler
target dates, 145 differential diagnosis, 313 nursing actions/interventions for. See specific
women’s health, 145–147 autonomic dysreflexia, risk for and actual, nursing diagnosis
related clinical concerns, 145 300 Choosing, 18t
related factors, 145 fatigue, 341 Chyme, 231
taxonomy linkages, 128t fluid volume, excess, 167 Circadian biological clock, 422
Breastfeeding, ineffective, 128t, 148–152 gas exchange, impaired, 347 Cognition, 443
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856 • Index
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Index • 857
Couvade syndrome, 749 Denial, ineffective, 771, 772, 781–782 Disproportionate growth, risk for, 280t,
Credé’s maneuver, 232 Dentition 353–359
Crying, infant, 609 caries, 124 defining characteristics, 353
Cues to action, 27, 27f infant, 123 definition, 353
Current data, 6 older adult, 126 differential diagnosis, 354
Cybernetic theory, 522, 580 school-age child, 125 nursing actions/interventions, 354–359
toddler and preschooler, 124 adult health, 354
D young adult, 125–126 child health, 355
DAR (Data, Action, Response), 12 Dentition, impaired, 129t, 155–158 expected outcome, 354
Data defining characteristics, 155 gerontic health, 358
collection, 5–6 definition, 155 home health, 358–359
evaluation, 13–14 differential diagnosis, 155 mental health, 356–357
Data grouping, 7 nursing actions/interventions, 156–158 target dates, 354
Database, 11 adult health, 156 women’s health, 355–356
Death anxiety, 527t, 548–553 child health, 156–157 related clinical concerns, 354
defining characteristics, 548 expected outcome, 155 related factors, 354
definition, 548 gerontic health, 157–158 taxonomy linkages, 280t
differential diagnosis, 548 home health/community health, 158 Disuse syndrome, risk for, 279t,
nursing actions/interventions, 549–553 mental health, 157 321–326
adult health, 549 target dates, 155 definition, 321
child health, 549–550 women’s health, 157 differential diagnosis, 322
expected outcome, 549 related clinical concerns, 155 nursing actions/interventions, 322–326
gerontic health, 552–553 related factors, 155 adult health, 322
mental health, 550–552 taxonomy linkages, 129t child health, 322–323
target dates, 549 Depression, postpartum, 750–751 expected outcome, 322
women’s health, 550 Descriptors, NANDA, 830 gerontic health, 325
related clinical concerns, 548–549 DETERMINE checklist, 126 home health, 326
taxonomy linkages, 527t Development. See also Delayed development, mental health, 323–325
Decisional conflict, 447t, 463–469 risk for; Disproportionate growth, risk for; target dates, 322
defining characteristics, 463 Growth and development, delayed women’s health, 323
definition, 463 activity-exercise pattern, 272–277 related clinical concerns, 321
differential diagnosis, 464 cognitive-perceptual pattern, 443–447 risk factors, 321
nursing actions/interventions, 464–469 coping–stress tolerance pattern, 742–744 taxonomy linkages, 279t
adult health, 464 elimination pattern, 233–234 Diversional activity, deficient, 279t, 323,
child health, 464–465 health perception–health management pattern, 327–331
expected outcome, 464 29–33 defining characteristics, 327
gerontic health, 468 nutritional-metabolic pattern, 123–127 definition, 327
home health, 468–469 role-relationship pattern, 608–612 differential diagnosis, 327
mental health, 467–468 self-perception/self-concept pattern, 523–527 nursing actions/interventions, 327–331
target dates, 464 sexuality-reproductive pattern, 715–717 adult health, 327–328
women’s health, 465–466 sleep-rest pattern, 423–425 child health, 328
related clinical concerns, 463–464 value-belief pattern, 802–803 expected outcome, 327
related factors, 463 Diagnosis. See Nursing diagnosis gerontic health, 331
taxonomy linkages, 447t Diagnostic statement, 7–8 home health, 331
Defecation reflex, 231 Diarrhea, 235t, 248–252 mental health, 329–330
Defensive coping, 771, 772, 780–781 defining characteristics, 248 target dates, 327
Delayed development, risk for, 353–359 definition, 248 women’s health, 328–329
defining characteristics, 353 differential diagnosis, 248 related clinical concerns, 327
definition, 353 bowel incontinence, 236 related factors, 327
differential diagnosis, 354 constipation, 242 taxonomy linkages, 279t
nursing actions/interventions, 354–359 fluid volume, deficient, risk for and actual, Divorce, nursing actions/interventions,
adult health, 354 162 571–572
child health, 355 nursing actions/interventions, 249–252 Documentation, 4, 11–13, 23
expected outcome, 354 adult health, 248–249 Domestic violence, nursing actions/interventions
gerontic health, 358 child health, 249 fear, 556–557
home health, 358–359 expected outcome, 248 hopelessness, 565
mental health, 356–357 gerontic health, 251 powerlessness, 583
target dates, 354 home health/community health, 251–252 social isolation, 691
women’s health, 355–356 target dates, 248 violence, risk for, 702–703
related clinical concerns, 354 women’s health, 250–251 Double-bind communication, 524
related factors, 354 related clinical concerns, 248 Dressing and grooming
Delinquency, 526 related factors, 242, 248 self-care deficit, 386
Delirium, nursing actions/interventions, 513 taxonomy linkages, 235t toddler and preschooler, 274
Delusions, nursing actions/interventions, Diet. See Nutritional-metabolic pattern “Due to,” 7
509–511 Discipline, 524 Duodenocolic reflex, 231
Dementia, nursing actions/interventions, Disorganized infant. See Infant behavior, disor- Dysfunctional grieving. See Grieving, dysfunc-
512–513 ganized, risk for and actual tional
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858 • Index
Dysfunctional ventilatory weaning response related clinical concerns, 37 defining characteristics, 761
(DVWR), 279t, 331–336 related factors, 36–37 definitions, 760
defining characteristics, 331–332 taxonomy linkages, 33t differential diagnosis, 761–762
definition, 331 Environmental interpretation syndrome, caregiver role strain, risk for and actual,
differential diagnosis, 332 impaired, 447t–448t, 469–473 620
nursing actions/interventions, 333–336 defining characteristics, 469 health maintenance, ineffective, 43
adult health, 333 definition, 469 home maintenance, impaired, 360
child health, 333–335 differential diagnosis, 469 parental role conflict, 664
expected outcome, 332 nursing actions/interventions, 469–473 parenting, impaired, risk for and actual, 664
gerontic health, 335–336 adult health, 469–470 self-care deficit, 387
home health, 336 child health, 470 therapeutic regimen management, ineffec-
target dates, 332 expected outcome, 469 tive, 81
women’s health, 335 gerontic health, 472–473 violence, self-directed, risk for, 700
related clinical concerns, 332 home health, 473 nursing actions/interventions, 762–769
related factors, 332 mental health, 471–472 adult health, 762
taxonomy linkages, 279t target dates, 469 child health, 762–763
Dysgeusia, 126 women’s health, 471 expected outcome, 762
Dysreflexia, autonomic. See Autonomic dysre- related factors, 469 gerontic health, 767
flexia, risk for and actual taxonomy linkages, 447t–448t home health, 767
Etiology, 7–8 mental health, 763–766
E Evaluation, 13–14, 15f, 16f target dates, 762
Echolalia, 609 Evaporation, 123 women’s health, 763
Edema, 168 Exchanging, 18t related clinical concerns, 761
Eldercare Locator, 623 Exercise pattern. See Activity-exercise pattern related factors, 761
Elderly. See Older adult Expected outcomes, 8–9 taxonomy linkages, 745t
Electrolytes, 122 Expiratory reserve volume, 293t Family coping, readiness for enhanced, 745t,
Elimination Extremities, tissue perfusion. See Tissue perfu- 767–771
bowel, 231–232 sion, ineffective defining characteristics, 767–768
conceptual information, 230–231 definition, 767
urinary, 232–233 F differential diagnosis, 768
Elimination pattern, 229–267 Failure to thrive, adult, 127t, 128, 132–135 family coping, compromised and disabled,
assessment, 230, 835–836 defining characteristics, 131 761
bowel elimination, 231–232 definition, 131 nursing actions/interventions, 768–771
bowel incontinence, 236–240 differential diagnosis, 131 adult health, 768
conceptual information, 230–233 dentition, impaired, 155 child health, 769
constipation, 237, 240–248 nursing actions/interventions, 132–135 expected outcome, 768
description, 230 adult health, 132–133 gerontic health, 770–771
developmental considerations, 233–234 expected outcome, 132 home health, 771
adolescent, 234 gerontic health, 134–135 mental health, 769–770
adult, 234 home health/community health, 135 target dates, 768
infant, 233 mental health, 133–134 women’s health, 769
older adult, 234 target dates, 132 related clinical concerns, 768
school-age child, 234 related clinical concerns, 132 related factors, 768
toddler and preschooler, 233–234 related factors, 132 taxonomy linkages, 745t
young adult, 234 taxonomy linkages, 127t Family processes, dysfunctional, differential
diarrhea, 242, 248–252 Faith, 801–802. See also Value-belief pattern diagnosis, therapeutic regimen manage-
taxonomy linkages, 235t–236t Falls, risk for, 279t, 336–340 ment, ineffective, 81
urinary elimination, 232–233 defining characteristics, 336 Family processes, dysfunctional: alcoholism,
urinary elimination, readiness for enhanced, definition, 336 613t, 635–646
252–254 differential diagnosis, 337 defining characteristics, 635–636
urinary incontinence, 254–262 nursing actions/interventions, 337–340 definition, 635
urinary retention, 263–266 adult health, 337 differential diagnosis, 636
Enactive mode, 443 child health, 338 nursing actions/interventions, 637–646
Enema, 231 expected outcome, 337 adult health, 637
Energy field, disturbed, 33t, 36–42 gerontic health, 338–339 child health, 638
defining characteristics, 36 home health/community health, 340 expected outcome, 636–637
definition, 36 mental health, 338 gerontic health, 645
differential diagnosis, 37 target dates, 337 home health, 645–646
nursing actions/interventions, 37–42 women’s health, 338 mental health, 642–644
adult health, 37–38 related clinical concerns, 337 target dates, 637
child health, 38–39 taxonomy linkages, 279t women’s health, 639–640
expected outcome, 37 Family related clinical concerns, 636
gerontic health, 41–42 life cycle, 743–744 related factors, 636
home health, 42 types, 608 taxonomy linkages, 613t
mental health, 39–41 Family coping, compromised and disabled, 745t, Family processes, interrupted, 613t, 635–646
women’s health, 39 760–767 defining characteristics, 635–636
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Index • 859
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860 • Index
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Index • 861
disuse syndrome, risk for, 326 powerlessness, risk for and actual, 585–586 related clinical concerns, 360
diversional activity, deficient, 331 protection, ineffective, 106 related factors, 360
dysfunctional ventilatory weaning response, rape-trauma syndrome, 724 taxonomy linkages, 280t
336 religiosity, impaired, 807 Hope, 523
energy field, disturbed, 42 religiosity, readiness for enhanced, 810 Hopelessness, 523, 527t, 562–569
environmental interpretation syndrome, relocation stress syndrome, risk for and defining characteristics, 562
impaired, 473 actual, 677–678 definition, 562
failure to thrive, adult, 135 role performance, ineffective, 683 developmental considerations
falls, risk for, 340 sedentary lifestyle, 385 adolescent, 526
family coping, compromised and disabled, self-care deficit, 392–393 adult, 526–527
767 self-concept, readiness for enhanced, 590 infant, 524
family coping, readiness for enhanced, self-esteem, chronic low/situational low/situa- school-age child, 525
771 tional low, risk for, 597 toddler and preschooler, 525
family processes, interrupted, 645–646 self-mutilation, risk for and actual, differential diagnosis, 524, 562
family processes, readiness for enhanced, 601–602 environmental conditions, 523–524
645–646 sensory perception, disturbed, 505–506 nursing actions/interventions, 563–569
fatigue, 346 sexual dysfunction, 731 adult health, 563
fear, 561–562 sexuality patterns, ineffective, 736 child health, 563–564
fluid balance, readiness for enhanced, 161 sleep, readiness for enhanced, 439–440 expected outcome, 562
fluid volume, deficient, risk for and actual, sleep pattern, disturbed, 436–437 gerontic health, 568
167 social interaction, impaired, 688 home health, 568–569
fluid volume, excess, 172–173 social isolation, 694 mental health, 565–568
fluid volume, imbalanced, risk for, 176 sorrow, chronic, 699 target dates, 563
gas exchange, impaired, 351–352 spiritual distress, 817–818 women’s health, 564–565
grieving, anticipatory, 653 spiritual distress, risk for, 823–824 related clinical concerns, 562
grieving, dysfunctional, risk for and actual, spiritual well-being, readiness for enhanced, related factors, 562
659 827–828 taxonomy linkages, 527t
growth and development, delayed, 358–359 sudden infant death syndrome, risk for, Human response patterns, 16–17, 18t
health maintenance, ineffective, 48–49 112–114 Hygiene
health-seeking behaviors, 53 suicide, risk for, 796 self-care deficit, 386
home maintenance, impaired, 364–365 surgical recovery, delayed, 111 toddler and preschooler, 274
hopelessness, 568–569 therapeutic regimen management, effective, Hypersomnia, 422
hyperthermia, 181 79–80 Hypertension, pregnancy-induced, 287–288
hypothermia, 186 therapeutic regimen management, ineffective, Hyperthermia, 130t, 176–181
individual coping, ineffective, 783–784 90–92 defining characteristics, 176
individual coping, readiness for enhanced, therapeutic regimen management, readiness definition, 176
782 for enhanced, 95–96 differential diagnosis, 177
infant behavior, disorganized, risk for and thermoregulation, ineffective, 216 body temperature, imbalanced, risk for, 140
actual, 370 thought process, disturbed, 513–514 hypothermia, 182
infant behavior, readiness for enhanced organ- tissue integrity, impaired, 226–227 infection, risk for, 54
ized, 370 tissue perfusion, ineffective, 405 thermoregulation, ineffective, 214
infant feeding pattern, ineffective, 189 transfer ability, impaired, 408 nursing actions/interventions, 177–181
infection, risk for, 58–59 unilateral neglect, 516 adult health, 177–178
injury, risk for, 68–70 urinary incontinence, 261–262 child health, 178–179
knowledge, deficient, 479 urinary retention, 266 expected outcome, 177
knowledge, readiness for enhanced, 481–482 ventilation, spontaneous, impaired, 396 gerontic health, 180–181
latex allergy response, 75 violence, self-directed, risk for, 710–711 home health/community health, 181
loneliness, risk for, 574–575 walking, impaired, 411 mental health, 179–180
memory, impaired, 486 wandering, 415 newborn health, 179
nausea, 192 Home maintenance, impaired, 280t, 360–365 target dates, 177
nutrition, enhanced, readiness for, 193 defining characteristics, 360 women’s health, 179
nutrition, imbalanced, less than body require- definition, 360 related clinical concerns, 176
ments, 204 differential diagnosis, 360 related factors, 176
nutrition, imbalanced, more than body health maintenance, ineffective, 43 taxonomy linkages, 130t
requirements, 209 health-seeking behaviors, 50 Hypotension, orthostatic, 272
pain, acute and chronic, 496–497 injury, risk for, 61 Hypothermia, 130t, 182–186
parent, infant, and child attachment, impaired, therapeutic regimen management, ineffec- defining characteristics, 182
risk for, 662 tive, 81 definition, 182
parenting, impaired, risk for and actual, nursing actions/interventions, 361–365 differential diagnosis, 182
672–673 adult health, 361 body temperature, imbalanced, risk for, 140
perioperative-positioning injury, risk for, 100 child health, 361 hyperthermia, 177
peripheral neurovascular dysfunction, risk for, expected outcome, 360 thermoregulation, ineffective, 214
373 gerontic health, 364 nursing actions/interventions, 182–186
personal identity, disturbed, 578–579 home health/community health, 364–365 adult health, 182–184
physical mobility, impaired, 380–381 mental health, 363–364 child health, 184
post-trauma syndrome, risk for and actual, target dates, 360 expected outcome, 182
791 women’s health, 362 gerontic health, 186
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862 • Index
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Index • 863
Inspiratory capacity, 294t Knowledge, readiness for enhanced, 448t, defining characteristics, 482
Inspiratory reserve volume, 293t 479–482 definition, 482
Interventions. See specific nursing diagnosis defining characteristics, 479 differential diagnosis, 483
Interviewing, 6 definition, 479 confusion, acute and chronic, 455
Intracranial adaptive capacity, decreased, 447t, differential diagnosis, 479 wandering, 412
450–454 nursing actions/interventions, 480–482 nursing actions/interventions, 483–486
defining characteristics, 450 adult health, 480 adult health, 483
definition, 450 child health, 480 child health, 483
differential diagnosis, 450 expected outcome, 479 expected outcome, 483
nursing actions/interventions, 451–454 gerontic health, 481 gerontic health, 485–486
adult health, 451 home health/community health, 481–482 home health, 486
child health, 451–452 mental health, 481 mental health, 484–485
expected outcome, 450 target dates, 480 target dates, 483
gerontic health, 454 women’s health, 481 women’s health, 484
home health, 454 taxonomy linkages, 448t related clinical concerns, 482
mental health, 454 related factors, 482
target dates, 450 L taxonomy linkages, 448t
women’s health, 452–453 Labor. See also Postpartum period; Pregnancy Menopause, nursing actions/interventions
related clinical concerns, 450 pain, nursing actions/interventions, 491 anxiety, 536
related factors, 450 preterm, 286–287 sleep disturbance and, 424
taxonomy linkages, 447t Lactose intolerance, 121 Mental health, nursing actions/interventions
Intravenous nutrition, 198 Landau reflex, 444 activity intolerance, risk for and actual,
Latex allergy response, 35t, 70–75 290–291
J defining characteristics, 70 adaptive capacity, intracranial, decreased, 454
Joint Commission on Accreditation of definition, 70 adjustment, impaired, 751–755
Healthcare Organizations (JCAHO), 4, differential diagnosis, 70 anxiety, 537–539
5, 5f nursing actions/interventions, 71–75 aspiration, risk for, 138–139
adult health, 71–72 autonomic dysreflexia, risk for and actual, 303
K child health, 72–73 bed mobility, impaired, 306
Kidney expected outcome, 70 body image, disturbed, 545–547
infant, 124 gerontic health, 75 body temperature, imbalanced, risk for,
tissue perfusion. See Tissue perfusion, ineffec- home health, 75 142–143
tive mental health, 75 bowel incontinence, 239
Kinesthesia deficit, nursing actions/interven- target dates, 70 breastfeeding, interrupted, 154
tions, 499, 500, 503 women’s health, 73–74 breathing pattern, ineffective, 310–311
Kinship system, 608 related clinical concerns, 70 cardiac output, decreased, 318–319
Kleine-Levin syndrome, 423 related factors, 70 caregiver role strain, risk for and actual,
Knowing, 18t taxonomy linkages, 35t 623–624
Knowledge, deficient, 448t, 474–479 Laxatives, 231 communication, impaired verbal, 630–633
defining characteristics, 474 Less-than-perfect infant, nursing actions/inter- communication, readiness for enhanced, 633
definition, 474 ventions confusion, acute and chronic, 457–460
differential diagnosis, 474 chronic sorrow, 697 constipation, 246
decisional conflict, 464 decisional conflict, 466 death anxiety, 550–552
fear, 554 spiritual distress, 815 decisional conflict, 467–468
health maintenance, ineffective, 43 Levine’s conservation model, 14 dentition, impaired, 157
home maintenance, impaired, 360 Lifestyle, sedentary. See Sedentary lifestyle diarrhea, 251
injury, risk for, 61 Locus of control, 580 disuse syndrome, risk for, 323–325
knowledge, readiness for enhanced, Loneliness, risk for, 528t, 569–575 diversional activity, deficient, 329–330
479 definition, 569 energy field, disturbed, 39–41
nutrition, imbalanced, less than body differential diagnosis, 569 environmental interpretation syndrome,
requirements, 195 nursing actions/interventions, 569–575 impaired, 471–472
social interaction, impaired, 684 adult health, 569–570 failure to thrive, adult, 134–135
social isolation, 689 child health, 570 falls, risk for, 338
therapeutic regimen management, ineffec- expected outcome, 569 family coping, compromised and disabled,
tive, 81 gerontic health, 574 763–766
nursing actions/interventions, 474–479 home health, 574–575 family coping, readiness for enhanced,
adult health, 474–475 mental health, 572–574 769–770
child health, 475 target dates, 575 family processes, dysfunctional: alcoholism,
expected outcome, 474 women’s health, 571–572 642–644
gerontic health, 478 related clinical concerns, 569 family processes, interrupted, 640–642
home health, 479 risk factors, 569 family processes, readiness for enhanced, 644
mental health, 477–478 taxonomy linkages, 528t fatigue, 344
target dates, 474 Lung capacities and volumes, 293t–294t fear, 558–560
women’s health, 475–477 fluid balance, readiness for enhanced, 160
related clinical concerns, 474 M fluid volume, deficient, risk for and actual,
related factors, 474 Meconium, 233 166
taxonomy linkages, 448t Memory, impaired, 448t, 482–486 fluid volume, excess, 171–172
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Mental health (Continued) spiritual distress, risk for, 821–823 mental health, 191
fluid volume, imbalanced, risk for, 175 spiritual well-being, readiness for enhanced, target dates, 190
gas exchange, impaired, 350–351 827 women’s health, 191
grieving, anticipatory, 650–652 suicide, risk for, 793–795 related clinical concerns, 190
growth and development, delayed, 356–357 surgical recovery, delayed, 110 related factors, 189
health maintenance, ineffective, 47–48 swallowing, impaired, 212–213 taxonomy linkages, 130t
health-seeking behaviors, 51–52 therapeutic regimen management, effective, Near-miss sudden infant death syndrome, 423
home maintenance, impaired, 363–364 77–78 Neglect, unilateral. See Unilateral neglect
hopelessness, 565–568 therapeutic regimen management, ineffective, Neonate. See Infant
hyperthermia, 179–180 86–89 NNN Taxonomy of Nursing Practice, 20–22,
hypothermia, 185 therapeutic regimen management, readiness 21t–22t
individual coping, ineffective, 777–782 for enhanced, 94–95 Nocturia, 126
individual coping, readiness for enhanced, thermoregulation, ineffective, 215 Noncompliance, 80, 81, 82–83. See also
782 thought process, disturbed, 509–511 Therapeutic regimen management, ineffec-
infant behavior, disorganized, risk for and tissue integrity, impaired, 224–226 tive
actual, 370 tissue perfusion, ineffective, 401–404 differential diagnosis, knowledge, deficient,
infant behavior, readiness for enhanced organ- transfer ability, impaired, 408 474
ized, 370 unilateral neglect, 515 Non–rapid eye movement (NREM) sleep, 422
infection, risk for, 57–58 urinary elimination, readiness for enhanced, North American Nursing Diagnosis Association-
injury, risk for, 65–67 254 International (NANDA-I), 2, 7–8. See also
knowledge, deficient, 477–478 urinary incontinence, 260–261 Taxonomy
knowledge, readiness for enhanced, 481 urinary retention, 265–266 axes, 829–830
latex allergy response, 75 violence, self-directed, risk for, 704–708 descriptors, 830
loneliness, risk for, 572–574 walking, impaired, 410 “Not me,” 522
memory, impaired, 484–485 wandering, 413 Nursing, 3
nausea, 191 wheelchair mobility, impaired, 417 Nursing action, 10–11. See also specific nursing
nutrition, enhanced, readiness for, 193 Metabolic acidosis, 122 diagnosis
nutrition, imbalanced, less than body require- Metabolic pattern. See Nutritional-metabolic Nursing diagnosis, 7
ments, 201–203 pattern functional health patterns, 14–16, 17t
nutrition, imbalanced, more than body Metabolic rate, infant, 273 human response patterns, 16–17, 18t
requirements, 208 Metabolism, bed rest effects, 272 NNN Taxonomy, 20–22, 21t–22t
pain, acute and chronic, 492–495 Mobility, 271. See also Activity-exercise pattern; patterns, 14–22
parent, infant, and child attachment, impaired, Walking, impaired; Wandering taxonomies, 17–22, 18t–20t, 21t–22t
risk for, 661 bed. See Bed mobility, impaired Taxonomy II, 17–20, 18t–20t
parental role conflict, 669–672, 672–673 physical. See Physical mobility, impaired Nursing Interventions Classification, 2. See also
parenting, impaired, risk for and actual, wheelchair. See Wheelchair mobility, Taxonomy
669–672 impaired Nursing models, 14
parenting, readiness for enhanced, 672 Moro reflex, 444 Nursing Outcomes Classifications, 2. See also
perioperative-positioning injury, risk for, 99 Moving, 18t Taxonomy
personal identity, disturbed, 576–578 Mucous membrane integrity, 122–123 Nursing process, 2–14
physical mobility, impaired, 377–379 Musculoskeletal system assessment, 5–6
post-trauma syndrome, risk for and actual, bed rest effects, 271–272 care planning, 3–4
787–791 developmental considerations conceptual frameworks, 14–23
powerlessness, risk for and actual, 583–585 adolescent, 275–276 diagnostic divisions, 17–20, 18t–20t
protection, ineffective, 104–105 adult, 276–277 functional health patterns, 14–16, 17t
rape-trauma syndrome, 722–724 infant, 272–273 human response patterns, 16–17, 18t
religiosity, impaired, 806–807 older adult, 277–278 models, 14
religiosity, readiness for enhanced, 810 school-age child, 274–275 data, 5–6
relocation stress syndrome, risk for and toddler and preschooler, 273–274 data grouping, 7
actual, 675–676 young adult, 276 definition, 3
role performance, ineffective, 681–683 Mutilation behavior. See Self-mutilation, risk for diagnosis, 7–8. See also Nursing diagnosis
sedentary lifestyle, 383–384 and actual and specific diagnoses
self-care deficit, 390–391 documentation, 11–13
self-concept, readiness for enhanced, 588–589 N essential skills, 6
self-esteem, chronic low/situational low/situa- NANDA Nursing Diagnosis, 829–830 evaluation, 13–14, 15f, 16f
tional low, risk for, 594–596 Narcolepsy, 422 implementation, 9–11
self-mutilation, risk for and actual, 599–601 National League for Nursing Accrediting models, 14
sensory perception, disturbed, 503–504 Commission (NLNAC), 4 patterns, 14–22
sexual dysfunction, 728–730 Nausea, 130t, 189–192 planning, 8–9
sexuality patterns, ineffective, 734–735 defining characteristics, 189 purpose, 2–3
sleep, readiness for enhanced, 439 definition, 189 steps, 5–14
sleep deprivation, 428–429 nursing actions/interventions, 190–192 Nursing standards, 3, 3t, 4, 4t
sleep pattern, disturbed, 435 adult health, 190 Nutrition, 121–122
social interaction, impaired, 686–687 child health, 190–191 Nutrition, imbalanced, less than body require-
social isolation, 691–693 expected outcome, 190 ments, 130t, 194–204
sorrow, chronic, 697–698 gerontic health, 191–192 defining characteristics, 194–195
spiritual distress, 816–817 home health/community health, 192 definition, 194
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differential diagnosis, 195 assessment, 120–121, 834–835 Olfactory deficit, nursing actions/interventions,
constipation, 242 body temperature, imbalanced, risk for, 136, 500, 502
dentition, impaired, 155 139–144 Ondine’s curse, 423
diarrhea, 248 breastfeeding Oral mucous membrane, impaired, 132t,
failure to thrive, adult, 127 effective, 144–147 216–227
fatigue, 341 ineffective, 148–152 defining characteristics, 216–217
fluid volume, deficient, risk for and actual, interrupted, 152–155 definition, 216
161–162 conceptual information, 121–123 differential diagnosis
growth and development, delayed, 354 dentition, impaired, 155–158 fluid volume, deficient, risk for and actual,
infant feeding pattern, ineffective, 187 description, 120 161–162
infection, risk for, 54 developmental considerations, 123–127 infection, risk for, 54
physical mobility, impaired, 374 adolescent, 125 swallowing, impaired, 210
swallowing, impaired, 210 adult, 126 nursing actions/interventions, 218–227
nursing actions/interventions, 195–204 infant, 123–124 adult health, 218–220
adult health, 195–198 older adult, 126–127 child health, 220–221
child health, 198–199 school-age child, 125 expected outcome, 218
expected outcome, 195 toddler and preschooler, 124–125 gerontic health, 226
gerontic health, 203–204 young adult, 125–126 home health/community health, 226–227
home health/community health, 204 enhanced nutrition, readiness for, 190, mental health, 224–226
mental health, 201–203 193–194 newborn health, 224
newborn health, 200–201 failure to thrive, adult, 127, 132–135 target dates, 218
target dates, 195 fluid balance, readiness for enhanced, women’s health, 221–224
total parenteral nutrition, 198 158–161 related clinical concerns, 217
tube feedings, 197 fluid volume, 122 related factors, 217
women’s health, 199–201 deficient, 161–167 taxonomy linkages, 132t
related clinical concerns, 195 excess, 167–173 Overweight, 122
related factors, 195 imbalanced, risk for, 173–176
taxonomy linkages, 130t hyperthermia, 174, 176–181 P
Nutrition, imbalanced, more than body require- hypothermia, 177, 182–186 Pain, acute and chronic, 449t, 483, 486–497
ments, 131t, 204–209 infant feeding pattern, ineffective, 182, defining characteristics, 486–487
defining characteristics, 204–205 186–189 definitions, 483, 486
definitions, 204 nausea, 189–192 developmental considerations
differential diagnosis, 205 nutrition, 121–122 adolescent, 446
constipation, 242 imbalanced adult, 446–447
fluid volume, excess, 167 less than body requirements, 194–204 preschooler, 445
nutrition, enhanced, readiness for, 193 more than body requirements, school-age child, 445
physical mobility, impaired, 374 204–209 toddler, 445
nursing actions/interventions, 205–209 swallowing, impaired, 209–213 differential diagnosis, 487
adult health, 205–207 taxonomy linkages, 128t–132t airway clearance, ineffective, 293
child health, 207 thermoregulation, 123 energy field, disturbed, 37
expected outcome, 205 ineffective, 213–216 nutrition, imbalanced, less than body
gerontic health, 209 tissue integrity, 122–123 requirements, 195
home health/community health, 209 impaired, 216–227 nursing actions/interventions, 487–497
mental health, 208 adult health, 487–488
target dates, 205 O child health, 489–490
women’s health, 207–208 Objective data, for nursing process, 6 expected outcome, 487
related clinical concerns, 205 Older adult gerontic health, 495–496
related factors, 205 activity-exercise pattern, 277–278 home health, 496–497
taxonomy linkages, 131t cognitive-perceptual pattern, 446–447 mental health, 492–495
Nutrition, readiness for enhanced, 130t, 193–194 coping–stress tolerance pattern, 743 target dates, 487
defining characteristics, 192, 193 elimination pattern, 234 women’s health, 490–492
definition, 192 health perception–health management pattern, related clinical concerns, 487
differential diagnosis, 193 32–33 related factors, 487
nursing actions/interventions, 193–194 hearing development, 446 Palpation, 6
adult health, 193 nursing actions/interventions for. See specific Panic, 532. See also Anxiety
child health, 193 nursing diagnosis Parachute reflex, 444
expected outcome, 193 nutritional-metabolic pattern, 126–127 Parataxic mode, 522
gerontic health, 193 proprioception, 446 Parent, infant, and child attachment, impaired,
home health/community health, 193 role-relationship pattern, 612 risk for, 614t, 659–662
mental health, 193 self-perception/self-concept pattern, 527 definition, 659
target dates, 193 sexuality-reproductive pattern, 717 differential diagnosis, 660
women’s health, 193 sleep-rest pattern, 425 nursing actions/interventions, 660–662
related clinical concerns, 193 smell development, 446 adult health, 660
related factors, 193 taste development, 446 child health, 660–661
taxonomy linkages, 130t touch development, 446 expected outcome, 660
Nutritional-metabolic pattern, 120–228 value-belief pattern, 803 home health, 662
aspiration, risk for, 132, 136–139 vision development, 446 mental health, 661
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Relocation stress syndrome (Continued) family processes, readiness for enhanced, infection, risk for, 54
mental health, 675–676 635–646 nutrition, imbalanced, less than body
target dates, 674 grieving, anticipatory, 646–653 requirements, 195
women’s health, 675 grieving, dysfunctional, risk for and actual, sensory perception, disturbed, 498
related clinical concerns, 674 654–659 therapeutic regimen management, ineffec-
related factors, 674 parent, infant, and child attachment, impaired, tive, 81
taxonomy linkages, 615t–616t risk for, 659–662 dressing and grooming, 282t, 386
Reproductive pattern. See Sexuality-reproductive parental role conflict, 662–673 feeding, 281t, 386
pattern parenting, impaired, risk for and actual, nursing actions/interventions, 387–393
Residual volume, 293t 662–673 adult health, 387–388
Respiration parenting, readiness for enhanced, 662–673 child health, 388
activity-exercise pattern, 276 relocation stress syndrome, risk for and expected outcome, 387
bed rest effects, 271–272 actual, 673–678 gerontic health, 392
developmental considerations role performance, ineffective, 678–683 home health, 392–393
infant, 273 social interaction, impaired, 684–688 mental health, 390–391
older adult, 277 social isolation, 688–694 target dates, 387
school-age child, 275 sorrow, chronic, 695–699 women’s health, 389–390
toddler and preschooler, 274 taxonomy linkages, 613t–618t related clinical concerns, 386
Respiratory acidosis, 271–272 violence, self-directed and other-directed, risk related factors, 386
Respiratory rate for, 700–711 toileting, 282t, 386
adolescent, 275 Role strain, caregiver. See Caregiver role strain differential diagnosis
adult, 276, 277 Roy’s adaptation model, 14 bowel incontinence, 237
school-age child, 275 constipation, 242
toddler and preschooler, 274 S urinary retention, 263
Rest, 422 School-age child Self-concept, 520–523. See also Self-
Rest pattern. See Sleep-rest pattern activity-exercise pattern, 274–275 perception/self-concept pattern
Reticular activating system, 422 cognitive-perceptual pattern, 445–446 Self-concept, readiness for enhanced, 529t,
“Risk for,” 8 coping–stress tolerance pattern, 742–743 586–590
Role, 607–608 elimination pattern, 234 defining characteristics, 586
gender, 714–715 health perception–health management pattern, definition, 586
Role achievement, 607 31 differential diagnosis, 586
Role performance, ineffective, 616t, 678–683 nursing actions/interventions. See specific self-esteem, chronic low/situational low/
defining characteristics, 678 nursing diagnosis situational low, risk for, 591
definition, 678 nutritional-metabolic pattern, 125 nursing actions/interventions, 587–590
differential diagnosis, 679 pain sensation, 445 adult health, 587
nursing actions/interventions, 679–683 role-relationship pattern, 610–611 child health, 587
adult health, 679 self-perception/self-concept pattern, 525–526 expected outcome, 586
child health, 680 sexuality-reproductive pattern, 716 gerontic health, 589
expected outcome, 679 sleep-rest pattern, 424 home health, 590
gerontic health, 683 value-belief pattern, 802 mental health, 588–589
home health, 683 Secondary prevention, 29 target dates, 586
mental health, 681–683 “Secondary to,” 7 women’s health, 588
target dates, 679 Sedentary lifestyle, 281t, 381–385 related clinical concerns, 586
women’s health, 680–681 defining characteristics, 381 taxonomy linkages, 529t
related clinical concerns, 679 definition, 381 Self-disclosure, 523
related factors, 678–679 nursing actions/interventions, 382–385 Self-esteem, chronic low/situational low/situa-
taxonomy linkages, 616t adult health, 382 tional low, risk for, 529t, 590–598
Role-relationship pattern, 605–665 child health, 382–383 defining characteristics, 590
assessment, 606–607, 839–840 expected outcome, 381 definitions, 590
caregiver role strain, risk for and actual, gerontic health, 384–385 differential diagnosis, 591
618–626 home health/community health, 385 body image, disturbed, 541
communication, impaired verbal, 618–626 mental health, 383–384 diarrhea, 248
communication, readiness for enhanced, target dates, 381 nutrition, imbalanced, less than body
618–626 women’s health, 383 requirements, 195
conceptual information, 607–608 related factors, 381 personal identity, disturbed, 575
description, 606 taxonomy linkages, 281t self-concept, readiness for enhanced, 586
developmental considerations, 608–612 Seizures, infant, 444 nursing actions/interventions, 591–599
adolescent, 611 Self, 520–523. See also Self-perception/self- adult health, 591–592
middle-age adult, 612 concept pattern child health, 592–593
neonate and infant, 608–609 Self-care deficit, 281t–282t, 386–393 expected outcome, 591
older adult, 612 bathing and hygiene, 281t, 386 gerontic health, 597
school-age child, 610–611 defining characteristics, 386 home health, 597
toddler and preschooler, 609–610 definition, 386 mental health, 594–596
young adult, 611–612 differential diagnosis, 386–387 target dates, 598
family processes, dysfunctional: alcoholism, activity intolerance, risk for and actual, 284 women’s health, 593–594
635–646 fluid volume, deficient, risk for and actual, 162 related clinical concerns, 591
family processes, interrupted, 635–646 health maintenance, ineffective, 43 related factors, 590–591
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Tissue perfusion (Continued) home health/community health, 408 stress, 254, 255
nutrition, imbalanced, less than body mental health, 408 taxonomy linkages, 235t–236t
requirements, 195 target dates, 406 total, 254, 255
peripheral neurovascular dysfunction, risk women’s health, 407 urge, 255–256
for, 371 related clinical concerns, 406 Urinary retention, 232, 263–266
surgical recovery, delayed, 107 taxonomy linkages, 283t defining characteristics, 263
nursing actions/interventions, 397–405 Trauma. See Injury, risk for; Post-trauma syn- definition, 263
adult health, 397–398 drome; Rape-trauma syndrome; Violence, differential diagnosis, 263
child health, 398–399 self-directed and other-directed, risk for autonomic dysreflexia, risk for and actual,
expected outcome, 397 Tube feeding, 197 300
gerontic health, 404 fluid volume, excess, 168
home health, 405 U nursing actions/interventions, 263–266
mental health, 401–404 Underweight, 121 adult health, 263–264
target dates, 397 Unilateral neglect, 450t, 514–516 child health, 264–265
women’s health, 400–401 defining characteristics, 514 expected outcome, 263
related clinical concerns, 397 definition, 514 gerontic health, 266
related factors, 397 differential diagnosis, 514 home health, 266
Today’s Caregiver, 623 nursing actions/interventions, 514–516 mental health, 265–266
Toddler adult health, 514–515 target dates, 263
activity-exercise pattern, 273–274 child health, 515 women’s health, 265
cognitive-perceptual pattern, 444–445 expected outcome, 514 related clinical concerns, 263
coping–stress tolerance pattern, 742 gerontic health, 516 related factors, 263
dental caries, 124 home health, 516 taxonomy linkages, 236t
elimination pattern, 233–234 mental health, 515
health perception–health management pattern, target dates, 514 V
29–31 women’s health, 515 Valsalva maneuver, 232
hopelessness, 525 related clinical concerns, 514 Value-belief pattern, 799–828
motor development, 273–274 related factors, 514 assessment, 800, 841
nutritional-metabolic pattern, 124–125 taxonomy linkages, 450t conceptual information, 800–802
pain sensation, 445 Unwanted pregnancy, 465–466 developmental considerations, 802–803
role-relationship pattern, 609–610 Urethral sphincter, 232 impaired religiosity, 804–807
self-perception/self-concept pattern, 524–525 Urge incontinence, 255–256 religiosity, impaired, risk for, 811–812
sexuality-reproductive pattern, 715–716 Urinary elimination, 232–233 religiosity, readiness for enhanced, 808–810
sleep-rest pattern, 424 Urinary elimination, readiness for enhanced, spiritual distress, 812–818
smell sense development, 445 252–254 spiritual distress, risk for, 818–824
taste sense development, 445 defining characteristics, 252 spiritual well-being, readiness for enhanced,
touch sense development, 445 definition, 252 824–828
value-belief pattern, 802 nursing actions/interventions, 252–254 taxonomy linkages, 803t
vision development, 444–445 adult health, 252–253 Valuing, 18t
Toileting child health, 253 Ventilation, spontaneous, impaired, 282t,
self-care deficit, 282t, 386 expected outcome, 252 393–396
differential diagnosis gerontic health, 254 defining characteristics, 393
bowel incontinence, 237 mental health, 254 definition, 393
constipation, 242 target dates, 252 differential diagnosis, 394
urinary retention, 263 women’s health, 254 nursing actions/interventions, 394–396
toddler and preschooler, 274 taxonomy linkages, 235t adult health, 394
TORCH infections, 30 Urinary incontinence, 232, 235t–236t, 254–262 child health, 394–395
Total lung capacity, 293t defining characteristics, 255 expected outcome, 394
Total parenteral nutrition, 197 definitions, 254–255 gerontic health, 396
Touch, developmental considerations differential diagnosis, 256 home health, 396
adolescent, 446 fluid volume, deficient, risk for and actual, target dates, 394
adult, 446 162 women’s health, 396
infant, 444 urinary retention, 263 related clinical factors, 393
toddler, 445 functional, 254, 255 related factors, 393
women’s, 502–503 nursing actions/interventions, 256–262 taxonomy linkages, 282t
Touch deficit, nursing actions/interventions, 500, adult health, 256–258 Ventilatory weaning response, dysfunctional.
502–503 child health, 258–259 See Dysfunctional ventilatory weaning
Transfer ability, impaired, 283t, 406–408 expected outcome, 256 response (DVWR)
defining characteristics, 406 gerontic health, 261 Verbal communication, impaired. See
definition, 406 home health, 261–262 Communication, impaired verbal
differential diagnosis, 406 mental health, 260–261 Violence, self-directed and other-directed, risk
nursing actions/interventions, 406–408 target dates, 256 for, 617t–618t, 700–711
adult health, 406–407 women’s health, 259–260 defining characteristics, 700
child health, 407 reflex, 254, 255 definition, 700
expected outcome, 406 related clinical concerns, 256 differential diagnosis, 700–701
gerontic health, 408 related factors, 255–256 coping, ineffective, 772
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