1. Principles related to normal nutrition (e.g., anatomy and
physiology)
2. Components of normal nutrition: definitions, basic function,
common food sources, daily requirements (e.g., from the food
Guide Pyramid exchange lists)
b. Proteins
c. Fats
d. Vitamins
e. Minerals
f. Fiber
g. Fluids
3. Common nutritional disturbances (e.g., altered ingestion,
digestion and absorption, nutritional deficiencies)
4. Factors affecting nutrition
a. Developmental level: infancy through senescence
b. Individual preferences and patterns (e.g., vegetarian diet, health
habits, use of vitamin supplements, knowledge level, cooking habits)
c. Physical condition (e.g., dental status, metabolic rate, weight status,
level of physical activity, circulation status, status of peristalsis)
d. Ethnic and cultural considerations (e.g., religious restrictions,
traditional ethnic foods, cultural preferences/taboos)
e. Socioeconomic factors (e.g., income level, work habits)
f. Environmental factors (e.g., means of procuring food, food storage,
refrigeration, eating facilities)
5. Theoretical basis fore interventions to promote nutrition
a. Physiological considerations (e.g., oral care, increased activity,
positioning)
b. Enteral nutrition: oral and tube feedings
c. Parenteral nutrition: total parenteral nutrition (TPN), lipid emulsions,
total nutrient admixture (three-in-one)
d. Altered consistency of diets
1) Clear liquid
2) Full liquid
3) Soft
e. Vitamin and mineral supplements
B. Nursing care related to theoretical framework
1. Assessment: gather and synthesize data about the patient's
nutritional status in relation to the patient's functional health
patterns
a. Obtain the patient's dietary history (e.g., daily nutritional status,
intolerance to certain foods, food preferences, food allergies, pattern of
intake [24-hour food diary], loss of appetite [Anorexia], dysphagia,
nausea and vomiting)
b. Assess factors affecting nutrition (see IA4)
c. Obtain objective data (e.g., weight changes; skin turgor; level of
physical activity; condition of hair and nails; amount, type, and pattern
of intake; triceps skin fold thickness)
d. Review laboratory and other diagnostic data (e.g., serum albumin,
complete blood count [CBC])
2. Analysis: identify the nursing diagnosis (patient problem)
and determine the expected outcomes (goals) of patient care
a. Identify nursing diagnoses (e.g., altered nutrition: less than body
requirements related to hectic schedule; altered nutrition: more than
body requirements related to dependence on fast foods; altered health
maintenance related to insufficient knowledge of nutritional needs)
b. Set priorities and establish expected outcomes (patient-centered
goals) for care (e.g., patient will identify form the Food Guide Pyramid
preferred foods that are accessible and easy to prepare, patient will
select low-calorie foods from fast-food menus, patient will select a
balanced daily diet from a basic food list)
3. Planning: formulate specific strategies to achieve the
expected outcomes
a. Incorporate factors affecting nutrition in planning the patient's care
(e.g., plan a clear liquid diet for a patient following surgery, plan a
nutritionally adequate diet based on patient's religious preferences,
plan a nutritionally adequate diet for an older adult) (see IA4)
b. Plan nursing measures to help the patient achieve the expected
outcomes (e.g., review nutritional requirements based on the Food Guide
Pyramid, monitor the patient's weight)
4. Implementation: carry out nursing plans designed to move
the patient toward the expected outcomes
a. Assist in food selection (e.g., for a patient with altered chewing or
swallowing ability, for patients of various developmental levels, for a
patient with an imbalanced diet)
b. Use nursing measures appropriate to particular feeding methods (e.g.,
provide nasogastric tube feedings, administer gastrostomy tube
feedings, monitor TPN)
c. Structure an environment conducive to nutritional intake (e.g.,
remove noxious stimuli form the environment, make the patient
comfortable)
d. Use nursing measures specific to prescribed vitamin and mineral
supplements (e.g., administer iron supplements with orange juice,
administer vitamin supplements as ordered, check the serum albumin
level for a patient who is receiving a high-protein liquid supplement)
e. Provide information and instruction regarding nutrition (e.g., instruct
the patient regarding food preservation and preparation, instruct the
patient how to read nutritional content on food labels, instruct the
patient with lactose intolerance about alternate food sources)
5. Evaluation: appraise the effectiveness of the nursing
intervention relative to the nursing diagnosis and the
expected outcomes
a. Record and report patient's response to nursing actions (e.g., weight
changes, improved skin turgor, changes in nutritional intake,
noncompliance)
b. Reassess and revise the patient's plan of care as necessary (e.g.,
provide small, frequent feedings for a patient with loss of appetite
[anorexia])
II. Elimination
A. Theoretical framework: basis for care
1. Principles related to normal elimination (e.g., anatomy and
physiology, microbiology)
2. Common disturbances of intestinal elimination (e.g.,
constipation, diarrhea, impaction, flatulence, incontinence)
3. Common disturbances of urinary elimination (e.g.,
incontinence, frequency, urgency, retention, suppression,
dysuria, polyuria)
4. Factors affecting intestinal and urinary elimination
a. Developmental level: infancy through senescence
b. Individual preferences and patterns (e.g., use of laxatives, health
habits)
d. Ethnic and cultural considerations (e.g., fasting)
e. Socioeconomic factors (e.g., excess intake of refined carbohydrates,
decreased intake of fresh fruits and vegetables)
f. Environmental factors (e.g., access to sanitary facilities, privacy, time
schedule demands)
g. Psychological factors (e.g., hospitalization, loneliness, anxiety,
depression, stress)
5. Theoretical basis for interventions to promote intestinal
and urinary elimination
a. Physiological considerations (e.g., positioning exercise, gastrocolic
reflex)
b. Medications (e.g., stool softeners, cathartics, urinary tract antiseptics
and analgesics, antidiarrheal agents)
c. Catheterization (e.g., indwelling, external, straight)
d. Enemas (e.g., cleansing, carminative, retention)
e. Dietary modifications (e.g., after intake of fiber, establish regular
eating times, alter intake of fluids)
B. Nursing care related to theoretical framework
1. Assessment: gather and synthesize data about the patient's
elimination status in relation to the patient's functional health
patterns
a. Obtain the patient's elimination history (e.g., pattern of bowel
elimination [time of day and frequency], use of laxatives and cathartics,
anorexia, frequency of urination, dysuria)
b. Assess factors affecting elimination (see IIA4)
c. Obtain objective data (e.g., intake and output, color, and amount;
altered bowel sounds; bladder distention)
d. Review laboratory and other diagnostic data (e.g., specific gravity,
stool for guaiac, urinalysis, culture and sensitivity, stool for ova and
parasites)
e. Collect specimens
2. Analysis: identify the nursing diagnosis (patient problem)
and determine the expected outcomes (goals) of patient care
a. Identify nursing diagnoses (e.g., constipation related to decreased
abdominal muscle tone associated with aging, constipation related to
immobility, urinary retention related to loss of muscle tone, stress
incontinence related to weak pelvic muscles, high risk for urinary tract
infection related to improper perineal hygiene)
b. Set priorities and establish expected outcomes (patient-centered
goals) for care (e.g., patient will pass a soft, formed stool at regular
intervals; patient will remain free of infection; patient will verbalize
understanding of perineal floor exercises; patient will wipe perineal
area from front to back after urinating and defecating)
3. Planning: formulate specific strategies to achieve the
expected outcomes
a. Incorporate factors affecting elimination in planning the patient's care
(e.g., for a patient with an indwelling catheter, for an older adult on bed
rest, for a patient with increased urine specific gravity) (see IIA4)
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (e.g., discuss the problems
associated with the misuse of laxatives and enemas, establish an
elimination routine, encourage the patient to practice perineal floor
exercised q2h while awake)
4. Implementation: carry out nursing plans designed to move
the patient toward the expected outcomes
a. Ensure appropriate intake (e.g., encourage adequate intake of fiber,
provide daily fluid intake appropriate to the patient's developmental
level)
b. Ensure appropriate activity (e.g., encourage ambulation, provide
range-of-motion exercises)
c. Establish an environment conducive to elimination (e.g., decrease
stress, provide proper positioning, ensure privacy)
d. Use nursing measures appropriate to particular elimination needs
(e.g., perform bladder catheterizations and irrigations, insert rectal tube,
administer enema, administer laxatives and stool softeners, provide
bladder and bowel retraining)
e. Provide information and instruction regarding toilet training for their
child, instruct the patient regarding hygiene and asepsis)
5. Evaluation: appraise the effectiveness of the nursing
intervention relative to the nursing diagnosis and the
expected outcomes
a. Record and report patient's response to nursing actions (e.g., relief of
subjective symptoms, increased fluid intake, altered consistency of
stool, increase in volume of urine, adverse reactions to treatments)
b. Reassess and revise patient's plan of care as necessary (e.g., change
pattern of patient's fluid intake to control enuresis, use a fracture pan
rather than a regular bedpan, use a bedside commode when it is
difficult for the patient to reach the toilet)
III. Oxygenation
A. Theoretical framework: basis for care
1. Principles related to normal oxygenation (e.g., anatomy and
physiology)
2. Common disturbances of oxygenation (e.g., altered oxygen
intake and supply, altered oxygen absorption and
transportation, altered cellular demand for oxygen)
3. Factors affecting oxygenation
a. Developmental level: infancy through senescence
b. Individual preferences and patterns (e.g., smoking, sedentary
lifestyle)
c. Physical condition (e.g., breathing patterns, body weight, body
temperature, hemoglobin, exercise patterns)
d. Environmental factors (e.g., pollution, high altitudes, room ventilation,
air temperature changes, overcrowded conditions)
e. Psychological factors (e.g., stress, emotional status, anxiety)
4. Theoretical basis for interventions to promote oxygenation
a. Positioning (e.g., elevation of the extremities, Fowler's position)
b. Activity and rest patterns (e.g., passive and active exercise, stress
reduction)
c. Dietary modifications (e.g., sodium restriction, increased fluids, caloric
restriction, modifications to promote erythrogenesis)
d. Administration of oxygen (e.g., nasal cannula, mask, humidification)
e. Airway maintenance (e.g., coughing and deep breathing, cupping and
clapping, incentive spirometry, nasopharyngeal suctioning, pursed-lip
breathing, postural drainage)
B. Nursing care related to theoretical framework
1. Assessment: gather and synthesize data about the patient's
oxygenation status in relation to the patient's functional
health patterns
a. Obtain the patient's oxygenation history (e.g., dyspnea, fatigue,
altered sensation, occupation, health habits)
b. Assess factors affecting oxygenation (see III3A)
c. Obtain the objective data (e.g., respiratory rate and rhythm,
peripheral pulses, skin color, breath sounds, restlessness, tachycardia,
apnea, tachypnea, pallor, cyanosis, confusion, hypoventilation,
hyperventilation, airway patency, capillary refill)
d. Review laboratory and other diagnostic data (e.g., blood gases,
hemoglobin, hematocrit, sputum cultures, chest X ray, pulmonary
function studies, pulse oximetry)
e. Collect specimens
2. Analysis: identify the nursing diagnosis (patient problem)
and determine the expected outcomes (goals) for patient care
a. Identify nursing diagnoses (e.g., ineffective airway clearance related
to immobility, noncompliance with smoking cessation related to
physiological addiction, activity intolerance related to shortness of
breath)
b. Set priorities and establish expected outcomes (patient-centered
goals) for care (e.g., patient's breath sounds will be clear, patient will
enroll in a behavior modification program for smoking cessation, patient
will ambulate 200 feet without shortness of breath)
3. Planning: formulate specific strategies to achieve the
expected outcomes
a. Incorporate factors affecting oxygenation in planning the patient's
care (e.g., plan for humidification, ensure adequate ventilation, discuss
with parents the effects of secondary smoke, space activities to allow
for periods of rest) (see IIIA3)
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (e.g., established physical
activity program, plan coughing and deep-breathing regimen with the
patient, plan for frequent position changes, refer the patient to smoking
cessation programs in the community)
4. Implementation: carry out nursing plans designed to move
the patient toward the expected outcomes
a. Maintain oxygen intake and supply (e.g., assist with turning, deep
breathing, and coughing; perform nasopharyngeal suctioning; provide
cupping, vibrating, and postural drainage; administer oxygen via mask,
tent, and cannula; maintain a patent airway; increase fluid intake;
perform Heimlich maneuver; encourage the use of an incentive
spirometer)
b. Promote oxygen absorption and transport (e.g., encourage an
increased intake of dietary protein, iron, and vitamin C; encourage an
increase in exercise; promote good peripheral circulation by avoiding
constricting positions, clothing, and dressings, etc.)
c. Reduce cell demand for oxygen (e.g., promote rest, reduced anxiety,
encourage weight loss, prevent shivering)
d. Use safety measures related to oxygen therapy (e.g., enforce no-
smoking regulations, check electrical outlets)
e. Provide information and instruction regarding oxygenation (e.g.,
instruct the patient about the benefits of aerobic conditioning, provide
instruction regarding occupational exposure to pollutants)
5. Evaluation: appraise the effectiveness of the nursing
intervention relative to the nursing diagnosis and the
expected outcomes
a. Record and report patient's response to nursing actions (e.g., changes
in vital signs, alteration is skin colour, improvement in blood gas values,
increased or decreased alertness, improved tolerance for activities,
alterations in level of consciousness)
b. Reassess and revise the patient's plan for care as necessary (e.g.,
provide additional pillows for the patient who is experiencing
orthopnea)
IV. Fluid and Electrolyte Balance
A. Theoretical framework: basis for care
1. Principles related to normal fluid and electrolyte balance
(e.g., anatomical. physical, and chemical principles relating to
fluid compartments and the movement of substances across
semipermeable membranes; the role of specific electrolytes in
normal body function; homeostatic mechanisms controlling the
levels of fluids and electrolytes in the body)
2. Common disturbances of fluid balance (e.g., dehydration,
hypovolemia, hypervolemia, edema, ascites, fluid shifts, acid-
base balance)
3. Common disturbances of electrolyte balance: deficits and
excesses of sodium, potassium, calcium, and magnesium
4. Factors affecting fluid and electrolyte balance
a. Developmental level: infancy through senescence
b. Individual preferences and patterns (e.g., excessive salt intake, NPO
status)
c. Physical condition (e.g., general adaptation syndrome, altered level of
consciousness, vomiting, diarrhea, increased body temperature, renal
and cardiac status)
d. Ethnic and cultural factors (e.g., diet, religious restrictions)
e. Socioeconomic factors (e.g., income level)
f. Environmental factors (e.g., hot climate)
g. Psychological factors (e.g., stress)
5. Theoretical basis for interventions to promote fluid and
electrolyte balance
a. Dietary modifications (e.g., encourage fluid intake, maintain dietary
restrictions)
c. Medications (e.g., diuretics, electrolyte supplements, exchanges resins)
B. Nursing care related to theoretical framework
1. Assessment: gather and synthesize data about the patient's
fluid and electrolyte status in relation to the patient's
functional health patterns
a. Obtain the patient's history relative to fluid and electrolyte balance
(e.g., urinary elimination patterns; dietary habits; symptoms of
imbalance such as lethargy, thirst, and muscle weakness)
b. Assess factors affecting fluid and electrolyte balance (see IVA4)
c. Obtain objective data (e.g., skin turgor, body weight, intake and
output, weight changes, twitching, fatigue, vital signs, increased
abdominal girth, edema, dehydration, Trousseau's sign, Chvostek's sign)
d. Review laboratory and other diagnostic data (e.g., hematocrit, serum
electrolyte levels, specific gravity of urine, blood urea nitrogen [BUN])
2. Analysis: identify the nursing diagnosis (patient problem)
and determine the expected outcomes (goals) of patient care
a. Identify nursing diagnoses (e.g., fluid volume excess related to high
sodium intake, fluid volume deficit related to diarrhea, activity
intolerance related to potassium loss from diuretic therapy, fluid
volume deficit related to alterations in renal function associated with
aging)
b. Set priorities and establish expected outcomes (patient-centered
goals) for care (e.g., patient will identify foods that are high in sodium,
infant's fontanelle will regain normal contours, patient's serum
potassium level will be within normal limits, patient will drink four to
six 8-oz glasses of water a day)
3. Planning: formulate specific strategies to achieve the
expected outcomes
a. Incorporate factors affecting fluid and electrolyte status in planning
the patient's care (e.g., establish a pattern of fluid intake based on an
older adult's preferences and physical needs, replace fluid and
electrolyte for a patient with gastrointestinal fluid loss) (see IVA4)
b. Plan nursing measures on the basis of established priorities to help
the patient achieve the expected outcomes (e.g., plan instruction
regarding the sodium content of prepared foods, monitor the
administration of oral rehydration solutions, administer prescribes
potassium as ordered, plan instruction regarding the need for additional
fluids)
4. Implementation: carry out nursing plans designed to move
the patient toward the expected outcomes
a. Promote fluid and electrolyte balance (e.g., assist with food and fluid
selection, adapt measures to patient's development level)
b. Use nursing measures appropriate to fluid and electrolyte deficits
1) Natural replacements of fluids (e.g., establish daily fluid
regimen with patient)
2) Artificial replacement of fluids (e.g., assist with parenteral
administration of fluids, which includes calculating flow rate,
monitoring flow rate adding a new IV solution)
3) Natural replacement of electrolytes (e.g., modify dietary intake)
4) Artificial replacement of electrolytes (e.g., administer
parenteral or oral potassium chloride)
5) Prevention of excessive fluid and electrolyte loss (e.g.,
administer antiemetics, antipyretics, antidiarrheal agents; alter
room temperature as needed)
c. Use nursing measures appropriate to fluid and electrolyte excesses
1) Dietary restrictions (e.g., limit PO intake to 1,000 ml/day, limit
sodium intake)
2) Medications (e.g., administer thiazide diuretics, administer
sodium polystyrene sulfonate [Kayexalate])
3) Parenteral therapy (e.g., monitor for signs of fluid excess)
d. Provide information and instruction regarding fluid and electrolyte
requirements (e.g., instruct the patient receiving a loop diuretic to
increase dietary intake of oranges and bananas, provide instruction
regarding increased intake of salt prior to strenuous exercise in hot
weather)
5. Evaluation: appraise the effectiveness of the nursing
intervention relative to the nursing diagnosis and the
expected outcomes
a. Record and report patient's response to nursing actions (e.g., weight
changes, altered hematocrit levels, altered urine specific gravity,
alterations in output, increased energy level, adverse effects, signs or
symptoms of untoward reactions)
b. Reassess and revise patient's plan of care as necessary (e.g.,
recommend that the patient further increases intake of foods high in
potassium)
