NANDA Nursing

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ÿÿÿ ÿ Dx Page Definition AEB Risk (R/T) Sugg. NOC Client Outcomes
Sugg. NIC Intervention Pediatric
Geriatric Multicultural Home Care
Teaching ÿÿÿÿ ÿ
ÿÿÿÿ ÿ T T T T T T T T T T
T T T
T T T T T T T ÿÿÿÿ ÿ 139 24 139 139 139 139 139 139 139 139
139 139 139
139 80 80 80 80 80 ÿÿÿÿ ÿ Activity Intolerance 128 Insufficent
physiological or psychological energy to endure or complete required or
desired daily activites Verbal report of fatigue or weakness; abnormal heart
rate or blood pressure response Bed rest or immobility; generalized weakness;
sedentary lifestyle; imbalance between oxygen supply and demand Activity
Tolerance; Endurance; Energy Conservation; Self-Care: IADLs CLIENT WILL
(Specify Time Frame): (1) participate in prescribed physical activity with
appropriate increases in HR, BP, and breathing rate; maintains monitor
pattterns (rhythm & ST segment) within normal limits. (2) State symptoms of
adverse effects of exercise and reports onset of symptoms immediately. (3)
Maintain normal skin color & skin is warm & dry with activity. (4) Verbalize
an understanding of the need to gradually increase activity based on testing,
tolerance, & symptoms. (5) Express an understanding of the need to balance
rest and activity. (6) Demonstrate increased activity tolerance. Activity
Therapy; Energy Management (1) Determine cause of activity intolerance and
determine whether cause is physical, psychological, or motivational. (2)
Assess the client daily for appropriateness of activity and bed rest orders.
(3) If the client is able to walkk and has COPD, consider the use of an
accelerometer to assess walking ability. (4) If the client is able to walk and
has heart failure, consider use of the 6-mintue walk test to determine
physical ability. (5) If mainly on bed rest, minimize cardiovascular
deconditioning by positioning a client as close to the upright position as
possible several times a day. (6) When appropriate, gradually increase
activity, allowing the client to assist with positioning, transferring, and
self-care as possible. Progress from sitting in bed to dangling, to standing,
to ambulation. (7) Ensure that the client changes position slowly. Consider
using a chair-bed (stretcher-chair) for a client who cannot get out of bed.
Monitor for symptoms of activity intolerance. (8)..........
(1) Slow the pace of care. Allow the client extra time to carry out
activities. (2) Encourage families to help/allow an elderly client to be
independent in whatever activities possible. (3) If the client has heart
disease causing activity intolerance, refer for cardiac rehabilitation. (4)
Refer the client to physcial therapy for resistance exercise training as able,
including abdominal crunch, leg press, leg extension, leg curl, calf press,
and more. (5) When mobilizing the elderly client, watch for orthostatic
hypotension accompanied by dizziness and fainting. (6) Once the client is able
to walk independently and needs an exercise program, suggest the client enter
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an exercise program with a friend. (1) Begin discharge planning as soon as

possible with case manager or social worker to assess need for home support
systems and the need for community or home health services. (2) Assess the
home environment for factors that precipitate or contribute to decreased
activity tolerance: stairs, lack of assistive bed or bathroom devices;
distance to bathroom; presense of allergens such as dust, smoke, and those
associated with pets; temperature; energy-intensive patterns; and furniture
placement. Refer to occupational therapy if needed to assist the client in
restructuring the home and ADL patterns. (3) Refer to physical therapy for
strength training, possible weight training. (4) Support strength training
program prescribed by physical therapist. (5) Normalize the client's activity
intolerance; encourage progress with positive feedback. The client's
experience should be validated as within expected norms. Recognition of
progress enhances motivation. (5) Teach the client/family the.........
(1) Instruct the client on rationale and techniques for avoiding intolerance.
(2) Teach the client to use controlled breathing techniques with activity. (3)
Teach the client the importance and method of coughing, clearing secretions.
(4) Instruct the client in the use of relaxation techniques during activity.
(5) Help client with energy conservation and work simplification techniques in
ADLs. (6) Teach the client the importance of proper nutrition. (7) Describe to
the client the symptoms of activity intolerance, including which symptoms to
report to the physician. (8) Explain to the client how to use assistive
devices or medications before or during activity. (9) Help client set up an
activity log to record exercise and exercise tolerance. ÿÿÿÿ ÿ Activity
intolerance, risk for 135 At risk for experiencing physiological or
psychological energy to endure or complete required or desired daily
activities History of intolerance to activity; deconditioned status; presence
of circulatory or respiratory problems; inexperience with activity See risk
factors Activity Tolerance; Endurance; Energy Conservation None Listed.
Energy Management; Exercise Promotion; Strength Training; Activity Therapy
See care plan for activity intolerance
See care plan for activity intolerance See care plan for activity
intolerance
See care plan for activity intolerance ÿÿÿÿ ÿ Adjustment, impaired 136
Inability to modify lifestyle/behavior in a manner consistent with a change in
health status Denial of health status change; failure to achieve optimal
sense of control; failure to take actions that would prevent further health
problems; demonstration of nonacceptance of health status change, occurs
within a recent time period of notification of alteration in health status
requiring a change in client behavior Expressed negitivity; intense emotional
state; negative attitude toward health behavior; failure to intend to change
behavior; multiple stressors; absence of social support for change in beliefs
and practices; disability or health status change requiring change in
lifestyle; lack of motivation to change behaviors, family system pressure to
remain status quo Acceptance: Health Status; Coping; Grief Resolution;
Health-Seeking Behavior; Participation in Health Care Decisions; Psychosocial
Adjustment: Life Change; Treatment Behavior: Illness or Injury CLIENT WILL
(Specify time frame): (1) State acceptance of change in health status. (2)
Request assistance in altering behaviors to adapt to change. (3) State
personal goals for dealing with change in health status and means to prevent
further health problems. Coping Enhancement (1) Assess the client's
perception about the illness/event. Ask the client to state feelings related
to the change in health status. (2) Assess the client and family for the
presence of additional stressors (e.g., financial difficulty, health of other
family members, occupational changes). (3) Assess the client's feelings about
whether change in health status is personally being dealt with effectively.
(4) Assess for negative affect and internalization of problems. (5) Assess the
socioeconomic status of all clients. (6) Allow the client adequate time to
express feelings about the change in health status. (7) Help the client work
through the stages of grief. Denial is usually the initial response.
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Achknowledge that grief takes time, and give the client permission to grieve;
accept crying. (8) Recognize that denial may be adaptive at certain stages of
a threatening encounter. (9) Discuss resources that have worked previously
when dealing with changes in lifestyle or health status........
(1) Assess for signs of depression resulting from illness-associated changes
and make appropriate referral. (2) Monitor the client for agitation. (3)
Increase and mobilize support available to the elderly client. Encourage
interaction with family and friends. (1) Assess for the influence of cultural
beliefs, norms, and values on the client's ability to modify health behaviors.
(2) Encourage spirituality as a source of support for coping. (3) Discuss with
the client those aspects of health behavior/lifestyle that will remain
unchanged by their health status. (4) Negotiate with the client regarding the
aspects of health behavior which will need to be modified. (5) Assess the role
of fatalism on the client's ability to modify health behavior. (6) Identify
which family members the client can rely on for support. (7) Validate the
client's feelings regarding the impact of health status on current lifestyle.
(1) Include a spiritual assessment in overal assessment of client and family
resources. (2) Refer to medical social services to facilitate the listed
interventions and support client care goals. (3) Assess affective climate
within the family and family support system. (4) Observe for signs of
caregiver stress on an ongoing basis. Refer to necessary support services. (5)
Refer the client to counselor or therapist for follow-up care. Initiate
community referrals as needed.
(1) Teach the client to maintain a positive outlook by listing current
strengths. (2) Teach a client and his or her family relaxation techniques
(controlled breathing, guided imagery) and help them practice. (3) Allow the
client to proceed at own pace in learning; provide time for return
demonstrations. (4) Involve significan others in planning and teaching. (5) If
long-term deficits are expected, inform the family as soon as possible. (6)
Teach families intervention techniques for family members such as setting
limits, communicating acceptable behavior, and having time-outs. (7) Educate
and prepare families regarding the appearance of the client and the
environment before initial exposure. ÿÿÿÿ ÿ Airway clearance, ineffective
141 Inability to clear secretions or obstructions from the respiratroy tract
to maintain a clear airway Dyspnea; diminished breath sounds; orthopnea;
adventitious breath sounds (crackles, wheezes); cough, ineffective or absent;
sputum production; cyanosis; difficulty vocalizing; wide-eyed; changes in
respiratory rate and rhythm; restlessness ENVIRONMENTAL: Smoking; smoke
inhalation; second-hand smoke; obstructed airway; airway spasm; retained
secretions; excessive mucus; presence of artificial airway; foreign body in
airway; secretions in bronchi; exudate in alveoli PHYSIOLOGICAL: Neromuscular
dysfunction; hyperplasia of bronchial wall; COPD; infection; asthma; allergic
airways Aspiration Prevention; Respiratroy Status: Airway Patency, Gas
Exchange, Ventilation CLIENT WILL (Specify Time Frame): (1) Demonstrate
effective coughing and clear breath sounds; is free of cyanosis and dyspnea.
(2) Maintain a patent airway at all at times. (3) Relate methods to enhance
secretion removal. (4) Relate the significance of changes in sputum to include
color, character, amount, and odor. (5) Identify and avoid specific factors
that inhibit effective airway clearance. Airway Management; Airway
Suctioning; Cough Enhancement (1) Auscultate breat sounds q 1-4 h. Breath
sounds are normally clear or scattered fine cracles at bases, which clear with
deep breathing. (2) Monitor respiratory patterns, including rate, depth, and
effot. A normal respiratory rate for an adult without dyspnea is 12-16. (3)
Monitor blood gas values and pulse oxygen saturation levels as available. (4)
Position the client to optimize respiration. (5) Position the client to
optimize respiration. (6) If the client has unilateral lung disease, alternate
a semi-Fowler's position with a lateral position (with a 10- to 15-degree
elevation and "good lung down") for 60 to 90 minutes. This method is
contraindicated for a client with a pulmonary abscess or hemorrhage or with
interstitial emphysema. (7) Help the client to deep breathe and perform
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controlled coughing. Have the client inhale deeply, hold breath for several
seconds, and cough two or three times with mouth open while tightening the
upper abdominal muscles..................p143
(1) Encourage ambulation as tolerated without causing exhaustion. (2) Actively
encourage the elderly to deep breathe and cough. (3) Ensure adequate hydration
within cardiac and and renal reserves. (1) Some of the above interventions
may be adapted for home care use. (2) Begin discharge planning as soon as
systems, assistive devies, and community or home health services. (3) Assess
home environment for factors that exacerbate airway clearance problems. (4)
Assess affective climate within family and family support system. (5) Provide
the client with emotional support in dealing with symptoms of respiratory
distress. (6) Provide family with support for care of a client with chronic or
terminal illness. (7) Instruct the client to avoid exposure to persons with
upper respiratory infections. (8) Provide/teach percussion and postural
drainage per physician orders. Teach adaptive breathing techniques. (9)
Determine client adherence to medical regimen. Instruct client and family in
importance of reporting effectiveness of current medications to physician.
(10) Teach the client how and when to use inhalant.(p145)
(1) Teach imprtance of not smoking. Be aggressive in approach, ask to set a
date for smoking cessation, and recommend nicotine replacement therapy. Refer
to smoking cessation programs, and encourage clients who relapse to keep
trying to quit. (2) Teach the client how to use a flutter clearance device if
ordered, which vibrates to loosen mucus and gives positive pressure to keep
airways open. (3) Teach the client how to use peak expiratory flow rate (PEFR)
meter if ordered and when to seek medical attention if PEFR reading drops.
Also teach how to use metered dose inhalers and self-administre inhaled
corticosteroids following precautions to decrease side effects. (4) Teach
client how to deep breathe and cough effectively. Teach how to use the ELTGOL
method--an airway clearance method that uses lateral posture and different
lung volumes to control expiratory flow of air to avoid airway compression.
(5) Teach the client/family to identify and avoid specific factors that
exacerbate..(p146) ÿÿÿÿ ÿ Allergy response, latex 148 An immunological
reaction to natural rubber latex (NRL) TYPE I REACTIONS: Immediate
hypersensitivity response, which is IgE mediated. Symptoms include contact
urticaria progressing to systemic urticaria, angioedema, rhinitis,
conjunctivitis, bronchospasm, and anaphylaxis. MAY ALSO INCLUDE: Orofacial
characteristics: edema of sclera or eyelids, erythema and/or itching of the
eyes, tearing of the eyes, nasal congestion, itching and/or erythema,
rhinorrhea, facial erythema, facial itching, gastrointestinal characteristics:
abdominal pain, nausea; generalized characteristics: flushing, general
discomfort, generalized edema, increasing complaint of total body warmth,
restlessness. TYPE IV REACTIONS: Allergic contact dermatitis (delayed
hypersensitivity, also sometimes called chemical sensitivity dermatitis):
eczema; irritation; may progress to oozing skin blisters; rach usually begins
24 to 48 hours after contact. IRRITANT CONTACT DERMATITIS: Dry, itchy,
irritated areas on the skin; chapped or cracked skin; blisters. No immune
mechanism response. Allergic Response: Localized, Systemic; Immune
Hypersensitivity Response; Symptom Severity; Tissue Integrity: Skin and Mucous
Membranes CLIENT WILL (Specify Time Frame): (1) Identify presence of NRL
allergy. (2) List history of risk factors. (3) Identify type of reaction. (4)
State reasons not to use or to have anyone use latex products. (5) Experience
a latex-free environment for all health care procedures. (6) Avoid areas where
thre is powder from NRL gloves. (7) State the importance of wearing a
Medic-Alert bracelet and wear one. (8) State the importance of carrying an
emergency kit with a supply of nonlatex gloves, antihistamines, and an
autoinjectable epinephrine syringe (Epi-Pen), and carry one. Allergy
Management; Latex Precautions (1) Identify clients at risk: those persons who
are most likely to exhibit a sensitivity to NRL that may result in varying
degrees of reactivity. Consider the following client groups: ..... (2) Take a
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thorough history of the client at risk. (3) Question the client about
associated symptoms of itching, swelling, and redness after contact with
rubber products such as rubber gloves, balloons, and barrier contraceptives,
or swelling of the tongue and lips after dental examinations. (4) Consider a
skin prick test with NRL extracts to identify IgE-mediated immunity. (5) All
latex-sensitive clients are treated as if they have NRL allergy. (6) Patients
with spina bifida and others with a positive history of NRL sensitivity or NRL
allergy should have all medical/surgical/dental procedures performed in a
latexcontrolled environment. (7) The most effective approach to preventing NRL
anaphylaxis is complete latex avoidance. Medications may reduce certain
symptoms. (8) Materials and items that ....
(1) Assess the home environment for presence of NRL products (e.g.,
balloons, condoms, gloves, and products of related allergies, such as bananas,
avocados, and poinsettia plants). (2) At onset of care, assess client history
and current status of NRL allergy response. (3) Seek medical care as
necessary. (4) Do not use NRL products in caregiving (5) Assist the client in
identifying and obtaining alternatives to NRL products. (6)
(1) Provide written information about NRL allergy and sensitivity. (2)
Instruct the client to inform health care professionals if he or she has an
NRL allergy, particularly if they are scheduled for surgery. (3) Teach the
client what products contain NRL and to avoid direct contact with all latex
products and foods that trigger allergic reactions. ÿÿÿÿ ÿ Allergy
response, latex, risk for 154 At risk for exposure to natural rubber latex
(NRL) products RISK FACTORS: Children with three or more surgeries,
especially as a neonate; neural tube defects; allergies to bananas, avocados,
tropical fruits, kiwis, chestnuts, apples, carrots, celery, potatoes,
tomatoes; professions with daily exposure to latex; conditions needing
continuous or intermettent catheterization; history of the reactions to latex
Allergic Response: Systemic; Immune Hypersensitivity Response; Knowledge:
Health Behavior; Risk Control; Risk Detection; Tissue Integrity: Skin and
Mucous Membranes CLIENT WILL (Specify Time Frame): (1) State risk factors for
NRL allergy. (2) Request latex-free environment. (3) Demonstrate knowledge of
plan to treat NRL allergic reaction. Allergy Management; Latex Precautions
(1) Clients at high risk need to be identified, such as those with frequent
bladder catheterizations, occupational exposure to latex, past history of
atopy (hayfever, dermatitis, or food allergy to fuits such as bananas,
avocados, papaya, chestnut, or kimi); those with a history of anaphylaxis of
uncertain etiology, especially if associated with surgery; health care
workers; and females exposed to barrier contraceptives and routine
examinations during gynecological and obstetric procedures. (2) Clients with
spina bifida are a high-risk group for NRL allergy and should remain latex
free from the first day of life. (3) Children who are on home ventilation
should be assessed for NRL allery. (4) Assess for NRL allergy in clients who
are exposed to "hidden" latex. (5) See care plan for Latex Allergy response.
(1) Ensure that the client has a medical plan if a response develops.
Prompt treatment decreases potential severity of response. (2 See care plan
for Latex Allergy response. Note client history and environmental assessment.
(1) A client who has had symptoms of NRL allergy or who suspects he or she is
allergic to latex should tell his or her employer and contact his or her
institution's occupational health services. (2) Health care workers should
avoid the use of latex gloves and seek alternatives such as gloves made from
nitrile. ÿÿÿÿ ÿ Anxiety 157 A vague, uneasy feeling of discomfort or dread
accompanied by an autonomic response, with the source often nonspecific or
unknown to the individual; a feeling of apprehension caused by anticipation of
danger. Anxiety is an alerting signal that warns of impending danger and
enables the individual to take measrues to deal with threat. BEHAVIORAL:
Diminished productivity; scanning and vigilance; poor eye contact;
restlessness; glancing about; extraneous movement; expressed concerns
resulting from change in life events; insomnia; fidgeting. AFFECTIVE:
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Regretful; irritability; anguish; scared; jittery; overexcited; painful and

persistent increased helplessness; rattled; uncertainty; increased wariness;
focus on self; feelings of inadequacy; fearful; distressed; apprehension;
anxious. PHYSIOLOGICAL: Voice quivering. OBJECTIVE: Trembling/hand tremors;
insomnia. SUBJECTIVE: Shakiness; worried regretful. PHYSIOLOGICAL-SYMPATHETIC:
Increased pulse; increase BP; increased tension; cardiovascular excitation;
heart pounding; superficial vasoconstriction; respiratory difficulties;
increased respiration; increased perspiration; facial flushing; facial
tension; pupil dilation; anorexia; dry mouth; weakness; increased reflexes;
twitching. PHYSIOLOGICAL-PARASYMPATHETIC: Decreased pulse; decreased BP;
abdominal pain; CONT. SEE BOOK Unconscious conflict regarding essential
values or life goals; threat to self-concept; threat of death; threat to or
change in health status, environment, interaction patterns; situational or
maturational crises; interpersonal transmission of contagion; unmet needs
Aggression Self-Control; Anxiety Level; Anxiety Self-Control; Coping; Impulse
Self-Control CLIENT WILL (Specify Time Frame): (1) Identify and verbalize
symptoms of anxiety. (2) Identify, verbalize, and demonstrate techniques to
control anxiety. (3) Verbalize absence of or decrease in subjective distress.
(4) Have vital signs that reflect baseline or decreased sympathetic
stimulation. (5) Have posture, facial expressions, gestures, and activity
levels that reflect decreased distress. (6) Demonstrate improved concentration
and accuracy of thoughts. (7) Identify and verbalize anxiety precipitants,
conflicts, and threats. (8) Demonstrate return of basic problem-solving
skills. (9) Demonstrate increased external focus. (10) Demonstrate some
ability to reassure self. Anxiety Reduction (1) Assess the client's level of
anxiety and physical reactions to anxiety (e.g., tachycardia, tachypnea,
nonverbal expressions of anxiety). Use the Sheehan Patient-Rated Anxiety Scale
(SPRAS). Validate observations by asking the client, "Are you feeling anxious
now?" Consider the use of a "faces scale" to assess anxiety in critically ill
clients. (2) Use presence, touch (with permission), verbalization, and
demeanor to remind clients that they are not alone and to encourage expression
or clarification of needs, concerns, unknowns, and questions. (3) Accept the
client's defenses; do not confront, argue, or debate. (4) Allow and reinforce
the client's personal reaction to or expression of pain, discomfort, or
threats to well-being (e.g., talking, crying, walking, other physical or
nonverbal expressions). (5) Help the client identify precipitants of anxiety
that may indicate interventions. (6) If the situational response is rational,
use empathy to encourage the client to interpret.....
(1) Monitor the client for depression. Use appropriate interventions and
referrals. (2) Provide a protective and safe environment. Use consistent
caregivers and maintain the accustomed environmental structure. (3) Observe
for adverse changes if antianxiety drugs are taken. (4) Provide a quiet
environment with diversion. (1) Assess for the presence of culture-bound
anxiety states. (2) Assess for the influence of cultural beliefs, norms, and
values on the client's perspective of a stressful situation. (3) Identify how
anxiety is manifested in the culturally diverse client. (4) Acknowledge that
value conflicts from acculturation stresses may contribute to increased
anxiety. (5) Acknowledge that socioeconomic factors may contribute to
increased stress and anxiety. (6) For the diverse client experiencing
preoperative anxiety, provide music of their choice. (1) Above interventions
may be adapted for home care use. (2) Approach the client's anxiety in
nonjudgmental fashion. (3) Assist family to be supportive of the client in the
face of anxiety symptoms. (4) Adapt treatment needs to specific anxiety
type.(5) Assess for presence of depression. Depression and anxiety co-occur
frequently. (6) Consider referral for the prescription of antianxiety or
antidepressant medications for clients who have panic disorder (PD) or other
anxiety-related psychiatric disorders. (7) Assist the client/family to
institute medication regimen appropriately. Instruct in side effects,
importance of taking medications as ordered, and effects to report immediately
to nurse or physician. (8) Assess for suicidal ideation. Implement emergency
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plan as indicated. (9) Encourage use of appropriate community resources:

family, friends, neighbors, selfhelp and support groups, volunteer agencies,
churches, clubs and centers for recreation, and other persons with similar
......
(1) Teach the client/family the symptoms of anxiety. (2) Because intensive
care unit (ICU) stays are increasingly shorter, provide written teaching
information that is readily available to clients when they are transferred
out. (3) Help client to define anxiety levels (from "easily tolerated" to
"intolerable") and select appropriate interventions. (4) Teach the client
techniques to self-manage anxiety. (5) Teach the client to identify and use
distraction or diversion tactics when possible. (6) Teach the client to allow
anxious thoughts and feelings to be present until they dissipate (7) Teach
progressive muscle relaxation techniques. (8) Teach relaxation breathing for
occasional use: client should breathe in through nose,fill slowly from abdomen
upward while thinking "re," and then breathe out through mouth, from chest
downward, and think "lax." (9) Teach the client to visualize or fantasize
about the absence of anxiety or pain, successful experience of the situation,
resolution of ... ÿÿÿÿ ÿ Anxiety, Death 165 The apprehensions, worry, or
fear related to death or dying. Worrying about impact of one's own death on
significant others; powerless over issues related to dying; fear of loss of
physical and/or mental abilities when dying; anticipated pain related to
dying; deep sadness; dear of process of dying; concerns of overworking
caregiver as terminal illness incapacitates self; concern about meeting one's
creator or feeling doubtful about existence of God or higher being; total loss
of control over any aspect of one's own death; negative death images or
unpleasant thoughts about any event related to death or dying; fear of delayed
demise; fear of premature death because it prevents accomplishment of
important life goals; worrying about being the cause of others' grief and
suffering; fear of leaving family alone after death; fear of developing a
terminal illness; denial of one's own mortality or impending death see
Defining Characteristics Dignified Life Closure; Fear Self-Control; Health
Beliefs: Perceived Threat (1) State concerns about impact of death on others.
(2) Express feelings associated with dying. (3) Seek help in dealing with
feelings. (4) Discuss concerns about God or higher being. (5) Discuss
realistic goals. (6) Use prayer or other religious practice for comfort.
Dying Care; Grief Work Facilitation; Spiritual Support (1) Assess the
client's level of anxiety and physical reactions to anxiety (e.g.,
tachycardia, tachypnea, nonverbal expressions of anxiety). Use the Sheehan
Patient-Rated Anxiety Scale (SPRAS). Vaildate observation by asking the
client, "Are you feeling anxious now?" consider the use of a "faces scale" to
assess anxiety in critically ill clients. (2) use presence, touch (with
permission), verbalization, and demeanor to remind clients that they are not
alone and to encourage expression or clarification of needs, concerns,
unknowns, and questions. (3) Accept the client's defenses; do not confront,
argue, or debate. (4) Allow and reinforce the client's personal reaction to or
expression of pain, discomfort, or threats to well-being (e.g., talking,
crying, walking, other physical or nonverbal expressions). (5) Help the client
identify preciptants of anxiety that may indicate interventions. (6) If the
situational response is rational, use empathy to encourage the SEE BOOK
!!!!!!!!!!!!!
(1) Monitor the client for depression. Use appropriate interventions and
referrals. (2) Provide a protective and safe environment. Use consistent
caregivers and maintain the accustomed environmental structure. (3) Observe
for adverse changes if antianxiety drugs are taken. (4) Provide a quiet
environment with diversion. (1) Assess for the presence of culture-bound
anxiety states. (2) Assess for theinfluence of cultural beliefs, norms, and
values on the client's perspective of stressful stiuation. (3) Identify how
anxiety is manifested in the culturally diverse client. (4) Acknowledge that
value conflicts from acculturation stresses may contribute to increased
anxiety. (5) Acknowledge that socioeconomic factors may contribute to
Page 7
increased stress and anxiety. (6) For the diverse experiencing preoperative
anxiety, provide music of thier choice. (1) Above interventions may be
adapted for home care use. (2) Approach the client's anxiety in nonjudgmental
fashion. (3) Assist family to be supportive of the client in the face of
anxiety symptoms. (4) Adapt treatment needs to specific anxiety type. (5)
Assess for presence of depression. (6) Consider referral for the prescription
of antianxiety or antidepressant medications for clients who have panic
disorder (PD) or other anxiety-related psychiatric disorders. (7) Assist the
client/family to institute medication regimen appropriately. Instruct in side
effects, importance of taking meds as ordered, and effects to report
immediately to nurse or physician. (8) Assess for suicidal ideation. Implement
emergency plan as indicated. (9) Encourage use of appropriate community
resources: family, friends, neighbors, self-help and support groups, volunteer
agencies, churches, clubs, and centers for recreation, and other persons with
similar interests. (10) Refer for a psychiatric home health...
(1) Teach the client/family the symptoms of anxiety. (2) Because intensive
care unit ICU) stary are iincreasingly shorter, provide written teaching
information that is readily available to clients when they are transferred
out. (3) Help client to define anxiety levels (from "easily tolerated" to
"intolerable") and select appropriate interventions. (4) Teach client
techniques to self-manage anxiety. (5) Teach the client to identify and use
distraction or diversion tactics when possible. (6) Teach the client to allow
anxious thoughts and feelings to be present until they dissipate. (7) teach
progressive muscle relaxation techniques. (8) Teach relaxation hreathing for
occasional use: client should breathe in through nose, fill slowly from
abdomen upward while thinking "re", and then breathe out through mouth, from
chest downward, and think"lax". (9) Teach the client to visualize or fantasize
about the absence of anxiety or pain, sucessful experience of the situation,
resolution of ....... ÿÿÿÿ ÿ Aspiration, risk for 169 At risk for entry of
gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into
the tracheobronchial passages. RISK FACTORS: Increased intragastric
pressure; tube feedings; situations hindering elevation of upper body; reduced
level of consciousness; presence of tracheostomy or endotracheal tube;
medication administration; wired jaws; increased gastric residual; incomplete
lower esophageal sphincter; impaired swallowing; gastrointestinal tubes;
facial, oral, or neck surgery or trauma; depressed cough and gag reflexes;
decreased gastrointestinal motility; delayed gastric emptying Aspiration
Prevention; Respiratory Status: Ventilation; Swallowing Status (1) Swallow
and digest oral, nasogastric, or gastric feeding without aspiration. (2)
Maintain patent airway and clear lung sounds. Aspiration Precautions (1)
Monitor respiratory rate, depth, and effort. Note any signs of aspiration such
as dyspnea, cough, cyanosis, wheezing, or fever. (2) Auscultate lung sounds
frequently and before and after feedings; note any new onset of crackles or
wheezing. (3) Take vital signs frequently, noting onset of a temperature. (4)
Before initiating oral feeding, check client's gag reflex and ability to
swallow by feeling the laryngeal prominence as the client attempts to swallow.
(5) When feeding client, watch for signs of impaired swallowing or aspiration,
including coughing, choking, spitting food, or excessive drooling. If client
is having problems swallowing, see Nursing Interventions for Impaired
Swallowing. (6) Have suction machine available when feeding high-risk clients.
(7) Keep head of bed elevated when feeding and for at least an hour afterward.
(8) Note presence of any nausea, vomiting, or diarrhea. Treat nausea promptly
with antiemetics. (9) Listen to bowel sounds frequently, noting if ......
(1) Carefully check elderly client's gag reflex and ability to swallow before
feeding. (2) Watch for signs of aspiration pneumonia in the elderly with
cerebrovascular accidents, even if there are no apparent signs of difficulty
swallowing or of aspiration. (3) The central nervous system depressants
cautiously; elderly clients may have an increased incidence of aspiration with
altered levels of consciousness. (4) Keep the elderly, mostly bedridden client
sitting upright for 2 hours following meals. (1) Above interventions may be
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adapted for home care use. (2) For clients at high risk for aspiration, obtain
complete information from the discharging institution regarding institutional
management. (3) Assess the client and family for willingness and cognitive
ability to learn and cope with swallowing, feeding, and related disorders. (4)
Assess caregiver understanding and reinforce teaching regarding positioning
and assessment of the client for possible aspiration. (5) Provide the client
with emotional support in dealing with fears of aspiration. (6) Establish
emergency and contingency plans for care of client. (7) Have a speech and
occupational therapist assess client's swallowing ability and other
physiological factors and recommend strategies for working with client in the
home (e.g., pureeing foods served to client; providing adaptive equipment for
independence in eating). (8) Obtain suction equipment for the home as
necessary. (9) Teach caregivers safe, effective use of ........
(1) Teach the client and family signs of aspiration and precautions to prevent
aspiration. (2) Teach the client and family how to safely administer tube
feeding. ÿÿÿÿ ÿ Attachment, impaired parent/infant/child, risk for 175
Disruption of the interactive process between parent/significant other and
infant/child that fosters the development of a protective and nurturing
reciprocal relationship. RISK FACTORS: Physical barriers; anxiety
associated with the parent role; substance abuse; premature infant, ill
infant/child who is unable to effectively initiate parental contact as a
result of altered behavioral organization; lack of privacy; inability of
parents to meet personal needs; separation. Caregiver Adaptation to Patient
Institutionalization; Child Development: 2 Months, 4 Months, 6 Months, 12
Months, 2 Years, 3 years, 4 years, Preschool; Coping; Parent-Infant
Attachment; Family Physical Environment; Parenting Performance; Parenting:
Psychosocial Safety; Safe Home Environment (1) Infant/child development
appropriate for age. (2) parent(s) able to participate in caregiving for
infant/child. (3) Parent(s) visit nursery/hospital unit. (4) Parent(s) respond
to infant/child cues. (5) Parent(s) eliminate controllable environmental
hazards. (6) Parent(s) use community and other resources as appropriate.
Anticipatory Guideance; Attachment Process; Attachment Promotion; Coping
Enhancement; Developmental Care; Developmental Enhancement; Child;
Environmental management: Attachment Process; Family Integrity promotion;
Parent Education: Infant; Parenting promotion; Role Enhancement FAMILY: (1)
Establish a trusting relationship with the parents. (2) Assist parents in
recognizing behaviors used by infant/child to communicate avoidance/stress and
approach/engagement. (3) Support parents' ability to alleviate
infant's/child's distress. (4) If necessary, allow parents to verbalize their
fears of "ghosts in the nursery" that may influence attachment to their
infant/child. Ghosts in the nursery are parents' early memories of painful
experiences (e.g., unanswered cries, feeling abandoned, being abused) and are
real and powerful. (5) Listen to the parents' stories to understand their
struggle to attach. Acknowledge the parents' point of view and stories as
worthy of respect; important truths can be learned, such as what they think
and how they feel about themselves and their infant. (6) Assist parents with
recognizing how their infant/child learns thru the senses and with strategies
that can be used, such as timing, intensity, imitation, repetition, to
initiate .......... Provide lyrical, soothing music in the nursery as
appropriate (be aware that this may not be an appropriate intervention for
premature infants). (2) Protect and enhance infant's interactive capabilities
through organization of the environment. (3) Provide therapeutic touch for
children with anxiety.
(1) Discuss cultural normas with families to provide care that is
appropriate for enhancing attachment with the infant/child. (2) Encourage a
reciprocal attachment process. (3) Promote the attachment process by providing
a treatment environment that is culturally based and women centered. (1)
Above interventions may be adapted for home care use. (2) Assess quality of
interaction between parent and infant/child. (3) use interaction coaching:
teach mother about infant's behavioral cues and hot to match infant's
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preferences; have mother position infant in direct line of sight; demonstrate

responsive behaviors that can be modulated (e.g, facial, expression, voice,
touch); encourage practice by trial and error; reinforce sensitive
responsiveness as it occurs; give positive reinforcement for success.
ÿÿÿÿ ÿ Autonomic dysreflexia 180 life-threatening, uninhibited
sympathetic response of the nervous system to a noxious stimulus after a
spinal cord injury at T7 or above Pallor (below the injury); paroxysmal
hypertension (sudden, periodic elevated blood pressure where systolic pressure
is >140 mmHg and diastolic is >90 mmHg); red splotches on skin (above the
injury); bradycardia or tachycardia; diaphoresis above the injury; headache
(diffuse pain in different parts of the head, not confined to any nerve
distribution area); blurred vision; chest pain; chilling; conjunctival
congestion; Horner's syndrome (contraction of pupil on one side, partial
ptosis of the eyelid, recession of eyeball into the head, occasional loss of
sweating over the affected side of the face); metallic taste in mouth; nasal
congestion; paresthesia; pilomotor reflex (gooseflesh formation when skin is
cooled) Bladder distention; bowel distention; skin irritation; lack of client
and caregiver knowledge Neurological Status; Neurological Status: Autonomic;
Vital Signs (1) maintain normal vital signs. (2) Remain free of dysreflexia
symptoms. (3) Explain symptoms, prevention, and treatment of dysreflexia
Dysreflexia management (1) Monitor client for symptoms of dysreflexia. See
Defining Characteristics (aeb). (2) observe with physician the cause of
dysreflexia (e.g., distended bladder, impaction, pressure ulcer, urinary
calculi, bladder infection, acute condition in the abdomen, penile pressure,
ingrown toenail, or other source of noxious stimuli). (3) Initiate
antihypertensive therapy as soon as ordered. (4) Be careful not to increase
noxious sensory stimuli. If numbing agent is ordered, use it on anus and 1
inch of rectum before attempting to remove fecal impaction. (5) Monitor vital
signs every 3-5 minutes during acute event; continue to monitor vital signs
after event is resolved. (6) Watch for complication of dysreflexia, including
signs of cerebral hemorrhage, seizures, MI, or intraocular hemorrhage. (7)
Because episodes can reoccur, notify all health care team members of the
possibility of a dysreflexia episode.........
(1) Above interventions may be adapted for home care use. (2) Instruct the
client with any known proclivity toward dysreflexia to wear a Medic-Alert
bracelet and carry a Medic-Alert wallet card when not in a safe environment.
(3) Establish an emergency plan; obtain physician orders for medications to be
used in situations in which first aid does not work (e.g., nifedipine,
nitroglycerin ointment). (4) If orders have not been obtained or client does
not have medications, use emergency medical services. (5) If episode of
dysreflexia is resolved, monitor blood pressure every 30 to 60 min.s for next
4-5 hrs or admit to institution for observation. (6) Institute case management
of frail elderly to support continued independent living. Nervous system
difficulties represent and can lead to increasing needs for assistance in
using the health care system effectively. Case management combines nursing
activities of client and family assessment, planning and coordination of care
among all .......
(1) Teach recognition of the earliest symptoms of dysreflexia, the actions
that should be taken when they occur, and the need to summon help immediately.
Give client a written card that contains this info. (2) Teach steps to prevent
dysreflexia episodes: care of bladder, bowel, and skin prevention of other
forms of noxious stimuli (i.e., not wearing lcothing that is too tight). ÿÿÿÿ
ÿ Autonomic dysreflexia, risk for 183 At risk for life-threatening,
uninhibited response of the sympathetic nervous system; post-spinal shock in
an individual with spinal cord injury or lesion at T6 or above (has been
demonstrated in clients with injuries T7 or T8) An injury/lesion at T6 or
above and at least one of the following noxious stimuli: NEUROLOGICAL STIMULI:
Painful/irritating stimuli below the level of injury. UROLOGICAL
STIMULI:Bladder distention; detrusor sphincter dyssynergia; bladder spasms;
instrumentation or surgery; epididymitis; urethritis; UTI; calculi; cystitis;
Page 10
catheterization. GASTROINESTINAL: Bowel distention; fecal impaction; digital

stimulation; suppositories; hemorrhoids; difficult passage of feces;
constipation; enemas; gastrointestinal system pathology; gastric ulcers;
esophageal reflux; gallstoes. REPRODUCTIVE: Menstruation; sexual intercourse;
pregnancy; labor and delivery; ovarian cyst; ejaculation. REGULATORY: Temp
fluctuations; extreme environmental temps. MUSCULOSKELETAL: Cutaneous
stimulations; heterotrophic bone; pressure over bony prominences or genitalia;
spasm; fractures; ROM exercises; wounds; sunburn. SITUATIONAL: Positioning;
drug reactions; constrictive clothing; surgical procedures. Pulm. embolus, DVT
Neurological Status; Neurological Status: Autonomic; Vital Signs Refer to
care plan for Autonomic dysreflexia. Dysreflexia Management See Care Plan
for Autonomic Dysreflexia
See Care Plan for Autonomic Dysreflexia
See Care Plan for Autonomic Dysreflexia ÿÿÿÿ ÿ Body image, disturbed 185
Confusion in mental picture of one's physical self Nonverbal response to
actual or perceived change in structure and/or function; verbalization of
feelings that reflect an altered view of one's body in appearance, structure,
or function; verbalization of perceptions that reflect an altered view of
one's body in appearance, structure, or function; behaviors of avoidance,
monitoring, or acknowledgement of one's body. OBJECTIVE: Missing body part;
actual change in structure or function; avoidance of looking at or touching
body part; intentional or unintentional hiding or overexposure of body part;
trauma to nonfunctioning part; change in social involvement; change in ability
to estimate spatial relationship of body to environment. SUBJECTIVE: Change in
lifestyle; fear of rejection or reaction by others; focus on past strength,
function, or appearance; negative feelings about body; feelings of
helplessness, hopelessness, or pwerlessness; preoccupation with change or
loss; emphasis on remaining strengths and heightened achievement; etc.
Psychosocial, biophysical, cognitive/perceptual. cultural, spiritual, or
developmental changes; illness; trauma or injury; surgery; illness treatment
Body Image; Child Development: 2 Years, 3 Years, 4 Years, Preschool, Middle,
Childhood, Adolescence; Distorted Thought Self-Control; Grief Resolution;
Psychosocial Adjustment: Life Change; Self-Esteem (1) State or demonstrate
acceptance of change or loss and an ability to adjust to lifestyle change. (2)
Call body part or loss by appropriate name. (3) Look at and touch changed or
missing body part. (4) Care for changed or nonfunctioning part w/o inflicting
trauma. (5) Return to previous social involvement. (6) Correctly estimate
relationship of body to environment. Body Image Enhancement (1) Use a tool
such as the Body Image Instrument (BII) to identify clients who have concerns
about changes in body image. The five BII subscales—General Appearance, Body
Competence, Others' Reaction to Appearance, Value of Appearance, and Body
Parts—exhibited moderate to high internal reliability and concurrent validity
(2) Assess for body dysmorphic disorder (BDD) and make appropriate referrals.
The severity of BDD varies. Some youth experience manageable distress about
their appearance and are able to function well, although not up to their
potential. Psychiatric treatment is often effective in decreasing BDD symptoms
and the suffering they cause (3) Observe client's usual coping mechanisms
during times of extreme stress and reinforce their use in the current crisis.
(4) Acknowledge denial, anger, or depression as normal feelings when adjusting
to changes in body and lifestyle. (5) Identify clients at risk for body image
disturbance (e.g., body builders, cancer survivors). .....
(1) Focus on remaining abilities. Have client make a list of strengths.
Clinical Research: Results from unstructured interviews with women aged 61 to
92 years regarding their perceptions and feelings about their aging bodies
suggest that women exhibit the internalization of ageist beauty norms, even as
they assert that health is more important to them than physical attractiveness
and comment on the "naturalness" of the aging process (1) Assess for the
influence of cultural beliefs, norms, and values on the client's body image.
(2) Validate the client's feelings with regard to the impact of health status
on disturbances in body image. (3) Acknowledge that body image disturbances
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can affect all individuals regardless of culture, race, or ethnicity. (4)

Assess for the presence of conflicting cultural demands. (1) Above
interventions may be adapted for home care use. (2) Assess client's stage of
grieving or acceptance of body change on return to home setting. Include the
future role of sexuality in the psychological assessment of acceptance as
appropriate. (3) Assess family/caregiver level of acceptance of client's body
changes. (4) Recognize that older women may continue their younger
preoccupation with weight and recurrent dieting, despite being at normal
weight. Assess source of low weight or weight loss with this in mind. (5) Be
accepting of body changes in all interactions with client and
family/caregivers. (6) Help client to see new or changing roles in family.
Point out ways in which the community can help support client and family
strengths. (7) Refer to medical social services to address level of acceptance
and possible financial impact of changes. (8) Teach all aspects of care.
Involve client and caregivers in self-care as soon as possible. Do this in
stages if client still has ...
(1) Teach appropriate care of surgical site (e.g., mastectomy site, amputation
site, ostomy site). (2) Inform client of available community support groups;
offer to make initial phone call. (3) Refer the client to counseling for help
adjusting to body change. (4) Provide printed material and didactic
information for significant others. (5) Encourage significant others to offer
support. (6) Direct social support as follows: instruct regarding practical
care (bandaging), encourage appraisal support (listening), encourage
self-esteem support (favorable comparisons between client's and others'
appearance), and encourage sense of belonging (assist with socializing). The
preceding are four categories of support recognized in the body-image care
model. (7) Refer an interdisciplinary team to clients with ostomies who are
having difficulty with personal acceptance, personal and social body-image
disruption, sexual concerns, reduced self-care skills, and the management of
surgical complic..... ÿÿÿÿ ÿ Body temperature, imbalanced, risk for 191 At
risk for failure to maintain body temp within a normal range Altered
metabolic rate; extremes of age or weight; exposure to cool./cold or hot/warm
environment; dehydration; inactivity or vigorous activity; medications that
cause vasoconstriction or vasodilatation; sedation; clothing inappropriate for
environmental temp; illness or trauma that affects body temp regulation
Thermoregulaton; Thermoregulation: Newborn (1) Maintain temp within normal
range of 97 to 99 F in the adult. (2) Explain measures needed to maintain
normal temp. (3) Identify symptoms of hypothermia or hyperthermia Temperature
Regulation; Temperature Regulation: Intraoperative; Vital Signs Monitoring
(1) Monitor temp q 1 to 4 hrs or use continuous temp monitoring as
appropriate. Normal adult temp is usually identified at 98.6 F (37 C), but in
actuality the normal temp fluctuates throughout the day. In early morning it
may be as low as 96.4 F (35.8 C) and in the late afternoon or evening as high
as 99.1 F (37.3 C). (2) If client is awake, take temp orally in the adult,
instead of by use of a tympanic thermometer or an axillary temp. (3) Take
vital signs q 1 to 4 hrs, noting changes associated with hypothermia: first,
increased blood pressure, pulse, and respirations; then, decreased values as
hypothermia progresses. (4) Note changes in vital signs associated
w/hyperthermia: rapid, bounding pulse; increased respiratory rate; and
decreased BP with orthostatic hypotension present. (5) Monitor the client for
signs of hyperthermia (e.g., headache, nausea and vomiting, weakness, absence
of sweating, delirium, and coma). (6) maintain a consistent room temp (72 F).
(7) Promote adequate .... Recognize that pediatric clients have a decreased
ability to adapt to temperature extreme. Take the following actions to
maintain body temp in the infant/child: a. Keep the head covered. b. Use
blankets to keep the client warm. c. Keep client covered during procedures,
transport, and diagnostic testing. d. Maintain a consistent room temp of 72 F.
(2) Recognize that the infant and small child are vulnerable to develop heat
stroke in hot weather and ensure they receive sufficient fluids and are
protected from hot environments.
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(1) Do not allow geriatric clients to become chilled. Keep covered when giving
a bath or doing a procedure. Offer socks to wear in bed and a head covering if
desired. (2) Assess medication profile for potential risk of drug-related
altered body temp. (3) Ensure that elderly clients receive sufficient fluids
during hot days and stay out of the sun. (1) Above interventions may be
adapted for home care use. PREVENTION OF HYPOTHERMIA IN COLD WEATHER: (1)
Avoid prolonged exposure outside. Wear a hat and gloves. Wool or fleece
clothing can help to maintain body heat. (2) Keep room temp at 68 to 72 F. (3)
Ensure adequate source of heat; refer to social services if client is low
income and heat could be turned off. (4) Help elderly client determine a warm
environment they can go to for safety in cold weather if his or her home
environment is no longer warm. PREVENTION OF HYPERTHERMIA IN HOT WEATHER: (1)
Encourage the client to wear lightweight loose-fitting cotton clothing. Help
the elderly remove their usual sweaters. (2) Ensure that the client drinks
adequate amounts of fluids (2000 mL/d), avoiding caffeine and alcohol. (3)
help client obtain a fan to increase evaporation, or an air conditioner as
needed, using social services if needed. (4) Take the temp of the elderly in
hot weather. (5) help elderly client determine a cool envir...
(1) Teach the client and family the signs of hypothermia and hyperthermia and
the appropriate actions they should take if either condition develops. (2)
Teach the client and family proper method for taking temp. (3) Teach to avoid
alcohol and meds that depress cerebral function. ÿÿÿÿ ÿ Bowel incontinence
195 Change in normal bowel elimination habits characterized by involuntary
passage of stool. Costant dribbling of soft stool, fecal odor; inability to
delay defecation; rectal urgency; self-report of inability to feel rectal
fullness or presence of stool in bowel; fecal staining of underclothing;
recognition of rectal fullness but reported inability to expel formed stool;
inattention to urge to defecate; inability to recognize urge to defecate; red
perineal skin Change in stool consistency (diarrhea, constipation, fecal
impaction); abnormal motility (metabolic disorders, inflammatory bowel
disease, infectious disease, drug induced motility disorders, food
intolerance); defects in rectal vault function (low rectal compliance from
ischemia, fibrosis, radiation, infectious proctitis, Hirschprung's disease,
local or infiltrating neoplasm, sever rectocele); sphincter dysfunction
(obstetric or traumatic induced incompetence, fistula or abscess, prolapse,
third-degree hemorrhoids, pseudodyssynergia of the pelvic muscles);
neurological disorders impacting gastrointestinal motility, rectal vault
function and sphincter function (CVA, spinal injury, traumatic brain injury,
CNS tumor, advanced stage dementia, encephalopathy, profound mental
retardation, multiple sclerosis, myelodysplasia and related neural tube
defects, gastroparesis of diabetes mellituts, heavy metal poisoning, chronic
alcoholism, infectious or autoimmune neurological disorders, etc. Bowel
continence; Bowel Elimination (1) Have regular, complete evacuation of fecal
contents from the rectal vault (pattern may vary from every day to every 3-5
days). (2) Have regulation of stool consistency (soft, formed stools). (3)
Reduce or eliminate frequency of incontinent episodes. (4) Demonstrate intact
skin in the perianal/perineal area. (5) Demonstrate the ability to isolate,
contract and relax pelvic muscles (when incontinence related to sphincter
incompetence, pseudodyssynergia). (6) Increased pelvic muscle strength (when
incontinence related to sphincter incompetence). Bowel Incontinence Care;
Bowel Incontinence Care: Encopresis; Bowel Training (1) In a reasonably
private setting, directly question any client at risk about the presence of
fecal incontinence. If the client reports altered bowel elimination patterns,
problems with bowel control or "uncontrollable diarrhea," complete a focused
nursing history including previous and present bowel elimination routines,
dietary history, frequency and volume of uncontrolled stool loss, aggravating
and alleviating factors. (2) Complete a focused physical assessment including
inspection of perineal skin, pelvic muscle strength assessment, digital
examination of the rectum for presence of impaction and anal sphincter
strength, and evaluation of functional status (mobility, dexterity, visual
Page 13
acuity). (3) Complete an assessment of cognitive function. (4) Document

patterns of stool elimination and incontinent episodes via a bowel record
including frequency of bowel movements, stool consistency, frequency and
severity of incontinent episodes, precipitating factors, dietary and fluid
......
(1) Evaluate all elderly clients for established or acute fecal incontinence
when the elderly client enters the acute or long-term care facility and
intervene as indicated. (2) Evaluate cognitive status in the elderly person
with a NEECHAM confusion scale (Neelan et al, 1992) for acute cognitive
changes, a Folstein Mini-Mental Status Examination (Folstein et al, 1975), or
other tool as indicated. (1) Above interventions may be adapted for home
care use. (2) Assess and teach a bowel management program to support
continence. Address timing, diet, fluids, and actions taken independently to
deal with bowel incontinence. (3) Instruct caregiver to provide clothing that
is nonrestrictive, can be manipulated easily for toileting, and can be changed
with ease. (4) Assist the family in arranging care in a way that allows the
client to participate in family or favorite activities without embarrassment.
(5) If the client is limited to bed (or bed and chair), provide a commode or
bedpan that can be easily accessed. If necessary, refer the client to physical
therapy services to learn side transfers and to build strength for transfers.
(6) If the client is frequently incontinent, refer for home health aide
services to assist with hygiene and skin care.
(1) Teach the client and family to perform a bowel reeducation program,
scheduled, stimulated program, or other strategies to manage fecal
incontinence. (2) Teach the client and family about common dietary sources for
fiber, as well as supplemental fiber or bulking agents as indicated (3) Refer
the family to support services to assist with in-home management of fecal
incontinence as indicated. (4) Teach nursing colleagues and nonprofessional
care providers the importance of providing toileting opportunities and
adequate privacy for the client in an acute or long-term care facility. NOTE:
Refer to nursing diagnoses Diarrhea and Constipation for detailed management
of these related conditions
ÿÿÿÿ ÿ Breastfeeding, effective 201 Mother-infant dyad/family exhibits
adequate proficiency and satisfaction with the breastfeeding process
Effective mother/infant communication patterns; regular and sustained
suckling/swallowing at the breast; appropriate infant weight pattern for age;
infant content after feeding; mother able to position infant at breast to
promote a successful latch-on response; signs and/or symptoms of oxytocin
release; adequate infant elimination patterns for age; eagerness of infant to
nurse; maternal verbalization of satisfaction with the breastfeeding process
Basic breastfedding knowledge/normal breast structure/normal infant oral
structure/infant gestational age> 34 weeks/support sources (e.g., encouraging
partner, history of positive breastfeeding experiences among relatives and
friends, access to support groups such as La Leche League)/maternal confidence
Breastfeeding Establishment: Infant, Maternal; Breasfeeding Maintenance (1)
Maintain effective breastfeeding. (2) Maintain normal growth patterns
(infant). (3) Verbalize satisfaction with breastfeeding process (mother).
Breastfeeding Assistance, Lactation Counseling (1) Encourage rooming-in and
breastfeeding on demand. (2) Monitor the breasfeeding process. (3) Identify
opportunities to enhance knowledge and experience regarding breastfeeding.
Support and teaching must be individualized to the client's level of
understanding. (4) Give encouragement/positive feedback r/t breastfeeding
mother-infant interactions. (5) Monitor for signs and symptoms of nipple pain
and/or trauma. (6) Discuss prevention and treatment of common breastfeeding
problems. Permits the nurse to identify the need for info and clarification.
(7) Monitor infant responses to breastfeeding. (8) identify current support
person network and opportunities for continued breastfeeding support. (8)
Avoid supplemental bottle feedings and do not provide samples of formula on
discharge. Provide follow-up contact; as available provide home visits and/or
peer counseling.
Page 14
(1) Assess for the influence of cultural beliefs, norms, and values on
current breastfeeding practices. (2) Assess for when the mother wishes to
begin breastfeeding. (3) Validate the client's concerns about the amount of
milk taken.
(1) Include the father and other family members in education about
breastfeeding. (2) Teach the client the importance of maternal nutrition.
Generally, no special diet is required but drinking to satisfy thirst and a
healthy diet using foods from a variety of sources is recommended. (3)
Reinforce the infant's subtle hunger cues (e.g., quiet-alert state, rooting,
sucking, hand-to-mouth activity) and encourage the client to nurse whenever
signs are apparent. (4) Review guidelines for frequency (every 2 to 3 hours,
or at least eight feedings per 24 hours) and duration (until suckling and
swallowing slow down and satiety is reached). (5) Provdie anticipatroy
guidance about common infant behavior. (6) Provide info about additional
breastfeeding resources. ÿÿÿÿ ÿ Breastfeeding, ineffective 206
Dissatisfaction or difficulty a mother, infant, or child experiences with the
breasfeeding process Unsatisfactory breasfeeding process; nonsustained
suckling at the breast; resisting latching on; unresponsive to comfort
measures; persistence of sore nipples beyond first week of breastfeeding;
observable signs of inadequate infact intake; insufficient emptying of each
breast per feeding; infant inability to latch on to maternal breast correctly;
infant arching and crying at the breast; infant exhibiting fussiness and
crying within the first hour after breastfeeding; actual or perceived
inadequate milk supply; no observable signs of oxytocin release; insufficient
opportunity for suckling at the breast Non-supportive partner/family;
previous breast surgery; infant receiving supplemental feedings with
artificial nipple; prematurity; previous history of breasfeeding failure; poor
infant suckling reflex; maternal breast anomaly; maternal anxiety or
ambivalence; interruption in breastfeeding; infant anomaly; knowledge deficit
Breastfeeding Establishment: Infant, Maternal; Breastfeeding Maintenance;
Breastfeeding Weaning; Knowledge: Breastfeeding (1) Achieve effective
breasfeeding (dyad). (2) verbalize/demonstrate techniques to manage
breastfeeding problems (mother). (3) manifest signs of adequate intake at the
breast (infant). (4) Manifest positive self-esteem in relation to the infant
feeding process (mother). (5)Explain alternative method of infant feeding if
unable to continue exclusive breastfeeding (mother). Breastfeeding
Assistance; Lactation Counseling (1) Identify women with risk factors for
lower breastfeeding initiation and continuation rates (age <20 years, low
socioeconomic status) as well as factors contributing to ineffective
breastfeeding as early as possible in the perinatal experience. (2) Use valid
and reliable tools to measure breastfeeding performance and to predict early
discontinuance of breastfeeding whenever possible/feasible. (3) Encourage
rooming-in and feeding on demand. (4) Evaluate the breast and nipple
structures and provide appropriate measures as needed. (5) Observe a full
breastfeeding session (every 8 hours in the early postpartum and once per
visit on follow-up). (6) Provide evidence-based teaching and breastfeeding
assistance appropriate to the client's individualized needs (see Client/Family
Teaching). (7) Promote comfort and relaxation to reduce pain and anxiety. (8)
Provide time for clients to express their expectations and concerns and give
emotional support. (9) Avoid supplemental feedings. (10) ....
(1) Assess for the influence of cultural beliefs, norms, and values on
breastfeeding attitudes. (2) Assess whether the client's concerns about the
amount of milk taken during breastfeeding is contributing to dissatisfaction
with the breastfeeding process. (3) Assess the influence of family support on
the decision to continue or discontinue breastfeeding. (4) Validate the
client's feelings regarding the difficulty or dissatisfaction with
breastfeeding. (1) Above interventions may be adapted for home care use. (2)
Investigate availability/refer to public health department or hospital home
follow-up breastfeeding program. Some hospitals and public health departments
have follow-up breastfeeding programs, particularly for high-risk mothers
Page 15
(e.g., older mothers, past history substance use, risk of physical abuse).
Instructions initiated during hospitalization are continued. (3) Monitor for
specific difficulties contributing to bonding difficulties between mother and
infant.
(1) Review maternal and infant benefits of breastfeeding. (2) Instruct the
client on maternal breastfeeding behaviors/techniques (preparation for,
positioning, initiation of/promoting latch-on, burping, completion of session,
and frequency of feeding). Difficulties in these practices contribute to
ineffective breastfeeding. (3) Teach the client self-care measures for the
breastfeeding woman (e.g., Breast care, Management of breast/nipple
discomfort, Nutrition/fluid, rest/activity). (4) Provide information regarding
infant cues and behaviors related to breastfeeding and appropriate maternal
responses (e.g., cues that infant is ready to feed, behaviors during feeding
that contribute to effective breastfeeding, measures of infant feeding
adequacy). (5) Provide education to father/family/significant others as
needed. ÿÿÿÿ ÿ Breastfeeding, interrupted 214 Break in the continuity of
the breastfeeding process as a result of inability or inadvisability to
putting the infant to the breast for feeding Infant does not receive
nourishment at the breast for some or all feedings; maternal desire to
maintain lactation and provide (or eventually provide) her breast milk for her
infant's nutritional needs; separation of mother and infant; lack of knowledge
regarding expression and storage of breast milk Maternal or infant illness;
prematurity; maternal employment; contraindications to breastfeeding (e.g.,
drugs, true breast milk jaundice); need to abruptly wean infant (with intent
to resume at later date) Breastfeeding Establishment: Infant, Maternal;
Breastfeeding maintenance; Knowledge: Breastfeeding; Parent-Infant Attachment
INFANT: (1) Receive mother's breast milk if not contraindicated by maternal
conditions (e.g., certain drugs, infections) or infant conditions (e.g., true
breast milk jaundice). MATERNAL: (1) Maintain lactation. (2) Achieve effective
breastfeeding or satisfaction with the breastfeeding experience. (3)
Demonstrate effective methods of breast milk collection and storage. Bottle
Feeding; Breastfeeding Assistance; Emotional Support; Kangaroo Care; Lactation
Counseling (1) Discuss mother's desire/intention to begin or resume
breastfeeding. (2) Provide anticipatory guidance to the mother/family
regarding potential duration of the interruption when possible/feasible. (3)
Reassure mother/family that early measures to sustain lactation and promote
parent/infant attachment can make it possible to resume breastfeeding when the
conditoin/situation requiring interruption is resolved. (4) Reassure the
mother/family that the infant will benefit from any amount of breast milk
provided. (5) Provide time for mother/family to express their expectations and
concerns and give emotional support. Emotional responses regarding events
leading to the interrruption that may arise include feelings of grief/loss,
guilt, anxiety, and failure. (6) Collaborate with the moterh/family/health
care providers/employers (as needed) to develop a plan for expression of
breast milk/infant feeding/and kangaroo care/skin-to-skin contact (KC). (7)
Monitor for signs indicating infants....
(1) Assess for the influence of cultural beliefs, norms, values on current
decision to stop breastfeeding. (2) Assess the influence of family support on
th edecision to continue or discontinue breastfeeding. (3) Assess whether the
client's concerns about the amount of milk taken during breastfeeding is
contributing to decision to stop breastfeeding. (4) Validate the client's
feelings with regard to the difficulty of or her dissatisfaction with
breastfeeding.
(1) Teach mother effective methods to express breast milk. (2) teach
mother/parents about kangaroo care. (3) Instruct mother on safe breast milk
handling techniques. (4) Provide education to father/family/significant others
as needed. ÿÿÿÿ ÿ Breathing pattern, ineffective 221 Inspiration and/or
expiration that does not provide adequate ventilation. Decreased
inspiratory/expiratory pressure; decreased minute ventilation; use of
accessory muscles to breathe; nasal flaring; dyspnea; altered chest excursion;
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shortness of breath; assumption of a three-point position; pursed-lip

breathing; prolonged expiration phases; increased anteroposterior diameter;
respiratory rate (audlts <11 or >24; infants <25 or >60; ages 1-4 <20 or >30;
ages 5-14 <14 or >25); depth of breathing (adults ventilation 500 ml at rest;
infants 6 to 8 ml/kg); timing ratio; decreased vital capacity
Hyperventilation; hypoventilation syndrome; bony deformity; pain; chest wall
deformity; anxiety; decreased energy/fatigue; neuromuscular dysfunction;
musculoskeletal impairment; perception/cognitive impairment; obesity; spinal
cord injury; body position; neurological immaturity; respiratory muscle
fatigue Respiratory Status: Airway Patency, Ventilation; Vital Signs (1)
Demonstrate a breathing pattern that supports blood gas results within the
client's normal parameters. (2) Report ability to breathe comfortably. (3)
Demonstrate ability to perform pursed-lip breathing and controlled breathing
and use relaxation techniques effectively (4) identify and avoid specific
factors that exacerbate episodes of ineffective breathing patterns. Airway
Management; Respiratory Monitoring (1) Monitor respiratory rate, depth, and
ease of respiration. Normal respiratory rate is 12 to 16 breaths/min in the
adult. (2) Note pattern of respiration. If the client is dyspneic, note what
seems to cause the dyspnea, the way in which the client deals with the
condition, and how the dyspnea resolves or gets worse. (3) Attempt to
determine if client's dyspnea is physiological or psychogenic in cause.
PSYCHOGENIC DYSPNEA--HYPERVENTILATION: (1) Assess cause of hyperventilation by
asking client about current emotions and psychological state. (2) Ask the
client to breathe with you to slow down respiratory rate. Maintain eye contact
and give reassurance. (3) consider having client use a paper bag to breathe
into and rebreathe air or help to do diaphragmatic breathing. (4) If pain is
the cause of hyperventilation, provide medication routinely as ordered to
prevent severe pain. Use distraction techniques to help client deal with pain.
See interventions for Acute Pain. (5) If client has....
(1) Encourage ambulation as tolerated. (2) Encourage elderly clients to sit
upright or stand and to avoid lying down for prolonged periods during the day.
(1) Above interventions may be adapted for home care use. (2) Assist the
client and family with identifying other factors that precipitate or
exacerbate episodes of ineffective breathing patterns (i.e., stress,
allergens, stairs, activities that have high energy requirements). (3) Assess
client knowledge of and compliance with medication regiment. (4) Teach the
client and family the importance of maintaining regimen and having prn drugs
easily accessible at all times. (5) Provide the client with emotional support
in dealing with symptoms of respiratory difficulty. Provide family with
support for care of a client with chronic or terminal illness. (6) Identify an
emergency plan including when to call the physician or 911. (7) Refer the
client to an outpaitent pulmonary rehabilitation program or a home-based
training program for COPD. (8) Refer to occupational therapy for evaluation
and teaching of energy conservation techniques. (9) Refer to home health aide
services as needed to .......
(1) Teach pursed-lip and controlled breathing techniques. (2) using a
prerecorded tape, teach client progressive muscle relaxation techniques ÿÿÿÿ ÿ
Cardiac output, decreased 227 Inadequate blood pumped by the heart to meet
metabolic demands of the body ALTERED HEART RATE/RHYTHM: Dysrhythmias
(tachycardia, bradycardia); palpitatoins; electrocardiographic changes.
ALTERED PRELOAD: jugular vein distention; fatigue; edema; murmurs;
increased/decreased central venous pressure (CVP); increased/decreased
pulmonary arter wedge pressure (PAWP); weight gain. ALTERED AFTERLOAD:
Cold/clammy skin; shortness of breath/dyspnea; oliguria; prolonged capillary
refill; decreased peripheral pulses; variations in BP readings;
increased/decreased systemic vascular resistance (SVR); increased/decreased
pulmonary vascular resistance (PVR); skin color changes. ALTERED
CONTRACTILITY: Crackles; cough; orthopnea/paroxysmal nocturnal dyspnea;
cardiac output <4 L/min; cardiac incex less than 2.5 L/min; decreased ejection
fraction; stroke volume index (SVI); left ventricular stroke work index
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(LVSWI); S3 or S4 sounds. BEHAV.: Anxiety, restlessness Altered heart

rate/rhythm; altered stroke volume: altered preload, altered afterload,
altered contractility. Cardiac Pump Effectiveness; Circulation Status; Tissue
Perfusion: Abdominal Organs, Peripheral; Vital Signs (1) Demonstrate adequate
cardiac output as evidenced by BP and pulse rate and rhythm within normal
parameters for client; strong peripheral pulses; and an ability to tolerate
activity w/o symptoms of dyspnea, syncope, or chest pain. (2) Remain free of
side effects from the medications used to achieve adequate cardiac output. (3)
Explain actions and precautions to take for cardiac disease. Cardiac Care;
Cardiac Care: Acute (1) Monitor for symptoms of heart failure and decreased
cardiac output; listen to heart sounds, lung sounds, note symptoms including
paroxysmal nocturnal dyspnea, neck vein distention, crackles in lung bases, S3
gallop, increased venous pressure greater than 16 cm H2O, and positive
hepatojugular reflex. (2) Observe for symptoms of cardiogenic shock including
impaired mentation, hypotension with blood pressure lower than 90 mm Hg,
decreased peripheral pulses, cold clammy skin, signs of pulmonary congestion
and decreased organ function. If present, notify physician immediately. (3) If
shock is present, monitor hemodynamic parameters for an increase in pulmonary
wedge pressure, an increase in systemic vascular resistance, or a decrease in
cardiac output and index. (4) Titrate inotropic and vasoactive medications
within defined parameters to maintain contractility, preload, and afterload
per physician's order. (5) Observe for chest pain or discomfort; note
location, radiation, severity,...
(1) Observe for atypical pain; the elderly often have jaw pain instead of
chest pain or may have silent MIs with symptoms of dyspnea or fatigue. (2) If
client has heart disease causing activity intolerance, refer for cardiac
rehabilitation. (3) Observe for syncope, dizziness, palpitations, or feelings
of weakness associated with an irregular heart rhythm (4) Observe for side
effects from cardiac medications. (1) Some of the above interventions may
be adapted for home care use (2) Begin discharge planning as soon as possible
with case manager or social worker to assess home support systems and the need
for community or home health services. Support services may be needed to
assist with home care, meal preparations, housekeeping, personal care,
transportation to doctor visits, or emotional support. (3) Consider
development of a clinical pathway to address focused interventions with
congestive heart failure (CHF), coronary artery bypass graft (CABG). (4)
Assess or refer to case manager or social worker to evaluate client ability to
pay for prescriptions. (5) Continue to monitor client for exacerbation of
heart failure when discharged home. (6) Monitor women for differential
symptoms of MI and institute emergency treatment measures as indicated. (7)
Assess client for understanding of and compliance with medical regimen,
including medications, activity level, and diet. Client/family may .......
(1) Teach symptoms of heart failure and appropriate actions to take if client
becomes symptomatic. (2) Teach importance of smoking cessation and avoidance
of alcohol intake. Clients who continue to smoke increase their chance of
dying by at least 50%, and alcohol depresses heart contractility (3) Teach
stress reduction (e.g., imagery, controlled breathing, muscle relaxation
techniques). (4) Explain necessary restrictions, including consumption of a
sodium-restricted diet, guidelines on fluid intake, and the avoidance of
Valsalva's maneuver. Teach the importance of pacing activities, work
simplification techniques, and the need to rest between activities to prevent
becoming overly fatigued. Sodium retention leading to fluid overload is a
common cause of hospital readmission (5) Assist the client in understanding
the need for and how to incorporate lifestyle changes. Refer to cardiac
rehabilitation for assistance with coping and adjustment. Psychoeducational
programs including info...... ÿÿÿÿ ÿ Caregiver role strain 235 Defficulty
in performing family caregiver role ACTIVITES: Apprehension about possible
institutionalization of care receiver; apprehension about the future regarding
care receiver's health and caregiver's ability to provide care; difficulty
performing/completing required tasks; apprehension about care receiver's care
Page 18
if the caregiver becomes ill or dies; preoccupation with care routine.

PHYSICAL: Gastrointestinal upset; weight change; rash; hypertension;
cardiovascular disease; diabetes; fatigue; headache. EMOTIONAL: impaired
inidividual coping; feeling of depression; disturbed sleep; anger; stress;
somatization; increased nervousness; increased emotional lability; impatience;
lack of time to meet personal needs; frustration. SOCIOECONOMIC: Withdrawal
from social life; changes in leisure activities; low work productivity;
refusal of career advancement. RELATIONSHIP: Grief and/or uncertainty
regarding changed relationship with care receiver; difficulty watching care
receiver go through the illness. Family conflict; concerns about fam Illness
severity; illness chronicity; increaing care needs/dependency;
unpredictability of illness course; instability of care receiver's health;
problem behaviors; psychological or cognitive problems; addiction or
codependency. Amount of activities; complexity of activities; 24-hour care
responsibilities; ongoing changes in activities; discharge of family members
to home w/significant care needs; years of caregiving; unpredictability of
care situation. Physical problems; psychological or cognitive problems;
addiction or codependency; marginal coping patterns; unrealistic expectations
of self; inability to fulfill one's own or others expectations. Isolation from
others; competing role commitments; alienation from family, friends, and
coworkers; insufficient recreational resources. History of poor relationship;
presence of abuse or violence; unrealistic expectations of caregiver by care
receiver; mental status of elder that inhibits conversation. History of
marginal family coping; etc. Caregiver Emotional Health; Caregiver Lifestyle
Disruption; Caregiver Performance: Direct Care, Indirect Care; Caregiver
Physical Health; Caregiver Stressors; Caregiver Well-Being; Role Performance
(1) Caregiver will maintain physical and psychological health. (2) Caregiver
will identify resources available to help in giving care. (3) Care receiver
will obtain appropriate care. Caregiver Support (1) Use an evaluation tool
to determine caregiver coping and strain. Various instruments have been
developed, including the Burden Interview, the Caregiver Strain Index, the
Caregiver Burden Inventory, and the Subjective and Objective Burden Scale. (2)
Watch for signs of depression in the caregiver, especially if the marital
relationship is poor. Intervene to help the caregiver cope. If signs are
present, refer to the care plan for Hopelessness. (3) Monitor the quality of
care by the caregiver for adequacy and need for improvement. (4) Observe for
signs of addiction or codependency in the caregiver or care receiver. (5)
Arrange for a home health nurse to provide nursing care and case management
following discharge. (6) Arrange intervals of respite care for the caregiver;
encourage use if available. (7) Help the caregiver to identify supports and be
assertive in using them. (8) Encourage the caregiver to grieve over loss of
the care receiver's function. Give the caregiver permission ...
(1) Monitor the caregiver for psychological distress and signs of depression,
especially if caring for a mentally impaired elder or if there was an
unsatisfactory marital relationship before caregiving. (2) Assess the health
of the caregiver at intervals, especially if he or she has chronic illness in
addition to caregiving role. (3) Recognize that it is hard for the elderly to
accept any change in caregivers or in the environment. (1) Assess for the
influence of cultural beliefs, norms, values, and expectations on the family's
experience of caregiving. (2) Assess for conflicts between the caregiver's
cultural obligations to provide care and competing factors like employment.
(3) Negotiate with the client regarding the aspects of caregiving that can be
modified while still honoring cultural beliefs. (4) Refer the family to social
services or other supportive services to assist with the impact of caregiving.
(5) Assist the family/caregiver in identifying barriers that would prevent the
use of social services or other supportive services that could help reduce the
impact of caregiving. (6) Encourage the family to use support groups or other
service programs. (7) Encourage caregiver use of spirituality or religion as
a source of support for the caregiver. (8) Validate the family's feelings
regarding the impact of caregiving on family and personal lifestyle. (1)
Page 19
Identify client and caregiver factos that necessitated the use of formal home
care services and that may affect provision of care or need to be addressed
before the client can be safely discharged. (2) Assess the client and
caregiver at every visit for quality of relationship, quality of care
provided, functional disability of care recipient, and signs of caregiver
stress. Document all observations objectively. (3) Assess perceived level of
power experienced by the caregiver in daily activites. (4) Assess preexisting
strengths and weaknesses the caregiver brings to the situation, as well as
current responses, depression, and fatigue levels. (5) Identify strengths of
caregiver and efforts to gain control of unpredictable situations. (6) Help
the caregiver to stay connected with the client who may be behaving
differently than usual, to make life as routine as possible, to help the
client set goals and sustain hope, and to allow the client space to experience
progress. (7) ...........
(1) Teach the caregiver methods for managing behavioral symptoms if the care
receiver has dementia. (2) Teach the caregiver how to provide the physical
care needed. (3) Refer to counseling or support groups to assist in adjusting
to the caregiver role. ÿÿÿÿ ÿ Caregiver role strain, risk for 246
Caregiver vulnerability for felt difficulty in performing family caregiver
role Lack of developmental readiness on part of caregiver for caregiving
role; inadequate physical environment for providing care; unpredictable
illness course or instability in care receiver's health; psychological or
cognitive problems in care receiver; presence of situational stressors that
normally affect families; presence of abuse or violence; premature birth or
congenital defect; past history of poor relationship between caregiver and
care receiver; marginal family adaptation or dysfunction before caregiving
situation; marginal coping patterns on part of caregiver; lack of respite and
recreation for caregiver; inexperience with caregiving; female gender of
caregiver; addiction or codependency; demonstration of deviant or bizarre
behavior by care receiver; competing role commitments of caregiver; high
complexity/amount of caregiving tasks; developmental delay or retardation of
care receiver or caregiver; discharge of family member w/significant home care
needs; ETC. Caregiver Emotional Health; Caregiver Lifestyle Disruption;
Caregiver Performance: Direct Care, Indirect Care; Caregiver Physical Health;
Caregiver Stressors; Caregiver Well-Being; Role Performance (1)Maintain
physical and psychological health. (2) identify resources available to help in
giving care. (3) Obtain appropriate care. Caregiver Support; Family Support;
Home Maintenance Assistance; Normalization Promotion; Respite Care; Support
Group See the care plan for Caregiver Role Strain
See the care plan for Caregiver Role Strain See the care plan for Caregiver
Role Strain See the care plan for Caregiver Role Strain
See the care plan for Caregiver Role Strain ÿÿÿÿ ÿ Comfort, impaired 247
State in which an individual experiences an uncomfortable sensation in
response to a noxious stimulus. Unpleasant sensation of being physically ill
at ease that may be localized or generalized but is not described in terms of
tissue damage. Verbalization of discomfort (specific examples include aches,
pruritis); observed behaviors indicative of discomfort; shifting and/or
restlessness; tenseness; shivering and covering up or removing of covers;
avoidance; malaise; aching; stiffness; distention; hunger and thirst; reduced
mobility; itching; reddened, irritated skin (pruritus). Reaction to chemical
irritants (including allergies); dry skin; illness and/or immobility; unmet
physical needs (food, fluid, bathing, etc); fever; disease processes;
pregnancy; immobility; musculoskeletal disorders; inflammation; intestinal
gas, colic; medication side effects; contagious diseases (chickenpox, etc.).
Comfort Level; Symptom Control (1) State he or she is comfortable. (2) State
that his or her uncomfortable sensations (aches, itching, etc.) are relieved.
(3) Explain methods to decrease own discomfort. (4) Display improved physical
discomfort. (5) Appear less restless and more at ease. Acupressure; Bathing;
Distraction; Exercise promotion; Exercise Promotion: Stretching; Heat/Cold
Application; Medication Administration; Music Therapy; Positioning;
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Progressive Muscle Relaxation; Pruritus Management; Simple Guided Imagery;

Simple Massage; Simple Relaxation Therapy; Skin Care; Topical Treatments (1)
Assess client needs holistically. Physical discomfort often coexists with and
is exacerbated by emotional and spiritual discomfort; therefore addressing
nonphysical needs can improve the client's perception of physical comfort. The
nurse's therapeutic approach and demeanor can have a profound impact on
perception of comfort (2) Consult with the physician for medication to reduce
discomforting symptoms such as aching. (3) Provide distraction techniques such
as music, television, or games. (4) Encourage early mobilization to decrease
physical discomforts associated with bed rest. (5) Provide simple massage. (6)
Provide gentle, soothing touch, which may be well suited for clients who
cannot tolerate more stimulating interventions such as simple massage. (7)
Position the client to maximize comfort. (8) Inform the client of options for
control of discomfort such as self-hypnosis and guided imagery, and provide
these interventions if appropriate. (9) Individualize the timing and........
(1) Comforting touch is helpful for elders because they respond to touch more
than to verbal comforting. (2) Frail elderly clients should be protected from
cold discomfort. (1) Assess for the influence of cultural beliefs, norms, and
values on the client's perceptions of skin and/or hair status and practices.
(2) Identify and clarify cultural language used to describe skin and hair. (3)
Assess skin for ashy appearance. (4) Encourage the use of lanolin-based
lotions for African American clients with dry skin. (5) Offer hair oil and
lanolin-based lotion for dry scalp and skin. (6) Use soap sparingly if the
skin is dry. (1) Assist the client and family in identifying and avoiding
irritants that exacerbate pruritus (e.g., wool, cleansers, allergens).
Avoidance of irritants decreases discomfort of pruritus (2) Teach the family
to use mild, nonscented, and non-bleach-containing laundry products. Chemical
irritants increase the discomfort of pruritus. (3) Keep the temperature of the
home moderate to cool. Use a humidifier. Overheated home environments increase
sweating, which adds salts to the skin and increases irritation. Raising the
moisture in the air helps to keep moisture in the skin (Hardy, 1996). Nursing
Research: Cool ambient temperature has been reported to reduce pruritus in
some clients (4) Support the use of the client's preferred body lotion, as
long as it has not been found to exacerbate pruritus. Have the client apply
lotion after bathing before blotting skin dry. Clients are more likely to
continue past practices. Applying lotion while the skin is still wet increases
the moisturizing.....
(1) Teach techniques to use when the client is uncomfortable, including
relaxation techniques, guided imagery, hypnosis, and music therapy. (2)
Instruct the client and family on prescribed medications and therapies that
improve comfort. (3) Perform a complete assessment to determine the cause of
pruritus (e.g., dry skin, contact with irritating substance, medication side
effect, insect bite, infection, healing burns, underlying systemic disease).
(4) Assess for sleep disturbances. (5) Implement soaks with cool or cold
washcloths or offer cool baths if appropriate. (6) Keep the client's
fingernails short; have the client wear mitts if necessary. (7) Leave pruritic
area open to the air if possible. (8) Use nonallergenic mild soap and use it
sparingly. (9) Keep skin well lubricated. After bathing, while the skin is
still moist, apply nonallergenic moisturizers such as Medilan that are alcohol
free and available in cream or ointment form. Apply moisturizers daily. (10)
Provide simple ..... ÿÿÿÿ ÿ Communication, readiness for enhanced 254
Pattern of exchanging information and ideas with others that is sufficient for
meeting one's needs and life's goals and can be strengthened. Expresses
willingness to enhance communication; able to speak or write a language; forms
words, phrases, and language; expresses thoughts and feelings; uses and
interprets nonverbal cues appropriately; expresses satisfaction w/ability to
sahre information and ideas w/others To be developed Communication;
Communication: Expressuve, Receptive (1) Express willingness to enhance
communication. (2) Demonstrate ability to speak or write a language. (3) Form
Page 21
words, phrases, and language. (4) Express thoughts and feelings. (5) Use and
interpret nonverbal cues appropriately. (6) Express satisfaction with ability
to share information and ideas w/others. Active Listening; Communication
Enhancement: Hearing Deficit, Speech Deficit (1) Establish a good
nurse-client relationship: provide appropriate education for the client,
demonstrate caring by being present to the client. (2) Carefully assess the
client's readiness to communicate. (3) Assess the client's literacy level. (4)
Listen attentively and provide a comfortable environment for communicating;
use these practical guidelines to assest in communication: a) slow down and
listen to the client's story. b) Use " living room" language. c) use pictures
and stories to illustrate important points. d) Repeat instructions; limit the
amoundt of info given. e) Have the client "teach back" to confirm
understanding. f) Avoid asking, "Do you understand?" g) Be respectful, caring,
and sensitive. (5) Provide communication with specialty nurses who have
knowledge about the client's situation. (6) Refer couples in maladjusted
relationships to psychosocial intervention and social support to strengthen
communication nurse specialists.
(1) Assess for hearing and vision impairments and make appropriate referrals
for hearing aids. (2) Use touch if culturally acceptable when communicating
with older clients and thier families. (3) Caregivers may sing when delivering
care and instructions. (1) Nurses should become more sensitive to the meaning
of a culture's nonverbal communication modes, such as eye contact, facial
expression, touching, body language, and distancing practices, in
cross-cultural encounters. (2) Nurses should realize that thier good
intentions and their usual nonverbal communication style may sometimes be
interpreted as offensive and insulting by a specific cultural group. (3)
Assess for the influence of cultural beliefs, norms, and values on the
client's communication process. (4) Assess personal space needs, acceptable
communication styles, acceptable body language, interpretation of eye contact,
perception of touch, and use of paraverbal modes when communicating with the
client. (5) Take extreme care when using touch. (6) Modify the communication
approach in keeping with the client's particular culture. (7) use an
interpreter if the client speak a different language. (8) Use therapeutic
communication techniques that emphasize acceptance, offer the ... (1) The
interventions described previously may be used in home care. (2) Refer to the
care plan for Impaired verbal Communication.
ÿÿÿÿ ÿ Communication, verbal, impaired 259 Decreased, delayed, or absent
ability to receive, process, transmit, and use a system of symbols. Willful
refusal to speak; disorientation in the three spheres of time, space, and
person; inability to speak dominant language; failure or inability to speak;
speaking or verbalization w/difficulty; inappropriate verbalizations;
difficulty forming words ro sentences (e.g., aphonia, dyslalia, dysarthria);
difficulty expressing thoughts verbally (e.g., aphasia, dysphasia, apraxia,
dyslexia); stuttering; slurring; dyspnea; absence of eye contact or difficulty
in selectively attending; difficulty in comprehending and maintaining usual
communication pattern; partial or total visual deficit; inability to use or
difficulty in using facial or body expressions Decrease in circulation to
brain; brain tumor; physical harrier (e.g., tracheostomy, intubation);
anatomical defect; cleft palate; alteration of neuromuscular visual system,
auditory system, phonatory apparatus; psychological barriers (e.g., psychosis,
lack of stimuli); cultural difference; differences related to developmental
age; side effects of medication; environmental barriers; absence of
significant others; altered perceptions; lack of information; stress;
alteration of self-esteem or self-concept; physiological conditions;
alteration of CNS; weakening of musculoskeletal system; emotional conditions
Communication; Communication: Expressive, Receptive (1) Use effective
communication techniques. (2) Use alternative methods of communication
effectively. (3) Demonstrate congruency of verbal and nonverbal behavior. (4)
Demonstrate understanding even if not able to speak. (5) Express desire for
social interactions. Active Listening; Communication Enhancement: Hearing
Page 22
Deficit, Speech Deficit (1) When the client is having difficulty

communicating, assess and refer for consultation for hearing problems. Hearing
loss might be suspected when a person does not always hear sounds such as
ringing telephone or doorbell, turns his or her ear toward the source of
sound, frequently asks the speaker to repeat, turns the volume on the TV or
radio up too loud, or shows obvious signs of confusion or misunderstanding of
speech. (2) Involve a familiar person when attemtping to communicate with a
person who has difficulty with communication. (3) Determine the language
spoken; obtain alanguage dictionary or interpreter if possible and accepted by
the client. (4) LIsten carefully. Validate verbal and nonverbal expressions.
(5) Spend time communicating with the client. (6) Use simple communication,
speak in a well-modulated voice, smile, and show concern for the client. Such
techniques have been described by clients as demonstrating caring. (7) Involve
clients with mental retardation in ....
(1) Initiate communication with the client with dementia. (2) Carefully assess
the client for hearing difficulty using an audiometer. (3) Encourage the
client to wear prescribed eyeglasses and hearing aids. (4) When communicating
with a client, face toward his or her unaffected side or better ear. (5)
Provide sufficient light and remove distractions such as glare and background
noise. (6) use low voice tones and recognize that perception of the sounds f,
s, th, ch, sh, b, t p k and d is impaired with age-related hearing loss. (7)
Allow time for thought comprehension when communicating with the client. (8)
Schedue time to listen to the client's life story. (9) use touch as culturally
appropriate. (1) Assess for the influence of cultural beliefs, norms, and
values on the client's communication process. (2) Assess personal space needs,
acceptable communication styles, acceptable body language, interpretation of
eye contact, perception of touch, and use of paraverbal modes when
communicating wit hthe client. (3) Take extrreme care when using touch. (4)
Modify the communication approach in keeping with the client's particular
culture. (5) Use an interpreter if the client speaks a different language. (6)
Use therapeutic communcation techniques that emphasize acceptance, offer the
self, validate the client's concerns, and convey respect. (7) Use reminiscence
therapy as a language intervention. (1) The interventions described previosly
possible with the case manager or social worker to assess the need for home
support systems, assistive devices, and community or home health services. (3)
Continue with speech therapy services per the physician's order. Support the
speech therapy plan of care. (4) Assess the cause of communication difficulty
and the psychological response to communication difficulty. Refer for mental
health assessment as indicated. (5) Use an understanding of the client's
specific physiological changes to implement asctions that will assist client
communication, provide support, and decrease stress. (6) Assess the family for
possible role changes resulting from communication impairment of a family
member. (7) When possible, encourage the family to include the client in
family activites using enhanced communication techniques with sensitivity. (8)
Refer to medical srvies as necessary ....
(1) Teach the client and family techniques to increase communication. (2)
Teach basic signs to indicate needs, such as "eat," drink," "toilet," "more,"
"finished." (3) Encourage signifcant others to use touch, such as holding the
client's hand or stroling the arm. (4) Teach the client how to use
communication devices. (5) Refer the client to a speech-language pathologist
or audiologist. (6) Refer to a specialist for possible surgical interventions
when clients have surgical defects caused by cancer of the maxillary sinus and
alveolar ridge. ÿÿÿÿ ÿ Conflict, decisional (specify) 266 Uncertainty
about course of action to be taken when choice among competing actions
involves risk, loss, or challenge to personal life values Verbalization of
uncertainty about choices of undesired consequences of alternative actions
being considered; vacillation between alternative choices; delayed decision
making; verbalization of feelings of distress while attempting to make a
decision; self-focusing; physical signs of distress or tension (e.g.,
Page 23
increased HR, increased muscle tension, restlessness); questioning of personal

values and beliefs while attempting to make a decision. Support systemt
deficit; perceived threat to value system; lack of experience or interference
with decision making; multiple or divergent sources of information; lack of
relevant information; unclear personal values/beliefs. Decision Making;
Information Processing; Participation in Health Care Decisions (1) State the
advantages and disadvantages of choices. (2) Share fears and concerns
regarding choices and responses of others. (3) Make an informed choice.
Decision-Making Support (1) Observe for factors causing or contributing to
conflict (e.g., value conficts, fear of outcome, poor problem-solving skills).
(2) Work with and allow the client to make decisions in a way that is
comfortable for the client, such as deferring, or deliberating. (3) give the
client time and permission to express feelings associated with decision
making. (4) Explore the client's perception of the future with regard to
different decisions. (5) Demonstrate reassurance with unconditional respect
for and acceptance of the client's values, spiritual beliefs, and culutral
norms. (6) Encourage the client to list the advantages and disadvantages or
each alternative. (7) Initiate health teaching and referrals when needed. (8)
Facilitate communicationn between the client and family members regarding the
final decision; offer support to the person actually making the decision. (9)
Provide detailed info on benefits and risks using functional terms and
probabilities tailored to clinical risk, .....
(1) Work with the clients in setting goals for the plans of care. (2) Review
with the client and family the importance of discussing and recording
end-of-life decisions. (3) If end-of-life discussions are being avoided,
describe the possible consequences. (4) Discuss the purpose of living will and
advance directives. (5) Discuss choices or changes to be made. (6) Teach
family members how to be supportive of the final decision or how to refrain
from being destructive if they are unable to be supportive. (1) Assess for
the influence of cultural beliefs, norms, and values on the client's
decision-making conflict. (2) Identify who will be involved in the
decision-making process. (3) Use cross-cultural decisions aids whenever
possible. (4) Validate the client's feelings regarding the decisional
conflict. NOTE: Before addressing decisional conflict, nurses should be aware
of their existing biases and preconceptions, and avoid superimposing them on
the client's decision-making process. For examply, clients making end-of-life
decisions must process multiple issues regarding their choices; nurses'
discomfort with end-of-life issues could interfere with client's ability to
reflect on choices. (1) The interventions described previously may be adapted
for home care use. (2) Before providing any home care, assess the client plan
for advance directives. If a plan exists, place a copy in the client file.
Refer for assistance in completing advance directives as necessary. (3)
Determine the relevance of the decisional conflict to the plan of care. (4)
Assess the client and family for consensus (or lack thereof) regarding the
issue in conflict. When the conflict involves end-of-life decisions, work to
shift the client's and family's expectations from curative to palliative. (5)
If a decision is....
(1) Instruct the client and family members to provide advance directives in
the following areas: person to contact in an emergeny; preference (if any) to
die at home or in the hospital; desire to sign a living will; desire to donate
an organ; funeral arrangement. (2) Inform the family of treatment options;
encourage and defend self-determination. (3) Identify reasons for family
decisions regarding care. Explore ways in which ramily decisions can be
reported. (4) Recognize and allow the client to discuss the selection of
complementary therapies available, such as spiritual support, relxation,
imagery, exercise, lifestyle changes, diet, and nutritional supplementation.
(5) Include families in client care conferences. As a client's condition
changes, it may be necessary to rethink the goal of treatment. The goal may
change from restoration and cure to stabilization of functioning or
preparation for comfortable and dignified death. ÿÿÿÿ ÿ Conflict, parental
Page 24
role 272 Parent's experience of role confusion and conflict in response to

crisis. Expresses concerns about changes in parental role, family
functioning, family communication, family health; expresses concerns/feelings
of inadequacy with regard to providing for child's physical and emotional
needs during hospitalization or at home; shows reluctance to participate in
usual caregiving activities, even with encouragement and support; demonstrates
disruption in care and caregiving routines; expresses concern about perceived
loss of control regarding decisions relating to child; verbalizes or
demonstrates feelings of guilt, anger, fear, anxiety, and frustration
concerning effect of child's illness on family processes Change in marital
status; home care of child w/special needs; interruptions of family life as a
result of home care regimens; separation from child as a result of chronic
illness; intimidation by invasive or restrictive modalities Acceptance:
Health Status; Caregiver Adaptation to Patient Institutionalization; Caregiver
Home Care Readiness; Caregiver Lifestyle Disruption; Coping; Grief
Resolutioin; Hope; Parent-Infant Attachment; Parenting Performance;
Psychosocial Adjustment: Life Change; Role Performance (1) Express feelings
and perceptions regarding impacts of illness, disability, and/or
hospitalization on parental role. (2) Participate in hospital and home care as
much as able to given the availability of resources and support systems. (3)
Exhibit assertiveness and responsibility in active family decision making
regarding care of the child. (4) Describe and select available resources to
support parental management of the child's and family's needs. Abuse
Protection Support: Child; Caregiver Support; Counseling; Crisis Intervention;
Decision-Making Support; Environmental Management: Attachment Process; Family
Process Maintenance; Family Therapy; Role Enhancement (1) Assess parents'
previous coping behaviors. (2) Explore parent/family sources of stress, usual
methods of coping, and perceptions of illness/condition. Capitalize on the
strengths identified. Involve both parents in the assessment. (3) Consider the
use of family theory as a framework to help guide intervention. (4) Sustain
parental involvement in shard decision making with regard to care by using the
following steps: incorporate parents' information concerning the child's
condition and progress; normalize the home/hospital environment as much as
possible; collaborate in care by providing choices when possible. (5) Seek and
support parental participation in care. (6) Provide support for each parent's
primary coping strategies. (7) Evaluate the family's perceived strength of its
social support system. Encourage the family to use social support to increase
its resiliency and to moderate stress. (8) Offer respite care to assist
parents in maintaining sufficient energy and personal .....
(1) Acknowledge racial/ethnic differences at the onset of care. (2) Assess
for the influence of cutural beliefs, norms, and values on the client'
perceptions of the parental role. (3) Acknowledge that value conflicts arising
from acculturation stresses may contribute to increased anxiety and
significant conflict with parental role. (4) Promote the female parenting role
by providing a treatment environment that is culturally based and woman
centered. (5) Validate the client's feelings with regard to parental rold
confusion and conflict. (1) The interventions described previously may be
adapted for home care use. (2) Assess family adjustment prenatally and
postpartum; assist new parents to renegotiate behavior around issues such as
amount of time spent together, sexual relationship, resolution of
disagreements, and provision of sufficient time for leisure/reacreational
activities. (3) Assess interference with family functioning.
(1) Furnish clear explanations about condition, disease or disability,
associated treatments, and prognosis. Describe circumstances involving
emotional and physical reactions of the child and types of family member
reactions that might be anticipated in response to the condition or crisis.
Provide ample time for skill practice. (2) For parents of children with
chronic disabilities, tailor educational opportunites based on the
experiential phase of the parents (protection, survival, or development of the
parent as a central person) as parents develop an identity as the central
Page 25
caregivers for their child. (3) Involve parents in formal and/or informal
social support situationis, including parent-to-parent groups, community
agencies, and counseling resources. ÿÿÿÿ ÿ Confusion, acute 278 Abrupt
onset of a cluster of global, transient changes, and distribution in
attention, cognition, psychomotor activity level, consciousness, or sleep-wake
cycle Lack of motivation to initiate and/or follow through with goal-directed
or purposeful behavior; fluctuation in psychomotor activity; misperceptions;
fluctuation in cognition; increased agitation or restlessness; fluctuation in
level of consciousness; fluctuation in sleep-wake cycle; hallucinations Age
over 70 years; alcohol abuse; abuse; cognitive impairment; uncontrolled pain;
multiple comorbidities; medications; dehydration; infection; sensory deficit;
compromised activities of daily living Cognitive Orientation; Distorted
Thought Self-Control; Information Processing; Memory; Neurological Status:
Consciousness; Sleep (1) Demonstrate restoration of cognitive status to
baseline. (2) Obtain adequate amount of sleep. (3) Demonstrate appropriate
motor behavior. (4) Maintain functional capacity. (5) Optimize hydration and
nutrition Delirium Management; Delusion Management (1) Assess the client's
behavior and cognition systematically and continually throughout the day and
night, as appropriate.(2)Perform an accurate mental status examination that
includes the following:
Overall appearance, manner, and attitude
Behavior characteristics and level of psychomotor behavior
Mood and affect (presence of suicidal or homicidal ideation as observed by
others and reported by the client)
Insight and judgment Cognition as evidenced by level of consciousness,
orientation (to time, place, and person), thought process and content
(perceptual disturbances such as illusions and hallucinations, paranoia,
delusions, abstract thinking)
.......
(1) Mobilize the client as soon as possible; provide active and passive range
of motion. (2) Provide sufficient medication to relieve pain. (3) Explain
hospital routines and procedures slowly and in simple terms; repeat
information as necessary. (4) Provide continuity of care when possible (e.g.,
provide the same caregivers, avoid room changes). (5) If clients know that
they are not thinking clearly, acknowledge the concern. (6) Do not use the
intercom to answer a call light. (7) Keep the client's sleep-wake cycle as
normal as possible (e.g., avoid letting the client take daytime naps, avoid
waking the client at night, give sedatives but not diuretics at bedtime,
provide pain relief and back rubs). (8) Maintain normal sleep-wake patterns
(treat with bright light for 2 hours in the early evening). (1) Some of
the interventions described previously may be adapted for home care use. (2)
Assess and monitor for acute changes in cognition and behavior. (3) Delirium
is reversible but can become chronic if untreated, and the client may be
discharged from the hospital to home care in state of undiagnosed delirium.
(4) Assess for treatable causes of changes in cognition and behavior. (5)
Assess fluid intake, dementia status, and occurrence of a fall within the past
30 days in evaluating confusion. (6) Avoid preconceptions about the source of
acute confusion; assess each occurrence on the basis of available evidence.
(7) Institute case management of frail elderly clients to support continued
independent living.
(1) Teach the family to recognize signs of early confusion and seek medical
help. (2) Counsel the client and family regarding the symptoms of delirium,
its management, and its sequelae. ÿÿÿÿ ÿ Confusion, chronic 283
Irreversible, long-standing, and/or progressive deterioration of intellect and
personality characterized by decreased ability to interpret environmental
stimuli and decreased capacity for intellectual thought processes, and
manifested by disturbances of memory, orientation, and behavior Altered
interpretation and/or response to stimuli; clinical evidence of organic
impairment; altered personality; impaired memory (short and long term);
impaired socialization; no change in level of consciousness; decreased ability
Page 26
to participate in self-care; decreased ability for meaningful interaction with

the environment Multi-infarct dementia; Karsokoff's psychosis; brain injury;
Alzheimer's disease and related dementia Cognition; Cognitive Orientation;
Distorted Thought Self-Control (1) Remain content and free from harm. (2)
Function at maximal cognitive level. (3) Participate in activities of daily
living at the maximum of functional ability Dementia management;
Environmental Management; Reality Orientation; Surveillance: Safety (1)
Determine the client's cognitive level using a screening tool such as the
Mini-Mental State Exam (MMSE). (2) Gather information about the client's
predementia functioning, including social situation, physical condition, and
psychological functioning. (3) Assess the client for signs of depression:
insomnia, poor appetite, flat affect, and withdrawn behavior. (4) Ensure that
the client is in a safe environment by removing potential hazards such as
sharp objects and harmful liquids. (5) Place an identification bracelet on
client. (6) Avoid as much as possible exposing the client to unfamiliar
situations and people. Maintain continuity of caregivers. Maintain routines of
care by observing established eating, bathing, and sleeping schedules. Send a
familiar person with the client when the client goes for diagnostic testing or
into unfamiliar environments. (7) Keep the environment quiet and
nonstimulating. Avoid or minimize sights and sounds that have a high potential
for ...........
NOTE: Most of the aforementioned interventions apply to the geriatric client.
(1) Use reminiscence and life review therapeutic interventions; ask questions
about the client's work, child raising, or time spent in the service. Ask
questions such as, "What was really important to you as you look back?" (1)
family's or caregiver's understanding of chronic confusion or dementia. (2)
Inform the client's family or caregiver of the meaning of and reasons for
common behavior observed in clients with dementia. (3) Assist the family or
caregiver in identifying barriers that would prevent the use of social
services or other supportive services that could help reduce the impact of
caregiving. (4) Assess the client for the presence of an instrumental activity
of daily living (IADL) disability and chronic health conditions. (5) Refer the
family to social services or other supportive services to assist in meeting
the demands of caregiving for the client with dementia. (6) Encourage the
family to make use of support groups or other service programs. (7) Validate
the family members' feelings with regard to the impact of the client's
behavior on family lifestyle. NOTE: Keeping the client as independent as
possible is important. Because communitybased care is usually less structured
than institutional care, however, in the home setting the goal of maintaining
safety for the client takes on primary importance. (1) Assess and monitor the
client for acute changes in cognition and behavior. (2) Assess for treatable
causes of changes in cognition and behavior. The mnemonic DEMENTIA can be used
to remember potential causes (3) Before providing any home care, assess the
client plan for advance directives (living will and power of attorney). If a
plan exists, place a copy in the client file. If no plan exists, offer
information on advance directives according to agency policy. Refer for
assistance in completing advance directives as necessary. Do not witness a
living will. (4) Assess the client's memory and executive function deficits
before assuming the inability to make any medical decisions. (5) Assess the
home for safety features and client needs...
(1) In the early stages of confusion (e.g., initial period following stroke),
provide the caregiver with information on illness processes, needed care, and
likely trajectory of progress. (2) Recommend that the family develop a memory
aid wallet or booklet for the client, which contains pictures and text that
chronicle the client's life.(3) Teach the family how to set up the environment
and use the care techniques/ interventions listed so that cognitive and
functional impairments that interact with the client's progressively lowered
stress threshold (PLST) will be addressed. Identify stressors and initiate
compensatory modifications of the environment. (4) Discuss with the family
Page 27
what to expect as the dementia progresses. (5) Counsel the family about
resources available regarding end-of life-decisions and legal concerns. Inform
the family that, as dementia progresses, hospice care may be available in the
home in the terminal stages to help the caregiver. ........ ÿÿÿÿ ÿ
Constipation 294 Decrease in normal frequency of defecation, accompanied by
difficult or incomplete passage of stool and/or passage of excessively hard,
dry stool Change in bowel pattern; bright red blood with stool; presence of
soft, pastelike stool in rectum; distended abdomen; dark, black, or tarry
stool; increased abdominal pressure; percussed abdominal dullness; pain with
defecation; decreased volume of stool; straining w/defecation; decreased
frequency of stool; dry, hard, formed stool; palpable rectal mass; feeling of
rectal fullness or pressure; abdominal pain; inability to pass stool;
anorexia; headache; change in abdominal growling (borborygmi); indigestion;
atypical presentation in older adults (e.g., change in mental status, urinary
incontinence, unexplained falls, elevated body temp); severy flatus;
generalized fatigue; hypoactive or hyperactive bowel sounds; palpable
abdominal mass; abdominal tenderness with or w/o palpable muscle resistance;
nausea and/or vomiting; oozing of liquid stool FUNCTIONAL: Recent
environmental changes; habitual denial or ignoring of urge to defecate;
insufficient physical activity; irregular defecation habits; inadequate
toileting; abdominal muscle weakness. PSYCHOLOGICAL: Depression; emotional
stress; mental confusion. PHARMACOLOGICAL: Antilipemic agents; overdose of
laxatives; calcium carbonate; aluminum-containing antacids; NSAIDS; opiates;
anticholinergics; diuretics; iron salts; phenothiazines; sedatives;
sympathomimetics; bismuth salts; antidepressants; calcium channel blockers.
MECHANICAL: Rectal abscess or ulcer; pregnancy; rectal anal fissure; tumor;
megacolon (Hirschprung's disease); electrolyte imbalance; rectal prolapse;
prostate enlargement; neurological impairment; reactal anal stricture;
rectocele; postsurgical obstruction; hemorrhoids; obesity. PHYSIOLOGICAL: Poor
eating habits; decreased motility of GI tract; inadequate dentition or oral
hygiene; insufficient fiber intake; insufficient fluid intake; change in usual
foods, etc Bowel Elimination; Hydration (1) Maintain passage of soft, formed
stool every 1-3 days w/o straining. (2) State relief from discomfort of
constipation. (3) Identify measures that prevent or treat constipation.
Constipation/Impaction Management (1) Assess usual pattern of defecation,
including time of day, amount and frequency of stool, consistency of stool;
history of bowel habits or laxative use; diet including fluid intake; exercise
patterns; personal remedies for constipation; obstetrical/ gynecological
history; surgeries; alterations in perianal sensation; present bowel
regimen.(2) Have the client or family keep a diary of bowel habits using a
Management of Constipation Assessment Inventory, including information such as
time of day; usual stimulus; consistency, amount, and frequency of stool;
fluid consumption; and use of any aids to defecation. (3) Review the client's
current medications. (4) If the client is receiving opioids, request an order
for stool softeners from the primary care practitioner and institute a bowel
regimen before the onset of constipation. (5) Palpate for abdominal
distention, percuss for dullness, and auscultate bowel sounds. (6) Check for
impaction; if present, perform digital removal per ......
(1) Explain the importance of adequate fiber intake, fluid intake, activity,
and established toileting routines to ensure soft, formed stool. (2) Determine
the client's perception of normal bowel elimination; promote adherence to a
regular schedule. (3) Explain Valsalva's maneuver and the reason it should be
avoided. (4) Respond quickly to the client's call for help with toileting. (5)
Avoid regular use of enemas in the elderly. (6) Use opioids cautiously. If
they are ordered, use stool softeners and bran mixtures to prevent
constipation. (7) Position the client on the toilet or commode and place a
small footstool under the feet. (1) The interventions described previously
may be adapted for home care use. (2) Take complaints seriously and evaluate
claims of constipation in a matter-of-fact manner. (3) Assess the self-care
management activities the client is already using. (4) Although the use of a
Page 28
bedside commode may be necessitated by the client's condition, allow the

client to use the toilet in the bathroom when possible and provide assistance.
(5) Carefully monitor the bowel patterns of clients under pain management with
opioids. In older clients, routinely advise consumption of fluids, fruits, and
vegetables as part of the diet, and ambulation if the client is able.
Introduce a bowel management program at the first sign of constipation. (6)
Refer for consideration of the use of polyethylene glycol 3350 (PEG-3350) for
constipation. (7) Advise the client against attempting to remove impacted
feces on his or her own. (8) Instruct the client and family in appropriate
expectations for having bowel movements.....
(1) Instruct the client on normal bowel function and the need for adequate
fluid and fiber intake, activity, and a defined toileting pattern in a bowel
program. (2) Encourage the client to heed defecation warning signs and develop
a regular schedule of defecation by using a stimulus such as a warm drink or
prune juice. (3) Encourage the client to avoid long-term use of laxatives and
enemas and to gradually withdraw from their use if they are used regularly.
(4) If not contraindicated, teach the client how to do bent-leg sit-ups to
increase abdominal tone; also encourage the client to contract the abdominal
muscles frequently throughout the day. Help the client develop a daily
exercise program to increase peristalsis. ÿÿÿÿ ÿ Constipation, perceived
300 State in which individual makes a self-diagnosis of constipation and
ensures daily bowel movement through abuse of laxatives, enemas, and
suppositories Expectation of a daily bowel movement that results in overuse
of laxatives, enemas, and suppositories; expectation of a bowel movement at
same time every day Cultural or family beliefs; faulty appraisals;impaired
thought processes Bowel Elimination; Health Beliefs; Health Beliefs:
Perceived Threat (1) Regularly defecate soft, formed stool w/o using any
aids. (2) Explain the need to decrease or eliminate the use of laxatives,
suppositories, and enemas. (3) Identify alternatives to laxatives, enemas, and
suppositories for ensuring defecation. (4) Explain that defecation does not
have to occur every day. Bowel Management; Medication Management (1) Have
the client keep a diary of bowel habits, using a Management of Constipation
Assessment Inventory, including information such as time of day, usual
stimulus; consistency, amount, and frequency of stool; fluid consumption; and
use of any aids to defecation. (2) Determine the client's perception of an
appropriate defecation pattern. (3) Monitor the use of laxatives,
suppositories, or enemas and suggest replacing them with increased fiber
intake along with increased fluids to 2 L/day. (4) Ask the client to keep a
food log of the foods eaten for the last 24 hours or recall the usual foods
eaten. If necessary, teach the blient the need to eat five to nine fruits and
vegetables per day, and at least three servings of whole-grain foods. (5) In
place of laxatives, use a mixture of 1 cup of Kellogg's All-Bran cereal, 1 cup
of applesauce, and 1 cup of prune juice; begin administration in small amounts
and gradually increase amount. Refer to references dor dosing. Keep
refrigerated. .....
(1) The interventions described previously may be adapted for home care
use. (2) Take complaints seriously and evaluate claims of constipation in a
matter-of-fact manner. (3) Obtain family and client histories of bowel or
other patterned behavior problems. (4) Observe family cutural patterns related
to eating and bowel habits. (5) Encourage a mindset and program of self-care
management. Elicit from the client the self-talk he or she uses to describe
body perceptions; correct catastrophizing interpretations. Instruct the client
in a healthy lifestyle that support normal bowel function and encourage
progressive inclusion of these elements into daily activities. (6) Discuss the
client's self-image. Help the client to reframe the self-concept as capable.
(7) Instruct the client and family in appropraite expectations for having
bowel movements. Offer instruction and reassurance regarding explanations for
variation from the previous pattern of bowel movements. (8) Contract with the
client...
Explain normal bowel function and the necessary ingredients for a regular
Page 29
bowerl regimen. (2) Work with the client and family to develop a diet that
fits the client's lifestyle and includes increased fiber. (3) Teach the client
that it is not necessary to have daily bowel movements and that the passage of
anywhere from three stools each day to three stools in a week is considered
normal. (4) Explain to the client the harmful effects of the continual use of
defecation aids such as laxatives and enemas. (5) Encourage the client to
gradually decrease the use of the usual laxative and enemas and to set a date
to have eliminated the use of all defecation aids. (6) Explain what Valsalva's
maneuver is and why it should be avoided. (7) Work with the client and family
to design a bowelr training routine that is based on precious patterns (before
laxative or enema abuse) and incorporates the consumption of warm fluids,
increased fiber, and increased fluids; privacy; and a predictable routine. ÿ
ÿÿÿ ÿ Constipation, risk for 304 At risk for decrease in individual's
normal frequency of defecation accompanied by difficult or incomplete passage
of stool and/or passage of excessively hard, dry stool FUNCTIONAL: Recent
environmental changes; habitual denial or ignoring of urge to defecate;
insufficient physical activity; irregular defecation habits; inadequate
toileting; abdominal muscle weakness. PSYCHOLOGICAL: Emotional stress; mental
confusion; depression. PHYSIOLOGICAL: Poor eating habits; decreased motility
of GI tract; inadequate dentition or oral hygiene; insufficient fiber intake;
insufficient fluid intake; change in usual foods & eating patterns;
dehydration. PHARMACOLOGICAL: Phenothiazides; antilipemic agents; overuse of
laxatives; calcium carbonate; aluminum-containing antacids; NSAIDS; opiates;
anticholinergics; iron salts; sedatives; sympathomimetics; bismuth salts;
antidepressants; calcium channel blockers; anticonvulsants. MECHANICAL: Rectal
abscess or ulcer; pregnancy; postsurgical obstruction; rectal anal fissure;
tumor; megacolon (Hirschsprung's disease) electrolyte imbalance; rectal
prolapse; prostate enlargement; neurological impairment; rectal anal
stricture... Bowel Elimination (1) Maintain passage of soft, formed stool
every 1-3 days w/o straining. (2) Identify measures that prevent constipation.
(3) Explain rationale for not using laxatives and enemas.
Constipation/Impaction Management See care plan for constipation
See care plan for constipation
See care plan for constipation ÿÿÿÿ ÿ Coping, ineffective 306 Inability to
form a valid appraisal of internal or external stressors, inadequate choices
of practiced responses, and/or inability to access or use available resources
Lack of goal-directed behavior or resolution of problem, including inability
to attend; difficulty with organized information; sleep disturbance; abuse of
chemical agents; depcreased use of social support; use of forms of coping that
impede adaptive behavior; poor concentration; fatigue; inadequate problem
solving; verbalized inability to cope or ask for help; inability to meet basic
needs; destructive behavior toward self or others; inability to meet role
expectations; high illness rate; change in usual communication patterns; risk
taking Gender differences in coping strategies; inadequate level of
confidence in ability to cope; uncertainty; inadequate social support created
by characteristics of relationships; inadequate level of perception of
control; indequate resource availability; high degree of threat; situational
crises; maturational crises; disturbance in pattern of tension release;
inadequate opportunity to prepare for stressor; inability to conserve adaptive
energies; disturbance in pattern of appraisal of threat; chronic conditions;
alteration in body integrity; cultural variables Coping; Decision making;
Impulse Self-Control; Information Processing (1) Verbalize ability to cope
and ask for help when needed. (2) Demonstrate ability to solve problems r/t
current needs. (3) Remain free of destructive behavior toward self or others.
(4) Communicate needs and negotiate w/others to meet needs. (5) Discuss how
recent life stressors have overwhelmed normal coping strategies. (6)
Demonstrate new effective coping strategies. (7) Have illness and accident
rates not excessive for age and developmental level Coping Enhancement;
Decision-Making Support (1) Observe for causes of ineffective coping such as
poor self-concept, grief, lack of problem-solving skills, lack of support, or
Page 30
recent change in life situation. (2) Observe for strengths such as the ability
to relate the facts and to recognize the source of stressors. (3) Assess the
risk of the client's harming self or others and intervene appropriately. See
the care plan forRisk for Suicide. (4) Help the client set realistic goals and
identify personal skills and knowledge. (5) Use empathetic communication and
encourage the client and family to verbalize fears, express emotions, and set
goals. (6) Encourage the client to make choices and participate in the
planning of care and scheduled activities. (7) Provide mental and physical
activities within the client's ability (e.g., reading, television, radio,
crafts, outings, movies, dinners out, social gatherings, exercise, sports,
games). (8) If the client is physically able, encourage moderate aerobic
exercise. (9) Provide info.......
(1) Engage the client in reminiscence. (2) Assess and report possible
physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection,
changes in temperature, fluid and electrolyte imbalances, and use of
medications with known cognitive and psychotropic side effects). (3) Determine
if the individual is displaying a change in personality as a manifestation of
difficulty with coping. (4) Increase and mobilize the support available to the
elderly client. Encourage interaction with family and friends. (1) Assess
for the influence of cultural beliefs, norms, and values on the client's
perceptions of effective coping. (2) Assess for intergenerational family
problems that can overwhelm coping abilities. (3) Encourage spirituality as a
source of support for coping. (4) Negotiate with the client with regard to the
aspects of coping behavior that will need to be modified. (5) Identify which
family members the client can count on for support. (6) Use an empowerment
framework to redefine coping strategies. (7) Assess the influence of fatalism
on the client's coping behavior. (8) Assess the influence of cultural
conflicts that may affect coping abilities. (1) The interventions described
previously may be adapted for home care use. (2) Observe the family for coping
behavior patterns. Obtain family and client history as possible. (3) Assess
for suicidal tendencies. Refer for mental health care immediately if
indicated. Identify an emergency plan should the client become suicidal. (4)
Encourage the client to use self-care management to increase the experience of
personal control. Identify with the client all available supports and sense of
attachment to others. Refer to the care plan for Powerlessness. (5) Refer to
medical social services for evaluation and counseling, which will promote
adequate coping as part of the medical plan of care. If no primary medical
diagnosis has been made, request medical social services to assist with
community support contacts. (6) Refer the client and family to support groups.
(7) If monitoring medication use, contract with the client or solicit
assistance from a responsible caregiver. (8) Institute case..
(1) Teach the client to problem solve. Have the client define the problem and
cause, and list the advantages and disadvantages of the options. (2) Provide
the seriously ill client and his or her family with needed information
regarding the condition and treatment. (3) Teach relaxation techniques. (4)
Work closely with the client to develop appropriate educational tools that
address individualized needs. (5) Teach the client about available community
resources (e.g., therapists, ministers, counselors, self-help groups). ÿÿÿÿ ÿ
Coping, readiness for enhanced 313 Pattern of cognitive and behavioral
efforts to manage demands that is sufficient for well-being and can be
strengthened Defines stressors as manageable; seeks social support; uses a
broad range of problem-oriented emotion-oriented strategies; uses resources;
acknowledges power; seeks knowledge of new strategies; is aware of possible
environmental changes Coping; Decision Making; Social Support (1)
Verbalize ability to cope and ask for help when needed. (2) Demonstrate
ability to solve problems r/t current needs. (3) Coomunicate needs and
negotiate w/others to meet needs. (4) State that stressors are manageable. (5)
Demonstrate new effective coping strategies. (6) Seek social support for
problems associated w/coping. (7) Seek spiritual support for personal choice
Coping Enhancement; Decision-Making Support (1) Use empathetic communication
Page 31
and encourage the client and family to verbalize fears, express emotions, and
set goals. (2) Observe for strengths such as the ability to relate the facts
and to recognize the source of stressors. (3) Encourage epxression of positive
thoghts and emotions. (4) Encourage the use of cognitive behavioral
relaxation. (5) Encouarge the client to use spiritual coping mechanisms such
as faith and prayer. (6) help the client set realistic goals and identify
personal skills and knowledge. (7) Help the client with depression to maintain
social support networks or assist in building new ones. (8) Consider a
workplace stress managemetn program to enhance coping skills. (9) Refer for
cognitive behavioral therapy. (10) Refer the client with breast cancer to a
psychosocial group intervention for coping skills training, stress management,
relaxation exercises, and psychosocial support.
(1) Refer the client with Alzheimer's disease who is terminally ill to
hospice. (2) Refer the widowed older client to self-help support groups. (1)
client's perceptions of effective coping. (2) Encourage spirituality as a
source of support for coping. (3) Identify which family members the client can
count on for support. (4) Support the inner resources that clients use for
coping. (5) use an empowerment framework to redefine coping strategies. (1)
The interventions described previously may be adapted for home care use. (2)
Observe the family for coping behavior patterns. Obtain family and client
history as possible. (3) Encourage the client to use self-care management to
increase the experience of personal control. Identify with the client all
available supports and sense of attachment to others. (4)Refer the client and
family to support groups.
(1) Teach relaxation techniques. (2) Teach the client about available
community resources. ÿÿÿÿ ÿ Coping, community, ineffective 317 Pattern of
community activities (for adaptation and problem solving) that is
unsatisfactory for meeting the demands or needs of the community Expressed
community powerlessness; failure of community to meet its own expectations;
deficits of community participation; deficits in communication methods;
excessive community conflicts; expressed difficulty in meeting demands for
change; expressed vulnerability; high illness rates; stressors perceived as
excessive; increased social problems (e.g., homicides, vandalism arson,
terrorism, robbery, infanticide, abuse, divorce, unemployment, poverty,
militancy, mental illness) Natural or manmade disasters; ineffective or
nonexistent community systems (e.g., lack or emergency medical,
transportation, or disaster planning systems); deficits in community social
support services and resources; inadequate resources for problem solving
Community Competence; Community Health Status (1) Participate in community
actions to improve power resources. (2) Develop improved communication among
community members. (3) Participate in problem solving. (4) Demonstrate
cohesiveness in problem solving. (5) Develop new strategies for problem
solving. (6) Express power to deal w/change and manage problems.
Environmental Management: Community; Health Policy Monitoring NOTE: The
diagnosis of Ineffective Coping does not apply and should not be used when
stress is being imposed by external sources or circumstances. If the community
is a victim of circumstances, using the nursing diagnosis Ineffective Coping
is equivalent to blamig the victim. See the care plan for Ineffective
community Therapeutic regimen managemed and Readiness for enhanced community
Coping. (1) Establish a collaborative partnership with the community (see the
care plan for Ineffective community Therapeutic regimen management for
references). (2) Participate with community members in the identification of
stressors and assessment of distress; for example, observe and participate in
community meetings and task forces. (3) Identify community strengths with
community members and avoid defining the community in objective terms. (4)
Determine the extent of stress proliferation (i.e., primary stressors
associated with contextual circumstances such as poverty) and the presence of
..........
(1) Acknowledge ths stressors unique to racial/ethnic communities. (2)
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Identify the health services and info resources that are currently available
in the community. (3) Work with members of the community to prioritize and
target health goals specific to the community. (4) Approach community leaders
and members of color with respect, warmth, and professional courtesy. (5)
Establish and sustain partnerships with key individuals withing communities
when developing and implementing programs. (6) Use community church settings
as a forum for advocacy, teaching, and program implementation. (7) Ask
political leaders to become part of the partnership process. (8) Protect
children from exposure to community conflicts.
(1) Teach strategies for stress management. ÿÿÿÿ ÿ Coping, community,
readiness for enhanced 321 Pattern of community activities for adaptation
and problem solving that is satisfactroy for meeting the demands or needs of
the community but that can also be improved for management of current and
future problems and stressors One or more of the following characteristics
that indicate effective coping: positive communication between
community/aggregates and larger community; availability of programs for
recreation and relaxation; sufficiency of resources for managing stressors;
agreement that community is responsible for stress management; active planning
by community for predicted stressors; active problem solving by community when
faced with issues; positive communication among community members Community
Competence; Community Health Status (1) Develop enhanced coping strategies.
(2) Maintain effective coping strategies for management of stress
Environmental Management: Community; Health Policy Monitoring NOTE:
Interventions depend on the specific aspects of community coping that can be
enhanced (e.g., planning for stress management, communicatioon, development of
community power, community perceptions of stress, community coping
strategies). (1) Describe the role of the community/public health nurse in
working with healthy communities. (2) Help the community to obtain funds for
additional programs. (3) Encourage positive attitudes toward the community
through the media and other sources. (4) Help community members to colaborate
with one another for poewr enhancement and coping skills. (5) Encourage
critical thinking. (6) Demonstrate optimum use of the power resources of
knowledge, motivation, belief system (hope), physical strength and reserve,
psychological stamina and support network, positive self-concept, and energy.
(7) Collaborate with community members to improve educational levels within
the community.
(1) Acknowledge the stresses unique to racial/ethnic communites. (2)
Identify what health services and info are currently available in the
community. (3) Work with members of the community to prioritize and target
health goals specific to the community. (4) Approach community leaders and
members of color with respect, warmth, and professional courtesy. (5)
Establish and sustain partnerships with key individuals within communities
when developing and implementing programs. (6) Use community church settings
as a forum for advocacy, teaching, and program implementation.
(1) Review coping skills, power for coping, and the use of poewr resources. ÿ
ÿÿÿ ÿ Coping, defensive 324 Repeated projection of falsely positive
self-evaluations based on self-protective pattern that defends against
underlying perceived threats to positive self-regard Grandiosity;
rationalization of failures; hypersensitivity to slight/criticism; denial of
obvious problems/weaknessess; projection of blame/responsibility; lack of
follow-through or participation in treatment or therapy; superior attitude
toward others; hostile laughter or ridicule of others; difficulty in
perception of reality, reality testing; difficulty establishing/maintaining
relationships, occurs when a specific pattern of ineffective (defensive)
coping is sustained over time Situational crises; psychological impairment;
substance abuse; HIV infection Coping; Decision Making; Impulse Self-Control;
Information Processing (1) Acknowledge need for change in coping style. (2)
Accept responsibility for own behavior. (3) Establish realistic goals with
validation from caregivers. (4) Solicit caregiver evaluation in decision
making Self-Awareness Enhancement (1) Assess for the presence of denial as a
Page 33
coping mechanism. (2) Do not confront denial if its consequences are not a
significant threat to health (3) Determine whether the client has a positive
or negative overall appraisal of a given event. (4) Develop a trusting,
therapeutic relationship with the client and family. (4) Determine the
client's perception of the problem and then provide reality-based examples of
the true situation (e.g., witnesses to an accident, blood alcohol levels,
problems with alcohol). (5) Help the client identify patterns of response in
life that may be maladaptive. (6) Promote the client's feelings of self-worth
by using group or individual therapy, role playing, one-to-one interactions,
and role modeling. (7) Support strengths and normal observations with "I not
that" or "I want you to notice". Tell clients when they do something well. (8)
Teach the client to use positive thinking by blocking negative thoughts with
the word "Stop!" and inserting positive .....
(1) Assess the client for anger and identify previous outlets for anger. (2)
Explore new outlets for anger, including physcial activities within the
client's capabilities (e.g., hitting a pillow, woodworking, sanding, scrubbing
floors). (3) Assess the client for dementia or depression. (4) If a traumatic
event has occurred, support positive religious coping behaviors. ........ (1)
client's feelings of defensiveness. (2) Acknowledge racial/ethnic differences
at the onset of care. (3) Use therapeutic communication techniques that
emphasize acceptance, offer the self, validate the client's concerns, and
convey respect. (4) Give a rationale when assessing ethnically diverse clients
for alcohol use/misuse or other sensitive behaviors. (1) The intervention
described previously may be adapted for home care use. (2) Include in the
initial assessment client and family histories of mental health problems. (3)
Observe family dynamics for dysfunctional and supportive communication. (4)
Refer to a mental health professional for possible psychodrama therapy,
especially if the client experiences difficulty in coping with a traumatic
event. (5) In the absence of primary medical diagnoses, refer to medical
social services for assistance in contacting appropriate community services.
(6) Refer to a therapist for debriefing if a traumatic or critical event has
occurred. (7) Refer for psychiatric home health care services for client
reassurance and implementation of a therapeutic regimen.
(1) Teach the client the actions and side effects of meds and the importance
of taking them as prescribed, even when the client is feeling good. (2) Work
with the client's support group to identify harmful behaviors and to seek help
for the client if he or she is unable to control behavior. (3) When a
traumatic event has occurred, encourage the use of written disclosure.
Instruct the person to write about the event over a period of days. (4)
Support family efforts using religious coping behaviors. ÿÿÿÿ ÿ Coping,
family, compromised 330 Situation in which usually supportive primary person
provides insufficient, ineffective, or compromised support, comfort,
assistance, or encouragement that may be needed by client to manage or master
adaptive tasks r/t health challenge OBJECTIVE: Significant person attempts
assistive or supportive behaviors with less than satisfactroy results;
significant person displays protective behavior disproportionate to client's
abilities or need for autonomy; significant person withdraws or enters into
limited or temporary personal communication w/client at time of need.
SUBJECTIVE: Client expresses or confirms a concern or complaint about
significant other's response to his or her health problems; significant person
describes or confirms an inadequate understanding or knowledge base, which
interferes w/effective assistance or supportive behaviors; significant person
describes preoccupatoin w/personal reaction to client's illness, disability,
or other situational developmental crisis. Temporary preoccupation of a
significant person who tries to manage emotional conflicts and personal
suffering and is unable to perceive or act effectively w/regard to client's
needs; temporary family disorganization and role changes; prolonged disease or
disability progression that exhausts supportive capacity of significant
person; other situational or developmental crises or problems significant
Page 34
person may be facing; inadequate or incorrect information or understanding by

primary person; lack of support given by client to significant person Anxiety
Self-Control; Caregiver Emotional Health; Caregiver-Patient Relationship;
Caregiver Well-being; Family Coping; Hope; Knowledge: Health behavior, Health
Resources; Participation in Health Care Decisions; Social Support (1)
Verbalize internal resources to help deal w/the situation. (2) Verbalize
knowledge and understanding of illness, disability, or disease. (3) Provide
support and assistance as needed. (4) Identify need for and seek outside
support. Anticipatory Guidance; Caregiver Support; Coping Enhancement;
Emotional Support; Family Integrity Promotion; Family Involvement Promotion;
Family Mobilization; Family Support; Hope Instillation; Mutual Goal Setting;
Normalization Promotion; Support System Enhancement (1) Assess the strengths
and deficiencies of the family system. (2) Consider the use of family theory
as a framework to help guide interventions (e.g., family stres theory, social
exchange theory). (3) Assess the adolescent's perception of support from
family and friends during crisis. (4) Observe the cause of family problems.
(5) Assist the signifcant person in expanding the repertoire of coping skills.
(6) Help family members recognize the need for help and teach them how to ask
for it. (7) Assess how family members interact with each other; observe verbal
and nonverbal communication and individual and group responses to stress. (8)
Help family members identify strengths and make a list that each member can
refer to for positive reinforcement. (9) Encourage family members to verbalize
feelings. (10) Mothers may require additional support in their role of caring
for chronically ill children. (11) Involve the client and family in planning
of care as much as possible. (12) Provide .....
(1) Assess the physical, emotional, and spiritual needs of the significant
person and meet needs while visiting (e.g., ensure that a person with diabetes
eats meals). (2) Assist in finding transportation to enable family members to
visit. (1) Acknowledge racial/ethnic differences at the onset of care. (2)
Approach families of color with respect, warmth, and professional courtesy.
(3) Assess for the influence of cultural beliefs, norms, and values on the
family's perceptions of coping. (3) Give a rationale when assessing families
with regard to sensitive areas. (4) Use a family-centered approach when
working with Latino, Asian, African American, and Native American clients. (5)
Facilitate modeling and role playing for family regarding healthy ways to
communicate and interact. (6) Validate the family's feelings regarding the
impact of the client's illness on the family's lifestyle. (7) Work to provide
caregivers who understand the importance of cultural beliefs and values the
family may hold. (1) The interventions described previously may be adapted
for home care use. (2) Assess the reason behind the breakdown of family
coping. (3) During the time of compromised coping, increase visits to ensure
the safety of client, support of the family, and assistance with coping
strategies. (4) Assess the needs of the caregiver in the home. Intervene to
meet needs as appropriate to total case management and explore all available
resources that may be used to provide adequate home care (e.g., parish nursing
as an effective adjunct, home health aide services to relieve caregiver's
fatigue). Encourage caregivers not to neglect their own physical, mental, and
spiritual health and give more specific info about the client's need and ways
to meet them. (5) Refer the family to medical social services for evaluation
and supportive counseling. (6) Serve as an advocate, mentor, and role model
for caregiving. Write down or contract for the care needed by the client. (7)
When a terminal illness ....
(1) Provide truthful info for the family and significan people regarding the
client's specific illness or condition, including anticipatory guidance for
expected outcomes. (2) Promote individual and family relaxation and
stress-reduction strategies. (3) Involve the client and family in the planning
of care as often as possible, mutual goal setting is often an effective
strategy. ÿÿÿÿ ÿ Coping, family, disabled 336 Behavior of significant
person (family member or other primary person) that disables his or her
capacity and client's capacity to effectively address tasks essential to
Page 35
either person's adaptation to the health challenge Intolerance; agitation;

depression; aggression; hostility; taking on of illness signs of client;
rejection; psychosomaticism; neglectful relationships with other family
members; neglectful care of client with regard to basic human needs and/or
illness treatment; distortion of reality regarding client's health problem,
including extreme denial about its existence or severity; impaired
restructuring of meaningful life for self; impaired individualization;
prolonged overconcern for client; desertion; decisions and actions that are
detrimental to economic or social well-being; continuation of usual routines,
disregard of client's needs; abandonment; client's development of helpless,
inactive dependence; disregard of needs Chronically unexpressed feelings of
guilt, anxiety, hostility, despair, etc., in significant person; arbitirary
handling of family's resistance to treatment, which tends to solidify
defensiveness by dealing inadequately with underlying anxiety; dissonant or
discrepant coping styles for dealing with adaptive tasks by significant person
and client or among significant people; highly ambivalent family relationships
Abuse Protection; Abusive Behavior Self-Restraint; Anxiety Self-Control;
Caregiver Emotional Health; Caregiver-Patient Relationship; Caregiver
Performance: Direct Care, Indirect Care; Caregiver Stressors; Caregiver
Well-Being; Family Coping; Hope; Knowledge: Health Behaviors, Health
Resources; Participation in Health Care Decisions; Social Support (1) Express
realistic understanding and expectations of the client. (2) participate
positively in the client's care within the limits of his or her abilities. (3)
Identify responses that are harmful. (4) Acknowledge and accept the need for
assistance with circumstances. (5) Express feelings openly, honestly, and
appropriately. Abuse Protection Support; Anticipatory Guidance; Anxiety
Reduction; Caregiver Support; Coping Enhancement; Counseling; Crisis
Intervention; Emotional support; Family Integrity Promotion; Family
Involvement Promotion; Family Mobilization; Family Support; Family Therapy;
Guilt Work Facilitation; Mutual Goal Setting; Normalization Promotion; Support
System Enhancement (1) Observe for causitive and contributing factors. (2)
Review the client' background. (3) identify patterns of family behaviors and
interactions before the illness occurred. (4) consider the use of family
theory as a framework to help guide intervention (.e.g, family stress theory,
social exchange theory). (5) Identify current behaviors of family members,
such as withdrawal, anger and hostility toward the client and others, or
expression of guilt. (6) Note other stressors in the family. (7) Encourage
family members to verbalize feelings by discussing way to solve problems
associated with the client's condition. (8) Assess the adolescent's perception
of support from family and friends during crisis. (9) Serve as a role m odel
for interpersonal skills that will help the family members improve thier
verbal interaction. (10) Provide consistent structure for family interactions.
(11) Help the family identify its personal strengths. (12) Encourage family
members to participate in ..........
(1) Refer the family to appropriate senior community resources (e.g., senior
centers, Medicare assistance, meal programs, parish nursing services,
charitable organizations). (2) If actual or potential abuse or neglect is an
issue, report it to the appropriate agency. (3) Encourage the family member to
participate in appropriate support groups (e.g., COPD support groups,
Arthritis I Can Cope groups, Alzheimer's support groups). (4) Work with the
family to manage common challenges related to normal aging. (1) Work to
provide caregivers who understand the importance of cultural beliefs and
values the family may hold. (2) Acknowledge racial/ethnic differences at the
onset of care. (3) Approach families of color with respcet, warmth, and
professional courtesy. (4) Assess for the influence of cultural beliefs,
norms, and values on the family's perceptions of coping. (5) Give a rationale
when assessing families with regard to sensitive issure. (6) Use a
family-centered approach when working with Latino, Asian, African American and
Native American clients. (7) Facilitate modeling and role playing for the
family regarding healthy ways to communicate and interact. (8) Validate the
Page 36
feelings of family members or significant caregivers regarding the impact of

the client's illness on family lifestyle. NOTE: This diagnosis prsents the
complex and difficult problem of securing an appropriate response by the
family to a client's illness and caregiving needs. The same problem in the
home setting creates an unusually high risk for abuse of the client. The nurse
is cautioned that the margin of time for planning and effectively supporting
the family unit to avoid abuse may be minimal or even negligible. Suspected or
actual abuse should be reported to adult protective services. (1) The
interventions described previously may be adapted for home care use. (2) If
the client has been in an institution, establish empathetic contact with the
client and family before discharge (3) Assess the family members' ability and
willingness to assist in client care. Determine if the family member is an
appropriate source of support for the client. (4) Assess the family member's
understanding of the client's illness and behavior. Instruct in appropriate
expectations of the client and correct any ...........
(1) Encourage family members to ask for a break in caregiving and to spend
time away from the client. (2) Provide truthful information regarding the
client's illness to the family; use anticipatory guidance to prepare for
expected outcomes. (3) Involve the client and family in the planning of care
as often as possible, mutual goal setting is often an effective strategy. (4)
Discuss with the family appropraite ways to demonstrate feelings. (5) Help the
family identify the health care needs of the client and family; teach the
skills necessary to address health care needs. (6) Promote individual and
family relaxation and stress-reduction strategies. ÿÿÿÿ ÿ Coping, family,
readiness for enhanced 343 Effective management of adaptive tasks by family
member involved with client' health challenge, who now exhibits desire and
readiness for enhanced health and growth with regard to self and in relation
to client Individual expresses interest in making contact on a one-to-one
basis or through mutual aid group with another person who has experienced a
similar situation; attempts to describe growth impact of the crisis on his or
her own values, priorities, goals, or relationships; moves in the direction of
health promotion and health-enriching lifestyle that supports and monitors
maturational processes; audits and negotiates treatment programs and generally
chooses experiences that optimize wellness. Needs sufficiently gratified and
adaptive tasks effectively addressed to enable goals of self-actualization to
surface. Anxiety Self-Control; Caregiver Emotional Health; Caregiver-Patient
Relationship; Caregiver Well-Being; Family Coping; Hope; Knowledge: Health
Behavior, Health Resources; Participation in Health Care Decisions; Social
Support (1) State a plan for growth. (2) Perform tasks needed for change.
(3)State positive effects of changes made. Anticipatory Guidance; Caregiver
Support; Coping Enhancement; Emotional Support; Family Integrity Promotion;
Family Involvement Promotion; Family Mobilization; Family Support; Hope
Instillation; Mutual Goal Setting; Normalization Promotion; Support System
Enhancement (1) Observe the traits the family possesses that will help
initiate change, such as having a positive attitude or stating that change is
possible. (2) Consider the use of family theory as a framework to help guide
interventions. (3) Allow family members time to verbalize their concerns;
provide one-to-one interaction with the family. (4) Provide truthful
information and constructive advice about the client's illness and treatment.
(5) Evaluate the family's perceived strength of its social support system.
Encourage the family to use social support to increase its resiliency and to
moderate stress. (6) When a client is having surgery, give the family a 5- to
10-minute progress report about halfway through the surgical procedure. (7)
Allow the family to be present during invasive procedures and resuscitation
efforts. (8) Have family members share the responsibility for change and
encourage all to have input. (9) Explore with the family members way to attain
their goals (e.g., adult ......
(1) Encourage family members to reminisce with the older family member. (2)
Start and maintain a log of anecdotal stories about the older family member.
(3) Encourage children in the family to spend time with and share activities
Page 37
with the older family member. (4) Refer the family to parenting classes and
classes for coping with the needs of older parents. (1) Acknowledge
racial/ethnic differences at the onset of care. (2) Approach famillies of
color with respect, warmth, and professional courtesy. (3) Assess for the
influence of cultural beliefs, norms, and values on the family's perceptions
of coping. (4) Use a family-centered approach when working with Latino, Asian,
African American and Native American clients. (5) Facilitate modeling and role
playing for family with regard to healthy ways to communicate and interact.
(6) Validate family members' feelings regarding the impact of the client's
illness on family lifestyle. (1) The nursing interventions described
previously in the care plan for Compromised family Coping should be used in
the home environment with adaptations as necessary.
(1) Teach that it is normal for changes in family relationships to occur.
Work with the family to manage common challenges related to family dynamics.
(2) Promote individual and family relaxation and stress-reduction strategies.
ÿÿÿÿ ÿ Death syndrome; sudden infant, risk for 346 Presence of risk
factors for sudden death of an infant under 1 year of age MODIFIABLE:
Infants placed to sleep in the prone or side-lying position; Prenatal and/or
postnatal infant smoke exposure; Infant overheating/overwrapping; Soft
underlayment/loose articles in the sleep environment; Delayed or nonattendance
of prenatal care. POTENTIALLY MODIFIABLE: Low birth weight; Prematurity; Young
maternal age. NONMODIFIABLE: Male gender; ethnicity (e.g., African American,
Native American race of mother); seasonality of sudden infant death syndrome
(SIDS) deaths (higher in winter and fall months); SIDS mortality peaks between
infant age of 2 to 4 months Knowledge: Child Physical Safety; Parenting
Performance; Safe Home Environment (1) Explain appropriate measures to
prevent SIDS. (2) Demonstrate correct techniques for positioning the infant,
protecting the infant from harm. Infant Care; Teaching: Infant Safety (1)
Position infant of thier back to sleep, do not position in the prone position.
(2) Avoid use of loose bedding such as blankets and sheets for sleeping. (3)
Avoid overheating the infant by lightly clothing the child for sleep, and
avoiding overbundling. The infant should not feel hot to touch. (4) Provide
the infant a certain amount of time in prone position or "tummy time" while
the infant is awake and observed. (5) use electronic respiratory or cardiac
monitors to detect cardiorespiratory arrest only if ordered.
(1) Discuss cultural norms with families in order to provide care that is
appropriate for promoting safety for the infant in sleeping arrangements and
care. (2) Encourage American Indian mothers to avoid drinking and avoid
wrapping infants in excessive blankets or clothing. (3) Encourage African
American mothers to find alternatives to bed sharing and to avoid placing
pillows, soft toys, and soft bedding in the sleep environment. (1) Most of
the interventions above are relevant. (2) Evaluate home for potential safety
hazards such as inappropriate cribs, cradles, or strollers. (3) Determine
where and how the child sleeps.
(1) Teach families to not place the infant in the prone position and to
instead position the infant on his or her back for sleep. (2) Teach the
parents to place the infant supine to sleep with the head rotated to one side
for a week, and then to the other side for a week. (3) Teach parents that the
supine position (wholly on the back) confers the lowerst risk of SIDS and is
preferred. However, while side sleeping is not as safe as supine, it also has
a significantly lower risk than prone. If the sid eposition is used, bring the
dependent arm forward to lessen the likelihood of the infant orlling to the
prone position. (4) ....... (5) Teach parents the need to obtain a crib that
conforms to the safety standards of the Consumer Product Safety Commision.
Although many cradles and bassinets also may provide safe sleeping enclosure,
safety standards have not been established for these items. (6) Teach parents
that sleeping with an infant may be hazardous under certain conditoins,
......... ÿÿÿÿ ÿ Denial, ineffective 352 The conscious or unconscious
attempt to reduce anxiety or fear by disavowing the knowledge or meaning of an
event, leading to the detriment of health. Delays seeking or refuses health
Page 38
care attention to the detriment of health; does not perceive personal

relevance of symptoms or danger; displaces source of symptoms to other organs;
displays inappropriate affect; does not admit fear of death or invalidism;
makes dismissive gestures or comments when speaking of distressing evets;
minimizes symptoms; unable to admit impact of disease on life pattern; uses
home remedies (self-treatment) to relieve symptoms; displaces fear of impact
of condition. Fear of consequences; chronic or terminal illness; actual or
perceived fear of possible losses; refusal to acknowledge substance abuse
problem; fear of the social stigma associated with disease Acceptance: Health
Status; Anxiety Self-Control; Health Beliefs: Perceived Threat; Symptom
Control (1) Seek out appropriate health care attention when needed. (2) Use
home remedies only when appropriate. (3) Display appropriate affect and
verbalize fears. (4) Remain substance free. (5) Actively engage in treatment
program related to identified "substance" of abuse. (6) Demonstrate alternate
adaptive coping mechanism Anxiety Reduction (1) Assess the client'
understanding of symptoms and illness. (2) Spend time with the client, allow
time for responses. (3) Assess whether the use of denial is helping or
hindering the patient's care. (4) Allow the client to express and use denial
as a coping mechanism. (5) Assess for subtle signs of denial (e.g.,
unrealistic display of optimism, downplaying of symptoms, inability to admit
one's own fear). (6) Avoid controntation. (7) Support the client's spiritual
coping measures. (8) Develop a trusting, therapeutic relationship with the
client/family. (9) Encourage individual family members to share their concerns
and worries. (10) ..... (11) Sit at eye level. (12) Use touch if appropriate
and with permission. Touch the client's hand or arm. (13) Explain signs and
symptoms of illess; as necessary, reinforce use of prescribed treatment plan.
(14) Have the client make choices regarding treatment and actively involve him
or her in the decision-making process. (15) Help the client.......
(1) Identify recent losses of the client, because grieving may prolong denial.
Encourage the client to take one day at a time. (2) Encourage the client to
verbalize feeling. (3) Encourage communication among family members. (4)
Recognize denial. (5) Use reality-focusing techniques. Whenever possible,
provide realistic feedback, allowig the client to validate his or her
perceptions. (1) Assess for the influence of cultural beliefs, norms, and
vlaues on the client's understanding of and ability to acknowledge health
status. (2) Discuss with the client those apsects or his or her health
behavior/lifestyle that will remain unchanged by health status. (3) Neogtiate
with the client regarding the aspects of health behavior that will need to be
modified as a result of health status. (4) Assess the role of fatalism on the
client's ability to acknowledge health status. (5) Validate the client's
feelings of anxiety and fear related to health status. (1) Observe family
interaction and roles. Assess whether denial is being used to meet the needs
of another family member. (2) Refer the client and family to psychiatric
clinical nurse specialist or medical social services for evaluation and
treatment as indicated per physician order. (3) Refer the client/family for
follow-up if prolonged denial is a risk. (4) Identify an emergency plan,
including how to contact hotlines and receive emergency services. (5)
Encourage communication between family members, particularly when dealing with
the loss of a significant person.
(1) Teach signs and symptoms of illness and approrpiate responses (e.g.,
taking meds, going to the emergency department, calling the physician).
Provide al ist of names and numbers. (2) Teach family members that denial may
continue throughout the adjustment to home and not to be confrontational. (3)
If the problem is substance aubse, refer to an appropriate community agency
(e.g., Alcoholics Anonymous). (4) Teach families of clients with brain
injuries that denial has been associated with damage to the right hemisphere.
(5) Inform family of available community support resources. ÿÿÿÿ ÿ
Dentition, impaired 357 Disruption in tooth development/eruption patterns or
structural integrity of individual teeth Excessive plaque; crown or root
caries; halitosis; tooth enamel discoloration; toothache; loose teeth;
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excessive calculus; incomplete eruption for age (may be primary or permanent

teeth); malocclusion or tooth misalignment; premature loss of primary teeth;
worn down or abraded teeth; tooth fracture(s); missing teeth or complete
absence; erosion of enamel; asymmetrical facial expression Ineffective oral
hygiene; sensitivty to heat or cold; barriers to self-care; nutritional
deficits; dietary habits; genetic predisposition; selected prescription
medications; premature loss of primary teeth; excessive intake of fluorides;
chronic vomiting; chronic use of tobacco, coffee, tea, red wine; lack of
knowledge ragarding dental health; excessive use of abrasive cleaning agents;
bruxism Oral Hygiene; Self-Care: Oral Hygiene (1) have clean teeth, gums
healthy pink color, mouth with pleasant odor. (2) Demonstrate ability to
masticate foods without difficulty. (3) State no pain originating from teeth.
(4) Demonstrate measures can take to improve dental hygiene. Oral Health
Maintenance; Oral Health Promotion: Oral Health Restoration (1) Inspect oral
cavity/teeth at least once daily and note any discoloration, presence of
debris, amount of plaque buildup, presence of lesions, edema, or bleeding,
inteactness of teeth. Refer to a dentist or periodontist as appropriate. (2)
Monitor the client's nutritional and fluid status to determine if adequate.
(3) Assess the client for underlying medical condition that may be causing
halitosis. (4) Determine the client's mental status and manual dexterity; if
the client is unable to care for self, dental hgiene must be provided by
nursing personnel. The nursing diagnosis Bathing/hygiene Self-care deficit is
then also applicable. (5) Determine the client's usual method of oral care.
Whenever possible, build on the client's existing knowledge base and current
practices to develop an individualized plan of care. (6) If the client is free
of bleeding disorders and is able to swallow, encourage the client to brush
teeth with a soft toothbrush using fluoride-containing toothpaste ..... (1)
Expectant mothers should eat a healthy, balanced diet that is rich in calcium.
A set o teeth is in place when the baby is born. The teeth usually start to
form in the gums during the second trimester of pregnancy. To encourage the
development of good, strong teeth, expectant omothers should eat a healthy,
balanced diet that is rich in calcium. (2) Gently wipe a baby's gums with a
washcloth or sterile gauze at least one a day. (3) never allow child to fall
asleep with a bottle containing milk, formula, fruit juice, or sweetened
liquids. If a child needs a comforter between regular feedings, at night, or
during naps, fill a bottle with cool water or give the child a clean pacifier
recommended by your dentist or physician. Never give child a pacifier dipped
in any sweet liquid. Avoid filling child's bottle with liquids such as sugar
water and soft drinks. (4) When multiple teeth appear, brush with small
toothbrush with small (pea-sized) amount of fluoride toothpaste. Recommend
.......
(1) Consider recommending use of an ultrasonic toothbrush if any impairment of
manual dexterity exists. (2) Carefully observe oral cavity and lips for
abnormal lesions when providing dental care. (3) Consider professional oral
health care for the elderly in nursing homes. (4) Ensure that dentures are
removed and cleaned regularly, preferable after every meal and before bedtime;
select appropriate adhesives to improve breath. Dentures left in the mouth at
night impede circuation to the palate and predispose the client to oral
lesions. (5) Recognize that halitosis in older adults is a common condition
that may have oral or nonoral sources. (1) Assess for the influence of
cultural beliefs, norms, and values on the client's understanding of dental
care. (2) Assess for access to dental care insurance. (3) Instruct mothers on
the dangers of feeding infants bottles filled with soda, juice, or milk when
the infant goes to sleep. (4) Assess for dental anxiety. (5) Validate the
client's feelings with regard to dental health and access to dental care. (1)
Assess client patterns for daily and professional dental care and related
patterns. Assess for environmental influences on dental status. (2) Assess
client facilities and financial resources for providing dental care. (3)
Request dietary log from the client, adding column for type of food (ie. soft,
pureed, regular). (4) Observe typical meal to assess first-hand the impact of
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impaired dentition on nutritioin. (5) Identify mechanical needs for food

preparation and ease of ingestion/digestion to meet the client'
dental/nutritional needs. (6) Assist the client in accessing financial or
other resources to support optimum dental and nutritional status.
(1) Teach how to inspect the oral cavity and monitor for problems with teeth
and gums. (2) Teach how to implement a personal plan of dental hygiene,
including appropriate brushing of teeth and tongue and use of dental floss.
(3) Teach the client the value of having an optimal fluoride concentration in
drinking water, and to brush teeth twice daily with fluoride toothpaste. (4)
Teach clients of all ages the nedd to decrease intake of sugary foods and to
brush teeth regularlr. (5) Suggest chewing gum with sugar to reduce oral
malodor. (6) Inform individuals who are considering tongue piercing of the
potential complications such as chipping and cracking of teeth and possible
trauma to the gingiva. If piecrcing is done, teach the client how to care for
the wound, and prevent complications. ÿÿÿÿ ÿ Development, delayed, risk for
363 At risk for delay of 25% or more in one or more of the areas of social or
self-regulatory behavior or cognitive, language, gross, or fine motor skills.
PRENATAL: Maternal age younger than 15 or older than 35 years; substance
abuse; infections; genetic or endocrine disorders; unplanned or unwanted
pregnancy; lack of, late, or poor prenatal care; inadequate nutrition;
illiteracy; poverty; depression or other mental disorders; lack of knowledge;
domestic abuse. INDIVIDUAL: Prematurity; seizures;congenital or genetic
disorders; positive drug screening test; brain damage (e.g., hemorrhage in
postnatal period, shaken baby, abuse, accident); vision impairment; hearing
impairment or frequent otitis media; chronic illness; technology dependence;
failure to thrive; inadequate nutrition; foster or adopted child; lead
poisoning; chemotherapy; radiation therapy; natural disaster; behavior
disorders; substance abuse. ENVIRONMENTAL: Poverty; violence. CAREGIVER:
Abuse; mental illness; mental retardation or severe learning disability Child
Development: 2 Months, 4 Months, 6 Months, 12 Months, 2 Years, 3 Years, 4
years, Middle childhood, Adolescence; Mobility; Neurological Status; Physical
Maturation: Female, Male; Self- Care: ADA, Bathing, Dressing, Eating, Hygiene,
IADL, Toileting (1) Describe realistic, age-apprpriate patterns of
development. (2) Promote activities and interactions that support age-related
developmental tasks Active Listening; Developmental Enhancement: Child;
Emotional Support; Kangaroo Care; Self-Care Assistance; Self-Responsibility
Facilitation (1) Refer to the care p lan for Delayed Growth and development.
NOTE: Determination of the etiology for delayed development is critical
because it will direct the selection of interventions for treating the
diagnosis. Parenting skill deficits, lack of consistency between caregivers,
and hospitalization versus a chronic medical condition/developmental
disability will necessitate different strategies. A hospitalization experience
with regressive behaviors can be a transient occurrence as opposed to a
chronic situation, which may have more severe and longer delays requiring
more in-depth intervention. Parenting skills and ocnsistent expectation
between multiple caregivers can be addressed by more intensive education
efforts.
perceptions of child development. (3) Use a neutral, indirect style when
addressing areas in which improvemen is needed (such as a need for verbal
stimulation) when working with clients. (4) Assess whether exposure to
community violence is contributing to developmental problems. (5) Validate the
client's feelings and concerns related to child's development. (1) Assess for
the presence of substances that could cause developmental delay. (2) Assist
family to identify appropriate skill-building activities for child. (3)
Provide emotional support for family members' reactions to evidence of
developmental delay. (4) If possible, refer family to a program of
animal-assisted therapy.
(1) Encourage mothers to abstain from alcohol and cocaine use during
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pregnancy; refer to treatment programs for substance abuse. (2) Provide

support groups and education on the human immunodeficiency virus (HIV) and
caring for infants with this diagnosis. (3) Provide developmental care
interventions to preterm infants to improve neurodevelopmental outcomes. (4)
provide neonatal positioning procedures for preterm infants to prevent
extremity malalignment, skull deforities, and gross motor delay. (5) Encourage
adequate antepartum and postpartum care for both mother and child. (6) Counsel
parents, siblings, and caregivers about the importance of smoking cessation
and the necessity of eliminating all second hand smoke exposure. (7) Teach
caregivers of children appropriate developmental interactions; use
anticipatory guidance to facilitate preparation for developmental milestones.
ÿÿÿÿ ÿ Diarrhea 367 Passage of loose, unformed stools hyperactive bowel
sounds; at least three loose liquid stools per day; abdominal pain; cramping
PSYCHOLOGICAL: High stress levels and anxiety. SITUATIONAL: Alcohol abuse;
toxins; laxative abuse; radiation; tube feedings; adverse effects of
medications; contaminants; travel. PHYSIOLOGICAL: Inflammation; malabsorption;
infectious processes; irritation; parasites Bowel Elimination; Electrolytes
and Acid-Base Balance; Fluid Balance; Hydration; Treatment Behavior: Illness
or Injury (1) Defecate formed, soft stool every day to every third day. (2)
Maintain a rectal area free of irritation. (3) State relief from cramping and
less or no diarrhea. (4) Explain cause of diarrhea and rationale for
treatment. (5) Maintain good skin turgor and weight at usual level. (6)
Contain stool appropriately (if previously incontinent). Diarrhea Management
(1)Assess pattern of defecation or have the client keep a diary that includes
the following: time of day defecation occurs; usual stimulus for defecation;
consistency, amount, and frequency of stool; type of, amount of, and time food
consumed; fluid intake; history of bowel habits and laxative use; diet;
exercise patterns; obstetrical/gynecological, medical, and surgical histories;
medications; alterations in perianal sensations; and present bowel regimen.
(2) Identify cause of diarrhea if possible (e.g., viral, rotavirus, HIV);
food; medication effect; radiation therapy; protein malnutrition; laxative
abuse; stress). See Related Factors (r/t). (3) If the client has watery
diarrhea, a low-grade fever, abdominal cramps, and a history of antibiotic
therapy, consider possibility ofClostridium difficileinfection. (4) If the
client has diarrhea associated with antibiotic therapy, consult with primary
care practitioner regarding the use of probiotics such as yogurt with active
cultures......
(1) Evaluate medications the client is taking. Recognize that many medications
can result in diarrhea, including digitalis, propranolol,
angiotensin-converting enzyme (ACE) inhibitors, histamine-receptor
antagonists, NSAIDs, anticholinergic agents, oral hypoglycemia agents,
antibiotics, and others. (2) Monitor the client closely to detect whether an
impaction is causing diarrhea; remove impaction as ordered. (3) Seek medical
attention if diarrhea is severe or persists for more than 24 hours, or if the
client has symptoms of dehydration or electrolyte disturbances such as
lassitude, weakness, or prostration. (4) Provide emotional support for clients
who are having trouble controlling unpredictable episodes of diarrhea. (1)
Above interventions may be adapted for home care use. (2) Assess the home for
general sanitation and methods of food preparation. Reinforce principles of
sanitation for food handling. (3) Assess for methods of handling soiled
laundry if the client is bed bound or has been incontinent. Instruct or
reinforce Universal Precautions with family and bloodborne pathogen
precautions with agency caregivers. (4) When assessing medication history,
include over-the-counter drugs, both general and those currently being used to
treat the diarrhea. Instruct clients not to mix over-thecounter medications
when self-treating. (5) Evaluate current medications for indication that
specific interventions are warranted. (6) Consult with physician regarding
need for blood work or stool specimens. (7) Evaluate need for home health aide
or homemaker service referral. (8) Evaluate need for durable medical equipment
in the home.
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(1) Encourage avoidance of coffee, spices, milk products, and foods that
irritate or stimulate the gastrointestinal tract. (2) Teach appropriate method
of taking ordered antidiarrheal medications; explain side effects. (3) Explain
how to prevent the spread of infectious diarrhea (e.g., careful hand washing,
appropriate handling and storage of food). (4) Help the client to determine
stressors and set up an appropriate stress reduction plan. (5) Teach signs and
symptoms of dehydration and electrolyte imbalance. (6) Teach perirectal skin
care. ÿÿÿÿ ÿ Disuse syndrome, risk for 373 At risk for a deterioration of
body systems as the result of prescribed or unavoidable musculoskeletal
inactivity Paralysis; altered level of consciouness; mechanical
immobilization; prescribed immobilization; severe pain (NOTE: compications
from immobility can include pressure ulcer, constipation, stasis of pulmonary
secretions, thromosis, urinary tract infection and/or retention, decreased
strength or endurance, orthostatic hypotension, decreased range of joint
motion, disorientation, disturbed body image, and powerlessness.) Endurance;
Immobility Consequences: Physiological; Mobility; Neurological Status:
Consciousness; Pain Level (1) Maintain full range of motion in joints. (2)
Maintain intact skin, good peripheral blood flow, and normal pulmonary
function. (3) Maintain normal bowel and bladder function. (4) Express feelings
about imposed immobility. (5) Explain methods to prevent complications of
immobility. Energy Management; Exercise Therapy: Joint Mobility, Muscle
control (1) Use a functional assessment instrument to evaluate abilities
including instruments such as the Barthel Index, the Katz Indext of ADLs, or
the FIM instrument. (2) Have the client do exercises in bed if not
contraindicated (e.g., flexing and extending feet and quadriceps, performing
gluteal and abdominal sitting exercises, lifting small weights to maintain
muscle strength). (3) If not contraindicated by the client's condition, obtain
referral to physical therapy for use of tilt table to provide weight bearing
on long bones. (4) Perform ROM exercises for all possible joints at least
twice daily; perform passive or active ROM exercises as appropriate. (5) Use
high-top sneakers or specialized boots from the occupational therapy
department to prevent footdrop; remove shoes twice daily to provide foot care.
(6) Position the client so that joints are in normal anatomical alignment at
all times. (7) Get the client up in a chair as soon as appropriate; use a
stretcher-chair if necessary...
(1) Recognize the importance of keeping elderly clients active if possible.
(2) If geriatric, the client is scheduled for an elective surgery that will
result in admission into ICU and immobility, or recovery from a knee
replacement, initiate a prehabilitation program that includes a warm-up,
aerobic strength, flexibility, and functional task work. (3) Refer to physical
therapy for an individualized strength training program. Monitor for signs of
depression; flat affect, poor appetite, insomnie, many somatic complaints. (4)
Keep careful track of bowel function in the elderly; do not allow the client
to become constipated. NOTE: Care for all body systems because the
immobilized or otherwise at risk client must continue in the home as stated in
the previously mentioned interventions. The primary nurse monitors and adjucts
the plan of care accordingly per physcian orders. (1) Some of the above
interventions may be adapted for home care use. (2) Begin discharge planning
as soon as possible with care manager or social worker to assess need for home
support systems and community or home health services. (2) Become oriented to
all programs of care for the client before discharge from institutional care.
(3) Confirm the immediate availability of all necessary assistive devices for
the home. (4) Continuity in management of care promotes success in meeting
client-centered goals. (5) Perform complete physical assessment and recent
history at initial visit. (6) Refer to physical and occupational therapies for
immediate evaluations of the client's potential for independence and
functioning in the home setting ......
(1) Teach how to perform ROM exercises in bed if not contraindicated. (2)
Teach the family how to turn and position the client and provide all care
necessary. NOTE: Nursing diagnoses that are commonly relevant when the client
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is on bed rest include: Constipation, Risk for impaired Skin integrity,

Distrubed Sensory perception, Disturbed Sleep pattern, Adult Failure to
thrive, and Powerlessness. ÿÿÿÿ ÿ Diversional activity, deficient 378
Decreased stimulation from or interest or engagement in recreational or
leisure activities Usual hobbies cannot be undertaken in hospital; patient's
statements regarding boredom and the wish for something to do, to read, etc.
Environmental lack or diversional activity as a result of long-term
hospitalization or frequent or lengthy treatments Leisure Participation; Play
Participation; Social Involvement (1) Engage in personally satisfying
diversional activities Recreation Therapy; Self-Responsibility Facilitation
(1) Observe for symptoms of deficient diversional activity: yawning,
restlessness, flat facial expression, and statements of boredom. (2) Observe
ability to engage in activities that require good vision and use of hands. (3)
Discuss activities with clients that are interesting and feasible in the
present environment. (4) Encourage a mix of physical and mental activities
(e.g., crafts, videotapes). Provide activites that are entertaining, such as
videotapes, joke books, or a "humor room". (5) Use "bread therapy"--have
clients bake bread with a bread maker two times per day or prn. (6) Arrange
animal-assisted therapy, with a dog or cat for the client to interact with and
care for. (7) Encourage the client to schedule visitors so that they are not
all present at once or at inconvenient times. (8) Provide reading material,
TV, radio, and books on tape. Provide virtual reality experiences for
children, which can be used as distraction techniques during chemotherapy
treatments. Recommend...
(1) If the client is able, arrange for him or her to attend group senior
citizen exercise session for progressive training, even if exercise can only
be done while seated. (2) Encourage involvement in senior citizen activities
(e.g., AARP, YMCA, church groups, Gray Panthers). Arrange transportation to
activities as needed. (3) Encourage clients to use their ability to help
others by volunteering. (4) Provide an environment that promotes activity;
allow periods of solitude and privacy. (5) Use reminiscence therapy either
individually or in groups. (6) Use the Eden Alternaitve with the elderly,
bring in appropriate plants for the elderly client to care for, animals such
as birds, fish, dogs, and cats as appropriate for the client, and children to
visit. (1) Assess for the influence of cultural beliefs, norms, and values on
the client's leisure activity interests. (2) Validate the client's feelings
and concerns related to lack of stimulation or interest in leisure activities.
NOTE: Many of the previosly listed interventions should be administered in the
home setting (e.g., modifying the environment to stimulate the client,
scheduling visitors to allow for rest and activity). Some adaptations may be
necessary. (1) Explore with the client previous interests; consider related
activities that are within the client's capabilities. (2) Assess the client
for depression. Refer for mental health services as indicated. (3) Refer to
occupational therapy to assist the client and family with identifying
diversional activities within the capability of the client and family. (4)
Assess the family's ability to respond to the client's psychosocial needs for
stimulation. (5) Introduce (or continue) friendly volunteer visitors if the
client is willing and able to have the company. If transportation is an issue
or if the client does not want visitors in the home, consider alternatives
(e.g., telephone contacts, computer messaging). (6) In the presence of a
psychiatric ......
(1) Work with the client and family on learning diversional activites that the
client is interested in (e.g., knitting, hooking rugs, writing memoirs). (2)
If the client is in isolation, give the client complete info on why isolation
is needed and how it should be accomplished, especially guidelines for
visitors. ÿÿÿÿ ÿ Energy field, disturbed 383 A disruption of the flow of
energy surrounding a person's being, which results in a disharmony of mind and
spirit Temperature change (warmth/coolness); visual changes (image/color);
disruption of the field (vacant/hold/spike/bulge), movement
(wave/tingling/dense/flowing), sounds (tone/words) Comfort Level; Spiritual
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Health (1) State sense of well-being. (2) State feeling of relaxation. (3)
State decreased pain. (4) State decreased tension. (5) Demonstrate evidence of
physical relaxation (e.g., decreased BP, pulse, respiration rate, muscle
tension) Therapeutic Touch (1) Refer to care plans for Anxiety, Acute Pain,
and Chronic Pain. (2) Administer therapeutic touch (TT) as described in the
following discussion (may also include healing touch and Reki practice). (3)
Guidelines for Therapeutic Touch..........(4) Administer TT by performing the
following steps..............
client's sense of disharmony of mind and spirit. (2) Assess for the presence
of specific culture-bound syndromes that may manifest as disturbances in
energy or spirit. (3) Validate the client's feelings and concerns related to
sense of disharmony or energy disturbance. (1) See guidelines for Therapeutic
Touch. (2) Help the client and family accept TT as a healing intervention.
Consultation and collaboration with a specialist may be the best approach to
nursing care. Numberous studies have reported outcomes of Healing Touch as a
noninvasive complementary therapy. (3) Assist the family with providing an
appropriate space in which TT can be administered. (4) Assess clients with
bipolar disorder for the occurence of social rhythm disruption, particulary
during periods of stressful life events. Refer for mental health treatment.
(5) In the presence of a psychiatric disorder, refer for psychiatric home
health care services for client reassurance and implementation of therapeutic
regimen.
(1) Teach the TT process to family members, TT enables caregivers to embrace
their compassion and to touch people with effect. (2) Teach that when working
with the very young, old, or ill, or on the head area, TT should be gently and
used only for short periods. Exercise caution when using TT with patients who
may exhibit an extreme sensitivity to the process (e.g., premature infants,
frail elderly, psychotic clients). (3) Teach the client how to use guided
imagery. The nurse can facilitate healing by helping the client recontact and
reclaim parts of the self (resolve energy disturbance) through guided imagery.
(4) Teach the client to use deep breathing to relax. Ask the client to have
the disease, affected organ, or symptom assume an image. After the image has
been identified, ask the client to speak with the image to address an
unresolved issue. By describing a previously unacknowledged part of the self,
liberted energy can transform resistance, defenses, and disease in
............. ÿÿÿÿ ÿ Environmental interpretation syndrome, impaired 387
Consistent lack or orientation to person, place, and time, or circumstances
for more than 3 to 6 months, necessitating a protective environment Chronic
confusional states; consistent dirorientation in known and unknown
environments; loss of occupation or social functioning resulting from memory
decline; slow to respond to questions; inability to follow simple
directions/instructions, concentrate, or reason Depression; dementia (e.g.,
Alzheimer's, multi-infarct, Pick's disease, AIDS, Parkinson's disease,
alcoholism) Cognitive Orientation; Concentration; Information processing;
Memory; Neurological Status: Consciousness (1) Remain content and free from
harm. (2) Function at maximal cognitive level. (3) Independently participate
in ADLs at the maximum of functional ability. Dementia Managemet;
Environmental Management; Reality Orientation; Surveillance: Safety See care
plan for Chronic Confusion
See care plan for Chronic Confusion See care plan for Chronic Confusion See
care plan for Chronic Confusion
See care plan for Chronic Confusion ÿÿÿÿ ÿ Failure to thrive, adult 388
Progressive functional deterioration of a physical and cognitive nature with
remarkably diminished ability to live with multisystem diseases, cope with
ensuing problems, and manage care Anorexia--does not eat meals when offered;
states does not have an appetite, is not hungery, or "I don't want to eat";
inadequate nutritional intake--eating less than body requirements; consumption
of minimal to no food at most meals; weight loss--5% unintentional loss in 1
mo or 10% unintentional loss in 6 mo; physical decline--evidence of fatigue,
Page 45
dehydration, incontinence of bowel and bladder; frequent exacerbations of

chronic health problems AEB problems w/responding appropriately to
environmental stimuli, demonstrated difficulty in reasoning, decision making,
judgment, memory, and concentration; decreased perception; decreased social
skill; social withdrawal--noticeable decrease from usual past behavior in
attempts to form or participate in cooperative & interdependent relationships;
decreased participation in ADLs that the older person once enjoyed; self-care
deficit-no longer looks after or takes charge of physical cleanliness or
appearance; ETC. Depression; apathy; fatigue Physical Aging; Psychosocial
Adjustment: Life Change; Will to Live (1) Resume highest level of functining
possible. (2) Consume adequate dietary intake for weight and height. (3)
Maintain usual weight. (4) Have adequate fluid intake with no signs of
dehydration. (5) Participate in ADLs. (6) Participate in social interactions.
(7) Maintain clean personal and home environment. (8) Express feelings
associated with losses. Hope Instillation; Mood Management; Self-Care
Assistance (1) Elderly clients who have failure to thrive (FTT) should be
evaluated by review of the patient's ADLs, cognitive function, and mood; a
targeted history and physical examination; and selected laboratory studies.
(2) Assess possible causes for adult FTT and treat any underlying problems
such as depression, malnutrition, diarrhea, renal failure, and illnesses that
are caused by physical and cognitive changes. (3) Carefully assess for elder
abuse and refer for treatment. (4) Assess for signs of fatigue and sensory
changes that may indicate an infection is present that may be related to
undetected diabetes mellitus or HIV. (5) Assess for all etiologies including
depression using a geriatric depression scale. Be alert for depression in
clients newly admitted to nursing homes. (6) Note changes in the elderly
client's appetite and assess for depression. (7) Note if the client is
irritable and is blaming others. (8) Screen for depression in persons with
adult macular degeneration (AMD) .....
family's or caregiver's understanding of FTT. (2) Validate the family's
feelings and concerns related to the FTT symptoms. (1) Above interventions
systems, assistive devices, and community or home health services. (3) Assess
and track areas of decreased functioning resulting from failure to thrive.
Ensure that all symptomatology is considered for necessary action. (4) Give
permission for role activity changes. Negotiate and clarify role expectations
and reevaluate as necessary. (5) Provide support for family/caregivers. (6) If
FTT is due to a dementing illness, refer to care plan for Chronic Confusion.
(7) Refer to medical social services or mental health counseling, resource
identification, and/or community support groups. If necessary, contract with
the client to attend sessions. (8) Refer to home health aide services for
assistance with ADLs throughout the duration of decreased participation. (9)
Institute case management of frail elderly to support.....
(1) If adult FTT is related to dementia, help the caregiver to understand the
diagnosis and help to identify needs that the caregiver will have to assist
the client with, such as nutrition, maintenance of adequate fluid intake,
toileting, self-care, and safety. (2) Instruct the family on the use of verbal
cues to encourage eating, such as "Pick up your spoon; use the spoon to scoop
up the pudding; now put the spoon with the pudding in your mouth." (3) Discuss
the possibility with the physician of a drug holiday when the etiology is
delirium. (4) Provide referral for evaluation of hearing and appropriate
hearing aids. (5) Refer for psychotherapy and possible medication if the
etiology is depression. (6) Refer for possible medication therapy when the
diagnosis is dementia. ÿÿÿÿ ÿ Falls, risk for 396 Increased susceptibility
to falling that may cause physical harm ADULTS: History of falls;
wheelchair use; 65 yrs or older; female (if elderly); lives alone; lower limb
prosthesis; use of assistive devices. PHYSIOLOGICAL: Presence of acute
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illness; postoperative conditions; visual difficulties; hearing difficulties;

arthritis; orthostatic hypotension; sleeplessness; fatigue when turning or
extending neck; anemias; vascular disease; neoplasms (see text pg 396).
MEDICATION: Antihypertensive agents; ACE inhibitors; diuretics; tricyclic
antidepressants; alcohol use; antianxiety agents; opiates; hypnotics or
tranquilizers. ENVIRONMENTAL: Restraints; weather conditions; throw/scatter
rugs; cluttered environment; unfamiliar, dimly lit room; no antislip material
in bath and/or shower. CHILDREN (< 2yrs) Male gender when younger than 1 year;
lack of autorestraints; lack of gate on stairs; lack of window guard; bed
located near window; unattended infant on bed/changing table/sofa/lack of
parental supervision Fall Prevention Behavior; Knowledge: Child Physical
Safety (1) Remain free of falls. (2) Change environment to minimize the
incidence of falls. (3) Explain methods to prevent injury. Dementia
Management; Fall Prevention; Surveillance: Safety (1) Determine risk of
falling by using an evaluation tool such as the Fall Risk Assessment (Farmer,
2000), The Conley Scale (Conley et al, 1999), or the FRAINT Tool for fall risk
assessment (2) Screen all clients for stability and mobility skills (supine
to sit, sitting supported and unsupported, sit to stand, standing, walking and
turning around, transferring, stooping to floor and recovering, and sitting
down). Use tools such as the Balance Scale by Tinetti or the Get Up and Go
Scale by Mathais (3) Recognize that when people attend to another task while
walking, such as carrying a cup of water, clothing, or supplies, they are more
likely to fall.(4) Be careful when getting a mostly immobile the client up. Be
sure to lock the bed and wheelchair and have sufficient personnel to protect
the client from falls. (5) Identify clients likely to fall by placing a "Fall
Precautions" sign on the doorway and by keying the Kardex and chart. Use a
"high-risk fall" arm band and room marker to.....
(1) Encourage the client to wear glasses and use walking aids when ambulating.
(2) Help the client obtain and wear a specially designed hip protector when
ambulating. Hip protectors are worn in a specially designed stretchy
undergarment containing a pocket on each side for placement of the protector.
(3) Consider use of a "Merri-walker" adult walker that surrounds body if the
client is mobile but unsafe because of wobbling. (4) If the client experiences
dizziness because of orthostatic hypotension when getting up, teach methods to
decrease dizziness, such as rising slowly, remaining seated several minutes
before standing, flexing feet upward several times while sitting, sitting down
immediately if feeling dizzy, and trying to have someone present when
standing. (5) If the client is experiencing syncope, determine symptoms that
occur before syncope, and note medications that the client is taking. Refer
for medical care. The circumstances surrounding syncope often suggest the
cause...... (1) Some of the above interventions may be adapted for home
care use. (2) If the client was identified as a fall risk in the hospital,
recognize that there is a high incidence of falls after discharge, and use all
measures possible to reduce the incidence of falls. (3) Assess and monitor for
acute changes in cognition and behavior. (4) Assess home environment for
threats to safety: clutter, slippery floors, scatter rugs, unsafe stairs and
stairwells, blocked entries, extension cords (across pathway), high beds,
pets, and pet excrement. Use antiskid acrylic floor wax, nonskid rugs, use of
stair rails, and skid-proof strips near the bed to prevent slippage. Evaluate
need for safety devices in bathing area (e.g., hand grip, shower chair,
hand-held showerhead). (5) Institute a home-based, nurse-delivered exercise
program to reduce falls or refer to physical therapy services for client and
family education of safe transfers and ambulation and for strengthening
exercises (for the client)....
(1) Teach the client how to safely ambulate at home, including using safety
measures such as hand rails in bathroom, and need to avoid carrying things or
performing other tasks while walking (2) Teach the client the importance of
maintaining a regular exercise program such as walking. ÿÿÿÿ ÿ Family
processes: alcoholism, dysfunctional 404 The state in which the
psychosocial, spiritual, and physiological functions of the family unit are
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chronically disorganized, leading to conflict, denial of problems, resistance

to change, ineffective problem solving, and a series of self-perpetuating
crises ROLES AND RELATIONSHIPS: Inconsistent parenting/low perception of
parental support; ineffective spouse communication/marital problems; intimacy
dysfunction; deterioration in family relationships/disturbed family dynamics;
altered role function/disruption of family roles; closed communication
systems; chronic family problems; family denial; lack of cehesiveness;
neglected obligations; lack of skill necessary for relationships; reduced
ability of family members to relate to each other for mutual growth and
maturation; family unable to meet security needs of its members; disrupted
family rituals; economic problems; family does not demonstrate respect for
individuality and autonomy of its members; triangulating family relationships;
pattern of rejection. BEHAVIORAL: Refusal to get help/inability to accept and
receive help appropriately; inadequate understanding or knowledge of
alcoholism; ineffective problem-solving skills; loss of control of drinking;
manipulation; LOTS MORE; SEE BOOK! Abuse of alcohol; genetic predisposition;
lack of problem-solving skills; family history of alcoholism; resistance to
treatment; biochemical influences; addictive personality Family Coping;
Family Functioning; Family Health Status; Substance Addiction Consequences
(1) Develop relatinship with nurse that demonstrates at least minimal level of
trust. (2) Demonstrate an understanding of alcoholism as a famiy illness and
the severity of the threat to emotional and physical health of family members.
(3) Develop and state a belief in feasibility and effectiveness of efforts to
address alcoholism. (4) Demonstrate change from dysfunctional patterns by
moving from inappropriate to appropriate role relationships, improving
cohesion among family members, decreasing conflict and social isolation, and
improving coping behaviors. (5) Maintain improvements. Family Process
Maintenance; Substance Use Treatment (1) Demonstrate high levels of empathy
and expectancy of positive outcomes in interactions with family members. (2)
When completing a family assessment, assess behaviors of alcohol abuse, loss
of control of drinking, denial, nicotine addiction, impaired communication,
inappropriate expression of anger, and enabling behaviors. (2) Screen clients
for at-risk drinking during routine primary care visits. At-risk drinking is
defined as consuming an average of two or more drinks per day (chronic
drinking), or, in the past month, one or more occasion of drining after
consuming three or more drinks (drinking and driving) (3) ..... (4) Educate
family members about alcoholism, being careful not to label or stigmatize
them. (5) Educate family members about available educational and support
programs. (6) Stress individual self-focus as a first step in problem
resolution. (7) Help family to restructure family patterns of interaction and
function to support the development of consistency, a ........
(1) Include assessment of possible alcohol abuse when assessing elderly family
members. (2) Use CAGE tool with the population and include drug use along with
drinking. An affirmative answer to two or more of the following questions is
considered a basis for suspicion of alcohol abuse: C: Have you ever felt you
ought to Cut Down on drinking? A: have people every Annoyed you by criticizing
your drinking? G: Have you ever felt bad or Guilty about your drinking? E:
Have you ever had a drink first thing in the morning to steady your nerves or
get rid of a hangover (Eye Opener)? (1) Acknowledge racial/ethnic differences
at the onset of care. (2) Approach families of color with respect, warmth, and
professional courtesy. (3) Give rationale when assessing black families about
alcohol use and misuse. (4) Use a family-centered approach when working with
Latino, Asian, African American, and Native American clients. (5) When forking
with Asian American clients, provide opportunites for the family to save face.
NOTE: In the community setting, alcoholism as an etiology for dysfunctional
family porcesses must be considered in two categories. The first is when the
client suffers personally from the illness, the second is when a significant
other suffers from the illness, that is, the client is not the active
alcoholic but may be dependent on the alcoholic for caregiving. The listed
considerations apply to both situation with appropriate adaptation for the
Page 48
circumstances. (1) Above interventions may be adapted for home care use. (2)
Identify client/family expectations of the home care nurse and nurse
expectationsof the client/family by the use of a well-defined contract. Be
specific and realistic. Adjust the contract only with clear consent and
understanding from client/family. (3) Establish well-defined contingency and
emergency plans for the care of the client. (4) Requiest concrete, measurable
tasks of the client and family for caregiving and provide concrete,
nonjudgmental instruction to .....
ÿÿÿÿ ÿ Family processes, readiness for enhanced 411 A pattern of family
functioning that is sufficient to support the well-being of family members and
can be strengthened. Expresses willingness to enhance family dynamics; Family
functioning meets physical, social, and psychological needs of family members;
Activities support for the safety and growth of family members; Communication
is adequate; Relationships are generally positive; interdependent with
community; family task are accomplished; Family roles are flexible and
appropriate for developmental stages; Respect for family members is evident;
Family adapts to change; Boundaries of family members are maintained; Energy
level of family supports activities of daily living; Family resilience is
evident; Balance exists between autonomy and cohesiveness Family Coping;
Family Physical environment; Health Orientation; Health Promoting Behavior;
Health Seeking Behavior; Leisure Particpation; Parent-Infant Attachment;
Parenting Performance; Psychosocial Adjustment: Life Change; Risk Control;
Role Performance; Social Support; Spiritual Health (1) Identify ways to cope
effectively and use appropriate support systems (family). (2) Meet physical,
psychosocial, and spiritual needs of members or seeks appropriate assistance
(family). (3) Demonstrate knowledge of potential environmental, lifestyle, and
genetic risks to health and use appropriate measures to decrease possibility
of risk (family). (4) Focus on wellness, disease prevention, and maintenance
(family and individual). (5) Seek balance among exercise, work, leisure, rest,
and nutrition (family and individual). Active Listening; Anticipatory
Guidance; Attachment Promotion; Coping Enhancement; Decision-Making Support;
Environmental management: Attachment Process; Exercise Promotion; Family
Integrity Promotion; Family Involvement Promotion; Family Mobilization; Family
Process Maintenance; Health Screening; Mutual Goal Setting; Parent Education:
Adolescent, Childrearing Family; Risk Identification; Role Enhancement (1)
Assess the family's stress level and coping abilities during the initial
nursing assessment. (2) Use family-centered care, and role modeling for
holistic care of families. (3) Discuss with the family members how they have
handled previous crises. (4) Support family empowerment; strength and
resourcefulness. (5) Provide parenting class series based on individual and
couple changes in meaning/identity, roles, and relationship/interaction during
the transition to parenthood. Address mother/father roles, infant
communication abilities, and patterns of the first 3 months of life in a
mutually enjoyable, possiblity-focues way. (6) Encourage family members to
find meaning in a serious illness like cancer. (7) Have family members
participate in client conferences that involve all members of the health care
team. (8) Provide family-centered care to explore and use all available
resources appropraite for situation (e.g., counseling, social services,
self-help groups, pastoral care).
(1) Carefully listen to residents and family members in the long-term care
facility. (2) Support caregivers' awareness of the positive effects of thier
contribution to the well-being of parents. (3) Teach family members about
impact of developmental events (e.g., retirement, death, change in health
status, and household composition). (4) Encourage social networks, social
integration, and social engagement with friends. (1) Assess for the influence
of cultural beliefs, norms, and values on the family's perceptions of normal
functioning. (2) With the client's consent, facilitate a gorup meeting for
family members to discuss how the family is functioning. (3) Facilitate
modeling and role-playing for the client and family regarding healthy ways to
start a discussion about the client's prognosis. (4) Identify and acknowledge
Page 49
the stresses unique to racial/ethnic families. (5) Offer frequent gestures of

support to family members. (6) Encourage the family members to demonstrate and
offer caring and support to each others. (7) Validate the family's feelings
regarding concerns about family functioning. (8) Provide post partum home care
for immigrant women who have a longer than usual post partum hospital stay, of
more than 36 hours, and whose health and social concerns have not been
documented as resolved. (1) The nursing interventions described previously
for Readiness for enhance Family processes should be used in the home
environment with adaptations as necessary. (2) Provide a videophone network
for peer support for frail elderly people living at home. (3) Encourage
families to assist women caring for husbands with chronic obstructive
pulmonary disease (COPD) to provide respite care so the women may have
recreation time.
(1) Refer to Client/Family Teaching in Readiness for enhanced family Coping
for suggestions that may be used with minor adaptations. ÿÿÿÿ ÿ Family
processes, interrupted 415 Change in family relationship and/or functioning.
Changes in power alliances; assigned tasks; effectiveness in completing
assigned tasks; mutual support; availability for affective responsiveness and
intimacy; patterns and rituals, participation in problem solving;
participation in decision making; communication patterns; availability for
emotional support; satisfaction with family; stress-reduction behaviors;
expressions of conflict with and/or isolation from community resources;
somatic complaints; expressions of conflict within family Power shift of
family members; family roles shift; shift in health status of a family member;
developmental transition and/or crisis; situational transition and/or crisis;
informal or formal interaction with community; modification in family social
status; modification in family finances Family Coping; Family Social Climate;
Family Functioning; Family Normalization; Parenting Performance; Psychosocial
Adjustment: Life Change; Role Performance. (1) Express feelings (family). (2)
Identify ways to cope effectively and use appropriate support systems
(family). (3) Treat impaired family member as normally as possible to avoid
overdependence (family). (4) Meet physical, psychosocial, and spiritual needs
of members or seeks appropriate assistance (family). (4) Demonstrate knowledge
of illness or injury, treatment modalities, and prognosis (family). (5)
Demonstrate knowledge of illness or injury, treatment modalities, and
prognosis (family). (6) Participate in the development of the plan of care to
the best of ability (significant person). Family Integrity Promotion; Family
Process Maintenance; Family Therapy; Normalization Promotion; Role
Enhancement; Support System Enhancement (1) Assess the family's stress level
and coping abilities during the initial nursing assessment. (2) Use
family-centered care role modeling for holistic care of families. (3) Spend
time with family members, allow them to verbalize their feelings. (4)
Acknowledge the range of emotions and feelings that may be experienced when
there is a change in health status in a family member; cousel family members
that it is to be normal to be angry, afraid, etc.(5) Encourage family to visit
the client; adjust visiting hours to accommodate family's schedule. Assist
with sleeping arrangements if family is spending the night; provide a place to
lie down, pillows, and blankets. (6) Allow and encourage family to assist in
the client's care. Allow family presence during invasive procedures and
resustitation. (7) Consider the use of video home traning as a method of early
support in problems of family life control. (8) Provide family-centered care
to explore and use all available resources appropriate ...
(1) Teach family members about the impact of developmental events (e.g.,
retirement, death, change in health status, and household composition). (2)
Encourage family members to be involved in the care of relatives who are in
residential care setting. (3) Support group problem solving among family
members and include the older member. (4) Support group problem solving among
family members and include the older member. (5) Refer family for counseling
with a psycholtherapiest who is knowledgeable about gerontology. (6) Refer to
care plan for Readiness for enhanced family Coping. (1) Assess for the
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influence of cultural beliefs, norms, and values on the family's perception of

normal functioning. (2) With the client's consent, facilitate a group meeting
for family members to discuss how the family is functioning. (3) Facilitate
modeling and role-playing for the client and family regarding healthy ways to
start a discussion about the client's prognosis. (4) Identify and acknowledge
the stresses unique to racial/ethnic families. (5) Offer frequent gestures of
support to family members. (6) Validate the family's feelings regarding
concerns about the current crisis and family functioning. (1) The nursing
interventions described previously for Compromised family Coping should be
used in the home environment with adaptations as necessary. (2) Assist help
from the family when communicating with clients in advanced stages of cancer
who are no longer able to communicate their illness and symptom needs.
(1) Refer to Client/Family Teaching in Compromised family Coping and Readiness
for enhanced family Coping for suggestions that may be used with minor
adaptations. ÿÿÿÿ ÿ Fatigue 420 An overwhelming, sustained sense of
exhaustion and decreased capacity for physical and mental work at usual level
Inability to restore energy even after sleep; lack of energy or inability to
maintain usual level of physical activity; increase in rest requirements;
tired; inability to maintain usual routines; verbalization of an unremitting
and overwhelming lack of energy; lethargic or listless; perceived need for
additional energy to accomplish routine tasks; increase in physical
complaints; compromised concentration; disinterest in surroundings,
introspection; decreased performance; compromised libido; drowsy; feelings of
guilt for not keeping up with responsibilities. PSYCHOLOGICAL: Boring
lifestyle; stress; anxiety; depression. ENVIRONMENTAL: humidity; lights;
noise; temperature. SITUATIONAL: Negative life events; occupation.
PHYSIOLOGICAL: Sleep depreivation; pregnancy; poor physical condition; disease
states (cancer, HIV, multiple sclerosis); increased physical exertion;
malnutrition; anemia Concentration; Endurance; Energy Conservation;
Nutritional Status: Energy. (1) Verbalize increased energy and improved
well-being. (2) Explain energy conservation plant to offset fatigue. Energy
Management (1) Assess severity of fatigue on a scale of 0 to 10; assess
frequency of fatigue, activities associated with increased fatigue, ability to
perform activities of daily living (ADLs), times of increased energy, ability
to concentrate, mood, and usual pattern of activity. Consider use of an
instrument such as the Profile of Mood State Short Form Fatigue Subscale, the
Multidimensional Assessment of Fatigue, the Lee Fatigue Scale, the
Multidimensional Fatigue Inventory, the HIV-Related Fatigue Scale, or the
Dutch Fatigue Scale to accurately assess fatigue. (2) Evaluate adequacy of
nutrition and sleep. Encourage the client to get adequate rest. Refer to
Imbalanced Nutrition: less than body requirements or Disturbed Sleep pattern
if appropriate. NOTE: Sometimes clients with chronic fatigue syndrome can
sleep excessively and need support to limit sleeping. (3) Determine with help
from the primary care practitioner whether there is a physiological or
psychological cause of fatigue that .......
(1) Identify recent losses; monitor for depression as a possible contributing
factor to fatigue. (2) Review medications for side effects. (1) Above
interventions may be adapted for home care use. (2) Assess the client's
history and current patterns of fatigue as they relate to the home
environment; environmental and behavioral triggers of increased fatigue. (3)
Refer to occupational therapy if substantial intervention is needed to assist
the client in adapting to home and daily patterns. (4) Assist the client with
identifying or creating a safe, restful place within the home that can be used
routinely (e.g., a room with familiar, nonthreatening, or nonfrightening
belongings). (5) For clients receiving chemotherapy, intervene to: Relieve
symptom distress (negative mood, nausea, difficulty sleeping; Encourage as
much physical activity as possible; Support a positive attitude for the
future; Support adequate recovery time between treatments. (6) Refer cancer
clients to a community-based pain and fatigue management program, such as the
I Feel Better program, if available. (7) Teach the client/family the
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importance of and ...

(1) Share information about fatigue and how to live with it, including need
for positive self-talk. (2) Teach strategies for energy conservation (e.g.,
sitting instead of standing during showering, storing items at waist level).
(3) Teach the client to carry a pocket calendar, make lists of required
activities, and post reminders around the house. (4) Teach the importance of
following a healthy lifestyle with adequate nutrition and rest, pain relief,
and appropriate exercise to decrease fatigue. (5) Teach stress-reduction
techniques such as controlled breathing, imagery, and use of music. (6) See
Anxiety care plan if appropriate; anxiety is correlated with increased
fatigue. ÿÿÿÿ ÿ Fear 426 Response to perceived threat that is consciously
recognized as a danger Report of apprehension; increased tension; decreased
self-assurance; excitement; being scared; jitterness; dread; alarm; terror;
panic. COGNITIVE: Identifies object of fear; stimulus believed to be a threat;
diminished productivity, learning ability, problem-solving ability. BEHAVIORS:
Increased alertness; avoidance or attack behaviors; impulsiveness; narrowed
focus on "it". PHYSIOLOGICAL: Increased pulse; anorexia; nausea; vomiting;
diarrhea; muscle tightness; fatigue; increased respiratory rate and shortness
of breath; pallor; increased perspiration; increased systolic BP; pupil
dilation; dry mouth. natural/innate origin (e.g., sudden noise, height, pain,
loss of physical support); learned response (e.g., conditioning, modeling from
or identification with others); separation from support system in potentially
stressful situation (e.g., hospitalization, hospital procedures);
unfamiliarity with environmental experience(s); language barrier; sensory
impairment; innate releasers (neurotransmitters) phobia stimulus Fear
Self-Control (1) Verbalize known fears. (2) State accurate information about
the situation. (3) Identify, verbalize, and demonstrate those coping behaviors
that reduce own fear. (4) Report and demonstrate reduced fear. Anxiety
Reduction; Coping Enhancement; Security Enhancement (1) Assess source of fear
with the client. (2) Have the client draw the object of their fear. (3)
Discuss situation with the client and help distinguish between real and
imagined threats to well-being. (4) If the client's fear is a reasonable
response, empathize with the client. Avoid false reassurances and be truthful.
Reassure clients that seeking help is both a sign of strength and a step
toward resolution of the problem (5) If possible, remove the source of the
client's fear with accurate and appropriate amounts of information. (6) If
possible, help the client confront the fear. (7) Stay with clients when they
express fear; provide verbal and nonverbal (touch and hug with permission and
if culturally acceptable) reassurances of safety if safety is within control.
The nurse's presence and touch demonstrate caring and diminish the intensity
of feelings such as fear (8) Explain all activities, procedures (in advance
when possible), and issues that involve the client; use nonmedical... (1)
Instruct parents that nighttime fear is common in children. (2) Explore coping
skills used previously by the client to deal with fear. Children generally
rate their coping behaviors as helpful. (3) Teach parents to use
cognitive-behavioral strategies such as positive coping statements ("I am a
brave girl [boy]. I can take care of myself in the dark.") and rewards of
bravery tokens for appropriate behavior. (4) Screen for depression in clients
who report social/school fears.
(1) Establish a trusting relationship so that all fears can be identified. (2)
Monitor for dementia and use appropriate interventions. (3) Note if the client
is irritable and is blaming others. (4) Provide a protective and safe
environment, use consistent caregivers, and maintain the accustomed
environmental structure. (5) Observe for untoward changes if antianxiety drugs
are taken. (6) Assess for fear of falls in hospitalized patients with hip
fractures to determine risk of poor health outcomes. (7) Encourage exercises
to improve physical skills and levels of mobility to decrease fear of falling.
Improving physical skills and levels of mobility counteract excessive fear
during activity performance (1) Assess for the presence of culture-bound
anxiety/fear states. (2) Assess for the influence of cultural beliefs, norms,
Page 52
and values on the client's perspective of a stressful situation. (3) Identify

what triggers fear response. (4) Identify how the client expresses fear. (5)
Validate the client's feelings regarding fear. (1) Above interventions may
be adapted for home care use. (2) Assess to differentiate the presence of fear
versus anxiety. (3) Refer to care plan for Anxiety. (4) During initial
assessment, determine whether current or previous episodes of fear relate to
the home environment (e.g., perception of danger in home or neighborhood or of
relationships that have a history in the home). (5) Identify with the client
what steps may be taken to make the home a "safe" place to be. (6) Encourage
the client to seek or continue appropriate counseling to reduce fear
associated with stress or to resolve alterations in irrational thought
processes. (7) Encourage the client to have a trusted companion, family
member, or caregiver present in the home for periods when fear is most
prominent. Pending other medical diagnoses, a referral to homemaker/home
health aide services may meet this need. (8) Offer to sit with a terminally
ill client quietly as needed by the client or family, or provide hospice
vol....
(1) Teach the client the difference between warranted and excessive fear. (2)
Teach stress management interventions to clients who experience emotions of
fear. (3) Teach families to share personal stories about an illness using the
computer-based psychoeducational application experience journal. (4) Teach the
client to visualize or fantasize absence of the fear or threat and successful
resolution of the conflict or outcome of the procedure. (5) Teach the client
to identify and use distraction or diversion tactics when possible. (6) Teach
clients to use guided imagery when they are fearful: have them use all senses
to visualize a place that is "comfortable and safe" for them. (7) Teach the
client to allow fearful thoughts and feelings to be present until they
dissipate. (8) Teach use of appropriate community resources in emergency
situations (e.g., hotlines, emergency departments, law enforcement, judicial
systems). (9) Encourage use of appropriate community resources in
nonemergency... ÿÿÿÿ ÿ Fluid balance, readiness for enhanced 432 A pattern
of equilibrium between fluid volume and chemical composition of body fluids
that is sufficient for meeting physical needs and can be strengthened
Expresses willingness to enhance fluid balance; stable weight; moist mucous
membranes; food and fluid intake adequate for daily needs; straw-colored urine
with specific gravity within normal limits; good tissue turgor; no excessive
thirst; urine output appropriate for intake; no evidence of edema or
dehydration Motivation to improve hydration status Fluid Balance; Hydration;
Nutritional Status: Food and Fluid Intake (1) Maintain light yellow urine
output. (2) Maintain elastic skin turgor, moist tongue, and mucous membranes.
(3) Explain measures that can be taken to improve fluid intake. Fluid
Management (1) Discuss normal fluid requirements. A guideline is 1 ml of
fluid per each calories needed, so an average intake would be between 2000 and
3000 ml/day, or 8 to 12 cups o fluid. (2) Recommend mainly intake of water,
but milk or fruit juice can also be effective in maintain good fluid balance.
(3) Recommend the client avoid the use of alcoholic beverages containing
caffeine to provide fluid to the body. (4) Recommend the client avoid intake
of carbonated beverages, instead suggest the client drink water.
(1) Encourage the elderly client to develop a pattern of drinking water
regularly.
(1) Teach the client to drink water before an during engaging in activities
that can result in dehydration quickly such as the distance runner or the
gardener in hot weather. (2 hours before activity-2 to 3 cups; 15 minutes
before activity-1 to 2 cups; Every 15 mintues during activity-1/2 to 1 cup;
After activity--at least 2 cups for every pound of body weight loss) (2) Teach
clients who work in hot environments or exercise in hot environments to
increase intake of both water and use of electrolyte-carbohydrate beverages,
the sports drinks are needed when exercie exceeds 1 hour or during prolonged
competitive games that require repeated intermittent activity. (3) Ask the
client to monitor the color of urine to tell if adequately hydrated. ÿÿÿÿ ÿ
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Fluid volume, deficient 434 Decreased intravascular, interstitial, and/or

intracellular fluid (refers to dehydration, water loss alone without change in
sodium level) Decreased urine output; increased urine concentration;
weakness; sudden weight loss (except in third-spacing); decreased venous
filling; increased body temp; decreased pulse volume/pressure; change in
mental state; elevated hematocrit; decreased skin/tongue turgor; dry
skin/mucous membranes; thirst; increased pulse rate; decreased blood pressure
Active fluid volume loss; failure of regulatory mechanisms Electrolyte and
Acid-Base Balance; Fluid Balance; Hydration; Nutritional Status: Food and
Fluid Intake (1) Maintain urine output more than 1300 ml/day (or at least 30
ml/hr). (2) Maintain normal BP, pulse, and body temp. (3) Maintain elestic
skin turgor; moist tongue and mucous membrances; and orientation to person,
place, and time. (4) Explain measures that can be taken to treat or prevent
fluid volume loss. (5) Describe symptoms that indicate the need to consult
with health care provider. Fluid Management; Hypovolemia Management; Shock
Management: Volume (1) Monitor for the existence of factors causing deficient
fluid volume (e.g., vomiting, diarrhea, difficulty maintaining oral intake,
fever, uncontrolled type 2 diabetes, diuretic therapy). (2)Watch for early
signs of hypovolemia, including restlessness, weakness, muscle cramps, and
postural hypotension. (3) Monitor total fluid intake and output every 8 hours
(or every hour for the unstable client). Recognize that urine output is not
always an accurate indicator of fluid balance. (4) Watch trends in output for
3 days; include all routes of intake and output and note color and specific
gravity of urine. (5) Monitor daily weight for sudden decreases, especially in
the presence of decreasing urine output or active fluid loss. Weigh the client
on the same scale with the same type of clothing at same time of day,
preferably before breakfast. (6) Monitor vital signs of clients with deficient
fluid volume every 15 minutes to 1 hour for the unstable client (every 4 hours
for the stable......
(1) Monitor elderly clients for deficient fluid volume carefully, noting new
onset of weakness, dizziness, or dry mouth with longitudinal furrows. (2)
Check skin turgor of elderly client on the forehead, sternum or inner thigh;
also look for the presence of longitudinal furrows on the tongue and dry
mucous membranes. (3) Encourage fluid intake by offering fluids regularly to
cognitively impaired clients. (4) Incorporate regular hydration into daily
routines (e.g., extra glass of fluid with medication or social activities).
Consider use of a beverage cart and a hydration assistant to routinely offer
increased beverages to clients in extended care. (5) Note the color of urine
and compare against a urine color chart to monitor adequate fluid intake. (6)
Monitor elderly clients for excess fluid volume during the treatment of
deficient fluid volume: listen to lung sounds, watch for edema, and note vital
signs. (1) Determine if it is appropriate to intervene for deficient fluid
volume or to allow the client to die comfortably without fluids as desired.
(2) Teach family members how to monitor output in the home (e.g., use of
commode "hat" in the toilet, urinal, or bedpan, or use of catheter and closed
drainage). Instruct them to monitor both intake and output (3) When weighing
the client, use same scale each day. Be sure scale is on a flat (not
cushioned) surface. Do not weigh the client with scale placed on any kind of
rug. Use bed or chair scales for clients who are unable to stand. (4) Teach
family about complications of deficient fluid volume and when to call
physician. (5) If the client is receiving intravenous fluids, there must be a
responsible caregiver in thehome. Teach caregiver about administration of
fluids, complications of intravenous administration (e.g., fluid volume
overload, speed of medication reactions), and when to call for assistance.
Assist caregiver with admin.....
(1) Instruct the client to avoid rapid position changes, especially from
supine to sitting or standing. (2) Teach the client and family about
appropriate diet and fluid intake. (3) Teach the client and family how to
measure and record intake and output accurately. (4) Teach the client and
family about measures instituted to treat hypovolemia and to prevent or treat
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fluid volume loss. (5) Instruct the client and family about signs of deficient
fluid volume that indicate they should contact health care provider.
ÿÿÿÿ ÿ Fluid volume, excess 440 Increased isotonic fluid retention
Jugular vein distention; decreased hemoglobin and hematocrit; weight gain over
short period; changes in respiratory pattern, dyspnea, or SOB; orthopnea;
abnormal breath sounds (rales or crackles); pulmonary congestion; pleural
effusion; intake exceeds output; S3 heart sound; change in mental status;
restlessness; anxiety; BP changes; pulmonary artery pressure changes;
increased central venous pressure; oliguria; azotemia; specific gravity
changes; altered electrolytes; edema, may progress to anasarca; positive
hepatojugular reflex Compromised regulatory mechanism; excess fluid intake;
excess sodium intake Electrolyte and Acid-Base Balance; Fluid Balance;
Hydration (1) Remain free of edema, effusion, anasarca; weight appropriate
for the client. (2) Maintain clear lung sounds; no evidence of dyspnea or
orthopnea. (3) Remain free of jugular vein distention, positive hepatojugular
reflex, and gallop heart rhythm. (4) Maintain normal central venous pressure,
pulmonary capillary wedge pressure, cardiac output, and vital signs. (5)
Maintain urine output within 500 ml of intake and normal urine osmolality and
specific gravity. (6) Remain free of restlessness, anxiety, or confusion. (7)
Explain measures that can be taken to treat or prevent excess fluid volume,
especially fluid and dietary restrictions and medications. (8) Describe
symptoms that indicate the need to consult with health care provider. Fluid
Management; Fluid Monitoring (1) Monitor location and extent of edema; use a
millimeter tape in the same area at the same time each day to measure edema in
extremities. (2) Monitor daily weight for sudden increases; use same scale and
type of clothing at same time each day, preferably before breakfast. (3)
Monitor lung sounds for crackles, monitor respirations for effort, and
determine the presence and severity of orthopnea. (4) With head of bed
elevated 30 to 45 degrees, monitor jugular veins for distention in the upright
position; assess for positive hepatojugular reflex. (5) Monitor central venous
pressure, mean arterial pressure, pulmonary artery pressure, pulmonary
capillary wedge pressure, and cardiac output; note and report trends
indicating increasing pressures over time. (6) Monitor vital signs; note
decreasing blood pressure, tachycardia, and tachypnea. Monitor for gallop
rhythms. If signs of heart failure are present, see nursing care plan for
Decreased Cardiac output. (7) Monitor serum osmolality, ....
(1) Recognize that the presence of risk factors for excess fluid volume is
particularly serious in the elderly. Decreased cardiac output and stroke
volume are normal aging changes that increase the risk for excess fluid volume
(1) Assess client and family knowledge of disease process causing excess
fluid volume. Teach about disease process and complications of excess fluid
volume, including when to contact physician. (2) Assess client and family
knowledge and compliance with medical regimen, including medications, diet,
rest, and exercise. Assist family with integrating restrictions into daily
living. (3) If the client is confined to bed rest or has difficulty reclining,
follow previously mentioned positioning recommendations. (4) Teach and
reinforce knowledge of medications. Instruct the client not to use
over-thecounter medications (e.g., diet medications) without first consulting
the physician. Instruct the client to make primary physician aware of
medications ordered by other physicians.(5) Identify emergency plan for
rapidly developing or critical levels of excess fluid volume when diuresing is
not safe at home. (6) Teach about signs and symptoms of both excess and
deficient fluid volume and when ......
(1) Describe signs and symptoms of excess fluid volume and actions to take if
they occur. (2) Teach the importance of fluid and sodium restrictions. Help
the client and family to devise a schedule for intake of fluids throughout
entire day. Refer to dietitian concerning implementation of low-sodium diet.
(3) Teach how to take diuretics correctly: take one dose in the morning and
second dose (if taken) no later than 4 PM. Adjust potassium intake as
appropriate for potassiumlosing or potassium-sparing diuretics. Note the
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appearance of side effects such as weakness, dizziness, muscle cramps,

numbness and tingling, confusion, hearing impairment, palpitations or
irregular heartbeat, and postural hypotension. (4) For the client undergoing
hemodialysis, spend time with the client to detect any factors that may
interfere with the client's compliance with the fluid restriction or
restrictive diet. (5) Emphasize the need to consult with health care provider
before taking over-thecounter meds. ÿÿÿÿ ÿ Fluid volume, deficient, risk for
444 At risk for experiencing vascular, cellular, or intracellular
dehydration. Factors influencing fluid needs (e.g., hypermetabolic states);
extremes of age; extremes of weight; excessive losses of fluid through normal
routes (e.g., diarrhea); loss of fluids through abnormal routes (e.g.,
indwelling tubes); deviations affecting access, intake, or absorption of
fluids (e.g., physical immobility); knowledge deficiency regarding fluid
volume; medication (e.g., diuretics) Fluid Balance; Hydration; Knowledge:
Treatment Regimen (1) Maintain urine output of more than 1300 ml/day (or at
least 30 ml/hr). (2) Maintain normal BP, pulse, and body temp. (3) Maintain
elastic skin turgor; moist tongue and mucous membranes; and orientation to
person, place, and time. (4) Explain measures that can be taken to treat or
prevent fluid volume loss. (5) Describe symptoms that indicate the need to
consult with health care provider. Fluid Management; Fluid Monitoring;
Hypovolemia Management (1) Use appropriate preoperative fasting guidelines as
ordered: "allow the consumption of clear liquids up two two hours before
elective surgery, a light breakfast (tea and toast for example) six hours
before the procedure, and a heavier meal eight hours beforehand". (2) See care
plan for Deficient Fluid volume.
(1) Aim for 1500 ml of oral liquids per day unless contraindicated by a
medical condition such as congestive heart failure. (2) Allow adequate time
for eating and drinking at meals. (3) Provide water that is freely available
on the bedside or beside the chair. (4) Incorporate regular hydration into
daily routines (e.g. extra glass of fluid with medication or social
activities). consider use of a beverage cart and hydration assistant to
reoutinely offecr increased beverages to clients in extended care. (5) Note
the color of urine and compare against a urine color chart to monitor
adequate fluid intake. (6) Encourage consumption of fluids with meds. (7)
Ensure that clients who are immobile or restrained get adequate fluilds.
(1) Teach client who work in hot environments or exercise in hot environments
to increase intake of both water and use of electrolyte-carbohydrate
beverages. ÿÿÿÿ ÿ Fluid volume, imbalanced, risk for 447 At risk for
decrease, increase, or rapid shift from one to the other of intravascular,
interstitial, and/or intracellular fluid (refers to body fluid loss, gain, or
both) Major invasive procedures. Electrolyte and Acid-Base Balance; Fluid
Balance; Hydration (1) Have clear lung sounds, show respiratory rate of 12 to
20 breaths/min, and be free of dyspnea postoperatively. (2) Maintain urine
output of at least 30 to 50 ml/hr, 1300 ml/24 hr. (3) Have BP, pulse rate, and
pulse oximetry within preoperative limits. (4) Have laboratory values within
expected range. (5) Have nonedematous extremities and dependent areas. (6)
Have mental orientation unchaged from preoperative status. Acid-Base
Management; Acid-Base Monitoring; Autotransfusion; Bleeding Precautions;
Bleeding Reduction: Wound; Electrolyte Management; Fluid Management; Fluid
Monitoring; Hemodynamic Regulation; Hypervolemia Management; Hypovolemia
Management; Intravenous Therapy; Invasive Hemodynamic Monitoring; Shock
Management: Volume; Vital Signs Monitoring (1) Carefully assess the client's
preoperative status and history. (2) Use appropriate preoperative fasting
guidelines as ordered: "allow the consumption of clear liquids up to two hours
before elective surgery, a light breakfast (tea and toast, for example) six
hours before the procedure, and a heavier meal eight hours beforehand". (3)
Monitor vital signs, noting especially pulse rate and BP. If systolic BP is
less than 100, notify the anesthesiologist. (4) Monitor for signs of
hypovolemia. (5) Monitor for signs of third spacing. (6) In the critically ill
surgical client with a pulmonary artery catheter, monitor pressures,
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especially wedge pressure. (7) If hypotension develops, administer fluid

challenge as ordered, giving a specified amount of IV fluids, such as rapidly
delivered IV 0.9% normal saline, and monitoring response by observing vital
signs, lung sounds, andurine output. (8) Carefully keep track of input and
output of fluids during surgery. (9) Measure urine output ........ (1)
Monitor the pediatric surgical client closely for signs of fluid loss.
(1) Be especially vigilant when monitoring vital signs and fluids in elderly
surgical clients. (2) Assess for preoperative dehydration.
ÿÿÿÿ ÿ Gas exchange, impaired 451 Excess or deficit in oxygenation and/or
carbon dioxide elimination at the alveolar-capillary membrane Visual
disturbance; decreased carbon dioxide; dyspnea; abnormal arterial blood gas
levels; hypoxia; irritability; somnolence; restlessness; hypercapnia;
tachycardia; cyanosis; abnormal skin color (pale, dusky); hypoxemia;
hypercarbia; headache on awakening; abnormal rate, rhythm, depth of breathing;
diaphoresis; abnormal arterial pH; nasal flaring Ventilation-perfusion
imbalance; alveolar-capillary membrane changes Respiratory Status: Gas
Exchange, Ventilation (1) Demonstrate improved ventilation and adequate
oxygenation as evidenced by blood gas levels within normal parameters for that
client. (2) Maintain clear lung fields and remain free of signs of respiratory
distress. (3) Verbalize understanding of oxygen supplementation and other
therapeutic interventions. Acid-Balse Management; Airway Management (1)
Monitor respiratory rate, depth, and effort, including use of accessory
muscles, nasal flaring, and abnormal breathing patterns. (2) Auscultate breath
sounds every 1 to 2 hours. (3) Monitor the client's behavior and mental status
for the onset of restlessness, agitation, confusion, and (in the late stages)
extreme lethargy. (4) Monitor oxygen saturation continuously using pulse
oximetry. Note blood gas results as available. (5) Observe for cyanosis of the
skin; especially note color of the tongue and oral mucous membranes. (6) If
the client has unilateral lung disease, alternate semi-Fowler's position with
a lateral position (with 10- to 15-degree elevation and "good lung down" for
60 to 90 minutes). This method is contraindicated for clients with pulmonary
abscess or hemorrhage or interstitial emphysema. (7) If the client has
bilateral lung disease, position the client in either semi-Fowler's or a
side-lying position, which increases oxygenation as indicated by pulse
oximetry....
(1) Use central nervous system depressants carefully to avoid decreasing
respiration rate. (2) Maintain low-flow oxygen therapy. (3) Encourage the
client to stop smoking. (1) Assess the home environment for irritants that
impair gas exchange. Help the client to adjust the home environment as
necessary (e.g., install an air filter to decrease the level of dust).
(2) Refer the client to occupational therapy as necessary to assist the client
in adaptation to the home and environment and in energy conservation. (3)
Assist the client with identifying and avoiding situations that exacerbate
impairment of gas exchange (e.g., stress-related situations, exposure to
pollution of any kind, proximity to noxious gas fumes such as chlorine
bleach). (4) Instruct the client to keep the home temperature above 20° C (68°
F) and to avoid cold weather. (5) Instruct the client to limit exposure to
persons with respiratory infections. (6) Instruct the family in the
complications of the disease and the importance of maintaining the medical
regimen, including when to call a physician. (7) Assess nutritional status.
Instruct the client to eat several small meals and use......
(1) Teach the client how to perform pursed-lip breathing and controlled
diaphragmatic breathing, and how to use the tripod position. Have the client
watch the pulse oximeter to note improvement in oxygenation with these
breathing techniques. (2) Teach the client energy conservation techniques and
the importance of alternating rest periods with activity. See nursing
interventions for Fatigue. (3) Teach the importance of not smoking; be
aggressive in approach, and ask the client to set a date for smoking
cessation. Recommend nicotine replacement therapy (nicotine patch or gum).
Refer the client to smoking-cessation programs. Encourage clients who relapse
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to keep trying to quit. (4) Instruct the family regarding home oxygen therapy
if ordered (e.g., delivery system, liter flow, safety precautions). (5) Teach
the client relaxation techniques to help reduce stress responses and panic
attacks resulting from dyspnea. ÿÿÿÿ ÿ Grieving 456 State in which an
individual or group of individuals reacts to an actual or perceived loss,
which may be loss of a person, object, function, status, relationship, or body
part. NOTE: Grieving is not an official NANDA diagnosis, but it is included
because the authors believe that grieving is part of the normal human response
to loss and that nurses can use interventions to help the client grieve.
Grieving is a well-ness oriented nursing diagnosis. Verbal expression of
distress; anger; sadness; crying; difficulty in expressing loss; alterations
in eating habits, sleep patterns, dream patterns, activity levels, or libido;
reliving of past experiences; interference with life function; alterations in
concentration or pursuit of tasks. Actual or perceived object loss, which may
include loss of people, possessions, job, status, home, ideals, or parts and
processes of the body Grief Resolution; Hope; Mood Equilibrium; Psychosocial
Adjustment: Life Change (1) Express feelings of guilt, fear, anger, or
sadness. (2) Identify problems associated with grief (e.g., changes in
appetite, insomnia, loss of libido, decreased energy, alteration in activity
level). (3) Plan for future one day at a time. (4) Function at normal
developmental level and perform activities of daily living Grief Work
Facilitation; Grief Work Facilitation: Perinatal Death (1) Use a grief
instrument such as the Hogan Grief Reaction Checklist (HGRC) to evaluate the
client with regard to the six factors in the normal trajectory of the grieving
process: Despair, Panic Behavior, Blame and Anger, Detachment,
Disorganization, and Personal Growth. (2) Allow family members to participtae
in care of the body of the deceased if desired. Help survivors say goodbye in
the most loving and caring way possible. (3) Allow the family "holding"
behaviors, including taking photographs of the deceased or clipping a piece of
hair. (4) Help the bereaved client survive during times of acute grief. Ensure
that the client maintains sufficient nutrtion and help the client determine a
routine to make it through each day. (5) Encourage the client to shar memories
and tell stories of the person or object of loss by making comments such as,
"Tell me about your wife [husband, parent]." Conduct an in-depth personal
interview to learn about the client and loved one or loss. (6) ......
(1) Use reminiscence therapy in conjunction with the expression of emotions.
(2) Identify pervious losses and assess the client for depression. (3) Monitor
an older adult who has been treated for bereavement-related depression for
relapse or recurrence. (4) Evaluate the social support system of the elderly
client. If the support system is minimal, help the client determine how to
increase availabe support. (5) Provide support for the family when the loss is
associated with dementia of the family member. (1) Assess for the influence
of cultural beliefs, norms, and values on the client's grief and mourning
practices. (2) Assess for the influence of cultural beliefs, norms, and values
on the client's expressions of grief. (3) Identify whether the client had been
notified of the deceased's health status and was able to be present at the
deathbed. (4) Validate the client's feelings regarding the loss. NOTE:
Grieving may be encountered as the client comes to terms with his or her own
loss or heath, or as the family reacts to the client's death. (1) The
interventions described previously may be adapted for home care use. (2)
Listen actively as the client grieves his or her own death, or real or
perceived loss. Normalize the client's expression of grief for himself or
herself. (3) If the agency has served the decreased as a client, allow the
primary caregivers to attend the services. (4) Plan the first home visit
within 10 days after the loss by the client; be guided by the type of loss and
the family's schedule following the loss. (5) If the loss of a loved one,
allow the client to express feelings about the loss through interaction with
the home environment. Symbols of the lost loved one can be comforting and
allow the bereaved to accept the loss in stages. (6) A wide range of behaviors
and perceptions occurs during the grieving response. Do not react with shock
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or disbelief at a ...
ÿÿÿÿ ÿ Grieving, anticipatory 463 Intellectual and emotional responses
and behaviors by which individuals, families, and communities work through the
process of modifying self-concept based on the perception of potential loss.
Expression of distress at potential loss; sorrow; guilt; denial of potential
loss; anger; altered communication patterns; potential loss of significant
object (e.g., people, possessions, job, status, home, ideals, parts and
processes of the body); denial of significance of the loss; bargaining;
alteration in eating habits, sleep patterns, dream patterns, activity level,
or libido; difficulty taking on new or different roles; resolution of grief
before the reality of loss Perceived or actual impending loss of people,
objects, possessions, job, status, home, ideals, or parts and processes of the
body. Coping; Family Coping; Grief Resolution; Psychosocial Adjustment: Life
change. (1) Express feelings of guilt, anger, or sorrow. (2) Identify
problems associated with anticipatory grief (e.g., changes in activity, eating
or libido). (3) Seek help in dealing with anticipated problems. (4) Plan for
the future one day at a time. Grief Work Facilitation; Grief Work
Facilitation: Perinatal Death (1) If grief results from the impending death
of a loved one, allow family members to stay with the loved one during the
dying process if desired and help them determine appropriate times to take
breaks. (2) Encourage family members to touch the dying client if they are
comfortable with doing so. (3) Encourage family members to listen carefully to
messages given by the dying lovel one; they may hear symbolic or obscure
language referring to the dying process. (4) If the dying client id denying
the seriousness of his or her condition, do not negate the denial. (5) Help
the dying client to maintain hope by focusing on the moment, reviewing his or
her assets, and maintaining important relationships. (6) Use therpeutic
communication with open-ended questions such as "What are your thoughts and
fears?" (7) Keep family members informed about the clent's condition. (8)
Actively listen to the client's and/or family's expression of grief; do not
interrup, do not tell your own story, and do ....
(1) Assist the client with end-of-life decisions and advance directives. (1)
Assess for the influence of cultural beliefs, norms, and values on the clients
grief and mourning practices. (2) Assess for the influence of cultural
beliefs, norms, and values on the client's expression of grief. NOTE: Hospice
care encourages clients and families to experience the client's final days in
the setting of choice. All of the previously memtioned interventions can and
should be applied to the home setting when that is the setting selected. (1)
Listen actively; normalize the client's and family's expression of grief for a
loved one who is expected to die. (2) When the potential loss is of a loved
one, refer the grieving client to hospice volunteer services for support. (3)
When the client has a history of loss of a pregnancy, assess the client's need
for a counseling referral during subsequent pregnancies.
(1) Teach caregivers that they are doing anticipatory grieving as they care
for their loved ones, which is part of the reason care can be so difficult.
The grief can become more acute as death approaches. ÿÿÿÿ ÿ Grieving,
disfunctional 468 Extended unsuccessful use of intellectual and emotional
responses by which individuals, families, and communities attempt to work
through the process of modifying self-concept based on the perception of loss.
NOTE: It is now recognized that sometimes what was previously diagnosed as
Dysfunctional Grieving might instead be Chronic Sorrow, in which grief lingers
and is reactivated at intervals. Refer to the nursing diagnosis Chronic Sorrow
is appropriate. Repetitive use of ineffectual behaviors associated with
attempts to reinvest in relationships; crying; sadness; reliving of past
experiences with little or no reduction (diminishment) of intensity of grief;
labile affect; expression of unresolved issues; interference with life
functioning; verbal expression of distress at tloss; idealization of lost
object (e.g., people, possessions, job, status, home, ideals, parts and
processes of the body); difficulty in expressing loss; denial of loss, anger;
alterations in eating habits, sleep patterns, dream patterns, activity level,
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libido, concentration, and/or pursuit of tasks; developmental regression;

expression of guilt; prolonged interference with life functioning; onset or
exacerbation of somatic or psychosomatic responses. Actual or perceived
object loss (e.g., of people, possessions, job, status, home, ideals, parts
and processes of the body) Coping; Family Coping; Grief Resolution;
Psychosocial Adjustment: Life Change (1) Express appropriate feelings of
guilt, fear, anger, or sadness. (2) Identify problems associated with grief
(e.g., changes in appetite, insomnia, nightmares, loss of libido, decreased
energy, alteration in activity levels). (3)Seek help in dealing with
grief-associated problems. (4) Plan for the future one day at a time. (5)
Identify personal strengths (6) Function at a normal developmental level and
perform activities of daily living after an appropriate length of time. Grief
Work Facilitation; Grief Work Facilitation: Perinatal Death; Guilt Work
Facilitation (1) Assess the client's state of grieving. Use a tool such as
the Hogan Grief to Personal Growth Model or the Grief Experience Inventory.
(2) Assess for the causes of dysfunctional grieving (e.g., sudden bereavement
[less than 2 weeks to prepare for the oncoming loss], highly dependent or
ambivalent relationship with the deceased, inadequate coping skills, lack of
social support, previous physical or mental health problems, death of a child,
loss of a spouse). (3) Observe for the following reactions to loss, which
predispose a client to dysfunctional grieving: see book. (4) Identify problems
of eating and sleeping; ensure that basic human needs are being met. Losses
often interrupt appetite and sleep (5) Develop a trusting relationship with
the client by using therapeutic communication techniques. (6) Establish a
defined time to meet and discuss feelings about the loss and to perform grief
work. (7) Encourage the client to "cry out" grief and to talk about feelings
of anger, ......
(1) Use reminiscence therapy in conjunction with the expression of emotions

(2) Identify previous losses and assess the client for depression. Signs of
depression are often masked by somatic complaints. (3) Evaluate the social
support system of the elderly client. If the support system is minimal, help
the client determine how to increase available support. (1) Assess for the
influence of cultural beliefs, norms, and values on the client's grief and
mourning practices. (2) Assess for the influence of cultural beliefs, norms,
and values on the client's expressions of grief. (3) Identify whether the
client had been notified of the health status of the deceased and was able to
be present during illness and death. (4) Validate the client's feelings
regarding the loss. (1) The interventions described previously may be adapted
for home care use. (2) Encourage the client to make choices about daily living
and the home environment that acknowledge the loss. (3) Evaluate the long-term
support system of the bereaved client. Encourage the client to interact with
the support system at defined intervals. (4) Discourage the client from making
any drastic life changes immediately. (5) Refer the client to or encourage
continued interaction with hospice volunteers and bereavement programs as
continuing forms of support. (6) Refer the client to medical social services,
especially the hospice program social worker, for assistance with grief work.
(7) Evaluate the need for psychiatric referral. (8) After loss of a pregnancy,
encourage the client to follow through with a counseling referral. (9) If the
client is identified as having a psychiatric disorder, refer for psychiatric
home health care services or "interapy" (online therapy) for client
reassurance and .....
ÿÿÿÿ ÿ Growth and development, delayed 474 Deviations from age-group
norms Altered physical growth; delay or difficulty in exercising skills
(motor, social, expressive) typical of age group; inability to perform
self-care or self-control activities appropriate for age; flat affect;
listlessness; decreased responses Prescribed dependence; indifference;
separation from significant others; environmental and stimulation
deficiencies; effects of physical disability; inadequate caretaking,
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inconsistent responsiveness; multiple caretakers Child Development: 2 Months,

4 Months, 6 Months, 12 Months, 2 Years, 3 Years, 4 years, Preschool, Middle
Childhood, Adolescence; Growth; Mobility; Neurological Status; Physical
Maturation: Female, Male; Self-Care: ADLs, Bathing, Dressing, Eating, Hygiene,
IADLs, Toileting; Personal Well-Being (1) Describe realistic, age-appropriate
patterns of growth and development. (2) Promote activities and interactions
that support age-related developmental tasks. (3) Display consistent,
sustained achievement of age-appropriate behaviors (social, interpersonal,
and/or cognitive) and/or motor skills. (4) Achieve realistic developmental
and/or growth milestones based on existing abilities, extent of disability,
and functional age. (5) Exhibit limited temporary behavioral regression that
reverses shortly after episode of illness or hospitalization. (6) Attain
steady gains in growth patterns. Active Listening; Body Image enhancement;
Developmental Enhancement: Adolescent, Child; Emotional Support; Kangaroo
Care; Nutrition Therapy; Nutritional Monitoring; Positioning; Self-Care
Assistance; Self-Responsibility Facilitation NOTE:Determination of the
etiological basis for delayed growth and development if critical because it
will direct the selection of interventions for treating the client. Parenting
skill deficits, lack of consistency between caregivers, hospitalizartion, and
a chronic medical condition or developmental disability will necessitate
different strategies. A hospitalization experience with regressive behaviors
can be a transient occurence, whereas a chronic situation may result in more
severe and longer delays requiring more in-depth intervention. Parenting
skills and consistent expectations by multiple caregivers can be addressed by
more intensive education efforts. (1) To determine risk for or actual
deviations in normal development, consider the use of a screening tool. One
such tool is the Family Protective-Risk Index, which was developed by
examining eight factors--mother's education, father's education, family income
sufficiency, type of family, family relations, stressful life .......
perceptions of child development. (3) use a neutral, indirect style in
addressing areas in which improvement is needed (such as a need for verbal
stimulation) when working with Native American clients. (4) Assess whether
exposure to community violence is contributing to developmental problems. (5)
Validate the client's feelings and concerns related to the child's
development. (1) The interventions described previously may be adapted for
home care use. (2) Assess for the presence of substances that could cause
developmental delay. (3) Refer maternal drug users to home intervention
programs. (4) help the family to identify appropriate skill-building
activities for the child. (5) Provide emotional support for family members in
their reactions to evidence of developmental delay. (6) If possible, refer the
family to a program of animal-assited therapy.
(1) Provide anticipatory guidance for parents and/or caregivers regarding
realistic expectations for attainment of growth and development liestones.
Clarify expectations and correct misconceptions. (2) Have parents and/or
caregivers rehearse coping strategies for approaching developmental milestones
and acknowledge positive actions and behaviors. (3) Teach methods of providing
meaningful stimulation for infants and children. (4) Instruct the client with
regard to age-appropriate activites and play, nutrition, discipline, and
safety, and support growth and development. (5)Elicit the involvement about
the community resources. ÿÿÿÿ ÿ Growth disproportionate, risk for 480 At
risk for growth above the 97th percentile or below the 3rd percentile for age,
crossing two percentile channels; disproportionate growth. PRENATAL:
Congenital/genetic disorders; maternal malnutrition; multiple gestation;
teratogen exposure; substance use/abuse. INDIVIDUAL: Infection; prematurity;
malnutrition; organic and inorganic factors; caregiver and/or individual
maladaptive feeding behaviors; anorexia; insatiable appetite; infection;
chronic illness; substance abuse. ENVIRONMENTAL: Deprivation; teratogen
exposure; lead poisoning; poverty; violence; natural disasters. CAREGIVER:
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Abuse; mental illness; mental retardation or severe learning disability. Body

Image; Child Development: 2 Months, 4 Months, 6 Months, 12 Months, 2 Years, 3
Years, 4 Years, Preschool, Middle childhood, Adolescence; Coping; Growth;
Impulse Self-Control; Knowledge: Diet; Nutritional Status: Nutrient Intake;
Physical Maturation: Female, Male; Self-Esteem; Weight: Body Mass (1) State
information related to possible teratogenic agents. (2) State information
related to adequate nutrition. (3) Seek help from appropriate professionals
for nutritional needs. Behavior Management; Behavior Modification; Counseling
Developmental Enhancement: Adolescent, Child; Impulse Control Training;
Nutrition Therapy; Nutritional Monitoring; Teaching: Infant Nutrtion, Toddler
Nutrition NOTE: Management of a risk diagnosis necessitates the use of
approaches incorporating primary and secondary prevention. Primary preventions
interventions, which include activites such as nutrition counseling, focus on
thwarting the development of a disease or condition. Secondary prevention is
achieved through screening, monitoring, and surveillance. (1) Assess and limit
exposure to all drugs (prescription, "recreational," and OTC) and give the
mother info on known teratogenic agents. (2) Reduce the risk of TORCH
infections (toxoplastimosis, other infections, rubella, cytomegalovirus [CMV]
infection, and herpes simplex): ...... (3) Promote a team approach toward
preconception and pregnancy glucose control for women with diabetes. (4) Women
with PKU are urged to maintain phenylalanine restriction throughout their
childbearing years. (5) Provide for adequate nutrition and nutritional
monitoring in clients with developmental disorders. (6) Adequate intake of
Vit.D is set at 200 IU/day ...
(1) Assess for the inlfuence of cultural beliefs, norms, values, and
expectations on parents' perceptions of normal growth and development. (2)
negotiate with clients regarding which aspects of healthy nutrition can be
modified while still honoring cultural beliefs. (3) Assess whether the parents
are concerned about the amount of food eaten. (4) Assess the influence of
family support on patterns of nutritional intake. (1) The interventions
described previously may be adapted for home care use. (2) provide aids to
assist in compliance with the care plan (e.g., prepare medication schedules
and put a week's medication in daily containers). (3) Provide sufficient
outside supports (e.g., written notices, calendars, planned ride shares) to
assist wit follow-through of the agreed-upon actions. (4) Include a health
promotion focus for cliets with disabilities, with goals of reducing secondary
conditions (e.g., obesity, hypertension, pressure ulcers), maintaining
functional independence, providing opportunities for leisure and enjoyment,
and enhancing overall quality of life. (5) Encourage a mind-set and program of
self-care management. (6) Establish a written contract with the client to
follow the agreed-upon health care regimen. (7) meet with the client following
completion of the proposed actions to review the contract and determine the
next course of action. Do this until the client is able to ..........
(1) Provide anticipatory guidance for parents and caregivers regarding
expectations for normal patterns of growth. Clairfy expectations and correct
misconceptions. (2) Refer clients to a registered dietitian for nutritional
counseling. (3) Teach families the importance of taking measures to prevent
lead poisoning. Wash the hands before prepraing the child's food. Wash the
child's hands before serving food. Wash the child's toys fequently. Stomp the
feet before coming into the house to clean the shoes outside of soil that may
carry lead from the exterior hous paint. Damp mop frequently along baseboards,
around door frames, under windowsills, and around iron radiators. Wash
windowsills and window wells frequently. Move the crib away from window wells.
Always damp mop before sweeping or vaccuming. Home vacuum cleaners do not trap
lead dut; they blow it into the air. ÿÿÿÿ ÿ Health Maintenance, ineffective
487 Inability to identify, manage, or seek out help to maintain health
History of lack of health-seeking behavior; reported or observed lack of
equipment, financial, and/or other resources; reported or observed impairment
of personal support systems; expressed interest in improving health behaviors;
demonstrated lack of knowledge regarding basic health practices; demonstrated
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lack of adequate behaviors to internal and external environmental changes;

reported or observed inability to take responsibility for following basic
health practices in any or all functional pattern areas. Disabled family
coping; perceptual-cognitive impairment (complete or partial lack of gross or
fine motor skills); lack of or significant alteration in communication skills
(written, verbal, or gestural); unachieved developmental tasks; lack of
material resources; dysfunctional grieving; disabling spiritual distress;
inability to make deliberate and thoughtful judgments; ineffective coping
Health Beliefs: Perceived Resources; Health-Promoting Behavior; Health-Seeking
Behavior (1) Discuss fear of or blocks to implementing health regimen. (2)
Follow mutually agreed upon health care maintenance plan. (3) Meet goals for
health care maintenance. Health Education; Health System Guidance; Support
System Enhancement (1) Assess the client's feelings, values, and reasons for
not following the prescribed plan of care. See Related Factors. (2) Assess for
family patterns, economic issues, and cultural patterns that influence
compliance with a given medical regimen. (3) Help the client determine how to
arrange a daily schedule that incorporates the new health care regimen (e.g.,
taking pills before meals). (4) Refer the client to social services for
financial assistance if needed. (5) Identify support groups related to the
disease process (e.g., Reach to Recovery for a woman who has had a
mastectomy). (6) Help the client to choose a healthy lifestyle and to have
appropriate diagnostic screening tests. (7) Assist the client in reducing
stress. (8) Identify complementary healing modalities such as herbal remedies,
acupuncture, healing touch, yoga, or cultural shamans that the client uses in
addition to or instead of the prescribed allopathic regimen. (9) Refer the
client to community agencies for.........
(1)Assess sensory deficits and psychomotor skills in terms of the client's
ability to comply with a health program. (2) Discuss "symptoms of daily
living" in addition to the major illness. (3) Recognize resistance to change
in lifelong patterns of personal health care. (4) Discuss with the client
realistic goals for changes in health maintenance. (5) Instruct the client in
the symptoms of myocardial infarction and the need for timeliness in seeking
care. (6) Consider the age of the client when suggesting screening for
disease. (1) Assess for the influence of cultural beliefs, norms, and values
on the client's ability to modify health behavior. (2) Discuss with the client
those aspects of health behavior and lifestyle that will remain unchanged by
health status. (3) Negotiate with the client regarding the aspects of health
behavior that will need to be modified. (4) Assess the effect of fatalism on
the client's ability to modify health behavior. (5) Validate the client's
feelings regarding the impact of health status on current lifestyle. (1) The
Provide aids to assist in compliance with the plan of care (e.g., prepare
medication schedules and put a week's medication in daily containers). (3)
Provide sufficient outside supports (e.g., written notices, calendars, planned
ride shares) to assist with follow-through on the agreed-upon actions. (4)
Include a health promotion focus for the client with disabilities, with the
goals of reducing secondary conditions (e.g., obesity, hypertension, pressure
sores), maintaining functional independence, providing opportunities for
leisure and enjoyment, and enhancing overall quality of life. (5) Encourage a
mind-set and program of self-care management. (6) Establish a written contract
with the client to follow the agreed-upon health care regimen. (7) Establish a
written contract with the client to follow the agreed-upon health care
regimen. (8) Meet with the client following completion of the proposed
...........
(1) Provide the family with lists of addresses where information can be
obtained from the Internet. (Most libraries have Internet access with printing
capabilities.) (2) Have the client and family demonstrate at least twice any
procedures to be done at home. (3) Teach the client about the symptoms
associated with discontinuation of a selective serotonin reuptake inhibitor
(SSRI) and consider dosage tapering. (4) Explain nonthreatening aspects before
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introducing more anxiety-producing possible side effects of the disease or

medical regimen. (5) Treat tobacco use as a chronic problem. Acknowledge the
pleasure associated with smoking. Encourage the client to work towards a goal
of permanent abstinence. Advise the client about possible relapse. (6) ÿÿÿÿ ÿ
Health-seeking behaviors 493 Active seeking (by individual in stable
health) of ways to alter personal health habits and/or environment to move
toward higher level of health. NOTE: Stable health is defined as the
achievement of age-appropriate illness-prevention measures; report of good or
excellent health from the client; and control of signs and symptoms of
disease, if present. Expressed or observed desire to seek higher level of
wellness for self or family; demonstrated or observed lack of knowledge of
health-promoting behaviors; stated or observed unfamiliarity with wellness
community resources; expressed concern about effect of current environmental
conditions on health stats; expressed or observed desire for increased control
of health practices. Role change; change in developmental level (e.g.,
marriage, parenthood, empty-nest status, retirement); lack of knowledge
regarding need for preventive health behaviors, appropriate health screenings,
optimal nutrition, weight control, regular exercise program, stress
management, supportive social network, and responsible role participation.
Adherence Behavior; Health Beliefs; Health Orientation; Health-Promoting
Behavior; Health-Seeking Behavior (1) Maintain ideal weight and be
knowledgeable about nutritious diet. (2) Demonstrate ways to fit newly
prescribed change in health habits into lifestyle. (3) List community
resources available for assistance with achieving wellness. (4) List ways to
include wellness behaviors in current lifestyle. Health Education; Health
System Guidance; Support System Enhancement (1) Discuss the client's beliefs
about health and his or her ability to maintain health. (2) Identify barriers
and benefits to being healthy. (3) Identify environmental and social factors
that the client perceives as health promtoing. (4) Determien the client's
height and weght. Compaire results with the standard weight for age and
height. (5) Encourage the client to eat a diet that contains fresh foods, is
low in staurated (visible) fat, and contains no added salt. (6) Assess the
role that stress plays in overeating and weight-cycling. (7) Advise the client
to consult with a physician for testing to determine the ability to tolerate a
specific regiment. (8) Explore with the client weightlifting options to
increase muscle strength and stamina. (9) Help the client focus on the
enjoyment of exercise. Set up a support and reward system. (10) Consider using
music with exercise. (11) Encourage aerobic exercises that increase heart rate
within the prescribed limit. Encourage the client .....
(1) Assess the client's awareness of deficits that may result from normal
aging (eg.g., changes in sleep patterns or frequency of urination, loss of
visual acuity in night driving, loss of hearing, dietary changes, memory
changes, loss of significant others). (2) Identify coping mechanisms that
promote wellness and place contorl of life choices back with the client. (3)
Find suitable housing that provides support, safety, protection, meals, and
social events. (4) Give the client info about community resources for the
elderly (eg, services providing transportation to appointments,
Meals-on-Wheels, home visitation services, pets, AARP, Elder Hostel, Internet
addresses). (5) Assess the environment for signs of elder abuse and report as
appropriate. (6) Teach health-protecting behaviors to elderly; monitoring
cholesterol intake, exercising, having the stool checked for occult blood, or
undergoing a mammorgram, Pap test, or prostate or skin evaluation. (7) Teach
the importance of ......... (1) Assess for the influence of cultural beliefs,
norms, and values on the client's beliefs about health behavior. (2)
Acknowledge and praise those aspects of the client's behavior and lifestyle
that are health promoting. (3) Negotiate with the client the aspects of health
behaviro that will require further modification. (4) Validate the client's
feelings regarding the impact of health behavior on current lifestyle. NOTE:
All the previously listed nursing interventions are applicable to the home
care setting. For more info, see Home Care Intervention in the care plan for
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Ineffective Health maintenance.

(1) Discuss the role of environmental and social factors in supporting a
healthy family life. (2) Use videos and written material to provide info. (3)
Provide and review pamphlets about health-seeking opportunities and wellness
and provide the family with lists of addresses where information can be found
on the internet. ÿÿÿÿ ÿ Home maintenance, impaired 500 Inability to
independently maintain a safe and growth-promoting immediate environment.
SUBJECTIVE: Household members express difficulty in maintaining their home in
a comfortable fashion; household members describe outstanding debts or
financial crises; household requests assistance with home maintenance.
OBJECTIVE: Disorderly surroundings; unwashed or unavailable cooking equipment,
clothes, or linen; accumulation of dirt, food wastes, or hygienic wastes;
offensive odors; inappropriate household temperature; overtaxed family members
(e.g., exhausted, anxious); lack of necessary equipment or aids; presence of
vermin or rodents; repeated hygienic disorders, infestations, or infections.
Client/family member with disease or injury; unfamiliarity with neighborhood
resources; lack of role modeling; lack of knowledge; insufficient family
organization or planning; inadequate support systems; impaired cognitive or
emotional functioning; insufficient finances Family Functioning; Parenting:
Psychosocial Safety; Parenting Performance; Role Performance; Self-Care: IADL
(1) Wear clean clothing, eat nutritious meals, and have a sanitary and safe
home. (2) Have the resources to cope physically and emotionally with the
chronic illness process. (3) Use community resources to assist with treatment
needs. Home Maintenance Assistance (1) Establish a plan of care with the
client and family based on the client's needs and the caregiver's
capabilities. (2) Assess the concern's of family members, especially the
primary caregiver, about long-term home care. (3) Set up a system of relief
for the main caregiver in the home and plan for sharing of household duties.
(4) Encourage social relationships with family and friends, even if by phone.
(5) Initiate referral to community agencies as needed, including housekeeping
servies, Meals-on-Wheels, wheelchair-compatible transportation services, and
O2 therapy services. (6) Obtain adaptive equipment and telemedical equipment,
as appropriate, to help family members continue to maintain the home
envrionment. (7) Consider the use of permethrin-impregnated mattress liners to
control dust mites. (8) Refer the client to social services to help with debt
consolidation or financial concerns. (9) Ask family to identify support people
who can help with home maintenance.
(1) Explore community resources to assest with home care (e.g, senior centers,
Dept. of Aging, hospital discharge planners, the internet, or church parish
nurse). (2) Visit the client's home to assess safety features (e.g., no throw
rugs, safety bars in the bathroom stair borders that distinguish each step,
adequate nonglare lighting). (3) Encourage regular eye examinations. (4)
.....see book..... (5) During the home visit, be alert for signs of elder
abuse. Report any findings. (1) Acknowledge the stresses unique to
racial/ethnic communities. (2) identify what services and info are currently
available in the community to assist with housing needs. (3) Approach families
of color with respect, warmth, and professional courtesy. NOTE: By
definition, this nursing diagnosis consists of primarily community-based
interventions. Home care and publich health nursing are two community
resources that can help the family to restore or improve home management. The
previous intervention incorporate these resources.
(1) Teach the caregiver the need to set aside some personal time every day to
meet his or her own needs. (2) Encourage family members to perform home
maintenance activities (e.g., cooking, cleaning, fire prevention). (3)
identify support groups within the community to assist families in the
caregiver role. (4) Provide support when the family must move their family
member to an assisted living facility. (5) Prvide written instructions for
medication management and side effects, written instructions for equipment
brought to the home, and resource phone numbers for emergency needs. ÿÿÿÿ ÿ
Hopelessness 505 Subjective state in which individual sees limited or
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unavailable alternatives or personal choices and is unable to mobilize energy

for problem solving on his or her own behalf. Passivity; decreased
verbalization; blunted or flat affect; verbal cues (e.g., saying "I can't",
sighing); closing of eyes; anorexia; decreased response to stimuli;
increased/decreased sleep; lack of initiative; lack or involvement in care;
passively allowing care; shrugging in response to speaker, turning away from
speaker Abandonment; prolonged activity restriction creating isolation; loss
of beliefs in transcendent values/God; long-term stress; failing or
deteriorating chronic phsyiological and/or psychological condition; negative
life review; perception of demands that overwhelm personal resources Decision
Making; Hope; Mood Equilibrium; Nutritional Status: Food and Fluid Intake;
Quality of Life; Sleep (1) Verbalize feelings, participate in care. (2) Make
positive statements (e.g., "I can" or "I will try"). (3) Set goals. (4) Make
eye contact, focus on speaker. (5) Maintain appropriate appetite for age and
physical health. (6) Sleep appropriate length of time for age and physical
health. (7) Express concern for another. (8) Initiate activity. Hope
Instillation (1) Monitor and document the potential for suicide. (Refer the
client for appropriate treatment if a potential for suicide is identified.)
See the care plan for Risk for Suicide for specific interventions. (2) Explore
the client's definition of hope. (3) Assist in identifying sources of hope.
(4) Assist the client in identifying reasons for living. (5) Provide realistic
feedback. (6) Assess for pain and respond with appropriate measures for pain
relief. (7) Assist with problem solving and decision making. (8) Determine
appropriate approaches based on the underlying condition or situation that is
contributing to feelings of hopelessness. (9) Assist the client in looking at
alternatives and setting goals that are important to him or her. (10) In
dealing with possible long-term deficits, work with the client to set small,
attainable goals. (11) Spend one-on-one time with the client. Use empathy; try
to understand what the client is saying and communicate this understanding to
the client..
(1) Assess for clinical signs and symptoms of depression; differentiate
depression from organic dementia. (2) If depression is suspected, confer with
the primary physician regarding referral for mental health services. (3) Take
threats of self-harm or suicide seriously. (4) Identify significant losses
that may be leading to feelings of hopelessness. (5) Discuss stages of
emotional responses to multiple losses. (6) Use reminiscence and life-review
therapies to identify past coping skills. (7) Express hope to the client and
give positive feedback whenever appropriate. (8) Identify the client's past
and current sources of spirituality. Help the client explore life and identify
those experiences that are noteworthy. The client may want to read the Bible
or other religious text or have it read to him or her. (9) Encourage visits
from children. (10) Administer medications as ordered and evaluate for
possible drug interactions that may produce and/or exacerbate observed
symptoms. ............ (1) Assess for the influence of cultural beliefs,
norms, and values on the client's feelings of hopelessness. (2) Assess the
effect of fatalism on the client's expression of hopelessness. (3) Encourage
spirituality as a source of support for hopelessness. (4) Validate the
client's feelings regarding the impact of health status on current lifestyle.
(1) Assess for isolation within the family unit. Encourage the client to
participate in family activities. If the client cannot participate, encourage
him or her to be in the same area and watch family activities. If possible,
move the client's bed or primary sitting place to an active household area.
(2) If depression is suspected, confer with the primary health care provider
regarding referral for mental health services. (3) Reminisce with the client
about his or her life. (4) Identify areas in which the client can have
control. Allow the client to set achievable goals in these areas. Assist the
client when necessary to negotiate desirable outcomes. (5) Clearly explain
potential benefits and risks of a proposed intervention. (6) If illness
precipitated the hopelessness, discuss knowledge of and previous experience
with the disease. Help the client to identify past coping strengths. (7)
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Provide plant or pet therapy if possible. (8) Provide a safe environment so

that the client .......
(1) Provide information regarding the client's condition, treatment plan, and
progress. (2) Provide positive reinforcement, praise, and acknowledgment of
the challenges of caregiving to family members. (3) Teach the use of
stress-reduction techniques, relaxation, and imagery. Many cassette tapes on
relaxation and meditation are available. Assist the client and caregivers with
relaxation based on their preference from the initial assessment. (4)
Encourage families to express love, concern, and encouragement, and allow the
client to verbalize feelings. (5) Refer the client to self-help groups such as
I Can Cope and Make Today Count. (6) Refer the family to community support
groups targeted to the specific needs of the family caregivers. (7) Supply a
crisis phone number and negotiate a no-suicide contract with the client
stating that the crisis number will be used if thoughts of self-harm occur. ÿ
ÿÿÿ ÿ Hyperthermia 512 Body temperature elevated above normal range. NOTE:
Elevated body temperature can be either fever or hyperthermia. Fever is a
normal response in which the core body temperature increases at least 0.8 to
1.1 C (1.5 to 2.0 F) above an individual's normal temp (>38C [>100.5 F]). This
elevation is in response to a chemical signal (endogenous pyrogen) released as
part of an inflammatory response, such as in infection or tissue injury.
Because there is a proportional enhancement of the immune system for each
degree of temp elevation, fever is believed to be adaptive to 40 C (104 F).
Hyperthermia is an abnormal increase in core body temp, usually above 40 C
(104 F), that occurs as a result of disorders of temp control. Causes include
brain trauma, heat stroke, drugs (e.g., cocaine, ecstasy), or malignant
hyperthermia of anesthesia. Hyperthermia is not adaptive and should be treated
as a medical emergency. FEVER: core body temp elevated at least 0.8 to 1.1 C
(1.5 to 2.0 F) above individual's normal temp (>38 C [>100.5 F]).
HYPERTHERMIA: body temp above 40 C (104 F) with flushed or hot skin, increased
respiratory rate, and tachycardia. FEVER: Infection; tissue injury or trauma;
dehydration; blood transfusion; medication; neoplasm; increased metabolic
rate. HYPERTHERMIA: Exposure to hot environment; vigorous activity;
inappropriate clothing; inability or decreased ability to perspire; brain
injury; medication; anesthesia; severe illness; trauma Thermoregulation;
Thermoregulation: Newborn (1) Maintain oral temp within adaptive levels
(below 40 C [104 F]) or lower, depending on the presence of cardiopulmonary
illness and client comfort. (2) Remain free of dehydration. Fever Treatment;
Malignant Hyperthermia Precautions; Temperature Regulation (1) Assess an
afrebile hospitalized client's temp per institutional policy if the client
exhibitis signs or symptoms of infection. (2) Measure and record a febrile
client's temp at least every 4 to 6 hours or whenever a change in condition
occurs (e.g., chills, change in mental status). (3) Temp can be measured with
acceptable accuracy using an electronic probe in the mouth or via the external
auditory canal (tympanic membrane). Although inconvenient, rectal temp
measurement is highly accurate. Use of a glass (mercury) thermometier is also
highly accurate but involve increased time (6-7 minutes), risk of mercury
contamination, and risk of rectal perofration, although the occurrence is
rare. Where equipment is available in ICU settings, temp measurement by
intravascular or bladder thermistor is a highly accurate method. Axillary
measurements should not be used. (4) Use the same site and method (device) for
temp measurement for a given client so that temp trends are assessed .........
(1) An oral temp of 0.8 to 1.1 C (1.5 to 2.0 F) above baseline or above 37.2 C
(99.5 F) rectal temp should be considered a fever in the elderly. (2) Rectal
temp may be useful to diagnose fever. Nursing judgment must be used to
determine if rectal temp measurement is acceptable to the client, especially a
client with mental changes or dementia. (3) Assess for other signs and
symptoms of infection in additionto or in the absence of fever in the elderly.
(4) Help the client seek medical attention immediately if fever is present. To
diagnose the fever source, assess for possible precipitating factors, includig
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changes in medication, environmental changes, and recent medical interventions

or infectious exposures. (5) In hot weather, encourage elderly clients to
drink 8 to 10 glasses of fluid per day (within their cardiac and renal
reserves) regardless of whether they are thirsty. Assess for the need for and
presence of fans or air conditioning. (6) In hot weather, monitor the elderly
...... (1) Some of the interventions described previously may be adapted
for home care use. (2) Assess whether the client or family has a thermometer.
Instruct as needed in the type of thermometer (non-mercury containing
preferred; sublingual or tympanic location rather than skin patches) and how
to use and read it accurately. (3) Teach the client and family to use
acetaminophen rather than aspirin or ibuprofen for fever reduction at home to
prevent possible adverse effects. (NOTE: Acetaminophen may be harmful if the
client has liver or kidney dysfunction.) (4) Help the client prevent and
monitor for heat stroke/hyperthermia during times of high outdoor temps. (5)
In the event of temp elevation above the adaptive range, institue measres to
decrease temp (e.g., get the client out of the sun and into a cool place,
remove excess clothing, have the client drink fluids). Keep the physician
informed if temp does not stabilize below 40 C (104 F). Use an emergency plan
as directed by a physican .....
(1) Teach that infection-induced fever enhances the immune system (the
beneficial effect occurs at oral temps of less than 40 C [104 F]), so that
client can particpate in the decision of whether to treat the fever. If
treatment is elected or appropraite, instruct in the use of acetominophen as
the most effective means for fever reduction with fewer potential side effects
than other antipyretics. (2) Teach the client that shivering with
infection-induced fever has detrimental effect and that acitivites that can
cause shivering (e.g., blanket removal, lowering of room temp, tepid water
baths, ice packs) should be avoided. (3) Recommend a liberal intake of fluids
to prevent heat-induced hyperthermia and dehydration in the presence of fever,
but avoidance of liquids that contain alcohol, caffeine, or large amounts of
sugar. (4) Teach the client to stay in a cooler environment during periods of
excessive outdoor heat, or if the client does go out, to avoid vigorous
physical activity, ..... ÿÿÿÿ ÿ Hypothermia 517 Body temp below normal
range Pallor; reduction in body temp below normal range; shivering; cool
skin; cyanotic nailbeds; hypertension and then hypotension; piloerection; slow
capillary refill; tachycardia Exposure to cool or cold environment; use of
meds casuing vasodilation; malnutrition; inadequate clothing; illness or
trauma; evaporation from skin in cool environment; decreased metabolic rate;
damage to hypothalamus; consumption of alcohol; aging; inability or decreased
ability to shiver; inactivity Thermoregulation; Thermoregulation: Newborn
(1) Maintain body temp within normal range. (2) Identify risk factors of
hypothermia. (3) State measures to prevent hypothermia. (4) Identify symptoms
of hypothermia and actions to take when hypothermia is present. Hypothermia
Treatment; Temperature Regulation; Temperature Regulation: Intraoperative;
Vital Signs Monitoring (1) Remove the client from the cause of the
hypothermic episode (e.g, cold envronment, cold or wet clothing). Ensure that
the client is in a warm environment. (2) cover the client with warm blankets
and apply a covering to the head and neck to conserve body heat. (3) Take the
temp at least hourly; if more than mild hypothermia is present (temp lower
than 35 C [95 F]), use continuous temp-monitoring device. (4) If the client is
awake, measure the oral temp, instead of the tympanic or axillary temp. (5)
Monitor the client's vital signs every hour and as appropriate. Note changes
associated with hypothermia, such as initially increased pulse rate,
respiratory rate, and BP with moderate to severe hypothermia. (6) Attach
electrode and a cardiac monitor. Watch for dysrhythmias. (7) Montior for signs
of hypothermia (e.g., shivering, cool skin, piloerection, pallor, slow
capillary refill, cyanotic nailbeds, decreased mentation, coma). (8) Monitor
for signs of coagulopathy (e.g., oozing .....
(1) Assess neurological signs frequently, watching for confusion and decreased
level of consciousness. (2) Warm a hypothermic elderly client slowly, at a
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rate of 0.6 C [1 F] per hour. NOTE: Hypothermia is not a symptom that

appears in the normal course of home care. When it oocurs, it is a clinical
emergency and the client/family should access emergency medical services
immediately. (1) Some of the interventions described earlier may be adapted
for home care use. (2) Before a medical crisis occurs, confirm that the client
or family has a thermometer and can read it. Instruct as needed. Verify that
the thermometer registers accurately. (3) Instruct the client or family to ake
the temp when the client displays cyanosis, pallor, or shivering. (4) Monitor
temp every hour, as noted previously. (5) If temp continues to drop, activate
the emergency system and notify a physician. (6) If the client is in hospice
care, or is terminally ill, follow advance directives, client wishes, and the
physician's orders. Keep the client free of pain.
(1) Teach the client and family signs of hypothermia and the methods of taking
the temp (age-appropriate). (2) Teach the client methods to prevent
hypothermia: wearing adequate clothing, including a hat and mittens; heating
the environment to a minimum of 20 C [68 F] ; and ingesting adequate food and
fluid. (3) Teach the client and family about meds such as sedatives, opioid,
and anxiolytics that predispose the client to hypothermia (as appropriate). ÿ
ÿÿÿ ÿ Identity, personal, disturbed 522 Inability to distinguish between
self and nonself Withdrawal from social contact; change in ability to
determine relationship of the body to the environment; inappropriate or
grandiose behavior. Situational crisis; psychological impairment; chronic
illness; pain Identity; Personal Autonomy (1) Show interest in surroundings.
(2) Respond to stimuli with appropriate affect. (3) Perform self-care and
self-control activities appropriate for age. (4) Acknowledge personal
strengths. (5) Engage in interpersonal relationships. (6) Verbalize
willingness to change lifestyle and use appropriate community resources.
Decision-Making Support; Self-Esteem Enhancement (1) Assess carefully for a
history of abuse. (2) Assess for any history of seizure disorders; adhere to
the diagnostic criteria for dissociative disorder in the DSM-IV and conduct a
structured clinical interview. (3) Avoid labeling the client in terms such as
multiple personality disorder (MPD). (4) Offer reassurance to the client and
use therapeutic communication at frequent intervals. (5) Work with the client
on setting personal goals. (6) Address the client by name. Let the client know
who is approaching and orient the client to the surroundings. (7) Have the
client describe his or her perceptions of the environment as concretely as
possible. (8) Give the client permission to share his or her experiences. The
client has always lived in secrecy and is not sure how much it is safe to
reveal or who believes that the client's illness is an actual illness. (9) Use
touch only after a thorough assessment and as appropriate. (10) Have all team
members approach the client in a consistent....
(1) Monitor for signs of depression, grief, and withdrawal and make an
appropriate referral. (2) Address the client by his or her full name preceded
by the proper title (Mr., Mrs., Ms., Miss); use a nickname or fist name only
if suggested by the client, and do not use terms of endearment (e.g., honey).
(3) Practice reality orientation principles; ask specifically how the client
feels about events that are happening. (4) Ask the client about important past
experiences. (5) If the client's symptoms are associated with a stroke, refer
the client for longer rehavilitation that inlcudes physical programs
addressing psychological as well as neuromuscular issues. (1) Assess for the
influence of cultural beliefs, norms, and values on the family's perceptions
of infant/child behavior. (2) use a neutral, indirect style when addressing
areas in which improvement is needed (such as a need for verbal or oral
stimulation) when owrking with Native American clients. (3) Acknowledge and
praise parenting strengths noted. (4) Use therapeutic communication techniques
that emphasize acceptance, offer the self, validate the client's concerns, and
convey respect when discussing infant/child behavior. (1) The interventions
described previously may be adapted for home care use. (2) Assess the client's
immediate support system and family for relationship patterns and content of
communication. (3) Encourage the family to provide support and feedback
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regarding the client's identity and ego boundaries. (4) If the client is
involved in couseling or self-help groups, monitor and encourage attendance.
Help the client identify the value of group participation after each group
encounter. (5) If the client is taking prescribed psychotropic meds, assess
for understanding of possible side effects and the reasons for taking
madication. Teach as necessary. (6) Assess meds for effectiveness and side
affects and monitor for compliance. (7) If the client is homebound, refer for
psychiatirc home health care services for client reassurance and
implementation of a therapeutic regimen.
(1) Teach stress reduction and relaxation techniques. (2) Refer to community
resources or other self-help appropriate for the client's underlying problem.
(3) Refer to appropriate treatment as soon as signs of depression are noted.
(4) Be a role model for family members: talk to, not around, the client; give
choices to the client when family members may be listening; always address the
client by name; and do not interrupt when the client is attempting to
communicate. ÿÿÿÿ ÿ Incontinence, urinary, functional 527 Impairment or
loss of continence due to functional deficits, including altered mobility,
dexterity, or cognition, or environmental barriers. The relationship between
functional limitations and urinary incontinence remains controversial. While
functional impairment clearly exacerbates the severity of urinary
incontinence, the underlying factors that contribute to these functional
limitations themselves contribute to abnormal lower urinary tract function and
impaired incontinence. Cognitive disorders (delirium, dementia, severe or
profound retardation); neuromuscular limitations impairing mobility or
dexterity; environmental barriers to toileting Urinary Continence; Urinary
Elimination (1) Eliminate or reduce incontinent episodes. (2) Eliminate or
overcome environmental barriers to toileting. (3) Use adaptive equipment to
reduce or eliminate incontinence related to impaired mobility or dexterity.
(4) Use portable urinary collection devices or urine containment devices when
access to the toilet is not feasible. Urinary Habit Training; Urinary
Incontinence Care (1) Perform a history taking and physical assessment
focusing on bothersome lower urinary tract symptoms, cognitive status,
functional status (particularly physical mobility and dexterity), frequency
and severity of leakage episodes, and alleviating and aggravating factors. (2)
Consult with the client and family, the client's physician, and other health
care professionals concerning treatment of incontinence in the elderly client
undergoing detailed geriatric evaluation. (3) Complete a bladder log of
diurnal and nocturnal urine elimination patterns, and patterns of urinary
leakage. (4) Assess the client for potentially reversible or modifiable causes
of acute/transient urinary incontinence (e.g., urinary tract infection;
atrophic urethritis; constipation or impaction; use of sedatives or narcotics
interfering with the ability to reach the toilet in a timely fashion,
antidepressants or psychotropic medications interfering with efficient
detrusor contractions, parasympatholytics, or ....
(1) Institute aggressive continence management programs for the cognitively
intact, community-dwelling client in consultation with the client and family.
(2) Monitor the elderly client in a long-term care facility, acute care
facility, or home for dehydration. (1) The interventions described
previously may be adapted for home care use. (2) Assess current strategies
used to reduce urinary incontinence, including limitation of fluid intake,
restriction of bladder irritants, prompted or scheduled toileting, and use of
containment devices. (3) Encourage a mind-set and program of self-care
management. (4) Implement a bladder training program, including
self-monitoring activities (reducing caffeine intake, adjusting amount and
timing of fluid intake, decreasing long voiding intervals while awake,
instituting dietary changes to promote bowel regularity), bladder training,
and pelvic muscle exercise. (5) For a memory-impaired elderly client,
implement an individualized scheduled toileting program (on a schedule
developed in consultation with the caregiver, approximately every 2 hours,
with toileting reminders provided and existing patterns incorporated, such
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toileting before or after meals). (6) Teach the family the general principles
of bladder....
(1) Work with the client, family, and their extended support systems to assist
with needed changes in the environment and wardrobe, and other alterations
required to maximize toileting access. (2) Work with the client and family to
establish a reasonable, manageable prompted voiding program using
environmental and verbal cues to remind caregivers of voiding intervals, such
as television programs, meals, and bedtime. (3) Teach the family to use an
alarm system for toileting or to carry out a check-andchange program and to
maintain an accurate log of voiding and incontinence episodes. ÿÿÿÿ ÿ
Incontinence, urinary, reflex 534 Involuntary loss of urine at somewhat
predictable intervals when a specific bladder volume is reached. Involuntary
loss of urine caused by a defect in the spinal cord between the nerve roots at
or below the first cervical segment and those above the second sacral segment.
Urine elimination occurs at unpredictable intervals; micturition may be
elicited by tactile stimuli, including stroking of inner thigh or perineum.
Absent or diminshed sensation or urge to void; incomplete emptying caused by
dyssynergia of striated sphincter mechanism, which produces functional outlet
obstruction of bladder, may be associated with sweating and acute elevation in
BP and pulse rate in clients with spinal cord injury (see the care plan for
Autonomic dysreflexia). Paralyzing spinal disorder affecting spinal segments
C1 to S2. Urinary Continence; Urinary Elimination (1) Follow prescribed
schedule for bladder evacuation. (2) Demonstrate successful use of triggering
techniques to stimulate voiding. (3) Have intect perineal skin. (4) Remain
clear of symptomatic urinary tract infection. (5) Demonstrate how to apply
containment device or inset indwelling catheter or be able to provide
caregiver with instructions for performing these procedures. (6) Demonstrate
awareness of risk of autonomic dysreflexia, its prevention and management.
Urinary Catheterization: intermittent; Urinary Elimination Management; Urinary
Incontinence Care (1) Assess the client's neurological status, including the
type of neurological disorder, the funcitonal level of neurological
impairment, its completeness (effect on motor and sensory function), and the
ability to perform bladder management tasks, including tnertmittent
catheterization, application of condom catheter, etc. (2) Perform a focused
assessment of the urinary system, including perineal skin integrity. (3)
Complete a bladder log to determine pattern of urine elimination, incontinence
episodes, and current bladder management program. (4) Consult with the
physician concerning current bladder function and the potential of the bladder
to produce upper urinary tract distress (hydronephrosis, vesicoureteral
reflux, febrile urinary tract infection, or compromised renal function). (5)
Determine a bladder management program in consultation with the client,
family, and rehabilitation team. (6) In consultation with the rehabilitation
team, counsel the client and family concerning .....
(1) If difficulties are encouraged in client teaching, refer the elderly
client to a nurse who specializes in care of the aging client with urinary
incontinence. (1) The interventions described previously may be adapted for
home care use. (2) Teach the client what the complications of reflex
incontinence are and when to report changes to a physician or primary nurse.
(3) If the client is taught intermittent self-catheterization, arrange for
contingency care in the event that the client is unable to perform
self-catheterization. (4) Assess and instruct the client and family in care of
the catheter and supplies in the home. (5) Encourage a mind-set and program of
self-care management. (6) Assist the family with arranging care in a way that
allows the client to participated in family or favorite activities without
embarrassment. Elicit discussion of the client's concerns about the social or
emotional burden of incontinence. (7) If meds are ordered, instruct the family
or caregivers and the client in medication administration.
(1) Teach the client with a spinal injury the signs of autonomic dysreflexia,
its relationship to bladder fullness, and management of the condition. (Refer
to the care plan for Autonomic dysreflexia.) (2) Teach the client and several
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significant others the techniques of intermittent catheterization, indwelling

catheter care and removal, or condom catheter management as appropriate. (3)
Teach the client and family techniques to clean catheters used for
intermittent catheterization, including washing with soap and water and
allowing to air dry, and using microwave cleaning techniques. ÿÿÿÿ ÿ
Incontinence, urinary, stress 539 State in which the individual experiences
urine loss of less than 50 ml accompanied by increased intra-abdominal
pressure. NOTE: The value of less than 50 ml for the volume of urine loss may
be exceeded by women and men with severe stress incontinence caused by
intrinsic sphincter deficiency. This is sometimes classified as "total
incontinence." In this book, however, "total incontinence" will be used to
refer exclusively to incontinence due to extraurethral causes, and all forms
of stress incontinence are reviewed under this diagnosis, regardless of
severity. Observed urine loss with physical exertion (sign of stress
incontinence); reported loss of urine associated with physical exertion or
activity (symptom of stress incontinence); urine loss associated with
increased abdominal pressure (urodynamic stress urinary incontinence).
Urethral hypermobility/pelvic organ prolapse (familial predisposition,
multiple vaginal deliveries, delivery of infant large for gestational age,
forceps-assisted or breech delivery, obesity, changes in estrogen levels at
climacteric, extensive abdominopelvic or pelvic surgery). Intrinsic sphincter
deficiency (multiple urethral suspensions in women, radical prostatectomy in
men, uncommon complication of transurethral prostatectomy or cryosurgery of
prostate, spinal lesion affecting sacral segments 2 to 4 or cauda equina,
pelvic fracture). Urinary Continence; Urinary Elimination (1) Report relief
from stress incontinence or report decrease in the incidence or severity of
incontinence episodes. (2) Experience reduction in grams of urine loss
measured objectively by a pad test. (3) Identify containment devices that
assist in management of stress incontinence. Pelvic Muscle Exercise; Urinary
Incontinence Care (1) Take a focused history addressing duration of urinary
leakage and related lower urinary tract symptoms, including daytime voiding
frequency, urgency, freuqency of nocturia, frequency of urinary leakage, and
factors provoking urine loss. (2) Perform a focused physical assessment,
including skin assessment, evaluation of the vaginal mucosa, reproduction of
the sign of stree incontinence, and observation of urethral hypermobility and
related pelvic descent (prolapse). (3) Determine the client's current use of
containment devices; evaluate the devices for their ability to adequately
contain urine loss, protect clothing, and control odor. Assest the client in
identifying containment devices specifically designed to contain urinary
leakage. (4) With the client and in close consultation with the physician,
review treatment options, including behavioral management; drug therapy; use
of a pessary, vaginal device, or urethral insert, and surgery. Outline their
potential benefits, efficacy,..
(1) Evaluate the elderly client's functional and cognitive status to determine
the impact of functional limitations on the frequency and severity of urine
loss and on plans for management. (1) The interventions described
previously may be adapted for home care use. (2) Elicit discussion of the
client's concerns about the social or emotional burden of stress incontinence.
(3) Encourage a mind-set and program of self-care management. (4) Implement a
bladder training program, including self-monitoring activities (reducing
caffeine intake, adjusting amount and timing of fluid intake, decreasing long
voiding intervals while awake, making dietary changes to promote bowel
regularity), bladder training, and pelvic muscle exercise. (5) Consider the
use of an indwelling catheter for continuous drainage in the client with
severe stress urinary incontinence who is homebound, bed-bound, and receiving
pallitive care (requires a physician's order). (6) When an indwelling catheter
is in place, follow the prescribed maintenance protocols for managing the
catheter, drainage bag, and perineal skin and urethral meatus. (7) Assist the
client in adapting to the catheter. Encourage ...........
(1) Teach the client to perform pelvic muscle exercise using an audiotape or
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videotape if indicated. (2) Teach the client the importance of avoiding

dehydration and instruct the client to consume fluid at the rate of 30 ml/kg
of body weight daily. (3) Teach the client the importance of avoiding
constipation by combination of adequate fluid intake, adequate intake of
dietary fiber, and exercise. (4) Teach the client to apply and remove support
devices such as bladder neck support prosthesis. (5) Teach the client to
select and apply urine containment device. ÿÿÿÿ ÿ Incontinence, urinary,
total 545 State in which the individual experiences continuous and
unpredictable loss of urine. NOTE: In this book, the diagnosis Total urinary
Incontinence will be used to refer to continuous urine loss due to an
extraurethral cause, and the diagnosis Stress urinary Incontinence will be
used to refer to leakage caused by urethral sphincter incompetence, regardless
of severity. Continuous urine flow varying from dribbling incontinence
superimposed on an otherwise identifiable pattern of voiding to severe urine
loss without identifiable micturition episodes. Ectopia (ectopic ureter opens
into vaginal vault or cutaneously; bladder ectopia with exstrophy/epispadias
complex. Fistula (opeing brom bladder or urethra to vagina or skin that
bypasses urethral sphincter mechanism, allowing continuous urine loss) Tissue
Integrity; Skin and Mucous Membranes; Urinary Continence; Urinary Elimination
(1) Experience urine loss that is adequately contained, with clothing
remaining unsoiled and odor controlled. (2) Maintain intact perineal skin. (3)
Maintain dignity, hide urine containment device in clothing, and minimize bulk
and noise related to device. Urinary Incontinence Care (1) Obtain a history
of the duration and severity of urine loss, prior management, and aggravating
or alleviating features. (2) Perform a focused physical assessment, including
inspection of the perineal skin, examination of the vaginal vault,
reproduction of the sign of stress incontinence (refer to the care plan for
Stress urinary Incontinence), and testing of bulbocavernosus reflex and
perineal sensations. (3) Consult a physician concerning the results of
colposcopy, cystourethroscopy, intravenous urogram, cystogram, Pyridium pad
test, or pelvic examination. (4) Assist the client in selecting and applying a
urine containment device(s). Review types of containment products with the
client, including advantages and potential complications associated with each
type of product. (5) Evaluate disposable vs. reusable products for urine
containment, considering the setting (home care vs. acute care vs. long-term
care), preferences of the client and caregiver(s), and immediate
..............
(1) Provide privacy and support when changing incontinent devices in elderly
clients. (2) Avoid brisk scrubbing and use of a washcloth when cleansing the
skin of an aging client. (3) Employ meticulous infection control procedures
when using an indwelling catheter. (1) The interventions described
previously may be adapted for home care use. (2) Encourage a mind-set and
program of self-care management. (3) Implement a bladder training program,
including self-monitoring activities (reducing caffeine intake, adjusting
amount and timing of fluid intake, decreasing long voiding intervals while
awake, making dietary changes to promote bowel regularity), bladder training,
and pelvic muscle exercise as appropriate. (4) Assist the family with
arranging care in a way that allows the client to participate in family or
favorite activities without embarrassment. Elicit discussion of the client's
concerns about the social or emotional burden of incontinence. (5) Consider
the use of an indwelling catheter for continuous drainage in the client with
severe urinary incontinence who is homebound, bed-bound, and receiving
palliative or end-of-life care (requires a physician's order). (6) When an
indwelling catheter is in place, follow the prescribed maintenance.....
(1) Teach the family to obtain, apply, and dispose of or clean and reuse urine
containment devices. (2) Teach the family a routine perineal skin care
regimen, including daily or every other day hygiene and cleansing with
containment product changes. (3) Teach the client and family to recognize and
manage perineal dermatitis, ammonia contact dermatitis, and monilial rash. (4)
Teach the client to maintain adequate fluid intake (30 ml/kg of body weight
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per day). (5) Teach the client and family to recognize and manage urinary
tract infection. ÿÿÿÿ ÿ Incontinence, urinary, urge 550 State in which the
individual experiences involuntary passage of urine with precipitous desire to
urinate. Urge incontinence is usually defined within the context of overactive
bladder syndrome. The overactive bladder is characterized by bothersome
urgency, with or without incontinence, and accompanied by frequent daytime
voiding and nocturia. Diurnal urinary frequency (voiding more than once every
2 hours while awake); urgency (subjective report of precipitous or immediate
need to urinate when urgency is perceived); years of age and more than once
per night to urinate for persons younger than 65 years of age and more than
twice per night for persons older than 65 years); symptom of urge incontinence
(urine loss associated with desire to urinate); enuresis (involuntary passage
of urine while asleep). (1) Neurological disorders (brain disorders,
including cerebrovascular accident, brain tumor, normal pressure
hydrocephalus, traumatic brain injury). (2) Inflammation of bladder (calculi;
tumor, including transitional cell carcinoma and carcinoma in situ;
inflammatory lesions of the bladder; urinary tract infection). (3) Bladder
outlet obstruction (see Urinary retention). (4) Stress urinary incontinence
(mixed urinary incontinence; these conditions often coexist but relationship
between them remains unclear). (5) Idiopathic causes (implicated factors
include depression, sleep apnea/hypoxia). Tissue Integrity: Skin and Mucous
Membranes; Urinary Continence; Urinary Elimination (1) Report relief from
urge urinary incontinence or a decrease in the incidence or severity of
iincontinent episodes. (2) Identify containment devices that assist in the
management of urge urinary incontinence. Urinary Habit Training; Urinary
Incontinence Care (1) Take a nursing history focusing on duration of urinary
incontinence, diurnal frequency, nocturia, severity of symptoms, and
alleviating and aggravating factors. (2) Complete a urinalysis, examining for
the presence of nitrites, leukocytes, glucose, or hemoglobin (RBCs). (3)
Complete a bladder log, including frequency of diurnal micturition and
nocturia, patterns of incontinence, symptoms of accompanying urine loss, and
the type and volume of fluids consumed. (4) Review all meds the client is
receiving, paying particular attention to sedatives, narcotics, diuretics,
antidepressants, psychotropic drugs, and cholinergics. Consult the physician
about altering or eliminating these meds if they are suspected of affecting
incontinence. (5) Assess the client for urinary retention (see care plan for
Urinary Retention). (6) Assess the client for functional limitiations
(environmental barriers, limited mobility or dexterity, impaired cognitive
function [see care plan for Functional .........
(1) Assess the functional and cognitive status of the elderly client with urge
incontinence. (2) Plan care in long-term care facilities based on knowledge of
the elderly client's established voiding patterns, paying particular attention
to patterns of nocturia. (3) Carefully monitor the elderly client for
potential adverse effects of antispasmodic meds, including a severely dry
mouth interfering with the use of dentures, eating, or speaking, or confusion,
nightmares, constipation, mydriasis, or heat intolerance. (1) The
interventions described previously may be adapted for home care use. (2) Teach
the importance of avoiding dehydration or excessive fluid consumption and the
paradoxical relationship between dehydration and symptoms or urgency. (3)
Teach the family and client to identify and correct environmental barriers to
toileting iwthin the home. (4) Encourage a mind-set and program of self-care
management. (5) Implement a bladder training program as appropriate, including
self-monitoring activities (reducing caffeine intake, adjusting amount and
timing of fluid intake, decreasing long voiding intervals while awake, making
dietary changes to promote bowel regularity), bladder training, and pelvic
muscle exercise. (6) Help the client and family to identify and correct
environmental barriers to toileting within the home.
(1) Teach the client and family to recognize foods and beverages that are
unliekly to irritate the bladder. (2) Teach the family and client to recognize
and manage side effects of antispasmodic meds used to treat incontinence. (3)
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Help the client and family to recognize and manage side effects of
anticholinergic meds used to manage irritative lower urinary tract symptoms. ÿ
ÿÿÿ ÿ Incontinence, urinary, urge, risk for 555 At risk for involuntary
loss of urine associated with a sudden, strong sensation or urinary urgency.
Effects of medications, caffeine, alcohol, detrusor hyperreflexia from
cystitis, urethritis, tumors, renal calculi, central nervous system disorders
above the pontine micturition center; detrusor muscle instability with
impaired contractility; involuntary sphincter relaxation; ineffective
toileting habits; small bladder capacity. Tissue Integrity: Skin and Mucous
Membranes; Urinary Continence; Urinary Elimination (1) Report relief from
urge urinary incontinence or a decrease in the incidence or severity of
incontinent episodes. (2) Identify containment devices that assist in the
management of urge urinary incontinence Urinary Habit Training; Urinary
Incontinence Care (1) Take a nursing history focusing on the following lower
urinary tract symptoms: daytime voiding frequency, nocturia, presence of
bothersome urgency (precipitous desire to urinate that interferes with ADLs),
and presence of urine loss. (2) Query the client about specific risk factors
for urge urinary incontinence, such as childhood enuresis, depression,
prostate enlargement with bladder outlet obstruction, and neurological
disorders, including stroke or parkinsonism. (3) Assess the client's
functional status, focusing on mobility, dexterity, and cognitive status. (4)
Complete a urinalysis, focusing on the presence of nitrates, leukocytes,
glucose, or hemoglobin (RBCs). (5) complete bladder log, including frequency
of diurnal micturition and nocturia, and the type and volume of fluids
consumed. (6) Review with the client the types of beverages consumed, focusing
on the intake of bladder irritants, including caffeine and alcohol. Advise the
client to reduce or eliminate the intake ....
(1) Assess the functional and cognitive status of an elderly client with
irritative lower urinary tract symptoms or urge incontinence. (2) Advise a
male client with bothersome lower urinary tract symptoms to see his physician
or nurse-practitioner, since these symptoms may be related to prostate
enlargement. (3) Carefully monitor the elderly client for potential adverse
effects of anticholinergic meds, including severe dry mouth interfering with
the use of dentures, eating, or speaking, or the occurence of confusion,
nightmares, constipation, mydriasis, or heat intolerance. (1) The
Encourage mind-set program of self-care management. (3) Implement a bladder
training program, including self-monitoring activites (reducing caffeine
intake, adjusting amount and timing of fluid intake, decreasing long voiding
intervals while awake, making dietary changes to promote bowel regularity),
bladder training, and pelvic muscle exercise. (4) Teach the client and family
to recognize foods and beverages that are likely to irritate the bladder. (5)
Teach the importance of avoiding dehydration or excessive fluid consumption
and the paradoxical relationshiip between dehydration and symptoms of urgency.
(6) Teach the family and client to recognize and manage side effects of
anticholinergic meds used to treat irritative lower urinary tract symptoms.
(7) Teach the family and client to identify and correct environmental barriers
to toileting. (8) Assist the family with arranging care in a way that
allows...
(1) Teach the client and family to recognize foods and beverages that are
likely to irritate the bladder. (2) Teach the importance of avoiding
dehydration or excessive fluid consumption and the paradoxical relationship
between dehydration and symptoms of urgency. ÿÿÿÿ ÿ Infant behavior,
disorganized 560 Disintegrated physiological and neurobehavioral responses
to the environment Regulatory problems; instability to inhibit startle;
irritability STATE-ORGANIZATION SYSTEM: Active awake (fussy, worried gaze);
diffuse/unclear sleep, state-oscillation; quiet-awake (staring, gaze
aversion); irritable or panicky crying. ATTENTION-INTERACTION SYSTEM: Abnormal
response to sensory stimuli (e.g., difficult to soothe, inability to sustain
alert status). MOTOR SYSTEM: Increased, decreased, or limp tone; finger splay,
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fisting, or hands to face; hyperextension of arms and legs; tremors, startles,

twitches; jittery, jerky, uncoordinated movement; altered primitive rreflexes.
PHYSIOLOGICAL: Bradycardia, tachycardia, or dysrhythmias; pale, cyanotic,
mottled, or flushed color; "time-out signals" (e.g., gaze, grasp, hiccough,
cough, sneeze, sigh, slack jaw, open mouth, tongue thrust); oximeter reading:
desaturation; feeding intolerances (aspiration or emesis) PRENATAL:
Congenital or genetic disorders; teratogenic exposure. POSTNATAL: Manutrition;
oral/motor problems; pain; feeding intolerance; invasive/painful procedures;
prematurity. INDIVIDUAL: Illness; immature neurological system, gestational
age; postconceptual age. ENVIRONMENTAL: Physical environment
inappropriateness; sensory inappropriateness; sensory overstimulation; sensory
deprivation. CAREGIVER: Cue misleading; cue-deficient knowledge; environmental
stimulation contribution Child Development: 2 Months, 4 Months, 6 Months;
Growth; Neurological Status; Newborn Adaptation; Nutritional Status: Food and
Fluid Intake; Preterm Infant Organization; Sleep; Thermoregulation: Newborn;
Vital Signs INFANT/CHILD: (1) Have stable vital signs (2) Display smooth and
synchronous body movements. (3) Display smooth transitions between sleep and
wake states. (4) Demonstrate self-consoling behaviors. (5) Demonstrate ability
to tolerate feedings. (6) Display stable color. PARENTS/SIGNIFICANT OTHER: (1)
Recognize infant/child behaviors as a unique way of communicating needs and
goals. (2) Recognize infant behavior used to communicate stress, avoidance and
approach, and regulation. (3) Recognize and support infant's/child's drive and
behaviors used to self-regulate. (4) Demonstrate ways of being more responsive
to infant/child cues and needs. (5) Recognize the way their interactions
affect the infant's/child's responses and that allowing the infant/child to
take the lead in the interaction fosters adaptive communication patterns. (6)
Structure and modify the environment in response to infant/child behaviors.
(7) identify appropriate positioning and handling techniques to enhance
comfort..... Developmental Care; Parent Education: Infant; Positioning; Sleep
Enhancement (1) Identify infant's/child's level of neurobehavioral
organization as a unique way of communicating. (2) Recognize behavior used to
communicate stress, avoid, approach, and regulate. (3) Identify and support
the infant's/child's self-regulatory behaviors used for mastery of the
environment. (4) Cluster caregiving whenever possible to allow for longer
periods of uninterruped sleep. (5) Correlate the evidence of stress or
disorganization to internal factors (e.g., pain, hunger, discomfort) or
external factors (e.g., lights, noise, handling). (6) Structure and modify
care and environment. (7) Facilitate the use of developmentally supportive
positioning and handling. (8) Consider the use of infant massage if
appropriate. (9) Support parents' competence in appraising thier infant's
behavior and responses. (10) Facilitate Kangaroo Care/skin-to-skin contact to
promote infant's adaptibility to external environment. (11) Identify
techniques to assist development of state modulation and .......
family's perceptions of infant/child behavior. (2) Use a neutral, indirect
style when addressing areas where improvement is needed (such as a need for
verbal or oral stimulation) when working with Native American clients. (3)
Acknowledge and praise parenting strengths noted. (4) Use therapeutic
communication techniques that emphasize acceptance, offer the self, validate
the client's concerns, and convery respect when discussing the infant/child
behavior. (1) Above interventions may be adapted for home care use. (2)
Assist families in structuring home environment. (3) Encourage families to
teach friends/visitors to recognize and respond to infant's behavior cues.
(1) Assist families/support systems in recognizing and responding to infant's
unique behavioral cues. (2) Give anticipatory guidance to parents about what
infant/child behaviors are possible in given situations. (3) Model calming
interventions to provide parents with tools for positive interactions with
their infant/child. (4) Nurture paraents so that they in turn can nurture
their infant/child. ÿÿÿÿ ÿ Infant behavior, disorganized, risk for 566
Risk for alteration in integrating and modulation of the physiological and
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neurobehavioral systems of functioning (i.e., autonomic, motor, state,

organizational, self-regulatory, and attentional-interactional systems).
Pain; invasive/painful procedures; lack of containment/boundaries; oral/motor
problems; prematurity/ environmental overstimulation See care plan for
Disorganized Infant Behavior See care plan for Disorganized Infant Behavior
See care plan for Disorganized Infant Behavior See care plan for Disorganized
Infant Behavior
See care plan for Disorganized Infant Behavior See care plan for
Disorganized Infant Behavior
See care plan for Disorganized Infant Behavior ÿÿÿÿ ÿ Infant behavior,
organized, readiness for enhanced 566 A pattern of modulation of the
physiological and behavioral systems of functioning (i.e., autonomic motor,
state-organizational, self-regulatory, and attentional-interactional systems)
in an infant that is satisfactory but that can be improved, resulting in
higher levels of integration in response to environmental stimuli Definite
sleep-wake states; use of some self-regulatory; response to visual/auditory
stimuli; stable physiological measures Pain; prematurity Child Development:
2 Months, 4 Months, 6 Months; Growth; Neurological Status; Newborn Adaptation;
Nutritional Status: Food and Fluid Intake; Preterm Infant Organization;
Sleep; Thermoregulation: Newborn; Vital Signs INFANT/CHILD: (1) Have stable
vital signs. (2) Display smooth and synchronous body movements (3)) Display
smooth transitions between sleep and wake states (4) Demonstrate
self-consoling behaviors (5) Demonstrate ability to tolerate feedings (6)
Display stable color PARENTS/SIGNIFICANT OTHER: (1) Recognize infant/child
behavior as a unique way of communicating needs and goals (2) recognize infant
behavior used to communicate stress, avoidance and approach, and regulation
(3) Recognize and support infant's/child's drive behaviors used to
self-regulate (4) Demonstrate ways of being more responsive to infant/child
cues and needs (5) Recognize the way interctions affect the infant's/child's
responses and that allowing the infant/child to take lead in the interaction
fosters adaptive communication patterns (6)Structure and modify the
environment in response to infant/child behaviors (7)Identify appropriate
positioning and handling techniques to enhance comfort and normal development
and .... Developmental Care; Environmental management; Kangaroo Care; Newborn
Monitoring; Nonnutrituve Sucking; Positioning; Sleep Enhancement (1) Identify
infant's/child's level of neurobehavioral organization as a unique way of
communicating. (2) Recognize behavior used to communicate stress, avoid and
approach, and regulated. (3) Identify and support infant's/child's
self-regulatory coping behaviors used for mastery of the environment. (4)
Cluster caregiving whenever possible to allow for longer periods of
uninterrupted sleep. (5) Structure and modify care and environment. (6)
Facilitate the use of developmentally supportive positioning and handling. (7)
Consider the use of infant massage if appropriate. (8) Facilitate Kangaroo
Care/skin-to-skin contact to promote infant's adaptability to external
environment. (9) Identify techniques to assist development of state modulation
and organization. (10) Identify and support infant's/child's attention
capabilities. (11) Enhance normal developmental patterns through appropriate
sensorimotor stimulation.
(1) Assess for the influence of cultuarl beliefs, norms, and values on the
parents'/caregiver's perceptions of infant/child behavior. (2) Use a neutral,
indirect style when addressing areas where improvement is needed (such as a
need for verbal or oral stimulation) when working with Native American
clients. (3) Acknowledge and praise parenting strengths and ability to respond
to infant/child. (4) Use therapeutic communication techniques when discussing
the infant/child. (1) Assist families in structuring home environment. (2)
Encourage families to teach friends/visitors to recognize and respond to
infant's unique behavioral cues.
(1) Assist families/support systems in recognizing and responding to infant's
unique behavioral cues. (2) Support parents' competence in appraising their
infant's behavior and responses. (3) Give anticipatory guidance to parents
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about what infant/child behaviors are possible in given situations. ÿÿÿÿ ÿ

Feeding pattern, infant, ineffective 572 Impaired ability to suck or
coordinate the suck-swallow response Inability to coordinate sucking,
swallowing, and breathing; inability to initiate or sustain an effective suck
Prolonged NPO; anatomic abnormality; neurological impairment/delay; oral
hypersensivity; prematurity Breastfeeding Establishment: Infant, Maternal;
Breastfeeding: Maintenance; Growth; Hydration; Knowledge: breastfeeding;
Neurological Status: Central Motor Control, Cranial Sensory/Motor Function;
Nutritional Status: Food and Fluid Intake INFANT: (1) Receive adequate
nourishment, without compromising autonomic stability (2) Progress to a normal
feeding pattern. FAMILY: (1) Learn successful techniques for feeding the
infant Aspiration Precautions; Bottle Feeding; Breastfeeding Assistance;
Enteral Tube Feeding; Fluid Monitoring; Kangaroo Care; Lactation Counseling;
Nonnutritive Sucking; Swallowing Therapy; Teaching: Infant Safety; Tube Care:
Umbilical Line (1) Assess infant's oral reflexes (i.e., root, gag, suck, and
swallow). (2) Determine infant's ability to coordinate suck, swallow, and
breathing reflexes. (3) Collaborate with other health care providers (e.g.,
physician, neonatal nutritionist, physical and occupationsl therapists,
lactation specialists) to develop a feeding plan. (4) Implement gavage
feedings (or another alternative feeding method), using breast milk whenever
possible, before infant's readiness for feedings by mouth. (5) Provide
opportunities for nonnutritive sucking during gavage feedings (or other
alternative feeding methods) and for 5 minutes before initiating oral
feedings. (6) Evaluate feeding environment and minimize sensory stimuli. (7)
Position preterm infant in a flexed feeding posture that is similar to the
posture used for a full-term infant. (8) Attempt to nipple feed baby only when
infant is in a quiet-alert state. (9) Allow appropriate time for nipple
feeding to ensure infant's safety without ..........
(1) Provide anticipatory guidance for infant's expected feeding course. (2)
Teach parents infant feeding methods. (3) Teach parents how to recognize
infant cues. (4) Provide anticipatory guidance for the infant's discharge. ÿ
ÿÿÿ ÿ Infection, risk for 576 At increased risk for being invaded by
pathogenic organisms Invasive procedures; insufficient knowledge regarding
avoidance of exposure to pathogens; trauma; tissue destruction and increased
environmental exposure; rupture of amniotic membranes; pharmaceutical agents
(e.g., immunosuppressants); malnutrition; increased environmental exposure to
pathogens; immunosuppression; inadequate acquired immunity; inadequate
secondary defenses (e.g., decreased hemoglobin, leukopenia, suppressed
inflammatory response); inadequate primary defenses (e.g., broken skin,
traumatized tissue, decrease in ciliary action, stasis of body fluids, change
in pH secretions, altered peristalsis); chronic disease Immune Status;
Knowledge: Infection Control; Risk control; Risk Detection (1) Remain free of
symptoms of infection. (2) State symptoms of infection of which to be aware.
(3) Demonstrate appropriate care of infection-prone site. (4) Maintain white
blood cell (WBC) count and differential within normal limits. (5) Demonstrate
appropriate hygienic measures such as hand washing, oral care, and perineal
care Immunization/Vaccination Administration; Infection control; Infection
Protection (1) Observe and report signs of infection such as redness, warmth,
discharge, and increased body temperature. (2) Assess temperature of
neutropenic clients every 4 hours; report a single temperature of greater than
38.5° C or three temperatures of greater than 38° C in 24 hours. (3) Oral or
tympanic thermometers may be used to assess temperature in adults and infants.
(4) Use oral thermometers for critically ill adults. (5) Note and report
laboratory values (e.g., WBC count and differential, serum protein, serum
albumin, and cultures). (6) Remove the granulocytopenic client from areas
exposed to construction dust so that the client will not inhale fungal spores.
Remove all plants and flowers from the client's room. (7) Assess skin for
color, moisture, texture, and turgor (elasticity). Keep accurate, ongoing
documentation of changes. Preventive skin assessment protocol, including
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documentation, assists in the prevention of skin breakdown. (8) Carefully wash

and pat dry skin.............
(1) Recognize that geriatric clients may be seriously infected but have less
obvious symptoms. The immune system declines with aging. (2) Suspect pneumonia
when the client has symptoms of fatigue or confusion. (3) Most clients develop
NP by either aspirating contaminated substances or inhaling airborne
particles. Refer to care plan for Risk for Aspiration. (4) Foot care other
than simple toenail cutting should be performed by a podiatrist. (5) Observe
and report if the client has a low-grade temperature or new onset of
confusion. (6) During the peak of the influenza epidemic, limit visits by
relatives and friends. (7) Recommend that the geriatric client receive an
annual influenza immunization and one-time pneumococcal vaccine. (8) Recognize
that chronically ill geriatric clients, particularly those with depression,
have an increased susceptibility to infection; practice meticulous care of all
invasive sites. (9) Recognize that older adults are at risk for
HIV/AIDS......... (1) Some of the above interventions may be adapted for
home care use. (2) Review standards for surveillance of infections in home
care. (3) Assess home environment for general cleanliness, storage of food
items, and appropriate waste disposal. Instruct as necessary in proper
disposal and use of disinfecting agents. (4) Assess home care environment for
appropriate disposal of used dressing materials. (5) Role-model all preventive
behaviors in care of the client (e.g., Universal Precautions). Do not visit
the client when you are ill. (6) Maintain the cleanliness of all irrigation
and cleansing solutions. Change solutions when cleanliness has not been
maintained—do not wait to finish bottle. (7) Assess and teach clients about
current medications and therapies that promote susceptibility to infection:
corticosteroids, immunosuppressants, chemotherapeutic agents, and radiation
therapy. (8) Assess the client for knowledge of infections that have been drug
resistant. (9) Instruct the.....
(1) Teach the client risk factors contributing to surgical wound infection,
smoking, and higher body mass index. (2) Teach the client and family the
symptoms of infection that should be promptly reported to a primary medical
caregiver (e.g., redness; warmth; swelling; tenderness or pain; new onset of
drainage or change in drainage from wound; increase in body temperature). (3)
Teach signs of hepatitis B virus (HBV)/AIDS symptoms: malaise, abdominal pain,
vomiting or diarrhea, enlarged glands, rash; tuberculosis symptoms: cough,
night sweats, dyspnea, changes in sputum, changes in breath sounds;
insulin-dependent diabetes mellitus (IDDM) symptoms: sores or wounds that do
not heal). (4) Encourage high-risk persons, including health care workers, to
have influenza vaccinations. (5) Assess whether the client and family know how
to read a thermometer; provide instructions if necessary. Chemical dot
thermometers are easy to use and decrease risk of infection. Clients need to
know that.... ÿÿÿÿ ÿ Injury, risk for 584 At risk of injury as a result of
the interaction of environmental conditions interacting with the individual's
adaptive and defensive resources. NOTE: This nursing diagnosis overlaps with
other diagnoses such as Risk for Falls, Risk for Trauma, Risk for Poisoning,
Risk for Suffocation, Risk for Aspiration, and if the client is at risk of
bleeding, Ineffective Protection. See care plans for these diagnoses if
appropriate. EXTERNAL: Mode of transport or transportation; people or
provider (e.g., nosocomial agents; staffing patterns; cognitive, affective,
and psychomotor factors); physical (e.g., vitamins, food types); biological
(e.g., immunization level of community, microorganism); chemical (e.g.,
pollutants, poisons, drugs, pharmaceutical agents, alcohol, caffeine,
nicotine, preservatives, cosmetics, dyes). INTERNAL: Psychological (affective
orientation); malnutrition; abnormal blood profile (e.g.,
leukocytosis/leukopenia); altered clotting factors; thrombocytopenia; sickle
cell; thalassemia; decreased hemoglobin; immune-autoimmune dysfunction;
biochemical, regulatory function (e.g., sensory dysfunction, integrative
dysfunction, effector dysfunction, tissue hypoxia); developmental age
(physiological, psychosocial); physical (e.g., broken skin, altered mobility)
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Fall Prevention Behavior; Fetal Status: intrapartum; Immune Status; Maternal

Status: Intrapartum; Parenting: Psychosocial Safety; Personal Safety Behavior;
Risk Control; Safe Home Environment (1) Remain free of injuries. (2) Explain
methods to prevent injury Behavior Modification; Health Education; Patient
Contracting; Self-Modification Assistance (1) Prevent iatrogenic harm to the
client by following these guidelines for giving care: Use at least two methods
to identify the client before administering medications or blood products,
such as the client's name and birth date. (2) Prior to beginning any invasive
or surgical procedure, have a final verification to confirm the correct
client, the correct procedure, and the correct site for the procedure using
active or passive communication techniques (3) When taking verbal or telephone
orders, always require a verification back of the complete order by the person
taking the orders. (4) Standardize use of abbreviations and eliminate
abbreviations that are prone to cause errors. (5) Take high alert medications
off the nursing unit, such as potassium chloride. (6) Use only intravenous
pumps that prevent free flow of intravenous solution when the tubing is taken
out of the pump. (7) Improve the effectiveness of alarm systems in the
clinical area. (8) Thoroughly orient the client......
(1) Teach parents the need for close supervision of all young children
playing near water. If child has epilepsy, recommend showers instead of tub
baths, and no unsupervised swimming is ever allowed. (2) Teach parents and
children the need to maintain safety for the exercising child, including
wearing helmets when biking, using breakaway bases for baseball, and having
the needed conditioning for the activity. (3) Teach both parents and children
the need for gun safety.
(1) Encourage the client to wear glasses and hearing aids and to use walking
aids when ambulating. (1) Acknowledge racial/ethnic differences at the onset
of care. (2) Assess for the influence of cultural beliefs, norms, and values
on the client's perceptions of risk for injury. (3) Assess whether exposure to
community violence is contributing to risk for injury. (4) Use culturally
relevant injury prevention programs whenever possible. (5) Validate the
client's feelings and concerns related to environmental risks. (1) Some of
the above interventions may be adapted for home care use. (2) Assess home
environment for threats to safety: clutter, inappropriate storage of
chemicals, slippery floors, scatter rugs, unsafe stairs and stairwells,
blocked entries, dim lighting, extension cords across pathways, unsafe
electrical or gas connections, unsafe heating devices, unsafe oxygen
placement, high beds without rails, excessively hot water, pets, and pet
excrement. (3) Instruct the client and family or caregivers in correcting
identified hazards. Refer to occupational therapy services for assistance if
needed. Notify landlord or code enforcement office of any structural building
hazards. (4) Refer to physical therapy services for the client and family
education in safe transfers and ambulation and for strengthening exercises for
ambulation and transfers. (5) Avoid extreme hot and cold around clients at
risk for injury (e.g., heating pads, hot water for baths/showers). Clients
with decreased cognition....
(1) Teach how to safely ambulate at home, including using safety measures such
as handrails in bathroom. (2) If the client has visual impairment, teach the
client and caregiver to label with bright colors such as yellow or red
significant places in environment that must be easily located (e.g., stair
edges, stove controls, light switches). (3) Teach the client to avoid
excessive noise at work or at home, wearing hearing protection when necessary.
Any noise that hurts the ears or is above 90 decibels is excessive. (4) Teach
clients winter safety information: Burn only untreated wood for heat. Keep
portable space heaters at least 3 feet from anything that can burn.
Install smoke alarms and carbon monoxide alarm near bedrooms. Check the
chimney and flue each year. Avoid sitting in an idling car in winter when snow
can obstruct the exhaust pipe. Follow safety guidelines for use of snow
blowers.
ÿÿÿÿ ÿ Injury, perioperative positioning, risk for 591 At risk for injury
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as a result of the environmental conditions found in the perioperative setting

RISK FACTORS: Disorientation; edema; emaciation; immobilization; muscle
weakness; obesity; sensory/perceptual disturbances resulting from anesthesia.
High pressure for short periods of time and low pressure for extended periods
of time are risk factors for tissue injury. NOTE: The following systems are
most frequently affected by surgical positioning: neurological,
musculoskeletal, integumentary, respiratory, and cardiovascular. Risk factors
contributing to the incidence of injury related to surgical positioning
include but are not limited to the client's age; height; weight; nutritional
status; skin condition; the presence of preexisting conditions such as
diabetes, vascular, and/or respiratory disease; immunocompromise; impaired
nerve function; physical mobility limitations such as arthritis, limited range
of mmtion (ROM), implants/prosthesis, or malignancy; effects of anesthesia;
staff's knowledge of the procedure. As a result of these factors, there is the
potential for impaired... COMPLICATIONS OF SURGICAL POSITIONING:
Complications of positioning include, but are not limited to, mechanical
restriction of the rib cage, vasodilatation, hyper/hypotension, decreased
cardiac output, inhibition or normal compensatory mechanisms, redistribution
and congestion of the blood supply, and nerve muscle trauma due to stretching
and compression. NURSING RESEARCH: Several studies have shown that procedures
lasting more than 2.5 to 3 hours significantly increase the risk for pressure
ulcer formation. Occlusion, causing restriction or blockage of blood flow, has
been shown to occur when external pressure exceeds the normal capillary
interface pressure of 23 to 32 mm Hg. Transient physiological reactions to
surgical positioning include skin redness and/or bruising, lumbar backache,
stiffness in the limbs and neck, numbness, and generalized muscle aches that
usually resolve within 24 to 48 hours without treatment. Lumbar back pain,
previously considered a transient physiological.. Circulation Status;
Neurological Status; Risk Control; Tissue Integrity: Skin and Mucous
Membranes; Tissue Perfusion: Peripheral (1) Be free of injury related to
positioning during the surgical procedure. (2) Demonstrate unchanged or
improved physical mobility from preoperative status. (3) Demonstrate unchanged
or improved cardiovascular status from preoperative status. (4) Demonstrate
unchanged or improved peripheral sensory integrity from preoperative status.
(5) Maintain sense of privacy and dignity Positioning: Intraoperative;
Pressure Ulcer Prevention; Risk identification; Skin Surveillance (1) Proper
positioning requires knowledge of not only the equpment, but also anatomy and
the application of physiological principles. (2) A preoperative assessment,
which includes a determination of the client's ROM/mobility, is necessary to
determine the need for positioning aids and should be completed prior to the
surgical procedure. (3) Clients with limited mobility/ROM should be asked to
position themselves under the nurse's guidance before induction of anesthesia
so that the client can verify that a position of comfort has been obtained.
(4) Appropriate numbers of personnel should be present to assist in
positioning the client. (5) Monitor pressure being applied to the client
intraoperatively by staff, equipment, and/or instruments. (5) Keep linens on
the OR table free of wrinkles. (6) Maintain equipment in good working order
and use according to manufacturer's instructions: Verify that the equipment is
clean, operating properly, free of sharp edges, able to maintain normal ....
ÿÿÿÿ ÿ Intracranial adaptive capacity, decreased 600 Intracranial fluid

dynamic mechanisms that normally compensate for increases in intracranial
volumes are compromised, resulting in repeated disproportionate increases in
intracranial pressure (ICP) in response to a variety of noxious and
non-noxious stimuli. Repeated increases in ICP of greater than 10 mm Hg for
more than 5 min following a variety of external stimuli; disproportionate
increases in ICP following a single environmental or nursing maneuver
stimulus; baseline ICP greater than 10 mm Hg; elevated P2 componnt of ICP
waveform; wide-amplitude ICP waveform; volume-pressure response test variation
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(volume-pressure ratio of 2, pressure-volume index of less than 10).

Decreased cerebral perfusion less than 50 to 60 mm Hg; sustained increase in
ICP greater than 10 to 15 mm Hg; systemic hypotension with intracranial
hypertension; brain injuries Neurological Status; Neurological Status:
Consciousness (1) Experience fewer than five episodes of disproportionate
increases in ICP (DIICP) in 24 hours. (2) Have neurological status changes
that are not triggered by episodes of DIICP. (3) Have CPP remains greater than
60 to 70 mm Hg in adults. Cerebral Edema Management; Cerebral Perfusion
Promotion; Intracranial Pressure (ICP) Monitoring; Neurological Monitoring
(1) ...... (2) Elevate HOB if the client maintains CPP. (3) ..... (4) Addition
of sedation (e.g., morphine, midazolam, propofol) and analgesia with or
without paralysis (eg. antracurium, pancuronium [Pavulon]) if body movements
or fighting respirator continuously stimulate CPP decrease. (5) Bolus
administration of osmotic diuretic or other hyperosmotic agent (e.g.,
mannitol, mannitol plus furosemide) may be followed with continuous
administration if CPP is not maintained with bolus administration. Note that
it is essential to keep serum osmolality less than 320 mOsm/L to prevent
hyperosmolality-related seizures. (6) Control hyperventilation, maintaining
Pco2 of 30 to 35 mm Hg unless ICP continues to be refractory, in which case
Pco2 may be briefly decreased below 30 mm Hg if ICP is responsive. (7)
.....(8) .....
NOTE: Clients experiencing potentially rapid changes in ICP are not
cadidtes for home care. However, clients experiencing potentially gradual
changes in ICP (i.e., clients with developmental delays resulting from genetic
dysfunction), or clients post ICP changes secondary to brain trauma, may be
served by home care with the following considerations: (1) Some of the above
interventions may be adapted for home care use. (2) Identify baseline
neurological data before discharge from institutional care. (3) Evaluate
neurological functioning at regular intervals. (4) Instruct the client/family
in appropriate expectations of cognitve recovery following minor brain injury.
(5) For clients with a history of traumatic brain injury, assess for mood,
thought process, or personality disturbances and refer for appropriate mental
health follow-up. (6) Institute case management of frail elderly to support
continued independent living.
ÿÿÿÿ ÿ Knowledge, deficient 607 Absence or deficiency of cognitive
information related to a specific topic Verbalization of the problem;
inaccurate follow-through of instruction; inaccurate performance of test;
inappropriate or exaggerated behaviors (e.g., hysterical, hostile, agitated,
apathetic) Lack of exposure; lack of recall; information misinterpretation;
cognitive limitation; lack of interest in learning; unfamiliarity with
information resources Knowledge: Diet, Disease Process, Energy Conservation,
Health Behavior, Health Resources, Infection Control, Medication, Personal
Safety, Prescribed Activity, Substance Use Control, Treatment Procedure(s),
Treatment Regimen (1) Explain disease state, recognize need for medications,
and understand treatments. (2) Explain how to incorporate new health regimen
into lifestyle. (3) State an ability to deal with health situation and remain
in control of life. (4) Demonstrate how to perform procedure(s)
satisfactorily. (5) List resources that can be used for more information or
support after discharge. Teaching: Disease Process, Individual, Infant Safety
(1) Observe the client's ability and readiness to learn (e.g., mental acuity,
ability to see or hear, no existing pain, emotional readiness, absence of
language or cultural barriers) and previous knowledge. (2) Assess barriers to
learning (e.g., perceived change in lifestyle, financial concerns, cultural
patterns, lack of acceptance by peers or coworkers). (3) Involve clients in
writing specific outcomes for the teaching session, such as identifying what
is most important to learn from their viewpoint and lifestyle. (4) When
teaching, build on the client's literacy skills. (5) Present material that is
most significant to the client first, such as how to give injections or change
dressings; present additional material once the client's most pressing
educational needs have been met. (6) Determine the client's understanding of
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common medical terminology, such as "empty stomach," "emesis," and

"palpation." (7) Evaluate the readability of the material in pamphlets or
written instructions...
(1) Adapt the teaching process for the physical constraints of the aging
process (e.g., speak clearly, use a variety of audio-visual-psychomotor
methods, provide examples, and allow time for the client to repeat and
review). (2) Ensure that the client uses necessary reading aids (e.g.,
eyeglasses, magnifying lenses, large-print text) or hearing aids. (3) Use
printed material, videotapes, lists, diagrams, and Internet addresses that the
client can refer to at another time. (4) Repeat and reinforce information
during several brief sessions. (5) Discuss healthy lifestyle changes that
promote wellness for the older adult. (6) Evaluate readability of the
material. (7) Consider health education programs using television and
newspapers. (1) Acknowledge racial/ethnic differences at the onset of care.
client's knowledge base. (3) Use a neutral indirect style when addressing
areas where improvement is needed when working with Native American clients.
(4) Validate the client's feelings and concerns related to previous learning
experiences. (5) Approach individuals of color with respect, warmth, and
professional courtesy. (6) Provide health care information to mothers and
grandmothers in African American families. NOTE: Because home care is an
intermittent model of care having a goal of safety and optimal wellness of the
client between visits, the importance of teaching (by the nurse) and learning
(by the client) should not be understated. All of the previously mentioned
interventions are applicable to the home setting. (1) Select a space and time
for teaching in which the client and/or caregiver can focus on information to
be learned. (2) Consider the complexity of material or behaviors to be
learned. Adjust care plan and respective teaching and learning experiences
accordingly to build client confidence in ability to learn (and change). (3)
Assess the client for low or absent literacy. Use illustrations for
instruction that are as closely equivalent as possible to written
instructions. (4) Assess the client/family learning needs and current level of
knowledge. (5) Assess for specific areas of learning that have the potential
for strong emotional responses by the client or family/caregiver....
ÿÿÿÿ ÿ Knowledge of (specify), readiness for enhanced 612 The presence or
acquisition of cognitive information related to a specific topic is sufficient
for meeting health-related goals and can be strengthened Expresses an
interest in learning; explains knowledge of the topic; behaviors congruent
with expressed knowledge; describes previous experiences pertaining to the
topic To be developed Knowledge: Health Promotion (1) Demonstrate knowledge
of new information. (2) Meet personal health-related goals. (3) Explain how to
incorporate new health regimen into lifestyle. (4) List sources to obtain
information. Health Education; Learning Readiness Enhancement (1) Include
clients as members of health care team when providing education. (2) Use
open-ended questions and encourage two-way communication. (3) Provide
appropraite individualized health education when clients visit health care
providers. (4) Ensure that clients receive appropriate health-oriented
education during rehabilitation hospitalization. (5) When developing written
information, assess and provide info that is important to clients. (6)
Carefully develop written materials to ensure that the client's literacy
levels, including English as a second language, are addressed. (7) Assist
clients to find access to the Internet, libraries, and schools to find health
info. (8) Assist clients with questions about health info to find quality
sites on the Internet. (9) Provide a previsit questionnaire to facilitate
individualized proactive planning before the visit to health care provider.
(10) Provide appropriate health care info and screening for clients with
physical disabilities. ......
(1) Consider using an interactive multimedia computer software program to
disburse education. (1) Refer to Deficient Knowledge care plan. (2) Provide
health care information to mothers and grandmothers in African American
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families. NOTE: Because home care is an intermittent model of care having a

goal of safety and optimal wellness of the client between visitis, the
importance of teaching (by the nurse) and learning (by the client) should not
be understated. All of the previously mentioned interventions are applicable
to the home setting. (2) Consider high-tech options for delivery of home-based
instruction.
ÿÿÿÿ ÿ Loneliness, risk for 617 At risk for experiencing vague dysphoria
Affectional deprivation; social isolation; cathectic deprivation; physical
isolation Loneliness Severity; Social Interaction Skills; Social Involvement;
Social Support (1) Maintain one or more meaningful relationship (growth
enhancing versus codependent or abusive in nature)--relationships allowing
self-disclosure--and demonstrate a balance between emotional dependence and
independence. (2) Participate in ongoing positive and relevant social
activities and interactions that are personally meaningful (3) Demonstrate
positive use of time alone when socialization is not possible. Family
Integrity Promotion; Socialization Enhancement; Visitation Facilitation (1)
Use active listening skills. Establish therapeutic relationship and spend time
with client. (2) Assess the client's perception of loneliness (Is the person
alone by choice, or do others impose the aloneness?). (3) Assist the client
with identifying loneliness as a feeling and the causes related to loneliness.
(4) Assess the client's ability and/or inability to meet physcial,
psychosocial, spiritual, and financial needs and how unmet needs further
challenge the ability to be socially integrated (e.g., loss of job leading to
inability to afford usual and familiar social interaction, fatigue; lack of
energy necessary for social interaction and personal engagement; impaired skin
integument and its relationship to real and/or perceived social isolation).
(5) Use active listening skills including assessment and clarification of the
client's verbal and nonverbal responses and interactions. (6) Evaluate the
client's desire for social interaction in relation to actual social
interaction.... ADOLESCENTS: (1) Assess the client's social support system.
(2) Evaluate the depth and level of character traits, shyness, and
self-esteem, particularly of younger and middle adolescent clients. (3)
Evaluate the family stability of younger and middle adolescent clients and
advocate and encourage healthy, growth-producing relationships with family and
support systems. (4) For older adolescents, encourage close relationships with
peers and involvement with groups and organizations. (5) Consider use of pets
to cope with loneliness.
(1) Assess caregivers for Alzheimer clients for depression related to
loneliness. (2) Identify community support systems specific to elderly
popluations. (3) Consider a retirement village. (4) Encourage support by
friends and family when the decision to stop driving must be made. (5) Assess
the client's adaptive sensory functions or any other health deviations that
may limit or decrease his or her ability to interact with others. (6) Assess
the client's potential or actual hearing loss or hearing impairment and make
appropriate referrals if a problem is identified. (7) Encourage physcial
activity such as aerobics or stretching and toning in a group. (8) Provide
reading materials for clients who are able to read. (1) Acknowledge
racial/ethnic differences at the onset of care. (2) Assess for the influence
of cultural beliefs, norms, and values on the client's perception of social
activity and relationships. (3) Approach individuals of color with respect,
warmth, and professional courtesy. (4) Assess the use of personal space needs,
communication styles, acceptable body language, eye contact, perception of
touch, and use of paraverbals when communicating with the client. (5) Use a
family-centered approach when working with Latino, Asian American, Afircan
American, and Native American. (6) Promote a sense of ethnic attachment. (7)
Validate the client's feelings regarding isolation and loneliness. (1) Above
interventions may be adapted for home care use. (2) Assess for depression with
lonely elderly client and make appropriate referrals. (3) If the client is
experiencing somatic complaints, evaluate client complaints to ensure physcial
needs are being met, and then identify relationship between somatic complaints
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and loneliness. (4) Help the client to identify periods when loneliness is
greatest (e.g., certain times of the day, anniversaries of past special
events). With the client's permission, refer for services of visiting
volunteers. (5) To keep older people independent, interventions to prevent
loneliness should be explored. Consider using art as an intervention. (6)
Identify alternatives to eating alone. (7) Identify alternative to being alone
(e.g., telephone contact). (8) Consider using computers and the Internet to
alleviate or reduce loneliness and social isolation. (9) Support religious
beliefs. (10) Discuss the meaning of death and fears associated with dying
alone.
(1) Encourage positive use of solitude to prevent loneliness (e.g., reading,
listening to music, enjoying nature and art.). (2) Include the family in all
client-teaching activities, and give them accurate info regarding the illness
severity. (3) Give family members something to do such as holding a hand,
applying lotion, or assisting with feeding. (4) Encourage family members to
express caring by telling the client where they will be and sending messages
when they cannot be present. ÿÿÿÿ ÿ Memory, impaired 624 Inability to
remember or recall bits of information or behavioral skills; impaired memory
may be attributed to pathophysiological or situational causes that are either
temporary or permanent. Inability to recal factual information; inability to
recall recent or past events; inability to learn or retain new skills or
information; inability to determine whether a behavior was performed; observed
or reported experiences of forgetting; inability to perform a previously
learned skill; forgets to perform a behavior at a scheduled time Fluid and
electrolyte imbalance; neurological disturbances; excessive environmental
disturbances; anemia; acute or chronic hypoxia; decreased cardiac output
Cognitive Orientation; Memory; Neurological Status: Consciousness (1)
Demonstrate use of techniques to help with memory loss. (2) State has improved
memory Memory Training (1) Assess neurological function; use an assessment
tool such as the metamemory in adutlhoos (NIA) questionnaire or the
Mini-Mental State Examination (MMSE). (2) Determine whether onset of memory
loss is gradual or sudden. If memory loss is sudden, refer the client to a
physician for evaluation. (3) Determine amount and pattern of alcohol intake.
(4) Note the client's current meds and intake of any mind-altering substances
such as benzodiazepines, exstasy, marijuana, cocaine, or glucocorticoids. (5)
Note the client's current level of stress. (6) Determine the client's sleep
patterns. If insufficient, refer to care plan for Disturbed Sleep pattern. (7)
Determine the client's bood sugar levels. If the are elevated, refer to
physcian for treatment and encourage a healthy diet and exercise to improve
memory. (8) If signs of depression such as weight loss, insomnia, or sad
affect are evident, refer the client for psychotherapy. (9) Encourage the
client to develop an aerobic exercise .......
(1) Assess for signs of depression. (2) Evaluate all meds that the client is
taking to determine whether they are causing the memory loos. (3) Recommend
that elderly clients maintain a positive attitude and active involvement with
the world around them and that they maintain good nutrition. (4) Encourage the
elderly to believe in themselves and to work to improve their memory. (5)
refer the client to a memory class that focuses on helping older adults learn
membory strategies. (6) Help family develop a memory aid booklet or wallet
that contains pictures with a narration. (7) Help family label items such as
the bathroom or sock drawer to increase recall. (1) Assess for th einfluence
of cultural beliefs, norms, and values on the family or caregiver's
understanding of impaired memory. (2) Use bias-free instruments when assessing
memory in the culturally diverse client. (3) Inform the client's family or
caregiver of meaning of and reasons for common behavior observed in the client
with impaired memory. (4) Validate family members' feelings regarding the
impact of the client's behavior on family lifestyle. (1) Above interventions
may be adapted for home care use. (2) Arrange cures for mdeication taking that
are focused around daily events (e.g., meals and bedtimes). (3) Assess the
client's need for outside assistance with recall or treatment, med, and
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willingness/ability of family to provide needed support. (4) Identify a

checking-in support system (e.g., Lifeline or significant others). (5) Keep
furnitiure placement and household patterns consistent. (6) In the presence of
a medical disorder, institute case management of frail elderly to support
continued independent living.
(1) When teaching the client, determine what the client knows about memory
techniques and then build on that knowledge. (2) When teaching a skill to the
client, set up a series of practice attempts. Begin with simple tasks so that
the client can be positively reinforced and progress to more difficult
concepts. (3) Teach clients to use memory techniques such as repeating info
they want to remember, making mental associations to remember info, and
placing items in strategic places so that they will not be forgotten. ÿÿÿÿ ÿ
Mobility, bed, impaired 630 Limitation of independent movement from one bed
position to another. Impaired ability to turn from side to side; impaired
ability to move from supine to sitting or sitting to supine; impaired ability
to "scoot" or reposition self in bed; impaired ability to move from supine to
prone or prone to supine; impaired ability to move from supine to long sitting
or long sitting to supine Intolerance to activity; decreased strength and
endurance; pain or discomfort; perceptual or cognitive impairment;
neuromuscular impairment; musculoskeletal impairment; depression; severe
anxiety. Suggested functional level classifications include the following:
0--Completely independent; 1--Requires use of equipment or device; 2--Requires
help from another person; 3--Requires help from another person and equipment
device; 4--Dependent (does not participate in activity) Mobility; Self-Care:
ADLs (1) Demonstrate optimal independence in positioning, exercising, and
performing functional activities in bed. (2) Demonstrate ability to direct
others on how to do bed positioning, exercising, and functional activities
Bed Rest Care (1) Perform accurate physical assessment to determine the
client's risk for ICP, respiratory abnormalities, aspiration, pressure ulcer
formation, muscle tone abnormalities, and pain levels. (2) Use critical
thinking and priority setting to decide the most therapeutic bed positions and
frequency of turns based on the client's history, risk profile, and
preventative needs. (3) If the client has increased ICP, refer to care plan
for Decreased Intracranial adaptive capacity. (4) If the client is dysphagic,
assist to sit upright during and after feedings or ingestion of pills. Refer
to care plan for Impaired Swallowing. (5) Position the client in an upright
position at intervals as tolerated by condition. If possible, elevate HOB
incrementally. If vital signs, pulse pattern and oxygen saturation levels are
stable, dangle the client or move the client from bed to a "stretcher
chair"--a stretcher that turns into a chair--to get out of bed and into a more
vertical position. (6) Maintain the...
(1) Devleop appropriate strategies for positioning and bed mobility based on
the client's multiple chronic and disabling conditions. (2) Assess the family
caregivers' strength, health history, and cognitive status to predict ability
and risk for helping clients with positioning and bed m obility tasks. Help
foamily explore and develop other options if helping clients would place them
at too high a risk. (3) Prvent failure by assessing the client's stamina and
energy level during exercising and bed mobility activities; give assistance or
rest breaks as needed. (4) Spread out bed activities, exercise programs, and
ADLs rather than clumping them together. (5) Incorporate memory aids and
strategies (e.g., written schedules, directions, sketches, or notes), timers,
audiotaped instructions, etc, so that clients with cognitive decline can
function independently. (1) Some of the interventions may be adapted for
home care use. (2) Begin discharge planning as soon as possible with case
manager or social worker to assess need for home support systems, assistive
devices, and community or home health services. (3) Encourage use of the
client's regular bed in the home unless contraindicated for specific medical
reasons. (4) Place indented or grooved-out areas in wood pieces under each leg
of the bed and set bed against the walls in a corner of the room. (5) Suggest
rearranging furniture at thome to make it accessible to meet sleeping,
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toileting, and living needs. (6) Discuss the psychological and physical
benefits of allowing clients to be as self-sufficient as possible in bed
mobility and repositioning, even though it may be time consuming. (7) Prepare
family members for potential regression in self-care during transition from
hospital to home environment. (8) Offer emotional support and suggest
community resources and social supports to help ......
(1) Use various sensory modalities to teach the client, family, and caregivers
correct techniques for ROM, exercising, repositioning, and bed mobility
activities. give info visually (demonstration, sketches, instructional videos,
written instructions). Give tactile stimulation (manual guidance, hand-on-hand
technique, return deomstrations, note taking). Give auditiory info (verbal
instructions, instructional audiotapes, verbal repeating of instructions,
self-talk during motor activity, reading aloud written instructions). (2)
Schedule time with family and caregivers for client education and practice
sessions in addition to sharing info informally. Suggest that family members
come prepared with their questions and wearing appropriate clothing and shoes
for practice. (3) Teach caregivers proper body mechanics and use of assistive
devices (if applicable) while assisting clients with bed mobility activities.
ÿÿÿÿ ÿ Mobility, physical, impaired 643 A limitation in independent,
purposeful physical movement of the body or of one or more extremities
Postural instability during performance of routine ADLs; limited ability to
perform gross motor skills; limited ability to perform fine motor skills;
uncoordinated or jerky movements; limited ROM; difficulty turning; decreased
reaction time; movement-induced SOB; gait changes; engages in substitutions
for movement; slowed movement; movement-induced tremor; Medications;
prescribed movement restrictions; discomfort; lack of knowledge regarding
value of physical activity; body mass index greater than 30; sensoriperceptual
impairments; neuromuscular impairment; pain; musculoskeletal impairment;
intolerance to activity/decreased strength and endurance; depressive mood
state or anxiety; cognitive impairment; decreased muscle strength, control,
and/or mass; reluctance to initiate movement; sedentary lifestyle or disuse or
deconditioning; selective or generalized malnutrition; loss of integrity of
bone structures; developmental delay; joint stiffness or contractures......see
book for more..... SUGGESTED FUNCTIONAL LEVEL CLASSIFICATIONS INCLUDE THE
FOLLOWING: 0--Completely independent; 1--Requires use of equipment or device;
2--Requires help from another person for assistance, supervision, or teaching;
3--Requires help from another person and equipment device; 4--Dependent (does
not participate in activity) Ambulation; Ambulation: Wheelchair; Mobility;
Self-Care: ADLs; Transfer Performance (1) Increase physical activity. (2)
Meet mutually defined goals of increased mobility. (3) Verbalize feeling of
increased strength and ability to move. (4) Demonstrate use of adaptive
equipment to increase mobility Exercise Therapy: Ambulation, Joint Mobility;
Positioning (1) Screen for mobility skills in the following order: (1) bed
mobility; (2) supported and unsupported sitting; (3) transition movements such
as sit to stand, sitting down, and transfers; and (4) standing and walking
activities. Use a physical activity tool if available to evaluate mobility.
(2) Observe the client for cause of impaired mobility. Determine whether cause
is physical or psychological. (3) Monitor and record the client's ability to
tolerate activity and use all four extremities; note pulse rate, blood
pressure, dyspnea, and skin color before and after activity. See care plan for
Activity intolerance. (4) Before activity, observe for and, if possible, treat
pain. Ensure that the client is not oversedated. (5) Consult with physical
therapist for further evaluation, strength training, gait training, and
development of a mobility plan. (6) Obtain any assistive devices needed for
activity, such as walking belts, walkers, canes, crutches, or wheelchairs,
before the activity.....
(1) Help the mostly immobile client achieve mobility as soon as possible,
depending on physical condition. (2) Use the Outcome Expectation for Exercise
Scale to determine client's self-efficacy expectations and outcomes
expectations toward exercise. (3) For a client who is mostly immobile,
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minimize cardiovascular deconditioning by positioning the client as close to

the upright position as possible several times daily. (4) If the client is
mostly immobile, encourage him or her to attend a low-intensity aerobic chair
exercise class that includes stretching and strengthening chair exercises. (5)
Initiate a walking program in which the client walks with or without help
every day as part of daily routine. (6) Refer the client to physical therapy
for resistance exercise training as able including abdominal crunch, leg
press, leg extension, leg curl, calf press, and more. (7) Use the WALC
Intervention (Walk; Address pain, fear, fatigue during exercise; Learn about
exercise; Cue by self-...... (1) Above interventions may be adapted for
home care use. (2) Begin discharge planning as soon as possible with case
manager or social worker to assess need for home support systems, assistive
devices, and community or home health services. (3) Assess home environment
for factors that create barriers to physical mobility. Refer to occupational
therapy services if needed to assist the client in restructuring home and
daily living patterns. (4) Refer to home health aide services to support the
client and family through changing levels of mobility. Reinforce need to
promote independence in mobility as tolerated. (5) Refer to physical therapy
for gait training, strengthening, and balance training. (6) Assess skin
condition at every visit. Establish a skin care program that enhances
circulation and maximizes position changes. (7) Once the client is able to
walk independently, and needs an exercise program, suggest the client enter an
exercise program with a friend. (8) Provide support to...
(1) Teach the client to get out of bed slowly when transferring from the bed
to the chair. (2) Teach the client relaxation techniques to use during
activity. (3) Teach the client to use assistive devices such as a cane, a
walker, or crutches to increase mobility. (4) Teach family members and
caregivers to work with clients during self-care activities such as eating,
bathing, grooming, dressing, and transferring rather than having the client be
a passive recipient of care. (5) Work with the client using the
Transtheoretical Model of behavior change and determine if the client is in
the precontemplation, contemplation, preparation, action, or maintenance state
of behavior change about exercise. Provide appropriate strategies to support
change to exercising based on determined state of change. (6) Develop a series
of contracts with mutually agreed on goals of increased activity. Include
measurable landmarks of progress, consequences for meeting or not meeting
goals, and evaluation dates. ÿÿÿÿ ÿ Mobility, wheelchair, impaired 650
Limitation of independent movement within the environment using a device
equipped with wheels. Impaired ability to operate a manual or power
wheelchair on even or uneven surface; impaired ability to operate manual or
power wheelchair on an incline or decline; impaired ability to operate
wheelchair on curbs Intolerance to activity; decreased strength and
endurance; pain or discomfort; perceptual or cognitive impairment;
neuromuscular impairment; musculoskeletal impairment; depression; severe
anxiety; amputation. SUGGESTED FUNCTIONAL LEVEL CLASSIFICATIONS INCLUDE THE
FOLLOWING: 0--Completely independent; 1--Requires use of equipment or device;
2--Requires help from another person for assistance, supervision, or teaching;
3--Requires help from another person and equipment device; 4--Dependent (does
not participate in activity) Ambulation: Wheelchair (1) Demonstrate optimal
independence in operating and moving a wheelchair or other device equipped
with wheels. (2) Demonstrate the ability to direct others in operating and
moving a wheelchair or other device equipped with wheels. (3) Demonstrate
therapeutic positioning, pressure relief, and safety principles while
operating and moving wheelchair or other device equipped with wheels.
Exercise Therapy: Muscle Control; Positioning: Wheelchair (1) Assist or
remind the client to don appropriate equipment (e.g., braces, corsets, shells,
splints, orthoses, immobilizers, and abdominal binders) in bed before
wheelchair mobility; loosen or remove equipment after the client returns to
bed. (2) Obtain referrals for physcial therapy, occupational therapy, or a
wheelchair seating clinic to ensure that the wheelchair and seating system
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fits the build, abilities, postural support needs, and pressure ulcer
prvention of the older client. The seating system should allow the client to
propel the chair, safely and ably use the hands to complete
ADLs/self-care/job/recreational activities, reach the foot rests and floor
with the feet, stand up from the chair without falling, and not be harmed by
the wheelchair legs and foot rests. (3) For the client with loss of sensory
and motor functioning, emphasize importance of weight shifts every 15 minutes.
Reinofrce side leans (leaning toward opposite side of chair), forward leans
(leaning forward ....
(1) Alternate wheelchair mobility with rest periods when resting pulse rate,
respiratory patterns, and BP reading suggest compromised activity tolerance.
(2) Avoid using restraints on elderly or confused clients, or those with
deformities or spinal curvatures who are at risk for falling because they
slide down in a wheelchair or try to reposition self. (3) Ensure proper lower
extremity positioning when the client is sitting up. Do not use elevating leg
rests as a means to prevent sliding down in the wheelchair. Custom foot rests
may be needed. Place both feet either on foot rests or on the floor when
wheelchair is stationary. (4) Assess for side effects of meds and potential
need for dosage readjustments related to increasing physical activity. (5)
Allow the client to move at his or her own speed. Avoid rushing. (1) Assess
the client and obtain complete history with references to reasons for
impairment. (2) Assess home environment for all barriers to wheelchair access.
(3) Assess for skin breakdown. Establish a skin care program to enhance
circulation and decrease risk of skin breakdown. (4) Teach advantages,
disadvantages, and long-term care involved with various cushions to reduce
buttock and sacral pressure during chair sitting. (5) Supply home health aide
services as appropriate for assistance with ADLs and skin care. (6) Provide
support to clients with long-term impairments and their caregivers. Refer to
medical social services or mental health/support groups ervices as necessary.
(7) Ensure that the client has info on advocay, options for disability access,
and related issues (e.g., education, personnel, and equipment availability)
under the Americans with Disabilities Act. (8) Rearrange room functions,
furniture, and cupboards so that toileting sleeping, bathing, and preparing
and .....
(1) Suggest that the client test-drive wheelchairs and try out cushions and
postural supports before purchasing them. (2) Instruct and have the clinet
return demonstrate reinflation of pneumatic tires; encoruage the client to
monitor tire pressure every 2 to 3 weeks. (3) Teach or secure social services
referral to educate clients on financial coverage/regulations of third-party
apyers and HCFA for durable medical equipment. Realize that light and
ultralight wheelchairs may be easier to propel and may be more comfortable and
adjustable than heavier models. They initially are expensive, but over time
they cost less to operate than heavier chairs. (4) Supervise and reinforce the
client's and family's correct performance of pressure relief techniques (which
should be performed every 15 minitues). (5) Teach client to prevent carpal
tunnel sungdrome and ulnar neuropathy by not putting pressure on the elbows.
Client should reditribute pressure along the entire forearm, especially when
....... ÿÿÿÿ ÿ Nausea 658 An unpleasant wave-like sensation in the back of
the throat, epigastrium, or throughout the abdomen that may or may not lead to
vomiting Usually precedes vomiting, but may be experienced after vomiting or
when vomiting does not occur; accompanied by pallor, cold and clammy skin,
increased salivation, tachycardia, gastric stasis, and diarrhea; accompanied
by swallowing movements affected by skeletal muscles; reports "nausea" or
"sick to stomach". R/T TREATMENT: Gastric irritation: pharmaceuticals,
alcohol, iron, and blood, gastric distention: delayed gastric emptying caused
by pharmacological interventions, pharmaceuticals, toxins. BIOPHYSICAL:
Biochemical disorders, cardiac pain, cancer of stomach or intra-abdominal
tumors, esophageal or pancreatic disease, gastric distention due to delayed
gastric emptying, pyloric intestinal obstruction, genitourinary and biliary
distension, upper bowel stasis, external compression of the stomach, excess
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food intake, gastric irritation due to pharyngeal and/or peritoneal

inflammation, liver or splenetic capsule stretch, local tumors, motion
sickness, Meniere's disease, or labyrinthitis. PHYSICAL: Examples included
increased intracranial pressure, meningitis, and toxins. SITUATIONAL:
Psychological factors Comfort Level; Hydration; Nutritional Status: Food and
Fluid Intake, Nutrient Intake (1) State relief of nausea. (2) Explain methods
they can use to decrease nausea and vomiting (N&V) Distraction; Medication
Administration; Progressive Muscle Relaxation; Simple Guided Imagery;
Therapeutic Touch (1) Determine cause of N&V (e.g., medication effects, viral
illness, food poisoning, extreme anxiety, pregnancy). (2) Keep a clean emesis
basin and tissues within the client's reach.
(3) Provide oral care after the client vomits. (4) Stay with the client to
give support, place hand on shoulder, and hold the emesis basin. (5) Provide
distraction from sensation of nausea using soft music, television, and videos
per the client preference. (6) Maintain a quiet, well-ventilated environment.
(7) Avoid sudden movement of the client; allow the client to lie still. (8)
After vomiting is controlled and nausea abates, begin feeding the client small
amounts of clear fluids such as clear soda or preferably ginger ale, and then
crackers; progress to a soft diet. (9) Remove cover of food tray before
bringing it into the client's room. (10) Refer HIV-positive clients for
management of antiretroviral-related nausea................
(1) Administer antiemetic drugs carefully; watch for side effects. (1)
Above interventions may be adapted for home care use. (2) Assist the client
and family with identifying and avoiding irritants in the home setting that
exacerbates nausea (e.g., strong odors from food, plants, perfume, and room
deodorizers).
(1) Teach the client techniques to use when uncomfortable, including

relaxation techniques, guided imagery, hypnosis, and music therapy. ÿÿÿÿ ÿ
Neglect, unilateral 664 Lack of awareness and attention to one side of the
body Consistent inattention to stimuli on an affected side; does not look
toward affected side; inadequate positioning and/or safety precautions with
regard to the affected side; inadequate self-care; leaves food on plate on the
affected side Effects of disturbed perceptual abilities. NOTE: Because the
right hemisphere is dominant in directing attention, unilateral neglect is
more common if neurological pathology occurs in the right hemisphere of the
brain, which results in left-sided neglect. Also, unilateral neglect
frequently occurs with damage to the right parietal lobe, the right frontal
lobe, the thalamus, and basal ganglia. Body Image; Body Positioning;
Self-Care: ADLs (1) Demonstrate techniques that can be used to minimize
unilateral neglect. (2) Care for both side of the body appropriately and keep
affected side free from harm. Unilateral Neglect Management (1) Monitor the
client for signs of unilateral neglect (e.g. not washing, shaving, or dressing
one side of the body; sitting or lying inappropriately on affected arm or leg,
failing to respond to stimuli on the contralateral side of lesion; eating food
only one side of plate; or failing to look to one side of the body). (2) If
available, use the "star cancellation test" to evaluate presence of unilateral
neglect. (3) Use the Draw-A-Man test as a means of verifying the presence of
unilateral neglect. (4) Provdie a safe, well-lighted, and clutter-free
environment. Place a call light on unaffected side. Keep side rails up when
the client is in bed. Cue the client to environmental hazards when mobile. (5)
..... (6) Refer to a rehabilitation nurse specialist, a neuropsychologist, or
an occupational therapiest for continued help in dealing with unilaterl
neglect.
(1) Many of the listed interventions may be adapted for use in the home
care setting.
(1) Explain pathology and symptoms of unilateral neglect to both the client
and family. Teach the client how to scan regualrly to check the position of
body parts and to regularly turn head from side to side for safety when
ambulating, using a wheelchair, or doing other tasks. Recommend the client
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think of self like a horizon-illuminating lighthouse. ÿÿÿÿ ÿ Noncompliance

667 Behavior of person and/or caregiver that fails to coincide with a
health-promoting or therapeutic plan agreed on by the person (and/or family
and/or community) and health care professional; in the presence of an
agreed-on, health promoting, or therapeurtic plan, person's or caregiver's
behavior is fully or partially nonadherent and may lead to clinically
ineffective or partially ineffective outcomes Behavior indicative of failure
to adhere (directly observed or verbalized by patient or significant others)
(critical); objective tests (e.g., physiological measures, detection of
markers); evidence of development of complications; evidence of exacerbation
of symptoms; failure to keep appointments; failure to progress HEALTH CARE
PLAN: Duration; significant others; cost; intensity; complexity. INDIVIDUAL
FACTORS: Personal and developmental abilities; health beliefs, cultural
influences, spiritual values; individual's value system; knowledge and skill
relevant to the regiment behavior; motivational forces. HEALTH SYSTEM:
Satisfaction with care; credibility of provider; access and convenience of
care; financial flexibility of plan; client-provider relationships; provider
reimbursement of teaching and follow-up; provider continuity and regular
follow-up individual health coverage; communication and teaching skills of the
provider. NETWORK: Involvement of members in health plan; social value
regarding plan; perceived beliefs of significant others. NOTE: The nursing
diagnosis Noncompliance is judgmental and places blame on the client. The
author recommends use of the diagnosis Ineffective Therapeutic regimen
management in place of the diagnosis Noncompliance. SEE BOOK FOR
MORE!.......... Adherrence Behavior; Compliance Behavior; Pain Level; Symptom
Control; Treatment Behavior: Illness or injury (1) Describe consequence of
continued noncompliance with treatment regiment. (2) State goals for health
and the means by which to obtain them. (3) communicate an understanding of
disease and treatment. (4) List treatment regimens and expectations and agree
to follow through. (5) List alternative ways to meet goals. (6) Describe the
importance of family participation to help achieve goals. Health System
Guidance; Self-Modification Assistance (1) Ask the client why he or she has
not cimplied with the prescribed treatment. Have the client "tell his or her
story". (2) Make the client an active partner in his or her own health care
management. Recognize that the client has absolute control over whether he or
she follows the health care regimen. (3) Observe for cause of noncompliance
(see Related Factors). Recognize that noncompliance is very common. (4)
Recognize that behavioral change comes slowly, and often in stages
(precontemplation, contemplation, preparation, action, maintenance.....) (5)
If the client is in denial; provide info, communicate unconditional positive
regard, avoid distancing yourself, and look for opportunities for authentic
contact with your client, being present psychologically and physically. (6)
Determine the client's and family's knowledge of illness and treatment. Teach
them about illness and purpose of the treatment regimen if necessary. (7)
Observe whether locus of control is internal or external..
(1) If the client has sensory and coordination deficits, use a med organizer
and have the home health nurse or family place the client's meds in daily
compartments. (2) Help the client feel like a partner in managing health care
condition; use caring, encouragement, written goals, and a "power with"
relationship with the nurse. (3) Ask clients if they can afford meds. Refer
for financial help from social worker or case manager if needed. (4) Monitor
the client for signs of depression associated with noncompliance (e.g.,
refusing to eat or take meds). Refer the client for treatment of depression as
needed. (5) use repetition, verbal cues, and memory aids such as pictures,
schedule, or reminder sheet when teaching the health care regimen. Use events
such as meals, bedtime, etc. as reminders when to take meds. (6) Consider
assistive medication technology: talking reminders, pill dispenser, etc. (1)
client's ability to modify health behavior. (2) Discuss with the client those
aspects of their health behavior/lifestyle that will remain unchanged by their
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health status. (3) Negotiate with the client regarding the aspects of health
behavior that will need to be modified. (4) Assess the role of fatalism on the
client's ability to modify health behavior. (5) Validate the client's feelings
regarding the impact of health status on current lifestyle. NOTE: Because the
home care nurse enters the client's home as a guest, the ability of the nurse
to establish a supportive, therapeutic relationship is especially important.
(1) Above interventions may be adapted for home care use. (2) Before providing
any care, review the Home Health Care Bill of Rights with the client,
including the right to refuse treatment. ..... (3) If noncompliance
compromises the client's health status, refer for psychiatric home health care
services to assess the client's motivation and implement therapeutic regimen.
(4) If noncompliant behavior continues and the client chooses not to cooperate
with medical regimen, the home health care agency cannot continue to provide
services. (5) If care is to be termianted, identify all possible alternatives
for the client, and assist with making an informed choice about future health
actions. (6) Respect the wishes of terminally ill clients to refuse selected
aspects of medical regimen.
(1) Teach clients about medication side effects (e.g., mental changes, sexual
dysfunction) so that they understand them and feel comfortable discussing
them. (2) Teach clients to control their "self-talk" by giving themselves
positive messages that will be used to promote desired behaviors, such as
taking medications and controlling food intake. ÿÿÿÿ ÿ Nutrition, readiness
for enhanced 675 A pattern of nutrient intake that is sufficient for meeting
metabolic needs and can be strengthened. Expresses willingness to enhance
nutrition; eats regularly; consumes adequate food and fluid; expresses
knowledge of healthy food and fluid choices; follows an appropriate standard
for intake; safe preparation and storgae of food and fluids; attitude toward
eating and drinking is congruent with health goals. Motivation to improve
health through diet Nutritional Status; Nutritional Status: Food and Fluid
Intake, Nutrient Intake; Weight Control (1) Explain how to eat according to
the US Dietary Guidelines. (2) Design dietary modifications to meet individual
long-term goal of health, using principles of variety, balance, and
moderation. (3) Weigh within normal range for height and age. Nutrition
Management; Nutritional Counseling; Weight Reduction Assistance (1) Ask the
client to keep a one day to three day food diary where everything eatin or
drank is recorded. (2) Determine the client's knowledge of a nutritious diet
and need for supplements. (3) Determine the client's motivation to improve
nutrition level, whether for appearance or health benefits. (4) Recommend the
client follow the US Dietary Guidelines which can be found at this URL:
http://www.health.gov/dietaryguidelines/dga2000/DIETGD.PDF. (5) Help the
client determine their body mass index (BMI) Use a chart or one of the
formulas in the book on pg 677. (6) Review the client's current exercise
level. With the client and primary health care provider, design a long-term
exercise program. Encourage the client to adopt an exercise program that
involves 45 minutes of exercise five times/week. (7) Explain the value of the
Food Pyramid to the client. With the client'sinput, evaluate the client's
intake based on the Food Pyramid. (8) Demonstrate the use of food labels to
make healthful...
(1) Assess changes in lifestyle and eating patterns. (2) Recommend the client
discuss the need for a low-dose balanced multiple vitamin and mineral
supplement with physician. (3) Assess fluid intake. Recommend routine drinks
of water whether thirsty or not. (4) Observe for socioeconomic factors that
influence food choices (e.g., funds, cooking facilities). (5) Suggest a
variety of seasonings. (1) Assess for dietary intake of essential nutrients.
client's nutritional knowledge. (3) Discuss with the client those acpects of
their diet that will remain unchanged. (4) Determine the motivational factors
operating within the client at the present time. (5) Negotiate with the client
regarding aspects of his or her diet that will need to be modified. (6)
Explore strategies that appeal to the client. (7) Validate the client's
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feelings regarding the impact of current lifestyle, finances, and

transportation on ability to obtain nutritious food.
(1) The majority of the interventions above involve teaching. (2) Work with
the family members regarding info on how to improve nutritional status. (3)
Teach the importance of exercise in a weight control program. ÿÿÿÿ ÿ
Nutrition: less than body requirements, imbalanced 681 Intake of nutrients
insufficient to meet metabolic needs. Body weight less than 20% under ideal
weight; pale conjunctival and mucous membranes; weakness of muscles required
for swallowing or mastication; sore, inflammed buccal cavity; satiety
immediately after ingesting food; reported or evidence of lack of food;
reported inadequate food intake less than RDA; reported altered taste
sensation; perceived inability to ingest food; misconceptions; loss of weight
with adequate food intake; aversion to eating; abdominal cramping; poor
muscle tone; abdominal pain with or without pathology; lack of interest in
food; capillary fragility; diarrhea and/or steatorrhea; excessive loss of
hair; hyperactive bowel sounds; lack of information; misinformation Inability
to ingest or digest food or absorb nutrients because of biological,
psychological, or economic factors. Nutritional Status; Nutritional Status:
Food and Fluid Intake, Nutrient Intake; Weight Control (1) Progressively gain
weight toward desired goal. (2) Weigh within normal range for height and age.
(3) Recognize factors contributing to underweight. (4) Identify nutritional
requirements. (5) Consume adequate nourishment. (6) Be free of signs of
malnutrition Eating Disorders management; Electrolyte Management:
Hypophophatemia; Enteral Tube Feeding; Feeding; Nutrition Management;
Nutrition Therapy; Nutritional Counseling; Nutritional Monitoring; Swallowing
Therapy; Weight Gain Assistance; Weight Management (1) Determine healthy body
weight for age and height. Refer to dietitian for complete nutrition
assessment if 10% under healthy body weight or if rapidly losing weight. Legal
intervention may be necessary. (2) Compare usual food intake with the U.S.
Department of Agriculture Food Pyramid, noting slighted or omitted food
groups. (3) If the client is a vegetarian, evaluate vitamin B12 and iron
intake. (4) Assess the client's ability to obtain and use essential nutrients.
(5) Observe the client's ability to eat (time involved, motor skills, visual
acuity, and ability to swallow various textures). (6) If the client lacks
endurance, schedule rest periods before meals and open packages and cut up
food for the client. (7) Evaluate the client's laboratory studies (serum
albumin, serum total protein, serum ferritin, transferrin, hemoglobin,
hematocrit, vitamins, and minerals). (8) Maintain a high index of suspicion of
malnutrition as a contributing factor in infections and vice versa. (9) Be...
(1) Assess for protein-energy malnutrition in elderly clients regardless of

setting. (2) Assess for factors contributing to a current acute illness. (3)
Implement strategies to prevent recurrence of illness. (4) Interpret
laboratory findings cautiously. (5) Offer high protein supplements based on
individual needs and capabilities. (6) Give the client a choice of supplements
to increase personal control. If the client is unwilling to drink a glass of
liquid supplement, offer 30 ml/hr in a medication cup. (7) Offer liquid energy
supplements. When given liquid preloads 60 minutes before the next meal, older
persons consistently ate a greater total energy load (8) Unless medically
contraindicated, permit self-selected seasonings and foods. (9) Play relaxing
dinner music during mealtime. (10) Assess components of bone health: calcium
intake. (11) Assess components of bone health: vitamin D status. (12) Assess
components of bone health: regular exercise. (13) Instruct in wise use of
....... (1) Assess for dietary intake of essential nutrients. (2) Assess for
the influence of cultural beliefs, norms, and values on the client's
nutritional knowledge. (3) Discuss with the client those aspects of their diet
that will remain unchanged. (4) Negotiate with the client regarding the
aspects of his or her diet that will need to be modified. (5) Validate the
client's feelings regarding the impact of current lifestyle, finances, and
transportation on ability to obtain nutritious food. (1) Above interventions
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may be adapted for home care use. (2) Monitor food intake. Instruct the client
in intake of small frequent meals and liquid supplements (e.g., Ensure,
Instant Breakfast). (3) Assess the client for depression. Refer for mental
health services as indicated. (4) Recognize that older women may continue
their younger preoccupation with weight and recurrent dieting, despite being
at normal weight. Assess source of low weight or weight loss with this in
mind. (5) Monitor and effect total parenteral nutrition (TPN) as ordered by
physician. TPN requires monitoring for potential complications and
client/caregiver education (6) In the presence of depression diagnosis, refer
for psychiatric home health care services for client reassurance and
implementation of therapeutic regimen.
(1) Build on the strengths in the client's/family's food habits. Adapt changes
to their current practices. Accepting the client's/family's preferences shows
respect for their culture. (2) Select appropriate teaching aids for the
client's/family's background. (3) Implement instructional follow-up to answer
the client's/family's questions. (4) Suggest community resources as suitable
(food sources, counseling, Meals on Wheels,Senior Centers). (5) Teach the
client and family how to manage tube feedings or parenteral therapy at home.
ÿÿÿÿ ÿ Nutrition: more than body requirements, imbalanced 690 Intake of
nutrients that exceeds metabolic needs Triceps skin fold of more than 25 mm
in women; triceps skin fold of more than 15 mm in men; body weight more than
20% over ideal for height and frame; eating in response to external cues;
eating in response to internal cues; reported or observed dysfunctional eating
pattern pairing food with other activities; sedentary activity level;
concentration of food intake at the end of the day Excessive intake in
relation to metabolic needs; deficient knowledge related to desirability of
nutritional supplements Nutritional Status: Food and Fluid Intake, Nutrient
Intake; Weight control (1) State pertinent factors contributing to weight
gain. (2) Identify behaviors that remain under the client's control. (3) Claim
ownership for current eating patterns. (4) Design dietary modifications to
meet individual long-term goal of weight control, using principles of variety,
balance, and moderation. (5) Accomplish desired weight loss in a reasonable
period (1-2 lb/week). (6) Incorporate appropriate activities requiring energy
expenditure into daily life. (7) Use sound scientific sources to evaluate need
for nutritional supplements. Eating Disorders Management; Nutrition
Management; Nutritional Counseling; Weight Management; Weight Reduction
Assistance (1) Obtain a thorough history. Refer to a dietitian if the client
has a medical condition. (2) Evaluate the client's physiological status in
relation to weight control. Refer as appropriate. (3) Assess dietary intake
through 24-hour recall or questions regarding the usual intake of food groups.
(4) Evaluate the client's usual intake of fiber. (5) Determine the client's
knowledge of a nutritious diet and need for supplements. (6) Calculate body
mass index (BMI) using either of the following formulas. Weight in kilograms
divided by height (in meters) squared (kg/m2); Weight in pounds multiplied by
705, divided by height in inches, divided again by height in inches (7)
Compute the waist-to-hip ratio (WHR). (8) Determine the client's motivation to
lose weight, whether for appearance or health benefits. (9) Observe for
situations that indicate a nutritional intake of more than body requirements.
(10) Suggest that the client keep a diary of food intake and the circumstances
surrounding .....
(1) Assess changes in lifestyle and eating patterns. (2) Assess fluid intake.
Recommend routine drinks of water whether thirsty or not. (3) Observe for
socioeconomic factors that influence food choices (e.g., inadequate funds or
cooking facilities). (4) Suggest a variety of seasonings. (1) Assess for the
influence of cultural beliefs, norms, and values on the client's nutritional
knowledge and practices. (2) Assess for the influence of cultural beliefs,
norms, and values on the client's ideal of acceptable body weight and body
size. (3) Discuss with the client those aspects of his or her diet that will
remain unchanged, and work with the client to adapt cultural core foods. (4)
Negotiate with the client regarding the aspects of his or her diet that will
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need to be modified. (5) Validate the client's feelings regarding the impact
of current lifestyle, finances, and transportation on the ability to obtain
and prepare nutritious food.
(1) Provide the client and family with information regarding the treatment
plan options. (2) Inform the client about the health risks associated with
obesity for adults and children in the family. (3) Treatment for childhood
obesity should be started when weight gain exceeds established percentiles for
age and gender (4) Inform the client and family of the disadvantages of trying
to lose weight by dieting alone. (5) Teach the importance of exercise in a
weight control program. (6) Teach stress reduction techniques as alternatives
to eating. ÿÿÿÿ ÿ Nutrition: more than body requirements, risk for
imbalanced 697 At risk for intake of nutrients that exceeds metabolic needs.
Reported use of solid food as major food source before 5 months of age;
concentration of food intake at end of day; reported or observed obesity in
one or both parents; reported or observed higher baseline weight at beginning
of each pregnancy; rapid transition acress growth percentiles in infants or
children; pairing of food with other activities; observed use of food as
reward or comfort measure; eating in response to internal cues other than
hunger; eating in response to external cues; dysfunctional eating patterns
Nutritional Status: Food and Fluid Intake, Nutrient Intake; Weight Control
(1) Explain concept of a balanced diet. (2) Compare current eating pattern
with recommended healthy one. (3) Design dietary modifications to meet
individual long-term goal of weight control, using principles of variety,
balance, and moderation. (4) Identify role of exercise in weight control. (5)
use sound scientific sources to evaluate need for nutritional supplements
Nutrition Management; Nutritional Counseling; Weight Management (1) Observe
for the presence of risk factors (see Related Factors). (2) Assess nutritional
intake, including the use of supplements. (3) Determine the client's knowledge
of nutrition. (4) Assess the client's nutritional practices. (5) Assess
activity level and motivational factors. (6) Discuss the wise selection, use,
and discontinuation of supplements. (7) Clients at risk for milk-alkali
syndrome, such as those using thiazides and those with renal failure, should
be monitored for hypercalcemia. (8) Vitamin C rebound scurvy has occurred
inclients who suddenly discontinued megadoses of vitamin C (ten times the
RDA), because the body cannot adjust quickly enough and continues to absorrb a
meaher proportion of the now-smaller dose. (9) Establish a plan with the
client, using techniques listed in the care plan for Imbalanced Nutrition:
more than body requirements.
(1) Give the client credit for making enough wise choices to have lived to an
advanced age. (2) Encourage the use of varying suppliers of foodstuffs in the
unlikely event of contamination. (1) Assess for the influence of cultural
beliefs, norms, and values on the client's nutritional knowledge and
practices. (2) Assess for influence of cultural beliefs, norms, and values on
the client's ideal of acceptable body weight. (3) Disucss with the client
those aspects of the diet that will remain unchanged and work with the client
to adapt cutlural core foods. (4) negotiate with the client regarding the
aspects of his or her diet that will need to be modified. (5) Assess for the
influence of the family on patterns of eating. (6) Validate the client's
feelings regarding the impact of current lifestyle, finances, and
transportation on his her ability to obtain and prepare nutritious food.
(1) Analyze the client's nutritional pattern and suggest lower-calorie
substitutes for high-calorie dished. (2) Demonstrate the use of food labels to
make healthful choices. Alert the client and family to focus on serving size,
total fat, and simple carbohydrates. ÿÿÿÿ ÿ Oral mucous membrane, impaired
701 Disruption of lips and soft tissues of oral cavity Purulent drainage or
exudates; gingival recession, pockets deeper than 4 mm; tonsils enlarged
beyond what is developmentally appropriate; smooth, atrophic, sensitive
tongue; geographic tongue; mucosal denudation; presence of pathogens;
difficulty in speech; self-report of bad taste; gingival or mucosal pallor;
oral pain/discomfort; xerostomia (dry mouth); vesicles, nodules, or papules;
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white patches/plaques, spongy patches, or white curdlike exudate; oral lesions

or ulcers; halitosis; edema; hyperemia; desquamation; coated tongue;
stomatitis; self-report of difficult eating or swallowing; self-report of
diminished or absent taste; bleeding; macroplasia; gingival hyperplasia;
fissures; cheilitis; red or bluish masses Chemotherapy; chemical exposure
(e.g., alcohol, tobacco, acidic foods, regular use of inhalers); depression;
immunisuppression; agin-related loss of connective, adipose, or bone tissue;
barriers to professional care; cleft lip or palate; medication side effects;
lack of or decreased salivation; chemical trauma; pathological
conditions--oral cavity (radiation to head or neck); NPO status for more than
24 hours; mouth breathing; malnutrition or vitamin deficiency; dehydration;
infection; ineffective oral hygiene; mechanical factors (e.g., ill-fitting
dentures, braces, tubes [endotracheal/nasogastric], surgery in oral cavity);
decreased platelet count; immunocompromise; radiation therapy; barriers to
oral self-care; diminished hormone levels (women); stress; loss of supportive
structures Oral Hygiene; Tissue Integrity: Skin and Mucous Membranes (1)
Maintain intact, moist oral mucous membranes that are free of ulceration and
debris. (2) Demonstrate measures to regain or maintain intact oral mucous
membranes Oral Health Restoration (1) Inspect the oral cavity at least once
daily and note any discoloration, lesions, edema, bleeding, exudate, or
dryness. Refer to a physician or specialist as appropriate. (2) Assess for
mechanical agents such as ill-fitting dentures and chemical agents such as
frequent exposure to tobacco that could cause or increase trauma to oral
mucous membranes. (3) Monitor the client's nutritional and fluid status to
determine if it is adequate. Refer to the care plan for Deficient Fluid volume
or Imbalanced Nutrition: less than body requirements if applicable. (4)
Monitor the client's nutritional and fluid status to determine if it is
adequate. Refer to the care plan for Deficient Fluid volume or Imbalanced
Nutrition: less than body requirements if applicable. (5) Determine the
client's mental status. If the client is unable to care for himself or
herself, oral hygiene must be provided by nursing personnel. The nursing
diagnosis Bathing/Hygiene Self-care deficit is then also applicable......
(1) Determine the functional ability of the client to provide his or her own
oral care. If the client has problems with self-care function, ensure that
oral care is provided. Refer to Bathing/Hygiene Self-Care Deficit. (2)
Carefully observe the oral cavity and lips for abnormal lesions such as white
or red patches, masses, ulcerations with an indurated margin, or a raised
granular lesion. (3) Ensure that dentures are removed and scrubbed at least
once daily, removed and rinsed thoroughly after every meal, and removed and
kept in an appropriate solution at night. (4) If the client has xerostomia,
evaluate medications to see if they could be the cause, provide synthetic
saliva products to moisten the oral cavity, and offer frequent sips of water
and sugarless gum or candy to provide lubrication. (5) Provide appropriate
oral care to the elderly, brushing the teeth after every meal. (1) The
interventions described previously may be adapted for home care use. (2) If
dryness is a side effect of the client's medication(s), instruct the client in
the use of artificial saliva. Monitor sodium intake in hypertensive clients
(Humphrey, 1994). Use alternatives to sodium chloride rinses. (3) Instruct the
client to avoid alcohol-based or hydrogen peroxide-based commercial products
for mouth care and to avoid other irritants to the oral cavity (e.g., tobacco,
spicy foods). (4) Instruct the client in ways to soothe the oral cavity (e.g.,
cool beverages, Popsicles, viscous lidocaine) (5) If the client often breathes
by mouth, add humidity to the room unless contraindicated. (6) If necessary,
refer for home health aide services to support the family in oral care and
observation of the oral cavity.
(1) Teach the client how to inspect the oral cavity and monitor for signs and
symptoms of infection or complications, and when to call the health care
practitioner ÿÿÿÿ ÿ Pain, acute 710 Pain is whatever the experiencing
person says it is, existing whenever the person says it does; unpleasant
sensory and emotional experience arising from actual or potential tissue
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damage or described in terms of such damage; sudden or slow onset of pain of

any intensity from mild to severe with anticipated or predictable end
SUBJECTIVE: Pain is always subjective and cannot be proved or disproved. A
client's report of pain is the most reliable indicator of pain. A client with
cognitive ability who can speak or point should use a pain rating scale (e.g.,
1-10) to identify the current level of pain intensity (self-report) and
determine a comfort/function goal. Establishment of a comfort/function goal
involves helping the client to select a pain rating level that will allow the
client to easily perform identified functional goals. OBJECTIVE: Expressions
of pain are extremely variable and cannot be used in lieu of self-report.
Neither behavior nor vital signs can substitute for the client's self-report.
However, observable responses to pain may be helpful in assessing clients who
cannot or will not use a self-report pain rating scale. Observable responses
may be loss of appetite and inability to deep breathe, ambulate, sleep, or
perform ADLs. Clients may show guarding, self-protective behavior.......SEE
BOOK... Actual or potential tissue damage Comfort Level; Pain Control; Pain:
Disruptive Effects; Pain Level (1) Use pain rating scale to identify current
pain intensity and determine comfort/function goal (if the client has
cognitive abilities). (2) Describe how unrelieved pain will be managed. (3)
Report that pain management regimen relieves pain to satisfactory level with
acceptable and manageable side effects. (4) Perform activities of recovery
with reported acceptable level of pain (if pain is above comfort/function
goal, take action that decreases pain or notify a member of health care team).
(6) State ability to obtain sufficient amounts of rest and sleep. (7) Describe
nonpharmacological method that can be used to help control pain. Analgesic
Administration; Pain Management; Patient-Controlled Analgesia (PCA) Assistance
(1) Determine whether the client is experiencing pain at the time of the
initial interview. If so, intervene at that time to provide pain relief.
Assess and document the intensity, character, onset, duration, and aggravating
and relieving factors of pain during the initial evaluation of the client. (2)
Ask the client to describe past experiences with pain and the effectiveness of
methods used to manage pain, including experiences with side effects, typical
coping responses, and the way the client expresses pain (3) Describe the
adverse effects of unrelieved pain (4) Tell the client to report the location,
intensity (using a pain rating scale), and quality when experiencing pain.
Assess and document the intensity of the pain and discomfort after any known
pain-producing procedure, with each new report of pain, and at regular
intervals. (5) If the client is cognitively impaired and unable to report pain
and use a pain rating scale, assess and document behaviors that might be
............
(1) Always take the elderly client's reports of pain seriously and ensure that
the pain is relieved. (2) When assessing pain, speak clearly, slowly, and
loudly enough for the client to hear, and if the client uses a hearing aid, be
sure it is in place; repeat information as needed. Be sure the client can see
well enough to read the pain scale (use an enlarged scale) and written
materials (3) Handle the client's body gently. Allow the client to move at his
or her own speed. (4) Use acetaminophen and NSAIDs with low side-effect
profiles, such as the selective COX-2 NSAIDs (COX-2 inhibitors), choline and
magnesium salicylates (Trilisate), and diflunisal (Dolobid), and watch for
side effects, such as gastrointestinal disturbances and bleeding problems. (5)
Avoid or use with caution drugs with a long half-life, such as the NSAID
piroxicam (Feldene), the opioids methadone (Dolophine) and levorphanol (Levo-
Dromoran), and the benzodiazepine diazepam (Valium). (6) Use opioids with
caution..... (1) Assess pain in a client from a different culture using a
self-report 0 to 10 numerical pain rating scale or the Wong Baker Faces pain
rating scale (see Appendix E). Have the scale translated into the client's
native language if necessary (2) Administer analgesics on a preventive basis
to keep pain ratings at or below an acceptable level. (3) Assess for the
influence of cultural beliefs, norms, and values on the client's perception
and experience of pain. (4) Assess for the effect of fatalism on the client's
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beliefs regarding the current state of comfort. Nursing Research: Fatalistic

perspectives, which involve the belief that one cannot control one's own fate,
may influence health behaviors in some African American and Latino populations
(5) Incorporate safe and effective folk health care practices and beliefs into
care whenever possible. (6) Use a family-centered approach to care. (7) Use
culturally relevant pain scales (e.g., the Oucher Scale), if available, to
assess pain ...... (1) Develop the treatment plan with the client and
caregivers. (2) Develop a full medication profile, including medications
prescribed by all physicians and all over-the-counter medications. Assess for
drug interactions. Instruct the client to refrain from mixing medications
without physician approval. (3) Assess the client's and family's knowledge of
side effects and safety precautions associated with pain medications (e.g.,
use caution in operating machinery when opioids are first taken or dosage has
been increased significantly). (4) If medication is administered using highly
technological methods, assess the home for the necessary resources (e.g.,
electricity) and ensure that there will be responsible caregivers available to
assist the client with administration. (5) Assess the knowledge base of the
client and family with regard to highly technological medication
administration. Teach as necessary. Be sure the client knows when, how, and
whom to contact if analgesia is.............
(1) Provide written materials on pain control such as Understanding Your Pain:
Using a Pain Rating Scale (McCaffery, Pasero, and Portenoy, 2001) (see pages
706-707 for instructions on the use of pain rating scales). (2) Discuss the
various discomforts encompassed by the word pain and ask the client to give
examples of previously experienced pain. Explain the pain assessment process
and the purpose of the pain rating scale. (3) Teach the client to use the pain
rating scale to rate the intensity of past or current pain. Ask the client to
set a comfort/function goal by selecting a pain level on the rating scale that
makes it easy to perform recovery activities (e.g., turn, cough, deep
breathe). If pain is above this level, the client should take action that
decreases pain or notify a member of the health care team. (See pages 706-707
for information on teaching clients to use the pain rating scale.) (4)
Demonstrate medication administration and the use of supplies and
equipment........... ÿÿÿÿ ÿ Pain, chronic 719 Pain is whatever the
experiencing person says it is, existing whenever the person says it does;
unpleasant sensory and emotional experience arising from actual or potential
tissue damage or described in terms of such damage; sudden or slow onset of
pain of any intensity from mild to severe with anticipated or predictable end
SUBJECTIVE: Pain is always subjective and cannot be proved or disproved. A
client's report of pain is the most reliable indicator of pain. A client with
cognitive ability who can speak or point should use a pain rating scale (e.g.,
1-10) to identify the current level of pain intensity (self-report) and
determine a comfort/function goal. Establishment of a comfort/function goal
involves helping the client to select a pain rating level that will allow the
client to easily perform identified functional goals. OBJECTIVE: Expressions
of pain are extremely variable and cannot be used in lieu of self-report.
Neither behavior nor vital signs can substitute for the client's self-report.
However, observable responses to pain may be helpful in assessing clients who
cannot or will not use a self-report pain rating scale. Observable responses
may be loss of appetite and inability to deep breathe, ambulate, sleep, or
perform ADLs. Clients may show guarding, self-protective behavior.......SEE
BOOK... Actual or potential tissue damage; tumor progression and related
pathology; diagnositic and therapeutic procedures; central or peripheral nerve
injury (neuropathic pain). NOTE: The cause of chronic nonmalignant pain may
not be known because pain study is a new science and an area encompassing
diverse types of problems. Comfort Level; Pain Control; Pain: Disruptive
Effects; Pain Level (1) Use pain rating scale to identify current level of
pain intensity, determine comfort/function goal, and maintain a pain diary (if
client has cognitive abilities). (2) Describe total plan for pharmacological
and nonpharmacological pain relief, including how to safely and effectively
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take medicines and integrate nondrup therapies. (3) Demonstrate ability to

pace self, taking rest breaks before they are needed. (4) Function on
acceptable ability level with minimal interference from pain and medication
side effects (if pain is above comfort/function goal, take action that
decreases pain or notify a member of health care team). (5) If cognitively
impaired, demonstrate a reduction in pain behaviors, have manageable and
tolerable side effects, and perform ADLs satisfactorily. Analgesic
Administration; Pain Management (1) Determine whether the client is
experiencing pain at the time of the initial interview. If so, intervene at
that time to provide pain relief. Assess and document the intensity,
character, onset, duration, and aggravating and relieving factors of pain
during the initial evaluation of the client. (2) Ask the client to describe
past and current experiences with pain and the effectiveness of the methods
used to manage the pain, including experiences with side effects, typical
coping responses, and the way the client expresses pain. (3) Describe the
adverse effects of unrelieved pain. (4) Tell the client to report pain
location, intensity, and quality when experiencing pain. Assess and document
the intensity of pain and discomfort after any known painproducing procedure,
with each new report of pain, and at regular intervals. (5) Ask the client to
maintain a diary of pain ratings, timing, precipitating events, medications,
treatments, and steps that work best to relieve pain. (6) ......
(1) Always take an elderly client's reports of pain seriously and ensure that
the pain is relieved. (2) When assessing pain, speak clearly, slowly, and
loudly enough for the client to hear, and if the client uses a hearing aid, be
sure it is in place; repeat information as needed. Be sure the client can see
well enough to read the pain scale (use an enlarged scale) and written
materials. (3) Handle the client's body gently. Allow the client to move at
his or her own speed. (4) Use acetaminophen and NSAIDs with low side-effect
profiles, such as the selective COX-2 NSAIDs (COX-2 inhibitors), choline and
magnesium salicylates (Trilisate), and diflunisal (Dolobid), and watch for
side effects, such as gastrointestinal disturbances and bleeding problems. (5)
Avoid or use with caution drugs with a long half-life, such as the NSAID
piroxicam (Feldene), the opioids methadone (Dolophine) and levorphanol (Levo-
Dromoran), and the benzodiazepine diazepam (Valium). (6) Use opioids with
caution .... (1) Assess pain in a client from a different culture using a
self-report 0 to 10 numerical pain rating scale or the Wong Baker Faces pain
rating scale (see Appendix E). Have the scale translated into the client's
native language if necessary. (2) Administer analgesics on a preventive basis
to keep pain ratings at or below an acceptable level. (3) Assess for the
influence of cultural beliefs, norms, and values on the client's perception
and experience of pain. (4) Assess for the effect of fatalism on the client's
beliefs regarding the current state of comfort. (5) Incorporate safe and
effective folk health care practices and beliefs into care whenever possible.
(6) Use a family-centered approach to care. (7) Use culturally relevant pain
scales (e.g., the Oucher Scale), if available, to assess pain in the client.
(8) Ensure that directions for medication use are available in the client's
language of choice and are understood by the client and caregiver. (1)
Develop the treatment plan with the client and caregivers. (2) Develop a full
medication profile, including medications prescribed by all physicians and all
over-the-counter medications. Assess for drug interactions. Instruct the
client to refrain from mixing medications without physician approval. (3)
Assess the client's and family's knowledge of side effects and safety
precautions associated with pain medications (e.g., use caution if operating
machinery when opioids are first taken or dosage has been increased
significantly). (4) Collaborate with the health care team (including the
client and family) on an ongoing basis to determine an optimal pain control
profile. Identify the most effective interventions and the medication
administration routes most acceptable to the client and family. (5) If
medication is administered using highly technological methods, assess the home
for necessary resources (e.g., electricity) and ensure that responsible
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caregivers will be available to ....

(1) Provide written materials on pain control such as Understanding Your Pain:
Using a Pain Rating Scale (McCaffery, Pasero, and Portenoy, 2001) (see pages
706-707 for instructions on the use of a pain rating scale). (2) Discuss the
various discomforts encompassed by the word pain and ask the client to give
examples of previously experienced pain. Explain the pain assessment process
and the purpose of the pain rating scale. (3) Ask the client to set a
comfort/function goal by selecting a pain level on the rating scale that makes
it easy to perform recovery activities (e.g., turn, cough, deep breathe). If
pain is above this level, the client should take action that decreases pain or
notify a member of the health care team. (See pages 706-707 for information on
teaching clients to use the pain rating scale.) (4) Discuss the total plan for
pharmacological and nonpharmacological treatment, including the medication
plan for ATC administration and supplemental doses, the maintenance of...... ÿ
ÿÿÿ ÿ Parenting, readiness for enhanced 728 Pattern of providing
environment for children or other dependent person(s) that is sufficient to
nurture growth and development and can be strengthened. Expresses willingness
to enhance parenting; children or other dependent person(s) express
satisfaction with home environment; emotional and tacit support of children or
dependent person(s) is evident; bonding or attachment is evident; physical and
emotional needs of children or other dependent person(s) are met; realistic
expectations of children or other dependent person(s) are exhibited Child
Development: 1 Month, 2 Months, 4 Months, 6 Months, 12 Months, Preschool,
Middle childhoos, Adolescence; Growth; Health-Promoting Behavior;
Health-Seeking Behavior; Immunization Behavior; Knowledge: Breastfeeding,
Child Physical Safety, Diet, Health Behavior, Health Resources, Infection
Control, Medication, Personal Safety; Leisure Participation; Nutritional
Status; Parent-Infant Attachment; Parenting Performance; Parenting:
Psychological Safety; Risk Control; Risk Detection; Role Performance; Safe
Home Environment; Self-Esteem (1) Affirm desire to improve parenting skills
to further support growth and development of children. (2) Demonstrate loving
relationship with children. (3) Provide a safe, nurturing environment. (4)
Assess risks in home/environment and takes steps to prevent possivility of
harm to children. (5) Meet physical, psychosocial, and spiritual needs or seek
appropriate assistance. Anticipatory Guidance; Attachment Promotion;
Developmental Enhancement: Adolescent, Child; Family Integrity Promotion:
Childbearing Family; Infant Care; Newborn Care; Parent Education: Adolescent,
Childrearing Family, Infant; Parenting Promotion; Teaching: Infant Stimulation
(1) Use family-centered care and role modeling for holistic care of families.
(2) Assess parents' feelings when dealing with a child who has a chronic
illness. (3) Encourage positive parenting: respect for children, understanding
of normal development, and use of creative and loving approached to meet
parenting challenges. (4) Provide opportunities for mother-infant skin-to-skin
contact (kangaroo care [KC]) for preterm infants. (5) Provide the parent with
the opportunity to assist the newborn's first bath, allowing a flexible bath
time. (6) When the person who is ill is the parent, use family-centered
assessment skills to determine the impact of an adult's illness on the child
and then guide the parent through those topics that are most likely to be of
concern, including (a) the name of the illness, (b) the cause of the illness,
(c) the potential contagion or spread of the illness, and (d) the ultimate
impact of th illness on the life of the child. (7) have family members
.............
client's perception of parenting. (2) Acknowledge racial/ethnic differences
at the onset of care. (3) Acknowledge the value conflicts from acculturation
stresses may contribute to increased anxiety and significant conflict with
children. (4) Acknowledge and praise parenting strengths noted. (5) Refer to
the care plancs for Impaired Parenting, Risk for impaired Parenting, and Risk
for impaired parent/infant/child Attachment for additional interventions that
could be used with slight modification. The nursing interventions described
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previously should be used in the home environment with adaptation as

necessary. (1) Refer to a parenting program to facilitate learning of
parenting skills.
Refer to Client/Family Teaching for Impaired Parenting and Risk for impaired
Parenting for suggestions that may be used with minor adaptations. (1) Teach
parents home safety: reduction of hot water temp, proper poison storage, use
of smoke alarms, installation of safety gates for stairs, and use of ipecac
syrup. (2) Teach parents and young teens conflict resolution using a
hypothetical conflict solution with and without a structured conflict
resolution guide. (3) Refer mothers of children with type 1 diabetes for
community support in baby-sitting, child care, or respite. (4) Support
empowerment of parents of children with asthma. (5) Teach families the
importance of monitoring television viewing and limiting exposure to violence.
ÿÿÿÿ ÿ Parenting, impaired 732 Inability of primary caretaker to create,
maintain, or regain an environment that promotes optimum growth and
development of the child. INFANT/CHILD: Poor academic performance; frequent
illness; running away; physical and psychological trauma or abuse; frequent
accidents; lack of attachment; failure to thrive; behavioral disorders; poor
social competence; lack of separation anxiety; poor cognitive development.
PARENTAL: Inappropriate child care arrangements; rejection of or hostility
toward child; statements of inability to meet child's needs; inflexibility in
meeting needs of child or situation; poor or inappropriate caretaking skills;
regular punitive behavior; inconsistent care; child abuse; inadequate child
health maintenance; unsafe home envirnoment; verbalization of inability to
control child; negative statements about child; verbalization of role
inadequacy or frustration; inappropriate visual, tactile, or auditory
stimulation of child; abandonment; insecure attachment or lack of attachment
to infant; inconsistent behavior management; child neglect; little cuddling;
maternal-child interaction deficit; see book.. SOCIAL: Lack of access to
resources; social isolation; lack of resources; poor home environment; lack of
family cohesiveness; inadequate child care arrangements; lack of
transportation; unemployment or job problems; role strain or overload; marital
conflict, declining satisfaction; lack of value of parenthood; change in
family unit; low socioeconomic class; unplanned or unwanted pregnancy;
presence of stress (e.g., financial or legal difficulties, recent crisis,
cultural move); lack of or poor parental role model; single parenthood; lack
of social support network; lack of involvement of father of child; history of
being abusive; history of being abused; financial difficulties; maladaptive
coping strategies; poverty; poor problem-solving skills; inability to put
child's needs before own; low self-esteem; relocation; legal difficulties.
KNOWLEDGE: Lack of knowledge about child maintenance; lack of knowledge about
parenting skills; unrealistic expectations for self, infant, partner.......
Abuse Cessation; Abuse Protection; Abuse Recovery: Emotional; Abusive Behavior
Self-Restraint; Child development: 2 Months, 4 Months, 6 Months, 2 Years, 3
Years, 4 Years, Preschool, Middle Childhood, Adolescence; Coping; Knowledge:
Child Physical Safety; neglect Recovery; Parent-Infant Attachment; Parenting
Performance; Parenting: Psychosocial Safety; Role Performance; Safe Home
Environment; Social Support (1) Affirm desire to develop constructive
parenting skills to support infant/chilld growth and development. (2) Initiate
appropriate measures to develop a safe, nurturing environment. (3) Acquire and
display attentive, supportive parenting behaviors. (4) identify strategies to
protect child from harm and/or neglect and initiate action when indicated.
Abuse Protection Support: Child; Attachment Promotion; Caregiver Support;
Developmental Enhancement: Adolescence, Child; Environmental Management:
Attachment Process; Family Integrity Promotion; Family Support; Family
Therapy; Infant Care; Parent Education: Adolescent, Childrearing Family,
Infant (1) Use the Parenting Risk Scale to assess parenting. (2) Institute
abuse/neglect protection measures if there is evidence of an inability to cope
with family stressors or crisis, signs of parental substance abuse are
observed, or a significant level of social isolation is apparent. (3) For a
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mother with a toddler, assess maternal depression, perceptions of difficult

temperament in the toddler, and low maternal self-efficacy. Make appropriate
referral. (4) Appraise the parent's resources and the availability of social
support systems. Determine the single mother's particular sources of support,
especially the availability of her own mother and partner. Encourage the use
of healthy, strong support systems. (5) Provide education to at-risk parents
on behavioral management techniques such as looking ahead, giving good
instructions, providing positive reinforcement, redirecting, planned ignoring,
and instituting time-outs. (6) Support parents' competence in appraising their
infant's ......
client's perception of parenting. (2) Acknowledge racial/ethnic differences at
the onset of care. (3) Approach individuals of color with respect, warmth, and
professional courtesy. (4) Give a rationale when assessing African American
individuals about sensitive issues. (5) Acknowledge that value conflicts from
acculturation stresses may contribute to increased anxiety and significant
conflict with children. (6) Use a neutral, indirect style when addressing
areas in which improvement is needed (such as a need for verbal stimulation)
when working with Native American clients. (7) Provide support for Chinese
families caring for children with disabilities. (8) Acknowledge and praise
parenting strengths noted. (9) Validate the client's feelings regarding
parenting. (10) Facilitate modeling and role playing to help the family
improve parenting skills. (1) The interventions described previously may be
adapted for home care use. (2) Assess the single mother's history regarding
childhood and partner abuse, and current status regarding depressive symptoms,
abusive parenting attitudes (lack of empathy, favorable opinion of corporal
punishment, parent-child role-reversal, inappropriate expectations). Refer for
mental health services as indicated. (3) Implement behavioral parent training
(BPT), including enhancement of skills in child-directed play, effective use
of commands, use of discipline measures such as imposing time-outs and
providing immediate and natural consequences, problem solving, and
communication strategies.
(1) Explain individual differences in children's temperaments and compare and
contrast with the parents' expectations. Help parents determine and understand
the implications of their child's temperament. (2) Discuss sound disciplinary
techniques, which include catching children being good, listening actively,
conveying positive regard, ignoring minor transgressions, giving good
directions, using praise, and imposing time-outs. (3) Encourage positive
parenting: respect for children, understanding of normal development, and
creative and loving approaches to meet parenting challenges. (4) Initiate
referrals to community agencies, parent education programs, stress management
training, and social support groups. (5) Provide information regarding
available telephone counseling services. (6) Refer to the care plan for
Delayed Growth and development for additional teaching interventions. (7) Plan
parental education directed toward the following age-related parental
concerns:....... ÿÿÿÿ ÿ Parenting, impaired, risk for 739 Risk for
inability of primary caretaker to create, maintain, or regain an environment
that promotes optimum growth and development of the child SOCIAL: marital
conflict, declining satisfaction; history of being abused; poor
problem-solving skills; role strain/overload; social isolation; legal
difficulties; lack of resources; lack of value of parenthood; relocation;
poverty; poor home environment; lack of family cohesiveness; lack of or poor
parental role model; lack of involvement of father of child; history of being
abusive; financial difficulties; low self-esteem; lack of resources; unplanned
or unwanted pregnancy; inadequate child care arrangements; maladaptive coping
strategies; low socioeconomic class; lack of transportation; change in family
unit; unemploy6ment or job problems; single parenthood; lack of social support
network; inability to pupt child's needs before own; stress. KNOWLEDGE: Low
educational level or attainment; unrealistic expectations of child; lack of
knowledge about parenting skills; poor communication skills; preference for
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physical punishment; inability to recognize and act on infant cues; see

book... Abuse Recovery: Emotional, Physical, Sexual; Abusive Behavior
Self-Restraint; Caregiver Emotional Health; Caregiver Stressors; Coping
Parent-Infant Attachment; Parenting Performance; Risk Control: Unintended
Pregnancy; Social Interaction Skills (1) Successfully establish a nurturing
parenting role. (2) Affirm desire to acquire and maintain constuctive
parenting skills to support infant/child growth and development. (3) Maintain
appropriate measures to develop a safe, nurturing environment. (4) Display
attentive, supportive parenting bahaviors. (5) Have knowledge of strategies to
protect child from harm and/or neglect. Abuse Protection Support: Child,
Attachment Promotion; Caregiver Support; Developmental Enhancement:
Adolescent, Child; Environmental Management: Attachment Process; Family
Integrity Promotion; Family Support; Family Therapy; Infant Care; Kangaroo
Care; Parent Education: Adolescent, childrearing Family, Infant; Risk
Identification: Childrearing Family; Role Enhancement NOTE: Management of
risk diagnosis necessitates approached using primary and secondary prevention.
Primary prevention interventions include activities such as safety instruction
and focus on forestalling the development of a disease or condition. Early
detection through screening, monitoring, and surveillance is secodnary
prevention. (1) Conduct risk identification, noting the presence of a history
of abuse, parental/family stressors, strength, and adequacy of social support
systems, established coping styles, and other related factors (see Related
Factors). (2) Screen for maternal psychiatric-mental health symptoms and
negative experiences in the mother's family of origin. (3) Support parents'
competence in appraising their infant's behavior and responses. (4) Encourage
skin-to-skin care by parents of preterm infants. (5) Provide education to
at-risk parents on behavioral management techniques such as looking ahead,
giving good instructions, providing positive reinforcement, .........
(1) Assess for the influence of cultrual beliefs, norms, and values on the
client's perceptions of parenting. (2) Acknowledge racial/ethnic differences
at the onset of care. (3) Approach individuals of color with respect, warmth,
and professinal courtesy. (4) Give a rationale when assessing African American
individuals about sensitive issues. (5) Acknowledge that value conflicts from
acculturation stresses may contribute to increased anxiety and significant
conflict with children. (6) Use a neutral, indirect style when addressing
areas in which improvement is needed (such as a need for verbal stimulation)
when working with Native American clients. (7) Acknowledge the client's
feelings regarding parenting. (8) Facilitate modeling and role playing to help
the family improve parenting skills. (1) The interventions described
previously may be adapted for home care use.
(1) Initiate referrals to an appropriate community agency for early follow-up
if an actual problem is identified. (2) Refer to the care plan for Impaired
Parenting for additional teaching interventions. ÿÿÿÿ ÿ Peripheral
neurovascular dysfunction, risk for 743 At risk for disruption in
circulation, sensation, or motion of an extremity Trauma; fractures;
mechanical compression (e.g., tourniquet, cast, brace, dressing, restraints);
orthopedic surgery; immobilization; burns; vascular obstruction Circulation
Status; Joint Movement: Passive; Neurological Status: Spinal Sensory/Motor
Function; Risk Detection; Tissue Perfusion: Peripheral (1) Maintain
circulation, sensation, and movement of an extremity within client's own
normal limits. (2) Explain signs of neurovascular compromise and ways to
prevent venous stasis. Exercise Therapy: Joint Movility; Peripheral Sensation
Management (1) Perfomr neurovascular assessment every 1-4 hours or every 15
minutes as ordered. Use the six P's of assessment: (Pain.....Pulses...
Pallor/Piokilothermia.... Paresthesia..... Paralysis..... Pressure). (2)
Monitor the client for symptoms of compartment syndrome evidenced by decreased
sensation, weakness, loss of movement, pain with passive movement, pain
greater than expected. These symptoms are not always present and can be
difficult to assess. (3) Monitor appropriate application and function of
corrective device (e.g., cast, splint, traction) every 1 to 4 hours as needed.
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(4) Position the extremity in correct alignment with each position change;
check every hours to ensure appropriate alignment. (5) Get the client out of
bed and mobilize the client as soon as possible, after consultation with the
physician. (6) Monitor for signs of DVT, especially in high-risk populations,
including persons older than 40 years of age; persons with immobility or
obesity; persons taking estrogen....
(1) Use heat and cold therapies cautiously; elderly clients often have
decreased sensation and circulation. (1) Assess the knowledge base of the
client and family following any institutional care. Teach about the disease
process and care as necessary. (2) If risk is related to fractures and cast
care, teach the family to complete a neurovascular assessment; it may be
performed as often as every 4 hours but is more commonly done two to three
times per day. (3) If the fracture is peripheral, position the limb for
comfort and change position frequently, avoiding dependent positions for
extended periods. (4) Refer to physical therapy services as necessary to
establish an exercise program and safety in transfers or mobility within
limiitations of physical status. (5) Establish an emergency plan.
(1) Teach the client and family to recognize signs of neurovascular
dysfunction and to report signs immediately to the appropriate person. (2)
Emphasize proper nutrition to promote healing. (3) If necessary, refer the
client to a rehabilitation facility for instruction in proper use of assistive
devices and measures to improve mobility without compromising neurovascular
function. ÿÿÿÿ ÿ Poisoning, risk for 747 Accentuated risk of accidental
exposure to, or ingestion of, drugs or dangerous products in doses sufficient
to cause poisoning. EXTERNAL: Unprotected contact with heavy metals or
chemicals; storage of medicines in unlocked cabinets accessible to children or
confused persons; presence of poisonous vegetation; presence of atmospheric
pollutants, paint, lacquer, etc., in poorly ventilated areas or without
effective protection; flaking, peeling paint or plaster in presence of young
children; chemical contamination of food and water; availability of illicit
drugs potentially contaminated by poisonous additives; presence of large
supplies of drugs in home; placement or storage of dangerous products within
reach of children or confused persons. INTERNAL: Verbalization that
occupational setting is without adequate safeguards; reduced vision; lack of
safety or drug education; lack of proper precautions; insufficient finances;
cognitive or emotional difficulties. Knowledge: Child Physical Safety,
Medication, Personal Safety; Parenting Performance; Risk Control; Risk
Control: Alcohol Use, Drug Use; Risk Detection; Safe Home Environment (1)
Prevent inadvertent ingestion of or exposure to toxins or poisonous
substances. (2) Explain and undertake appropriate safety measures to prevent
ingestion of or exposure to toxins or poisonous substances. Environmental
Management: Safety; First Aid; Health Education; Medication management;
Surveillance; Surveillance: Safety. (1) Identify risk factors for poisoning,
noting special circumstances in which preventive or protective measures are
indicated. (2) Evaluate lead exposure risk and cosult the health care provider
regarding lead screening measures as indicated (public/ambulatory health). (3)
Properly label medications, using large print for the visually impaired.
Supply "Mr. Yuk" labels for families with children. (4) Detect possible
interactions and cumulative or other adverse effects among prescribed meds,
self-administered OTC products, culturally based home treatments, and foods.
(5) Prevent iatrogenic harm to client caused by receiving the wrong med or
dose by following these guidelines for giving care: (a) Use at least two
methods to identify the client, such as name and birth date, before
administering meds or blood products. (b) When giving verbal or telephone
orders, always require the person taking the orders to verify them by
repeating them back. (c) Standardize use of abbreviations and .....
(1) The interventions described previously may be adapted for home care
use. (2) Provide the client and/or family with a poison control diagram to be
kept on the refrigerator or bulletin board. Ensure that the telephone number
for local poison control info is readily available. (3) Prepour meds for a
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client who is at risk of ingesting too much of a given medication because of

mistakes in preparation. Delegate this task to the family or caregivers if
possible. (4) Identify the risk of toxicity from environmental activities such
as spraying trees or roadside shrubs. Contact local departments of agriculture
or transportation to obtain material substance data sheets or to prevent the
activity in desired areas. (5) Identify poisonous subtances in the immediate
surroundings of the home, such as a garage or barn, including paints and
thinners, fertilizers, rodent and bug control substances, animal meds,
gasoline, and oil. Label with the name, a poison warning sign, and a poison
control ......
(1) Cousel the client and family membrs regarding medication therapy: (a)
Avoid sharing prescriptions. (b) Read and follow labeling instructions on all
products; adjust dosage for age. (c) Avoid excessive amounts and/or frequency
of doses ("If a little does some good, a lot should do more"). (2) Advise the
family to post first aid charts and poison center instructions in an
accessible location. Poison control center telephone numbers should be posted
close to the telephone. Ajpoison control center should always be called
immediately before initiating any first aid measures. Advise family when
calling the poison control center to: (a) Give as much info as possible,
including your name, location, and telephone number, so that the poison
control operator can call back in case you are disconnected or summon help if
needed. (b) Give the name of the potential poison ingested and, if possible,
give the trade name and ingredients if they are listed. (c) Describe the state
of the poisoning .... ÿÿÿÿ ÿ Post-trauma syndrome 752 Sustained
maladaptive response to a traumatic, overwhelming event Avoidance;
repression; difficults in concentrating; grief; intrusive thoughts;
neurosensory irritability; palpitations; enuresis (in children); anger and/or
rage; intrusive dreams; nightmares; aggression; hypervigilance; exaggerated
startle response; hopelessness; altered mood state; shame; panic attack;
alienation; denial; horror; substance abuse; depression; anxiety; guilt; fear;
gastric irritability; detachment; psychogenic amnesia; irritability; numbing;
compulsive behavior; flashbacks; headaches Events outside range of usual
human experience; physical and psychosocial abuse; tragic occurence involving
multiple deaths; epidemic; sudden destruction of one's home or community;
confinement as prisoner of war or criminal victimization (torture); war; rape;
natural and/or manmade disaster; serious accident; witnessing or mutilation,
violent death, or other horror; serious threat or injury to self or loved
ones; industrial or motor vehicle accident; military combat. Abuse Cessation;
Abuse Protection; Abuse Recovery: Emotional, Sexual; Coping; Impulse
Self-Control; Self-Mutilation Restraint (1) Return to pretrauma level of
functioning as quickly as possible. (2) Acknowledge traumatic event and begin
to work with the trauma by talking about the experience and expressing
feelings of fear, anger, anxiety, guilt, and helplessness. (3) Identify
support systems and available resources and be able to connect with them. (4)
Return to and strengthen coping mechanisms used in previous traumatic event.
(5) Acknowledge event and perceive it without distortions. (6) Assimilate
event and move forward to set and pursue life goals. Counseling; Support
System Enhancement (1) Observe for a reaction to a traumatic event in all
clients regardless of age. (2) Provide a safe and therapeutic environment that
enables the client to regain control. (3) Remain with the client and provide
support during periods of overwhelming emotions. (4) provide opportunities for
emotional expression through activities. (5) Avoid pressuring the client to
express emotions if he or she is not ready to do so. (6) Explore and enhance
available support systems. (7) Assist the client in regaining previous
sleeping and eating habits. (8) Consider the use of medication. (9) Help the
client use positive cognitive restructuring to reestablish feelings of
self-worth. (10) Provide the means for clients to express feelings through
therapeutic drawing. (11) Normalize symptoms; help the client to understand
that his or her feelings and thoughts are a result of trauma and do not
indivate mental illness. (12) Encourage the client to return to the normal
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routine as quickly as possible. (13) ...

(1) Use environmental assessment skills to identify elderly clients who are
traumatized by disaster, loss or both. (2) Observe the client for concurrent
losses that may affect copig skills. (3) Allow the lcient more time to
establish trust and express anger, guilt, and shame about the trauma. Review
past coping skills and give the client positive reinforcement for the
successfully dealing with other life crises. (4) Monitor the client for
clinical signs of depression and anxiety, refer to a physician for medication
if appropriate. (5) Instill hope. (1) Assess for the influence of cultural
beliefs, norms, and values on the client's ability to cope with a traumatic
experience. (2) Acknowledge racial/ethnic differences at the onset of care.
(3) Use a family-centered approach when working with Latino, Asian, African
American, and Native American clients. (4) When owrking with an Asian American
client, provide opportunities by which the family can save face. (5) Validate
the client's feelings regarding the trauma. (1) Assess family support and the
response to the client's coping mechanisms. Refer the family for medical
social services or other counseling as necessary. (2) Provide a stable routine
of day-to-day activites consistent with pretrauma experience. (3) If the
client is receiving meds, assess the client's self-medicating ability. Assign
a responsible person to administer meds if necessary. (4) Assess the impact of
the trauma on significant others (e.g., a father may have to take ovre his
partner's parenting responsibility after she has been raped and injured).
(1) Explain to the client and family what to expect the first few days after
the traumatic event and in the future. (2) Teach positive coping skills and
avoidance of negative coping skills. (3) Teach stress reduction methods such
as deep breathing, visualization, meditation, and physcial exercise. Encourage
their use especially when intrusive thoughts or flashbacks occur. (4)
Encourage other healthy living habits of proper diet, adequate sleep, regular
exercise, family activites, and spiritual pursuits. (5) Refer the client to
peer support groups. (6) Refer the client who has been in an accident to
counseling for PTSD (7) Refer the client who has suffered traumatic brain
injury (TBI) for counseling for PTSD. (8) Instruct the family in ways to be
helpful to and supportive of the traumatized person. Emphasize the importance
of listening and being there. Also emphasize that there is no magic phrases
capable of easing the person's emotional suffering. (9) consider the use of
............. ÿÿÿÿ ÿ Post-trauma syndrome, risk for 757 At risk for
maladaptive response to a traumatic, overwhelming event. Exaggerated sense
of responsibility; perception of event; survivor's role in the event;
occupation (e.g., police, fire, rescue, corrections, emergency dept., mental
health worker); displacement from home; inadequate social support;
nonsupportive environment; diminished ego strength; duration of event Abuse
Cessation; Abuse Protection; Abuse Recovery: Emotional; Aggression
Self-Control; Anciety Self-Control; Coping; Grief Resolution; Sleep (1)
Identify symptoms associated with post-traumatic stress disorder (PTSD) and
seek help. (2) Identify the event in realistic, cognitive terms. (3) State
that he or she is not to blame for the event. Counsleing; Support System
Enhancement (1) Assess for PTSD in a client who has chronic illness, anxiety,
or personal disorder; was a witness to serious injury or edeath; or
experienced sexual molestation. (2) consider the use of the Standord Acute
Stress Reaction Questionnaire to evaluate anxieety and dissociation symptoms
after traumatic events. (3) Consider screening for PTSD in a client who is a
high utilizer of medical care. (4) Provide peer support to contact co-workers
experiencing trauma to remind them that others in the organization are
concerned about their welfare; provide an opportunity to discuss the traumatic
incident and assess for the need for further post-trauma services. (5) Provide
post-trauma debriefing. Effective post-trauma coping skills are taught, and
each participant creates a plan for his or her recovery. During the
debriefing, the facilitators assess participants to determine their needs for
further services in the form of post-trauma cousneling. For maxiamum
effectiveness, the debriefing should...
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(1) Carefully assess the elderly client's response to a traumatic event (e.g.,
a natural disaster) and use the critical incident stress techniques described
previously to prevent symptoms associated with PTSD. (1) Assess for the
influence of cultural beliefs, norms, and values on the client's ability to
cope with a traumatic experience. (2) Acknowledge racial/ethnic differences at
the onset of care. (3) Assure the client of confidentiality. (4) Validate the
client's feelings regarding the trauma and allow the client to tell the trauma
story. (1) Assess the client's ability to meet primary needs of shelter,
nourishment, and safety. Refer to medical social services, state departments
of human services, or other organizations as appropriate. (2) Identify other
losses or stressors that may affect coping ability (e.g., role or relationship
changes, deaths). (3) Assess the family's response to the client's risk. Refer
the family to medical social services or mental health services or support
groups as necessary. (4) If the client is on medication, assess its
effectiveness and the client's compliance with the regimen. Identify who
administers the medication. (5) Assist the client in the home in identifying
and establishing daily patterns that have meaning for the client. (6) For a
client who is displaced from the home, identify internal values that can be
maintained while the lcient is displaced, such as respite, contact with
specific persons, and honesty. (7) Encourage the client to verbalie feelings
of risk and trauma to ......
(1) Instruct the family and friends to use the following critical incident
stress management techniques. FOR FAMILY MEMBERS AND FRIENDS: (1) Listen
carefully. (2) Spend time with the traumatized person. (3) Offer your
assistance and a listening ear, even if the person has not asked for help. (4)
Help the person with everyday tasks like clenaing, cooking, caring for the
family, and minding children. (5) Give the person some private time. (6) Don't
take the individual's anger or other feelings personally. (7) Don't tell the
person that he or she is "lucky it wasn't worse"; such statements do not
console traumatized people. Instead, tell the person that you are sorry such
an event has occurred and you want to understand and assist him or her. (8)
Teach the client and family to recognize symptoms of PTSD and to seek
treatment when the client does the following: (a) Relives the traumatic event
by thinking or dreaming about it frequently. (b) Is unselttled or distressed
in other areas of.... ÿÿÿÿ ÿ Powerlessness 763 Perception that one's own
actions will not significantly affect an outcome, perceived lack of control
over current situation or immediate happening LOW: Expressions of uncertainty
about fluctuating energy levels; passivity. MODERATE: Nonparticpation in care
or decision making when opportunities are provided; resentment, anger, and
guilt; reluctance to express true feelings; passivity; dependence on others
that may result in irritability; fearing alienation from caregivers;
expressions of dissatisfaction and frustration because of inability to perform
previous tasks/activities; expression of doubt regarding role performance;
failure to monitor progress; failure to defend self-care practices when
challenged; inability to seek info regarding care. SEVERE: Verbal expressions
of having no control over self-care, or influence over situation, or influence
over outcome; apathy; depression regarding physical deterioration that occurs
despite client's compliance with regimens Health care environment;
interpersonal interatctions; lifestyle helplessness; illness-related regimen
Depression Self-Control; Health Beliefs; Health Beliefs: Perceived Ability to
Perform, Perceived Control, Perceived Resources; Participation in Health Care
Decisions (1) State feelings of powerlessness and other feelings related to
powerlessness (e.g., anger, sadness, hopelessness) (2) Identify factors that
are uncontrollable. (3) Participate in planning and implementing care; make
decisions regarding care and treatment when possible. (4) Ask questions about
care and treatment. (5) Verbalize hope for the future and sense of
participation in planning and implementing care. Cognitive Restructuring;
Complex Relationship Building; Mutual Goal Setting; Self-Esteem Enhancement;
Self-Responsibility Facilitation NOTE: Prior to implementation of
interventions in the face of client powerlessness, nurses should examine their
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own philosophies of care to ensure that control issues or lack of faith in

client capabilities will not bias the ability to intervene sincerely and
effectively. (1) Observe for factors contributing to powerlessness (e.g.,
immobility, hospitalization, unfavorable prognosis, lack of support system,
misinformation about situation, inflexible routine, chronic illness). (2)
Assess for ineffective therapeutic regimen management or noncompliance. (3)
Assess the client's locus of control related to his or her health. (4) Assess
for signs/symptoms of hopelessness depression and pay particular attention to
the availibility of social support. Hopelessness depression is characterized
by a negative cognitive style (e.g., a tendency to perceive negative events as
stable and global). (5) Establish a therapeutic relationship with the client
by spending one-on-one time with him or her, ....
(1)Initiate focused assessment questioning and education regarding syndromes
common in elderly. (2) Explore feelings of powerlessness--the feeling that the
client's behavior will not affect outcomes. (3) Explore personality resources
and inner strengths that the client has used in the past. Incorporate these
into the treatment plan. (4) Establish therapeutic relationships by listening;
participate with the client in generating choices and incorporate his or her
statement of limitations. (5) Emphasize client control in all possible ADLs.
(6) Encourage the positive use of solitude--reading, listening to music,
enjoying nature--to prevent loneliness. Encourage socialization with others
when possible; advocate for the client regarding family visitation if
relationships are viewed positively by the client. (7) Monitor the use of
alternative therapies but do not intervene unless the therapy interacts
negatively with the existing therapeutic regimen. Ensure that all health care
providers.... (1) Assess for the influence of cultural beliefs, norms, and
values on the client's feelings of powerlessness. The client's expression of
powerlessness may be based on cultural perceptions or expectations. (2) Assess
the effect of fatalism on the client's expression of powerlessness. (3)
Encourage spirituality as a source of support to decrease powerlessness. (4)
Validate the client's feelings regarding the impact of health status on
current lifestyle. (5) For inner-city clients, help the client to redefine
behaviors as ways of coping with a hostile environment and to reconnect with
community supports. (1) Include an initial and ongoing assessment and
evaluation of potential abuse and neglect. Photograph evidence of abuse or
neglect when possible. (2) If neglect or abuse is suspected, identify an
emergency plan that addresses the problem immediately, ensures client safety,
and includes a report to the appropriate authorities. (3) Develop a
therapeutic relationship in the home setting that respects the client's
domain. (4) Empower the client by encouraging the client to guide specifics of
care such as wound care procedures and dressing and grooming details. Confirm
the client's knowledge and document in the chart that the client is able to
guide procedures. Document in the home and in the chart the perferred approach
to procedures. Orient the family and caregivers to the client's role. (5)
Develop a written contract with the client that designates what care will be
given and who has responsibility for care elements. Focus should be on care
that is controlled by the client. (6) ......
(1) Explain all relevant symptoms, procedures, treatments, and expected
outcomes. (2) Procude written instructions for treatments and procedures for
which the client will be responsible. (3) Continually assess the client for
signs of inappropriate exercise of self-care. Confront such applications of
self-care; instruct the client in the dangers that inappropriate care may
present and in alternatives for care that would be more effective. (4) Teach
stress reduction. relaxation, and imagery. Many cassette tapes are available
on relaxation and meditation. Assist the client with relaxation based on the
client;s preference indicated in the initial assessment. (5) Teach
cognitive-behavioral activities, such as active problem solving, reframing
(reappraising the situation from a different perspective), or thought stopping
(in response to a negative thought, picturing a large stop sign and replacing
the image with a prearranged positive alternative. Teach the client to
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confront his or her..... ÿÿÿÿ ÿ Powerlessness, risk for 774 At risk for
perceived lack of control over a situation and/or one's ability to
significantly affect an outcome. PHSIOLOGICAL: Chronic or acute illness
(hospitalization, intubation, ventilator use, suctioning); acute injury or
progressive debilitating disease process (e.g., multiple sclerosis); aging
(e.g., decreased physical strength, decreased motility); dying. PSYCHOLOGICAL:
Lack of knowledge of illness or health care system; lifestyle of dependency
with inadequate coping patterns; absence of integrity (e.g., essence of
power); decreased self-esteem; low or unstable body image Depression
Self-Control; Health Beliefs; Health Beliefs: Perceived Ability to Perform,
Perceived Control, Perceived Resources; Participation in Health Care Decisions
(1) State feelings of powerlessness and other feelings related to
powerlessness (e.g., anger, sadness, hopelessness) (2) Identify factors that
are uncontrollable. (3) Participate in planning and implementing care; make
decisions regarding care and treatment when possible. (4) Ask questions about
care and treatment. (5) Verbalize hope for the future and sense of
participation in planning and implementing care. Cognitive Restructuring;
Complex Relationship Building; Mutual Goal Setting; Self-Esteem Enhancement;
Self-Responsibility Facilitation See care plan for Powerlessness
See care plan for Powerlessness See care plan for Powerlessness See care
plan for Powerlessness
See care plan for Powerlessness ÿÿÿÿ ÿ Protection, ineffective 776
Decrease in ability to guard self from internal or external threats such as
illness or injury Maladaptive stress response; neurosensory alteration;
impaired healing; deificient immunity; altered clotting; dyspnea; insomsnia;
weakness; restlessness; pressure ulcers; perspiring; itching; immobility;
chilling; fatigue; disorientation; cough anorexia Abnormal blood profiles
(e.g., leukopenia, thrombocytopenia, anemia, coagulation); extremes of age;
inadequate nutrition; alcohol abuse; drug therapies (e.g, antineoplastic,
corticosteroid, immune, anticoagulant, thrombolytic); treatments (e.g,
surgery, radiation); diseases such as cancer and immune disorders Abuse
Protection; Blood Coagulation; Endurance; Immune Status (1) Remain free of
infection (2) Remain free of any evidence of new bleeding (3) Explain
precautions to take to prevent infection (4) Explain precautions to take to
prevent bleeding Bleeding Precautions; Infection Control; Infection
Protection (1) Take temperature, pulse, and blood pressure (e.g, q 1 to 4
hrs) (2) Obsreve nutritional status (e.g, weight, serum protein and albumin
levels, muscle mass, usual food intake). Work with the dietician to improve
nutritional status if needed. All clients diagnosed with HIV should have a
dietary consult. (3) Observe the client's sleep pattern; if altered, see
Nursing Interventions for Disturbed Sleep patterns. (4) Determine the amount
of stress in the client's life. If stress is uncontrollable, see Nursing
Interventions for Ineffective Coping. PREVENTION OF INFECTION: (1) Monitor for
and report any signs of infection (e.g. fever, chills, flushed skin, drainage,
edema, redness, abnormal laboratory values, and pain) and notify the
physician. (2) Use appropriate "hand hygiene" (i.e. hand washing, or use of
alcohol-based hand rubs). (3) When using an alcohol-based hand rub, apply
product to palm of one hand and rub hands together, covering all surfaces of
hands and fingers. until .......
(1) If not contraindicated, promote exercise to strengthen the immune system
in the elderly. (2) Give elderly client with imbalanced nutrition a
nutritional supplement to enhance immune function. (3) See care plan for Risk
for Infection for more interventions related to the prevention of infection.
(1) Some of the interventions described previously may be adapted for home
care use. (2) Consider institution of a nurse-administered mobile care unti
for monitoring anticoagulant therapy. (3) For terminally ill clients, teach
and institute all of the aformentioned noninvasive precautions that will
maintain quality of life. Discuss with the client, family, and physician the
consequences of contracting infection. Determine which precautions do not
maintain quality of life and should not be used (e.g., physical assessment
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twice daily, multiple vital sign assessments).

DEPRESSED IMMUNE FUNCTION: (1) Teach precautions to take to decrease the
chance of infection (e.g, avoiding uncooked fruits or vegetables, using
appropriate self-care, ensuring a safe environment). (2) Teach the client and
family to notify the physician of elevated temp, even in the absence of other
symptoms of infection. (3) teach the client to avoid crowds and contact with
persons who have infections. BLEEDING DISORDER: (1) Teach the client to wear a
medical alert bracelet and notify all health care personnel of the bleeding
disorder. (2) Teach the client and family the signs of bleeding, precautions
to take to prevent bleeding, and action to take if bleeding begins. Caution
the client to avoid taking over-the-counter meds w/o the permission of the
physcian. (3) Teach the client to wear loose-fitting cloths and avoid physical
activity that might cause trauma. ÿÿÿÿ ÿ Rape-trauma syndrome 783
sustained maladaptive response to forced, violent sexual act (penetration may
not actually occur) against the victim's will and conset. Fear
disorganization; change in relationships; confusion; physical trauma (e.g.,
bruising, tissue irritation; injjuries identified by use of new technology);
suicide attempt; denial; guilt, paranoia; humiliation; embarrassment;
aggression; muscle tensoin and/or spasms; mood swings; dependence;
powerlessness; nightmares and sleep disturbances; secual dysfrunction; desire
for revenge; phobias; loss of self-esteem; inability to make decisions;
dissociattive disorders; self-blame; hyperalertness; vulnerability; substance
abuse; depression; helplessness; anger; anxiety; agitation; shame; shock
Rape; sexual assault; abuse Abuse Cessation; Abuse Protection; Abuse
Recovery: Emotional, Sexual; Coping; Impulse Self-Control; Self-Mutilation
Restraint (1) Share feelings, concerns, and fears. (2) Recognize that the
rape or attempt was not the client's own fault. (3) State that, no matter what
the situation, no one has the right to assault another. (4) Describe
medical/legal treatment procedures and reasons for treatment. (5) Report
absence of physical complications or pain. (6) Identify support people and be
able to ask them for help in dealing with this trauma. (7) Function at same
level as before crisis, including sexual functioning. (8) Recognize that it is
normal for full recovery to take a minimum of 1 year. Couseling; Rape-Trauma
Treatment (1) Observe the client's responses, including anger, fear,
self-blame, sleep patterns disturbances and phobias. (2) Monitor the client's
verbal and nonverbal psychological state (e.g., crying, hand wringing,
avoidance of interactions or eye contact with staff, silence and denial). (3)
Stay with (or have a trusted person stay with ) the client initially. If a law
envrocement interview is permitted, provide support by staying with the
client, but only at the client's request. (4) Explain the entire medical/legal
examination to the client before beginning any procedures. Obtain written
permission to perform the examination but explain that at any time during the
exam the client may withdraw consent. Discuss the importance of collection of
evidence. The exam will include several procedures that might be unconfortable
or painful and the client should know this in advance. Before moving on to
each procedure, repeat the explanation and offer the client the right to skip
any part of the ......
(1) Build a trusting relationship with the client. (2) Explain reporting and
encourage the client to report. (3) Observe for psychosocial distress (e.g.,
memory impairment, sleep disturbances, regress, changes in bodily function).
(4) All examinations should be done on the elderly as they would be done on
any adult client after sexual assault. Evidence should be collected and
consent for collection, photography, and law enforcement contact should be
obtained in all cases. Special attention should be given to the explanation of
the genital exam, especially as it related to the use of a speculum. (5)
Modify the rape protocol to promote comfor for the geriatric client. Consider
positioning female clients with pillows rather than stirrups and consider
using a small speculum. (6) Assess for mobility limitations and cognitive
impairment. (7) Respect the client's need for privacy. (8) Consider
arrangements for temporary housing. Most sexual assaults of older clients
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occur in the home or ..... (1) Assess for the influence of cultural beliefs,
norms, and values on the client's ability to cope with the trauma of the rape
experience. (2) Acknowledge racial/ethnic differences at the onset of care.
(3) Use a family-centered approach when working with Latino, Asian, African
Americans, and native American clients' (4) Provide opportunites by which the
family and individual can save face when working with Asian American clients.
(5) Assure the client of confidentiality. (6) Validate the client's feelings
regarding the rape and allow the client to tell his or her rape story. (7) A
culturally sensitive approach should be part of the training of all SARTs and
members of the team. (1) Some of the interventions described previously may
be adapted for home care use. (2) Interact with the client realistically
assessing the home setting for safety and/or selecting a safe environment in
which to live. (3) Ensure that the client has a support system in place for
long-term support. Instruct the family that recovery may take a long time.
Refer for counseling if necessary. (4) Assis the client with realistically
assessing the home setting for safety and/or selecting a safe environment in
which to live. (5) Make sure that physical symptoms from the rape or other
physical conditions are followed up. Follow-up should include a visit to the
primary care physician or the local health department in 3-4 weeks for repeat
pregnancy testing and STD testing. Explain to the client that additional
medication may be necessary for the treatment of STDs or pregnancy. (6) If the
client is homebound, refer for psychiatric home health care services for
client reassurance and ............
(1) Provide information on prophylactic antibiotic therapy, hep B, and tetanus
prophylaxis for nonimmunized clients with trauma. (2) Discharge instructions
should be written out for the client. (3) Give instructions to significant
others. (4) Explain the purpose of the "morning-after pill". Explain the
potential for common side effects related to treatment with norgestrel, such
as breast swelling or nausea and vomiting. (Call the emergency department if
the client vomits within 1 hour of taking the pill because the pill may need
to be taken again.) (Discuss any issues about prophylactic meds at the
follow-up visit in 3-4 weeks.) It may take 3-30 days for the menstrual period
to start; if menstruation has not begun in 30 days, contact a physician. (5)
Explain the potential for severe side effects related to treatment with
norgestrel, such as severe leg or chest pain, trouble breathing, coughing up
of blood, severe headache or dizziness, and trouble seeing or talking. (6)
Advise the .... ÿÿÿÿ ÿ Rape-trauma syndrome: compound reaction 791 Forced
violent sexual act (penetration may not actually occur) against victim's will
and consent resulting in a trauma syndrome that includes an acute phase of
disorganization of victim's lifestyle and a long-term process or
reorganization of lifestyle Change in lifestyle (e.g., changing residence,
dealing with repetitive nightmares and phoboias, seeking family support,
seeking social network support in long-term phase); emotional reaction (e.g.,
anger, embarrassment, fear pof physical violence and death, humiliation,
desire for revenge, self-blame in acute phase); multiple physical symptoms
(e.g., GI irritability, GU discomfort, muscle tension, sleep pattern
disturbance in acute phase); reactivated symptoms of previous conditions
(i.e., physical illness, psychiatric illness in acute phase); reliance on
alcohol and/or drugs (acute phase) Rape; sexual assault; abuse Abuse
Cessation; Abuse Protection; Abuse Recovery: Emotional, Sexual; Coping;
Impulse Self-Control; Self-Mutilation Restraint (1) Share feelings, concerns,
and fears. (2) Recognize that the rape or attempt was not the client's own
fault. (3) State that, no matter what the situation, no one has the right to
assault another. (4) Describe medical/legal treatment procedures and reasons
for treatment. (5) Report absence of physical complications or pain. (6)
Identify support people and be able to ask them for help in dealing with this
trauma. (7) Function at same level as before crisis, including sexual
functioning. (8) Recognize that it is normal for full recovery to take a
minimum of 1 year. Couseling; Rape-Trauma Treatment See care plan for
Rape-trauma syndrome, Powerlessness, Ineffective Coping, Dysfunctional
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Grieving, Anxiety, Fear, Risk for self-directed Violence, and Sexual

dysfunction
(1) A new subgroup of rape victims resides in nursing homes. Treatment is
necessary. (1) Assess for the influence of cultural beliefs, norms, and
values on the client's ability to cope with the trauma of the rape experience.
(2) Provide opportunities by which the family and individual can save face
when working with Asian American clients. (3) Assure the client of
confidentiality. (4) Validate the client's feelings regarding the rape and
allow the client to tell his or her rape story. (5) A culturally sensitive
approach should be part of the training of all sexual assault response teams
and members of teams. (1) If the client has pusued psychiatric counseling,
monitor and encourage attendance. (2) If the client is receiving medication,
assess the client's knowledge of its purpose, side effects, and interactions
with meds for other diagnoses. Monitor for effectiveness, side effeccts, and
interations. (3) Establish an emergency plan including hotlines. Contract
with the clinet to use the emergency plan. Role play using the hotlines. (4)
For other home care and hospics considerations, see care plan for Rape-trauma
syndrome.
(1) Teach the client what reactions to expect during the acute and long-term
phases: acute phase--anger, fear, self-blame, embarrassment, vengeful
feelings, physical symptoms, muscle tension, sleeplessness, stomach upset, GU
discomfort; long-term phase--changes in lifestyle or residence, nightmares,
phobias, seeking of family and social network support. (2) Encourage
psychiatric consultation if the client is suicidal, violent, or unable to
continue ADLs. (3) Discuss any of the client's current stress-relieving meds
that may result in substance abuse. ÿÿÿÿ ÿ Rape-trauma syndrome: silent
reaction 794 Forced violent sexual act (penetration may not actually occur)
against victim's will and consent resulting in a trauma syndrome that includes
an acute phase ofdisorganization of victim's lifestyle and a long-term process
of reorganization of lifestyle Increased anxiety during interview (e.g.,
blocking of associations. long periods of silience, minor stuttering, phsycial
distress); sudden onset of phobic reactions; lack of verbalization about the
rape; abrupt changes in relationships with males; increased nightmares;
pronounced changes in sexual behavior Rape; sexual assault; abuse Abuse
Cessation; Abuse Protection; Abuse Recovery: Emotional, Sexual; Coping;
Impulse Self-Control; Self-Mutilation Restraint (1) Resume previous level of
relationships with significant others. (2) State improvement in sleep and
fewer nightmares. (3) Express feelings about and discusses the rape
(Nondisclosure about a sexual assault may arise out of self=protection, but
this defensive coing style acts as a pressure cooker and is associated with
more intense depressive stymptoms. Clients should be assured that disclosure
of an incident of sexual assault to a care provider or advocate has guaranteed
confidentiality and does not necessitate notification of law enforcement. (4)
Return to usual pattern of sexual behavior (Women who are sexually active
after the assault report lower levels of depression. However, being sexually
active cannot be construed to mean that the client has adjusted to or resolved
the sexual trauma.) (5) Remain free of phobic reactions. See care plan for
Rape-trauma syndrome. Counseling; Support System Enhancement (1) See the
care plan for Rape-trauma syndrome, Powerlessness, Ineffective Coping,
Dysfunctional Grieving, Anxiety, Fear, Risk for self-directed Violence, Sexual
dysfunction, and Impaired verbal Communication. (2) Observe for disruption in
relationships with significant others. (3) Monitor for signs of increased
anxiety (e.g, silence, stuttering, physical distress, irribility, unexplained
crying spells). (4) Focus on the client's coping strengths. (5) Observe for
changes in sexual behavior. (6) Identify phobic reactions to persons or
objects in the environment (e.g, strangers, doorbells, groups of people,
knives). (7) Provide support by listening when the client is ready to talk.
(8) Be nonjudgmental when feelings are expressed. Explain that anger is normal
and needs to be verbalized. (9) Remain with an anxious client even if the
client is silent. use gentle speech and actions; move slowly. (10) Evaluate
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somatic complaints.
(1) A new subgroup of rape victims resides in nursing homes. Treatment is
necessary. (1) Assess for the influence of cultural beliefs, norms, and
values on the client's ability to cope with the trauma of the rape experience.
(2) Provide opportunites by which the family and individual can save face when
working with Asian American clients' (3) Assure the client of confidentiality.
(4) Allow the client to tell is or her rape story without probing. See the
care plan for Rape-trauma syndrome.
(1) Reassure the client that he or she is not bad and is not at fault. Avoid
questions beginning with "why". "Why" questions may sound judgmental and feed
into self-blame. (2) Refer the client to a sexual assault counselor. (3) Offer
information about testing, treatment, and procedures related to pregnancy, hep
B, and STD. Do not wait for the client ot request info. See care plan for
Rape-trauma syndrome ÿÿÿÿ ÿ Relocation stress syndrome 797 Physiological
and/or psychosocial disturbances that result from transfer from one
environment to another. NOTE: Recent research on the nursing diagnosis of
relocation stress syndrome may indicate that the nursing diagnosis is not
valid or may not be valied when applied to group moves of clients. More
research is needed in this area to validate this nursing intervention.
Temporary and/or permanent move; voluntary and/or involuntary move; aloneness,
alienation, or loneliness; depression; anxiety (e.g., separation); sleep
disturbance; withdrawal; anger; loss of identity, self-worth, or self-esteem;
increased verbalization of needs, unwillingness to move or concern over
relocation; increased physical symptoms/illness (e.g., GI disturbance, weight
change); dependency; insecurity; pessimism; frustration; worry; fear
Unpredictability of experience/isolation from family/friends; passive coping;
language barrier; decreased health status; impaired psychosocial health; past,
concurrent, and recent losses; feeling of powerlessness; lack of adequate
support system/group; lack of predeparture counseling Anxiety Self-Control;
Child Adaptation to Hospitalization; Coping; Depression Level; Depression
Self-Control; Loneliness Severity; Psychosocial Adjustment: Life change;
Quality of Life (1) Recognize and know the name of at least one staff member.
(2) Express concern about the move when encouraged to do so during individual
contacts. (3) Carry out ADLs in usual manner. (4) maintain previous mental and
physical health status (e.g., nutrition, elimination, sleep, social
interaction). Anxiety Reduction; Coping Enhancement; Discharge Planning; Hope
Instillation; Self-Responsibility Facilitation (1) Obtain a history,
including the reason for the move, the client's usual coping mechanisms,
history of losses, and family support for the client. (2) If the client is an
adolescent, try to aviod a move in the middle of the school year, find a
newcomer's club for the adolescent ot join and refer for counseling if needed.
(3) Provide support for a child and family who must relocate to be near a
transplant center. (4) Identify previous routines for ADLs. Try to maintain as
much continuity with the previous schedule as possible. (5) bring in familiar
items from home. (6) Thoroughly orient the client to the new environment and
routines; repeat directions as needed. (7) Spend one-on-one time with the
client. Allow the client to express feelings and convey acceptance of them;
emphasize that the client's feelings are real and individual and that it is
acceptable to be sad or angry about moving. (8) Assign the same staff members
to the client; maintain consistency in the personnel the .....
(1) Monitor the need for transfer and transfer only when necessary. (2)
Protect the client from injuries such as falls. (3) After the transfer,
determine the client's mental status. Document and observe for any new onset
of confusion. (4) Refer for music therapy. (5) Use a reality orientation if
needed (e.g., "Today is.....", "The date is...," "You are at .....facility").
Repeat the info as needed and provide a clock or calendar.
(1) Teach family members about relocation stress syndrome. Encourage them to
monitor for signs of the syndrome. (2) help significan others learn how to
support the client in the move by setting up a schedule of visits, arranging
for holidays, bringing familiar items from home, and establishing a system for
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contact when the client needs support. ÿÿÿÿ ÿ Relocation stress syndrome,
risk for 801 At risk for physiological and/ro psychosocial disturbances that
result from transfer from one environment to another. Moderate to high
degree of environmental change (e.g., physical, ethnic, cultural); temporary
and/or permanent move; voluntary and/or involuntary move; lack of adequate
support system/group; feelings of powerlessness; moderate and mental
competence (e.g., alert enough to experience ); unpredictability of
experiences; decreased psychosocial or physical health status; lack of
predeparture counseling; passive coping; past, current, or recent losses
Anxiety Self-Control; Child Adaptation to Hospitalization; Coping; Depression
Level; Depression Self-Control; Loneliness Severity; Psychosocial Adjustment:
Life change; Quality of Life (1) Recognize and know name of at least one
staff member. (2) Express concern about move when encouraged to do so during
individual contacts. (3) Carry out ADLs in usual manner. (4) maintain previous
mental and physical health (e.g., nutrition, elimination, sleep, social
interaction) Anxiety Reduction; Coping Enhancement; Discharge Planning; Hope
Instillation; Self-Responsibility Facilitation (1) Adequately prepare the
client and family for transfer from the ICU. (2) Assist caregivers with the
use of respite care for family members, acknowledge the importance of
caregivers' role, and seek their assistance in planning the client's care. (3)
Relocation to more supportive housing is a potentially stressful life event
for an older adult. Nurses have a critical role to play in helping the family
identify the most appropriate housing alternative, assisting in planning the
relocation, and helping older adults, especially ethnic elders, adjust to
their new homes. (4) Consider 24 hr in-home care as an alternative to nursing
home placement. (5) Provide support for spouses who have placed a partner in a
care home. Support a continued relationship with the partner. (6) Refer to the
care plan for Relocation Stress Syndrome.
Refer to the care plan for Relocation Stress Syndrome.
Refer to the care plan for Relocation Stress Syndrome. ÿÿÿÿ ÿ Role
performance, ineffective 804 Patterns of behavior and self-expression that
do not match the environmental context, norms, and expectations Change in
self-perception; role denial; inadequate external support for role enactment;
inadequate adaptation to change or transition, system conflict; change in
usual patterns of responsibility; discrimination; domestic violence;
harassment uncertainty; altered role perceptions; role strain; inadequate
self-management; role ambivalence; pessimistic attitude; inadequate
motivation; inadequate confidence; inadequate role competency and skills;
inadequate knowledge; inappropriate developmental expectations; role conflict;
role confusion; powerlessness; inadequate coping; anxeity or depression; role
overload; change in other's perception or role; role dissatisfaction;
inadequate opportunities for role enactment SOCIAL: Inadequate or
inappropriate linkage with the health care system; job schedule demands; young
age; developmental level; lack of rewards; poverty; family conflict;
inadequate support system; inadequate role socialization; low socioeconomic
status; stress and conflict; domestic violence; lack of resources KNOWLEDGE:
Inadequate role preparation; lack of knowledge about role, role skills, role
transition; lack of opportunity for role rehearsal; developmental transitions;
unrealistic role expectations; education attainment level; lack of or
inadequate role model. PHYSIOLOGICAL: inadequate/inappropriate linkage with
health care system; substance abude; mental illness; body image alteration;
physical illness; cognitive deficits; health alterations; depression; low
self-esteem; pain; fatigue. NOTE: There is a typology of roles: sociopersonal,
home management intimacy, leisure/exercise/recreation, self-management,
socialization, community contributor, and religious. Coping; Psychosocial
Adjustment: Life Change (1) Identify realistic perception of role. (2) State
personal strengths. (3) Acknowledge problems contributing to inability to
carry out usual role. (4) Accept physical limitations regarding role
responsibility and consider ways to change lifestyle to accomplish goals
associated with role performance. (5) Demonstrate knowledge of appropriate
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behaviors associated with new or changed role. (6) State knowledge of change
in responsibility and new behaviors associated with new responsibility. (7)
Verbalize acceptance of new responsibility. Role Enhancement (1) Obsreve the
client's knowledge of behaviors associated with role. (2) Allow the client to
express feelings regarding the role change. (3) Ask the client direct
questions regarding new roles and how the health care system can help him or
her continue roles. (4) Assis new parents to adjust to changes in workload
associated with childbirth. (5) Reinforce the client's strengths, have the
client identify past coping skills, and support the continued use of these
skills. (6) Have the client make a list of strenths that are needed for the
new role. Acknowledge which strengths the client has and which strengths need
to be developed. Work with the client to set goals for desired role. (7) Have
the client list problems associated with the new role and identify ways of
overcoming them. (8) Provide parents with coping skills when the role change
is associated with a critically ill child. (8) Assist parents in coping with
infants with colic, a condition common in infants. (9) Assist families...
(1) Support the client's religious beliefs and activities and provide
appropriate spiritual support persons. (2) Encourage the use of humor by
family caregivers to describe their role reversal. (3) Explore community needs
after assessing the client's strengths. Suggest functional activities. (4)
Refer to appropriate support groups for adjustment to role changes. (5) Refer
to home health agency for home visits when there is an infant who has
excessive crying. (6) Refer to therapy to improve memroy for patients with
Alzheimer disease. (1) Assess for the influence of cultural beliefs, norms,
values, and expectations on the individual's role. (2) Assess for conflicts
between the caregiver's cultural role obligations and competing factors like
employment. (3) Negotiate with client regarding the aspects of their role that
can be modified and still honor cultural beliefs. (4) Encourage family to use
support groups or other service programs to assist with role changes. (5)
validate the individual's feelings regarding the impact of role changes on
family and personal lifestyle. (1) Above interventions may be adapted for
home care use. (2) Determine the anticipated duration of role change. (3)
Assess family's ability to physically or psychologically assume
responsiblities of decrease or change in the client's role function. (4) Offer
a referral to medical social services to assist with assessing the short- and
long-term impacts of role change.
(1) Teach significant others about health care changes to expect when the
client returns home. (2) help the client identify resources for assistance in
caring for a disabled or aging parent. (3) Refer to appropriate community
agencies to learn skills for functioning in the new or changed role. ÿÿÿÿ ÿ
Self-care deficit, bathing/hygiene 809 Impaired ability to perform or
complete bathing/hygiene activities for oneself Inability to: wash body or
body parts; obtain or get to water source; regulate temperature or flow of
bath water; get bath supplies; dry body; get in and out of bathroom
Decreased or lack of motivation; weakness and tiredness; severe anxiety;
inability to perceive body part or spatial relationship; perceptual or
cognitive impairment; pain; neuromuscular impairment; musculoskeletal
impairment; environmental barriers Self-Care: Activities of Daily Living
(ADL), Bathing, Hygiene (1) Remain free of body odor and maintain intact
skin (2) State satisfaction with ability to use adaptive devices to bathe (3)
Bathe with assistance of caregiver as needed without anxiety (4) Explain and
use methods to bathe safely and with minimal difficulty Bathing; Self-Care
Assistance: Bathing/Hygiene (1) If in a typical bathing setting for the
client, assess the client's ability to bathe self via direct observation using
physical performance tests for ADLs. (2) Ask the client for input on bathing
habits and cultural bathing preferences. (3) Develop a bathing care plan based
on the client's own history of bathing practices that addresses skin needs,
self-care needs, client response to bathing and equipment needs. (4)
Individualize bathing by identifying function of bath (e.g., odor or urine
removal), frequency required to achieve function, and best bathing form (e.g.,
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towel bathing, tub, or shower) to meet client preferences, preserve client

dignity, make bathing a soothing experience, and reduce client aggression. (5)
Request referrals for occupational and physical therapy. (6) Plan activities
to prevent fatigue during bathing and seat the client with feet supported.
(7) Provide pain relief measures: ice packs, heat, analgesics 45 minutes
before bathing if needed. (8) Consider....
(1) Develop client muscle strength building plan to build the client's
physiological capacity. (2) Include exercise and walking program in plan of
care. (3) Assess self-efficacy (The Self-Efficacy for Functional Activities
scale); assess outcome expectations (Outcome Expectations for Functional
Activities scale). Based on assessment promote motivation and self-efficacy
for ADL functioning by: role modeling via videotape or partnering; verbal
encouragement; individualize care using humor, kindness, joy and excitement
with achievements; social supports; and decrease unpleasant sensations with
the ADL function. (4) Provide same type of bathrobe and bathing articles, such
as scented dusting powder and bath oil, that the client used previously. (5)
Assess for grieving resulting from loss of function. (6) Arrange bathing
environment to promote sensory comfort: reduce noise of voices and water and
decrease glare from tiles, white walls, and artificial lights. (7) When
bathing a cognitively... (1) Based on functional assessment and
rehabilitation capacity, refer for home health aide services to assist with
bathing and hygiene. (2) Turn down temperature of hot water heater.(3) Show
caregiver videotape of caregiver self-care activities (organizing day, talking
when frustrated, self-time, and nonjudgmental person with whom to talk)
followed by a discussion. (4) Cue cognitively impaired clients in steps of
hygiene. (5) Respect the preference of terminally ill clients to refuse or
limit hygiene care. (6) If a terminally ill client requests hygiene care, make
an extra effort to meet request and provide care when client and family will
most benefit (e.g., before visitors, at bedtime, in the early morning). (7)
Maintain temperature of home at a comfortable level when providing hygiene
care to terminally ill clients.
(1) Teach the client and family how to use adaptive devices for bathing, and
teach bathing techniques that promote safety (e.g., getting into tub before
filling it with water, emptying water before getting out, using an antislip
mat, wall-grab bars, tub bench). (2) Teach the client and family an
individualized bathing routine that includes a schedule, privacy, skin
inspection, soap or lubricant, and chill prevention. ÿÿÿÿ ÿ Self-care
deficit, dressing/grooming 814 Impaired ability to perform or complete
dressing and grooming activities for self Impaired ability to put on or take
off necessary items of clothin; impaired ability to fasten clothing; impaired
ability to obtain or replace articles of clothing; inability to clothe upper
body; inability to clothe lower body; inability to choose clothing; inability
to use assistive devices; inability to use zippers; inability to remove
clothes; inability to put on socks; inability to maintain appearance at a
satisfactory level; inability to pick up clothing; inability to put on shoes
Decreased or lack of motivation; pain; severe anxiety; perceptual or cognitive
impairment; weakness or tiredness; neuromuscular impairment; musculoskeletal
impairment; discomfort; environmental barriers. NOTE: See suggested Functional
Level Classification in care plan for Impaired physical Mobility. Self -Care:
ADLs, Dressing, Hygiene (1) Dress and groom self to optimal potential. (2)
Use adaptive devices to dress and groom. (3) Explain and use methods to
enhance strengths during dressing and grooming. (4) Dress and groom with
assistance of caregiver as needed. Dressing; Hair Care; Self-Care Assistance:
Dressing/Grooming (1) Observe the client's ability to dress and groom self
through direct observation and from the client/caregiver report, noting
specific deficits and their causes. (2) Consider environmental and human
factors that may limit dressing/grooming ability, such as reaching for clothes
or grooming aids in closets or drawers. Help the client arrange clothing and
grooming devices within easy reach. Installing turntables and closet rods or
drawers between eye and hip level is helpful. (3) Identify and include the
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client's strengths in dressing and grooming to individualize the dressing

process. (4) Ask the client for input on clothing choices and how to increase
the ease of dressing. (5) Request referrals for occupational and physical
therapy. (6) Provide medication for pain 45 minutes before dressing and
grooming if needed. (7) Provide privacy and limit people/caregivers in room.
(8) Select larger-sized clothing, clothing with elastic waistbands, wide
sleeves and pant legs, dresses that.......
(1) Assess for grieving resulting from loss of function. (2) Provide
medication for pain if needed and plan activities to prevent fatigue before
dressing/grooming. (3) Assess tasks the client can complete, noting areas of
indepence and difficulty to make adaptations. (4) Assess self-efficacy; assess
outcome expections. Based on assessment, promote motivation and self-eficacy
for ADL functioning by: role modeling via videotape or partnering; verbal
encouragement; individualize care using humor, kindness, joy, and excitement
with achievements; social supports; and decrease unpleasant sensations with
the ADL function. (5) Allow the client or caregiver adequate time to complete
dressing. (6) Telehomecare can be an effective way to assess and monitor ADL
performance for older adults. (1) Involve the client in planning of
informal care and provide access to health professionals and financial support
for the care. (2) Based on functional assessment and rehabilitation capacity,
refer for home health aide services to assist with dressing and grooming. (3)
Have caregiver view videotape showing caregiver self-care activities followed
by a discussion. (4) Cue cognitively impaired clients in steps of dressing and
grooming. (5) Respect the preference of the terminally ill client to refuse
dressing and limit drooming. (6) If terminally ill client request dressing and
grooming, make an extra effort to meet the request and provide care when the
client and family will most benefit. (7) Maintain the temp of the home at a
comfortable level when dressing terminally ill client.
(1) Teach the client to dress the affected side first, then the unaffected
side. (2) Teach the simplest step in a task until mastered, and then proceed
to more complicated steps. Give praise. (3) Teach the client how to use
adaptive devices for dressing and grooming. (4) Teach the client and family to
select clothes appropriate for the season, temp, and weather. ÿÿÿÿ ÿ
Self-care deficit, feeding 818 Impaired ability to perform or complete
feeding activities
Inability to swallow food; inability to prepare food for ingestion;
inability to handle utensils; inability to chew food; inability to use
assistive device; inability to get food onto utensils; inability to open
containers; inability to ingest food safely; inability to manipulate food in
mouth; inability to bring food from a receptacle to the mouth; inability to
complete a meal; inability to ingest food in a socially acceptable manner;
inability to pick up cup or glass; inability to ingest sufficient food
Weakness or tiredness; severe anxiety; neuromuscular impairment; pain;
perceptual or cognitive impairment; discomfort; environmental barriers;
decreased or lack of motivation; musculoskeletal impairment NOTE: See
suggested Functional Level Classification in the care plan Impaired physical
Mobility (1)Feed self (2) State satisfaction with ability to use adaptive
devices for feeding (3) Provide assistance with feeding when necessary
(caregiver) Feeding; Self-Care Assistance: Feeding (1) Assess the client's
ability to feed self. Test gag reflex bilaterally, and note specific deficits
(2) Observe for cause of inability to feed self independently (see Related
Factors). (3) Ask the client for input on methods to facilitate eating and
feeding (e.g., cultural foods, other food and fluid preferences), and provide
four entre´e choices, including ethnic choice. (4) Request referral for
occupational and physical therapy; request a dietician. (5) Ensure that the
client has dentures, hearing aids, and glasses in place. (6) Use any necessary
adaptive feeding equipment (e.g., rocker knives, plate guards, suction mats,
built-up handles on utensils, scoop dishes, large-handled cups). (7) Seat the
client at table using name card and place mat with meal in visual range next
to role model who can eat, if applicable. (8) Help the client into sitting
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position; ensure that the client's head is flexed slightly forward and
shoulders are supported while eating and for 1 hr after a meal..
(1) Develop client muscle strength building plan to build the client's
physiological capacity. (2) Implement Hospital Elder Life Program, a model of
care to prevent functional and cognitive decline of older persons during
hospitalization. (3) Provide medication for pain before meals if needed and
plan activities to prevent fatigue before meals. (4) Assess and maintain
documentation about poststroke client's eating and nutrition (include weight)
upon admission to long-term care. (5) Serve meals "family-style" with food in
serving bowls and an empty plate to be filled by patient. (6) Obtain and value
patient's view of agency's food selection and presentation. Present views to
administration. (7) Ensure adequate staffing at meal times.(8) Choose soft
foods rather than liquids, or use dietary thickeners. (9) Assess for
intolerance to food texture and, if found, reverse food texture pattern as
tolerated, progressing finally to texture stage of thick liquids.(10) Provide
finger foods for.... (1) Based on functional assessment and rehabilitation
capacity, refer for home health aide services to assist with feeding. (2)
Telehomecare can be an effective way to assess and monitor ADL performance for
older adults. (3) Cue cognitively impaired client when feeding. (4) Respect
the preference of terminally ill clients to refuse nutrition or assistance
with eating. Refer to care plans for Imbalanced Nutrition: less than body
requirements and Impaired Swallowing. (5) If terminally ill client requests
nutrition, take special care to provide foods and assistive devices that
protect the client from aspiration, minimize energy requirements, and meet the
client's taste preferences.
(1) Teach the client how to use adaptive devices. (2) Teach the client with
hemianopsia to turn head so that the plate is in the line of vision. (3) Teach
visually impaired client to locate foods according to numbers on a clock. ÿÿÿÿ
ÿ Self-care deficit, toileting 823 Impaired ability to perform or complete
own toileting activities. Defining ability to get to toilet or commode;
inability to sit on or rise from toilet or commode; inability to manipulate
clothing for toileting; inability to carry out proper toilet hygience;
inability to flush toilet or commode. Environmental barriers; weakness or
tiredness; decreased or lack of motivation; severe anxiety; impaired mobility
status; impaired transfer ability; musculoskeletal impairment; neuromuscular
impairment; pain; perceptual or cognitive impairment. NOTE: See suggested
Functional Level Classification in care plan for Impaired physical Mobility.
Self-Care ADLs, Toileting (1) Remain free of incontinence and impaction with
no urine or stool on skin. (2) State satisfaction with ability to use adaptive
devices for toileting. (3) Explain and use methods to be safe and independent.
Environmental management; Self-Care Assistance: Toileting (1) Observe cause
ofinability to toilet independently. (2) Assess ability to toilet; not
specific deficits. (3) Ask the client for input on toileting methods and
timing and how to better provide toileting activity assestance. (4) Assess the
client's usual bowel and bladder toileting patterns and the terminology used
for toileting. (5) Request referral for occupational and physical therapy for
help in working with the client to transfer from bed to commode. (6) use any
necessary assistive toiling equipment. (7) Provide privay. (8) Develop
toileting schedule using clocks, written schedules, or verbal prompting as
cues for the client and provide assistance at scheduled times. (9) Schedule
toileting to occur when the defecation urge is strongest or voiding is likely.
Assist the client until self-care ability icnreases. (10) Allow the client to
particpate as able in toileting, and provide praise for accomplishments.
Increase tasks as the client is able, and work with the client to aim .....
(1) Develop client muscle building plan to build the client's physiological
capacity. (2) Include exercise and walking program of care. (3) Implement
Hospital Elder Life Program, a model of care to prevent functional and
cognitive decline of older persons during hospitalization. (4) Assess
self-efficacy (The Self-Efficacy for Functional Activities scale); assess
outcome expectations (Outcome Expectations for functional Activities scale).
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Based on assessment, promote motivation and self-efficacy for ADL frunctioning

by: role modeling via videotape or partnering; verbal encouragement;
individualize care using humor, kindness, joy and excitement with
achievements; social supports; and decrease unpleasant sensations with the ADL
function. (5) Monitor clients with dementia for behavioral toileting cues and
assist with prompt toileting, or use an individualized schedule toileting for
memory impaired elderly. (6) Assess the client' mobility status and speed of
movement. (7) Reassure the ... (1) have caregiver view videotape showing
caregiver self-care activities (organizing day, talking when frustrated,
self-time, and nonjudgmental person with whom to talk) followed by a
discussion. (2) Based on functional assessment and rehabilitation capacity,
refer for home health aide services to assist with toileting. (3) Cue
cognitively impaired clients in steps of toileting. (4) Avoid the use of meds
that place undue toileting stress on the client who is terminally ill. (5)
Provide pain meds for terminally ill clients 20 to 45 mins before toileting in
anticipation of possible pain. See care plan for constipation. (6) Consider
use of an indwelling catheter for terminally ill clients in too much pain to
move when hygiene and skin integrity are difficult to maintain.
(1) Teach the client and family how to toilet the client with adaptive and
safety devices. (2) Have family instal toilet seat of a contrasting color. (3)
Prepare the client for toileting needs by teaching the action of meds such as
diuretics. (4) help the visually impaired client to develop a plan for
locating bathrooms in new environments. ÿÿÿÿ ÿ Self-concept, readiness for
enhanced 828 A pattern of perceptions or ideas about the self that is
sufficient for well-being and can be strengthened. Expresses willingness to
enhance self-concept. Expresses satisfaction with thoughts about self, sense
of worthiness, role performance, body image, and personal identity; Actions
are congruent with expressed feelings and thoughts; Expresses confidence in
abilities; Accepts strengths and limitations. To be developed.....
Self-Esteem (1) State willingness to enhance self-concept. (2) State
satisfaction with thoughts about self, sense of worthiness, role performance,
body image, and personal identity. (3) Demonstrate actions that are congruent
with expressed feelings and thoughts. (4) State confidence in abilities. (6)
Accept strengths and limitations. Self-Esteem Enhancement (1) Assess and
support activities that promote self-concept developmentally. (2) Consider the
development of a Healthy Kids mentoring program that has four components: A)
relationship building, B) self-esteem enhancement, C) goal setting, and D)
academic assistence (tutoring). Mentors met with students twice each week for
1.5 hours each session on schoo grounds. during each meeting, mentors devoted
time to each program component. (3) Assess and provide referrals to mental
health professionals for clients with unresolved worries associated with
terrorism. (4) provide an alternative school based program for pregnant and
parenting teenagers. (5) Support the client's choice of alternative therapy as
an adjunct treatment. (6) Support establishing a church-based community health
promotion programs (CBHPPs) with the following key elements: partnerships,
positive health values, availability of services, access to church
facilities, community-focused interventions, health behavior change, ....
(1) Carefully assess each client and allow families to participate in
providing care that is acceptable based on the client's cultural beliefs;
silent presence, quiet prayers, telling stories and singing songs in their
native language. (2) Provide support for health promoting behavior and
self-concept for clients from diverse cultures. (3) Refer to care plans for
Disturbed Body Image; Chronic low Self-esteem; and Readiness for enhanced
Spiritual well-being. (1) Above interventons may be used in the home care
setting.
ÿÿÿÿ ÿ Self-esteem, chronic low 830 Long-standing negative
self-evaluations/feelings about self or self-capabilities. Rationalizes
away/rejects positive feedback and exaggerates negative feedbacl about self
(long-standing or chronic); self-negating verbalization (long-standing or
chronic); hesitant to try new things/situations (long-standing or chronic);
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expressions of shame/guilt (long-standing or chronic); evaluates self as

unable to deal with events (long-standing or chronic); lack of eye contact;
nonassertive/passive; frequent lack of success in work or other life events;
excessively seeks reassurance; overly confroming, dependent on others'
opinions; indecisive To be developed..... Self-Esteem (1) Demonstrate
improved ability to interact with others (e.g., maintain eye contact,
expresses feelings) (2) Verbalize increased self-acceptance through use of
positive self-statements. (3) Identify personal strengths. (4) Set small,
achievable goals. (5) Attempt independent decision-making. Self-Esteem
Enhancement (1) Actively listen to and respect the client. (2) Assis the
client with identifying and confronting problems of not valuing self or
enduring abuse from others. (3) Assess existing strengths and coping
abilities, and provide opportunities for their expression and recognition. (4)
Reinforce the personal strengths and positive self-perceptions that the client
identifies. (5) Identify and limit the client's negative self-assessments. (6)
Encourage realistic and achievable goal setting, resources, and impediments to
achievement. (7) Demonstrate and promote effective communication techniques;
spend time with the client. (8) Envourage independent decision-making by
reviewing options and their possible consequences with the client. Autonomy
enhances self-esteem. (9) Assist the client to challence negative perceptions
of self and performance. (10) Use failure as an opportunity to provide
valuable feedback. (11) Promote a positive environment and activities that
enhance self-esteem. (12) ......
(1) Support the client in identifying and adapting to functional changes. (2)
Use reminiscence therapy to identify patterns of strength and accomplishment.
(3) Encourage participation in peer group activities. (4) Encourage activities
in which the client can support/help others. (1) Assess for the influence of
cultural beliefs, norms, and values on the client's sense of self-esteem (2)
Validate the client's feelings regarding ethnic or racial identity. (1) Above
interventions may be adapted for home care use. (2) Assess the client's
immediate support system/family relationship patterns and content of
communication. (3) Encourage family to provide support and feedback regarding
client value or worth. (4) Encourage/assist the client to identify interest
areas; ways of becoming involved with interest areas; ways of becoming
involved with and helping others. (5) Encourage the client to become involved
with self-care management. (6) Refer to medical social services to assist the
fmaily in patterns changes that could benefit the client. (7) If the client is
involved in cousleing or self-help groups, monitor and encourage attendance.
Help the client identify value of group participation after each group
encounter. (8) If the client is taking prescribed psychotropic meds, assess
for knowledge of med side effects and reasons for taking medication. Teach as
necessary. (9) Assess the meds for effectiveness and side effects and monitor
the .....
(1) Refer to community agencies for psychotherpeutic counseling. (2) Refer to
psychoeducational groups on stress reduction and coping skills. (3) Refer to
self-help support groups specific to needs. ÿÿÿÿ ÿ Self-esteem, situational
low 834 Development of a negative perception of self-worth in response to
current situation (specify) Verbally reports current situational challenge to
self-worth; self-negating verbalizations; indecisive, nonassertive behavior;
evaluation of self as unable to deal with situations or events; expressions of
helplessness and uselessness Developmental changes (specify); disturbed body
image; functional impairment (specify); loss (specify); social role changes
(specify); lack of recognition/rewards; behavior inconsistent with values;
failures/rejections Self-Esteem; Decisoin making (1) State effect of life
events on feelings about self. (2) State personal strengths. (3) Acknowledge
presence of guilt and not blame self if an action was related to another
person's appraisal. (4) Seek help when necessary. (5) Demonstrate
self-perceptions that are accurate given physical capabilities. (6)
Demonstrate separation of self-perceptions from societal stigmas. Self-Esteem
Enhancement (1) Assess the client for symptoms of depression and potential
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for suicide or violence. If present, immediately notify appropriiate personnel

of symptoms. (2) Actively listen to, demonstrate respect for, and accept the
client. (3) Assist in the identification of problems and situational factors
that contribute to problems, offering options for resolution. (4) Use
statements such as, "No one can make you feel guilty w/o your consent," to
help the client recognize that no one else can control the client's feelings.
(5) Mutually identify strengths, resources, and previously effective coping
strategies. (6) Have the client list strengths. (7) Accept the client's own
pace in working through grief or crisis situations. (8) Accept the client's
own defenses in dealing with the crisis. (9) Assess for unhealthy coping
mechanisms such as substance abuse. (10) Assess the client for symptoms of
depression and potential for suicide or violence. If present, immediately
notify appropriate personnel...
(1) Support the client in identifying and adapting to functional changes. (2)
Use reminiscence therapy to identify patterns of strength and accomplishment.
(3) Encourage participation in peer group activities. (4) Encourage activities
in which the client can support/help others. (1) Assess for the influence of
cultural beliefs, norms, and values on the client's sense of self-esteem. (2)
Validate the client's feelings regarding ethnic or racial identity. (1) Above
interventions may be adapted for home care use. (2) Assist the client to
initiate effective problem-solving toward currect situation. (3) Establish an
emergency plan and contract with the client for its use. (4) Access supplies
that support the client's success at independent living. (5) See care plan for
Chronic Low Self-esteem.
(1) Assess person's support system (family, friends, community) and involve if
desired. Educate the client and family regarding the grief process. (2) Teach
the client and family that the crisis is temporary. (3) Refer to appropriate
community resources or crisis intervention centers. (4) Refer to resources for
handicap and/or disability services. (5) Refer to illness-specific consumer
support groups. (6) Refer to self-help support groups specific to needs. ÿÿÿÿ
ÿ Self-esteem, situational low, risk for 838 At risk for developing
negative perception of self-worth in response to a current situation (specify)
Developmental changes (specify); disturbed body image; functional impairment
(specify); loss (specify); social role changes (specify); history of learned
helplessness; history of abuse, neglect, or abandonment; unrealistic
self-expectations; behavior inconsistent with values; lack of
recognition/rewards; failures/rejections; decreased power/control over
environment; physical illness (specify)
Self-Esteem; Decisoin making (1) State accurate self-appraisal (2)
Demonstrate the ability to self-validate (3) Demonstrate the ability to make
decisions independent of primary peer group (4) Express effects of media on
self-appraisal (5) Express influence of substances on self-esteem (6) Identify
strengths and healthy coping skills (7) State life events and change as
influencing self-esteem Self-Esteem Enhancement (1) Help the client to
identify environmental and/or developmental factors, which increase risk for
low self-esteem. (2) Help the client to identify current behaviors resulting
from low self-esteem. (3) Encourage creative problem solving through writing
exercises. (4) Encourage the client to maintain highest level of functioning,
including work schedule. (5) Encourage the client to verbalize thoughts and
feelings about the current situation, individually or in groups. (6) Help the
client to identify what has helped maintain positive self-esteem thus far. (7)
Help the client to identify the resources and social support network available
to him or her at this time. (8) Encourage the client to find a self-help or
therapy group that focuses on self-esteem enhancement. (9) Encourage the
client to create a sense of competence through short-term goal setting and
goal achievement. (10) Educate female clients about self-esteem differences
between genders, and encourage exploration. (11) .......
(1) Help the client to identify age-related and/or developmental factors that
may be affecting self-esteem. (2) Assist the client in life review and
identifying positive accomplishments. (3) Help the client to establish a peer
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group and structured daily activities. (1) Above interventions may be

adapted for home care use (2) Assess current environmental stresses and
identify community resources. (3) Assist the client to initiate effective
problem solving toward current situation. (4) Encourage family members to
acknowledge and validate the client's strengths. (5) Assess the need for
establishing an emergency plan. (6) See care plans for Situational low
Self-esteem and Chronic low Self-esteem.
(1) Refer the client/family to community-based self-help and support groups.
(2) Refer to educational classes on stress management, relaxation training,
etc.(3) Refer to community agencies that offer support and environmental
resources. ÿÿÿÿ ÿ Self-mutilation 841 Deliberate self-injurious behavior
causing tissue damage with the intent of causing non-fatal injury to attain
relief of tension Cuts/scratches on body; picking at wounds; self-inflicted
burns (e.g., eraser, cigarette); ingestion/inhalation of harmful
substances/objects; biting; abrading; severing; insertion of object(s) into
body orifice(s); hitting; constricting a body part Psychotic state (command
hallucinations); inability to express tension verbally; childhood sexual
abuse; violence between parental figures; family divorce; family alcoholism;
family history of self-destructive behaviors; adolescence; peers who
self-mutilate; isolation from peers; perfectionism; substance abuse; eating
disorders; sexual identity crisis; low or unstable self-esteem; low or
unstable body image; labile behavior (mood swings); history of inability to
plan solutions or see long-term consequences; use of manipulation to obtain
nurturing relationship with others; chaotic/disturbed interpersonal
relationships; emotionally disturbed, battered child; feels threatened with
actual or potential dissociation or depersonalization; mounting tension that
is intolerable; impulsivity; inadequate coping; irresistible urge to
cut/damage self; needs quick reduction of stress; childhood illness or
surgery; foster, group, or institutional care; incarceration; character
disorder; borderline.... Aggression Self-Control; Distorted Thought
Self-Control; Impulse Self-Control; Mood Equilibrium; Risk Detection;
Self-Mutilation Restraint (1) Have injuries treated. (2) Refrain from further
self-injury. (3) State appropriate ways to cope with increased psychological
or physiological tension. (4) Express feelings. (5) Seek help when having
urges to self-mutilate. (6) maintain self-control without supervision. (7) Use
appropriate community agencies when caregivers are unable to attend to
emotional needs Active Listening; Anger Control Assistance; Behavior
Management: Self-Harm; Calming Technique; Environmental Management: Safety;
Limit Setting; Mood Management; Mutual Goal Setting; Risk Identification;
Self-Responsibility Facilitation NOTE: Prior to implementation of
intervention in the face of self-mutilation, nurses should examine their own
emotional responses to incidents of self-harm, to ensure that interventions
will not be based on countertransference reactions. (1) Provide medical
treatment for injuries. (2) Assess for risk of suicide. (3) Assess for signs
of depression, anxiety, and impulsivity. (4) Assess for presence of
hallucinations Ask specific questions such as, "Do you hear voices that other
people do not hear? Are they telling you to hurt yourself?" (5) Assure the
client that he or she will not be alone and will be safe during
hallucinations. Provide referrals for medication. (6) Monitor the client's
behavior using 15-minute checks at irregular times so that the client does not
notice a pattern. (7) Establish trust. (8) Be extremely cautious about
touching the client when he or she is experiencing abreaction (reenactment of
preciptation trauma). Sometimes physically holding a client is necessary ...
See care plan for Risk for Self-Mutilation.

See care plan for Risk for Self-Mutilation. ÿÿÿÿ ÿ Self-mutilation, risk for
845 At risk for deliberate self-injurious behavior causing tissue damage with
the intent of causing nonfatal injury to attain relief of tension.
Psychotic state (command hallucinations); inability to express tension
verbally; childhood sexual abuse; violence between parental figures; family
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divorce; family alcoholism; family history of self-destructive behaviors;

adolescence; peers who self-mutilate; isolation from peers; perfectionism;
substance abuse; eating disorders; sexual identity crisis; low or unstable
self-esteem; low or unstable body image; labile behavior (mood swings);
history of inability to plan solutions or see long-term consequences; use of
manipulation to obtain nurturing relationship with others; chaotic/disturbed
interpersonal relationships; emotionally disturbed, battered child; feels
threatened with actual or potential dissociation or depersonalization;
mounting tension that is intolerable; impulsivity; inadequate coping;
irresistible urge to cut/damage self; needs quick reduction of stress;
childhood illness or surgery; foster, group, or institutional care;
incarceration; character disorder; borderline.... Abuse Recovery: Emotional;
Aggression Self-control; Distorted Thoughts Self-Control; Impulse
Self-Control; Mood Equilibrium; Risk Detection; Self-Mutilation Restraint (1)
Refrain from self-injury. (2) Identify triggers to self-mutilation. (3) State
appropriate ways to cope with increased psychological or physiological
tension. (4) Express feelings. (5) Seek help when having urges to
self-mutilate. (6) Maintain self-control without supervision. (7) use
appropriate community agencies when caregivers are unable to attend to
emotional needs. Active Listening; Anger control Assistance; Behavior
Management: Self-Harm; Calming Technique; Counseling; Environmental
Management: Safety; Limit Setting; Mood Management; Mutual Goal Setting; Risk
Identification ; Self-Awareness Enhancement; Self-Esteem Enhancement;
Self-Modification Assistance; Self-Responsibility Facilitation NOTE: Prior to
implementation of intervention in the face of self-mutilation, nurses should
examine their own emotional responses to incidents of self-harm, to ensure
that interventions will not be based on countertransference reactions. (1)
Assessment data from the client and family members may have to be gathered at
different times; allowing a family member or trusted friend with whom the
client is comfortable to be present during the assessment may be helpful. (2)
Assess for risk factors of self-mutilation, including the categories of
psychiatric disorders (particularly borderline personality disorder,
psychosis, eating disorders, autism); psychological precursors (e.g., low
tolerance for stress, impulsivity, perfectionism); psychosocial dysfunction
(e.g., inability to plan solutions or see long-term consequences of behavior),
personal history (e.g., childhood illness or surgery, past self-injurious
behavior), and peer influences (e.g., friends who mutilate, isolation from
peers)..
(1) Provide hand or back rubs, calming music when elderly client experiences
symptoms of anxiety. (2) provide soft objects for elderly clients to hold and
manipulate when self-mutilation occurs as a function of delirium or dementia.
(3) Older adults who show self-destructive behaviors should be evaluated for
dementia. (1) Communicate degree of risk to family/caregiver; assess the
family and caregiving situation for ability to protect the client, and to
understand the client's self-mutilative behavior. Provide family and
caregivers with guidelines on how to manage self-harm behaviors in the home
environment. (2) Establish an emergency plan, including when to use hotlines
and 911. Develop a contract with client and family for use of the emergency
plan. Role-play access to the emergency resources with the client and
caregivers. (3) Assess the home environment for harmful objects. Have family
remove or lock objects as able. (4) If client behaviors intensify, institue
emergency plan for mental health intervention. (5) Refer for homemaker or
psychiatric home health care services for respite, client reassurance, and
implementation of therapeutic regimen. (6) If the client is on psychotropic
medications, assess client and family knowledge of medication administration
and side effects. Teach as necessary....
(1) Explain all relevant symptoms, procedures, treatments, and expected
outcomes for self-mutilation that is illness-based (e.g, borderline
personality disorder, autism). (2) Provide written instructioins for
treatments and procedures for which the client will be responsible. (3)
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Instruct the client in coping strategies (assertiveness training, impulse

control training, deep breathing, progressive muscle relaxation). (4) Role
play (e.g., say "Tell me how you will respond if someone ignores you"). (5)
Teach cognitive-behavioral activities, such as active problem solving,
reframing (reappraising the situation from a different perspective), or
thought-stopping (in response to a negative thought, picture a large stop sign
and replace the image with a prearranged positive alternative). Teach the
client to confron his or her own negative thought patterns (or cognitive
distortions), such as catastophizing (expecting the very worst), dichotomous
thinking (perceiving events in only on of two... ÿÿÿÿ ÿ Sensory perception,
disturbed 854 Change in the amount or patterning of incoming stimuli
accompanied by a diminished, exaggerated, distorted, or impaired response to
such stimuli
Poor concentration; auditory distortions; change in usual response to
stimuli; restlessness; reported or measured change in sensory acuity;
irritability; disoriented in time, in place, or with people; change in
problem-solving abilities; change in behavior pattern; altered communication
patterns; hallucinations; visual distortions Altered sensory perception;
excessive environmental stimuli; psychological stress; altered sensory
reception, transmission, and/or integration/insufficient environmental
stimuli; biochemical imbalances for sensory distortion (e.g., illusions,
hallucinations); electrolyte imbalance; biochemical imbalance Body Image;
Cognitive Orientation; Sensory Function: Vision; Vision Compensation Behavior;
Cognitive Orientation; Communication: Receptive; Distorted Thought
Self-Control; Hearing Compensation Behavior (1) Demonstrate understanding by
a verbal, written, or signed response (2) Demonstrate relaxed body movements
and facial expressions (3) Explain plan to modify lifestyle to accommodate
visual or hearing impairment (4) Remain free of physical harm resulting from
decreased balance or a loss of vision,hearing, or tactile sensation (5)
Maintain contact with appropriate community resources Communication
Enhancement: Hearing Deficit, Visual Deficit; Environmental Management (1)
Identify name and purpose when entering the client's room. (2) Orient to time,
place, person, and surroundings. Provide a radio or talking books. (3) Keep
doors completely open or closed. Keep furniture out of path to bathroom, and
do not rearrange furniture. (4) Feed the client at mealtimes if blindness is
temporary. (5) Keep side rails up using half or three-quarter rails, and
maintain bed in a low position. Explain this precaution to the client. (6)
Converse with and touch the client frequently during care if frequent touch is
within the client's cultural norm. (7) Walk the client by having the client
grasp nurse's elbow and walk partly behind nurse. Walk a frightened or
confused client by having the client put both hands on nurse's shoulders;
nurse backs up in desired direction while holding the client around the waist.
(8) Keep call light button within client's reach, and check location of call
light button before leaving the room. (9) For blind client, consider
referring.....
(1) Keep environment quiet, soothing, and familiar. Use consistent caregivers.
(2) Avoid providing extremely hot or cold foods or using hot bath water if the
client has decreased sensation in mouth, hands, or feet. (3) If the client has
a sensory deprivation, encourage family to provide sensory stimulation with
music, voices, photographs, touch, and familiar smells. (4) For a hearing
impairment in the elderly, use the Hearing Handicap Inventory for the Elderly
(HHIE-S) to determine how individuals perceive the emotional and social
problems associated with a hearing loss. (5) the client has a hearing or
vision loss, work with the client to ensure contact with others and to
strengthen the social network. (1) The listed interventions are applicable
in the home care setting.
(1) Teach the client how to use a lighted magnification device to increase the
ability to read text or see details. (2) Teach the client to put a sheet of
yellow acetate over text to make the text more visible. An alternative method
is to highlight the text with a green or yellow highlighter (3) Put red or
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yellow identifiers on important items that need to be seen, such as a red

strip at the edge of steps, red behind a light switch, or a red dot on a stove
or washing machine to indicate how far to turn knob. (4) Use a watch or clock
that verbally tells time and a phone with large numbers and emergency numbers
programmed in. (5) Teach blind client how to feed self; associate food on
plate with hours on a clock so that the client can identify location of food.
(6) Use low-vision aids including magnifying devices for near vision and
telescopes for seeing objects at a distance, a closed-circuit television that
magnifies print, guides for writing checks and envelopes. (7) Refer to
......... ÿÿÿÿ ÿ Sexual dysfunction 859 Change in sexual function that is
viewed as unsatisfying, unrewarding, inadequate Change of interest in self
and others; conflicts involving values; inability to achieve desired
satisfaction; verbalization of problem; alteration in relationship with
significant other; alteration in achieving sexual satisfaction; actual or
perceived limitation imposed by disease or therapy; seeking confirmation of
desirability; alteration in achieving perceived sex role Misinformation or
lack of knowledge; vulnerability; value conflict; psychosocial abuse (e.g.,
harmful relationships); physical abuse; lack of privacy; ineffectual or absetn
role models; altered body structure of function (e.g., pregnancy, recent
childbirth, drugs, surgery, anomalies, disease process, trauma, radiation);
lack of significant other; biopsychosocial alterations in sexuality Abuse
Recovery: Sexual; Child Development: Adolescence; Physical Aging Status; Risk
Control; Sexually Transmitted Diseases (STD); Sexual Functioning (1) Identify
individual cause of sexual dysfunction. (2) Ientify stressors that contribute
to dysfunction. (3) Discuss alternative, satisfying, and acceptable sexual
practices for self and partner. (4) Discuss with partner concerns about body
image and sex role. Sexual Counseling (1) Gather the clien'ts sexual
history, noting normal patterns of functioning and the client's vocabulary.
(2) Determine the client's and partner's current knowledge and understanding.
(3) Observe for stress, anxiety, and depression as possible causes of
dysfunction. (4) Observe for grief related to loss (e.g., amputation,
mastectomy, ostomy). (5) Explore physical causes such as diabetes,
arteriosclerotic heart disease, arthritis, drug or med side effects, or
smoking (males). (6) Provide privacy and be verbally and nonverbally
nonjudgmental. (7) Provide privacy to allow sexual expression between client
and partner (e.g., private romm, "Do Not Disturb" sign for a specified length
of time). (8) Explain the need for the client to share concerns with partner.
(9) Validate the client's feelings, let the client know that he or she is
normal, and correct misinformation. (10) Refer to appropriate medical
providers for consideration of medication with premature ejaculation.
(1) Teach about normal changes that occur with aging: Female--reduction in
vaginal lubrication, decrease in the degree and spedd of vaginal expansion,
reduction in the duration and resolution of orgasm. Male--increase in time
required for erection, increase in erection time without ejaculation, less
firm erection, decrease in volume of seminal fluid, increase in time before
another erection can occur (12 to 24 hours). (2) suggest the following to
enhance sexual functioning: Female--use water-based vaginal lubricant,
increase foreplay time, avoid direct stimulation of the clitoris if painful
(clitoris may be exposed because of atrophy to the labia), practice Kegel
exercises (alternately contracting and relaxing the muscles in the pelvic
area), urinate immediately after coitus to prevent irritation of the urethra
and bladder, and consult with a physician about use of systemic estrogen
therapy or topical estrogen cream. Male--have female partner try a new coital
position by being her..... (1) Assess for the influence of cultural beliefs,
norms, and values on the client's perception of normal sexual functioning. (2)
Discuss with the client those aspects of sexual health/lifestyle that remain
unchanged by his or her health status. (3) Validate the client's feelings and
emotions regarding the changes in sexual behavior. (1) Above interventions
may be adapted for home care use. (2) Identify specific sources of concern
over sexual activity. Provide reassurance and instruction on appropriate
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expectations as indicated. (3) Help the client and significant other to

identify a place and time in the home and daily living for privacy to share
sexual or relationship activity. If necessary, help the client to communicate
the need for privacy to other family members. Consider periodic escapes to
desirable surroundings. (4) Confirm that physical reasons for dysfunction have
been addressed. Encourage participation in support groups or therapy if
appropriate. (5) Reinforce or teach the client about sexual functioning,
alternative sexual practices, and necessary sexual precautions. Update
teaching as the client status changes
(1) Teach the importance of resting before sexual activity. For some clients,
morning are the best time for sexual activity. (2) Teach the client to resume
intimate physical contact by using mutual touching 3 to 6 weeks after a MI.
(3) teach the client to begin vigorous sexual activity after a MI when the
client can walk rapidly for 10 minutes and then climb two flights of stair in
10 senconds. (4) Teach the client to take prescribed pain meds before sexual
activity. (5) Teach possible need for modifying positions (e.g., side-to-side,
limited resting on arms, heavier person on bottom). (6) Refer to appropriate
community resources, such as a clinical specialist, family counselor, or
sexual counselor. If appropriate, include both parnters in the discussion. (7)
Teach vaginal dilation to prevent stenosis. Inform the client to expect a bit
of spotting after first session. (8) Teach how drug therapy affects sexual
response (e.g., the possible side effects and the need to report them) .....
ÿÿÿÿ ÿ Sexuality patterns, ineffective 866 Expressions of concern
regarding own sexuality Reported difficulties, limitations, or changes in
sexual behavior or activites Lack of significant other; conflicts with sexual
orientation or vairant preferences; fear of pregnancy or of acquiring a STD;
impaired relationship with significant other; ineffective or absent role
models; knowledge/skill deficit about alternative responses to health-related
transitions, altered body function or structure, illness or medical treatment;
lack of privacy Abuse Recovery: Sexual; Child Development: Adolescence; Risk
Control:STD; Role Performance; Self-Esteem; Sexual Functioning (1) State
knowledge of difficulties, limitations, or changes in sexual behaviors or
activities. (2) State knowledge of sexual anatomy and functioning. (3) State
acceptance of altered body structure or functioning. (4) Describe acceptable
alternative sexual practices. (5) Identify importance of discussing sexual
issues with significant other. (6) Describe practice of safe sex with regard
to pregnancy and avoidance of STDs Sexual Counseling (1) After establishing
rapport or therapeutic relationship, give the client the permission to discuss
issues dealing with sexuality. Ask the client specifically, "Have you been or
are you concerned about functioning sexually because of your health status?"
(2) Determine the client's and partner's current knowledge and understanding.
(3) Discuss alternative sexual expressions for altered body function or
structure. Closeness and touching are other forms of expression. (4) Some
clients choose masturbation for sexual release. (5) If mutual masturbation is
a choice of expression, provide latex gloves. (6) Discuss modifying positions
to accommodate the altered physical state; instruct in the use of pillows for
comfort. (7) Encourage the client to discuss concerns with his or her partner.
(8) Provide client privacy for sexual expression. (9) Provide support for the
client's chosen ways to cope with HIV or AIDS.
(1) Help the client redefine sexuality in broader terms such as sharing,
communication, and intimacy. (2) Explore possible changes in sexualited
related to menopause. (3) Allow the client to verbalize feelings regarding
loss of sexual partner or significant other. Acknowledge problems such as
disapproval of children, lack of available partner for women, and
environmental variables that make forming new relationships difficult. (4)
Provide a milieu that allows for discussion of sexual issues and a higher
level of sexual satisfaction. Allow couples to room together and bring in
double beds from home. (5) Provide clients with the following info: a)
Exercise, such as walking, swimming, cycling, and riding a stationary bike,
will help control flabby thighs and weak musculature and make people feel more
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sexually attractive. b) overindulgence in food or alcohol can affect sexual

activity. c) Resting and sleep on a firm mattress may augment sexual desire.
d) Femininity and musculinity are... (1) Assess for the influence of cultural
beliefs, norms, and values on client's perceptions of normal sexual behavior.
(2) Discuss with the client those aspects of his or her secxual
health/lifestyle that remain unchanged by thier health status. (3) Validate
the client's feelings and emotions regarding the changes in sexuality
patterns. (1) Above interventions may be adapted for home care use. (2) Help
the client and significant other to identify a place and time in the home and
daily living for privacy in sharing sexual or relationship activity. If
necessary, help the client to communicate the need for privacy to other family
members. (3) confirm that physical reasons for dysfunction have been
addressed. Encourage participation in support groups or therapy if
appropriate. (4) Reinforce or teach about sexual functioning, alternative
sexual practices, and necessary sexual precautions.
(1) Refer to appropriate community agencies (e.g., certified sex counselor,
Reach to Recovery, Ostomy Associatiom). (2) Provude information regarding
self-care and sexuality for the woman who has cancer and her partner. (3)
Sexuality education is important to all populations, whether hearing or deaf,
sighted or blind, disabled, or not disabled. Discuss contraceptive choices.
Refer to appropriate health professional (e.g, gynecologist, nurse
practitioner). (4) Teach safe sex, which includes using latex condoms, washing
with soap immediately after sexual contact, not ingesting semen, avoiding
oral-gential contact, not exchanging saliva, avoiding multiple partners,
abstaining from sexual activity when ill, and avoiding recreational drugs and
alcohol when engaging in sexual activity. Contraty to previously published
info, the use of a spermicide containing nonoxynot-9 (N-9) should not be
recommmended as a preventative strategy for HIV infection. ÿÿÿÿ ÿ Skin
integrity, impaired 871 Altered epidermis and/or dermis
Invasion of body structures; destruction of skin layers (dermis); disruption
of skin surface (epidermis)
External
Hyperthermia; hypothermia; chemical substance (e.g., incontinence); mechanical
factors (e.g., friction, shearing forces, pressure, restraint); physical
immobilization; humidity; extremes in age; moisture; radiation; medications
Internal
Altered metabolic state; altered nutritional state (e.g., obesity,
emaciation); altered circulation; altered sensation; altered pigmentation;
skeletal prominence; developmental factors; immunological deficit; alterations
in skin turgor (change in elasticity); altered fluid status
Tissue Integrity: Skin and Mucous Membranes; Wound Healing: Primary
Intention, Secondary Intention (1) Regain integrity of skin surface (2)
Report any altered sensation or pain at site of skin impairment (3)
Demonstrate understanding of plan to heal skin and prevent reinjury (4)
Describe measures to protect and heal the skin and to care for any skin lesion
Incision Site Care; Pressure Ulcer Care; Skin Care: Topical Treatments; Skin
Surveillance; Wound Care (1) Assess site of skin impairment and determine
etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure
ulcer, skin tear) NOTE: For wounds deeper into subcutaneous tissue, muscle, or
bone (stage III or stage IV pressure ulcers), see the care plan for Impaired
Tissue integrity. (2) Monitor site of skin impairment at least once a day for
color changes, redness, swelling, warmth, pain, or other signs of infection.
Determine whether the client is experiencing changes in sensation or pain. Pay
special attention to high-risk areas such as bony prominences, skinfolds, the
sacrum, and heels. (3) Monitor the client's skin care practices, noting type
of soap or other cleansing agents used, temperature of water, and frequency of
skin cleansing. (4) Individualize plan according to the client's skin
condition, needs, and preferences. (5) Monitor the client's continence status,
and minimize exposure of skin impairment and other areas to moisture from
incontinence, ............
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(1) Instruct and assist the client and caregivers to remove or control
impediments to wound healing (e.g., management of underlying disease, improved
approach to client positioning, improved nutrition). (2) Initiate a
consultation in a case assignment with a wound, ostomy, continence nurse (WOC
nurse) to establish a comprehensive plan as soon as possible.
(1) Teach skin and wound assessment and ways to monitor for signs and symptoms
of infection, complications, and healing. (2) Teach the client to use a
topical treatment that is matched to client, wound, and setting. (3) If
consistent with overall client management goals, teach how to turn and
reposition at least every 2 hours. (4) Teach the client to use pillows, foam
wedges, and pressure-reducing devices to prevent pressure injury. ÿÿÿÿ ÿ
Skin integrity, impaired, risk for 875 At risk for skin being adversely
altered EXTERNAL: Hypothermia; hyperthermia; chemical subtance; exretions
and/or secretions; mechanical factors; radiation; physical immobilization;
humidity; moisture; extremes of age. INTERNAL: Medication; altered
nutritional state; altered metabolic state; altered circulation; altered
sensation; altered pigmentation; skeletal prominence; developmental factors;
immunological deficit; alterions in skin turgor; psychogenetic, immunological
factors. NOTE: Risk should be determined by the use of a risk assessment tool
(e.g., Norton scale, Braden scale) Immobility Consequences: Physiological;
Tissue Integrity: Skin and Mucous Membranes (1) Report altered sensation or
pain at risk areas. (2) Demonstrate understanding of personal risk factors for
impaired skin integrity. (3) Verbalize a personal plan for preventing impaired
skin integrity. Positioning; Pressure management; Pressure Ulcer Care;
Pressure Ulcer Prvention; Skin Surveillance (1) Monitor skin condition at
least one a day for color and texture changes, dermatological conditions, or
lesions. Determine whether the client is experiencing loss of sensation or
pain. (2) Identify clients at risk for impaired integrity as a result of
compromised perfusion, immunocompromised status, or chronic medical condition
such as diabetes meelitus or renal failure. (3) Monitor the client's skin care
practices, noting type of soap or other cleansing agents used, temp of water,
and frequency of skin cleansing. (4) Avoid harsh cleansing agents, hot water,
extreme friction of force, or too-frequent cleansing. (5) Monitor the client's
continence status, and minimize exposure of the site of skin impairment and
other areas to moisture from incontinence, perspiration, or wound drainage.
(6) If the client is incontinent, implement an incontinence management plan to
prevent exposure to chemicals in urine and stool that can strip or erode the
skin; refer to a physician for an incontin...
(1) Limit number of complete baths to two or three per week, and alternate
them with partial baths. Use tepid water temp (between 90 and 105 F) for
bathing. (2) Use lotions and moisturizers to prevent skin from drying out,
especially in the winter. (3) Increase fluid intake within cardiac and renal
limits to a minimum of 1500 ml/day. (4) Increase humidity in the environment,
especially during the winter, by using a humidifier or placing a container of
water on a warm object. (1) Assess caregiver vigilance and ability. (2)
Initiate a consultation in a case assignment with a wound, ostomy, continence
nurse (WOC nurse) to establish a comprehensive plan as soon as possible. (3)
See the care plan for Impaired Skin Integrity.
(1) Teach the client skin assessment and ways to monitor for impending skin
breakdown. (2) If consistent with overall client management goals, teach how
to turn and reposisiton the client at least every 2 hours. (3) Teach the
client to use pillows, foam wedges, and pressure-reducing devices to prevent
pressure injury. ÿÿÿÿ ÿ Sleep deprivation 879 Prolonger periods without
sleep (sustained natural, periodic suspension of relative unconsciousness)
Daytime drowsiness; decreased ability to function; malaise; tiredness;
lethargy; restlessness; irritability; heightened sensitivity to pain;
listlessness; apathy; slowed reaction; inability to concentrate; perceptual
disorders (e.g. disturbed body sensation, delusions, feeling afloat);
hallucinations; acute confusion; transient paranoia; agitated or combative;
anxious; mild, fleeting nystagmus; hand tremors Prolonged physical discomfor;
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prolonged psychological discomfort; sustained inadequate sleep hygiene;

prolonged use of pharmacological or dietary antisoporifics; agin-realted sleep
stage shifts; sustained circadian asynchrony; inadequate daytime activity;
sustained environmental stimulation; sustained unfamiliar or uncomfortable
sleep environment; nonsleep-inducing parenting practices; sleep apean;
periodic limb movement (e.g., resltess leg syndrome, nocturnal myoclonus);
sundowner's syndrome; narcolepsy; idiopathic CNS hypersomnolence; sleep
walking; sleep tremor; sleep-related enuresis; nightmares; familiar sleep
paralysis; sleep-related painful erections; dementia Rest; Sleep; Symptom
Severity (1) Wake up less frequently during night. (2) Awaken refreshed and
be less fatigued during day. (3) Fall asleep without difficulty (4) Verbalize
plan to implement bedtime routines. (5) Identify actions can take to improve
quality of sleep Sleep Enhancement (1) Obtain a sleep history including
bedtime routines, history of sleep problems, changes in sleep with present
illness, and use of medications and stimulants. (2) Ask the client to keep a
sleep diary for several weeks, which includes bedtime, rise time, number of
awakenings, naps, and more. (3) Observe for underlying physiological illnesses
causing insomnia (e.g, cardiovascular, pulmonary, gastrointestinal,
hyperthyroidism, nocturia occurring with benign hypertrophic prostatitis or
pain). (4) Determine level of anxiety. If the client is anxious, utilize
relaxtion techniques. See further Nursing Interventions and Rationales for
Anxiety. (5) Assess for signs of depression: depressed mood state, statements
of hopelessness, poor appetite, Refer for counseling/treatment as appropriate.
(6) Assess the client for other symptoms of bipolar disorder (mania,
hypomania). Refer for mental health services as indicated. (7) Monitor for
presence of nocturnal symptoms of restless leg syndrome with...
(1) Determine if the client has a physiological problem that could result in
insomnia such as pain, cardiovasuclar disease, pulmonary disease, neurological
problems such asdementia, or urinary problems. (2) Observe elimination
patterns. Have the client decrease fluid intake in the evening, and ensure
that diuretics are taken early in the morning. (3) If the client is waking
frequently during the night with periods of apnea or increased leg movements,
consider the presence of sleep apnea problems or periodic leg movement
disorder and refer to a sleep clinic for evaluation. (4) Encourage social
activities. Help elderly get outside for increased light exposure and to enjoy
nature. (5) Suggest light reading or TV viewing that does not excite as an
evening activity. (6) Increase daytime physical activity, and social
activities to replace napping. Encourage wlaking as the client is able. (7)
Reduce daytime napping in the late afternoon; limit nap to short intervals as
early in the day as... (1) Above interventions may be adapted for home care
use. (2) Obtain a full current assessment and history of sleep activity, sleep
disturbance, and sleep disturbance-related behaviors. (3) Instruct the
client/family in expectations for normal sleep. Elicit expectations for sleep,
previous sleep patterns; correct misconceptions that influence emotional
response to deviation from expectations. (4) Have the client maintain s sleep
diary, describing daily activity levels, use of stimulants, activities or
physical sensations around bedtime. Assess diary for potential areas of
intervention. (5) Assess environment for possible hazards to the client during
period of deprivation. (6) Obtain a listing of expected daily behaviors,
before and since the onset of deprivation (e.g., mowing lawn, shaving,
cooking). Identify tasks that may be delegated. Establish level of client
participation in tasks. Use short task periods for the client. (7) Assess
client support system for availability of ........
(1) Encourage the client to avoid coffee and other caffeinated foods and
liquid and to avoid eating large high-protein or high-fat meals close to
bedtime. (2) Advise the client to avoid use of alcohol or hypnotics to induce
sleep. Avoid alcohol ingestion 4-6 hours before bedtime. (3) Teach somatic
relaxation techniques to induce the relaxation response and facilitate sleep.
(4) Teach the client need for increased exercise. Encourage to take a daily
walk 5-6 hours before retiring. (5) Encourage the client to devleop a bedtime
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that includes quiet activites such as reading, television, or crafts. (6)

Teach the following sleep hygiene guidelines for improving sleep habits: A) Go
to bed only when sleepy. B) When awake in the middle of the night, go to
another room, do quiet activites, and go back to bed only when sleepy. C) use
the bed only for sleeping--not for reading or snoozing in front of the TV.
D)Avoid afternoon and evening naps. E) Get up at the same time every morning
............. ÿÿÿÿ ÿ Sleep patterns, disturbed 885 Time-limited disruption
of sleep (natural periodic suspension of consciousness)
Prolonged awakenings; sleep maintenance insomnia; self-induced impairment

of normal pattern; sleep onset >30 minutes; early morning insomnia; awakening
earlier or later than desired; verbal complaints of difficulty falling asleep;
verbal complaints of not feeling well-rested; increased proportion of stage 1
sleep; dissatisfaction with sleep; less than age-normed total sleep time;
three or more nighttime awakenings; decreased proportion of Stages 3 and 4
sleep (e.g., hyporesponsiveness, excess sleepiness, decreased motivation);
decreased proportion of REM sleep (e.g., REM rebound, hyperactivity, emotional
lability, agitation and impulsivity, atypical polysomnographic features);
decreased ability to function
Ruminative presleep thoughts; daytime activity pattern; thinking about home;
body temperature; temperament; dietary; childhood onset; inadequate sleep
hygiene; sustained use of antisleep agents; circadian asynchrony; frequently
changing sleep-wake schedule; depression; loneliness; frequent travel across
time zones; daylight/darkness exposure; grief; anticipation; shift work;
delayed or advanced sleep phase syndrome; loss of sleep partner, life change;
preoccupation with trying to sleep; periodic gender-related hormonal shifts;
biochemical agents; fear; separation from significant others; social schedule
inconsistent with chronotype; aging-related sleep shifts; anxiety;
medications; fear of insomnia; maladaptive conditioned wakefulness; fatigue;
boredom
Environmental
Noise; unfamiliar sleep furnishings; ambient temperature, humidity; lighting;
othergenerated awakening; excessive stimulation; physical restraint; lack of
sleep privacy/control; interruptions for therapeutics, monitoring, Comfort
Level; Pain Level; Personal Well-Being; Psychosocial Adjustment: Life Change;
Quality of Life; Rest; Sleep (1) Wake up less frequently during night (2)
Awaken refreshed and not be fatigued during day (3) Fall asleep without
difficulty (4) Verbalize plan to implement bedtime routines Sleep
Enhancement (1) Obtain a sleep history including bedtime routines, history
of sleep problems, changes in sleep with present illness, and use of
medications and stimulants. (2) Ask the client to keep a sleep diary for
several weeks, which includes bedtime, rise time, number of awakenings, naps,
and more. (3) Determine level of anxiety. If the client is anxious, utilize
relaxation techniques. See further Nursing Interventions and Rationales
forAnxiety. (4) Assess for signs of new onset of depression: depressed mood
state, statements of hopelessness, poor appetite. Refer for counseling as
appropriate. (5) Observe the client's medication, diet, and caffeine intake.
Look for hidden sources of caffeine, such as over-the-counter medications. (6)
Provide measures to take before bedtime to assist with sleep (e.g., quiet time
to allow the mind to slow down, carbohydrates such as crackers). (7) Provide a
back massage before bedtime. (8) Provide pain relief shortly before bedtime
and position the client .....
(1) Determine if the client has new onset of a physiological problem that
could result in insomnia such as pain, cardiovascular disease, pulmonary
disease, neurological problems such as dementia, or urinary problems. (2)
Observe elimination patterns. Have the client decrease fluid intake in the
evening, and ensure that diuretics are taken early in the morning. (3) Do a
careful history of all medications including over-the-counter medications and
alcohol intake. (4) If the client is waking frequently during the night,
consider the presence of sleep apnea problems and refer to a sleep clinic for
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evaluation. (5) Evaluate the client for presence of depression or anxiety,

which can result in insomnia. Refer for treatment as appropriate. (6)
Encourage social activities. Help elderly get outside for increased light
exposure and to enjoy nature. (7) Suggest light reading or TV viewing that
does not excite as an evening activity. (8) Increase daytime physical
activity, and social activities.... (1) Above interventions may be adapted
for home care use (2) Provide support to the family of the client with chronic
sleep pattern disturbance. (3) Instruct the client/family in expectations for
normal sleep. Elicit expectations for sleep, previous sleep patterns; correct
misconceptions that influence emotional responses to deviation from
expectations. (4) Assess the client for sleep apnea, particularly poststroke
(e.g., interview partner regarding the client's sleep pattern and behaviors,
have the client maintain sleep log). (5) Assess the client for depression or
other psychiatric disorder. Refer for mental health services as indicated. (6)
Have the client maintain a sleep diary, describing daily activity levels, use
of stimulants, activities or physical sensations around bedtime. Assess diary
for potential areas of intervention. (7) Initiate nonpharmacological
interventions for insomnia: stimulus control, sleep restriction, relaxation
techniques, increasing sunlight exposure,......
(1) Encourage the client to avoid coffee and other caffeinated foods and
liquids and also to avoid eating large high-protein or high-fat meals close to
bedtime. (2) Advise the client to avoid use of alcohol or hypnotics to induce
sleep. Avoid alcohol ingestion 4 to 6 hours before bedtime. (3) Ask the client
to keep a sleep diary for several weeks. (4) Teach somatic and cognitive
relaxation techniques to induce the relaxation response and facilitate sleep.
(5) Teach the client need for increased exercise. Encourage to take a daily
walk 5 to 6 hours before retiring. (6) Encourage the client to develop a
bedtime ritual that includes quiet activities such as reading, television, or
crafts (7) Teach the following guidelines for good sleep hygiene to improve
sleep habits:
Go to bed only when sleepy.
When awake in the middle of the night, go to another room, do quiet
activities, and go back to bed only when sleepy.
Use the bed only for sleeping—not for reading or snoozing in front...... ÿÿÿÿ
ÿ Sleep, readiness for enhanced 891 A pattern of natural, periodic
suspension of consciousness that provides adequate rest, sustains a desired
lifestyle, and can be strengthened Expresses willingness to enhance sleep;
amount of sleep and REM sleep is congruent with developmental needs; expresses
a feeling of being rested after sleep; follows sleep rountines that promote
sleep habits, occasional or infrequent use of meds to induce sleep Desire to
improve sleep Personal Well-Being; Rest Sleep (1) Awaken refreshed and is
not fatigued during day. (2) Fall alseep without difficulty. (3) Verbalize
plan to implement improved bedtime routines. Sleep Enhacnement (1) Obtain a
sleep history including bedtime routines, sleep patterns, and use of meds and
stimulants. (2) Ask the client to keep a sleep diary for several weeks, which
includes bedtime, rise time, number of awakenings, naps, and more. (3)
Determine level of anxiety. If the client is anxious, use relaxation
techniques. See further Nursing Interventions for Anxiety. (4) Observe the
client's medication, diet, and caffeine intake. (5) Provide measures to take
before bedtime to assist with sleep (e.g., quiet time to allow the mind to
slow down, carbohydrates such as crackers). (6) Provide a back massage before
bedtime. (7) Initiate nonpharmacological interventions for improved sleep.
(1) Encourage the client to develop a bedtime ritual that includes quiet
activities such as reading, television, or crafts. (2) Encourage the client
take a warm bath in the evening. (3) Observe elimination patterns. Have the
client decrease fluid intake in the evening, and ensure that diuretics are
taken early in the morning. (4) Encourage social activities. (5) Increase
daytime activity. Encourage walking as the client is able. (6) Recommend
avoiding use of hypnotics and alcohol to sleep. (7) Reduce daytime napping in
the late afternoon; limit naps to short intervals as early in the day as
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possible. (8) Help the client recognize that there are changes in length of
sleep with aging.
(1) Teach somatic and cognitive relaxation techniques to induce the realxation
response and facilitate sleep. (2) Advise the client to avoid use of alcohol
or hypnotics to induce sleep. Avoid alcohol ingestion 4-6 hours before
bedtime. (3) Teach the following guidelines for good sleep hygiene to improve
sleep habits: A) Go to bed only when sleepy. B) When awake in the middle of
the night, go to another room, do quite activities, and go back to bed only
when sleepy. C) use the bed only for sleeping, not for reading or snoozing in
front of the TV. D) Avoid afternoon and evening naps. E) Get up at the same
time every morning. F) Recognize that not everyone needs 8 hours of sleep. G)
Move the alarm clock away from the bed so it cannot be seen. H) Do not
associate lulls in performance with sleeplessness; sleeplessness should not be
blamed for everything that goes wrong during the day. (4) Encourage the client
to develop a bedtime ritual that includes quiet activities such as reading,
...... ÿÿÿÿ ÿ Social interaction, impaired 894 Insufficient or excessive
quantity or ineffective quality of social exchange. Verbalized or observed
inability to receive or communicate a satisfying sense of belonging, caring,
interest, or shared history; verbalized or observed discomfort in social
situations; observed use of unsuccessful social interaction behaviors;
dysfunctional interaction with peers, family, and/or others; family report of
change style or pattern of interaction Knowledge/skill deficit regarding ways
to enhance mutuality; therapeutic isolation, sociocultural dissonance; limited
physical mobility; environmentl barriers; communication barriers; altered
thought processes; absence of available significant others or peers;
celf-concept disturbance Child Development: 1 Month, 2 Months, 4 Months, 6
Months, 12 Months, 2 Years, 3 Years, 4 Years, Preschool, Middle Childhood,
Adolescence; Play Participation; Role Performance; Social Interaction Skills;
Social Involvement (1) Identify barriers that cause impaired social
interactions. (2) Discuss feelings that accompany impaired and succesful
social interactions. (3) Use available opportunities to practice interactions.
(4) Use successful social interaction behaviors. (5) Report increased comfort
in social situations. (6) Communicate, state feelings of belonging,
demonstrate caring and interest in others. (7) Report effective interactions
with others. Socialization Enhancement (1) Observe for cause of discomfort
in social situations; ask the client to explain when discomfort began and
identify any losses (e.g., loss of health, job, or significant other; aging)
and changes (e.g., marriage, birth or adoption of a child, change in body
appearance). (2) Assess the client's social support system. (3) Spend time
with the client. (4) use active listening skills including assessment and
clarification of the client's verbal and nonverbal responses and interactions.
(5) Envourage social support for patients with visual impairments. (6) Have
the client list behaviors that are associated with being disconnected, and
discuss alternative responses that may increase comfort. (7) Monitor the
client's use of defense mechanisms, and support healthy defenses (e.g., the
client focuses on present and avoids placing blame on others for personal
behavior). (8) Have the client list behaviors that cause discomfort. Discuss
alternative ways to alleviate discomfort (e.g., focusing ...
(1) Avoid assuming that social isolation is normal for elderly client. (2)
Assess the client's potential or actual hearing loss or hearing impairment and
make appropriate referrals if a problem is identified. (3) Monitor for
depression, a particular risk in the elderly. (4) Provide group situations for
the client. (5) Encourage physical activity such as aerobics or stretching and
toning in a group. (6) Have clients reminisce. (7) Consider the use of
language to promote socialization. (1) Acknowledge racial/ethnic differences
at the onset of care. (2) Assess for the influence of cultural beliefs, norms,
and values on the client's perception of social activity and relationships.
(3) Approach individuals of color with respect, warmth, and professional
courtesy. (4) Assess the use of personal space needs, communication styles,
acceptable body language, eye contact, perception of touch, and paraverbals
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when communicating with the client. (5) Validate the client's feelings
regarding social interaction. (1) Above interventions may be adapted for home
care use. (2) Assess family and living environment for social dynamics. Refer
for medical social services to assist with family dynamics if appropriate. (3)
Assess the client for a psychiatric disorder. Refer for mental health services
as indicated. (4) Assess the client social skills; provide feedback regarding
maladaptive skills, and opportunities to role play alternative communication
styles. (5) Suggest that the client avoid contact with negative persons. (6)
Identify activities that the client does alone and assist the client with
balancing solitary and social activities. (7) Establish pattern of care and
daily activities that involve the client socially (e.g., Meals on Wheels, home
health aide visits). Give supportive feedback for positive and appropriate
interactions. (8) refer to or support involvement with supportive groups and
counseling. (9) In the presence of a psychiatric disorder, refer for
psychiatric home health care .....
(1) Help the client accept responsibility for own behavior. Have the client
keep a journal, and review it together at prescheduled intervals. Give the
client positive feedback for appropriate behaviors, and suggest alternative
approached for behaviors that do not enhance social interaction. Positive
reinforcement perpetuates appropriate behaviors. Teach social interaction
skills for use in actual situations the client is faced with daily. (2)
Practice social skills one-to-one and, when the client is ready, in group
sessions. (3) Refer to appropriate social agencies for assistance. ÿÿÿÿ ÿ
Social isolation 900 Aloneness experienced by the individual and perceived
as imposed by others and as a negative or threatened state. OBJECTIVE:
Absence of supportive significant others; projection of hostility in voice and
behavior; withdrawal; uncommunicativeness; demonstration of behavior
unaccepted by dominant cultural group; desire to be alone or exist in a
subculture; repetitive and meaningless actions; preoccupation with own
thoughts; lack of eye contact; inappropriate or immature activities for
developmental age/stage; evidence of physical/mental handicap or altered state
of wellness; sad, dull affect. SUBJECTIVE: Expression of feelings of aloneness
imposed by others; expression of feelings of rejection; inappropriate or
immature interests for developmental age/stage; inadequate or absent
significant purpose in life; inability to meet expectations of others;
expression of values acceptable to subculture but unacceptable to dominant
cultural group; expression of interest inappropriate to developmental
age/stage; feelings of differences from others; insecurity in public
Alterations in mental status; inability to engage in satisfying personal
relationships; unacceptable social values; unacceptable social behavior;
inadequate personal resources; immature interests; factors contributing to
absence of satisfying personal relationship; alterations in physical
appearance; altered state of wellness Loneliness Severity; Mood Equilibrium;
Personal Well-Being; Play Participation; Social Interaction Skills; Social
Involvement; Social Support (1) identify feelings of isolation. (2) Practice
social and communication skills needed to interact with others. (3) Initiate
interactions with others, set and meet goals. (4) Particpate in activities and
programs at level of ability and desire. (5) Describe feelings of self-worth.
Socialization Enhancement (1) Establish a therapeutic relationship by being
emotionally present and authentic. (2) Observe for barriers to social
interaction (e.g., illness; incontinence, decreasing ability to form
relationships; lack of transportation, money, support system, or knowledge).
(3) Note risk factors (e.g., membership in ethnic/cultural minority, chronic
physiological or psychological illness or deformities, advanced age). (4)
Discuss causes of perceived or actual isolation. (5) Promote social
interactions. Support grieving and verbalization of feelings. (6) Establish
trust one one one and then gradually introduce the client to others. Allow the
client opportunities to introduce issues and to describe his or her daily
life. (7) Use active listening skills. Establish therapeutic relationship and
spend time with the client. (8) help the client experience success by working
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together with the client to establish easily attainable goals (e.g., spending
10 minutes conversing with peer). (9) Provide ......
(1) Observe for aggression or other interpersonal problems, poor self-image or
signs of powerlessness, confusion of the past with the present, complaints
about feeling confined or deserted, or difficulty setting goals and making
decisions. (2) Assess for hearing deficit. Provide aids and use adaptive
techniques such as facing the individual when speaking, speaking slowly,
lowering the pitch of the voice, and enunciating clearly. (3) If the client is
in a health care facility, visit him or her for at least 10 minutes every 2-3
hours. (4) Involve nonprofessionals in activities, projects, and goal setting
with the client. Practice interdisciplinary management for unit-based
activities: engaging in arts and crafts projects, sewing, watching videos,
reading large-print books, reading magazines, playing games, playing musical
instruments, and using assistive listening devices. (5) Offer the client a
choice of activities and persons with whom to sit and socialize.
Introductions to stranger.. (1) Acknowledge racial/ethnic differences at the
onset of care. (2) Approach individuals of color with respect, warmth, and
professional courtesy. (3) Assess personal space needs, communication styles,
acceptable body language, attitude toward eye contact, perception of touch,
and paraverbal messages when communicating with the client. (4) Use a
family-centered approach when working with Latino, Asian, African American,
and Native American clients. (5) Promote a sense of ethnic attachment. (1)
The interventions described previously may be adapted for home care use. (2)
Assess the client for depression or other psychiatric disorder. Refer for
mental health services as indicated. (3) Confirm that the home setting has a
telephone. Obtain one if necessary for medical safety. If the client lives
alone, set up a Lifeline safety system that requires the client to answer the
telephone. (4) Consider the use of the computer and Internet to decrease
isolation. (5) Encourage family involvement in daily life in small,
nonthreatening activities such as short outings, assistance with shipping, and
solicitation of input from the isolated person in decision making. (6)
Establish a pattern of care and daily activities that involves the client
socially (e.g., Meals-on-Wheels, home health aide visitis). (7) have the
client keep a diary of social experiences. Discuss the diary during visits.
(8) Identify activities that the client does alone. Assist the client with
balancing solitary and ...
(1) Teach skills related to problem solving, communication, social
interaction, activities of daily living, and positive self-esteem. (2)
Consider the use of telecommunication and group support via the Internet. (3)
Teach role playing (practicing communication skills in specific situations).
(4) Encourage the client to initiate contacts with self-help groups,
counselors, and therapists. (5) Provide information to the client about senior
citizen services, house sharing, pets, day care centers, churches, and
community resources. (6) Refer socially isolated caregivers to appropriate
support groups as well. (7) Teach caregivers methods to deal with troublesome
behaviors related to memory disturbances, restlessness, and agitation,
catastrophic reactions, day/night disturbances, delusions, wandering, and
physical violence. A general method for clinicians to manage these problems
involves the identification of the behavioral problems include fatigue, a
change in routine, excessive demands,... ÿÿÿÿ ÿ Sorrow, chronic 907
Cyclical, recurring, and potentially progressive pattern of pervasive sadness
that is experienced (by client, parent or caregiver, or individual with
chronic illness or disability) in response to continual loss throught out the
trajectory of an illness or disability. Feelings that vary in intensity, are
periodic, may progress and intensify over time, and may interfere with
client's ability to reach his or her highest level of personal and social
well-being; expression of periodic, recurrent feelings of sadness; expression
of one or more of the following feelins: anger, being misunderstood,
confusion, depression, disappoitment, emptiness, fear, frustration,
guilt/self-blame, helplessness, hopelessness, loneliness, low self-esteem,
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recurring hoss, being overwhelmed. Death of a loved one; experiences of

chronic physcial or mental illness or disability such as mental retardation,
multiple sclerosis, prematurity, spina bidida or other birth defects, chronic
mental illness, infertility, cancern, Parkinson's disease; experience of one
or more trigger events (e.g., crises in management of illness, crises related
to developmental stages and missed opportunities or milestones that bring
comparisons with developmental, social, or personal norms); unending
caregiving as constant reminder of loss Acceptance: Health Status; Depression
Level; Depression Self-Control; Grief Resolution; Hope; Mood Equilibrium (1)
Express appropriate feelings of guilt, fear, anger, or sadness. (2) Identify
problems associated with sorrow (e.g., changes in appetite, insomnia,
nightmares, loss of libido, decreased energy, alteration in activity levels).
(3) Seek help in dealing with grief-associated problems. (4) Plan for future 1
day at a time. (5) Function at normal developmental level. Grief Work
Facilitation; Grief Work Facilitation: Perinatal Death (1) Assess the
client's degree of sorrow. use the Burke/NCRS chronic Sorrow Questionaire (for
individual or caregiver if appropriate) if available. (2) Idenfity problems of
eating and sleeping; ensure that basic human needs are being met. (3) Spend
time with the client and family. (4) Devleop a trusting relationship with the
client by using empathetic therapeutic communication techniques. (5) Help the
client to understand that sorrow may be ongoing. Life may be characterized by
good times and then bad times when sorrow is triggered by events. (6) help the
client recognize that, although sadness will occur at intervals for the rest
of his or her life, it will become bearable. In time the client may develop a
relationship with grief that is lifelong but livable, and as much filled with
comfort as it is with sorrow. (7) Encourage the use of positive coping
techniques: A) Taking action: Suggested strategies include keeping busy,
keeping personal interests, going away, getting out of the...
(1) Use reminiscence therapy in conjuction with the expression of emotions.
(2) identify previous losses and assess the client for depression. (3)
Evaluate the social support system of the elderly client. If the support
system is minimal, help the client determine how to increase available
support. (1) Assess for the influence of cultural beliefs, norms, and values
on the client's expressions of sorrow. (2) Identify whether the client had
been notified of the health status of the deceased and was able to be present
during death and illness. (3) Validate the client's feelings regarding the
loss. (1) The interventions described previously may be adapted for home care
use. Identify causes for chronic sorrow and observe the client's expression of
this sorrow. (2) Assess the client for depression. Refer for mental health
services as indicated. (3) When sorrow is focused around loss of a pregnancy,
encourage the client to follow through on a counseling referral. (4) Encourage
the client to participate in activities that are diversionary and uplifting as
tolerated (e.g., outdoor activities, hobby groups, church-related activities,
pet care). (5) Encourage the client to participate in support groups
apprpriate to the area of loss or illness (e.g., Crohn's disease support group
or Widow to Widow). (6) Provide psychological support for family/caregivers.
(7) In the presence of psychiatric disorder, refer for psychiatric regimen.
(8) See the care plans for Impaired Adjustment, Chronic low Self-esteem, Risk
for Loneliness, and Hopelessness.
ÿÿÿÿ ÿ Spiritual distress 913 Impaired ability to experience and
integrate meaning and purpose in life through the individual's connectedness
with self, others, art, music, literature, nature, or a power greater than
oneself
Connections to self: Expresses lack of hope, meaning and purpose in life,
peace/serenity, acceptance, love, forgiveness of self, courage; expresses
anger, guilt, poor coping
Connections with others: Refuses interactions with spiritual leaders; refuses
interactions with friends and family; verbalizes being separated from their
support system, expresses alienation
Connections with art, music, literature, nature: Demonstrates inability to
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experience previous state of creativity (singing, listening to music,

writing), disinterest in nature,and disinterest in reading spiritual
literature
Connections with power greater than oneself: Demonstrates inability to pray,
inability to participate in religious activities, expressions of being
abandoned by or having anger toward God; requests to see a religious leader;
demonstrates sudden changes in spiritual practices, inability to be
introspective/inward turning; expresses being hopeless and suffering
Self-alienation; loneliness/social isolation; anxiety; sociocultural

deprivation; death and dying of self or others; pain; life change; chronic
illness of self or others Acceptance: Health Status
Dignified Life Closure
Grief Resolution
Hope
Spiritual Health
Suffering Severity
(1) Express sense of connectedness with self, others, arts, music,
literature, or power greater than oneself (2) Express meaning and purpose in
life (3) Express sense of optimism and hope in the future (4) Express ability
to forgive (5) Express desire to discuss health state and integrate care in
lifestyle (6) Discuss personal response to dying (7) Discuss personal response
to grieving
Grief Work Facilitation; Hope Instillation; Humor; Music Therapy; Presence;

Reminiscence Therapy; Simple Guided Imagery; Simple Massage; Simple Relaxation
Therapy; Spiritual Support; Therapeutic Touch ;Touch
(1) Observe the client for loss of meaning, purpose, and hope in life. (2)
Respect the client's beliefs; avoid imposing your own spiritual beliefs on the
client. Be aware of your own belief systems and accept the client's
spirituality. Allow for selfdisclosure. Promote a sense of love, caring, and
compassion. (3) Monitor and promote supportive social contacts. (4) Refer the
client to a support group. (5) Be physically present and actively listen to
the client. (6) Support meditation, guided imagery, therapeutic touch,
journaling, relaxation, and involvement in art, music, or poetry. Support
outdoor activities. (7) Offer or suggest visits with spiritual and/or
religious advisors. (8) Help the client make a list of important and
unimportant values. (9) Assist the client in identifying and creating his or
her own meaningful experiences. Help the client develop skills to deal with
illness or lifestyle changes. Include the client in care planning. (10) Ask
how to be most helpful; encour...
(1) Discuss personal definitions of spiritual wellness with the client. (2)
Identify the client's past sources of spirituality. Help the client explore
his or her life and identify those experiences that are noteworthy. Clients
may want to read the Bible or other religious text or have it read to them.
client's ability to cope with spiritual distress. (2) Acknowledge the value
conflicts from acculturation stresses that may contribute to spiritual
distress. (3) Encourage spirituality as a source of support. (4) Validate the
client's spiritual concerns and convey respect for his or her beliefs. (1)
All of the nursing interventions described previously apply in the home
setting.
ÿÿÿÿ ÿ Spiritual distress, risk for 918 At risk for altered sense of
harmonious connectedness with all life and the universe in which dimensions
that transcend and empower the self may be disrupted Energy-consuming
anxiety; low self-esteem; mental illness; physical illness; blocks to
self-love; poor relationships; physical or psychological stress; substance
abuse; loss of loved one; natural disaster; situational loss; maturational
loss; inability to forgive Acceptance: Health Status; Dignified Life Closure;
Health Beliefs; Hope; Grief Resolution; Quality of Life; Spiritual Health;
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Suffering Severity (1) Express sense of connectedness with self, others,

arts, music, literature, or power greater than oneself. (2) Express maining
and purppose in life. (3) Express sense of optimism and hope in the future.
(4) Express ability to forgive. (5) Express desire to discuss health state and
integrate care in lifestyle. (6) Discuss personal response to grieving. (7)
Express satisfaction with life circumstances. Forgiveness Facilitation; Grief
Work Facilitation; Hope Instillation; Humor; Music Therapy; Presence;
Reminiscence Therapy; Simple Guided Imagery; Simple Massage; Simple Relaxation
Therapy; Spiritual Support; Touch; Therapeutic Touch (1) Observe the client
for loss of meaning, purpose, and hope in life. (2) Respect the client's
beliefs, avoid imposing your own spiritual beliefs on the client. Be aware of
your own belief systems and accept the client's spirituality. Allow
self-disclosure. Promote a sense of love, caring, and compassion. (3) Monitor
and promote supportive social contacts. (4) Inform the client about available
support groups. (5) Be physically present and actively listen to the client.
(6) Support meditation, guided imagery, therapeutic touch, journaling,
relaxation, and involvement in art, music, or poetry. Support outdoor
activities. (7) Offer or suggest visits with spiritual and/or religious
advisors. (8) Help the client make a list of important and unimportant values.
(9) Assist the client in identifying and creating his or her own meaningful
experiences. (10) Ask how to be most helpful; encourage the client to look
inward, look outward, reflect, and seek clarification. (11) If the client is
.....
client's ability to cope with spiritual distress. (2) Acknowledge the value
conflicts from acculturaition stresses that may contribute to spiritual
distress. (3) Encourage spirituality as a source of support. (4) Validate the
client's spiritual concerns and convery respect for his or her beliefs. (1)
Interventions mentioned under other subheadings in the nursing diagnosis also
apply to home care.
ÿÿÿÿ ÿ Spiritual well-being, readiness for enhanced 922 Ability to
experience and integrate meaning and purpose in life through connectedness
with self, others, art, music, literature, nature, or a power greater than
oneself. (1) Connection to self: Desires enhanced connections; expresses
hope, meaining, and purpose in life, peace and serenity, acceptance,
surrender, love, forgiveness of self, satisfying philosophy of life, joy,
courage, heightened coping, and meditation. Connections with others: Provides
service to others, requests interaction with spiritual leaders, requests
forgiveness of others, requests interaction with friends and family.
Connections with art, music, literature, nature: Displays creative energy
(e.g., writing poetry), sings, listens to music, reads spiritual literature,
spends time outdoors. Connection with a power greater than self: Prays,
reports mystical experiences, participates in religious activities, expresses
reverence and awe Health-seeking behaviors; empathy; self-care;
self-awareness; desire for harmonious interconnectedness; desire to find
meaning and purpose in life Acceptance: Health Status; Adherence Behavior;
Caregiver Emotional Health; Caregiver Well-Being; Caregiver-Patient
Relationship; Comfort Level; Coping; Dignified LIfe Closure; Endurance; Family
Integrity; Grief Resolution; Health Beliefs; Health-Promoting Behavior; Hope;
Knowledge: Health Behavior; Leisure Participation; Personal Well-Being;
Psychosocial Adjustment: Life Change; Quality of Life; Self-Esteem; Social
Involvement; Spiritual Health (1) Express hope. (2) Express sense of meaning
and purpose in life. (3) Express peace and serenity. (4) Express acceptance.
(5) Express surrender. (6) Express forgiveness of self and others. (7) Express
satisfaction with philosophy of life. (8) Express joy. (9) Express courage.
(10) Describe being able to cope. (11) Describe practicing meditation. (12)
Describe being in service to others. (13) Describe interaction with spiritual
leaders, friends, and family. (14) Describe appreciation for art, music,
literature, and nature. Active Listening; Animal-Assisted Therapy;
Anticipatory Guidance; Anxiety Reduction; Art Therapy; Coping Enhancement;
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Counseling; Crisis Intervention; Decision-Making Support; Dying Care;

Emotional Support; Forgiveness Facilitation; Grief Work Facilitation; Guilt
Work Facilitation; Hope Instillation; Humor; Meditation Faciliitation; Music
Therapy; Mutual Goal Setting; Presence; Religious Ritual Enhancement;
Reminiscence Therapy; Security Enhancement; Self-Awareness Enhancement;
Self-Esteem Enhancement; simple Guided Imagery; Simple Relaxation Therapy;
Socialization Enhancement; Spiritual Growth Facilitation; Spiritual Support;
Support Group; Support System Enhancement; Touch; Truth Telling; Value
Clarification (1) Perform a spiritual assessment that includes the client's
relationship with God, meaning and purposeful in life, religious affiliation,
and any other significant beliefs. (2) Be present for the client. (3) Listen
actively to the client. (4) Encourage the client to pray, setting the example
by praying with and for the client. (5) Encourage involvement in group
religious social support. (6) Encourage increased quality of life through
social support. (7) Assist the client in identifying religious or spiritual
beliefs that encourage integration of meaning and purpose in the client's
life. (8) Encourage the client to use music as a means of reducing stress. (9)
Encourage the client to engage regularly in bibliotherapy. (10) Encourage
storytelling. (11) Offer to read to the client. (12) Support involvement in
expressive art. (13) Support the use of humor by the client. (14) Encourage
the client to practice forgiveness. (15) Support the client in contemplating,
viewing, and/or ...........
client's perception of spirituality. (2) Encourage expressions of
spirituality. (3) Validate the client's spiritual concerns and convey respect
for his or her beliefs. (1) All of the nursing interventions mentioned
previously apply in the home care setting. (2) Refer the client to parish
nurses.
ÿÿÿÿ ÿ Suffocation, risk for 927 Accentuated risk of accidental
suffocation (inadequate air available for inhalation). EXTERNAL: Vehicle
warming in closed garage; use of fuel-burning heaters not vented to outside;
smoking in bed; children's playing with plastic bags or inserting small
objects into their mouths or nosses; placement of propped bottle in infant's
crib; placement of pillow in infant's crib; consumption of large mouthfuls of
food; failure to remove doors on discarded or unused refrigerators or
freezers; leaving children unattended in bathtubs or pools; household gas
leaks; low-strung clothesline;hanging of pacifier around infant's neck.
INTERNAL: Reduced olfactory sensation; reduced motor abilities; cognitive or
emotional difficulties; disease or injury process; lack of safety education;
lack of safety precautions Knowledge: Child Physical Safety, Personal Safety;
Parenting: Adolescent Physical Safety, Early/Middle Childhood Physical Safety,
Infant/Toddler Physical Safety; Risk Control; Risk Detection; Safe Home
Environment; Substance Addiction Consequences (1) Explain and undertake
appropriate measures to prevent suffocation. (2) Demonstrate correct
techniques for emergency rescue maneuvers (e.g., Heimlich maneuver, rescue
breathing, cardiopulmonary resuscitation [CPR]) and describe situations that
require them. Aspiration Precautions; Environmental Management: Safety;
Infant Care; Positioning; Security Enhancement; Surveillance; Surveillance:
Safety; Teaching: Infant Safety NOTE: Management of a risk diagnosis
necessitates approached using primary and secondary prevention. Primary
prevention interventions, which include activities such as safety instruction,
focus on thwarting the development of a disease or condition. Secondary
prevention is achieved through screening, monitoring, and surveillance. (1)
Conduct risk factor identification, noting special circumstances in which
preventive or protective measures are indicated. Note the presence of
environmental hazards, including the following: Plastic bags, cribs with slats
wider than 2 3/4 inches, ill-fitting mattresses that can allow the infant to
become wedged between the mattress and crib, pillows in cribs, abandoned large
appliance such as refrigerators, dishwashers, or freezers, clothing with cords
or hoods that can become entangled, bibs, pacifiers on a string, drapery
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cords, pull-toy strings, earth cave-ins, food items. (2) identify hospitalized
clients at particular risk for suffocation, ..........
(1) Assess the status of the swallow reflex and dentition; offer appropriate
foods and beverages accordingly. (2) Observe the client for pocketing food in
the side of the mouth; remove food as needed. (3) Position the client in high
Fowler's position when eating and for 1 hour afterward. (4) Use care in pillow
placement when positioning frail elderly clients who are on bed rest. (1)
Assess the home for potential safety hazards in systems that are not likely to
be fixed. Assist the family in having these areas assessed and making
appropriate safety arrangements.
(1) Counsel families on the following: (a) Following general safety practices
such as not smoking in bed, properly disposing of large appliances, using
properly functioning heating systems and ventilation, having functional smoke
detectors, and opening garage doors when warming up a car. (b) Taking safety
measures appropriate to the functional developmental age of the client (with
emphasis on cirb safety in particular). (c) not placing the infant in the
prone position but instead positioning on the back and not placing any soft
bedding near the infant's airway. (d) Not allowing the infant or small child
to sleep in the same bed as adults and avoiding consuming alcohol or illicit
drugs, or smoking if the infant is sleeping with an adult. (2) Advise parents
to avoid food that can be inhaled. Non food items smaller than 1 1/4 inches in
diameter. (3) Provide information to parents about obtaining the "no-choke
test tube" if desired. (4) underscore the necessity of not allowing children
... ÿÿÿÿ ÿ Suicide, risk for 931 At risk for self-inflicted,
life-threatening injury Behavioral: History of previous suicide attempt;
impulsiveness; purchase of gun; stockpiling of medicines; making or changing
of a will; giving away of possessions; sudden euphoric recovery from major
depression; marked changes in behavior, attitude, or school performance.
Verbal:Threats of killing oneself; statement of desire to die/end it all
.Situational: Living alone; retirement; relocation, institutionalization;
economic instability; loss of autonomy/ independence; presence of gun in home;
residence of adolescent in nontraditional setting (e.g., juvenile detention
center, prison, half-way house, group home) Psychological: Family history of
suicide; alcohol and substance use/abuse; psychiatric illness/disorder (e.g.,
depression, schizophrenia, bipolar disorder); abuse in childhood; guilt; gay
or lesbian orientation in youth Demographic: Age: elderly, young adult male,
adolescent; race: white, Native American; gender: male; marital status:
divorced, widowed
Physical........ Depression Level; Distorted Thought Self-Control; Impulse
Self-Control; Loneliness Severity; Mood Equilibrium; Risk Detection;
Self-Mutilation Restraint; Suicide Self-Restraint
(1) Not harm self (2) Maintain connectedness in relationships (3) Disclose
and discuss suicidal ideas if present; seek help (4) Express decreased anxiety
and control of impulses (5) Talk about feelings; express anger appropriately
(6) Refrain from using mood-altering substances (7) Obtain no access to
harmful objects (8) Yield access to harmful objects (9) Maintain self-control
without supervision Anger Control Assistance; Anxiety Reduction; Calming
Technique; Coping Enhancement; Crisis Intervention; Delusion Management;
Medication Administration; Mood Management; Substance Use Prevention; Suicide
Prevention; Support System Enhancement; Surveillance
NOTE: Prior to implementation of interventions in the face of suicidal
behavior, nurses should examine their own emotional responses to incidents of
suicide to ensure that interventions will not be based on countertransference
reactions. Nursing and Clinical Research: Suicidal behavior can lead to
stigmatization and discrediting of the client, as it may tap into the nurse's
fears about mental illness, concerns about being able to respond effectively,
and expectations that persons with mental illness tend toward violence
(Joachim and Acorn, 2000; Steadman et al, 1998; Wilson et al, 1999). In one
study, medical nurses reported that they could not understand why people harm
themselves, and they felt they did not have the skills to deal with suicidal
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clients (1) Establish a therapeutic relationship with the client. Use a

direct, nonjudgmental approach in discussing suicide. (2) Monitor, document,
and report the client's potential for suicide. (3) Question family members
regarding the.....
(1) Perform careful assessment and ongoing evaluation of the potential for
suicidal ideation in the older adult, particularly the older man. (2) Evaluate
the older client's mental and physical health status and financial stressors.
(3) Monitor the older adult for subtle signs of suicidal risk. (4) Explore
triggers of and barriers to suicidal behavior, with particular attention to
real and perceived losses (e.g., professional role, health). (5) An older
adult who shows self-destructive behaviors should be evaluated for dementia.
(6) Advocate for the older client with other professionals in securing
treatment for suicidal states. (1) Assess for the influence of cultural
beliefs, norms, and values on the individual's perceptions of suicide. (2)
Facilitate modeling and role playing for the client and family regarding
healthy ways to start a discussion about the client's suicide attempt (3)
Identify and acknowledge the stresses unique to culturally diverse
individuals. (4) Identify and acknowledge unique cultural responses to
stressors in determining sensitive interventions to prevent suicide. (5)
Encourage family members to demonstrate and offer caring and support to each
other. (6) Foster the client's use of available family and religious supports.
(7) Validate the individual's feelings regarding concerns about the current
crisis and family functioning. (1) Establish an emergency plan, including
when to use hotlines and 911. Develop a contract with the client and family
for use of the emergency plan. Role play access to the emergency resources
with the client and caregivers. (2) Assess the home environment for harmful
objects. Have the family remove or lock up objects as possible. (3) Counsel
parents and homeowners to restrict unauthorized access to potentially lethal
prescription drugs and firearms within the home. (4) Identify the client's
concerns and implement interventions to address the consequences of disability
in a client with medical illness. (5) If the client's suicidal ideation
intensifies, or if a suicide plan with access to means becomes evident,
institute an emergency plan for mental health intervention. (6) Refer for
homemaker or psychiatric home health care services for respite, client
reassurance, and implementation of a therapeutic regimen. (7) If the client is
on psychotropic medications, assess the client's and...
(1) Establish a supportive relationship with family members. (2) Explain all
relevant symptoms, procedures, treatments, and expected outcomes for suicidal
ideation that is illness based (e.g., depression, bipolar disorder). (3) Teach
the family how to recognize that the client is at increased risk for suicide
(changes in behavior and verbal and nonverbal communication, withdrawal,
depression, or sudden lifting of depression). (4) Provide written instructions
for treatments and procedures for which the client will be responsible. (5)
Instruct the client in coping strategies (assertiveness training, impulse
control training, deep breathing, progressive muscle relaxation). (6) Role
play (e.g., say, "Tell me how you will respond if a friend asks why you were
in the hospital"). (7) Teach cognitive behavioral activities, such as active
problem solving, reframing (reappraising the situation from a different
perspective), or thought stopping (in response to a negative thought,
picturing ...... ÿÿÿÿ ÿ Surgical recovery, delayed 944 Extension in number
of postoperative days required for individuals to initiate and perform on
their own behalf activities that maintain life, health, and well-being
Evidence of interrupted healing of surgical area (e.g., redness, induration,
draining, immobility); loss of apetite with or without nausea; difficulty in
moving about; need for help to complete self-care; fatigue; report of pain or
discomfort; postponement in resumption of employment activities; perception
that more time is needed to recover To be developed. Endurance; Infection
Severity; Mobility; Pain Control; Self-Care: ADLs; Wound Healing: Primary
Intention, Secondary Intention (1) Have surgical area that shows evidence of
healing; no redness, induration, drainage, or immobility. (2) State that
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appetite is regained. (3) State that no nausea is present. (4) Demonstrate

ability to move about. (5) Demonstrate ability to complete self-care
activities. (6) State that no fatigue is present. (7) State that pain is
controlled or relieved after nursing interventions. (8) Resume employment
activities/ADLs. Incision Site Care; Nutrition Management; Pain Management;
Self-Care Assistance (1) Perform a thorough assessment of the client,
including risk factors. (2) Assess for the presence of medical conditions and
treat appropriately before surgery. If the client is diabetic, maintain normal
blood glucose levels before surgery. (3) Provide preoperative teaching by a
nurse to decrease postoperative problems of anxiety, pain, nausea, and lack of
independence. (4) Provide preoperative information in verbal and written form.
(5) Play music of the client's choice before surgery. (6) Consider using
healing touch in the perianesthesia setting. (7) For female premenopausal
clients, assess the date when the menstrual cycle is mots likely to occur and
schedule surgery on alternate dates if possible. (8) Consider the use of an
adjustable recliner if not contraindicated for recovery. (9) Do not offer
fluids in the immediate postoperative period. (10) In a client with
postoperative nausea and vomiting, consider the use of multiple antiemetic
meds (double or triple combinations of ...
(1) Carefully assess the fluid and electrolyte status and glomerular
filtration rate (GFR) of elderly clients before surgery. Provide fluild and
electrolyte replacement per the physician's order. (2) Carefully evaluate the
client's temp. Know what is normal and abnormal for each client. Check
baseline temp and monitor trens. (3) To maximaize the recovery of walking
ability in elderly clients with hip fracture, a multidisciplinary approach
using skilled medical, nursing, and paramedical care appears to be optimal.
(4) Offer spiritual support.
(1) To decrease postoperative nausea and vomiting, the client should be
instructed to fast before surgery, with the time frame to be determined by the
physician. ÿÿÿÿ ÿ Swallowing, impaired 949 Abnormal functioning of the
swallowing mechanism associated with deficits in oral, pharyngeal, or
esophageal structure or function Oral phase impairment:
Lack of tongue action to form bolus; weak suck resulting in inefficient
nippling; incomplete lip closure; pushing of food out of mouth; slow bolus
formation; falling of food 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 position; inadequate laryngeal elevation; food refusal;
unexplained fever; 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; vomitus on pillow; repetitive swallowing or ruminating;
..... 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, or esophageal defects; traumatic head injury;
developmental delay; nasal or nasopharyngeal cavity defects; oral cavity or
oropharynx abnormalities; prematurity
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Swallowing Status; Swallowing Status: Esophageal Phase, Oral Phase,

Pharyngeal Phase (1) Demonstrate effective swallowing without choking or
coughing (2) Remain free from aspiration (e.g., lungs clear, temperature
within normal range) Aspiration Precautions; Swallowing Therapy (1)
Determine the client's readiness to eat. The client needs to be alert, able to
follow instructions, able to hold the head erect, and able to move the tongue
in the mouth. (2) If the swallowing impairment is of new onset, ensure that
the client receives a diagnostic workup. (3) Assess ability to swallow by
positioning the thumb and index finger on the client's laryngeal protuberance.
Ask the client to swallow; feel the larynx elevate. Ask the client to cough;
test for a gag reflex on both sides of the posterior pharyngeal wall (lingual
surface) with a tongue blade. Do not rely on the presence of a gag reflex to
determine when to feed. (4) Consider the use of the Massey Bedside Swallowing
Screen to screen for swallowing dysfunction. (5) Observe for signs associated
with swallowing problems (e.g., coughing, choking, spitting of food, drooling,
difficulty handling oral secretions, double swallowing or major delay in
swallowing, watering eyes, nasal discharge, wet or gurgly voice, ..... (1)
Refer to a physician a child who has difficulty swallowing and symptoms such
as difficulty manipulating food, delayed swallow response, and pocketing of a
bolus of food. (2) When feeding an infant or child, place the infant/child in
a 90-degree position with the head slightly flexed. Change the consistency of
the diet as needed, and use a curly straw for young children to facilitate
tucking the chin, which helps improve swallowing ability (3) Give oral motor
stimulation that increases oral-sensory awareness by waking the mouth using
exercises that focus on temperature, taste, and texture. (4) For infants with
poor sucking and swallowing, do the following: Support the cheeks and jaw to
increase sucking skills. Pace or rhythmically move the bottle, which
encourages better suck-swallow-breath synchrony. (5) Work with the dietitian.
Some infants may need a high-calorie formula so that food volume can be
decreased (which requires the infant to expend less energy) while still
meeting....
(1) Evaluate medications the client is presently taking, especially if
elderly. Consult with the pharmacist for assistance in monitoring for
incorrect dosages and drug interactions that could result in dysphagia. (2)
Recognize that the elderly client with dementia needs a longer time to eat.
(3) Recognize that the loss of teeth can cause problems with chewing and
swallowing.
(1) Teach the client and family exercises prescribed by the dysphagia team.
(2) Teach the client a step-by-step method of swallowing effectively. (3)
Educate the client, family, and all caregivers about rationales for food
consistency and choices. (4) Teach the family how to monitor the client to
prevent aspiration during eating. ÿÿÿÿ ÿ Therapeutic regimen management,
effective 956 Pattern of regulating and integrating into daily living a
program for treatment of illness and its sequelae that is satisfactory for
meeting specific health goals. Appropriate choices of daily activities for
meeting goals of a treatment or prevention program; illness symptoms within
normal range of expectation; verbalization of desire to manage treatment of
illness and prevenntion of sequelae; verbalization of intent to reduce risk
factos for progression of illness and sequelae None. Related factors are not
relevant with strength diagnoses. Knowledge: Treatment Regimen; Participation
in Health Care Decisions; Risk Control; Symptom Control (1) Acknowledge
appropriateness of choices for meeting goals of treatment or prevention
programs. (2) Agree to continue making appropriate choices. (3) Verbalize
intent to contact health provider(s) for additional information, support, or
resources needed. Anticipatory Guidance; Health Education; Health Screening;
Health System Guidance; Learning Facilitation; Learning Readiness Enhancement;
Risk Identification; Self-Modification Assistance NOTE: Little or no research
is being done to investigate interventions to maintain strengths. Theoretical
rationales are provided as evidence rather than as research findings. (1)
Acknowledge the conguence of ADLs with health-related goals. (2) Support
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decisions regarding methods of integrating therapeutic regimens into ADLs. (3)

Provide information on possible illness trajectories to allow planning for
future management. (4) Assist the client in resolving ambivalent feelings
about illness and management of the therapeutic regimen. (5) Review methods of
cotnacting health care provider(s) for changes in therapeutic regimen and/or
methods of incorporating therapeutic regimens into ADLs. (6) Record the
effectiveness of managing the therapeutic regimens.
individual's perceptions of the therapeutic regimen. (2) Use a family-centered
approach when working with Latino, Asian, African American, and Native
American clients. (3) Discuss with the client those aspects of health and
lifestyle that will remain unchanged by his or her health status. (4) Validate
the client' feelings regarding the ability to manage his or her own care and
the impact on current lifestyle.
(1) Teach about the disease trajectory and ways to manage disease symptoms as
the trajectory changes. ÿÿÿÿ ÿ Therapeutic regimen management, ineffective
958 Pattern of regulating and integrating into daily living a program for
treatment of illness and its sequelae that is unsatisfactory for meeting
specific health goals Choices of daily living ineffective for meeting goals
of a treatment or prevention program; verbalization that client did not take
action to reduce risk factors for progression of illness and sequelae;
verbalization of desire to manage treatment of illness and prevention of
sequelae; verbalization of difficulty with regulation of one or more
prescribed regimensfor prevention of complications and treatment of illness or
its effects; verbalization that client did not take action to include
treatment regimens in daily routines
Perceived barriers; social support deficits; powerlessness; perceived
susceptibility; perceived benefits; mistrust of regimen and/or health care
personnel; knowledge deficit; family patterns of health care; family conflict;
excessive demands made on individual or family; economic difficulties;
decisional conflicts; complexity of therapeutic regimen; complexity of health
care system; faulty perception of illness seriousness; inadequate number and
types of cues to action
Decision Making; Knowledge: Disease Process, Treatment Regimen;
Participation in Health Care Decisions; Symptom Severity; Treatment Behavior:
Illness or Injury (1) Describe daily food and fluid intake that meets
therapeutic goals (2) Describe activity/exercise patterns that meet
therapeutic goals (3) Describe scheduling of medications that meets
therapeutic goals (4) Verbalize ability to manage therapeutic regimens (5)
Collaborate with health providers to decide on therapeutic regimen that is
congruent with health goals and lifestyle Anticipatory Guidance; Health
Education; Health Screening; Health System Guidance; Learning Facilitation;
Learning Readiness Enhancement; Risk Identification; Self- Modification
Assistance NOTE: This diagnosis does not have the same meaning as the
diagnosis Noncompliance. This diagnosis is made with the client. If the client
does not agree with the diagnosis, it should not be made (Bakker, Kastermans,
and Dassen, 1995). The emphasis is on helping the client to direct his or her
own life and health, not on the client's compliance with the provider's
instructions (1) See the care plans for Effective Therapeutic regimen
management andIneffective family Therapeutic regimen management. (2) Establish
a collaborative partnership with the client for purposes of meeting
healthrelated goals. (3) Discuss all strategies with the client in the context
of the client's culture. (4) Assist the client in resolving ambivalent
feelings. (5) Review factors of the Health Belief Model with the client (i.e.,
individual perceptions of seriousness and susceptibility, demographic and
other modifying factors, and perceived benefits and barriers). (6) Identify
the reasons for actions that are......
(1) Conduct a self-assessment of the relation of culture to ethically based
care. (2) Assess the influence of cultural beliefs, norms, values, and
attitudes on the client's ability to modify health behavior. (3) Discuss with
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the client those aspects of his or her health behavior/lifestyle that will
remain unchanged by the therapeutic regimen. (4) Assess temporal orientation
and its relationship to the management of the therapeuticregimen. (5) Assess
the effect of fatalism on the client's ability to adopt the therapeutic
regimen. (6) Validate the client's feelings regarding the impact of the
therapeutic regimen on current lifestyle.
(1) Identify what the client and/or family knows and adjust teaching
accordingly. (2) Teach ways to adjust daily activities for inclusion of
therapeutic regimens. (3) Teach safety in taking medications. (4) Teach the
client to act as a self-advocate with health providers who prescribe
therapeutic regimens. ÿÿÿÿ ÿ Therapeutic regimen management, readiness for
enhanced 963 Pattern of regulating and integrating into dauly living a
program(s) for treatment of illness and its sequelae that is sufficient for
meeting health-related goals and can be strengrthened Expression of desire to
manage treatment of illness and prevention of sequelae; choices of daily
living that are appropriate for meeting goals of treatment or prevention;
expression of little to no difficulty with regulation/integration of one or
more prescribed regimens for treatment of illness or preventon of
complications; reduction of risk factors for progression of illness and
sequelae; lack of unexpected accerleration of illness symptoms
Health-Promoting Behavior; Health-Seeking Behavior; Knowledge: Health
Behavior, Health Promotion, Health Resources, Illness Care, Medication,
Prescribed Activity, Treatment Regimen (1) Describe integration of
therapeutic regimen into daily living. (2) Demonstrate continued commitment to
integration of therapeutic regimen into daily living routines. Anticipatory
Guidelines; Mutal Goal Setting; Patient Contracting; Self-Modification
Assistance; Self=Responsiblity Facilitation; Support System Enhancement;
Teaching: Disease Process (1) Explore attitudes toward the illness/disease
and the need for management of a therapeutic regimen. (2) Review the factors
contributing to the likelihood of taking action for health promotion and
health protection. Use Pender's Health Promotion Model and Becker's Health
Belief Model to identify contributing factors. (3) Further develop and
reinforce contributing factors that might change with ongoing management of
therapeutic regimen (e.g, knowledge, self-efficacy, self-esteem, and perceived
benefits. (4) Reivew the client's strengths in the management of the
therapeutic regimen. (5) Collaborate with the client to identify strategies to
maintain strengths and develop additional strengths as indicated. (6) Identify
contributing factors that may need to be improved now or in the future. (7)
Provide knowledge as needed related to the pathophysiology of the
disease/illness, prescribed activities, prescribed medications, and nutrition.
(8) Use coaching strategies such as educational ....
(1) Acknowledge the cultural dimensions of health promotion and protection
behaviors. (2) Assist the client in integrating cutlural patterns with
prescribed activites, prescribed meds, and prescribed diet. (3) Manipulate
community factors that may affect the management of the therapeutic regimen
(e.g., barriers, supports, insurance, education about the illness, and
provider-client relationships).
Community Teaching: (1) Refer therapeutic regimens and their optimum
integration with daily living routines. (2) Teach disease processes and
therapeutic regimens for managemetn of these disease processes. ÿÿÿÿ ÿ
Therapeutic regimen management, community, ineffective 966 Pattern of
regulating and integrating into community processes programs for the treatment
of illness and its sequelae that is unsatisfactory for meeting health-related
goals Illness symptoms above norm expected for number and type of population;
unexpected acceleration of illness(es); number of health care resources
insufficient for incidence or prevalence of illness(es); deficits in
aggregates for specific groups, deficits in people and programs to be
accountable for illness care of specific groups, deficits in community
activities for secondary and tertiary prevention; unavailability of health
care resources for illness care. To be developed. Decision Making;
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Knowledge: Disease Process, Treatment Regimen; Participation in Health Care

Decisions; Symptom Severity; Treatment Behavior: Illness or Injury (1) Secure
community members and/or health providers who will be accountable for illness
care of specific groups. (2) Remain involved in advocacy for illness care and
prevention programs. (3) Develop health care plans for effective prevention
and treatment of illnesses. (4) Make resources available for illness care and
prevention. (5) Initiate or improve strategies for prevention of the sequelae
of illness. Community Health Development; Environmental Management:
Community; Health Policy Monitoring; Teaching: Disease Process. NOTE: NIC
interventions that were developed for use with individuals can be adapted for
use with communites. NOTE: Nursing interventions are conducted in
collaboration with key members of the community, community/public health
nurses, and members of other disciplines. (1) Seek community leaders who are
willing to learn about community assessment data and diagnoses and have
potential to work in partnership with nurses and other providers in planning
for positive change. (2) Examine the perceptions of community members
regarding service needs. (3) Apply the concept of caring to the community as
client. (4) Advocate for and with the community in multiple arenas. (5)
Provide information to public and private sources about community assessment,
diagnosis, and plans of care. (6) Mobilize support for the community to obtain
the resources necessary for illness care and prevention. (7) Provide informal
helping roles as health educator and/or change agent. (8) Recruit additional
health providers as needed. (9) Determine the cultural appropriateness of all
programs. (10) Write grant proposals for ......
(1) Identify the health services and information resources that are
currently available in the community. (2) Identify cultural barriers such as
acculturation issues, lack of community support, and lack of past experience
with a health behavior. (3) Work with members of the community to prioritize
and target health goals specific to the community. (4) Approach community
leaders and members of color with respect, warmth, and professional courtesy.
(5) Establish and sustain partnerships with key individuals within the
community in developing and implementing programs. (6) Use community church
settings as a forum for advocacy, teaching, and program implementation.
ÿÿÿÿ ÿ Therapeutic regiment management, family, ineffective 970 Pattern
of regulating and integrating into family processes a program for treatment of
illness and its sequelae that is unsatisfactory for meeting specific health
goals Inappropriate family activities for meeting goals of treatment or
prevention program; acceleration of illness symptoms of a family member; lack
of attention to illness and its sequelae; verbalization of difficulty with
regulation/integration of one or more activites or prevention of
complications; verbalization of desire to manage treatment of illness and
prevention of its sequelae; verbalization that family did not take action to
reduce risk factors for progression of illness and sequelae Complexity of
health care system; complexity of therapeutic regimen; decisional conflicts;
economic difficulties; excessive demands on individual or family; family
conflict Health Orientation; Health-Promoting Behavior; Health-Seeking
Behavior; Knowledge: Treatment Regimen; Participation in Health Care
Decisions; Treatment Behavior: Illness or Injury (1) Make adjustments in
usual activites (e.g., diet, activity, stress management) to incorporate
therapeutic regimens of its members. (2) Reduce illness symptoms of family
members. (3) Desire to manage therapeutic regimens of its members. (4)
Describe a decrease in the difficulties of managing therapeutic regimens. (5)
Describe actions to reduce risk factors. Family Involvement Promotion; Family
Mobilization; Family Process Maintenance; Teaching: Disease Process (1) Base
family interventions on your knowledge of the family, family context, and
family function. (2) Use a family approach when helping an individual with a
health problem that requires therapeutic management. (3) Ensure that all
strategies for working with the family are congruent with the culture of the
family. (4) Support religious beliefs and the comfort role of religion. (5)
Identify family interactions and their embedded contexts relative to specific
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health objectives. (6) Review with family members the congruence and
incongruence of family behaviors and health-related goals. (7) help family
members make decisions regarding ways to integrate therapeutic regimens into
daily living. Provide advice or suggestions as solicited and accepted by the
family. (8) Demonstrate respect for and trust in family decisions. (9)
Acknowledge the challenge of integrating therapeutic regimens with family
toward development of greater self-efficacy in relation to these symptoms.
(10) Provide .....
(1) Acknowledge racial/ethnic differences at the onset of care. (2) Approach
families of color with respect, warmth, and professional courtesy. (3) Assess
for the influence of cultural beliefs, norms, and values on the family's
perceptions of the therapeutic regimen. (4) Give a rationale when assessing
African American families about sensitive issues. (5) Use a family-centered
approach when working with Latino, Asian, African American, and Native
American. (6) Facilitate modeling and role-playing for the family regarding
healthy ways to communicate and interact. (7) Validate family members'
feelings regarding the impact of the therapeutic regimen on the family
lifestyle.
(1) Teach about all aspects of therapeutic regimens. Provide as much knowledge
as family members will accept, adjust instructions to account for what the
family already knows, and provide information in a culturally congruent
manner. (2) Teach ways to adjust family behaviors to include therapeutic
regiments. (3) Teach safety in taking meds. (4) Teach family members to act as
self-advocates with health providers who prescribe therapeutic regimens. ÿÿÿÿ
ÿ Thermoregulation, ineffective 975 Temperature fluctuation between
hypothermia and hyperthermia Fluctuations in body temp above or below normal
range; cool skin; cyanotic nail beds; flushed skin; hypertension; increased
respiratory rate; pallor (moderate); piloerection; reduction in body temp
below normal range; seiquzres/convulsions; shivering (mild); slow capillary
refill; tachycardia; warmth to touch Trauma; illness; immaturity; aging;
fluctuating environmentla temperature Thermoregulation; Thermoregulation:
Newborn (1) Maintain temperature within normal range. (2) Explain measures
needed to maintain normal temperature. (3) Explain symptoms of hypothermia or
hypethermia. Temperature Regulation; Temperature Reguation: Inoperative (1)
Monitor temp every 1-4 hours or use continuous temp monitoring as appropriate.
(2) If the client is awake, measure the oral temp, instead of tympanic or
axillary temp. (3) Take vital signs every 1-4 hours, noting changes associated
with hypothermia: first, increased BP, pulse, and respirations; then,
decreased values as hypothermia progresses. (4) Note changes in vital signs
associated with hyperthermia: rapid, bounding pulse, increased respiratory
rate; and decreased blood pressure accompanied by orthostatic hypotension. (5)
Monitor the client for signs of hyperthermia (e.g., headache, nausea,
vomiting, weakness, absence of sweating, delirium, and coma). (6) Note vital
sign changes associated with hypothermia: first increased and then decreased
BP, pulse rate, and respiratory rate. (7) Monitor the client for signs of
hypothermia (e.g., shivering, cool sking, piloerection, pallor, slow capillary
refill, cyanotic nailbeds, decreased mentation, dysrhythmias). (8) Maintain a
......... (1) Recognize that pediatric clients have a decreased ability to
adapt to temp extremes. Take the following actions to maintain body temp in
the infant/child: a) Keep the head covered. b) Use blankets to keep the client
warm. c) Keep the client covered during procedures, transport, and diagnostic
testing. d) Keep the room temp at 22.2 C (72 F).
(1) Do not allow an elderly client to become chilled. Keep the client covered
when giving a bath and offer socks to wear in bed. (2) Assess the medication
profile for the p otential risk of drug-related altered body temperature.
(1) Instruct the client to avoid prolonged exposure outdoors. When outdoors,
the client should wear gloves and a cap on the head. Wool or fleece clothing
can help to maintain body heat. (2) Keep the room temp at 20 to 22.2 C (68 to
72 F). (3) Ensure an adequate source of heat. Refer to social services if the
client/family has a low income and heat could be turned off. (4) help the
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elderly client locate a warm environment to which the client can go for safety
in cold weather if the home environment is no longer warm. (5) ........
......... .........
(1) Teach the client and family the signs of hypothermia and hyperthermia and
appropriate actions to take if either condition develops. (2) Teach the client
and family an age-appropriate method for taking the temperature. (3) Teach the
client to avoid alcohol and meds that depress cerebral function. ÿÿÿÿ ÿ
Thought processes, disturbed 978 Disruption in cognitive operations and
activities Cognitive dissonance; memory deficit/problems; inaccurate
interpretation of environment; hypovigilance; hypervigilance; distractibility;
egocentricity; inappropriate non-reality-based thinking Organic brain changes
(specify); changes in physical health (specify); mental illness (specify)
Cognition; Cognitive Orientation; Concentration; Decision Making; Distorted
Thought Self-Control; Identity; Information Processing; Memory; Neurological
Status; Consciousness (1) Demonstrate orientation to time, place, and person;
demonstrate imrpoved cognitive function. (2) Be free from physical harm. (3)
Perform ADLs appropriately and inedepently. (4) Identify community resources
for help. Delusion Management; Dementia Management (1) Observe for causes of
altered thought processess (see Related Factors). (2) Monitor, record, and
report changes in the client's neurological status (level of consciousness,
increased intracranial pressure), mental status (memory, cognition, judgment,
concentration), vital signs, laboratory results, and ability to follow
commands. (3) Obtain a medical history to rule out physical illness causes for
mental status changes. (4) Complete a mental status examination of the client.
(5) Report any new onset or sudden increase in confusion. (6) Adjust
communication style to the client. (7) Assess pain and promply provide comfort
measures. (8) Identify and remove potentially dangerous items from the
environement. (9) Limit the use of sedatives and drugs affecting the nervous
systms. (10) Use soft restraints with discretion and with a physician's order.
(11) Orient the client and call the client by name; introduce yourself on each
contact; frequently mention time, date, and place; ...........
(1) Monitor for dementia, as evidenced by a gradual onset and a progressive
deterioration, or for delirium, as evidence by an acute onset and generally
reversible course. (2) Focus on the feelings associated with hallucinations
and delusions rather than their content. (1) Assess for the influence of
cultural beliefs, norms, and values on the family's or caregiver's
understanding of distubred thought processes. (2) Inform the client's family
or caregiver of the meaning of and reasons for common behaviors observed in
client with disturbed thought processes. (3) Validate the family members'
feelings regarding the impact of the client's behavior on family lifestyle.
(1) The interventions described previously may be adapted for home care use.
(2) Assess the client for the presence of a psychiatric disorder. Refer for
mental health services as indicated. (3) Assess the family's knowledge of the
disease process and plan of care; teach as necessary. (4) Identify the
strengths of the caregiver and the caregiver's efforts to gain control of
unpredictable situations. Help the caregiver to stay connected with a client
who may be behaving differently than usual, to make life as routine as
possible, to help the client set goals and sustain hope, and to allow the
client space to experience progress. (5) Assess the client's functional status
as it relates to the ability for self-care; refer to a physician for
evaluation of medication levels as indicated. (6) Assess the home environment
for the availability of distractions from hallucinations, such as playing
music over headphones. (7) If the client's condition deteriorates, seek acute
medical or mental ......
(1) Teach family member reorientation techniques and the need to repeat
instructions frequently. (2) Teach the client distraction techniques to
manage hallucinations. (3) Teach family members way to support the client
without supporting delusional beliefs. (4) Help the family identify coping
skills, environmental supports, and community services for dealing with the
chronically mentally ill client. (5) Discuss the caregiver's need for respite.
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Offer support, encouragement, and info for meeting that need. ÿÿÿÿ ÿ Tissue
integrity, impaired 985 Damage to mucous membrane, corneal, integumentary,
or subcutaneous tissues
Damaged or destroyed tissue (e.g., cornea, mucous membrane, integumentary
or subcutaneous tissue)
Mechanical factors (e.g., pressure, shear, friction); radiation (including
therapeutic radiation); nutritional deficit or excess; thermal factors
(temperature extremes); knowledge deficit; chemical irritants (including body
excretions, secretions, medications); impaired physical mobility; altered
circulation; fluid deficit or excess
Tissue Integrity: Skin and Mucous Membranes; Wound Healing: Primary
Intention, Secondary Intention (1) Report any altered sensation or pain at
site of tissue impairment; (2) Demonstrate understanding of plan to heal
tissue and prevent injury; (3) Describe measures to protect and heal the
tissue, including wound care; (4) Experience a wound that decreases in size
and has increased granulation tissue Incision Site Care; Pressure Ulcer
Care; skin Care: Topical Treatments; Skin Surveillance; Wound Care (1) Assess
the site of impaired tissue integrity and determine the cause (e.g., acute or
chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer). (2)
Determine the size and depth of the wound (e.g., full-thickness wound, stage
III or stage IV pressure ulcer). (3) Classify pressure ulcers in the following
manner (National Pressure Ulcer Advisory Panel, 1989): Stage III:
Full-thickness skin loss involving damage to or necrosis of subcutaneous
tissue that may extend down to but not through underlying fascia; ulcer
appears as a deep crater with or without undermining of adjacent tissue Stage
IV: Full-thickness skin loss with extensive destruction; tissue necrosis; or
damage to muscle, bone, or supporting structures (e.g., tendons, joint
capsules) (4) Monitor the site of impaired tissue integrity at least once
daily for color changes, redness, swelling, warmth, pain, or other signs of
infection. Determine whether the client is experiencing changes in sensation
or pain. ....
(1) Some of the interventions described previously may be adapted for home
care use.(2) Assess the client's current phase of wound healing (inflammation,
proliferation, maturation) and stage of injury; initiate appropriate wound
management.(3) Instruct and assist the client and caregivers with removing or
controlling impediments to wound healing (e.g., management of underlying
disease, improvement in approach to client positioning, improved nutrition).
(4) Initiate a consultation in a case assignment with a wound, ostomy, and
continence nurse to establish a comprehensive plan as soon as possible. Plan
case conferencing to promote optimal wound care. (5) Refer for consideration
of treatment options for leg ulcers:
(1) Teach skin and wound assessment and ways to monitor for signs and symptoms
of infection, complications, and healing. (2) Teach the use of a topical
treatment that is matched to the client, wound, and setting. (3) If it is
consistent with overall client management goals, teach how to turn and
reposition the client at least every 2 hours. (4) Teach the use of pillows,
foam wedges, and pressure-reducing devices to prevent pressure injury. ÿÿÿÿ ÿ
Tissue perfusion, ineffective (specify type: renal, cerebral,
cardiopulmonary, gastrointestinal, peripheral)
990 Decrease in oxygen resulting in failure to nourish tissues at capillary
level Renal
Altered blood pressure outside of acceptable parameters; hematuria; oliguria
or anuria; elevation in blood urea nitrogen/creatinine ratio
Cerebral
Speech abnormalities; changes in pupillary reactions; extremity weakness or
paralysis; altered mental status; difficult in swallowing; changes in motor
response; behavioral changes
Cardiopulmonary
Altered respiratory rate outside of acceptable parameters; use of accessory
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muscles; capillary refill longer than 3 seconds; abnormal arterial blood gas
levels; chest pain; sense of impending doom; bronchospasms; dyspnea;
dysrhythmias; nasal flaring; chest retraction
Gastrointestinal
Hypoactive or absent bowel sounds; nausea; abdominal distention; abdominal
pain or tenderness
Peripheral
Edema; positive Homans' sign; altered skin characteristics (hair, moisture) or
nails; weak or absent pulses; skin discolorations; skin temperature changes;
altered sensations; diminished arterial pulsations; pale skin color upon
elevation of leg.. Hypovolemia; interruption of arterial flow; hypervolemia;
exchange problems; interruption of venous flow; mechanical reduction of venous
and/or arterial blood flow; hypoventilation; impaired transport of oxygen
across alveolar and/or capillary membrane; mismatch of ventilation with blood
flow; decreased hemoglobin concentration in blood; enzyme poisoning; altered
affinity of hemoglobin for oxygen Cardiac Pump Effectiveness; Circulation
Status; Fluid Balance; Hydration; Tissue Perfusion: Cardiac, Cerebral,
Peripheral; Urinary Elimination (1) Demonstrate adequate tissue perfusion as
evidenced by palpable peripheral pulses, warm and dry skin, adequate urinary
output, and absence of respiratory distress (2) Verbalize knowledge of
treatment regimen, including appropriate exercise and medications and their
actions and possible side effects (3) Identify changes in lifestyle that are
needed to increase tissue perfusion Circulatory Care: Arterial Insufficiency
(1) If the client experiences dizziness because of postural hypotension when
getting up, teach methods to decrease dizziness, such as remaining seated for
several minutes before standing, flexing feet upward several times while
seated, rising slowly, sitting down immediately if feeling dizzy, and trying
to have someone present when standing. (2) Monitor neurological status;
perform a neurological examination; if symptoms of a cerebrovascular accident
occur (e.g., hemiparesis, hemiplegia, or dysphasia), call 911 and send the
client to the emergency department. (3) If an ischemic stroke is present,
consider keeping the head of the bed lower or flat as long as the airway is
maintained, after consulting with the physician. (4) See the care plans for
Decreased Intracranial adaptive capacity, Risk for Injury, and Acute
Confusion. PERIPHERAL PERFUSION: (1) Check the dorsalis pedis, posterior
tibial, and popliteal pulses bilaterally. If unable to find them, use a
Doppler stethoscope and ......
(1) Change the client's position slowly when getting the client out of bed.
(2) Recognize that the elderly have an increased risk of developing pulmonary
embolism and that, if it is present, the symptoms are nonspecific and often
mimic those of heart failure or pneumonia (1) The interventions described
previously may be adapted for home care use. (2) Differentiate between
arterial and venous insufficiency. (3) If arterial disease is present and the
client smokes, aggressively encourage smoking cessation. See the care plan for
Health-seeking behaviors. (4) Examine the feet carefully at frequent intervals
for changes and new ulcerations. (5) Assess the client's nutritional status,
paying special attention to obesity, hyperlipidemia, and malnutrition. Refer
to a dietitian if appropriate. (6) Monitor for development of gangrene, venous
ulceration, and symptoms of cellulitis (redness, pain, and increased swelling
in an extremity).
(1) Explain the importance of good foot care. Teach the client and family to
wash and inspect the feet daily. Recommend that the diabetic client wear
padded socks, special insoles, and jogging shoes. (2) Teach the diabetic
client that he or she should have a comprehensive foot examination at least
annually, including assessment of sensation using the Semmes-Weinstein
monofilaments. If good sensation is not present, refer to a footwear
professional for fitting of therapeutic shoes and inserts, the cost of which
is covered by Medicare. (3) For arterial disease, stress the importance of not
smoking, following a weight loss program (if the client is obese), carefully
controlling a diabetic condition, controlling hyperlipidemia and hypertension,
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and reducing stress. (4) Teach the client to avoid exposure to cold, to limit
exposure to brief periods if going out in cold weather, and to wear warm
clothing. (5) Teach the client to recognize the signs and symptoms that should
be reported to a... ÿÿÿÿ ÿ Transfer ability, impaired 996 Limitation of
independent movement between two nearby surfaces. Impaired ability to
transfer: from bed to chair and chair to bed/on or off toilet or
commode/between uneven levels/from chair to car or car to chair/from chair to
floor or floor to chair/from standing to floor or floor to standing See
defining Characteristics (aeb) Balance; Body Positioning: Self-Initiated (1)
Transfer from bed to chair and back successfully. (2) Transfer from chair to
chair successfully. (3) Transfer from chair to toilet and back successfully.
(4) Transfer from chair to car and back successfully Exercise Promotion:
Strength training; Exercise Therapy: Muscle Control (1) Request a consult for
PT and/or OT for an upper and lower extremity exercise and strengthening
program early in the client's progressive mobilization and recovery. (2)
Obtain a consult for a PT, OT, or orthotist to evaluate, prescribe, measure,
and fit the client with the proper orthoses, braces, splints, walking aids,
raised toilet seats, etc. (3) Inquire about and learn the specific techniques
and instructions the OT and PT have taught about and learn the specific
techniques and instructions the OT and PT have taught the client to reinforce
and assist the client as he or she transfers to various surfaces. (4)
Ergonomically assess the client's dependence level, size, weight, strength,
movement abilities in bed, balance, tolerance to position change, sensation,
behavior, and cognition, as well as equipment availability and staff ratios
and experience to decide whether to perform a manual or device-assisted life,
transfer, or weighing of the client. (If a PT has already evaluated...
(1) Obtain a referral for an OT and/or PT to develop home exercise and
transfer regimens aand evaluate the need for home modifications such as wider
doorways, safe floor surface, grab bars, clutter elimination, adeuate
lighting, adequate seting (proper chair height, stability, support, and
firmness), optimum furniture placement (for maneuverability and stability in
using to asses in getting up if a fall occurs), fitted bedspreads and blankets
so that the client does not trip, etc. (2) Involve a social worker to educate
the client and family about equipment costs and financial bnefits and
regulations associated with Medicare, Medicaid, and third-party payers, as
well as local community options for securing durable medical equipment and
home care servies. (3) Coordinate with therapy services to reinforce client
and family education regarding safe and effective transfer methods, equipment;
application, removal, and care of assistive devices; skin checks and care
associated with the use...
(1) Begin discharge planning as soon aspossible with the care manager or
social worker to assess the need for home support systems, assistive devices,
and community or home health services. (2) Obtain referral for an OT and/or PT
to develop home exercise and transfer regimes, and evaluate home modification
and equipment needs such as wheelchairs, tub seats, hand rails, and raised
toilet seats. (3) Involve a social workers to educate the client and family
about equipment costs and financela benefits and regulations associated with
Medicare, Medicaid, and third-party payers, as well as local community options
for seciring durable medical equipment and home care services. (4) coordinate
with therapy services to reinforce client and family education regarding safe
and effective transfer methods; application, removal, and care of assistive
devices; skin checks and care associated with the use of braces, splints,
immobiliers, etc. and skin checks and care associated with the use of ........
ÿÿÿÿ ÿ Trauma, risk for 1004 Accentuated risk of accidental tissue injury
(e.g., wound, burn, fracture) EXTERNAL: High-crime neighborhood and client
vulnerability; pot handles facing toward front of stove; knives stored
combustibles or corrosives; highly flammable children's toys or clothing;
obstructed passageways; high beds; large icicles hanging from roof; nonuse or
misuse of seat restraints; overexposure to sun, sunlamps, or radiotherapy;
overload eletrical outlets; overloaded fuse boxes; play or work near vehicle
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pathways; playing with fireworks or gun-powder; unlocked storage of guns or

ammunition; contact with rapidly moving machinery, industrial belts, or
pulleys;; litter or liquid spills on floors or stairways; defective
appliances; bathing in very hot water; bathtub without hand grip or antislip
equipment; children's playing with matches, candles, cigarettes, or
sharp-edged toys; children's playing at top of stairs without gates; children
riding infron seat of car; delayed lighting of gas burner or oven; contact
with intense cold; collection of grease waste on stove; ......... Risk
Control; Fall Prevention Behavior (1) Remain free from trauma. (2) Explain
actions that can be taken to prevent trauma. Environmental Management Safety;
Skin Surveillance (1) Provide vision aids for visually impaired clients. (2)
Assist the client with ambulation. (3) Have a family member evaluate water
temperature for the client. (4) Assess the client for causes of impaired
cognition. (5) use reality orientation to improve the client's cognition. (6)
Teach safety measures to prevent trauma. (7) Keep walkways clear of snow,
debris, and household items. (8) Provide assistive devices in bathroom. (9)
Ensure that call-light systems are functioning and that the client is able to
use them. (10) Use a night light after dark. (11) Never leave young children
unsupervised around water or cooking areas. (12) Keep flammable and
potentially flammable articles out of the reach of young children. (13) Lock
up harmful objects such as guns. (14) Teach the client to observe safety
precautions in high-crime neighborhoods. (15) Instruct the client not to drive
under the influence of alcohol or drugs. Assess for substance abuse problem
and refer to appropriate ...........
(1) Assess the geriatric client's level of functioning both at admission and
periodically. (2) Perform a home safety assesssment and recommend the
following preventive measures: keep electrical cords out of the flow of
traffic; remove small rugs or make sure they are slip resistant; increase
lighting in hallways and other dark areas; place a light in the bathroom; keep
towels, curtain, and other items that might catch fire away from the stove;
store harmful products away from food products; provide at least one grab bar
in tubs and showers; check prescribed meds for appropriate albels, store meds
in original containers or in a dispenser of some type; if the client cannot
administer meds according to directions, secire someone to administer meds.
(3) Mark stove knobs with bright colors, and outline the borders of steps. (4)
Discourage driving at night. (5) Encourage family members to reminisce with an
agitated client. Encourage the client to participtae in resistance and impact
.......
(1) Educate the family regarding age-appropriate child safety precautions,
environmental safety precautions, and intervention in an emergency. (2)
Educate the client and family regarding helmet use during recreation and
sports activities. (3) Teach the family to assess a day care center's or
babysitter's knowledge regarding child safety, environmental safety
precautions, and assistance of a child in an emergency. (4) Encourage the use
of proper car seats and safety belts. (5) Teach how to plan safe prom and
graduation parties. (6) Teach parents the importance of monitoring youths
after school. (7) Teach firearm safety. Encourage the family to keepf firearms
and ammunition in locked storage. (8) Educate that the use of psychotropic
meds may increase the risk of falls and that wiethdrawal of psychotropic meds
should be considered. (9) For further info, see the care plans for Risk for
Aspiration, Impaired Home maintenance, Risk for Injury, Risk for Poisoning,
and Risk for Suffocation. ÿÿÿÿ ÿ Urinary Elimination, readiness for enhanced
1009 A pattern of urinary functions that is sufficient for meeting
eliminatory needs and can be strengthened Expresses willingness to enhance
urinary elimination, urine is straw colored with on odor; specific gravity is
within normal limits; amoount of ouptut is within normal limits for age and
other factors; positions self for emptying bladder; fluid intake is adequate
for daily needs Urinary Continence; Urinary Elimination (1) Eliminate or
reduce incontinent episodes. (2) Recognize sensory stimulus indicating
readiness for urine elimination. (3) Respond to prompts for toileting.
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Urinary Elimination Management (1) Assess the client for readiness for
improving urine elimination patterns, focusing on need for physical assistance
to access toilet, cognitive awareness of sensations indicating readiness for
urine elimination and currect continence status. (2) Complete a bladder diary
of diurnal and nocturnal urine elimination patterns and patterns of urinary
leakage. (3) Begin a scheduled toileting program (usually every 2-3 hours) for
the client who is normally continent (recognizes cues to toilet and expresses
readiness to toilet) but requires physcial assistance to access toilet. (4)
Remove environmental barriers to toilet access. (5) Provide a urinal or
bedside tiolet as indicated. (6) Assist client to remove clothing, transfer to
the toilet, cleanse the perineal skin, and redress as indicated. (7) Ensure
that toileting opportunities are offered both during daytime hours and during
hours of sleep. (8) Ensure that toileting opportunities are offered both
during daytime hours and during hrs....
ÿÿÿÿ ÿ Urinary elimination, impaired 1011 Disturbance in urine

elimination. NOTE: This broad diagnosis may be used to describe many
dysfunctional coiding conditions. Refer to Functional urinary Incontinence,
Reflex urinary incontinence, Stress urinary Incontinence, Total urinary
Incontinence, urge urinary Incontinence, and Urinary retention for info on
these more specific diagnoses. Too many to list; SEE BOOK !! Bothersome
lower urinary tract symptoms (urological disorders, neurological lesions,
gynecological conditions, dysfunction of bowel elimination); incontinence
(refer to specific diagnosis); urinary retention (refer to specific
diagnosis); acute urinary retention (refer to Urinary retention) Urinary
Continence; Urinary Elimination; Knowledge: Medication (1) Demonstrate
diurnal frequency no more than every 2 hours. (2) Demonstrate nocturia zero to
one time per night for adults younger than 70 years and no more than two times
per night for persons 70 or older. (3) Be able to postpone voiding until
toileting facility is accessed and clothing is removed. (4) Be able to
perceive and recognize cues for toileting, move to toilet or use urinal or
portable toileting apparatus, and remove clothing as necessary for toileting.
(5) Demonstrate postvoidng residual volumes less than 200 ml or 25% of total
bladder capacity. (6) State absence of pain or excessive urgency with bladder
filling and with urination Urinary Elimination Management (1) Routinele
screen all adult women and agins men for urinaryincontinence or lower urinary
tract symptoms including bothersome urgency. (2) Complete a more detailed
assessment on selected clients including a bladder log and
functional/cognitive assessment. (Refer to Functional urinary Incontinence,
Reflex urinary Incontinence, Stress urinary Incontinence, Total urianry
Incontinence, and Urge urinary Incontinence.) (3) Consult the physician for
culture and sensitivity testing and antibiotic treatment in the individual
with evidence of a urinary infection. (4) Refer the individual with
irritative symptoms; chronic, burning bladder; andurethral pain to a urologist
or specialist in the management of pelvic pain. (5) Teach the client to
recognize symptoms of UTI (dysuria that crescendos as the bladder nears
complete evacuation; urgency to urinate followed by micturition of only a few
drips; suprapubic aching; discomfort; malaise; voiding frequency; sudden
exacerbation of urinary .........
(1) Provide an environment that encourages toileting for the elderly client
cared for in the home or in acute care, long-term care, or critical care
units. (2) Perform urinalysis in all elderly person who experience a sudden
change in urine elimination patterns, lower abdominal discomfort, acute
confusioin, aor a fever of unclear origin. (3) Encourage elderly women to
drink at least 10 ounces of cranberry juice daily, regularly consume one to
two servings of fresh blueberries, or supplement the diet with cranberry
concentrate capsules (usually taken in 500 mg doses with each meal)
(1) Provide all clients with the basic principles for optimal bladder
function. (2) Teach the community and health care providers that urinary
incontinence is not a normal part of aging and that incontinence can be
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corrected or managed with proper evaluation and care. (3) Provide informaiton
to health care providers and the community about the signs, symptoms, and
management of urinary tract infections and interstitial cystitis. (4) Teach
all persons the signs and symptoms of urinary tract infection and its
management. (5) Teach all persons to recognize hematuria and to promptly seek
care if this sympom occurs. ÿÿÿÿ ÿ Urinary retention 1016 Incomplete
emptying of the bladder Measured urinary residual greater than 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)
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)
Urinary Continence; Urinary Elimination (1( Completely and regularly
eliminate urine from the bladder; measured urinary residual volume is less
than 150 to 200 ml or 25% of total bladder capacity (voided volume plus
urinary residual volume) (2) Experience correction or relief from obstructive
symptoms (3) Experience correction or alleviation of irritative symptoms (4)
Be free of upper urinary tract damage (renal function remains sufficient;
febrile urinary infections are absent) Urinary Retention Care (1)Obtain a
focused urinary history emphasizing the character and duration of lower
urinary symptoms. Query the client about episodes of acute urinary retention
(complete inability to void) or chronic retention (documented elevated
postvoid residual volumes). (2) Question the client concerning specific risk
factors for urinary retention including: Disorders affecting the sacral spinal
cord such as spinal cord injuries of vertebral levels T12 to L2, disk
problems, cauda equina syndrome, tabes dorsalis; Acute neurological injury
causing sudden loss of mobility such as spinal shock; Metabolic disorders such
as diabetes mellitus, chronic alcoholism, and related; conditions associated
with polyuria and peripheral polyneuropathies Heavy-metal poisoning (lead,
mercury) causing peripheral polyneuropathies; Advanced stage HIV; Medications
including antispasmodics/parasympatholytics, alpha-adrenergics,
antidepressants, sedatives, narcotics, psychotropic medications, illicit
drugs; Recent ......
(1) Aggressively assess elderly clients, particularly those with dribbling
urinary incontinence, urinary tract infections, and related condition for
urinary retention. (2) Assess elderly clients for impaction when urinary
retention is documented or suspected. (3) Assess elderly male clients for
retention related to BPH or prostate cancer. (1) The interventions listed
previously may be adapted for home care use. (2) Encourage the client to
report any inability to void. (3) Maintain an up-to-date medication list;
evaluate side-effect profiles for risk of urinary retention. (4) Refer the
client for physician evaluation if there is a new occurrence of urinary
retention.
(1) Teach techniques for intermittent catheterization including use of clean
rather than sterile technique, washing using soap and water or a microwave
technique, and reuse of the catheter. (2) Teach the client with an indwelling
catheter to assess the tube for patency, maintain the drainage system below
the level of the symphysis pubis, and routinely cleanse the bedside bag. (3)
Teach the client with an indwelling catheter or undergoing intermittent
catheterization the symptoms of a significant urinary infection including
Page 153
hematuria, acuteonset incontinence, dysuria, flank pain, or fever. ÿÿÿÿ ÿ

Ventilation, spontaneous, impaired 1022 Decreased energy reserves result in
an individual's inability to maintain breathing adequate for supporting life
Dyspnea; increased metabolic rate; increased heart rate; decreased Po2,
increased Pco2, decreased Sao2; increased restlessness; apprehension;
increased use of accessory muscles; decreased tidal volume; decreased
cooperation Metabolic factors; respiratory muscle fatigue Neurological
Status: Central Motor Control; Respiratory Status: Gas Exchange, Ventilation
(1) maintain arterial blood gases within safe parameters. (2) Remain free of
dyspnea or restlessness. (3) Effectively maintain airway. (4) Effectively
mobilize secretions. Artificial Airway Management; Mechanical Ventilation;
Respiratory Monitoring; Resuscitation Neonate; Ventilation Assistance (1)
Collaborate with the client, family, and physician regarding possible
intubation and ventilation. Ask whether the client has advanced directives
and, if so, integrate them into the pan of care in conjunctio with clinical
data regarding overall health and reversiblity of the medical condition. (2)
Assess and respond to changes in the client's respiratory Status. Monittor the
client for dyspnea, including respiratory rate, use of accessory muscles,
intercostal retractions, flaring of notrils, and subjective complaints. (3)
Have the client use a numerical scale (0-10) to describe dyspnea. (4) Assess
for chronic disorderds when administering oxygen. With COPD the respiratory
drive is primarily in response to hypoxia, not hypercarbia; oxygenating too
aggressivlely can result in respiratory depression. (5) Collaborate with the
physician and respiratory therapists in determining the appropriateness of
noninvasive positive pressure ventilation )NPPV) for the decompensated client
w/COPD....
(1) Recognize that elderly have a high rate of moribidity when mechanically
ventilated. (1) Some of the interventions listed previously may be adapted
for home care use. (2) Begin discharge planning as soon as possible with the
case manager or social worker to assess the need for home support systems,
assistive devices, and community or home health services. (3) With the help
from a medical social worker, assist the client and family to determine the
fiscal impact of home care vs. and extended care facility. (4) Assess the home
setting during the discharge process to ensure the home can safely accommodate
ventilator support. (5) Have the family contact the electric company and place
the client residence on a high-risk list in case of a power outage. (6)
Assess the caregivers for commitment to support a ventilator-dependent client
in the home. (7) Be sure that the client and family or caregivers are familiar
with operation of all ventilation devices, kinow how to suction if needed, are
competent in doing tracheostomy care, and know schedules for cleaning
equipment. ......
(1) Explain to the client the potential sensations that will be experience
including relief of dyspnea, the feeling of lung inflations, the noise of the
ventilator, and the reality of alarms. (2) Explain to the client and family
about being unable to speak, and work out an alternative system of
communication. See previous intervention. (3) Demonstrate to the family how to
perform simple procedures such as suctioning the mouth witha Haneur catheter,
providing ROM exercises, and reconnecting the ventilator immediately if it
becomes disconnected. (4) Offer both the client and family explanations of how
the ventilator works and answer any questions asked. ÿÿÿÿ ÿ Ventilatory
weaning response, dysfunctional 1028 Inability to adjust to lowered levels
of mechanical support that interrupts and prolongs the weaning process
SEVERE: Deterioration in arterial blood gases from current baseline;
respiratory rate increases significantly from baseline; increase from baseline
BP (20 mm Hg); agitation; increase from baseline HR (20 beats/min);
paradoxical abdominal breathing; adventitious breath sounds, audible airway
secretions; cyanosis; decreased level of consciousness; full respiratory
accessory muscle use; shallow, gasping breaths; profuse diaphoresis; breathing
uncoordinated with the ventilator. MODERATE: Slight increase from baseline BP
(<20 mm Hg); baseline increae in respiratory rate (< 5 breaths/min); slight
Page 154
increase in baseline HR (< 20 beats/min); pale; slight cyanosis; slight

respiratory accessory muscle use; inability to respond to coaching; inability
to cooperate; apprehension; color changes; decreased air entry on
auscultation; diaphoresis; eye widening; wide-eyed look; hypervigilance to
activities. MILD: Warmth; restlessness; slight increase of respiratory rate
from baseline; queries about ..... PHYSIOLOGICAL: Ineffective airway
clearance; sleep pattern disturbance; inadequate nutrition; uncontrolled pain
or discomfort. PSYCHOLOGICAL: Knowledge deficit of the weaning process and
client role; perceived inefficacy about the ability to wean; decreased
motivation, decreased self-esteem; moderate or severe anxiety or fear;
hopelessness; powerlessness; insufficient trust in nurse. SITUATIONAL:
Uncontrolled episodic energy demands or problems; inappropriate pacing of
diminished ventilator support; inadequate social support; adverse environment;
low nurse-client ratio; extended nurse absence from bedside; unfamiliar
nursing staff; history of ventilator dependence for > 4days to 1 week; history
of multiple unsuccessful weaning attempts. Respiratory Status: Gas Exchange,
Ventilation (1) Wean from ventilator with adequate arterial blood gases. (2)
Remain free of unresolved dyspnea or restlessness. (3) Effectively clear
secretions. Mechanical Ventilation; Mechanical Ventilatory Weaning (1)
Assess client's readiness for weaning as evidenced by the following: a)
Hemodynamic stability with adequate heart function. b) Resolution of initial
medical problem that led to ventilaor dependence. c) Adequate nutritional
status with serum albumin levels > 2.5 g/dl. d) Adequate sleep. e)
Psychological readiness. FLUID AND ELECTROLYTE BALANCE: (1) For best results,
ensure that the client is in an optimal physiological and psychological state
before introducing the stress of weaning. (2) Initiate conditioning for the
client including strength training where the client uses a T piece or low
intermittent mandatory ventilation for short durations or endurance training
where the client uses pressure support ventilation on inspiration to prepare
for weaning. (3) Identify reasons for previous unsuccessful weaning attempts,
and include that information in development of the weaning plan. (4)
Collaborate with an interdisciplinary team to develop a weaning plan with a
timeline and goals; ..
(1) Recognize that older clients may require longer periods of time to wean.
NOTE: Weaning from a ventilator at home should be based on client stability
and comfort of the client and caregivers under an intermittent care plan. The
client and/or family may be more comfortable having the client rehospitalized
for the process. (1) Assess comfort and coping ability of the client and/or
family to wean at home, as well as fiscal implications and home care coverage.
(2) Establish an emergency plan and methods of implementation. Include
emergency aeration and reestablishment of the ventilation assistive device.
(3) Obtain orders for alternative routes of medication administration when
meds have been administered via a ventilation device. Instruct the client and
family in changes.
ÿÿÿÿ ÿ Violence, other-directed, risk for 1033 At risk for behaviors in
which an individual demonstrates that he or she can be physically,
emotionally, and/or sexually harmful to others. Body language: rigid
posutre, clenching of fists and jaw, hyperactivity, pacing, breathlessness,
threatening stances; history of violence against others; history of threats of
violence; history of violent antisocial behavior; history of violence,
indirect; neurological impairment; cognitive impairment; history of childhood
abuse; history of witnessing family violence; cruelty to animals; fire
setting; prenatal/perinatal complications or abnormalities; history of drug of
alcohol abuse; pathological intoxication; psychotic symptomatology; motor
vehicle offenses; suicidal behavior; impulsivity; availability/possession of
weapons Abuse Cessation; Abusive Behavior Self-Restraint; Aggression
Self-Control; Distorted Though Self-Control; Impulse Self-Control; Parenting:
Psyhcosocial Safety; Risk Detectioin (1) Stop all forms of abuse. (2) Have
cessation of abuse reported by victim. (3) Display no aggressive activity. (4)
Refrain from verbal outbursts. (5) Refrain from violating others' personal
Page 155
space. (6) refrain from antisocial behaviors. (7) Maintain relaxed body
language and decreased motor actvity. (8) Identify factors contributing to
abusive/aggressive behavior. (9) Demonstrate impulse control or state feelings
of control. (10) Identify impulsive behaviors. (11) Identify
feelings/behaviors that lead to impulsive actions. (12) Identify consequences
of impulsive actions to self and others. (13) Avoid high-risk environments and
situations. (14) Identify and talk about feelings; express anger
appropriately. (15) Express decreased anxiety and control of hallucinations as
applicable. (16) Displace anger to meaningful activities. (17) Communicate
needs appropraitely. (18) Identify responsibility to maintain control. (19)
Express empathy for victim. (19) Obtain no access or yield access.... Abuse
Protection Support; Anger Control Assistance; Behavior Management; Calming
Techniqe; Coping Enhancement; Crisis Intervention; Delusion Management;
Dementia Management; Distraction; Environmental Management: Violence
Prevention; Mood Management; Physical Restraint; Seclusion; Substance Use
Prevention (1) MOnitor the environment, evaluate situations that could become
violent, and intervene early to de-escalet the situation. Enlist support from
other staff rather than attempting to handle the situation alonge. (2) Know
and follow instituation's policies and procedures concerning violence. (3)
Assess the client for risk factors of violence including those in the
following categories: psychiatric disorders; psychological precursors; coping
difficulties; and personal history. (4) Assess for potential indicators of
impending violence against others: frequent medication change, high use of
sedative drugs, past violent behavior, a DSM-IV diagnosis of antisocial
personality or borderline personality disorder, and long hospitalization.
Other indicators include hypervigilance, hostility, substance sue, and lack of
adherence to medication regimen. (5) Assess the client with history of
previous assaults. Listen to and acknowledge feelings of anger, observe for
increased motor activity, and ...
(1) Assess for changes in physiological functions or impairment of the ability
to meet basic needs. (2) Observe for dementia and delirium. (3) Assess sensory
impairments and the influence they may have on the client's behavior. (4)
Observe for signs of fear, anxiety, anger, and agitation, and intervne
immediately. (5) Monitor for paradoxical drug reactions, and report any to the
physcian. (6) Assess for brain insults such as recent falls or injuries,
strokes, or transient ischemic attacks. (7) Decrease environmental stimuli if
violence is directed at others. (8) Provide hand or back rubs and calming
music when elderly client experiences agitation. (9) If abuse or neglect of an
elderly client is suspected, report the suspicion to alocal Adult Protective
Services Agency. (1) Assess family members or caregivers for their ability
to protect the client and themselves. (2) Include an initial and ongoing
assessment and evaluation of potential abuse and neglect. Photograph evidence
of abuse or neglect when possible. (3) If neglect of abuse is syspected,
identify an emergency plan that addresses the problem immediately, ensures
client safety, and includes a report to the appropriate authorities. Discuss
when to use hotlines and 911. Role-play access to emergency resources with the
client and caregivers. (4) Encourage appropriate safety behaviors in abused
women; call the client at intervals during a 6-month period to determine
whether safety behaviors are being carried out. (5) Assess the home
envirnoment for harmful objects. Have the family remove or lack objects as
able. (6) Refer for homemaker or psychiatric home health care services for
respite, client reassurance, and implementation of a therapeutic regimen. (7)
If the client is taking psychotoropic ....
(1) Teach relaxation and exercise as ways to release anger. (2) Teach
cognitive-behavioral activities such as active problem solving, reframing, or
thought stopping. Teach the client to confront his or her own negative thought
patterns such as catastophizing, dichotomous thinking; or unrealistic
expectations. (2) For religious couples, encourage the use of prayer. (3)
Refer to individual or group therapy. (4) Teach the adolescent client violence
prevention and encourage him or her to become involved in community service
Page 156
activities. (5) Teach caregivers and family members of clients with dementia
to use expressive physical touch and verbalization (EPT/V) when caring for
these clients. (6) Teach the use of appropriate community resources in
emergency situations. (7) Inform the client and family about medication
actions, side effects, target symptoms, and toxic reactions. ÿÿÿÿ ÿ
Violence, self-directed, risk for 1044 At risk for behaviors in which an
individual demonstrates that he or she can be physically, emotionally, and/or
sexually harmful to self Body language; rigid posture; clenching of fists
and jaw, hyperactivity, pacing, breathlessness, threatening stances; history
of violence against others; history of threats of violence; history of violent
antisocial behavior; history of violence, indirect; neurological impairment;
cognitive impairment; history of childhood abuse; history of witnessing family
violence; cruelty to animals; fire setting; prenatal/perinatal complications
or abnormalities; history of drug or alcohol abuse; pathological intoxication;
psychotic symptomology; motor vehible offenses; suicidal behavior;
impulsivity; availability/possession of weapons Depression Self-Control;
Distored Thought Self-Control; Impulse Self-Control; Loneliness Severity; Mood
Equilibrium; Risk Detection; Self-Mutilation Restraint; Suicide Self-Restraint
(1) Refrain from self-injury. (2) State appropriate ways to cope with
increased psychological or physiological tension. (3) Talk about feelings,
express anger appropriately. (4) Seek help when feeling self-destructive or
having urges to self-mutilate. (5) Maintain self-control without supervision.
(6) use appropriate community agencies when cargivers are unable to attend to
emotional needs. (7) Maintain connectedness in relationships. (8) Express
decreased anxiety and control of impulses. (9) Refrain from using
mood-altering substances. (10) Obtain no access to harmful objects. (11) Yield
access to harmful objects. (12) Maintain self-control without supervision.
Anger Control Assistance; Anciety Reduction; Behavior Management: Self-Harm;
Calming Technique; Coping Enhancement; Crisis Intervention; Mood Management;
Substance Use Prevention; Suicide Prevention Surveillance (1) Refer to the
care plan for Risk for Suicide. (2) Refer to the care plans for
Self-mutilation and Risk for Self-mutilation.
ÿÿÿÿ ÿ Walking, impaired 1045 Limitation of independent movement within

the environment on foot (or artificial limb) Impaired ability to climb
stairs; walk on uneven surface; walk required distances; walk on even
surfaces; walk on an incline or decline; navigate curbs Intolerance to
activity; decreased strength and endurance; pain or discomfort; perceptual or
cognictive impairment; neuromuscular impairment; musculoskeletal impairment;
depression; severe anxiety; lower extremity amputation. NOTE: These are the
same as the etiiologies for Impaired physical Mobility with the addition of
lower extremity amputation. Suggested functional level classifications follow:
0--Completely independent, 1--Requires use of equipment or device, 2--Requires
help from another person for assistance, supervision, or teaching, 3--Requires
help from another person and equipment device, 4--Dependent (does not
participate in activity) Ambulation; Mobility (1) Demonstrate optimal
independence and safety in walking. (2) Demonstrate the ability to direct
others on how to assist with walking. (3) Demonstrate the ability to properly
and safely use and care for assistive walking devices. Exercise Therapy:
Ambulation (1) Reinforce or request physical therapy consult to teach
"bridging"; have client use the technique to move side to side in bed and to
raise buttocks off the bed. (2) Apply antiembolic stockings, leg bandage
wraps, and abdominal binders; elevate the HOB in small increments to as high a
degree as tolerated; change positions slowly and provide adequate hydration to
persons who are at risk for or who initially display postural hypotension when
standing, sitting, and walking. Assess by comparing lying, sitting, and
standing BP changes. If there is a BP discrepancy (lower in upright positions)
or symptoms occur, consult the physician for medication review. (3) Remind
clients of physician orders regarding weight-bearing limitations during
walking. (3) Explain meaning and goals of progressive mobilization (gradual
Page 157
elevation of HOB, tilt table, reclined chair sitting, etc.) to the client who
has been on prolonged bed rest and who has poor circulation functioning. (4)
Implement the ...........
(1) Monitor pulse, respirations, and BP before and 5 minutes after a new
activity. Stop activity if any of the following are detected: resting heart
rate >100bpm, exercise heart rate that is 35% > resting rate, exercise
systolic BP > 25-35 mmHg above resting pressure, or a decrease in systolic BP
that is > 20 mm Hg. (2) Recognize that the use of a walking aid increases
energy and therefore may raise pulse and BP; however, they are often
prescribed to give stability and support for clients with lower extremity
weakness, poor balance, or weight-bearing restrictions. (3) For elderly
clients use safety and fall precautions such as the following: visual
identification (arm bands, etc.), especially in clients at high risk of
falling, a call system within reach; client education to call for help before
standing and walking; a bed-chair alarm or one-to-one observation, especially
for clients with cognitive or memory impairment; obstacle clearance; and
assistive devices that are properly ..... (1) Assess the client and obtain
a complete history with reference to reasons for impairment. (2) Explain the
importance of having adequate lighting both day and night; tacking carpet
edges down, removing throw rugs from traffic flow areas, and having nonskid
backings on those that are used; applying nonskid wax on floors; and removing
clutter, especially small objects, from the floor. (3) Assess the home
environment for all barriers to walking. (4) If the client lives alone, assess
his or her support system for emergency and contingency care. (5) Use safety
devices such as a gait belt when assisting the client in ambulation. (6) Refer
to physical and occupational therapists for skills building, strength builing,
options for restructuring the environment, and present alternative mobility
options. (7) Refer to home health aide services as appropriate for assistance
with ADLs. (8) Provide support to the client and caregivers during long-term
impairment. Refer to case manager/medical ....
(1) Recommend that the client and family check assistive devices to keep them
in safe working order. (2) Recommend daily weight-bearing activity and
walking, calcium and vitamin D supplementation if dietary intake is low, and
avoidance of smoking to prevent osteoporosis and related fractures. Assess for
and strongly encourage client not to substitue beverages with caffeine
(including cola) and alocohol for milk at meal time. Estrogen-replacement
therapy may be helpful; therefore the client may need to consult with a
physician. ÿÿÿÿ ÿ Wandering 1052 Meandering; aimless or repetitive
locomotion that exposes the individual to harm; frequently incongruent with
boundaries, limits, or obstacles 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 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 Caregiver Home Care Readiness; Fall
Prevention Behavior; Falls Occurrence (1) Decrease incidence of falls
(preferably free of falls) (2) Decrease incidence of elopements (3) Maintain
Page 158
appropriate body weight (4) Be able to explain interventions he or she can use
to provide a safe environment for a care receiver who displays wandering
behavior Dementia Management (1) Assess and document the amount(frequency
and duration), pattern (random, lapping, or pacing), and 24-hour distribution
of wandering behavior over a 3-day interval. (2) Document particular aspects
of wandering that are troubling. (3) Obtain a history of personality
characteristics and behavioral responses to stress. (4) Evaluate for
neurocognitive strengths and limitations, particularly language, attention,
visuospatial skills, and perseveration. (5) Assess for physical distress or
needs such as hunger, thirst, pain, discomfort, or elimination. (6) Assess for
emotional or psychological distress such as anxiety, fear, or feeling lost.
(7) Observe wandering episodes for antecedents and consequences. (8) Apply
observed consequences of wandering such as personal attention, food, and so
forth at times when the person is not wandering, and withhold them while the
person is wandering. (9) Assess regularly for the presence of or potential for
negative outcomes of wandering such as weight...
family's understanding of wandering behavior. (2) Refer the family to social
services or other supportive services to assist with the impact of caregiving
for the wandering client. (3) Encourage the family to use support groups or
other service programs. (4) Validate the family's feelings regarding the
impact of client wandering on family lifestyle. (1) Help the caregiver set
up a plan to deal with wandering behavior using the interventions mentioned in
Nursing Interventions and Rationales. (2) Assess the home environment for
modifications that will protect the client and preventelopement. (3) Enroll
wanderers in the Safe Return Program of the Alzheimer's Association, and help
the caregiver develop a plan of action to use if the client elopes. (4) Help
the caregiver develop a plan of action to use if the client elopes. (5)
Institute case management of frail elderly clients to support continued
independent living. (6) Refer for homemaker or psychiatric home health care
services for respite, client reassurance, and implementation of a therapeutic
regimen. Refer to the care plan for Caregiver role strain.
(1) Inform the client and family of the meaning of and reasons for wandering
behavior. An understanding of wandering behavior will enable the client and
family to provide the client with a safe environment. (2) Teach the
caregiver/family methods to deal with wandering behavior using the
interventions mentioned in Nursing Interventions and Rationales. ÿ
Page 159

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an exercise program with a friend. (1) Begin discharge planning as soon as

Regretful; irritability; anguish; scared; jittery; overexcited; painful and

plan as indicated. (9) Encourage use of appropriate community resources:

preferences; have mother position infant in direct line of sight; demonstrate

catheterization. GASTROINESTINAL: Bowel distention; fecal impaction; digital

can affect all individuals regardless of culture, race, or ethnicity. (4)

acuity). (3) Complete an assessment of cognitive function. (4) Document

shortness of breath; assumption of a three-point position; pursed-lip

(LVSWI); S3 or S4 sounds. BEHAV.: Anxiety, restlessness Altered heart

if the caregiver becomes ill or dies; preoccupation with care routine.

Progressive Muscle Relaxation; Pruritus Management; Simple Guided Imagery;

Deficit, Speech Deficit (1) When the client is having difficulty

increased HR, increased muscle tension, restlessness); questioning of personal

role 272 Parent's experience of role confusion and conflict in response to

to participate in self-care; decreased ability for meaningful interaction with

bedside commode may be necessitated by the client's condition, allow the

person may be facing; inadequate or incorrect information or understanding by

either person's adaptation to the health challenge Intolerance; agitation;

feelings of family members or significant caregivers regarding the impact of

care attention to the detriment of health; does not perceive personal

excessive calculus; incomplete eruption for age (may be primary or permanent

impaired dentition on nutritioin. (5) Identify mechanical needs for food

pregnancy; refer to treatment programs for substance abuse. (2) Provide

is on bed rest include: Constipation, Risk for impaired Skin integrity,

dehydration, incontinence of bowel and bladder; frequent exacerbations of

illness; postoperative conditions; visual difficulties; hearing difficulties;

chronically disorganized, leading to conflict, denial of problems, resistance

the stresses unique to racial/ethnic families. (5) Offer frequent gestures of

influence of cultural beliefs, norms, and values on the family's perception of

importance of and ...

and values on the client's perspective of a stressful situation. (3) Identify

Fluid volume, deficient 434 Decreased intravascular, interstitial, and/or

appearance of side effects such as weakness, dizziness, muscle cramps,

especially wedge pressure. (7) If hypotension develops, administer fluid

libido, concentration, and/or pursuit of tasks; developmental regression;

(1) Use reminiscence therapy in conjunction with the expression of emotions

inconsistent responsiveness; multiple caretakers Child Development: 2 Months,

Abuse; mental illness; mental retardation or severe learning disability. Body

lack of adequate behaviors to internal and external environmental changes;

introducing more anxiety-producing possible side effects of the disease or

Ineffective Health maintenance.

unavailable alternatives or personal choices and is unable to mobilize energy

Provide plant or pet therapy if possible. (8) Provide a safe environment so

changes in medication, environmental changes, and recent medical interventions

rate of 0.6 C [1 F] per hour. NOTE: Hypothermia is not a symptom that

significant others the techniques of intermittent catheterization, indwelling

videotape if indicated. (2) Teach the client the importance of avoiding

fisting, or hands to face; hyperextension of arms and legs; tremors, startles,

neurobehavioral systems of functioning (i.e., autonomic, motor, state,

about what infant/child behaviors are possible in given situations. ÿÿÿÿ ÿ

documentation, assists in the prevention of skin breakdown. (8) Carefully wash

Fall Prevention Behavior; Fetal Status: intrapartum; Immune Status; Maternal

as a result of the environmental conditions found in the perioperative setting

ÿÿÿÿ ÿ Intracranial adaptive capacity, decreased 600 Intracranial fluid

(volume-pressure ratio of 2, pressure-volume index of less than 10).

common medical terminology, such as "empty stomach," "emesis," and

families. NOTE: Because home care is an intermittent model of care having a

willingness/ability of family to provide needed support. (4) Identify a

minimize cardiovascular deconditioning by positioning the client as close to

food intake, gastric irritation due to pharyngeal and/or peritoneal