Nursing Dx

Taxonomy II: Perception/Cognition—Class 4 Cognition (00129)
[Diagnostic Division: Neurosensory]
Submitted 1994
Definition: Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli; decreased capacity for intellectual thought processes; and manifested by disturbances of memory, orientation, and behavior

Related Factors
Alzheimer’s disease [dementia of the Alzheimer’s type]
Korsakoff ’s psychosis
Multi-infarct dementia
Cerebrovascular accident
Head injury

Defining Characteristics
OBJECTIVE
Clinical evidence of organic impairment
Altered interpretation/response to stimuli
Progressive/long-standing cognitive impairment

No change in level of consciousness
Impaired socialization
Impaired memory (short-term, long-term)
Altered personality

Desired Outcome/Evaluation
Criteria—Client Will:
• Remain safe and free from harm.
Family/SO Will:
• Verbalize understanding of disease process/prognosis and client’s needs.
• Identify/participate in interventions to deal effectively with situation.
• Provide for maximal independence while meeting safety needs of client.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess degree of impairment:
• Evaluate responses on diagnostic examinations (e.g., memory impairments, reality orientation, attention span, calculations).
• Test ability to receive and send effective communication.
• Note deterioration/changes in personal hygiene or behavior.
• Talk with SO(s) regarding baseline behaviors, length of time since onset/progression of problem, their perception of prognosis, and other pertinent information and concerns for client.
• Evaluate response to care providers/receptiveness to interventions.
• Determine anxiety level in relation to situation. Note behavior that may be indicative of potential for violence.

NURSING PRIORITY NO. 2. To prevent further deterioration/ maximize level of function:
• Provide calm environment, eliminate extraneous noise/stimuli.
• Ascertain interventions previously used/tried and evaluate effectiveness.
• Avoid challenging illogical thinking because defensive reactions may result.
• Encourage family/SO(s) to provide ongoing orientation/ input to include current news and family happenings.
• Maintain reality-oriented relationship/environment (e.g., clocks, calendars, personal items, seasonal decorations). Encourage participation in resocialization groups.

• Allow client to reminisce, exist in own reality if not detrimental to well-being.
• Provide safety measures (e.g., close supervision, identification bracelet, medication lockup, lower temperature on hot water tank).

NURSING PRIORITY NO. 3. To assist SO(s) to develop coping strategies:
• Determine family resources, availability and willingness to participate in meeting client’s needs.
• Identify appropriate community resources (e.g., Alzheimer’s or brain injury support group, respite care) to provide support and assist with problem-solving.
• Evaluate attention to own needs, including grieving process.
• Refer to ND risk for Caregiver Role Strain.

NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Determine ongoing treatment needs and appropriate resources.
• Develop plan of care with family to meet client’s and SO’s individual needs.
• Provide appropriate referrals (e.g.,Meals on Wheels, adult day care, home care agency, respite care).

Documentation Focus
ASSESSMENT/REASSESSMENT
• Individual findings, including current level of function and rate of anticipated changes.
PLANNING
• Plan of care and who is involved in planning.
IMPLEMENTATION/EVALUATION
• Response to interventions and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs/referrals and who is responsible for actions to be taken.
• Available resources, specific referrals made

Taxonomy II: Perception/Cognition—Class 4 Cognition (00128)
[Diagnostic Division: Neurosensory]
Submitted 1994
Definition: Abrupt onset of a cluster of global, transient changes and disturbances in attention, cognition, psychomotor activity, level of consciousness, and/or sleep/wake cycle

Related Factors
Over 60 years of age
Dementia
Alcohol abuse, drug abuse
Delirium [including febrile epilepticum (following or instead of an epileptic attack), toxic and traumatic]
[Medication reaction/interaction; anesthesia/surgery; metabolic imbalances]
[Exacerbation of a chronic illness, hypoxemia]
[Severe pain]
[Sleep deprivation]

Defining Characteristics
SUBJECTIVE
Hallucinations [visual/auditory]
[Exaggerated emotional responses]
OBJECTIVE
Fluctuation in cognition
Fluctuation in sleep/wake cycle
Fluctuation in level of consciousness
Fluctuation in psychomotor activity [tremors, body movement]
Increased agitation or restlessness
Misperceptions, [inappropriate responses]
Lack of motivation to initiate and/or follow through with goaldirected or purposeful behavior

Desired Outcomes/Evaluation
Criteria—Client Will:
• Regain/maintain usual reality orientation and level of consciousness.
• Verbalize understanding of causative factors when known.
• Initiate lifestyle/behavior changes to prevent or minimize recurrence of problem.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Identify factors present, including substance abuse, seizure history, recent ECT therapy, episodes of fever/pain, presence of acute infection (especially urinary tract infection in elderly client), exposure to toxic substances, traumatic events; change in environment, including unfamiliar noises, excessive visitors.
• Investigate possibility of drug withdrawal, exacerbation of psychiatric conditions (e.g., mood disorder, dissociative disorders, dementia).
• Evaluate vital signs for indicators of poor tissue perfusion (i.e., hypotension, tachycardia, tachypnea).
• Determine current medications/drug use—especially antianxiety agents, barbiturates, lithium, methyldopa, disulfiram, cocaine, alcohol, amphetamines, hallucinogens, opiates (associated with high risk of confusion)—and schedule of use as combinations increase risk of adverse reactions/interactions (e.g., cimetidine + antacid, digoxin + diuretics, antacid + propranolol).
• Assess diet/nutritional status.
• Note presence of anxiety, fear, other physiological reactions.
• Monitor laboratory values, noting hypoxemia, electrolyte imbalances, BUN/Cr, ammonia levels, serum glucose, signs of infection, and drug levels (including peak/trough as appropriate).
• Evaluate sleep/rest status, noting deprivation/oversleeping. Refer to ND disturbed Sleep Pattern, as appropriate.

NURSING PRIORITY NO. 2. To determine degree of impairment:
• Talk with SO(s) to determine historic baseline, observed changes, and onset/recurrence of changes to understand and clarify current situation.
• Evaluate extent of impairment in orientation, attention span, ability to follow directions, send/receive communication, appropriateness of response.
• Note occurrence/timing of agitation, hallucinations, violent behaviors. (“Sundown syndrome” may occur, with client oriented during daylight hours but confused during night.)
• Determine threat to safety of client/others.

NURSING PRIORITY NO. 3. To maximize level of function, prevent further deterioration:
• Assist with treatment of underlying problem (e.g., drug intoxication/ substance abuse, infectious process, hypoxemia, biochemical imbalances, nutritional deficits, pain management).

• Monitor/adjust medication regimen and note response. Eliminate nonessential drugs as appropriate.
• Orient client to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result.
• Encourage family/SO(s) to participate in reorientation as well as providing ongoing input (e.g., current news and family happenings).
• Maintain calm environment and eliminate extraneous noise/ stimuli to prevent overstimulation. Provide normal levels of essential sensory/tactile stimulation—include personal items/pictures, and so on.
• Encourage client to use vision/hearing aids when needed.
• Give simple directions. Allow sufficient time for client to respond, to communicate, to make decisions.
• Provide for safety needs (e.g., supervision, siderails, seizure precautions, placing call bell within reach, positioning needed items within reach/clearing traffic paths, ambulating with devices).
• Note behavior that may be indicative of potential for violence and take appropriate actions.
• Administer psychotropics cautiously to control restlessness, agitation, hallucinations.
• Avoid/limit use of restraints—may worsen situation, increase likelihood of untoward complications.
• Provide undisturbed rest periods. Administer short-acting, nonbenzodiazepine sleeping medication (e.g., Benadryl) at bedtime.

NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Explain reason for confusion, if known.
• Review drug regimen.
• Assist in identifying ongoing treatment needs.
• Stress importance of keeping vision/hearing aids in good repair and necessity of periodic evaluation to identify changing client needs.
• Discuss situation with family and involve in planning to meet identified needs.
• Provide appropriate referrals (e.g., cognitive retraining, substance abuse support groups, medication monitoring program,Meals on Wheels, home health, and adult day care).

Documentation Focus
ASSESSMENT/REASSESSMENT
• Nature, duration, frequency of problem.
• Current and previous level of function, effect on independence/ lifestyle (including safety concerns).

PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Response to interventions and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions to be taken.
• Available resources and specific referrals.

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.

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

Related Factors
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

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.

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. 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.

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.

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.