Nursing Dx

Taxonomy II: Role Relationships—Class 2 Family Relationships (00058)
[Diagnostic Division: Social Interaction] Submitted 1994

Definition: Disruption of the interactive process between parent/SO and infant that fosters the development of a protective and nurturing reciprocal relationship

Risk Factors
Inability of parents to meet personal needs
Anxiety associated with the parent role
Substance abuse
Premature infant; ill infant/child who is unable to effectively initiate parental contact due to altered behavioral organization
Separation; physical barriers
Lack of privacy
[Parents who themselves experienced altered attachment]
[Uncertainty of paternity; conception as a result of rape/sexual abuse]
[Difficult pregnancy and/or birth (actual or perceived)]

NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes/Evaluation
Criteria—Parent Will:
• Identify and prioritize family strengths and needs.
• Exhibit nurturant and protective behaviors toward child.
• Identify and use resources to meet needs of family members.
• Demonstrate techniques to enhance behavioral organization of the infant/child.
• Engage in mutually satisfying interactions with child.

Actions/Interventions
NURSING PRIORITY NO.1. To identify causative/contributing factors:
• Interview parents, noting their perception of situation, individual concerns.
• Assess parent/child interactions.
• Ascertain availability/use of resources to include extended family, support groups, and financial.
• Evaluate parents’ ability to provide protective environment, participate in reciprocal relationship.

NURSING PRIORITY NO.2. To enhance behavioral organization of infant/child:
• Identify infant’s strengths and vulnerabilities. Each child is born with his or her own temperament that affects interactions with caregivers.
• Educate parents regarding child growth and development, addressing parental perceptions. Helps clarify realistic expectations.

• Assist parents in modifying the environment  to provide appropriate stimulation.
• Model caregiving techniques that best support behavioral organization.
• Respond consistently with nurturance to infant/child.

NURSING PRIORITY NO.3. To enhance best functioning of parents:
• Develop therapeutic nurse-client relationship. Provide a consistently warm, nurturant, and nonjudgmental environment.
• Assist parents in identifying and prioritizing family strengths and needs. Promotes positive attitude by looking at what they already do well and using those skills to address needs.
• Support and guide parents in process of assessing resources.
• Involve parents in activities with the infant/child that they can accomplish successfully. Enhances self-concept.
• Recognize and provide positive feedback for nurturant and protective parenting behaviors. Reinforces continuation of desired behaviors.
• Minimize number of professionals on team with whom parents must have contact to foster trust in relationships.

NURSING PRIORITY NO.4. To support parent/child attachment during separation:
• Provide parents with telephone contact as appropriate.
• Establish a routine time for daily phone calls/initiate calls as indicated. Provides sense of consistency and control; allows for planning of other activities.
• Invite parents to use Ronald McDonald House or provide them with a listing of a variety of local accommodations, restaurants when child is hospitalized out of town.
• Arrange for parents to receive photos, progress reports from the child.
• Suggest parents provide a photo and/or audiotape of themselves for the child.
• Consider use of contract with parents to clearly communicate expectations of both family and staff.
• Suggest parents keep a journal of infant/child progress.
• Provide “homelike” environment for situations requiring supervision of visits.

NURSING PRIORITY NO.5. To promote wellness (Teaching/ Discharge Considerations):
• Refer to addiction counseling/treatment, individual counseling, or family therapies as indicated.
• Identify services for transportation, financial resources, housing, and so forth.
• Develop support systems appropriate to situation (e.g., extended family, friends, social worker).

• Explore community resources (e.g., church affiliations, volunteer groups, day/respite care).

Documentation Focus
ASSESSMENT/REASSESSMENT
• Identified behaviors of both parents and child.
• Specific risk factors, individual perceptions/concerns.
• Interactions between parent and child.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Parents’/child’s responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible.
• Plan for home visits to support parents and to ensure infant/ child safety and well-being.
• Specific referrals made.

Taxonomy II: Safety/Protection—Class 2 Physical Injury (00039)
[Diagnostic Division: Respiration]
Submitted 1988
read more : http://nursingscript.blogspot.com/2012/01/risk-for-aspiration.html

risk for Aspiration

Definition: At risk for entry of gastrointestinal secretions, oropharyngeal secretions, or [exogenous food] solids or fluids into tracheobronchial passages [due to dysfunction or absence of normal protective mechanisms]

Reduced level of consciousness
Depressed cough and gag reflexes

Impaired swallowing [owing to inability of the epiglottis and true vocal cords to move to close off trachea]
Facial/oral/neck surgery or trauma; wired jaws Situation hindering elevation of upper body [weakness, paralysis]
Incomplete lower esophageal sphincter [hiatal hernia or other esophageal disease affecting stomach valve function], delayed gastric emptying, decreased gastrointestinal motility, increased intragastric pressure, increased gastric residual
Presence of tracheostomy or endotracheal (ET) tube; [inadequate or overinflation of tracheostomy/ET tube cuff]
[Presence of] gastrointestinal tubes; tube feedings/medication administration

NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes/Evaluation
Criteria—Client Will:
• Experience no aspiration as evidenced by noiseless respirations, clear breath sounds; clear, odorless secretions.
• Identify causative/risk factors.
• Demonstrate techniques to prevent and/or correct aspiration.

Actions/Interventions
NURSING PRIORITY NO.1. To assess causative/contributing factors:
• Note level of consciousness/awareness of surroundings,cognitive impairment.
• Evaluate presence of neuromuscular weakness, noting muscle groups involved, degree of impairment, and whether they are of an acute or progressive nature (e.g., Guillain-Barré,amyotrophic lateral sclerosis—ALS).
• Assess amount and consistency of respiratory secretions and strength of gag/cough reflex.
• Observe for neck and facial edema, for example, client with head/neck surgery, tracheal/bronchial injury (upper torso burns, inhalation/chemical injury).
• Note administration of enteral feedings, being aware of potential for regurgitation and/or misplacement of tube.
• Ascertain lifestyle habits, for instance, use of alcohol, tobacco, and other CNS-suppressant drugs; can affect awareness and muscles of gag/swallow.

NURSING PRIORITY NO.2. To assist in correcting factors that can lead to aspiration:
• Monitor use of oxygen masks in clients at risk for vomiting. Refrain from using oxygen masks for comatose individuals.
• Keep wire cutters/scissors with client at all times when jaws are wired/banded  to facilitate clearing airway in emergency situations.
• Maintain operational suction equipment at bedside/chairside.
• Suction (oral cavity, nose, and ET/tracheostomy tube) as needed to clear secretions. Avoid triggering gag mechanism when performing suction or mouth care.
• Assist with postural drainage  to mobilize thickened secretions that may interfere with swallowing.
• Auscultate lung sounds frequently (especially in client who is coughing frequently or not coughing at all; ventilator client being tube-fed)  to determine presence of secretions/silent aspiration.
• Elevate client to highest or best possible position for eating and drinking and during tube feedings.
• Feed slowly, instruct client to chew slowly and thoroughly.
• Give semisolid foods; avoid pureed foods  (increased risk of aspiration) and mucus-producing foods (milk). Use soft foods that stick together/form a bolus (e.g., casseroles, puddings, stews) to aid swallowing effort.
• Provide very warm or very cold liquids  (activates temperature receptors in the mouth that help to stimulate swallowing). Add thickening agent to liquids as appropriate.
• Avoid washing solids down with liquids.
• Ascertain that feeding tube is in correct position. Measure residuals when appropriate to prevent overfeeding. Add food coloring to feeding to identify regurgitation.
• Determine best position for infant/child (e.g., with the head of bed elevated 30 degrees and infant propped on right side after feeding because upper airway patency is facilitated by upright position and turning to right side decreases likelihood of drainage into trachea).
• Provide oral medications in elixir form or crush, if appropriate.
• Refer to speech therapist for exercises to strengthen muscles and techniques to enhance swallowing.

NURSING PRIORITY NO.3. To promote wellness (Teaching/ Discharge Considerations):
• Review individual risk/potentiating factors.
• Provide information about the effects of aspiration on the lungs.
• Instruct in safety concerns when feeding oral or tube feeding. Refer to ND impaired Swallowing.
• Train client to suction self or train family members in suction techniques (especially if client has constant or copious oral secretions) to enhance safety/self-sufficiency.
• Instruct individual/family member to avoid/limit activities that increase intra-abdominal pressure (straining, strenuous exercise, tight/constrictive clothing), which may slow digestion/increase risk of regurgitation.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings/conditions that could lead to problems of aspiration.
• Verification of tube placement, observations of physical findings.
PLANNING
• Interventions to prevent aspiration or reduce risk factors and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s responses to interventions/teaching and actions performed.
• Foods/fluids client handles with ease/difficulty.
• Amount/frequency of intake.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions to be taken.

Taxonomy II: Coping/Stress Tolerance—Class 2 Coping Response (00147)
[Diagnostic Division: Ego Integrity]
Submitted 1998

Definition: Apprehension, worry, or fear related to death or dying

Related Factors
To be developed

Defining Characteristics
SUBJECTIVE

Fear of: developing a terminal illness; the process of dying; loss of physical and/or mental abilities when dying; premature death because it prevents the accomplishment of important life goals; leaving family alone after death; delayed demise

Negative death images or unpleasant thoughts about any event related to death or dying; anticipated pain related to dying

Powerlessness over issues related to dying; total loss of control over any aspect of one’s own death

Worrying about: the impact of one’s own death on SOs; being the cause of other’s grief and suffering

Concerns of overworking the caregiver as terminal illness incapacitates self; about meeting one’s creator or feeling doubtful about the existence of God or higher being

Denial of one’s own mortality or impending death
OBJECTIVE
Deep sadness
(Refer to ND anticipatory Grieving.)

Desired Outcomes/Evaluation
Criteria—Client Will:
• Identify and express feelings (e.g., sadness, guilt, fear) freely/effectively.
• Look toward/plan for the future one day at a time.
• Formulate a plan dealing with individual concerns and eventualities of dying.

Actions/Interventions
NURSING PRIORITY NO.1. To assess causative/contributing factors:
• Determine how client sees self in usual lifestyle role functioning and perception and meaning of anticipated loss to him or her and SO(s).
• Ascertain current knowledge of situation to identify misconceptions, lack of information, other pertinent issues.
• Determine client’s role in family constellation. Observe patterns of communication in family and response of family/ SO to client’s situation and concerns. In addition to identifying areas of need/concern, also reveals strengths useful in addressing the concerns.
• Assess impact of client reports of subjective experiences and past experience with death (or exposure to death); for example, witnessed violent death or as a child viewed body in casket, and so on.
• Identify cultural factors/expectations and impact on current situation/feelings.
• Note physical/mental condition, complexity of therapeutic regimen.
• Determine ability to manage own self-care, end-of-life and other affairs, awareness/use of available resources.
• Observe behavior indicative of the level of anxiety present (mild to panic)  as it affects client’s/SO’s ability to process information/participate in activities.
• Identify coping skills currently used and how effective they are. Be aware of defense mechanisms being used by the client.
• Note use of drugs (including alcohol), presence of insomnia, excessive sleeping, avoidance of interactions with others.
• Note client’s religious/spiritual orientation, involvement in religious/church activities, presence of conflicts regarding spiritual beliefs.
• Listen to client/SO reports/expressions of anger/concern, alienation from God, belief that impending death is a punishment for wrongdoing, and so on.
• Determine sense of futility, feelings of hopelessness, helplessness, lack of motivation to help self.May indicate presence of depression and need for intervention.
• Active-listen comments regarding sense of isolation.
• Listen for expressions of inability to find meaning in life or suicidal ideation.

NURSING PRIORITY NO.2. To assist client to deal with situation:
• Provide open and trusting relationship.
• Use therapeutic communication skills of Active-listening, silence, acknowledgment. Respect client desire/request not to talk. Provide hope within parameters of the individual situation.
• Encourage expressions of feelings (anger, fear, sadness, etc.). Acknowledge anxiety/fear. Do not deny or reassure client that everything will be all right. Be honest when answering questions/providing information. Enhances trust and therapeutic relationship.
• Provide information about normalcy of feelings and individual grief reaction.
• Make time for nonjudgmental discussion of philosophic issues/questions about spiritual impact of illness/situation.
• Review life experiences of loss and use of coping skills, noting client strengths and successes.
• Provide calm, peaceful setting and privacy as appropriate. Promotes relaxation and ability to deal with situation.
• Assist client to engage in spiritual growth activities, experience prayer/meditation and forgiveness to heal past hurts. Provide information that anger with God is a normal part of the grieving process. Reduces feelings of guilt/conflict, allowing client to move forward toward resolution.
• Refer to therapists, spiritual advisors, counselors to facilitate grief work.
• Refer to community agencies/resources to assist client/SO for planning for eventualities (legal issues, funeral plans, etc.).

NURSING PRIORITY NO.3. To promote independence:
• Support client’s efforts to develop realistic steps to put plans into action.
• Direct client’s thoughts beyond present state to enjoyment of each day and the future when appropriate.
• Provide opportunities for client to make simple decisions. Enhances sense of control.
• Develop individual plan using client’s locus of control  to assist client/family through the process.
• Treat expressed decisions and desires with respect and convey to others as appropriate.
• Assist with completion of Advance Directives and cardiopulmonary resuscitation (CPR) instructions.


Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings, including client’s fears and signs/symptoms being exhibited.
• Responses/actions of family/SO(s).
• Availability/use of resources.
PLANNING
• Plan of care and who is involved in planning.
IMPLEMENTATION/EVALUATION
• Client’s response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Identified needs and who is responsible for actions to be taken.
• Specific referrals made.