Ineffective airway clearance (NDx) Related to stasis of secretions associated with decreased activity during illness and an age-related decrease in ciliary activity and cough effectiveness

Impaired gas exchange (NDx)

• Reduced airflow associated with loss of alveolar elasticity, restricted chest expansion, and premature closure of small airways

• Decreased pulmonary blood flow associated with a decrease in the number of capillaries surrounding the alveoli, fibrosis of the pulmonary vessels, and a generalized decrease in tissue perfusion

CLINICAL MANIFESTATIONS:

RISK FACTORS:

• Sedentary lifestyle

• Chronic illness

• Respiratory system changes

DESIRED OUTCOMES: The client will experience adequate respiratory function as evidenced by:

a. Normal rate and depth of respirations

b. Absence of dyspnea

c. Symmetrical chest excursion

d. Usual or improved breath sounds

e. Usual mental status

f. Oximetry results within normal range for an elderly client

g. Arterial blood gas values within normal range for an elderly client

NOC OUTCOMES: Respiratory status: ventilation; respiratory status: airway patency; respiratory status: gas exchange

NIC INTERVENTIONS: Respiratory monitoring; airway management; chest physiotherapy; oxygen therapy; cough enhancement

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis RISK FOR DEFICIENT FLUID VOLUME NDx

Definition: Decreased intravascular, interstitial, and/or intracellular fluid. This refers to dehydration, water loss alone without change in sodium.

• Decreased fluid intake associated with:

• Restrictions imposed by current illness and/or treatment plan

• Diminished thirst sensation

• Desire to avoid nocturia and/or urinary incontinence

CLINICAL MANIFESTATIONS:

Subjective	Objective
Report of dry mouth, report of confusion	Decreased skin turgor; dry skin and mucous membranes; weight loss of 2% or greater over a short period; hypotension; weak, rapid pulse; capillary refill time >2 to 3 seconds; flat neck veins when lying flat; elevated BUN, serum creatinine, and hematocrit (Hct) levels; oliguria; change in mental status; decreased urine output

RISK FACTORS:

• Changes in regulatory systems

• Inadequate fluid intake

• Medication regimen

DESIRED OUTCOMES: The client will not experience deficient fluid volume as evidenced by:

a. Normal skin and tongue turgor for client

b. Moist mucous membranes

c. Stable weight

d. B/P and pulse within normal range for client with no further increase in postural hypotension

e. Capillary refill time <2 to 3 seconds

f. BUN and Hct levels within normal range for age

g. Usual mental status

h. Balanced intake and output

NOC OUTCOMES: Fluid balance

NIC INTERVENTIONS: Fluid monitoring; fluid management; hypovolemia management; intravenous (IV) therapy

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis IMBALANCED NUTRITION: LESS THAN BODYREQUIREMENTS NDx

Definition: Intake of nutrients insufficient to meet metabolic needs

• Anorexia resulting from factors such as depression, loneliness, diminished sense of smell and/or taste, early satiety, and dyspepsia

• Difficulty chewing and swallowing food resulting from poor dentition, a decreased amount of saliva, and weakened chewing and swallowing muscles

• Decreased ability to purchase and/or prepare healthy foods

• Decreased utilization of nutrients associated with impaired digestion resulting from:

• Decreased ability to chew foods thoroughly

• Reduced secretion of digestive enzymes (e.g., salivary ptyalin, hydrochloric acid, pepsin, lipase)

• Reduced absorption of nutrients associated with hypochlorhydria, decreased intestinal blood flow, and atrophy of the absorptive surface of the intestine

CLINICAL MANIFESTATIONS:

Subjective	Objective
Reports of abdominal pain and cramping; sore buccal cavity	Aversion to eating; body weight 20% or more under ideal; capillary fragility; hair loss; lack of food; lack of interest in food; pale mucous membranes; low serum albumin, prealbumin, Hct, and hemoglobin (Hgb) levels, and low lymphocyte count

RISK FACTORS:

• Living on a fixed income

• Changes in taste sensation

• Medication regimen

DESIRED OUTCOMES: The client will maintain an adequate nutritional status as evidenced by:

a. Weight within normal range for client

b. Normal serum albumin, prealbumin, Hct, and Hgb levels and normal lymphocyte count for client’s age

c. Usual strength and activity tolerance

d. Healthy oral mucous membrane

NOC OUTCOMES: Nutritional status

NIC INTERVENTIONS: Nutritional monitoring; appetite; nutrition management; nutrition therapy; nutritional counseling

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis IMPAIRED COMFORT NDx (DYSPEPSIA, GASTRIC FULLNESS, AND/OR GAS PAIN)

Definition: Perceived lack of ease, relief, and transcendence in the physical, psychospiritual, environmental, and social dimensions

• Gastroesophageal reflux associated with decreased tone of the lower esophageal sphincter

• Impaired digestion of many foods associated with reduced secretion of digestive enzymes (e.g., hydrochloric acid, pepsin, lipase)

• Delayed esophageal and gastric emptying associated with decreased gastroesophageal motility

• Accumulation of intestinal gas associated with decreased peristalsis

CLINICAL MANIFESTATIONS:

Subjective	Objective
Reports of indigestion, feeling of fullness; reports of gas pain; reluctance to eat; reluctance to move	Grimacing; clutching at the abdomen; frequent eructation

RISK FACTORS:

• Medication regimen

• Sedentary lifestyle

• Changes in GI system functioning

DESIRED OUTCOMES: The client will experience diminished dyspepsia, gastric fullness, and gas pain as evidenced by:

a. Verbalization of same

b. Relaxed facial expression and body positioning

c. Diminished eructations

NOC OUTCOMES: Comfort level

NIC INTERVENTIONS: Flatulence reduction

NURSING ASSESSMENT

	RATIONALE
Assess for signs and symptoms of dyspepsia, gastric fullness, or gas pain (e.g., verbal reports of indigestion, fullness, or gas pain; grimacing; clutching and guarding of abdomen; rubbing epigastric area; restlessness; reluctance to move; frequent eructation; reluctance to eat).	Early recognition of signs and symptoms of dyspepsia, gastric fullness, or gas pain allows for prompt intervention.

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis DISTURBED SENSORY PERCEPTION NDx

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

CLINICAL MANIFESTATIONS:

Subjective	Objective
Reports of difficulties with vision, hearing, smell, and taste; reports of difficulty moving	Overreaching or underreaching for objects; high volume on radio or television; heavy use of spices on foods; lack of coordination; unsteady when on feet; use of heating pad at higher-than-expected temperatures

RISK FACTOR:

• Changes in ability to receive and perceive stimuli

DESIRED OUTCOMES: The client will demonstrate adaptation to disturbed sensory perception as evidenced by:

a. Appropriate verbal and nonverbal responses

b. Expected level of participation in self-care activities and treatment plan

c. Safe responses to environmental stimuli

NOC OUTCOMES: Hearing compensation behavior; sensory function: cutaneous; sensory function: hearing; sensory function: proprioception; sensory function: taste and smell; sensory function: vision

NIC INTERVENTIONS: Communication enhancement: visual deficit; communication enhancement: hearing deficit; environmental management; peripheral sensation management

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis RISK FOR IMPAIRED SKIN INTEGRITY NDx

Definition: At risk for skin being adversely altered

• Frequent contact with irritants if urinary incontinence is present

• Accumulation of waste products and decreased oxygen and nutrient supply to the skin and subcutaneous tissue associated with decreased blood flow to the skin resulting from:

• Prolonged pressure on the tissues if mobility is decreased

NOC OUTCOMES: Tissue integrity: skin and mucous membrane

NIC INTERVENTIONS: Skin surveillance; positioning; skin care: topical treatments; pressure ulcer prevention

RISK FACTORS:

• Poor nutritional status

• Chronic illness

• Sedentary lifestyle

• Inadequate fluid intake

DESIRED OUTCOMES: The client will maintain skin integrity as evidenced by:

a. Absence of redness and irritation

b. No skin breakdown

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis IMPAIRED ORAL MUCOUS MEMBRANE NDx

Definition: Disruption of the lips and soft tissue of the oral cavity

Irritation and breakdown Related to dryness and thinning of the oral mucosa

CLINICAL MANIFESTATIONS:

Subjective	Objective
Reports of dryness, irritation	Breakdown of oral mucosa

RISK FACTORS:

• Chronic changes

• Inadequate fluid intake

• Medication regimen

DESIRED OUTCOMES: The client will maintain a moist, intact oral mucous membrane.

NOC OUTCOMES: Oral hygiene

NIC INTERVENTIONS: Oral health maintenance; oral health restoration; oral health promotion

NURSING ASSESSMENT

	RATIONALE
Assess client for dryness, irritation, and breakdown of the oral mucosa.	Early recognition of signs and symptoms of impaired mucous membranes allows for prompt intervention.