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IMPAIRED ADJUSTMENTS Nursing Care Plan

Impaired adjustments is a nursing diagnosis used when there's inability in the patient to modify lifestyle or his or her behavior in a manner of consistent with a change in health status.

Related Factors
Disability or health status requiring change in lifestyle.
Multiple stressors; intense emotional state.
Low state of optimism; negative attitudes toward health behavior; lack of motivation to change behaviors.
Failure to intend to change behavior.
Absence of social support for changed beliefs and practices.
[Physical and/or learning disability]

Defining Characteristics
SUBJECTIVE:
Denial of health status change
Failure to achieve optimal sense of control

OBJECTIVE:
Failure to take actions that would prevent further health problems
Demonstration of nonacceptance of health status change

MATURATIONAL ENURESIS Nursing Care Plan

      So what's the meaning of maturational enuresis? Maturational enuresis occurs in children during night. It is when a child experience involuntary voiding while sleeping and it is not pathologic in origin. Do not use this diagnosis when enuresis results from urinary tract infection, constipation, epilepsy and diabetes. Instead, you can use this when enuresis is from small bladder capacity, failure to perceive cues with a maturational issue such as new siblings or school pressures. We provided one sample of nursing care plan for maturational enuresis below.

ASSESSMENT:
Subjective:
"I always peed my bed every night," the boy said.

Objective:
(The boy is actually normal since this nursing diagnosis is not pathologic in nature.)

RISK FOR ADVERSE REACTION TO IODINATED CONTRAST MEDIA Nursing Care Plan

        This diagnosis is use if the patient is experiencing unintended reaction associated with the use of iodinated contrast media that can occur within seven(7) days after contrast media injection. Iodinated contrast media is infused to the client when the client will undergo radiographic diagnostic tests. Nurses caring clients scheduled for this test must be aware if the client has a higher risk for adverse events. Reactions can be mild and self-limiting to severe and self-limiting. Nurses in radiology department are responsible for assessing high risk clients. They review renal function status of the client prior to the procedure, monitoring signs of reactions and using protocols if indicated.

        We will provide a sample of nursing care plan for this risk for adverse reaction to iodinated contrast media, which is stated below:

ASSESSMENT:
Subjective:
"I have an allergy to iodine", the patient said verbally.

Objectives
- Records of past history of allergic reactions to iodinated contrast media.

DIAGNOSIS:
Risk for adverse reaction to iodinated contrast media related to history of allergy to iodinanted contrast media.

PLANNING:
After 1 hour of nursing intervention, the patient will be able to understand the need to report and describe the delayed reactions of iodinated contrast media.

INTERVENTIONS:
- Review the client history of allergic reactions to contrast media.

- Explain the delayed reactions of contrast media, advise the client and the family that a delayed contrast reaction can occur anytime between 3 hours to 7 days following the administration of contrast. Explain that delayed reactions may be cutaneous exantherm or commonly called widespread rashes, pruritus without hives, nausea, vomiting, drowsiness, and headache.

- Advise them to report any said reactions to the physician. If difficulty of swallowing or breathing occurs, immediately go to E.R.

EVALUATION:
After 1 hour of nursing intervention, the patient understood the need to report and described the delayed reactions of iodinated contrast media.

Note: Remember this contrast media reactions:
Mild reactions:
- Scattered urticaria
- Nausea
- Diaphoresis
- Pruritus
- Brief blenching
- Coughing
- Rhinorrhea
- Vomiting
- Dizziness

Moderate reactions:
- Persistent vomiting
- Facial edema
- Palpitations
- Diffuse urticaria
- Tachycardia
- Mild bronchospasm or dyspnea
- Headache
- Hypertension
- Abdominal cramps

Severe reactions
- Life-treatening arrhythmias
- Pulmonary Edema
- Death
- Laryngeal Edema
- Seizures
- Overt brochospasm
- Syncope

Nonidiosyncratic
- Bradycardia
- Neuropathy
- Nausea and vomiting
- Hypotension
- Cardiovascular reactions
- Sensations of warmth
- Vasovagal reactions
- Extravasations
- Metalic taste in mouth

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IMPAIRED PARENTING Nursing Care Plan

Impaired Parenting
Inability of the primary caregiver to create, maintain, or regain
an environment that promotes the optimum growth and development
of the child
Defining Characteristics
The home environment must be assessed for safety before discharge:
location of bathroom, access to water, cooking facilities,
and environmental barriers (stairs, narrow doorways).
Inappropriate and/or nonnurturing parenting behaviors
Lack of behavior indicating parental attachment
Inconsistent behavior management
Inconsistent care
Frequent verbalization of dissatisfaction or disappointment with
infant/child
Verbalization of frustration with role
Verbalization of perceived or actual inadequacy
Diminished or inappropriate visual, tactile, or auditory stimulation
of infant
Evidence of abuse or neglect of child
Growth and development challenges in infant/child
Related Factors
Individuals or families who may be at risk for developing or
experiencing
parenting difficulties
Parent(s)
Financial resources
Single
Addicted to drugs
Adolescent
Terminally ill
Abusive
Acutely disabled
Psychiatric disorder
Accident victim
Alcoholic

Child
Of unwanted pregnancy
With undesired characteristics
Terminally ill
With hyperactive characteristics
Mentally handicapped
Of undesired gender
Physically handicapped
Situational (Personal, Environmental)
Related to interruption of bonding process secondary to:
Illness (child, parent)
Relocation/change in cultural environment
Incarceration
Related to separation from nuclear family
Related to lack of knowledge
Related to inconsistent caregivers or techniques
Related to relationship problems (specify):
Marital discord
Stepparents
Divorce
Live-in partner
Separation
Relocation
Related to little external support and/or socially isolated family
Related to lack of available role model
Related to ineffective adaptation to stressors associated with:
Illness
Economic problems
New baby
Substance abuse
Elder care
Maturational
Adolescent Parent
Related to the conflict of meeting own needs over child’s
Related to history of ineffective relationships with own parents
Related to parental history of abusive relationship with parents
Related to unrealistic expectations of child by parent
Related to unrealistic expectations of self by parent
Related to unrealistic expectations of parent by child
Related to unmet psycho-social needs of child by parent

Author's Notes
The family environment should provide the basic needs for a child’s
physical growth and development: stimulation of the child’s emotional,
social, and cognitive potential; consistent, stable reinforcement to learn
impulse control; reality testing; freedom to share emotions; and moral
stability (Pfeffer, 1981). This environment nurtures a child to develop, as
Pfeffer (1981) states, “the ability to disengage from the family constellation
as part of a process of lifelong individualization.” It is the role of
parents to provide such an environment. Most parenting difficulties stem
from lack of knowledge or inability to manage stressors constructively.
The ability to parent effectively is at high risk when the child or parent
has a condition that increases stress on the family unit (e.g., illness,
financial
problems). “The phenomenon of parenting is relevant to many
disciplines, including nursing” (Gage, Everett, & Bullock, 2006).
Impaired Parenting describes a parent experiencing difficulty creating
or continuing a nurturing environment for a child. Parental Role Conflict
describes a parent or parents whose previously effective functioning
is challenged by external factors. In certain situations, such as illness,
divorce, or remarriage, role confusion and conflict are expected. If
parents do not receive assistance in adapting their role to external
factors,
Parental Role Conflict can lead to Impaired Parenting.

Goal
The parent/primary caregiver demonstrates two effective skills
to increase parenting effectiveness, as evidenced by the following
indicators:
• Will acknowledge an issue with parenting skills.
• Identify resources available for assistance with improvement of
parenting skills that are culturally considerate.

Interventions
Encourage Parents to Express Frustrations Regarding Role
Responsibilities, Parenting, or Both
• Convey empathy.
• Reserve judgment.
• Convey/offer educational information based on assessment.
• Help foster realistic expectations.
• Encourage discussion of feelings regarding unmet expectations.
• Discuss individualized, achievable, and culturally considerate
strategies (e.g., discussing with partner, child; setting personal
goals).
Educate Parents About Normal Growth and Development and Age-
Related Expected Behaviors (Refer to Delayed Growth and Development)
Explore With Parents the Child’s Problem Behavior
• Frequency, duration, context (when, where, triggers)
• Consequences (parental attention, discipline, inconsistencies in
response)
• Behavior desired by parents
Discuss Positive Parenting Techniques
• Convey to child that he or she is loved.
• Catch child being good; use good eye contact.
• Set aside “special time” when parent guarantees time with
child without interruptions.
• Ignore minor transgressions by having no physical contact, eye
contact, or discussion of the behavior.
• Practice active listening. Describe what child is saying, reflect
back the child’s feelings, and do not judge.
• Parents need to identify the difference between discipline and
punishment, with parents focusing their communications with
children on discipline (Deloian & Berry, 2009).
• Use “I” statements when disapproving of behavior. Focus on
the act, not the child, as undesirable.
• Positive reinforcement is an effective and recommended
discipline technique for all ages (Banks, 2002). Redirecting is
effective for infant to school age, whereas verbal instruction/
explanation is most effective for school-age and adolescents
(Banks, 2002).
• Different child temperaments may challenge parenting behaviors,
as evidenced when an infant is demanding and a parent
lacks resilience or when the child’s behavior is normal and the
parents’ expectations are unrealistic.
Explain the Discipline Technique of “Time Out,” Which Is a
Method to Stop Misconduct, Convey Disapproval, and Provide
Both Parent and Child Time to Regroup (Christophersen, 1992;
Herman-Staab, 1994)
• Time out is most effective for the toddler and school-age child
and provides a time for both parent and child to “cool off”
(Banks, 2002; Hockenberry, 2011).
• Outline the procedure.
• Place child in or bring the child to a chair in a quiet place with
few distractions (not the child’s room or an isolated place).
• Instruct child to stay in the chair. Set timer for 1 minute of
quiet time for each year of age.
• Start the timer when the child is quiet.
• If the child misbehaves, cries, or gets off the chair, reset the
timer.
• When the timer goes off, tell the child it is okay to get up.
• Explain to the child.
• This is not a game.
• Practice it once when the child is behaving.
• Explain rules and then ask the child questions to ensure
understanding (if older than 3 years).
• Remember:
• Do not warn child before sending for time out.
• If time out is appropriate, use it; do not threaten.
• If child laughs during time out, ignore it.
• Be sure no television is on or can be seen.
• Do not look at or talk to or about child during time out.
• Do not act angry; remain calm.
• Keep yourself busy; let the child see you and what he or she
is missing.
• Do not give up or give in.
If Additional Sources of Conflict Arise, Refer to the Specific
Nursing Diagnosis (e.g., Caregiver Role Strain, Fatigue)
Take Opportunities to Model Effective Parenting Skills; If Relevant,
Share Some Frustrations You Have Experienced With Your Child to
Help Normalize the Frustrations
Acknowledge Cultural Impacts
Clarify the Strengths of the Parents or Family
Role-Play Asking for Help or Disciplining a Child
Provide General Parenting Guidelines
Practice open, honest dialogues. Never threaten with vague
parameters
(e.g., “If you are bad, I won’t take you to the movies”).
• Do not lecture. Tell the child he or she was wrong and let it
go. Spend time talking about pleasant experiences.
• Compliment children on their achievements. Make each child
feel important and special. Especially tell a child when he or
she has been good; try not to focus on negative behavior.
• Provide appropriate physical affection to children.
• Set limits and be consistent. Expect cooperation.
• Encourage the child to participate in activities. Let the child
help you as much as possible. “Nurses can encourage parents
in their roles beyond childbearing, help them to solve problems,
perform parenting tasks, and understand what is developmentally
appropriate” (Gage, Everett, & Bullock, 2006).
• Discipline the child by restricting activity. Sit a younger child
in a chair for 3 to 5 minutes. If the child gets up, reprimand
once and put him or her back. Continue until the child sits for
the prescribed time. For an older child, restrict bicycle riding
or going to the movies (pick an activity that is important to
him or her).
• Make sure the discipline corresponds to the unacceptable
behavior.
• Allow children opportunities to make mistakes and to express
anger verbally.
• Stay in control. Try not to discipline when you are irritated.
• When long explanations are needed, give them after the
discipline.
• Remember to examine what you are doing when you are not
disciplining your child (e.g., enjoying each other, loving each
other).
• Never reprimand a child in front of another person (child or
adult). Take the child aside and talk.
• Never decide you cannot control a child’s destructive behavior.
Examine your present response. Are you threatening? Do you
follow through with the punishment or do you give in? Has
the child learned you do not mean what you say?
• Be a good model (the child learns from you whether you
intend it or not). Never lie to a child even when you think it
is better; the child must learn that you will not lie, no matter
what.
• Give each child a responsibility suited to his or her age, such
as picking up toys, making beds, or drying dishes. Expect the
child to complete the task.
• Share your feelings with children (happiness, sadness, anger).
Respect and be considerate of the child’s feelings and of his or
her right to be human.
Initiate Health Teaching and Referrals, as Indicated
• Community resources such as counseling, social services,
parenting classes, support groups, self-help, church.
• Support cultural considerations of parenting skills as age
appropriate.

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IMBALANCED NUTRITION: MORE THAN BODY REQUIREMENTS Nursing Care Plan

Imbalanced Nutrition: More Than Body Requirements
Intake of nutrients that exceeds metabolic needs
Defining Characteristics
Major (Must Be Present, One or More)
Overweight (weight 10% over ideal for height and frame), or
Obese (weight 20% or more over ideal for height and frame)*
Triceps skinfold greater than 15 mm in men and 25 mm in women*
Minor (May Be Present)
Reported undesirable eating patterns
Intake in excess of metabolic requirements
Sedentary activity patterns
Related Factors
Pathophysiologic
Related to excessive intake in relation to metabolic needs*
Related to altered satiety patterns secondary to (specify)
Related to decreased sense of taste and smell
Treatment Related
Related to altered satiety secondary to:
Medications (corticosteroids, antihistamines, estrogens)
Radiation (decreased sense of taste and smell)
Situational (Personal, Environmental)
Related to stress
Related to overeating
Related to dysfunctional eating pattern (e.g., pairing with other activities,
fast foods)
Related to risk to gain more than 25 to 30 lb when pregnant
Related to lack of basic nutrition knowledge

Author's Notes
Using this diagnosis to describe people who are overweight or obese places
the focus of interventions on nutrition. Obesity is a complex condition with
sociocultural, psychological, and metabolic implications. When the focus is
primarily on limiting food intake, as with many weight-loss programs, the
chance of permanent weight loss is slim. To be successful,
a weight-loss
program must focus on behavior modification and lifestyle changes.
The nursing diagnosis Imbalanced Nutrition: More Than Body
Requirements does not describe this focus. Rather, Risk-Prone Health
Behavior related to intake in excess of metabolic requirements better
reflects the need to increase metabolic requirements through exercise and
decreased intake. For some people who desire weight loss, Ineffective
Coping related to increased eating in response to stressors could be useful
in addition to Risk-Prone Health Behavior.
The nurse should be cautioned against applying a nursing diagnosis
for an overweight or obese person who does not want to participate
in a weight-loss program. Motivation for weight loss must come from
within. Nurses can gently and expertly teach the hazards of obesity but
must respect a client’s right to choose—the right of self-determination.
Imbalanced Nutrition: More Than Body Requirements does have clinical
usefulness for people at risk for or who have experienced weight gain
because of pregnancy, taste or smell changes, or medications
(e.g., corticosteroids).

Goal
The person will describe why he or she is at risk for weight gain as
evidenced by the following indicators:
• Describe reasons for increased intake with taste or olfactory
deficits.
• Discuss the nutritional needs during pregnancy.
• Discuss the effects of exercise on weight control.

Interventions
Refer to Related Factors
Explain the Effects of Decreased Sense of Taste and Smell on
Perception of Satiety After Eating. Encourage Client to:
• Evaluate intake by calorie counting, not feelings of satiety.
• If not contraindicated, season foods heavily to satisfy decreased
sense of taste. Experiment with seasonings (e.g., dill, basil).
• When taste is diminished, concentrate on food smells.
Explain the Rationale for Increased Appetite Owing to Use of
Certain Medications (e.g., Steroids, Androgens)
Discuss Nutritional Intake and Weight Gain During Pregnancy
Assist Client to Decrease Calorie Intake
• Request that client write down all the food he or she ate in the
past 24 hours.
• Instruct client to keep a diet diary for 1 week that specifies the
following:
• What, when, where, and why eaten
• Whether he or she was doing anything else (e.g., watching
television, cooking) while eating
• Emotions before eating
• Others present (e.g., snacking with spouse, children)
• Review the diet diary to point out patterns (e.g., time, place,
emotions, foods, persons) that affect food intake.
• Review high- and low-calorie food items.
Teach Behavior Modification Techniques to Decrease
Caloric Intake
• Eat only at a specific spot at home (e.g., the kitchen table).
• Do not eat while performing other activities.
• Drink an 8-oz glass of water immediately before a meal.
• Decrease second helpings, fatty foods, sweets, and alcohol.
• Prepare small portions, just enough for one meal, and discard
leftovers.
• Use small plates to make portions look bigger.
• Never eat from another person’s plate.
• Eat slowly and chew food thoroughly.
• Put down utensils and wait 15 seconds between bites.
• Eat low-calorie snacks that must be chewed to satisfy oral
needs (e.g., carrots, celery, apples).
Instruct Client to Increase Activity Level to Burn Calories
• Use the stairs instead of elevators.
• Park at the farthest point in parking lots and walk to buildings.
• Plan a daily walking program with a progressive increase in
distance and pace.
• Note: Urge client to consult with a primary provider before
beginning any exercise program.
Initiate Referral to a Community Weight Loss Program (e.g.,
Weight Watchers), If Indicated

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IMPAIRED SWALLOWING Nursing Care Plan

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

Defining Characteristics
Major (Must Be Present, One or More)*
Observed evidence of difficulty in swallowing and/or:
Stasis of food in oral cavity
Coughing before a swallow
Coughing after food or fluid intake
Choking
Gagging
Minor (May Be Present)
Nasal-sounding voice
Drooling*
Slurred speech
Vomiting*
Regurgitation*
Lack of chewing*
Related Factors
Pathophysiologic
Related to decreased/absent gag reflex, mastication difficulties, or decreased
sensations secondary to:
Cerebral palsy*
Muscular dystrophy
Poliomyelitis
Parkinson’s disease
Guillain–Barré syndrome
Myasthenia gravis
Amyotrophic lateral sclerosis
CVA
Neoplastic disease affecting
brain
Right or left hemispheric brain
damage
Vocal cord paralysis
Cranial nerve damage (V, VII,
IX, X, XI)
Related to tracheoesophageal tumors, edema
Related to irritated oropharyngeal cavity
Related to decreased saliva
Treatment Related
Related to surgical reconstruction of the mouth, throat, jaw, or nose
Related to decreased consciousness secondary to anesthesia
Related to mechanical obstruction secondary to tracheostomy tube
Related to esophagitis secondary to radiotherapy
Situational (Personal, Environmental)
Related to fatigue
Related to limited awareness, distractibility
Maturational
Infants/Children
Related to decreased sensations or difficulty with mastication
Related to poor suck/swallow/breathe coordination
Older Adult
Related to reduction in saliva, taste

Goal
The client will report improved ability to swallow, as evidenced by
the following indicators:
• Describe causative factors when known.
• Describe rationale and procedures for treatment.

Interventions
Assess for Causative or Contributing Factors
Refer to Related Factors.
• Consult with a speech therapist for a bedside swallowing
assessment
and recommended plan of care.
• Alert all staff that client has impaired swallowing.
Reduce or Eliminate Causative/Contributing Factors in People With:
Mechanical Impairment of Mouth
• Assist client with moving the bolus of food from the anterior to
the posterior part of mouth. Place food in the posterior mouth,
where swallowing can be ensured, using:
• A syringe with a short piece of tubing attached
• A glossectomy spoon
• Soft, moist food of a consistency that can be manipulated by
the tongue against the pharynx, such as gelatin, custard, or
mashed potatoes.
• Prevent/decrease thick secretions with:
• Artificial saliva Papain tablets dissolved in mouth 10 minutes
before eating
• Meat tenderizer made from papaya enzyme applied to oral
cavity 10 minutes before eating
• Frequent mouth care
• Increase fluid intake to 8 glasses of liquid (unless contraindicated)
• Check medications for potential side effects of dry mouth/
decreased salivation
• Use of Haberman or comparable nipple when bottle feeding
for infant with cleft lip/palate and Möbius syndrome
Muscle Paralysis or Paresis
• Establish a visual method to communicate with staff at bedside
that client is dysphagic.
• Plan meals when client is well rested; ensure that reliable
suction equipment is on hand during meals. Discontinue feeding
if client is tired.
• If indicated, use modified supraglottic swallow technique
(Emick-Herring & Wood, 1990).
• Position the head of the bed in semi- or high Fowler’s position,
with the neck flexed forward slightly and chin tilted down.
• Use cutout cup (remove and round out one third of side of
foam cup).
• Take bolus of food and hold in strongest side of mouth for
1 to 2 seconds, then immediately flex the neck with chin
tucked against chest.
• Without breathing, swallow as many times as needed.
• When mouth is emptied, raise chin and clear throat.
• Note the consistency of food that is problematic. Select
consistencies that are easier to swallow, such as:
• Highly viscous foods (e.g., mashed bananas, potatoes,
gelatin, gravy)
• Thick liquids (e.g., milkshakes, slushes, nectars, cream soups)
• If drooling is present, use a quick-stretch stimulation just before
and toward the end of each meal (Emick-Herring & Wood, 1990):
• Digitally apply short, rapid, downward strokes to edge of
bottom lip, mostly on the affected side.
• Use a cold washcloth over finger for added stimulation.
• If a bolus of food is pocketed in the affected side, teach client
how to use tongue to transfer food or apply external digital
pressure to cheek to help remove the trapped bolus (Emick-
Herring & Wood, 1990).
Impaired Cognition or Awareness
General
• Remove feeding tube during training if increased gag reflex is
present.
• Concentrate on solids rather than liquids because liquids usually
are less well tolerated.
• Minimize extraneous stimuli while eating (e.g., no television or
radio, no verbal stimuli unless directed at task).
• Have client concentrate on task of swallowing.
• Have client sit up in chair with neck slightly flexed.
• Instruct client to hold breath while swallowing.
• Observe for swallowing and check mouth for emptying.
• Avoid overloading mouth because this decreases swallowing
effectiveness.
• Give solids and liquids separately.
• Progress slowly. Limit conversation.
• Provide several small meals to accommodate a short attention
span.
Client With Aphasia or Left Hemispheric Damage
• Demonstrate expected behavior.
• Reinforce behaviors with simple, one-word commands.
Client With Apraxia or Right Hemispheric Damage
• Divide task into smallest units possible.
• Assist through each task with verbal commands.
• Allow to complete one unit fully before giving next command.
• Continue verbal assistance at each eating session until no
longer needed.
• Incorporate written checklist as a reminder to client.
• Note: Client may have both left and right hemispheric damage
and require a combination of the above techniques.
Reduce the Possibility of Aspiration
• Before beginning feeding, assess that the client is adequately
alert and responsive, can control the mouth, has cough/gag
reflex, and can swallow saliva.
• Have suction equipment available and functioning properly.
• Position client correctly:
• Sit client upright (60 to 90 degrees) in chair or dangle his or her
feet at side of bed if possible (prop with pillows if necessary).
• Client should assume this position 10 to 15 minutes before
eating and maintain it for 10 to 15 minutes after finishing
eating.
• Flex client’s head forward on the midline about
45 degrees to keep esophagus patent.
• Keep infant’s head elevated during and immediately after
feedings
• Keep client focused on task by giving directions until he or she
has finished swallowing each mouthful.
• “Take a breath.”
• “Move food to middle of tongue.”
• “Raise tongue to roof of mouth.”
• “Think about swallowing.”
• “Swallow.”
• “Cough to clear airway.”
• Reinforce voluntary action.
• Start with small amounts and progress slowly as client learns to
handle each step:
• Ice chips
• Eyedropper partly filled with water
• Whole eyedropper filled with water
• Juice in place of water
• ¼ teaspoon semisolid food
• ½ teaspoon semisolid food
• 1 teaspoon semisolid food
• Pureed or commercial baby foods
• One half cracker
• Soft diet
• Regular diet; chew food well
• For a client who has had a CVA, place food at back of tongue
and on side of face he or she can control:
• Feed slowly, making certain client has swallowed the
previous
bite.
• Some clients do better with foods that hold together
(e.g., soft-boiled eggs, ground meat and gravy).
• If the above strategies are unsuccessful, consultation with a
physician may be necessary for alternative feeding techniques
such as tube feedings or parenteral nutrition.
Initiate Health Teaching and Referrals, as Indicated
Teach Exercises to Strengthen (Grober, 1984):
Lips and Facial Muscles
• Alternate a tight frown with a broad smile with lips closed.
• Puff out cheeks with air and hold.
• Blow out of pursed lips.
• Practice pronouncing u, m, b, p, w.
• Suck hard on a popsicle.
Tongue
• Lick a popsicle or lollipop.
• Push tip of tongue against roof and floor of mouth.
• Count teeth with tongue.
• Pronounce la, la, la; ta, ta, ta; d; n; z; s.
• See Impaired Oral Mucous Membranes.
• See Imbalanced Nutrition: Less Than Body Requirements.

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!

IMBALANCED NUTRITION: LESS THAN BODY REQUIREMENTS Nursing Care Plan

Imbalanced Nutrition: Less Than Body Requirements
Intake of nutrients insufficient to meet metabolic needs

Major (Must Be Present, One or More)
The client who is not NPO reports or is found to have food intake
less than the recommended daily allowance (RDA) with or without
weight loss
and/or
Actual or potential metabolic needs in excess of intake with
weight loss
Minor (May Be Present)
Weight 10% to 20% or more below ideal for height and frame
Triceps skinfold, mid-arm circumference, and mid-arm muscle
circumference less than 60% standard measurement
Muscle weakness and tenderness
Mental irritability or confusion
Decreased serum albumin
Decreased serum transferrin or iron-binding capacity
Sunken fontanel in infant
Related Factors
Pathophysiologic
Related to increased caloric requirements and difficulty in ingesting
sufficient
calories secondary to:
Burns (postacute phase)
Cancer
Infection
Trauma
Chemical dependence
Preterm infants
Gastrointestinal (GI)
complications/deformities
AIDS
Related to dysphagia secondary to:
Cerebrovascular accident
(CVA)
Parkinson’s disease
Möbius syndrome
Muscular dystrophy
Cerebral palsy
Cleft lip/palate
Amyotrophic lateral sclerosis
Neuromuscular disorders
Related to decreased absorption of nutrients secondary to:
Crohn’s disease
Lactose intolerance
Necrotizing enterocolitis
Cystic fibrosis
Related to decreased desire to eat secondary to altered level of consciousness
Related to self-induced vomiting, physical exercise in excess of caloric
intake, or refusal to eat secondary to anorexia nervosa
Related to reluctance to eat for fear of poisoning secondary to paranoid
behavior
Related to anorexia, excessive physical agitation secondary to bipolar
disorder
Related to anorexia and diarrhea secondary to protozoal infection
Related to vomiting, anorexia, and impaired digestion secondary to
pancreatitis
Related to anorexia, impaired protein and fat metabolism, and impaired
storage of vitamins secondary to cirrhosis
Related to anorexia, vomiting, and impaired digestion secondary to
GI malformation or necrotizing enterocolitis
Related to anorexia secondary to gastroesophageal reflux
Treatment Related
Related to protein and vitamin requirements for wound healing and
decreased intake secondary to:
Surgery
Surgical reconstruction of
mouth
Radiation therapy
Medications (chemotherapy)
Wired jaw
Related to inadequate absorption as a medication side effect of (specify):
Colchicine
Neomycin
Pyrimethamine
Para-aminosalicylic acid
Antacid
Related to decreased oral intake, mouth discomfort, nausea, and vomiting
secondary to:
Radiation therapy
Tonsillectomy
Chemotherapy
Oral trauma
Situational (Personal, Environmental)
Related to decreased desire to eat secondary to:
Anorexia
Social isolation
Depression
Nausea and vomiting
Stress
Allergies
Related to inability to procure food (physical limitation or financial
or transportation problems)
Related to inability to chew (damaged or missing teeth, ill-fitting
dentures)
Related to diarrhea* secondary to (specify)
Maturational
Infant/Child
Related to inadequate intake secondary to:
Lack of emotional/sensory
stimulation
Lack of knowledge of caregiver
Inadequate production of
breast milk
Related to malabsorption, dietary restrictions, and anorexia secondary to:
Celiac disease
Lactose intolerance
Necrotizing enterocolitis
Cystic fibrosis
GI malformation
Gastroesophageal reflux
Related to sucking difficulties (infant) and dysphagia secondary to:
Cerebral palsy
Cleft lip and palate
Neurologic impairment
Related to inadequate sucking, fatigue, and dyspnea secondary to:
Congenital heart disease
Viral syndrome
Hyperbilirubinemia
Prematurity
Respiratory distress syndrome
Developmental delay

Author's Notes
Nurses are usually the primary diagnosticians and often the prescribers
for improving nutritional status. Although Imbalanced Nutrition is not a
difficult diagnosis to validate, interventions for it can challenge the nurse.
Many factors influence food habits and nutritional status: personal,
family, cultural, financial, functional ability, nutritional knowledge, disease
and injury, and treatment regimens. Imbalanced Nutrition: Less Than Body
Requirements describes people who can ingest food but eat an inadequate
or imbalanced quality or quantity. For instance, the diet may have
insufficient protein or excessive fat. Quantity may be insufficient because
of increased metabolic requirements (e.g., cancer, pregnancy, trauma,
or interference with nutrient use [e.g., impaired storage of vitamins in
cirrhosis]).
The nursing focus for Imbalanced Nutrition is assisting the client or
family to improve nutritional intake. Nurses should not use this diagnosis
to describe clients who are NPO or cannot ingest food. They should use
the collaborative problems RC of Electrolyte Imbalance or RC of Negative
Nitrogen Balance to describe those situations.

Goal
The client will ingest daily nutritional requirements in accordance
with activity level and metabolic needs, as evidenced by the
following
indicators:
• Relate importance of good nutrition.
• Identify deficiencies in daily intake.
• Relate methods to increase appetite.

Interventions
Explain the Need for Adequate Consumption of Carbohydrates,
Fats, Protein, Vitamins, Minerals, and Fluids
Consult With a Nutritionist to Establish Appropriate Daily Caloric
and Food Type Requirements for the Client
Discuss With the Client Possible Causes of Decreased Appetite
Encourage the Client to Rest Before Meals
Offer Frequent, Small Meals Instead of a Few Large Ones; Offer
Foods Served Cold
With Decreased Appetite, Restrict Liquids With Meals and Avoid
Fluids 1 Hour Before and After Meals
Encourage and Help the Client to Maintain Good Oral Hygiene
Arrange to Have High-Calorie and High-Protein Foods Served at
the Times That the Client Usually Feels Most Like Eating
Take Steps to Promote Appetite
• Determine the client’s food preferences and arrange to have
them provided, as appropriate.
• Eliminate any offensive odors and sights from the eating area.
• Control any pain and nausea before meals.
• Encourage the client’s family to bring permitted foods from
home, if possible.
• Provide a relaxed atmosphere and some socialization during
meals.
Provide for Supplemental Dietary Needs Amplified by Acute Illness
Give the Client Printed Materials Outlining a Nutritious Diet That
Includes the Following:
• High intake of complex carbohydrates and fiber
• Decreased intake of sugar, salt, cholesterol, total fat, and
saturated
fats
• Alcohol use only in moderation
• Proper caloric intake to maintain ideal weight
Pediatric Interventions
• Teach parents the following regarding infant nutrition:
• Adequate infant feeding schedule and weight gain requirements
for growth: 100 to 120 kcal/kg/day for growth
• Proper preparation of infant formula
• Proper storage of breast milk and infant formula
• Proper elevation of infant’s head during and immediately after
feedings
• Proper chin/cheek support techniques for orally compromised
infants
• The age-related nutritional needs of their children (consult
an appropriate textbook on pediatrics or nutrition for specific
recommendations).
• Discuss the importance of limiting snacks high in salt, sugar, or
fat (e.g., soda, candy, chips) to limit risks for cardiac disorders,
obesity, and diabetes mellitus. Advise families to substitute
healthy snacks (e.g., fresh fruits, plain popcorn, frozen fruit
juice bars, fresh vegetables).
• Assist families in evaluating their nutritional patterns.
• Discuss strategies to make meals a social event and to avoid
struggles (Dudek, 2009; Hockenberry & Wilson, 2009).
• Allow the child to select one type of food he or she does not
have to eat.
• Provide small servings (e.g., one tablespoon of each food for
every year of age).
• Make snacks as nutritiously important as meals (e.g., hardboiled
eggs, raw vegetable sticks, peanut butter/crackers, fruit
juices, cheese, and fresh fruit).
• Offer a variety of foods.
• Encourage all members to share their day.
• Involve the child in monitoring healthy eating (e.g., create a
chart where the child checks off intake of healthy foods daily).
• Replace passive television watching with a group activity (e.g.,
Frisbee tossing, biking, walking).
• Address strategies to improve nutrition when eating fast foods:
• Drink skim milk.
• Avoid french fries.
• Choose grilled foods.
• Eat salads and vegetables.
• Substitute quick, nutritious fast meals (e.g., frozen dinners).
Maternal Interventions
• Teach the importance of adequate calorie and fluid intake
while breastfeeding in relation to breast milk production.
• Explain physiologic changes and nutritional needs during
pregnancy.
Discuss the effects of alcohol, caffeine, and artificial sweeteners
on the developing fetus.
• Explain the different nutritional requirements for pregnant
girls 11 to 18 years of age, pregnant young women 19 to
24 years of age, and women older than 25 years.
• Determine if a woman needs more calories because of daily
activity.
• 28.5 kcal/kg for 11 to 14 years
• 24.9 kcal/kg for 15 to 18 years
• 23.3 kcal/kg for 19 to 24 years
• 21.9 kcal/kg for 25 to 50 years
• Multiply resting caloric needs by:
• 1.5 for light activity
• 1.6 for moderate activity
• 1.9 for heavy activity
Geriatric Interventions
Determine the Client’s Understanding of Nutritional Needs With:
• Aging
• Medication use
• Illness
• Activity
Assess Whether Any Factors Interfere With Procuring or Ingesting
Foods (Miller, 2009)
• Anorexia from medications, grief, depression, or illness
• Impaired mental status leading to inattention to hunger or
selecting insufficient kinds/amounts of food
• Impaired mobility or manual dexterity (paresis, tremors,
weakness, joint pain, or deformity)
• Voluntary fluid restriction for fear of urinary incontinence
• Small frame or history of undernutrition
• Inadequate income to purchase food
• Lack of transportation to buy food or facility to cook
• New dentures or poor dentition
• Dislike of cooking and eating alone
• Client regularly eats alone
• Client has more than two alcoholic drinks daily
Explain Decline in Sensitivity to Sweet and Salty Tastes; If
Indicated, Consult With Home Health Nurse to Evaluate Home
Environment (e.g., Cooking Facilities, Food Supply, Cleanliness)
Access Community Agencies as Indicated (e.g., Nutritional
Programs, Community Centers, Home-Delivered Grocery Services)

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MORAL DISTRESS Nursing Care Plan

Moral Distress

Definition
Response to the inability to carry out one’s chosen ethical/moral
decision/action

The state in which a person experiences psychological disequilibrium,
physical discomforts, anxiety, and/or anguish that results
when a person makes a moral decision but does not follow
through with the moral behavior**
Defining Characteristics*
Expresses anguish (e.g., powerlessness, guilt, frustration, anxiety,
self-doubt, fear) over difficulty acting on one’s moral choice
Related Factors
When Moral Distress is used to describe a response in nurses, as
explained in this section, related factors are not useful. These
diagnoses
are not documented but rather represent a response
that requires actions by the nurse, unit, and/or institution.
The related factors listed below represent a variety of situations
that can precipitate Moral Distress.
Situational (Personal, Environmental)
End-of-Life Decisions*
Related to providing treatments that were perceived as futile for
terminally
ill client (e.g., blood transfusions, chemotherapy, organ
transplants, mechanical ventilation)
Related to conflicting attitudes toward advanced directives
Related to participation of life-saving actions when they only prolong
dying
Treatment Decisions
Related to the client’s/family’s refusal of treatments deemed appropriate
by the health care team
Related to inability of the family to make the decision to stop ventilator
treatment of terminally ill client
Related to a family’s wishes to continue life support even though it is
not in the best interest of the client
Related to performing a procedure that increases the client’s suffering
Related to providing care that does not relieve the client’s suffering
Related to conflicts between wanting to disclose poor medical practice
and wanting to maintain trust in the physician
Professional Conflicts
Related to insufficient resources for care (e.g., time, staff)
Related to failure to be included in the decision-making process
Related to more emphasis on technical skills and tasks than relationships
and caring
Cultural Conflicts
Related to decisions made for women by male family members
Related to cultural conflicts with the American health care system

Author's Notes
This NANDA-I nursing diagnosis, accepted in 2006, has application in all
settings where nurses practice. The literature to support this diagnosis
when submitted was focused primarily on moral distress in nursing.
If moral distress occurs in a client or family, this author suggests a
referral
to a professional expert in this area; for example, a counselor,
therapist, or nurse spiritual advisor. Refer also to Spiritual Distress. Nurses
should expect to experience moral distress as they struggle to make clinical
decisions involving conflicting ethical principles (Zuzelo, 2007).
This author will present Moral Distress as a Department of
Nursing—Standard of Practice. This standard addresses prevention
of moral distress with specific individual nurse, unit, and department
interventions. Strategies for addressing moral distress for individual
nurses, on units, in the department of nursing and in the institution will
be presented.
In this 14th edition, this author has developed and included Risk for
Moral Distress.
Moral Distress represents proactive strategies for individuals, groups,
and institutions to prevent moral distress in nurses. This diagnosis has
not yet been submitted to NANDA-I.
Most Americans fear how they will die than death itself (Beckstrand,
Callister, Kirchhoff, 2006). Eighty-six percent of Americans polled
reported
nurses have very high or high ethical standards, ranking nurses
at the top of other professions

Goal
The nurse will relate strategies to address moral distress as evidenced
by the following indicators:
• Identify source(s) of moral distress.
• Share their distress with a colleague.
• Identify two strategies to enhance decision-making with clients
and family.
• Identify two strategies to enhance discussion of the situation
with the physician.

Interventions
Identify Sources of Moral Stress (AACN, 2004)
• Staffing
• Competency of nurses, physicians
• Nurse–physician communication
• Futile care
• Needless pain and suffering
• End-of-life conflicts
• Deception/incomplete information
• Inadequate symptom management
• Disrespectful interactions
• Violence in the workplace
Determine Actions or Strategy Options
• Evaluate the risks and benefits of options.
• Consider the worse possible outcome to your action.
• Consider the risks of doing nothing (personal, client, family,
unit).
• Avoid rationalization.
Do Not Try to Avoid or Shrug Off Moral Distress
• Acknowledge your distress.
• Affirm your professional obligation to act.
• Ask for help and clarification.
“Use the Chain of Command to Share and Discuss Issues That
Have Escalated Beyond the Problem-Solving Ability and/or Scope
of Those Immediately Involved” (LaSala & Bjarnason, 2010)
Explore Moral Work and Action
• Educate yourself about moral distress. Refer to articles on the
Bibliography.
• Share your stories of moral distress. Elicit stories from coworkers.
• Read stories of moral action. Refer to Gordon’s Life Support:
Three Nurses on the Front Lines and Kritek’s Reflections on
Healing: A Central Construct (see the Bibliography).
Investigate How Clinical Situations That Are Morally Problematic
Are Managed in the Institution; If an Ethics Committee Exists,
Determine Its Mission and Procedures
Initiate Dialogue With the Client, If Possible, and Family
• Explore what the perception of the situation is (e.g., How do
you think your ___ is doing?)
• Pose questions (e.g., “What options do you have in this
situation?”)
Elicit feelings about the present situation. Does the
family know that the client is terminal? Is the client improving?
• Access the physician to clarify misinformation. Stay in the
room to promote sharing.
• Encourage the client/family to write down questions for the
physician.
• Be present during physician’s round to ensure client’s/family’s
understanding.
• Avoid deception or supporting deception.
Gently Explore Client/Family End-of-Life Decisions
• Explain the options (e.g., “If you or your loved one’s heart/
breathing stops...”)
• Give medications, oxygen
• Cardio defibrillation (shock)
• Cardiopulmonary resuscitation
• Intubation and use of respirator
• Advise the client/family that they can choose all, some, or none
of the above.
• Differentiate between prolonging life versus prolonging dying.
• Document the discussion and decisions according to institute
on policy.
If Indicated, Explain “No Code” Status and Explain the Focus of
Palliative Care That Replaces Aggressive and Futile Care (e.g., Pain
Management, Symptom Management, Less or No Intrusive/Painful
Procedures)
Seek To Transfer Individual From Intensive Care Unit, If Possible
Dialogue With Unit Colleagues About the Situation That Causes
Moral Distress
Seek support and Information From Nurse Manager
Enlist a Colleague as a Coach or Engage as a Coach for a Coworker
• For advice, seek out colleagues who implement actions when
they are distressed.
Start With an Approach to Address an Unsatisfactory Moral Clinical
Situation That Has a Low Risk; Evaluate the Risks Before Taking
Action; Be Realistic
Engage in Open Communication With Involved Physicians or
Nurse Manager; Start the Conversation With Your Concern, for
Example, “I Am Not Comfortable With...,” “The Family Is Asking/
Questioning/Feeling...,” “Mr. X Is Asking/Questioning/Feeling...”
Dialogue With Other Professionals: Chaplains, Social Workers,
or Ethics Committee
Advocate for End-of-Life Decision Dialogues With All Clients
and Their Families, Especially When the Situation Is Not Critical;
Direct the Client to Create Written Documents of Their Decisions,
and Advise Family About the Document
Integrate Health Promotion and Stress Reduction in Your Lifestyle
(e.g. Smoking Cessation, Weight Management, Regular Exercise,
Meaningful Leisure Activities)

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IMPAIRED PHYSICAL MOBILITY Nursing Care Plan

Impaired Physical Mobility
Limitation in independent, purposeful physical movement of the
body or of one or more extremities

Defining Characteristics
Major (Must Be Present; 80% to 100%)
Compromised ability to move purposefully within the environment
(e.g., bed mobility, transfers, ambulation)
Range-of-motion (ROM) limitations
Minor (May Be Present; 50% to 80%)
Imposed restriction of movement
Reluctance to move
Related Factors
Pathophysiologic
Related to decreased muscle strength* and endurance* secondary to:
Neuromuscular impairment
Autoimmune alterations
(e.g., multiple sclerosis,
arthritis)
Nervous system diseases
(e.g., Parkinson’s disease,
myasthenia gravis)
Respiratory conditions
(e.g., chronic obstructive
pulmonary disease [COPD])
Muscular dystrophy
Partial paralysis (spinal cord
injury, stroke)
Central nervous system (CNS)
tumor
Trauma
Cancer
Increased intracranial pressure
Sensory deficits
Musculoskeletal impairment
Fractures
Connective tissue disease
(systemic lupus
erythematosus)
Cardiac conditions
Related to joint stiffness* or contraction* secondary to:
Inflammatory joint disease
Post–joint-replacement or spinal surgery
Degenerative joint disease
Degenerative disc disease

Treatment Related
Related to external devices (casts or splints, braces, intravenous [IV]
tubing)
Related to insufficient strength and endurance for ambulation with
(specify):
Prosthesis
Crutches
Walker
Situational (Personal, Environmental)
Related to:
Fatigue
Depressive mood state*
Decreased motivation
Sedentary lifestyle*
Pain*
Deconditioning*
Obesity
Dyspnea
Cognitive impairment*
Maturational
Children
Related to abnormal gait secondary to:
Congenital skeletal deficiencies
Congenital hip dysplasia
Legg–Calvé–Perthes disease
Osteomyelitis
Older Adult
Related to decreased motor agility
Related to decreased muscle mass and strength

Author's Notes
leg(s) or limited muscle strength. Nurses should not use this diagnosis
to describe complete immobility; in this case, Risk for Disuse Syndrome
is more applicable. Limitation of physical movement can also be the
etiology of other nursing diagnoses, such as Self-Care Deficit and Risk
for Injury. Nursing interventions for Impaired Physical Mobility focus on
strengthening and restoring function and preventing deterioration. If the
client can exercise but does not, refer to Sedentary Lifestyle. If the client
has no limitations in movement but is deconditioned and has reduced
endurance, refer to Activity Intolerance.

Goal
The client will report increased strength and endurance of limbs,
as evidenced by the following indicators:
• Demonstrate the use of adaptive devices to increase mobility.
• Use safety measures to minimize potential for injury.
• Demonstrate measures to increase mobility.
• Evaluate pain and quality of management

Interventions
Assess Causative Factors
Refer to Related Factors.
Consult With Physical Therapy for Evaluation and Development
of a Mobility Plan
Promote Optimal Mobility and Movement
Promote Motivation and Adherence (Addams & Clough, 1998)
• Explain the problem and the objective of each exercise.
• Establish short-term goals.
• Ensure that initial exercises are easy and require minimal
strength and coordination.
• Progress only if the client is successful at the present exercise.
• Provide written instructions for prescribed exercises after
demonstrating and observing return demonstration.
• Document and discuss improvement specifically (e.g., can lift
leg 2 inches higher).
• Evaluate level of motivation and depression. Refer to a specialist
as needed.
Increase Limb Mobility and Determine Type of ROM Appropriate
for the Client (Passive, Active Assistive, Active, Active Resistive)
• Perform passive or active assistive ROM exercises (frequency
determined by client’s condition):
• Teach the client to perform active ROM exercises on unaffected
limbs at least four times a day, if possible.
• Perform passive ROM on affected limbs. Do the exercises
slowly to allow the muscles time to relax, and support the
extremity above and below the joint to prevent strain on
joints and tissues.
• For passive ROM, the supine position is most effective.
The client who performs ROM himself or herself can use a
supine or sitting position.
• Do ROM daily with bed bath three or four times daily if
there are specific problem areas. Try to incorporate into
activities of daily living.
• Support extremity with pillows to prevent or reduce swelling.
• Medicate for pain as needed, especially before activity**
(see Impaired Comfort).
• Apply heat or cold to reduce pain, inflammation, and hematoma
(after 48 hours).**
• Apply cold to reduce swelling after injury (usually first
48 hours).**
• Encourage the client to perform exercise regimens for specific
joints as prescribed by physician, nurse practitioner, or physical
therapist (e.g., isometric, resistive).
Position in Alignment to Prevent Complications
• Use a footboard.
• Avoid prolonged sitting or lying in the same position.
• Change the position of the shoulder joints every 2 to 4 hours.
• Use a small pillow or no pillow when in Fowler’s position.
• Support the hand and wrist in natural alignment.
• If the client is supine or prone, place a rolled towel or small
pillow under the lumbar curvature or under the end of the
rib cage.
• Place a trochanter roll alongside the hips and upper thighs.
• If the client is in the lateral position, place pillow(s) to support
the leg from groin to foot, and use a pillow to flex the shoulder
and elbow slightly. If needed, support the lower foot in dorsal
flexion with a towel roll or special boot.
• For upper extremities:
• Arms abducted from the body with pillows
• Elbows in slight flexion
• Wrist in a neutral position, with fingers slightly flexed and
thumb abducted and slightly flexed
• Position of shoulder joints changed during the day
(e.g., adduction, abduction, range of circular motion)
Maintain Good Body Alignment When Mechanical Devices Are
Used
Traction Devices
• Assess for correct position of traction and alignment of bones.
• Observe for correct amount and position of weights.
• Allow weights to hang freely, with no blankets or sheets on
ropes.
• Assess for changes in circulation; check pulse quality, skin
temperature, color of extremities, and capillary refill (should be
less than 3 seconds).
• Assess for feelings of numbness, tingling, and/or pain.
• Assess for changes in mobility (ability to flex/extend unaffected
joints).
• Assess for signs of skin irritation (redness, ulceration, blanching).
• Assess skeletal traction pin sites for loosening, inflammation,
ulceration, and drainage; clean pin insertion sites (procedure
may vary with type of pin and physician’s order).
• Encourage isometrics** and prescribed exercise program.
Casts
• Assess for proper fit of cast (should not be too loose or too
tight).
• Assess circulation to the encased area every 2 hours (color
and temperature of skin, pulse quality, capillary refill less than
2 seconds).
• Assess for changes in sensation of extremities every 2 hours
(numbness, tingling, pain).
• Assess motion of uninvolved joints (ability to flex and extend).
• Assess for skin irritation (redness, ulceration, or complaints of
pain under the cast).
• Keep the cast clean and dry; do not allow sharp objects to be
inserted under the cast; petal rough edges with adhesive tape;
place soft cotton under edges that seem to be causing pressure
points.
• Allow the cast to air dry while resting on pillows to prevent
dents.
• Observe the cast for areas of softening or indentation.
• Exercise joints above and below the cast if allowed (e.g., wiggle
fingers and toes every 2 hours).
• Assist with prescribed exercise regimens and isometrics of
muscles enclosed in casts.*
• Keep extremities elevated after cast application to reduce
swelling.
Braces
• Assess for correct positioning of braces.
• Observe for signs of skin irritation (redness, ulceration,
blanching, itching, pain).
• Assist with exercises as prescribed for specific joints.
• Have the client demonstrate correct application of the brace.
Prosthetic Devices
• Observe for signs of skin irritation of the stump before
applying
prosthetic device (stump should be clean and dry;
Ace bandage should be rewrapped and securely in place).
• Have the client demonstrate correct application of the prosthesis.
• Assess for gait alterations or improper walking technique.
• Proceed with health teaching, if indicated.
Ace Bandages
• Assess for correct position of Ace bandage.
• Apply Ace bandage with even pressure, wrapping from distal to
proximal portions and making sure that the bandage is not too
tight or too loose.
• Observe for bunching of the bandage.
• Observe for signs of irritation of skin (redness, ulceration,
excessive tightness).
• Rewrap Ace bandage twice daily or as needed, unless contraindicated
(e.g., if the bandage is a postoperative compression
dressing, it should be left in place).
• When wrapping lower extremity, leave the heel exposed, using
figure-8 technique.
Slings
• Assess for correct application; sling should be loose around the
neck and should support the elbow and wrist at the level of the
heart.
• Remove slings for ROM.**
• Note: Some mechanical devices may be removed for exercises,
depending on the nature of the injury or type and purpose of
the device. Consult with the physician to ascertain when the
client may remove the device.
Provide Progressive Mobilization
• Assist the client slowly to a sitting position.
• Allow the client to dangle legs over the side of the bed for a
few minutes before standing.
• Limit time to 15 minutes, three times a day the first few times
out of bed.
• Increase time out of bed, as tolerated, by 15-minute increments.
• Progress to ambulation with or without assistive devices.
• If the client cannot walk, assist him or her out of bed to a
wheelchair or chair.
• Encourage ambulation for short, frequent walks (at least three
times daily), with assistance if unsteady.
• Increase lengths of walks progressively each day.
Encourage Use of Affected Arm When Possible
• Encourage the client to use affected arm for self-care activities
(e.g., feeding self, dressing, brushing hair).
• For post-CVA neglect of upper limb, see Unilateral Neglect.
• Instruct the client to use the unaffected arm to exercise the
affected arm.
• Use appropriate adaptive equipment to enhance the use of arms.
• Universal cuff for feeding in clients with poor control in
both arms and hands
• Large-handled or padded silverware to assist clients with
poor fine-motor skills
• Dishware with high edges to prevent food from slipping
• Suction-cup aids to prevent sliding of plate
• Use a warm bath to alleviate early-morning stiffness and improve
mobility.
• Encourage the client to practice handwriting skills, if able.
• Allow time to practice using affected limb.
• Determine if other factors are interfering with mobility.
• If the pain is interfering with mobility, refer to Acute or
Chronic Pain.
• If depression is interfering with mobility, refer to Ineffective
Individual Coping.
• If fatigue is interfering with mobility, refer to Fatigue.
Teach Methods of Transfer From Bed to Chair or Commode and to
Standing Position
• Refer to Impaired Transfer Ability for interventions.
Teach the Client How to Ambulate With Adaptive Equipment (e.g.,
Crutches, Walkers, Canes)
• Instruct client in weight-bearing status.
• Observe and teach the use of the following equipment.
Crutches
• Do not exert pressure on axilla; use hand strength.
• Type of gait varies with client’s diagnosis.
• Measure crutches 2 to 3 inches below axilla and tips 6 inches
away from feet.
Walkers
• Use arm strength to support weakness in lower limbs.
• Gait varies with the client’s problems.
• Adjust to ensure a slight bend at the elbow when client is
standing with hands on the walker.
Prostheses (Teach About the Following)
• Stump wrapping before application of the prosthesis
• Application of the prosthesis
• Principles of stump care
• Importance of cleaning the stump, keeping it dry, and applying
the prosthesis only when the stump is dry
• Safety precautions
• Protect areas of decreased sensation from extremes of heat
and cold.
• Practice falling and how to recover from falls while transferring
or ambulating.
• For decreased perception of lower extremity (post-CVA
“neglect”), instruct the client to check where limb is placed
when changing positions or going through doorways; also
check to make sure both shoelaces are tied, that affected leg
is dressed with trousers, and that pants are not dragging.
• Instruct people who are confined to a wheelchair to shift
position and lift up buttocks every 15 minutes to relieve
pressure; maneuver curbs, ramps, inclines, and around
obstacles; and lock wheelchairs before transferring.
• Practice proper positioning, ROM (active or passive), and
prescribed exercises.
• Practice climbing stairs if client’s condition permits.
• Refer to physical therapy for continued structured physical
therapy.
Initiate Health Teaching and Referrals, as Indicated
• Home health nurse and physical therapist.

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IMPAIRED MEMORY Nursing Care Plan

Impaired Memory
Inability to remember or recall bits of information or behavioral
skills
Defining Characteristics*
Major (Must Be Present, One or More)
Reports experiences of forgetting
Inability to recall if a behavior was performed
Inability to learn or retain new skills or information
Inability to perform a previously learned skill
Inability to recall factual information
Inability to recall events
Related Factors
Pathophysiologic
Related to neurologic disturbances* secondary to:
Degenerative brain disease
Lesion
Head injury
Cerebrovascular accident
Related to reduced quantity and quality of information processed
secondary to:
Visual deficits
Hearing deficits
Poor physical fitness
Fatigue
Learning habits
Intellectual skills
Educational level
Related to nutritional deficiencies (e.g., vitamins C and B12, folate,
niacin, thiamine)
Treatment Related
Related to effects of medication (specify) on memory storage
Situational (Personal, Environmental)
Related to self-fulfilling expectations
Related to excessive self-focus and worry secondary to:
Grieving
Anxiety
Depression
Related to alcohol consumption
Related to lack of motivation
Related to lack of stimulation
Related to difficulty concentrating secondary to:
Stress
Pain
Distractions
Lack of intellectual stimulation
Sleep disturbances

Author's Notes
This diagnosis is useful when the client can be helped to function
better because of improved memory. If the client’s memory cannot
be improved
because of cerebral degeneration, this diagnosis is not
appropriate.
Instead, the nurse should evaluate the effects of impaired
memory on functioning, such as Self-Care Deficits or Risk for Injury. The
focus of interventions for these nursing diagnoses would be improving
self-care or protection, not improving memory.

Goal
The client will report increased satisfaction with memory, as evidenced
by the following indicators:
• Identify three techniques to improve memory.
• Relate factors that deter memory.

Interventions
Discuss the Client’s Beliefs About Memory Deficits
• Correct misinformation.
• Explain that negative expectations can result in memory deficits.
Assess for Factors That May Negatively Affect Memory (e.g.,
Pathophysiologic, Literacy, Stressors)
If the Client Has Difficulty Concentrating, Explain the Favorable
Effects of Relaxation and Imagery
Teach the Client Two or Three of the Following Methods to
Improve Memory Skills (Maier-Lorentz, 2000; Miller, 2009):
• Write things down (e.g., use lists, calendars, notebooks).
• Use auditory cues (e.g., timers, alarm clocks) in conjunction
with written cues.
• Use environmental cues (e.g., you might remove something
from its usual place, then return it to its normal location after
it has served its purpose as a reminder).
• Have specific places for specific items; keep items in their
proper place (e.g., keep keys on a hook near the door).
• Put reminders in appropriate places (e.g., place shoes to be
repaired near the door).
• Use visual images (“A picture is worth a thousand words”).
Create a picture in your mind when you want to remember
something; the more bizarre the picture, the more likely you
will remember.
• Use active observation—pay attention to details around you
and be alert to the environment.
• Make associations or mental connections (e.g., “Spring ahead
and fall back” for changing clocks to and from daylight savings
time).
• Make associations between names and mental images
(e.g., Carol and Christmas carol).
• Rehearse items you want to remember by repeating them
aloud or writing them on paper.
• Use self-instruction—say things aloud (e.g., “I’m putting my
keys on the counter so I remember to turn off the stove before
I leave”).
• Divide information into small chunks that can be remembered
easily (e.g., to remember an address or a zip code, divide it into
groups [“seven hundred sixty, fifty-five”]).
• Organize information into logical categories (e.g., shampoo and
hair spray, toothpaste and mouthwash, soap and deodorant).
• Use rhyming cues (e.g., “In 1492, Columbus sailed the ocean
blue”).
• Use first-letter cues and make associations (e.g., to remember
to buy carrots, apples, radishes, pickles, eggs, and tea bags,
remember the word carpet).
• Make word associations (e.g., to remember the letters of your
license plate, make a word, such as “camel” for CML).
• Search the alphabet while focusing on what you are trying to
remember (e.g., to remember that someone’s name is Martin,
start with names that begin with “A” and continue naming
names through the alphabet until your memory is jogged for
the correct one).
• Make up a story to connect things you want to remember (e.g.,
if you have to go to the cleaners and post office, create a story
about mailing a pair of pants).
When Trying to Learn or Remember Something:
• Minimize distractions.
• Do not rush.
• Maintain some form of organization of routine tasks.
• Carry a note pad or calendar or use written cues.
When Teaching (Miller, 2009):
• Determine if there are barriers to learning (e.g., stress, alcohol
use/abuse, pain, depression, low literacy).
• Eliminate distractions.
• Present information as concretely as possible.
• Use practical examples.
• Allow learner to pace the learning.
• Use visual, auditory aids.
• Provide advance organizers; outlines, written cues.
• Encourage use of aids.
• Make sure glasses are clean and lights are soft white.
• Correct wrong answers immediately.
• Encourage verbal responses.
• Try to organize self-care activities in the same order and same
time each day.
Geriatric Interventions
• Provide accurate information about age-related changes.
• Explain the difference between age-related forgetfulness and
dementia.

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RISK FOR LONELINESS Nursing Care Plan

Risk for Loneliness
At risk for experiencing discomfort associated with a desire or
need for more contact with others

Risk Factors
Pathophysiologic
Related to fear of rejection secondary to:
Obesity
Cancer (disfiguring surgery of head or neck, superstition from
others)
Physical handicaps (paraplegia, amputation, arthritis, hemiplegia)
Emotional handicaps (extreme anxiety, depression, paranoia,
phobias)
Incontinence (embarrassment, odor)
Communicable diseases (acquired immunodeficiency syndrome
[AIDS], hepatitis)
Psychiatric illness (schizophrenia, bipolar affective disorder,
personality disorders)
Related to difficulty accessing social events secondary to:
Debilitating diseases
Physical disabilities
Treatment Related
Related to therapeutic isolation
Situational (Personal, Environmental)
Related to affectional or cathectic deprivation*
Related to physical or social isolation*
Related to insufficient planning for retirement
Related to death of a significant other
Related to divorce
Related to visible physical disabilities
Related to fear of rejection secondary to:
Obesity
Hospitalization or terminal
illness (dying process)
Extreme poverty
Unemployment
Related to moving to another culture (e.g., unfamiliar language)
Related to history of unsatisfactory social experiences secondary to:
Drug abuse
Unacceptable social behavior
Alcohol abuse
Delusional thinking
Immature behavior
Related to loss of usual means of transportation
Related to change in usual residence secondary to:
Long-term care Relocation
Maturational
Child
Related to protective isolation or a communicable disease
Related to autism
Older Adult
Related to loss of usual social contacts secondary to:
Retirement
Death of (specify)
Relocation
Loss of driving ability

Author's Notes
Risk for Loneliness was added to the NANDA list in 1994. Currently,
Social Isolation is also on the NANDA list. Social Isolation is a conceptually
incorrect diagnosis because it does not represent a response, rather
a cause. ElSadr, Noureddine, & Kelley (2009), in a concept analysis of
loneliness, found the literature that supports social isolation as a possible
cause of loneliness. Loneliness and Risk for Loneliness better describe the
negative state of aloneness.
Loneliness is a subjective state that exists whenever a client says it
does and perceives it as imposed by others. Social isolation is not the
voluntary solitude necessary for personal renewal, nor is it the creative
aloneness of the artist or the aloneness—and possible suffering—
a client may experience from seeking individualism and independence
(e.g., moving to a new city, going away to college).

Goal
The client will report decreased feelings of loneliness, as evidenced
by the following indicators:
• Identify the reasons for his or her feelings of isolation.
• Discuss ways to increase meaningful relationships.

Interventions
The nursing interventions for various contributing factors that
might be associated with Risk for Loneliness are similar.
Identify Causative and Contributing Factors (Refer to Related
Factors)
Reduce or Eliminate Causative and Contributing Factors
• Promote social interaction.
• Support the client who has experienced a loss as he or she
works through grief (refer to Grieving).
• Encourage client to talk about feelings of loneliness and their
causes.
• Encourage development of a support system or mobilize
client’s existing family, friends, and neighbors to form one.
• Discuss the importance of high-quality, rather than highquantity,
socialization.
• Refer to social skills teaching (see Impaired Social Interaction).
• Offer feedback on how the client presents himself or herself
to others (refer to Impaired Social Interaction).
Decrease Barriers to Social Contact
• Help identify transportation options.
• Determine available transportation in the community (public,
church-related, volunteer).
• Determine if client must learn how to use alternative transportation.
Help desensitize client to fear/stigma of using public
transportation.
• Assist with the development of alternative means of communication
for people with compromised sensory ability
(e.g., amplifier on phone, taped instead of written letters; refer
to Impaired Communication).
• Assist with management of aesthetic problems (e.g., consult
enterostomal therapist if ostomy odor is a problem; teach
client with cancer to control odor of tumors by packing area
with yogurt or pouring in buttermilk, then rinsing well with
saline solution).
• Refer to Impaired Urinary Elimination for specific interventions
to control incontinence.
Identify Strategies to Expand the World of the Isolated
• Senior centers and church groups
• Volunteer assignments (e.g., hospital, church)
• Foster grandparent programs
• Adult day-care centers
• Retirement communities
• House sharing, group homes, community kitchens
• Adult education classes, special interest courses
• Pets
• Regular contact to diminish the need to obtain attention
through a crisis (e.g., suicidal gesture)
• Psychiatric day hospital or activity program
Implement the Following for People With Poor or Offensive Social
Skills
• Refer to Impaired Social Interactions.
Discuss the Anticipatory Effects of Retirement; Assist With
Planning
• Prepare for ambivalent feelings and short-term negative effects
on self-esteem.
Discuss Those Factors That Contribute to Successful Retirement
(Santrock, 2004; Murray, Zentner, & Yakimo, 2009)
• Stable health status
• Adequate income and health benefits
• Active in community, church, or professional organizations
• Higher education level and ability to pursue new goals/activities
• Extended social network, family friends, colleagues
• Satisfied with life before retirement
• Satisfied with living arrangements
• Plan to ensure adequate income
• Decreased time at work the last 2 to 3 years (e.g., shorter days,
longer vacations)
• Cultivate friends outside work.
• Develop routines at home to replace work structure.
• Rely on others rather than spouse for leisure activities.
• Cultivate realistic leisure activities (energy, cost).
• Engage in community or church programs or professional
organizations.
Initiate Referrals, as Indicated
• Community-based groups that contact the socially isolated
• Self-help groups for clients isolated because of specific medical
problems (e.g., Reach to Recovery, United Ostomy Association)
• Wheelchair groups
• Psychiatric consumer rights associations

If you like nursing care plan right in your hand, I highly recommend this handbook Nursing Care Plans: Diagnoses, Interventions, and Outcomes, 8e to you. This book provides the latest nursing diagnosis and it is much cheaper than the other books (others are $66 above). Professors and professional nurses also recommend this book (you can check their reviews on comments' section). Get this book here to have a free shipping!