Nursing Diagnosis Disturbed Sleep pattern

Nursing care Plans Disturbed Sleep pattern. NANDA Nursing Diagnosis Definition Disturbed Sleep pattern Time-limited disruption of sleep

Disturbed Sleep pattern Characteristics:

Prolonged awakenings, sleep maintenance insomnia, self-induced impairment of normal pattern, sleep onset more than 30 minutes, early morning insomnia, awakening earlier or later than desired, verbal complaints of difficulty falling asleep, verbal complaints of not feeling well-rested, increased proportion of Stage 1 sleep, dissatisfaction with sleep, less than age-normed total sleep time, three or more nighttime awakenings, decreased proportion of Stages 3 and 4 sleep, decreased ability to function

Related Factors:

Daytime activity pattern, Thinking about home, Body temperature, Temperament, Dietary, Childhood onset, Inadequate sleep hygiene, Sustained use of antisleep agents, Circadian asynchrony, Frequently changing sleep-wake schedule, Depression, Loneliness, Frequent travel across time zones, daylight/darkness exposure, grief, anticipation, shift work, delayed or advanced sleep phase syndrome, loss of sleep partner, life change, preoccupation with trying to sleep, periodic gender-related hormonal shifts, biochemical agents, fear, separation from significant others; social schedule inconsistent with chronotype, aging-related sleep shifts, anxiety, medications, fear of insomnia, maladaptive conditioned wakefulness, fatigue, boredom

Nursing Outcomes Nursing care Plans Disturbed Sleep pattern

• Sleep
• Rest
• Well-Being
• Psychosocial Adjustment: Life Change
• Quality of Life
• Pain Level
• Comfort Level

Client Outcomes

• Wakes up less frequently during night
• Awakens refreshed and is not fatigued during day
• Falls asleep without difficulty
• Verbalizes plan to implement bedtime routines

NIC Interventions (Nursing Interventions Classification)

• Sleep Enhancement

Nursing Interventions nursing care Plans Disturbed Sleep pattern

• Assess client's sleep patterns and usual bedtime rituals and incorporate these into the plan of care.
• Determine current level of anxiety, if client is anxious.
• Assess for signs of new onset of depression: depressed mood state, statements of hopelessness, poor appetite.
• Observe client's medication, diet, and caffeine intake. Look for hidden sources of caffeine, such as over-the-counter medications.
• Provide measures to take before bedtime to assist with sleep.
• Provide pain relief shortly before bedtime and position client comfortably for sleep.
• Keep environment quiet. 
• Do a careful history of all medications including over-the-counter medications and alcohol intake.
• If client is waking frequently during the night, consider the presence of sleep apnea problems and refer to a sleep clinic for evaluation.
• Evaluate client for presence of depression or anxiety.
• Encourage social activities.
• Suggest light reading or TV viewing that does not excite as an evening activity.
• Increase daytime physical activity. Encourage walking as client is able.
• Avoid use of hypnotics and alcohol to sleep.
• Reduce daytime napping in the late afternoon; limit naps to short intervals as early in the day as possible.
• Use soothing sound generators with sounds of the ocean, rainfall, or waterfall to induce sleep, or use "white noise" such as a fan to block out other sounds.
• Determine if client has a physiological problem that could result in insomnia such as pain, cardiovascular disease, pulmonary disease, neurological problems such as dementia, or urinary problems. 
• Observe elimination patterns. Have client decrease fluid intake in the evening, and ensure that diuretics are taken early in the morning.
• If client continues to have insomnia despite developing good sleep hygiene habits, refer to a sleep clinic for further evaluation.

Client/Family Teaching for Disturbed Sleep pattern

• Teach the following guidelines for good sleep hygiene to improve sleep habits: Go to bed only when sleepy, When awake in the middle of the night, go to another room, do quiet activities, and go back to bed only when sleepy, Use the bed only for sleeping not for reading or snoozing in front of the television, Avoid afternoon and evening naps, Get up at the same time every morning, Recognize that not everyone needs 8 hours of sleep, Move the alarm clock away from the bed if it is a source of distraction.
• Encourage client to avoid coffee and other caffeinated foods and liquids and also to avoid eating large high-protein or high-fat meals before bedtime.
• Advise client to avoid use of alcohol or hypnotics to induce sleep.
• Ask client to keep a sleep diary for several weeks.
• Teach relaxation techniques, pain relief measures, or the use of imagery before sleep.
• Teach client need for increased exercise.
• Encourage client to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts.

Read More »»

Nursing Diagnosis Disturbed Body Image

NANDA Nursing diagnosis Definition Confusion in mental picture of one's physical self Defining Characteristics: Nonverbal response to actual or perceived change in structure and/or function; verbalization of feelings that reflect an altered view of one's body in appearance, structure, or function; verbalization of perceptions that reflect an altered view of one's body in appearance, structure, or function; behaviours of avoidance, monitoring, or acknowledgment of one's body

Objective

Missing body part; actual change in structure or function; avoidance of looking at or touching body part; intentional or unintentional hiding or overexposure of body part; trauma to non-functioning part; change in social involvement; change in ability to estimate spatial relationship of body to environment

Subjective

Change in lifestyle; fear of rejection or reaction by others; focus on past strength, function, or appearance; negative feelings about body; feelings of helplessness, hopelessness, or powerlessness; preoccupation with change or loss; emphasis on remaining strengths and heightened achievement; extension of body boundary to incorporate environmental objects; personalization of part or loss by name; depersonalization of part or loss by impersonal pronouns; refusal to verify actual change

Related Factors: Psychosocial, biophysical, cognitive/perceptual, cultural, spiritual, or developmental changes; illness; trauma or injury; surgery; illness treatment

NOC Outcomes (Nursing Outcomes Classification)

• Body Image

• Child Development: 2 Years

• Child Development: 3 Years

• Child Development: 4 Years

• Child Development: 5 Years

• Child Development: Middle Childhood (6-11 Years)

• Child Development: Adolescence (12-17 Years)

• Distorted Thought Control

• Grief Resolution

• Psychosocial Adjustment: Life Change

• Self-Esteem

Client Outcomes

• States or demonstrates acceptance of change or loss and an ability to adjust to lifestyle change
• Calls body part or loss by appropriate name
• Looks at and touches changed or missing body part
• Cares for changed or nonfunctioning part without inflicting trauma
• Returns to previous social involvement
• Correctly estimates relationship of body to environment

NIC Interventions (Nursing Interventions Classification)

• Use a tool such as the Body Image Instrument (BII) to identify clients who have concerns about changes in body image.
• Observe client's usual coping mechanisms during times of extreme stress and reinforce their use in the current crisis
• Acknowledge denial, anger, or depression as normal feelings when adjusting to changes in body and lifestyle.
• Identify clients at risk for body image disturbance (e.g. body builders, cancer survivors).
• Clients should not be rushed into sharing their feelings.
• Do not ask clients to explore feelings unless they have indicated a need to do so.
• Explore strengths and resources with client. Discuss possible changes in weight and hair loss; select a wig before hair loss occurs.
• Encourage client to purchase clothes that are attractive and that de-emphasize their disability.
• Allow client and others gradual exposure to the body change.
• Encourage client to discuss interpersonal and social conflicts that may arise.
• Encourage client to make own decisions, participate in plan of care, and accept both inadequacies and strengths.
• Help client accept help from others; provide a list of appropriate community resources.
• Help client describe self-ideal, identify self-criticisms, and be accepting of self.
• Encourage client to write a narrative description of their changes.
• Avoid looks of distaste when caring for clients who have had disfiguring surgery or injuries. Provide privacy; care should be completed without unnecessary exposure.
• Encourage client to continue same personal care routine that was followed before the change in body image.
• Focus on remaining abilities. Have client make a list of strengths.

Home health Care Interventions

• Assess client's stage of grieving or acceptance of body change upon return to home setting. Include the future role of sexuality in the psychological assessment of acceptance as appropriate.
• Assess family/caregiver level of acceptance of client's body changes.
• Be accepting of changes in all interactions with client and family/caregivers.
• Help client to see new or changing roles in family.
• Refer to medical social services for level of acceptance and possible financial impact of changes.
• Teach all aspects of care. Involve client and caregivers in self-care as soon as possible. Do this in stages if client still has difficulty.
• Teach family and client complications of medical condition and when to contact physician.
• Refer to occupational therapy if necessary to evaluate home setting for safety and adaptive equipment and to assist client with return to normal activities.
• If appropriate, provide home health aide support to help the client and family through ADL transition.
• Refer to physical therapy if necessary to build range-of-joint-motion (ROJM) flexibility and strength, prevent contractures.
• Assess for and promote good nutrition and sleep patterns. Adapt nutrition to specific physiological situations.

Read More »»

Nursing Diagnosis Fatigue

Nursing Definition for Nursing Diagnosis Fatigue An overwhelming, sustained sense of exhaustion and decreased capacity for physical and mental work at usual level

Characteristics: Inability to restore energy even after sleep; lack of energy or inability to maintain usual level of physical activity; increase in rest requirements; tired; inability to maintain usual routines; verbalization of an unremitting and overwhelming lack of energy; lethargic or listless; perceived need for additional energy to accomplish routine tasks; increase in physical complaints; compromised concentration; disinterest in surroundings, introspection; decreased performance; compromised libido; drowsy; feelings of guilt for not keeping up with responsibilities

Related Factors:

Boring lifestyle; stress; anxiety; depression

Humidity; lights; noise; temperature

Negative life events; occupation

Sleep deprivation; pregnancy; poor physical condition; disease states (cancer, HIV, multiple sclerosis); increased physical exertion; malnutrition; anemia

NOC Outcomes (Nursing Outcomes Classification)
• Endurance
• Concentration
• Energy Conservation
• Nutritional Status: Energy

Client Outcomes

• Verbalizes increased energy and improved well-being
• Explains energy conservation plan to offset fatigue 

NIC Interventions (Nursing Interventions Classification)
Energy Management

Nursing Interventions

• Assess severity of fatigue on a scale of 0 to 10; assess frequency of fatigue, activities associated with increased fatigue, ability to perform activities of daily living (ADLs), times of increased energy, ability to concentrate, mood, and usual pattern of activity.
• Evaluate adequacy of nutrition and sleep. Encourage the client to get adequate rest. Refer to Imbalanced Nutrition: less than body requirements or Disturbed Sleep pattern if appropriate.
• Determine with help from the primary care practitioner whether there is a physiological or psychological cause of fatigue that could be treated, such as anemia, electrolyte imbalance, hypothyroidism, depression, or medication effect.
• Work with the physician to determine if the client has chronic fatigue syndrome.
• Encourage client to express feelings about fatigue; use active listening techniques and help identify sources of hope.
• Encourage client to keep a journal of activities, symptoms of fatigue, and feelings.
• Assist client with ADLs as necessary; encourage independence without causing exhaustion.
• Help client set small, easily achieved short-term goals such as writing two sentences in a journal daily or walking to the end of the hallway twice daily.
• With physician's approval, refer to physical therapy for carefully monitored aerobic exercise program.
• Refer client to diagnosis-appropriate support groups such as National Chronic Fatigue Syndrome Association or Multiple Sclerosis Association.
• Help client identify essential and nonessential tasks and determine what can be delegated.
• Give client permission to limit social and role demands if needed (e.g., switch to part-time employment, hire cleaning service).
• Refer client to occupational therapy to learn new energy-conserving ways to perform tasks.
• If client is very weak, refer to physical therapy for prescription and use of a mobility aid such as a walker.
• Identify recent losses; monitor for depression as a possible contributing factor to fatigue.
• Review medications for side effects. Certain medications (e.g., beta-blockers, antihistamines, pain medications) may cause fatigue in the elderly. 

Home Care Interventions

• Assess client's history and current patterns of fatigue as they relate to the home environment. Fatigue may be more pronounced in specific settings for physical or psychological reason.
• Assess home for environmental and behavioral triggers of increased fatigue
• When assisting client with adapting to home and daily patterns, avoid activities of high energy output. Refer to occupational therapy to accomplish this if necessary.
• Assist client with identifying or creating a safe, restful place within the home that can be used routinely (e.g., a room with familiar, nonthreatening, or nonfrightening belongings).

Client/Family Teaching

• Share information about fatigue and how to live with it, including need for positive self-talk.
• Teach strategies for energy conservation
• Teach client to carry a pocket calendar, make lists of required activities, and post reminders around the house.
• Teach the importance of following a healthy lifestyle with adequate nutrition and rest, pain relief, and appropriate exercise to decrease fatigue.
• Teach stress-reduction techniques such as controlled breathing, imagery, and use of music. See Anxiety care plan if appropriate; anxiety is correlated with increased fatigue.

Read More »»

Nursing care plans NANDA Nursing Diagnosis: Disturbed Sensory perception

NANDA Nursing Diagnosis Definition: Change in the amount or patterning of incoming stimuli accompanied by a diminished, exaggerated, distorted, or impaired response to such stimuli

Defining Characteristics: Poor concentration, auditory distortions, change in usual response to stimuli, restlessness, reported or measured change in sensory acuity, irritability, disoriented in time, in place, or with people; change in problem-solving abilities; change in behavior pattern; altered communication patterns; hallucinations; visual distortions

NOC Outcomes

• Body Image
• Cognitive Orientation
• Sensory Function: Vision
• Vision Compensation Behavior
• Cognitive Orientation
• Communication: Receptive Ability
• Distorted Thought Control
• Hearing Compensation Behavio

Client Outcomes

• Demonstrates understanding by a verbal, written, or signed response
• Demonstrates relaxed body movements and facial expressions
• Explains plan to modify lifestyle to accommodate visual or hearing impairment
• Remains free of physical harm resulting from decreased balance or a loss of vision, hearing, or tactile sensation
• Maintains contact with appropriate community resources

NIC Interventions

• Communication Enhancement: Hearing Deficit
• Cognitive Stimulation
• Environmental Management

Nursing Interventions and Rationales

Read More »»

Nursing care plans for Disturbed Body Image

Nursing Diagnosis : Disturbed Body Image
Nursing care plans for Disturbed Body Image
NANDA Definition: Confusion in mental picture of one's physical self

Defining Characteristics: Nonverbal response to actual or perceived change in structure and or function, verbalization of feelings that reflect an altered view of one's body in appearance, structure, or function, erbalization of perceptions that reflect an altered view of one's body in appearance, structure, or function, behaviors of avoidance, monitoring, or acknowledgment of one's body

Objective
Missing body part; actual change in structure or function; avoidance of looking at or touching body part,  intentional or unintentional hiding or overexposure of body part; trauma to nonfunctioning part; change in social involvement, change in ability to estimate spatial relationship of body to environment

Subjective
Change in lifestyle, fear of rejection or reaction by others,  focus on past strength, function, or appearance, negative feelings about body,  feelings of helplessness, hopelessness, or powerlessness; preoccupation with change or loss; emphasis on remaining strengths and heightened achievement; extension of body boundary to incorporate environmental objects; personalization of part or loss by name; depersonalization of part or loss by impersonal pronouns; refusal to verify actual change

Related Factors: Psychosocial, biophysical, cognitive/perceptual, cultural, spiritual, or developmental changes; illness; trauma or injury; surgery; illness treatment

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Body Image
• Child Development: 2 Years
• Child Development: 3 Years
• Child Development: 4 Years
• Child Development: 5 Years
• Child Development: Middle Childhood (6-11 Years)
• Child Development: Adolescence (12-17 Years)
• Distorted Thought Control
• Grief Resolution
• Psychosocial Adjustment: Life Change
• Self-Esteem

Client Outcomes
• States or demonstrates acceptance of change or loss and an ability to adjust to lifestyle change
• Calls body part or loss by appropriate name
• Looks at and touches changed or missing body part
• Cares for changed or nonfunctioning part without inflicting trauma
• Returns to previous social involvement
• Correctly estimates relationship of body to environment

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

Nursing Interventions and Rationales

• Use a tool such as the Body Image Instrument (BII) to identify clients who have concerns about changes in body image The five BII subscales-General Appearance, Body Competence, Others' Reaction to Appearance, Value of Appearance, and Body Parts-exhibited moderate to high internal reliability and concurrent validity.
• Observe client's usual coping mechanisms during times of extreme stress and reinforce their use in the current crisis. Clients are in shock during acute phase, and their own value system must be considered. Clients deal better with change over time.
• Acknowledge denial, anger, or depression as normal feelings when adjusting to changes in body and lifestyle. Changes in body image cause anxiety. People in this situation use a variety of unconscious coping mechanisms to deal with their altered body image (ABI). Defense mechanisms are normal, unless they are used so much that they interfere with rather than improve self-esteem.
• Identify clients at risk for body image disturbance (e.g., body builders, cancer survivors). The results of one study suggest that male body builders are at risk for body image disturbance and the associated psychological characteristics that have been commonly reported among eating disorder patients. These psychological characteristics also appear to predict steroid use in this group of males. Steroid users reported an elevated drive to put on muscle mass in the form of bulk.
• Clients should not be rushed into sharing their feelings. Feelings associated with complicated and emotionally powerful issues involving an altered body image take time to work through and express.
• Do not ask clients to explore feelings unless they have indicated a need to do so. Patients reported keeping their feelings to themselves as a frequently used coping strategy.
• Explore strengths and resources with client. Discuss possible changes in weight and hair loss; select a wig before hair loss occurs. Emphasizing strengths promotes a positive self-image. Planning for an event such as hair loss helps to decrease the anxiety associated with a sudden change in appearance.
• Encourage client to purchase clothes that are attractive and that de-emphasize their disability. Individuals with osteoporosis are not usually disabled but may perceive themselves as unattractive and experience social isolation as a result of ill-fitting clothes that accentuate the physical changes.
• Allow client and others gradual exposure to the body change. Begin by having the client touch the affected area; then use a mirror to look at it. Go to a hospital shop with a nurse or support person and discuss feelings associated with the reaction of others to the body change. Part of the rehabilitation process is graded exposure-the client moves from a protected to an unprotected environment with the support of the nurse. 
• Encourage client to discuss interpersonal and social conflicts that may arise. A good perception of body image is best achieved within a supportive social framework. Clients with an active social support network are likely to make better progress. Changes in physical appearance and function associated with disease processes need to be integrated into the interaction that occurs between patients and lay caregivers.
• Encourage client to make own decisions, participate in plan of care, and accept both inadequacies and strengths. It is important for clients to be involved in their own care. If they have received information about their altered body image, treatment, and rehabilitation, they will be able to make their own choices. Consequently they will be more likely to come to terms with and adapt to their ABI. Healthy adaptation to body image exists when the person is able to maximize ability despite disability .
• Help client accept help from others; provide a list of appropriate community resources (e.g., Reach to Recovery, Ostomy Association). Motivation, sharing of experiences, camaraderie with and support from peers, and knowledge of not being alone have been identified as advantages of group learning. 
• Help client describe self-ideal, identify self-criticisms, and be accepting of self. The perception of self-image involves knowing the self and what is important and valued. Disability causes individuals to live as changed human beings whether they are willing to or not.
• Encourage client to write a narrative description of their changes. An analysis based on the grounded theory method revealed that one's experience of coping or adjustment to a disability is represented as narratives about himself or herself. Each person with TBI reconstructed certain self-narratives when coping with their changed self-images and daily lives.
• Avoid looks of distaste when caring for clients who have had disfiguring surgery or injuries. Provide privacy; care should be completed without unnecessary exposure. Nurses must be aware of their nonverbal behavior; clients often become acutely aware of nurses' feelings as a result of the nurses' facial expressions, tone of voice, touch, or other behaviors.
• Encourage client to continue same personal care routine that was followed before the change in body image. It is preferable that this care be completed in the bathroom and not in bed. This routine gives the client privacy and also prevents the client from settling into an "invalid" role. Research has shown that women who resume familiar routines and habits heal better and suffer less depression than those who settle into the role of patient.

Geriatric

• Focus on remaining abilities. Have client make a list of strengths. Results from unstructured interviews with women aged 61 to 92 regarding their perceptions and feelings about their aging bodies suggest that women exhibit the internalization of ageist beauty norms, even as they assert that health is more important to them than physical attractiveness and comment on the "naturalness" of the aging process. Motivation and self-worth are increased in the elderly by highlighting their capabilities. Even a severely disabled client is usually capable of accomplishing some tasks. Normal changes in body image occur as a result of the aging process.
  

Multicultural

• Assess for the influence of cultural beliefs, norms, and values on the client's body image. The client's body image may be based on cultural perceptions, as well as influences from the larger social context.
• Validate the client's feelings with regard to the impact of health status on disturbances in body image. Validation lets the client know that the nurse has heard and understands what was said and promotes the nurse-client relationship.
• Acknowledge that body image disturbances can affect all individuals regardless of culture, race, or ethnicity. Body image disturbances are pervasive across western cultures and appear to increase in other cultures with acculturation to western ideals.

Home Care Interventions

• Assess client's stage of grieving or acceptance of body change upon return to home setting. Include the future role of sexuality in the psychological assessment of acceptance as appropriate.
• Assess family/caregiver level of acceptance of client's body changes.
• Be accepting of changes in all interactions with client and family and caregivers. Acceptance promotes trust.
• Help client to see new or changing roles in family. Point out ways in which the community can help support client and family strengths.
• Refer to medical social services for level of acceptance and possible financial impact of changes. Clients and caregivers may see the nurse's visit as being solely involved with physiological issues such as dressing, especially under managed care systems. Social worker visits can support the client or caregivers with dedicated time and can help the nurse be supportive and adapt interventions to promote acceptance. The nurse or social worker can introduce or reinforce use of community resources.
• Teach all aspects of care. Involve client and caregivers in self-care as soon as possible. Do this in stages if client still has difficulty looking at or touching changed body part. The quicker the involvement in self-care, the greater the chances for permanent acceptance and positive self-esteem.
• Teach family and client complications of medical condition and when to contact physician.
• Refer to occupational therapy if necessary to evaluate home setting for safety and adaptive equipment and to assist client with return to normal activities. The quicker the reinvolvement in daily living activities and self-care, the greater the chances for permanent acceptance and positive self-esteem.
• If appropriate, provide home health aide support to help the client and family through ADL transition.
• Refer to physical therapy if necessary to build range-of-joint-motion (ROJM) flexibility and strength, prevent contractures, assist with transfer/ambulation safety, or obtain use of a prosthetic device in the home setting.
• Assess for and promote good nutrition and sleep patterns. Adapt nutrition to specific physiological situations (e.g., client with ostomy). Good nutrition and sleep patterns promote faster healing and better coping.
• Assist family with obtaining needed supplies. Cost of ostomy supplies and adaptive equipment can be an added stressor for the client. Community resources can assist.

Client/Family Teaching

• Teach appropriate care of surgical site (e.g., mastectomy site, amputation site, ostomy site). Patient teaching by ET nurses may alleviate problems associated with altered body image in relation to the presence of an ostomy.
• Inform client of available community support groups; offer to make initial phone call. Motivation, sharing of experiences, camaraderie with and support from peers, and knowledge of not being alone have been identified as advantages of group learning.
• Refer client to counseling for help adjusting to body change. Counseling is important for a client who is trying to create a new body ideal or work through a grief process.
• Provide printed material and didactic information for significant others. Some significant others prefer to receive didactic material rather than vent their feelings as a way of showing support.
• Encourage significant others to offer support. Social support from significant others enhances both emotional and physical health.
• Direct social support as follows: instruct regarding practical care, encourage appraisal support, encourage self-esteem support, and encourage sense of belonging. The preceding are four categories of support recognized in the body-image care model. Clients with an active social support network are likely to make better progress than those without support.
• Refer to an interdisciplinary team clients with ostomies who are having difficulty with personal acceptance, personal and social body-image disruption, sexual concerns, reduced self-care skills, and the management of surgical complications Many clinical studies have found patients with ostomies to be a group facing multiple adjustment demands. One of these demands is coping with a significant change in body image. At the Medical College of Wisconsin, a team approach has been initiated; the ET nurse, the psychologist, and the surgeon deal with body image concerns together. The multidisciplinary approach has been demonstrated to be successful in facilitating adaptation to an altered body image.

Read More »»

Nursing Care Plans for Diarrhea

Nursing Diagnosis: Diarrhea
Nursing care plans for Diarrhea
NANDA Definition: Passage of loose, unformed stools

Defining Characteristics:  Hyperactive bowel sounds, at least three loose liquid stools per day, urgency, abdominal pain, cramping

Related Factors:
Psychological
High stress levels and anxiety
Situational
Alcohol abuse,  toxins,  laxative abuse, radiation, tube feedings , adverse effects of medications, contaminants, travel
Physiological
Inflammation, malabsorption, infectious processes, irritation, parasites

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
• Bowel Elimination
• Electrolyte and Acid-Base Balance
• Fluid Balance
• Hydration
• Treatment Behavior: Illness or Injury

Client Outcomes
• Defecates formed, soft stool every day to every third day
• Maintains a rectal area free of irritation
• States relief from cramping and less or no diarrhea
• Explains cause of diarrhea and rationale for treatment
• Maintains good skin turgor and weight at usual level
• Contains stool appropriately (if previously incontinent)

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
• Diarrhea Management

Nursing Interventions and Rationales Nursing Care Plans for Diarrhea

• Assess pattern of defecation or have client keep a diary that includes the following: time of day defecation occurs; usual stimulus for defecation; consistency, amount, and frequency of stool; type of, amount of, and time food consumed; fluid intake; history of bowel habits and laxative use; diet; exercise patterns; obstetrical/gynecological, medical, and surgical histories; medications; alterations in perianal sensations; and present bowel regimen. Assessment of defecation pattern will help direct treatment.
• Identify cause of diarrhea if possible (e.g., viral, rotavirus, human immunodeficiency virus/HIV), food, medication effect, radiation therapy, protein malnutrition, laxative abuse, stress). Identification of the underlying cause is imperative because the treatment and expected outcome depend on it. If the onset of diarrhea is sudden with no obvious cause, a colonoscopy is recommended to rule out colon cancer. When reviewing medication, assess for medications that increase peristalsis, such as metoclopramide. HIV infection is also commonly associated with diarrhea.
• If client has watery diarrhea, a low-grade fever, abdominal cramps, and a history of antibiotic therapy, consider possibility of Clostridium difficile infection. difficile infection and pseudomembranous colitis have become increasingly common because of the frequent use of broad-spectrum antibiotics.
• Use Standard Precautions when caring for clients with diarrhea to prevent spread of infectious diarrhea; use gloves and handwashing. Clostridium  difficile has been shown to be contagious and at times epidemic. One study of medical patients demonstrated that more than 30% developed nosocomial diarrhea after admission to a nursing unit, and the majority of cases were caused by Clostridium  difficile. Clostridium   difficile is spread by direct or indirect contact, placing other clients at risk for infection.
• Obtain stool specimens as ordered to either rule out or diagnose an infectious process (e.g., ova and parasites, Clostridium   difficile infection, bacterial cultures).
•  If client has infectious diarrhea, avoid using medications that slow peristalsis. If an infectious process is occurring, such as Clostridium   difficile infection or food poisoning, medication to slow down peristalsis should generally not be given. The increase in gut motility helps eliminate the causative factor, and use of antidiarrheal medication could result in a toxic megacolon.
• Observe and record number and consistency of stools per day; if desired, use a fecal incontinence collector for accurate measurement of output. Documentation of output provides a baseline and helps direct replacement fluid therapy.
• Inspect, palpate, percuss, and auscultate abdomen; note whether bowel sounds are frequent.
• Assess for dehydration by observing skin turgor over sternum and inspecting for longitudinal furrows of the tongue. Watch for excessive thirst, fever, dizziness, lightheadedness, palpitations, excessive cramping, bloody stools, hypotension, and symptoms of shock. Severe diarrhea can cause deficient fluid volume with extreme weakness  and cause death in the very young, the chronically ill, and the elderly.
• Observe for symptoms of sodium and potassium loss (e.g., weakness, abdominal or leg cramping, dysrhythmia). Note results of electrolyte laboratory studies. Stool contains electrolytes; excessive diarrhea causes electrolyte abnormalities that can be especially harmful to clients with existing medical conditions.
• Monitor and record intake and output; note oliguria and dark, concentrated urine. Measure specific gravity of urine if possible. Dark, concentrated urine, along with a high specific gravity of urine, is an indication of deficient fluid volume.
• Weigh client daily and note decreased weight. An accurate daily weight is an important indicator of fluid balance in the body.
• Give clear fluids as tolerated, serving at lukewarm temperature.
• For children with diarrhea, give oral rehydration therapy liquids (Pedialyte) as directed by physician. Oral rehydration therapy is effective for treating mild to moderate dehydration in children with diarrhea and may help prevent the need for hospitalization with administration of IVs.
• If diarrhea is associated with cancer or cancer treatment, once infectious cause of diarrhea is ruled out, provide medications as ordered to stop diarrhea. The loss of proteins, electroytes, and water from diarrhea in a cancer client can lead to rapid deterioration and possibly fatal dehydration.
• If diarrhea is chronic and there is evidence of malnutrition, consult with primary care practitioner for a dietary consult and possible use of a hydrolyzed formula to maintain nutrition while the gastrointestinal system heals. A hydrolyzed formula contains protein that is partially broken down to small peptides or amino acids for people who cannot digest nutrients.
• Encourage client to eat small, frequent meals and to consume foods that normally cause constipation and are easy to digest . Encourage client to avoid milk products, foods high in fiber, and caffeine. Bland, starchy foods are initially recommended when starting to eat solid food again.
• Provide a readily available bedpan, commode, or bathroom.
• Maintain perirectal skin integrity. Cleanse with a mild cleansing agent (perineal skin cleanser). Apply protective ointment prn. If skin is still excoriated and desquamated, apply a wound hydrogel. Avoid the use of rectal Foley catheters. Moisture-barrier ointments protect the skin from excoriation. Rectal Foley catheters can cause rectal necrosis, sphincter damage, or rupture, and the nursing staff may not have the time to properly follow the necessary and very time-consuming steps of their care.
• If client is receiving a tube feeding, do not assume it is the cause of diarrhea. Perform a complete assessment to rule out other causes such as medication effects, sorbitol in medications, or an infection. Research has shown that tube feedings do not usually cause diarrhea. Howeve, sorbitol in medication has been linked to diarrhea.
• If client is receiving a tube feeding , suggest formulas that contain a bulking agent such as Jevity. Note rate of infusion, and prevent contamination of feeding by rinsing container every 8 hours and replacing it every 24 hours. Rapid administration of tube feeding and contaminated feedings have been associated with diarrhea. Bulking agents are useful in tube feedings to prevent diarrhea.

Geriatric

• Evaluate medications client is taking. Recognize that many medications can result in diarrhea, including digitalis, propranolol, ACE inhibitors, Hx-receptor antagonists, NSAIDS, anticholinergic agents, oral hypoglycemia agents, antibiotics, and others. A drug-associated cause should always be considered when treating diarrhea in the older person; many drugs can result in diarrhea.
• Monitor client closely to detect whether an impaction is causing diarrhea; remove impaction as ordered. Impactions are more common in the elderly than in younger clients. It is very important that the client be checked for impaction before being given any antidiarrheal medication.
• Seek medical attention if diarrhea is severe or persists for more than 24 hours, or if client has symptoms of dehydration or electrolyte disturbances such as lassitude, weakness, or prostration. Elderly clients can dehydrate rapidly. The greatest concern for elderly clients with severe diarrhea is hypokalemia. Hypokalemia is treatable but when missed can be fatal.
• Provide emotional support for clients who are having trouble controlling unpredictable episodes of diarrhea. Diarrhea can be a great source of embarrassment to the elderly and can lead to social isolation and a feeling of powerlessness.

Home Care Interventions Nursing Care Plans for Diarrhea

• Assess the home for general sanitation and methods of food preparation. Reinforce principles of sanitation for food handling.
• Assess for methods of handling soiled laundry if client is bedbound or has been incontinent. Instruct or reinforce Standard Precautions with family and bloodborne pathogen precautions with agency caregivers. The Bloodborne Pathogen Regulations of the Occupational Safety and Health Administration (OSHA) identify legal guidelines for caregivers.
• When assessing medication history, include over-the-counter drugs, both general and those currently being used to treat the diarrhea. Instruct clients not to mix over-the-counter medications when self-treating. Mixing over-the-counter medications can further irritate the gastrointestinal system, intensifying the diarrhea or causing nausea and vomiting.

Client and Family Teaching Nursing Care Plans for Diarrhea

• Encourage avoidance of coffee, spices, milk products, and foods that irritate or stimulate the gastrointestinal tract.
• Teach appropriate method of taking ordered antidiarrheal medications; explain side effects.
• Explain how to prevent the spread of infectious diarrhea (e.g., careful handwashing, appropriate handling and storage of food).
• Help client to determine stressors and set up an appropriate stress reduction Care plans .
• Teach signs and symptoms of dehydration and electrolyte imbalance.

Read More »»

Nursing Care Plans for Deficient Knowledge

Nursing care plans with Nursing Diagnosis: Deficient Knowledge

NANDA Diagnosis Definition: Absence or deficiency of cognitive information related to a specific topic

Defining Characteristics: Verbalization of the problem; inaccurate follow-through of instruction; inaccurate performance of test; inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated, apathetic)

Related Factors: Lack of exposure; lack of recall; information misinterpretation; cognitive limitation; lack of interest in learning; unfamiliarity with information resources

NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
· Knowledge of: Diet
· Disease Process
· Energy Conservation
· Health Behaviors
· Health Resources
· Infection Control
· Medication
· Personal Safety
· Prescribed Activity
· Substance Use Control
· Treatment Procedures
· Treatment Regimen

Client Outcomes
· Explains disease state, recognizes need for medications, understands treatments
· Explains how to incorporate new health regimen into lifestyle
· States an ability to deal with health situation and remain in control of life
· Demonstrates how to perform procedures satisfactorily
· Lists resources that can be used for more information or support after discharge

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
· Teaching: Disease Process
· Teaching: Individual
· Teaching: Infant Care

Nursing Interventions and Rationales

• Observe client's ability and readiness to learn (e.g., mental acuity, ability to see or hear, no existing pain, emotional readiness, absence of language or cultural barriers). Education in self-care must take into account physical, sensory, mobility, sexual, and psychosocial changes related to age.
• Assess barriers to learning (e.g., perceived change in lifestyle, financial concerns, cultural patterns, lack of acceptance by peers or coworkers). The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences.
• Determine client's previous knowledge of or skills related to his or her diagnosis and the influence on willingness to learn. New information is assimilated into previous assumptions and facts and may involve negotiating, transforming, or stalling.
• Involve clients in writing specific outcomes for the teaching session, such as identifying what is most important to learn from their viewpoint and lifestyle. Objectives put the content into focus, provide a forum for evaluation outcomes, and ensure continuity. Client involvement improves compliance with health regimen and makes teaching and learning a partnership.
• When teaching, build on client's literacy skills. In patients with low literacy skills, materials should be short and have culturally sensitive illustrations.
• Present material that is most significant to client first, such as how to give injections or change dressings; present additional material once client's most pressing educational needs have been met. Information building begins with explaining simple concepts and moves on to explanations of complex application situations.
• Determine client's understanding of common medical terminology, such as "empty stomach," "emesis," and "palpation." Clients are expected to read and understand labels on medicine containers, appointment slips, and informed consents, yet an estimated 40 million adults are functionally illiterate.
• Evaluate the readability of the material in pamphlets or written instructions. Nonadherence of older adults to new medication regimens appears to be a function of decreased cognitive ability and comprehension of instruction, poor communication, and increased physical limitations.
• Use visual aids such as diagrams, pictures, videotapes, audiotapes, and interactive Internet web sites. Verbal reinforcement of personalized, written instructions appears to be the best tested intervention. Computer-generated, personalized instructions improved adherence when compared with handwritten instructions. This evidence-based study suggested leaflets as a useful resource for information provision.
• Provide preadmission self-instruction materials to prepare client for postoperative exercises. Providing clients with preadmission information about exercises has been shown to increase positive feelings and the ability to perform prescribed exercises.
• Identify the primary family support person; be aware of that person's ability to learn and incorporate needed changes.
• Assess willingness of family to incorporate new information, immunizations, medical/dental care, and diet/behavior modifications in support of the client. Attention needs to be directed at family adjustment factors. For example, women recovering from alcohol abuse are at risk for relapse if their spouse continues to drink alcohol, and modification of eating patterns plus social and partnership support have had more success than modification alone.
• Help client identify community resources for continuing information and support. Learning occurs through imitation, so persons who are currently involved in lifestyle changes can help the client anticipate adjustment issues. Community resources can offer financial and educational support. For example, role modeling and skill training have been used to monitor symptoms and solve asthma problems.
• Evaluate client's learning through return demonstrations, verbalizations, or the application of skills to new situations. Presenting information along with with examples of how to apply the information has been found more successful than providing information alone in a home care setting.

Geriatric Nursing Care Plans

• Adapt the teaching process for the physical constraints of the aging process (e.g., speak clearly, use a variety of audio-visual-psychomotor methods, provide examples, and allow time for client to repeat and review). Adults are capable of learning at any age. Age modifies but does not inhibit learning. Older adults need practice to use new technology.
• Ensure that the client uses necessary reading aids (e.g., glasses, magnifying lenses, large-print text) or hearing aids. Visual and hearing deficits require amplification or clarification of sensory input.
• Use printed material, videotapes, lists, diagrams, and Internet addresses that the client can refer to at another time. These methods provide a reference that can be used in a less stressful setting, decreasing barriers to learning. This study demonstrated the effectiveness of printed material and a web-based format for education. The web-based format demonstrated two additional benefits when compared with printed material: increased social support and decreased anxiety.
• Assess client's previous knowledge and resistance or blocks to incorporating new information into the current lifestyle. The client brings to the learning situation a unique personality, established social interaction patterns, cultural norms and values, and environmental influences.
• Repeat and reinforce information during several brief sessions. Understanding past information is essential to acquiring new knowledge. Brief sessions focus attention on essential information.
• Discuss healthy lifestyle changes that promote wellness for the older adult. It is never too late to stop smoking, lose weight, or modify dietary intake of fats and alcohol. Quality vs. quantity of life may be the key issue in teaching self-care health habits.
• Evaluate readability of the material. Nonadherence of older adults to new medication regimens appears to be a function of decreased cognitive ability, comprehension of instruction, poor communication, and increased physical limitations.
• Consider health education programs using television and newspapers. There was a significant increase in stroke knowledge (52% more likely to know a risk factor and 35% know a symptom, p = 0.032) following this health education program as demonstrated through a telephone pretest and posttes.

Multicultural Nursing Care Plans Interventions and Rationales

• Acknowledge racial/ethnic differences at the onset of care. Acknowledgement of racial/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes.
• Assess for the influence of cultural beliefs, norms, and values on the client's knowledge base. The client's knowledge base may be influenced by cultural perceptions.
• Use a neutral indirect style when addressing areas where improvement is needed when working with Native American clients. Using indirect statements such as "I had a client who tried 'X' and it seemed to work very well" will help avoid resentment from the client.
• Validate the client's feelings and concerns related to previous learning experiences. Validation lets the client know the nurse has heard and understands what was said.
• Approach individuals of color with respect, warmth, and professional courtesy. Instances of disrespect and lack of caring have special significance for individuals of color.

 Home Care Interventions

• Because home care is an intermittent model of care having a goal of safety and optimal wellness of the client between visits, the importance of teaching (by nurse) and learning (by client) should not be understated. All of the previously mentioned interventions are applicable to the home setting.
• Select a space and time for teaching in which client and/or caregiver can focus on information to be learned. The home setting provides many distractions that may impair the ability of the client to learn.
• Consider the complexity of material or behaviors to be learned. Adjust care plan and respective teaching and learning experiences accordingly to build client confidence in ability to learn (and change). Confidence in ability to learn and change is part of readiness to learn.
• Assess for specific areas of learning that have the potential for strong emotional responses by the client or family/caregiver. Allow time for expression of feelings and encourage acceptance of need for learning. An individual's perception of barriers and benefits has consistently been most predictive of subsequent behavior. Clinicians should develop interventions that increase benefits and decrease barriers.
• Document client's and caregivers' responses to learning. Clear documentation supports continuity in the learning experience

Read More »»

Nursing Care Plans With Nursing Diagnosis: Deficient Fluid volume

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.

Read More »»

Nursing Care Plans for Decreased Cardiac output

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.

Read More »»

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.

Geriatric

• 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.

Read More »»