Nursing Dx

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.CausesConstipation 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...

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....

Desired Outcomes/EvaluationCriteria—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/InterventionsNURSING...

Taxonomy II: Role Relationships—Class 1 Caregiving Roles (00061)[Diagnostic Division: Social Interaction]Submitted 1992; Nursing Diagnosis Extension and Classification (NDEC) Revision 1998; 2000Definition: Difficulty in performing caregiver roleRelated FactorsCARE RECEIVER HEALTH STATUSIllness severity/chronicityUnpredictability of illness course; instability of care receiver’s healthIncreasing care needs and dependencyProblem...

Desired Outcomes/EvaluationCriteria—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...

Taxonomy II: Activity/Rest—Class 4 Cardiovascular/Pulmonary Responses (00029)[Diagnostic Division: Circulation]Submitted 1975; Revised 1996, 2000Definition: 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...

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Actions/InterventionsNURSING 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...

Taxonomy II: Activity/Rest—Class 4Cardiovascular/Pulmonary Responses (00032)[Diagnostic Division: Respiration]Submitted 1980; Revised 1996, and Nursing DiagnosisExtension and Classification (NDEC) 1998Definition: Inspiration and/or expiration that does not provide adequate ventilationRelated FactorsNeuromuscular dysfunction; SCI; neurological immaturityMusculoskeletal impairment; bony/chest wall deformityAnxietyPainPerception/cognitive...

Taxonomy II: Role Relationships—Class 3 Role Performance (00105)[Diagnostic Division: Food/Fluid]Submitted 1992Definition: Break in the continuity of the breastfeeding process as a result of inability or inadvisability to put baby to breast for feedingRelated FactorsMaternal or infant illnessPrematurityMaternal employmentContraindications to breastfeeding (e.g., drugs, true breast milk jaundice)Need to abruptly wean infantDefining...