Anxiety [specify level:mild,moderate, severe, panic]
Definition:Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat.
RELATED FACTORS
Unconscious conflict about essential [beliefs]/goals and values of life
Situational/maturational crises
Stress
Familial association/heredity
Interpersonal transmission/contagion
Threat to self-concept [perceived or actual]; [unconscious conflict]
Threat of death [perceived or actual]
Threat to or change in health status [progressive/debilitating disease, terminal illness], interaction patterns, role function/status, environment [safety], economic status
Unmet needs
Exposure to toxins
Substance abuse
[Positive or negative self-talk]
[Physiological factors, such as hyperthyroidism, pulmonary embolism, dysrhythmias, pheochromocytoma, drug therapy including steroids]
Unconscious conflict about essential [beliefs]/goals and values of life
Situational/maturational crises
Stress
Familial association/heredity
Interpersonal transmission/contagion
Threat to self-concept [perceived or actual]; [unconscious conflict]
Threat of death [perceived or actual]
Threat to or change in health status [progressive/debilitating disease, terminal illness], interaction patterns, role function/status, environment [safety], economic status
Unmet needs
Exposure to toxins
Substance abuse
[Positive or negative self-talk]
[Physiological factors, such as hyperthyroidism, pulmonary embolism, dysrhythmias, pheochromocytoma, drug therapy including steroids]
DEFINING CHARACTERISTICS
Subjective
Behavioral
Expressed concerns due to change in life events; insomnia
Affective
Regretful; scared; rattled; distressed; apprehensive; uncertainty; fearful; feelings of inadequacy; jittery;
worried; painful/persistent increased helplessness; [sense of impending doom]; [hopelessness]
Cognitive
Fear of unspecific consequences; awareness of physiological symptoms
Physiological
Shakiness
Sympathetic
Dry mouth, heart pounding; weakness; respiratory difficulties; anorexia; diarrhea
Parasympathetic
Tingling in extremeties; nausea; abdominal pain; diarrhea; urinary frequency/hesitancy; faintness; fatigue; sleep disturbance; [chest, back, neck pain]
Subjective
Behavioral
Expressed concerns due to change in life events; insomnia
Affective
Regretful; scared; rattled; distressed; apprehensive; uncertainty; fearful; feelings of inadequacy; jittery;
worried; painful/persistent increased helplessness; [sense of impending doom]; [hopelessness]
Cognitive
Fear of unspecific consequences; awareness of physiological symptoms
Physiological
Shakiness
Sympathetic
Dry mouth, heart pounding; weakness; respiratory difficulties; anorexia; diarrhea
Parasympathetic
Tingling in extremeties; nausea; abdominal pain; diarrhea; urinary frequency/hesitancy; faintness; fatigue; sleep disturbance; [chest, back, neck pain]
Objective
Behavioral
Poor eye contact, glancing about, scanning and vigilance, extraneous movement [e.g., foot shuffling, hand/arm movements, rocking motion]; fidgeting; restlessness; diminished productivity; [crying/tearfulness]; [pacing/purposeless activity], [immobility]
Behavioral
Poor eye contact, glancing about, scanning and vigilance, extraneous movement [e.g., foot shuffling, hand/arm movements, rocking motion]; fidgeting; restlessness; diminished productivity; [crying/tearfulness]; [pacing/purposeless activity], [immobility]
Affective
Increased wariness; focus on self; irritability; overexcited; anguish
Cognitive
Preoccupation; impaired attention; difficulty concentrating; forgetfulness; diminished ability to problem-solve; diminished learning ability; rumination; tendency to blame others; blocking of thought; confusion; decreased perceptual field
Physiological
Voice quivering; trembling/hand tremors; increased tension, facial tension, increased perspiration
Sympathetic
Cardiovascular excitation; facial flushing; superficial vasoconstriction; increased pulse/respiration; increased blood pressure; pupil dilation; twitching, increased reflexes
Parasympathetic
Urinary urgency; decreased blood pressure/pulse
Increased wariness; focus on self; irritability; overexcited; anguish
Cognitive
Preoccupation; impaired attention; difficulty concentrating; forgetfulness; diminished ability to problem-solve; diminished learning ability; rumination; tendency to blame others; blocking of thought; confusion; decreased perceptual field
Physiological
Voice quivering; trembling/hand tremors; increased tension, facial tension, increased perspiration
Sympathetic
Cardiovascular excitation; facial flushing; superficial vasoconstriction; increased pulse/respiration; increased blood pressure; pupil dilation; twitching, increased reflexes
Parasympathetic
Urinary urgency; decreased blood pressure/pulse
Sample Clinical Applications:Major life changes/events, hospital admissions/surgery, cancer, hyperthyroidism, drug intoxication/abuse, mental health disorders
DESIRED OUTCOMES/EVALUATION CRITERIA
Client Will (Include Specific Time Frame)
• Appear relaxed and report anxiety is reduced to a manageable level.
• Verbalize awareness of feelings of anxiety.
• Identify healthy ways to deal with and express anxiety.
• Demonstrate problem-solving skills.
• Use resources/support systems effectively.
• Appear relaxed and report anxiety is reduced to a manageable level.
• Verbalize awareness of feelings of anxiety.
• Identify healthy ways to deal with and express anxiety.
• Demonstrate problem-solving skills.
• Use resources/support systems effectively.
ACTIONS/INTERVENTIONS
NURSING PRIORITY NO.1. To assess level of anxiety:
• Review familial/physiological factors, such as genetic depressive factors, psychiatric illness; active medical conditions (e.g., thyroid problems, metabolic imbalances, cardiopulmonary disease, anemia, dysrhythmias); recent/ongoing stressors (e.g., family member illness/death, spousal conflict/abuse, loss of job). These factors can cause/exacerbate anxiety/anxiety disorders.
• Review familial/physiological factors, such as genetic depressive factors, psychiatric illness; active medical conditions (e.g., thyroid problems, metabolic imbalances, cardiopulmonary disease, anemia, dysrhythmias); recent/ongoing stressors (e.g., family member illness/death, spousal conflict/abuse, loss of job). These factors can cause/exacerbate anxiety/anxiety disorders.
• Determine current prescribed medication regimen and recent drug history of prescribed or OTC medications (e.g., steroids, thyroid preparations, weight-loss pills, caffiene. Can heighten feelings/sense of anxiety.
• Identify client’s perception of the threat represented by the situation. Distorted perceptions of the situation may magnify feelings. Understanding client’s point of view promotes a more accurate plan of care.
• Note cultural factors that may influence anxiety. Individual responses are influenced by the cultural values/beliefs and culturally learned patterns of family of origin. (For example, ArabAmericans are very expressive about feelings, whereas Chinese are more reticent). Biological factors may also be involved.
• Monitor physical responses; for example, palpitations/rapid pulse, repetitive movements, pacing. Changes in vital signs may suggest degree of anxiety client is experiencing or reflect the impact of physiological factors such as endocrine imbalances, medication effect.
• Observe behavior indicative of anxiety, which can be a clue to the client’s level of anxiety:
Mild
Alert, more aware of environment, attention focused on environment and immediate events.
Restless, irritable, wakeful, reports of insomnia.
Motivated to deal with existing problems in this state.
Moderate
Perception narrower, concentration increased and able to ignore distractions in dealing with problem(s).
Voice quivers or changes pitch.
Trembling, increased pulse/respirations.
Severe
Range of perception is reduced; anxiety interferes with effective functioning.
Preoccupied with feelings of discomfort/sense of impending doom.
Increased pulse/respirations with reports of dizziness, tingling sensations, headache, and so forth.
Panic
Ability to concentrate is disrupted; behavior is disintegrated; client distorts the situation and does not have realistic perceptions of what is happening. May be experiencing terror or confusion or be unable to speak or move (paralyzed with fear).
• Note own feelings of anxiety or uneasiness. Feelings of anxiety are circular, and those in contact with the client may find themselves feeling more anxious.
• Note use of drugs (including alcohol), insomnia, or excessive sleeping, and limited/avoidance of interactions with others, which may be behavioral indicators of use of drugs/withdrawal to deal with problems.
• Review results of diagnostic tests (e.g., drug screens, cardiac testing, complete blood count, chemistry panel), which can point to physiological sources of anxiety.
• Review coping skills used in past. Can determine those that might be helpful in currentcircumstances.
• Identify client’s perception of the threat represented by the situation. Distorted perceptions of the situation may magnify feelings. Understanding client’s point of view promotes a more accurate plan of care.
• Note cultural factors that may influence anxiety. Individual responses are influenced by the cultural values/beliefs and culturally learned patterns of family of origin. (For example, ArabAmericans are very expressive about feelings, whereas Chinese are more reticent). Biological factors may also be involved.
• Monitor physical responses; for example, palpitations/rapid pulse, repetitive movements, pacing. Changes in vital signs may suggest degree of anxiety client is experiencing or reflect the impact of physiological factors such as endocrine imbalances, medication effect.
• Observe behavior indicative of anxiety, which can be a clue to the client’s level of anxiety:
Mild
Alert, more aware of environment, attention focused on environment and immediate events.
Restless, irritable, wakeful, reports of insomnia.
Motivated to deal with existing problems in this state.
Moderate
Perception narrower, concentration increased and able to ignore distractions in dealing with problem(s).
Voice quivers or changes pitch.
Trembling, increased pulse/respirations.
Severe
Range of perception is reduced; anxiety interferes with effective functioning.
Preoccupied with feelings of discomfort/sense of impending doom.
Increased pulse/respirations with reports of dizziness, tingling sensations, headache, and so forth.
Panic
Ability to concentrate is disrupted; behavior is disintegrated; client distorts the situation and does not have realistic perceptions of what is happening. May be experiencing terror or confusion or be unable to speak or move (paralyzed with fear).
• Note own feelings of anxiety or uneasiness. Feelings of anxiety are circular, and those in contact with the client may find themselves feeling more anxious.
• Note use of drugs (including alcohol), insomnia, or excessive sleeping, and limited/avoidance of interactions with others, which may be behavioral indicators of use of drugs/withdrawal to deal with problems.
• Review results of diagnostic tests (e.g., drug screens, cardiac testing, complete blood count, chemistry panel), which can point to physiological sources of anxiety.
• Review coping skills used in past. Can determine those that might be helpful in currentcircumstances.
NURSING PRIORITY NO.2 To assist client to identify feelings and begin to deal with problems:
• Establish a therapeutic relationship, conveying empathy and unconditional positive regard. Enables client to become comfortable and to begin looking at feelings and dealing with situation.
• Be available to client for listening and talking. Establishes rapport, promotes expression of feelings, and helps client/SO look at realities of the illness/treatment without confronting issues they are not ready to deal with.
• Establish a therapeutic relationship, conveying empathy and unconditional positive regard. Enables client to become comfortable and to begin looking at feelings and dealing with situation.
• Be available to client for listening and talking. Establishes rapport, promotes expression of feelings, and helps client/SO look at realities of the illness/treatment without confronting issues they are not ready to deal with.
• Encourage client to acknowledge and to express feelings—for example, crying (sadness), laughing (fear, denial), swearing (fear, anger), and using Active-listening, reflection. Often acknowledging feelings enables client to accept and deal more appropriately with situation, thus relieving anxiety.
• Assist client to develop self-awareness of verbal and nonverbal behaviors. Becoming aware helps client to control these behaviors and begin to deal with issues that are causing anxiety.
• Clarify meaning of feelings/actions by providing feedback and checking meaning with the client. Validates meaning and ensures accuracy of communication.
• Acknowledge anxiety/fear. Do not deny or reassure client that everything will be all right. Validates reality of feelings. False reassurances may be interpreted as lack of understanding or honesty, further isolating client.
• Be aware of defense mechanisms being used (e.g., denial, regression, and so forth). Use of defense mechanisms may be helpful coping mechanisms initially. However, continued use of such mechanisms diverts the energy that the client needs for healing, thus delaying the client from focusing and dealing with his actual problems.
• Identify coping skills the individual is using currently, such as anger, daydreaming, forgetfulness, eating, smoking, or lack of problem-solving. These may be useful for the moment but may eventually interfere with resolution of current situation.
• Provide accurate information about the situation. Helps client to identify what is reality based and provides opportunity for client to feel reassured.
• If the client is a child, be truthful, avoid bribing, and provide physical contact (e.g., hugging, rocking). Soothes fears and provides assurance. Children need to recognize that their feelings are not different from others.
• Assist client to develop self-awareness of verbal and nonverbal behaviors. Becoming aware helps client to control these behaviors and begin to deal with issues that are causing anxiety.
• Clarify meaning of feelings/actions by providing feedback and checking meaning with the client. Validates meaning and ensures accuracy of communication.
• Acknowledge anxiety/fear. Do not deny or reassure client that everything will be all right. Validates reality of feelings. False reassurances may be interpreted as lack of understanding or honesty, further isolating client.
• Be aware of defense mechanisms being used (e.g., denial, regression, and so forth). Use of defense mechanisms may be helpful coping mechanisms initially. However, continued use of such mechanisms diverts the energy that the client needs for healing, thus delaying the client from focusing and dealing with his actual problems.
• Identify coping skills the individual is using currently, such as anger, daydreaming, forgetfulness, eating, smoking, or lack of problem-solving. These may be useful for the moment but may eventually interfere with resolution of current situation.
• Provide accurate information about the situation. Helps client to identify what is reality based and provides opportunity for client to feel reassured.
• If the client is a child, be truthful, avoid bribing, and provide physical contact (e.g., hugging, rocking). Soothes fears and provides assurance. Children need to recognize that their feelings are not different from others.
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risk for latex Allergy Response
Definition: Risk of hypersenitivity to natural latex rubber products
RISK FACTORS
History of reactions to latex
Allergies to bananas, avocados, tropical fruits, kiwi, chestnuts, poinsettia plants
History of allergies and asthma
Professions with daily exposure to latex
Multiple surgical procedures, especially from infancy
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
History of reactions to latex
Allergies to bananas, avocados, tropical fruits, kiwi, chestnuts, poinsettia plants
History of allergies and asthma
Professions with daily exposure to latex
Multiple surgical procedures, especially from infancy
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Sample Clinical Applications:Multiple allergies, neural tube defects (e.g., spina bifida, myelomeningoceles), multiple surgeries at early age, chronic urological conditions (e.g., neurogenic bladder, exstrophy of bladder), spinal cord trauma
DESIRED OUTCOMES/EVALUATION CRITERIA
Client Will (Include Specific Time Frame)
• Identify and correct potential risk factors in the environment.
• Demonstrate appropriate lifestyle changes to reduce risk of exposure.
• Identify resources to assist in promoting a safe environment.
• Recognize need for/seek assistance to limit response/complications.
• Identify and correct potential risk factors in the environment.
• Demonstrate appropriate lifestyle changes to reduce risk of exposure.
• Identify resources to assist in promoting a safe environment.
• Recognize need for/seek assistance to limit response/complications.
ACTIONS/INTERVENTIONS
NURSING PRIORITY NO.1 To assess causative/contributing factors:
• Identify persons in high-risk categories such as those with history of certain food allergies (e.g., banana, avocado, chestnut, kiwi, papya, peach, nectarine); asthma; skin conditions (e.g., eczema); those occupationally exposed to latex products (e.g., healthcare workers, police/firefighters, emergency medical technicians [EMTs], food handlers, hairdressers, cleaning staff, factory workers in plants that manufacture latex-containing products); those with neural tube defects (e.g., spina bifida) or congenital urological conditions requiring frequent surgeries and/or catheterizations (e.g., extrophy of the bladder). Note: The most
severe reactions tend to occur with latex proteins contacting internal tissues during invasive procedures and when they touch mucous membranes of the mouth, vagina, urethra, or rectum.
• Question client regarding latex allergy upon admission to healthcare facility, especially when procedures are anticipated (e.g., laboratory, emergency department, operating room, wound care management, one-day surgery, dentist). Current information indicates that natural latex is found in thousands of medical supplies; however, many manufacturers are now using synthetic SB latex. These products have not been associated with allergic reactions, even among individuals that are sensitive to natural latex.
• Identify persons in high-risk categories such as those with history of certain food allergies (e.g., banana, avocado, chestnut, kiwi, papya, peach, nectarine); asthma; skin conditions (e.g., eczema); those occupationally exposed to latex products (e.g., healthcare workers, police/firefighters, emergency medical technicians [EMTs], food handlers, hairdressers, cleaning staff, factory workers in plants that manufacture latex-containing products); those with neural tube defects (e.g., spina bifida) or congenital urological conditions requiring frequent surgeries and/or catheterizations (e.g., extrophy of the bladder). Note: The most
severe reactions tend to occur with latex proteins contacting internal tissues during invasive procedures and when they touch mucous membranes of the mouth, vagina, urethra, or rectum.
• Question client regarding latex allergy upon admission to healthcare facility, especially when procedures are anticipated (e.g., laboratory, emergency department, operating room, wound care management, one-day surgery, dentist). Current information indicates that natural latex is found in thousands of medical supplies; however, many manufacturers are now using synthetic SB latex. These products have not been associated with allergic reactions, even among individuals that are sensitive to natural latex.
NURSING PRIORITY NO.2 To assist in correcting factors that could lead to latex allergy:
• Ascertain that facilities have established policies and procedures. Promotes awareness in the workplace to address safety and reduce risk to workers and client.
• Create latex-safe environments in care setting (e.g., substitute nonlatex products, such as natural rubber gloves, PCV IV tubing, latex-free tape, thermometers, electrodes, oxygen cannulas, etc.). Reduces risk of exposure.
• Promote good skin care when latex gloves may be preferred/required for barrier protection (e.g., in specific disease conditions such as HIV or during surgery). Use powder-free gloves, wash hands immediately after glove removal; refrain from use of oil-based hand cream. Reduces dermal and respiratory exposure to latex proteins that bind to the powder in gloves.
• Discuss necessity of avoiding latex exposure. Recommend/assist client/family to survey environment and remove any medical or household products containing latex. Avoidance of latex is the only way to prevent the allergy.
• Provide worksite review/recommendations to prevent exposure. Latex allergy can be a disabling occupational disease. Education about the problem promotes prevention of allergic reaction, facilitates timely intervention, and helps nurse to protect clients, latex-sensitive colleagues, and themselves.
• Ascertain that facilities have established policies and procedures. Promotes awareness in the workplace to address safety and reduce risk to workers and client.
• Create latex-safe environments in care setting (e.g., substitute nonlatex products, such as natural rubber gloves, PCV IV tubing, latex-free tape, thermometers, electrodes, oxygen cannulas, etc.). Reduces risk of exposure.
• Promote good skin care when latex gloves may be preferred/required for barrier protection (e.g., in specific disease conditions such as HIV or during surgery). Use powder-free gloves, wash hands immediately after glove removal; refrain from use of oil-based hand cream. Reduces dermal and respiratory exposure to latex proteins that bind to the powder in gloves.
• Discuss necessity of avoiding latex exposure. Recommend/assist client/family to survey environment and remove any medical or household products containing latex. Avoidance of latex is the only way to prevent the allergy.
• Provide worksite review/recommendations to prevent exposure. Latex allergy can be a disabling occupational disease. Education about the problem promotes prevention of allergic reaction, facilitates timely intervention, and helps nurse to protect clients, latex-sensitive colleagues, and themselves.
NURSING PRIORITY NO.3 To promote wellness (Teaching/Discharge Considerations):
• Instruct client/care providers about types of potential reactions. Reaction may be gradual and progressive (e.g., irritant contact rash with gloves); can be progressive, affecting multiple body systems; or may be sudden and anaphylactic requiring lifesaving treatment.
• Identify measures to take if reactions occur and ways to avoid exposure to latex products to reduce risk of injury. (Refer to ND latex Allergy Response.)
• Refer to allergist for testing as appropriate. Testing may include challenge test with latex gloves, skin patch test, or blood test for IgE.
• Encourage client to wear medical ID bracelet and emphasize importance of informing all new care providers of hypersensitivity to reduce preventable exposures.
• Refer to resources (e.g., Latex Allergy News, National Institute for Occupational Safety and Health [NIOSH], Kendall’s Healthcare Products [Web site], Hudson RCI [Web site]) for further information about common latex products in the home, latex-free products, and assistance.
• Instruct client/care providers about types of potential reactions. Reaction may be gradual and progressive (e.g., irritant contact rash with gloves); can be progressive, affecting multiple body systems; or may be sudden and anaphylactic requiring lifesaving treatment.
• Identify measures to take if reactions occur and ways to avoid exposure to latex products to reduce risk of injury. (Refer to ND latex Allergy Response.)
• Refer to allergist for testing as appropriate. Testing may include challenge test with latex gloves, skin patch test, or blood test for IgE.
• Encourage client to wear medical ID bracelet and emphasize importance of informing all new care providers of hypersensitivity to reduce preventable exposures.
• Refer to resources (e.g., Latex Allergy News, National Institute for Occupational Safety and Health [NIOSH], Kendall’s Healthcare Products [Web site], Hudson RCI [Web site]) for further information about common latex products in the home, latex-free products, and assistance.
DOCUMENTATION FOCUS
Assessment/Reassessment
• Assessment findings, pertinent history of contact with latex products, and frequency of exposure.
• Assessment findings, pertinent history of contact with latex products, and frequency of exposure.
Planning
• Plan of care and who is involved in planning.
• Teaching plan.
• Plan of care and who is involved in planning.
• Teaching plan.
Implementation/Evaluation
• Response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
• 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 to be taken.
• Specific referrals made.
• Long-term needs and who is responsible for actions to be taken.
• Specific referrals made.
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The Nursing Process
Over time, the nursing process expanded to five steps and has gained widespread acceptance as the basis for providing effective nursing care. Nursing process is now included in the conceptual framework of all nursing curricula, is accepted in the legal definition of nursing in the Nurse Practice Acts of most states, and is included in the ANA Standards of Clinical Nursing Practice.
The five steps of the nursing process consist of the following:
The five steps of the nursing process consist of the following:
- Assessment is an organized dynamic process involving three basic activities: a) systematically gathering data, b) sorting and organizing the collected data, and c) documenting the data in a retrievable fashion. Subjective and objective data are collected from various sources, such as the client interview and physical assessment. Subjective data are what the client or significant others report, believe, or feel, andobjective data are what can be observed or obtained fromother sources, such as laboratory and diagnostic studies,old medical records, or other healthcare providers. Usinga number of techniques, the nurse focuses on eliciting aprofile of the client that supplies a sense of the client’s overall health status, providing a picture of the client’s physical,psychological, sociocultural, spiritual, cognitive, and developmental levels; economic status; functional abilities; and lifestyle. The profile is known as the client database.
- Diagnosis/need identification involves the analysis of collected data to identify the client’s needs or problems, also known as the nursing diagnosis. The purpose of this step is to draw conclusions regarding the client’s specific needs or human responses of concern so that effective care can be planned and delivered. This process of data analysis uses diagnostic reasoning (a form of clinical judgment) in which conclusions are reached about the meaning of the collected data to determine whether or not nursing intervention is indicated. The end product is the client diagnostic statement that combines the specific client need with the related factors or risk factors (etiology), and defining charac-
teristics (or cues) as appropriate. The status of the client’s needs are categorized as actual or currently existing diagnoses and potential or risk diagnoses that could develop due to specific vulnerabilities of the client. Ongoing changes in healthcare delivery and computerization of the client record require a commonality of communication to ensure continuity of care for the client moving from one setting/level of healthcare to another. The use of standardized terminology or NANDA International nursing diagnosis labels provides nurses with a common language for identifying client needs. Furthermore, the use of standardized nursing diagnosis labels also promotes identification of appropriate goals, provides acuity information, is useful in creating standards for nursing practice, provides a base for quality improvement, and facilitates research supporting evidence-based nursing practices. - Planning includes setting priorities, establishing goals, identifying desired client outcomes, and determining specific nursing interventions. These actions are documented as the plan of care. This process requires input from the client/ significant others to reach agreement regarding the plan to facilitate the client taking responsibility for his or her own care and the achievement of the desired outcomes and goals. Setting priorities for client care is a complex and dynamic challenge that helps ensure that the nurse’s attention and subsequent actions are properly focused. What is perceived today to be the number one client care need or appropriate nursing intervention could change tomorrow, or, for that matter, within minutes, based on changes in the client’s condition or situation. Once client needs are prioritized, goals for treatment and discharge are established that indicate the general direction in which the client is expected to progress in response to treatment. The goals may be shortterm—those that usually must be met before the client is discharged or moved to a lesser level of care—and/or long-
term, which may continue even after discharge. From these goals, desired outcomes are determined to measure the client’s progress toward achieving the goals of treatment or the discharge criteria. To be more specific, outcomes are client responses that are achievable and desired by the client that can be attained within a defined period, given the situation and resources. Next, nursing interventions are chosen that are based on the client’s nursing diagnosis, the established goals and desired outcomes, the ability of the nurse to successfully implement the intervention, and the ability and the willingness of the client to undergo or participate in the intervention, and they reflect the client’s age/situation and individual strengths, when possible. Nursing interventions are direct-care activities or prescriptions for behaviors, treatments, activities, or actions that assist the client in achieving the measurable outcomes. Nursing interventions, like nursing diagnoses, are key elements of the knowledge of nursing and continue to grow as research supports the connection between actions and outcomes (McCloskey & Bulechek, 2000). Recording the planning step in a written or computerized plan of care provides for continuity of care, enhances communication, assists with determining agency or unit staffing needs, documents the nursing process, serves as a teaching tool, and coordinates provision of care among disciplines. A valid plan of care demonstrates individualized client care by reflecting the concerns of the client and significant others, as well as the client’s physical, psychosocial, and cultural needs and capabilities. - Implementation occurs when the plan of care is put into action, and the nurse performs the planned interventions. Regardless of how well a plan of care has been constructed, it cannot predict everything that will occur with a particular client on a daily basis. Individual knowledge and expertise and agency routines allow the flexibility that is necessary to adapt to the changing needs of the client. Legal and ethical concerns related to interventions also must be considered. For example, the wishes of the client and family/significant others regarding interventions and treatments must be discussed and respected. Before implementing the interventions in the plan of care, the nurse needs to understand the reason for doing each intervention, its expected effect, and any potential hazards that can occur. The nurse must also be sure that the interventions are a) consistent with the established plan of care, b) implemented in a safe and appropriate manner, c) evaluated for effectiveness, and d) documented in a timely manner.
- Evaluation is accomplished by determining the client’s progress toward attaining the identified outcomes and by monitoring the client’s response to/effectiveness of the selected nursing interventions for the purpose of altering the plan as indicated. This is done by direct observation of the client, interviewing the client/significant other, and/or reviewing the client’s healthcare record. Although the process of evaluation seems similar to the activity of assessment, there are important differences. Evaluation is an ongoing process, a constant measuring and monitoring of the client status to determine: a) appropriateness of nursing actions, b) the need to revise interventions, c) development of new client needs, d) the need for referral to other resources, and e) the need to rearrange priorities to meet changing demands of care. Comparing overall outcomes and noting the effectiveness of specific interventions are the clinical components of evaluation that can become the basis for research for validating the nursing process and supporting evidenced-based practice. The external evaluation process is the key for refining standards of care and determining the protocols, policies, and procedures necessary for the provision of quality nursing care for a specific situation or setting.
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latex Allergy Response
Definition: A hypersensitive reaction to natural latex rubber products
RELATED FACTORS
Hypersensitivity to natural latex rubber protein
Hypersensitivity to natural latex rubber protein
DEFINING CHARACTERISTICS
Subjective
Life-threatening reactions occurring <1 hour after exposure to latex proteins:
Tightness in chest; [feeling breathless]
Gastrointestinal characteristics: Abdominal pain; nausea
Orofacial characteristics: Itching of the eyes; nasal/facial/oral itching; nasal congestion
Generalized characteristics: Generalized discomfort; increasing complaints of total body warmth
Type IV reactions occurring >1 hour after exposure to latex protein:
Discomfort reaction to additives such as thiurams and carbamates
Objective
Life-threatening reactions occurring <1 hour after exposure to latex proteins:
Contact urticaria progressing to generalized symptoms
Edema of the lips/tongue/uvula/throat
Dyspnea; wheezing; bronchospasm; respiratory arrest
Hypotension; syncope; cardiac arrest
Orofacial characteristics: Edema of sclera/eyelids; erythema/tearing of the eyes; nasal facial/erythema; rhinorrhea
Generalized characteristics: Flushing; generalized edema; restlessness
Type IV reactions occurring >1 hour after exposure to latex protein:
Eczema; irritation; redness
Subjective
Life-threatening reactions occurring <1 hour after exposure to latex proteins:
Tightness in chest; [feeling breathless]
Gastrointestinal characteristics: Abdominal pain; nausea
Orofacial characteristics: Itching of the eyes; nasal/facial/oral itching; nasal congestion
Generalized characteristics: Generalized discomfort; increasing complaints of total body warmth
Type IV reactions occurring >1 hour after exposure to latex protein:
Discomfort reaction to additives such as thiurams and carbamates
Objective
Life-threatening reactions occurring <1 hour after exposure to latex proteins:
Contact urticaria progressing to generalized symptoms
Edema of the lips/tongue/uvula/throat
Dyspnea; wheezing; bronchospasm; respiratory arrest
Hypotension; syncope; cardiac arrest
Orofacial characteristics: Edema of sclera/eyelids; erythema/tearing of the eyes; nasal facial/erythema; rhinorrhea
Generalized characteristics: Flushing; generalized edema; restlessness
Type IV reactions occurring >1 hour after exposure to latex protein:
Eczema; irritation; redness
Sample Clinical Applications:Multiple allergies, neural tube defects (e.g., spina bifida,
myelomeningoceles), multiple surgeries at early age, chronic urological conditions (e.g.,
neurogenic bladder, exstrophy of bladder), spinal cord trauma
myelomeningoceles), multiple surgeries at early age, chronic urological conditions (e.g.,
neurogenic bladder, exstrophy of bladder), spinal cord trauma
Client Will (Include Specific Time Frame)
• Be free of signs of hypersensitive response.
• Verbalize understanding of individual risks/responsibilities in avoiding exposure.
• Identify signs/symptoms requiring prompt intervention.
• Be free of signs of hypersensitive response.
• Verbalize understanding of individual risks/responsibilities in avoiding exposure.
• Identify signs/symptoms requiring prompt intervention.
NURSING PRIORITY NO.1 To assess contributing factors:
• Identify persons in high-risk categories such as those with history of certain food allergies (e.g., banana, avocado, chestnut, kiwi, papaya, peach, nectarine), prior allergies, asthma, and skin conditions (e.g., eczema and other dermatitis), those occupationally exposed to latex products (e.g., healthcare workers, police/firefighters, emergency medical technicians [EMTs], food handlers, hairdressers, cleaning staff, factory workers in plants that manufacture latex-containing products), those with neural tube defects (e.g., spina bifida) or congenital urological conditions requiring frequent surgeries and/or catheterizations (e.g., extrophy of the bladder). Note: The most severe reactions tend to occur with latex proteins contacting internal tissues during invasive procedures and when they touch mucous membranes of the mouth, vagina, urethra, or rectum.
• Question new client regarding latex allergy upon admission to healthcare facility, especially when procedures are anticipated (e.g., laboratory, emergency department, operating room, wound care management, one-day surgery, dentist). Basic safety information to help healthcare providers prevent/prepare for safe environment for client and themselves while providing care.
• Discuss history of exposure: client works in environment where latex is manufactured or latex gloves are used frequently; child was blowing up balloons (may be an acute reaction to the powder); use of condoms (may affect either partner); individual requires frequent catheterizations. Finding cause of reaction may be simple or complex but often requires diligent investigation and history-taking from multiple sources.
• Administer or note presence of positive skin-prick test (SPT), when performed. Sensitive, specific, and rapid test but should be used with caution in persons with suspected sensitivity, as it carries risk of anaphylaxis.
• Perform challenge/patch test, if appropriate, to identify specific allergens in client with known type IV hypersensitivity.
• Note response to radioallergosorbent test (RAST) or enzyme-linked latex-specific IgE (ELISA). Performed to measure the quantity of IgE antibodies in serum after exposure to specific antigens and has generally replaced skin tests and provocation tests, which are inconvenient, often painful, and/or hazardous to the client.
• Identify persons in high-risk categories such as those with history of certain food allergies (e.g., banana, avocado, chestnut, kiwi, papaya, peach, nectarine), prior allergies, asthma, and skin conditions (e.g., eczema and other dermatitis), those occupationally exposed to latex products (e.g., healthcare workers, police/firefighters, emergency medical technicians [EMTs], food handlers, hairdressers, cleaning staff, factory workers in plants that manufacture latex-containing products), those with neural tube defects (e.g., spina bifida) or congenital urological conditions requiring frequent surgeries and/or catheterizations (e.g., extrophy of the bladder). Note: The most severe reactions tend to occur with latex proteins contacting internal tissues during invasive procedures and when they touch mucous membranes of the mouth, vagina, urethra, or rectum.
• Question new client regarding latex allergy upon admission to healthcare facility, especially when procedures are anticipated (e.g., laboratory, emergency department, operating room, wound care management, one-day surgery, dentist). Basic safety information to help healthcare providers prevent/prepare for safe environment for client and themselves while providing care.
• Discuss history of exposure: client works in environment where latex is manufactured or latex gloves are used frequently; child was blowing up balloons (may be an acute reaction to the powder); use of condoms (may affect either partner); individual requires frequent catheterizations. Finding cause of reaction may be simple or complex but often requires diligent investigation and history-taking from multiple sources.
• Administer or note presence of positive skin-prick test (SPT), when performed. Sensitive, specific, and rapid test but should be used with caution in persons with suspected sensitivity, as it carries risk of anaphylaxis.
• Perform challenge/patch test, if appropriate, to identify specific allergens in client with known type IV hypersensitivity.
• Note response to radioallergosorbent test (RAST) or enzyme-linked latex-specific IgE (ELISA). Performed to measure the quantity of IgE antibodies in serum after exposure to specific antigens and has generally replaced skin tests and provocation tests, which are inconvenient, often painful, and/or hazardous to the client.
NURSING PRIORITY NO.2 To take measures to reduce/limit allergic response/avoid exposure to allergens:
• Ascertain client’s current symptoms, noting rash, hives, itching, eye symptoms, edema, diarrhea, nausea, and feeling of faintness. Baseline for determining where the client is along a continuum of symptoms so that appropriate treatments can be initiated.
• Determine time since exposure (e.g., immediate or delayed onset such as 24 to 48 hours).
• Assess skin (usually hands but may be anywhere) for dry, crusty, hard bumps, horizontal cracks caused by irritation from chemicals used in/on the latex item (e.g., latex or powder used in latex gloves, condoms, etc.). Dry itchy rash (contact irritation) is the most common response and is not a true allergic reaction but can progress to a delayed type of allergic contact dermatitis with oozing blisters and spread in a way similar to poison ivy.
• Assist with treatment of contact dermatitis/type IV reaction:
Wash affected skin with mild soap and water.
Wash hands between glove changes and after each glove removal.
Avoid oil-based salves or lotions when using latex gloves.
Consider application of topical steroid ointment.
Inform client that the most common cause is latex gloves but that many other products contain latex and could aggravate condition.
• Monitor closely for signs of systemic reactions (e.g., difficulty breathing or swallowing; wheezing; hoarseness; stridor; hypotension; tremors; chest pain; tachycardia; dysrhythmias; edema of face, eyelids, lips, tongue, and mucous membranes). Type IV response can progress to type I anaphylaxis.
• Note behavior such as agitation, restlessness, and expressions of fearfulness, in the presence of above listed symptoms. Indicative of severe allergic response that can result in anaphylactic reaction and lead to respiratory/cardiac arrest.
• Administer treatment, as appropriate, if severe/life-threatening reaction occurs:
Stop treatment or procedure, if needed.
Support airway and administer 100% oxygen or mechanical ventilation, if needed.
Administer emergency medications and treatments per protocol (e.g., antihistamines, epinephrine, corticosteroids, and IV fluids).
• Educate care providers in ways to prevent inadvertent exposure (e.g., post latex precaution signs in client’s room, document allergy to latex in chart, routinely monitor client’s environment for latex-containing products and remove them promptly) and in emergency treatment measures should they be needed.
• Ascertain that latex-safe environment (e.g., surgery/hospital room) and products are available according to recommended facility guidelines and standards, including equipment and supplies, (e.g., powder-free, low-protein latex products) and latex-free items (e.g., gloves, syringes, catheters, tubings, tape, thermometers, electrodes, oxygen cannulas, underpads, storage bags, diapers, feeding nipples, etc.), as appropriate.
• Notify physicians, colleagues, and medical products suppliers of condition (e.g., pharmacy so that medications can be prepared in latex-free environment, home-care oxygen company to provide latex-free cannulas).
• Encourage client to wear medical ID bracelet to alert providers to condition if client is unresponsive.
• Ascertain client’s current symptoms, noting rash, hives, itching, eye symptoms, edema, diarrhea, nausea, and feeling of faintness. Baseline for determining where the client is along a continuum of symptoms so that appropriate treatments can be initiated.
• Determine time since exposure (e.g., immediate or delayed onset such as 24 to 48 hours).
• Assess skin (usually hands but may be anywhere) for dry, crusty, hard bumps, horizontal cracks caused by irritation from chemicals used in/on the latex item (e.g., latex or powder used in latex gloves, condoms, etc.). Dry itchy rash (contact irritation) is the most common response and is not a true allergic reaction but can progress to a delayed type of allergic contact dermatitis with oozing blisters and spread in a way similar to poison ivy.
• Assist with treatment of contact dermatitis/type IV reaction:
Wash affected skin with mild soap and water.
Wash hands between glove changes and after each glove removal.
Avoid oil-based salves or lotions when using latex gloves.
Consider application of topical steroid ointment.
Inform client that the most common cause is latex gloves but that many other products contain latex and could aggravate condition.
• Monitor closely for signs of systemic reactions (e.g., difficulty breathing or swallowing; wheezing; hoarseness; stridor; hypotension; tremors; chest pain; tachycardia; dysrhythmias; edema of face, eyelids, lips, tongue, and mucous membranes). Type IV response can progress to type I anaphylaxis.
• Note behavior such as agitation, restlessness, and expressions of fearfulness, in the presence of above listed symptoms. Indicative of severe allergic response that can result in anaphylactic reaction and lead to respiratory/cardiac arrest.
• Administer treatment, as appropriate, if severe/life-threatening reaction occurs:
Stop treatment or procedure, if needed.
Support airway and administer 100% oxygen or mechanical ventilation, if needed.
Administer emergency medications and treatments per protocol (e.g., antihistamines, epinephrine, corticosteroids, and IV fluids).
• Educate care providers in ways to prevent inadvertent exposure (e.g., post latex precaution signs in client’s room, document allergy to latex in chart, routinely monitor client’s environment for latex-containing products and remove them promptly) and in emergency treatment measures should they be needed.
• Ascertain that latex-safe environment (e.g., surgery/hospital room) and products are available according to recommended facility guidelines and standards, including equipment and supplies, (e.g., powder-free, low-protein latex products) and latex-free items (e.g., gloves, syringes, catheters, tubings, tape, thermometers, electrodes, oxygen cannulas, underpads, storage bags, diapers, feeding nipples, etc.), as appropriate.
• Notify physicians, colleagues, and medical products suppliers of condition (e.g., pharmacy so that medications can be prepared in latex-free environment, home-care oxygen company to provide latex-free cannulas).
• Encourage client to wear medical ID bracelet to alert providers to condition if client is unresponsive.
NURSING PRIORITY NO.3 To promote wellness (Teaching/Learning):
• Instruct in signs of reaction and emergency treatment needs. Reactions range from skin irritation to anaphylaxis. Reaction may be gradual but progressive, affecting multiple body systems, or may be sudden, requiring lifesaving treatment. Allergy can result in chronic illness, disability, career loss, hardship, and death. There is no cure except complete avoidance of latex
• Emphasize the critical importance of taking immediate action for type I reaction to limit life-threatening symptoms.
• Demonstrate procedure and recommend client carry auto-injectable epinephrine to provide timely emergency treatment, as needed.
• Emphasize necessity of informing all new care providers of hypersensitivity to reduce preventable exposures.
• Instruct in signs of reaction and emergency treatment needs. Reactions range from skin irritation to anaphylaxis. Reaction may be gradual but progressive, affecting multiple body systems, or may be sudden, requiring lifesaving treatment. Allergy can result in chronic illness, disability, career loss, hardship, and death. There is no cure except complete avoidance of latex
• Emphasize the critical importance of taking immediate action for type I reaction to limit life-threatening symptoms.
• Demonstrate procedure and recommend client carry auto-injectable epinephrine to provide timely emergency treatment, as needed.
• Emphasize necessity of informing all new care providers of hypersensitivity to reduce preventable exposures.
• Instruct client/family/SO that latex exposure occurs through contact with skin or mucous membrane, by inhalation, parenteral injection, or wound inoculation.
• Instuct client/SO(s) to survey and routinely monitor environment for latex-containing products, and replace as needed.
• Provide printed lists or Web sites for identifying common household products that may contain latex (e.g, carpet backing, hoses, rubber grip utensils, diapers, undergarments, shoes, toys, pacifiers, computer mouse pad, erasers, rubber bands, and much more) and where to obtain latex-free products and supplies.
• Provide resource and assistance numbers for emergencies. When allergy is suspected or the potential for allergy exists, protection must begin with identification and removal of possible sources of latex.
• Provide worksite review/recommendations to prevent exposure. Latex allergy can be a disabling occupational disease. Education about the problem promotes prevention of allergic reaction, facilitates timely intervention, and helps nurse to protect clients, latex-sensitive colleagues, and themselves.
• Recommend full medical workup for client presenting with hand dermatitis, especially if job tasks include use of latex.
• Contact suppliers to verify that latex-free equipment, products, and supplies are available, including (but not limited to) low-allergen/powder-free synthetic gloves, airways, masks, stethoscope tubings, IV tubing, tape, thermometers, urinary catheters, stomach and intestinal tubes, electrodes, oxygen cannulas, pencil erasers, wrist name bands, and rubber bands.
• Ascertain that procedures are in place to identify and resolve problems with medical devices relevant to allergic reactions or glove performance.
• Refer to resources, including but not limited to ALERT (Allergy to Latex Education & Resource Team, Inc.), Latex Allergy News, Spina Bifida Association, National Institute for Occupational Safety and Health (NIOSH), Kendall’s Healthcare Products [Web site], Hudson RCI [Web site]), for further information about common latex products in the home, latex-free products, and assistance.
• Instuct client/SO(s) to survey and routinely monitor environment for latex-containing products, and replace as needed.
• Provide printed lists or Web sites for identifying common household products that may contain latex (e.g, carpet backing, hoses, rubber grip utensils, diapers, undergarments, shoes, toys, pacifiers, computer mouse pad, erasers, rubber bands, and much more) and where to obtain latex-free products and supplies.
• Provide resource and assistance numbers for emergencies. When allergy is suspected or the potential for allergy exists, protection must begin with identification and removal of possible sources of latex.
• Provide worksite review/recommendations to prevent exposure. Latex allergy can be a disabling occupational disease. Education about the problem promotes prevention of allergic reaction, facilitates timely intervention, and helps nurse to protect clients, latex-sensitive colleagues, and themselves.
• Recommend full medical workup for client presenting with hand dermatitis, especially if job tasks include use of latex.
• Contact suppliers to verify that latex-free equipment, products, and supplies are available, including (but not limited to) low-allergen/powder-free synthetic gloves, airways, masks, stethoscope tubings, IV tubing, tape, thermometers, urinary catheters, stomach and intestinal tubes, electrodes, oxygen cannulas, pencil erasers, wrist name bands, and rubber bands.
• Ascertain that procedures are in place to identify and resolve problems with medical devices relevant to allergic reactions or glove performance.
• Refer to resources, including but not limited to ALERT (Allergy to Latex Education & Resource Team, Inc.), Latex Allergy News, Spina Bifida Association, National Institute for Occupational Safety and Health (NIOSH), Kendall’s Healthcare Products [Web site], Hudson RCI [Web site]), for further information about common latex products in the home, latex-free products, and assistance.
DOCUMENTATION FOCUS
Assessment/Reassessment
• Assessment findings/pertinent history of contact with latex products/frequency of exposure.
• Type/extent of symptoms.
Planning
• Plan of care and interventions and who is involved in planning.
• 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.
Assessment/Reassessment
• Assessment findings/pertinent history of contact with latex products/frequency of exposure.
• Type/extent of symptoms.
Planning
• Plan of care and interventions and who is involved in planning.
• 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.
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ineffective Airway Clearance
Definition: Inability to clear secretions or obstructions from the respiratory tract to maintaina clear airway
RELATED FACTORS
Environmental
Smoking; secondhand smoke; smoke inhalation
Obstructed airway
Retained secretions; secretions in the bronchi; exudate in the alveoli; excessive mucus; airway spasm; foreign body in airway; presence of artificial airway
Physiological
Chronic obstructive pulmonary disease (COPD); asthma; allergic airways; hyperplasia of the bronchial walls
Neuromuscular dysfunction
Infection
Environmental
Smoking; secondhand smoke; smoke inhalation
Obstructed airway
Retained secretions; secretions in the bronchi; exudate in the alveoli; excessive mucus; airway spasm; foreign body in airway; presence of artificial airway
Physiological
Chronic obstructive pulmonary disease (COPD); asthma; allergic airways; hyperplasia of the bronchial walls
Neuromuscular dysfunction
Infection
DEFINING CHARACTERISTICS
Subjective
Dyspnea
Objective
Diminished/adventitious breath sounds [rales, crackles, rhonchi, wheezes]
Cough, ineffective/absent; excessive sputum
Changes in respiratory rate and rhythm
Difficulty vocalizing
Wide-eyed; restlessness
Orthopnea
Cyanosis
Subjective
Dyspnea
Objective
Diminished/adventitious breath sounds [rales, crackles, rhonchi, wheezes]
Cough, ineffective/absent; excessive sputum
Changes in respiratory rate and rhythm
Difficulty vocalizing
Wide-eyed; restlessness
Orthopnea
Cyanosis
Sample Clinical Applications: COPD, pneumonia, influenza, acute respiratory distress syndrome (ARDS), cancer of lung/head and neck, congestive heart failure (CHF), cystic fibrosis, neuromuscular diseases, inhalation injuries
Client Will (Include Specific Time Frame)
• Maintain airway patency.
• Expectorate/clear secretions readily.
• Demonstrate absence/reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange (e.g., absence of cyanosis, ABG results within client norms).
• Verbalize understanding of cause(s) and therapeutic management regimen.
• Demonstrate behaviors to improve or maintain clear airway.
• Identify potential complications and how to initiate appropriate preventive or corrective actions.
• Maintain airway patency.
• Expectorate/clear secretions readily.
• Demonstrate absence/reduction of congestion with breath sounds clear, respirations noiseless, improved oxygen exchange (e.g., absence of cyanosis, ABG results within client norms).
• Verbalize understanding of cause(s) and therapeutic management regimen.
• Demonstrate behaviors to improve or maintain clear airway.
• Identify potential complications and how to initiate appropriate preventive or corrective actions.
NURSING PRIORITY NO.1 To maintain adequate, patent airway:
• Identify client populations at risk. Persons with impaired ciliary function (e.g., cystic fibrosis, status post-heart-lung transplantation); those with excessive or abnormal mucus production (e.g., asthma, emphysema, pneumonia, dehydration, bronchiectasis, mechanical ventilation); those with impaired cough function (e.g., neuromuscular diseases, such as muscular dystrophy; neuromotor conditions, such as cerebral palsy, spinal cord injury); those with swallowing abnormalities (e.g., poststroke, seizures, head/neck cancer, coma/sedation, tracheostomy, facial burns/trauma/surgery); those who are immobile (e.g., sedated individual, frail elderly, developmental delay); infant/child (e.g., feeding intolerance, abdominal distention, and emotional stressors that may compromise airway) are all at risk for problems with maintenance of open airways.
• Assess level of consciousness/cognition and ability to protect own airway. Information essential for identifying potential for airway problems, providing baseline level of care needed, and influencing choice of interventions.
• Evaluate respiratory rate/depth and breath sounds. Tachypnea is usually present to some degree and may be pronounced during respiratory stress. Respirations may be shallow. Some degree of bronchospasm is present with obstruction in airways and may/may not be manifested in adventitious breath sounds, such as scattered moist crackles (bronchitis), faint sounds with expiratory wheezes (emphysema), or absent breath sounds (severe asthma).
• Position head appropriate for age and condition/disorder. Repositioning head may, at times, be all that is needed to open or maintain open airway in at-rest or compromised individual, such as one with sleep apnea.
• Insert oral airway, using correct size for adult or child, when indicated. Have appropriate emergency equipment at bedside (such as tracheostomy equipment, ambu-bag, suction apparatus) to restore or maintain an effective airway.
• Evaluate amount and type of secretions being produced. Excessive and/or sticky mucus can make it difficult to maintain effective airways, especially if client has impaired cough function, is very young or elderly, is developmentally delayed, has restrictive or obstructive lung disease, or is mechanically ventilated.
• Note ability/effectiveness of cough. Cough function may be weak or ineffective in diseases and conditions such as extremes in age (e.g., premature infant or elderly), cerebral palsy, muscular dystrophy, spinal cord injury, brain injury, postsurgery, and/or mechanical ventilation due to mechanisms affecting muscles of throat, chest, and lungs.
• Suction (nasal/tracheal/oral), when indicated, using correct-size catheter and suction timing for child or adult to clear airway when secretions are blocking airways, client is unable to clear airway by coughing, cough is ineffective, infant is unable to take oral feedings because of secretions, or ventilated client is showing desaturation of oxygen by oximetry or ABGs.
• Identify client populations at risk. Persons with impaired ciliary function (e.g., cystic fibrosis, status post-heart-lung transplantation); those with excessive or abnormal mucus production (e.g., asthma, emphysema, pneumonia, dehydration, bronchiectasis, mechanical ventilation); those with impaired cough function (e.g., neuromuscular diseases, such as muscular dystrophy; neuromotor conditions, such as cerebral palsy, spinal cord injury); those with swallowing abnormalities (e.g., poststroke, seizures, head/neck cancer, coma/sedation, tracheostomy, facial burns/trauma/surgery); those who are immobile (e.g., sedated individual, frail elderly, developmental delay); infant/child (e.g., feeding intolerance, abdominal distention, and emotional stressors that may compromise airway) are all at risk for problems with maintenance of open airways.
• Assess level of consciousness/cognition and ability to protect own airway. Information essential for identifying potential for airway problems, providing baseline level of care needed, and influencing choice of interventions.
• Evaluate respiratory rate/depth and breath sounds. Tachypnea is usually present to some degree and may be pronounced during respiratory stress. Respirations may be shallow. Some degree of bronchospasm is present with obstruction in airways and may/may not be manifested in adventitious breath sounds, such as scattered moist crackles (bronchitis), faint sounds with expiratory wheezes (emphysema), or absent breath sounds (severe asthma).
• Position head appropriate for age and condition/disorder. Repositioning head may, at times, be all that is needed to open or maintain open airway in at-rest or compromised individual, such as one with sleep apnea.
• Insert oral airway, using correct size for adult or child, when indicated. Have appropriate emergency equipment at bedside (such as tracheostomy equipment, ambu-bag, suction apparatus) to restore or maintain an effective airway.
• Evaluate amount and type of secretions being produced. Excessive and/or sticky mucus can make it difficult to maintain effective airways, especially if client has impaired cough function, is very young or elderly, is developmentally delayed, has restrictive or obstructive lung disease, or is mechanically ventilated.
• Note ability/effectiveness of cough. Cough function may be weak or ineffective in diseases and conditions such as extremes in age (e.g., premature infant or elderly), cerebral palsy, muscular dystrophy, spinal cord injury, brain injury, postsurgery, and/or mechanical ventilation due to mechanisms affecting muscles of throat, chest, and lungs.
• Suction (nasal/tracheal/oral), when indicated, using correct-size catheter and suction timing for child or adult to clear airway when secretions are blocking airways, client is unable to clear airway by coughing, cough is ineffective, infant is unable to take oral feedings because of secretions, or ventilated client is showing desaturation of oxygen by oximetry or ABGs.
• Assist with/prepare for appropriate testing (e.g., pulmonary function/sleep studies) to identify causative/precipitating factors.
• Assist with procedures (e.g., bronchoscopy, tracheostomy) to clear/maintain open airway.
• Keep environment free of smoke, dust, and feather pillows according to individual situation. Precipitators of allergic type of respiratory reactions that can trigger/exacerbate acute episode.
• Assist with procedures (e.g., bronchoscopy, tracheostomy) to clear/maintain open airway.
• Keep environment free of smoke, dust, and feather pillows according to individual situation. Precipitators of allergic type of respiratory reactions that can trigger/exacerbate acute episode.
NURSING PRIORITY NO.2 To mobilize secretions:
• Elevate head of the bed/change position, as needed. Elevation/upright position facilitates respiratory function by use of gravity; however, the client in severe distress will seek position of comfort.
• Position appropriately (e.g., head of bed elevated, side-to-side) and discourage use of oilbased products around nose to prevent vomiting with aspiration into lungs. (Refer to NDs risk for Aspiration, impaired Swallowing.)
• Encourage/instruct in deep-breathing and directed-coughing exercises; teach (presurgically) and reinforce (postsurgically) breathing and coughing while splinting incision to maximize cough effort, lung expansion, and drainage, and to reduce pain impairment.
• Mobilize client as soon as possible. Reduces risk or effects of atelectasis, enhancing lung expansion and drainage of different lung segments.
• Administer analgesics, as indicated. Analgesics may be needed to improve cough effort when pain is inhibiting. Note: Overmedication, especially with opioids, can depress respirations and cough effort.
• Administer medications (e.g., expectorants, anti-inflammatory agents, bronchodilators, and mucolytic agents), as indicated, to relax smooth respiratory musculature, reduce airway edema, and mobilize secretions.
• Increase fluid intake to at least 2000 mL/day within cardiac tolerance (may require IV in acutely ill, hospitalized client). Encourage/provide warm versus cold liquids, as appropriate. Warm hydration can help liquefy viscous secretions and improve secretion clearance. Note: Individuals with compromised cardiac function may develop symptoms of CHF (crackles, edema, weight gain).
• Provide ultrasonic nebulizer/room humidifier, as needed, to deliver supplemental humidification, helping to reduce viscosity of secretions.
• Assist with use of respiratory devices and treatments (e.g., intermittent positive-pressure breathing [IPPB], incentive spirometer [IS], positive expiratory pressure [PEP] mask, mechanical ventilation, oscillatory airway device [flutter], assisted and directed cough techniques, etc.). Various therapies/modalities may be required to maintain adequate airways, improve respiratory function and gas exchange. (Refer to NDs ineffective Breathing Pattern, impaired Gas Exchange, impaired spontaneous Ventilation.)
• Perform/assist client in learning airway clearance techniques, particularly when airway congestion is a chronic/long-term condition. Numerous techniques may be used, including (but not limited to) postural drainage and percussion (CPT), flutter devices, high-frequency chest compression with an inflatable vest, intrapulmonary percussive ventilation administered by a percussinator, and active cycle breathing (ACB), as indicated. Many of these techniques are the result of research in treatments of cystic fibrosis and muscular dystrophy as well as other chronic lung diseases.
• Elevate head of the bed/change position, as needed. Elevation/upright position facilitates respiratory function by use of gravity; however, the client in severe distress will seek position of comfort.
• Position appropriately (e.g., head of bed elevated, side-to-side) and discourage use of oilbased products around nose to prevent vomiting with aspiration into lungs. (Refer to NDs risk for Aspiration, impaired Swallowing.)
• Encourage/instruct in deep-breathing and directed-coughing exercises; teach (presurgically) and reinforce (postsurgically) breathing and coughing while splinting incision to maximize cough effort, lung expansion, and drainage, and to reduce pain impairment.
• Mobilize client as soon as possible. Reduces risk or effects of atelectasis, enhancing lung expansion and drainage of different lung segments.
• Administer analgesics, as indicated. Analgesics may be needed to improve cough effort when pain is inhibiting. Note: Overmedication, especially with opioids, can depress respirations and cough effort.
• Administer medications (e.g., expectorants, anti-inflammatory agents, bronchodilators, and mucolytic agents), as indicated, to relax smooth respiratory musculature, reduce airway edema, and mobilize secretions.
• Increase fluid intake to at least 2000 mL/day within cardiac tolerance (may require IV in acutely ill, hospitalized client). Encourage/provide warm versus cold liquids, as appropriate. Warm hydration can help liquefy viscous secretions and improve secretion clearance. Note: Individuals with compromised cardiac function may develop symptoms of CHF (crackles, edema, weight gain).
• Provide ultrasonic nebulizer/room humidifier, as needed, to deliver supplemental humidification, helping to reduce viscosity of secretions.
• Assist with use of respiratory devices and treatments (e.g., intermittent positive-pressure breathing [IPPB], incentive spirometer [IS], positive expiratory pressure [PEP] mask, mechanical ventilation, oscillatory airway device [flutter], assisted and directed cough techniques, etc.). Various therapies/modalities may be required to maintain adequate airways, improve respiratory function and gas exchange. (Refer to NDs ineffective Breathing Pattern, impaired Gas Exchange, impaired spontaneous Ventilation.)
• Perform/assist client in learning airway clearance techniques, particularly when airway congestion is a chronic/long-term condition. Numerous techniques may be used, including (but not limited to) postural drainage and percussion (CPT), flutter devices, high-frequency chest compression with an inflatable vest, intrapulmonary percussive ventilation administered by a percussinator, and active cycle breathing (ACB), as indicated. Many of these techniques are the result of research in treatments of cystic fibrosis and muscular dystrophy as well as other chronic lung diseases.
NURSING PRIORITY NO.3 To assess changes, note complications:
• Auscultate breath sounds, noting changes in air movement to ascertain current status/effects of treatments to clear airways.
• Auscultate breath sounds, noting changes in air movement to ascertain current status/effects of treatments to clear airways.
• Monitor vital signs, noting blood pressure/pulse changes. Observe for increased respiratory rate, restlessness/anxiety, and use of accessory muscles for breathing, suggesting advancing respiratory distress.
• Monitor/document serial chest radiographs, ABGs, pulse oximetry readings. Identifies baseline status, influences interventions, and monitors progress of condition and/or treatment response.
• Evaluate changes in sleep pattern, noting insomnia or daytime somnolence. May be evidence of nighttime airway incompetence or sleep apnea. (Refer to ND Insomnia.)
• Document response to drug therapy and/or development of adverse reactions or side effects with antimicrobial agents, steroids, expectorants, bronchodilators. Pharmacological therapy is used to prevent and control symptoms, reduce severity of exacerbations, and improve health status. The choice of medications depends on availability of the medication and the client’s decision making about medication regimen and response to any given medication.
• Observe for signs/symptoms of infection (e.g., increased dyspnea, onset of fever, increase in sputum volume, change in color or character) to identify infectious process/promote timely intervention.
• Obtain sputum specimen, preferably before antimicrobial therapy is initiated, to verify appropriateness of therapy. Note: The presence of purulent sputum during an exacerbation of symptoms is a sufficient indication for starting antibiotic therapy, but a sputum culture and antibiogram (antibiotic sensitivity) may be done if the illness is not responding to the initial antibiotic.
• Monitor/document serial chest radiographs, ABGs, pulse oximetry readings. Identifies baseline status, influences interventions, and monitors progress of condition and/or treatment response.
• Evaluate changes in sleep pattern, noting insomnia or daytime somnolence. May be evidence of nighttime airway incompetence or sleep apnea. (Refer to ND Insomnia.)
• Document response to drug therapy and/or development of adverse reactions or side effects with antimicrobial agents, steroids, expectorants, bronchodilators. Pharmacological therapy is used to prevent and control symptoms, reduce severity of exacerbations, and improve health status. The choice of medications depends on availability of the medication and the client’s decision making about medication regimen and response to any given medication.
• Observe for signs/symptoms of infection (e.g., increased dyspnea, onset of fever, increase in sputum volume, change in color or character) to identify infectious process/promote timely intervention.
• Obtain sputum specimen, preferably before antimicrobial therapy is initiated, to verify appropriateness of therapy. Note: The presence of purulent sputum during an exacerbation of symptoms is a sufficient indication for starting antibiotic therapy, but a sputum culture and antibiogram (antibiotic sensitivity) may be done if the illness is not responding to the initial antibiotic.
NURSING PRIORITY NO.4 To promote wellness (Teaching/Discharge Considerations):
• Assess client’s/caregiver’s knowledge of contributing causes, treatment plan, specific medications, and therapeutic procedures to determine educational needs.
• Provide information about the necessity of raising and expectorating secretions versus swallowing them, to note changes in color and amount.
• Identify signs/symptoms to be reported to primary care provider. Prompt evaluation and intervention is required to prevent/treat infection.
• Demonstrate/assist client/SO in performing specific airway clearance techniques (e.g., forced expiratory breathing [also called “huffing”] or respiratory muscle strength training, chest percussion), if indicated.
• Review breathing exercises, effective coughing techniques, and use of adjunct devices (e.g., IPPB or incentive spirometry) in preoperative teaching to facilitate postoperative recovery, reduce risk of pneumonia.
• Instruct client/SO/caregiver in use of inhalers and other respiratory drugs. Include expected effects and information regarding possible side effects and interactions of respiratory drugs with other medications/OTC/herbals. Discuss symptoms requiring medical follow-up. Client is often taking multiple medications that have similar side effects and potential for interactions. It is important to understand the difference between nuisance side effects (such as fast heartbeat after albuterol inhaler) and adverse effects (such as chest pain, hallucinations, or uncontrolled cardiac arrhythmia).
• Encourage/provide opportunities for rest; limit activities to level of respiratory tolerance. Prevents/diminishes fatigue associated with underlying condition or efforts to clear airways.
• Urge reduction/cessation of smoking. Smoking is known to increase production of mucus and to paralyze (or cause loss of) cilia needed to move secretions to clear airway and improve lung function.
• Assess client’s/caregiver’s knowledge of contributing causes, treatment plan, specific medications, and therapeutic procedures to determine educational needs.
• Provide information about the necessity of raising and expectorating secretions versus swallowing them, to note changes in color and amount.
• Identify signs/symptoms to be reported to primary care provider. Prompt evaluation and intervention is required to prevent/treat infection.
• Demonstrate/assist client/SO in performing specific airway clearance techniques (e.g., forced expiratory breathing [also called “huffing”] or respiratory muscle strength training, chest percussion), if indicated.
• Review breathing exercises, effective coughing techniques, and use of adjunct devices (e.g., IPPB or incentive spirometry) in preoperative teaching to facilitate postoperative recovery, reduce risk of pneumonia.
• Instruct client/SO/caregiver in use of inhalers and other respiratory drugs. Include expected effects and information regarding possible side effects and interactions of respiratory drugs with other medications/OTC/herbals. Discuss symptoms requiring medical follow-up. Client is often taking multiple medications that have similar side effects and potential for interactions. It is important to understand the difference between nuisance side effects (such as fast heartbeat after albuterol inhaler) and adverse effects (such as chest pain, hallucinations, or uncontrolled cardiac arrhythmia).
• Encourage/provide opportunities for rest; limit activities to level of respiratory tolerance. Prevents/diminishes fatigue associated with underlying condition or efforts to clear airways.
• Urge reduction/cessation of smoking. Smoking is known to increase production of mucus and to paralyze (or cause loss of) cilia needed to move secretions to clear airway and improve lung function.
• Refer to appropriate support groups (e.g., stop-smoking clinic, COPD exercise group, weight reduction, American Lung Association, Cystic Fibrosis Foundation, Muscular Dystrophy Association).
• Instruct in use of nocturnal positive pressure airflow for treatment of sleep apnea. (Refer to NDs Insomnia, Sleep Deprivation.)
• Instruct in use of nocturnal positive pressure airflow for treatment of sleep apnea. (Refer to NDs Insomnia, Sleep Deprivation.)
DOCUMENTATION FOCUS
Assessment/Reassessment
• Related factors for individual client.
• Breath sounds, presence/character of secretions, use of accessory muscles for breathing.
• Character of cough/sputum.
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 to plan of care.
Discharge Planning
• Long-term needs and who is responsible for actions to be taken.
• Specific referrals made.
Assessment/Reassessment
• Related factors for individual client.
• Breath sounds, presence/character of secretions, use of accessory muscles for breathing.
• Character of cough/sputum.
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 to plan of care.
Discharge Planning
• Long-term needs and who is responsible for actions to be taken.
• Specific referrals made.
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risk for Activity Intolerance
Definition: At risk of experiencing insufficient physiological or psychological energy to endure or complete required or desired daily activities
RISK FACTORS
History of previous intolerance
Presence of circulatory/respiratory problems, [dysrhythmias]
Deconditioned status; [aging]
Inexperience with the activity
[Diagnosis of progressive disease state/debilitating condition, anemia]
[Verbalized reluctance/inability to perform expected activity]
NOTE: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred; rather, nursing interventions are directed at prevention.
Sample Clinical Applications: Anemias, angina aortic stenosis, bronchitis, emphysema, dysmenorrhea, heart failure, HIV/AIDS, labor/preterm labor, leukemias, mitral stenosis, obesity, pain, pericarditis, peripheral vascular disease, rheumatic fever, thrombocytopenia, tuberculosis, uterine bleeding
RISK FACTORS
History of previous intolerance
Presence of circulatory/respiratory problems, [dysrhythmias]
Deconditioned status; [aging]
Inexperience with the activity
[Diagnosis of progressive disease state/debilitating condition, anemia]
[Verbalized reluctance/inability to perform expected activity]
NOTE: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred; rather, nursing interventions are directed at prevention.
Sample Clinical Applications: Anemias, angina aortic stenosis, bronchitis, emphysema, dysmenorrhea, heart failure, HIV/AIDS, labor/preterm labor, leukemias, mitral stenosis, obesity, pain, pericarditis, peripheral vascular disease, rheumatic fever, thrombocytopenia, tuberculosis, uterine bleeding
Client Will (Include Specific Time Frame)
• Verbalize understanding of potential loss of ability in relation to existing condition.
• Participate in conditioning/rehabilitation program to enhance ability to perform.
• Verbalize understanding of potential loss of ability in relation to existing condition.
• Participate in conditioning/rehabilitation program to enhance ability to perform.
• Identify alternative ways to maintain desired activity level (e.g., if weather is bad, walking in a shopping mall could be an option).
• Identify conditions/symptoms that require medical reevaluation.
• Identify conditions/symptoms that require medical reevaluation.
NURSING PRIORITY NO.1 To assess factors affecting current situation:
• Note presence of medical diagnosis and/or therapeutic regimens (e.g., AIDS, COPD, cancer, heart failure/other cardiac problems, anemia, multiple medications/treatment modalities, extensive surgical interventions, musculoskeletal trauma, neurological disorders) that have potential for interfering with client’s ability to perform at a desired level of activity.
Note: Many factors cause or contribute to fatigue, but activity intolerance implies that the individual cannot endure or adapt to increased energy or oxygen demands caused by an actvity.
• Ask client/SO about usual level of energy to identify potential problems and/or client’s/SO’s perception of client’s energy and ability to perform needed/desired activities.
• Identify factors (e.g., age, functional decline, painful conditions, breathing problems, client resistive to efforts; vision or hearing impairments, climate, or weather; unsafe areas to exercise; need for mobility assistance, etc.) that could block/affect desired level of activity.
• Determine current activity level and physical condition with observation, exercise tolerance testing, use of functional level classification system (e.g., Gordon’s), as appropriate. Provides baseline for comparison and opportunity to track changes.
• Note presence of medical diagnosis and/or therapeutic regimens (e.g., AIDS, COPD, cancer, heart failure/other cardiac problems, anemia, multiple medications/treatment modalities, extensive surgical interventions, musculoskeletal trauma, neurological disorders) that have potential for interfering with client’s ability to perform at a desired level of activity.
Note: Many factors cause or contribute to fatigue, but activity intolerance implies that the individual cannot endure or adapt to increased energy or oxygen demands caused by an actvity.
• Ask client/SO about usual level of energy to identify potential problems and/or client’s/SO’s perception of client’s energy and ability to perform needed/desired activities.
• Identify factors (e.g., age, functional decline, painful conditions, breathing problems, client resistive to efforts; vision or hearing impairments, climate, or weather; unsafe areas to exercise; need for mobility assistance, etc.) that could block/affect desired level of activity.
• Determine current activity level and physical condition with observation, exercise tolerance testing, use of functional level classification system (e.g., Gordon’s), as appropriate. Provides baseline for comparison and opportunity to track changes.
NURSING PRIORITY NO.2 To develop/investigate alternative ways to remain active within the limits of the disabling condition/situation:
• Implement physical therapy/exercise program in conjunction with the client and other team members such as a physical and/or occupational therapist, exercise/rehabilitation physiologist. Collaborative program with short-term achievable goals enhances likelihood of success and may motivate client to adopt a lifestyle of physical exercise for enhancement of health.
• Promote/implement conditioning program and support inclusion in exercise/activity groups to prevent/limit deterioration.
• Instruct client in proper performance of unfamiliar activities and/or alternate ways of doing familiar activities to learn methods of conserving energy and promote safety in performing activities.
• Implement physical therapy/exercise program in conjunction with the client and other team members such as a physical and/or occupational therapist, exercise/rehabilitation physiologist. Collaborative program with short-term achievable goals enhances likelihood of success and may motivate client to adopt a lifestyle of physical exercise for enhancement of health.
• Promote/implement conditioning program and support inclusion in exercise/activity groups to prevent/limit deterioration.
• Instruct client in proper performance of unfamiliar activities and/or alternate ways of doing familiar activities to learn methods of conserving energy and promote safety in performing activities.
NURSING PRIORITY NO.3 To promote wellness (Teaching/Discharge Considerations):
• Discuss with client/SO relationship of illness/debilitating condition to inability to perform desired activity(ies). Understanding these relationships can help with acceptance of limitations or reveal opportunity for changes of practical value.
• Discuss with client/SO relationship of illness/debilitating condition to inability to perform desired activity(ies). Understanding these relationships can help with acceptance of limitations or reveal opportunity for changes of practical value.
• Provide information regarding factors, such as smoking when one has respiratory problems, weight management, lack of motivation/interest in exercise. Education is essential to encourage modification of potential interferences to activity.
• Assist client/SO(s) with planning for changes that may become necessary (e.g., shifting of family responsibilities, use of supplemental oxygen to improve client’s ability to participate in desired activities). Anticipatory guidance facilitates adaptation if symptoms occur. (Refer to ND Activity Intolerance.)
• Identify and discuss symptoms for which client needs to seek medical assistance/ evaluation, providing for timely intervention.
• Refer to appropriate sources for assistance (e.g., smoking cessation, dietary counseling) and/or equipment, as needed, to sustain or improve activity level and to promote client safety.
• Assist client/SO(s) with planning for changes that may become necessary (e.g., shifting of family responsibilities, use of supplemental oxygen to improve client’s ability to participate in desired activities). Anticipatory guidance facilitates adaptation if symptoms occur. (Refer to ND Activity Intolerance.)
• Identify and discuss symptoms for which client needs to seek medical assistance/ evaluation, providing for timely intervention.
• Refer to appropriate sources for assistance (e.g., smoking cessation, dietary counseling) and/or equipment, as needed, to sustain or improve activity level and to promote client safety.
DOCUMENTATION FOCUS
Assessment/Reassessment
• Identified/potential risk factors for individual.
• Current level of activity tolerance and blocks to activity.
Planning
• Treatment options, including physical therapy/exercise program, other assistive therapies
and devices.
• Lifestyle changes that are planned, who is to be responsible for each action, and monitoring
methods.
Implementation/Evaluation
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modification of plan of care.
Discharge Planning
• Referrals for medical assistance/evaluation.
Assessment/Reassessment
• Identified/potential risk factors for individual.
• Current level of activity tolerance and blocks to activity.
Planning
• Treatment options, including physical therapy/exercise program, other assistive therapies
and devices.
• Lifestyle changes that are planned, who is to be responsible for each action, and monitoring
methods.
Implementation/Evaluation
• Responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modification of plan of care.
Discharge Planning
• Referrals for medical assistance/evaluation.
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Activity Intolerance [specify level]
Definition: Insufficient physiological or psychological energy to endure or complete required or desired daily activities
RELATED FACTORS
Generalized weakness
Sedentary lifestyle
Bedrest/immobility
Imbalance between oxygen supply and demand, [anemia]
[Cognitive deficits/emotional status; secondary to underlying disease process/depression]
[Pain, vertigo, dysrhythmias, extreme stress]
DEFINING CHARACTERISTICS
Subjective
Verbal report of fatigue/weakness
Exertional discomfort/dyspnea
[Verbalizes no desire and/or lack of interest in activity]
Objective
Abnormal heart rate/blood pressure response to activity
Electrocardiographic changes reflecting arrhythmias/or ischemia
[Pallor, cyanosis]
FUNCTIONAL LEVEL CLASSIFICATION (GORDON, 1987):
Level I: Walk, regular pace, on level indefinitely; one flight or more but more short of breath
than normally
Level II: Walk one city block [or] 500 ft on level; climb one flight slowly without stopping
Level III: Walk no more than 50 ft on level without stopping; unable to climb one flight of stairs without stopping
Level IV: Dyspnea and fatigue at rest
RELATED FACTORS
Generalized weakness
Sedentary lifestyle
Bedrest/immobility
Imbalance between oxygen supply and demand, [anemia]
[Cognitive deficits/emotional status; secondary to underlying disease process/depression]
[Pain, vertigo, dysrhythmias, extreme stress]
DEFINING CHARACTERISTICS
Subjective
Verbal report of fatigue/weakness
Exertional discomfort/dyspnea
[Verbalizes no desire and/or lack of interest in activity]
Objective
Abnormal heart rate/blood pressure response to activity
Electrocardiographic changes reflecting arrhythmias/or ischemia
[Pallor, cyanosis]
FUNCTIONAL LEVEL CLASSIFICATION (GORDON, 1987):
Level I: Walk, regular pace, on level indefinitely; one flight or more but more short of breath
than normally
Level II: Walk one city block [or] 500 ft on level; climb one flight slowly without stopping
Level III: Walk no more than 50 ft on level without stopping; unable to climb one flight of stairs without stopping
Level IV: Dyspnea and fatigue at rest
Sample Clinical Applications: Anemias, angina, aortic stenosis, bronchitis, emphysema, diabetes mellitus, dysmenorrhea, heart failure, human immunodeficiency virus/acquired immunodeficiency disease (HIV/AIDS), labor/preterm labor, leukemias, mitral stenosis, obesity, pain, pericarditis, peripheral vascular disease, rheumatic fever, thrombocytopenia, tuberculosis, uterine bleeding
Client Will (Include Specific Time Frame)
• Identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible.
• Use identified techniques to enhance activity tolerance.
• Participate in necessary/desired activities.
• Report measurable increase in activity tolerance.
• Demonstrate a decrease in physiological signs of intolerance (e.g., pulse, respirations, and
blood pressure remain within client’s usual range).
• Identify negative factors affecting activity tolerance and eliminate or reduce their effects when possible.
• Use identified techniques to enhance activity tolerance.
• Participate in necessary/desired activities.
• Report measurable increase in activity tolerance.
• Demonstrate a decrease in physiological signs of intolerance (e.g., pulse, respirations, and
blood pressure remain within client’s usual range).
NURSING PRIORITY NO.1 To identify causative/precipitating factors:
• Note presence of acute or chronic illness, such as heart failure, hypothyroidism, diabetes mellitus, AIDS, cancers, acute and chronic pain, etc. Many factors cause or contribute tofatigue, but acitivity intolerance implies that the client cannot endure or adapt to increasedenergy or oxygen demands caused by an actvity.
• Assess cardiopulmonary response to physical activity by measuring vital signs, noting heart rate/regularity, respiratory rate/work of breathing, and blood pressure before, during, andafter activity. Note progression/accelerating degree of fatigue. Dramatic changes in heartrate and rhythm, changes in usual blood pressure, and progressively worsening fatigue resultfrom imbalance of oxygen supply and demand. These changes are potentially greater in thefrail, elderly population.
• Note treatment-related factors such as side effects/interactions of medications. Caninfluence presence and degree of fatigue.
• Determine if client is receiving medications such as vasodilators, diuretics, or beta-blockers.Orthostatic hypotension can occur with activity because of medication effects(vasodilation), fluid shifts (diuresis), or compromised cardiac pumping function.
• Note client reports of difficulty accomplishing tasks or desired activities. Evaluate current limitations/degree of deficit in light of usual status and what the client perceives causes, exacerbates, and helps the problem. Provides comparative baseline and influences choice of interventions and may reveal causes that the client is unaware of affecting energy, such as sleep deprivation, smoking, poor diet, depression, or lack of support. 1
• Ascertain ability to sit, stand, and move about as desired. Note degree of assistance necessary, and/or use of assistive equipment. Helps to differentiate between problems relating to movement and problems with oxygen supply and demand characterized by fatigue and weakness.
• Identify activity needs versus desires (e.g., client barely able to walk upstairs but states would like to play racquetball). Assists caregiver in dealing with reality of situation, as well as the feasibility of goals client wants to achieve when developing activity plan.
• Ascertain ability to sit, stand, and move about as desired. Note degree of assistance necessary, and/or use of assistive equipment. Helps to differentiate between problems relating to movement and problems with oxygen supply and demand characterized by fatigue and weakness.
• Identify activity needs versus desires (e.g., client barely able to walk upstairs but states would like to play racquetball). Assists caregiver in dealing with reality of situation, as well as the feasibility of goals client wants to achieve when developing activity plan.
• Assess emotional/psychological factors affecting the current situation. Stress and/or depression may be exacerbating the effects of an illness, or depression may be the result of therapy/limitations.
NURSING PRIORITY NO.2 To assist client to deal with contributing factors and manage activities within individual limits:
• Monitor vital signs, before and during activity, watching for changes in blood pressure, heart and respiratory rate, as well as postactivity vital sign response. Vital signs increase during activity and should return to baseline within 5 to 7 minutes after activity if response to activity is normal.
• Observe respiratory rate, noting breathing pattern, breath sounds, skin color, and mental status. Pallor and/or cyanosis, presence of respiratory distresss, or confusion may be indicative of need for oxygen during activities, especially if respiratory infection or compromise is present.
• Plan care with rest periods between activities to reduce fatigue.
• Assist with self-care activities. Adjust activities/reduce intensity level, or discontinue activities that cause undesired physiological changes. Prevents overexertion.
• Increase exercise/activity levels gradually; encourage stopping to rest for 3 minutes during a 10-minute walk, sitting down instead of standing to brush hair, etc. Methods of conserving energy.
• Encourage expression of feelings contributing to/resulting from condition. Provide positive atmosphere while acknowledging difficulty of the situation for the client. Helps to minimize frustration, rechannel energy.
• Involve client/significant others (SOs) in planning of activities as much as possible. May give client opportunity to perform desired/essential activities during periods of peak energy.
• Assist with activities and provide/monitor client’s use of assistive devices. Enables client to maintain mobility while protecting from injury.
• Promote comfort measures and provide for relief of pain to enhance client’s ability and desire to participate in activities. (Refer to NDs acute Pain, chronic Pain.)
• Provide referral to collaborative disciplines such as exercise physiologist, psychological counseling/therapy, occupational/physical therapy, and recreation/leisure specialists. May be needed to develop individually appropriate therapeutic regimens.
• Prepare for/assist with and monitor effects of exercise testing. May be performed to determine degree of oxygen desaturation and/or hypoxemia that occurs with exertion, or to optimize titration of supplemental oxygen when used.
• Implement graded exercise/rehabilitation program under direct medical supervision. Gradual increase in activity avoids excessive myocardial workload/excessive oxygen demand.
• Monitor vital signs, before and during activity, watching for changes in blood pressure, heart and respiratory rate, as well as postactivity vital sign response. Vital signs increase during activity and should return to baseline within 5 to 7 minutes after activity if response to activity is normal.
• Observe respiratory rate, noting breathing pattern, breath sounds, skin color, and mental status. Pallor and/or cyanosis, presence of respiratory distresss, or confusion may be indicative of need for oxygen during activities, especially if respiratory infection or compromise is present.
• Plan care with rest periods between activities to reduce fatigue.
• Assist with self-care activities. Adjust activities/reduce intensity level, or discontinue activities that cause undesired physiological changes. Prevents overexertion.
• Increase exercise/activity levels gradually; encourage stopping to rest for 3 minutes during a 10-minute walk, sitting down instead of standing to brush hair, etc. Methods of conserving energy.
• Encourage expression of feelings contributing to/resulting from condition. Provide positive atmosphere while acknowledging difficulty of the situation for the client. Helps to minimize frustration, rechannel energy.
• Involve client/significant others (SOs) in planning of activities as much as possible. May give client opportunity to perform desired/essential activities during periods of peak energy.
• Assist with activities and provide/monitor client’s use of assistive devices. Enables client to maintain mobility while protecting from injury.
• Promote comfort measures and provide for relief of pain to enhance client’s ability and desire to participate in activities. (Refer to NDs acute Pain, chronic Pain.)
• Provide referral to collaborative disciplines such as exercise physiologist, psychological counseling/therapy, occupational/physical therapy, and recreation/leisure specialists. May be needed to develop individually appropriate therapeutic regimens.
• Prepare for/assist with and monitor effects of exercise testing. May be performed to determine degree of oxygen desaturation and/or hypoxemia that occurs with exertion, or to optimize titration of supplemental oxygen when used.
• Implement graded exercise/rehabilitation program under direct medical supervision. Gradual increase in activity avoids excessive myocardial workload/excessive oxygen demand.
• Administer supplemental oxygen, medications, prepare for surgery, as indicated. Type of therapy or medication is dependent on the underlying condition and might include medications (such as antiarryhthmics) or surgery (e.g., stents or CABG) to improve myocardial perfusion and systemic circulation. Other treatments might include iron preparations or blood transfusion to treat severe anemia, or use of oxygen and bronchodilators to improve respiratory function.
NURSING PRIORITY NO.3 To promote wellness (Teaching/Discharge Considerations):
• Review expectations of client/SO(s)/providers and explore conflicts/differences. Helps to establish goals and to reach agreement for the most effective plan.
• Assist/direct client/SO to plan for progressive increase of activity level aiming for maximal activity within the client’s ability. Promotes improved or more normal activity level, stamina, and conditioning.
• Instruct client/SOs in monitoring response to activity and in recognizing signs/symptoms that indicate need to alter activity level. Assists in self-management of condition and in understanding of reportable problems.
• Give client information that provides evidence of daily/weekly progress to sustain motivation.
• Assist client to learn and demonstrate appropriate safety measures to prevent injuries.
• Provide information about proper nutrition to meet metabolic and energy needs, obtaining or maintaining normal body weight. Energy is improved when nutrients are sufficient to meet metabolic demands.
• Encourage client to use relaxation techniques such as visualization/guided imagery as appropriate. Useful in maintaining positive attitude and enhancing sense of well-being.
• Encourage participation in recreation/social activities and hobbies appropriate for situation. (Refer to ND deficient Diversional Activity.)
• Monitor laboratory values (such as for anemia) and pulse oximetry.
• Review expectations of client/SO(s)/providers and explore conflicts/differences. Helps to establish goals and to reach agreement for the most effective plan.
• Assist/direct client/SO to plan for progressive increase of activity level aiming for maximal activity within the client’s ability. Promotes improved or more normal activity level, stamina, and conditioning.
• Instruct client/SOs in monitoring response to activity and in recognizing signs/symptoms that indicate need to alter activity level. Assists in self-management of condition and in understanding of reportable problems.
• Give client information that provides evidence of daily/weekly progress to sustain motivation.
• Assist client to learn and demonstrate appropriate safety measures to prevent injuries.
• Provide information about proper nutrition to meet metabolic and energy needs, obtaining or maintaining normal body weight. Energy is improved when nutrients are sufficient to meet metabolic demands.
• Encourage client to use relaxation techniques such as visualization/guided imagery as appropriate. Useful in maintaining positive attitude and enhancing sense of well-being.
• Encourage participation in recreation/social activities and hobbies appropriate for situation. (Refer to ND deficient Diversional Activity.)
• Monitor laboratory values (such as for anemia) and pulse oximetry.
DOCUMENTATION FOCUS
Assessment/Reassessment
• Level of activity as noted in Functional Level Classification.
• Causative/precipitating factors.
• Client reports of difficulty/change.
Planning
• Plan of care and who is involved in planning.
Implementation/Evaluation
• Response to interventions/teaching and actions performed.
• Implemented changes to plan of care based on assessment/reassessment findings.
• Teaching plan and response/understanding of teaching plan.
• Attainment/progress toward desired outcome(s).
Discharge Planning
• Referrals to other resources.
• Long-term needs and who is responsible for actions.
Assessment/Reassessment
• Level of activity as noted in Functional Level Classification.
• Causative/precipitating factors.
• Client reports of difficulty/change.
Planning
• Plan of care and who is involved in planning.
Implementation/Evaluation
• Response to interventions/teaching and actions performed.
• Implemented changes to plan of care based on assessment/reassessment findings.
• Teaching plan and response/understanding of teaching plan.
• Attainment/progress toward desired outcome(s).
Discharge Planning
• Referrals to other resources.
• Long-term needs and who is responsible for actions.
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