Chapter 2

Nursing Diagnosis Care Plans

For additional care plans and an Online Care Plan Constructor, go to at http://evolve.elsevier.com/Gulanick

 Activity Intolerance

Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities

Most activity intolerance is related to generalized weakness and debilitation secondary to acute or chronic illness and disease. This is especially apparent in older patients with a history of orthopedic, cardiopulmonary, diabetic, or pulmonary-related problems. The aging process itself causes reduction in muscle strength and function, which can impair the ability to maintain activity. Activity intolerance may also be related to factors such as obesity, malnourishment, anemia, side effects of medications (e.g., beta-blockers), or emotional states (e.g., depression or lack of confidence to exert oneself). Nursing goals are to reduce the effects of inactivity, promote optimal physical activity, and assist the patient with maintaining a satisfactory quality of life.

Related Care Plans

Impaired physical mobility, p. 126

Sedentary lifestyle, p. 119

 Ineffective Airway Clearance

Definition: Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Maintaining a patent airway is vital to life. Coughing is the main mechanism for clearing the airway. However, the cough may be ineffective in both normal and disease states secondary to factors such as pain from surgical incisions or trauma, respiratory muscle fatigue, or neuromuscular weakness. Other mechanisms that exist in the lower bronchioles and alveoli to maintain the airway include the mucociliary system, macrophages, and the lymphatics. Factors such as anesthesia and dehydration can affect function of the mucociliary system. Likewise, conditions that cause increased production of secretions (e.g., pneumonia, bronchitis, chemical irritants) can overtax these mechanisms. Ineffective airway clearance can be an acute (e.g., postoperative recovery) or chronic (e.g., from cerebrovascular accident [CVA] or spinal cord injury) problem. Older patients, who have an increased incidence of emphysema and a higher prevalence of chronic cough or sputum production, are at high risk.

Related Care Plans

Pneumonia, p. 476

Tracheostomy, 

Tuberculosis, p. 502

 Latex Allergy Response

Definition: A hypersensitive reaction to natural latex rubber products

Latex allergy is a hypersensitivity reaction to the proteins in natural rubber latex derived from the sap of the rubber tree, Hevea brasiliensis. Products made from synthetic rubber may be called latex but do not contain the proteins known to cause an allergic response. The incidence of latex allergy increased after 1985 with the introduction of standard precautions to prevent the spread of bloodborne pathogens such as the human immunodeficiency virus. Soft rubber products such as gloves have the highest content of latex protein and the most potential to cause an allergic response. The people at highest risk for latex allergy include those who wear latex gloves as part of their jobs, such as health care workers, food service workers, housekeepers, and hairdressers. People employed in industries that manufacture latex rubber products are at risk, too. Another group of people at risk are those who undergo repeated surgeries, especially if the surgeries begin in childhood. Evidence indicates a high incidence of latex allergy in people with spina bifida who have had multiple surgeries in childhood. People with a variety of food allergies and sensitivities also have increased risk for latex allergy. Natural latex rubber allergies are IgE-mediated reactions to at least 10 different low-molecular-weight, water-soluble proteins contained in the rubber tree sap. The range of hypersensitivity reactions to latex rubber includes mild to severe contact dermatitis, respiratory allergic symptoms, and anaphylaxis.

 Anxiety

Definition: Vague, uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with the threat.

Anxiety represents an emotional response to environmental stressors and is therefore part of the person’s stress response. Each individual’s experience with anxiety is different. Some people are able to use the emotional edge that anxiety provokes to stimulate creativity or problem-solving abilities; others can become immobilized to a pathological degree. These pathological anxiety disorders include panic attacks, social phobias, specific phobias, obsessive-compulsive disorder, and post-traumatic stress disorder. Anxiety is generally categorized into four levels: mild, moderate, severe, and panic. Mild anxiety can enhance a person’s perception of the environment and readiness to respond. Moderate anxiety is associated with a narrowing of the person’s perception of the situation. The person with moderate anxiety may be more creative and more effective in solving problems. Severe anxiety is associated with increasing emotional and physical feelings of discomfort. Perceptions are further narrowed. The person with severe anxiety begins to manifest excessive autonomic nervous system signs of the fight-or-flight stress response. The person in a panic stage of anxiety has distorted perceptions of the situation. His or her thinking skills become limited and irrational. The person may be unable to make decisions. In the severe and panic stages of anxiety, the nurse needs to intervene to promote patient safety. The nurse can encounter the anxious patient anywhere in the hospital or community. The presence of the nurse may lend support to the anxious patient and provide strategies for effectively coping with anxious moments or panic attacks.

 Risk for Aspiration

Definition: At risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into tracheobronchial passages

Aspiration is the entry of secretions or materials such as foods or liquids into the trachea and lungs and occurs when protective reflexes are decreased or compromised. Aspiration from the oropharynx into the lungs can result in aspiration pneumonia. Depending on the acidity of the aspirate, even small amounts of gastric acid contents can damage lung tissue, resulting in chemical pneumonitis. Both acute and chronic conditions can place patients at risk for aspiration. Acute conditions, such as postanesthesia effects from surgery or diagnostic tests, occur predominantly in the acute care setting. Chronic conditions, including altered consciousness from head injury, spinal cord injury, neuromuscular weakness, hemiplegia and dysphagia from stroke, use of tube feedings for nutrition, and artificial airway devices such as tracheostomies, may be encountered in the home, rehabilitative, or hospital setting. Older and cognitively impaired patients are at high risk. Aspiration is a common cause of death in comatose patients. The National Quality Forum recommends that every patient should be evaluated for aspiration risk upon admission and periodically during the patient’s stay.

 Risk for Bleeding

Definition: At risk for a decrease in blood volume that may compromise health

A patient may experience bleeding when disease or the effects of disease treatments disrupt the normal mechanisms that support hemostasis. Some diseases such as hemophilia interfere with genetic expression of normal clotting factors. Risk for bleeding occurs with disorders that decrease the quantity or quality of circulating platelets (thrombocytopenia). Cancers of the blood and blood-forming organs are associated with a decrease in production of platelets from the bone marrow. Immune thrombocytopenic purpura (ITP) is associated with increased destruction of platelets. Impaired liver function leads to a decrease in the synthesis of clotting factors. Any condition that disrupts the “closed circuit” integrity of the circulatory system increases the risk for bleeding. Examples of these conditions include major organ surgery, traumatic injury, and the many inflammatory or ulcerative disorders of the gastrointestinal system, (e.g., peptic ulcer disease, inflammatory bowel disease). Drugs that suppress bone marrow function or interfere with the action of normal clotting factors increases the patient’s risk for bleeding as a side effect. These drugs include anticoagulants, nonsteroidal anti-inflammatory drugs (NSAIDs), and cancer chemotherapy agents. Herbal preparations may contribute to risk for bleeding through direct effect on clotting factors or interactions with anticoagulants.

 Risk for Unstable Blood Glucose Level

Definition: Risk for variation of blood glucose/sugar levels from the normal range

Serum glucose is regulated by a complex interaction of insulin and glucagon. Insulin is secreted by the beta cells of the islets of Langerhans in the pancreas in response to elevated levels of blood glucose. This pancreatic hormone facilitates the movement of glucose across the cell membranes to be used for metabolic activity. The alpha cells of the islets of Langerhans secrete glucagon when blood glucose levels are low. Glucagon facilitates the conversion of stored glycogen to glucose. When cells are unable to use blood glucose as a metabolic fuel, glucagon stimulates the breakdown of fatty acids and protein. Elevated blood glucose levels (hyperglycemia) may occur in a variety of clinical situations. Diabetes mellitus is the most common disorder associated with elevated blood glucose levels. Prolonged physiological stress contributes to hyperglycemia through increased levels of cortisol as part of the neuro-endocrine stress response. Intravenous infusions containing dextrose may cause elevated blood glucose. Many drugs have hyperglycemia as a side effect.

Hypoglycemia occurs most often as the result of excess insulin administration in the person with diabetes mellitus. In the person without diabetes, hypoglycemia may occur with excess alcohol consumption, prolonged fasting and starvation states, adrenal insufficiency, and eating disorders such as anorexia nervosa. Hypoglycemia after meals may be related to gastric bypass surgery or excess consumption of refined carbohydrates and is the result of increased insulin secretion. This care plan focuses on general nursing care for the person who experiences fluctuations in blood glucose.

 Disturbed Body Image

Definition: Confusion in mental picture of one’s physical self

Body image is the attitude a person has about the actual or perceived structure or function of all or parts of his or her body. This attitude is dynamic and is altered through interaction with other people and situations, and it is influenced by age and developmental level. As an important part of one’s self-concept, body image disturbance can have a profound impact on how individuals view their overall selves.

Throughout the life span, changes in a person’s body related to normal growth and development can result in changes in the person’s body image. For example, a woman may experience disturbed body image during pregnancy. Physical changes associated with aging may result in body image disturbance for the older adult.

Societal and cultural norms for ideal body shape, size, and appearance have a significant influence on a person’s body image. Variations from the norm can result in body image disturbance. The value that an individual places on a body part or function may be more important in determining the degree of disturbance than the actual alteration in the structure or function. Therefore the loss of a limb may result in a greater body image disturbance for an athlete than for a computer programmer. The loss of a breast to a fashion model or a hysterectomy in a nulliparous woman may cause serious body image disturbances even though the overall health of the individual has been improved. Removal of skin lesions, altered elimination resulting from bowel or bladder surgery, and head and neck resections are other examples that can lead to body image disturbance. Chronic illness can contribute to changes in the person’s body image related to decline in body function.

The nurse’s assessment of the perceived alteration and importance placed by the patient on the altered structure or function will be very important in planning care to address body image disturbance.

 Bowel Incontinence

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

Bowel incontinence, also called fecal incontinence, may occur as a result of injury to nerves and other structures involved in normal defecation or as the result of diseases that alter the normal function of defecation. Treatment of bowel incontinence depends on the cause. Injury to rectal, anal, or nerve tissue from trauma, childbirth, radiation, or surgery, can result in bowel incontinence. Infection with resultant diarrhea or neurological disease such as stroke, multiple sclerosis, and diabetes mellitus can also result in bowel incontinence. In older patients, dementia can contribute to bowel incontinence when the individual cannot respond to normal physiological cues for defecation. Normal aging causes changes in the intestinal musculature that may contribute to bowel incontinence. Fecal impaction, as a result of chronic constipation or denial of the defecation urge, can result in involuntary leakage of stool past the impaction. Loss of mobility can result in functional bowel incontinence when the person is unable to reach the toilet in a timely manner. Loss of bowel continence is an embarrassing problem that leads to social isolation, and it is one of the most common reasons that older patients are admitted to long-term care facilities. Goals of management include reestablishing a continent bowel elimination pattern, preventing loss of skin integrity, and/or planning management of fecal incontinence in a manner that preserves the individual’s self-esteem.

 Ineffective Breathing Pattern

Definition: Inspiration and/or expiration that does not provide adequate ventilation

Ineffective breathing patterns are considered a state in which the rate, depth, timing, rhythm, or chest/abdominal wall excursion during inspiration, expiration, or both do not maintain optimum ventilation for the individual. Most acute pulmonary deterioration is preceded by a change in breathing pattern. Respiratory failure may be associated with changes in respiratory rate, abdominal and thoracic patterns for inspiration and expiration, and in depth of ventilation. Breathing pattern changes may occur in a multitude of conditions: heart failure, airway obstruction, respiratory infection, neuromuscular impairment, trauma or surgery resulting in musculoskeletal impairment/pain, diaphragmatic paralysis, cognitive impairment and anxiety, metabolic abnormalities (e.g., diabetic ketoacidosis, uremia, or thyroid dysfunction), peritonitis, drug overdose, pleural inflammation, and chronic respiratory disorders such as asthma or chronic obstructive pulmonary disease (COPD).

Related Care Plans

Ineffective airway clearance, p. 12

Pneumonia, p. 476

Tuberculosis, p. 502

 Decreased Cardiac Output

Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body

Common causes of reduced cardiac output include myocardial infarction, hypertension, valvular heart disease, congenital heart disease, cardiomyopathy, pulmonary disease, arrhythmias, drug effects, fluid overload, decreased fluid volume, and electrolyte imbalance. Older patients are especially at risk because the aging process causes reduced compliance of the ventricles, which further reduces contractility and cardiac output. Patients may have acute, temporary problems or experience chronic, debilitating effects of decreased cardiac output. Patients may be managed in an acute care, ambulatory care, or home care setting.

Related Care Plans

Dysrhythmias,

Shock, cardiogenic, p. 380

Chest trauma, p. 425

Heart failure, chronic, p. 325

Deficient fluid volume, p. 76

Acute coronary syndromes/myocardial infarction, p. 285

 Caregiver Role Strain

Definition: Difficulty in performing family caregiver role

The focus of this care plan is on the supportive care rendered by family members, significant others, or caregivers responsible for meeting the physical/emotional needs of the patient. With limited access to health care for many people, most diseases are diagnosed and managed in the outpatient setting. Rapid hospital discharges for even the most complex health problems result in the care of acute and chronic illnesses being essentially managed in the home environment. Today’s health care environment places high expectations on the designated caregiver, whether a family member or someone for hire. For many older patients, the only caregiver is a fragile spouse overwhelmed by his or her own health problems. Even in cultures in which care of the ill is the anticipated responsibility of family members, the complexities of today’s medical regimens, the chronicity of some disease processes, and the burdens of the caregiver’s own family or environmental milieu provide an overwhelming challenge. Caregivers have special needs for knowledge and skills in managing the required activities, access to affordable community resources, and recognition that the care they are providing is important and appreciated. Moreover, caregivers can be considered “secondary patients” who are at high risk for injury and adverse events. Nurses can assist caregivers by providing the requisite education and skill training and offering support through home visits; special clinic sessions; telephone access for questions and comfort; innovative strategies, such as telephone or computer support or “chat groups”; opportunities for respite care; and guidance in engaging in activities that promote their own health (nutrition, exercise, sleep, stress management).

 Impaired Verbal Communication

Definition: Decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols

Human communication takes many forms. People communicate verbally through the vocalization of a system of sounds that has been formalized into a language. They communicate using body movements to supplement, emphasize, or even alter what is being verbally communicated. In some cases, such as American Sign Language (the formal language of the deaf community) or Signed English, communication is conducted entirely through hand gestures that may or may not be accompanied by body movements and pantomime. Language can be read by watching an individual’s lips to observe words as they are shaped. Humans communicate through touch, intuition, written means, art, and sometimes a combination of all of the mechanisms. Communication implies the sending of information as well as the receiving of information. When communication is received, it ceases to be the sole product of the sender as the entire experiential history of the receiver takes over and interprets the information sent. At its best, effective communication is a dialogue that not only involves the transmission of information but also clarification of points made, expansion of ideas and concepts, and exploration of factors that fall out of the original thoughts transmitted. Communication is a multifaceted, kinetic, reciprocal process. Communication may be impaired for any number of reasons, but rarely are all avenues for communication compromised at one time. The task for the nurse, whether encountering the patient in the hospital or in the community, becomes recognizing when communication has become ineffective and then using strategies to improve transmission of information.

 Chronic Confusion

Definition: An irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli, decreased capacity for intellectual thought processes, and manifested by disturbances of memory, orientation, and behavior

Chronic confusion is not limited to any one age-group, gender, or clinical problem. Chronic confusion can occur in a variety of settings, including the home, hospital, and long-term care facilities. Although often associated with older adults with dementia, younger adults with chronic illnesses also may be affected. Depression, multiple sclerosis, brain infections and tumors, repeated head trauma (as seen in athletes), abnormalities resulting from hypertension, diabetes, anemia, endocrine disorders, malnutrition, and vascular disorders are examples of illnesses that may be associated with chronic confusion. The person with chronic confusion experiences a gradual but progressive decline in cognitive function. Over months or years, the person has increasing problems with memory, comprehension, judgment, abstract thinking, and reasoning. The loss of cognitive ability may result in problems for the person with communication, ADLs, and emotional stability. Chronic confusion can have a profound impact on family members and family processes as the patient requires more direct supervision and care. This care plan discusses the management of chronic confusion in any setting. It also identifies the importance of addressing the needs of the caregivers.

Related Care Plan

Alzheimer’s disease/dementia, p. 509

 Constipation

Definition: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool

Constipation is a common, yet complex problem; it is especially prevalent among older patients. Diet, exercise, and daily routine are important factors in maintaining normal bowel patterns. Too little fluid, too little fiber, inactivity or immobility, and disruption in daily routines can result in constipation. Use of medications, particularly opioid analgesics or overuse of laxatives or enemas, can cause constipation. Patients who ignore the need to defecate for long periods are at risk for developing constipation. Psychological disorders such as stress and depression can cause constipation. Because privacy with defecation is an issue for most people, being away from home, hospitalized, or otherwise being deprived of adequate privacy can result in constipation. Because “normal” patterns of bowel elimination vary so widely from individual to individual, some people believe they are constipated if a day passes without a bowel movement; for others, every third or fourth day is normal. Chronic constipation can result in the development of hemorrhoids; diverticulosis (particularly in older patients who have a high incidence of diverticulitis); straining at stool, and although rare, perforation of the colon. Constipation is usually episodic, although it can become a lifelong, chronic problem. Because tumors of the colon and rectum can result in obstipation (complete lack of passage of stool), it is important to rule out these possibilities. Nonpharmacological management (fluids, activity, and fiber) remains the most effective treatment for constipation.

 Ineffective Coping

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

For most people, everyday life includes its share of stressors and demands, ranging from family, work, and professional role responsibilities to major life events such as divorce, illness, and the death of loved ones. How one responds to such stressors depends in part on the person’s coping resources. Such resources can include optimistic beliefs, social support networks, personal health and energy, problem-solving skills, and material resources. Sociocultural and religious factors may influence how people view and handle their problems. Some cultures may prefer privacy and avoid sharing their fears in public, even to health care providers. As resources become limited and problems become more acute, this strategy may prove ineffective. Vulnerable populations such as older patients, those in adverse socioeconomic situations, those with complex medical problems such as substance abuse, or those who find themselves suddenly physically challenged may not have the resources or skills to cope with their acute or chronic stressors. Such problems can occur in any setting (e.g., during hospitalization for an acute event, in the home or rehabilitation environment as a result of chronic illness, or in response to another threat or loss).

 Impaired Dentition

Definition: Disruption in tooth development/eruption patterns or structural integrity of individual teeth

Good oral health can affect a person’s quality of life through such aspects as appearance, self-esteem, enjoyment from food, absence from dental pain and infections, and overall improved health status. Recent studies have examined the relationship between dentition status and dietary habits. It has been shown that many of the foods avoided by people with poor dentition status (e.g., high-fiber fruits, vegetables) are the ones found to be protective against cardiovascular disease, stroke, metabolic syndrome, and some cancers. Similarly, many people with tooth loss choose easier-to-eat foods containing more saturated fat and refined carbohydrates, putting them at great health risk. Oral health measures to prevent dental caries and tooth loss need to be addressed throughout one’s life, especially among older adults, who are at the greatest risk for systemic health problems related to impaired dentition.

 Diarrhea

Definition: Passage of loose, unformed stools

Diarrhea may result from a variety of factors, including intestinal malabsorption disorders, increased secretion of fluid by the intestinal mucosa, and hypermotility of the intestine. Diarrhea may result from infection (i.e., viral, bacterial, or parasitic); inflammatory bowel diseases (e.g., Crohn’s disease); side effects of drugs (e.g., antibiotics); increased osmotic loads (e.g., tube feedings); radiation; or increased intestinal motility such as with irritable bowel disease. Diarrhea may be an acute, short-lived episode of increased bowel elimination or it may be a long-term, chronic problem for the patient. Problems associated with diarrhea include fluid and electrolyte imbalances, impaired nutrition, and altered skin integrity. In older patients, or those with chronic disease, diarrhea can be life threatening. Treatment is based on addressing the cause of the diarrhea, replacing fluids and electrolytes, providing nutrition, and maintaining skin integrity. Health care workers and other caregivers must take precautions (e.g., diligent hand washing) to avoid transmission of infection associated with some causes of diarrhea.

 Risk for Electrolyte Imbalance

Definition: At risk for change in serum electrolyte levels that may compromise health

Many clinical disorders and their treatments place the patient at risk for imbalances in serum electrolyte concentrations. Imbalanced dietary intake may contribute to electrolyte imbalances. Electrolyte losses may occur from draining wounds and fistulas, especially gastrointestinal fistulas. Imbalances in sodium and chloride concentrations occur most often in situations related to fluid imbalances, especially gastrointestinal fluid losses such as vomiting, diarrhea, or suctioning. Alterations in secretion of antidiuretic hormone and aldosterone put the patient at risk for sodium imbalances. The risk for potassium imbalances increases in patients receiving diuretics. Diarrhea, renal failure, and altered aldosterone secretion also contribute to the patient’s risk for potassium imbalance. Alterations in thyroid and parathyroid function put the patient at risk for calcium imbalances. Magnesium imbalances often occur in the same situations as calcium and potassium imbalances. Changes in aldosterone secretion influence magnesium balance. Electrolyte imbalances affect a variety of functions in the body. The patient with an electrolyte imbalance may experience problems with fluid balance, muscle tone and strength, bone density, electrical conduction in the heart, wound healing, and renal stones. This care plan focuses on imbalances of sodium, potassium, calcium, and magnesium.

Related Care Plans

Syndrome of inappropriate antidiuretic hormone (SIADH), 

Diabetes insipidus, 

Total parenteral nutrition, p. 261

Thyroidectomy, p. 930

Renal failure, chronic/end-stage renal disease, p. 817

 Disturbed Energy Field

Definition: Disruption of the flow of energy surrounding a person’s being that results in a disharmony of the body, mind, or spirit

Each person is an open energy system. The energy field is one aspect of the human energy system, the other parts being the chakras and meridians. This threefold system is vibrational in nature and continuously interacts within itself and with all other systems of the body. In energy field disruption the patient may present any number of concerns indicating disharmony and imbalance in one or more of these energy systems (e.g., pain, fatigue, stress, depression, addiction, nausea, also side effects from anesthesia and various therapies).

In many cases the patient has tried several avenues of Western medicine and is not satisfied with the results. Treatment of the physical problem by surgical procedure or medication is often not adequate to bring balance and harmony to the person. The integration of energy work from the traditions of Eastern medicine with Western medicine is ideal. Energy-based therapies may identify problems before symptoms develop in the body. Nurses can help patients heal in body, mind, and spirit by using energy techniques grounded in traditions thousands of years old (i.e., Reiki, Therapeutic Touch, Healing Touch, and other energy therapies). Nurses acquainted with energy work can assist the patient with healing and restoring energy field balance in any patient care setting, including hospital, home, long-term care, or ambulatory care. This care plan is limited to the most basic energy therapy techniques.

 Risk for Falls

Definition: Increased susceptibility to falling that may cause physical harm

Falls are a major safety risk for adults, especially older adults. According to the Centers for Disease Control and Prevention (CDC), approximately one in three community-dwelling adults older than age 65 fall each year, and women fall more frequently than men in this age-group. This number increases to approximately 75% of nursing home residents because of their older age, frailty, chronic medical conditions, and cognitive impairments. Fall-related injuries are the most common cause of accidental death in individuals older than 65 years. Injuries sustained as a result of a fall include soft tissue injury, fractures (hip, spine, and wrist), and traumatic brain injury. Fall-related injuries are associated with prolonged hospitalization for older adults. For those surviving a fall, the quality of life is significantly changed after a fall-related injury.

The morbidity, mortality, and economic burdens resulting from patient falls pose serious risk management issues facing the health care industry. Patient falls are caused by multiple factors. Prevention of falls is an important dimension of the nursing care of patients in hospitals and long-term care settings. In 2005, The Joint Commission added the requirement for fall risk assessment and periodic reassessment as a National Patient Safety Goal in the acute care setting, and in 2006 added the requisite of implementing and evaluating a fall prevention program. The Nursing Home Quality Initiative project has a similar focus for that population. Implementation of successful fall prevention programs is an essential part of nursing care in any health care setting and requires a multifaceted approach. The Agency for Healthcare Research and Quality (AHRQ) provides a comprehensive review of risk assessment instruments for various settings, selected prevention strategies, and recommendations from evidence-based practice and research implications. Nurses also have a major role in educating patients, families, and caregivers about the prevention of falls across the care continuum.

 Interrupted Family Processes

Definition: Change in family relationships and/or functioning

Interrupted family processes occur as a result of the inability of one or more members of the family to adjust or perform. The result of this inability to adjust is family dysfunction and an interruption in the development of the family. Family development is closely related to the developmental changes experienced by adult members. Over time, families must adjust to change within the family structure brought on by both expected and unexpected events, including illness or death of a member/changes in social or economic strengths precipitated by divorce, retirement, and loss of employment. The addition of new family members through birth or adoption may require adaptation to new roles and status for existing family members. Health care providers must also be aware of the changing constellation of families: gay couples raising children, single parents with children, older grandparents responsible for grandchildren or foster children, and other situations.

 Fatigue

Definition: An overwhelming sustained sense of exhaustion and decreased capacity for physical and mental work at usual level

Fatigue is a subjective complaint with both acute and chronic illnesses. In an acute illness, fatigue may have a protective function that keeps the person from sustaining injury from overwork in a weakened condition. As a common symptom, fatigue is associated with a variety of physical and psychological conditions. Fatigue is a prominent finding in many viral infections such as hepatitis. Patients with rheumatoid arthritis, fibromyalgia, systemic lupus erythematosus, myasthenia gravis, and depression report fatigue as a profound symptom that reduces their ability to participate in their own care and fulfill role responsibilities. Fatigue has become the most common and distressing complaint for patients with cancer, especially during treatment. The patient with a chronic illness experiencing fatigue may be unable to work full-time and maintain acceptable performance on the job. The economic impact on the individual and the family can be significant. The social effects of fatigue occur as the person decreases his or her participation in social activities. Recently, attention has focused on sleep-disordered breathing as a cause for daytime somnolence, fatigue, and decreased alertness. Common screening methods are available.

Chronic fatigue syndrome is a poorly understood condition that is characterized by prolonged, debilitating fatigue, neurological problems, general pain, gastrointestinal problems, and flulike symptoms. Although the exact cause of chronic fatigue syndrome is not known, one theory suggests that the disorder may represent an abnormal response of the immune system to highly stressful physiological or psychological events.

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