Functional Urinary Incontinence

Inability of usually continent person to reach toilet in time to avoid unintentional loss of urine

Defining Characteristics: The relationship between functional limitations and urinary incontinence remains controversial (Hunskaar et al, 1999). While functional impairment clearly exacerbates the severity of urinary incontinence, the underlying factors that contribute to these functional limitations themselves contribute to abnormal lower urinary tract function and impaired continence.

Related Factors:

• Cognitive disorders (delirium, dementias, severe or profound retardation); 
• neuromuscular limitations impairing mobility or dexterity; 
• impaired vision; 
• psychological factors; 
• weakened supporting pelvic structures; 
• environmental barriers to toileting.

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Urinary Continence
• Urinary Elimination

Client Outcomes

• Eliminates or reduces incontinent episodes
• Eliminates or overcomes environmental barriers to toileting
• Uses adaptive equipment to reduce or eliminate incontinence related to impaired mobility or dexterity
• Uses portable urinary collection devices or urine containment devices when access to the toilet is not feasible

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Urinary Incontinence Care

Nursing Interventions and Rationales

1. Perform a focused history of the incontinence including duration, frequency and severity of leakage episodes, and alleviating and aggravating factors.
The history provides clues to the causes, the severity of the condition, and its management.

2. Complete a bladder log of diurnal and nocturnal urine elimination patterns and patterns of urinary leakage.
The bladder log provides a more objective verification of urine elimination patterns as compared with the history (Resnick et al, 1994) and a baseline against which the results of management can be evaluated.

3. Assess client for potentially reversible causes of acute/transient urinary incontinence (e.g., urinary tract infection [UTI], atrophic urethritis, constipation or impaction, sedatives or narcotics interfering with the ability to reach the toilet in a timely fashion, antidepressants or psychotropic medications interfering with efficient detrusor contractions, parasympatholytics, alpha adrenergic antagonists, polyuria caused by uncontrolled diabetes mellitus, or insipidus).
Transient or acute incontinence can be eliminated by reversing the underlying cause (Urinary Incontinence Guideline Panel, 1996).

4. Assess client for established/chronic incontinence: stress urinary incontinence, urge urinary incontinence, reflex, or extraurethral ("total") urinary incontinence. If present, begin treatment for these forms of urine loss.
Functional incontinence often coexists with another form of urinary leakage, particularly among the elderly (Gray, 1992).

5. Assess the home, acute care, or long-term care environment for accessibility to toileting facilities, paying particular attention to the following:

• Distance of toilet from bed, chair, living quarters
• Characteristics of the bed, including presence of side rails and distance of bed from the floor
• Characteristics of the pathway to the toilet, including barriers such as stairs, loose rugs on the floor, and inadequate lighting
• Characteristics of the bathroom, including patterns of use; lighting; height of toilet from floor; presence of hand rails to assist transfers to toilet; and breadth of door and its accessibility for wheelchair, walker, or other assistive device

Functional continence requires access to the toilet; environmental barriers blocking this access can produce functional incontinence (Wells, 1992).

6. Assess client for mobility, including ability to rise from chair and bed; ability to transfer to toilet and ambulate; and need for physical assistive devices such as a cane, walker, or wheel chair.
Functional continence requires the ability to gain access to a toilet facility, either independently or with the assistance of devices to increase mobility (Jirovec, Wells, 1990; Wells, 1992).

7. Assess client for dexterity, including the ability to manipulate buttons, hooks, snaps, Velcro, and zippers needed to remove clothing. Consult physical or occupational therapist to promote optimal toilet access as indicated.
Functional continence requires the ability to remove clothing to urinate (Maloney, Cafiero, 1999; Wells, 1992).

8. Evaluate cognitive status with a NEECHAM confusion scale (Neelan et al, 1992) for acute cognitive changes, a Folstein Mini-Mental Status Examination (Folstein, Folstein, McHugh, 1975), or other tool as indicated.
Functional continence requires sufficient mental acuity to respond to sensory input from a filling urinary bladder by locating the toilet, moving to it, and emptying the bladder (Maloney, Cafiero, 1999; Colling et al, 1992).

9. Remove environmental barriers to toileting in the acute care, long-term care or home setting. Help the client remove loose rugs from the floor and improve lighting in hallways and bathrooms.

10. Provide an appropriate, safe urinary receptacle such as a 3-in-1 commode, female or male hand-held urinal, no-spill urinal, or containment device when toileting access is limited by immobility or environmental barriers.
These receptacles provide access to a substitute toilet and enhance the potential for functional continence (Rabin, 1998; Wells, 1992).

11. Assist the client with limited mobility to obtain evaluation for a physical therapist and to obtain assistive devices as indicated (Maloney, Cafiero, 1999); assist the client to select shoes with a nonskid sole to maximize traction when arising from a chair and transferring to the toilet.

12. Assist the person to alter their wardrobe to maximize toileting access. Select loose-fitting clothing with stretch waist bands rather than buttoned or zippered waist; minimize buttons, snaps, and multilayered clothing; and substitute Velcro or other easily loosened systems for buttons, hooks, and zippers in existing clothing.

13. Begin a prompted voiding program or patterned urge response toileting program for the elderly client with functional incontinence and dementia in the home or long-term care facility:

• Determine the frequency of current urination using an alarm system or check and change device
• Record urinary elimination and incontinent patterns on a bladder log to use as a baseline for assessment and evaluation of treatment efficacy
• Begin a prompted toileting program based on the results of this program; toileting frequency may vary from every 1.5 to 2 hours, to every 4 hours
• Praise the client when toileting occurs with prompting
• Refrain from any socialization when incontinent episodes occur; change the client and make her or him comfortable 

Prompted voiding or patterned urge response toileting have been shown to markedly reduce or eliminate functional incontinence in selected clients in the long-term care facility and in the community setting (Colling et al, 1992; Eustice, Roe, Patterson, 2000).
Geriatric

1. Institute aggressive continence management programs for the community-dwelling client in consultation with the patient and family.
Uncontrolled incontinence can lead to institutionalization in an elderly person who prefers to remain in a home care setting (O'Donnell et al, 1992).

2. Monitor elderly clients for dehydration in the long-term care facility, acute care facility, or home. Dehydration can exacerbate urine loss, produce acute confusion, and increase the risk of morbidity and morality, particularly in the frail elderly client (Colling, Owen, McCreedy, 1994).

Home Care Interventions

1. Assess current strategies used to reduce urinary incontinence, including fluid intake, restriction of bladder irritants, prompted or scheduled toileting, and use of containment devices.
Many elders and care providers use a variety of self-management techniques to manage urinary incontinence such as fluid limitation, avoidance of social contacts, and absorptive materials that may or may not be effective for reducing urinary leakage or beneficial to general health (Johnson et al, 2000).

2. Teach the family general principles of bladder health, including avoidance of bladder irritants, adequate fluid intake, and a routine schedule of toileting (refer to care plan for Impaired Urinary elimination).

3. Teach prompted voiding to the family and patient with mild to moderate dementia (refer to previous description) (Colling, 1996; McDowell et al, 1994).

4. Advise the patient about the advantages of using disposable or reusable insert pads, pad-pant systems, or replacement briefs specifically designed for urinary incontinence (or double urinary and fecal incontinence) as indicated. Many absorptive products used by community-dwelling elders are not designed to absorb urine, prevent odor, and protect the perineal skin. Substitution of disposable or reusable absorptive devices specifically designed to contain urine or double incontinence are more effective than household products, particularly in moderate to severe cases (Shirran, Brazelli, 2000; Gallo, Staskin, 1997).

5. Assist the family with arranging care in a way that allows the patient to participate in family or favorite activities without embarrassment. Careful planning can retain the dignity and integrity of family patterns.

6. Teach principles of perineal skin care, including routine cleansing following incontinent episodes, daily cleaning and drying of perineal skin, and use of moisture barriers as indicated. Routine cleansing and daily cleaning with appropriate products help maintain integrity of perineal skin and prevent secondary cutaneous infections (Fiers, Thayer, 2000).

7. Refer to occupational therapy for help in obtaining assistive devices and adapting the home for optimal toilet accessibility.

8. Consider use of an indwelling catheter for continuous drainage in the patient who is both homebound and bed-bound and receiving palliative or end of life care (requires physician order). An indwelling catheter may increase patient comfort, ease care provider burden, and prevent urinary incontinence in bed-bound patients receiving end of life care.

9. When an indwelling catheter is in place, follow prescribed maintenance protocols for managing the catheter, drainage bag, perineal skin, and urethral meatus. Teach infection control measures adapted to the home care setting. Proper care reduces the risk of catheter-associated UTI.

Client/Family Teaching

1. Work with the client, family, and their extended support systems to assist with needed changes in the environment and wardrobe and other alterations needed to maximize toileting access.

2. Work with the client and family to establish a reasonable, manageable prompted voiding program using environmental and verbal cues, such as television programs, meals, and bedtime, to remind caregivers of voiding intervals.

3. Teach the family to use an alarm system for toileting or to perform a check and change program and to maintain an accurate log of voiding and incontinent episodes.

READ MORE - Functional Urinary Incontinence

Hopelessness

A subjective state in which an individual sees limited or unavailable alternatives or personal choices and is unable to mobilize energy on own behalf

Defining Characteristics:

• Passivity; 
• decreased verbalization; 
• decreased affect; 
• verbal cues (e.g., saying "I can't," sighing); 
• closing eyes; 
• decreased appetite; 
• decreased response to stimuli; 
• increased/decreased sleep; 
• lack of initiative; 
• lack of involvement in care; 
• passively allowing care; 
• shrugging in response to speaker; 
• turning away from speaker

Related Factors:

• Abandonment; 
• prolonged activity restriction creating isolation; 
• lost beliefs in transcendent values/God;
• long-term stress; 
• failing or deteriorating physiological condition

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Decision Making
• Hope
• Mood Equilibrium
• Nutritional States: Food and Fluid Intake
• Quality of Life
• Sleep

Client Outcomes

• Verbalizes feelings, participates in care
• Makes positive statements (e.g., "I can" or "I will try")
• Makes eye contact, focuses on speaker
• Maintains appropriate appetite for age and physical health
• Sleeps appropriate amount of time for age and physical health

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Hope Instillation

Nursing Interventions and Rationales

1. Monitor and document potential for suicide. (Refer client for appropriate treatment if potential for suicide is identified.) See care plan for Risk for self-directed Violence for specific interventions.
Hopelessness is directly associated with suicidal behavior and also with a variety of other dysfunctional personal characteristics (Fritsch et al, 2000). Previous suicide attempts and hopelessness are the most powerful clinical predictors of future completed suicide (Malone et al, 2000).

2. Assess the client for and point out reasons for living.
Interventions that increase the awareness of reasons for living may decrease hopelessness and decrease risk for suicide (Malone et al, 2000).

3. Assess for impaired problem-solving ability and dysfunctional attitude.
Impaired problem-solving ability and dysfunctional attitude have been shown to correlate with hopelessness (Cannon et al, 1999).

4. Evaluate client by realistically assessing the predicament or threat.
Understanding the etiologic basis of the client's hopelessness is important in order to intervene (Wake, Miller, 1992). Unless there is a threat that is acknowledged and assessed, hope does not exist (Morse, Doberneck, 1995).

5. Determine appropriate approaches based on the underlying condition or situation that is contributing to feelings of hopelessness. Either encourage a positive mental attitude (discourage negative thoughts) or brace client for negative outcomes (i.e., client may need to accept some long-term limitations).
Truthful information is generally preferred by families; surprise information regarding a change in status may cause the family to worry that information is being withheld from them (Johnson, Roberts, 1996). A person awaiting a transplant may need to express only hope or optimism, whereas a person with an injury with long-term effects, such as a spinal-cord injury, may need to prepare for possible negative outcomes and slow progress (Morse, Doberneck, 1995).

6. Assist client with looking at alternatives and setting goals that are important to him or her.
Mutual goal setting ensures that goals are attainable and helps to restore a cognitive-temporal sense of hope (Johnson, Dahlen, Roberts, 1997). Clients who do not know what to hope for are without hope. Thus an integral part of developing hope is determining and setting goals. The significance of the goal to the individual is complex and critical to sustaining hope (Morse, Doberneck, 1995).

7. In dealing with possible long-term deficits, work with the client to set small, attainable goals.
Mutual goal setting ensures that goals are attainable and helps to restore a cognitive-temporal sense of hope (Johnson, Dahlen, Roberts, 1997). Clients with spinal cord injury focused hope only on small gains, one step at a time. "Every little step I took was more important to me than what I had in the end" (Morse, Doberneck, 1995).

8. Spend one-on-one time with client. Use empathy; try to understand what a client is saying, and communicate this understanding to the client.
Experiencing warmth, empathy, genuineness, and unconditional positive regard can inspire hope (Cutcliffe, 1998). Empathy allows the nurse to communicate understanding without expressing feelings of judgingment (Johnson, Roberts, 1996).

9. Encourage expression of feelings, and acknowledge acceptance of them.
Active listening is a tool used by nurses to enable them to listen to all ideas and feelings without judgment. Active listening may help clients to express themselves (Johnson, Roberts, 1996). A client's ability to express a negative emotion can be a very healthy sign; strong emotions are potentially dangerous if not expressed (Barry, 1994).

10. Give client time to initiate interactions. After an appropriate amount of time is allowed, approach client in an accepting and nonjudgmental manner.
Clients who have feelings of hopelessness need extra time to initiate relationships and sometimes are not able to. Approaching the client in an unhurried, nonjudgmental manner allows the client to feel secure and provides an atmosphere conducive to venting fears and asking questions (Anderson, 1992).

11. Encourage client to participate in group activities.
Group activities provide social support and help the client to identify alternative ways to problem-solve.

12. Encourage exercise of the mind to alleviate boredom. Watching or listening to the news, listening to music, and writing letters help to relieve the monotomy of hospitalization.
Focusing attention outside the self can decrease thoughts of hopelessness (Wake, Miller, 1992). Boredom may become a serious problem, leading to apathy, loss of hope, and depression (Anderson, 1992).

13. Review client's strengths with client. Have client list own strengths on a note card and carry this list for future reference.
Having individual worth affirmed inspires hope (Cutcliffe, 1998). Listing strengths provides reinforcement of positive self-regard.

14. Use humor as appropriate.
Humor is an effective intervention for hopelessness (Hunt, 1993).

15. Involve family and significant others in plan of care.
The importance of the need for hope has been emphasized by families during the critical illness of a family member (Johnson, Roberts, 1996). Frequent meetings between the staff and family can creat a safe, positive atmosphere for the discussion of feelings (Anderson, 1992).

16. Encourage family and significant others to express care, hope, and love for client.
Helping the family to provide client reinforcement, to understand the client's feelings, and to be physically present and involved in care are strategies that enable the family to alter the client's hope state (Wake, Miller, 1992). Clients awaiting transplants had only one alternative, and that was hoping to receive a transplant. These clients solicited mutually supportive relationships. They sought social and emotional support from staff, family, clergy, and friends, and it was the intensity of these social relationships that enabled them to survive the precarious nature of their physical conditions (Morse, Doberneck, 1995).

17. Use touch, if appropriate and with permission, to demonstrate caring, and encourage the family to do the same.
Human touch and human presence may in some way directly and/or indirectly restore the human-centered dignity and affirmation of being that is necessary for the emergence of hope (Cutcliffe, 1998).

18. For additional interventions, see care plans for Spiritual distress, Readiness for enhanced Spiritual well-being, and Disturbed Sleep pattern.

Geriatric

1. Assess for clinical signs and symptoms of depression; differentiate depression from functional or organic dementia.
Hopelessness and suicidal wishes in older adults are present with high levels of depressive symptoms suggestive of treatable pathology (Uncapher et al, 1998). It can be difficult to distinguish depression from dementia in people >65 years of age because some symptoms (e.g., disorientation, memory loss, and distractibility) may suggest dementia. Concurrent medical illnesses, prescription medications, and concealed alcohol or substance abuse can also appear to be dementia (Agency for Health Care Policy and Research, 1993).

2. If depression is suspected, confer with primary physician regarding referral for mental health.
In older adults, hopelessness and suicidal wishes are present with high levels of depressive symptoms suggestive of treatable pathology (Uncapher et al, 1998).

3. Take threats of self-harm or suicide seriously.
The elderly have the highest rate of completed suicide of all age groups (Uncapher et al, 1998). Hopelessness is often linked to depression and suicidal ideation in the elderly. Elderly people who are depressed or have experienced recent losses and live alone are at the highest risk (Uncapher et al, 1998).

4. Identify significant losses that might be leading to feelings of hopelessness.

5. Discuss stages of emotional responses to multiple losses.

6. Use reminiscence and life-review therapies to identify past coping skills.
Help clients acknowledge positive accomplishments and review survival of past illnesses to promote hope for dealing with current illness (Johnson, Dahlen, Roberts, 1997). Reminiscence can activate past sources of self-esteem and aid coping (Nugent, 1995). Memories and reminiscence have been used successfully with elderly persons to evoke pleasure and achieve therapeutic goals (Woods, Ashley, 1995).

7. Express hope to client, and give positive feedback whenever appropriate.
Sharing hope with a client who is experiencing hopelessness was identified as helpful for redirecting thoughts (Wake, Miller, 1992).

8. Identify client's past and current sources of spirituality. Help client explore life and identify those experiences that are noteworthy. Clients may want to read the Bible or have it read to them.
Spirituality is often identified by clients as a bridge between hopelessness and a sense of meaning (Fryback, Reinert, 1999).

9. Use simulated presence therapy (SPT). SPT is a personalized audiotape composed of a family member's or caregiver's portion of a telephone conversation and soundless spaces that correspond to the client's side of the conversation. On the SPT audiotape, a caregiver "converses" about cherished memories, loved ones, family antidotes, and other valued experiences of the client's life. The SPT audiotape is played by using headphones and a lightweight automatic-reverse cassette player that is inserted into a hip pack. (SPT is a patented product of SIM-PRES Inc., Boston, Massachusetts.)
Recorded messages can be used for proximity enhancement. Proximity enhancement helps to remove the threat of distant loved ones at a time of trauma (Johnson, Roberts, 1996). SPT builds on strengths of cognitively impaired elderly people because it relies on their remote memory, which is more likely to be retained than their recent memory. SPT produces a positive environment for cognitively impaired elderly people; the selected memories of SPT seem to provide enough stimulation to evoke the elder's interest, involvement, and pleasure (Woods, Ashley, 1995).

10. Encourage visits from children.
Children stimulate a sense of hope in many older adults (Gaskins, Forte, 1995).

11. Position clients by window, take them outside, or encourage activities such as gardening (if ability allows).
Any change in environment breaks the monotony that can lead to hopelessness (Wake, Miller, 1992). Enjoyment of nature fosters hope (Gaskins, Forte, 1995).

Multicultural

1. Assess for the influence of cultural beliefs, norms, and values on the client's feelings of hopelessness.
The client's expressions of hopelessness may be based on cultural perceptions (Leininger, 1996).

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

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

4. Validate the client's feelings regarding the impact of health status on current lifestyle.
Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).

Home Care Interventions

1. Assess for isolation within the family unit. Encourage client to participate in family activities. If client cannot participate, encourage him or her to be in the same area and watch family activities. If possible, move client's bed or primary sitting place to active household area.
Participation in events increases energy and promotes a sense of belonging.

2. If depression is suspected, confer with primary physician regarding referral for mental health.
In older adults, hopelessness and suicidal wishes are present with high levels of depressive symptoms suggestive of treatable pathology (Uncapher et al, 1998).

3. Reminisce with client about his or her life.
Help clients acknowledge positive accomplishments and review survival of past illnesses to promote hope for dealing with current illness (Johnson, Dahlen, Roberts, 1997). Reminiscence can activate past sources of self-esteem and aid coping (Nugent, 1995).

4. Identify areas in which client can have control. Allow client to set achievable goals in these areas.
Restoring control over the illness can increase the physiological sense of hope (Johnson, Dahlen, Roberts, 1997).

5. If illness precipitated the hopelessness, discuss knowledge of and previous experience with the disease. Help client to identify own strengths.
Uncertainty is a danger when it results in pessimism. Knowledge of and previous experience with the disease decrease uncertainty.

6. Provide plant or pet therapy if possible.
Caring for pets or plants helps to redefine the client's identity and makes him or her feel needed and loved.

7. Provide a safe environment so client cannot harm self. (See also no-suicide contract in following section). Provide one-to-one contact when necessary. Refer client for immediate mental health treatment if needed.
Hopelessness is an accurate indicator of suicidal risk. A safe environment reassures the client.

Client/Family Teaching

1. Provide information regarding client's condition, treatment plan, and progress.
Honest information regarding these issues in terms that the family can understand can give the family a sense of control and may allay some anxiety (Johnson, Roberts, 1996).

2. Teach use of stress reduction techniques, relaxation, and imagery. Many cassette tapes on relaxation and meditation are available. Assist the client with relaxation based on the client's preference from the initial assessment.
These techniques reduce physical stressors, which in turn increases the physiological sense of hope (Johnson, Dahlen, Roberts, 1997). Relaxation techniques, desensitization, and guided imagery can help clients cope, increase their control, and allay anxiety (Narsavage, 1997).

3. Encourage families to express love, concern, and encouragement, and allow client to vent feelings.
Helping the family to provide positive client reinforcement, to understand the client's feelings, and to be physically present and involved in care are strategies that enable the family to alter the client's hope state (Wake, Miller, 1992). One study showed that hope is partially sustained through relationships with the social network—families. The availability of significant sources of support can perpetuate hopefulness with cardiac transplant recipients (Hirth, Stewart, 1994).

4. Refer client to self-help groups such as I Can Cope and Make Today Count.
These groups allow the client to recognize the love and care of others, and they promote a sense of belonging (Bulechek, McCloskey, 1992).

5. Supply a crisis phone number, and secure a no-suicide contract from the client stating that the crisis number will be used if thoughts of self-harm occur.
A no-suicide contract is one type of intervention used with clients who have suicidal thoughts (Valente, 1989).

READ MORE - Hopelessness

Impaired Comfort—pruritis

State in which an individual experiences an uncomfortable sensation in response to a noxious stimulus (Carpenito, 1993)

Defining Characteristics: Verbalization or demonstration of discomfort, itching, reddened irritated skin

Related Factors:  Chemical irritants, dry skin

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Comfort Level

Client Outcomes

• States he or she is comfortable, itching relieved
• Explains methods to decrease itching

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Pruritis Management

Nursing Interventions and Rationales

1. Determine cause of pruritus (e.g., dry skin, contact with irritating substance, medication side effect, insect bite, infection, symptom of systemic disease).
The etiology of pruritus helps direct treatment. Pruritus may be caused by serious illnesses such as renal failure, liver failure, malignancy, or diabetes (Eaglestein, McKay, Pariser, 1994), as well as by dry skin and various skin conditions.

2. Apply soaks with washcloths wrung out in cool water or ice water as needed.
The application of cool or cold washcloths can depress the itching sensation.

3. Keep client's fingernails short; have client wear mitts if necessary.
Scratching with fingernails can excoriate the area and increase skin damage.

4. Leave pruritic area open to the air if possible.
Covering the area with a nonventilated dressing can increase itching sensation and warmth in the area.

5. Use nonallergenic mild soap and use it sparingly.
Many soaps can be irritating to the skin and increase the itching sensation.

6. Keep skin well lubricated. After bathing while the skin is still moist, apply nonallergenic moisturizers such as Medilan that are alcohol free and available in cream or ointment form. Apply moisturizers daily.
These agents lubricate the skin surface and make the skin feel smoother and less dry (Hardy, 1996). Medilan is a hypoallergenic lanolin that has soothing and hydrating properties. It can be helpful for the treatment of eczema and other dry skin conditions (Stone, 2000). Creams and ointments are more effective than lotions because they contain less water (Frantz, Gardner, 1994). Daily application of moisturizers can have the persistent clinical effect of relieving dry skin (Tabata et al, 2000).

7. Provide distraction techniques such as music, television, or massage.
These activities help to temporarily distract the client from the itching sensation. Massage has been helpful for some people with atopic dermatitis (Koblenzer, 1999).

8. Consult with physician for medication to relieve itching.
Medications such as topical steroids or antihistamines can be helpful (Koblenzer, 1999).

Geriatric

1. Limit number of complete baths to one every other day. Use a tepid water temperature of 90° to 105° F for bathing.
Excessive bathing, especially in hot water, depletes aging skin of moisture and increases dryness.

2. Use a superfatted soap such as Dove, Tone, Basis, or Caress.
Superfatted soaps help retain moisture in dry, elderly skin (Hardy, 1996).

3. Increase fluid intake within cardiac or renal limits to a minimum of 1500 ml/day.
Dry skin is caused by loss of fluid through the skin; increasing fluid intake rehydrates the skin. Adequate hydration helps decrease itching (Koblenzer, 1999).

4. Use a humidifier or a container of water on heat source to increase humidity in the environment, especially during winter.
Increasing moisture in the air helps to keep moisture in the skin (Hardy, 1996). During times of cold weather and low humidity, dermatitis of the hands is common (Uter, Gefeller, Schwanitz, 1998).

Multicultural

1. Assess for the influence of cultural beliefs, norms, and values on the client’s perceptions of skin and/or hair status and practices.
What the client considers normal and abnormal skin and hair condition may be based on cultural perceptions (Leininger, 1996).

2. Identify and clarify cultural language used to describe skin and hair.

3. Assess skin for ashy appearance.
Black skin and the skin of other people of color will appear ashy as a result of the flaking off of the top layer of the epidermis (Smith, Burns, 1999; Jackson, 1998).

4. Encourage use of lanolin-based lotions for black clients with dry skin.
Vaseline may clog the pores and cause cellulitis or other skin problems (Jackson, 1998).

5. Offer hair oil and lanolin-based lotion for dry scalp and skin.
Black skin seems to produce less oil than lighter colored skin; therefore blacks may use more lubricants as a normal part of skin hygiene (Smith, Burns, 1999).

6. Use soap sparingly if the skin is dry.
Black skin tends to be dry, and soap will exacerbate this condition (Jackson, 1998).

Home Care Interventions

1. Assist client and family with identifying and avoiding irritants that exacerbate pruritus (e.g., wool).
Avoiding irritants decreases discomfort of pruritus (Koblenzer, 1999).

2. Teach family to use mild, nonscented, and nonbleach laundry products.
Chemical irritants increase discomfort of pruritus.

3. Keep temperature of home moderated. Use a humidifier.
Overheated home environments increase sweating, which adds salts to the skin and increases irritation. Increasing moisture in the air helps to keep moisture in the skin (Hardy, 1996).

Client/Family Teaching

1. Teach techniques to use when client is uncomfortable, including relaxation techniques, guided imagery, hypnosis, and music therapy.
Interventions such as progressive muscle relaxation training, guided imagery, hypnosis, and music therapy can effectively decrease the itching sensation.

2. Teach client with pruritus to substitute rubbing, pressure, or vibration for scratching when itching is severe and irrepressible.

3. Teach client to see primary care practitioner if itching persists and no cause is found.
Itching can be a symptom of other conditions (Eaglestein, McKay, Pariser, 1994; Koblenzer, 1999).

READ MORE - Impaired Comfort—pruritis

Impaired Gas exchange

Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane

Defining Characteristics:

• Visual disturbances; 
• decreased carbon dioxide; 
• dyspnea; 
• abnormal arterial blood gases; 
• hypoxia; 
• irritability; 
• somnolence; 
• restlessness; 
• hypercapnia;
• tachycardia; 
• cyanosis (in neonates only); 
• abnormal skin color (pale, dusky); 
• hypoxemia; 
• hypercarbia; 
• headache on awakening; 
• abnormal rate, rhythm, depth of breathing; 
• diaphoresis; 
• abnormal arterial pH; 
• nasal flaring

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Respiratory Status: Gas Exchange
• Respiratory Status: Ventilation
• Tissue Perfusion: Pulmonary
• Vital Signs Status
• Electrolyte and Acid-Base Balance

Client Outcomes

• Demonstrates improved ventilation and adequate oxygenation as evidenced by blood gases within client's normal parameters
• Maintains clear lung fields and remains free of signs of respiratory distress
• Verbalizes understanding of oxygen and other therapeutic interventions

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Airway Management
• Oxygen Therapy
• Respiratory Monitoring
• Acid-Base Management

Nursing Interventions and Rationales

1. Monitor respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns.
Increased respiratory rate, use of accessory muscles, nasal flaring, abdominal breathing, and a look of panic in the client's eyes may be seen with hypoxia.

2. Auscultate breath sounds q __ h(rs).
Presence of crackles and wheezes may alert the nurse to an airway obstruction, which may lead to or exacerbate existing hypoxia.

3. Monitor client's behavior and mental status for onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy.
Changes in behavior and mental status can be early signs of impaired gas exchange (Misasi, Keyes, 1994). In late stages the client becomes lethargic, somnolent, and then comatose (Pierson, 2000).

4. Monitor oxygen saturation continuously, using pulse oximeter. Note blood gas results as available.  
An oxygen saturation of <90% (normal: 95% to 100%) or a partial pressure of oxygen of <80 (normal: 80 to 100) indicates significant oxygenation problems.


5. Observe for cyanosis in skin; especially note color of tongue and oral mucous membranes.
Central cyanosis of tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in extremities may or may not be serious (Carpenter, 1993).

6. If client is acutely dyspneic, coach the client to slow respiratory rate using touch on the shoulder, demonstrating slower respirations while making eye contact with the client, and communicating in a calm, supportive fashion.
Anxiety can exacerbate dyspnea, causing the client to enter into a dyspneic panic state (Gift, Moore, Soeken, 1992; Bruera et al, 2000). The nurse's presence, reassurance, and help in controlling the client's breathing can be very beneficial (Truesdell, 2000).

7. Demonstrate and encourage the client to use pursed-lip breathing.
Pursed-lip breathing results in increased use of intercostal muscles, decreased respiratory rate, increased tidal volume, and improved oxygen saturation levels (Breslin, 1992). Pursed-lip breathing can result in increased exercise performance (Casciarai et al, 1981), and it empowers the client to self-manage dyspnic incidences (Truesdell, 2000).

8. Position client with head of bed elevated, in a semi-Fowler's position as tolerated.
Semi-Fowler's position allows increased lung expansion because the abdominal contents are not crowding the lungs.

9. If client has unilateral lung disease, alternate semi-Fowler's position with lateral position (with a 10- to 15-degree elevation and "good lung down" for 60 to 90 minutes). This method is contraindicated for clients with a pulmonary abscess or hemorrhage or interstitial emphysema.
Gravity and hydrostatic pressure cause the dependent lung to become better ventilated and perfused, which increases oxygenation (Lasater-Erhard, 1995; Yeaw, 1992).

10. If client has a bilateral lung disease, position in either a semi-Fowler's or side-lying position, which increases oxygenation as indicated by pulse oximetry (or if client has pulmonary catheter, venous oxygen saturation). Turn client every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return to baseline promptly, turn the client back into a supine position and evaluate oxygen status.
Turning is important to prevent complications of immobility, but in critically ill clients with low hemoglobin levels or decreased cardiac output, turning on either side can result in desaturation (Winslow, 1992). Critically ill clients should be turned carefully and watched closely (Gawlinksi, Dracup, 1998).

11. If client is obese or has ascites, consider positioning client in reverse Trendelenburg position at 45 degrees for periods as tolerated.
A study demonstrated that use of the reverse Trendelenburg position at 45 degrees resulted in increased tidal volumes and decreased respiratory rates in a group of intubated clients with obesity, abdominal distention, and ascites (Burns et al, 1994; Winslow, 1996).

12. Consider positioning the client prone with upper thorax and pelvis supported, allowing the abdomen to protrude. Monitor oxygen saturation, and turn back if desaturation occurs. Do not put in prone position if client has multisystem trauma.
Partial pressure of arterial oxygen has been shown to increase in the prone position, possibly because of greater contraction of the diaphragm and increased function of ventral lung regions (Douglas et al, 1977; Lasater-Erhard, 1995; Curley, 1999). Prone positioining improves hypoxemia significantly (Dupont et al, 2000). In one study clients with multisystem trauma had serious iatrogenic injuries with prone positioning, including wound dehiscence, chest wall pressure necrosis, and a cardiac arrest (Offner et al, 2000).

13. If client is acutely dyspnic, consider having client lean forward over a bedside table, if tolerated.
Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm (Celli, 1998). The tripid position can be helpful during times of dypnea (Dunn, 2001).

14. Help client 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 as tolerated.
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
NOTE: If client has excessive fluid in respiratory system, see interventions for Ineffective Airway clearance.

15. Monitor the effects of sedation and analgesics on client's respiratory pattern; use judiciously.
Both analgesics and medications that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the sympathetic nervous system discharge that accompanies hypoxia.

16. Schedule nursing care to provide rest and minimize fatigue.
The hypoxic client has limited reserves; inappropriate activity can increase hypoxia.

17. Administer humidified oxygen through appropriate device (e.g., nasal cannula or face mask per physician's order); watch for onset of hypoventilation as evidenced by increased somnolence after initiating or increasing oxygen therapy.
A client with chronic lung disease client may need a hypoxic drive to breathe and may hypoventilate during oxygen therapy.

18. Provide adequate fluids to liquefy secretions within the client's cardiac and renal reserve.
If client is severely debilitated from chronic respiratory disease, consider use of a wheeled walker to help in ambulation.

19. Use of a wheeled walker has been shown to result in significant decrease in disability, hypoxemia, and breathlessness during a 6-minute walk test (Honeyman, Barr, Stubbing, 1996).

20. Monitor nutritional status. Refer client for a dietary consult if needed.
Many clients with emphysema are malnourished. Improved nutrition can help improve inspiratory muscle function (Meeks et al, 1999).

21. If chronic pulmonary disease is interfering with quality of life, refer client for pulmonary rehabilitation.
Pulmonary rehabilitation programs that include desensitization to dyspnea and guided mastery with monitored exercise are preferable. Pulmonary rehabilitation has been shown to improve exercise capacity, ability to walk, and sense of well-being (Fishman, 1994; American Thoracic Society, 1999; Janssens, 2000). The processes of desensitization and guided mastery for control of dyspnea have helped clients learn to be in control of their condition and have increased the amount of activity they can tolerate (Carrieri-Kohlman et al, 1993).

22. Refer client to pulmonary rehabilitation team if client has chronic respiratory disease.
This team is multidisciplinary, and working together can help increase exercise capacity, decrease dyspnea, improve quality of life, and decrease admissions to the hospital (Celli, 1998).
NOTE: If client becomes ventilator-dependent, see care plan for Impaired spontaneous Ventilation.

Geriatric

1. Use central nervous system depressants carefully to avoid decreasing respiration rate.
An elderly client is prone to respiratory depression.

2. Maintain low-flow oxygen therapy.
An elderly client is susceptible to oxygen-induced respiratory depression.

3. Encourage client to stop smoking.
There are substantial health benefits for elderly clients who stop smoking (Foyt, 1992).

Home Care Interventions

1. Assess the home environment for irritants that impair gas exchange. Help the client to adjust home environment as necessary (e.g., installing air filter to decrease presence of dust).

2. Refer client to occupational therapy as necessary to assist with adapting to home environment and energy conservation.

3. Assist client with identifying and avoiding situations that exacerbate impairment of gas exchange (e.g., stress-related situations, proximity to noxious gas fumes such as chlorine bleach).
Irritants in the environment decrease the client's effectiveness in accessing oxygen during breathing.

4. Instruct client to limit exposure to persons with respiratory infections.

5. Instruct family in complications of disease and importance of maintaining medical regimen, including when to call physician.

6. Assess nutritional status. Instruct client to eat several small meals daily and to use dietary supplements as necessary.
Clients with decreased oxygenation have little energy to use for eating and will avoid meals. Malnutrition significantly affects the aerobic capacity of muscle and exercise tolerance in clients with chronic obstructive pulmonary disease (COPD) (Palange et al, 1995). When nutritional status is clearly improved, it is accompanied by improvements in strength of the respiratory muscles and, in some studies, increased distance of walking (Larson, Leidy, 1998).

7. Refer client for home health aide services as necessary to assist with activities of daily living (ADLs).
Clients with decreased oxygenation have decreased energy to carry out personal and role activities.

8. Assess family role changes and coping ability. Refer client to medical social services as appropriate for assistance in adjusting to chronic illness.
Inability to maintain pre-illness level of social involvement leads to frustration and anger in the client and may create a threat to the family unit. In one study, clients with chronic lung problems were described as negative, helpless, confused, and socially obstreperous by their family members (Leidy, Traver, 1996).

9. Refer to outpatient pulmonary rehabilitation program, or a home-based training program for COPD.
Outpatient rehabilitation programs can achieve worthwhile benefits, including decreased perception of dypnea, increased walking distance, and less fatigue, with benefits that persist for a period of 2 years (Glell R et al, 2000). A simple home-based program of exercise training can achieve improvement in exercise tolerance, dyspnea, and quality of life for COPD patients (Hernandez et al, 2000). In mild COPD, a weight-training program was shown to result in increased strength and increased exercise tolerance (Clark et al, 2000).

10. Support family of client with chronic illness.
Severely compromised respiratory functioning causes fear and anxiety in clients and their families. Reassurance from the nurse can be helpful.

Client/Family Teaching

1. Teach client these techniques to use during acute dypneic episodes:

• Pursed-lip breathing and controlled diaphragmatic breathing: Have client watch pulse oximetry to note improvement in oxygenation with breathing techniques. Controlled breathing techniques can help control anxiety and decrease panic and dyspnea (Celli, 1998; Dunn, 2001).
• Progressive muscle relaxation with or without guided imagery. Progressive relaxation eases the workload of muscles that are not being used to breathe, reducing the body's oxygen requirement (Dunn, 2001).
• Assistive breathing technique: Fold arms just below ribcage and push into belly while exhaling, then release during inhalation; repeat process until breathing becomes more controlled. This technique can help push the diaphragm up and force out the trapped air that was causing the feeling of pressure (Dunn, 2001).

2. Instruct client to keep home temperature above 68ø F and to avoid cold weather.
Cold air temperatures cause constriction of the blood vessels and increased moisture, impairing the client's ability to absorb oxygen.

3. Teach clients to keep humidity levels in their homes between 40% and 50%, using a humidifier or dehumidifier as needed.
Both high humidity and low humidity can affect the ability of the COPD client to breathe comfortably (Dunn, 2001).

4. Teach client energy conservation techniques and the importance of alternating rest periods with activity. See nursing interventions for Fatigue.

5. Teach the importance of not smoking. Be aggressive in approach, and ask client to set a date for smoking cessation. Recommend nicotine replacement therapy (nicotine patch or gum). Refer client to smoking cessation programs. Encourage clients who relapse to keep trying to quit.
All health care clinicians should be aggressive in helping smokers quit (Agency for Health Care Policy Research, 1996).

6. Instruct family regarding home oxygen therapy if ordered (e.g., delivery system, liter flow, safety precautions). If need for oxygen is chronic, encourage use of a portable system. Explain advantages of transtracheal oxygen delivery systems. Encourage client to use oxygen as ordered.
Clients with portable oxygen therapy spent more time outside and walked futher than people with fixed delivery systems (Vergeret, Brambilla, Mounier, 1989). Clients with transtracheal oxygen delivery systems were more independent than those with fixed delivery systems and had increased morale (Bloom et al, 1989; Larson, Leidy, 1998). Clients who used oxygen for longer periods had decreased mortality (Pierson, 2000).

7. Teach client relaxation therapy techniques to help reduce stress responses and panic attacks resulting from dyspnea.
Relaxation therapy includes progressive muscle relaxation, autogenic techniques, visualization, and diaphragmatic breathing. This therapy can help to modify the symptoms of dyspnea and help the client deal with feelings associated with the chronic disease (Jerman, Haggerty, 1993).

READ MORE - Impaired Gas exchange

Impaired Oral mucous membrane

Disruptions of the lips and soft tissues of the oral cavity

Defining Characteristics:

• Purulent drainage or exudates; 
• gingival recession, pockets deeper than 4 mm; 
• enlarged tonsils beyond what is developmentally appropriate; 
• smooth atrophic, sensitive tongue; 
• geographic tongue; 
• mucosal denudation; 
• presence of pathogens; 
• difficult speech; 
• self-report of bad taste; 
• gingival or mucosal pallor; 
• oral pain/discomfort; 
• xerostomia (dry mouth); 
• vesicles, nodules, or papules; 
• white patches/plaques, spongy patches, or white curd-like exudate; 
• oral lesions or ulcers; 
• halitosis; 
• edema; 
• hyperemia; 
• desquamation; 
• coated tongue; 
• stomatitis; 
• self-report of difficult eating or swallowing; 
• self-report of diminished or absent taste; 
• bleeding; macroplasia; gingival hyperplasia; 
• fissures, cheilitis; 
• red or bluish masses (e.g., hemangiomas)

Related Factors:

• Chemotherapy; 
• chemical (e.g., alcohol, tobacco, acidic foods, regular use of inhalers); 
• depression; 
• immunosuppression; 
• aging-related loss of connective, adipose, or bone tissue; 
• barriers to professional care; 
• cleft lip or palate; 
• medication side effects; 
• lack of or decreased salivation; 
• chemical trauma (e.g., acidic foods, drugs, noxious agents, alcohol);
• pathological conditions—oral cavity (radiation to head or neck); 
• NPO for more than 24 hours; 
• mouth breathing; 
• malnutrition or vitamin deficiency; 
• dehydration; 
• infection; 
• ineffective oral hygiene; 
• mechanical (e.g., ill-fitting dentures, braces, tubes [endotracheal/nasogastric], surgery in oral cavity); 
• decreased platelets; 
• immunocompromised; 
• impaired salivation; 
• radiation therapy; 
• barriers to oral self-care; 
• diminished hormone levels (women); 
• stress; 
• loss of supportive structures

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Oral Health
• Tissue Integrity: Skin and Mucous Membranes

Client Outcomes

• Maintains intact, moist oral mucous membranes that are free of ulceration and debris
• Describes or demonstrates measures to regain or maintain intact oral mucous membranes

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Oral Health Restoration

Nursing Interventions and Rationales

1. Inspect oral cavity at least once daily and note any discoloration, lesions, edema, bleeding, exudate, or dryness. Refer to a physician or specialist as appropriate.
Oral inspection can reveal signs of oral disease, symptoms of systemic disease, drug side effects, or trauma of the oral cavity (White, 2000).

2. Assess for mechanical agents such as ill-fitting dentures or chemical agents such as frequent exposure to tobacco that could cause or increase trauma to oral mucous membranes.
Irritative and causative agents for stomatitis should be eliminated (Rhodes, McDaniel, Johnson, 1995).

3. Monitor client's nutritional and fluid status to determine if adequate. Refer to the care plan for Deficient Fluid volume or Imbalanced Nutrition: less than body requirements if applicable.
Dehydration and malnutrition predispose clients to impaired oral mucous membranes.

4. Encourage fluid intake up to 3000 ml per day if not contraindicated by client's medical condition (Rhodes, McDaniel, Johnson, 1995).
Fluids help increase moisture in the mouth, which protects the mucous membranes from damage and helps the healing process.

5. Determine client's mental status. If client is unable to care for self, oral hygiene must be provided by nursing personnel. The nursing diagnosis Bathing/Hygiene Self-care deficit is then also applicable.

6. Determine client's usual method of oral care and address any concerns regarding oral hygiene.
Whenever possible, build on client's existing knowledge base and current practices to develop an individualized plan of care.

7. If client does not have a bleeding disorder and is able to swallow, encourage to brush teeth with a soft pediatric-sized toothbrush using a fluoride-containing toothpaste after every meal and to floss teeth daily. '
The toothbrush is the most important tool for oral care. Brushing the teeth is the most effective method for reducing plaque and controlling periodontal disease (Buglass, 1995; Stiefel et al, 2000; Roberts, 2000).

8. Use tap water or normal saline to provide oral care; do not use commercial mouthwashes containing alcohol or hydrogen peroxide. Also, do not use lemon-glycerin swabs.
Alcohol dries the oral mucous membranes Hydrogen peroxide can damage oral mucosa and is extremely foul tasting to clients (Tombes, Gallucci, 1993; Winslow, 1994). Lemon-glycerin swabs can result in decreased salivary amylase and oral moisture, as well as erosion of tooth enamel (Crosby 1989, Stiefel et al, 2000; Roberts, 2000).

9. Use foam sticks to moisten the oral mucous membranes, clean out debris, and swab out the mouth of the edentulous client. Do not use to clean the teeth or else the platelet count is very low, and the client is prone to bleeding gums.
Studies have shown that foam sticks are probably not effective for removing plaque from teeth (Roberts, 2000). However, they are useful for cleaning the mouth of the edentulous client (Curzio, McCowan, 2000).

10. If client's oral cavity is dry, the keep inside of the mouth moist with frequent sips of water and salt water rinses (1/2 tsp salt in 8 oz of warm water) or artificial saliva.
Moisture promotes the cleansing effect of saliva and helps avert mucosal drying, which can result in erosions, fissures, or lesions (Rhodes, McDaniel, Johnson, 1995). Sodium chloride rinses have been shown to be effective for the prevention and treatment of stomatitis (Feber, 1994).

11. Keep lips well lubricated using petroleum jelly or a similar product (Yeager et al, 2000).

12. For clients with stomatitis, increase frequency of oral care up to every hour while awake if necessary.
Increasing the frequency of oral care has been shown to be effectively decrease stomatitis (Armstrong, 1994).

13. Provide scrupulous oral care to critically ill clients.
Cultures of the teeth of critically ill clients have yielded significant bacterial colonization, which can cause nosocomial pneumonia (Scannapieco, Stewart, Mylotte, 1992).

14. If mouth is severely inflamed and it is painful to swallow, contact the physician for a topical anesthetic agent or analgesic order. Modification of oral intake (e.g., soft or liquid diet) may also be necessary to prevent friction trauma. The nursing diagnosis Imbalanced Nutrition: less than body requirements may apply.

15. If whitish plaques are present in the mouth or on the tongue and can be rubbed off readily with gauze, leaving a red base that bleeds, suspect a fungal infection and contact the physician for follow-up.
Oral candidiasis (moniliasis) is extremely common secondary to antibiotic therapy, steroid therapy, HIV infection, diabetes, or immunosuppressive drugs and should be treated with oral or systemic antifungal agents (Fauci et al, 1998; Epstein, Chow, 1999).

16. If client is unable to swallow, keep suction nearby when providing oral care.

17. Refer to Impaired Dentition if the client has problems with the teeth.

Geriatric

1. Carefully observe oral cavity and lips for abnormal lesions such as white or red patches, masses, ulcerations with an indurated margin, or a raised granular lesion.
Malignant lesions are more common in elderly persons than in younger persons (especially if there is a history of smoking or alcohol use), and many elderly persons rarely visit a dentist (Aubertin, 1997).

2. Ensure that dentures are removed and scrubbed at least once daily, removed and rinsed thoroughly after every meal, and removed and kept in an appropriate solution at night.
This is an evidence-based protocol for denture care (Curzio, McCowan, 2000). Denture plaque-containing candidiasis can cause denture-induced stomatitis, which is more common with unhealthy lifestyles and poor oral hygiene than otherwise (Sakki et al, 1997; Nikawa, Hamada, Yamamoto, 1998).

Home Care Interventions

1. Instruct client to avoid alcohol- or hydrogen peroxide-based commercial products for mouth care and to avoid other irritants to the oral cavity (e.g., tobacco, spicy foods).
Oral irritants can further damage the oral mucosa and increase the client's discomfort.

2. Instruct client in ways to soothe the oral cavity (e.g., cool beverages, Popsicles, viscous lidocaine) (Jaffe, Skidmore-Roth, 1993).

3. If client often breathes by mouth, add humidity to room unless contraindicated.

4. If necessary, refer for home health aide services to support family in oral care and observation of the oral cavity.

Client/Family Teaching

1. Teach client how to inspect the oral cavity and monitor for signs and symptoms of infection, complications, and healing.

2. Teach how to implement a personal plan of oral hygiene including a schedule of care.
Encouragement and reinforcement of oral care are important to oral outcomes (Armstrong, 1994).

READ MORE - Impaired Oral mucous membrane

Impaired Parenting

Inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child

Defining Characteristics:

Infant/child

• Poor academic performance; 
• frequent illness; 
• runaway; 
• incidence of physical and psychological trauma or abuse; 
• frequent accidents; 
• lack of attachment; 
• failure to thrive; 
• behavioral disorders; 
• poor social competence; 
• lack of separation anxiety; 
• poor cognitive development

Parental

• Inappropriate child care arrangements; 
• rejection of or hostility to child; 
• statements of inability to meet child's needs; 
• inflexibility in meeting needs of child or situation; 
• poor or inappropriate caretaking skills; 
• regularly punitive; 
• inconsistent care; 
• child abuse; 
• inadequate child health maintenance; 
• unsafe home environment; 
• verbalization of inability to control child; 
• negative statements about child; 
• verbalization of role inadequacy or frustration; 
• inappropriate visual, tactile, auditory stimulation; 
• abandonment; 
• insecure or lack of attachment to infant; 
• inconsistent behavior management; 
• child neglect; little cuddling; 
• maternal-child interaction deficit; 
• poor parent-child interaction

Related Factors:

Social

• Lack of access to resources; 
• social isolation; 
• lack of resources; 
• poor home environment; 
• lack of family cohesiveness; 
• inadequate child care arrangements; 
• lack of transportation; 
• unemployment or job problems; 
• role strain or overload; 
• marital conflict, declining satisfaction; 
• lack of value of parenthood; 
• change in family unit; 
• low socioeconomic class; 
• unplanned or unwanted pregnancy; 
• presence of stress (e.g., financial, legal, recent crisis, cultural move); 
• lack of or poor parental role model; 
• single parent; 
• lack of social support network; 
• father of child not involved; 
• history of being abusive; 
• history of being abused; 
• financial difficulties; 
• maladaptive coping strategies; 
• poverty; 
• poor problem-solving skills; 
• inability to put child's needs before own; 
• low self-esteem; 
• relocations;
• legal difficulties

Knowledge

• Lack of knowledge about child health maintenance;
• lack of knowledge about parenting skills; 
• unrealistic expectations for self, infant, partner; 
• limited cognitive functioning; 
• lack of knowledge about child development; 
• inability to recognize and act on infant cues; 
• low educational level or attainment; 
• poor communication skills; 
• lack of cognitive readiness for parenthood; 
• preference for physical punishment

Physiological

Physical illness

Infant/child

• Premature birth;
• illness; 
• prolonged separation from parent; 
• not desired gender; 
• attention deficit hyperactivity disorder; 
• difficult temperament; 
• separation from parent at birth; 
• lack of goodness of fit (temperament) with parental expectations; 
• unplanned or unwanted child; 
• handicapping condition or developmental delay; 
• multiple births; 
• altered perceptual abilities

Psychological

• History of substance abuse or dependencies; 
• disability; 
• depression; 
• difficult labor and/or delivery; 
• young age, 
• especially adolescent; 
• history of mental illness; 
• high number of or closely spaced pregnancies; 
• sleep derivation or disruption; 
• lack of or late prenatal care; 
• separation from infant/child

NOTE: It is important to reaffirm that adjustment to parenting in general is a normal maturational process that elicits nursing behaviors to prevent potential problems and to promote health.

NOC Outcomes (Nursing Outcomes Classification)

Suggested NOC Labels

• Child Development: 2 Months
• 4 Months
• 6 Months
• 2 Years
• 3 Years
• 4 Years
• 5 Years
• Middle Childhood (6 - 11 Years)
• Adolescence (12 - 17 Years)
• Parent-Infant Attachment
• Parenting
• Parenting: Social Safety
• Role Performance
• Safety Behavior: Home Physical Environment
• Social Support

Client Outcomes

• Affirms desire to develop constructive parenting skills to support infant/child growth and development
• Initiates appropriate measures to develop a safe, nurturing environment
• Acquires and displays attentive, supportive parenting behaviors
• Identifies strategies to protect child from harm and/or neglect and initiates action when indicated

NIC Interventions (Nursing Interventions Classification)

Suggested NIC Labels

• Abuse Protection: Child
• Attachment Promotion
• Developmental Enhancement
• Family Integrity Promotion
• Parenting Promotion

Nursing Interventions and Rationales

1. Use active listening to explore parent's understanding of developmental needs and expectations of child and self within the context of cultural perspectives and influences.
Interviewing with empathy while reserving judgment allows parent to more freely express frustrations and disappointments regarding negative feelings, needs, and parenting skills. Unrealistic expectations may be present when parent does not discern what is normal for the child (Denehy, 1992; Herman-Staab, 1994; Mrazek, Mrazek, Klinnert, 1995).

2. Examine characteristics of parenting style and behaviors, including the following:

• Emotional climate at home
• Attribution of negative traits to child
• Failure to support child's increases in autonomy
• Type of interaction with infant/child
• Competition with child for spousal/significant other attention
• Lack of knowledge/concern about health maintenance or behavioral problems
• Other behaviors or concerns

Children are at risk for neglect, abuse, and other negative psychosocial outcomes in families with dysfunctions (Mrazek, Mrazek, Klinnert, 1995).

3. Institute abuse/neglect protection measures if evidence of inability to cope with family stressors or crisis, signs of parental substance abuse, or significant level of social isolation apparent.
Risk of abuse/neglect is higher in families with high levels of stress, substance abuse, or lack of social support systems (Devlin, Reynolds, 1994).

4. For mothers with toddlers, assess maternal depression, perceptions of difficult temperament in toddler, and low maternal self-efficacy.
Self-efficacy is defined as one's judgment of how effectively one can execute a task or manage a situation that may contain novel, unpredictable, and stressful elements. A cyclic relationship among depression, perceived difficult temperament, and self-efficacy has been identified. Negative feelings about oneself and one's child are likely to negatively influence the parent-child relationship (Gross et al, 1994).

5. Appraise parent's resources and availability of social support systems. Determine single mother's particular sources of support, especially availability of her own mother and partner. Encourage use of healthy, strong support systems.
Before adequate interventions and education can be initiated, understanding of the current support system and concerns must occur. The mother's partner and her mother are often important sources of support (Zacharia, 1994).

6. Model age- and cognitively appropriate caregiver skills by doing the following:

• Communicating with child at an appropriate cognitive level of development
• Giving child tasks and responsibilities appropriate to age or functional age/level
• Instituting safety considerations such as assistive equipment
• Encouraging child to perform activities of daily living (ADLs) as appropriate

These activities illustrate parenting and child-rearing skills and behaviors for parents and family (McCloskey, Bulechek, 1992).

Multicultural

1. Assess for the influence of cultural beliefs, norms, and values on the client's perception of parenting.
What the client considers normal parenting may be based on cultural perceptions (Leininger, 1996).

2. Acknowledge racial/ethnic differences at the onset of care.
Acknowledgement of racial/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes (D'Avanzo et al, 2001).

3. Approach individuals of color with respect, warmth, and professional courtesy.
Instances of disrespect have special significance for individuals of color (D'Avanzo et al, 2001).

4. Give rationale when assessing black individuals about sensitive issues.
Blacks may expect white caregivers to hold negative and preconceived ideas about them. Giving rationale for questions will help alleviate this perception (D'Avanzo et al, 2001).

5. Acknowledge that value conflicts from acculturation stresses may contribute to increased anxiety and significant conflict with children.
Challenges to traditional beliefs and values are anxiety provoking (Charron, 1998). Less acculturated parents may experience conflict with their more acculturated children as the children demand greater independence and freedom (True, 1995).

6. Use a neutral, indirect style when addressing areas where improvement is needed (such as a need for verbal stimulation) when working with Native American clients.
Using indirect statements such as "Other mothers have tried..." or "I had a client who tried 'X' and it seemed to work very well" will help to avoid resentment from the parent (Seiderman et al, 1996).

7. Acknowledge and praise parenting strengths noted.
This will increase trust and foster a working relationship with the parent (Seiderman et al, 1996).

8. Validate the client's feelings regarding parenting.
Validation lets the client know that the nurse has heard and understands what was said, and it promotes the nurse-client relationship (Stuart, Laraia, 2001; Giger, Davidhizer, 1995).

9. Facilitate modeling and role-playing to help family improve parenting skills.
It is helpful for families and the client to practice parenting skills in a safe environment before trying them in real-life situations (Rivera-Andino, Lopez, 2000).

Client/Family Teaching

1. Explain individual differences in child temperaments and compare and contrast with reality of parents' expectations. Help parents determine and understand the implications of their child's temperament.
Promoting parental understanding of temperament facilitates development of more realistic expectations (McClowry, 1992; Melvin, 1995).

2. Discuss sound disciplinary techniques, which include catching children being good, active listening, conveying positive regard, ignoring minor transgressions, giving good directions, use of praise, and use of time-out.
Disciplinary methods are subject to a variety of opinions. Proper discipline provides children with security, and clearly enforced rules help them learn self-control and social standards. Parenting classes can be beneficial when parent has had little formal or informal preparation (Herman-Staab, 1994).

3. Foster acquisition of positive parenting skills.
Parents may feel powerless. Helping them develop necessary skills or gain knowledge maintains the integrity of the parental role, and parents are then unlikely to use maladaptive coping styles (Baker, 1994).

4. Plan parental education directed toward the following age-related parental concerns:

• Birth to 2 years Transition, sleep, aggression
• 3 to 5 years Transition, parent-child relationship, sleep
• 6 to 10 years School, parent-child relationship, divorce
• 11 to 18 years Parent-child relationship, divorce, school

Parents with children of any age may seek basic information about a variety of concerns, which can be anticipated and addressed by providing ongoing information and support (Jones, Maestri, McCoy, 1993).

5. Initiate referrals to community agencies, parent education opportunities, stress management training, and social support groups.
The parent needs support to manage angry or inappropriate behaviors. Use of support systems and social services can provide an opportunity to decrease feelings of inadequacy (Campbell, 1992; Baker, 1994).

6. Provide information regarding available telephone counseling services.
Telephone counseling services can provide confidential advice and support to families who might not otherwise have access to help in dealing with behavioral problems and parenting concerns (Jones, Maestri, McCoy, 1993).

7. Refer to care plan for Delayed Growth and development for additional teaching interventions.

READ MORE - Impaired Parenting

Impaired Physical Mobility

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).

Geriatric

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

Altered epidermis and/or dermis

Defining Characteristics:

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

Related Factors:

External

• Hyperthermia; 
• hypothermia; 
• chemical substance (e.g., incontinence); 
• mechanical factors (e.g., friction, shearing forces, pressure, restraint); 
• physical immobilization; 
• humidity; 
• extremes in age; 
• moisture; 
• radiation; 
• medications

Internal

• Altered metabolic state; 
• altered nutritional state (e.g., obesity, emaciation); 
• altered circulation; 
• altered sensation; 
• altered pigmentation; 
• skeletal prominence; 
• developmental factors; 
• immunological deficit; 
• alterations in skin turgor (change in elasticity); 
• altered fluid status

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.

READ MORE - Impaired Skin integrity