Geri Chapter 32

Front 1

State the nursing diagnosis for each cause or contributing factor

Back 1

Blank

Front 2

Depression, lack of motivation, sensory overload, fatigue, medications

Back 2

Activity Intolerance

Front 3

Threat to self-concept, losses

Back 3

Ansiety

Front 4

Psychomotor slowing, medications, inactivity, lack of recognition of need to defecate

Back 4

Constipation

Front 5

Anxiety, medications, stress

Back 5

Diarrhea

Front 6

Hyperactivity, sensory overload, suicidal attempt

Back 6

Pain

Front 7

Impaired cerebral function, anxiety, suspiciousness

Back 7

Impaired Verbal Communication

Front 8

Stress, altered body function, low self-esteem, dependency, sensory overload, loss of significant other

Back 8

Ineffective Coping

Front 9

Patient dependency; history of poor family relationships

Back 9

Disabled Family Coping

Front 10

Physical, mental, or social limitations

Back 10

Deficient Diversional Activity

Front 11

New or misperceived environment, losses

Back 11

Fear

Front 12

Loss of body part, function, role, sigificant other

Back 12

Anticipatory Greiving

Front 13

Cognitive impairment, lack of motivation, misperceptions

Back 13

Ineffective Health Maintenance

Front 14

Cognitive impairment, misperceptions, lack of motivation

Back 14

Impaired Home Maintenance

Front 15

Medications, inactivity, inability to protect self

Back 15

Risk for Infection

Front 16

Cognitive impairment, fatigue, medications, suicidal attempt

Back 16

Risk for Injury

Front 17

Medications, fatigue

Back 17

Impaired Physical Mobility

Front 18

Cognitive impairment, lack of motivation or capacity, suicidal desires

Back 18

Noncompliance

Front 19

Depression, anxiety, stress, paranoia, cognitive impairment, suicidal attempt

Back 19

Impaired Nutrition: Less Than Body Requirements

Front 20

Depression, anxiety, cognitive impairment, inactivity, suicidal attempt

Back 20

Impaired Nutrition: More Than Body Requirements

Front 21

Paranoia, depression, disability, stress

Back 21

Powerlessness

Front 22

Cognitive impairment, lack of motivation, knowledge, skill

Back 22

Self-Care Deficit

Front 23

Altered body image or function, losses, ageism

Back 23

Body Image Disturbance

Front 24

Cognitive impairment, medications, paranoia, sensory deficits, isolation, stress

Back 24

Sensory-Perceptual Alterations

Front 25

Depression, anxiety, paranoia, guilt, stress, altered self-concept, medications

Back 25

Sexual Dysfunction

Front 26

Cognitive impairment (inability to protect self), malnutrition

Back 26

Impaired Skin Integrity

Front 27

Anxiety, paranoia, depression, confusion, medications

Back 27

Disturbed Sleep Pattern

Front 28

Altered body part or function, cognitive impairment, anxiety, depression, misperceptions, paranoia, hypochondriasis

Back 28

Impaired Social Interaction

Front 29

Anxiety, depression, paranoia, cognitive impairment

Back 29

Social Isolation

Front 30

Cognitive impairment, fear, depression, anxiety, stress, isolation

Back 30

Disturbed Thought Process

Front 31

Cognitive impairment, anxiety, depression, medications

Back 31

Impaired Urinary Elimination

Front 32

Cognitive impairment, paranoia, stress, misperceptions, fear, suicidal attempt

Back 32

Risk for Other-Directed Violence

Front 33

Criteria for Diagnosing Alcoholism

Back 33

Drinks a fifth of whiskey a day or its equivalent in wine or beer (for 180 lb person)
Alcoholic blackouts
Blood alcohol level greater than 150 mg/100mL
Withdrawal syndrome; hallucinations, convulsions, gross tremors, delirium tremens (DTs)
Continued drinking, despite medical advice or problems caused by drinking

Front 34

State possible causes of behaviors

Back 34

Blank

Front 35

Violent/physically abusive (e.g., hitting, kicking, biting, others)

Back 35

Dementia
Paranoia
Misinterpretation of actions of others
Anger
Feeling powerless
Anxiety
Fatigue

Front 36

Verbally abusive (e.g., insulting, accusing, threatening)

Back 36

Dementia
Feeling powerless
Anger

Front 37

Resisting care

Back 37

Dementia
Misinterpretation of actions, objects, environment
Depression

Front 38

Undressing inappropriately

Back 38

Dementia
Soiled clothing
Irritation from clothing
Feeling to warm

Front 39

Repetitive actions

Back 39

Dementia
Agitation
Anxiety
Boredom

Front 40

Wandering

Back 40

Dementia
Boredom
Restlessness
Anxiety

Front 41

Night wandering, restlessness

Back 41

Dementia
Excess daytime sleeping
Misinterpretation of environment
Sundowner syndrome
Medications (e.g., sedatives, hypnotics, diuretics, laxatives)

Front 42

Inappropriate sexual behavior

Back 42

Denentia, leading to poor judgment, loss of inhibition
Misinterpretation of actions and messages from others

Front 43

Suspiciousness

Back 43

Paranoid state
Dementia
Suspicious personality
Medications (e.g., anticholinergics, L-dopa, tolbutamide)

Front 44

State nursing actions for possible behaviors

Back 44

Blank

Front 45

Violent/physically abusive (e.g., hitting, kicking, biting, others)

Back 45

Avoid putting person in situations that trigger behaviors
Recognize warning signs (e.g., cursing, pacing)
Get help to protect self and others
Address in calm, quiet manner
Distract
Move person to area away from others

Front 46

Verbally abusive (e.g., insulting, accusing, threatening)

Back 46

Avoid arguing, reasoning, reacting to comments
Distract with activities
Reinforce positive behaviors
Allow maximum decision-making and participation

Front 47

Resisting care

Back 47

Prepare for activities
Break activities into single, simple steps
Use alternatives if possible (e.g., sponge bath instead of tub)
Monitor hygiene, nutritional status, I&O, elimination

Front 48

Undressing inappropriately

Back 48

Ensure clothing is clean, dry; replace as necessary
Examine clothing for irritation, poor fit
Inspect skin for irritation
Redress
Use clothing that is difficult to unfasten
Offer positive reinforcement when person remains dressed

Front 49

Repetitive actions

Back 49

Ignore
Distract with other activities
Replace with a more acceptable repetitive activity (e.g., folding laundry, stacking papers)

Front 50

Wandering

Back 50

Schedule times for supervised walking
Provide activities
Safeguard environment (e.g., alarm doors, install door locks that require punching in code to open, ensure window screens cannot be removed)
Ensure person is wearing some form of identification
Familiarize person with environment; orient

Front 51

Night wandering, restlessness

Back 51

Provide daytime activities
Provide late day exercise
Toilet before bed time
Keep night light on in bedroom and bathroom
Reassure and orient when person awakens
Safeguard environment

Front 52

Inappropriate sexual behavior

Back 52

Relocate person to private area
Distract with other activities
Set limits and remind of acceptable behaviors
Review medications for those that can cause reduced inhibitions (e.g., antianxiety agents) or that increase libido (e.g., L-dopa)
Provide acceptable means of touch, human contact

Front 53

Suspiciousness

Back 53

Assess cause
Don’t react to behavior; depersonalize
Protect from harm
Provide explanations; prepare for activities, changes
Afford maximum decision-making
Do not try to explain to person that suspicions are unfounded or wrong; this will not be helpful