Tuesday, April 29, 2014

Nursing Care Plan for Acute Confusion

Confusion is a mental state characterized by a change in thinking and attention deficit, followed by problems in comprehension. Confusion in accompanied by memory loss and sometimes short-tempered alternative to sleepy.

  • The cause is usually alcohol and drug.
  • Confusion can also follow fever, heart failure, head injury and anesthesia.
  • Another cause is hypoxia, hypoglycemia, weight offending liquid electrolyte, sepsis, liver and renal failure, poison and drug overdoses.
  • Dementia can cause the severity of chronic confusion that be afect on memory, judgment, thinking abstractly, which cause loss of independent social and personal.
  • Alzheimer's disease.

Risk factors
Is a variation of the risk factors.

Three mechanisms of development of acute confusion;
  1. Damage to the brain swelling, loss of oxygen, blood, or both (functional impairment).
  2. Damage to the nervous system by the action of chemicals or other substances.
  3. Rebound depression centers of the brain activity. Injury that results in an increase in ICP. Chemicals that cross the blood-brain barrier, such as alcohol damage neuron cell metabolism. When the action of the drug in patients below the center of the brain over-active. Over-activity of developing acute confusion, combativesness, and abnormal behavior.
Chronic confusional state resulting from the destruction of brain tissue, biochemical imbalances, or compression of the brain. Just as an example; Alzheimer's disease is a shortage of acetylcholine, a neurotransmitter that is needed on the short memory. Other disorders can be caused by such a virus; cretzfeld-jacob disease, encephalitis.

Clinical manifestations
  1. Attentional problems, loss of concentration.
  2. Restlessness.
  3. Emotionally labile.
  4. Insomnia / drowsiness.
  5. Vivid nightmare.
  6. Looks like anxiety and be crazy (going crazy).
  7. Disruption continues to stupor and coma.
  8. Fluctuations in cognitive (thinking skills and reasoned.
  9. Lost memory.
  10. Delirium.
  11. Perceptual errors, hallucinations, illusions and delusions.

Nursing Diagnosis

Sleep pattern disturbance related to daytime napping and night time hallucinations

Increased sleep patterns,

characterized by: sleep 4-6 hours every night and do not sleep at noon.

  1. Intervention at night planned not to interrupt sleep.
  2. Assess the pattern of REM sleep with eye movements, if the REM phase should not be disturbed (recall cycle requires 2-3 hours of sleep and loss of REM can increase confusion).
  3. Patients should be active every so tired during the day at night, so it can rest.
  4. Giving medication to sleep "seldom" given for changing the sleep cycle and "deplete" the patient to REM sleep.

Wednesday, April 23, 2014

Nursing Intervention for Activity Intolerance (NCP)

Activity Intolerance

related to:
  • bedrest,
  • mobility,
  • sedentary lifestyles (heavy rare activity),
  • general body weakness,
  • imbalance between oxygen supply to use.

characterized by:
  • expression of fatigue and weakness,
  • abnormal response to activities such as discomfort and dyspnoe
Goal :
  1. Clients can maintain the normal function of the musculoskeletal shown by the whole range of motion in the joints of the body within normal limits, muscle mass and strength can be maintained.
  2. Minimize the incidence of cardiovascular events are shown in vital signs are still within the limits of normal and signs of adequate venous blood flow (absence of edema, inflammation, venous distention, skin changes.
  3. Respiratory function in the normal state characterized by a normal breath sounds on auscultation, normal chest expansion and the absence of chest pain, fever, or other signs of respiratory indicator of lung damage, embioli or atelectasis.
  4. Maintaining the pattern of provision of proper nutrition and fluids that are able to be shown by weight , adequate tissue turgor, fluid balance input and output, and serum protein values within normal limits.
  5. Maintain normal elimination patterns, which can be seen clearly through the urine output of at least 1500 ml per day, the absence of signs of urinary retention, urinary tract infection .
  6. Maintaining the integrity of the skin that can be seen through the skin clean, intact skin hydration either lack of emphasis marks on the skin
  7. Maintaining the stability of the emotional, social and intellectual, which can be seen from the active participation of the client, consulted in determining the action, able to maintain good relationships with others.

Nursing Interventions :

1. Perform proper exercise program (isotonic, active or passive exercise) at least 4 hours at a time on the hands, feet, and neck as indicated.
Rationale: isotonic exercises to prevent contractures and muscle atrophy, maintain isometric muscle strength, joint motion maintains a passive exercise.

2. Motivation active Participation in self-care.
Rationale: Self-care can move the joints and muscles of the body are active.

3. Compare the size and strength of muscle as baseline data on each side of the body every day.
Rationale: Early detection of muscle atrophy and decreased muscle strength can facilitate early intervention anyway.

4. Position the client in accordance with body alignment.
Rational: by positioning the client in accordance with body alignment can help prevent contractures and maintain structural integrity of joints and muscles.

5. Moving Assist clients Help clients wherever possible or stand at the bedside.
Rational : the move to prevent disuse osteoporosis.

6. Monitor vital signs according to client needs or other health or body.
Rationale : Routine monitoring allows nurses to detect early alteration.

7. Teach the client how to avoid Valsalva maneuver.
Rationale : Valsalva menauver can add to the pressure on the heart.

8. Use anti- embolism stockings on the client as indicated.
Rational : the use of anti- embolism stockings can prevent thrombus formation, venous engorgement, edema, and orthostatic hypotension.

9. At some time the foot is lifted for about 20 minutes every day.
Rational : with the elevation adds to the peripheral circulation.

10. Assess the state of the lower limbs leather and calf circumference measurement as indicated.
Rationale : Inspection and routine measurements can enable nurses to detect early changes.

11. See also intervene to function on musculoskletal.
Rational : all these actions also stimulates blood circulation and prevent cardiovascular complications.

12. Assess breath sounds and chest expansion at least 8 hours per day.
Rationale : This action is done the nurse to detect breathing abnormalities and the inadequate chest expansion.

13. Instruct the client to take a deep breath and shape of every waking hour.
Rational : the breathing and effective coughing can increase alveolar expansion, prevent stasis secretion, improving gas exchange, and maintain a patent airway.

14. Create a schedule change positions, and clients are encouraged to change position every 2 hours, Assist clients to move if possible or seat the client in the chair.
Rationale: The change in the position of providing free lung area for expansion, and help move and then removed through skret during coughing.

15. Monitor client weight, tissue turgor, income and expenditure fluid and serum protein values.
Rational : normality of the data were found to exhibit adequate hydration and nutritional intake.

16. Monitor color, clarity, acidity number, and urine specific gravity, color and stool characteristics, frequency of defecation. Ask if the client feels pain when urinating .
Rationale : reduced urine output, gloom / no clear urine and pain on urination indicative of infection and urinary retention, constipation can be associated with the occurrence of immobilization.

17. Instruct clients to choose foods that are high in fiber.
Rationale: A high-fiber diet may improve intestinal peristaltic and defecation.

18. Instruct the client to make a decision as much as possible, such as : moving parts of private property, plan daily activities, to use clothing.
Rationale : decision making by the client itself can increase client self-respect.

19. Plan free time is right for the client.
Rational: to foster mutual trust with clients very well done because it can motivate the client to express feelings.

20. Assess the activities that make the client happy, and freely plan their daily activities.
Rationale : daily activities that please the client can prevent boredom on the client and motivate clients to look and think ahead.

Friday, April 11, 2014

Impaired Swallowing

Impaired Swallowing Definition

Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function

Defining Characteristics:

Oral phase impairment
Lack of tongue action to form bolus; weak suck resulting in inefficient nippling; incomplete lip closure; food pushed out of mouth; slow bolus formation; food falls from mouth; premature entry of bolus; nasal reflux; inability to clear oral cavity; long meals with little consumption; coughing, choking, or gagging before a swallow; abnormality in oral phase of swallow study; piecemeal deglutition; lack of chewing; pooling in lateral sulci; sialorrhea or drooling

Pharyngeal phase impairment
Altered head positions; inadequate laryngeal elevation; food refusal; unexplained fevers; delayed swallow; recurrent pulmonary infections; gurgly voice quality; nasal reflux; choking, coughing, or gagging; multiple swallows; abnormality in pharyngeal phase by swallowing study

Esophageal phase impairment
Heartburn or epigastric pain; acidic smelling breath; unexplained irritability surrounding mealtime; vomitous on pillow; repetitive swallowing or ruminating; regurgitation of gastric contents or set burps; bruxism; nighttime coughing or awakening; observed evidence of difficulty in swallowing (e.g., stasis of food in oral cavity, coughing, or choking); hyperextension of head, arching during or after meals; abnormality in esophageal phase by swallow study; odynophagia; food refusal or volume limiting; complaints of "something stuck"; hematemesis; vomiting

Related Factors:
  • Congenital deficits; 
  • upper airway anomalies; 
  • failure to thrive; protein energy malnutrition; 
  • conditions with significant hypotonia; 
  • respiratory disorders; 
  • history of tube feeding; 
  • behavioral feeding problems; 
  • self-injurious behavior; 
  • neuromuscular impairment (e.g., decreased or absent gag reflex, decreased strength or excursion of muscles involved in mastication, perceptual impairment, or facial paralysis); 
  • mechanical obstruction (e.g., edema, tracheotomy tube, or tumor); 
  • congenital heart disease; 
  • cranial nerve involvement; 
  • neurological problems; 
  • upper airway anomalies; 
  • laryngeal abnormalities; 
  • achalasia; 
  • gastroesophageal reflux disease; 
  • acquired anatomic defects; 
  • cerebral palsy; 
  • internal or external traumas; 
  • tracheal, laryngeal, esophageal defects; 
  • traumatic head injury; 
  • developmental delay; 
  • nasal or nasopharyngeal cavity defects; 
  • oral cavity or oropharynx abnormalities; 
  • premature infants

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Swallowing Status
  • Swallowing Status: Esophageal Phase, Oral Phase, Pharyngeal Phase
Client Outcomes
  • Demonstrates effective swallowing without choking or coughing
  • Remains free from aspiration (e.g., lungs clear, temperature within normal range)

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Aspiration Precautions
  • Swallowing Therapy

Nursing Interventions and Rationales

1. Determine client's readiness to eat. Client needs to be alert, able to follow instructions, hold head erect, and able to move tongue in mouth.
If one of these factors is missing, it may be advisable to withhold oral feeding and use enteral feeding for nourishment (McHale et al, 1998). Cognitive deficits can result in aspiration even if able to swallow adequately (Poertner, Coleman, 1998).

2. If new onset of swallowing impairment, ensure that client receives a diagnostic workup.
There are multiple causes of swallowing impairment, some of which are treatable (Schechter, 1998).

3.Assess ability to swallow by positioning examiner's thumb and index finger on client's laryngeal protuberance. Ask client to swallow; feel larynx elevate. Ask client to cough; test for a gag reflex on both sides of posterior pharyngeal wall (lingual surface) with a tongue blade. Do not rely on presence of gag reflex to determine when to feed.
Normally the time taken for the bolus to move from the point at which the reflex is triggered to the esophageal entry (pharyngeal transit time) is (1 second (Logeman, 1983). Cardiovascular accident (CVA) clients with prolonged pharyngeal transit times (prolonged swallowing) have a greatly increased chance of developing aspiration pneumonia (Johnson, McKenzie, Sievers, 1993). Clients can aspirate even if they have an intact gag reflex (Baker, 1993; Lugger, 1994).

4. Observe for signs associated with swallowing problems (e.g., coughing, choking, spitting of food, drooling, difficulty handling oral secretions, double swallowing or major delay in swallowing, watering eyes, nasal discharge, wet or gurgly voice, decreased ability to move tongue and lips, decreased mastication of food, decreased ability to move food to the back of the pharynx, slow or scanning speech).
These are all signs of swallowing impairment (Baker, 1993; Lugger, 1994).

5. If client has impaired swallowing, refer to a speech pathologist for bedside evaluation as soon as possible. Ensure that client is seen by a speech pathologist within 72 hours after admission if client has had a CVA.
Speech pathologists specialize in impaired swallowing. Early referral of CVA clients to a speech pathologist, along with early initiation of nutritional support, results in decreased length of hospital stay, shortened recovery time, and reduced overall health costs (Scott, 1998). Research demonstrates that a program of diagnosis and treatment of dysphagia in acute stroke management decreases the incidence of pneumonia (AHCPR, 1999).

6. For impaired swallowing, use a dysphagia team composed of a rehabilitation nurse, speech pathologist, dietitian, physician, and radiologist who work together.
The dysphagia team can help the client learn to swallow safely and maintain a good nutritional status (Poertner, Coleman, 1998).

7. If client has impaired swallowing, do not feed until an appropriate diagnostic workup is completed. Ensure proper nutrition by consulting with physician for enteral feedings, preferably a PEG tube in most cases.
Feeding a client who cannot adequately swallow results in aspiration and possibly death. Enteral feedings via PEG tube are generally preferable to nasogastric tube feedings because studies have demonstrated that there is increased nutritional status and possibly improved survival rates (Bath, Bath, Smithard, 2000).

8. If client has an intact swallowing reflex, attempt to feed. Observe the following feeding guidelines:
  • Position client upright at a 90-degree angle with the head flexed forward at a 45-degree angle (Galvan, 2001). This position forces the trachea to close and esophagus to open, which makes swallowing easier and reduces the risk of aspiration.
  • Ensure client is awake, alert, and able to follow sequenced directions before attempting to feed. As the client becomes less alert the swallowing response decreases, which increases the risk of aspiration.
  • Begin by feeding client one-third teaspoon of applesauce. Provide sufficient time to masticate and swallow.
  • Place food on unaffected side of tongue.
  • During feeding, give client specific directions (e.g., "Open your mouth, chew the food completely, and when you are ready, tuck your chin to your chest and swallow").
9. Watch for uncoordinated chewing or swallowing; coughing immediately after eating or delayed coughing, which may indicate silent aspiration; pocketing of food; wet-sounding voice; sneezing when eating; delay of more than 1 second in swallowing; or a change in respiratory patterns. If any of these signs are present, put on gloves, remove all food from oral cavity, stop feedings, and consult with a speech and language pathologist and a dysphagia team.
These are signs of impaired swallowing and possible aspiration (Baker, 1993; Galvan, 2001).

10. If client tolerates single-textured foods such as pudding, hot cereal, or strained baby food, advance to a soft diet with guidance from the dysphagia team. Avoid foods such as hamburgers, corn, and pastas that are difficult to chew. Also avoid sticky foods such as peanut butter and white bread.
The dysphagia team should determine the appropriate diet for the client on the basis of progression in swallowing and ensuring that the client is nourished and hydrated.

11. Avoid providing liquids until client is able to swallow effectively. Add a thickening agent to liquids to obtain a soft consistency that is similar to nectar, honey, or pudding, depending on degree of swallowing problems.
Liquids can be easily aspirated; thickened liquids form a cohesive bolus that the client can swallow with increased efficiency (Langmore, Miller, 1994; Poertner, Coleman, 1998).

12. Preferably use prepackaged thickened liquids, or use a viscosometer to ensure appropriate thickness.
Often staff members overthicken liquids, resulting in decreased palatability with decreased intake. Using prepackaged thickened liquids can increase intake, which increases hydration and nutrition (Goulding, Bakheit, 2000; Boczko, 2000).

13. Work with client on swallowing exercises prescribed by dysphagia team (e.g., touching palate with tongue, stimulating tonsillar arch and soft palate with a cold metal examination mirror [thermal stimulation], labial/lingual range of motion exercises).
Swallowing exercises can improve the client's ability to swallow (Langmore, Miller, 1994). Exercises need to be done at intervals necessitating nursing involvement (Poertner, Coleman, 1998).

14. For many adult clients, avoid using straws if recommended by speech pathologist.
Use of straws can increase the risk of aspiration because straws can result in spilling of a bolus of fluid in the oral cavity as well as decrease control of posterior transit of fluid to the pharynx (Travers, 1999).

15. Provide meals in a quiet environment away from excessive stimuli such as a community dining room.
A noisy environment can be an aversive stimulus and can decrease effective mastication and swallowing. Talking and laughing while eating increases the risk of aspiration (Galvan, 2001).

16. Ensure that there is adequate time for client to eat.
Clients with swallowing impairments often take two to four times longer than others to eat, if being fed. Often, food is offered rapidly to speed up the task, and this can increase the chance of aspiration (Poertner, Coleman, 1998).

17. Have suction equipment available during feeding. If choking occurs and suctioning is necessary, discontinue oral feeding until client is safely assessed with a videofluoroscopic swallow study and fiberoptic endoscopic evaluation of swallowing (FEES), whichever client can safely tolerate.
Suctioning may be necessary if the client is choking on food and could aspirate.

18. Check oral cavity for proper emptying after client swallows and after client finishes meal. Provide oral care at end of meal. It may be necessary to manually remove food from client's mouth. If this is the case, use gloves and keep client's teeth apart with a padded tongue blade.
Food may become pocketed in the affected side and cause stomatitis, tooth decay, and possible later aspiration.

19. Praise client for successfully following directions and swallowing appropriately.
Praise reinforces behavior and sets up a positive atmosphere in which learning takes place.

20. Keep client in an upright position for 30 to 45 minutes after a meal.
An upright position ensures that food stays in the stomach until it has emptied and decreases the chance of aspiration following meals (Galvan, 2001).

21. Watch for signs of aspiration and pneumonia. Auscultate lung sounds after feeding. Note new crackles or wheezing, and note elevated temperature. Notify physician as needed.
The presence of new crackles or wheezing, an elevated temperature or white blood cell count, and a change in sputum could indicate aspiration of food (Murray, Brzozowski, 1998) It could also indicate the presence of pneumonia (Galvan, 2001). Clients with dysphagia are at serious risk for aspiration pneumonia (Langmore, 1994).
22. Watch for signs of malnutrition and dehydration. Keep a record of food intake.
A food intake record will allow the nurse, speech and language pathologist, and dietician to determine the adequacy of nutritional intake (Beadle, Townsend, Palmer, 1995). Malnutrition is common in dysphagic clients (Galvan, 2001). Clients with dysphagia are at serious risk for malnutrition and dehydration, which can lead to aspiration pneumonia resulting from depressed immune function and weakness, lethargy, and decreased cough (Langmore, 1999).

23. Weigh client weekly to help evaluate nutritional status.

24. Evaluate nutritional status daily. If not adequately nourished, work with dysphagia team to determine whether client needs to avoid oral intake (NPO) with therapeutic feeding only or needs enteral feedings until client can swallow adequately.
Enteral feedings can maintain nutrition if client is unable to swallow adequate amounts of food (Grant, Rivera, 1995).

25. If client has a tracheotomy, ask for a diagnostic workup for adequacy of swallowing before attempting to feed, and ensure all staff members know appropriate feeding technique.
Aspiration is common in clients with tracheotomies, and care must be used in feeding (Murray, Brzozowski, 1998). See care plan for Risk for Aspiration.


1. Refer to physician children with difficult swallowing and symptoms such as difficulty manipulating food, delayed swallow response, and pocketing a bolus of food.
Research has indicated that structural deficits should be corrected by surgery (e.g. pyloric stenosis, neurological disorders that involve cranial nerve pathways, and structures resulting in swallowing changes such as brain injury and cerebral palsy [Rosenthal, Sheppard, Lotze, 1995]). Respiratory and gastrointestinal system disorders (GERD) and esophagitis can affect swallowing and nutrition. These systemic disorders are diagnosed by a physician and treated with medications.

2. When feeding an infant or child, place the infant/child in a 90 degree position with head slightly flexed. Change consistency of diet as needed, and use a curly straw for young children to facilitate a chin tuck, which helps improve swallowing ability.

3. Give oral motor stimulation that increases oral-sensory awareness by waking the mouth with exercises that focus on temperature, taste, and texture.
Many of these infants require supplemental tube feedings as well as special nipples or bottles to boost oral intake.

4. For infants with poor sucking and swallowing:
  • Support the cheeks and jaw to increase sucking skills. Pace or rhythmically move the bottle, which encourages better coordination of suck-swallow-breath synchrony.
  • Work with dietitian. Some infants may need a high-calorie formula so that food volume may be decreased (which requires infant to expend less energy) while nutritional requirements are met (Klein, Tracey, 1994). Some infants may also need to have their tongue brushed, which promotes tongue stimulation (tongue tip and tongue lateralization), lip seal, and lip pursing.
  • Watch for indicators of aspiration: coughing, a change in web vocal quality while feeding, perspiration and color changes during feeding, sneezing, and increased heart rate and breathing.
  • Watch for warning signs of reflux: sour-smelling breath after eating, sneezing, lack of interest in feeding, crying and fussing extraordinarily when feeding, pained expressions when feeding, and excessive chewing and swallowing after eating (Johnson, McGonigel, Kaufman, 1991).
Many premature and medically fragile children are surviving as a result of technological advances and sustaining growth and respiratory deficits from an underlying dysphagia diagnosis. They present with limited food intake at a time when extra calories are essential for faster growth and lung repair. Some infants may need to work harder to breathe and develop a decreased tolerance for food intake. They also demonstrate inconsistent arousal and poor/uncoordinated suck-swallow-breath synchrony. Many of these infants require supplemental tube feedings, as well as special nipples or bottles to boost oral intake.


1. Evaluate medications client is presently taking, especially if elderly. Consult with the pharmacist for assistance in monitoring for incorrect doses and drug interactions that could result in dysphagia.
Dysphagia is more prevalent in the elderly than in younger persons because of the coexistence of a variety of neurological, neuromuscular, or oncological conditions (Kosta, Mitchell, 1998). Most elderly clients take numerous medications, which when taken individually can slow motor function, cause anxiety and depression, and reduce salivary flow. When taken together, these medications can interact, resulting in impaired swallowing function. Drugs that reduce muscle tone for swallowing and can cause reflux include calcium channel blockers and nitrates. Drugs that can reduce salivary flow include antidepressants, antiparkinsonism drugs, antihistamines, antispasmodics, antipsychotic agents or major tranquilizers, antiemetics, antihypertensives, and drugs for treating diarrhea and anxiety (Sonies, 1992; Sliwa, Lis, 1993; Schechter, 1998).

Client/Family Teaching

1. Teach client and family exercises prescribed by dysphagia team.

2. Teach client a step-by-step method of swallowing effectively.

3. Educate client, family, and all caregivers about rationales for food consistency and choices.
It is common for family members to disregard necessary dietary restrictions and give client inappropriate foods that predispose to aspiration (Poertner, Coleman, 1998).

4. Teach family how to monitor client to prevent aspiration during eating.

Wednesday, November 6, 2013

Acute Pain

Acute Pain Definition

Pain is whatever the experiencing person says it is, existing whenever the person says it does (McCaffery, 1968); an 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 any intensity from mild to severe with an anticipated or predictable end and a duration of  less than 6 months (NANDA)

Defining Characteristics:


Pain is always subjective and cannot be proved or disproved. A client's report of pain is the most reliable indicator of pain (Acute Pain Management Guideline Panel, 1992). A client with cognitive ability who can speak or point should use a pain rating scale (e.g., 0 to 10) to identify the current level of pain intensity (self-report) and determine a comfort/function goal (McCaffery, Pasero, 1999).


Expressions of pain are extremely variable and cannot be used in lieu of self-report. Neither behavior nor vital signs can substitute for the client's self-report (McCaffery, Ferrell, 1991, 1992; McCaffery, Pasero, 1999). However, observable responses to pain are helpful in clients who cannot or will not use a self-report pain rating scale. Observable responses may be loss of appetite and inability to deep breathe, ambulate, sleep, or perform activities of daily living (ADLs). Clients may show guarding, self-protective behavior, self-focusing or narrowed focus, distraction behavior ranging from crying to laughing, and muscle tension or rigidity. In sudden and severe pain, autonomic responses such as diaphoresis, blood pressure and pulse changes, pupillary dilation, or increases or decreases in respiratory rate and depth may be present.

Related Factors: 

  • Actual or potential tissue damage (mechanical [e.g., incision or tumor growth], 
  • thermal [e.g., burn], 
  • or chemical [e.g., toxic substance])


Suggested NOC Labels
  • Pain Level, Pain Control, Comfort Level
  • Pain: Disruptive Effects
Client Outcomes
  • Uses a pain rating scale to identify current level of pain intensity and determines a comfort/function goal (if client has cognitive abilities)
  • Describes how unrelieved pain will be managed
  • Reports that the pain management regimen relieves pain to a satisfactory level with acceptable or manageable side effects
  • Performs activities of recovery with a reported acceptable level of pain (if pain is above the comfort/function goal, takes action that decreases pain or notifies a member of the health care team)
  • States an ability to obtain sufficient amounts of rest and sleep
  • Describes a nonpharmacological method that can be used to control pain


Suggested NIC Labels
  • Conscious Sedation
  • Patient-Controlled Analgesia (PCA) Assistance

Nursing Interventions and Rationales

1. Determine whether client is experiencing pain at the time of the initial interview. If so, intervene at that time to provide pain relief.
The intensity, character, onset, duration, and aggravating and relieving factors of pain should be assessed and documented during the initial evaluation of the patient (American Pain Society Quality of Care Committee, 1995; JCAHO, 2000).

2. Ask client to describe past experiences with pain and effectiveness of methods used to manage pain, including experiences with side effects, typical coping responses, and how he or she expresss pain.
A number of concerns (barriers) may affect patients' willingness to report pain and use analgesics (Ward et al, 1993).

3. Describe adverse effects of unrelieved pain.
Numerous pathophysiological and psychological morbidity factors may be associated with pain (McCaffery, Pasero, 1999; Page, Ben-Eliyahu, 1997; Puntillo, Weiss, 1994).

4. Tell client to report location, intensity (using a pain rating scale), and quality when experiencing pain.
The intensity of pain and discomfort should be assessed and documented after any known pain-producing procedure, with each new report of pain, and at regular intervals (American Pain Society Quality of Care Committee, 1995; JCAHO, 2000).

5. Determine client's current medication use.
To aid in planning pain treatment, obtain a medication history (Acute Pain Management Guideline Panel, 1992).

6. Explore the need for both opioid (narcotic) and non-opioid analgesics.
Pharmacological interventions are the cornerstone of pain management (Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).

7. Obtain a prescription to administer a non-opioid (acetaminophen, Cox-2 inhibitor, or a nonsteroidal antiinflammatory drug [NSAID]), unless contraindicated, around the clock (ATC).
NSAIDs act mainly in the periphery to inhibit the initiation of pain impulses (Dahl, Kehlet, 1991). Unless contraindicated, all patients with acute pain should receive a non-opioid ATC (Acute Pain Management Guideline Panel, 1992). The analgesic regimen should include a non-opioid, even if pain is severe enough to require the addition of an opioid (Jacox et al, 1994; McCaffery, Pasero, 1999).

8. Obtain a prescription to administer opioid analgesia if indicated, especially for severe pain.
Opioid analgesics are indicated for the treatment of moderate to severe pain (Jacox et al, 1994; McCaffery, Pasero, 1999).

9. Administer opioids orally or intravenously, not intramuscularly. Use a preventive approach to keep pain at or below an acceptable level. Provide PCA and intraspinal routes of administration when appropriate and available.
The least invasive route of administration capable of providing adequate pain control is recommended. The intramuscular (IM) route is avoided because of unreliable absorption, pain, and inconvenience. The intravenous (IV) route is preferred for rapid control of severe pain. For ongoing pain, give analgesia ATC. PRN dosing is appropriate for intermittent pain (Jacox et al, 1994; McCaffery, Pasero, 1999).

10. Discuss client's fears of undertreated pain, overdose, and addiction.
A number of concerns may affect clients' willingness to report pain and use opioid analgesics (Ward et al, 1993). Because of the many misconceptions regarding pain and its treatment, education about the ability to control pain effectively and correction of myths about the use of opioids should be included as part of the treatment plan (Jacox et al, 1994; McCaffery, Pasero, 1999). Addiction is extremely unlikely after patients use opioids for acute pain (Acute Pain Management Guideline Panel, 1992).

11. When opioids are administered, assess pain intensity, sedation, and respiratory status at regular intervals.
Opioids may cause respiratory depression because they reduce the responsiveness of carbon dioxide chemoreceptors located in the respiratory centers of the brain. Because even more opioid is required to produce respiratory depression than is required to produce sedation, patients with clinically significant respiratory depression are usually also sedated. Respiratory depression can be prevented by assessing sedation and decreasing the opioid dose when the patient is arousable but has difficulty staying awake (McCaffery, Pasero, 1999; Pasero, McCaffery, 1994).

12. Review client's flow sheet and medication records to determine overall degree of pain relief, side effects, and analgesic requirements during the past 24 hours.
Systematic tracking of pain appears to be an important factor in improving pain management (Faries et al, 1991; JCAHO, 2000).

13. Administer supplemental opioid doses as needed to keep pain ratings at or below an acceptable level.
A PRN order for supplementary opioid doses between regular doses is an essential backup (American Pain Society, 1999).

14. Obtain prescriptions to increase or decrease opioid doses as needed; base prescriptions on client's report of pain severity and response to the previous dose in terms of relief, side effects, and ability to perform the activities of recovery.
Increase or decrease the dose of opioid based on assessment of the patient's response. Patients' responses, and therefore their requirements, vary widely, so it is less important to focus on the amount given than on the response (McCaffery, Pasero, 1999; Pasero, McCaffery, 1994).

15. When client is able to tolerate oral analgesics, obtain a prescription to change to the oral route; use an equianalgesic chart to determine initial dose. (See Appendix E for an equianalgesic chart.)
The oral route is preferred because it is the most convenient and cost-effective (Jacox et al, 1994). Use of equianalgesic doses when switching from one opioid or route of administration to another will help to prevent loss of pain control from underdosing and side effects from overdosing (McCaffery, Pasero, 1999).

16. In addition to use of analgesics, support client's use of nonpharmacological methods to control pain, such as distraction, imagery, relaxation, massage, and heat and cold application.
Cognitive-behavioral strategies can restore the clients' sense of self-control, personal efficacy, and active participation in own care (Jacox et al, 1994).

17. Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions.
Nonpharmacological interventions should be used to supplement, not replace, pharmacological interventions (Acute Pain Management Guideline Panel, 1992).

18. Plan care activities around periods of greatest comfort whenever possible.
Pain diminishes activity (Jacox et al, 1994; McCaffery, Pasero, 1999).

19. Ask client to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to improve these functions. Obtain a prescription for a peristaltic stimulant to prevent opioid-induced constipation.
Because there is great individual variation in the development of opioid-induced side effects, these side effects should be monitored and, if their development is inevitable (e.g., constipation), prophylactically treated. Opioids cause constipation by decreasing bowel peristalsis (Jacox et al, 1994; McCaffery, Pasero, 1999).


1. Always take the elderly client's reports of pain seriously and ensure that the pain is relieved.
In spite of what many professionals and clients believe, pain is not an expected part of normal aging (McCaffery, Pasero, 1999).

2. When assessing pain, speak clearly, slowly, and loudly enough for client to hear; repeat information as needed. Be sure client can see well enough to read pain scale (use enlarged scale) and written materials.

3. Handle client's body gently. Allow client to move at own speed.

4. Use acetaminophen and NSAIDs with low side-effect profiles such as choline and magnesium salicylates (Trilisate) and diflunisal (Dolobid), and watch for side effects, such as GI disturbances and bleeding problems.
Elderly people are at increased risk for gastric and renal toxicity from NSAIDs (Griffin et al, 1991; Acute Pain Management Guideline Panel, 1992).

5. Avoid or use with caution drugs with a long half-life, such as the NSAID piroxicam (Feldene), the opioids methadone (Dolophine) and levorphanol (Levo-Dromoran), and the benzodiazepine diazepam (Valium).
The higher prevalence of renal insufficiency in the elderly than in younger persons can result in toxicity from drug accumulation (American Pain Society, 1999; Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).

6. Use opioids with caution in the elderly client.
The elderly are more sensitive to the analgesic effects of opioid drugs because they experience a higher peak effect and a longer duration of pain relief. Reduce the initial recommended adult starting opioid dose by 25% to 50%, especially if the client is frail and debilitated; then increase the dose if safe and necessary (Acute Pain Management Guideline Panel, 1992).

7. Avoid the use of opioids with toxic metabolites, such as meperidine (Demerol) and propoxyphene (Darvon, Darvocet), in elderly clients.
Meperidine's metabolite, normeperidine, can produce CNS irritability, seizures, and even death; propoxyphene's metabolite, norpropoxyphene, can produce both CNS and cardiac toxicity. Both of these metabolites are eliminated by the kidneys, making meperidine and propoxyphene particularly poor choices for elderly clients, many of whom have at least some degree of renal insufficiency (Acute Pain Management Guideline Panel, 1992; McCaffery, Pasero, 1999).


1. Assess pain in a culturally diverse client using a self-report 0 to 10 numerical pain rating scale or the Wong Baker Faces pain rating scale. Have scale translated into client's native language if necessary..
Inadequate pain management is widespread, especially among minority groups, and a major reason is the failure to assess pain properly. The more cultural differences between patient and nurse, the more difficult it is for the nurse to assess and treat pain. Self-report of pain is the single most reliable indicator of pain, regardless of culture (McCaffery, 1999; McCaffery, Pasero, 1999).

2. Administer analgesics on a preventive basis to keep pain ratings at or below an acceptable level.
Regardless of the patient's cultural background, pain rated at (4 on a 0 to 10 pain rating scale interferes significantly with daily function. Perceived quality of life appears to be comparable across cultures, with pain ratings of >6 interfering markedly with a person's ability to enjoy life (McCaffery, 1999; McCaffery, Pasero, 1999).

3. Assess for the influence of cultural beliefs, norms, and values on the client's perception and experience of pain.
The client's experience of pain may be based on cultural perceptions (Leininger, 1996).

4. Assess for the role of fatalism on the client's beliefs regarding their current state of comfort.
Fatalistic perspectives in some African-American and Latino populations involve the belief that you cannot control your own fate and influence your health behaviors (Philips, Cohen, Moses, 1999; Harmon, Castro, Coe, 1996).

5. Incorporate folk health care practices and beliefs into care whenever possible.
Incorporating folk health care beliefs and practices into pain management care increased compliance with the treatment plan (Juarez, Ferrell, Borneman, 1998).

6. Use a family-centered approach when working with Latino, Asian American, African-American, and Native American clients.
Involving family in pain management care increased compliance with the treatment regimen (Juarez, Ferrel, Borneman, 1998).

7. Use culturally relevant pain scales (e.g., the Oucher scale) to assess pain in the client.
Culturally diverse clients may express pain differently than clients from the majority culture. The Oucher scale has African-American and Hispanic versions and is used to assess pain in children (Beyer, Denyes, Villarruel, 1992).

8. Ensure that directions for medications are available in the client's language of choice and are understood by client and caregiver.
Bilingual instructions for medications increased compliance with the pain management plan (Juarez, Ferrell, Borneman, 1998).

9. Validate the client's feelings and emotions regarding current health status.
Validation lets the client know the nurse has heard and understands what was said, and it promotes the nurse-client relationship. (Stuart, Laraia, 2001;Giger, Davidhizer, 1995).

Home Care Interventions

1. Review with client and caregivers the cause(s) of pain and the medical regimen specific to the cause. Assess client knowledge and teach disease process as necessary.
Compliance with the medical regimen for diagnoses involving pain improves the likelihood of successful management (Humphrey, 1994).

2. Develop a full medication profile, including medications prescribed by all physicians and all over-the-counter medications. Assess for drug interactions. Instruct client to refrain from mixing medications without physician approval.
Pain medications may significantly impact or be impacted by other medications and may cause severe side effects. Some combinations of drugs are specifically contraindicated (Jacox et al, 1994).

3. Assess client and family knowledge of side effects and safety precautions associated with pain medications (e.g., use caution when operating machinery when opioids are initiated or dose has been increased).
The cognitive effects of opioids usually subside within a week of initial dosing or dose increases (McCaffery, Pasero, 1999). The use of long-term opioid treatment does not appear to affect neuropsychological performance. Pain itself may deteriorate performance of neuropsychological tests more than oral opioid treatment (Sjogren et al, 2000).

4. If administering medication using highly technological methods, assess home for necessary resources (e.g., electricity), and ensure that there will be responsible caregivers available to assist client with administration.
Some routes of medication administration require special conditions and procedures to be safe and accurate (McCaffery, Pasero, 1999).

5. Assess knowledge base of client and family for highly technological medication administration. Teach as necessary. Be sure clients know when, how, and who to contact if analgesia is unsatisfactory.
Appropriate instruction in the home increases the accuracy and safety of medication administration (McCaffery, Pasero, 1999).

Client/Family Teaching

NOTE: To avoid the negative connotations associated with the words drugs and narcotics, use the words pain medicine when teaching clients.

1. Provide written materials on pain control such as the Agency for Health Care Policy and Research (AHCPR) pamphlet, Pain Control: Patient Guide.

2. Discuss the various discomforts encompassed by the word pain, and ask client to give examples of previously experienced pain. Explain pain assessment process and purpose of the pain rating scale.

3. Teach client to use the pain rating scale to rate intensity of past or current pain. Ask client to set a comfort/function goal by selecting a pain level on the rating scale that makes it easy to perform recovery activities (e.g., turn, cough, deep breathe). If pain is above this level, client should take action that decreases pain or notify a member of the health care team. (See Appendix E for information on teaching clients to use the pain rating scale.)

4. Demonstrate medication administration and use of supplies and equipment. If PCA is ordered, determine client's ability to press appropriate button. Remind client and staff that the PCA button is for patient-only use.

5. Reinforce importance of taking pain medications to keep pain under control.

6. Reinforce that taking opioids for pain relief is not addiction and that addiction is very unlikely to occur.

7. Demonstrate use of appropriate nonpharmacological approaches for controlling pain, such as heat, cold, distraction techniques, relaxation breathing, visualization, rocking, stroking, music, and television.

Activity Intolerance

Activity Intolerance Definition

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

Defining Characteristics:

  • 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
Related Factors:
  • Bed rest or immobility; 
  • generalized weakness;
  • sedentary lifestyle; 
  • imbalance between oxygen supply and demand


Suggested NOC Labels
  • Endurance
  • Energy Conservation
  • Activity Tolerance
  • Self-Care: Activities of Daily Living (ADLs)
Client Outcomes
  • Participates in prescribed physical activity with appropriate increases in heart rate, blood pressure, and breathing rate; maintains monitor patterns (rhythm and ST segment) within normal limits
  • States symptoms of adverse effects of exercise and reports onset of symptoms immediately
  • Maintains normal skin color and skin is warm and dry with activity
  • Verbalizes an understanding of the need to gradually increase activity based on testing, tolerance, and symptoms
  • Expresses an understanding of the need to balance rest and activity
  • Demonstrates increased activity tolerance


Suggested NIC Labels
  • Energy Management
  • Activity Therapy

Nursing Interventions and Rationales

1. Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational.
Determining the cause of a disease can help direct appropriate interventions.

2. Assess client daily for appropriateness of activity and bed rest orders.
Inappropriate prolonged bed rest orders may contribute to activity intolerance. A review of 39 studies on bed rest resulting from 15 disorders demonstrated that bed rest for treatment of medical conditions is associated with worse outcomes than early mobilization (Allen, Glasziou, Del Mar, 1999).

3. Minimize cardiovascular deconditioning by positioning clients as close to the upright position as possible several times daily.
The hazards of bed rest in the elderly are multiple, serious, quick to develop, and slow to reverse. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Resnick, 1998).

4. If appropriate, gradually increase activity, allowing client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to chair sitting, to standing, to ambulation.
Increasing activity helps to maintain muscle strength, tone, and endurance. Allowing the client to participate decreases the perception of the client as incapable and frail (Eliopoulous, 1998).

5. Ensure that clients change position slowly. Consider using a chair-bed (stretcher-chair) for clients who cannot get out of bed. Monitor for symptoms of activity intolerance.
Bed rest in the supine position results in loss of plasma volume, which contributes to postural hypotension and syncope (Creditor, 1993).

6. When getting clients up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs.
Heart rate and blood pressure responses to orthostasis vary widely. Vital sign changes by themselves should not define orthostatic intolerance (Winslow, Lane, Woods, 1995).

7. Perform range-of-motion exercises if client is unable to tolerate activity.
Inactivity rapidly contributes to muscle shortening and changes in periarticular and cartilaginous joint structure. These factors contribute to contracture and limitation of motion (Creditor, 1994).

8. Refer client to physical therapy to help increase activity levels and strength.

9. Monitor and record client's ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before and after activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately (ACSM, 1995):
  • Excessive fatigue
  • Lightheadedness, confusion, ataxia, pallor, cyanosis, dyspnea, nausea, or any peripheral circulatory insufficiency
  • Onset of angina with exercise
  • Palpitations
  • Dysrhythmia (symptomatic supraventricular tachycardia, ventricular tachycardia, exercise-induced left bundle block, second- or third-degree atrioventricular block, frequent premature ventricular contractions)
  • Exercise hypotension (drop in systolic blood pressure of more than 10 mm Hg from baseline blood pressure despite an increase in workload, when accompanied by other evidence of ischemia)
  • Excessive rise in blood pressure (systolic greater than 220 mm Hg or diastolic greater than 110 mm Hg); NOTE: these are upper limits; activity may be stopped before reaching these values
  • Inappropriate bradycardia (drop in heart rate greater than 10 beats/min) with no change or increase in workload
  • Increased heart rate above the prescribed limit

10. Instruct client to stop activity immediately and report to physician if experiencing the following symptoms: new or worsened intensity or increased frequency of discomfort, tightness, or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger.
These are common symptoms of angina and are caused by a temporary insufficiency of coronary blood supply. Symptoms typically last for minutes as opposed to momentary twinges. If symptoms last longer than 5 to 10 minutes, the client should be evaluated by a physician (McGoon, 1993). The client should be evaluated before resuming activity (Thompson, 1988).

11. Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity. Rest periods decrease oxygen consumption (Prizant-Weston, Castiglia, 1992).

12. Observe and document skin integrity several times a day. Activity intolerance may lead to pressure ulcers.
Mechanical pressure, moisture, friction, and shearing forces all predispose to their development (Resnick, 1998).

13. Assess urinary incontinence related to functional ability. Assess independent ability to get to the toilet and remove and adjust clothing.
The loss of functional ability that accompanies disease often leads to continence problems. The cause may not be the person's bladder instability but his or her ability to get to the toilet quickly (Nazarko, 1997).

14. Assess for constipation.
Impaired mobility is associated with increased risk of bowel dysfunction, including constipation. Constipation increases the risk of urinary tract infection and urge incontinence (Nazarko, 1997).

15. Consider dietitian referral to assess nutritional needs related to activity intolerance.
Severe malnutrition can lead to activity intolerance. Dietitians can recommend dietary changes that can improve the client's health status (Peckenpaugh, Poleman, 1999).

16. Refer the cardiac client to cardiac rehabilitation for assistance in developing safe exercise guidelines based on testing and medications.
Cardiac rehabilitation exercise training improves objective measures of exercise tolerance in both men and women, including elderly patients with coronary heart disease and heart failure. This functional improvement occurs without significant cardiovascular complications or other adverse outcomes (Wenger et al, 1995).

17. Ensure that the chronic pulmonary client has oxygen saturation testing with exercise. Use supplemental oxygen to keep oxygen saturation 90% or above or as prescribed with activity.
Supplemental oxygen increases circulatory oxygen levels and improves activity tolerance (Petty, Finigan, 1968; Casaburi, Petty, 1993).

18. Monitor a chronic obstructive pulmonary disease (COPD) client's response to activity by observing for symptoms of respiratory intolerance such as increased dyspnea, loss of ability to control breathing rhythmically, use of accessory muscles, and skin tone changes such as pallor and cyanosis.

19. Instruct and assist COPD clients in using conscious controlled breathing techniques such as pursing their lips and diaphragmatic breathing.
Training clients with COPD to slow their respiratory rate with a prolonged exhalation (with or without pursed lips) helps control dyspnea and results in improved ventilation, increased tidal volume, decreased respiratory rate, and a reduced alveolar-arterial oxygen difference. This breathing pattern not only helps relieve dyspnea but can improve the ability to exercise and carry out ADLs (Mueller, Petty, Filley, 1970; Casaburi, Petty, 1993).

20. Provide emotional support and encouragement to client to gradually increase activity.
Fear of breathlessness, pain, or falling may decrease willingness to increase activity.

21. Refer the COPD client to a pulmonary rehabilitation program.
Pulmonary rehabilitation has been shown to improve exercise capacity, walking ability, and sense of well-being (Fishman, 1994).

22. Observe for pain before activity. If possible, treat pain before activity, and ensure that client is not heavily sedated.
Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.

23. Obtain any necessary assistive devices or equipment needed before ambulating client (e.g., walkers, canes, crutches, portable oxygen).
Assistive devices can increase mobility by helping the client overcome limitations.

24. Use a walking belt when ambulating a client who is unsteady.
With a walking belt the client can walk independently, but the nurse can provide support if the client's knees buckle.

25. Work with client to set mutual goals that increase activity levels.


1. Slow the pace of care. Allow client extra time to carry out activities.

2. Encourage families to help/allow elder to be independent in whatever activities possible. Sometimes families believe they are assisting by allowing clients to be sedentary.
Encouraging activity not only enhances good functioning of the body's systems but also promotes a sense of worth by providing an opportunity for productivity (Eliopoulous, 1997).

3. When mobilizing the elderly client, watch for orthostatic hypotension accompanied by dizziness and fainting.
Orthostatic hypotension is common in the elderly as a result of cardiovascular changes, chronic diseases, and medication effects (Mobily, Kelley, 1991).

Home Care Interventions

1. Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems and the need for community or home health services.

2. Assess the home environment for factors that precipitate decreased activity tolerance: presence of allergens such as dust, smoke, and those associated with pets; temperature; energy-intensive activity patterns; and furniture placement. Refer to occupational therapy if needed to assist the client in restructuring the home and activity of daily living patterns.
Clients and families often estimate energy requirements inaccurately during hospitalization because of the availability of support.

3. Teach the client/family the importance of and methods for setting priorities for activities, especially those having a high energy demand (e.g., home/family events).

4. Provide client/family with resources such as senior centers, exercise classes, educational and recreational programs, and volunteer opportunities that can aid in promoting socialization and appropriate activity.
Social isolation can contribute to activity intolerance.

5. Discuss the importance of sexual activity as part of daily living. Instruct the client in adaptive techniques to conserve energy during sexual interactions.
Families may make unsafe choices for sexual activity or place added stress on themselves trying to cope with this issue without proper support or teaching.

6. Instruct the client and family in the importance of maintaining proper nutrition and rest for energy conservation and rehabilitation.

7. Refer to medical social services as necessary to assist the family in adjusting to major changes in patterns of living.

8. Assess the need for long-term supports for optimal activity tolerance of priority activities (e.g., assistive devices, oxygen, medication, catheters, massage), especially for hospice patients. Evaluate intermittently.
Assessments ensure the safety and appropriate use of these supports.

9. Refer to home health aide services to support the client and family through changing levels of activity tolerance. Introduce aide support early. Instruct the aide to promote independence in activity as tolerated.
Providing unnecessary assistance with transfers and bathing activities may promote dependence and a loss of mobility (Mobily, Kelley, 1991).

10. Be aware of increased risk of bone fracture even after muscle strength is normalized, especially in osteopenic-prone individuals such as estrogen-deficient women and the elderly.
Reduction in weight bearing muscle activity during bed rest invariably produces significant changes in calcium balance and, in weeks, changes in bone mass (Bloomfield, 1997)

11. Allow terminally ill clients and their families to guide care.
Control by the client or family promotes effective coping.

12. Provide increased attention to comfort and dignity of the terminally ill client in care planning. For example, oxygen may be more valuable as a support to the client's psychological comfort than as a booster of oxygen saturation.

Client/Family Teaching

1. Instruct client on rationale and techniques for avoiding activity intolerance.
2. Teach client to use controlled breathing techniques with activity.
3. Teach client the importance and method of coughing, clearing secretions.
4. Instruct client in the use of relaxation techniques during activity.
5. Help client with energy conservation and work simplification techniques in ADLs.
6. Teach client the importance of proper nutrition.
7. Describe to client the symptoms of activity intolerance, including which symptoms to report to the physician.
8. Explain to client how to use assistive devices or medications before or during activity.
9. Help client set up an activity log to record exercise and exercise tolerance.

Tuesday, November 5, 2013

Acute Confusion

Acute Confusion Definition 

Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, or the sleep/wake cycle

Defining Characteristics:

  • Lack of motivation to initiate and/or follow through with goal-directed or purposeful behavior; 
  • fluctuation in psychomotor activity; 
  • misperceptions; 
  • fluctuation in cognition; 
  • increased agitation or restlessness; 
  • fluctuation in level of consciousness; 
  • fluctuation in sleep-wake cycle; 
  • hallucinations

Related Factors:
  • 60 years of age; 
  • dementia; 
  • alcohol abuse; 
  • abuse; 
  • delirium; 
  • uncontrolled pain; 
  • multiple morbidities and medications


Suggested NOC Labels
  • Distorted Thought Control
  • Information Processing
  • Memory
  • Neurological Status: Consciousness
  • Safety Behavior: Personal
  • Sleep

Client Outcomes
  • Cognitive status restored to baseline
  • Obtains adequate amount of sleep
  • Demonstrates appropriate motor behavior
  • Maintains functional capacity


Suggested NIC Labels
  • Delusion Management

Nursing Interventions and Rationales

1. Assess client’s behavior and cognition systematically and continually throughout the day and night as appropriate.
Rapid onset and fluctuating course are hallmarks of delirium (Murphy, 2000). The Confusion Assessment Method is sensitive, specific, reliable, and easy to use (Inouye et al, 1990). Nurses play a vital role in assessing acute confusion because they provide 24- hours-a-day care and see the client in a variety of circumstances (Marr, 1992). Delirium always involves acute change in mental status; therefore knowledge of the client’s baseline mental status is key in assessing delirium (Flacker, Marcantonio, 1998).

2. Perform an accurate mental status exam that includes the following:
  • Overall appearance, manner, and attitude
  • Behavior observations and level of psychomotor behavior
  • Mood and affect (presence of suicidal or homicidal ideation as observed by others and reported by client)
  • Insight and judgment
  • Cognition as evidenced by level of consciousness, orientation (to time, place, and person), thought process and content (perceptual disturbances such as illusions and hallucinations, paranoia, delusions, abstract thinking)
  • Attention
Abnormal attention is an important diagnostic feature of delirium (Flacker, Marcantonio, 1998). Delirium is a state of mind, while agitation is a behavioral manifestation. Some clients may be delirious without agitation and may actually have withdrawn behavior. This is a hypoactive form of delirium. Some clients have a mixed hypoactive/hyperactive type of delirium (O’Keefe, Lavan, 1999).

3. Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, medications with known cognitive and psychotropic side effects).
Such alterations may be contributing to confusion and must be corrected (Matthiesen et al, 1994). Medications are considered the most common cause of delirium in the ICU (Harvey, 1996).

4. Treat underlying causes of delirium in collaboration with the health care team: Establish/maintain normal fluid and electrolyte balance; establish/maintain normal nutrition, body temperature, oxygenation (if patients experience low oxygen saturation treat with supplemental oxygen), blood glucose levels, blood pressure.

5. Communicate client status, cognition, and behavioral manifestations to all necessary providers. Monitor for any trending of these.
Recognize that client’s fluctuating cognition and behavior is a hallmark for delirium and is not to be construed as client preference for caregivers (Inouye et al, 1990). Careful monitoring may allow for various symptoms to be related to various causes and interventions (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).

6. Lab results should be closely monitored and physiological support provided as appropriate.
Once acute confusion has been identified, it is vital to recognize and treat the associated underlying causes (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).

7. Establish or maintain elimination patterns.
Disruption of elimination may be a cause for confusion (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997). Changes in elimination patterns may also be a symptom of acute confusion. Prompt response to requests for assistance with elimination in addition to timed voids may assist in maintaining regular elimination, orientation, and patient safety (Rosen, 1994).

8. Plan care that allows for appropriate sleep-wake cycle.
Disruptions in usual sleep and activity patterns should be minimized as those clients with nocturnal exacerbations endure more complications from delirium.

9. Review medication.
Medication is one of the most important modifiable factors that can cause delirium, especially use of anticholinergics, antipsychotics, and hypnosedatives (Flacker, Marcantonio, 1998).

10. Decrease caffeine intake.
Decreasing caffeine intake helps to reduce agitation and restlessness (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).

11. Modulate sensory exposure and establish a calm environment.
Extraneous lights and noise can give rise to agitation, especially if misperceived. Sensory overload or sensory deprivation can result in increased confusion (Rosen, 1994). Clients with a hyperactive form of delirium often have increased irritability and startle responses and may be acutely sensitive to light and sound (Casey et al, 1996).

12. Manipulate the environment to make it as familiar to the patient as possible. Use a large clock and calendar. Encourage visits by family and friends. Place familiar objects in sight.
An environment that is familiar provides orienting clues, maintains an appropriate balance of sensory stimulation, and secures safety (Rosen, 1994).

13. Identify self by name at each contact; call patient by his or her preferred name. Appropriate communication techniques for clients at risk for confusion (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).

14. Use orientation techniques. However, if client becomes distressed or argumentative about what is real, do not argue with the client.
Rather, explore the emotion behind the client’s non–reality-based statements (Rosen, 1994).

15. Offer reassurance to the client and use therapeutic communication at frequent intervals.
Client reassurance and communication are nursing skills that promote trust and orientation and reduce anxiety (Harvey, 1996).

16. Provide supportive nursing care.
Delirious patients are unable to care for themselves as a result of their confusion. Their care and safety needs must be anticipated by the nurse (Foreman, 1999).

17. Identify, evaluate, and treat pain quickly (see care plan for Acute Pain). Untreated pain is a potential cause for delirium.


1. Mobilize client as soon as possible; provide active and passive range of motion.
Older clients who had a low level of physical activity before injury are at a particular risk for acute confusion (Matthiesen et al, 1994).

2. Provide sufficient medication to relieve pain.
Older clients may give inaccurate pain histories; underreport symptoms; not want to bother the nurse; and exhibit restlessness, agitation, or increased confusion (Matthiesen et al, 1994).

3. Because anxiety and sensory impairment decrease the older client's ability to integrate new information, explain hospital routines and procedures slowly and in simple terms, repeating information as necessary (Matthiesen et al, 1994).

4. Provide continuity of care when possible (e.g., provide the same caregivers, avoid room changes).
Continuity of care helps decrease the disorienting effects of hospitalization (Matthiesen et al, 1994).

5. If clients know that they are not thinking clearly, acknowledge the concern.
Confusion is very frightening (Matthiesen et al, 1994).

6. Do not use the intercom to answer a call light.
The intercom may be frightening to an older confused client (Matthiesen et al, 1994).

7. Keep client's sleep-wake cycle as normal as possible (e.g., avoid letting client take daytime naps, avoid waking clients at night, give sedatives but not diuretics at bedtime, provide pain relief and backrubs).
Acute confusion is accompanied by disruption of the sleep-wake cycle (Matthiesen et al, 1994).

8. Maintain normal sleep/wake patterns (treat with bright light for 2 hours in the early evening).
This facilitates normal sleep/wake patterns (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).

Home Care Interventions

1. Monitor for acute changes in cognition and behavior.
An acute change in cognition and behavior is the classic presentation of delirium. It should be considered a medical emergency.

Client/Family Teaching

1. Teach family to recognize signs of early confusion and seek medical help.
Early intervention prevents long-term complications (Rapp, Iowa Veterans Affairs Nursing Research Consortium, 1997).

Sunday, November 3, 2013

Adult Failure to Thrive

Adult Failure to Thrive Definition

Progressive functional deterioration of a physical and cognitive nature with remarkably diminished ability to live with multisystem diseases, cope with ensuing problems, and manage care

Defining Characteristics:

  • Anorexia-does not eat meals when offered; 
  • states does not have an appetite, is not hungry, or "I don't want to eat"; 
  • inadequate nutritional intake-eating less than body requirements; 
  • consumption of minimal to no food at most meals (i.e., consumes less than 75% of normal requirements); 
  • weight loss (from baseline weight)-5% unintentional weight loss in 1 month or 10% unintentional weight loss in 6 months; 
  • physical decline (decline in bodily function) — evidence of fatigue, dehydration, incontinence of bowel and bladder; 
  • frequent exacerbations of chronic health problems (e.g. pneumonia, urinary tract infections); 
  • cognitive decline (decline in mental processing) as evidenced by problems with responding appropriately to environmental stimuli, 
  • demonstrated difficulty in reasoning, decision making, judgment, memory, and concentration; decreased perception; 
  • decreased social skills; 
  • social withdrawal-noticeable decrease from usual past behavior in attempts to form or participate in cooperative and interdependent relationships (e.g., decreased verbal communication with staff, family, friends); 
  • decreased participation in ADLs that the older person once enjoyed; 
  • self-care deficit-no longer looks after or takes charge of physical cleanliness or appearance; 
  • difficulty performing simple self-care tasks; 
  • neglect of home environment and/or financial responsibilities; 
  • apathy as evidenced by lack of observable feeling or emotion in terms of normal ADLs and environment; 
  • altered mood state-expresses feelings of sadness, being low in spirit; 
  • expresses loss of interest in pleasurable outlets such as food, sex, work, friends, family, hobbies, or entertainment; 
  • verbalizes desire for death

Related Factors:
  • Depression; 
  • apathy; 
  • fatigue


Suggested NOC Labels
  • Physical Aging Status
  • Psychosocial Adjustment: Life Change
  • Will to Live
Client Outcomes
  • Resumes highest level of functioning possible
  • Consumes adequate dietary intake for weight and height
  • Maintains usual weight
  • Has adequate fluid intake with no signs of dehydration
  • Participates in ADLs
  • Participates in social interactions
  • Maintains clean personal and home environment
  • Expresses feelings associated with losses


Suggested NIC Labels
  • Mood Management
  • Self-Care Assistance

Nursing Interventions and Rationales

1. Elderly clients who have failure to thrive (FTT) should be evaluated by review of the patient's ADLs, cognitive function, and mood; a targeted history and physical examination; and selected laboratory studies.
Early recognition and management of FTT can reduce the risk of further functional deterioration, hospitalization, or nursing home placement (Palmer, Foley, 1990).

2. Assess possible causes for adult FTT and treat any underlying problems such as depression, malnutrition, and illnesses that are caused by physical and cognitive changes.
The characteristics of FTT in the elderly are malnutrition (undernutrition), loss of physical and cognitive function, and depression (Groom, 1993). Malnutrition is a frequent condition, both widely represented in the geriatric population and underestimated in diagnostic and therapeutic work-up, and is known to affect health status and life expectancy of elderly people (Vetta et al, 1999). An initial clinical assessment that combines multiple and varied sources of information is recommended to evaluate patients with suspected dementia (U.S. Department of Health and Human Services, 1996).

3. Assess for signs of fatigue and sensory changes that may indicate an infection is present that may be related to undetected diabetes mellitus.
Older adults may never exhibit the classic signs of polyuria, polydipsia, polyphagia, and weight loss; instead they may develop an infection and complain of fatigue and sensory changes (Faherty, 1994).

4. Assess for all etiologies including depression using a geriatric depression scale. Be alert for depression in clients newly admitted to nursing homes.
The geriatric depressions scale is recommended to determine the presence of depression (Jamison, 1997). Depression in newly admitted nursing home residents is a frequently overlooked area of nursing concern (Ryden et al, 1998). New depression may be the first sign of impending cognitive dysfunction (Sarkisian, Lachs, 1996).

5. Note if the client is irritable and is blaming others.
Recent findings in nursing research support the presence of these behaviors as symptomatic of depression (Proffitt, Augspurger, Byrne, 1996).

6. Provide cognitive therapy for clients who are identified as depressed. Reinforce their value as a person and provide reality as to "who they really are."
Clients who are depressed can be helped by examining "who they are" as compared to "who they believe they are" (Drake, Price, Drake, 1996).

7. Instill hope and encourage the expression of positive thoughts.
The findings from this study of 1002 older disabled women suggest that positive emotions can protect older persons against adverse health outcomes. Of the women studied, 351 were described as emotionally vital, and among the women without a specific disability at baseline, emotional vitality was associated with a significantly decreased risk for incident disability performing ADLs (RR = 0.81, 95% CI = 0.66-0.99), for incident disability walking 1/4 mile (RR = 0.73, 95% CI = 0.59-0.92), and for incident disability lifting/carrying 10 pounds (RR = 0.77, 95% CI = 0.63-0.95). Emotional vitality was also associated with a lower risk of dying (RR = 0.56, 95% CI = 0.39-0.80). These results were not simply caused by the absence of depression because protective health effects remained when emotionally vital women were compared with 334 women who were not emotionally vital and not depressed (Pennix et al, 2000).

8. Monitor elderly client's weight and note any unexplained weight loss.
The FTT of an elderly client is usually accompanied by weight loss that occurs without immediate explanation (Palmer, Foley, 1993).

9. Play soothing music during mealtimes to increase the amount of food eaten.
One study suggested that dinner music, particularly soothing music, can reduce irritability, fear, panic, and depressed mood and can stimulate the appetite of demented patients in a nursing home. In this study the patients were less irritable, anxious, and depressed during the periods when music was playing (Ragneskog et al, 1996).

10. Note changes in the elderly client's appetite and assess for depression.
Depression can lead to FTT by two routes: a direct path of decreased appetite as a symptom of depression and an indirect path of increasing disability as an effect of depression (Katz, DiFilippo, 1997).

11. Offer comfort foods and happy hour: foods associated with bygone years, intended to trigger recollections of pleasant childhood experiences and feelings of caring and healing, and a "happy hour" beverage, presented in a social milieu.
These are two approaches that have demonstrated effectiveness in stimulating oral intake in the FTT client (Wood, Vogen, 1998).

12. Provide appropriate nutrition for the client whose obesity may be affecting physical performance and thus has limited ability to perform ADLs, which leads to functional dependence.
Malnutrition includes obesity (overnutrition); obesity among older persons is defined as being (30% above ideal body weight. Obesity may contribute to the previously mentioned problems (Still, Apovian, Jensen, 1997).

14. Encourage clients to reminiscence about past experiences. Reminiscing helps to foster social relatedness (Jamison, 1997).
A standard reminiscence interview and one that focused on successfully met challenges reduced state anxiety and enhanced coping self-efficacy (Rybarczyk, Auerbach, 1990).

15. Encourage clients to pray if they wish.
Various studies have discovered that various groups of people have used prayer for managing their symptoms of aging or illness (Meraviglia, 1999).

16. Encourage elderly clients to interact with others on a regular basis. Have them participate in activities for seniors in their community.
FTT of an elderly client is usually accompanied by social withdrawal (Palmer, Foley, 1993).

17. Help clients to participate in activities by assessing motivation and helping them to identify reasons to participate such as better mobility, more independence, feelings of well-being.
Motivation has been identified as an important factor in the older adult's ability to perform functional activities (Resnick, 1998).

18. Provide physical touch for clients. Touch their hand or arm when speaking with them; offer hugs with permission.
Touch helps with integration and fosters social relatedness. Tactile stimulation benefits the older adult's psychological well-being (Jamison, 1997).

19. Administer therapeutic touch (TT).
Results of this study of (n = 16) patients in the advanced stages of dementia of the Alzheimer's type (DAT), showed that discomfort levels decreased significantly after five therapeutic touch sessions, becoming significantly lower than levels in the control group (n = 10) (Giasson et al, 1999).

20. Refer to care plans for Imbalanced Nutrition: less than body requirements, Hopelessness, and Disturbed Energy field.


1. Assess for the influence of cultural beliefs, norms, and values on the family's or caregiver's understanding of FTT.
What the family considers normal and abnormal health behavior may be based on cultural perceptions (Leininger, 1996).

2. Validate the family's feelings and concerns related to the FTT symptoms.
Validation lets the family know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).

Home Care Interventions

1. Assess and track areas of decreased functioning resulting from failure to thrive. Ensure that all symptomatology is considered for necessary action.
Clients may change response to stressors/needs with changes in environment or interventions.

2. Give permission for role activity changes. Negotiate and clarify role expectations and reevaluate as necessary.
Failure to thrive may require an extended period of recovery. Chronic illness often requires role changes to preserve a functional unit. Comfort level with role activities supports continued recovery.

3. Provide support for family/caregivers.
Support for caregivers decreases caregiver burden.

4. Refer to medical social services or mental health counseling and/or community support groups. If necessary, contract with client to attend sessions.
Counseling support can increase coping ability; group participation provides support and offers new problem-solving strategies to the client.

5. Refer to home health aide services for assistance with ADLs throughout the duration of decreased participation.
Maintaining ADLs and the integrity of the environment prevents further decline in status of those areas and decreases frustration as the client recovers and resumes responsibility for them.

Client/Family Teaching

1. If adult FTT is related to dementia, help the caregiver to understand the diagnosis and help to identify needs that the caregiver will have to assist client with, such as nutrition, maintenance of adequate fluid intake, toileting, self-care, and safety.
When the etiology of adult FTT is dementia, the caregiver needs to be educated on how to handle (Jamison, 1997).

2. Instruct the family on the use of verbal cues to encourage eating, such as "Pick up your spoon; use the spoon to scoop up the pudding; now put the spoon with the pudding in your mouth."
Verbal cueing is effective for improving nutritional status (Jamison, 1997).

3. Discuss the possibility with the physician of a drug holiday when the etiology is delirium.
Delirium may resolve with a drug holiday (Jamison, 1997).

4. Provide referral for evaluation of hearing and appropriate hearing aids.
This study of 60 subjects >65 years of age (mean age 79 years) living in nursing homes demonstrated that hearing loss affects the communication, sociability, and psychological aspects of quality of life (Tsuruoka et al, 2001).

5. Refer for psychotherapy and possible medication if the etiology is depression.
Treatment of the etiology is necessary; the previously mentioned are treatments that may be used for depression (Jamison, 1997).