Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

Nursing Diagnosis ACTIVITY INTOLERANCE NDx

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

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbal report of fatigue or weakness	Abnormal heart rate or blood pressure response to activity; exertional discomfort or dyspnea; electrocardiographic changes reflecting dysrhythmias or ischemia; unable to speak with physical activity

RISK FACTORS:

• Bedrest or immobility

• Generalized weakness

• Sedentary lifestyle

• Imbalance between oxygen supply/demand

DESIRED OUTCOMES: The client will demonstrate an increased tolerance for activity as evidenced by:

a. Verbalization of feeling less fatigued and weak

b. Ability to perform activities of daily living without exertional dyspnea, chest pain, diaphoresis, dizziness, and significant changes in vital signs

DOCUMENTATION:

• Activity level

• Statements of weakness and fatigue

• Exertional dyspnea, chest pain, diaphoresis, or dizziness

• Vital signs before, during, and after activity

• Therapeutic interventions

• Client teaching

NOC OUTCOMES: Activity tolerance; discomfort level; endurance; fatigue level; psychomotor energy; self-care status; self-care: activities of daily living; vital signs; energy conservation

NIC INTERVENTIONS: Activity therapy; energy management; oxygen therapy; nutrition management; sleep enhancement; cardiac care; cardiac rehabilitation; teaching regarding prescribed activity

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis AIRWAY CLEARANCE, INEFFECTIVE NDx

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

CLINICAL MANIFESTATIONS:

Subjective	Objective
Verbal report of shortness of breath	Dyspnea, orthopnea; diminished breath sounds; adventitious breath sounds (crackles, rhonchi, wheezes); cough, ineffective or absent sputum production; difficulty vocalizing; wide-eyed; restlessness; changes in respiratory rate and rhythm; cyanosis

RISK FACTORS:

• Environmental: Smoking; smoke inhalation; second-hand smoke

• Obstructed airway: Airway spasm; retained secretions; excessive mucus; presence of artificial airway; foreign body in airway; secretions in the bronchi; exudates in the alveoli

• Physiological: Neuromuscular dysfunction; hyperplasia of the bronchial walls; chronic obstructive pulmonary disease; infection; asthma; allergic/reactive airways

DESIRED OUTCOMES: The client will maintain clear, open airways as evidenced by:

a. Normal breath sounds

b. Normal rate and depth of respirations

c. Absence of dyspnea

DOCUMENTATION:

• Breath sounds

• Rate, depth, and ease of respirations

• Characteristics of cough

• Description of sputum

• Therapeutic interventions

• Client teaching

NOC OUTCOMES: Aspiration prevention; mechanical ventilation response: respiratory status: airway patency; respiratory status: ventilation

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

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis ANXIETY NDx

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

CLINICAL MANIFESTATIONS:

RISK FACTORS:

• Exposure to toxins

• Threat to or change in role status

• Unconscious conflict about essential values/goals of life

• Familial association/hereditary

• Unmet needs

• Interpersonal transmission/contagion

• Situational/maturational crises

• Threat of death

• Threat to or change in health status

• Threat to or change in interaction patterns

• Threat to or change in role function

• Threat to self-concept

• Threat to or change in environment

• Stress

• Threat to or change in economic status

• Substance abuse

DESIRED OUTCOMES: The client will experience a reduction in anxiety as evidenced by:

a. Verbalization of feeling less anxious

b. Usual sleep pattern

c. Relaxed facial expression and body movements

d. Stable vital signs

e. Usual perceptual ability and interaction with others

DOCUMENTATION:

• Verbalization of feeling anxious

• Sleep pattern

• Facial expression and body movement

• Vital signs

• Focus on self

• Client’s perception of precipitating factors

• Therapeutic interventions

• Client/family teaching

NOC OUTCOMES: Anxiety level; anxiety self-control; concentration; coping; hyperactivity level

NIC INTERVENTIONS: Anxiety reduction; calming technique; emotional support; presence

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis ASPIRATION, RISK FOR NDx

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

CLINICAL MANIFESTATIONS:

Subjective	Objective
Report of shortness of breath, difficulty swallowing	Rhonchi; dull percussion note over affected lung area; cough; tachypnea; tachycardia; presence of tube feeding in tracheal aspirate; dyspnea, cough, excessive drooling

RISK FACTORS:

• Reduced level of consciousness

• Depressed cough and gag reflexes

• Presence of tracheostomy or endotracheal tube

• Incompetent lower esophageal sphincter

• Gastrointestinal tubes

• Tube feedings

• Medication administration

• Situations hindering elevation of upper body

• Increased intragastric pressure

• Increased gastric residual

• Decreased gastrointestinal motility

• Delayed gastric emptying

• Impaired swallowing

• Facial, oral, neck surgery or trauma

• Wired jaws

DESIRED OUTCOMES: The client will not aspirate secretions or foods/fluids as evidenced by:

a. Clear breath sounds

b. Resonant percussion note over lungs

c. Absence of cough, tachypnea, and dyspnea

DOCUMENTATION:

• Breath sounds

• Percussion note over lungs

• Respiratory rate and effort

• Presence of cough

• Pulse rate

• Color of tracheal aspirate

• Therapeutic interventions

• Client/family teaching

NOC OUTCOMES: Aspiration prevention; body positioning: self initiated; gastrointestinal function; nausea and vomiting control; respiratory status; risk control; swallowing status

NIC INTERVENTIONS: Aspiration precautions; respiratory monitoring; swallowing therapy; airway suctioning

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis BREATHING PATTERN, INEFFECTIVE NDx

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

CLINICAL MANIFESTATIONS:

Subjective

Objective

Verbal reports of shortness of breath

Dyspnea; orthopnea; respiratory rate (adults [ages ≥14 years], <11 or >24 breaths/min; infants, <25 or >60 breaths/min; ages 1 to 4 years, <20 or >30 breaths/min; ages 5 to 14 years, <14 or >25 breaths/min); depth of breathing (tidal volume: adults, 500 mL at rest; infants, 6 to 8 mL/kg); decreased inspiratory/expiratory pressure; decreased minute ventilation; decreased vital capacity; nasal flaring; use of accessory muscles to breathe; assumption of three-point position; altered chest excursion; pursed-lip breathing; prolonged expiration phases; increased anterior-posterior chest diameter; decreased pulse oximetry readings

RISK FACTORS:

• Hyperventilation

• Hypoventilation syndrome

• Bony deformity

• Pain

• Perception/cognitive impairment

• Anxiety

• Decreased energy/fatigue

• Neuromuscular dysfunction

• Musculoskeletal impairment

• Chest wall deformity

• Obesity

• Spinal cord injury

• Body position

• Neurological immaturity

• Respiratory muscle fatigue

DESIRED OUTCOMES: The client will maintain an effective breathing pattern as evidenced by:

a. Normal rate and depth of respirations

b. Symmetrical chest excursion

c. Absence of dyspnea

DOCUMENTATION:

• Rate, depth, and ease of respirations

• Chest excursion

• Oximetry results

• Therapeutic interventions

• Client teaching

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

NIC INTERVENTIONS: Respiratory monitoring; ventilation assistance; anxiety reduction

NURSING ASSESSMENT

	RATIONALE
Assess for signs and symptoms of an ineffective breathing pattern (e.g., shallow respirations, tachypnea, limited chest excursion, dyspnea, use of accessory muscles when breathing).	Early recognition of signs and symptoms of an ineffective breathing pattern allows for prompt intervention.
Monitor for and report a significant decrease in oximetry results.	Oximetry is a noninvasive method of measuring arterial oxygen saturation. The results assist in evaluating respiratory status.

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis CARDIAC OUTPUT, DECREASED NDx

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

CLINICAL MANIFESTATIONS:

RISK FACTORS:

• Altered heart rate/rhythm

• Altered stroke volume

• Altered preload

• Altered afterload

• Altered contractility

DESIRED OUTCOMES: The client will maintain adequate CO as evidenced by:

a. BP within normal range for client

b. Apical pulse regular and 60 to 100 beats/min

c. Absence of gallop rhythms

d. Absence of fatigue and weakness

e. Unlabored respirations at 12 to 20 breaths/min

f. Clear, audible breath sounds

g. Usual mental status

• Ease of respirations

• Mental status

• Peripheral pulses

• Capillary refill time

• Skin color and temperature

• Urine output

• Presence of edema

• Presence of JVD

• Hemodynamic measurements (e.g., CO, pulmonary artery pressure [PAP], pulmonary capillary wedge pressure [PCWP], CVP)

• Therapeutic interventions

• Client teaching

• Dysrhythmias

NOC OUTCOMES: Cardiac pump effectiveness; cardiopulmonary status; circulation status; fluid overload severity; tissue perfusion: abdominal organs, cardiac, cellular, cerebral, and peripheral; vital signs

NIC INTERVENTIONS: Cardiac care: acute; invasive hemodynamic monitoring; hemodynamic regulation; cardiac precautions; dysrhythmia management; oxygen therapy; hypovolemia management; hypervolemia management; electrolyte management: hypomagnesemia; electrolyte management: hyperkalemia; cardiac care: rehabilitative

NURSING ASSESSMENT

THERAPEUTIC INTERVENTIONS

Nursing Diagnosis COMFORT, READINESS FOR ENHANCED NDx

For a full, detailed care plan on this topic, go to http://evolve.elsevier.com/Haugen/careplanning/.

Nursing Diagnosis CONFUSION, RISK FOR ACUTE NDx

Definition: At risk for set of reversible disturbances of consciousness, attention, cognition, and perception that develops over a short period

CLINICAL MANIFESTATIONS:

Subjective	Objective
Report of visual, auditory hallucinations	Exaggerated emotional responses; fluctuations in level of consciousness/cognition; alterations in normal sleep/wake cycle; increased agitation/restlessness; altered perceptive ability (inappropriate responses); lack of ability to initiate or follow through with goal-directed or purposeful behavior

RISK FACTORS:

• Medication reaction/drug-to-drug interaction

• Substance abuse

• Delirium

• Metabolic imbalances

• Chronic illness exacerbation

DESIRED OUTCOMES: The client will regain usual reality orientation and level of consciousness as evidenced by:

a. Ability to participate independently in activities of daily living

b. Decrease in agitation/restlessness

c. Improvement in sleep/wake cycles

d. Appropriate responses to environmental stimuli

DOCUMENTATION:

• Level of consciousness/orientation

NOC OUTCOMES: Cognitive orientation; neurological status: consciousness; fatigue level; anxiety level; agitation level; sleep; electrolyte and acid-base balance; respiratory status: gas exchange; blood glucose level

NIC INTERVENTIONS: Delirium management; electrolyte monitoring; electrolyte management; acid-base management; oxygen therapy; peripheral sensation management

NURSING ASSESSMENT

	RATIONALE
Assess for signs and symptoms of acute confusion (e.g., changes in level of consciousness, changes in baseline behavior, increased agitation, hallucinations, and impaired perceptive ability).	Early recognition of signs and symptoms of acute confusion allows for prompt intervention.
Assess vital signs for evidence of poor perfusion (e.g., hypotension, tachycardia, tachypnea).	Poor perfusion to vital organs such as the brain, which can be exacerbated by hypotension or extreme tachycardia, can alter normal cognitive states, leading to confusion.
Monitor serum glucose levels, drug levels for abnormalities. Monitor pulse oximetry for hypoxemia.	Altered metabolic parameters (e.g., hypoglycemia and hypoxia) can contribute to confusion and as a priority must be ruled out as potential causes of confusion. Failure to rule out possible metabolic causes of confusion can lead to serious adverse patient outcomes.
Assess for contributing factors (e.g., substance abuse/withdrawal, episodes of high fever, exposure to toxic substances, drug-to-drug interactions, chronic illness exacerbations, sleep alterations, diet/nutritional alterations).	Because of the reversible nature of acute confusion, contributing factors should be identified and corrected to return the patient to his/her normal state of cognition.