NANDA-NURSING diagnoses, Interventions, ect Exam 1 – Flashcards

-risk for imbalanced nutrition related to high-calorie diet and sedentary lifestyle -more than body requirements -risk for impaired skin integrity related to lifetime of sun exposure -caregiver role strain related to long-term care of aging parents -sedentary lifestyle related to lack of resources (money, time, facilities) -stress overload related to chronic illness -risk-prone health behavior related to inadequate comprehension -ineffective relationship related to stressful life events

-identify behaviors and factors that affect risk of falls -monitor gait, balance, and fatigue level with ambulation -assist unsteady individual with ambulation -post signs to alert staff that patient is at a high risk for falls -instruct patient to wear prescription glasses, as appropriate, when out of bed -avoid clutter on floor surfaces -educate family members about risk factors that contribute to falls and how they can decrease these risks

-disturbed personal identity related to social role change and depression -risk for injury related to unstable gait and decreased vision from cataracts -risk for loneliness related to death of spouse -ineffective coping related to diagnosis of chronic illness -impaired physical mobility related to severe arthritic changes in legs -impaired memory related to cognitive impairment from onset of Alzheimer's disease -risk for acute confusion related to dementia

-bathing self-care deficit related to sognitive deficits -impaired oral mucous membrane related to ineffective oral hygiene -impaired social interaction related to negative body image

-monitor functional ability while bathing -offer hand washing after toileting and before meals -use fun bathing techniques with children, such as wash dolls or toys -bathe in water of a comfortable temp -monitor skin condition while bathing -apply lubricant ointment and cream to dry skin areas

-ineffective airway clearance related to fatigue -impaired gas exchange related to smokes one packs of cigs per day -ineffective breathing pattern related to anxious about results of cardiac catheterization and possible cardiac surgery

-maintain patent airway -auscultate breath sounds, noting areas of decreased or absent ventilation and presence of adventitious sounds -initiate and maintain supplemental oxygen as prescribed -administer appropriate pain meds to prevent hypoventilation -ambulate 3-4 times daily -monitor respiratory and oxygenation status -administer meds (bronchodilators and inhalers) that promote airway patency and gas exchange -teach pursed-lip breathing techniques -initiate a program of respiratory muscle strength and/or endurance training

-anxiety related to social isolation or high risk for infection -activity intolerance related to effects of infectious process or generalized weakness

-identify safety hazards in the environment -modify the environment to minimize hazards and risks -provide pt with emergency phone numbers -initiate and/or conduct screening programs for environmental hazards -educate high-risk individuals and groups about environmental hazards

-activity intolerance related to CHF -impaired physical mobility related to musculoskeletal impairement

-determine the pt's ability to participate in activities requiring balance -evaluate sensory functions and provide assistive devices -provide a safe environment for practice of exercises -encourage the patient to maintain a wide base of support -assist to stand or sit and rock the body from side to side to stimulate balance mechanisms -assist the pt to practice standing with eyes closed for short periods at regular intervals to stimulate proprioception -monitor the pt's response to balance exercises

-consult with family to establish pt's cognitive baseline -inform pt of recent nonthreatening news events -offer environmental stimulation through contact with varied personnel -provide a calendar -orient to time, place, and person -provide planned sensory stimulation -use tv, radio, or music as part of planned stimuli program -reinforce or repeat info -present change gradually -talk to patient

-impaired verbal communication related to decrease in circulation to the brain -disturbed energy field related to slowing or blocking of energy flows secondary to illness, injury, immobility, pain, anxiety, or age-related developmental crises

-constipation related to dehydration -deficient knowledge related to lack of interest in learning -sexual dysfunction related to adverse effects of anti-hypertensive drug

-medication administration -teaching -medication reconciliation -medication management -analgesic administration

-disturbed sleep pattern: difficulty falling asleep related to worries about family and lack of destressing rituals -disturbed sleep pattern: difficulty remaining awake related to noise of hospital environment and need for periodic treatments -disturbed sleep pattern: altered sleep-wake patterns related to frequent rotations of shift and overtime

-determine effects of pts meds on sleep pattern -adjust environment to promote sleep -encourage pt to establish a bedtime routine to facilitate from wakefulness to sleep -facilitate maintenance of pts usual bedtime routines, presleep cues/props, and familiar objects as appropriate -instruct pt to avoid bedtime foods and beverages that interfere with sleep -instruct pt how to perform autogenic muscle relaxation or other nonpharmacologic forms of sleep inducement -initiate/implement comfort measures of massage, poisitioning, and affective touch -discuss with pt and family sleep-enhancing techniques

-pain:acute postoperative related to fear of taking prescribed analgesics -pain related to prolonged labor (dystocia) and commitment to natural childbirth -chronic pain: headaches related to inadequate pain management secondary to belief that somehow pt "deserves this pain" -chronic pain related to inadequate pain management of metastatic cancer involving bone

-perform a comprehensive assessment of pain to include location, characteristics, onset/duration, frequency, quality, intensity, and precipitating factors -consider cultural influences on pain response -explore with pt factors that relieve/worsen pain -assure pt attentive analgesic care