Impaired Physical Mobility

Rabu, 31 Juli 2013

A limitation in independent, purposeful physical movement of the body or of one or more extremities

Defining Characteristics:

  • Postural instability during performance of routine activities of daily living (ADLs); 
  • limited ability to perform gross motor skills; 
  • limited ability to perform fine motor skills; 
  • uncoordinated or jerky movements; 
  • limited range of motion; 
  • difficulty turning; 
  • decreased reaction time; 
  • movement-induced shortness of breath; 
  • gait changes (e.g., decreased walking speed, difficulty initiating gait, small steps, shuffles feet, exaggerated lateral postural sway); 
  • engages in substitutions for movement (e.g., increased attention to other's activity, controlling behavior, focus on preillness/predisability); 
  • slowed movement; 
  • movement-induced tremor

Related Factors:
  • Medications; 
  • prescribed movement restrictions; 
  • discomfort; 
  • lack of knowledge regarding value of physical activity; 
  • body mass index >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; 
  • limited cardiovascular endurance; 
  • altered cellular metabolism; 
  • lack of physical or social environmental supports; 
  • cultural beliefs regarding age-appropriate activity

Suggested functional level classifications
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

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Ambulation: Walking
  • Ambulation: Wheelchair
  • Joint Movement: Active
  • Mobility Level
  • Self-Care: Activities of Daily Living (ADLs)
  • Transfer Performance
Client Outcomes
  • Increases physical activity
  • Meets mutually defined goals of increased mobility
  • Verbalizes feeling of increased strength and ability to move
  • Demonstrates use of adaptive equipment (e.g., wheelchairs, walkers) to increase mobility
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Exercise Therapy: Ambulation
  • Exercise Therapy: Joint Mobility
  • Positioning

Nursing Interventions and Rationales

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.
Screening mobility skills helps provide baselines of performance that can guide mobility-enhancement programming and allows nursing staff to integrate movement and practice opportunities into daily routines and regular and customary care. There are many tools available to measure physical activity; selection of the appropriate tool depends on the setting and situation (Halfmann, Keller, Allison, 1997).

2. Observe client for cause of impaired mobility. Determine whether cause is physical or psychological.
Some clients choose not to move because of psychological factors such as an inability to cope or depression. See interventions for Ineffective Coping or Hopelessness.

3. Monitor and record 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 client is not oversedated.
Pain limits mobility and is often exacerbated by movement.

5. Consult with physical therapist for further evaluation, strength training, gait training, and development of a mobility plan.
Techniques such as gait training, strength training, and exercise to improve balance and coordination can be very helpful for rehabilitating clients (Tempkin, Tempkin, Goodman, 1997).

6. Obtain any assistive devices needed for activity, such as walking belts, walkers, canes, crutches, or wheelchairs, before the activity begins.
Assistive devices can help increase mobility.

7. If client is immobile, perform passive range of motion (ROM) exercises at least twice a day unless contraindicated; repeat each maneuver three times.
Passive ROM exercises help maintain joint mobility, prevent contractures and deformities, increase circulation, and promote a feeling of comfort and well-being (Kottke, Lehmann, 1990; Bolander, 1994).

8. If client is immobile, consult with physician for a safety evaluation before beginning an exercise program; if program is approved, begin with the following exercises:
  • Active ROM exercises using both upper and lower extremities (e.g., flexing and extending at ankles, knees, hips)
  • Chin-ups and pull-ups using a trapeze in bed (may be contraindicated in clients with cardiac conditions)
  • Strengthening exercises such as gluteal or quadriceps sitting exercises
These exercises help reverse weakening and atrophy of muscles.

9. Help client achieve mobility and start walking as soon as possible if not contraindicated.
The longer a client is immobile, the longer it takes to regain strength, balance, and coordination (Bolander, 1994). A study has shown that bed rest for primary treatment of medical conditions or after healthcare procedures is associated with worse outcomes than early mobilization (Allen, Glasziou, Del Mar, 1999).

10. Use a walking belt when ambulating the client.
The client can walk independently with a walking belt, but the nurse can rapidly ensure safety if the knees buckle.

11. Apply any ordered brace before mobilizing client.
Braces support and stabilize a body part, allowing increased mobility.

12. Increase independence in ADLs and discourage helplessness as client gets stronger.
Providing unnecessary assistance with transfers and bathing activities may promote dependence and a loss of mobility (Mobily, Kelley, 1991).

13. If client does not feed or groom self, sit side-by-side with client, put your hand over client's hand, support client's elbow with your other hand, and help client feed self; use the same technique to help client comb hair.
This feeding technique increases client mobility, range of motion, and independence, and clients often eat more food (Pedretti, 1996).


1. Help the mostly immobile client achieve mobility as soon as possible, depending on physical condition.
In the elderly, mobility impairment can predict increased mortality and dependence; however, this can be prevented by physical exercise (Hirvensalo, Rantanen, Heikkinen, 2000).

2. For a client who is mostly immobile, minimize cardiovascular deconditioning by positioning client as close to the upright position as possible several times daily.
The hazards of bed rest in the elderly are multiple, serious, quick to develop, and slow to reverse. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Resnick, 1998).

3. If client is mostly immobile, encourage him or her to attend a low-intensity aerobic chair exercise class that includes stretching and strengthening chair exercises.
Chair exercises have been shown to increase flexibility and balance (Mills, 1994).

4. Initiate a walking program in which client walks with or without help every day as part of daily routine.
Walking programs have been shown to be effective in improving ambulatory status and decreasing disability and the number of falls in the elderly (Koroknay et al, 1995).

5. Evaluate client for signs of depression (flat affect, insomnia, anorexia, frequent somatic complaints) or cognitive impairment (use Mini-Mental State Exam [MMSE]). Refer for treatment or counseling as needed.
Multiple studies have demonstrated that depression and decreased cognition in the elderly correlate with decreased levels of functional ability (Resnick, 1998).

6. Watch for orthostatic hypotension when mobilizing elderly clients. If relevant, have client flex and extend feet several times after sitting up, then stand up slowly with someone watching.
Orthostatic hypotension as a result of cardiovascular system changes, chronic diseases, and medication effects is common in the elderly (Matteson, McConnell, Linton, 1997).

7. Be very careful when getting a mostly immobile client up. Be sure to lock the bed and wheelchair and have sufficient personnel to protect client from falls.
The most important preventative measure to reduce the risk of injurious falls for nonambulatory residents involves increasing safety measures while transferring, including careful locking of equipment such as wheelchairs and beds before moves (Thapa et al, 1996). Elderly clients most commonly sustain the most serious injuries when they fall.

8. Help clients assume the prone position three times per week for 20 minutes each time. If clients are unable to do so, help them turn partially over and assume the position gradually.
The prone position helps prevent hip deformities that can interfere with balance and walking. This position may be contraindicated in some clients, such as morbidly obese clients, respiratory or cardiac clients who cannot lie flat, and neurological clients.

9. Do not routinely assist with transfers or bathing activities unless necessary.
The nursing staff may contribute to impaired mobility by helping too much. Encourage client independence (Mobily, Kelley, 1991).

10. Use gestures and nonverbal cues when helping clients move if they are anxious or have difficulty understanding and following verbal instructions.
Nonverbal gestures are part of a universal language that can be understood when the client is having difficulty with communication.

11. Recognize that wheelchairs are not a good mobility device and often serve as a mobility restraint.
Wheelchairs can be very effective restraints. In one study, only 4% of residents in wheelchairs were observed to propel them independently; only 45% could propel them, even with cues and prompts; no residents could unlock them without help; the wheelchairs were not fitted to residents; and residents were not trained in propulsion (Simmons et al, 1995).

12. Ensure that chairs fit clients. Chair seat should be 3 inches above the height of the knee. Provide a raised toilet seat if needed.
Raising the height of a chair can dramatically improve the ability of many older clients to stand up. Low, deep, soft seats with armrests that are far apart reduce a person's ability to get up and down without help.

13. If client is mainly immobile, provide opportunities for socialization and sensory stimulation (e.g., television and visits). See Deficient Diversional activity.
Immobility and a lack of social support and sensory input may result in confusion or depression in the elderly (Mobily, Kelley, 1991). See interventions for Acute Confusion or Hopelessness as appropriate.

Home Care Interventions

1. Assess home environment for factors that create barriers to physical mobility. Refer to occupational therapy services if needed to assist client in restructuring home and daily living patterns.

2. Refer to home health aide services to support client and family through changing levels of mobility. Reinforce need to promote independence in mobility as tolerated.
Providing unnecessary assistance with transfers and bathing activities may promote dependence and a loss of mobility (Mobily, Kelley, 1991).

3. Assess skin condition at every visit. Establish a skin care program that enhances circulation and maximizes position changes.
Impaired mobility decreases circulation to dependent areas. Decreased circulation and shearing place the client at risk for skin breakdown.

4. Provide support to client and family/caregivers during long-term impaired mobility.
Long-term impaired mobility may necessitate role changes within the family and precipitate caregiver stress (see care plan for Caregiver role strain).

Client/Family Teaching

1. Teach client to get out of bed slowly when transferring from the bed to the chair.

2. Teach client relaxation techniques to use during activity.

3. Teach 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 client be a passive recipient of care.
Maintaining as much independence as possible helps maintain mobility skills (Lipson, Braun, 1993).

5. 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. Sign the contracts with the client.
Using a series of evolving contracts to modify behavior toward increasing activity, help the client learn skills to change behavior (Boehm, 1992).
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Impaired Skin integrity

Selasa, 30 Juli 2013

Altered epidermis and/or dermis

Defining Characteristics:

  • Invasion of body structures; 
  • destruction of skin layers (dermis); 
  • disruption of skin surface (epidermis)

Related Factors:

  • 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
  • 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

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Tissue Integrity: Skin and Mucous Membranes
  • Wound Healing: Primary Intention
  • Wound Healing: Secondary Intention

Client Outcomes
  • Regains integrity of skin surface
  • Reports any altered sensation or pain at site of skin impairment
  • Demonstrates understanding of plan to heal skin and prevent reinjury
  • Describes measures to protect and heal the skin and to care for any skin lesion

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Incision Site Care
  • Pressure Ulcer Care
  • Skin Care: Topical Treatments
  • Skin Surveillance Wound Care

Nursing Interventions and Rationales

1. Assess site of skin impairment and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, skin tear) (Krasner, Sibbald, 1999).
Prior assessment of wound etiology is critical for proper identification of nursing interventions (van Rijswijk, 2001).

2. Determine that skin impairment involves skin damage only (e.g., partial-thickness wound, stage I or stage II pressure ulcer). Classify superficial pressure ulcers in the following manner:
  • Stage I: Observable pressure-related alteration of intact skin with indicators as compared with the adjacent or opposite area on the body that may include changes in one or more of the following: skin temperature (warmth or coolness), tissue consistency (firm or boggy feel), and/or sensation (pain, itching). The ulcer appears as a defined area of persistent redness in lightly pigmented skin, whereas in darker skin tones, the ulcer may appear with persistent red, blue, or purple hues (National Pressure Ulcer Advisory Panel, 1999).
  • Stage II: Partial-thickness skin loss involving epidermis or dermis superficial ulcer that appears as an abrasion, blister, or shallow crater (National Pressure Ulcer Advisory Panel, 1999).
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.

3. Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether client is experiencing changes in sensation or pain. Pay special attention to high-risk areas such as bony prominences, skinfolds, the sacrum, and heels.
Systematic inspection can identify impending problems early (Bryant, 1999).

4. Monitor client's skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing.

5. Individualize plan according to client's skin condition, needs, and preferences.
Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

6. Monitor client's continence status, and minimize exposure of skin impairment and other areas to moisture from incontinence, perspiration, or wound drainage.

7. If 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 urologist or gastroenterologist for incontinence assessment (Doughty, 1991; Wound, Ostomy, and Continence Nurses Society, 1992, 1994; Fantl et al, 1996).

8. For clients with limited mobility, use a risk-assessment tool to systematically assess immobility-related risk factors (van Rijswijk, 2001).
A validated risk-assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

9. Do not position client on site of skin impairment. If consistent with overall client management goals, turn and position client at least every 2 hours. Transfer client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear.

10. Evaluate for use of specialty mattresses, beds, or devices as appropriate (Fleck, 2001).
If the goal of care is to keep a client (e.g., a terminally ill client) comfortable, turning and repositioning may not be appropriate. Maintain the head of the bed at the lowest possible degree of elevation to reduce shear and friction, and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed. Evaluate for the use of specialty mattresses or beds as appropriate (Krasner, Rodeheaver, Sibbald, 2001; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Wilson, 1994).

11. Implement a written treatment plan for topical treatment of the site of skin impairment. A written plan ensures consistency in care and documentation (Maklebust, Sieggreen, 1996).
Topical treatments must be matched to the client, wound, and setting (Krasner, Sibbald 1999).

12. Select a topical treatment that will maintain a moist wound-healing environment and that is balanced with the need to absorb exudate.
Caution should always be taken not to dry out the wound (Bergstrom et al, 1994).

13. Avoid massaging around the site of skin impairment and over bony prominences.
Research suggests that massage may lead to deep-tissue trauma (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

14. Assess client's nutritional status. Refer for a nutritional consult, and/or institute dietary supplements as necessary.
Inadequate nutritional intake places individuals at risk for skin breakdown and compromises healing (Demling, De Santi, 1998).

Home Care Interventions

1. Instruct and assist client and caregivers to remove or control impediments to wound healing (e.g., management of underlying disease, improved approach to client positioning, improved nutrition).
Wound healing can be delayed or fail totally if impediments are not controlled (Krasner, Sibbald, 1999).

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.

Client/Family Teaching

1. Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing.
Early assessment and intervention help prevent serious problems from developing.

2. Teach client to use a topical treatment that is matched to the client, wound, and setting.
The topical treatment must be adjusted as the status of the wound changes (van Rijswijk, 2001; Krasner, Sibbald, 1999; Ovington, 1998).

3. If consistent with overall client management goals, teach how to turn and reposition at least every 2 hours.
If the goal of care is to keep a client (e.g., terminally ill client) comfortable, turning and repositioning may not be appropriate (Krasner, Rodeheaver, Sibbald, 2001; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

4. Teach client to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury.
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Impaired Swallowing

Senin, 29 Juli 2013

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

Defining Characteristics:

Oral phase impairment

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

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

NOC Outcomes (Nursing Outcomes Classification)

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

Suggested NIC Labels
  • Aspiration Precautions
  • Swallowing Therapy

Nursing Interventions and Rationales

1. Determine client's readiness to eat. Client needs to be alert, able to follow instructions, hold head erect, and able to move tongue in mouth.
If one of these factors is missing, it may be advisable to withhold oral feeding and use enteral feeding for nourishment (McHale et al, 1998). Cognitive deficits can result in aspiration even if able to swallow adequately (Poertner, Coleman, 1998).

2. If new onset of swallowing impairment, ensure that client receives a diagnostic workup.
There are multiple causes of swallowing impairment, some of which are treatable (Schechter, 1998).

3. Assess ability to swallow by positioning examiner's thumb and index finger on client's laryngeal protuberance. Ask client to swallow; feel larynx elevate. Ask client to cough; test for a gag reflex on both sides of posterior pharyngeal wall (lingual surface) with a tongue blade. Do not rely on presence of gag reflex to determine when to feed.
Normally the time taken for the bolus to move from the point at which the reflex is triggered to the esophageal entry (pharyngeal transit time) is (1 second (Logeman, 1983). Cardiovascular accident (CVA) clients with prolonged pharyngeal transit times (prolonged swallowing) have a greatly increased chance of developing aspiration pneumonia (Johnson, McKenzie, Sievers, 1993). Clients can aspirate even if they have an intact gag reflex (Baker, 1993; Lugger, 1994).

4. 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, decreased ability to move tongue and lips, decreased mastication of food, decreased ability to move food to the back of the pharynx, slow or scanning speech).
These are all signs of swallowing impairment (Baker, 1993; Lugger, 1994).

5. If client has impaired swallowing, refer to a speech pathologist for bedside evaluation as soon as possible. Ensure that client is seen by a speech pathologist within 72 hours after admission if client has had a CVA.
Speech pathologists specialize in impaired swallowing. Early referral of CVA clients to a speech pathologist, along with early initiation of nutritional support, results in decreased length of hospital stay, shortened recovery time, and reduced overall health costs (Scott, 1998). Research demonstrates that a program of diagnosis and treatment of dysphagia in acute stroke management decreases the incidence of pneumonia (AHCPR, 1999).

6. For impaired swallowing, use a dysphagia team composed of a rehabilitation nurse, speech pathologist, dietitian, physician, and radiologist who work together.
The dysphagia team can help the client learn to swallow safely and maintain a good nutritional status (Poertner, Coleman, 1998).

7. If client has impaired swallowing, do not feed until an appropriate diagnostic workup is completed. Ensure proper nutrition by consulting with physician for enteral feedings, preferably a PEG tube in most cases.
Feeding a client who cannot adequately swallow results in aspiration and possibly death. Enteral feedings via PEG tube are generally preferable to nasogastric tube feedings because studies have demonstrated that there is increased nutritional status and possibly improved survival rates (Bath, Bath, Smithard, 2000).

8. If client has an intact swallowing reflex, attempt to feed. Observe the following feeding guidelines:
  • Position client upright at a 90-degree angle with the head flexed forward at a 45-degree angle (Galvan, 2001). This position forces the trachea to close and esophagus to open, which makes swallowing easier and reduces the risk of aspiration.
  • Ensure client is awake, alert, and able to follow sequenced directions before attempting to feed. As the client becomes less alert the swallowing response decreases, which increases the risk of aspiration.
  • Begin by feeding client one-third teaspoon of applesauce. Provide sufficient time to masticate and swallow.
  • Place food on unaffected side of tongue.
  • During feeding, give client specific directions (e.g., "Open your mouth, chew the food completely, and when you are ready, tuck your chin to your chest and swallow").
9. Watch for uncoordinated chewing or swallowing; coughing immediately after eating or delayed coughing, which may indicate silent aspiration; pocketing of food; wet-sounding voice; sneezing when eating; delay of more than 1 second in swallowing; or a change in respiratory patterns. If any of these signs are present, put on gloves, remove all food from oral cavity, stop feedings, and consult with a speech and language pathologist and a dysphagia team.
These are signs of impaired swallowing and possible aspiration (Baker, 1993; Galvan, 2001).

10. If client tolerates single-textured foods such as pudding, hot cereal, or strained baby food, advance to a soft diet with guidance from the dysphagia team. Avoid foods such as hamburgers, corn, and pastas that are difficult to chew. Also avoid sticky foods such as peanut butter and white bread.
The dysphagia team should determine the appropriate diet for the client on the basis of progression in swallowing and ensuring that the client is nourished and hydrated.

11. Avoid providing liquids until client is able to swallow effectively. Add a thickening agent to liquids to obtain a soft consistency that is similar to nectar, honey, or pudding, depending on degree of swallowing problems.
Liquids can be easily aspirated; thickened liquids form a cohesive bolus that the client can swallow with increased efficiency (Langmore, Miller, 1994; Poertner, Coleman, 1998).

12. Preferably use prepackaged thickened liquids, or use a viscosometer to ensure appropriate thickness.
Often staff members overthicken liquids, resulting in decreased palatability with decreased intake. Using prepackaged thickened liquids can increase intake, which increases hydration and nutrition (Goulding, Bakheit, 2000; Boczko, 2000).

13. Work with client on swallowing exercises prescribed by dysphagia team (e.g., touching palate with tongue, stimulating tonsillar arch and soft palate with a cold metal examination mirror [thermal stimulation], labial/lingual range of motion exercises).
Swallowing exercises can improve the client's ability to swallow (Langmore, Miller, 1994). Exercises need to be done at intervals necessitating nursing involvement (Poertner, Coleman, 1998).

14. For many adult clients, avoid using straws if recommended by speech pathologist.
Use of straws can increase the risk of aspiration because straws can result in spilling of a bolus of fluid in the oral cavity as well as decrease control of posterior transit of fluid to the pharynx (Travers, 1999).

15. Provide meals in a quiet environment away from excessive stimuli such as a community dining room.
A noisy environment can be an aversive stimulus and can decrease effective mastication and swallowing. Talking and laughing while eating increases the risk of aspiration (Galvan, 2001).

16. Ensure that there is adequate time for client to eat.
Clients with swallowing impairments often take two to four times longer than others to eat, if being fed. Often, food is offered rapidly to speed up the task, and this can increase the chance of aspiration (Poertner, Coleman, 1998).

17. Have suction equipment available during feeding. If choking occurs and suctioning is necessary, discontinue oral feeding until client is safely assessed with a videofluoroscopic swallow study and fiberoptic endoscopic evaluation of swallowing (FEES), whichever client can safely tolerate.
Suctioning may be necessary if the client is choking on food and could aspirate.

18. Check oral cavity for proper emptying after client swallows and after client finishes meal. Provide oral care at end of meal. It may be necessary to manually remove food from client's mouth. If this is the case, use gloves and keep client's teeth apart with a padded tongue blade.
Food may become pocketed in the affected side and cause stomatitis, tooth decay, and possible later aspiration.

19. Praise client for successfully following directions and swallowing appropriately.
Praise reinforces behavior and sets up a positive atmosphere in which learning takes place.

20. Keep client in an upright position for 30 to 45 minutes after a meal.
An upright position ensures that food stays in the stomach until it has emptied and decreases the chance of aspiration following meals (Galvan, 2001).

21. Watch for signs of aspiration and pneumonia. Auscultate lung sounds after feeding. Note new crackles or wheezing, and note elevated temperature. Notify physician as needed.
The presence of new crackles or wheezing, an elevated temperature or white blood cell count, and a change in sputum could indicate aspiration of food (Murray, Brzozowski, 1998) It could also indicate the presence of pneumonia (Galvan, 2001). Clients with dysphagia are at serious risk for aspiration pneumonia (Langmore, 1994).

22. Watch for signs of malnutrition and dehydration. Keep a record of food intake.
A food intake record will allow the nurse, speech and language pathologist, and dietician to determine the adequacy of nutritional intake (Beadle, Townsend, Palmer, 1995). Malnutrition is common in dysphagic clients (Galvan, 2001). Clients with dysphagia are at serious risk for malnutrition and dehydration, which can lead to aspiration pneumonia resulting from depressed immune function and weakness, lethargy, and decreased cough (Langmore, 1999).

23. Weigh client weekly to help evaluate nutritional status.

24. Evaluate nutritional status daily. If not adequately nourished, work with dysphagia team to determine whether client needs to avoid oral intake (NPO) with therapeutic feeding only or needs enteral feedings until client can swallow adequately.
Enteral feedings can maintain nutrition if client is unable to swallow adequate amounts of food (Grant, Rivera, 1995).

25. If client has a tracheotomy, ask for a diagnostic workup for adequacy of swallowing before attempting to feed, and ensure all staff members know appropriate feeding technique.
Aspiration is common in clients with tracheotomies, and care must be used in feeding (Murray, Brzozowski, 1998). See care plan for Risk for Aspiration.


1. Refer to physician children with difficult swallowing and symptoms such as difficulty manipulating food, delayed swallow response, and pocketing a bolus of food.
Research has indicated that structural deficits should be corrected by surgery (e.g. pyloric stenosis, neurological disorders that involve cranial nerve pathways, and structures resulting in swallowing changes such as brain injury and cerebral palsy [Rosenthal, Sheppard, Lotze, 1995]). Respiratory and gastrointestinal system disorders (GERD) and esophagitis can affect swallowing and nutrition. These systemic disorders are diagnosed by a physician and treated with medications.

2. When feeding an infant or child, place the infant/child in a 90 degree position with head slightly flexed. Change consistency of diet as needed, and use a curly straw for young children to facilitate a chin tuck, which helps improve swallowing ability.

3. Give oral motor stimulation that increases oral-sensory awareness by waking the mouth with exercises that focus on temperature, taste, and texture.
Many of these infants require supplemental tube feedings as well as special nipples or bottles to boost oral intake.

4. For infants with poor sucking and swallowing:
  • Support the cheeks and jaw to increase sucking skills. Pace or rhythmically move the bottle, which encourages better coordination of suck-swallow-breath synchrony.
  • Work with dietitian. Some infants may need a high-calorie formula so that food volume may be decreased (which requires infant to expend less energy) while nutritional requirements are met (Klein, Tracey, 1994). Some infants may also need to have their tongue brushed, which promotes tongue stimulation (tongue tip and tongue lateralization), lip seal, and lip pursing.
  • Watch for indicators of aspiration: coughing, a change in web vocal quality while feeding, perspiration and color changes during feeding, sneezing, and increased heart rate and breathing.
  • Watch for warning signs of reflux: sour-smelling breath after eating, sneezing, lack of interest in feeding, crying and fussing extraordinarily when feeding, pained expressions when feeding, and excessive chewing and swallowing after eating (Johnson, McGonigel, Kaufman, 1991).
Many premature and medically fragile children are surviving as a result of technological advances and sustaining growth and respiratory deficits from an underlying dysphagia diagnosis. They present with limited food intake at a time when extra calories are essential for faster growth and lung repair. Some infants may need to work harder to breathe and develop a decreased tolerance for food intake. They also demonstrate inconsistent arousal and poor/uncoordinated suck-swallow-breath synchrony. Many of these infants require supplemental tube feedings, as well as special nipples or bottles to boost oral intake.


1. Evaluate medications client is presently taking, especially if elderly. Consult with the pharmacist for assistance in monitoring for incorrect doses and drug interactions that could result in dysphagia.
Dysphagia is more prevalent in the elderly than in younger persons because of the coexistence of a variety of neurological, neuromuscular, or oncological conditions (Kosta, Mitchell, 1998). Most elderly clients take numerous medications, which when taken individually can slow motor function, cause anxiety and depression, and reduce salivary flow. When taken together, these medications can interact, resulting in impaired swallowing function. Drugs that reduce muscle tone for swallowing and can cause reflux include calcium channel blockers and nitrates. Drugs that can reduce salivary flow include antidepressants, antiparkinsonism drugs, antihistamines, antispasmodics, antipsychotic agents or major tranquilizers, antiemetics, antihypertensives, and drugs for treating diarrhea and anxiety (Sonies, 1992; Sliwa, Lis, 1993; Schechter, 1998).

Client/Family Teaching

1. Teach client and family exercises prescribed by dysphagia team.

2. Teach client a step-by-step method of swallowing effectively.

3. Educate client, family, and all caregivers about rationales for food consistency and choices.
It is common for family members to disregard necessary dietary restrictions and give client inappropriate foods that predispose to aspiration (Poertner, Coleman, 1998).

4. Teach family how to monitor client to prevent aspiration during eating.
READ MORE - Impaired Swallowing

Impaired Tissue integrity

Minggu, 28 Juli 2013

Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues

Defining Characteristics: Damaged or destroyed tissue (e.g., cornea, mucous membrane, integumentary, or subcutaneous)

Related Factors:

  • Mechanical (e.g., pressure, shear, friction); 
  • radiation (including therapeutic radiation); 
  • nutritional deficit or excess; 
  • thermal (temperature extremes); 
  • knowledge deficit;
  • irritants, chemical (including body excretions, secretions, medications); 
  • impaired physical mobility; 
  • altered circulation; 
  • fluid deficit or excess

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Tissue Integrity: Skin and Mucous Membranes
  • Wound Healing: Primary Intention
  • Wound Healing: Secondary Intention
Client Outcomes
  • Reports any altered sensation or pain at site of tissue impairment
  • Demonstrates understanding of plan to heal tissue and prevent injury
  • Describes measures to protect and heal the tissue, including wound care
  • Wound decreases in size and has increased granulation tissue

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Incision Site Care
  • Pressure Ulcer Care
  • Skin Care: Topical Treatments
  • Skin Surveillance
  • Wound Care

Nursing Interventions and Rationales

1. Assess site of impaired tissue integrity and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer).
Prior assessment of wound etiology is critical for proper identification of nursing interventions (van Rijswijk, 2001).

2. Determine size and depth of wound (e.g., full-thickness wound, stage III or stage IV pressure ulcer). Wound assessment is more reliable when performed by the same caregiver, the client is in the same position, and the same techniques are used (Krasner, Sibbald, 1999; Sussman, Bates-Jensen, 1998).

3. Classify pressure ulcers in the following manner:
  • 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 (National Pressure Ulcer Advisory Panel, 1989).
  • Stage IV: Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures (e.g., tendons, joint capsules) (National Pressure Ulcer Advisory Panel, 1989).
4. Monitor site of impaired tissue integrity at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether client is experiencing changes in sensation or pain. Pay special attention to all high-risk areas such as bony prominences, skin folds, sacrum, and heels.
Systematic inspection can identify impending problems early (Bryant, 1999).

5. Monitor status of skin around wound. Monitor client's skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing.
Individualize plan according to client's skin condition, needs, and preferences. Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Bergstrom, 1994).

6. Monitor client's continence status and minimize exposure of skin impairment site and other areas to moisture from incontinence, perspiration, or wound drainage.

7. If 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 (e.g., urologist, gastroenterologist) for an incontinence assessment (Doughty, 2000; Wound, Ostomy, and Continence Nurses Society, 1992, 1994).

8. Monitor for correct placement of tubes, catheters, and other devices. Assess skin and tissue affected by the tape that secures these devices (Faller, Beitz, 2001).
Mechanical damage to skin and tissues as a result of pressure, friction, or shear is often associated with external devices.

9. In orthopedic clients, check every 2 hours for correct placement of foot boards, restraints, traction, casts, or other devices, and assess skin and tissue integrity. Be alert for symptoms of compartment syndrome (see care plan for Risk for Peripheral neurovascular dysfunction).
Mechanical damage to skin and tissues (pressure, friction, or shear) is often associated with external devices.

10. For clients with limited mobility, use a risk assessment tool to systematically assess immobility-related risk factors.
A validated risk assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown (Bergstrom et al, 1987; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Krasner, Sibbald, 1999).

11. Implement a written treatment plan for topical treatment of the skin impairment site.
A written treatment plan ensures consistency in care and documentation (Maklebust, Sieggreen, 1996). Topical treatments must be matched to the client, wound, and setting (Krasner, Sibbald, 1999; Ovington, 1998).

12. Identify a plan for debridement if necrotic tissue (eschar or slough) is present and if consistent with overall client management goals.
Healing does not occur in the presence of necrotic tissue (Panel for the Prediction and Prevention of Pressure ulcers in Adults, 1992; Bergstrom et al, 1994; Krasner, Sibbald, 1999).

13. Select a topical treatment that maintains a moist wound-healing environment that is balanced with the need to absorb exudate and fill dead space.
Caution should always be taken to not dry out the wound (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Bergtrom et al, 1994; Ovington, 1998).

14. Do not position client on site of impaired tissue integrity. If consistent with overall client management goals, turn and position client at least every 2 hours, and carefully transfer client to avoid adverse effects of external mechanical forces (pressure, friction, and shear).
Evaluate for use of specialty mattresses, beds, or devices as appropriate (Fleck, 2001). If the goal of care is to keep the client (e.g., a terminally ill client) comfortable, turning and repositioning may not be appropriate. Maintain the head of the bed at the lowest degree of elevation possible to reduce shear and friction, and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992; Krasner, Rodeheaver, Sibbald, 2001).

15. Avoid massaging around site of impaired tissue integrity and over bony prominences.
Research suggests that massage may lead to deep-tissue trauma (Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

16. Assess client's nutritional status; refer for a nutritional consultation and/or institute dietary supplements.
Inadequate nutritional intake places the client at risk for skin breakdown and compromises healing (Demling, De Santi, 1998).

Home Care Interventions

1. Instruct and assist 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).
Wound healing can be delayed or fail totally if impediments are not controlled (Krasner, Sibbald, 1999).

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.

Client/Family Teaching

1. Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing.
Early assessment and intervention helps prevent the development of serious problems (van Rijswijk, 2001).

2. Teach use of a topical treatment that is matched to client, wound, and setting.
The topical treatment needs to be adjusted as the status of the wound changes (Krasner, Sibbald, 1999).

3. If consistent with overall client management goals, teach how to turn and reposition client at least every 2 hours.
If the goal of care is to keep the client (e.g., a terminally ill client) comfortable, turning and repositioning may not be appropriate (Krasner, Rodeheaver, Sibbald, 2001; Panel for the Prediction and Prevention of Pressure Ulcers in Adults, 1992).

4. Teach use of pillows, foam wedges, and pressure-reducing devices to prevent pressure injury.
READ MORE - Impaired Tissue integrity

Ineffective Airway clearance

Sabtu, 27 Juli 2013

Inability to clear secretions or obstructions from the respiratory tract to maintain a clear airway

Defining Characteristics:

  • 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

Related Factors:

  • 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
  • Neuromuscular dysfunction; 
  • hyperplasia of bronchial walls; 
  • chronic obstructive pulmonary disease; 
  • infection; 
  • asthma; 
  • allergic airways
NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Respiratory Status: Ventilation
  • Respiratory Status: Airway Patency
  • Respiratory Status: Gas Exchange
  • Aspiration Control
Client Outcomes
  • Demonstrates effective coughing and clear breath sounds; is free of cyanosis and dyspnea
  • Maintains a patent airway at all times
  • Relates methods to enhance secretion removal
  • Relates the significance of changes in sputum to include color, character, amount, and odor
  • Identifies and avoids specific factors that inhibit effective airway clearance
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Airway Management
  • Airway Suctioning
  • Cough Enhancement

Nursing Interventions and Rationales

1. Auscultate breath sounds q __ h(rs).
Breath sounds are normally clear or scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during late inspiration indicates fluid in the airway; wheezing indicates an airway obstruction.

2. Monitor respiratory patterns, including rate, depth, and effort.
A normal respiratory rate for an adult without dyspnea is 12 to 16. With secretions in the airway, the respiratory rate will increase.

3. Monitor blood gas values and pulse oxygen saturation levels as available.
Normal blood gas values are a PO2 of 80 to 100 mm Hg and a PCO2 of 35 to 45 mm Hg. An oxygen saturation of less than 90% indicates problems with oxygenation. Hypoxemia can result from ventilation-perfusion mismatches secondary to respiratory secretions.

4. Position client to optimize respiration (e.g., head of bed elevated 45 degrees and repositioned at least every 2 hours).
An upright position allows for maximal air exchange and lung expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe. Studies have shown that in mechanically ventilated clients receiving enteral feedings, there is a decreased incidence of nosocomial pneumonia if the client is positioned at a 45-degree semirecumbent position as opposed to a supine position (Torres, Serra-Battles, Ros, 1992; Drakulovic et al, 1999).

5. 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.
Gravity and hydrostatic pressure allow the dependent lung to become better ventilated and perfused, which increases oxygenation (Yeaw, 1992; Smith-Sims, 2001).

6. Help client to deep breathe and perform controlled coughing. Have client inhale deeply, hold breath for several seconds, and cough two to three times with mouth open while tightening the upper abdominal muscles.
This technique can help increase sputum clearance and decrease cough spasms (Celli, 1998). Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective.

7. If the client has COPD, consider helping the client use the "huff cough." The client does a series of coughs while saying the word "huff."
This technique prevents the glottis from closing during the cough and is effective in clearing secretions in the centra airways (Lewis, Heitkemper, Dirksen, 1999).

8. Encourage client to use incentive spirometer.
The incentive spirometer is an effective tool that can help prevent atelectasis and retention of bronchial secretions (Peruzzi, Smith, 1995).

9. Assist with clearing secretions from pharynx by offering tissues and gentle suction of the oral pharynx if necessary. Do not do nasotracheal suctioning.
It is preferable for the client to cough up secretions. In the debilitated client, gentle suctioning of the posterior pharynx may stimulate coughing and help remove secretions; nasotracheal suctioning is dangerous because the nurse is unable to hyperoxygenate before, during, and after to maintain adequate oxygenation (Peruzzi, Smith, 1995).

10. Observe sputum, noting color, odor, and volume.
Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious.

11. When suctioning an endotracheal tube or tracheostomy tube for a client on a ventilator, do the following:
  • Hyperoxygenate before, between, and after endotracheal suction sessions. Nursing research has demonstrated that the client should be hyperoxygenated during suctioning (Winslow, 1993a).
  • Use a closed, in-line suction system. The closed, in-line suction system is associated with a decrease in nosocomial pneumonia (Deppe et al, 1990; Johnson et al, 1994; Mathews, Mathews, 2000), reduced suction-induced hypoxemia, and fewer physiological disturbances (including decreased development of dysrhythmia) and often saves money (Carroll, 1998).
  • Avoid saline instillation during suctioning. Saline instillation before suctioning has an adverse effect on oxygen saturation (Ackerman, Mick, 1998; Winslow, 1993b; Raymond, 1995).
 12. Document results of coughing and suctioning, particularly client tolerance and secretion characteristics such as color, odor, and volume.

13. Provide oral care every 4 hours.
Oral care freshens the mouth after respiratory secretions have been expectorated. Research is promising on the use of chlorhexidine oral rinses after oral care to reduce bacteria, and possibly reduce the incidence of nosocomial pneumonia (Kollef, 1999).

14. Encourage activity and ambulation as tolerated. If unable to ambulate client, turn client from side to side at least every 2 hours.
Body movement helps mobilize secretions. The supine position and immobility have been shown to predispose postoperative clients to pneumonia (Brooks-Brunn, 1995). See interventions for Impaired gas exchange for further information on positioning a respiratory client.

15. Encourage increased fluid intake of up to 3000 ml/day within cardiac or renal reserve.
Fluids help minimize mucosal drying and maximize ciliary action to move secretions (Carroll, 1994). Some clients cannot tolerate increased fluids because of underlying disease.

16. Administer oxygen as ordered.
Oxygen has been shown to correct hypoxemia, which can be caused by retained respiratory secretions.

17. Administer medications such as bronchodilators or inhaled steroids as ordered. Watch for side effects such as tachycardia or anxiety with bronchodilators, inflamed pharynx with inhaled steroids.
Bronchodilators decrease airway resistance secondary to bronchoconstriction.

18. Provide postural drainage, percussion, and vibration as ordered.
Chest physical therapy helps mobilize bronchial secretions; it should be used only when prescribed because it can cause harm if client has underlying conditions such as cardiac disease or increased intracranial pressure (Peruzzi, Smith, 1995).

19. Refer for physical therapy or respiratory therapy for further treatment.


1. Encourage ambulation as tolerated without causing exhaustion.
Immobility is often harmful to the elderly because it decreases ventilation and increases stasis of secretions, leading to atelectasis or pneumonia (Hoyt, 1992; Tempkin, Tempkin, Goodman, 1997).

2. Actively encourage the elderly to deep breathe and cough.
Cough reflexes are blunted and coughing is decreased in the elderly (Sparrow, Weiss, 1988).

3. Ensure adequate hydration within cardiac and renal reserves.
The elderly are prone to dehydration and therefore more viscous secretions because they frequently use diuretics or laxatives and forget to drink adequate amounts of water (Hoyt, 1992).

Home Care Interventions

1. Assess home environment for factors that exacerbate airway clearance problems (e.g., presence of allergens, lack of adequate humidity in air, stressful family relationships).

2. Limit client exposure to persons with upper respiratory infections.

3. Provide/teach percussion and postural drainage per physician orders. Teach adaptive breathing techniques.
Adaptive breathing, percussion, and postural drainage loosen secretions and allow more effective oxygenation.

4. Determine client compliance with medical regimen.

5. Teach client when and how to use inhalant or nebulizer treatments at home.

6. Teach client/family importance of maintaining regimen and having prn drugs easily accessible at all times.
Success in avoiding emergency or institutional care may rest solely on medication compliance or availability.

7. Identify an emergency plan, including criteria for use.
Ineffective airway clearance can be life threatening.

8. Refer for home health aide services for assist with ADLs.
Clients with decreased oxygenation and copious respiratory secretions are often unable to maintain energy for ADLs.

9. Assess family for role changes and coping skills. Refer to medical social services as necessary.
Clients with decreased oxygenation are unable to maintain role activities and therefore experience frustration and anger, which may pose a threat to family integrity.

10. Provide family with support for care of a client with a chronic or terminal illness.
Severe compromise to respiratory function creates fear in clients and caregivers. Fear inhibits effective coping.

Client/Family Teaching

1. Teach importance of not smoking. Be aggressive in approach, ask to set a date for smoking cessation, and recommend nicotine replacement therapy (nicotine patch or gum). Refer to smoking cessation programs, and encourage clients who relapse to keep trying to quit.
All health care clinicians should be aggressive in helping smokers quit (AHCPR Guidelines, 1996).

2. Teach client how to use a flutter clearance device if ordered, which vibrates to loosen mucus and gives positive pressure to keep airways open.
This device has been shown to effectively decrease mucous viscosity and elasticity (App et al, 1998), increase amount of sputum expectorated (Langenderfer, 1998; Bellone et al, 2000), and increase peak expiratory flow rate (Burioka et al, 1998).

3. Teach 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-administer inhaled corticosteroids following precautions to decrease side effects (Owen, 1999).

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 diferent lung volumes to control expiratory flow of air to avoid airway compression.
Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective. The ELTGOL method was shown to be more effective in secretion removal in chronic bronchitis than postural drainage (Bellone et al, 2000).

5. Teach client/family to identify and avoid specific factors that exacerbate ineffective airway clearance, including known allergens and especially smoking (if relevant) or exposure to second-hand smoke.

6. Educate client and family about the significance of changes in sputum characteristics, including color, character, amount, and odor.
With this knowledge the client and family can identify early the signs of infection and seek treatment before acute illness occurs.

7. Teach client/family need to take antibiotics until prescription has run out.
Taking the entire course of antibiotics helps to eradicate bacterial infection, which decreases lingering, chronic infection.
READ MORE - Ineffective Airway clearance

Ineffective Breastfeeding

Dissatisfaction or difficulty a mother, infant, or child experiences with the breastfeeding process

Defining Characteristics:

  • Unsatisfactory breastfeeding 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 infant 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

Related Factors:
  • Nonsupportive partner/family; 
  • previous breast surgery; 
  • infant receiving supplemental feedings with artificial nipple; 
  • prematurity; 
  • previous history of breastfeeding failure; 
  • poor infant sucking reflex; 
  • maternal breast anomaly; 
  • maternal anxiety or ambivalence; 
  • interruption in breastfeeding; 
  • infant anomaly; 
  • knowledge deficit

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Breastfeeding Establishment: Infant
  • Breastfeeding Establishment: Maternal
  • Breastfeeding Maintenance
  • Breastfeeding Weaning
  • Knowledge: Breastfeeding
Client Outcomes
  • Achieves effective breastfeeding
  • Verbalizes/demonstrates techniques to manage breastfeeding problems
  • Infant manifests signs of adequate intake at the breast
  • Mother manifests positive self-esteem in relation to the infant feeding process
  • Mother explains a safe alternative method of infant feeding if unable to continue exclusive breastfeeding
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Breastfeeding Assistance

Nursing Interventions and Rationales

Refer to care plan for Effective Breastfeeding

1. Assess for presence/absence of related factors or conditions that would preclude breastfeeding.
Some conditions (e.g. certain maternal drugs, maternal HIV-positive status, infant galactosemia) may preclude breastfeeding, in which case the infant needs to be started on a safe alternative method of feeding (Riordan, Auerbach, 2000; Lawrence, 2000).

2. Assess breast and nipple structure.
Normal nipple and breast structure or early detection and treatment of abnormalities with continuing support are important for successful breastfeeding (Vogel, Hutchison, Mitchell, 1999).

3. Evaluate and record the mother's ability to position, give cues, and help the infant latch on.
Correct positioning and getting the infant to latch on is critical for getting breastfeeding off to a good start and contributes to breastfeeding success (Duffy, Percival, Kershaw, 1997; Brandt, Andrews, Kvale, 1998).

4. Evaluate and record the infant's ability to properly grasp and compress the areola with lips, tongue, and jaw.
The infant must have a "competent suck" in order to achieve successful breastfeeding. The jaws must compress the milk sinuses beneath the areola. To do this the jaws must be well back on the areola with the tongue over the lower gum, forming a trough around the breast, and the lips must be flanged and sealed around the breast (Palmer, VandenBerg, 1998; Lau, Hurst, 1999; Hill, Kurkowski, Garcia, 2000).

5. Evaluate and record the infant's suckling and swallowing pattern at the breast.
When the infant sucks adequately, there is muscular movement visible above the ears. When breast milk is actively flowing, infants suck at a rate of once per second, and swallowing increases as milk supply increases (Palmer, VandenBerg, 1998; Lau, Hurst, 1999; Hill, Kurkowski, Garcia, 2000).

6. Evaluate and record signs of oxytocin release.
The let-down reflex (tingling sensation in the breasts, milk dripping from the breasts, and uterine cramping) is indication of oxytocin release and is necessary for transfer of milk to the infant (Uvnas-Moberg, Eriksson., 1996; Nissen et al, 1998; Neville, 1999).

7. Evaluate and record infant's state at the time of feeding.
Infants breastfeed best when in the quiet-alert state. Difficulties arise when trying to breastfeed a sleepy infant or a ravenously hungry and crying infant (Brandt, Andrews, Kvale, 1998).

8. Assess knowledge regarding psychophysiology of lactation and specific treatment measures for underlying problems.
Support and teaching must be individualized to the client's level of understanding. The mother must acquire knowledge and become cognitively and emotionally ready (Cox, Turnbull, 1998).

9. Assess psychosocial factors that may contribute to ineffective breastfeeding (e.g., anxiety, goals and values/lifestyle that contribute to ambivalence about breastfeeding).
The attitude of the mother toward breastfeeding is critical in achieving successful lactation, influencing milk production, and facilitating the art of breastfeeding (Brandt, Andrews, Kvale, 1998).

10. Assess support person network.
Social support is an important factor in successful breastfeeding (Trado, Hughes, 1996; Arlotti et al, 1998).

11. Promote comfort and relaxation to reduce pain and anxiety.
Discomfort associated with breastfeeding can cause some women to discontinue breastfeeding prematurely. Promoting comfort and relaxation can lead to more successful breastfeeding (Lavergne, 1997).

12. Provide support by actively helping the mother to correctly position the baby to attain a good latch on the nipple and encouraging her to continue trying.
Many problems that can lead to discontinuing breastfeeding can be prevented by giving a high level of practical and emotional support to the mother (Janken et al, 1999).

13. Bring infant to a quiet-alert state through alerting techniques (e.g., provide variety in auditory, visual, and kinesthetic stimuli by unwrapping the infant, placing the infant upright, or talking to the infant) or consoling techniques as needed.
A variety of stimuli can bring the infant to a quiet-alert state. Repetition can soothe a crying baby, thus making it easier to initiate breastfeeding (Brandt, Andrews, Kvale, 1998).

14. Enhance the flow of milk. Teach the mother to massage breast or burp infant and switch to other breast when infant's swallowing slows down.
The perception of inadequate milk supply can lead to early weaning. Infants should breastfeed from both breasts at each feeding. Breast massage can enhance the flow of milk and stimulate production (Riordan, Auerbach, 2000).

15. Evaluate adequacy of infant intake.
Infant intake can be measured by objective criteria such as number and quality of feedings, infant elimination and weight gain appropriate for age, as well as test-weights when necessary (Meier et al, 2000)

16. Discourage supplemental bottle feedings and encourage exclusive, effective breastfeeding.
Supplemental feedings can interfere with the infant's desire to breastfeed, increase the risk of allergies, and convey the subtle message that the mother's breast milk is not adequate (American Academy of Pediatrics, 1997; Chezem, Friesenl, 1998).

17. Acknowledge mother's feelings and support her decision to continue or choose an alternate plan.
Mastering infant feeding is an important first step in mothering, and the mother needs to be empowered so that she feels competent and capable of making intelligent decisions (Brandt, Andrews, Kvale, 1998; Mozingo et al, 2000).

18. Make appropriate referrals and ensure close follow-up.
Collaborative practice with neonatal nutritionists, physical or occupational therapist, home visiting nurses, or lactation specialists will help ensure feeding and parenting success (American Academy of Pediatrics, 1997; Pugh, Milligan, 1998; Locklin, Jansson, 1999).

19. If unsuccessful in achieving effective breastfeeding, help client accept and learn an alternate method of infant feeding.
Once the decision has been made to provide an alternate method of infant feeding, the mother needs support and education (Brandt, Andrews, Kvale, 1998; Mozingo et al, 2000).


1. Assess for the influence of cultural beliefs, norms, and values on breastfeeding attitudes.
The client's knowledge of breastfeeding may be based on cultural perceptions, as well as influences from the larger social context (Leininger, 1996).

2. Assess whether the client's concerns about the amount of milk taken during breastfeeding is contributing to dissatisfaction with the breastfeeding process.
Some cultures may add semisolid food within the first month of life as a result of concerns that the infant is not getting enough to eat and the perception that "big is healthy" (Higgins, 2000; Bentley et al, 1999).

3. Assess the influence of family support on the decision to continue or discontinue breastfeeding.
Women are the keepers and transmitters of culture in families. Female family members can play a dominant role in how infants are fed (Pillitteri, 1999).

4. Validate the client's feelings regarding the difficulty or dissatisfaction with breastfeeding.
Validation lets the client know that the nurse has heard and understands what was said and promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1991).

Client/Family Teaching

1. Provide instruction in correct positioning.
"Correct positioning is perhaps the most critical single measure for getting breastfeeding off to a good start. Many problems can be attributed to carelessness or inattention to this simple aspect of breastfeeding" (Righard, 1998).

2. Reinforce and add to knowledge base regarding underlying problems and specific treatment measures.
If mother understands rationale for recommended treatment, she may be more likely to comply with recommendations and less likely to perceive the problem as insurmountable (Cox, Turnbull, 1998; Susin et al, 1999).

3. Provide education to support persons as needed.
Informational support providers help the mother achieve a more positive outcome (Trado, Hughes, 1996; Tarkka, Paunonen, Laippala, 1999; Zimmerman 1999).
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Latex Allergy response

Jumat, 26 Juli 2013

An allergic response to natural latex rubber products

Defining Characteristics:

Type I reactions:
  • Immediate reactions (<1hour) to latex proteins (can be life threatening); 
  • contact urticaria progressing to generalized symptoms; 
  • edema of the lips, tongue, uvula, and/or throat; 
  • shortness of breath; 
  • tightness in chest; 
  • wheezing; 
  • bronchospasm leading to respiratory arrest; 
  • hypotension; 
  • syncope; 
  • cardiac arrest
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 twitching; 
  • gastrointestinal characteristics: abdominal pain, nausea; 
  • generalized characteristics: flushing, general discomfort, generalized edema, increasing complaint of total body warmth, restlessness
Type IV reactions:
  • delayed onset: eczema; 
  • irritation; 
  • reaction to additives causes discomfort (e.g., thiram, carbamates); 
  • redness; 
  • delayed onset (hours)
Irritant reactions:
  • erythema; 
  • chapped or cracked skin; 
  • blisters

Related Factors: No immune mechanism response

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Immune Hypersensitivity Control
  • Symptom Severity
  • Tissue Integrity: Skin and Mucous Membranes
Client Outcomes
  • Identifies presence of latex allergy
  • Lists history of risk factors
  • Identifies type of reaction
  • States reasons not to use or to have anyone use latex products
  • Experiences a latex-free environment for all health care procedures
  • Avoids areas where there is powder from latex gloves
  • States the importance of wearing a Medic-Alert bracelet and wears one
NIC Interventions (Nursing Interventions Classification)
Suggested NIC Labels
  • Allergy Management
  • Latex Precautions
Nursing Interventions and Rationales
1. Take a careful history of clients at risk: health care workers, rubber industry workers, clients with neural tube defects, and atopic individuals (hayfever, asthma, atopic eczema).
Individuals at highest risk of development of IgE-mediated latex allergy are either atopic, highly exposed to latex, or both (Kelly, Walsh-Kelly, 1998). Early recognition of sensitization to natural latex rubber is crucial to prevent the occurrence of life-threatening reactions in sensitized health care providers and their clients (Tarlo, 1998). Allergic reactions to natural rubber latex have increased during the past 10 years, especially in the many health care workers who have high exposure to latex allergens both by direct skin contact and by inhalation of latex particles from powdered gloves (Nielsen et al, 2000)
2. If IgE-mediated latex allergy is suspected, question the client about food allergies to chestnuts, avocados, bananas, kiwis, and other tropical fruits.
Clients with IgE-mediated allergy may have cross-reactivity with food allergens such as bananas, kiwis, and other tropical fruits (Kelly, Walsh-Kelly, 1998). Class I chitinases have been identified as the major panallergens in fruits associated with the latex-fruit syndrome, such as avocado, banana, and chestnut (Sanchez-Monge et al, 2000).
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.
A client's history can suggest the likelihood of his or her developing a reaction to latex; the itching and swelling mentioned are reliable indicators of significant sensitivity to latex (Dakin, Yentis, 1998).

4. Materials and items that contain latex must be identified, and latex-free alternatives must be found. A wide variety of products contain latex: medical supplies, personal protective equipment, and numerous household objects (Evangelisto, 1998).

5. All latex-sensitive clients (e.g., those who experience reddened, irritated areas under Band-Aid adhesive) are treated as if they have a latex allergy.
According to the Centers for Disease Control (CDC) guidelines, all latex-sensitive clients are treated as if they have a latex allergy (Harrau, 1998).

6. See Box III-1 for examples of products that may contain latex.

7. Five principles for management of latex-allergic clients:
(1) recognize the problem,
(2) avoid exposure to latex,
(3) inform the surgeons and operating room nurses,
(4) be prepared to treat anaphylaxis,
(5) be vigilant postoperatively and arrange follow-up care.
Reactions may be prevented by providing a latex-free environment (Kantor, Smith, Kalhan, 1999). Medical personnel must stay abreast of new data and product information to provide up-to-date care for patients, as well as protection for themselves (Floyd, 2000). Latex aeroallergen is primarily generated by active glove use; carpeting and fabric upholstery can serve as important aeroallergen repositories. Site-wide substitution of nonpowdered latex gloves eliminates detectable latex aeroallergen (Charous, Schuenemann, Swanson, 2000).

8. Anaphylaxis from latex allergy is a medical emergency and must be treated differently than anaphylaxis from other causes.
Clients with latex induced anaphylaxis must be placed in a latex-safe environment (Kelly, Walsh-Kelly, 1998).

9. Do not open or use powdered latex gloves in the client's room. At times it is necessary to convert the whole building to a latex-free environment to prevent inhalation of symptoms of IgE-mediated allergy.
Most inhalation allergen exposure derives from protein bound to the cornstarch donning powder on medical gloves. Transfer of this allergen to other products or even the air duct of buildings where gloves are used may result in exposure and clinical symptoms of rhinoconjunctivitis, throat irritation, airway edema, and asthma (Kelly, Walsh-Kelly, 1998). Gloves are the single most important piece of equipment responsible for triggering a reaction to latex. Starch or modified starch gloves are the worst culprits (Dakin, Yentis, 1998).

Home Care Interventions

1. Assess the home environment for presence of natural latex products (e.g., balloons, condoms, gloves, and products of related allergies, such as bananas, avocados, and poinsettia plants).
Identification and/or removal of allergy stimulants decreases allergic response risk.

2. At onset of care, assess client history and current status of latex allergy response. Seek medical care as necessary.
Immediate identification of allergic response promotes prompt treatment and decreases risk of severe response.

3. Do not use latex products in care giving.

4. Assist client in identifying and obtaining alternatives to latex products.
Preventing exposure to latex is the key to managing and preventing this allergy. Providing a safe environment for patients with latex allergy is the responsibility of all health care professionals (Baumann, 1999).

Client/Family Teaching

1. Provide written information about latex allergy and sensitivity.
Education of the public is necessary and has been provided by the development of a latex allergy pamphlet, which contains an explanation of symptoms and risk factors for latex allergy (Harrau, 1998).

2. Instruct clients to inform health care professionals if they have a latex allergy, particularly if they are scheduled for surgery.
To prevent problems associated with exposure to products containing latex, it is essential that clients with latex allergy are identified (Dakin, Yentis, 1998).

3. Teach clients what products contain natural rubber latex and to avoid direct contact with all latex products and foods that trigger allergic reactions.
Once latex allergy has developed, the client is at risk for anaphylaxis and needs to be informed as to what products contain latex (Tarlo, 1998). This allergy is potentially preventable for both the patient and nurse (Gritter, 1999).

4. Teach client to avoid areas where powdered latex gloves are used, as well as where latex balloons are inflated or deflated.
Exposure can lead to an anaphylactic reaction (Tarlo, 1998).

5. Instruct clients with latex allergy to wear a Medic-Alert bracelet that identifies them as such.
Identification of clients with latex allergy is critical for preventing problems and for early intervention with appropriate treatment if an exposure occurs (Kelly, Walsh-Kelly, 1998).

6. Instruct client to carry an autoinjectable epinephrine syringe if at risk for anaphylactic episode.
An autoinjectable epinephrine syringe should be prescribed to sensitized clientswho are at risk for an anaphylactic episode with accidental latex exposure (Tarlo, 1998).
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Ineffective Coping

Kamis, 25 Juli 2013

Inability to form a valid appraisal of stressors, inadequate choices of practiced responses, and/or inability to use available resources

Defining Characteristics:

  • Lack of goal-directed behavior/resolution of problem, including inability to attend, difficulty with organized information, sleep disturbance, abuse of chemical agents; 
  • decreased 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

Related Factors:
  • 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;
  • inadequate resources available; 
  • 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

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels
  • Coping
  • Decision Making
  • Impulse Control
  • Information Processing
Client Outcomes
  • Verbalizes ability to cope and asks for help when needed
  • Demonstrates ability to solve problems and participates at usual level in society
  • Remains free of destructive behavior toward self or others
  • Communicates needs and negotiates with others to meet needs
  • Discusses how recent life stressors have overwhelmed normal coping strategies
  • Has illness and accident rates not excessive for age and developmental level
NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels
  • Decision-Making Support

Nursing Interventions and Rationales

1. Observe for causes of ineffective coping such as poor self-concept, grief, lack of problem-solving skills, lack of support, or recent change in life situation.
Situational factors must be identified to gain an understanding of the client's current situation and to aid client with coping effectively (Norris, 1992).

2. Observe for strengths such as the ability to relate the facts and to recognize the source of stressors.
Family members who are coping with critical injuries often feel defeated, hopeless, and like a failure; therefore it is imperative to verbally commend them for their strengths and use those strengths to aid functioning (Leske, 1998).

3. Monitor risk of harming self or others and intervene appropriately. See care plan for Risk for Suicide.
Situational factors can lead to depression or risk for suicide. Identification of such factors leads to appropriate referral or help (Norris, 1992). A client with hopelessness and an inability to problem solve often runs the risk of suicide (Buchanan, 1991). In these cases immediate referral for mental health care is essential (Norris, 1992).

4. Help client set realistic goals and identify personal skills and knowledge.
Involving clients in decision making helps them move toward independence (Connelly et al, 1993).

5. Use empathetic communication, and encourage client/family to verbalize fears, express emotions, and set goals.
Acknowledging and empathizing creates a supportive environment that enhances coping (Feeley, Gottlieb, 1998). Clients report increased satisfaction and empowerment, greater compliance with mutually agreed-upon goals, and less anxiety and depression when communication is empathic (Wells-Federman et al, 1995). Acknowledgment of feelings communicates support and conveys that clients are understood (Leske, 1998).

6. Encourage client to make choices and participate in planning of care and scheduled activities.
Participation gives a feeling of control and increases self-esteem.

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).
Interventions that enhance body awareness such as exercise, proper nutrition, and muscular relaxation may be effective for treating anxiety and depression (Wells- Federman et al, 1995).

8. If the client is physically able, encourage moderate aerobic exercise.
Aerobic exercise increases one’s ability to cope with acute stress (Anshel, 1996).

9. Use touch with permission. Give client a back massage using slow, rhythmic stroking with hands. Use a rate of 60 strokes a minute for 3 minutes on 2-inch wide areas on both sides of the spinous process from the crown to the sacral area.
A gentle touch can display acceptance and empathy (Hopkins, 1994). Slow stroke back massage decreased heart rate, decreased systolic and diastolic blood pressure, and increased skin temperature at significant levels. The conclusion is that relaxation is induced by slow stroke back massage (Meek, 1993).

10. Provide information regarding care before care is given.
In traumatic situations, families have a need for information and explanations (Hopkins, 1994). Providing information prepares the family for understanding the situation and possible outcomes (Leske, 1998). Adequate information and training before and after treatment reduces anxiety and fear (Herranz, Gavilan, 1999).

11. Discuss changes with client before making them.
Communication with the medical staff provides patients and families with understanding of the medical condition (Grootenhuis, Last, 1997).

12. Discuss client’s/family’s power to change a situation or the need to accept a situation.
Such a discussion helps the client maintain self-esteem and look at the situation realistically with the aid of a trusted individual (Norris, 1992). In threatening situations, people search for reasons for the event(s). This search is an effort to make sense of the event, gain control, and cope (Grootenhuis, Last, 1997).

13. Use active listening and acceptance to help client express emotions such as crying, guilt, and anger (within appropriate limits).
Active listening provides the client and/or family a nonjudgmental person to listen to them and relieve their guilt feelings (Hopkins, 1994). Acknowledgment of feelings communicates support and conveys that they are understood (Leske, 1998).

14. Avoid false reassurance; give honest answers and provide only the information requested.
Identification of previously used effective coping mechanisms allow the nurse to focus attention on necessary education and referral (Norris, 1992).

15. Encourage client to describe previous stressors and the coping mechanisms used.
Describing previous experiences strengthens effective coping and helps eliminate ineffective coping mechanisms.

16. Be supportive of coping behaviors; allow client time to relax.
A supportive presence creates a supportive environment to enhance coping (Feeley, Gottlieb, 1998).

17. Help clients to define what meaning their symptoms might have for them.
In one study, the importance of helping clients find meaning in their suffering experiences was identified as a strategy perceived as helpful with a group of patients who had the diagnosis of multiple sclerosis (Pollock, Sands, 1997).

18. Encourage use of cognitive behavioral relaxation (e.g., music therapy, guided imagery).
Relaxation techniques, desensitization, and guided imagery can help clients cope, increase their sense of control, and allay anxiety (Narsavage, 1997). Relaxation with guided imagery is a technique used with increasing frequency to help individuals improve their performance and control their responses to stressful situations (Rees, 1993). Music is not a cure, but it can lift the human spirit, comfort the heart, and inspire the soul. Imagery is useful for relaxation and distraction (Fontaine, 1994). The provision of information and general mastery may play a role in decreasing helplessness and dysfunctional coping (Nicassio et al, 1997).

19. Use distraction techniques during procedures that cause client to be fearful.
Distraction is used to direct attention toward a pleasurable experience and block the attention of the feared procedure (DuHamel, Redd, Johnson-Vickberg, 1999).

20. Use systematic desensitization when introducing new people, places, or procedures that may cause fear and altered coping.
Fear of new things diminishes with repeated exposure (DuHamel, Redd, Johnson- Vickberg, 1999).

21. Provide the client/family with a video of any feared procedure to view before the procedure. Ensure that the video shows a patient of similar age and background.
Videos provide the client/family with the information necessary to eliminate fear of the unknown (DuHamel, Redd, Johnson-Vickberg, 1999).

22. Refer for counseling as needed.
Arranging for referral assists the client in working with the system, and resource use helps to develop problem-solving and coping skills (Feeley, Gottlieb, 1998).


1. Engage client in reminiscence.
Reminiscence can activate past sources of self-esteem and aid in coping (Nugent, 1995).

2. Be aware of client's fear of illness. Identify and reinforce patterns the elderly client has previously used to respond to stress. Allow client time to reminisce about past successes. The elderly client has had a lifetime of experience dealing with stressful events.
A standard reminiscence interview and one that focused on successfully met challenges reduced state anxiety and enhanced coping self-efficacy when measured against both attention-placebo and no-intervention control groups (Rybarczyk, Auerbach, 1990).

3. Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, medications with known cognitive and psychotropic side effects).
Such alterations may be contributing to confusion and must be corrected (Matthiesen et al, 1994). Medications are considered the most common cause of delirium in the ICU (Harvey, 1996).

4. Determine if the individual is displaying a change in personality as a manifestation of difficulty with coping. An older individual's responses to age-related stress will depend on the balance of personality strengths and weaknesses.
Severe or multiple stresses in late life may overwhelm an individual's coping skills and lead to personality change (Agronin, 1998).

5. Increase and mobilize support available to the elderly client. Encourage interaction with family and friends.
Friends and relatives have shared many of the older person's life experiences. Such mutual interests and overlapping memories can serve to stimulate and focus conversation and contribute effectively to the client's self-esteem (Erber, 1994). Support from family, friends, and the medical community aids coping ability (Grootenhuis, Last, 1997).

6. Maintain continuity of care by keeping the number of caregivers to a minimum.
Consistency in caregivers helps decrease anxiety and fosters trust by providing the client and family with familiar faces (Hopkins, 1994).


1. Assess for the influence of cultural beliefs, norms, and values on the client’s perceptions of effective coping.
The client’s coping behavior may be based on cultural perceptions of normal and abnormal coping behavior (Leininger, 1996).

2. Assess for intergenerational family problems that can overwhelm coping abilities.
Intergenerational family problems put families at risk of dysfunction (Seiderman et al, 1996).

3. Encourage spirituality as a source of support for coping.
Many African-Americans and Latinos identify spirituality, religiousness, prayer, and church-based approaches as coping resources (Samuel-Hodge et al, 2000; Bourjolly, 1998; Mapp, Hudson, 1997).

4. Negotiate with the client with regard to the aspects of coping behavior that will need to be modified.
Give and take with the client will lead to culturally congruent care (Leininger, 1996).

5. Identify which family members the client can rely on for support.
Many Latinos, Native Americans, and African-Americans rely on family members to cope with stress (Abraido-Lanza, Guier, Revenson, 1996; Seiderman et al, 1996).

6. Assess the influence of fatalism on the client’s coping behavior.
Fatalistic perspectives involve the belief in some African-American and Latino populations that you cannot control your own fate and influence health behaviors (Phillips, Cohen, Moses, 1999; Harmon, Castro, Coe, 1996).

Home Care Interventions

1. Observe family for coping behavior patterns. Obtain family and client history as able.
Obtaining a family assessment provides a wealth of information regarding current family functions and can guide interventions (Leske, 1998).

2. Assess for suicidal tendencies. Refer for mental health care immediately if indicated. Identify an emergency plan should the client become suicidal.
A suicidal client is not safe in the home environment unless supported by professional help.

3. 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.

4. If the client is involved with the mental health system, actively participate in mental health team planning.
Based on knowledge of the home and family, home care nurses can often advocate for clients. These nurses are often requested to monitor medications and therefore need to know the plan of care.

5. Refer patient/family to support groups.
Support groups foster the sharing of common experiences and help to build mutual support. They are particularly helpful when others within the family are unable to provide support because of their own grieving or coping needs (Leske, 1998).

6. If monitoring medications, contract with client or solicit assistance from a responsible caregiver. Pre-pouring of medications may be helpful with some clients.
Successful contracting provides the client with control of care and promotes self- esteem while establishing responsibility for desired actions.

NOTE: All of the previously mentioned interventions may be applied in the home setting. Home care may offer psychiatric nursing or the services of a licensed clinical social worker under special programs. Traditionally, insurance does not reimburse for counseling that is not related to a medical plan of care unless it falls under one of the programs just described. Public health agencies generally do not have the clinical support needed to offer psychiatric nursing services to clients. Clients are usually treated in the ambulatory mental health system.

Client/Family Teaching

1. Teach clients to problem solve. Have them define the problem and cause and list the advantages and disadvantages of their options.

2. Provide seriously ill clients and their families with needed information regarding their condition and treatment.
Information is an important need of families of critically ill patients (Henneman, Cardin, 1992). In one study, information structured to meet individual needs reduced anxiety and increased satisfaction with the information provided (McGaughey, Harrisson, 1994).

3. Teach relaxation techniques.
Problem-solving skills promote the client's sense of control. Relaxation decreases stress and enhances coping (Fontaine, 1994).

4. Suggest listening to music.
Listening to music has been found to decrease total mood disturbances scores (profile of mood states [POMS] scores). A decrease in POMS scores is indicative of decreased distress and a mood improvement (McNair, Lorr, Droppleman, 1992).

5. Teach process imagery (purposely evoking a mental image of a desired effect).
Using process imagery, a person can look at an old problem in a totally different way, making new connections and freeing the problem from the original memory. Imagery engenders a feeling of control and gives the client an effective tool for self-care (Stephens, 1993).

6. Work closely with the client to develop appropriate educational tools that address individualized coping strategies.
Collaboration between client and staff in the production of client information can improve client understanding and empower the client and family to take an active part in treatment (Willock, Grogan, 1998).

7. Teach client about available community resources (e.g., therapists, ministers, counselors, self-help groups).
Resource use helps to develop problem-solving and coping skills (Feeley, Gottlieb, 1998). Client and family teaching that promotes the ability to understand and carry out any necessary medical, rehabilitative, or daily living activities contributes to a sense of mastery, competency, and control and is vital to discharge planning and community- based assessments (Norris, 1992). Praying and religion are frequently used effective coping strategies (Grootenhuis, Last, 1998).
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