Nursing Diagnosis and Nursing Intervention


NANDA Impaired Swallowing Nursing Diagnosis

NANDA Definition: Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function

Defining Characteristics:

Oral phase impairment

  • Lack of tongue action to form bolus; 
  • weak suck resulting in inefficient nippling; 
  • incomplete lip closure; 
  • food pushed out of mouth; 
  • slow bolus formation; 
  • food falls from mouth; 
  • premature entry of bolus; 
  • nasal reflux; 
  • inability to clear oral cavity;
  • long meals with little consumption; 
  • coughing, choking, or gagging before a swallow; 
  • abnormality in oral phase of swallow study; 
  • piecemeal deglutition; 
  • lack of chewing; 
  • pooling in lateral sulci; 
  • sialorrhea or drooling
Pharyngeal phase impairment
  • Altered head positions; 
  • inadequate laryngeal elevation; 
  • food refusal; 
  • unexplained fevers; 
  • delayed swallow; 
  • recurrent pulmonary infections; 
  • gurgly voice quality; 
  • nasal reflux; 
  • choking, coughing, or gagging;
  • multiple swallows; 
  • abnormality in pharyngeal phase by swallowing study
Esophageal phase impairment
  • Heartburn or epigastric pain; 
  • acidic smelling breath; 
  • unexplained irritability surrounding mealtime; 
  • vomitous on pillow; 
  • repetitive swallowing or ruminating; 
  • regurgitation of gastric contents or set burps; 
  • bruxism; 
  • nighttime coughing or awakening; 
  • observed evidence of difficulty in swallowing (e.g., stasis of food in oral cavity, coughing, or choking); 
  • hyperextension of head, arching during or after meals; 
  • abnormality in esophageal phase by swallow study; 
  • odynophagia; 
  • food refusal or volume limiting; 
  • complaints of "something stuck"; 
  • hematemesis; 
  • vomiting

Related Factors:
  • Congenital deficits; 
  • upper airway anomalies; 
  • failure to thrive; 
  • protein energy malnutrition; 
  • conditions with significant hypotonia; 
  • respiratory disorders; 
  • history of tube feeding; 
  • behavioral feeding problems; 
  • self-injurious behavior; 
  • neuromuscular impairment (e.g., decreased or absent gag reflex, decreased strength or excursion of muscles involved in mastication, perceptual impairment, or facial paralysis); 
  • mechanical obstruction (e.g., edema, tracheotomy tube, or tumor); 
  • congenital heart disease; 
  • cranial nerve involvement; 
  • neurological problems; 
  • upper airway anomalies; 
  • laryngeal abnormalities; 
  • achalasia; 
  • gastroesophageal reflux disease; 
  • acquired anatomic defects; 
  • cerebral palsy;
  • internal or external traumas; tracheal, laryngeal, esophageal defects; 
  • traumatic head injury; 
  • developmental delay; 
  • nasal or nasopharyngeal cavity defects; 
  • oral cavity or oropharynx abnormalities; 
  • premature infants

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Swallowing Status
  • Swallowing Status: Esophageal Phase, Oral Phase, Pharyngeal Phase
Client Outcomes
  • Demonstrates effective swallowing without choking or coughing
  • Remains free from aspiration (e.g., lungs clear, temperature within normal range)
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Aspiration Precautions
  • Swallowing Therapy
Read More : http://nanda-nic-noc.blogspot.com/2013/03/impaired-swallowing-nursing-diagnosis.html

NANDA Risk for Falls Nursing Diagnosis

NANDA Definition: Increased susceptibility to falling that may cause physical harm

Related Factors: See Risk Factors

Risk Factors:

Adults

  • History of falls; 
  • wheelchair use; 
  • (65 years of age; 
  • female (if elderly); 
  • lives alone; 
  • lower limb prosthesis; 
  • use of assistive devices (e.g., walker, cane)
Physiological
  • Presence of acute illness; 
  • postoperative conditions; 
  • visual difficulties; 
  • hearing difficulties; 
  • arthritis; 
  • orthostatic hypotension; 
  • sleeplessness; 
  • faintness when turning or extending neck; 
  • anemias; 
  • vascular disease; 
  • neoplasms (i.e., fatigue/limited mobility, urgency and/or incontinence, diarrhea, decreased lower extremity strength, posprandial blood sugar changes, foot problems, impaired physical mobility, impaired balance, difficulty with gait, unilateral neglect, proprioceptive deficits, neuropathy)
Cognitive
  • Diminished mental status (e.g., confusion, delerium, dementia, impaired reality testing)
Medication
  • Antihypertensive agents; 
  • ACE-inhibitors; 
  • diuretics; 
  • tricyclic antidepressants; 
  • alcohol use; 
  • antianxiety agents; 
  • opiates; 
  • hypnotics or tranquilizers
Environment
  • Restraints; 
  • weather conditions (e.g., wet floors/ice); 
  • throw/scatter rugs; 
  • cluttered environment; 
  • unfamiliar, dimly lit room; 
  • no antislip material in bath and/or shower
Children (<2 years of age)
  • Male gender when <1 year of age; 
  • lack of auto restraints; lack of gate on stairs; 
  • lack of window guard; bed located near window; 
  • unattended infant on bed/changing table/sofa; 
  • lack of parental supervision


NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Safety Behavior: Fall Prevention
  • Knowledge: Child Safety
Client Outcomes
  • Remains free of falls
  • Changes environment to minimize the incidence of falls
  • Explains methods to prevent injury

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Fall Prevention
  • Dementia Management
  • Safety
Read More : http://nanda-nic-noc.blogspot.com/2013/04/risk-for-falls-nursing-diagnosis.html

NANDA Urinary Retention Nursing Diagnosis

NANDA Definition: Incomplete emptying of the bladder

Defining Characteristics:

  • Measured urinary residual >150 to 200 ml or 25% of total bladder capacity; 
  • obstructive lower urinary tract symptoms (poor force of stream, intermittency of stream, hesitancy of urination, postvoiding dribbling, feelings of incomplete bladder emptying); 
  • irritative lower urinary tract symptoms (urgency to urinate, diurnal frequency of urination, nocturia); 
  • overflow incontinence (dribbling urine loss caused when intravesical pressure overwhelms the sphincter mechanism)

Related Factors:
  • Bladder outlet obstruction: benign prostatic hyperplasia, prostate cancer, prostatitis, urethral stricture, bladder neck dyssynergia, bladder neck contracture, detrusor striated sphincter dyssynergia, obstructing cystocele or urethral distortion, urethral tumor, urethral polyp, posterior urethral valves, postoperative complication
  • Deficient detrusor contraction strength: sacral level spinal lesions, cauda equina syndrome, peripheral polyneuropathies, herpes zoster or simplex affecting sacral nerve roots, injury or extensive surgery causing denervation of pelvic plexus, medication side effect, complication of illicit drug use, impaction of stool
NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Urinary Elimination
  • Urinary Continence
Client Outcomes
  • Completely and regularly eliminates urine from the bladder; measured urinary residual volume is <150 to 200 ml or 25% of total bladder capacity (voided volume plus urinary residual volume) 
  • Correction or relief from obstructive symptoms 
  • Correction or alleviation of irritative symptoms
  • Client is free of upper urinary tract damage (renal function remains sufficient; absence of febrile urinary infections)
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Urinary Catheterization
Read More : http://nanda-nic-noc.blogspot.com/2013/04/urinary-retention-nursing-diagnosis.html

NANDA Wandering Nursing Diagnosis

NANDA Definition:
Meandering; aimless or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles

Defining Characteristics:

  • Frequent or continuous movement from place to place, often revisiting the same destinations; 
  • persistent locomotion in search of "missing" or unattainable people or places; 
  • haphazard locomotion; 
  • locomotion in unauthorized or private spaces; 
  • locomotion resulting in unintended leaving of a premise; 
  • long periods of locomotion without an apparent destination; 
  • fretful locomotion or pacing;
  • inability to locate significant landmarks in a familiar setting; 
  • locomotion that cannot be easily dissuaded or redirected; 
  • following behind or shadowing a caregiver's locomotion; 
  • trespassing; 
  • hyperactivity; 
  • scanning, seeking, or searching behaviors; 
  • periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping); 
  • getting lost

Related Factors:
  • Cognitive impairment, specifically memory and recall deficits, disorientation, poor visuoconstructive (or visuospatial) ability, and language (primarily expressive) defects; 
  • cortical atrophy; 
  • premorbid behavior (e.g., outgoing, sociable personality); 
  • premorbid dementia; 
  • separation from familiar people and places; 
  • sedation; 
  • emotional state, especially frustration, anxiety, boredom, or depression (agitation); 
  • overstimulating/understimulating social or physical environment; 
  • physiological state or need (e.g., hunger/thirst, pain, urination, constipation); 
  • time of day


NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Safety Status: Falls Occurrence
  • Safety Behavior: Fall Prevention
  • Caregiver Home Care Readiness
Client Outcomes
  • Decreased incidence of falls (preferably free of falls)
  • Decreased incidence of elopements
  • Appropriate body weight maintained
  • Caregiver able to explain interventions can use to provide a safe environment for care receiver who displays wandering behavior
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Dementia Management
Read More : http://nanda-nic-noc.blogspot.com/2013/04/wandering-nursing-diagnosis.html

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