Thursday, June 24, 2010

Nursing Diagnosis Disturbed Sleep pattern

. Thursday, June 24, 2010

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.


Saturday, June 19, 2010

Nursing Diagnosis Disturbed Body Image

. Saturday, June 19, 2010

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

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

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.


Friday, June 18, 2010

Nursing Diagnosis Fatigue

. Friday, June 18, 2010

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.


Thursday, May 7, 2009

Nursing outcomes, interventions and Patient teaching for Alzheimer's disease

. Thursday, May 7, 2009

Alzheimer's disease (AD) is a slowly progressive disease of the brain that is characterized by impairment of memory and eventually by disturbances in reasoning, planning, language, and perception. Many scientists believe that Alzheimer's disease results from an increase in the production or accumulation of a specific protein (beta-amyloid protein) in the brain that leads to nerve cell death.
Patient will:
  • Perform bathing and hygiene needs.
  • Maintain a regular bowel elimination pattern.
  • Use support systems and develop adequate coping behaviors.
  • Oriented to time, person, place, and situation to the fullest extent possible.
  • Perform dressing and grooming needs within the confines of the disease process.
  • Consume daily calorie requirements.
  • Show no signs of malnutrition.
  • Effectively communicate needs verbally or through the use of alternative means of communication.
  • Use support systems and develop adequate coping behaviors.
  • Free from signs and symptoms of infection.
  • Perform toileting needs within the confines of the disease process.

Nursing interventions for patient Alzheimer's disease
  • Establish an effective communication system with the patient and his family to help them adjust to the patient's altered cognitive abilities.
  • Provide emotional support to the patient and his family. Encourage them to talk about their concerns. Listen carefully to them, and answer their questions honestly and completely.
  • Because the patient may misperceive his environment, use a soft tone and a slow, calm manner when speaking to him.
  • Allow the patient sufficient time to answer your questions because his thought processes are slow, impairing his ability to communicate verbally.
  • Administer ordered medications to the patient and note their effects.
  • If the patient has trouble swallowing, check with a pharmacist to see if tablets can be crushed or capsules can be opened and mixed with a semi-soft food.
  • Protect the patient from injury by providing a safe, structured environment. Provide rest periods between activities because these patients tire easily.
  • Encourage the patient to exercise, as ordered, to help maintain mobility.
  • Encourage patient independence, and allow ample time for the patient to perform tasks.
  • Encourage sufficient fluid intake and adequate nutrition. Provide assistance with menu selection, and allow the patient to feed himself as much as he can. Provide a well-balanced diet with adequate fiber. Avoid stimulants, such as coffee, tea, cola, and chocolate. Give the patient semisolid foods if he has dysphagia. Insert and care for a nasogastric tube or a gastrostomy tube for feeding as ordered.
  • Because the patient may be disoriented or neuromuscular functioning may be impaired, take the patient to the bathroom at least every 2 hours, and make sure he knows the location of the bathroom.
  • Assist the patient with hygiene and dressing as necessary. Many patients with Alzheimer's disease are incapable of performing these tasks.

Family And Patient Teaching For Patient Alzheimer's Disease
  • Teach the patient's family about the disease. Explain that the cause of the disease is unknown. Review the signs and symptoms of the disease with them. Be sure to explain that the disease progresses but at an unpredictable rate and that patients eventually suffer complete memory loss and total physical deterioration. (See Teaching patients about Alzheimer's disease.)
  • Review the diagnostic tests that are to be performed and treatment the patient requires.
  • Advise family members to provide the patient with exercise. Suggest physical activities, such as walking or light housework, that occupy and satisfy the patient.
  • Stress the importance of diet. Instruct family members to limit the number of foods on the patient's plate so he doesn't have to make decisions. If the patient has coordination problems, tell family members to cut his food and to provide finger foods, such as fruit and sandwiches. Suggest using plates with rim guards, easy-grip utensils, and cups with lids and spouts.
  • Encourage family members to allow the patient as much independence as possible while ensuring his and others' safety. Tell them to create a routine for all the patient's activities, which helps them avoid confusion. If the patient becomes belligerent, advise family members to remain calm and try to distract him.
  • Refer family members to support groups such as the Alzheimer's Association. Set up an appointment with the social service department to help family members assess their needs.

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