Saturday, February 28, 2009

Nursing Care Plans With Nursing Diagnosis: Deficient Fluid volume

. Saturday, February 28, 2009

Nursing Diagnosis: Deficient Fluid volume

NANDA Definition for Deficient Fluid volume: Decreased intravascular, interstitial, and or intracellular fluid

Defining Characteristics Deficient Fluid volume : Decreased urine output, increased urine concentration, weakness, sudden weight loss,  decreased venous filling,  increased body temperature,  decreased pulse volume or pressure, change in mental state,  elevated hematocrit, decreased skin or tongue turgor; dry skin/mucous membranes,  thirst,  increased pulse rate,  decreased blood pressure.

Related Factors: Active fluid volume loss; failure of regulatory mechanisms

NOC Outcomes (Nursing Outcomes Classification): Suggested NOC Labels
· Fluid Balance
· Hydration
· Nutritional Status: Food and Fluid Intake

Client Outcomes
· Maintains urine output more than 1300 ml/day (or at least 30 ml/hr)
· Maintains normal blood pressure, pulse, and body temperature
· Maintains elastic skin turgor; moist tongue and mucous membranes; and orientation to person, place, time
· Explains measures that can be taken to treat or prevent fluid volume loss
· Describes symptoms that indicate the need to consult with health care provider

NIC Interventions (Nursing Interventions Classification) Suggested NIC Labels
· Fluid Management
· Hypovolemia Management
· Shock Management: Volume

Nursing Interventions and Rationales

  • Monitor for the existence of factors causing deficient fluid volume (e.g., gastrointestinal losses, difficulty maintaining oral intake, fever, uncontrolled type II diabetes mellitus, diuretic therapy). Early identification of risk factors and early intervention can decrease the occurrence and severity of complications from deficient fluid volume. The gastrointestinal system is a common site of abnormal fluid loss.
  • Watch for early signs of hypovolemia, including weakness, muscle cramps, and postural hypotension. Late signs include oliguria; abdominal or chest pain; cyanosis; cold, clammy skin; and confusion.
  • Monitor total fluid intake and output every 8 hours and every hour for the unstable client.
  • Watch trends in output for 3 days; include all routes of intake and output and note color and specific gravity of urine. Monitoring for trends for 2 to 3 days gives a more valid picture of the client's hydration status than monitoring for a shorter period. Dark-colored urine with increasing specific gravity reflects increased urine concentration.
  • Monitor daily weight for sudden decreases, especially in the presence of decreasing urine output or active fluid loss. Weigh client on same scale with same type of clothing at same time of day, preferably before breakfast. Body weight changes reflect changes in body fluid volume. A 1-pound weight loss reflects a fluid loss of about 500 cc.
  • Monitor vital signs of clients with deficient fluid volume every 15 minutes to 1 hour for the unstable client and every 4 hours for the stable client. Observe for decreased pulse pressure first, then hypotension, tachycardia, decreased pulse volume, and increased or decreased body temperature.  A decreasd pulse pressure is an earlier indicator of shock than is the systolic blood pressure.  Decreased intravascular volume results in hypotension and decreased tissue oxygenation. The temperature will be decreased as a result of decreased metabolism, or it may be increased if there is infection or hypernatremia present.
  • Check orthostatic blood pressures with client lying, sitting, and standing. A 15 mm Hg drop when upright or an increase of 15 beats/minute in the pulse rate are seen with deficient fluid volume.
  • Monitor for inelastic skin turgor, thirst, dry tongue and mucous membranes, longitudinal tongue furrows, speech difficulty, dry skin, sunken eyeballs, weakness, and confusion. Tongue dryness, longitudinal tongue furrows, dryness of the mucous membranes of the mouth, upper body muscle weakness, thirst, confusion, speech difficulty, and sunkenness of eyes are symptoms of deficient fluid volume.
  • Provide frequent oral hygiene, at least twice a day. Oral hygiene decreases unpleasant tastes in the mouth and allows the client to respond to the sensation of thirst.
  • Provide fresh water and oral fluids preferred by client, provide prescribed diet; offer snacks, instruct significant other to assist client with feedings as appropriate. The oral route is preferred for maintaining fluid balance. Distributing the intake over the entire 24 hour period and providing snacks and preferred beverages increases the likelihood that the client will maintain the prescribed oral intake.
  • Provide free water with tube feedings as appropriate. This provides water for replacement of intravascular or intracellular volume as necessary. Tube feeding has been found to increase the risk for dehydration.
  • Institute measures to rest the bowel when client is vomiting or has diarrhea,. Hydrate client with ordered IV solutions if prescribed. The most common cause of deficient fluid volume is gastrointestinal loss of fluid. At times it is preferable to allow the gastrointestinal system to rest before resuming oral intake.
  • Provide oral replacement therapy as ordered with a glucose-electrolyte solution when client has acute diarrhea or nausea or vomiting. Provide small, frequent quantities of slightly chilled solutions. Maintenance of oral intake stabilizes the ability of the intestines to digest and absorb nutrients; glucose-electrolyte solutions increase net fluid absorption while correcting deficient fluid volume.
  • Administer antidiarrheals and antiemetics as appropriate. The gastrointestinal tract is a common site for fluid loss. The goal is to stop the loss that results from vomiting or diarrhea.
  • If client requires IV fluid replacement, maintain patent IV access, set an appropriate IV infusion flow rate, and administer at a constant flow rate as ordered. Isotonic IV fluids such as 0.9% N/S or lactated ringers allow replacement of intravascular volume.
  • Assist with ambulation if client has postural hypotension. Postural hypotension can cause dizziness, which places the client at higher risk for injury.
  • Promote skin integrity (e.g., monitor areas for breakdown, ensure frequent weight shifts, prevent shearing, promote adequate nutrition). Deficient fluid volume decreases tissue oxygenation, which makes the skin more vulnerable to breakdown.
Critically ill Nursing Care Plans
  • Monitor central venous pressure, right atrial pressure, and pulmonary wedge pressure for decreases. Hemodynamic parameters are sensitive indicators of intravascular fluid volume, and hemodynamic measurements are especially needed in the client with cardiac or renal problems.
  • Monitor serum and urine osmolality, serum sodium, blood urea nitrogen (BUN)/creatinine ratio, and hematocrit for elevations. These are all measures of concentration and will be elevated with decreased intravascular volume.
  • When ordered, initiate a fluid challenge of crystalloids for replacement of intravascular volume; monitor client's response to prescribed fluid therapy and fluid challenge, especially noting vital signs, urine output, and lung sounds. A fluid challenge can help the client with deficient fluid volume regain intravascular volume quickly, but the client must be carefully observed to ensure that he or she does not go into fluid volume overload. In trauma clients, if there is no clinical improvement after 2 L of crystalloids, then generally a blood transfusion should be iniated.
  • Position client flat with legs elevated when hypotensive, if not contraindicated. This position enhances venous return, thus contributing to the maintenance of cardiac output.
  • If trauma client, monitor lactic acid levels as ordered, along with watching for signs of fluid deficit and shock. Increased lactic acid levels can help identify occult hypoperfusion, which results in decreased survival and increased incidence of respiratory complications and multiple organ failure in trauma clients.
  • Consult physician if signs and symptoms of deficient fluid volume persist or worsen. Prolonged deficient fluid volume increases the risk for development of complications, including shock, multiple organ failure, and death.
 Nursing Care Plans for Geriatric
  • Monitor elderly clients for deficient fluid volume carefully, noting new onset of weakness, dizziness, or dry mouth with longitudinal furrows. The elderly are predisposed to deficient fluid volume because of decreased fluid in body, decreased thirst sensation, and decreased ability to concentrate urine.
  • Check skin turgor of elderly client on the forehead or sternum; also look for the presence of longitudinal furrows on the tongue and dry mucous membranes. Elderly people commonly have decreased skin turgor from normal age-related loss of elasticity; therefore checking skin turgor on the arm is not reflective of fluid volume (Bennett, 2000). The presence of longitudinal furrows or dry mucous membranes is a good indication of dehydration in the elderly.
  • Encourage fluid intake by offering fluids regularly to cognitively impaired clients. The elderly have a decreased thirst sensation (Metheny, 2000), and short-term memory loss may impede the client's memory of fluid intake.
  • Incorporate regular hydration into daily routines Integration of hydration into regular routines increases the chance that the client will meet the daily fluid requirements.
  • Monitor elderly clients for excess fluid volume during the treatment of deficient fluid volume: listen to lung sounds, watch for edema, and note vital signs. The elderly client has a decreased ability to adapt to rapid increases in intravascular volume and can quickly develop heart failure.
Home Care Interventions
  • Determine if it is appropriate to intervene for defecient fluid volume or allow the client to die comfortably without fluids as desired. Deficient fluid volume may be a symptom of impending death in terminally ill clients. The deficit may result in a mild euphoria, and a more comfortable death.
  • Teach family members how to monitor output in the home. Instruct them to monitor both intake and output. An accurate measure of fluid intake and output is an important indicator of client fluid status.
  • When weighing client, use same scale each day. Be sure scale is on a flat surface. Do not weigh client with scale placed on any kind of rug. Use bed or chair scales for clients who are unable to stand. An accurate daily weight is an excellent reflection of fluid balance.
  • Teach family about complications of deficient fluid volume and when to call physician.
  • If the client is receiving IV fluids, there must be a responsible caregiver in the home. Teach caregiver about administration of  fluids, complications of IV administration, and when to call for assistance. Assist caregiver with administration for as long as necessary to maintain client safety. Administration of IV fluids in the home is a high-technology procedure and requires sufficient professional support to ensure safety of the client.
  • Identify an emergency plan, including when to call help. Some complications of deficient fluid volume cannot be reversed in the home and are life-threatening. Clients progressing toward hypovolemic shock will need emergency care.
Client and Family Teaching
  • Instruct client to avoid rapid position changes, especially from supine to sitting or standing.
  • Teach client and family about appropriate diet and fluid intake.
  • Teach client and family how to measure and record intake and output accurately.
  • Teach client and family about measures instituted to treat hypovolemia and to prevent or treat fluid volume loss.
  • Instruct client and family about signs of deficient fluid volume that indicate they should contact health care provider.


Friday, February 27, 2009

Nursing Care Plans for Decreased Cardiac output

. Friday, February 27, 2009

Nursing Diagnosis: Decreased Cardiac output
Nursing Care Plans for Decreased Cardiac output
NANDA Definition: Inadequate blood pumped by the heart to meet metabolic demands of the body

Defining Characteristics: Altered heart rate/rhythm: arrhythmias (tachycardia, bradycardia); palpitations; EKG changes; altered preload: jugular vein distention; fatigue; edema; murmurs; increased/decreased central venous pressure (CVP); increased/decreased pulmonary artery wedge pressure (PAWP); weight gain; altered afterload: cold/clammy skin; shortness of breath/dyspnea; oliguria; prolonged capillary refill; decreased peripheral pulses; variations in blood pressure readings; increased/decreased systemic vascular resistance (SVR); increased/decreased pulmonary vascular resistance (PVR); skin color changes; altered contractility: crackles; cough; orthopnea/paroxysmal nocturnal dyspnea; cardiac output less than 4 L/min; cardiac index less than 2.5 L/min; decreased ejection fraction, stroke volume index (SVI), left ventricular stroke work index (LVSWI); S3 or S4 sounds; behavioral/emotional: anxiety ; restlessness

Related Factors: Myocardial infarction or ischemia, valvular disease, cardiomyopathy, serious dysrhythmia, ventricular damage, altered preload or afterload, pericarditis, sepsis, congenital heart defects , vagal stimulation, stress, anaphylaxis, cardiac tamponade

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Cardiac Pump Effectiveness
• Circulatory Status
• Tissue Perfusion: Abdominal Organs
• Tissue Perfusion: Peripheral
• Vital Signs Status

Client Outcomes

  • Demonstrates adequate cardiac output as evidenced by blood pressure and pulse rate and rhythm within normal parameters for client; strong peripheral pulses; and an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain
  • Remains free of side effects from the medications used to achieve adequate cardiac output
  • Explains actions and precautions to take for cardiac disease

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Cardiac Care: Acute
• Circulatory Care

Nursing Interventions and Rationales

  • Monitor for symptoms of heart failure and decreased cardiac output, including diminished quality of peripheral pulses, cool skin and extremities, increased respiratory rate, presence of paroxysmal nocturnal dyspnea or orthopnea, increased heart rate, neck vein distention, decreased level of consciousness, and presence of edema. As these symptoms of heart failure progress, cardiac output declines.
  • Listen to heart sounds; note rate, rhythm, presence of S3, S4, and lung sounds. The new onset of a gallop rhythm, tachycardia, and fine crackles in lung bases can indicate onset of heart failure. If client develops pulmonary edema, there will be coarse crackles on inspiration and severe dyspnea.
  • Observe for confusion , restlessness, agitation, dizziness. Central nervous system disturbances may be noted with decreased cardiac output.
  • Observe for chest pain or discomfort; note location, radiation, severity, quality, duration, associated manifestations such as nausea, and precipitating and relieving factors. Chest pain/discomfort is generally indicative of an inadequate blood supply to the heart, which can compromise cardiac output. Clients with heart failure can continue to have chest pain with angina or can reinfarct.
  • If chest pain is present, have client lie down, monitor cardiac rhythm, give oxygen, run a strip, medicate for pain, and notify the physician. These actions can increase oxygen delivery to the coronary arteries and improve client prognosis.
  • Place on cardiac monitor; monitor for dysrhythmias, especially atrial fibrillation. Atrial fibrillation is common in heart failure.
  • Monitor hemodynamic parameters for an increase in pulmonary wedge pressure, an increase in systemic vascular resistance, or a decrease in cardiac output and index. Hemodynamic parameters give a good indication of cardiac function.
  • Titrate inotropic and vasoactive medications within defined parameters to maintain contractility, preload, and afterload per physician's order. By following parameters, the nurse ensures maintenance of a delicate balance of medications that stimulate the heart to increase contractility, maintaining adequate perfusion of the body.
  • Monitor intake and output. If client is acutely ill, measure hourly urine output and note decreases in output. Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output.
  • Note results of EKG and chest Xray. EKG can reveal previous MI,or evidence of left ventricular hypertrophy, indicating aortic stenosis or chronic systemic hypertension . Xray may provide information on pulmonary edema, pleural effusions, or enlarged cardiac silhouette found in dilated cardiomyopathy or large pericardial effusion.
  • Results of diagnostic imaging studies such as echocardiogram, radionuclide imaging or dobutamine stress echocardiography. The echocardiogram is the most important imaging tool for evaluation patients with symptoms of heart failure because overall systolic function and chamber size can be evaluated quickly. In addition, global versus regional left ventricular function, valvular abnormalities, and diastolic function can be defined, assisting in differential diagnosis. An ejection fraction in a healthy heart is approximately 50%. Most patients experiencing heart failure have an ejection fraction of less than 40%.
  • Watch laboratory data closely, especially arterial blood gases and electrolytes, including potassium. Client may be receiving cardiac glycosides and the potential for toxicity is greater with hypokalemia; hypokalemia is common in heart clients because of diuretic use.
  • Monitor lab work such as complete blood count, sodium level, and serum creatinine. Routine blood work can provide insight into the etiology of heart failure and extent of decompensation. A low serum sodium level often is observed with advanced heart failure and can bea poor prognostic sign.  Serum creatinine levels will elevate in clients with severe heart failure because of decreased perfusion to the kidneys.Creatinine may also elevate because of ACE inhibitors.
  • Administer oxygen as needed per physician's order.
  • Place client in semi-Fowler's position or position of comfort. Elevating the head of the bed may decrease the work of breathing, and also decrease venous return and preload.
  • Check blood pressure, pulse, and condition before administering cardiac medications such as angiotensin converting enzyme (ACE) inhibitors, digoxin, and beta-blockers such as carvedilol. Notify physician if heart rate or blood pressure is low before holding medications. It is important that the nurse evaluate how well the client is tolerating current medications before administering cardiac medications; do not hold medications without physician input. The physician may decide to have medications administered even though the blood pressure or pulse rate has lowered.
  • During acute events, ensure client remains on bed rest or maintains activity level that does not compromise cardiac output. In severe heart failure, restriction of activity often facilitates temporary recompensation.
  • Gradually increase activity when client's condition is stabilized by encouraging slower paced activities or shorter periods of activity with frequent rest periods following exercise prescription; observe for symptoms of intolerance. Take blood pressure and pulse before and after activity and note changes. Activity of the cardiac client should be closely monitored. See Activity intolerance .
  • Serve small sodium-restricted, low-cholesterol meals. Give only small amounts of caffeine-containing beverages,  if no resulting dysrhythmia. Sodium-restricted diets help decrease fluid volume excess. Low-cholesterol diets help decrease atherosclerosis, which causes coronary artery disease. Clients with cardiac disease tolerate smaller meals better because they require less cardiac output to digest. One cup of caffeinated coffee has generally not been found to have any significant effect (Schneider, 1987; Powell, 1993).
  • Monitor bowel function. Provide stool softeners as ordered. Caution client not to strain when defecating. Decreased activity can cause constipation. Straining when defecating that results in the Valsalva maneuver can lead to dysrhythmia, decreased cardiac function, and sometimes death.
  • Have clients use a commode or urinal for toileting and avoid use of a bedpan. Getting out of bed to use a commode or urinal does not stress the heart any more than staying in bed to toilet. In addition, getting the client out of bed minimizes complications of immobility and is often preferred by the client.
  • Provide a restful environment by minimizing controllable stressors and unnecessary disturbances. Schedule rest periods after meals and activities. Rest periods decrease oxygen consumption.
  • Weigh client at same time daily. An accurate daily weight is a good indicator of fluid balance. Increased weight and severity of symptoms can signal decreased cardiac function with retention of fluids.
  • Assess for presence of anxiety; see interventions for Anxiety  to facilitate reduction of anxiety in clients and family.
  • Consider using music to decrease anxiety and improve cardiac function. Music has been shown to reduce heart rate, blood pressure, anxiety, and cardiac complications.
  • Closely monitor fluid intake including IV lines. Maintain fluid restriction if ordered. In clients with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volumes.
  • Refer to heart failure program or cardiac rehabilitation program for education, evaluation, and guided support to increase activity and rebuild life. Exercise can help many patients with heart failure. Whereas rest was commonly recommended a few years ago, it has become clear that inactivity can worsen the skeletal muscle myopathy in these patients.A carefully monitored exercise program can improve both functional capacity, and left ventricular function. Exercise based cardiac rehabilitation programs apppear to be effective in reducing cardiac deaths, but the evidence base is weakened by poor quality trials.

Geriatric Care Plans

  • Observe for atypical pain; the elderly often have jaw pain instead of chest pain or may have silent myocardial infarctions with symptoms of dyspnea or fatigue. The elderly have altered pain pathways and often do not experience the usual chest pain of cardiac patients.
  • Observe for syncope, dizziness, palpitations, or feelings of weakness associated with a irregular heart rhythm. Dysrhythmias are common in the elderly.
  • Observe for side effects from cardiac medications. The elderly have difficulty with metabolism and excretion of medications due to decreased function of the liver and kidneys; therefore toxic side effects are more common.

Home Care Interventions for Decreased Cardiac output

  • Begin discharge planning as soon as possible with case manager or social worker to assess home support systems and the need for community or home health services. These may be to assist with home care, assistance with meal perparations, housekeeping, personal care, transportation to doctor visits, or emotional support. Clients often need help upon discharge. The existing social support network needs to be assessed and assistance provided as needed to meet client needs and to keep the support persons from being overwhelmed. Being discharged to home without adequate support has been shown to be related to readmission of elderly patients.
  • Assess or refer to case manager or social worker to evaluate client ability to pay for prescriptions. The cost of drugs may be a factor to fill prescriptions and adhere to a treatment plan.
  • Continue to monitor client for exacerbation of heart failure when discharged home. Transition to home can create increased stress and physiological instability related to diagnosis.
  • Assess client for understanding and compliance with medical regimen, including medications, activity level, and diet.
  • Instruct family and client about the disease process, complications of disease process, information on medications, need for weighing daily, and when it is appropriate to call doctor. Early recognition of symptoms facilitates early problem solving and prompt treatment. Clients with heart failure need intensive guideline gased education about these topics to help prevent readmission to the hospital.
  • Identify emergency plan, including use of CPR. Decreased cardiac output can be life threatening.
  • Help family adapt daily living patterns to establish life changes that will maintain improved cardiac functioning in the client. Transition to the home setting can cause risk factors such as inappropriate diet to reemerge.
  • Refer to physical therapy for strengthening exercises if client is not involved in cardiac rehabilitation.
  • Refer to medical social services as necessary for counseling about the impact of severe or chronic cardiac disease. Social workers can assist the client and family with acceptance of life changes.

Client/Family Teaching

  • Teach symptoms of heart failure and appropriate actions to take if client becomes symptomatic.
  • Teach importance of smoking cessation and avoidance of alcohol intake. Clients who continue to smoke increase their chance of dying by at least 50%, and alcohol depresses heart contractility. Smoking cessation advice and counsel given by nurses can be effective, and should be available to clients to help stop smoking.
  • Teach stress reduction (e.g., imagery, controlled breathing, muscle relaxation techniques).
  • Explain necessary restrictions, including consumption of a sodium-restricted diet, guidelines on fluid intake, and the avoidance of Valsalva's maneuver. Teach the importance of pacing activities, work simplification techniques, and the need to rest between activities to prevent becoming overly fatigued. Sodium retentiion leading to fluid overload is a common cause of hospital readmission.
  • Assist client in understanding the need for and how to incorporate lifestyle changes. Refer to cardiac rehabilitation for assistance with coping and adjustment. Psychoeducational programs including information on stress management and health education have been shown to reduce long term mortality and recurrence of myocardial infarction in heart patients.
  • Teach client actions, side effects, and importance of consistently taking cardiovascular medications. Medications can prolong the lives of heart failure clients but often are not taken, resulting in hospital readmissions.
  • Provide client/family with advance directive information to consider. Allow client to give advance directions about medical care or designates who should make medical decisions if he or she should lose decision-making capacity.
  • Instruct client on importance of getting a pneumonia shot  and yearly flu shots as prescribed by physician. Clients with decreased cardiac output are considered higher risk for complications or death if they do not get immunization injections.
  • Instruct client/family on the need to weigh daily and keep a weight log. Ask if client has a scale at home; if not, assist in getting one. Instruct on establishing baseline weight on own scale when gets home. Weighing daily is an essential aspect of self-management. A scale is necessary. Scales vary and the client needs to establish a baseline weight on their home scale.
  • Provide specific written materials and self care plan for client/caregivers to use for reference. Consult dietitian or assist client in understanding the need for a sodium-restricted diet. Provide alternatives for salt such as spices, herbs, lemon juice, or vinegar. Although the initial elimination of salt from the diet is very difficult for a person use to its taste, the taste of salt can be unlearned. The above can enhance the taste appeal of food while the preference for salt is changing.
  • Instruct family regarding cardiopulmonary resuscitation.


Nursing care plans For Constipation


Nursing Diagnosis: Constipation
Nursing care plans For Diagnosis Constipation
NANDA Definition: A decrease in a person's normal frequency of defecation, accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool

Defining Characteristics: Change in bowel pattern; bright red blood with stool; presence of soft paste-like stool in rectum; distended abdomen; dark, black, or tarry stool; increased abdominal pressure; percussed abdominal dullness; pain with defecation; decreased volume of stool; straining with defecation; decreased frequency; dry, hard, formed stool; palpable rectal mass; feeling of rectal fullness or pressure; abdominal pain; unable to pass stool; anorexia; headache; change in abdominal growing (borborygmi); indigestion; atypical presentation in older adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated body temperature); severe flatus; generalized fatigue; hypoactive or hyperactive bowel sounds; palpable abdominal mass; abdominal tenderness with or without palpable muscle resistance; nausea and/or vomiting; oozing liquid stool

Related Factors:
Functional Recent environmental changes; habitual denial or ignoring of urge to defecate; insufficient physical activity; irregular defecation habits; inadequate toileting, abdominal muscle weakness
Psychological Depression; emotional stress; mental confusion
Pharmacological Antilipemic agents; laxative overdose; calcium carbonate; aluminum-containing antacids; nonsteroidal antiinflammatory agents; opiates; anticholinergics; diuretics; iron salts; phenothiazides; sedatives; sympathomimetics; bismuth salts; antidepressants; calcium channel blockers
Mechanical Rectal abscess or ulcer; pregnancy; rectal anal fissures; tumors; megacolon (Hirschsprung's disease); electrolyte imbalance; rectal prolapse; prostate enlargement; neurological impairment; rectal anal stricture; rectocele; postsurgical obstruction; hemorrhoids; obesity
Physiological Poor eating habits; decreased motility of gastrointestinal tract; inadequate dentition or oral hygiene; insufficient fiber intake; insufficient fluid intake; change in usual foods and eating patterns; dehydration

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
· Bowel Elimination
· Hydration
Client Outcomes
· Maintains passage of soft, formed stool every 1 to 3 days without straining
· States relief from discomfort of constipation
· Identifies measures that prevent or treat constipation

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
· Constipation/Impaction Management

Nursing Interventions and Rationales

  • Observe usual pattern of defecation including time of day, amount and frequency of stool, consistency of stool, history of bowel habits or laxative use; diet including fluid intake; exercise patterns; personal remedies for constipation; obstetrical/gynecological history; surgeries; alterations in perianal sensation; present bowel regimen. There often are multiple reasons for constipation; the first step is assessment of usual patterns of bowel elimination.
  • Have the client or family keep a diary of bowel habits including time of day; usual stimulus; consistency, amount, and frequency of stool; fluid consumption; and use of any aids to defecation. A diary of bowel habits is valuable in treatment of constipation.
  • Review client's current medications. Many medications affect normal bowel function, including opiates, antidepressants, antihypertensives, anticholinergics, diuretics, anticonvulsants, antacids containing aluminum, iron supplements, and muscle relaxants.
  • Palpate for abdominal distention, percuss for dullness, and auscultate bowel sounds. In clients with constipation the abdomen is often distended with a palpable colon.
  • Check for impaction; perform digital removal per physician's order. If impaction is present, use cleansing regimen until you obtain a very soft stool. If using an enema, the client must be able to bodily retain the fluid. If the client has poor sphincter tone, use a cone tip irrigating bag to assist the client in retaining the fluids. This also decreases the amount of fluid necessary for cleansing.
  • Provide privacy for defecation. Assist the client to the bathroom and close the door if possible. Bowel elimination is a very private act, and a lack of privacy can contribute to constipation.
  • Encourage fiber intake of 25 g/day for adults. Emphasize foods such as fresh fruits, beans, vegetables, and bran cereals. Add fiber to diet gradually. Fiber helps prevent constipation by giving stool bulk. Add fiber to diet gradually because a sudden increase can cause bloating, gas, and diarrhea. A daily fiber intake of 25 g can increase frequency of stools in clients with constipation. Dietary supplements of fiber in the form of bran or wheat fiber are helpful for women experiencing constipation with pregnancy.
  • Encourage a fluid intake of 1.5 to 2 L/day (6 to 8 glasses of liquids per day). If oral intake is low, gradually increase fluid intake. Fluid intake must be within the cardiac and renal reserve. Adequate fluid intake is necessary to prevent hard, dry stools. Increasing fluid intake to 1.5 to 2 L/day along with fiber intake of 25 g can significantly increase frequency of stools in clients with constipation.
  • Encourage client to be out of bed as soon as possible, and to own activities of daily living (ADLs) as able. Encourage exercises such as turning and changing positions in bed, lifting their hips off the bed, doing range of motion exercises, alternating lifting each knee to the chest, doing wheelchair lifts, doing waist twists, stretching arms away from body, and pulling in the abdomen while taking deep breaths. Activity, even minimal, increases peristalsis, which is necessary to prevent constipation.
  • At each meal, sprinkle bran over client's food as allowed by client and prescribed diet. Ensure that client receives adequate fluid (1500 ml/day) along with bran. The number of bowel movements is increased and the use of laxatives is decreased in a client who eats wheat bran. A study done on institutionalized elderly male clients with chronic constipation demonstrated that with bran use, clients were able to discontinue use of oral laxatives.
  • Initiate a regular schedule for defecation, using the client's normal evacuation time whenever possible. Offer hot coffee, hot lemon water, or prune juice before breakfast, or while sitting on the toilet if necessary. An optimal time for many individuals is 30 minutes after breakfast because of the gastrocolic reflex. A schedule gives the client a sense of control, but more importantly it promotes evacuation before drying of stool and constipation occur. Hot liquids can stimulate peristasis and result in defecation.
  • Emphasize to the client the necessary ingredients for a normal bowel regimen (e.g., fluid, fiber, activity, and regular schedule for defecation). Help client onto bedside commode or toilet with client's hips flexed and feet flat. Have client deep breathe through mouth to encourage relaxation of the pelvic floor muscle and use the abdominal muscles to help evacuation.
  • Provide laxatives, suppositories, and enemas as needed and as ordered only; establish a client goal of eliminating their use. Avoid soapsuds enemas, or use a low concentration of castile soap only. Use of laxatives should be avoided. Soapsuds enemas can cause damage to the colonic mucosa. The use of a soapsuds enema was shown to increase stool output as compared with tap water enemas in preoperative liver transplant patients; amount of mucosal irritation was unknown.
  • For the stable neurological client, consider use of a bowel routine of Therevac enema or suppositories every other day, or performing digital stimulation with physician's permission. For persistent constipation, refer to physician for evaluation. Use of the Therevac SB mini-enema was found to cut time needed for bowel care by as much as one hour or more as compared with use of suppositories.
  • Explain the importance of fiber intake, fluid intake, and activity for soft, formed stool. Fiber intake, fluid intake, and activity are often decreased in elderly clients. Increasing fiber and fluids can effectively prevent constipation in the elderly.
  • Determine client's perception of normal bowel elimination; promote adherence to a regular schedule. Misconceptions regarding the frequency of bowel movements can lead to anxiety and overuse of laxatives.
  • Explain Valsalva's maneuver and the reason it should be avoided. Valsalva’s maneuver can cause bradycardia and even death in cardiac patients.
  • Respond quickly to client's call for help with toileting.
  • Avoid regular use of enemas in the elderly. Enemas can cause fluid and electrolyte imbalances ( and damage to the colonic mucosa.
  • Use opioids cautiously. If ordered, use stool softeners and bran mixtures to prevent constipation. Use of opioids can cause constipation.
  • Position client on toilet or commode and place a small footstool under the feet. Placing a small footstool under the feet increases intraabdominal pressure and makes defecation easier for an elderly client with weak abdominal muscles. 
 Home Care Interventions
  • Put client in bathroom to toilet when possible. Bowel elimination is a very private act, and a lack of privacy can contribute to constipation.
  • Carefully monitor bowel patterns of clients under pain management with opioids. Introduce a bowel management program at first sign of constipation. Constipation is a major problem for terminally ill or hospice clients who may need very high doses of opioids for pain management.
  • When using a bowel program, establish a pattern that is very regular and allows client to be part of family unit. Regularity of program promotes psychological and/or physiological "readiness" to evacuate. Families of home care clients often cannot proceed with normal daily activities until bowel programs are complete. 

Client/Family Teaching Nursing care plans For Constipation
  • Instruct client on normal bowel function and the necessity of fluid, fiber, and activity in a bowel program.
  • Encourage client to heed defecation warning signs and develop a regular schedule of defecation by using a stimulus such as a warm drink or prune juice. Most cases of constipation are mechanical and result from habitual neglect of impulses that signal appropriate time for defecation. This results in accumulation of a large, dry fecal mass.
  • Encourage client to avoid long-term use of laxatives and enemas and to gradually withdraw from their use if used regularly.
  • If not contraindicated, teach client how to do bent-leg sit-ups to increase abdominal tone; also encourage client to contract abdominal muscles frequently throughout the day. Help client develop a daily exercise program to increase peristalsis.


Nursing Care Plans For Chronic Pain


Nursing Diagnosis: Chronic Pain

Nursing Care Plans For Chronic Pain
NANDA  Definition: Pain is whatever the experiencing person says it is, existing whenever the person says it does,  an unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring, without an anticipated or predictable end and a duration >6 months; a state in which an individual experiences pain that persists for a month beyond the usual course of an acute illness or a reasonable duration for an injury to heal, is associated with a chronic pathologic process, or recurs at intervals for months or years.

Defining Characteristics:
Pain is always subjective and cannot be proved or disproved. The client's report of pain is the most reliable indicator of pain. Clients with cognitive abilities who can speak or point should use a pain rating scale (eg 0 to 10) to identify their current level of pain intensity  and determine a comfort/function goal .
Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report. However, observable responses to pain are helpful in its assessment, especially in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite or the inability to ambulate, perform activities of daily living (ADLs), work, or sleep. Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, and increase or decrease in respiratory rate and depth may be present but are usually not present with chronic pain that is relatively stable. Clients with chronic, cancer, or nonmalignant pain may experience threats to self-image; a perceived lack of options for coping; and worsening helplessness, anxiety, and depression. Chronic pain may affect almost every aspect of the client's daily life, including concentration, work, and relationships.

Related Factors: Actual or potential tissue damage; tumor progression and related pathology; diagnostic and therapeutic procedures; nerve injury (neuropathic pain)

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Pain Level
• Pain Control
• Comfort Level
• Pain: Disruptive Effects

Client Outcomes

  • Uses pain rating scale to identify current level of pain intensity, determines a comfort/function goal, and maintains a pain diary.
  • Describes the total plan for drug and nondrug pain relief, including how to safely and effectively take medicines and integrate nondrug therapies.
  • Demonstrates ability to pace self, taking rest breaks before they are needed.
  • Functions on an acceptable ability level with minimal interference from pain and medication side effects 

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Pain Management,  Analgesic Administration

Nursing Interventions and Rationales
  • Determine whether client is experiencing pain at time of initial interview. If so, intervene at that time to provide pain relief. The intensity, character, onset, duration, and aggravating and relieving factors of pain should be assessed and documented during the initial evaluation of the patient.
  • Ask client to describe past and current experiences with pain and effectiveness of the methods used to manage the pain, including experiences with side effects, typical coping responses, and how he or she expresses pain. A number of concerns (barriers) may affect client's willingness to report pain and use analgesics.
  • Describe the adverse effects of unrelieved pain. Numerous pathophysiological and psychological morbidity factors may be associated with pain.
  • Tell client to report pain location, intensity, and quality when experiencing pain. The intensity of pain and discomfort should be assessed and documented after any known pain-producing procedure, with each new report of pain, and at regular intervals.
  • Ask client to maintain a diary of pain ratings, timing, precipitating events, medications, treatments, and what works best to relieve pain. Systematic tracking of pain appears to be an important factor in improving pain management.
  • Determine client's current medication use. To aid in planning pain treatment, obtain a medication history 
  • Explore need for medications from the three classes of analgesics: opioids, and adjuvant medications. For chronic neuropathic pain, consider adjuvant medications that are analgesic, such as anticonvulsants and antidepressants. Some types of pain respond to non-opioid drugs alone. However, if pain is not responding, consider increasing the dosage or adding an opioid. At any level of pain, analgesic adjuvants may be useful. Analgesic combinations may enhance pain relief.
  • The oral route is preferred. If client is receiving parenteral analgesia, use an equianalgesic chart to convert to an oral or another noninvasive route as smoothly as possible. The least invasive route of administration capable of providing adequate pain control is recommended. The oral route is the most preferred because it is the most convenient and cost effective. Avoid the intramuscular (IM) route because of unreliable absorption, pain, and inconvenience.
  • Obtain a prescription to administer a non-opioid, unless contraindicated, around the clock (ATC). NSAIDs act mainly in the periphery to inhibit the initiation of pain signals. The analgesic regimen should include a non-opioid drug ATC, even if pain is severe enough to require the addition of an opioid .
  • For persistent cancer pain, obtain a prescription to administer opioid analgesics. When pain persists or increases, an opioid such as codeine or hydrocodone should be added to the non-opioid. If this is not effective, switch to morphine or other single-entity opioids.
  • Establish ATC dosing and administer supplemental opioid doses as needed to keep pain ratings at or below an acceptable level. A PRN order for a supplementary opioid dose between regular doses is an essential backup.
  • Ask client to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to improve these functions. Always obtain a prescription for a peristaltic stimulant to prevent opioid-induced constipation. Because there is great individual variation in the development of opioid-induced side effects, they should be monitored and, if their development is inevitable (e.g., constipation), prophylactically treated. Opioids cause constipation by decreasing bowel peristalsis.
  • Explain pain management approach that has been ordered, including therapies, medication administration, side effects, and complications. One of the most important steps toward improved control of pain is a better client understanding of the nature of pain, its treatment, and the role client needs to play in pain control.
  • Discuss client's fears of undertreated pain, addiction, and overdose. A number of concerns  may affect patients' willingness to report pain and use analgesics. Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan. Opioid tolerance and physical dependence are expected with long-term opioid treatment and should not be confused with addiction.
  • Review client's pain diary, flow sheet, and medication records to determine overall degree of pain relief, side effects, and analgesic requirements for an appropriate period (e.g., one week). Systematic tracking of pain appears to be an important factor in improving pain management.
  • Obtain prescriptions to increase or decrease analgesic doses when indicated. Base prescriptions on the client's report of pain severity and the comfort/function goal and response to previous dose in terms of relief, side effects, and ability to perform the daily activities and the prescribed therapeutic regimen. Opioid doses should be adjusted individually to achieve pain relief with an acceptable level of adverse effects.
  • If opioid dose is increased, monitor sedation and respiratory status for a brief time. Patients receiving long-term opioid therapy generally develop tolerance to the respiratory depressant effects of these agents.
  • In addition to the use of analgesics, support the client's use of nonpharmacological methods to control pain, such as distraction, imagery, relaxation, massage, and heat and cold application. Cognitive-behavioral strategies can restore clients' sense of self-control, personal efficacy, and active participation in their own care.
  • Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions. Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions.
  • Plan care activities around periods of greatest comfort whenever possible. Pain diminishes activity.
  • Ask clients to describe their appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments directed toward improving these functions. Because there is great individual variation in the development of opioid-induced side effects, clinicians should monitor and, if development is inevitable, prophylactically treat them.
  • Explore appropriate resources for management of pain on a long-term basis. Most patients with cancer or chronic nonmalignant pain are treated for pain in outpatient and home care settings. Plans should be made to ensure ongoing assessment of the pain and the effectiveness of treatments in these settings 
  • If client has progressive cancer pain, assist client and family with handling issues related to death and dying. Peer support groups and pastoral counseling may increase the client's and family's coping skills and provide needed support.
  • If client has chronic nonmalignant pain, assist client and family with minimizing effects of pain on interpersonal relationships and daily activities such as work and recreation. Pain reduces clients' options to exercise control, diminishes psychological well-being, and makes them feel helpless and vulnerable. Therefore clinicians should support active client involvement in effective and practical methods to manage pain.
  • Always take an elderly client's reports of pain seriously and ensure that the pain is relieved. In spite of what many professionals and clients believe, pain is not an expected part of normal aging.
  • When assessing pain, speak clearly, slowly, and loudly enough for client to hear; repeat information as needed. Be sure client can see well enough to read pain scale  and written materials.
  • Handle client's body gently. Allow client to move at own speed.
  • Use NSAIDs with caution and avoid ATC NSAID dosing. Opioids ATC are preferable to chronic NSAID administration in the elderly client because of an increased risk for NSAID adverse effects.
  • Use acetaminophen and NSAIDs with low side effect profiles such as choline and magnesium salicylates (Trilisate) and diflunisal (Dolobid). Watch for side effects such as GI disturbances and bleeding problems. Elderly clients are at increased risk for gastric and renal toxicity from NSAIDs.
  • Avoid or use with caution drugs with a long half-life, such as the NSAID piroxicam (Feldene), the opioids methadone (Dolophine) and levorphanol (Levo-Dromoran), and the benzodiazepine diazepam (Valium). A higher prevalence of renal insufficiency in the elderly than in younger persons can result in toxicity from drug accumulation.
  • In an elderly client, avoid the use of opioids with toxic metabolites, such as meperidine (Demerol) and propoxyphene (Darvon, Darvocet). Meperidine's metabolite, normeperidine, can produce CNS irritability, seizures, and even death; propoxyphene's metabolite, norpropoxyphene, can produce both CNS and cardiac toxicity. Both of these metabolites are eliminated by the kidneys, making meperidine and propoxyphene particularly poor choices for elderly clients, many of whom have at least some degree of renal insufficiency
Home Care Interventions
  • Review with client and caregivers the cause(s) of pain and the medical regimen specific to the cause. Assess client knowledge and teach disease process as necessary. Compliance with the medical regimen for diagnoses involving pain improves the likelihood of successful management.
  • Develop a full medication profile, including medications prescribed by all physicians and all over-the-counter medications. Assess for drug interactions. Instruct client to refrain from mixing medications without physician approval. Pain medications may significantly impact or be impacted by other medications and may cause severe side effects. Some combinations of drugs are specifically contraindicated.
  • Assess client and family knowledge of side effects and safety precautions associated with pain medications (e.g., use caution when operating machinery when opioids are initiated or dose has been increased). The cognitive effects of opioids usually subside within a week of initial dosing or dose increases. The use of long-term opioid treatment does not appear to affect neuropsychological performance. Pain itself may deteriorate performance of neuropsychological tests more than oral opioid treatment.
  • Collaborate with health care team on an ongoing basis (including client and family) to determine optimal pain control profile. Identify the most effective interventions and the medication administration routes most acceptable to the family and client. Success in pain control is partially dependent on the acceptability of the suggested intervention. Acceptability promotes compliance. Dosages vary among routes and will need to be adjusted accordingly to avoid breakthrough or transitional pain.
  • If administering medication using highly technological methods, assess home for necessary resources (e.g., electricity), and ensure that there will be responsible caregivers available to assist client with administration. Some routes of medication administration require special conditions and procedures to be safe and accurate.
  • Assess knowledge base of client and family for highly technological medication administration including the use of PCA pump. Teach as necessary. Appropriate instruction in the home increases the accuracy and safety of medication administration.
  • Support the client and family in the use of opioid analgesics. Well-intentioned friends and family may create added stress by expressing judgment or fears regarding the use of opioid analgesics.
Client And Family Teaching
  • To avoid the negative connotations associated with the words drugs and narcotics, use the words pain medicine when teaching clients.
  • Provide written materials regarding pain control, such as the Agency for Health Care Policy and Research pamphlet, Managing Cancer Pain: Patient Guide.
  • Discuss the various discomforts encompassed by the word pain and ask clients to give examples of pain they have experienced. Explain the pain assessment process and the purpose of the pain rating scale that will be used. Teach clients to use the pain rating scale to rate the intensity of current or past pain. Ask them to set a pain relief goal by selecting a pain rating on the scale; if pain goes above this level, they should take action that decreases pain or notify a member of the health care team.
  • Discuss the total plan for drug and nondrug treatment, including the medication plan for ATC administration and supplemental doses, the maintenance of a pain diary, and the use of supplies and equipment.
  • Reinforce the importance of taking pain medications to keep pain under control.
  • Reinforce that taking opioids for pain relief is not an addiction.
  • Explain to clients with chronic neuropathic pain the process of taking adjuvant analgesics (e.g., tricyclic antidepressants); a low dose is used initially and is increased gradually. Emphasize that pain relief is delayed and the drugs must be taken daily. Reassure the client that although the medicine is an antidepressant, it is used for analgesia and not depression. Comparable teaching should take place when an anticonvulsant is prescribed for analgesia.
  • Emphasize to clients with chronic nonmalignant pain the importance of participating in therapeutic regimens other than medication (e.g., physical therapy, group therapy).
  • Emphasize to clients the importance of pacing themselves and taking rest breaks before they are needed.
  • Demonstrate the use of appropriate nonpharmacological approaches for controlling pain.


Thursday, February 26, 2009

Nursing Care Plans For Chronic Confusion

. Thursday, February 26, 2009

Nursing Diagnosis: Chronic Confusion

Nursing Care Plans For Chronic Confusion
NANDA Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by a decreased ability to interpret environmental stimuli and a decreased capacity for intellectual thought processes, which manifest as disturbances of memory, orientation, and behavior

Defining Characteristics: Altered interpretation/response to stimuli; clinical evidence of organic impairment; altered personality; impaired memory (short and long term); impaired socialization; no change in level of consciousness
Related Factors: Multi-infarct dementia; Korsakoff's psychosis; head injury; Alzheimer's disease; cerebrovascular accident

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Cognitive Orientation
• Information Processing
• Memory
• Neurological Status: Consciousness

Client Outcomes
• Remains content and free from harm
• Functions at maximal cognitive level
• Participates in activities of daily living at the maximum of functional ability

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Dementia Management
• Environmental Management
• Reality Orientation
• Surveillance: Safety

Nursing Interventions and Rationales

  • Determine client's cognitive level using a screening tool such as the Mini Mental State Exam (MMSE). Using a standard evaluation tool such as the MMSE can help determine the client's abilities and assist with planning appropriate nursing interventions.
  • Gather information about client pre-dementia functioning, including social situation, physical condition, and psychological functioning. Knowing the client's background can help the nurse identify agenda behavior and use validation therapy, which will provide guidance for reminiscence. Background information may help the nurse to understand client’s behavior if client becomes delusional and hallucinates.
  • Assess the client for signs of depression: insomnia, poor appetite, flat affect, and withdrawn behavior. As much as 50% of clients with dementia have depressive symptoms.
  • Ensure that client is in a safe environment by removing potential hazards such as sharp objects and harmful liquids. Clients with dementia lose the ability to make good judgments and can easily harm self or others.
  • Place an identification bracelet on client. Clients with dementia wander and can become lost; identification bracelets increase client safety.
  • Avoid exposing client to unfamiliar situations and people as much as possible. Maintain continuity of caregivers. Maintain routines of care through established mealtimes, bathing, and sleeping schedules. Send familiar person with client when client goes for diagnostic testing or into unfamiliar environments. Situational anxiety associated with environmental, interpersonal, or structural change can escalate into agitated behavior.
  • Keep environment quiet and nonstimulating; avoid using buzzers and alarms if possible. Minimize sights and sounds that have a high potential for misinterpretation such as buzzers, alarms, and overhead paging systems. Sensory overload can result in agitated behavior in a client with dementia. Misinterpretation of the environment can also contribute to agitation.
  • Begin each interaction with client by identifying self and calling client by name. Approach client with a caring, loving, and accepting attitude and speak calmly and slowly. Dementia clients can sense feelings of compassion. A calm, slow manner projects a feeling of comfort to the client.
  • Touch client gently, stroking hand or arm in a soothing fashion if acceptable in client's culture.
  • Give one simple direction at a time and repeat as necessary. Use verbal and physical prompts, and model the desired action if needed and possible. People with dementia need time to assimilate and interpret your directions. If you rephrase your question, you give them something new to process, increasing their confusion.
  • Break down self-care tasks into simple steps. Dementia clients are unable to follow complex commands; breaking down an activity into simple steps makes completing the activity more feasible.
  • Keep questions simple; yes or no questions are often preferable to open-ended questions. Use positive statements and actions and avoid negative communication. Negative feedback leads to increased confusion and agitation. It is more effective to go along with the client and then redirect as necessary.
  • If eating in the dining room causes increased agitation, let client leave and eat in a quieter environment with a smaller number of people. The noise and confusion in a large dining room can be overwhelming for a dementia client and can result in agitated behavior. It is preferable to have dementia clients eat in small groups.
  • Provide finger food if patient has difficulty using eating utensils or if unable to sit to eat. Feeding oneself is a complex task and may prove challenging for someone with significant dementia.
  • Provide boundaries by placing red or yellow tape on the floor or by using a stop sign. Boundaries help the client identify safe areas; older clients can more easily see red and yellow than other colors.
  • Assess the etiology of wandering before or rather than attempting to control the wandering. Wandering indicates a problem and need for intervention; therefore the reason for the wandering behavior needs to be determined.
  • Write client's name in large block letters in the room and on client's clothing and possessions. Use symbols rather than words to identify areas such as the bathroom or kitchen.
  • Limit visitors to two and provide them with guidelines on appropriate topics to discuss and how to best communicate with client. 
  • Set up scheduled quiet periods in a recliner or room. Use blankets and other environmental cues to define rest periods. Quiet times allow the client's anxiety and building tension levels to decrease. Fatigue has been associated with the onset of increased confusion and agitation.
  • Provide quiet activities, such as listening to classical or religious music, or other cues that promote relaxation in the afternoon or early evening. An increase in confusion and agitation, referred to as sundowning syndrome, may occur in the late afternoon and early evening. Quiet activities can provide a calming environment.
  • Provide simple activities for the client, such as folding washcloths and sorting or stacking activities. Avoid misleading and frightening stimuli, which may include television, mirrors, and pictures of people or animals. Repetitive activities give the client with dementia a positive outlet for behavior. Dementia clients see, hear, and perceive a different world than other people. They may not recognize themselves in the mirror and be afraid of the stranger they see so close to them.
  • Consider using doll therapy. Ask family members to bring a large, safe doll or stuffed animal such as a teddy bear. Doll therapy can be soothing to some dementia clients.
  • If client becomes increasingly confused and agitated, perform the following steps:

  1. Monitor client for physiological causes, including acute hypoxia, pain, medication effects, malnutrition, infections such as urinary tract infection, fatigue, electrolyte disturbances, and constipation. An acute change in behavior is a medical emergency and should be evaluated. Many physiological factors can result in increased agitation of clients with dementia.
  2. Monitor for psychological causes, including changes in environment, caregiver, and routine; demands to perform beyond capacity; and multiple competing stimuli. It is important for the nurse to recognize precipitating events and subsequent behavior to prevent furthers incidents of agitation.
  3. Avoid confrontations with the client; allow client to dissipate energy by performing repetitive tasks or by pacing.

  • If client is delusional or hallucinating , do not confront him or her with reality. Use validation therapy to verbally reflect back the emotions that the client appears to be experiencing. Use statements such as, "It must be frightening to see a fire at the end of your bed," "I can see that you are afraid," "I will stay with you," or "Can you tell me more about what is going on right now?" Orienting the client to reality can increase agitation; validation therapy conveys empathy and understanding and can help determine the internal stimulus that is creating the change in behavior. In one study, training in validation therapy for staff resulted in decreased doses of psychotherapeutic medications and incidences of behavior problems.
  • Decrease stimuli in the environment (turn off Radio, take client to a quiet place). Institute activities associated with pleasant emotions, such as playing soft music the client likes, looking through a photo album, providing favorite food, or using simulated presence therapy. Decreasing stimuli can decrease agitation. Reassuring activities, such as simulated presence therapy wherein client listens to a tape of a loved one's phone conversation, can help bring about pleasant emotions that soothe the client.
  • Avoid using restraints if at all possible. Restraints are not benign interventions and should be used sparingly and judiciously only when alternatives to manage the behaviors have been tried and been unsuccessful. Side effects include falls, increased confusion , deconditioning, and incontinence.
  • Use prn or low dose regular dosing of psychotropic or antianxiety drugs only as a last resort. They are effective in managing symptoms of psychosis and aggressive behavior. Start with the lowest possible dose. Psychotropic drugs such as haloperidol (Haldol) and resperidone (Risperdol) may decrease client function and have side effects that need to be monitored.
  • Avoid use of anticholinergic medications such as Benadryl. Anticholinergic medications have a high side effect profile that includes disorientation, urinary retention, and excessive drowsiness (Nurses Drug Hand book). The anticholinergic side effects outweigh the antihistaminic effects.
  • For predictable difficult times, such as during bathing and grooming, try the following:

  1. Massage the client's hands lovingly or use therapeutic touch to relax the client. Hand massage and therapeutic touch have been shown to induce relaxation that may allow care activities to take place without difficulty.
  2. Use positive behavioral reinforcement for each of the small steps involved in bathing, such as praising client for walking toward the shower, sitting in the shower chair, and removing items of clothing. Positive behavioral reinforcement for desired behavior is effective for clients with dementia. Consider a towel bath if shower or tub bathing is too stressful for client.
  3. Treat the client with the utmost respect and give individualized care. Treating confused clients with respect and individualizing care can decrease aggression and increase nursing staff satisfaction.

  • For early dementia clients with primarily symptoms of memory loss, see care plan for Impaired Memory. For clients with self-care deficits, see appropriate care plan (Feeding Self-care deficit, Dressing/grooming Self-care deficit, Toileting Self-care deficit).

• Most of the preceding interventions apply to the geriatric client.
• Use reminiscence and life review therapeutic interventions; ask questions about client's work, child rearing,


  • Assess for the influence of cultural beliefs, norms, and values on the family or caregiver understanding of chronic confusion or dementia. What the family considers normal and abnormal health behavior may be based on cultural perceptions.
  • Inform client family or caregiver of the meaning of and reasons for common behavior observed in clients with dementia . An understanding of dementia behavior will enable the client family/caregiver to provide the client with a safe environment.
  • Refer family to social services or other supportive services to assist with meeting the demands of caregiving for the client with dementia. Black caregivers of dementia clients may evidence less desire than others to institutionalize their family members and are more likely to report unmet service needs . Families of dementia clients may report restricted social activity.
  • Encourage family to make use of support groups or other service programs. Studies indicate that some minority families of clients with dementia may use few support programs even though these programs could have a positive impact on caregiver well-being.
  • Validate the family members’ feelings with regard to the impact of client behavior on family lifestyle. Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship.
Home Care Interventions

  • Keeping the client as independent as possible is important. However, because community-based care is usually less structured than institutional care, in the home setting, the goal of maintaining safety for the client takes on primary importance.
  • Provide support to family of client with chronic and disabling condition.
  • If client will require extensive supervision on an ongoing basis, evaluate client for day care programs. Refer family to medical social services to assist with this process if necessary. Day care programs provide safe, structured care for the client and respite for the family. Respite care for caregivers is an essential part of successful long-term care for a confused client.
  • Encourage family to include client in family activities when possible. Reinforce use of therapeutic communication guidelines and sensitivity to the number of people present. These steps help the client maintain dignity and lead to familiar socialization of the client.
  • Assess family caregivers for caregiver burden. Caring for a loved one with a dementing process is highly stressful. Respite care is a necessary component to the overall care plan.

Client/Family Teaching

  • Recommend that the family develop a memory aid wallet or booklet for client that contains pictures and text that chronicle the client's life. Using memory aids such as wallets or booklets helps dementia clients make more factual statements and stay on topic, and it decreases the number of confused, erroneous, and repetitive statements.
  • Teach family how to converse with a memory-impaired person. Guidelines include the following:

  1. Ask client to have a conversation with you.
  2. Guide conversation to specific, nonthreatening topics and redirect the conversation back on topic when client begins to ramble.
  3. Reassure and help out when the client gets stuck or cannot find the right words.
  4. Smile and act interested in what client is saying even if unsure what it means.
  5. Thank client for talking.
  6. Avoid quizzing client or asking a lot of specific questions.
  7. Avoid correcting or contradicting something that was stated even if it is wrong.

  • Teach family how to set up environment and use care techniques/interventions listed so that client will experience a progressively lowered stress threshold. Alzheimer's clients are unable to deal with stress; decreasing stress can decrease confusion and changes in behavior.
  • Discuss with the family what to expect as the dementia progresses .
  • Counsel the family about resources available with regard to end-of-life decisions and legal concerns.
  • Inform family that as dementia progresses, hospice care may be available in the terminal stages in the home to help the caregiver. Hospice services in the late stages of dementia can help support the family with nursing services and visitation by primary care provider, home health aides, social services, volunteer visitors, and a spiritual counselor if desired as the client is dying.


Nursing Care Plans For Bowel incontinence


Nursing Diagnosis: Bowel incontinence
Nursing Care Plans For Bowel incontinence

NANDA Definition: Change in normal bowel habits characterized by involuntary passage of stool.

Defining Characteristics: Constant dribbling of soft stool, fecal odor; inability to delay defecation; rectal urgency; self-report of inability to feel rectal fullness or presence of stool in bowel; fecal staining of underclothing; recognizes rectal fullness but reports inability to expel formed stool; inattention to urge to defecate; inability to recognize urge to defecate, red perianal skin

Related Factors: Change in stool consistency (diarrhea, constipation, fecal impaction); abnormal motility (metabolic disorders, inflammatory bowel disease, infectious disease, drug induced motility disorders, food intolerance); defects in rectal vault function (low rectal compliance from ischemia, fibrosis, radiation, infectious proctitis, Hirschprung's disease, local or infiltrating neoplasm, severe rectocele); sphincter dysfunction (obstetric or traumatic induced incompetence, fistula or abscess, prolapse, third degree hemorrhoids, pseudodyssynergia of the pelvic muscles); neurological disorders impacting gastrointestinal motility, rectal vault function and sphincter function (cerebrovascular accident, spinal injury, traumatic brain injury, central nervous system tumor, advanced stage dementia, encephalopathy, profound mental retardation, multiple sclerosis, myelodysplasia and related neural tube defects, gastroparesis of diabetes mellitus, heavy metal poisoning, chronic alcoholism, infectious or autoimmune neurological disorders, myasthenia gravis)

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
• Bowel Continence
• Bowel Elimination

Client Outcomes
• Regular, complete evacuation of fecal contents from the rectal vault
• Defecates soft-formed stool
• Decreased or absence of bowel incontinence incidences
• Intact skin in the perianal/perineal area
• Demonstrates the ability to isolate, contract, and relax pelvic muscles , Increases pelvic muscle strength .

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Bowel Incontinence Care
• Bowel Training
• Bowel Incontinence Care: Encopresis

Nursing Interventions and Rationales

  • In a reasonably private setting, directly question any client at risk about the presence of fecal incontinence. If the client reports altered bowel elimination patterns, problems with bowel control or "uncontrollable diarrhea," complete a focused nursing history including previous and present bowel elimination routines, dietary history, frequency and volume of uncontrolled stool loss, and aggravating and alleviating factors. Unless questioned directly, patients are unlikely to report the presence of fecal incontinence. The nursing history determines the patterns of stool elimination to characterize involuntary stool loss and the likely etiology of the incontinence .
  • Complete a focused physical assessment including inspection of perineal skin, pelvic muscle strength assessment, digital examination of the rectum for presence of impaction and anal sphincter strength, and evaluation of functional status (mobility, dexterity, visual acuity). A focused physical examination helps determine the severity of fecal leakage and its likely etiology. A functional assessment provides information concerning the impact of functional status on stool elimination patterns and incontinence.
  • Complete an assessment of cognitive function. Dementia, acute confusion, and mental retardation are risk factors for fecal incontinence.
  • Document patterns of stool elimination and incontinent episodes via a bowel record, including frequency of bowel movements, stool consistency, frequency and severity of incontinent episodes, precipitating factors, and dietary and fluid intake. This document is used to confirm the verbal history and to assist in determining the likely etiology of stool incontinence. It also serves as a baseline to evaluate treatment efficacy.
  • Identify the probable causes of fecal incontinence. Fecal incontinence is frequently multifactorial; therefore identification of the probable etiology of fecal incontinence is necessary to select a treatment plan likely to control or eliminate the condition.
  • Improve access to toileting:

o Identify usual toileting patterns among persons in the acute care or long term care facility and plan opportunities for toileting accordingly.
o Provide assistance with toileting for patients with limited access or impaired functional status.
o Institute a prompted toileting program for persons with impaired cognitive status.
o Provide adequate privacy for toileting.
o Respond promptly to requests for assistance with toileting.

• For the client with intermittent episodes of fecal incontinence related to acute changes in stool consistency, begin a bowel reeducation program consisting of:
o Cleansing the bowel of impacted stool if indicated.
o Normalizing stool consistency by adequate intake of fluids and dietary or supplemental fiber.
o Establishing a regular routine of fecal elimination based on established patterns of bowel elimination

  • Begin a prompted defecation program for the adult with dementia, mental retardation, or related learning disabilities. Prompted urine and fecal elimination programs have been shown to reduce or eliminate incontinence in the long term care facility and community settings.
  • Begin a scheduled stimulation defecation program, including the following steps, for persons with neurological conditions causing fecal incontinence:

o Before beginning the program, cleanse the bowel of impacted fecal material.
o Implement strategies to normalize stool consistency, including adequate intake of fluid and fiber and avoidance of foods associated with diarrhea.
o Whenever feasible, determine a regular schedule for bowel elimination  based on previous patterns of bowel elimination.
o Provide a stimulus before assisting the patient to a position on the toilet. Digital stimulation, stimulating suppository, "mini-enema," or pulsed evacuation enema may be used.
The scheduled, stimulated defecation program relies on consistency of stool and a mechanical or chemical stimulus to produce a bolus contraction of the rectum with evacuation of fecal material.

  • Begin a pelvic floor reeducation or muscle exercise program for persons with sphincter incompetence or pseudodyssynergia of the pelvic muscles, or refer persons with fecal incontinence related to sphincter dysfunction to a nurse specialist or other therapist with clinical expertise in these techniques of care. Pelvic muscle reeducation, including biofeedback, pelvic muscle exercise, and/or pelvic muscle relaxation techniques, is a safe and effective treatment for selected persons with fecal incontinence related to sphincter or pelvic floor muscle dysfunction.
  • Begin a pelvic muscle biofeedback program among patients with urgency to defecate and fecal incontinence related to recurrent diarrhea. Pelvic muscle reeducation, including biofeedback, can reduce uncontrolled loss of stool among persons who experience urgency and diarrhea as provacative factors for fecal incontinence. Reducing the incidence of diarrhea can help to reduce bowel incontinence.
  • Cleanse the perineal and perianal skin following each episode of fecal incontinence. When incontinence is frequent, use an incontinence cleansing product specifically designed for this purpose. Frequent cleaning with soap and water may compromise perianal skin integrity and enhance the irritation produced by fecal leakage.
  • Apply mineral oil or a petroleum based ointment to the perianal skin when frequent episodes of fecal incontinence occur. These products form a moisture and chemical barrier to the perianal skin that may prevent or reduce the severity of compromised skin integrity with severe fecal incontinence.
  • Assist the patient to select and apply a containment device for occasional episodes of fecal incontinence. A fecal containment device will prevent soiling of clothing and reduce odors in the patient with uncontrolled stool loss.
  • Teach the caregivers of the patient with frequent episodes of fecal incontinence and limited mobility to regularly monitor the sacrum and perineal area for pressure ulcerations. Limited mobility, particularly when combined with fecal incontinence, increases the risk of pressure ulceration. Routine cleansing, pressure reduction techniques, and management of fecal and urinary incontinence reduces this risk.
  • Consult the physician concerning the use of an anal continence plug for the patient with frequent stool loss. The anal continence plug is a device that can reduce or eliminate persistent liquid or solid stool incontinence in selected patients.
  • Apply a fecal pouch to the patient with frequent stool loss, particularly when fecal incontinence produces altered perianal skin integrity. Fecal pouches contain stool loss, reduce odor, and protect the perianal skin from chemical irritation resulting from contact with stool. 
  • Consult the physician concerning the use of a rectal tube for the patient with severe fecal incontinence. A large-sized French indwelling catheter has been used for fecal containment when incontinence is severe and perianal skin integrity significantly compromised. The safety of this technique remains unknown.


  • Evaluate elderly client for established or acute fecal incontinence when client enters the acute or long term care facility; intervene as indicated. The rate of fecal incontinence among patients in acute care facilities is as high as 3%; in long term care facilities the rate is as high as 50%.
  • To evaluate cognitive status in the elderly person, use a NEECHAM confusion scale to identify acute cognitive changes, a Folstein Mini-Mental Status Examination, or other tool as indicated. Acute or established dementia increases the risk of fecal incontinence among elderly persons.

Home Care Interventions

  • Assess and teach a bowel management program to support continence.
  • Provide clothing that is nonrestrictive, can be manipulated easily for toileting, and can be changed with ease. Avoidance of complicated maneuvers increases the chance of success in toileting programs and decreases the client's risk for embarrassing incontinent episodes.
  • Assist the family in arranging care in a way that allows the client to participate in family or favorite activities without embarrassment. Careful planning can both help client retain dignity and maintain integrity of family patterns.
  • If the client is limited to bed (or bed and chair), provide a commode or bedpan that can be easily accessed. If necessary, refer the client to physical therapy services to learn side transfers and to build strength for transfers.
  • If the client is frequently incontinent, refer for home health aide services to assist with hygiene and skin care.

Client and Family Teaching

  • Teach the client and family to perform a bowel reeducation program; scheduled, stimulated program; or other strategies to manage fecal incontinence.
  • Teach the client and family about common dietary sources of fiber, as well as supplemental fiber or bulking agents as indicated.
  • Teach nursing colleagues and nonprofessional care providers the importance of providing toileting opportunities and adequate privacy for the patient in an acute or long term care facility.
  • Refer to nursing diagnoses Diarrhea and Constipation for detailed management of these related conditions.


Nursing Care Plan For Pregnancy Induced Hypertension (PIH) Preeclampsia and Eclampsia


Pregnancy-induced hypertension (PIH) is a potentially life-threatening disorder that usually develops after the 20th week of pregnancy. It typically occurs in nulliparous women and may be nonconvulsive or convulsive. Preeclampsia, the nonconvulsive form of the disorder, is marked by the onset of hypertension after 20 weeks of gestation. It develops in about 7% of pregnancies and may be mild or severe. The incidence is significantly higher in low socioeconomic groups.
Eclampsia, the convulsive form, occurs between 24 weeks' gestation and the end of the first postpartum week. The incidence increases among women who are pregnant for the first time, have multiple fetuses, and have a history of vascular disease. About 5% of women with preeclampsia develop eclampsia; of these, about 15% die of eclampsia or its complications. Fetal mortality is high because of the increased incidence of premature delivery PIH and its complications are the most common cause of maternal death in developed countries.

Cause of Preeclampsia 
The cause of preeclampsia is unknown, it is often called the “DISEASE OF THEORIES” because many causes have been proposed, yet none has been well established. than how does preeclampsia occur Experts believe that decreased levels of prostaglandins and a decreased resistance to angiotensin II lead to a generalized arterial vasospasm that then causes endothelial damage. The brain, liver, kidney, and blood are particularly susceptible to multiple dysfunctions. Several risk factors have been identified that may predispose a woman to developing preeclampsia: nulliparity; familial history; multiple gestation; patient history of diabetes mellitus, chronic hypertension, renal disease, trophoblastic disease, and malnutrition.

Generalized arteriolar vasoconstriction is thought to produce decreased blood flow through the placenta and maternal organs. This decrease can result in intrauterine growth retardation, placental infarcts, and abruptio placentae. Hemolysis, elevated liver enzyme levels, and a low platelet count characterize severe eclampsia. A unique form of coagulopathy is also associated with this disorder. Other possible complications include stillbirth of the neonate, seizures, coma, premature labor, renal failure, and hepatic damage in the mother.

Assessment Nursing care Plans For Pregnancy Induced Hypertension
A patient with mild preeclampsia typically reports a sudden weight gain of more than 3 lb (1.4 kg) per week during the second trimester or more than 1 lb (0.5 kg) per week during the third trimester.
The patient's history reveals hypertension, as evidenced by elevated blood pressure readings: 140 mm Hg or more systolic, or an increase of 30 mm Hg or more above the patient's normal systolic pressure, measured on two occasions, 6 hours apart; and 90 mm Hg or more diastolic, or an increase of 15 mm Hg or more above the patient's normal diastolic pressure, measured on two occasions, 6 hours apart.
Inspection reveals generalized edema, especially of the face. Palpation may reveal pitting edema of the legs and feet. Deep tendon reflexes may indicate hyperreflexia.
As preeclampsia worsens, the patient may demonstrate oliguria (urine output of 400 ml/day or less), blurred vision caused by retinal arteriolar spasms, epigastric pain or heartburn, irritability, and emotional tension. She may complain of a severe frontal headache.
In a patient with severe preeclampsia, blood pressure readings increase to 160/110 mm Hg or higher on two occasions, 6 hours apart, during bed rest. Also, ophthalmoscopic examination may reveal vascular spasm, papilledema, retinal edema or detachment, and arteriovenous nicking or hemorrhage.
Preeclampsia can suddenly progress to eclampsia with the onset of seizures. The patient with eclampsia may appear to cease breathing, then suddenly take a deep, stertorous breath and resume breathing. The patient may then lapse into a coma, lasting a few minutes to several hours. Awakening from the coma, the patient may have no memory of the seizure. Mild eclampsia may involve more than one seizure; severe eclampsia, up to 20 seizures.
Physical examination findings in a patient with eclampsia are similar to those of a patient with preeclampsia but more severe. Systolic blood pressure may increase to 180 mm Hg and even to 200 mm Hg. Inspection may reveal marked edema, but some patients exhibit no visible edema.

Diagnostic tests
Blood Hematocrit
Renal Function
Serum uric acid
Creatinine clearance
Coagulation Platelets
Fibrin degradation products

Nursing diagnoses Nursing Care Plan For Pregnancy Induced Hypertension

  • Activity intolerance
  • Anxiety
  • Disturbed sensory perception (visual)
  • Disturbed thought processes
  • Excess fluid volume
  • Fear
  • Impaired urinary elimination
  • Ineffective coping
  • Ineffective tissue perfusion: Cerebral, peripheral
  • Risk for injury

Key outcomes

  • The patient will be able to perform activities of daily living without excessive fatigue.
  • The patient will identify strategies to reduce anxiety.
  • The patient will maintain optimal functioning within the confines of the visual impairment.
  • The patient will maintain orientation to environment.
  • The patient's fluid volume will remain within normal parameters.
  • The patient will verbalize fears and concerns.
  • The patient's urine output will remain within normal limits.
  • The patient will demonstrate adaptive coping behaviors.
  • The patient will exhibit signs of adequate cerebral and peripheral perfusion.
  • The patient will avoid complications

Nursing interventions, Rationales  And Patient teaching
Related to nursing diagnosis

Nursing Management Of Preeclampsia

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