Nursing Diagnosis: Ineffective Coping

NANDA Definition: Inability to form a valid appraisal of internal or external stressors, inadequate choices of practiced responses, and/or inability to access or use available resources

Defining Characteristics: Lack of goal-directed behavior or resolution of problem, including inability to attend; difficulty with organized information; sleep disturbance; abuse of chemical agents; decreased use of social support; use of forms of coping that impede adaptive behavior; poor concentration; fatigue; inadequate problem solving; verbalized inability to cope or ask for help; inability to meet basic needs; destructive behavior toward self or others; inability to meet role expectations; high illness rate; change in usual communication patterns; risk taking

Related Factors: Gender differences in coping strategies; inadequate level of confidence in ability to cope; uncertainty; inadequate social support created by characteristics of relationships; inadequate level of perception of control; inadequate resource availability; high degree of threat; situational crises; maturational crises; disturbance in pattern of tension release; inadequate opportunity to prepare for stressor; inability to conserve adaptive energies; disturbance in pattern of appraisal of threat; chronic conditions; alteration in body integrity; cultural variables

Client Outcomes

1. Verbalize ability to cope and ask for help when needed
2. Demonstrate ability to solve problems related to current needs
3. Remain free of destructive behavior toward self or others
4. Communicate needs and negotiate with others to meet needs
5. Discuss how recent life stressors have overwhelmed normal coping strategies
6. Demonstrate new effective coping strategies
7. Have illness and accident rates not excessive for age and developmental level

Nursing Interventions and Rationales

• Observe for causes of ineffective coping such as poor self-concept, grief, lack of problem-solving skills, lack of support, or recent change in life situation. 
• Observe for strengths such as the ability to relate the facts and to recognize the source of stressors. 
• Assess the risk of the client's harming self or others and intervene appropriately.
  
• Help the client set realistic goals and identify personal skills and knowledge. 
• Use empathetic communication and encourage the client and family to verbalize fears, express emotions, and set goals. 
• Encourage the client to make choices and participate in the planning of care and scheduled activities. 
• Provide mental and physical activities within the client's ability (e.g., reading, television, radio, crafts, outings, movies, dinners out, social gatherings, exercise, sports, games). 
• If the client is physically able, encourage moderate aerobic exercise.
• Provide information regarding care before care is given. Adequate information and training before and after treatment reduces anxiety and fear (Herranz and Gavilan, 1999).
• Discuss changes with the client before making them. 
• Discuss the client's and family's power to change a situation or the need to accept a situation. 
• Use active listening and acceptance to help the client express emotions such as sadness, guilt, and anger (within appropriate limits). 
• Encourage the client to describe previous stressors and the coping mechanisms used. 
• Be supportive of coping behaviors; allow the client time to relax. 
• Help the client to define what meaning his or her symptoms might have for the client. 
• Encourage the use of cognitive behavioral relaxation (e.g., music therapy, guided imagery). 
• Use distraction techniques during procedures that cause the client to be fearful. Distraction is used to direct attention toward a pleasurable experience and block the attention to the feared procedure (DuHamel, Redd, and Johnson-Vickberg, 1999).
• Use systematic desensitization when introducing new people, places, or procedures that may cause fear and altered coping. Fear of new things diminishes with repeated exposure (DuHamel, Redd, and Johnson-Vickberg, 1999).
• Provide the client and/or family with a video of any feared procedure to view before the procedure. Ensure that the video shows a client of similar age and background. Videos provide the client and/or family with the information necessary to eliminate fear of the unknown (DuHamel, Redd, and Johnson-Vickberg, 1999).
• Refer for counseling as needed. 

Geriatric
• Engage the client in reminiscence. Reminiscence activates positive memories and evokes well-being (Puentes, 2002).
• Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, and use of medications with known cognitive and psychotropic side effects). 
• Determine if the individual is displaying a change in personality as a manifestation of difficulty with coping. An older individual's responses to age-related stress will depend on the balance of personality strengths and weaknesses. 
• Increase and mobilize the support available to the elderly client. Encourage interaction with family and friends.

Multicultural
• Assess for the influence of cultural beliefs, norms, and values on the client's perceptions of effective coping. 
• Assess for intergenerational family problems that can overwhelm coping abilities. 
• Encourage spirituality as a source of support for coping. 
• Negotiate with the client with regard to the aspects of coping behavior that will need to be modified. 
• Identify which family members the client can count on for support. 
• Use an empowerment framework to redefine coping strategies. 
• Assess the influence of fatalism on the client's coping behavior. 
• Assess the influence of cultural conflicts that may affect coping abilities.

  Home Care Interventions

  • The interventions described previously may be adapted for home care use.
  • Observe the family for coping behavior patterns. Obtain family and client history as possible. 
  • Assess for suicidal tendencies. Refer for mental health care immediately if indicated. Identify an emergency plan should the client become suicidal. Ineffective coping can occur in a crisis situation and can lead to suicidal ideation if the client sees no hope for a solution. A suicidal client is not safe in the home environment unless supported by professional help.
  • Encourage the client to use self-care management to increase the experience of personal control. Identify with the client all available supports and sense of attachment to others.
  • Refer to medical social services for evaluation and counseling, which will promote adequate coping as part of the medical plan of care. If no primary medical diagnosis has been made, request medical social services to assist with community support contacts. If the client is involved with the mental health system, actively participate in mental health team planning. Based on knowledge of the home and family, home care nurses can often advocate for clients. These nurses are frequently requested to monitor medication use and therefore need to know the plan of care.
  • Refer the client and family to support groups. 
  • If monitoring medication use, contract with the client or solicit assistance from a responsible caregiver. Prepouring of medications may be helpful with some clients. Caregivers in the home benefit from interventions that promote self-efficacy and provide a nurse for support (Dibartolo, 2002).
  • Institute case management for frail elderly clients to support continued independent living. Difficulties in coping with changes in health care needs can lead to increasing needs for assistance in using the health care system effectively. Case management combines the nursing activities of client and family assessment, planning and coordination of care among all health care providers, delivery of direct nursing care, and monitoring of care and outcomes. These activities are able to address continuity of care, mutual goal setting, behavior management, and prevention of worsening health problems (Guttman, 1999).
  • If the client is homebound, refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen. Psychiatric home care nurses can address issues relating to the client's ability to adjust to changes in health status. Behavioral interventions in the home can help the client to participate more effectively in the treatment plan (Patusky, Rodning, and Martinez-Kratz, 1996).
  • NOTE: All of the previously mentioned interventions may be applied in the home setting. Home care may offer psychiatric nursing or the services of a licensed clinical social worker under special programs. Traditionally, insurance does not reimburse for counseling that is not related to a medical plan of care unless it falls under one of the programs just described. Public health agencies generally do not have the clinical support needed to offer psychiatric nursing services to clients. Clients are usually treated in the ambulatory mental health system.

  Client/Family Teaching

• Teach the client to problem solve. Have the client define the problem and cause, and list the advantages and disadvantages of the options. 
• Provide the seriously ill client and his or her family with needed information regarding the condition and treatment. 
• Teach relaxation techniques. 
• Work closely with the client to develop appropriate educational tools that address individualized needs. 
• Teach the client about available community resources (e.g., therapists, ministers, counselors, self-help groups). 

 

Nursing Diagnosis: Disturbed Body Image (with Rationale)

Related Factors:

• Situational changes (e.g., pregnancy, temporary presence of a visible drain or tube, dressing, attached equipment)
• Permanent alterations in structure and/or function (e.g., mutilating surgery, removal of body part [internal or external])
• Malodorous lesions
• Change in voice quality

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Body Image                      
• Self-Esteem

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Body Image Enhancement
• Grief Work Facilitation
• Coping Enhancement                             

Ongoing Assessment

• Assess perception of change in structure or function of body part (also proposed change).--The extent of the response is more related to the value or importance the patient places on the part or function than the actual value or importance. Even when an alteration improves the overall health of the individual (e.g., an ileostomy for an individual with precancerous colon polyps), the alteration results in a body image disturbance.
• Assess perceived impact of change on activities of daily living (ADLs), social behavior, personal relationships, and occupational activities.
• Assess impact of body image disturbance in relation to patient’s developmental stage.--Adolescents and young adults may be particularly affected by changes in the structure or function of their bodies at a time when developmental changes are normally rapid, and at a time when developing social and intimate relationships is particularly important.
• Note patient’s behavior regarding actual or perceived changed body part or function.--There is a broad range of behaviors associated with body image disturbance, ranging from totally ignoring the altered structure or function to preoccupation with it.
• Note frequency of self-critical remarks.

Therapeutic Interventions

• Acknowledge normalcy of emotional response to actual or perceived change in body structure or function.--Stages of grief over loss of a body part or function is normal, and typically involves a period of denial, the length of which varies from individual to individual.
• Help patient identify actual changes.--Patients may perceive changes that are not present or real, or they may be placing unrealistic value on a body structure or function.
• Encourage verbalization of positive or negative feelings about actual or perceived change.--It is worthwhile to encourage the patient to separate feelings about changes in body structure and/or function from feelings about self-worth.
• Assist patient in incorporating actual changes into ADLs, social life, interpersonal relationships, and occupational activities.--Opportunities for positive feedback and success in social situations may hasten adaptation.
• Demonstrate positive caring in routine activities.--Professional caregivers represent a microcosm of society, and their actions and behaviors are scrutinized as the patient plans to return to home, to work, and to other activities.

Education/Continuity of Care

• Teach patient about the normalcy of body image disturbance and the grief process.
• Teach patient adaptive behavior (e.g., use of adaptive equipment, wigs, cosmetics, clothing that conceals altered body part or enhances remaining part or function, use of deodorants).--This compensates for actual changed body structure and function.
• Help patient identify ways of coping that have been useful in the past.--Asking patients to remember other body image issues (e.g., getting glasses, wearing orthodontics, being pregnant, having a leg cast) and how they were managed may help patient adjust to the current issue.
• Refer patient and caregivers to support groups composed of individuals with similar alterations.--Lay persons in similar situations offer a different type of support, which is perceived as helpful (e.g., United Ostomy Association, Y Me?, I Can Cope, Mended Hearts).

Nursing Diagnosis: Chronic Pain

Nursing Diagnosis: Chronic Pain
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels
* Pain Control
* Quality of Life
* Family Coping

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

* Pain Management
* Medication Management
* Acupressure
* Heat/Cold Application
* Progressive Muscle Relaxation
* Transcutaneous Electrical Nerve Stimulation (TENS)
* Simple Massage

NANDA Definition: Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage (International Association for the Study of Pain); sudden or slow onset of intensity from mild to severe; constant or recurring without an anticipated or predictable end and a duration of greater than 6 months

Chronic pain may be classified as chronic malignant pain or chronic nonmalignant pain. In the former, the pain is associated with a specific cause such as cancer. With chronic nonmalignant pain the original tissue injury is not progressive or has been healed. Identifying an organic cause for this type of chronic pain is more difficult.

Chronic pain differs from acute pain in that it is harder for the patient to provide specific information about the location and the intensity of the pain. Over time it becomes more difficult for the patient to differentiate the exact location of the pain and clearly identify the intensity of the pain. The patient with chronic pain often does not present with behaviors and physiological changes associated with acute pain. Family members, friends, coworkers, employers, and health care providers question the legitimacy of the patient’s pain complaints because the patient may not look like someone in pain. The patient may be accused of using pain to gain attention or to avoid work and family responsibilities. With chronic pain, the patient’s level of suffering usually increases over time. Chronic pain can have a profound impact on the patient’s activities of daily living, mobility, activity tolerance, ability to work, role performance, financial status, mood, emotional status, spirituality, family interactions, and social interactions.

* Defining Characteristics: Weight changes
* Verbal or coded report or observed evidence of protective behavior, guarding behavior, facial mask, irritability, self-focusing, restlessness, depression
* Atrophy of involved muscle group
* Changes in sleep pattern
* Fatigue
* Fear of reinjury
* Reduced interaction with people
* Altered ability to continue previous activities
* Sympathetic mediated responses (e.g., temperature, cold, changes of body position, hypersensitivity)
* Anorexia

* Related Factors: Chronic physical or psychosocial disability

* Expected Outcomes Patient verbalizes acceptable level of pain relief and ability to engage in desired activities.

Ongoing Assessment

* Assess pain characteristics:
o Quality (e.g., sharp, burning)
o Severity (1 to 10 scale)
o Anatomical location
o Onset
o Duration (e.g., continuous, intermittent)
o Aggravating factors
o Relieving factors
Gathering information about the pain can provide information about the extent of the chronic pain.
* Assess for signs and symptoms associated with chronic pain such as fatigue, decreased appetite, weight loss, changes in body posture, sleep pattern disturbance, anxiety, irritability, restlessness, or depression. Patients with chronic pain may not exhibit the physiological changes and behaviors associated with acute pain. Pulse and blood pressure are usually within normal ranges. The guarding behavior of acute pain may become a persistent change in body posture for the patient with chronic pain. Coping with chronic pain can deplete the patient’s energy for other activities. The patient often looks tired with a drawn facial expression that lacks animation.
* Assess the patient’s perception of the effectiveness of methods used for pain relief in the past. Patients with chronic pain have a long history of using many pharmacological and nonpharmacological methods to control their pain.
* Evaluate gender, cultural, societal, and religious factors that may influence the patient’s pain experience and response to pain relief. Understanding the variables that affect the patient’s pain experience can be useful in developing a plan of care that is acceptable to the patient.
* Assess the patient’s expectations about pain relief. The patient with chronic pain may not expect complete absence of pain, but may be satisfied with decreasing the severity of the pain and increasing activity level.
* Assess the patient’s attitudes toward pharmacological and nonpharmacological methods of pain management. Patients may question the effectiveness of nonpharmacological interventions and see medications as the only treatment for pain.
* For patients taking opioid analgesics, assess for side effects, dependency, and tolerance. Drug dependence and tolerance to opioid analgesics is a concern in the long-term management of chronic pain.
* Assess the patient’s ability to accomplish activities of daily living (ADLs), instrumental activities of daily living (IADLs), and demands of daily living (DDLs). Fatigue, anxiety, and depression associated with chronic pain can limit the person’s ability to complete self-care activities and fulfill role responsibilities.

Therapeutic Interventions

* Encourage the patient to keep a pain diary to help in identifying aggravating and relieving factors of chronic pain. Knowledge about factors that influence the pain experience can guide the patient in making decisions about lifestyle modifications that promote more effective pain management.
* Acknowledge and convey acceptance of the patient’s pain experience. The patient may have had negative experiences in the past with attitudes of health care providers toward the patient’s pain experience. Conveying acceptance of the patient’s pain promotes a more cooperative nurse-patient relationship.
* Provide the patient and family with information about chronic pain and options available for pain management. Lack of knowledge about the characteristics of chronic pain and pain management strategies can add to the burden of pain in the patient’s life.
* Assist the patient in making decisions about selecting a particular pain management strategy. Guidance and support from the nurse can increase the patient’s willingness to choose new interventions to promote pain relief. The patient may begin to feel confident about the effectiveness of these interventions.
* Refer the patient to a physical therapist for evaluation. The physical therapist can help the patient with exercises to promote muscle strength and joint mobility, and therapies to promote relaxation of tense muscles. These interventions can contribute to effective pain management.

Education/Continuity of Care

* Teach the patient and family about using nonpharmacological pain management strategies:
o Cold applications Cold reduces pain, inflammation, and muscle spasticity by decreasing the release of pain-inducing chemicals and slowing the conduction of pain impulses. This intervention requires no special equipment and can be cost effective. Cold applications should last about 20 to 30 min/hr.
o Heat applications Heat reduces pain through improved blood flow to the area and through reduction of pain reflexes. This is a cost-effective intervention that requires no special equipment. Heat applications should last no more than 20 min/hr. Special attention needs to be given to preventing burns with this intervention.
o Massage of the painful area Massage interrupts pain transmission, increases endorphin levels, and decreases tissue edema. This intervention may require another person to provide the massage. Many health insurance programs will not reimburse for the cost of therapeutic massage.
o Progressive relaxation, imagery, and music These centrally acting techniques for pain management work through reducing muscle tension and stress. The patient may feel an increased sense of control over his/her pain. Guided imagery can help the patient explore images about pain, pain relief, and healing. These techniques require practice to be effective.
o Distraction Distraction is a temporary pain management strategy that works by increasing the pain threshold. It should be used for a short duration, usually less than 2 hours at a time. Prolonged use can add to fatigue and increased pain when the distraction is no longer present.
o Acupressure Acupressure involves finger pressure applied to acupressure points on the body. Using the gate control theory, the technique works to interrupt pain transmission by "closing the gate." This approach requires training and practice.
o Transcutaneous Electrical Nerve Stimulation (TENS) TENS requires the application of 2 to 4 skin electrodes. Pain reduction occurs through a mild electrical current. The patient is able to regulate the intensity and frequency of the electrical stimulation.
Knowledge about how to implement nonpharmacological pain management strategies can help the patient and family gain maximum benefit from these interventions.
* Teach the patient and family about the use of pharmacological interventions for pain management:
o Nonsteroidal antiinflammatory agents (NSAIDs) These drugs are the first step in an analgesic ladder. They work in peripheral tissues by inhibiting the synthesis of prostaglandins that cause pain, inflammation, and edema. The advantages of these drugs are they can be taken orally and are not associated with dependency and addiction.
o Opioid analgesics These drugs act on the central nervous system to reduce pain by binding with opiate receptors throughout the body. The side effects associated with this group of drugs tend to be more significant that those with the NSAIDs. Nausea, vomiting, constipation, sedation, respiratory depression, tolerance, and dependency are of concern in patients using these drugs for chronic pain management.
o Anti-depressants These drugs may be useful adjuncts in a total program of pain management. In addition to their effects on the patient’s mood, the antidepressants may have analgesic properties apart from their antidepressant actions.
o Antianxiety agents These drugs may be useful adjuncts in a total program of pain management. In addition to their effects on the patient’s mood, the antidepressants may have analgesic properties apart from their antidepressant actions.
* Assist the patient and family in identifying lifestyle modifications that may contribute to effective pain management. Changes in work routines, household responsibilities, and the home physical environment may be needed to promote more effective pain management. Providing the patient and family with ongoing support and guidance will increase the success of these strategies.
* Refer the patient and family to community support groups and self-help groups for people coping with chronic pain. Adding to the patient’s network of social support can reduce the burden of suffering associated with chronic pain and provide additional resources.

Excess Fluid Volume Hypervolemia; Fluid Overload

Nursing Diagnosis: Excess Fluid Volume
Hypervolemia; Fluid Overload
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

* Fluid Balance

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

* Fluid Monitoring
* Fluid Management

NANDA Definition: Increased isotonic fluid retention

Fluid volume excess, or hypervolemia, occurs from an increase in total body sodium content and an increase in total body water. This fluid excess usually results from compromised regulatory mechanisms for sodium and water as seen in congestive heart failure (CHF), kidney failure, and liver failure. It may also be caused by excessive intake of sodium from foods, intravenous (IV) solutions, medications, or diagnostic contrast dyes. Hypervolemia may be an acute or chronic condition managed in the hospital, outpatient center, or home setting. The therapeutic goal is to treat the underlying disorder and return the extracellular fluid compartment to normal. Treatment consists of fluid and sodium restriction, and the use of diuretics. For acute cases dialysis may be required.

* Defining Characteristics: Weight gain
* Edema
* Bounding pulses
* Shortness of breath; orthopnea
* Pulmonary congestion on x-ray
* Abnormal breath sounds: crackles (rales)
* Change in respiratory pattern
* Third heart sound (S3)
* Intake greater than output
* Decreased hemoglobin or hematocrit
* Increased blood pressure
* Increased central venous pressure (CVP)
* Increased pulmonary artery pressure (PAP)
* Jugular vein distension
* Change in mental status (lethargy or confusion)
* Oliguria
* Specific gravity changes
* Azotemia
* Change in electrolytes
* Restlessness and anxiety

* Related Factors: Excessive fluid intake
* Excessive sodium intake
* Renal insufficiency or failure
* Steroid therapy
* Low protein intake or malnutrition
* Decreased cardiac output; chronic or acute heart disease
* Head injury
* Liver disease
* Severe stress
* Hormonal disturbances

* Expected Outcomes Patient maintains adequate fluid volume and electrolyte balance as evidenced by vital signs within normal limits, clear lung sounds, pulmonary congestion absent on x-ray, and resolution of edema.

Ongoing Assessment

* Obtain patient history to ascertain the probable cause of the fluid disturbance. This can help to guide interventions. May include increased fluids or sodium intake, or compromised regulatory mechanisms.
* Assess or instruct patient to monitor weight daily and consistently, with same scale and preferably at the same time of day. Instruction facilitates accurate measurement and helps to follow trends.
* Monitor for a significant weight change (2 pounds) in 1 day.
* Evaluate weight in relation to nutritional status. In some heart failure patients, weight may be a poor indicator of fluid volume status. Poor nutrition and decreased appetite over time result in a decrease in weight, which may be accompanied by fluid retention even though the net weight remains unchanged.
* If patient is on fluid restriction, review daily log or chart for recorded intake. Patients should be reminded to include items that are liquid at room temperature such as Jell-O, sherbet, and Popsicles.
* Monitor and document vital signs. Sinus tachycardia and increased blood pressure are seen in early stages. Elderly patients have reduced response to catecholamines, thus their response to fluid overload may be blunted, with less rise in heart rate.
* Monitor for distended neck veins and ascites. Monitor abdominal girth to follow any ascites accurately.
* Auscultate for a third sound, and assess for bounding peripheral pulses. These are signs of fluid overload.
* Assess for crackles in lungs, changes in respiratory pattern, shortness of breath, and orthopnea. These are early signs of pulmonary congestion.
* Assess for presence of edema by palpating over tibia, ankles, feet, and sacrum. Pitting edema is manifested by a depression that remains after one’s finger is pressed over an edematous area and then removed. Grade edema from trace (indicating barely perceptible) to 4 (severe edema). Measurement of an extremity with a measuring tape is another method of following edema.
* Monitor chest x-ray reports. As interstitial edema accumulates, the x-rays show cloudy white lung fields.
* Monitor input and output closely. Although overall fluid intake may be adequate, shifting of fluid out of the intravascular to the extravascular spaces may result in dehydration. The risk of this occurring increases when diuretics are given. Patients may use diaries for home assessment.
* Evaluate urine output in response to diuretic therapy. Focus is on monitoring the response to the diuretics, rather than the actual amount voided. At home, it is unrealistic to expect patients to measure each void. Therefore recording two voids versus six voids after a diuretic medication may provide more useful information. NOTE: Fluid volume excess in the abdomen may interfere with absorption of oral diuretic medications. Medications may need to be given intravenously by a nurse in the home or outpatient setting.
* Monitor for excessive response to diuretics: 2-pound loss in 1 day, hypotension, weakness, blood urea nitrogen (BUN) elevated out of proportion to serum creatinine level.
* Monitor serum electrolytes, urine osmolality, and urine-specific gravity.
* Assess the need for an indwelling urinary catheter. Treatment focuses on diuresis of excess fluid.
* During therapy, monitor for signs of hypovolemia. Monitoring prevents complications associated with therapy.
* If hospitalized, monitor hemodynamic status including CVP, PAP, and PCWP, if available. This direct measurement serves as optimal guide for therapy.

Therapeutic Interventions

* Institute/instruct patient regarding fluid restrictions as appropriate. This helps reduce extracellular volume. For some patients, fluids may need to be restricted to 1000 ml/day.
* Provide innovative techniques for monitoring fluid allotment at home. For example, suggest that patients measure out and pour into a large pitcher the prescribed daily fluid allowance (e.g., 1000 ml); then every time patient drinks some fluid, he or she is to remove that amount from the pitcher. This provides a visual guide for how much fluid is still allowed throughout the day.
* Restrict sodium intake as prescribed. Sodium diets of 2 to 3 g are usually prescribed.
* Administer or instruct patient to take diuretics as prescribed. Diuretic therapy may include several different types of agents for optimal therapy, depending on the acuteness or chronicity of the problem. For chronic patients, compliance is often difficult for patients trying to maintain a normal lifestyle.
* Instruct patient to avoid medications that may cause fluid retention, such as over-the-counter nonsteroidal antiinflammatory agents, certain vasodilators, and steroids.
* Elevate edematous extremities. This increases venous return and, in turn, decreases edema.
* Reduce constriction of vessels (e.g., use appropriate garments, avoid crossing of legs or ankles). This prevents venous pooling.
* Instruct in need for antiembolic stockings or bandages as ordered. These help promote venous return and minimize fluid accumulation in the extremities.
* Provide interventions related to specific etiological factors (e.g., inotropic medications for heart failure, paracentesis for liver disease).

* For acute patients: Consider admission to acute care setting for hemofiltration or ultrafiltration. This is a very effective method to draw off excess fluid.
* Collaborate with the pharmacist to maximally concentrate IVs and medications. This decreases unnecessary fluids.
* Apply saline lock on IV line. This maintains patency but decreases fluid delivered to patient in a 24-hour period.
* Administer IV fluids through infusion pump, if possible. This ensures accurate delivery of IV fluids.
* Assist with repositioning every 2 hours if patient is not mobile. This prevents fluid accumulation in dependent areas.

Education/Continuity of Care

* Teach causes of fluid volume excess and/or excess intake to patient or caregiver.
* Provide information as needed regarding the individual’s medical diagnosis (e.g., congestive heart failure [CHF], renal failure).
* Explain or reinforce rationale and intended effect of treatment program.
* Identify signs and symptoms of fluid volume excess.
* Explain importance of maintaining proper nutrition and hydration, and diet modifications.
* Identify symptoms to be reported.

Imbalanced Nutrition: Less than Body Requirements

Nursing Diagnosis: Imbalanced Nutrition: Less than Body Requirements
Starvation; Weight Loss; Anorexia
NOC Outcomes (Nursing Outcomes Classification)
Suggested NOC Labels

* Nutritional Status: Food and Fluid Intake
* Nutritional Status: Nutrient Intake

NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels

* Nutrition Monitoring
* Nutrition Therapy
* Nutrition Management

NANDA Definition: Intake of nutrients insufficient to meet metabolic needs

Adequate nutrition is necessary to meet the body’s demands. Nutritional status can be affected by disease or injury states (e.g., gastrointestinal [GI] malabsorption, cancer, burns); physical factors (e.g., muscle weakness, poor dentition, activity intolerance, pain, substance abuse); social factors (e.g., lack of financial resources to obtain nutritious foods); or psychological factors (e.g., depression, boredom). During times of illness (e.g., trauma, surgery, sepsis, burns), adequate nutrition plays an important role in healing and recovery. Cultural and religious factors strongly affect the food habits of patients. Women exhibit a higher incidence of voluntary restriction of food intake secondary to anorexia, bulimia, and self-constructed fad dieting. Patients who are elderly likewise experience problems in nutrition related to lack of financial resources, cognitive impairments causing them to forget to eat, physical limitations that interfere with preparing food, deterioration of their sense of taste and smell, reduction of gastric secretion that accompanies aging and interferes with digestion, and social isolation and boredom that cause a lack of interest in eating. This care plan addresses general concerns related to nutritional deficits for the hospital or home setting.

* Defining Characteristics: Loss of weight with or without adequate caloric intake
* 10% to 20% below ideal body weight
* Documented inadequate caloric intake

* Related Factors: Inability to ingest foods
* Inability to digest foods
* Inability to absorb or metabolize foods
* Inability to procure adequate amounts of food
* Knowledge deficit
* Unwillingness to eat
* Increased metabolic needs caused by disease process or therapy

* Expected Outcomes Patient or caregiver verbalizes and demonstrates selection of foods or meals that will achieve a cessation of weight loss.
* Patient weighs within 10% of ideal body weight.

Ongoing Assessment

* Document actual weight; do not estimate. Patients may be unaware of their actual weight or weight loss due to estimating weight.
* intervObtain nutritional history; include family, significant others, or caregiver in assessment. Patient’s perception of actual intake may differ.
* Determine etiological factors for reduced nutritional intake. Proper assessment guides intervention. For example, patients with dentition problems require referral to a dentist, whereas patients with memory losses may require services such as Meals-on-Wheels.
* Monitor or explore attitudes toward eating and food. Many psychological, psychosocial, and cultural factors determine the type, amount, and appropriateness of food consumed.
* Monitor environment in which eating occurs. Fewer families today have a general meal together. Many adults find themselves "eating on the run" (e.g., at their desk, in the car) or relying heavily on fast foods with reduced nutritional components.
* Encourage patient participation in recording food intake using a daily log. Determination of type, amount, and pattern of food or fluid intake is facilitated by accurate documentation by patient or caregiver as the intake occurs; memory is insufficient.
* Monitor laboratory values that indicate nutritional well-being/deterioration:
o Serum albumin This indicates degree of protein depletion (2.5 g/dl indicates severe depletion; 3.8 to 4.5 g/dl is normal).
o Transferrin This is important for iron transfer and typically decreases as serum protein decreases.
o RBC and WBC counts These are usually decreased in malnutrition, indicating anemia and decreased resistance to infection.
o Serum electrolyte values Potassium is typically increased and sodium is typically decreased in malnutrition.
* Weigh patient weekly. During aggressive nutritional support, patient can gain up to 0.5 pound/day.

Therapeutic Interventions

* Consult dietitian for further assessment and recommendations regarding food preferences and nutritional support. Dietitians have a greater understanding of the nutritional value of foods and may be helpful in assessing specific ethnic or cultural foods (e.g., "soul foods," Hispanic dishes, kosher foods).
* Establish appropriate short- and long-range goals. Depending on the etiological factors of the problem, improvement in nutritional status may take a long time. Without realistic short-term goals to provide tangible rewards, patients may lose interest in addressing this problem.
* Suggest ways to assist patient with meals as needed. Ensure a pleasant environment, facilitate proper position, and provide good oral hygiene and dentition. Elevating the head of bed 30 degrees aids in swallowing and reduces risk of aspiration.
* Provide companionship during mealtime. Attention to the social aspects of eating is important in both the hospital and home settings.
* For patients with changes in sense of taste, encourage use of seasoning.
* For patients with physical impairments, refer to occupational therapist for adaptive devices.
* For hospitalized patients, encourage family to bring food from home as appropriate. Patients with specific ethnic, religious preferences, or restrictions may not be able to eat hospital foods.
* Suggest liquid drinks for supplemental nutrition.
* Discourage beverages that are caffeinated or carbonated. These may decrease appetite and lead to early satiety.
* Discuss possible need for enteral or parenteral nutritional support with patient, family, and caregiver as appropriate. Enteral tube feedings are preferred for patients with a functioning GI tract. Feedings may be continuous or intermittent (bolus). Parenteral nutrition may be indicated for patients who cannot tolerate enteral feedings. Either solution can be modified to provide required glucose, protein, electrolytes, vitamins, minerals, and trace elements. Fat and fat-soluble vitamins can also be administered two or three times per week. These feedings may be used with in-hospital, long-term care, and subacute care settings, as well as in the home.
* Encourage exercise. Metabolism and utilization of nutrients are enhanced by activity.

Education/Continuity of Care

* Review and reinforce the following to patient or caregivers:
o The basic four food groups, as well as the need for specific minerals or vitamins Patients may not understand what is involved in a balanced diet.
o Importance of maintaining adequate caloric intake; an average adult (70 kg) needs 1800 to 2200 kcal/ day; patients with burns, severe infections, or draining wounds may require 3000 to 4000 kcal/day
o Foods high in calories and protein that will promote weight gain and nitrogen balance (e.g., small frequent meals of foods high in calories and protein)
* Provide referral to community nutritional resources such as Meals-on-Wheels or hot lunch programs for seniors as indicated.

Ways on how to easily remember clinical facts

1. To remember the difference between
transudate and exudate, focus on
the prefixes …
• Trans- means “across,” as in the
transcontinental railroad
• Ex- means “out of,” as in exhale.

2. To remember the difference between
aerobic and anaerobic, think of jogging …
• When you jog, an aerobic activity, your
body needs oxygen, or air— aerobic means
oxygen is required.
• Anaerobic means without oxygen.

3. To remember what allergies to ask your
patient about before a CT scan that
requires contrast medium, think of SIC …
Shellfish
Iodine
Contrast media (prior sensitive reaction).

4. To remember the signs and symptoms
of a hypersensitivity reaction to contrast
media, think PURR …
Pruritus
Urticaria
Rash
Respiratory distress.

5. To remember what to assess when
evaluating a skin lesion, think of A, B, C, D …
A for asymmetry
B for border
C for color and configuration
D for diameter and drainage.

6. To remember that cones are cells in
the eyes that respond to color, think of
brightly colored ice cream cones.

7. To remember which direction to move
the syringe when you want to slow down
the flow through the tube, think of …
• lower is slower, or …
• slow DOWN.

8. To remember the meaning of myasthenia
gravis …
think of grave muscle weakness.

9. To remember the progression of ARDS,
think of …
Assault to the pulmonary system
Respiratory distress
Decreased lung compliance
Severe respiratory failure.

10. To remember the progression of
signs and symptoms of Lyme disease,
remember LIME …
Lesions, lymph node swelling, like the flu (Stage 1)
Innervation problems, such as meningitis and
peripheral neuropathy (Stage 2)
Movement problems, such as arthritis (Stage 3)
Everything else, such as myocarditis and
arrhythmia (Stage 3).

11. To remember the difference between
depolarization and repolarization, think of …
the R in repolarization as standing for Rest.
Repolarization is the resting phase of the
cardiac cycle.

12. When performing an assessment, remember
this CAUTION from the American Cancer
Society…
Change in bowel or bladder habits
A sore that doesn’t heal
Unusual bleeding or discharge
Thickening or lump
Indigestion or difficulty swallowing
Obvious changes in a wart or mole
Nagging cough or hoarseness.

13. To remember the four causes of cell injury,
think of how the injury tipped (or TIPD)
the scale of homeostasis …
Toxin or other lethal (cytotoxic) substance
Infection
Physical insult or injury
Deficit or lack of water, oxygen, or nutrients.

14. When combining insulins, to remember
which to draw first, think of
“clear before cloudy.”
Who doesn’t prefer a clear day to a cloudy one?

15. Remember this jingle when
converting inches to centimeters …
“ 2.54, that’s 1 inch and no more.”

16. Remember that X factor is often used to
describe a person or event that could cause
uneXpected, or unknown, outcomes.
Keep this in mind when performing dosage
calculations and you’ll remember that X
represents the unknown part of a ratio or fraction.

17. To remember the conditions that affect
the length of patient stay, think of FOCUS …
Functional skills (and disabilities)
Other diseases
Chronicity
Urgency of needs
Support of systems.

18. To remind yourself of the need to
check and adjust flow rates, remember
the following tongue twister …
Fight fickle flow with frequent follow-up.

19. To remember which drugs can be given
safely through an endotracheal tube, think
of ALE…
Atropine
Lidocaine
Epinephrine.

20. To remember which drug should be
inhaled FIRST, think about your ABCs…
A Bronchodilator comes before a Corticosteroid.

21. When using an IN-LINE nebulizer,
remember to…
connect it to the IN-SPIRATORY side
of the ventilatory circuit.

NCP: pneumonia

Nursing Diagnosis:
Ineffective airway clearance related to decreased energy and fatigue resulting in decreased coughing and accumulation of secretions; tracheobronchial secretions related to inflammation resulting in increased mucus accumulation. Ineffective breathing pattern related to pain caused by positioning and coughing; decreased energy and fatigue caused by inflammatory process; decreased lung expansion caused by pain and fatigue resulting in hypoventilation.

Expected Outcomes: Adequate ventilation evidenced by respiratory rate, depth and ease within baseline limits.

Intervention and Rationale:
I. Assess for:

1. Respiratory status including rate, depth, ease, shallow or irregular breathing, dyspnea, use of accesory muscles, and diminished breath sounds, rhonchi or crackles on auscultation - provides data baseline.
2. Changes in mental status, skin color, cyanosis - indicates possible decrease in oxygenation.
3. Quality of cough and ability to raise secretions including consistency and characteristics od sputum - removal of secretions prevents obstruction of airways and stasis leading to further infection and consolidation of lungs; clearing airways facilitates breathing.

II. Monitor, record, describe:
Respiratory rate, quality and breath sounds q2-q4 - indicates airway resistance, air movement, severity of disease.

1. ABGs, oximeter reading - decreased oxygen levels result in hypoxemia.

III. Administer:

1. Oxygen therapy via cannula - maintain optimal oxygen level.
2. Antitussives/expectorants (terpin hydrate, guaifenesin) - acts on bronchial cells to increase fluid production and promote expectoration; guaifenesin reduces surface tension of secretions; both relieve non-productive cough
3. Mucolytic (acetylcysteine) - decrease viscosity of mucus for easier removal.
4. Antibiotic (ampicillin, cephalexin) - acts by binding to cell wall organisms preventing synthesis and destroying pathogens.

IV. Perform or Provide:

1. Position of comfort in semi or high fowlers and change position q2h - facilitates breathng and allows for full expansion of lungs.
2. Encourage coughing if sounds is moist; if dry and hacking, increase fluid intake and administer cough suppresant - reduces continual irritation to throat and liquefies secretions.
3. Coughing and deep breathing exercise q2h; use incintive spirometer 5-10 breaths if tolerated - coughing clears airway by propelling secretions to mouth deep breathing promoes ventilation and prolongs expiratory phase.
4. Assist with coughing by splinting chest; humidified air with cool mist - loosens seretions and improves ventilation, moistens mucous membranes
5. Postural drainage and percussion PRN - mobilizes secretion.
6. Suction secretions if cough ineffective - removal if unable to bring up secretions.
7. Oral care after expectoration and provide tissues and bag for disposal - promotes comfort and prevents transmission of organisms to others.