Nursing Dx

Bowel Incontinence

Taxonomy II: Elimination—Class 2 Gastrointestinal System (00014)
[Diagnostic Division: Elimination]
Submitted 1975; Nursing Diagnosis Extension and Classification (NDEC) Revision 1998
Definition: Change in normal bowel habits characterized by involuntary passage of stool

Related Factors
Self-care deficit—inefficient toileting; impaired cognition; immobility; environmental factors (e.g., inaccessible bathroom)
Dietary habits; medications; laxative abuse
Stress
Colorectal lesions
Incomplete emptying of bowel; impaction; chronic diarrhea
General decline in muscle tone; abnormally high abdominal or intestinal pressure
Impaired reservoir capacity
Rectal sphincter abnormality; loss of rectal sphincter control; lower/upper motor nerve damage

Defining Characteristics
SUBJECTIVE
Recognizes rectal fullness but reports inability to expel formed stool
Urgency
Inability to delay defecation
Self-report of inability to feel rectal fullness
OBJECTIVE
Constant dribbling of soft stool
Fecal staining of clothing and/or bedding
Fecal odor
Red perianal skin
Inability to recognize/inattention to urge to defecate

Desired Outcomes/Evaluation
Criteria—Client Will:
• Verbalize understanding of causative/controlling factors.
• Identify individually appropriate interventions.
• Participate in therapeutic regimen to control incontinence.
• Establish/maintain as regular a pattern of bowel functioning as possible.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Identify pathophysiological factors present (e.g., multiple sclerosis, acute/chronic cognitive impairment, spinal cord injury, stroke, ileus, ulcerative colitis).
• Note times/aspects of incontinent occurrence, preceding/ precipitating events.
• Check for presence/absence of anal sphincter reflex or impaction, which may be contributing factors.
• Review medication regimen for side effects/interactions.
• Test stool for blood (guaiac) as appropriate.
• Palpate abdomen for distention, masses, tenderness.
NURSING PRIORITY NO. 2. To determine current pattern of elimination:
• Note stool characteristics (color, odor, consistency, amount, shape, and frequency). Provides comparative baseline.
• Encourage client or SO to record times at which incontinence occurs, to note relationship to meals, activity, client’s behavior.
• Auscultate abdomen for presence, location, and characteristics of bowel sounds.
NURSING PRIORITY NO. 3. To promote control/management of incontinence:
• Assist in treatment of causative/contributing factors (e.g., as listed in the Related Factors and Defining Characteristics).
• Establish bowel program with regular time for defecation; use suppositories and/or digital stimulation when indicated. Maintain daily program initially. Progress to alternate days dependent on usual pattern/amount of stool.
• Take client to the bathroom/place on commode or bedpan at specified intervals, taking into consideration individual needs and incontinence patterns to maximize success of program.
• Encourage and instruct client/caregiver in providing diet high in bulk/fiber and adequate fluids (minimum of 2000 to 2400 mL/day). Encourage warm fluids after meals. Identify/ eliminate problem foods to avoid diarrhea/constipation, gas formation.
• Give stool softeners/bulk formers as indicated/needed.
• Provide pericare to avoid excoriation of the area.
• Promote exercise program, as individually able, to increase muscle tone/strength, including perineal muscles.
• Provide incontinence aids/pads until control is obtained.
• Demonstrate techniques (e.g., contracting abdominal muscles, leaning forward on commode, manual compression) to increase intra-abdominal pressure during defecation, and left to right abdominal massage to stimulate peristalsis.
• Refer to ND Diarrhea if incontinence is due to uncontrolled diarrhea; ND Constipation if diarrhea is due to impaction.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Review and encourage continuation of successful interventions as individually identified.
• Instruct in use of laxatives or stool softeners, if indicated, to stimulate timed defecation.
• Identify foods that promote bowel regularity.
• Provide emotional support to client and SO(s), especially when condition is long-term or chronic.
• Encourage scheduling of social activities within time frame of bowel program as indicated (e.g., avoid a 4-hour excursion if bowel program requires toileting every 3 hours and facilities will not be available) to maximize social functioning and success of bowel program.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Current and previous pattern of elimination/physical findings, character of stool, actions tried.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s/caregiver’s responses to interventions/teaching and actions performed.
• Changes in pattern of elimination, characteristics of stool.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Identified long-term needs, noting who is responsible for each action.
• Specific bowel program at time of discharge.

risk for imbalanced Body Temperature

Taxonomy II: Safety/Protection—Class 6 Thermoregulation (00005)
[Diagnostic division: Safety]
Submitted 1986; Revised 2000
Definition: At risk for failure to maintain body temperature within normal range

Risk Factors
Extremes of age, weight
Exposure to cold/cool or warm/hot environments
Dehydration
Inactivity or vigorous activity
Medications causing vasoconstriction/vasodilation, altered metabolic rate, sedation, [use or overdose of certain drugs or exposure to anesthesia]
Inappropriate clothing for environmental temperature
Illness or trauma affecting temperature regulation [e.g., infections, systemic or localized; neoplasms, tumors; collagen/ vascular disease]
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.

Desired Outcomes/Evaluation
Criteria—Client Will:
• Maintain body temperature within normal range.
• Verbalize understanding of individual risk factors and appropriate interventions.
• Demonstrate behaviors for monitoring and maintaining appropriate body temperature.

Actions/Interventions
NURSING PRIORITY NO. 1. To identify causative/risk factors present:
• Determine if present illness/condition results from exposure to environmental factors, surgery, infection, trauma.
• Monitor laboratory values (e.g., tests indicative of infection, drug screens).
• Note client’s age (e.g., premature neonate, young child, or aging individual), as it can directly impact ability to maintain/ regulate body temperature and respond to changes in environment.
• Assess nutritional status.
NURSING PRIORITY NO. 2. To prevent occurrence of temperature alteration:
• Monitor/maintain comfortable ambient environment. Provide heating/cooling measures as indicated.
• Cover head with knit cap, place infant under radiant warmer or adequate blankets.Heat loss in newborn/infants is greatest through head and by evaporation and convection.
• Monitor core body temperature. (Tympanic temperature may be preferred, as it is the most accurate noninvasive method.)
• Restore/maintain core temperature within client’s normal range. (Refer to NDs Hypothermia and Hyperthermia.)
• Refer at-risk persons to appropriate community resources (e.g., home care/social services, Foster Adult Care, housing agencies) to provide assistance to meet individual needs.
NURSING PRIORITY NO. 3. To promote wellness (Teaching/ Discharge Considerations):
• Review potential problem/individual risk factors with client/ SO(s).
• Instruct in measures to protect from identified risk factors (e.g., too warm, too cold environment; improper medication regimen; drug overdose; inappropriate clothing/shelter; poor nutritional status).
• Review ways to prevent accidental alterations, such as induced hypothermia as a result of overzealous cooling to reduce fever or maintaining too warm an environment for client who has lost the ability to perspire.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Identified individual causative/risk factors.
• Record of core temperature, initially and prn.
• Results of diagnostic studies/laboratory tests.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan, including best ambient temperature, and ways to prevent hypothermia or hyperthermia.
IMPLEMENTATION/EVALUATION
• Response 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 actions.
• Specific referrals made.

Taxonomy II: Self-Perception—Class 3 Body Image (00118)
[Diagnostic Division: Ego Integrity]
Submitted 1973; Revised 1998 (by small group work 1996)
Definition: Confusion [and/or dissatisfaction] in mental picture of one’s physical self

Related Factors
Biophysical illness; trauma or injury; surgery; [mutilation, pregnancy]; illness treatment [change caused by biochemical agents (drugs), dependence on machine]
Psychosocial
Cultural or spiritual
Cognitive/perceptual; developmental changes
[Significance of body part or functioning with regard to age, sex, developmental level, or basic human needs]
[Maturational changes]


Defining Characteristics
SUBJECTIVE
Verbalization of feelings/perceptions that reflect an altered view of one’s body in appearance, structure, or function; change in life style
Fear of rejection or of reaction by others
Focus on past strength, function, or appearance
Negative feelings about body (e.g., feelings of helplessness, hopelessness, or powerlessness); [depersonalization/grandiosity]
Preoccupation with change or loss
Refusal to verify actual change
Emphasis on remaining strengths, heightened achievement
Personalization of part or loss by name
Depersonalization of part or loss by impersonal pronouns
OBJECTIVE
Missing body part
Actual change in structure and/or function
Nonverbal response to actual or perceived change in structure and/or function; behaviors of avoidance, monitoring, or acknowledgment of one’s body
Not looking at/not touching body part
Trauma to nonfunctioning part
Change in ability to estimate spatial relationship of body to environment
Extension of body boundary to incorporate environmental objects
Hiding or overexposing body part (intentional or unintentional)
Change in social involvement
[Aggression; low frustration tolerance level]

Desired Outcomes/Evaluation
Criteria—Client Will:
• Verbalize acceptance of self in situation (e.g., chronic progressive disease, amputee, decreased independence, weight as is, effects of therapeutic regimen).
• Verbalize relief of anxiety and adaptation to actual/altered body image.
• Verbalize understanding of body changes.
• Recognize and incorporate body image change into selfconcept in accurate manner without negating self-esteem.
• Seek information and actively pursue growth.
• Acknowledge self as an individual who has responsibility for self.
• Use adaptive devices/prosthesis appropriately.

Actions/Interventions
NURSING PRIORITY NO. 1. To assess causative/contributing factors:
• Discuss pathophysiology present and/or situation affecting the individual and refer to additional NDs as appropriate. For example, when alteration in body image is related to neurological deficit (e.g., cerebrovascular accident—CVA), refer to ND unilateral Neglect; in the presence of severe, ongoing pain, refer to chronic Pain; or in loss of sexual desire/ability, refer to Sexual Dysfunction.
• Determine whether condition is permanent/no hope for resolution. (May be associated with other NDs, such as Self-Esteem [specify] or risk for impaired parent/infant/child Attachment, when child is affected.)
• Assess mental/physical influence of illness/condition on the client’s emotional state (e.g., diseases of the endocrine system, use of steroid therapy, and so on).
• Evaluate level of client’s knowledge of and anxiety related to situation. Observe emotional changes.
• Recognize behavior indicative of overconcern with body and its processes.
• Have client describe self, noting what is positive and what is negative. Be aware of how client believes others see self.
• Discuss meaning of loss/change to client. A small (seemingly trivial) loss may have a big impact (such as the use of a urinary catheter or enema for continence). A change in function (such as immobility) may be more difficult for some to deal with than a change in appearance. Permanent facial scarring of child may be difficult for parents to accept.
• Use developmentally appropriate communication techniques for determining exact expression of body image in child (e.g., puppet play or constructive dialogue for toddler). Developmental capacity must guide interaction to gain accurate information.
• Note signs of grieving/indicators of severe or prolonged depression to evaluate need for counseling and/or medications.
• Determine ethnic background and cultural/religious perceptions and considerations.
• Identify social aspects of illness/disease (e.g., sexually transmitted diseases, sterility, chronic conditions).
• Observe interaction of client with SO(s). Distortions in body image may be unconsciously reinforced by family members, and/or secondary gain issues may interfere with progress.
NURSING PRIORITY NO. 2. To determine coping abilities and skills:
• Assess client’s current level of adaptation and progress.
• Listen to client’s comments and responses to the situation. Different situations are upsetting to different people, depending on individual coping skills and past experiences.
• Note withdrawn behavior and the use of denial. May be normal response to situation or may be indicative of mental illness (e.g., schizophrenia). (Refer to ND ineffective Denial.)
• Note use of addictive substances/alcohol; may reflect dysfunctional coping.
• Identify previously used coping strategies and effectiveness.
• Determine individual/family/community resources.
NURSING PRIORITY NO. 3. To assist client and SO(s) to deal with/accept issues of self-concept related to body image:
• Establish therapeutic nurse-client relationship conveying an attitude of caring and developing a sense of trust.
• Visit client frequently and acknowledge the individual as someone who is worthwhile. Provides opportunities for listening to concerns and questions.
• Assist in correcting underlying problems to promote optimal healing/adaptation.
• Provide assistance with self-care needs/measures as necessary while promoting individual abilities/independence.
• Work with client’s self-concept without moral judgments regarding client’s efforts or progress (e.g., “You should be progressing faster; you’re weak/lazy/not trying hard enough”).
• Discuss concerns about fear of mutilation, prognosis, rejection when client facing surgery or potentially poor outcome of procedure/illness, to address realities and provide emotional support.
• Acknowledge and accept feelings of dependency, grief, and hostility.
• Encourage verbalization of and role-play anticipated conflicts to enhance handling of potential situations.
• Encourage client and SO(s) to communicate feelings to each other.
• Assume all individuals are sensitive to changes in appearance but avoid stereotyping.
• Alert staff to monitor own facial expressions and other nonverbal behaviors because they need to convey acceptance and not revulsion when the client’s appearance is affected.
• Encourage family members to treat client normally and not as an invalid.
• Encourage client to look at/touch affected body part to begin to incorporate changes into body image.
• Allow client to use denial without participating (e.g., client may at first refuse to look at a colostomy; the nurse says “I am going to change your colostomy now” and proceeds with the task). Provides individual time to adapt to situation.
• Set limits on maladaptive behavior, and assist client to identify positive behaviors to aid in recovery.
• Provide accurate information as desired/requested. Reinforce previously given information.
• Discuss the availability of prosthetics, reconstructive surgery, and physical/occupational therapy or other referrals as dictated by individual situation.
• Help client to select and use clothing/makeup to minimize body changes and enhance appearance.
• Discuss reasons for infectious isolation and procedures when used and make time to sit down and talk/listen to client while in the room to decrease sense of isolation/loneliness.
NURSING PRIORITY NO. 4. To promote wellness (Teaching/ Discharge Considerations):
• Begin counseling/other therapies (e.g., biofeedback/relaxation) as soon as possible to provide early/ongoing sources of support.
• Provide information at client’s level of acceptance and in small pieces to allow easier assimilation. Clarify misconceptions. Reinforce explanations given by other health team members.
• Include client in decision-making process and problemsolving activities.
• Assist client to incorporate therapeutic regimen into activities of daily living (ADLs) (e.g., including specific exercises, housework activities). Promotes continuation of program.
• Identify/plan for alterations to home and work environment/ activities to accommodate individual needs and support independence.
• Assist client in learning strategies for dealing with feelings/ venting emotions.
• Offer positive reinforcement for efforts made (e.g., wearing makeup, using prosthetic device).
• Refer to appropriate support groups.

Documentation Focus
ASSESSMENT/REASSESSMENT
• Observations, presence of maladaptive behaviors, emotional changes, stage of grieving, level of independence.
• Physical wounds, dressings; use of life-support–type machine (e.g., ventilator, dialysis machine).
• Meaning of loss/change to client.
• Support systems available (e.g., SOs, friends, groups).
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications of plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions.
• Specific referrals made (e.g., rehabilitation center, community resources).