Selected Nursing Diagnoses, Interventions, Rationales, and Documentation

CHAPTER 2


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













Nursing Diagnosis AIRWAY CLEARANCE, INEFFECTIVE NDx


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













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.













Nursing Diagnosis ASPIRATION, RISK FOR NDx


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













Nursing Diagnosis BREATHING PATTERN, INEFFECTIVE NDx


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













Nursing Diagnosis CARDIAC OUTPUT, DECREASED NDx


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














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











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.




Nursing Diagnosis CONSTIPATION NDx


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





CLINICAL MANIFESTATIONS:










Subjective Objective
Report of straining with defecation; pain with defecation; increased abdominal pressure; feeling of rectal fullness or pressure; inability to pass stool; headache; indigestion; verbalization of abdominal pain and tenderness, and nausea Change in bowel pattern; bright red blood with stool; presence of soft, pastelike stool in rectum; distended abdomen; dark, black, or tarry stool; percussed abdominal dullness; decreased volume of stool; decreased frequency; dry, hard, formed stool; palpable rectal mass; abdominal pain; anorexia; change in abdominal growling (borborygmi); atypical presentation in older adults (e.g., change in mental status, urinary incontinence; unexplained falls, elevated body temperature); severe flatus; hypoactive or hyperactive bowel sounds; palpable abdominal mass; abdominal tenderness with or palpable muscle resistance; nausea and/or vomiting; oozing liquid stool



RISK FACTORS:



• Functional: Recent environmental changes; habitual denying/ignoring of urge to defecate; insufficient physical activity; irregular defecation habits; inadequate toileting (e.g., timeliness, positioning for defecation, privacy); abdominal muscle weakness.


• Psychological: Depression; emotional stress; mental confusion


• Pharmacological: Anticonvulsants; antilipemic agents; laxative overdose; calcium carbonate; aluminum-containing antacids; nonsteroidal anti-inflammatory agents; opiates; anticholinergics; diuretics; iron salts; phenothiazines; sedatives; sympathomimetics; bismuth salts; antidepressants; calcium channel blockers


• Mechanical: Rectal abscess or ulcer; pregnancy; rectal anal fissures; tumors; megacolon (Hirschsprung’s disease); electrolyte imbalance; rectal prolapse; prostate enlargement; neurological impairment; rectal anal stricture; rectocele; postsurgical obstruction; hemorrhoids; obesity


• Physiological: Poor eating habits; decreased motility of gastrointestinal tract; inadequate dentition or oral hygiene; insufficient fiber intake; insufficient fluid intake; change in usual foods and eating pattern; dehydration









Nursing Diagnosis CONTAMINATION NDx/CONTAMINATION, RISK FOR NDx


Definition: Accentuated risk for or actual environmental contaminants in doses sufficient to cause adverse health effects















Nursing Diagnosis DIARRHEA NDx


Definition: Passage of loose, unformed stools









Feb 11, 2017 | Posted by in NURSING | Comments Off on Selected Nursing Diagnoses, Interventions, Rationales, and Documentation
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