Fecal impaction - Causes and Treatment
A fecal impaction is a large lump of dry, hard stool that remains stuck in the rectum. It is most often seen in patients with long-term constipation.
Causes
Constipation is when you are not passing stool as often as you normally do. Your stool becomes hard and dry, and it is difficult to pass.Fecal impaction is often seen in people who have had constipation for a long time and have been using laxatives. Impaction is even more likely when the laxatives are stopped suddenly. The muscles of the intestines forget how to move stool or feces on their own.
Persons at risk for chronic constipation and fecal impaction include those who:
- Do not move around much and spend most of their time in a chair or bed
- Have diseases of the brain or nervous system that damage the nerves that go to the muscles of the intestines
- Anticholinergics, which affect the interaction between nerves and muscles of the bowel
- Medicines used to treat diarrhea, if they are taken too often
- Narcotic pain medication, such as methadone and codeine
Symptoms
Common symptoms include:- Abdominal cramping and bloating
- Leakage of liquid or sudden episodes of watery diarrhea in someone who has chronic constipation
- Rectal bleeding
- Small, semi-formed stools
- Straining when trying to pass stools
- Bladder pressure or loss of bladder control
- Lower back pain
- Rapid heartbeat or light-headedness from straining to pass stool
Exams and Tests
The health care provider will examine your stomach area and rectum. The rectal exam will reveal a hard mass of stool in the rectum.If there has been a recent change in your bowel habits, your doctor may recommend a colonoscopy to evaluate for colon or rectal cancer.
Treatment
Treating a fecal impaction involves removing the impacted stool. After that, measures are taken to prevent future fecal impactions.Often a warm mineral oil enema is used to soften and lubricate the stool. However, enemas alone are usually not enough to remove a large, hardened impaction.
The mass may have to be broken up by hand. This is called manual removal:
- A health care provider will need to insert one or two fingers into the rectum and slowly break up the mass into smaller pieces so that it can come out.
- This process must be done in small steps to avoid causing injury to the rectum.
- Suppositories inserted into the rectum may be given between attempts to help clear the stool.
Almost anyone who has had a fecal impaction will need a bowel retraining program. Your doctor and a specially trained nurse or therapist will:
- Take a detailed history of your diet, bowel patterns, laxative use, medications, and medical problems
- Examine you carefully
- Recommend changes in your diet, how to use laxatives and stool softeners, special exercises, lifestyle changes, and other special techniques to retrain your bowel
- Follow you closely to make sure the program works for you
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Bowel Incontinence - Causes
Bowel Incontinence
(Also Called 'Constipation', 'Fecal Incontinence', 'Incontinence (Fecal/Bowel)')
Bowel or fecal incontinence is the loss of voluntary control of stool, or bowel movements. This condition can vary from being partial, in which a person loses only a small amount of liquid waste, to complete, in which the entire solid bowel movement cannot be controlled.Bowel incontinence affects more than 2% of the U.S. population. Both men and women suffer from this problem, though it is more common in women because of injury to the anal muscles or nerves that can occur during childbirth. Bowel incontinence becomes more common with advancing age as the muscles that control bowel movements (anal sphincter muscles) weaken.
Often, embarrassment and the stigma associated with incontinence prevent people from seeking treatment, even when incontinence affects his or her quality of life. Many people resort to altering their social and physical activities, even their employment, to cope with the problem. In addition, some people with bowel incontinence do not see a doctor because they just don't realize that their problem can be effectively treated. It's important to understand that bowel incontinence is not uncommon and can be successfully treated.
What causes bowel incontinence?
Normal control of bowel movements depends on proper functioning of the colon and rectum, the muscles surrounding the anus (anal sphincter muscles), the brain, and the body's nerves (the nervous system), plus the amount and consistency of waste products produced.There are many causes of bowel incontinence, including:
- Damage or injury to the anal sphincter muscles or the nerves surrounding these muscles
- Anal surgery for another condition
- Certain medications, such as antibiotics or Neurontin
- Improper diet
- Radiation treatment to the lower pelvic region
- Chemotherapy
- Stroke
- Conditions associated with chronic diarrhea or constipation
- Systemic (whole-body) diseases such as diabetes or scleroderma
- Spinal cord damage
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Caregiver Role Strain - Evaluation, Interventions, Documentation
Desired Outcomes/Evaluation
Criteria—Client Will:
• Identify resources within self to deal with situation.
• Provide opportunity for care receiver to deal with situation in own way.
• Express more realistic understanding and expectations of the care receiver.
• Demonstrate behavior/lifestyle changes to cope with and/or resolve problematic factors.
• Report improved general well-being, ability to deal with situation.
Criteria—Client Will:
• Identify resources within self to deal with situation.
• Provide opportunity for care receiver to deal with situation in own way.
• Express more realistic understanding and expectations of the care receiver.
• Demonstrate behavior/lifestyle changes to cope with and/or resolve problematic factors.
• Report improved general well-being, ability to deal with situation.
Actions/Interventions
NURSING PRIORITY NO. 1. To assess degree of impaired function:
• Inquire about/observe physical condition of care receiver and surroundings as appropriate.
• Assess caregiver’s current state of functioning (e.g., hours of sleep, nutritional intake, personal appearance, demeanor).
• Determine use of prescription/over-the-counter (OTC) drugs, alcohol to deal with situation.
• Identify safety issues concerning caregiver and receiver.
• Assess current actions of caregiver and how they are received by care receiver (e.g., caregiver may be trying to be helpful but is not perceived as helpful; may be too protective or may have unrealistic expectations of care receiver). May lead to misunderstanding and conflict.
• Note choice/frequency of social involvement and recreational activities.
• Determine use/effectiveness of resources and support systems.
NURSING PRIORITY NO. 1. To assess degree of impaired function:
• Inquire about/observe physical condition of care receiver and surroundings as appropriate.
• Assess caregiver’s current state of functioning (e.g., hours of sleep, nutritional intake, personal appearance, demeanor).
• Determine use of prescription/over-the-counter (OTC) drugs, alcohol to deal with situation.
• Identify safety issues concerning caregiver and receiver.
• Assess current actions of caregiver and how they are received by care receiver (e.g., caregiver may be trying to be helpful but is not perceived as helpful; may be too protective or may have unrealistic expectations of care receiver). May lead to misunderstanding and conflict.
• Note choice/frequency of social involvement and recreational activities.
• Determine use/effectiveness of resources and support systems.
NURSING PRIORITY NO. 2. To identify the causative/contributing factors relating to the impairment:
• Note presence of high-risk situations (e.g., elderly client with total self-care dependence, or family with several small children with one child requiring extensive assistance due to physical condition/developmental delays). May necessitate role reversal resulting in added stress or place excessive demands on parenting skills.
• Determine current knowledge of the situation, noting misconceptions, lack of information.May interfere with caregiver/ care receiver response to illness/condition.
• Identify relationship of caregiver to care receiver (e.g., spouse/lover, parent/child, sibling, friend).
• Ascertain proximity of caregiver to care receiver.
• Note physical/mental condition, complexity of therapeutic regimen of care receiver.
• Determine caregiver’s level of responsibility, involvement in and anticipated length of care.
• Ascertain developmental level/abilities and additional responsibilities of caregiver.
• Use assessment tool, such as Burden Interview, when appropriate, to further determine caregiver’s abilities.
• Identify individual cultural factors and impact on caregiver. Helps clarify expectations of caregiver/receiver, family, and community.
• Note co-dependency needs/enabling behaviors of caregiver.
• Determine availability/use of support systems and resources.
• Identify presence/degree of conflict between caregiver/care receiver/family.
• Note presence of high-risk situations (e.g., elderly client with total self-care dependence, or family with several small children with one child requiring extensive assistance due to physical condition/developmental delays). May necessitate role reversal resulting in added stress or place excessive demands on parenting skills.
• Determine current knowledge of the situation, noting misconceptions, lack of information.May interfere with caregiver/ care receiver response to illness/condition.
• Identify relationship of caregiver to care receiver (e.g., spouse/lover, parent/child, sibling, friend).
• Ascertain proximity of caregiver to care receiver.
• Note physical/mental condition, complexity of therapeutic regimen of care receiver.
• Determine caregiver’s level of responsibility, involvement in and anticipated length of care.
• Ascertain developmental level/abilities and additional responsibilities of caregiver.
• Use assessment tool, such as Burden Interview, when appropriate, to further determine caregiver’s abilities.
• Identify individual cultural factors and impact on caregiver. Helps clarify expectations of caregiver/receiver, family, and community.
• Note co-dependency needs/enabling behaviors of caregiver.
• Determine availability/use of support systems and resources.
• Identify presence/degree of conflict between caregiver/care receiver/family.
• Determine preillness/current behaviors that may be interfering with the care/recovery of the care receiver.
NURSING PRIORITY NO. 3. To assist caregiver in identifying feelings and in beginning to deal with problems:
• Establish a therapeutic relationship, conveying empathy and unconditional positive regard.
• Acknowledge difficulty of the situation for the caregiver/ family.
• Discuss caregiver’s view of and concerns about situation.
• Encourage caregiver to acknowledge and express feelings. Discuss normalcy of the reactions without using false reassurance.
• Discuss caregiver’s/family members’ life goals, perceptions and expectations of self to clarify unrealistic thinking and identify potential areas of flexibility or compromise.
• Discuss impact of and ability to handle role changes necessitated by situation.
NURSING PRIORITY NO. 4. To enhance caregiver’s ability to deal with current situation:
• Identify strengths of caregiver and care receiver.
• Discuss strategies to coordinate caregiving tasks and other responsibilities (e.g., employment, care of children/dependents, housekeeping activities).
• Facilitate family conference to share information and develop plan for involvement in care activities as appropriate.
• Identify classes and/or needed specialists (e.g., first aid/CPR classes, enterostomal/physical therapist).
• Determine need for/sources of additional resources (e.g., financial, legal, respite care).
• Provide information and/or demonstrate techniques for dealing with acting out/violent or disoriented behavior. Enhances safety of caregiver and receiver.
• Identify equipment needs/resources, adaptive aids to enhance the independence and safety of the care receiver.
• Provide contact person/case manager to coordinate care, provide support, assist with problem-solving.
• Identify strengths of caregiver and care receiver.
• Discuss strategies to coordinate caregiving tasks and other responsibilities (e.g., employment, care of children/dependents, housekeeping activities).
• Facilitate family conference to share information and develop plan for involvement in care activities as appropriate.
• Identify classes and/or needed specialists (e.g., first aid/CPR classes, enterostomal/physical therapist).
• Determine need for/sources of additional resources (e.g., financial, legal, respite care).
• Provide information and/or demonstrate techniques for dealing with acting out/violent or disoriented behavior. Enhances safety of caregiver and receiver.
• Identify equipment needs/resources, adaptive aids to enhance the independence and safety of the care receiver.
• Provide contact person/case manager to coordinate care, provide support, assist with problem-solving.
NURSING PRIORITY NO. 5. To promote wellness (Teaching/ Discharge Considerations):
• Assist caregiver to plan for changes that may be necessary (e.g., home care providers, eventual placement in long-term care facility).
• Discuss/demonstrate stress management techniques and importance of self-nurturing (e.g., pursuing self-development interests, personal needs, hobbies, and social activities).
• Encourage involvement in support group.
• Refer to classes/other therapies as indicated.
• Assist caregiver to plan for changes that may be necessary (e.g., home care providers, eventual placement in long-term care facility).
• Discuss/demonstrate stress management techniques and importance of self-nurturing (e.g., pursuing self-development interests, personal needs, hobbies, and social activities).
• Encourage involvement in support group.
• Refer to classes/other therapies as indicated.
• Identify available 12-step program when indicated to provide tools to deal with enabling/co-dependent behaviors that impair level of function.
• Refer to counseling or psychotherapy as needed.
• Provide bibliotherapy of appropriate references for self-paced learning and encourage discussion of information.
• Refer to counseling or psychotherapy as needed.
• Provide bibliotherapy of appropriate references for self-paced learning and encourage discussion of information.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings, functional level/degree of impairment, caregiver’s understanding/perception of situation.
• Identified risk factors.
PLANNING
• Plan of care and individual responsibility for specific activities.
• Needed resources, including type and source of assistive devices/durable equipment.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Caregiver/receiver response to interventions/teaching and actions performed.
• Identification of inner resources, behavior/lifestyle changes to be made.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Plan for continuation/follow-through of needed changes.
• Referrals for assistance/evaluation.
ASSESSMENT/REASSESSMENT
• Assessment findings, functional level/degree of impairment, caregiver’s understanding/perception of situation.
• Identified risk factors.
PLANNING
• Plan of care and individual responsibility for specific activities.
• Needed resources, including type and source of assistive devices/durable equipment.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Caregiver/receiver response to interventions/teaching and actions performed.
• Identification of inner resources, behavior/lifestyle changes to be made.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Plan for continuation/follow-through of needed changes.
• Referrals for assistance/evaluation.
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Caregiver Role Strain - Related Factors & Characteristics
Taxonomy II: Role Relationships—Class 1 Caregiving Roles (00061)
[Diagnostic Division: Social Interaction]
Submitted 1992; Nursing Diagnosis Extension and Classification (NDEC) Revision 1998; 2000
Definition: Difficulty in performing caregiver role
[Diagnostic Division: Social Interaction]
Submitted 1992; Nursing Diagnosis Extension and Classification (NDEC) Revision 1998; 2000
Definition: Difficulty in performing caregiver role
Related Factors
CARE RECEIVER HEALTH STATUS
Illness severity/chronicity
Unpredictability of illness course; instability of care receiver’s health
Increasing care needs and dependency
Problem behaviors; psychological or cognitive problems
Addiction or co-dependency of care receiver
CAREGIVING ACTIVITIES
Discharge of family member to home with significant care needs [e.g., premature birth/congenital defect]
Unpredictability of care situation; 24-hour care responsibility; amount/complexity of activities
Ongoing changes in activities; years of caregiving
CAREGIVER HEALTH STATUS
Physical problems; psychological or cognitive problems
Inability to fulfill one’s own or others’ expectations; unrealistic expectations of self
Marginal coping patterns
Addiction or co-dependency
SOCIOECONOMIC
Competing role commitments
Alienation from family, friends, and coworkers; isolation from others
Insufficient recreation
CARE RECEIVER HEALTH STATUS
Illness severity/chronicity
Unpredictability of illness course; instability of care receiver’s health
Increasing care needs and dependency
Problem behaviors; psychological or cognitive problems
Addiction or co-dependency of care receiver
CAREGIVING ACTIVITIES
Discharge of family member to home with significant care needs [e.g., premature birth/congenital defect]
Unpredictability of care situation; 24-hour care responsibility; amount/complexity of activities
Ongoing changes in activities; years of caregiving
CAREGIVER HEALTH STATUS
Physical problems; psychological or cognitive problems
Inability to fulfill one’s own or others’ expectations; unrealistic expectations of self
Marginal coping patterns
Addiction or co-dependency
SOCIOECONOMIC
Competing role commitments
Alienation from family, friends, and coworkers; isolation from others
Insufficient recreation
CAREGIVER-CARE RECEIVER RELATIONSHIP
Unrealistic expectations of caregiver by care receiver
History of poor relationship
Mental status of elder inhibits conversation
Presence of abuse or violence
FAMILY PROCESSES
History of marginal family coping/dysfunction
RESOURCES
Inadequate physical environment for providing care (e.g., housing, temperature, safety)
Inadequate equipment for providing care; inadequate transportation
Insufficient finances
Inexperience with caregiving; insufficient time; physical energy; emotional strength; lack of support
Lack of caregiver privacy
Lack of knowledge about or difficulty accessing community resources; inadequate community services (e.g., respite care, recreational resources); assistance and support (formal and informal)
Caregiver is not developmentally ready for caregiver role
Unrealistic expectations of caregiver by care receiver
History of poor relationship
Mental status of elder inhibits conversation
Presence of abuse or violence
FAMILY PROCESSES
History of marginal family coping/dysfunction
RESOURCES
Inadequate physical environment for providing care (e.g., housing, temperature, safety)
Inadequate equipment for providing care; inadequate transportation
Insufficient finances
Inexperience with caregiving; insufficient time; physical energy; emotional strength; lack of support
Lack of caregiver privacy
Lack of knowledge about or difficulty accessing community resources; inadequate community services (e.g., respite care, recreational resources); assistance and support (formal and informal)
Caregiver is not developmentally ready for caregiver role
note: The presence of this problem may encompass other numerous problems/high-risk concerns, such as deficient Diversional Activity, disturbed Sleep Pattern, Fatigue, Anxiety, ineffective Coping, compromised family Coping, and disabled family Coping, decisional Conflict, ineffective Denial, anticipatory Grieving, Hopelessness, Powerlessness, Spiritual Distress, ineffective Health Maintenance, impaired Home Maintenance, ineffective sexuality Pattern, readiness for enhanced family Coping, interrupted Family Processes, Social Isolation. Careful attention to data gathering will
identify and clarify the client’s specific needs, which can then be coordinated under this single diagnostic label.
identify and clarify the client’s specific needs, which can then be coordinated under this single diagnostic label.
Defining Characteristics
SUBJECTIVE
CAREGIVING ACTIVITIES
Apprehension about possible institutionalization of care receiver, the future regarding care receiver’s health and caregiver’s ability to provide care, care receiver’s care if caregiver becomes ill or dies
CAREGIVER HEALTH STATUS—PHYSICAL
Gastrointestinal (GI) upset (e.g., mild stomach cramps, vomiting, diarrhea, recurrent gastric ulcer episodes)
SUBJECTIVE
CAREGIVING ACTIVITIES
Apprehension about possible institutionalization of care receiver, the future regarding care receiver’s health and caregiver’s ability to provide care, care receiver’s care if caregiver becomes ill or dies
CAREGIVER HEALTH STATUS—PHYSICAL
Gastrointestinal (GI) upset (e.g., mild stomach cramps, vomiting, diarrhea, recurrent gastric ulcer episodes)
Weight change, rash, headaches, hypertension, cardiovascular disease, diabetes, fatigue
CAREGIVER HEALTH STATUS—EMOTIONAL
Feeling depressed; anger; stress; frustration; increased nervousness
Disturbed sleep
Lack of time to meet personal needs
CAREGIVER HEALTH STATUS—SOCIOECONOMIC
Changes in leisure activities; refuses career advancement
CAREGIVER-CARE RECEIVER RELATIONSHIP
Difficulty watching care receiver go through the illness
Grief/uncertainty regarding changed relationship with care receiver
FAMILY PROCESSES—CAREGIVING ACTIVITIES
Concern about family members
OBJECTIVE
CAREGIVING ACTIVITIES
Difficulty performing/completing required tasks
Preoccupation with care routine
Dysfunctional change in caregiving activities
CAREGIVER HEALTH STATUS—EMOTIONAL
Impatience; increased emotional lability; somatization
Impaired individual coping
CAREGIVER HEALTH STATUS—SOCIOECONOMIC
Low work productivity; withdraws from social life
FAMILY PROCESSES
Family conflict
CAREGIVER HEALTH STATUS—EMOTIONAL
Feeling depressed; anger; stress; frustration; increased nervousness
Disturbed sleep
Lack of time to meet personal needs
CAREGIVER HEALTH STATUS—SOCIOECONOMIC
Changes in leisure activities; refuses career advancement
CAREGIVER-CARE RECEIVER RELATIONSHIP
Difficulty watching care receiver go through the illness
Grief/uncertainty regarding changed relationship with care receiver
FAMILY PROCESSES—CAREGIVING ACTIVITIES
Concern about family members
OBJECTIVE
CAREGIVING ACTIVITIES
Difficulty performing/completing required tasks
Preoccupation with care routine
Dysfunctional change in caregiving activities
CAREGIVER HEALTH STATUS—EMOTIONAL
Impatience; increased emotional lability; somatization
Impaired individual coping
CAREGIVER HEALTH STATUS—SOCIOECONOMIC
Low work productivity; withdraws from social life
FAMILY PROCESSES
Family conflict
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decreased Cardiac Output - Evaluation & Intervention
Desired Outcomes/Evaluation
Criteria—Client Will:
• Display hemodynamic stability (e.g., blood pressure, cardiac output, renal perfusion/urinary output, peripheral pulses).
• Report/demonstrate decreased episodes of dyspnea, angina, and dysrhythmias.
• Demonstrate an increase in activity tolerance.
• Verbalize knowledge of the disease process, individual risk factors, and treatment plan.
• Participate in activities that reduce the workload of the heart (e.g., stress management or therapeutic medication regimen program, weight reduction, balanced activity/rest plan, proper use of supplemental oxygen, cessation of smoking).
• Identify signs of cardiac decompensation, alter activities, and seek help appropriately.
Criteria—Client Will:
• Display hemodynamic stability (e.g., blood pressure, cardiac output, renal perfusion/urinary output, peripheral pulses).
• Report/demonstrate decreased episodes of dyspnea, angina, and dysrhythmias.
• Demonstrate an increase in activity tolerance.
• Verbalize knowledge of the disease process, individual risk factors, and treatment plan.
• Participate in activities that reduce the workload of the heart (e.g., stress management or therapeutic medication regimen program, weight reduction, balanced activity/rest plan, proper use of supplemental oxygen, cessation of smoking).
• Identify signs of cardiac decompensation, alter activities, and seek help appropriately.
Actions/Interventions
NURSING PRIORITY NO. 1. To identify causative/contributing factors:
• Review clients at risk as noted in Related Factors. Note: Individuals with brainstem trauma, spinal cord injuries at T7 or above, may be at risk for altered cardiac output due to an uninhibited sympathetic response. (Refer to ND risk for Autonomic Dysreflexia.)
• Evaluate medication regimen; note drug use/abuse.
• Assess potential for/type of developing shock states: hematogenic, bacteremic, cardiogenic, vasogenic, and psychogenic.
• Review laboratory data (e.g., complete blood cell—CBC—count, electrolytes, ABGs, blood urea nitrogen/creatinine—BUN/Cr—cardiac enzymes, and cultures, such as blood/ wound/secretions).
NURSING PRIORITY NO. 2. To assess degree of debilitation:
• Determine baseline vital signs/hemodynamic parameters including peripheral pulses. (Provides opportunities to track changes.)
• Review signs of impending failure/shock, noting vital signs, invasive hemodynamic parameters, breath sounds, heart tones, and urinary output. Note presence of pulsus paradoxus, reflecting cardiac tamponade.
• Review diagnostic studies (e.g., pharmacological stress testing, ECG, scans, echocardiogram, heart catheterization).
• Note response to activity/procedures and time required to return to baseline vital signs.
NURSING PRIORITY NO. 3. To minimize/correct causative factors, maximize cardiac output:
NURSING PRIORITY NO. 1. To identify causative/contributing factors:
• Review clients at risk as noted in Related Factors. Note: Individuals with brainstem trauma, spinal cord injuries at T7 or above, may be at risk for altered cardiac output due to an uninhibited sympathetic response. (Refer to ND risk for Autonomic Dysreflexia.)
• Evaluate medication regimen; note drug use/abuse.
• Assess potential for/type of developing shock states: hematogenic, bacteremic, cardiogenic, vasogenic, and psychogenic.
• Review laboratory data (e.g., complete blood cell—CBC—count, electrolytes, ABGs, blood urea nitrogen/creatinine—BUN/Cr—cardiac enzymes, and cultures, such as blood/ wound/secretions).
NURSING PRIORITY NO. 2. To assess degree of debilitation:
• Determine baseline vital signs/hemodynamic parameters including peripheral pulses. (Provides opportunities to track changes.)
• Review signs of impending failure/shock, noting vital signs, invasive hemodynamic parameters, breath sounds, heart tones, and urinary output. Note presence of pulsus paradoxus, reflecting cardiac tamponade.
• Review diagnostic studies (e.g., pharmacological stress testing, ECG, scans, echocardiogram, heart catheterization).
• Note response to activity/procedures and time required to return to baseline vital signs.
NURSING PRIORITY NO. 3. To minimize/correct causative factors, maximize cardiac output:
ACUTE PHASE
• Position with HOB flat or keep trunk horizontal while raising legs 20 to 30 degrees in shock situation (contraindicated in congestive state, in which semi-Fowler’s position is preferred).
• Monitor vital signs frequently to note response to activities.
• Perform periodic hemodynamic measurements as indicated (e.g., arterial, CVP, pulmonary, and left atrial pressures; cardiac output).
• Monitor cardiac rhythm continuously to note effectiveness of medications and/or devices (e.g., implanted pacemaker/ defibrillator).
• Administer blood/fluid replacement, antibiotics, diuretics, inotropic drugs, antidysrhythmics, steroids, vasopressors, and/or dilators as indicated. Evaluate response to determine therapeutic, adverse, or toxic effects of therapy.
• Restrict or administer fluids (IV/PO) as indicated. Provide adequate fluid/free water, depending on client needs. Assess hourly or periodic urinary output, noting total fluid balance to allow for timely alterations in therapeutic regimen.
• Monitor rate of IV drugs closely, using infusion pumps as appropriate to prevent bolus/overdose.
• Administer supplemental oxygen as indicated to increase oxygen available to tissues.
• Promote adequate rest by decreasing stimuli, providing quiet environment. Schedule activities and assessments to maximize sleep periods.
• Assist with or perform self-care activities for client.
• Avoid the use of restraints whenever possible if client is confused. (May increase agitation and increase the cardiac workload.)
• Use sedation and analgesics as indicated with caution to achieve desired effect without compromising hemodynamic readings.
• Maintain patency of invasive intravascular monitoring and infusion lines. Tape connections to prevent air embolus and/ or exsanguination.
• Maintain aseptic technique during invasive procedures. Provide site care as indicated.
• Provide antipyretics/fever control actions as indicated.
• Weigh daily.
• Avoid activities, such as isometric exercises, rectal stimulation, vomiting, spasmodic coughing, which may stimulate a Valsalva response. Administer stool softener as indicated.
• Encourage client to breathe deeply in/out during activities that increase risk for Valsalva effect.
• Alter environment/bed linens to maintain body temperature in near-normal range. Provide psychological support. Maintain calm attitude but admit concerns if questioned by the client. Honesty can be reassuring when so much activity and “worry” are apparent to the client.
• Provide information about testing procedures and client participation.
• Assist with special procedures as indicated (e.g., invasive line placement, intra-aortic—IA—balloon insertion, pericardiocentesis, cardioversion, pacemaker insertion).
• Explain dietary/fluid restrictions.
• Refer to ND ineffective Tissue Perfusion.
NURSING PRIORITY NO. 4. To promote venous return:
POSTACUTE/CHRONIC PHASE
• Provide for adequate rest, positioning client for maximum comfort. Administer analgesics as appropriate.
• Encourage relaxation techniques to reduce anxiety.
• Elevate legs when in sitting position; apply abdominal binder if indicated; use tilt table as needed to prevent orthostatic hypotension.
• Give skin care, provide sheepskin or air/water/gel/foam mattress, and assist with frequent position changes to avoid the development of pressure sores.
• Elevate edematous extremities and avoid restrictive clothing. When support hose are used, be sure they are individually fitted and appropriately applied.
• Increase activity levels as permitted by individual condition.
NURSING PRIORITY NO. 5. To maintain adequate nutrition and fluid balance:
• Provide for diet restrictions (e.g., low-sodium, bland, soft, low-calorie/residue/fat diet, with frequent small feedings as indicated).
• Note reports of anorexia/nausea and withhold oral intake as indicated.
• Provide fluids as indicated (may have some restrictions; may need to consider electrolyte replacement/supplementation to minimize dysrhythmias).
• Monitor intake/output and calculate 24-hour fluid balance.
NURSING PRIORITY NO. 6. To promote wellness (Teaching/ Discharge Considerations):
• Note individual risk factors present (e.g., smoking, stress, obesity) and specify interventions for reduction of identified factors.
• Review specifics of drug regimen, diet, exercise/activity plan.
• Discuss significant signs/symptoms that need to be reported to healthcare provider (e.g., muscle cramps, headaches, dizzimineral loss, especially potassium.
• Review “danger” signs requiring immediate physician notification (e.g., unrelieved or increased chest pain, dyspnea, edema).
• Encourage changing positions slowly, dangling legs before standing to reduce risk for orthostatic hypotension.
• Give information about positive signs of improvement, such as decreased edema, improved vital signs/circulation to provide encouragement.
• Teach home monitoring of weight, pulse, and/or blood pressure as appropriate to detect change and allow for timely intervention.
• Promote visits from family/SO(s) who provide positive input.
• Encourage relaxing environment, using relaxation techniques, massage therapy, soothing music, quiet activities.
• Instruct in stress management techniques as indicated, including appropriate exercise program.
• Identify resources for weight reduction, cessation of smoking, and so forth to provide support for change.
• Refer to NDs Activity Intolerance; deficient Diversional Activity; ineffective Coping, compromised family Coping; Sexual Dysfunction; acute or chronic Pain; imbalanced Nutrition; deficient or excess Fluid Volume, as indicated.
• Position with HOB flat or keep trunk horizontal while raising legs 20 to 30 degrees in shock situation (contraindicated in congestive state, in which semi-Fowler’s position is preferred).
• Monitor vital signs frequently to note response to activities.
• Perform periodic hemodynamic measurements as indicated (e.g., arterial, CVP, pulmonary, and left atrial pressures; cardiac output).
• Monitor cardiac rhythm continuously to note effectiveness of medications and/or devices (e.g., implanted pacemaker/ defibrillator).
• Administer blood/fluid replacement, antibiotics, diuretics, inotropic drugs, antidysrhythmics, steroids, vasopressors, and/or dilators as indicated. Evaluate response to determine therapeutic, adverse, or toxic effects of therapy.
• Restrict or administer fluids (IV/PO) as indicated. Provide adequate fluid/free water, depending on client needs. Assess hourly or periodic urinary output, noting total fluid balance to allow for timely alterations in therapeutic regimen.
• Monitor rate of IV drugs closely, using infusion pumps as appropriate to prevent bolus/overdose.
• Administer supplemental oxygen as indicated to increase oxygen available to tissues.
• Promote adequate rest by decreasing stimuli, providing quiet environment. Schedule activities and assessments to maximize sleep periods.
• Assist with or perform self-care activities for client.
• Avoid the use of restraints whenever possible if client is confused. (May increase agitation and increase the cardiac workload.)
• Use sedation and analgesics as indicated with caution to achieve desired effect without compromising hemodynamic readings.
• Maintain patency of invasive intravascular monitoring and infusion lines. Tape connections to prevent air embolus and/ or exsanguination.
• Maintain aseptic technique during invasive procedures. Provide site care as indicated.
• Provide antipyretics/fever control actions as indicated.
• Weigh daily.
• Avoid activities, such as isometric exercises, rectal stimulation, vomiting, spasmodic coughing, which may stimulate a Valsalva response. Administer stool softener as indicated.
• Encourage client to breathe deeply in/out during activities that increase risk for Valsalva effect.
• Alter environment/bed linens to maintain body temperature in near-normal range. Provide psychological support. Maintain calm attitude but admit concerns if questioned by the client. Honesty can be reassuring when so much activity and “worry” are apparent to the client.
• Provide information about testing procedures and client participation.
• Assist with special procedures as indicated (e.g., invasive line placement, intra-aortic—IA—balloon insertion, pericardiocentesis, cardioversion, pacemaker insertion).
• Explain dietary/fluid restrictions.
• Refer to ND ineffective Tissue Perfusion.
NURSING PRIORITY NO. 4. To promote venous return:
POSTACUTE/CHRONIC PHASE
• Provide for adequate rest, positioning client for maximum comfort. Administer analgesics as appropriate.
• Encourage relaxation techniques to reduce anxiety.
• Elevate legs when in sitting position; apply abdominal binder if indicated; use tilt table as needed to prevent orthostatic hypotension.
• Give skin care, provide sheepskin or air/water/gel/foam mattress, and assist with frequent position changes to avoid the development of pressure sores.
• Elevate edematous extremities and avoid restrictive clothing. When support hose are used, be sure they are individually fitted and appropriately applied.
• Increase activity levels as permitted by individual condition.
NURSING PRIORITY NO. 5. To maintain adequate nutrition and fluid balance:
• Provide for diet restrictions (e.g., low-sodium, bland, soft, low-calorie/residue/fat diet, with frequent small feedings as indicated).
• Note reports of anorexia/nausea and withhold oral intake as indicated.
• Provide fluids as indicated (may have some restrictions; may need to consider electrolyte replacement/supplementation to minimize dysrhythmias).
• Monitor intake/output and calculate 24-hour fluid balance.
NURSING PRIORITY NO. 6. To promote wellness (Teaching/ Discharge Considerations):
• Note individual risk factors present (e.g., smoking, stress, obesity) and specify interventions for reduction of identified factors.
• Review specifics of drug regimen, diet, exercise/activity plan.
• Discuss significant signs/symptoms that need to be reported to healthcare provider (e.g., muscle cramps, headaches, dizzimineral loss, especially potassium.
• Review “danger” signs requiring immediate physician notification (e.g., unrelieved or increased chest pain, dyspnea, edema).
• Encourage changing positions slowly, dangling legs before standing to reduce risk for orthostatic hypotension.
• Give information about positive signs of improvement, such as decreased edema, improved vital signs/circulation to provide encouragement.
• Teach home monitoring of weight, pulse, and/or blood pressure as appropriate to detect change and allow for timely intervention.
• Promote visits from family/SO(s) who provide positive input.
• Encourage relaxing environment, using relaxation techniques, massage therapy, soothing music, quiet activities.
• Instruct in stress management techniques as indicated, including appropriate exercise program.
• Identify resources for weight reduction, cessation of smoking, and so forth to provide support for change.
• Refer to NDs Activity Intolerance; deficient Diversional Activity; ineffective Coping, compromised family Coping; Sexual Dysfunction; acute or chronic Pain; imbalanced Nutrition; deficient or excess Fluid Volume, as indicated.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Baseline and subsequent findings and individual hemodynamic parameters, heart and breath sounds, ECG pattern, presence/strength of peripheral pulses, skin/tissue status, renal output, and mentation.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s responses to interventions/teaching and actions performed.
• Status and disposition at discharge.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Discharge considerations and who will be responsible for carrying out individual actions.
ASSESSMENT/REASSESSMENT
• Baseline and subsequent findings and individual hemodynamic parameters, heart and breath sounds, ECG pattern, presence/strength of peripheral pulses, skin/tissue status, renal output, and mentation.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s responses to interventions/teaching and actions performed.
• Status and disposition at discharge.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Discharge considerations and who will be responsible for carrying out individual actions.
• Long-term needs.
• Specific referrals made.
• Specific referrals made.
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decreased Cardiac Output - Characteristics & related factors
Taxonomy II: Activity/Rest—Class 4 Cardiovascular/Pulmonary Responses (00029)
[Diagnostic Division: Circulation]
Submitted 1975; Revised 1996, 2000
[Diagnostic Division: Circulation]
Submitted 1975; Revised 1996, 2000
Definition: Inadequate blood pumped by the heart to meet the metabolic demands of the body. [Note: In a hypermetabolic state, although cardiac output may be within normal range, it may still be inadequate to meet the needs of the body’s tissues. Cardiac output and tissue perfusion are interrelated, although there are differences. When cardiac output is decreased, tissue perfusion problems will develop; however, tissue perfusion problems can exist without decreased cardiac output.]
Related Factors
Altered heart rate/rhythm, [conduction]
Altered stroke volume: altered preload [e.g., decreased venous return]; altered afterload [e.g., systemic vascular resistance]; altered contractility [e.g., ventricular-septal rupture, ventricular aneurysm, papillary muscle rupture, valvular disease]
Altered heart rate/rhythm, [conduction]
Altered stroke volume: altered preload [e.g., decreased venous return]; altered afterload [e.g., systemic vascular resistance]; altered contractility [e.g., ventricular-septal rupture, ventricular aneurysm, papillary muscle rupture, valvular disease]
Defining Characteristics
SUBJECTIVE
Altered Heart Rate/Rhythm: Palpitations
Altered Preload: Fatigue
Altered Afterload: Shortness of breath/dyspnea
Altered Contractility: Orthopnea/paroxysmal nocturnal dyspnea
[PND]
Behavioral/Emotional: Anxiety
OBJECTIVE
Altered Heart Rate/Rhythm: [Dys]arrhythmias (tachycardia, bradycardia); EKG [ECG] changes
Altered Preload: Jugular vein distention (JVD); edema; weight gain; increased/decreased central venous pressure (CVP); increased/decreased pulmonary artery wedge pressure (PAWP); murmurs
Altered Afterload: Cold, clammy skin; skin [and mucous membrane] color changes [cyanosis, pallor]; prolonged capillary refill; decreased peripheral pulses; variations in blood pressure readings; increased/decreased systemic vascular resistance (SVR)/pulmonary vascular resistance (PVR); oliguria; [anuria]
Altered Contractility: Crackles; cough; cardiac output, 4 L/min; cardiac index, 2.5 L/min; decreased ejection fraction, stroke volume index (SVI), left ventricular stroke work index (LVSWI); S3 or S4 sounds [gallop rhythm]
Behavioral/Emotional: Restlessness
SUBJECTIVE
Altered Heart Rate/Rhythm: Palpitations
Altered Preload: Fatigue
Altered Afterload: Shortness of breath/dyspnea
Altered Contractility: Orthopnea/paroxysmal nocturnal dyspnea
[PND]
Behavioral/Emotional: Anxiety
OBJECTIVE
Altered Heart Rate/Rhythm: [Dys]arrhythmias (tachycardia, bradycardia); EKG [ECG] changes
Altered Preload: Jugular vein distention (JVD); edema; weight gain; increased/decreased central venous pressure (CVP); increased/decreased pulmonary artery wedge pressure (PAWP); murmurs
Altered Afterload: Cold, clammy skin; skin [and mucous membrane] color changes [cyanosis, pallor]; prolonged capillary refill; decreased peripheral pulses; variations in blood pressure readings; increased/decreased systemic vascular resistance (SVR)/pulmonary vascular resistance (PVR); oliguria; [anuria]
Altered Contractility: Crackles; cough; cardiac output, 4 L/min; cardiac index, 2.5 L/min; decreased ejection fraction, stroke volume index (SVI), left ventricular stroke work index (LVSWI); S3 or S4 sounds [gallop rhythm]
Behavioral/Emotional: Restlessness
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Top Retention Strategies for Keeping the Best Nurses in the Profession
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ineffective Breathing Pattern - Action/ Intervention and Documentation Focus
Actions/Interventions
NURSING PRIORITY NO. 1. To identify etiology/precipitating factors:
• Auscultate chest, noting presence/character of breath sounds, presence of secretions.
• Note rate and depth of respirations, type of breathing pattern: tachypnea, Cheyne-Stokes, other irregular patterns.
• Assist with necessary testing (e.g., lung volumes/flow studies, pulmonary function/sleep studies) to diagnose presence/ severity of lung diseases.
• Review chest x-rays as indicated for severity of acute/chronic conditions.
• Review laboratory data, for example, ABGs (determine degree of oxygenation,CO2 retention); drug screens; and pulmonary function studies (determine vital capacity/tidal volume).
• Note emotional responses, for example, gasping, crying, tingling fingers. (Hyperventilation may be a factor.)
• Assess for concomitant pain/discomfort that may restrict/ limit respiratory effort.
NURSING PRIORITY NO. 2. To provide for relief of causative factors:
• Administer oxygen at lowest concentration indicated for underlying pulmonary condition, respiratory distress, or cyanosis.
• Suction airway as needed to clear secretions.
• Assist with bronchoscopy or chest tube insertion as indicated.
• Elevate HOB as appropriate to promote physiological/ psychological ease of maximal inspiration.
• Encourage slower/deeper respirations, use of pursed-lip technique, and so on to assist client in “taking control” of the situation.
• Have client breathe into a paper bag to correct hyperventilation.
• Maintain calm attitude while dealing with client and SO(s) to limit level of anxiety.
• Assist client in the use of relaxation techniques.
• Deal with fear/anxiety that may be present. (Refer to NDs Fear and/or Anxiety.)
• Encourage position of comfort. Reposition client frequently if immobility is a factor.
• Splint rib cage during deep-breathing exercises/cough if indicated.
• Medicate with analgesics as appropriate to promote deeper respiration and cough. (Refer to NDs acute Pain, or chronic Pain.)
• Encourage ambulation as individually indicated.
• Avoid overeating/gas-forming foods; may cause abdominal distention.
• Provide use of adjuncts, such as incentive spirometer, to facilitate deeper respiratory effort.
• Supervise use of respirator/diaphragmatic stimulator, rocking bed, apnea monitor, and so forth when neuromuscular impairment is present.
• Maintain emergency equipment in readily accessible location and include age/size appropriate ET/trach tubes (e.g., infant, child, adolescent, or adult).
NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Review etiology and possible coping behaviors.
• Teach conscious control of respiratory rate as appropriate.
• Maximize respiratory effort with good posture and effective use of accessory muscles.
• Assist client to learn breathing exercises: diaphragmatic, abdominal breathing, inspiratory resistive, and pursed-lip as indicated.
• Recommend energy conservation techniques and pacing of activities.
• Encourage adequate rest periods between activities to limit fatigue.
• Discuss relationship of smoking to respiratory function.
• Encourage client/SO(s) to develop a plan for smoking cessation. Provide appropriate referrals.
• Instruct in proper use and safety concerns for home oxygen therapy as indicated.
• Make referral to support groups/contact with individuals who have encountered similar problems.
• Administer oxygen at lowest concentration indicated for underlying pulmonary condition, respiratory distress, or cyanosis.
• Suction airway as needed to clear secretions.
• Assist with bronchoscopy or chest tube insertion as indicated.
• Elevate HOB as appropriate to promote physiological/ psychological ease of maximal inspiration.
• Encourage slower/deeper respirations, use of pursed-lip technique, and so on to assist client in “taking control” of the situation.
• Have client breathe into a paper bag to correct hyperventilation.
• Maintain calm attitude while dealing with client and SO(s) to limit level of anxiety.
• Assist client in the use of relaxation techniques.
• Deal with fear/anxiety that may be present. (Refer to NDs Fear and/or Anxiety.)
• Encourage position of comfort. Reposition client frequently if immobility is a factor.
• Splint rib cage during deep-breathing exercises/cough if indicated.
• Medicate with analgesics as appropriate to promote deeper respiration and cough. (Refer to NDs acute Pain, or chronic Pain.)
• Encourage ambulation as individually indicated.
• Avoid overeating/gas-forming foods; may cause abdominal distention.
• Provide use of adjuncts, such as incentive spirometer, to facilitate deeper respiratory effort.
• Supervise use of respirator/diaphragmatic stimulator, rocking bed, apnea monitor, and so forth when neuromuscular impairment is present.
• Maintain emergency equipment in readily accessible location and include age/size appropriate ET/trach tubes (e.g., infant, child, adolescent, or adult).
NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Review etiology and possible coping behaviors.
• Teach conscious control of respiratory rate as appropriate.
• Maximize respiratory effort with good posture and effective use of accessory muscles.
• Assist client to learn breathing exercises: diaphragmatic, abdominal breathing, inspiratory resistive, and pursed-lip as indicated.
• Recommend energy conservation techniques and pacing of activities.
• Encourage adequate rest periods between activities to limit fatigue.
• Discuss relationship of smoking to respiratory function.
• Encourage client/SO(s) to develop a plan for smoking cessation. Provide appropriate referrals.
• Instruct in proper use and safety concerns for home oxygen therapy as indicated.
• Make referral to support groups/contact with individuals who have encountered similar problems.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Relevant history of problem.
• Respiratory pattern, breath sounds, use of accessory muscles.
• Laboratory values.
• Use of respiratory supports, ventilator settings, and so forth.
PLANNING
• Plan of care/interventions and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Response to interventions/teaching, actions performed, and treatment regimen.
• Mastery of skills, level of independence.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs, including appropriate referrals and action taken, available resources.
• Specific referrals provided.
ASSESSMENT/REASSESSMENT
• Relevant history of problem.
• Respiratory pattern, breath sounds, use of accessory muscles.
• Laboratory values.
• Use of respiratory supports, ventilator settings, and so forth.
PLANNING
• Plan of care/interventions and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Response to interventions/teaching, actions performed, and treatment regimen.
• Mastery of skills, level of independence.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs, including appropriate referrals and action taken, available resources.
• Specific referrals provided.
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ineffective Breathing Pattern
Taxonomy II: Activity/Rest—Class 4
Cardiovascular/Pulmonary Responses (00032)
[Diagnostic Division: Respiration]
Submitted 1980; Revised 1996, and Nursing Diagnosis
Extension and Classification (NDEC) 1998
Definition: Inspiration and/or expiration that does not provide adequate ventilation
Cardiovascular/Pulmonary Responses (00032)
[Diagnostic Division: Respiration]
Submitted 1980; Revised 1996, and Nursing Diagnosis
Extension and Classification (NDEC) 1998
Definition: Inspiration and/or expiration that does not provide adequate ventilation
Related Factors
Neuromuscular dysfunction; SCI; neurological immaturity
Musculoskeletal impairment; bony/chest wall deformity
Anxiety
Pain
Perception/cognitive impairment
Decreased energy/fatigue; respiratory muscle fatigue
Body position; obesity
Hyperventilation; hypoventilation syndrome; [alteration of client’s normal O2:CO2 ratio (e.g., O2 therapy in COPD)]
Neuromuscular dysfunction; SCI; neurological immaturity
Musculoskeletal impairment; bony/chest wall deformity
Anxiety
Pain
Perception/cognitive impairment
Decreased energy/fatigue; respiratory muscle fatigue
Body position; obesity
Hyperventilation; hypoventilation syndrome; [alteration of client’s normal O2:CO2 ratio (e.g., O2 therapy in COPD)]
Defining Characteristics
SUBJECTIVE
Shortness of breath
OBJECTIVE
Dyspnea; orthopnea
Respiratory rate:
Adults >14 yr: <=11 or [>]24
Children 1 to 4 yr, <20 or >30
5 to 14 yr, <14 or >25
Infants [0 to 12 mo], <25 or >60
Depth of breathing:
Adult tidal volume: 500 mL at rest
Infant tidal volume: 6 to 8 mL/kg
Timing ratio; prolonged expiration phases; pursed-lip breathing
Decreased minute ventilation; vital capacity
Decreased inspiratory/expiratory pressure
Use of accessory muscles to breathe; assumption of three-point position
Altered chest excursion; [paradoxical breathing patterns]
Nasal flaring; [grunting]
Increased anterior-posterior diameter
SUBJECTIVE
Shortness of breath
OBJECTIVE
Dyspnea; orthopnea
Respiratory rate:
Adults >14 yr: <=11 or [>]24
Children 1 to 4 yr, <20 or >30
5 to 14 yr, <14 or >25
Infants [0 to 12 mo], <25 or >60
Depth of breathing:
Adult tidal volume: 500 mL at rest
Infant tidal volume: 6 to 8 mL/kg
Timing ratio; prolonged expiration phases; pursed-lip breathing
Decreased minute ventilation; vital capacity
Decreased inspiratory/expiratory pressure
Use of accessory muscles to breathe; assumption of three-point position
Altered chest excursion; [paradoxical breathing patterns]
Nasal flaring; [grunting]
Increased anterior-posterior diameter
Desired Outcomes/Evaluation
Criteria—Client Will:
• Establish a normal/effective respiratory pattern.
• Be free of cyanosis and other signs/symptoms of hypoxia with ABGs within client’s normal/acceptable range.
• Verbalize awareness of causative factors and initiate needed lifestyle changes.
• Demonstrate appropriate coping behaviors.
Criteria—Client Will:
• Establish a normal/effective respiratory pattern.
• Be free of cyanosis and other signs/symptoms of hypoxia with ABGs within client’s normal/acceptable range.
• Verbalize awareness of causative factors and initiate needed lifestyle changes.
• Demonstrate appropriate coping behaviors.
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interrupted Breastfeeding
Taxonomy II: Role Relationships—Class 3 Role Performance (00105)
[Diagnostic Division: Food/Fluid]
Submitted 1992
Definition: Break in the continuity of the breastfeeding process as a result of inability or inadvisability to put baby to breast for feeding
[Diagnostic Division: Food/Fluid]
Submitted 1992
Definition: Break in the continuity of the breastfeeding process as a result of inability or inadvisability to put baby to breast for feeding
Related Factors
Maternal or infant illness
Prematurity
Maternal employment
Contraindications to breastfeeding (e.g., drugs, true breast milk jaundice)
Need to abruptly wean infant
Maternal or infant illness
Prematurity
Maternal employment
Contraindications to breastfeeding (e.g., drugs, true breast milk jaundice)
Need to abruptly wean infant
Defining Characteristics
SUBJECTIVE
Infant does not receive nourishment at the breast for some or all of feedings
Maternal desire to maintain lactation and provide (or eventually provide) her breast milk for her infant’s nutritional needs
Lack of knowledge regarding expression and storage of breast milk
OBJECTIVE
Separation of mother and infant
SUBJECTIVE
Infant does not receive nourishment at the breast for some or all of feedings
Maternal desire to maintain lactation and provide (or eventually provide) her breast milk for her infant’s nutritional needs
Lack of knowledge regarding expression and storage of breast milk
OBJECTIVE
Separation of mother and infant
Desired Outcomes/Evaluation
Criteria—Client Will:
• Identify and demonstrate techniques to sustain lactation until breastfeeding is reinitiated.
• Achieve mutually satisfactory feeding regimen with infant content after feedings and gaining weight appropriately.
• Achieve weaning and cessation of lactation if desired or necessary.
Criteria—Client Will:
• Identify and demonstrate techniques to sustain lactation until breastfeeding is reinitiated.
• Achieve mutually satisfactory feeding regimen with infant content after feedings and gaining weight appropriately.
• Achieve weaning and cessation of lactation if desired or necessary.
Actions/Interventions
NURSING PRIORITY NO. 1. To identify causative/contributing factors:
• Assess client knowledge and perceptions about breastfeeding and extent of instruction that has been given.
• Encourage discussion of current/previous breastfeeding experience(s).
• Determine maternal responsibilities, routines, and scheduled activities (e.g., caretaking of siblings, employment in/out of home, work/school schedules of family members, ability to visit hospitalized infant).
• Note contraindications to breastfeeding (e.g., maternal illness, drug use); desire/need to wean infant.
• Ascertain cultural expectations/conflicts.
NURSING PRIORITY NO. 1. To identify causative/contributing factors:
• Assess client knowledge and perceptions about breastfeeding and extent of instruction that has been given.
• Encourage discussion of current/previous breastfeeding experience(s).
• Determine maternal responsibilities, routines, and scheduled activities (e.g., caretaking of siblings, employment in/out of home, work/school schedules of family members, ability to visit hospitalized infant).
• Note contraindications to breastfeeding (e.g., maternal illness, drug use); desire/need to wean infant.
• Ascertain cultural expectations/conflicts.
NURSING PRIORITY NO. 2. To assist mother to maintain or conclude breastfeeding as desired/required:
• Give emotional support to mother and accept decision regarding cessation/continuation of breastfeeding.
• Demonstrate use of manual and/or electric piston-type breast pump.
• Suggest abstinence/restriction of tobacco, caffeine, alcohol, drugs, excess sugar as appropriate when breastfeeding is reinitiated because they may affect milk production/let-down reflex or be passed on to the infant.
• Provide information (e.g., wearing a snug, well-fitting brassiere, avoiding stimulation, and using medication for discomfort to support weaning process).
NURSING PRIORITY NO. 3. To promote successful infant feeding:
• Review techniques for storage/use of expressed breast milk to provide optimal nutrition and promote continuation of breastfeeding process.
• Discuss proper use and choice of supplemental nutrition and alternate feeding method (e.g., bottle/syringe).
• Review safety precautions (e.g., proper flow of formula from nipple, frequency of burping, holding bottle instead of propping, formula preparation, and sterilization techniques).
• Determine if a routine visiting schedule or advance warning can be provided so that infant will be hungry/ready to feed.
• Provide privacy, calm surroundings when mother breastfeeds in hospital setting.
• Recommend/provide for infant sucking on a regular basis, especially if gavage feedings are part of the therapeutic regimen. Reinforces that feeding time is pleasurable and enhances digestion.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake as indicated to sustain adequate milk production and breastfeeding process.
• Identify other means of nurturing/strengthening infant attachment (e.g., comforting, consoling, play activities).
• Refer to support groups (e.g., La Leche League, Lact-Aid), community resources (e.g., public health nurse, lactation specialist).
• Promote use of bibliotherapy for further information.
• Give emotional support to mother and accept decision regarding cessation/continuation of breastfeeding.
• Demonstrate use of manual and/or electric piston-type breast pump.
• Suggest abstinence/restriction of tobacco, caffeine, alcohol, drugs, excess sugar as appropriate when breastfeeding is reinitiated because they may affect milk production/let-down reflex or be passed on to the infant.
• Provide information (e.g., wearing a snug, well-fitting brassiere, avoiding stimulation, and using medication for discomfort to support weaning process).
NURSING PRIORITY NO. 3. To promote successful infant feeding:
• Review techniques for storage/use of expressed breast milk to provide optimal nutrition and promote continuation of breastfeeding process.
• Discuss proper use and choice of supplemental nutrition and alternate feeding method (e.g., bottle/syringe).
• Review safety precautions (e.g., proper flow of formula from nipple, frequency of burping, holding bottle instead of propping, formula preparation, and sterilization techniques).
• Determine if a routine visiting schedule or advance warning can be provided so that infant will be hungry/ready to feed.
• Provide privacy, calm surroundings when mother breastfeeds in hospital setting.
• Recommend/provide for infant sucking on a regular basis, especially if gavage feedings are part of the therapeutic regimen. Reinforces that feeding time is pleasurable and enhances digestion.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Encourage mother to obtain adequate rest, maintain fluid and nutritional intake, and schedule breast pumping every 3 hours while awake as indicated to sustain adequate milk production and breastfeeding process.
• Identify other means of nurturing/strengthening infant attachment (e.g., comforting, consoling, play activities).
• Refer to support groups (e.g., La Leche League, Lact-Aid), community resources (e.g., public health nurse, lactation specialist).
• Promote use of bibliotherapy for further information.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Baseline findings maternal/infant factors.
• Number of wet diapers daily/periodic weight.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
ASSESSMENT/REASSESSMENT
• Baseline findings maternal/infant factors.
• Number of wet diapers daily/periodic weight.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Maternal response to interventions/teaching and actions performed.
• Infant’s response to feeding and method.
• Whether infant appears satisfied or still seems to be hungry.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Plan for follow-up and who is responsible.
• Specific referrals made.
• Maternal response to interventions/teaching and actions performed.
• Infant’s response to feeding and method.
• Whether infant appears satisfied or still seems to be hungry.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Plan for follow-up and who is responsible.
• Specific referrals made.
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