Unit 6

Front 1

Sensory Perception
Lifespan Considerations
Children

Back 1

Newborns should be screened for hearing loss prior to hospital discharge. Universal screening of all newborns is mandated in at least 30 states, and in all states screening is done for children who are at high risk (e.g., have a history of infection during gestation, or are born with anomalies of the head or face). If a hearing loss is detected early, treatment can begin early and complications such as speech loss can be prevented. If an infant is found to have a hearing loss, it is recommended that treatment begin before 6 months of age.

Front 2

Sensory Perception
Lifespan Considerations
Older Adults

Back 2

Normal changes of aging often result in varying degrees of impairments in sensory perception of the senses - hearing, vision, smell, taste, and touch. Diseases and conditions that are more common in older adults and which also alter sensory perception are diabetes, strokes, and other neurologic disorders such as Parkinson's disease. Nursing interventions need to be very specific and individualized and may be directed to either increase or decrease sensory stimuli.
The goals of nursing care should be focused on maintaining safety and communication with clients who have these impairments. Clients with dementia may have problems that fit more appropriately under "altered thought processes," but the goals should similar - to maximize their potential, maintain their quality of life and dignity, and at the same time, be aware of safety and communication issues.

Front 3

Sensory Perception
NANDA: Impaired Verbal Communication

Back 3

Def:
Decreased, delayed, or absent ability to receive, process, transmit, and/or use a system of symbols.

Front 4

Sensory Perception
NANDA: Impaired Verbal Communication

Back 4

Defining Characteristics:
Absence of eye contact; cannot speak; difficulty expressing thoughts verbally (e.g., aphasia, dysphasia, apraxia, dyslexia); difficulty forming sentences; difficulty forming words (e.g., aphonia, dyslalia, dysarthria); difficulty in comprehending usual communication pattern; difficulty in maintaining usual communication pattern; difficulty in selective attending; difficulty in use of body expressions; difficulty in use of facial expressions; disorientation to person; disorientation to space; disorientation to time; does not speak; dyspnea; inability to speak language of caregiver; inability to use body expressions; inability to use facial expressions; inappropriate verbalization; partial visual deficit; slurring; speaks with difficulty; stuttering; total visual deficit; verbalizes with difficulty; willful refusal to speak.

Front 5

Sensory Perception
NANDA: Impaired Verbal Communication

Back 5

Interventions and Rationales:
-Assess the language spoken, cultural considerations, literacy level, cognitive level, and use of glasses and/or hearing aids.
-Determine client's own perception of communication difficulties and potential solutions when possible.
-Involve a familiar person when attempting to communicate with a client who has difficulty with communication, if accepted by the client.
-Listen carefully. Validate verbal and nonverbal expressions particularly when dealing with pain and utilize nonverbal scales for pain when appropriate.
-Use therapeutic communication techniques: speak in a well-modulated voice, use simple communication, maintain eye contact at the client's level, get the client's attention before speaking, and show concern for the client.

Front 6

Sensory Perception
NANDA: Impaired Verbal Communication

Back 6

Interventions and Rationales:
-Avoid ignoring the client with verbal impairment; be engaged and provide meaningful responses to client concerns.
-Use touch as appropriate.
-Use presence. Spend time with the client, allow time for responses, and make the call light readily available.
-Explain all health care procedures.
-Be persistent in deciphering what the client is saying, and do not pretend to understand when the message is unclear.

Front 7

Sensory Perception
NANDA: Impaired Verbal Communication

Back 7

-Utilize an individualized and creative multidisciplinary approach to augmentative and alternative communication assistance and other interventions.
-Use consistent nursing staffing for those with communication impairments.
-Consult communication specialists as appropriate.
-When the client is having difficulty communicating, assess and refer for audiology consultation for hearing loss. Suspect hearing loss when:
1. Client frequently complains that people mumble, claims that others' speech is not clear, or client hears only parts of conversations.
2. Client often asks people to repeat what they said.
3. Client's friends or relatives state that client doesn't seem to hear very well, or plays the television or radio too loudly.
4. Client does not laugh at jokes due to missing too much of the story.
5. Client needs to ask others about the details of a meeting that the client attended.
6. Client cannot hear the doorbell or the telephone.
7. Client finds it easier to understand others when facing them, especially in a noisy environment.

Front 8

Sensory Perception
NANDA: Impaired Verbal Communication

Back 8

Interventions and Rationales:
-When communicating with a client with a hearing loss:
1. Obtain client's attention before speaking and face toward his or her unaffected side or better ear while allowing client to see speaker's face at a reasonable close distance.
2. Provide sufficient light and do not stand in front of window.
3. Remove masks if safe to do so, or use see-through masks and reduce background noise whenever possible.
4. Do not raise voice or over-enunciate.
5. Avoid making assumptions about the communication choice of those with hearing loss or voice impairments.

Front 9

Sensory Perception
Communicating with Clients Who Have a Visual or Hearing Impairment

Back 9

Visual Impairment:
-Always announce your presence when entering the client's room and identify yourself by name.
-Stay in the client's field of vision if the client has a partial vision loss.
-Speak in a warm and pleasant tone of voice. Some people ten to speak louder than necessary when talking to a blind person.
-Always explain what you are about to do before touching the person.
-Explain the sounds in the environment.
-Indicate when the conversation has ended and when you are leaving the room.

Front 10

Sensory Perception
Communicating with Clients Who Have a Visual or Hearing Impairment

Back 10

Hearing Impairment:
-Before initiating conversation, convey your presence by moving to a position where you can be seen or by gently touching the person.
-Decrease background noises (e.g., television) before speaking.
-Talk at a moderate rate and in a normal tone of voice. Shouting does not make your voice more distinct and in some instances makes understanding more difficult.
-Address the person directly. Do not turn away in the middle of a remark or story. Make sure the person can see your face easily and that it is well lighted.
-Avoid talking when you have something in your mouth, such as chewing gum. Avoid covering your mouth with your hand.
-Keep your voice at about the same volume throughout each sentence, without dropping the voice at the end of each sentence.

Front 11

Sensory Perception
Communicating with Clients Who Have a Visual or Hearing Impairment

Back 11

Hearing impairment:
-Always speak as clearly and accurately as possible. Articulate consonants with particular care.
-Do not "overarticulate"; mouthing or overdoing articulation is just as troublesome as mumbling. Pantomime or write ideas, or use sign language or finger spelling as appropriate.
-Use longer phrases, when tend to be easier to understand than short ones. For example, "Would you like a drink of water?" presents much less difficulty than "Would you like a drink?" Word choice is important: "Fifteen cents" and "fifty cents" may be confused, but "half a dollar" is clear.
-Pronounce every name and care. Make a reference to the name for easier understanding, for example, "Joan, the girl from the office" or "Sears, the big downtown store."
-Change to a new subject at a slower rate, making sure that the person follows the change to the new subject. A key word or two at the beginning of a new topic is a good indicator.

Front 12

Sensory Perception
Factors Affecting

Back 12

*Lifestyle
-Smoking, drugs, stress
*Environmental
-Chronic loud noise, inhalation of irritants
*Socioeconomic
-Cost of correction (eyeglasses/hearing aids)
*Psychological
-Stress, Pain, Fatigue, Mental status

Front 13

Mobility
NANDA: Impaired Physical Mobility

Back 13

Def:
A limitation in independent, purposeful physical movement of the body or of one of more extremities.

Front 14

Mobility
NANDA: Impaired Physical Mobility

Back 14

Defining Characteristics:
Decreased reaction time; difficulty turning; engages in substitutions for movement (e.g., increased attention to other's activity, controlling behavior, focus on pre-illness disability/activity); exertional dyspnea; gain changes; jerky movements; limited ability to perform gross motor skills; limited ability to perform fine moter skills; limited range of motion; movement-induced tremor; postural instability; slowed movement; uncoordinated movements.

Front 15

Mobility
NANDA: Impaired Physical Mobility

Back 15

Interventions and Rationales:
Note: Adults with disabilities should follow the adult guidelines; however, if not possible these persons should be as physically active as their abilities allow and avoid inactivity. Use "start low and go slow" approach for intensity and duration of physical activity if client highly deconditioned, functionally limited, or has chronic conditions affecting performance of physical tasks. When progressing client's activities, use an individualized and tailored approach based on client's tolerance and preferences.

Front 16

Mobility
NANDA: Impaired Physical Mobility

Back 16

Interventions and Rationales:
-Screen for mobility skills in the following order:
1. bed mobility; 2. supported and unsupported sitting; 3. transition movements such as sit to stand, sitting down, and transfers; 4. standing and walking activities. Use a tool such as the Assessment Criteria and Care Plan for Safe Patient Handling and Movement.
-Screen for additional measures of physical function to assess strength of muscle groups, including unassisted leg stand, use of balance platfomr, elbow flexion and knee extension strength, grip strength, timed chair stands, and the 6-minute walk.
-Assess the client for cause of impaired mobility. Determine whether cause is physical, psychological, or motivational.
-Use Self-Efficacy for exercise Scale and the Outcome Expectation for Exercise Scale to determine client's self-efficacy and outcome expectations toward exercise.
-Monitor and record the client's ability to tolerate activity and use all four extremities; note pulse rate, blood pressure, dyspnea, and skin color before and after activity.

Front 17

Mobility
NANDA: Impaired Physical Mobility

Back 17

Interventions and Rationales:
-Before activity, observe for and, if possible, treat pain with massage, heat pack to affected area, or medication. Ensure that the client is not oversedated.
-Consult with physical therapist for further evaluation, strength training, gait training, and development of a mobility plan.
-Obtain any assistive devices needed for activity, such as gait belt, weighted vest, walker, cane, crutches, or wheelchair, before the activity begins.
-If the client is immobile, perform passive ROM exercises at least twice a day unless contraindicated; repeat each maneuver three times.
-If the client is immobile, consult with physician for a safety evaluation before beginning an exercise program; if program is approved, begin with the following exercises:
1. Active ROM exercises using both upper and lower extremities (e.g., flexing and extending at ankles, knees, hips)
2. Chin-ups and pull-ups using a trapeze in bed (may be contraindicated in clients with cardiac conditions).
3. Strengthening exercises such as gluteal or quadriceps sitting exercises.

Front 18

Mobility
NANDA: Impaired Physical Mobility

Back 18

Interventions and Rationales:
-If client is immobile, consider use of vertical transfer techniques such as a transfer chair or gait belt pending weight-bearing status and client cooperation.
-Help the client achieve mobility and start walking as soon as possible in not contraindicated.
-Use a gait-walking belt when ambulating the client.
-Apply an ordered brace before mobilizing the client.
-Initiate a "No Lift" policy where appropriate assistive devices are used for manual lifting.

Front 19

Mobility
NANDA: Impaired Physical Mobility

Back 19

Interventions and Rationales:
-Increase independence in ADLs, encouraging self-efficacy and discouraging helplessness as the client gets stronger.
-If the client has osteoarthritis or rheumatoid arthritis, ask for a referral to a physical therapist to begin an exercise program that includes aerobic exercise, resistance exercise, and flexibility exercise (stretching).
-If client has had a CVA with hemiparesis, consider use of constraint-induced movement therapy (CIMT), where the functional extremity is purposely constrained and the client is forced to use the involved extremity.
-If the client has had a CVA, recognize that balance and mobility are likely impaired, and engage client in fall prevention strategies and protect from falling.
-If the client does not feed or groom self, sit side-by-side with the client, put your hand over the client's hand, support the client's elbow with your other hand, and help the client feed self; use the same technique to help the client comb hair.

Front 20

Mobility
NANDA: Activity Intolerance

Back 20

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

Front 21

Mobility
NANDA: Activity Intolerance

Back 21

Defining Characteristics:
Abnormal blood pressure response to activity; abnormal heart rate response to activity; EKG changes reflecting arrhythmias; EKG changes reflecting ischemia; exertional discomfort; exertional dyspnea; verbal report of fatigue; verbal report of weakness.

Front 22

Mobility
NANDA: Activity Intolerance

Back 22

Interventions and Rationales:
-Determine cause of activity intolerance and determine whether cause is physical, psychological, or motivational.
-If mainly on bed rest, minimize cardiovascular deconditioning by positioning the client in an upright position several times daily if possible.
-Assess the client daily for appropriateness of activity and bed rest orders. Mobilize the client as soon as it is possible.
-If client is mostly immobile, consider use of a transfer chair: a chair that becomes a stretcher.
-When appropriate, gradually increase activity, allowing the client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to standing, to ambulation. Always have the client dangle at the bedside before trying standing to evaluate for postural hypotension.

Front 23

Mobility
NANDA: Activity Intolerance

Back 23

Interventions and Rationales:
-When getting a client up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs; manual blood pressure monitoring is best.
-If the client experiences symptoms of postural hypotension, take precautions when getting the client out of bed. Put graduated compression stocking on client or use lower limb compression bandaging, of ordered, to return blood to the heart and brain. Have the client dangle at the side of the bed with legs hanging over the edge of the bed, flex and extend feet several times after sitting up, then stand up slowly with someone holding the client. If client becomes lightheaded or dizzy, return him to bed immediately.
-Perform ROM exercises if the client is unable to tolerate activity or is mostly immobile.
-Monitor and record the client's ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles and skin color before, during, and after the activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately:
1. Onset of chest discomfort or pain
2. Dyspnea
3. Palpitations
4. Excessive fatigue
5. Lightheadedness, confusion, ataxia, pallor, cyanosis, nausea, or any peripheral circulatory insufficiency
6. Dysrhythmia
7. Exercise hypotension
8. Excessive rise in blood pressure
9. Inappropriate bradycardia
10. Increased heart rate

Front 24

Mobility
NANDA: Activity Intolerance

Back 24

Interventions and Rationales:
-Instruct the client to stop the activity and report to the physician if the client is experienceing 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.
-Observe and document skin integrity several times a day.
-Assess for constipation.
-Refer the client to physical therapy to help increase activity levels and strength.
-Consider a dietitian referral to assess nutritional needs related to activity intolerance; provide nutrition as needed. If client is unable to eat food, use enteral or parenteral feedings as needed.

Front 25

Mobility
NANDA: Activity Intolerance

Back 25

Interventions and Rationales:
-Recognize that malnutrition causes significant morbidity due to the loss of lean body mass.
-Provide emotional support and encouragement to the client to gradually increase activity. Work with the client to set mutual goals that increase activity levels. Fear of breathlessness, pain, or falling may decrease willingness to increase activity.
-Observe for pain before activity. If possible, treat pain before activity and ensure that the client is not heavily sedated.
-Obtain any necessary assistive devices or equipment needed before ambulating the client (e.g., walkers, canes, crutches, portable oxygen).
-Use a gait walking belt when ambulating the client.

Front 26

Mobility
NANDA: Activity Intolerance

Back 26

Interventions and Rationales:
Activity Intolerance Due to Respiratory Disease:
-If the client is able to walk and has COPD, use the traditional 6-minute walk distance to evaluate ability to walk.
-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.
-Monitor a respiratory 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, nasal flaring, appearance of facial distress, and skin tone changes such as pallor and cyanosis.
-Instruct and assist a COPD client in using conscious, controlled breathing techniques during exercise, including pursed-lip breathing, and inspiratory muscle use.

Front 27

Mobility
NANDA: Activity Intolerance

Back 27

Interventions and Rationales:
Activity Intolerance Due to Respiratory Disease:
-Evaluate the client's nutritional status. Refer to a dietitian if needed. Use nutritional supplements to increase nutritional level if needed.
-For the client in the ICU, consider mobilizing the client in a four-phase method if there is sufficient knowledgeable staff available to protect the client from harm.
-Refer the COPD client to a pulmonary rehabilitation program.

Front 28

Mobility
NANDA: Activity Intolerance

Back 28

Interventions and Rationales:
Activity Intolerance Due to Cardiovascular Disease:
-If the client is able to walk and has heart failure, consider use of the 6-minute walk test to determine physical ability.
-Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity.
-Refer to a heart failure program or cardiac rehabilitation program for education, evaluation, and guided support to increase activity and rebuild life.

Front 29

Mobility
NANDA: Risk for Disuse Syndrome

Back 29

Def:
At risk for a deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity.

Front 30

Mobility
NANDA: Risk for Disuse Syndrome

Back 30

Interventions and Rationales:
-When client's condition is stable, screen for mobility skills in the following order: (1) bed mobility; (2) supported and unsupported sitting; (3) transition movements such as sit to stand, sitting down, and transfers; and (4) standing and walking activities. Use a tool such as the Assessment Criteria and Care Plan for Safe Patient Handling and Movement.
-Assess the level of assistance needed by the client and express in terms of amount of effort expended by the person assisting the client. The range is as follows: total assist, meaning client performs 0%-25% of task and, if client requires the help of more than one caregiver, it is referred to as a dependent transfer; maximum assist, meaning client gives 25% of effort while caregiver performs majority of the work; moderate assist, meaning client gives 50% of effort; minimal assist, meaning client gives 75% of effort; contact guard assist, meaning no physical assist is given but caregiver is physically touching client for steadying, guiding, or in case of loss of balance; stand by assist, meaning caregiver's hands are up and ready in case needed; supervision, meaning supervision of task is needed even if at a distance; modified independent, meaning client needs assistive device or extra time to accomplish task; and independent, meaning client is able to complete task safely without instruction or assistance.
-Request a referral to a physical therapist as needed so that client's range of motion, muscle strength, balance, coordination, and endurance can be part of the initial evaluation.
-Incorporate bed exercises such as flexing and extending feet and quadriceps or use of Thera-Bands for upper extremities into nursing care to help maintain muscle strength and tone.
-If not contraindicated by the client's condition, obtain a referral to physical therapy for use of tilt table to help determine the cause of syncope (fainting).

Front 31

Mobility
NANDA: Risk for Disuse Syndrome

Back 31

Interventions and Rationales:
-Perform range of motion exercises for all possible joints at least twice daily; perform passive or active range of motion exercises as appropriate.
-Use specialized boots to prevent pressure ulcers on the heels and footdrop; remove boots twice daily to provide foot care.
-When positioning a client on the side, tilt client 30 degrees or less while lying on side.
-Assess skin condition at least daily and more frequently if needed. Utilize a risk assessment tool such as the Braden Scale or the Norton Scale to predict the risk of developing pressure ulcers.
-Discuss with staff and management a "safe handling" policy that may include a "no lift" policy.

Front 32

Mobility
NANDA: Risk for Disuse Syndrome

Back 32

Interventions and Rationales:
--Turn clients at high risk for pressure/shear/friction frequently. turn clients at least every 2 to 4 hours on a pressure-reducing mattress/every 2 hours on standard foam mattress.
-Provide the client with a pressure-relieving horizontal support surface.
-Help the client out of bed as soon as able.
-When getting the client up after bed rest, do so slowly and watch for signs of postural (orthostatic) hypotension, tachycardia, nausea, diaphoresis (excessive sweating), or syncope. Take the blood pressure lying, sitting, and standing, waiting 2 minutes between each reading.
-Obtain assistive devices such as braces, crutches, or canes to help the client reach and maintain as much mobility as possible.
Interventions and Rationales:
-Apply graduated compression stockings as ordered. Ensure proper fit by measuring accurately. Remove the stockings at least twice a day, in the morning with the bath and in the evening to assess the condition of the extremity, and then reapply. Knee length is preferred rather than thigh length.

Front 33

Mobility
NANDA: Risk for Disuse Syndrome

Back 33

Interventions and Rationales:
-Observe for signs of VTE (venous thromoembolism), including pain, tenderness, and swelling in the calf and thigh. Also observe for new onset of breathlessness.
-Have the client cough and deep breathe or use incentive spirometry every 2 hours while awake.
-Monitor respiratory functions, noting breathe sounds and respiratory rate. Percuss for new onset of dullness in lungs.
-Note bowel function daily. Provide increased fluids, fiber, and natural laxatives such as prune juice as needed.
-Increase fluid intake to 2000 mL/day within the client's cardiac and renal reserve.
-Encourage intake of a balanced diet with adequate amounts of fiber and protein.

Front 34

Mobility
NANDA: Risk for Disuse Syndrome

Back 34

Interventions and Rationales:
Critical Care:
-Recognize that the client who has been in an intensive care environment may develop a neuromuscular dysfunction acquired in the absence of causative factors other than the underlying critical illness and its treatment, resulting in extreme weakness. The client may need a workup to determine the cause before satisfactory ambulation can begin.
-Consider use of a continuous lateral rotation therapy bed.
-For the stable client in the intensive care unit, consider mobilizing the client in a four-phase method from dangling at the side of the bed to walking if there is sufficient knowledgeable staff available to protect the client from harm.

Front 35

Cognition
NANDA: Acute confusion

Back 35

Def:
Abrupt onset of reversible disturbances of consciousness attention, cognition, and perception that develop over a short period of time.

Front 36

Cognition
NANDA: Acute confusion

Back 36

Defining Characteristics:
Fluctuation in cognition, level of consciousness, psychomotor activity; hallucinations; increased agitation; increased restlessness; lack of motivation to follow through with goal-directed behavior or purposeful behavior; lack of motivation to initiate goal-directed behavior or purposeful behavior; misperceptions.

Front 37

Cognition
NANDA: Acute confusion

Back 37

Interventions and Rationales:
-Assess the client’s behavior and cognition systematically and continually throughout the day and night, as appropriate. Utilize a validated tool to assess presence of delirium such as the Confusion Assessment Method (CAM) or Delirium Observation Screening Scale.
-Recognize that delirium may be superimposed on dementia; the nurse must be aware of the client’s baseline cognitive function.
-Recognize that there are three distinct types of delirium based on either arousal or motor disturbances:
1. Hyperactive: delirium characterized by restlessness, agitation, hypervigilance, hallucinations and delusions; may be combative.
2. Hypoactive: delirium characterized by psychomotor retardation, lethargy, sedation, reduced awareness of surroundings and confusion.
3. Mixture of bother hyper- and hypodelirium: the client fluctuates between periods of hyperactivity and agitation and hypoactivity and sedation.
-Identify clients who are at high risk for delirium.
-Identify precipitating factors that may precede the development of delirium: use of restrains, indwelling bladder catheter, metabolic disturbances, polypharmacy, pain, infection, dehydration, constipation, electrolyte imbalances, immobility, general anesthesia, hospital admission for fractures or hip surgery, anti-cholinergic medications, anxiety, sleep deprivation, and environmental factures.

Front 38

Cognition
NANDA: Acute confusion

Back 38

Interventions and Rationales:
-Perform an accurate mental status examination that includes the following:
--Overall appearance, manner, and attitude
--Behavior characteristics and level of psychomotor behavior (activity may be increased or decreased and may include spastic movements or tremors with delirium)
--Mood and affect (may be paranoid or fearful with delirium; may have rapid mood swings)
--Insight and judgment
--Cognition as evidenced by level of consciousness, orientation to time, place, and person, thought process (thinking may be disorganized, distorted, fragmented, slow or accelerated with delirium), and content (perceptual disturbances such as visual, auditory or tactile delusions or hallucinations)
--Level of attention (may be decreased with delirium; may be unable to focus, maintain attention or shift attention, or may be hypervigilant)
--Memory (recent and immediate memory is impaired with delirium; unable to register new information)
--Arousal (may fluctuate with delirium; sleep-wake cycle may be disturbed)
--Language (may have rapid, rambling, slurred, incoherent speech)

Front 39

Cognition
NANDA: Acute confusion

Back 39

Interventions and Rationales:
-Assess for and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypoxia, hypotension, infection, changes in temperature, fluid and electrolyte imbalance, and use of medications with known cognitive and psychotropic side effects).
-Treat the underlying risk factors or the causes of delirium in collaboration with the health care team: establish/maintain normal fluid and electrolyte balance; normal body temperature, normal oxygenation (of the client experiences low oxygen saturation, deliver supplemental oxygen), normal blood glucose levels, normal blood pressure.
-Conduct a medication review and eliminate unnecessary medications. Medication that should be minimized or discontinued include: anticholinergics, antihistamines, and benzodiazepines; cholinesterase inhibitors should be continued, as should carbidopa and levodopa for clients with Parkinsonism.
--Communicate client status, cognition, and behavioral manifestations to all necessary providers.
--Monitor for any trends occurring in these manifestations, including laboratory tests.
-Identify, evaluate and treat pain quickly and adequately. Around the clock acetaminophen may result in less opioid use.

Front 40

Cognition
NANDA: Acute confusion

Back 40

Interventions and Rationales:
-Promote regulation and bowel and bladder function.
-Ensure adequate nutritional and fluid intake.
-Promote early mobilization and rehabilitation.
-Promote continuity of care; avoid frequent changes in staff and surrounding.
-Plan care that allows for an appropriate sleep-wake cycle.
-Facilitate appropriate sensory input by having clients use aids (e.g., glasses, hearing aids) as needed; check for impacted ear wax.
-Modulate sensory exposure and establish a calm environment.
-Provide reality orientation, including identifying self by name at each contact with the client, calling the client by their preferred name, using orientation techniques, providing familiar objects from home such as an afghan, providing clocks and calendars, and gently correcting misperceptions. Facilitate regular visits from family and friends.
-Use gently, caring communication; provide reassurance of safety; give simple explanations of procedures.
-Provide supportive nursing care, including meeting basic needs such as feeding, toileting, and hydration.
-Recognize that delirium is frequently treated with an antipsychotic medication. Administer cautiously as ordered, of there is no other way to keep the client safe. Watch for side-effects of the medications.

Front 41

Cognition
NANDA: Acute confusion

Back 41

Interventions and Rationales:
Critical care:
-Recognize admission risk factors for delirium
-Monitor for delirium in each client in critical care daily. Utilize the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC).
-Sedate critical care clients carefully; monitor sedation, analgesia, and delirium scores.
-Awaken the client daily.
-Bundle awakening and breathing coordination, choosing the appropriate sedative, monitoring for delirium, and promotion of exercise and early mobility.
-Initiate mobilization, physical therapy, and occupational therapy early in the ICU stay.
-Encourage visits from families.

Front 42

Cognition
NANDA: Chronic confusion

Back 42

Def:
Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual though process; and manifested by disturbances of memory, orientation, and behavior.

Front 43

Cognition
NANDA: Chronic confusion

Back 43

Defining Characteristics:
Altered interpretation; altered personality; altered response to stimuli; clinical evidence of organic impairment; impaired long-term memory; impaired short-term memory; impaired socialization, long-standing cognitive impairment; no change in level of consciousness; progressive cognitive impairment.

Front 44

Cognition
NANDA: Chronic confusion

Back 44

Interventions and Rationales:
-Determine the client’s cognitive level using a screening tool such as the Mini-Mental State Exam (MMSE), Mini-Cog (includes a three-item recall and clock drawing test), or Montreal Cognitive Assessment.
- In clients who are complaining of memory loss, assess for depression, alcohol use, medication use, sleep, and nutrition.
- Recognize that pharmacological treatment to slow the progression of Alzheimer’s disease is most effective when used early in the course of the disease.
- If hospitalized, gather information about the client’s pre-admission cognitive functioning, daily routines and care, and decision-making capacity.
- Assess the client for signs of depression: anxiety, sadness, irritability, agitation, somatic complaints, tension, loss of concentration, insomnia, poor appetite, apathy, flat affect, and withdrawn behavior.
- Assess the client for anxiety if he or she reports worry regarding physical or cognitive health, reports feelings of being anxious, shortness of breath, dizziness, or exhibit behaviors such as restlessness, irritability, noise sensitivity, motor tension, fatigue, or sleep disturbances. The Rating Anxiety in Dementia (RAID) Scale may be utilized; this may require caregiver input. Recognize that anxiety is common in dementia, is often undiagnosed, and may significantly impact quality of life.

Front 45

Cognition
NANDA: Chronic confusion

Back 45

Interventions and Rationales:
- Recognize that clients with Alzheimer’s disease may experience apathy, anxiety and depression, psychomotor agitation, and psychotic or manic syndromes; nonpharmacological interventions for management should be attempted first.
- Determine client’s normal routines and attempt to maintain them.
- Obtain information about the client’s life history from the family; collaborate with family members to provide optimal care.
- Begin each interaction with the client by gaining and maintaining eye contact, identifying yourself and calling the client by name. Approach the client with a caring, loving, and an accepting attitude, and speak calmly and slowly.
- To enhance communication, use a calm approach, avoid distractions, show interest, keep communication simple, give clear choices, give the client time with word finding, use repetition and rephrasing, and utilize gestures, prompts, and cues or visual aids. Listen attentively to understand nonverbal messages, and engage in topics of interest to the client.

Front 46

Cognition
NANDA: Chronic confusion

Back 46

Interventions and Rationales:
- Engage the client in scheduled activities that relate to past interests, experiences, and hobbies and are matched to current preferences and abilities.
- Promote regular exercise.
- Provide opportunities for contact with nature or nature-based stimuli, such as facilitating time spent outdoors or indoor gardening.
- Provide animal-assisted therapy.
- Break down self-care tasks into simple steps (e.g., instead of saying, “Take a shower,” say to the client, “Please follow me. Sit down on the bed. Take off your shoes. Now take off your socks.”). Utilize gestures when giving directions; allow for adequate time and model the desired action if needed or possible.
- Promote routines and facilitate success by keeping frequently used items in a visible and consistent location.
- Use reminiscence and life review therapeutic interventions for clients in the early to middle stages of dementia; ask questions about the client’s past activities, important events and experiences from the past while utilizing photographs, videos, artifacts, music or newspaper clippings or multimedia technology to stimulate memories.
- For clients in the middle to late stages of dementia, engage them in creative expression through the use of TimeSlips story-telling groups.
- If the client is verbally agitated (repetitive verbalizations, complaints, moaning, muttering, threats, screaming), assess for and address unsatisfied basic needs or environmental factors that may be addressed.

Front 47

Cognition
NANDA: Chronic confusion

Back 47

Interventions and Rationales:
- Utilize music as a nonpharmacological approach to managing anxiety. Identify music preferences of the client; interview family members if necessary. For anxious clients who are having problems relaxing enough to eat, try having them listen to music during meals.
- Assist clients in wayfinding, monitoring them so that they do not get lost in unfamiliar settings
- For clients who wander, utilize technologies that monitor but do not restrict. Direct the client who is wandering to a more soothing location with lower light levels and less variation in noise if necessary.
- Promote sleep by promoting daytime activity, creating a restful sleep environment, decreasing waking, and promoting quiet.
- Provide structured social and physical activities that are individualized for the client.
- Provide activities for the client, such as folding washcloths and sorting or stacking activities or other hobbies the individual enjoyed prior to the onset of dementia.
- Use cues, such as picture boards denoting day, time, and location, to help client with orientation.

Front 48

Cognition
NANDA: Chronic confusion

Back 48

Interventions and Rationales:
- If the client becomes increasingly confused and/ or agitated, perform the following steps: Assess the client for physiological causes, including acute hypoxia, pain, medication effects, malnutrition, and infections such as urinary tract infection, fatigue, electrolyte disturbances, and constipation.
--Assess for psychological causes, including changes in the environment, caregiver, routine, demands to perform beyond capacity, or multiple competing stimuli, including discomfort.
In clients with agitated behaviors, rather than confronting the client, decrease stimuli in the environment or provide diversional activities such as quiet music, looking through a photo album, or providing the client with textured items to handle.
--If clients with dementia become more agitated, assess for pain.
- Avoid using restraints if at all possible.
- Use PRN or low-dose regular dosing of psychotropic or antianxiety drugs only as a last resort; start with the lowest possible dose. They can be effective in managing symptoms of psychosis and aggressive behavior, but have undesirable side effects.
- Avoid the use of anticholinergic medications such as diphenhydramine.
- For predictable difficult times, such as during bathing and grooming, try the following: Massage the client’s hands or back to relax the client.
- Approach the client in a client-centered framework: utilize respectful, positive statements, give directions one step at a time, provide short and clear cues, utilize verbal praise for successful task completion.
- Involve the family in care of the client.

Front 49

Pain/Comfort
NANDA: Acute Pain

Back 49

Def:
Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; 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.
Pain is whatever the experiencing person says it is, existing whenever the person says it does

Front 50

Pain/Comfort
NANDA: Acute Pain

Back 50

Defining Characteristics:
Subjective
Pain is a subjective experience, and its presence cannot be proved or disproved. Self-report is the most reliable method of evaluating pain presence and intensity. A client with cognitive ability who is able to speak or provide information about pain in other ways, such as pointing to numbers or words, should use a self-report pain tool (e.g., Numerical Rating Scale [NRS]) to identify the current pain intensity and establish a comfort-function goal.

Front 51

Pain/Comfort
NANDA: Acute Pain

Back 51

Defining Characteristics:
Objective
Pain is a subjective experience, and objective measurement is impossible. If a client cannot provide a self-report, there is no pain intensity level. Behavioral responses should never serve as the basis for pain management decisions if self-report is possible. However, observation of behavioral responses may be helpful in recognition of pain presence for clients who are unable to provide a self-report. Observable pain responses may include loss of appetite and inability to deep breathe, ambulate, sleep, and perform ADLs. Pain-related behaviors vary widely and are highly individual. They may include guarding, self-protective behavior, and self-focusing; and distraction behavior ranging from crying to laughing, as well as muscle tension or rigidity. Clients may be stoic and lie completely still despite having severe pain. Sudden acute pain may be associated with neurohumoral responses that can lead to increases in heart rate, blood pressure, and respiratory rate. However, physiological responses, such as elevated blood pressure or heart rate, are not sensitive indicators of pain presence and intensity as they do not discriminate pain from other sources of distress, pathological conditions, homeostatic changes, or medications. Behavioral or physiological indicators may be used to confirm other findings; however, the absence of these indicators does not mean that pain is absent.

Front 52

Pain/Comfort
NANDA: Acute Pain

Back 52

Interventions and Rationales:
- Determine if the client is experiencing pain at the time of the initial interview. If pain is present, conduct and document a comprehensive pain assessment and implement or request orders to implement pain management interventions to achieve a satisfactory level of comfort. Components of this initial assessment include location, quality, onset/ duration, temporal profile, intensity, aggravating and alleviating factors, and effects of pain on function and quality of life.
- Assess pain intensity level in a client using a valid and reliable self-report pain tool, such as the 0-10 numerical pain rating scale.
- Assess the client for pain presence routinely; this is often done at the same time as when a full set of vital signs are obtained, and during activity and rest. Also assess for pain with interventions or procedures likely to cause pain.
- Ask the client to describe prior experiences with pain, effectiveness of pain management interventions, responses to analgesic medications including occurrence of side effects, and concerns about pain and its treatment (e.g., fear about addiction, worries, or anxiety) and informational needs.
- Ask the client to identify a comfort-function goal, a pain level, on a self-report pain tool, that will allow the client to perform necessary or desired activities easily. This goal will provide the basis to determine effectiveness of pain management interventions. If the client is unable to provide a self-report, it will not be possible to establish a comfort-function goal.
- Describe the adverse effects of unrelieved pain.

Front 53

Pain/Comfort
NANDA: Acute Pain

Back 53

Interventions and Rationales:
- Use the Hierarchy of Pain Measures as a framework for pain assessment (McCaffery, Herr, & Pasero, 2011; Pasero, 2009a): (1) attempt to obtain the client’s self-report of pain; (2) consider the client’s condition and search for possible causes of pain (e.g., presence of tissue injury, pathological conditions, or exposure to procedures/ interventions that are thought to result in pain); (3) observe for behaviors that may indicate pain presence (e.g., facial expressions, crying, restlessness, and changes in activity); (4) evaluate physiological indicators, with the understanding that these are the least sensitive indicators of pain and may be related to conditions other than pain (e.g., shock, hypovolemia, anxiety); and (5) conduct an analgesic trial.
- Assume that pain is present if the client is unable to provide a self-report and has tissue injury, a pathological condition, or has undergone a procedure that is thought to produce pain.
- Conduct an analgesic trial for clients who are unable to provide self-report and have underlying pathology/ condition that is thought to be painful, or who demonstrate behaviors that may indicate pain is present. Administer a nonopioid if pain is thought to be mild and an opioid if pain is thought to be
moderate to severe. Reassess the client to evaluate intervention effectiveness within a specific period of time based on pharmacokinetics (intravenous [IV] 15 to 30 minutes, subcutaneous 30 minutes, oral 60 minutes).
- Determine the client’s current medication use. Obtain an accurate and complete list of medications the client is taking or has taken.

Front 54

Pain/Comfort
NANDA: Acute Pain

Back 54

Interventions and Rationales:
- Explain to the client the pain management approach, including pharmacological and nonpharmacological interventions, the assessment and reassessment process, potential side effects, and the importance of prompt reporting of unrelieved pain.
- Manage acute pain using a multimodal approach.
- Recognize that the oral route is preferred for pain management interventions. If the client is receiving parenteral analgesia, use an equianalgesic chart to convert to an oral analgesic as soon as possible.
- Provide PCA, perineural infusions, and intraspinal analgesia as ordered, when appropriate and available.
- Avoid giving pain medication by the intramuscular (IM) route of administration.
- Obtain a prescription to administer a nonopioid analgesic for mild to moderate pain and an opioid analgesic if indicated for moderate to severe acute pain.
- Treat acute pain in a comprehensive manner.
- Prevent pain by administering analgesia before painful procedures whenever possible (e.g., endotracheal suctioning, wound care, heel puncture, venipunctures, and peripherally inserted IV catheters). Use a topical local anesthetic or IV opioid as determined by individualized client status and severity of associated pain.

Front 55

Pain/Comfort
NANDA: Acute Pain

Back 55

Interventions and Rationales:
- Administer supplemental analgesic doses as ordered to keep the client’s pain level at or below the comfort-function goal, or desired outcome based on clinical judgment or behaviors if client is unable to provide a self-report.
- Perform nursing care when the client is comfortable. This is facilitated when the peak time (maximum serum concentration) of the analgesic is considered.
- Discuss the client’s fears of undertreated pain, side effects, and addiction.
- Assess pain level, sedation level, and respiratory status at regular intervals during opioid administration. Assess sedation and respiratory status every 1 to 2 hours during the first 24 hours of opioid therapy, then every 4 hours if respiratory status has been stable without episodes of hypoventilation, or more frequently as determined by individualized client status. Conduct the respiratory assessment before sedation assessment by evaluating the depth, regularity, and noisiness of respiration, and counting respiratory rate for 60 seconds. Awaken sleeping clients for assessment if the respiration is inadequate (e.g., if respirations are shallow, ineffective, irregular, or noisy [snoring], or periods of apnea occur). Snoring indicates respiratory obstruction and warrants prompt arousal, repositioning, and evaluation of respiratory risk factors. Discontinue titration or continuous opioid infusions immediately, and decrease subsequent opioid doses by 25% to 50% if the client develops excessive sedation

Front 56

Pain/Comfort
NANDA: Acute Pain

Back 56

Interventions and Rationales:
- Ask the client to report side effects, such as nausea and pruritus, and to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to prevent and improve these conditions and functions. Obtain a prescription for a combination stool softener plus peristaltic stimulant to prevent opioid-induced constipation.
- Review the client’s pain flowsheet and medication administration record to evaluate effectiveness of pain relief, previous 24-hour opioid requirements, and occurrence of side effects.
- Obtain orders to increase or decrease opioid doses as needed; base analgesic and dose on the client’s report of pain severity (clinical judgment of effectiveness if the client is unable to provide a self-report), response to the previous dose in terms of pain relief, occurrence of side effects, and ability to perform the activities of recovery or ADLs.
- When the client is able to tolerate oral intake, obtain a prescription to change analgesics to the oral route of administration; use an equianalgesic chart to determine the initial dose and adjust for incomplete cross tolerance.
- In addition to administering analgesics, support the client’s use of nonpharmacological methods to help control pain, such as distraction, imagery, relaxation, and application of heat and cold.
- Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions.

Front 57

Pain/Comfort
NANDA: Chronic Pain

Back 57

Def:
Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end.
Pain is whatever the experiencing person says it is, existing whenever the person says it does.

Front 58

Pain/Comfort
NANDA: Chronic Pain

Back 58

Defining Characteristics:
Pain is a subjective experience and its presence cannot be proved or disproved. Self-report is the most reliable method of evaluating pain presence and intensity (APS, 2008). Please refer to the Defining Characteristics in the Acute Pain care plan for further characteristics of pain.

Front 59

Pain/Comfort
NANDA: Chronic Pain

Back 59

Interventions and Rationales:
Determine if the client is experiencing pain at the time of the initial interview. If pain is present, conduct and document a comprehensive pain assessment and implement or request orders to implement pain management interventions to achieve a satisfactory level of comfort. Components of this initial assessment include location, quality, onset/ duration, temporal profile, intensity, aggravating and alleviating factors, and effects of pain on function and quality of life.
- Assess pain intensity level in a client using a valid and reliable self-report pain tool, such as the 0-10 numerical pain rating scale.
- Ask the client to describe prior experiences with pain, effectiveness of pain management interventions, responses to analgesic medications including occurrence of side effects, and concerns about pain and its treatment (e.g., fear about addiction, worries, or anxiety) and informational needs.
- Describe the adverse effects of persistent unrelieved pain.
- Ask the client to identify the pain level, on a self-report pain tool, that will allow the client to perform desired activities and achieve an acceptable quality of life. This comfort-function goal will provide the basis to determine effectiveness of the individualized pain management plan. If the client is unable to provide a self-report, it will not be possible to establish a comfort-function goal.
- Assess the client for the presence of pain routinely; this is often done at the same time as when a full set of vital signs are obtained in the inpatient setting. Assess pain during both activity and rest.

Front 60

Pain/Comfort
NANDA: Chronic Pain

Back 60

Interventions and Rationales:
- Ask the client to maintain a diary (if able) of pain ratings, timing, precipitating events, medications, and effectiveness of pain management interventions.
- Use the Hierarchy of Pain Measures as a framework for pain assessment (McCaffery, Herr, & Pasero, 2011; Pasero, 2009a): (1) attempt to obtain the client’s self-report of pain; (2) consider the client’s condition and search for possible causes of pain (e.g., presence of tissue injury, pathological conditions, or exposure to procedures/ interventions that are thought to result in pain); (3) observe for behaviors that may indicate pain presence (e.g., facial expressions, crying, restlessness, and changes in activity); (4) evaluate physiological indicators, with the understanding that these are the least sensitive indicators of pain and may be related to conditions other than pain (e.g., shock, hypovolemia, anxiety); and (5) conduct an analgesic trial.
- Assume that pain is present if the client is unable to provide a self-report and has tissue injury or a pathological condition or has undergone a procedure that is thought to produce pain.
- Conduct an analgesic trial for clients who are unable to provide self-report and have underlying pathology/ condition that is thought to be painful, or who demonstrate behaviors that may indicate pain is present. Administer a nonopioid if pain is thought to be mild and an opioid if pain is thought to be moderate to severe. Reassess the client to evaluate intervention effectiveness within a specific period of time based on pharmacokinetics (intravenous [IV] 15 to 30 minutes; subcutaneous 30 minutes; oral 60 minutes).

Front 61

Pain/Comfort
NANDA: Chronic Pain

Back 61

Interventions and Rationales:
- Determine the client’s current medication use.
- Explain to the client the pain management approach that has been ordered, including therapies, medication administration, side effects, and complications.
- Discuss the client’s fears of undertreated pain, addiction, and overdose.
- Manage chronic pain using a multimodal approach.
- Recognize that the oral route is preferred for pain management interventions. If the client is receiving parenteral analgesia, use an equianalgesic chart to convert to an oral analgesic as soon as possible.
- Avoid giving pain medication intramuscularly (IM).
- Recognize that many clients with chronic pain have neuropathic pain. (Please refer to assessment earlier.) Treat neuropathic pain with adjuvant analgesics, such as anticonvulsants, antidepressants, and topical local anesthetics.
- Administer a nonopioid analgesic for mild to moderate chronic pain, such as osteoarthritis or cancer pain.
- Recognize that opioid therapy may be indicated for some clients experiencing chronic pain.
- Treat chronic pain in a comprehensive manner.

Front 62

Pain/Comfort
NANDA: Chronic Pain

Back 62

Interventions and Rationales:
- Administer supplemental opioid doses for breakthrough pain as needed to keep pain ratings at or below the comfort-function goal.
- Assess pain level, sedation level, and respiratory status at regular intervals during opioid administration in the inpatient setting. Assess sedation and respiratory status every 1 to 2 hours during the first 24 hours of opioid therapy, then every 4 hours if respiratory status has been stable without episodes of hypoventilation, or more frequently as determined by individualized client status. Conduct the respiratory assessment before sedation assessment by evaluating the depth, regularity, and noisiness of respiration and counting respiratory rate for 60 seconds. Awaken sleeping clients for assessment if the respiration is inadequate (e.g., if respirations are shallow, ineffective, irregular, or noisy [snoring], or periods of apnea occur). Snoring indicates respiratory obstruction and warrants prompt arousal, repositioning, and evaluation of respiratory risk factors. Discontinue titration or continuous opioid infusions immediately, and decrease subsequent opioid doses by 25% to 50% if the client develops excessive sedation.
- Ask the 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 combination stool softener plus peristaltic stimulant to prevent opioid-induced constipation.

Front 63

Pain/Comfort
NANDA: Chronic Pain

Back 63

Interventions and Rationales:
- Question the client about any disruption in sleep.
- Watch for signs of depression in the clients with chronic pain, including sleeplessness, not eating, flat affect, statements of depression, or suicidal ideation.
- Review the client’s pain diary, flow sheet, and medication records to determine the overall degree of pain relief, side effects, and analgesic requirements for an appropriate period (e.g., 1 week).
- Obtain orders to increase or decrease opioid doses as needed; base analgesic and dose on the client’s report of pain severity (clinical judgment of effectiveness if the client is unable to provide a self-report), response to the previous dose in terms of pain relief, occurrence of side effects, and ability to perform the activities of recovery or activities of daily living (ADLs).
- In addition to administering analgesics, support the client’s use of nonpharmacological methods to help control pain, such as distraction, imagery, relaxation, and application of heat and cold.
- Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions.
- Encourage the client to plan activities around periods of greatest comfort whenever possible. Pain impairs function.
- Explore appropriate resources for management of pain on a long-term basis (e.g., hospice, pain care center).
- If the client has progressive cancer pain, assist the client and family with handling issues related to death and dying.

Front 64

Sleep
NANDA: Sleep Deprivation

Back 64

Def:
Prolonged periods of time without sleep (sustained natural, periodic suspension of relative consciousness)

Front 65

Sleep
NANDA: Sleep Deprivation

Back 65

Defining Characteristics:
Acute confusion, agitation, anxiety, apathy, combativeness, daytime drowsiness, decreased ability to function, fatigue, fleeting nystagmus, hallucinations, hand tremors, heightened sensitivity to pain, inability to concentrate, irritability, lethargy, listlessness, malaise, perceptual disorders (i.e., disturbed body sensation, delusions, feeling afloat), restlessness, slowed reaction, transient paranoia

Front 66

Sleep
NANDA: Sleep Deprivation

Back 66

Interventions and Rationales:
- Obtain a sleep history including amount of sleep obtained each night, use of medications and stimulants that may interfere with sleep amount, medical conditions and their treatment that limits sleep time, work and family responsibilities that limit sleep time, and daytime sequelae suggestive of sleep deprivation (e.g., drowsiness, inability to concentrate, slowed reactions).
- From the history, assess degree of sleep deprivation.
- From the history, identity factors leading to sleep deprivation.
- Assess evening pain medication use and, when feasible, administer pain medications that promote rather than interfere with sleep.
- Assess hypersensitivity to pain.
- Assess for underlying physiological illnesses causing sleep loss (e.g., cardiovascular, pulmonary, gastrointestinal, hyperthyroidism, nocturia occurring with benign hypertrophic prostatitis or pain).
- Assess for underlying psychiatric illnesses causing sleep loss (e.g., bipolar depression, anxiety disorders, schizophrenia).
- Monitor for nocturnal panic attacks. Refer for treatment as appropriate.

Front 67

Sleep
NANDA: Sleep Deprivation

Back 67

Interventions and Rationales:
- Monitor for sleep disordered breathing (e.g., apneas and hypopneas) and accompanying daytime sleepiness. Refer for diagnosis by sleep specialists as appropriate.
- Monitor for presence of nocturnal symptoms of restless leg syndrome with uncomfortable restless sensations in legs that occur before sleep onset or during the night. Refer for treatment as appropriate.
- Monitor for symptoms of overactive bladder.
- Assess for chronic insomnia.
- Monitor caffeine intake.
- Encourage napping as a way to compensate for sleep deprivation when severely restricted nighttime sleep cannot be avoided. Set a regular schedule for napping.
- Minimize factors that disturb the client’s sleep by consolidating care.
- Keep the sleep environment quiet (e.g., avoid use of intercoms, lower the volume on radio and television, keep beepers on nonaudio mode, anticipate alarms on intravenous [IV] pumps, talk quietly on unit).
- Mask noise in sleep area if noise cannot be eliminated.

Front 68

Sleep
NANDA: Disturbed Sleep Pattern

Back 68

Def:
Time-limited interruptions of sleep amount and quality due to external factors

Front 69

Sleep
NANDA: Disturbed Sleep Pattern

Back 69

Defining Characteristics:
Change in normal sleep pattern, reports not feeling well rested, dissatisfaction with sleep, decreased ability to function, reports being awakened, reports no difficulty falling asleep

Front 70

Sleep
NANDA: Disturbed Sleep Pattern

Back 70

Interventions and Rationales:
- Obtain a sleep history including bedtime routines, number of times awakened during the night, noise and light levels in the sleep environment, and activities occurring in the sleep environment during hours of sleep.
- From the history, assess whether client has an opportunity for normal sleep.
- From the history, assess environmental factors that interrupt sleep.
- If client has recurring pain, provide pain relief shortly before bedtime and position client comfortably for sleep.
- Keep environment quiet, room lighting dim, and bedding supportive of comfortable body alignment.
- Offer earplugs and eye masks if feasible.
- Establish a sleeping and waking routine with regular times for sleeping and waking, including routines for preparing for sleep.
- For hospitalized stable clients, consider instituting the following sleep protocol to a regular sleep-wake routine:
-- Night shift: Give the client the opportunity for uninterrupted sleep the first 3 to 4 hours of the sleep period. Keep environmental noise and light to a minimum. After major sleep period, allow 80 to 90 minutes between interruptions. (If client must be disturbed the first 3 to 4 hours, attempt to protect 90- to 110-minute blocks of time in between awakenings.)
-- Day shift: Encourage short morning and/ or after-lunch naps as needed. Promote a physical activity regimen as appropriate. Schedule newly ordered medications to avoid the need to wake the client the first few hours of the night.
-- Evening shift: Limit napping. Encourage a suitable bedtime routine. At sleep time, lower intensity of room and unit lights and keep noise and conversation on the unit to a minimum.

Front 71

Sleep
NANDA: Readiness for Enhanced Sleep

Back 71

Def:
A pattern of natural, periodic suspension of consciousness that provides adequate rest, sustains a desired lifestyle, and can be strengthened

Front 72

Sleep
NANDA: Readiness for Enhanced Sleep

Back 72

Defining Characteristics:
Expresses willingness to enhance sleep; amount of sleep is congruent with developmental needs; reports being rested after sleep; follows sleep routines that promote sleep habits; occasional use of pharmaceutical agents to induce sleep

Front 73

Sleep
NANDA: Readiness for Enhanced Sleep

Back 73

Interventions and Rationales:
- Obtain a sleep history including bedtime routines, sleep patterns, use of medications and stimulants, and use of complementary/ alternative medical practices for stress management and relaxation prior to bedtime.
- From the history, assess the client’s ability to initiate and maintain sleep, obtain adequate amounts of sleep, and manage daytime responsibilities free from fatigue and sleepiness.
- Based on assessment, teach one or more of the listed sleep promotion practices as appropriate.
-- Establish a regular schedule for sleep, exercise, napping, and mealtimes.
-- Avoid long periods of daytime sleep.
-- Arise at the same time each day even if sleep was poor during the previous night.
-- If not contraindicated have high-glycemic-index carbohydrate dinner and/ or bedtime snack.
-- Limit caffeine.
-- Limit alcohol use.
-- Avoid long-term use of sleeping pills.
-- Engage in relaxing activities before bed.
-- Provide backrub or other forms of massage.
-- Teach relaxation techniques.
-- Teach complementary and alternative interventions as culturally congruent.
-- Lower lighting in sleep area.
-- Mask noise in sleep area when it cannot be eliminated.
-- For anxious clients consider use of a lavender oil preparation in the health care setting.

Front 74

IV Complications
Infiltration

Back 74

Infiltration:
Unintended administration of a non-vesicant (does not cause blisters) drug or fluid into the subcutaneous tissue. Caused by puncture of the vein during venipuncture, dislodgement of the catheter, or a poorly secured infusion devise.
Signs and Symptoms:
-Coolness of skin around the site
-Skin blanching
-Edema at, above, or below the insertion site
-Leakage at insertion site
-Absence of or "pinkish" blood return
-Difference in size of opposite hand or arm

Front 75

IV Complications
Extravasation

Back 75

Extravasation:
Unintended administration of Vesicant (cause blisters) drugs or fluids into the subcutaneous tissue.
Signs and Symptoms:
-Pain, tenderness, or discomfort
-Edema at, above, or below the insertion site
-Skin blanching
-Change in temperature of skin at insertion site
-Burning at insertion site
-Feeling of tightness below the site

Front 76

IV Complications
Phlebitis

Back 76

Phlebitis:
Inflammation of the vein of which there are 3 types:
-Mechanical phlebitis - caused by too large of a catheter in a small vein causing irritation
-Chemical phlebitis - vein becomes inflamed by irritating or vesicant solutions or medications.
-Bacterial phlebitis - inflammation of the vein and a bacterial infection; can be caused by poor aseptic technique during insertion of the IV catheter and/or breaks in the integrity of the IV equipment.
Signs and Symptoms:
-Redness at the site
-Skin warm
-Swelling
-Palpable cord along the vein
-Increase in temperature

Front 77

IV Complications
5 Measures to help prevent infiltration and extravasation

Back 77

5 Measures to help prevent infiltration and extravasation:
1. Selection of venipuncture site (avoid hand, wrist, antecubital fossa)
2. Gauge of catheter should be smallest that can deliver the prescribed therapy in an appropriate size vein.
3. Knowing the osmolality and pH of medications and fluids. Hypertonic fluids and medications should not be infused through a peripheral vein.
4. Use of a manufactured catheter stabilization devise prevents unnecessary movement of the catheter in the vein.
5. Assessing patency of the catheter and vein frequently.

Front 78

Central Venous Catheters

Back 78

Central Venous Catheters
-long term IV therapy or parenteral nutritional, or a client is receiving IV medications that are damaging to vessels (e.g., chemotherapy)
-subclavian or jugular veins, with distal tip of the catheter resting in the superior vena cava just above right atrium.
-permit freedom of movement for ambulation
-risk of hemothorax or pneumothorax, cardiac perforation, thrombosis, and infection
-Assess for S.O.B., chest pain, cough, hypotension, tachycardia and anxiety after the insertion procedure.

Front 79

Central Venous Catheters

Back 79

Care:
-Strict aseptic technique (sterile gloves and mask)
-Assess for redness, swelling, tenderness, or drainage
-Chlorhexidino gluconate preferred agent to clean
-15 second scrub of connection surface
-Heparin - lowest possible concentration, for flush
-10 mL syringe to flush
-No blood pressure on side of central venous access

Front 80

Nasogastric Tube

Back 80

Nasogastric Tube:
-prevent nausea, vomiting, and gastric distention following surgery (suction)
-remove stomach contents for laboratory analysis
-lavage (wash) the stomach in cases of poisoning or overdose of medications
-feeding clients who have adequate gastric emptying, and who require short-term feedings

Front 81

IV Complications
Hematoma

Back 81

Hematoma:
-Tumor or swelling composed of blood.
-Caused by venipuncture, removing catheter too fast, selecting improper vein, tying tournaquet too tight.
Signs and Symptoms:
swelling, redness, tenderness, flush sluggish or nonexistant, inability to advance catheter.
Treatment:
Remove IV, apply pressure until bleeding stops, elevate extremity, discontinue IV therapy, restart IV

Front 82

IV Complications
Thrombophlebitis

Back 82

Thrombophlebitis:
Inflammation and clot due to trauma of vein
Signs and Symptoms:
Same as phlebitis, decreased arterial pulses, cyanosis of extremity, mottlin.