risk for Constipation
Taxonomy II: Elimination—Class 2 Gastrointestinal System (00015)[Diagnostic Division: Elimination]
Nursing Diagnosis Extension and Classification (NDEC)
Submission 1998
Definition: At risk for a decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool
Risk Factors
FUNCTIONAL
Irregular defecation habits; inadequate toileting (e.g., timeliness, positioning for defecation, privacy)
Insufficient physical activity; abdominal muscle weakness
Recent environmental changes
Habitual denial/ignoring of urge to defecate
PSYCHOLOGICAL
Emotional stress; depression; mental confusion
PHYSIOLOGICAL
Change in usual foods and eating patterns; insufficient fiber/ fluid intake, dehydration; poor eating habits
Inadequate dentition or oral hygiene
Decreased motility of gastrointestinal tract
PHARMACOLOGICAL
Phenothiazides; nonsteroidal anti-inflammatory agents; sedatives; aluminum-containing antacids; laxative overuse; iron salts; anticholinergics; antidepressants; anticonvulsants; antilipemic agents; calcium channel blockers; calcium carbonate; diuretics; sympathomimetics; opiates; bismuth salts
MECHANICAL
Hemorrhoids; pregnancy; obesity
Rectal abscess or ulcer; anal stricture; anal fissures; prolapse; rectocele
Prostate enlargement; postsurgical obstruction
Neurological impairment; megacolon (Hirschsprung’s disease); tumors
Electrolyte imbalance
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
FUNCTIONAL
Irregular defecation habits; inadequate toileting (e.g., timeliness, positioning for defecation, privacy)
Insufficient physical activity; abdominal muscle weakness
Recent environmental changes
Habitual denial/ignoring of urge to defecate
PSYCHOLOGICAL
Emotional stress; depression; mental confusion
PHYSIOLOGICAL
Change in usual foods and eating patterns; insufficient fiber/ fluid intake, dehydration; poor eating habits
Inadequate dentition or oral hygiene
Decreased motility of gastrointestinal tract
PHARMACOLOGICAL
Phenothiazides; nonsteroidal anti-inflammatory agents; sedatives; aluminum-containing antacids; laxative overuse; iron salts; anticholinergics; antidepressants; anticonvulsants; antilipemic agents; calcium channel blockers; calcium carbonate; diuretics; sympathomimetics; opiates; bismuth salts
MECHANICAL
Hemorrhoids; pregnancy; obesity
Rectal abscess or ulcer; anal stricture; anal fissures; prolapse; rectocele
Prostate enlargement; postsurgical obstruction
Neurological impairment; megacolon (Hirschsprung’s disease); tumors
Electrolyte imbalance
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:
• Maintain usual pattern of bowel functioning.
• Verbalize understanding of risk factors and appropriate interventions/ solutions related to individual situation.
Criteria—Client Will:
• Maintain usual pattern of bowel functioning.
• Verbalize understanding of risk factors and appropriate interventions/ solutions related to individual situation.
• Demonstrate behaviors or lifestyle changes to prevent developing problem.
Actions/Interventions
NURSING PRIORITY NO. 1. To identify individual risk factors/ needs:
• Auscultate abdomen for presence, location, and characteristics of bowel sounds reflecting bowel activity.
• Discuss usual elimination pattern and use of laxatives.
• Ascertain client’s beliefs and practices about bowel elimination, such as “must have a bowel movement every day or I need an enema.”
• Determine current situation and possible impact on bowel function (e.g., surgery, use of medications affecting intestinal function, advanced age, weakness, depression, and other risk factors as listed previously).
• Evaluate current dietary and fluid intake and implications for effect on bowel function.
• Review medications (new and chronic use) for impact on/ effects of changes in bowel function.
NURSING PRIORITY NO. 1. To identify individual risk factors/ needs:
• Auscultate abdomen for presence, location, and characteristics of bowel sounds reflecting bowel activity.
• Discuss usual elimination pattern and use of laxatives.
• Ascertain client’s beliefs and practices about bowel elimination, such as “must have a bowel movement every day or I need an enema.”
• Determine current situation and possible impact on bowel function (e.g., surgery, use of medications affecting intestinal function, advanced age, weakness, depression, and other risk factors as listed previously).
• Evaluate current dietary and fluid intake and implications for effect on bowel function.
• Review medications (new and chronic use) for impact on/ effects of changes in bowel function.
NURSING PRIORITY NO. 2. To facilitate normal bowel function:
• Instruct in/encourage balanced fiber and bulk in diet to improve consistency of stool and facilitate passage through the colon.
• Promote adequate fluid intake, including water and high-fiber fruit juices; suggest drinking warm, stimulating fluids (e.g., decaffeinated coffee, hot water, tea) to promote moist/soft stool.
• Encourage activity/exercise within limits of individual ability to stimulate contractions of the intestines.
• Provide privacy and routinely scheduled time for defecation (bathroom or commode preferable to bedpan).
• Administer routine stool softeners, mild stimulants, or bulkforming agents prn and/or routinely when appropriate (e.g., client taking pain medications, especially opiates, or who is inactive, immobile, or unconscious).
• Ascertain frequency, color, consistency, amount of stools. Provides a baseline for comparison, promotes recognition of changes.
• Instruct in/encourage balanced fiber and bulk in diet to improve consistency of stool and facilitate passage through the colon.
• Promote adequate fluid intake, including water and high-fiber fruit juices; suggest drinking warm, stimulating fluids (e.g., decaffeinated coffee, hot water, tea) to promote moist/soft stool.
• Encourage activity/exercise within limits of individual ability to stimulate contractions of the intestines.
• Provide privacy and routinely scheduled time for defecation (bathroom or commode preferable to bedpan).
• Administer routine stool softeners, mild stimulants, or bulkforming agents prn and/or routinely when appropriate (e.g., client taking pain medications, especially opiates, or who is inactive, immobile, or unconscious).
• Ascertain frequency, color, consistency, amount of stools. Provides a baseline for comparison, promotes recognition of changes.
NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Discuss physiology and acceptable variations in elimination. May help reduce concerns/anxiety about situation.
• Review individual risk factors/potential problems and specific interventions.
• Discuss physiology and acceptable variations in elimination. May help reduce concerns/anxiety about situation.
• Review individual risk factors/potential problems and specific interventions.
• Review appropriate use of medications.
• Encourage client to maintain elimination diary if appropriate to help monitor bowel pattern.
• Refer to NDs Constipation; perceived Constipation.
• Encourage client to maintain elimination diary if appropriate to help monitor bowel pattern.
• Refer to NDs Constipation; perceived Constipation.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Current bowel pattern, characteristics of stool, medications.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Individual long-term needs, noting who is responsible for actions to be taken.
• Specific referrals made.
ASSESSMENT/REASSESSMENT
• Current bowel pattern, characteristics of stool, medications.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Individual long-term needs, noting who is responsible for actions to be taken.
• Specific referrals made.
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Improving the Physician–Nurse Dynamic
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perceived Constipation
Taxonomy II: Elimination—Class 2 Gastrointestinal System (00012)
[Diagnostic Division: Elimination]
Submitted 1988
Definition: Self-diagnosis of constipation and abuse of laxatives, enemas, and suppositories to ensure a daily bowel movement
[Diagnostic Division: Elimination]
Submitted 1988
Definition: Self-diagnosis of constipation and abuse of laxatives, enemas, and suppositories to ensure a daily bowel movement
Related Factors
Cultural/family health beliefs
Faulty appraisal, [long-term expectations/habits]
Impaired thought processes
Defining Characteristics
SUBJECTIVE
Expectation of a daily bowel movement with the resulting overuse
of laxatives, enemas, and suppositories
Expected passage of stool at same time every day
Cultural/family health beliefs
Faulty appraisal, [long-term expectations/habits]
Impaired thought processes
Defining Characteristics
SUBJECTIVE
Expectation of a daily bowel movement with the resulting overuse
of laxatives, enemas, and suppositories
Expected passage of stool at same time every day
Desired Outcomes/Evaluation
Criteria—Client Will:
• Verbalize understanding of physiology of bowel function.
• Identify acceptable interventions to promote adequate bowel function.
• Decrease reliance on laxatives/enemas.
• Establish individually appropriate pattern of elimination.
Criteria—Client Will:
• Verbalize understanding of physiology of bowel function.
• Identify acceptable interventions to promote adequate bowel function.
• Decrease reliance on laxatives/enemas.
• Establish individually appropriate pattern of elimination.
Actions/Interventions
NURSING PRIORITY NO. 1. To identify factors affecting individual beliefs:
• Determine client’s understanding of a “normal” bowel pattern and cultural expectations.
• Compare with client’s current bowel functioning.
NURSING PRIORITY NO. 1. To identify factors affecting individual beliefs:
• Determine client’s understanding of a “normal” bowel pattern and cultural expectations.
• Compare with client’s current bowel functioning.
• Identify interventions used by client to correct perceived problem.
NURSING PRIORITY NO. 2. To promote wellness (Teaching/ Discharge Considerations):
• Discuss physiology and acceptable variations in elimination.
• Identify detrimental effects of drug/enema use.
• Review relationship of diet/exercise to bowel elimination.
• Provide support by Active-listening and discussing client’s concerns/fears.
• Encourage use of stress-reduction activities/refocusing of attention while client works to establish individually appropriate pattern.
NURSING PRIORITY NO. 2. To promote wellness (Teaching/ Discharge Considerations):
• Discuss physiology and acceptable variations in elimination.
• Identify detrimental effects of drug/enema use.
• Review relationship of diet/exercise to bowel elimination.
• Provide support by Active-listening and discussing client’s concerns/fears.
• Encourage use of stress-reduction activities/refocusing of attention while client works to establish individually appropriate pattern.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings/client’s perceptions of the problem.
• Current bowel pattern, stool characteristics.
PLANNING
• Plan of care/interventions and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s responses to interventions/teaching and actions performed.
• Changes in bowel pattern, character of stool.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Referral for follow-up care.
ASSESSMENT/REASSESSMENT
• Assessment findings/client’s perceptions of the problem.
• Current bowel pattern, stool characteristics.
PLANNING
• Plan of care/interventions and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s responses to interventions/teaching and actions performed.
• Changes in bowel pattern, character of stool.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Referral for follow-up care.
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Constipation - Nursing Care Plan, Actions and Interventions
Actions/Interventions
NURSING PRIORITY NO. 1. To identify causative/contributing factors:
• Review daily dietary regimen. Note oral/dental health that can impact intake.
• Determine fluid intake, to note deficits.
• Evaluate medication/drug usage and note interactions or side effects (e.g., narcotics, antacids, chemotherapy, iron, contrast media such as barium, steroids).
• Note energy/activity level and exercise pattern.
• Identify areas of stress (e.g., personal relationships, occupational factors, financial problems).
NURSING PRIORITY NO. 1. To identify causative/contributing factors:
• Review daily dietary regimen. Note oral/dental health that can impact intake.
• Determine fluid intake, to note deficits.
• Evaluate medication/drug usage and note interactions or side effects (e.g., narcotics, antacids, chemotherapy, iron, contrast media such as barium, steroids).
• Note energy/activity level and exercise pattern.
• Identify areas of stress (e.g., personal relationships, occupational factors, financial problems).
• Determine access to bathroom, privacy, and ability to perform self-care activities.
• Investigate reports of pain with defecation. Inspect perianal area for hemorrhoids, fissures, skin breakdown, or other abnormal findings.
• Discuss laxative/enema use. Note signs/reports of laxative abuse.
• Review medical/surgical history (e.g., metabolic or endocrine disorders, pregnancy, prior surgery, megacolon).
• Palpate abdomen for presence of distention, masses.
• Check for presence of fecal impaction as indicated.
• Assist with medical workup for identification of other possible causative factors.
• Investigate reports of pain with defecation. Inspect perianal area for hemorrhoids, fissures, skin breakdown, or other abnormal findings.
• Discuss laxative/enema use. Note signs/reports of laxative abuse.
• Review medical/surgical history (e.g., metabolic or endocrine disorders, pregnancy, prior surgery, megacolon).
• Palpate abdomen for presence of distention, masses.
• Check for presence of fecal impaction as indicated.
• Assist with medical workup for identification of other possible causative factors.
NURSING PRIORITY NO. 2. To determine usual pattern of elimination:
• Discuss usual elimination pattern and problem.
• Note factors that usually stimulate bowel activity and any interferences present.
NURSING PRIORITY NO. 3. To assess current pattern of elimination:
• Note color, odor, consistency, amount, and frequency of stool. Provides a baseline for comparison, promotes recognition of changes.
• Ascertain duration of current problem and degree of concern (e.g., long-standing condition that client has “lived with” or a postsurgical event that causes great distress) as client’s response may be inappropriate in relation to severity of condition.
• Auscultate abdomen for presence, location, and characteristics of bowel sounds reflecting bowel activity.
• Note laxative/enema use.
• Review current fluid/dietary intake.
NURSING PRIORITY NO. 4. To facilitate return to usual/acceptable pattern of elimination:
• Instruct in/encourage balanced fiber and bulk in diet to improve consistency of stool and facilitate passage through colon.
• Promote adequate fluid intake, including high-fiber fruit juices; suggest drinking warm, stimulating fluids (e.g., decaffeinated coffee, hot water, tea) to promote moist/soft stool.
• Encourage activity/exercise within limits of individual ability to stimulate contractions of the intestines.
• Provide privacy and routinely scheduled time for defecation (bathroom or commode preferable to bedpan).
• Encourage/support treatment of underlying medical cause where appropriate (e.g., thyroid treatment) to improve body function, including the bowel.
• Administer stool softeners, mild stimulants, or bulk-forming agents as ordered, and/or routinely when appropriate (e.g., client receiving opiates, decreased level of activity/immobility).
• Apply lubricant/anesthetic ointment to anus if needed.
• Administer enemas; digitally remove impacted stool.
• Provide sitz bath after stools for soothing effect to rectal area.
• Establish bowel program to include glycerin suppositories and digital stimulation as appropriate when long-term or permanent bowel dysfunction is present.
NURSING PRIORITY NO. 5. To promote wellness (Teaching/ Discharge Considerations):
• Discuss physiology and acceptable variations in elimination.
• Provide information about relationship of diet, exercise, fluid, and appropriate use of laxatives as indicated.
• Discuss rationale for and encourage continuation of successful interventions.
• Encourage client to maintain elimination diary if appropriate to facilitate monitoring of long-term problem.
• Identify specific actions to be taken if problem recurs to promote timely intervention, enhancing client’s independence.
• Discuss usual elimination pattern and problem.
• Note factors that usually stimulate bowel activity and any interferences present.
NURSING PRIORITY NO. 3. To assess current pattern of elimination:
• Note color, odor, consistency, amount, and frequency of stool. Provides a baseline for comparison, promotes recognition of changes.
• Ascertain duration of current problem and degree of concern (e.g., long-standing condition that client has “lived with” or a postsurgical event that causes great distress) as client’s response may be inappropriate in relation to severity of condition.
• Auscultate abdomen for presence, location, and characteristics of bowel sounds reflecting bowel activity.
• Note laxative/enema use.
• Review current fluid/dietary intake.
NURSING PRIORITY NO. 4. To facilitate return to usual/acceptable pattern of elimination:
• Instruct in/encourage balanced fiber and bulk in diet to improve consistency of stool and facilitate passage through colon.
• Promote adequate fluid intake, including high-fiber fruit juices; suggest drinking warm, stimulating fluids (e.g., decaffeinated coffee, hot water, tea) to promote moist/soft stool.
• Encourage activity/exercise within limits of individual ability to stimulate contractions of the intestines.
• Provide privacy and routinely scheduled time for defecation (bathroom or commode preferable to bedpan).
• Encourage/support treatment of underlying medical cause where appropriate (e.g., thyroid treatment) to improve body function, including the bowel.
• Administer stool softeners, mild stimulants, or bulk-forming agents as ordered, and/or routinely when appropriate (e.g., client receiving opiates, decreased level of activity/immobility).
• Apply lubricant/anesthetic ointment to anus if needed.
• Administer enemas; digitally remove impacted stool.
• Provide sitz bath after stools for soothing effect to rectal area.
• Establish bowel program to include glycerin suppositories and digital stimulation as appropriate when long-term or permanent bowel dysfunction is present.
NURSING PRIORITY NO. 5. To promote wellness (Teaching/ Discharge Considerations):
• Discuss physiology and acceptable variations in elimination.
• Provide information about relationship of diet, exercise, fluid, and appropriate use of laxatives as indicated.
• Discuss rationale for and encourage continuation of successful interventions.
• Encourage client to maintain elimination diary if appropriate to facilitate monitoring of long-term problem.
• Identify specific actions to be taken if problem recurs to promote timely intervention, enhancing client’s independence.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Usual and current bowel pattern, duration of the problem, and individual contributing factors.
• Characteristics of stool.
• Underlying dynamics.
PLANNING
• Plan of care/interventions and changes in lifestyle that are necessary to correct individual situation, and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses to interventions/teaching and actions performed.
• Change in bowel pattern, character of stool.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Individual long-term needs, noting who is responsible for actions to be taken.
ASSESSMENT/REASSESSMENT
• Usual and current bowel pattern, duration of the problem, and individual contributing factors.
• Characteristics of stool.
• Underlying dynamics.
PLANNING
• Plan of care/interventions and changes in lifestyle that are necessary to correct individual situation, and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Responses to interventions/teaching and actions performed.
• Change in bowel pattern, character of stool.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Individual long-term needs, noting who is responsible for actions to be taken.
• Recommendations for follow-up care.
• Specific referrals made.
• Specific referrals made.
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Constipation - Related Factors, Characteristics, Nursing Care Plan and Intervention
Taxonomy II: Elimination—Class 2 Gastrointestinal System (00011)
[Diagnostic Division: Elimination]
Submitted 1975; Nursing Diagnosis Extension and Classification (NDEC) Revision 1998
Definition: Decrease in normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard,dry stool
Related Factors
FUNCTIONAL
Irregular defecation habits; inadequate toileting (e.g., timeliness, positioning for defecation, privacy)
Insufficient physical activity; abdominal muscle weakness
Recent environmental changes
Habitual denial/ignoring of urge to defecate
PSYCHOLOGICAL
Emotional stress; depression; mental confusion
PHARMACOLOGICAL
Antilipemic agents; laxative overdose; calcium carbonate; aluminum-containing antacids; nonsteroidal anti-inflammatory agents; opiates; anticholinergics; diuretics; iron salts; phenothiazides; sedatives; sympathomimetics; bismuth salts; antidepressants; calcium channel blockers
MECHANICAL
Hemorrhoids; pregnancy; obesity
Rectal abscess or ulcer, anal fissures, prolapse; anal strictures; rectocele
Prostate enlargement; postsurgical obstruction
Neurological impairment; megacolon (Hirschsprung’s disease); tumors
Electrolyte imbalance
PHYSIOLOGICAL
Poor eating habits; change in usual foods and eating patterns; insufficient fiber intake; insufficient fluid intake, dehydration Inadequate dentition or oral hygiene
Decreased motility of gastrointestinal tract
FUNCTIONAL
Irregular defecation habits; inadequate toileting (e.g., timeliness, positioning for defecation, privacy)
Insufficient physical activity; abdominal muscle weakness
Recent environmental changes
Habitual denial/ignoring of urge to defecate
PSYCHOLOGICAL
Emotional stress; depression; mental confusion
PHARMACOLOGICAL
Antilipemic agents; laxative overdose; calcium carbonate; aluminum-containing antacids; nonsteroidal anti-inflammatory agents; opiates; anticholinergics; diuretics; iron salts; phenothiazides; sedatives; sympathomimetics; bismuth salts; antidepressants; calcium channel blockers
MECHANICAL
Hemorrhoids; pregnancy; obesity
Rectal abscess or ulcer, anal fissures, prolapse; anal strictures; rectocele
Prostate enlargement; postsurgical obstruction
Neurological impairment; megacolon (Hirschsprung’s disease); tumors
Electrolyte imbalance
PHYSIOLOGICAL
Poor eating habits; change in usual foods and eating patterns; insufficient fiber intake; insufficient fluid intake, dehydration Inadequate dentition or oral hygiene
Decreased motility of gastrointestinal tract
Defining Characteristics
SUBJECTIVE
Change in bowel pattern; unable to pass stool; decreased frequency; decreased volume of stool
Change in usual foods and eating patterns; increased abdominal pressure; feeling of rectal fullness or pressure
Abdominal pain; pain with defecation; nausea and/or vomiting; headache; indigestion; generalized fatigue
OBJECTIVE
Dry, hard, formed stool
Straining with defecation
Hypoactive or hyperactive bowel sounds; change in abdominal growling (borborygmi)
Distended abdomen; abdominal tenderness with or without palpable muscle resistance
Percussed abdominal dullness
Presence of soft pastelike stool in rectum; oozing liquid stool; bright red blood with stool; dark or black or tarry stool
Severe flatus; anorexia
Atypical presentations in older adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated body temperature)
SUBJECTIVE
Change in bowel pattern; unable to pass stool; decreased frequency; decreased volume of stool
Change in usual foods and eating patterns; increased abdominal pressure; feeling of rectal fullness or pressure
Abdominal pain; pain with defecation; nausea and/or vomiting; headache; indigestion; generalized fatigue
OBJECTIVE
Dry, hard, formed stool
Straining with defecation
Hypoactive or hyperactive bowel sounds; change in abdominal growling (borborygmi)
Distended abdomen; abdominal tenderness with or without palpable muscle resistance
Percussed abdominal dullness
Presence of soft pastelike stool in rectum; oozing liquid stool; bright red blood with stool; dark or black or tarry stool
Severe flatus; anorexia
Atypical presentations in older adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated body temperature)
Desired Outcomes/Evaluation
Criteria—Client Will:
• Establish/regain normal pattern of bowel functioning.
• Verbalize understanding of etiology and appropriate interventions/ solutions for individual situation.
• Demonstrate behaviors or lifestyle changes to prevent recurrence of problem.
• Participate in bowel program as indicated.
Criteria—Client Will:
• Establish/regain normal pattern of bowel functioning.
• Verbalize understanding of etiology and appropriate interventions/ solutions for individual situation.
• Demonstrate behaviors or lifestyle changes to prevent recurrence of problem.
• Participate in bowel program as indicated.
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chronic Confusion
Taxonomy II: Perception/Cognition—Class 4 Cognition (00129)
[Diagnostic Division: Neurosensory]
Submitted 1994
Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation, and behavior
[Diagnostic Division: Neurosensory]
Submitted 1994
Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation, and behavior
Related Factors
Alzheimer’s disease [dementia of the Alzheimer’s type]
Korsakoff ’s psychosis
Multi-infarct dementia
Cerebrovascular accident
Head injury
Alzheimer’s disease [dementia of the Alzheimer’s type]
Korsakoff ’s psychosis
Multi-infarct dementia
Cerebrovascular accident
Head injury
Defining Characteristics
OBJECTIVE
Clinical evidence of organic impairment
Altered interpretation/response to stimuli
Progressive/long-standing cognitive impairment
OBJECTIVE
Clinical evidence of organic impairment
Altered interpretation/response to stimuli
Progressive/long-standing cognitive impairment
No change in level of consciousness
Impaired socialization
Impaired memory (short-term, long-term)
Altered personality
Impaired socialization
Impaired memory (short-term, long-term)
Altered personality
Desired Outcome/Evaluation
Criteria—Client Will:
• Remain safe and free from harm.
Family/SO Will:
• Verbalize understanding of disease process/prognosis and client’s needs.
• Identify/participate in interventions to deal effectively with situation.
• Provide for maximal independence while meeting safety needs of client.
Criteria—Client Will:
• Remain safe and free from harm.
Family/SO Will:
• Verbalize understanding of disease process/prognosis and client’s needs.
• Identify/participate in interventions to deal effectively with situation.
• Provide for maximal independence while meeting safety needs of client.
Actions/Interventions
NURSING PRIORITY NO. 1. To assess degree of impairment:
• Evaluate responses on diagnostic examinations (e.g., memory impairments, reality orientation, attention span, calculations).
• Test ability to receive and send effective communication.
• Note deterioration/changes in personal hygiene or behavior.
• Talk with SO(s) regarding baseline behaviors, length of time since onset/progression of problem, their perception of prognosis, and other pertinent information and concerns for client.
• Evaluate response to care providers/receptiveness to interventions.
• Determine anxiety level in relation to situation. Note behavior that may be indicative of potential for violence.
NURSING PRIORITY NO. 1. To assess degree of impairment:
• Evaluate responses on diagnostic examinations (e.g., memory impairments, reality orientation, attention span, calculations).
• Test ability to receive and send effective communication.
• Note deterioration/changes in personal hygiene or behavior.
• Talk with SO(s) regarding baseline behaviors, length of time since onset/progression of problem, their perception of prognosis, and other pertinent information and concerns for client.
• Evaluate response to care providers/receptiveness to interventions.
• Determine anxiety level in relation to situation. Note behavior that may be indicative of potential for violence.
NURSING PRIORITY NO. 2. To prevent further deterioration/ maximize level of function:
• Provide calm environment, eliminate extraneous noise/stimuli.
• Ascertain interventions previously used/tried and evaluate effectiveness.
• Avoid challenging illogical thinking because defensive reactions may result.
• Encourage family/SO(s) to provide ongoing orientation/ input to include current news and family happenings.
• Maintain reality-oriented relationship/environment (e.g., clocks, calendars, personal items, seasonal decorations). Encourage participation in resocialization groups.
• Provide calm environment, eliminate extraneous noise/stimuli.
• Ascertain interventions previously used/tried and evaluate effectiveness.
• Avoid challenging illogical thinking because defensive reactions may result.
• Encourage family/SO(s) to provide ongoing orientation/ input to include current news and family happenings.
• Maintain reality-oriented relationship/environment (e.g., clocks, calendars, personal items, seasonal decorations). Encourage participation in resocialization groups.
• Allow client to reminisce, exist in own reality if not detrimental to well-being.
• Provide safety measures (e.g., close supervision, identification bracelet, medication lockup, lower temperature on hot water tank).
• Provide safety measures (e.g., close supervision, identification bracelet, medication lockup, lower temperature on hot water tank).
NURSING PRIORITY NO. 3. To assist SO(s) to develop coping strategies:
• Determine family resources, availability and willingness to participate in meeting client’s needs.
• Identify appropriate community resources (e.g., Alzheimer’s or brain injury support group, respite care) to provide support and assist with problem-solving.
• Evaluate attention to own needs, including grieving process.
• Refer to ND risk for Caregiver Role Strain.
• Determine family resources, availability and willingness to participate in meeting client’s needs.
• Identify appropriate community resources (e.g., Alzheimer’s or brain injury support group, respite care) to provide support and assist with problem-solving.
• Evaluate attention to own needs, including grieving process.
• Refer to ND risk for Caregiver Role Strain.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Determine ongoing treatment needs and appropriate resources.
• Develop plan of care with family to meet client’s and SO’s individual needs.
• Provide appropriate referrals (e.g.,Meals on Wheels, adult day care, home care agency, respite care).
• Determine ongoing treatment needs and appropriate resources.
• Develop plan of care with family to meet client’s and SO’s individual needs.
• Provide appropriate referrals (e.g.,Meals on Wheels, adult day care, home care agency, respite care).
Documentation Focus
ASSESSMENT/REASSESSMENT
• Individual findings, including current level of function and rate of anticipated changes.
PLANNING
• Plan of care and who is involved in planning.
IMPLEMENTATION/EVALUATION
• Response to interventions and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs/referrals and who is responsible for actions to be taken.
• Available resources, specific referrals made
ASSESSMENT/REASSESSMENT
• Individual findings, including current level of function and rate of anticipated changes.
PLANNING
• Plan of care and who is involved in planning.
IMPLEMENTATION/EVALUATION
• Response to interventions and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs/referrals and who is responsible for actions to be taken.
• Available resources, specific referrals made
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acute Confusion
Taxonomy II: Perception/Cognition—Class 4 Cognition (00128)
[Diagnostic Division: Neurosensory]
Submitted 1994
Definition: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, and/or sleep/wake cycle
[Diagnostic Division: Neurosensory]
Submitted 1994
Definition: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, and/or sleep/wake cycle
Related Factors
Over 60 years of age
Dementia
Alcohol abuse, drug abuse
Delirium [including febrile epilepticum (following or instead of an epileptic attack), toxic and traumatic]
[Medication reaction/interaction; anesthesia/surgery; metabolic imbalances]
[Exacerbation of a chronic illness, hypoxemia]
[Severe pain]
[Sleep deprivation]
Over 60 years of age
Dementia
Alcohol abuse, drug abuse
Delirium [including febrile epilepticum (following or instead of an epileptic attack), toxic and traumatic]
[Medication reaction/interaction; anesthesia/surgery; metabolic imbalances]
[Exacerbation of a chronic illness, hypoxemia]
[Severe pain]
[Sleep deprivation]
Defining Characteristics
SUBJECTIVE
Hallucinations [visual/auditory]
[Exaggerated emotional responses]
OBJECTIVE
Fluctuation in cognition
Fluctuation in sleep/wake cycle
Fluctuation in level of consciousness
Fluctuation in psychomotor activity [tremors, body movement]
Increased agitation or restlessness
Misperceptions, [inappropriate responses]
Lack of motivation to initiate and/or follow through with goaldirected or purposeful behavior
SUBJECTIVE
Hallucinations [visual/auditory]
[Exaggerated emotional responses]
OBJECTIVE
Fluctuation in cognition
Fluctuation in sleep/wake cycle
Fluctuation in level of consciousness
Fluctuation in psychomotor activity [tremors, body movement]
Increased agitation or restlessness
Misperceptions, [inappropriate responses]
Lack of motivation to initiate and/or follow through with goaldirected or purposeful behavior
Desired Outcomes/Evaluation
Criteria—Client Will:
• Regain/maintain usual reality orientation and level of consciousness.
• Verbalize understanding of causative factors when known.
• Initiate lifestyle/behavior changes to prevent or minimize recurrence of problem.
Criteria—Client Will:
• Regain/maintain usual reality orientation and level of consciousness.
• Verbalize understanding of causative factors when known.
• Initiate lifestyle/behavior changes to prevent or minimize recurrence of problem.
Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Identify factors present, including substance abuse, seizure history, recent ECT therapy, episodes of fever/pain, presence of acute infection (especially urinary tract infection in elderly client), exposure to toxic substances, traumatic events; change in environment, including unfamiliar noises, excessive visitors.
• Investigate possibility of drug withdrawal, exacerbation of psychiatric conditions (e.g., mood disorder, dissociative disorders, dementia).
• Evaluate vital signs for indicators of poor tissue perfusion (i.e., hypotension, tachycardia, tachypnea).
• Determine current medications/drug use—especially antianxiety agents, barbiturates, lithium, methyldopa, disulfiram, cocaine, alcohol, amphetamines, hallucinogens, opiates (associated with high risk of confusion)—and schedule of use as combinations increase risk of adverse reactions/interactions (e.g., cimetidine + antacid, digoxin + diuretics, antacid + propranolol).
• Assess diet/nutritional status.
• Note presence of anxiety, fear, other physiological reactions.
• Monitor laboratory values, noting hypoxemia, electrolyte imbalances, BUN/Cr, ammonia levels, serum glucose, signs of infection, and drug levels (including peak/trough as appropriate).
• Evaluate sleep/rest status, noting deprivation/oversleeping. Refer to ND disturbed Sleep Pattern, as appropriate.
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Identify factors present, including substance abuse, seizure history, recent ECT therapy, episodes of fever/pain, presence of acute infection (especially urinary tract infection in elderly client), exposure to toxic substances, traumatic events; change in environment, including unfamiliar noises, excessive visitors.
• Investigate possibility of drug withdrawal, exacerbation of psychiatric conditions (e.g., mood disorder, dissociative disorders, dementia).
• Evaluate vital signs for indicators of poor tissue perfusion (i.e., hypotension, tachycardia, tachypnea).
• Determine current medications/drug use—especially antianxiety agents, barbiturates, lithium, methyldopa, disulfiram, cocaine, alcohol, amphetamines, hallucinogens, opiates (associated with high risk of confusion)—and schedule of use as combinations increase risk of adverse reactions/interactions (e.g., cimetidine + antacid, digoxin + diuretics, antacid + propranolol).
• Assess diet/nutritional status.
• Note presence of anxiety, fear, other physiological reactions.
• Monitor laboratory values, noting hypoxemia, electrolyte imbalances, BUN/Cr, ammonia levels, serum glucose, signs of infection, and drug levels (including peak/trough as appropriate).
• Evaluate sleep/rest status, noting deprivation/oversleeping. Refer to ND disturbed Sleep Pattern, as appropriate.
NURSING PRIORITY NO. 2. To determine degree of impairment:
• Talk with SO(s) to determine historic baseline, observed changes, and onset/recurrence of changes to understand and clarify current situation.
• Evaluate extent of impairment in orientation, attention span, ability to follow directions, send/receive communication, appropriateness of response.
• Note occurrence/timing of agitation, hallucinations, violent behaviors. (“Sundown syndrome” may occur, with client oriented during daylight hours but confused during night.)
• Determine threat to safety of client/others.
• Talk with SO(s) to determine historic baseline, observed changes, and onset/recurrence of changes to understand and clarify current situation.
• Evaluate extent of impairment in orientation, attention span, ability to follow directions, send/receive communication, appropriateness of response.
• Note occurrence/timing of agitation, hallucinations, violent behaviors. (“Sundown syndrome” may occur, with client oriented during daylight hours but confused during night.)
• Determine threat to safety of client/others.
NURSING PRIORITY NO. 3. To maximize level of function, prevent further deterioration:
• Assist with treatment of underlying problem (e.g., drug intoxication/ substance abuse, infectious process, hypoxemia, biochemical imbalances, nutritional deficits, pain management).
• Assist with treatment of underlying problem (e.g., drug intoxication/ substance abuse, infectious process, hypoxemia, biochemical imbalances, nutritional deficits, pain management).
• Monitor/adjust medication regimen and note response. Eliminate nonessential drugs as appropriate.
• Orient client to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result.
• Encourage family/SO(s) to participate in reorientation as well as providing ongoing input (e.g., current news and family happenings).
• Maintain calm environment and eliminate extraneous noise/ stimuli to prevent overstimulation. Provide normal levels of essential sensory/tactile stimulation—include personal items/pictures, and so on.
• Encourage client to use vision/hearing aids when needed.
• Give simple directions. Allow sufficient time for client to respond, to communicate, to make decisions.
• Provide for safety needs (e.g., supervision, siderails, seizure precautions, placing call bell within reach, positioning needed items within reach/clearing traffic paths, ambulating with devices).
• Note behavior that may be indicative of potential for violence and take appropriate actions.
• Administer psychotropics cautiously to control restlessness, agitation, hallucinations.
• Avoid/limit use of restraints—may worsen situation, increase likelihood of untoward complications.
• Provide undisturbed rest periods. Administer short-acting, nonbenzodiazepine sleeping medication (e.g., Benadryl) at bedtime.
• Orient client to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result.
• Encourage family/SO(s) to participate in reorientation as well as providing ongoing input (e.g., current news and family happenings).
• Maintain calm environment and eliminate extraneous noise/ stimuli to prevent overstimulation. Provide normal levels of essential sensory/tactile stimulation—include personal items/pictures, and so on.
• Encourage client to use vision/hearing aids when needed.
• Give simple directions. Allow sufficient time for client to respond, to communicate, to make decisions.
• Provide for safety needs (e.g., supervision, siderails, seizure precautions, placing call bell within reach, positioning needed items within reach/clearing traffic paths, ambulating with devices).
• Note behavior that may be indicative of potential for violence and take appropriate actions.
• Administer psychotropics cautiously to control restlessness, agitation, hallucinations.
• Avoid/limit use of restraints—may worsen situation, increase likelihood of untoward complications.
• Provide undisturbed rest periods. Administer short-acting, nonbenzodiazepine sleeping medication (e.g., Benadryl) at bedtime.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Explain reason for confusion, if known.
• Review drug regimen.
• Assist in identifying ongoing treatment needs.
• Stress importance of keeping vision/hearing aids in good repair and necessity of periodic evaluation to identify changing client needs.
• Discuss situation with family and involve in planning to meet identified needs.
• Provide appropriate referrals (e.g., cognitive retraining, substance abuse support groups, medication monitoring program,Meals on Wheels, home health, and adult day care).
• Explain reason for confusion, if known.
• Review drug regimen.
• Assist in identifying ongoing treatment needs.
• Stress importance of keeping vision/hearing aids in good repair and necessity of periodic evaluation to identify changing client needs.
• Discuss situation with family and involve in planning to meet identified needs.
• Provide appropriate referrals (e.g., cognitive retraining, substance abuse support groups, medication monitoring program,Meals on Wheels, home health, and adult day care).
Documentation Focus
ASSESSMENT/REASSESSMENT
• Nature, duration, frequency of problem.
• Current and previous level of function, effect on independence/ lifestyle (including safety concerns).
ASSESSMENT/REASSESSMENT
• Nature, duration, frequency of problem.
• Current and previous level of function, effect on independence/ lifestyle (including safety concerns).
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Response to interventions and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions to be taken.
• Available resources and specific referrals.
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Response to interventions and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions to be taken.
• Available resources and specific referrals.
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