Nursing Dx

Taxonomy II: Role Relationships—Class 1 Role Performance (00064)
[Diagnostic Division: Social Interaction]
Submitted 1988
Definition: Parent experience of role confusion and conflict in response to crisis

Related Factors
Separation from child because of chronic illness [/disability]
Intimidation with invasive or restrictive modalities (e.g., isolation, intubation); specialized care centers, policies
Home care of a child with special needs (e.g., apnea monitoring, postural drainage, hyperalimentation)
Change in marital status
Interruptions of family life because of home-care regimen (treatments, caregivers, lack of respite)

Defining Characteristics
SUBJECTIVE
Parent(s) express(es) concerns/feeling of inadequacy to provide for child’s physical and emotional needs during hospitalization or in the home
Parent(s) express(es) concerns about changes in parental role, family functioning, family communication, family health
Express(es) concern about perceived loss of control over decisions relating to child
Verbaliz(es) feelings of guilt, anger, fear, anxiety and/or frustrations about effect of child’s illness on family process
OBJECTIVE
Demonstrates disruption in caretaking routines
Reluctant to participate in usual caretaking activities even with encouragement and support
Demonstrates feelings of guilt, anger, fear, anxiety, and/or frustrations about the effect of child’s illness on family process

Desired Outcomes/Evaluation
Criteria—Parent(s) Will:
• Verbalize understanding of situation and expected parent’s/ child’s role.
• Express feelings about child’s illness/situation and effect on family life.

• Demonstrate appropriate behaviors in regard to parenting role.
• Assume caretaking activities as appropriate.
• Handle family disruptions effectively.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributory factors:
• Assess individual situation and parent’s perception of/ concern about what is happening and expectations of self as caregiver.
• Note parental status including age and maturity, stability of relationship, other responsibilities. (Increasing numbers of elderly individuals are providing full-time care for young grandchildren whose parents are unavailable or unable to provide care.)
• Ascertain parent’s understanding of child’s developmental stage and expectations for the future to identify misconceptions/ strengths.
• Note coping skills currently being used by each individual as well as how problems have been dealt with in the past. Provides basis for comparison and reference for client’s coping abilities.
• Determine use of substances (e.g., alcohol, other drugs, including prescription medications).May interfere with individual’s ability to cope/problem-solve.
• Assess availability/use of resources, including extended family, support groups, and financial.
• Perform testing such as Parent-Child Relationship Inventory (PCRI) for further evaluation as indicated.

NURSING PRIORITY NO. 2. To assist parents to deal with current crisis:
• Encourage free verbal expression of feelings (including negative feelings of anger and hostility), setting limits on inappropriate behavior.
• Acknowledge difficulty of situation and normalcy of feeling overwhelmed and helpless. Encourage contact with parents who experienced similar situation with child and had positive outcome.
• Provide information, including technical information when appropriate, to meet individual needs/correct misconceptions.
• Promote parental involvement in decision making and care as much as possible/desired. Enhances sense of control.

• Encourage interaction/facilitate communication between parent(s) and children.
• Promote use of assertiveness, relaxation skills to help individuals to deal with situation/crisis.
• Assist parent to learn proper administration of medications/ treatments as indicated.
• Provide for/encourage use of respite care, parent time off to enhance emotional well-being.

NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Provide anticipatory guidance to encourage making plans for future needs.
• Encourage setting realistic and mutually agreed-on goals.
• Provide/identify learning opportunities specific to needs (e.g., parenting classes, equipment use/troubleshooting).
• Refer to community resources as appropriate (e.g., visiting nurse, respite care, social services, psychiatric care/family therapy, well-baby clinics, special needs support services).
• Refer to ND impaired Parenting, for additional interventions.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Findings, including specifics of individual situation/parental concerns, perceptions, expectations.
PLANNING
• Plan of care and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Parent’s responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for each action to be taken.
• Specific referrals made.

The ability of nurses to engage in ethical practice in everyday work and to deal with ethical situations, problems and concerns can be the result of decisions made at a variety of levels – individual, organizational, regional, provincial, national and international. Differing responsibilities, capabilities and ways of working toward change also exist at these various levels. For all contexts and levels of decision-making, the code offers guidance for providing care that is congruent with ethical practice and for actively influencing and participating in policy development, review and revision.

The complex issues in nursing practice have both legal and ethical dimensions. An ideal system of law would be compatible with ethics, in that adherence to the law should never require the violation of ethics. There may be situations in which nurses need to take collective action to change a law that is incompatible with ethics. Still, the domains of law and ethics remain distinct, and the code addresses ethical responsibilities only.

Taxonomy II: Life Principles—Class 3 Value/Belief/Action
Congruence (00083)
[Diagnostic Division: Ego Integrity]
Submitted 1988
Definition: Uncertainty about course of action to be taken when choice among competing actions involves risk, loss, or challenge to personal life values

Related Factors
Unclear personal values/beliefs; perceived threat to value system
Lack of experience or interference with decision making
Lack of relevant information, multiple or divergent sources of information
Support system deficit
[Age, developmental state]
[Family system, sociocultural factors]
[Cognitive, emotional, behavioral level of functioning]

Defining Characteristics
SUBJECTIVE
Verbalized uncertainty about choices or of undesired consequences of alternative actions being considered
Verbalized feeling of distress or questioning personal values and beliefs while attempting a decision
OBJECTIVE
Vacillation between alternative choices; delayed decision making
Self-focusing
Physical signs of distress or tension (increased heart rate; increased muscle tension; restlessness; etc.)

Desired Outcomes/Evaluation
Criteria—Client Will:
• Verbalize awareness of positive and negative aspects of choices/alternative actions.
• Acknowledge/ventilate feelings of anxiety and distress associated with choice/related to making difficult decision.
• Identify personal values and beliefs concerning issues.
• Make decision(s) and express satisfaction with choices.
• Meet psychological needs as evidenced by appropriate expression of feelings, identification of options, and use of resources.
• Display relaxed manner/calm demeanor, free of physical signs of distress.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Determine usual ability to manage own affairs. Clarify who has legal right to intervene on behalf of child (e.g., parent, other relative, or court appointed guardian/advocate). (Family disruption/conflicts can complicate decision process.)
• Note expressions of indecision, dependence on others, availability/involvement of support persons (e.g., lack of/conflicting advice). Ascertain dependency of other(s) on client and/ or issues of codependency.
• Active-listen/identify reason for indecisiveness to help client clarify problem.
• Determine effectiveness of current problem-solving techniques.
• Note presence/intensity of physical signs of anxiety (e.g., increased heart rate, muscle tension).
• Listen for expressions of inability to find meaning in life/ reason for living, feelings of futility, or alienation from God and others around them. (Refer to ND Spiritual Distress as indicated.)

NURSING PRIORITY NO. 2. To assist client to develop/effectively use problem-solving skills:
• Promote safe and hopeful environment, as needed, while client regains inner control.
• Encourage verbalization of conflicts/concerns.
• Accept verbal expressions of anger/guilt, setting limits on maladaptive behavior to promote client safety.
• Clarify and prioritize individual goals, noting where the subject of the “conflict” falls on this scale.
• Identify strengths and presence of positive coping skills (e.g., use of relaxation technique, willingness to express feelings).
• Identify positive aspects of this experience and assist client to view it as a learning opportunity to develop new and creative solutions.
• Correct misperceptions client may have and provide factual information. Provides for better decision making.
• Provide opportunities for client to make simple decisions regarding self-care and other daily activities. Accept choice not to do so. Advance complexity of choices as tolerated.
• Encourage child to make developmentally appropriate decisions concerning own care. Fosters child’s sense of self-worth, enhances ability to learn/exercise coping skills.
• Discuss time considerations, setting time line for small steps and considering consequences related to not making/postponing specific decisions to facilitate resolution of conflict.
• Have client list some alternatives to present situation or decisions, using a brainstorming process. Include family in this activity as indicated (e.g., placement of parent in long-term care facility, use of intervention process with addicted member). Refer to NDs interrupted Family Processes; dysfunctional Family Processes: alcoholism; compromised family Coping.
• Practice use of problem-solving process with current situation/ decision.

• Discuss/clarify spiritual concerns, accepting client’s values in a nonjudgmental manner.
NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Promote opportunities for using conflict-resolution skills, identifying steps as client does each one.
• Provide positive feedback for efforts and progress noted. Promotes continuation of efforts.
• Encourage involvement of family/SO(s) as desired/available to provide support for the client.
• Support client for decisions made, especially if consequences are unexpected, difficult to cope with.
• Encourage attendance at stress reduction, assertiveness classes.
• Refer to other resources as necessary (e.g., clergy, psychiatric clinical nurse specialist/psychiatrist, family/marital therapist, addiction support groups).

Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings/behavioral responses, degree of impairment in lifestyle functioning.
• Individuals involved in the conflict.
• Personal values/beliefs.
PLANNING
• Plan of care/interventions and who is involved in the planning process.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s and involved individual’s responses to interventions/ teaching and actions performed.
• Ability to express feelings, identify options; use of resources.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs/referrals, actions to be taken, and who is responsible for doing.
• Specific referrals made.

communication, and identifying specific needs/expectationshelps in developing realistic goals and determining likelihood of success.

• Evaluate mental status. Disorientation and psychotic conditionsmay be affecting speech and the communication ofthoughts, needs, and desires.

• Determine client’s developmental level of speech and language comprehension. Provides baseline information fordeveloping plan for improvement.

• Determine ability to read/write. Evaluating grasp of language as well as musculoskeletal states, including manual dexterity (e.g., ability to hold a pen and write), provides informationabout nature of client’s situation. Educational plan canaddress language skills. Neuromuscular deficits will requireindividual program to correct.

• Determine country of origin, dominant language, whetherclient is recent immigrant and what cultural, ethnic groupclient identifies as own. Recent immigrant may identify withhome country, and its people, language, beliefs, and healthcarepractices affecting desire to learn language and improveability to interact in new country.

• Ascertain if interpreter is needed/desired. Law mandates thatinterpretation services be made available. Trained, professionalinterpreter who translates precisely and possesses abasic understanding of medical terminology and healthcareethics is preferred to enhance client and provider satisfaction.

• Determine comfort level in expression of feelings andconcepts in nonproficient language. Anxiety about languagedifficulty can interfere with ability to communicate effectively.

• Note any physical barriers to effective communication (e.g.,talking tracheostomy, wired jaws) or physiological/neurologicalconditions (e.g., severe shortness of breath, neuromuscularweakness, stroke, brain trauma, hearing impairment, cleft palate, facial trauma). Client may be dealing withspeech/language comprehension or have voice productionproblems (pitch, loudness, or quality)that call attention tovoice rather than what speaker is saying. These barriers willneed to be addressed to enable client to improve communicationskills.

• Clarify meaning of words used by the client to describeimportant aspects of life and health/well-being (e.g., pain,sorrow, anxiety). Words can easily be misinterpreted whensender and receiver have different ideas about their meanings. This can affect the way both client and caregiver communicateimportant concepts. Restating what one has heardcan clarify whether an expressed statement has been understoodor misinterpreted.

• Evaluate level of anxiety, frustration, or fear; presence of angry,hostile behavior. Emotional/psychiatric issues can affect communicationand interfere with understanding.

• Evaluate congruency of verbal and nonverbal messages. It isestimated that 65% to 95% of communication is nonverbal,and communication is enhanced when verbal and nonverbalmessages are congruent.

• Determine lack of knowledge or misunderstanding of terms related to client’s specific situation. Indicators of need for additional information, clarification to help client improve ability to communicate.

• Evaluate need/desire for pictures or written communications and instructions as part of treatment plan. Alternative methods of communication can help client feel understood and promote feelings of satisfaction with interaction.

NURSING PRIORITY NO. 2. To improve client’s ability to communicate thoughts, needs, and ideas:
• Maintain a calm, unhurried manner. Provide sufficient time for client to respond. An atmosphere in which client is free to speak without fear of criticism provides the opportunity to explore all the issues involved in making decisions to improve communication skills.
• Pay attention to speaker. Be an active listener. The use of Active-listening communicates acceptance and respect for the client, establishing trust and promoting openness and honest expression. It communicates a belief that the client is a capable and competent person.
• Sit down, maintain eye contact, preferably at client’s level, and spend time with the client. Conveys message that the nurse has time and interest in communicating.
• Observe body language, eye movements, and behavioral clues. May reveal unspoken concerns, for example, when pain is present, client may react with tears, grimacing, stiff posture, turning away, and angry outbursts.
• Help client identify and learn to avoid use of nontherapeutic communication. These barriers are recognized as detriments  to open communication, and learning to avoid them maximizes the effectiveness of communication between client and others.
• Establish hand/eye signals if indicated. Neurological impairments may allow client to understand language but not be able to speak and/or may have a physical barrier to writing.

• Obtain interpreter with language or signing abilities as needed. May be needed to enhance understanding of words, language concepts, or needs to promote accurate interpretation of communication.
• Suggest use of pad and pencil, slate board, letter/picture board, if indicated.When client has physical impairments that interfere with spoken communication, alternate means can provide concepts that are understandable to both parties.
• Obtain/provide access to typewriter/computer. Use of these devices may be more helpful when impairment is longstanding or when client is used to using them.
• Respect client’s cultural communication needs. Different cultures can dictate beliefs of what is normal or abnormal (i.e., in some cultures, eye-to-eye contact is considered disrespectful, impolite, or an invasion of privacy; silence and tone of voice have various meanings, and slang words can cause confusion).
• Provide glasses, hearing aids, dentures, electronic speech devices as needed. These devices maximize sensory perception and can improve understanding and enhance speech patterns.
• Reduce distractions and background noises (e.g., close the door, turn down the radio/TV). A distracting environment can interfere with communication, limiting attention to tasks and making speech and communication more difficult. Reducing noise can help both parties hear clearly, improving understanding.
• Associate words with objects using repetition and redundancy, point to objects, or demonstrate desired actions. Speaker’s own body language can be used to enhance client’s understanding when neurological conditions result in difficulty understanding language.
• Use confrontation skills carefully when appropriate, within an established nurse-client relationship. Can be used to clarify discrepancies between verbal and nonverbal cues, enabling client to look at areas that may require change.

NURSING PRIORITY NO. 3. To promote optimum communication:
• Discuss with family/SO and other caregivers effective ways in which the client communicates. Identifying positive aspects of current communication skills enables family members to learn and move forward in desire to enhance ways of interacting.
• Encourage client and family use of successful techniques for communication, whether it is speech/language techniques or alternate modes of communicating. Enhances family relationships and promotes self-esteem for all members as they are able to communicate clearly regardless of the problems that have interfered with ability to interact.
• Reinforce client/SO(s) learning and use of therapeutic communication skills of acknowledgment, Active-listening, and I-messages. Improves general communication skills, emphasizes acceptance, and conveys respect, enabling family relationships to improve.
• Refer to appropriate resources (e.g., speech therapist, language classes, individual/family and/or psychiatric counseling). May need further assistance to overcome problems that are preventing family from reaching desired goal of enhanced communication.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings/pertinent history information (i.e., physical/ psychological/cultural concerns).
• Meaning of nonverbal cues, level of anxiety client exhibits.
PLANNING
• Plan of care and interventions (e.g., type of alternative communication/ translator).
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Discharge needs/referrals made, additional resources available.

Desired Outcomes/Evaluation
Criteria—Client Will:
• Verbalize or indicate an understanding of the communication difficulty and plans for ways of handling.
• Establish method of communication in which needs can be expressed.
• Participate in therapeutic communication (e.g., using silence, acceptance, restating reflecting, Active-listening, and Imessages).
• Demonstrate congruent verbal and nonverbal communication.
• Use resources appropriately.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Review history for neurological conditions that could affect speech, such as CVA, tumor, multiple sclerosis, hearing loss, and so forth.
• Note results of neurological testing such as electroencephalogram (EEG), computed tomography (CT) scan.
• Note whether aphasia is motor (expressive: loss of images for articulated speech), sensory (receptive: unable to understand words and does not recognize the defect), conduction (slow comprehension, uses words inappropriately but knows the error), and/or global (total loss of ability to comprehend and speak). Evaluate the degree of impairment.
• Evaluate mental status, note presence of psychotic conditions (e.g., manic-depressive, schizoid/affective behavior). Assess psychological response to communication impairment, willingness to find alternate means of communication.
• Note presence of ET tube/tracheostomy or other physical blocks to speech (e.g., cleft palate, jaws wired).

• Assess environmental factors that may affect ability to communicate (e.g., room noise level).
• Determine primary language spoken and cultural factors.
• Assess style of speech (as outlined in Defining Characteristics).
• Note level of anxiety present; presence of angry, hostile behavior; frustration.
• Interview parent to determine child’s developmental level of speech and language comprehension.
• Note parent’s speech patterns and manner of communicating with child, including gestures.

NURSING PRIORITY NO. 2. To assist client to establish a means of communication to express needs, wants, ideas, and questions:
• Determine ability to read/write. Evaluate musculoskeletal states, including manual dexterity (e.g., ability to hold a pen and write).
• Obtain a translator/written translation or picture chart when writing is not possible.
• Facilitate hearing and vision examinations/obtaining necessary aids when needed/desired for improving communication. Assist client to learn to use and adjust to aids.
• Establish relationship with the client, listening carefully and attending to client’s verbal/nonverbal expressions.
• Maintain eye contact, preferably at client’s level. Be aware of cultural factors that may preclude eye contact (e.g., some American Indians).
• Keep communication simple, using all modes for accessing information: visual, auditory, and kinesthetic.
• Maintain a calm, unhurried manner. Provide sufficient time for client to respond. Individuals with expressive aphasia may talk more easily when they are rested and relaxed and when they are talking to one person at a time.
• Determine meaning of words used by the client and congruency of communication and nonverbal messages.
• Validate meaning of nonverbal communication; do not make assumptions, because they may be wrong. Be honest; if you do not understand, seek assistance from others.
• Individualize techniques using breathing for relaxation of the vocal cords, rote tasks (such as counting), and singing or melodic intonation to assist aphasic clients in relearning speech.
• Anticipate needs until effective communication is reestablished.
• Plan for alternative methods of communication (e.g., slate board, letter/picture board, hand/eye signals, typewriter/ computer) incorporating information about type of disability present.

• Identify previous solutions tried/used if situation is chronic or recurrent.
• Provide reality orientation by responding with simple, straightforward, honest statements.
• Provide environmental stimuli as needed to maintain contact with reality; or reduce stimuli to lessen anxiety that may worsen problem.
• Use confrontation skills, when appropriate, within an established nurse-client relationship to clarify discrepancies between verbal and nonverbal cues.

NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Review information about condition, prognosis, and treatment with client/SO(s). Reinforce that loss of speech does not imply loss of intelligence.
• Discuss individual methods of dealing with impairment.
• Recommend placing a tape recorder with a prerecorded emergency message near the telephone. Information to include: client’s name, address, telephone number, type of airway, and a request for immediate emergency assistance.
• Use and assist client/SO(s) to learn therapeutic communication skills of acknowledgment, Active-listening, and Imessages. Improves general communication skills.
• Involve family/SO(s) in plan of care as much as possible. Enhances participation and commitment to plan.
• Refer to appropriate resources (e.g., speech therapist, group therapy, individual/family and/or psychiatric counseling).
• Refer to NDs ineffective Coping; disabled family Coping (as indicated); Anxiety; Fear.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings/pertinent history information (i.e., physical/ psychological/cultural concerns).
• Meaning of nonverbal cues, level of anxiety client exhibits.
PLANNING
• Plan of care and interventions (e.g., type of alternative communication/translator).
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care

DISCHARGE PLANNING
• Discharge needs/referrals made, additional resources available.