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The nursing diagnoses that follow are listed according to the NANDA (North American Nursing Diagnosis Association) Nursing Diagnosis Taxonomy I (1986). This taxonomy has nine major categories, which are viewed as human response patterns. They are:
Each major category has two or more secondary categories ("alterations"), which refer to "the process or state of becoming or being made different without changing into something else."
The nursing diagnoses in this chapter are organized according to both the major and secondary categories. For example,
Potential for infection
Not all categories nor all NANDA-approved nursing diagnoses are included in this chapter.
Potential for infection related to
Anorexia, failure to thrive, pain, weakness, lethargy, epistaxis, headache, visual disturbances, pete-chiae, pallor, fever, diarrhea, breaks in skin integrity;
altered lab values
The patient will remain free from any preventable infection as evidenced by:
Perform handwashing with designated antimicrobial agent before and after patient contact.
Report signs of systemic infection (e.g., fever); culture as indicated.
Monitor for signs of localized infection (e.g., sore throat, reddened or draining wounds, conjunctivitis, erythema).
Provide a private room.
Maintain protective/reverse isolation, based on hospital policy; keep plants and flowers out of room.
Encourage ambulation, deep breathing, range-of-mo-tion exercises every 2 hours and as needed.
Provide oral care at least once/shift to prevent oral lesions.
Provide and encourage perianal hygiene to prevent rectal abscess.
Maintain body hygiene by bathing daily and as necessary for postdiaphoresis, draining wounds.
Monitor vital signs every 1-2 hours and as needed.
Assess level of consciousness, headache, visual disturbances.
Monitor lab values (e.g., electrolytes, CBC with differential, total body protein, cultures and sensitivities as indicated).
Monitor fluid intake (optimal at least 2000 ml in 24 hours unless contraindicated).
Monitor pulmonary status: auscultate lung fields every 2-4 hours and as needed.
Teach patient signs and symptoms of infection (e.g., warmth, redness, temperature greater than 100°F, malaise, swelling, pain) and to report any to MD.
Avoid invasive procedures if possible.
Avoid giving medication or taking temperatures rec-tally.
Maintain output (1200-1600 ml in 24 hours).
For arterial/venous lines insertion site
Alteration in tissue perfusion: cerebral, cardiopul-monary, renal, gastrointestinal, peripheral related to
Cerebral: LOC, restlessness, disorientation, lethargy
Cardiopulmonary: decreased blood pressure, increased heart or respiratory rates, angina, dyspnea
Renal: hypertension, decreased urine output, edema
Gastrointestinal: abdominal distention, pain, nausea and vomiting, hiccups, constipation or diarrhea, thirst; stools and NG content test positive guaiac
Peripheral: delayed capillary refill, pallor, cyanosis, cool extremities, numbing and tingling, pain
The patient will maintain normal tissue perfusion as evidenced by:
Assess every 1-2 hours and as needed:
Change position every 2 hours and as needed; elevate head of bed to facilitate breathing if needed.
Massage pressure areas every 2 hours and as needed; note and report any redness and/or signs of skin breakdown.
Encourage/teach patient to do active range-of-motion exercises every shift and as needed; if patient is unable to do so, perform passive ones.
Provide balanced diet.
Provide external warmth.
Administer medications as ordered by physician:
Evaluate and record effects of medications. Record intake and output every shift.
Alteration in fluid volume: excess related to
Physical examination shows skin: pale, moist, taut, cool; edema: periorbital, facial, pitting (skin looks indented when depressed by thumb); distended neck veins at 45-degree head elevation; 5% weight increase; dyspnea, orthopnea, rales, productive cough; tires easily; anorexia, nausea, vomiting; decreased urine output (fluid volume is increased, intake greater than output); lethargy, confusion, apathy; S3; blood pressure increase, pulse bounding
The patient will regain fluid balance as evidenced by:
Monitor heart rate and regularity; take vital signs every 2-4 hours and record; report S3 to physician if present; arrange for ECG daily or as ordered.
Check for neck vein distention and take CVP reading every 2-4 hours and record; if greater than 12, increase head of bed 60°; report to physician.
Draw (or arrange to have drawn) blood for electrolytes, blood urea nitrogen (BUN), creatinine levels, and Hct daily or as ordered; report results to physician.
Arrange for chest x-ray as ordered by physician.
Listen to lung sounds every 4 hours; note increase in respiratory rate, complaints of shortness of breath (SOB); note if rales, rhonchi, wheezing are present; report these findings to physician.
Provide oxygen as ordered for dyspnea; elevate head of bed 60°; place pillows under both arms.
Increase head of bed 30°-45° or place in semi-Fowler's position; note color of sclera and amount of edema.
Record intake and output every 1 (SICU) or 8 hours; record for 24 hours daily.
Offer sips of fluid and record intake; offer small portions of low-sodium nutritious snacks at intervals.
Note amount and color of urine and record; check specific gravity.
Note skin color, temperature, turgor, evidence of breakdown.
Maintain fluid restrictions as ordered.
Note frequency, color, and consistency of cough and sputum; obtain sputum specimen and send to lab for culture and sensitivity and Gram's stain; consult physician about chest physiotherapy (CPT) with alupent treatments.
Provide pulmonary hygiene; reposition, cough, and deep breathe every 2 hours.
Instill natural tear drops every 4-6 hours, eye patches if needed.
Weigh daily; note increase/decrease.
Note behavior changes; orient patient to time and place with each contact; restrain with soft restraints if needed; encourage patient to verbalize needs; listen to patient.
Listen to heart sounds every 4 hours.
Support edematous extremity by elevating it on pillow; note increase/decrease of edema; turn and reposition; perform range-of-motion exercises every 2 hours.
Provide egg-crate mattress or Kin-Air bed for patient on prolonged bed rest.
Give laxatives as ordered; note amount, color, consistency of stool and record; note patterns or trends of BMs over several days.
Allow periods of rest; decrease noise, dim lights, provide medication if needed.
Have dietitian talk with patient about food preferences.
Alteration in cardiac output: decreased related to
Variation in hemodynamic readings; disrhythmias, ECG changes; fatigue, restlessness; cold and clammy skin, cyanosis, pallor of skin and mucous membranes; oliguria, anuria; jugular vein distention, decreased peripheral pulses; rales, dyspnea, orthopnea; angina; edema; change in mental status, syncope, vertigo; gallop rhythm, abnormal heart sounds; cough, frothy sputum
The patient will have adequate cardiac output as evidenced by:
Check vital signs every 2 hours or as ordered.
Check level of consciousness every 1-2 hours and as needed.
Auscultate heart and breath sounds every 2 hours or as needed.
Maintain IV fluids as ordered.
Continue cardiac monitoring via Swan-Ganz catheter, ECG, CVP; report changes.
Administer low-flow oxygen as ordered and as needed.
Measure intake and output.
Encourage deep breathing every 2 hours.
Weigh daily.
Organize care to prevent fatigue.
Change position every 2 hours; assess patient for fluid retention in sacral and pedal areas.
Maintain quiet environment; restrict activities as needed.
Observe for effect and toxicity of drugs.
Assess knowledge of disease state (e.g., symptom identification, reporting, activity, stress reduction, diet); initiate health teaching and referrals if indicated.
Maintain sodium-restricted diet.
Involve family/significant other in care and teaching.
Impaired gas exchange related to
Confusion; anxiety; tachypnea; decreased mental acuity; thick, cloudy secretions; dyspnea; cyanosis; restlessness
The patient will have adequate gas exchange as evidenced by:
Ensure that oxygen is maintained per physidan's order.
Monitor respiratory rate, pattern, and depth.
Reposition every hour; rotate from right to left laterally to semi-Fowler's position.
Observe and report signs of restlessness, confusion, irritability.
Monitor arterial blood gases (ABG) reports for ± of PaC02 and Pa02 of more than 10-15 mm/Hg.
Evaluate effects of prescribed medications and oxygen.
Record intake and output.
Take temperature every 4 hours.
Teach to use clean respiratory equipment.
Teach patient and family to avoid people with upper respiratory infections.
Ineffective airway clearance related to
Rales, rhonchi, wheezing, decreased breath sounds on auscultation; difficulty in expectoration;
abnormal respiratory rate, rhythm, depth; change in color (e.g., cyanosis, pallor); diaphoresis
The patient will maintain a patent airway as evidenced by:
Take vital signs every 2 hours and as needed. Position head of bed at a 30°-40° angle.
Observe for signs of respiratory distress (e.g., increased respiratory rate, restlessness, use of accessory muscles).
Administer oxygen if necessary and as ordered; evaluate results.
Suction endotracheal tube, trach area, and nasal/oral cavity as necessary.
Maintain proper position of endotracheal tube.
Change patient position from side-to-side and from supine to semi-Fowler's every 2 hours and as needed.
Provide supplemental humidification for tracheos-tomy tube.
Instruct and encourage coughing and deep breathing every 2 hours and as needed.
Ineffective breathing pattern related to
Dyspnea, orthopnea, tachypnea; abnormal rate, rhythm, or depth of respirations
The patient will provide air movement necessary to support the oxygen/carbon dioxide exchange as evidenced by:
Monitor skin/nailbed color, vital signs every 2 hours and as needed. Assess respiratory rate, rhythm, tidal volume, breath sounds every 2 hours and as needed.
Elevate head of bed 30° as tolerated.
Provide oxygen as required by patient or ordered by physician; evaluate results.
Monitor ABGs.
Report all lab results and changes in respiratory patterns to physician as necessary.
Change position and increase patient activity as tolerated.
Encourage deep breathing.
Observe for decreased chest expansion.
Assist to use incentive spirometer every hour with 10 repetitious breaths.
Instruct and assist to cough, deep breathe every 1-4 hours and as needed.
Potential for injury related to altered blood flow
Impaired mental status, confusion, tissue hypoxia, vertigo, syncope, seizure
The patient will remain free of injury as evidenced by:
Orient patient/family to surroundings, routines, regulations (fire/oxygen), communication system on admission and ward transfer.
Instruct patient/family about necessity of safety precautions.
Instruct patient to ask for assistance when needed.
Maintain nurse-call device within reach of patient.
Keep night light on during dark hours.
Maintain bed in low position.
Encourage use of orienting cues by staff and family (weave orienting facts into conversation).
Provide normal living cues: curtains open during day, clock and calendar in view, TV/radio, newspaper.
Monitor and assist patient with transfer/ambulation activities.
Offer assistance with elimination as needed.
Place patient-use items within reach.
Monitor patient at half-hour intervals.
While in bed, keep
Use soft protective devices when necessary to protect patient (e.g., wristlets or mitts, vest or pelvic support, waist belt).
Release extremities, massage and reposition patient every 2 hours.
Provide proper positioning and good body alignment.
Encourage family/volunteer involvement.
Spiritual distress related to separation from religious, cultural ties (Table 12.1)
Anxiety, fear, guilt, withdrawal, depression, restlessness, disruption in sleep pattern, lack of will to live, decreased hope, abandoning usual belief system, expressing concern about nonparticipation in usual spiritual practices, requesting spiritual counseling, requesting objects associated with worship, questioning existence or fairness of supreme being
The patient will begin to or completely resolve spiritual distress during hospitalization as evidenced by:
| Table 12.1 Stage of Spiritual Distress | |
| Disillusioned | Patient questions worth or credibility of religious beliefs, relationship with God, and reasons for or meaning of existence. |
| Patient may question "Why did God permit this to happen?" | |
| Investigation | Patient begins to blame God for illness or other difficulties experienced and feels anger toward God, |
| Patients faith and trust in God and spiritual beliefs decrease. | |
| Idolatry | Patient's usual religious practices and rituals change as she/he begins to seek for alternative beliefs. |
| Resolution | Patient expresses conflict or concern about his/her own religious beliefs and values. |
| With adequate resolution, spiritual distress is resolved. | |
Communicate acceptance of and respect for patient's religious beliefs by involving patient in care planning (e.g., planning diet in relation to religious beliefs).
Express a willingness to talk about spiritual beliefs and do so in a nonjudgmental manner.
Assist patient to recognize that spiritual longing or a desire to search for meaning in life or suffering is acceptable.
Assess patient and family desire and need for spiritual assistance; contact spiritual leader in community or hospital on request; communicate with leader information that is necessary and useful in helping patient prevent interruption during visit if possible.
Permit patient to continue beneficial religious practices as much as feasible; provide privacy and time for patient to observe religious practices.
Assist individuals with physical limitations in prayer and spiritual observances; arrange transporation to religious services in hospital.
Acknowledge limitations that hospitalization and illness impose on religious observances.
Determine religious or spiritual articles desired; help patient to obtain these items from clergy in hospital, spiritual leader, family, or members of spiritual group; allow patient to keep articles and books within reach as much as possible.
Assess patient concern about nonadherence to religious dietary laws; provide dietary consult; encourage family or friends to bring special foods when feasible.
Note any patient objection to prescribed medical procedure or treatment that conflicts with spiritual beliefs; question spiritual leader about restrictions and exemptions as they apply to those who are seriously ill or hospitalized.
Provide information about health regimen, treatments, and medications; explain nature and purpose of therapy; provide factual information regarding treatment without coercion (if conflicts with religious beliefs).
Encourage patient and physician to consider possible alternative methods of therapy as appropriate; support patient decision even if it conflicts with own values.
In emergency situation, delay treatment as much as possible until spiritual needs have been met (e.g., receiving last rites before OR).
Impaired adjustment related to hypertension requiring alteration in life-style
Denies need to alter life-style; does not ask questions or seek information about medical regimen, dietary changes, and so on; verbalizes distrust, disbelief, lack of confidence in health care providers; does not comply with prescribed medical regimen
The patient will begin to accept changed health status as evidenced by:
Identify and discuss patient's fears, feelings, concerns associated with medical diagnosis.
Assess and identify reasons/factors (e.g., educational, financial, occupational, religious and cultural practices) that may assist or deter acceptance and compliance with treatment plans.
Be aware that if diagnosis is new, patient may need time to grieve and mourn loss of previous health status.
Assess how family/significant others help or hinder patient to make needed adjustments.
Assess patient's readiness and willingness to learn; initiate education program when patient is ready.
Assess personality structure of patient; identify and discuss factors that contribute to stress, increased blood pressure.
Discuss behaviors that will help patient to reduce stress and ultimately blood pressure.
Discuss benefits, risks, long-term effects of compliance, noncompliance.
Explore with patient ways to integrate changes into life-style; refer for necessary assistance (e.g., counseling, financial aid).
Include both patient and family in development of treatment plan agreeable with family habits and personality of patient.
Impaired physical mobility related to
as these affect the cardiopulmonary, gastrointestinal, genitourinary, integumentary, and psychosodal systems
Inability to move, limited range of motion, decreased physical activity
Observe for skin blanching, capillary refill (notify physician if greater than 6 seconds), color, edema (especially in dependent areas such as sacrum, feet).
Instruct patient not to compress veins with crossed or hyperflexed legs; place foot cradle to avoid any pressure or constriction to lower extremities, if indicated.
Encourage passive/active range of motion every 2-4 hours; avoid excess isometric exercises such as pushing against high resistance.
If intubated:
Wash hands prior to suctioning or manipulating tubing; use sterile technique; auscultate lungs and suction as needed.
Turn and position every 2 hours to reach optimum lung expansion.
Monitor ABGs and report changing trends.
If not tubated:
Have patient cough and deep breathe at least every 2 hours; splint if abdomen is painful.
Teach use of incentive spirometer.
Offer oral hygiene with cleansing and mouth fresheners at least every 8 hours.
Maintain fluid intake of 2000 ml/24 hours unless con-traindicated.
Encourage increased activity as tolerated (e.g., placing head of bed in mid-Fowler's position).
Initiate discussion of nutritional status with physician within 24 hours of admission to intensive care unit.
Monitor frequency, consistency, and color of bowel movements.
Request orders for stool softener or laxative if necessary.
Maintain fluid intake of 2000 ml unless contraindicated.
Assess for occult blood.
Monitor blood glucose levels every 6 hours if patient is receiving parenteral feedings.
Provide therapeutic environment for meal periods or at time of evacuation; offer bedpan if communication is impaired.
Place patient on intake/output measurement; report if urinary output is less than 240 ml/8 hours. Maintain fluid intake of 2000 ml daily unless contraindicated.
Monitor insensible fluid loss (e.g., diaphoresis, hyperventilation, increased temperature). Observe urine color, consistency, odor. Weigh daily; monitor urine electrolytes.
Monitor fluid creatinine if patient on aminoglycoside therapy.
Maintain cleanness of skin with special attention to perineal areas, aged skin, obesity. Change position every 2 hours; position in correct body alignment; use pillows or other assistive devices as needed. Observe for reddened areas over bony prominences; massage when turning.
Use blanket or sheet when turning patient if needed.
Maintain fluid intake of 2000 ml/24 hours unless contraindicated.
Request order for special devices/beds such as air mattresses, flotation pads.
Teach patient and family members to record intake. Consult dietitian regarding protein, carbohydrate, and roughage needs; reinforce diet instructions. Request physical therapy consult for prolonged bed rest.
Assess patient's coping mechanisms and life-style prior to immobility.
Encourage presence of family/significant other. Provide an increase in environmental stimuli such as TV, radio, volunteers, occupational therapy. Support patient; use good communication skills.
Hopelessness related to feeling that one's physical condition is incurable
Feelings of despair, worthlessness, suicidal ideation, emptiness, withdrawal; impaired adjustment; self-destructive behavior (e.g., noncompliance with medications); altered mental status; decreased decision making; lack of interest in current status; passiveness; negative verbalizations
The patient will regain a degree of hope as evidenced by:
Encourage patient to express feelings; acknowledge them as valid.
Express empathy in order to help patient express concern, doubts, fears.
Provide support by sitting with patient, encouraging to talk at least once/shift.
Help patient to differentiate problems that cannot be solved from those that can be; assist patient to focus on the latter.
Point out hopeful things in patient's life as appropriate (e.g., relationships with family, significant others).
Involve patient in decisions regarding daily care in order to provide a sense of worth; advance from very simple to more complex decisions as appropriate; reinforce all efforts.
Help patient focus on short-term realistic goals.
Identify patient's strengths and emphasize them. Encourage patient to do daily activities that are pleasurable (e.g., reading a book, talking on telephone).
Involve in diversional activity as tolerated. Assess what patient knows about current conditions and correct any misinformation; encourage questions, provide honest answers. Work with family/significant others to involve them in patient's care as appropriate. Encourage patient to use community support services (e.g., self-help, post open heart groups).
Disturbance in self-concept: self-esteem related to
Verbalizes sense of little worth; withdrawal, depression, confusion; increased dependence on care-giver/significant others; denial; hostility
The patient will regain a positive sense of self as evidenced by:
Provide a therapeutic environment fostering patient's sense of personal self (e.g., allow patient to participate in plan of care; ask for patient's opinions; give compliments when appropriate on progress and decisions).
Encourage patient to verbalize concerns and anxieties regarding self; acknowledge them as usual ones (if true) for any patient in a similar situation.
Encourage patient to take responsibility for own behavior; encourage risk taking in exploring new behaviors (minor to major sequence, for example, mutually agreeing [nurse/patient] to try behavior modification for desired changes).
Progress from simple decisions regarding care to decisions of increasing complexity and number to allow for higher self-concept; provide positive reinforcement when appropriate.
Help patient to set realistic, achievable standards for self.
Help patient to develop problem-solving skills and strategies to facilitate developing a clearer sense of self.
Work with patient to plan for activities that will foster/promote/contribute to sense of personal identity.
Knowledge deficit regarding
Anxiety related to diagnosis; lack of compliance with medication use; inability to cope with health problem(s); inaccurate or lack of compliance with instructions; overdependence on health care workers; lack of recognition of need for medical services; inaccurate verbalization of alteration in health state; lack of information about current disease state, treatment options, prognosis
The patient will verbalize accurate and increased knowledge of health status; will develop skills and knowledge necessary for effective control of disease/ disability as evidenced by:
Assess patient's acceptance of altered health state, knowledge base, ability and readiness to learn.
Provide information as needed; give information in relation to patient's ability to use; have patient repeat information to ensure understanding.
Teach any skills patient needs to perform; explain and demonstrate each step in sequence, repeating as necessary.
Ask patient to do return demonstration; give encouragement and feedback; make corrections as necessary.
Use audio-visual teaching methods as appropriate.
Incorporate family/significant others in teaching plans.
Involve patient actively in care, plans, and decision making; give positive reinforcement for all efforts.
Provide information about community resources/support groups prior to discharge.
Alteration in comfort: pain related to
Guarding or protective behaviors, hands over painful area; autonomic responses (e.g., diaphoresis, pallor; changes in BP, pulse, stroke volume, respiration, muscle tone; dry mouth, pupillary dilatations, fatigue, decreased appetite); distracted behavior such as crying, restlessness; self-focusing, shortened attention span; altered time perception, impaired thought processes; verbalization of pain, fear, helplessness, hopelessness, anger; frustration at lack of treatment; increased irritability
The patient will state pain is relieved; will have pain controlled/reduced prior to transfer or discharge from intensive care unit.
Interventions
Assess patient's pain: location, intensity (on a scale of 1 [low]-10 [high]), what relieves it, what precipitates it, quality and characteristics; observe facial expressions, posture, motor activity, affect, verbal behavior; monitor vital signs, muscle tension; inspect and palpate painful areas; assess ability to perform range-of-motion exercises.
Administer medications as ordered at onset of pain and with regularity; assess effectiveness. Instruct patient to call nurse for any pain. Teach side effects and actions of pain-relieving medications.
Discuss activities that enhance or reduce pain. Provide for uninterrupted sleep at night if possible. Teach patient/family regarding strategies to relieve pain (e.g., position, immobilization, rest, distraction, relaxation techniques, back massage, supportive environment); assess which helps the most.
Anxiety related to actual or perceived threat to biologic integrity (e.g., disease process, invasive procedures, dying, outcome of impending surgery)
Moderate: increased ability to concentrate and verbalize, more alert, increased heart rate, tremulous
Severe: inability to concentrate or learn; hyperven-tilation, tachycardia, nausea, headache, dizziness, urinary frequency
The patient will experience decreased anxiety as evidenced by:
Determine level of anxiety. Assess resources and strengths available for patient to cope with anxiety. Allow patient to verbalize concerns; ask questions in order to reduce anxiety to a level where learning can begin.
Encourage expression of feelings; listen to and acknowledge what patient says. Stay with patient to provide empathy by holding hand, allowing to cry, talk, and so on. Provide simple, brief, and clear information; repeat as often as needed. Approach physical problem (e.g., hyperventilation) in calm, matter-of-fact manner. Remove excess stimulation. Provide positive feedback. Ask physician for order for drug therapy if needed.