ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html C:\Documents and Settings\elibrary\Desktop\NANDA_Nursing_D-MobileDB.

pdb PDB Name: NANDA Dx Creator ID: Mdb1 PDB Type: Mdb1 Attributes: 8 Version: 0 Unique ID Seed: 0 Creation Date: 3/24/1940 7:49:37 PM Modification Date: 3/24/1940 7:49:37 PM Last Backup Date: 1/1/1904 Modification Number: 0

Dx Page Definition AEB Risk (R/T) Sugg. NIC Intervention Pediatric Geriatric Multicultural Home Care Teaching

Sugg. NOC

Client Outcomes

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html an exercise program with a friend. (1) Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems and the need for community or home health services. (2) Assess the home environment for factors that precipitate or contribute to decreased activity tolerance: stairs, lack of assistive bed or bathroom devices; distance to bathroom; presense of allergens such as dust, smoke, and those associated with pets; temperature; energy-intensive patterns; and furniture placement. Refer to occupational therapy if needed to assist the client in restructuring the home and ADL patterns. (3) Refer to physical therapy for strength training, possible weight training. (4) Support strength training program prescribed by physical therapist. (5) Normalize the client's activity intolerance; encourage progress with positive feedback. The client's experience should be validated as within expected norms. Recognition of progress enhances motivation. (5) Teach the client/family the......... (1) Instruct the client on rationale and techniques for avoiding intolerance. (2) Teach the client to use controlled breathing techniques with activity. (3) Teach the client the importance and method of coughing, clearing secretions. (4) Instruct the client in the use of relaxation techniques during activity. (5) Help client with energy conservation and work simplification techniques in ADLs. (6) Teach the client the importance of proper nutrition. (7) Describe to the client the symptoms of activity intolerance, including which symptoms to report to the physician. (8) Explain to the client how to use assistive devices or medications before or during activity. (9) Help client set up an activity log to record exercise and exercise tolerance. Activity intolerance, risk for 135 At risk for experiencing physiological or psychological energy to endure or complete required or desired daily activities History of intolerance to activity; deconditioned status; presence of circulatory or respiratory problems; inexperience with activity See risk factors Activity Tolerance; Endurance; Energy Conservation None Listed. Energy Management; Exercise Promotion; Strength Training; Activity Therapy See care plan for activity intolerance See care plan for activity intolerance See care plan for activity intolerance See care plan for activity intolerance Adjustment, impaired 136 Inability to modify lifestyle/behavior in a manner consistent with a change in health status Denial of health status change; failure to achieve optimal sense of control; failure to take actions that would prevent further health problems; demonstration of nonacceptance of health status change, occurs within a recent time period of notification of alteration in health status requiring a change in client behavior Expressed negitivity; intense emotional state; negative attitude toward health behavior; failure to intend to change behavior; multiple stressors; absence of social support for change in beliefs and practices; disability or health status change requiring change in lifestyle; lack of motivation to change behaviors, family system pressure to remain status quo Acceptance: Health Status; Coping; Grief Resolution; Health-Seeking Behavior; Participation in Health Care Decisions; Psychosocial Adjustment: Life Change; Treatment Behavior: Illness or Injury CLIENT WILL (Specify time frame): (1) State acceptance of change in health status. (2) Request assistance in altering behaviors to adapt to change. (3) State personal goals for dealing with change in health status and means to prevent further health problems. Coping Enhancement (1) Assess the client's perception about the illness/event. Ask the client to state feelings related to the change in health status. (2) Assess the client and family for the presence of additional stressors (e.g., financial difficulty, health of other family members, occupational changes). (3) Assess the client's feelings about whether change in health status is personally being dealt with effectively. (4) Assess for negative affect and internalization of problems. (5) Assess the socioeconomic status of all clients. (6) Allow the client adequate time to express feelings about the change in health status. (7) Help the client work through the stages of grief. Denial is usually the initial response.

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Achknowledge that grief takes time, and give the client permission to grieve; accept crying. (8) Recognize that denial may be adaptive at certain stages of a threatening encounter. (9) Discuss resources that have worked previously when dealing with changes in lifestyle or health status........ (1) Assess for signs of depression resulting from illness-associated changes and make appropriate referral. (2) Monitor the client for agitation. (3) Increase and mobilize support available to the elderly client. Encourage interaction with family and friends. (1) Assess for the influence of cultural beliefs, norms, and values on the client's ability to modify health behaviors. (2) Encourage spirituality as a source of support for coping. (3) Discuss with the client those aspects of health behavior/lifestyle that will remain unchanged by their health status. (4) Negotiate with the client regarding the aspects of health behavior which will need to be modified. (5) Assess the role of fatalism on the client's ability to modify health behavior. (6) Identify which family members the client can rely on for support. (7) Validate the client's feelings regarding the impact of health status on current lifestyle. (1) Include a spiritual assessment in overal assessment of client and family resources. (2) Refer to medical social services to facilitate the listed interventions and support client care goals. (3) Assess affective climate within the family and family support system. (4) Observe for signs of caregiver stress on an ongoing basis. Refer to necessary support services. (5) Refer the client to counselor or therapist for follow-up care. Initiate community referrals as needed. (1) Teach the client to maintain a positive outlook by listing current strengths. (2) Teach a client and his or her family relaxation techniques (controlled breathing, guided imagery) and help them practice. (3) Allow the client to proceed at own pace in learning; provide time for return demonstrations. (4) Involve significan others in planning and teaching. (5) If long-term deficits are expected, inform the family as soon as possible. (6) Teach families intervention techniques for family members such as setting limits, communicating acceptable behavior, and having time-outs. (7) Educate and prepare families regarding the appearance of the client and the environment before initial exposure. Airway clearance, ineffective 141 Inability to clear secretions or obstructions from the respiratroy tract to maintain a clear airway Dyspnea; diminished breath sounds; orthopnea; adventitious breath sounds (crackles, wheezes); cough, ineffective or absent; sputum production; cyanosis; difficulty vocalizing; wide-eyed; changes in respiratory rate and rhythm; restlessness ENVIRONMENTAL: Smoking; smoke inhalation; second-hand smoke; obstructed airway; airway spasm; retained secretions; excessive mucus; presence of artificial airway; foreign body in airway; secretions in bronchi; exudate in alveoli PHYSIOLOGICAL: Neromuscular dysfunction; hyperplasia of bronchial wall; COPD; infection; asthma; allergic airways Aspiration Prevention; Respiratroy Status: Airway Patency, Gas Exchange, Ventilation CLIENT WILL (Specify Time Frame): (1) Demonstrate effective coughing and clear breath sounds; is free of cyanosis and dyspnea. (2) Maintain a patent airway at all at times. (3) Relate methods to enhance secretion removal. (4) Relate the significance of changes in sputum to include color, character, amount, and odor. (5) Identify and avoid specific factors that inhibit effective airway clearance. Airway Management; Airway Suctioning; Cough Enhancement (1) Auscultate breat sounds q 1-4 h. Breath sounds are normally clear or scattered fine cracles at bases, which clear with deep breathing. (2) Monitor respiratory patterns, including rate, depth, and effot. A normal respiratory rate for an adult without dyspnea is 12-16. (3) Monitor blood gas values and pulse oxygen saturation levels as available. (4) Position the client to optimize respiration. (5) Position the client to optimize respiration. (6) If the client has unilateral lung disease, alternate a semi-Fowler's position with a lateral position (with a 10- to 15-degree elevation and "good lung down") for 60 to 90 minutes. This method is contraindicated for a client with a pulmonary abscess or hemorrhage or with interstitial emphysema. (7) Help the client to deep breathe and perform

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html controlled coughing. Have the client inhale deeply, hold breath for several seconds, and cough two or three times with mouth open while tightening the upper abdominal muscles..................p143 (1) Encourage ambulation as tolerated without causing exhaustion. (2) Actively encourage the elderly to deep breathe and cough. (3) Ensure adequate hydration within cardiac and and renal reserves. (1) Some of the above interventions may be adapted for home care use. (2) Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems, assistive devies, and community or home health services. (3) Assess home environment for factors that exacerbate airway clearance problems. (4) Assess affective climate within family and family support system. (5) Provide the client with emotional support in dealing with symptoms of respiratory distress. (6) Provide family with support for care of a client with chronic or terminal illness. (7) Instruct the client to avoid exposure to persons with upper respiratory infections. (8) Provide/teach percussion and postural drainage per physician orders. Teach adaptive breathing techniques. (9) Determine client adherence to medical regimen. Instruct client and family in importance of reporting effectiveness of current medications to physician. (10) Teach the client how and when to use inhalant.(p145) (1) Teach imprtance of not smoking. Be aggressive in approach, ask to set a date for smoking cessation, and recommend nicotine replacement therapy. Refer to smoking cessation programs, and encourage clients who relapse to keep trying to quit. (2) Teach the client how to use a flutter clearance device if ordered, which vibrates to loosen mucus and gives positive pressure to keep airways open. (3) Teach the client how to use peak expiratory flow rate (PEFR) meter if ordered and when to seek medical attention if PEFR reading drops. Also teach how to use metered dose inhalers and self-administre inhaled corticosteroids following precautions to decrease side effects. (4) Teach client how to deep breathe and cough effectively. Teach how to use the ELTGOL method--an airway clearance method that uses lateral posture and different lung volumes to control expiratory flow of air to avoid airway compression. (5) Teach the client/family to identify and avoid specific factors that exacerbate..(p146) Allergy response, latex 148 An immunological reaction to natural rubber latex (NRL) TYPE I REACTIONS: Immediate hypersensitivity response, which is IgE mediated. Symptoms include contact urticaria progressing to systemic urticaria, angioedema, rhinitis, conjunctivitis, bronchospasm, and anaphylaxis. MAY ALSO INCLUDE: Orofacial characteristics: edema of sclera or eyelids, erythema and/or itching of the eyes, tearing of the eyes, nasal congestion, itching and/or erythema, rhinorrhea, facial erythema, facial itching, gastrointestinal characteristics: abdominal pain, nausea; generalized characteristics: flushing, general discomfort, generalized edema, increasing complaint of total body warmth, restlessness. TYPE IV REACTIONS: Allergic contact dermatitis (delayed hypersensitivity, also sometimes called chemical sensitivity dermatitis): eczema; irritation; may progress to oozing skin blisters; rach usually begins 24 to 48 hours after contact. IRRITANT CONTACT DERMATITIS: Dry, itchy, irritated areas on the skin; chapped or cracked skin; blisters. No immune mechanism response. Allergic Response: Localized, Systemic; Immune Hypersensitivity Response; Symptom Severity; Tissue Integrity: Skin and Mucous Membranes CLIENT WILL (Specify Time Frame): (1) Identify presence of NRL allergy. (2) List history of risk factors. (3) Identify type of reaction. (4) State reasons not to use or to have anyone use latex products. (5) Experience a latex-free environment for all health care procedures. (6) Avoid areas where thre is powder from NRL gloves. (7) State the importance of wearing a Medic-Alert bracelet and wear one. (8) State the importance of carrying an emergency kit with a supply of nonlatex gloves, antihistamines, and an autoinjectable epinephrine syringe (Epi-Pen), and carry one. Allergy Management; Latex Precautions (1) Identify clients at risk: those persons who are most likely to exhibit a sensitivity to NRL that may result in varying degrees of reactivity. Consider the following client groups: ..... (2) Take a

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html thorough history of the client at risk. (3) Question the client about associated symptoms of itching, swelling, and redness after contact with rubber products such as rubber gloves, balloons, and barrier contraceptives, or swelling of the tongue and lips after dental examinations. (4) Consider a skin prick test with NRL extracts to identify IgE-mediated immunity. (5) All latex-sensitive clients are treated as if they have NRL allergy. (6) Patients with spina bifida and others with a positive history of NRL sensitivity or NRL allergy should have all medical/surgical/dental procedures performed in a latexcontrolled environment. (7) The most effective approach to preventing NRL anaphylaxis is complete latex avoidance. Medications may reduce certain symptoms. (8) Materials and items that .... (1) Assess the home environment for presence of NRL products (e.g., balloons, condoms, gloves, and products of related allergies, such as bananas, avocados, and poinsettia plants). (2) At onset of care, assess client history and current status of NRL allergy response. (3) Seek medical care as necessary. (4) Do not use NRL products in caregiving (5) Assist the client in identifying and obtaining alternatives to NRL products. (6) (1) Provide written information about NRL allergy and sensitivity. (2) Instruct the client to inform health care professionals if he or she has an NRL allergy, particularly if they are scheduled for surgery. (3) Teach the client what products contain NRL and to avoid direct contact with all latex products and foods that trigger allergic reactions. Allergy response, latex, risk for 154 At risk for exposure to natural rubber latex (NRL) products RISK FACTORS: Children with three or more surgeries, especially as a neonate; neural tube defects; allergies to bananas, avocados, tropical fruits, kiwis, chestnuts, apples, carrots, celery, potatoes, tomatoes; professions with daily exposure to latex; conditions needing continuous or intermettent catheterization; history of the reactions to latex Allergic Response: Systemic; Immune Hypersensitivity Response; Knowledge: Health Behavior; Risk Control; Risk Detection; Tissue Integrity: Skin and Mucous Membranes CLIENT WILL (Specify Time Frame): (1) State risk factors for NRL allergy. (2) Request latex-free environment. (3) Demonstrate knowledge of plan to treat NRL allergic reaction. Allergy Management; Latex Precautions (1) Clients at high risk need to be identified, such as those with frequent bladder catheterizations, occupational exposure to latex, past history of atopy (hayfever, dermatitis, or food allergy to fuits such as bananas, avocados, papaya, chestnut, or kimi); those with a history of anaphylaxis of uncertain etiology, especially if associated with surgery; health care workers; and females exposed to barrier contraceptives and routine examinations during gynecological and obstetric procedures. (2) Clients with spina bifida are a high-risk group for NRL allergy and should remain latex free from the first day of life. (3) Children who are on home ventilation should be assessed for NRL allery. (4) Assess for NRL allergy in clients who are exposed to "hidden" latex. (5) See care plan for Latex Allergy response. (1) Ensure that the client has a medical plan if a response develops. Prompt treatment decreases potential severity of response. (2 See care plan for Latex Allergy response. Note client history and environmental assessment. (1) A client who has had symptoms of NRL allergy or who suspects he or she is allergic to latex should tell his or her employer and contact his or her institution's occupational health services. (2) Health care workers should avoid the use of latex gloves and seek alternatives such as gloves made from nitrile. Anxiety 157 A vague, uneasy feeling of discomfort or dread accompanied by an autonomic response, with the source often nonspecific or unknown to the individual; a feeling of apprehension caused by anticipation of danger. Anxiety is an alerting signal that warns of impending danger and enables the individual to take measrues to deal with threat. BEHAVIORAL: Diminished productivity; scanning and vigilance; poor eye contact; restlessness; glancing about; extraneous movement; expressed concerns resulting from change in life events; insomnia; fidgeting. AFFECTIVE:

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html plan as indicated. (9) Encourage use of appropriate community resources: family, friends, neighbors, selfhelp and support groups, volunteer agencies, churches, clubs and centers for recreation, and other persons with similar ...... (1) Teach the client/family the symptoms of anxiety. (2) Because intensive care unit (ICU) stays are increasingly shorter, provide written teaching information that is readily available to clients when they are transferred out. (3) Help client to define anxiety levels (from "easily tolerated" to "intolerable") and select appropriate interventions. (4) Teach the client techniques to self-manage anxiety. (5) Teach the client to identify and use distraction or diversion tactics when possible. (6) Teach the client to allow anxious thoughts and feelings to be present until they dissipate (7) Teach progressive muscle relaxation techniques. (8) Teach relaxation breathing for occasional use: client should breathe in through nose,fill slowly from abdomen upward while thinking "re," and then breathe out through mouth, from chest downward, and think "lax." (9) Teach the client to visualize or fantasize about the absence of anxiety or pain, successful experience of the situation, resolution of ... Anxiety, Death 165 The apprehensions, worry, or fear related to death or dying. Worrying about impact of one's own death on significant others; powerless over issues related to dying; fear of loss of physical and/or mental abilities when dying; anticipated pain related to dying; deep sadness; dear of process of dying; concerns of overworking caregiver as terminal illness incapacitates self; concern about meeting one's creator or feeling doubtful about existence of God or higher being; total loss of control over any aspect of one's own death; negative death images or unpleasant thoughts about any event related to death or dying; fear of delayed demise; fear of premature death because it prevents accomplishment of important life goals; worrying about being the cause of others' grief and suffering; fear of leaving family alone after death; fear of developing a terminal illness; denial of one's own mortality or impending death see Defining Characteristics Dignified Life Closure; Fear Self-Control; Health Beliefs: Perceived Threat (1) State concerns about impact of death on others. (2) Express feelings associated with dying. (3) Seek help in dealing with feelings. (4) Discuss concerns about God or higher being. (5) Discuss realistic goals. (6) Use prayer or other religious practice for comfort. Dying Care; Grief Work Facilitation; Spiritual Support (1) Assess the client's level of anxiety and physical reactions to anxiety (e.g., tachycardia, tachypnea, nonverbal expressions of anxiety). Use the Sheehan Patient-Rated Anxiety Scale (SPRAS). Vaildate observation by asking the client, "Are you feeling anxious now?" consider the use of a "faces scale" to assess anxiety in critically ill clients. (2) use presence, touch (with permission), verbalization, and demeanor to remind clients that they are not alone and to encourage expression or clarification of needs, concerns, unknowns, and questions. (3) Accept the client's defenses; do not confront, argue, or debate. (4) Allow and reinforce the client's personal reaction to or expression of pain, discomfort, or threats to well-being (e.g., talking, crying, walking, other physical or nonverbal expressions). (5) Help the client identify preciptants of anxiety that may indicate interventions. (6) If the situational response is rational, use empathy to encourage the SEE BOOK !!!!!!!!!!!!! (1) Monitor the client for depression. Use appropriate interventions and referrals. (2) Provide a protective and safe environment. Use consistent caregivers and maintain the accustomed environmental structure. (3) Observe for adverse changes if antianxiety drugs are taken. (4) Provide a quiet environment with diversion. (1) Assess for the presence of culture-bound anxiety states. (2) Assess for theinfluence of cultural beliefs, norms, and values on the client's perspective of stressful stiuation. (3) Identify how anxiety is manifested in the culturally diverse client. (4) Acknowledge that value conflicts from acculturation stresses may contribute to increased anxiety. (5) Acknowledge that socioeconomic factors may contribute to

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html increased stress and anxiety. (6) For the diverse experiencing preoperative anxiety, provide music of thier choice. (1) Above interventions may be adapted for home care use. (2) Approach the client's anxiety in nonjudgmental fashion. (3) Assist family to be supportive of the client in the face of anxiety symptoms. (4) Adapt treatment needs to specific anxiety type. (5) Assess for presence of depression. (6) Consider referral for the prescription of antianxiety or antidepressant medications for clients who have panic disorder (PD) or other anxiety-related psychiatric disorders. (7) Assist the client/family to institute medication regimen appropriately. Instruct in side effects, importance of taking meds as ordered, and effects to report immediately to nurse or physician. (8) Assess for suicidal ideation. Implement emergency plan as indicated. (9) Encourage use of appropriate community resources: family, friends, neighbors, self-help and support groups, volunteer agencies, churches, clubs, and centers for recreation, and other persons with similar interests. (10) Refer for a psychiatric home health... (1) Teach the client/family the symptoms of anxiety. (2) Because intensive care unit ICU) stary are iincreasingly shorter, provide written teaching information that is readily available to clients when they are transferred out. (3) Help client to define anxiety levels (from "easily tolerated" to "intolerable") and select appropriate interventions. (4) Teach client techniques to self-manage anxiety. (5) Teach the client to identify and use distraction or diversion tactics when possible. (6) Teach the client to allow anxious thoughts and feelings to be present until they dissipate. (7) teach progressive muscle relaxation techniques. (8) Teach relaxation hreathing for occasional use: client should breathe in through nose, fill slowly from abdomen upward while thinking "re", and then breathe out through mouth, from chest downward, and think"lax". (9) Teach the client to visualize or fantasize about the absence of anxiety or pain, sucessful experience of the situation, resolution of ....... Aspiration, risk for 169 At risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into the tracheobronchial passages. RISK FACTORS: Increased intragastric pressure; tube feedings; situations hindering elevation of upper body; reduced level of consciousness; presence of tracheostomy or endotracheal tube; medication administration; wired jaws; increased gastric residual; incomplete lower esophageal sphincter; impaired swallowing; gastrointestinal tubes; facial, oral, or neck surgery or trauma; depressed cough and gag reflexes; decreased gastrointestinal motility; delayed gastric emptying Aspiration Prevention; Respiratory Status: Ventilation; Swallowing Status (1) Swallow and digest oral, nasogastric, or gastric feeding without aspiration. (2) Maintain patent airway and clear lung sounds. Aspiration Precautions (1) Monitor respiratory rate, depth, and effort. Note any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, or fever. (2) Auscultate lung sounds frequently and before and after feedings; note any new onset of crackles or wheezing. (3) Take vital signs frequently, noting onset of a temperature. (4) Before initiating oral feeding, check client's gag reflex and ability to swallow by feeling the laryngeal prominence as the client attempts to swallow. (5) When feeding client, watch for signs of impaired swallowing or aspiration, including coughing, choking, spitting food, or excessive drooling. If client is having problems swallowing, see Nursing Interventions for Impaired Swallowing. (6) Have suction machine available when feeding high-risk clients. (7) Keep head of bed elevated when feeding and for at least an hour afterward. (8) Note presence of any nausea, vomiting, or diarrhea. Treat nausea promptly with antiemetics. (9) Listen to bowel sounds frequently, noting if ...... (1) Carefully check elderly client's gag reflex and ability to swallow before feeding. (2) Watch for signs of aspiration pneumonia in the elderly with cerebrovascular accidents, even if there are no apparent signs of difficulty swallowing or of aspiration. (3) The central nervous system depressants cautiously; elderly clients may have an increased incidence of aspiration with altered levels of consciousness. (4) Keep the elderly, mostly bedridden client sitting upright for 2 hours following meals. (1) Above interventions may be

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html adapted for home care use. (2) For clients at high risk for aspiration, obtain complete information from the discharging institution regarding institutional management. (3) Assess the client and family for willingness and cognitive ability to learn and cope with swallowing, feeding, and related disorders. (4) Assess caregiver understanding and reinforce teaching regarding positioning and assessment of the client for possible aspiration. (5) Provide the client with emotional support in dealing with fears of aspiration. (6) Establish emergency and contingency plans for care of client. (7) Have a speech and occupational therapist assess client's swallowing ability and other physiological factors and recommend strategies for working with client in the home (e.g., pureeing foods served to client; providing adaptive equipment for independence in eating). (8) Obtain suction equipment for the home as necessary. (9) Teach caregivers safe, effective use of ........ (1) Teach the client and family signs of aspiration and precautions to prevent aspiration. (2) Teach the client and family how to safely administer tube feeding. Attachment, impaired parent/infant/child, risk for 175 Disruption of the interactive process between parent/significant other and infant/child that fosters the development of a protective and nurturing reciprocal relationship. RISK FACTORS: Physical barriers; anxiety associated with the parent role; substance abuse; premature infant, ill infant/child who is unable to effectively initiate parental contact as a result of altered behavioral organization; lack of privacy; inability of parents to meet personal needs; separation. Caregiver Adaptation to Patient Institutionalization; Child Development: 2 Months, 4 Months, 6 Months, 12 Months, 2 Years, 3 years, 4 years, Preschool; Coping; Parent-Infant Attachment; Family Physical Environment; Parenting Performance; Parenting: Psychosocial Safety; Safe Home Environment (1) Infant/child development appropriate for age. (2) parent(s) able to participate in caregiving for infant/child. (3) Parent(s) visit nursery/hospital unit. (4) Parent(s) respond to infant/child cues. (5) Parent(s) eliminate controllable environmental hazards. (6) Parent(s) use community and other resources as appropriate. Anticipatory Guideance; Attachment Process; Attachment Promotion; Coping Enhancement; Developmental Care; Developmental Enhancement; Child; Environmental management: Attachment Process; Family Integrity promotion; Parent Education: Infant; Parenting promotion; Role Enhancement FAMILY: (1) Establish a trusting relationship with the parents. (2) Assist parents in recognizing behaviors used by infant/child to communicate avoidance/stress and approach/engagement. (3) Support parents' ability to alleviate infant's/child's distress. (4) If necessary, allow parents to verbalize their fears of "ghosts in the nursery" that may influence attachment to their infant/child. Ghosts in the nursery are parents' early memories of painful experiences (e.g., unanswered cries, feeling abandoned, being abused) and are real and powerful. (5) Listen to the parents' stories to understand their struggle to attach. Acknowledge the parents' point of view and stories as worthy of respect; important truths can be learned, such as what they think and how they feel about themselves and their infant. (6) Assist parents with recognizing how their infant/child learns thru the senses and with strategies that can be used, such as timing, intensity, imitation, repetition, to initiate .......... Provide lyrical, soothing music in the nursery as appropriate (be aware that this may not be an appropriate intervention for premature infants). (2) Protect and enhance infant's interactive capabilities through organization of the environment. (3) Provide therapeutic touch for children with anxiety. (1) Discuss cultural normas with families to provide care that is appropriate for enhancing attachment with the infant/child. (2) Encourage a reciprocal attachment process. (3) Promote the attachment process by providing a treatment environment that is culturally based and women centered. (1) Above interventions may be adapted for home care use. (2) Assess quality of interaction between parent and infant/child. (3) use interaction coaching: teach mother about infant's behavioral cues and hot to match infant's

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

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html can affect all individuals regardless of culture, race, or ethnicity. (4) Assess for the presence of conflicting cultural demands. (1) Above interventions may be adapted for home care use. (2) Assess client's stage of grieving or acceptance of body change on return to home setting. Include the future role of sexuality in the psychological assessment of acceptance as appropriate. (3) Assess family/caregiver level of acceptance of client's body changes. (4) Recognize that older women may continue their younger preoccupation with weight and recurrent dieting, despite being at normal weight. Assess source of low weight or weight loss with this in mind. (5) Be accepting of body changes in all interactions with client and family/caregivers. (6) Help client to see new or changing roles in family. Point out ways in which the community can help support client and family strengths. (7) Refer to medical social services to address level of acceptance and possible financial impact of changes. (8) Teach all aspects of care. Involve client and caregivers in self-care as soon as possible. Do this in stages if client still has ... (1) Teach appropriate care of surgical site (e.g., mastectomy site, amputation site, ostomy site). (2) Inform client of available community support groups; offer to make initial phone call. (3) Refer the client to counseling for help adjusting to body change. (4) Provide printed material and didactic information for significant others. (5) Encourage significant others to offer support. (6) Direct social support as follows: instruct regarding practical care (bandaging), encourage appraisal support (listening), encourage self-esteem support (favorable comparisons between client's and others' appearance), and encourage sense of belonging (assist with socializing). The preceding are four categories of support recognized in the body-image care model. (7) Refer an interdisciplinary team to clients with ostomies who are having difficulty with personal acceptance, personal and social body-image disruption, sexual concerns, reduced self-care skills, and the management of surgical complic..... Body temperature, imbalanced, risk for 191 At risk for failure to maintain body temp within a normal range Altered metabolic rate; extremes of age or weight; exposure to cool./cold or hot/warm environment; dehydration; inactivity or vigorous activity; medications that cause vasoconstriction or vasodilatation; sedation; clothing inappropriate for environmental temp; illness or trauma that affects body temp regulation Thermoregulaton; Thermoregulation: Newborn (1) Maintain temp within normal range of 97 to 99 F in the adult. (2) Explain measures needed to maintain normal temp. (3) Identify symptoms of hypothermia or hyperthermia Temperature Regulation; Temperature Regulation: Intraoperative; Vital Signs Monitoring (1) Monitor temp q 1 to 4 hrs or use continuous temp monitoring as appropriate. Normal adult temp is usually identified at 98.6 F (37 C), but in actuality the normal temp fluctuates throughout the day. In early morning it may be as low as 96.4 F (35.8 C) and in the late afternoon or evening as high as 99.1 F (37.3 C). (2) If client is awake, take temp orally in the adult, instead of by use of a tympanic thermometer or an axillary temp. (3) Take vital signs q 1 to 4 hrs, noting changes associated with hypothermia: first, increased blood pressure, pulse, and respirations; then, decreased values as hypothermia progresses. (4) Note changes in vital signs associated w/hyperthermia: rapid, bounding pulse; increased respiratory rate; and decreased BP with orthostatic hypotension present. (5) Monitor the client for signs of hyperthermia (e.g., headache, nausea and vomiting, weakness, absence of sweating, delirium, and coma). (6) maintain a consistent room temp (72 F). (7) Promote adequate .... Recognize that pediatric clients have a decreased ability to adapt to temperature extreme. Take the following actions to maintain body temp in the infant/child: a. Keep the head covered. b. Use blankets to keep the client warm. c. Keep client covered during procedures, transport, and diagnostic testing. d. Maintain a consistent room temp of 72 F. (2) Recognize that the infant and small child are vulnerable to develop heat stroke in hot weather and ensure they receive sufficient fluids and are protected from hot environments.

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html (1) Do not allow geriatric clients to become chilled. Keep covered when giving a bath or doing a procedure. Offer socks to wear in bed and a head covering if desired. (2) Assess medication profile for potential risk of drug-related altered body temp. (3) Ensure that elderly clients receive sufficient fluids during hot days and stay out of the sun. (1) Above interventions may be adapted for home care use. PREVENTION OF HYPOTHERMIA IN COLD WEATHER: (1) Avoid prolonged exposure outside. Wear a hat and gloves. Wool or fleece clothing can help to maintain body heat. (2) Keep room temp at 68 to 72 F. (3) Ensure adequate source of heat; refer to social services if client is low income and heat could be turned off. (4) Help elderly client determine a warm environment they can go to for safety in cold weather if his or her home environment is no longer warm. PREVENTION OF HYPERTHERMIA IN HOT WEATHER: (1) Encourage the client to wear lightweight loose-fitting cotton clothing. Help the elderly remove their usual sweaters. (2) Ensure that the client drinks adequate amounts of fluids (2000 mL/d), avoiding caffeine and alcohol. (3) help client obtain a fan to increase evaporation, or an air conditioner as needed, using social services if needed. (4) Take the temp of the elderly in hot weather. (5) help elderly client determine a cool envir... (1) Teach the client and family the signs of hypothermia and hyperthermia and the appropriate actions they should take if either condition develops. (2) Teach the client and family proper method for taking temp. (3) Teach to avoid alcohol and meds that depress cerebral function. Bowel incontinence 195 Change in normal bowel elimination habits characterized by involuntary passage of stool. Costant dribbling of soft stool, fecal odor; inability to delay defecation; rectal urgency; self-report of inability to feel rectal fullness or presence of stool in bowel; fecal staining of underclothing; recognition of rectal fullness but reported inability to expel formed stool; inattention to urge to defecate; inability to recognize urge to defecate; red perineal skin Change in stool consistency (diarrhea, constipation, fecal impaction); abnormal motility (metabolic disorders, inflammatory bowel disease, infectious disease, drug induced motility disorders, food intolerance); defects in rectal vault function (low rectal compliance from ischemia, fibrosis, radiation, infectious proctitis, Hirschprung's disease, local or infiltrating neoplasm, sever rectocele); sphincter dysfunction (obstetric or traumatic induced incompetence, fistula or abscess, prolapse, third-degree hemorrhoids, pseudodyssynergia of the pelvic muscles); neurological disorders impacting gastrointestinal motility, rectal vault function and sphincter function (CVA, spinal injury, traumatic brain injury, CNS tumor, advanced stage dementia, encephalopathy, profound mental retardation, multiple sclerosis, myelodysplasia and related neural tube defects, gastroparesis of diabetes mellituts, heavy metal poisoning, chronic alcoholism, infectious or autoimmune neurological disorders, etc. Bowel continence; Bowel Elimination (1) Have regular, complete evacuation of fecal contents from the rectal vault (pattern may vary from every day to every 3-5 days). (2) Have regulation of stool consistency (soft, formed stools). (3) Reduce or eliminate frequency of incontinent episodes. (4) Demonstrate intact skin in the perianal/perineal area. (5) Demonstrate the ability to isolate, contract and relax pelvic muscles (when incontinence related to sphincter incompetence, pseudodyssynergia). (6) Increased pelvic muscle strength (when incontinence related to sphincter incompetence). Bowel Incontinence Care; Bowel Incontinence Care: Encopresis; Bowel Training (1) In a reasonably private setting, directly question any client at risk about the presence of fecal incontinence. If the client reports altered bowel elimination patterns, problems with bowel control or "uncontrollable diarrhea," complete a focused nursing history including previous and present bowel elimination routines, dietary history, frequency and volume of uncontrolled stool loss, aggravating and alleviating factors. (2) Complete a focused physical assessment including inspection of perineal skin, pelvic muscle strength assessment, digital examination of the rectum for presence of impaction and anal sphincter strength, and evaluation of functional status (mobility, dexterity, visual

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html acuity). (3) Complete an assessment of cognitive function. (4) Document patterns of stool elimination and incontinent episodes via a bowel record including frequency of bowel movements, stool consistency, frequency and severity of incontinent episodes, precipitating factors, dietary and fluid ...... (1) Evaluate all elderly clients for established or acute fecal incontinence when the elderly client enters the acute or long-term care facility and intervene as indicated. (2) Evaluate cognitive status in the elderly person with a NEECHAM confusion scale (Neelan et al, 1992) for acute cognitive changes, a Folstein Mini-Mental Status Examination (Folstein et al, 1975), or other tool as indicated. (1) Above interventions may be adapted for home care use. (2) Assess and teach a bowel management program to support continence. Address timing, diet, fluids, and actions taken independently to deal with bowel incontinence. (3) Instruct caregiver to provide clothing that is nonrestrictive, can be manipulated easily for toileting, and can be changed with ease. (4) Assist the family in arranging care in a way that allows the client to participate in family or favorite activities without embarrassment. (5) If the client is limited to bed (or bed and chair), provide a commode or bedpan that can be easily accessed. If necessary, refer the client to physical therapy services to learn side transfers and to build strength for transfers. (6) If the client is frequently incontinent, refer for home health aide services to assist with hygiene and skin care. (1) Teach the client and family to perform a bowel reeducation program, scheduled, stimulated program, or other strategies to manage fecal incontinence. (2) Teach the client and family about common dietary sources for fiber, as well as supplemental fiber or bulking agents as indicated (3) Refer the family to support services to assist with in-home management of fecal incontinence as indicated. (4) Teach nursing colleagues and nonprofessional care providers the importance of providing toileting opportunities and adequate privacy for the client in an acute or long-term care facility. NOTE: Refer to nursing diagnoses Diarrhea and Constipation for detailed management of these related conditions Breastfeeding, effective 201 Mother-infant dyad/family exhibits adequate proficiency and satisfaction with the breastfeeding process Effective mother/infant communication patterns; regular and sustained suckling/swallowing at the breast; appropriate infant weight pattern for age; infant content after feeding; mother able to position infant at breast to promote a successful latch-on response; signs and/or symptoms of oxytocin release; adequate infant elimination patterns for age; eagerness of infant to nurse; maternal verbalization of satisfaction with the breastfeeding process Basic breastfedding knowledge/normal breast structure/normal infant oral structure/infant gestational age> 34 weeks/support sources (e.g., encouraging partner, history of positive breastfeeding experiences among relatives and friends, access to support groups such as La Leche League)/maternal confidence Breastfeeding Establishment: Infant, Maternal; Breasfeeding Maintenance (1) Maintain effective breastfeeding. (2) Maintain normal growth patterns (infant). (3) Verbalize satisfaction with breastfeeding process (mother). Breastfeeding Assistance, Lactation Counseling (1) Encourage rooming-in and breastfeeding on demand. (2) Monitor the breasfeeding process. (3) Identify opportunities to enhance knowledge and experience regarding breastfeeding. Support and teaching must be individualized to the client's level of understanding. (4) Give encouragement/positive feedback r/t breastfeeding mother-infant interactions. (5) Monitor for signs and symptoms of nipple pain and/or trauma. (6) Discuss prevention and treatment of common breastfeeding problems. Permits the nurse to identify the need for info and clarification. (7) Monitor infant responses to breastfeeding. (8) identify current support person network and opportunities for continued breastfeeding support. (8) Avoid supplemental bottle feedings and do not provide samples of formula on discharge. Provide follow-up contact; as available provide home visits and/or peer counseling.

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html (1) Assess for the influence of cultural beliefs, norms, and values on current breastfeeding practices. (2) Assess for when the mother wishes to begin breastfeeding. (3) Validate the client's concerns about the amount of milk taken. (1) Include the father and other family members in education about breastfeeding. (2) Teach the client the importance of maternal nutrition. Generally, no special diet is required but drinking to satisfy thirst and a healthy diet using foods from a variety of sources is recommended. (3) Reinforce the infant's subtle hunger cues (e.g., quiet-alert state, rooting, sucking, hand-to-mouth activity) and encourage the client to nurse whenever signs are apparent. (4) Review guidelines for frequency (every 2 to 3 hours, or at least eight feedings per 24 hours) and duration (until suckling and swallowing slow down and satiety is reached). (5) Provdie anticipatroy guidance about common infant behavior. (6) Provide info about additional breastfeeding resources. Breastfeeding, ineffective 206 Dissatisfaction or difficulty a mother, infant, or child experiences with the breasfeeding process Unsatisfactory breasfeeding process; nonsustained suckling at the breast; resisting latching on; unresponsive to comfort measures; persistence of sore nipples beyond first week of breastfeeding; observable signs of inadequate infact intake; insufficient emptying of each breast per feeding; infant inability to latch on to maternal breast correctly; infant arching and crying at the breast; infant exhibiting fussiness and crying within the first hour after breastfeeding; actual or perceived inadequate milk supply; no observable signs of oxytocin release; insufficient opportunity for suckling at the breast Non-supportive partner/family; previous breast surgery; infant receiving supplemental feedings with artificial nipple; prematurity; previous history of breasfeeding failure; poor infant suckling reflex; maternal breast anomaly; maternal anxiety or ambivalence; interruption in breastfeeding; infant anomaly; knowledge deficit Breastfeeding Establishment: Infant, Maternal; Breastfeeding Maintenance; Breastfeeding Weaning; Knowledge: Breastfeeding (1) Achieve effective breasfeeding (dyad). (2) verbalize/demonstrate techniques to manage breastfeeding problems (mother). (3) manifest signs of adequate intake at the breast (infant). (4) Manifest positive self-esteem in relation to the infant feeding process (mother). (5)Explain alternative method of infant feeding if unable to continue exclusive breastfeeding (mother). Breastfeeding Assistance; Lactation Counseling (1) Identify women with risk factors for lower breastfeeding initiation and continuation rates (age <20 years, low socioeconomic status) as well as factors contributing to ineffective breastfeeding as early as possible in the perinatal experience. (2) Use valid and reliable tools to measure breastfeeding performance and to predict early discontinuance of breastfeeding whenever possible/feasible. (3) Encourage rooming-in and feeding on demand. (4) Evaluate the breast and nipple structures and provide appropriate measures as needed. (5) Observe a full breastfeeding session (every 8 hours in the early postpartum and once per visit on follow-up). (6) Provide evidence-based teaching and breastfeeding assistance appropriate to the client's individualized needs (see Client/Family Teaching). (7) Promote comfort and relaxation to reduce pain and anxiety. (8) Provide time for clients to express their expectations and concerns and give emotional support. (9) Avoid supplemental feedings. (10) .... (1) Assess for the influence of cultural beliefs, norms, and values on breastfeeding attitudes. (2) Assess whether the client's concerns about the amount of milk taken during breastfeeding is contributing to dissatisfaction with the breastfeeding process. (3) Assess the influence of family support on the decision to continue or discontinue breastfeeding. (4) Validate the client's feelings regarding the difficulty or dissatisfaction with breastfeeding. (1) Above interventions may be adapted for home care use. (2) Investigate availability/refer to public health department or hospital home follow-up breastfeeding program. Some hospitals and public health departments have follow-up breastfeeding programs, particularly for high-risk mothers

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html (e.g., older mothers, past history substance use, risk of physical abuse). Instructions initiated during hospitalization are continued. (3) Monitor for specific difficulties contributing to bonding difficulties between mother and infant. (1) Review maternal and infant benefits of breastfeeding. (2) Instruct the client on maternal breastfeeding behaviors/techniques (preparation for, positioning, initiation of/promoting latch-on, burping, completion of session, and frequency of feeding). Difficulties in these practices contribute to ineffective breastfeeding. (3) Teach the client self-care measures for the breastfeeding woman (e.g., Breast care, Management of breast/nipple discomfort, Nutrition/fluid, rest/activity). (4) Provide information regarding infant cues and behaviors related to breastfeeding and appropriate maternal responses (e.g., cues that infant is ready to feed, behaviors during feeding that contribute to effective breastfeeding, measures of infant feeding adequacy). (5) Provide education to father/family/significant others as needed. Breastfeeding, interrupted 214 Break in the continuity of the breastfeeding process as a result of inability or inadvisability to putting the infant to the breast for feeding Infant does not receive nourishment at the breast for some or all feedings; maternal desire to maintain lactation and provide (or eventually provide) her breast milk for her infant's nutritional needs; separation of mother and infant; lack of knowledge regarding expression and storage of breast milk Maternal or infant illness; prematurity; maternal employment; contraindications to breastfeeding (e.g., drugs, true breast milk jaundice); need to abruptly wean infant (with intent to resume at later date) Breastfeeding Establishment: Infant, Maternal; Breastfeeding maintenance; Knowledge: Breastfeeding; Parent-Infant Attachment INFANT: (1) Receive mother's breast milk if not contraindicated by maternal conditions (e.g., certain drugs, infections) or infant conditions (e.g., true breast milk jaundice). MATERNAL: (1) Maintain lactation. (2) Achieve effective breastfeeding or satisfaction with the breastfeeding experience. (3) Demonstrate effective methods of breast milk collection and storage. Bottle Feeding; Breastfeeding Assistance; Emotional Support; Kangaroo Care; Lactation Counseling (1) Discuss mother's desire/intention to begin or resume breastfeeding. (2) Provide anticipatory guidance to the mother/family regarding potential duration of the interruption when possible/feasible. (3) Reassure mother/family that early measures to sustain lactation and promote parent/infant attachment can make it possible to resume breastfeeding when the conditoin/situation requiring interruption is resolved. (4) Reassure the mother/family that the infant will benefit from any amount of breast milk provided. (5) Provide time for mother/family to express their expectations and concerns and give emotional support. Emotional responses regarding events leading to the interrruption that may arise include feelings of grief/loss, guilt, anxiety, and failure. (6) Collaborate with the moterh/family/health care providers/employers (as needed) to develop a plan for expression of breast milk/infant feeding/and kangaroo care/skin-to-skin contact (KC). (7) Monitor for signs indicating infants.... (1) Assess for the influence of cultural beliefs, norms, values on current decision to stop breastfeeding. (2) Assess the influence of family support on th edecision to continue or discontinue breastfeeding. (3) Assess whether the client's concerns about the amount of milk taken during breastfeeding is contributing to decision to stop breastfeeding. (4) Validate the client's feelings with regard to the difficulty of or her dissatisfaction with breastfeeding. (1) Teach mother effective methods to express breast milk. (2) teach mother/parents about kangaroo care. (3) Instruct mother on safe breast milk handling techniques. (4) Provide education to father/family/significant others as needed. Breathing pattern, ineffective 221 Inspiration and/or expiration that does not provide adequate ventilation. Decreased inspiratory/expiratory pressure; decreased minute ventilation; use of accessory muscles to breathe; nasal flaring; dyspnea; altered chest excursion;

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html (LVSWI); S3 or S4 sounds. BEHAV.: Anxiety, restlessness Altered heart rate/rhythm; altered stroke volume: altered preload, altered afterload, altered contractility. Cardiac Pump Effectiveness; Circulation Status; Tissue Perfusion: Abdominal Organs, Peripheral; Vital Signs (1) Demonstrate adequate cardiac output as evidenced by BP and pulse rate and rhythm within normal parameters for client; strong peripheral pulses; and an ability to tolerate activity w/o symptoms of dyspnea, syncope, or chest pain. (2) Remain free of side effects from the medications used to achieve adequate cardiac output. (3) Explain actions and precautions to take for cardiac disease. Cardiac Care; Cardiac Care: Acute (1) Monitor for symptoms of heart failure and decreased cardiac output; listen to heart sounds, lung sounds, note symptoms including paroxysmal nocturnal dyspnea, neck vein distention, crackles in lung bases, S3 gallop, increased venous pressure greater than 16 cm H2O, and positive hepatojugular reflex. (2) Observe for symptoms of cardiogenic shock including impaired mentation, hypotension with blood pressure lower than 90 mm Hg, decreased peripheral pulses, cold clammy skin, signs of pulmonary congestion and decreased organ function. If present, notify physician immediately. (3) If shock is present, monitor hemodynamic parameters for an increase in pulmonary wedge pressure, an increase in systemic vascular resistance, or a decrease in cardiac output and index. (4) Titrate inotropic and vasoactive medications within defined parameters to maintain contractility, preload, and afterload per physician's order. (5) Observe for chest pain or discomfort; note location, radiation, severity,... (1) Observe for atypical pain; the elderly often have jaw pain instead of chest pain or may have silent MIs with symptoms of dyspnea or fatigue. (2) If client has heart disease causing activity intolerance, refer for cardiac rehabilitation. (3) Observe for syncope, dizziness, palpitations, or feelings of weakness associated with an irregular heart rhythm (4) Observe for side effects from cardiac medications. (1) Some of the above interventions may be adapted for home care use (2) Begin discharge planning as soon as possible with case manager or social worker to assess home support systems and the need for community or home health services. Support services may be needed to assist with home care, meal preparations, housekeeping, personal care, transportation to doctor visits, or emotional support. (3) Consider development of a clinical pathway to address focused interventions with congestive heart failure (CHF), coronary artery bypass graft (CABG). (4) Assess or refer to case manager or social worker to evaluate client ability to pay for prescriptions. (5) Continue to monitor client for exacerbation of heart failure when discharged home. (6) Monitor women for differential symptoms of MI and institute emergency treatment measures as indicated. (7) Assess client for understanding of and compliance with medical regimen, including medications, activity level, and diet. Client/family may ....... (1) Teach symptoms of heart failure and appropriate actions to take if client becomes symptomatic. (2) Teach importance of smoking cessation and avoidance of alcohol intake. Clients who continue to smoke increase their chance of dying by at least 50%, and alcohol depresses heart contractility (3) Teach stress reduction (e.g., imagery, controlled breathing, muscle relaxation techniques). (4) Explain necessary restrictions, including consumption of a sodium-restricted diet, guidelines on fluid intake, and the avoidance of Valsalva's maneuver. Teach the importance of pacing activities, work simplification techniques, and the need to rest between activities to prevent becoming overly fatigued. Sodium retention leading to fluid overload is a common cause of hospital readmission (5) Assist the client in understanding the need for and how to incorporate lifestyle changes. Refer to cardiac rehabilitation for assistance with coping and adjustment. Psychoeducational programs including info...... Caregiver role strain 235 Defficulty in performing family caregiver role ACTIVITES: Apprehension about possible institutionalization of care receiver; apprehension about the future regarding care receiver's health and caregiver's ability to provide care; difficulty performing/completing required tasks; apprehension about care receiver's care

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html if the caregiver becomes ill or dies; preoccupation with care routine. PHYSICAL: Gastrointestinal upset; weight change; rash; hypertension; cardiovascular disease; diabetes; fatigue; headache. EMOTIONAL: impaired inidividual coping; feeling of depression; disturbed sleep; anger; stress; somatization; increased nervousness; increased emotional lability; impatience; lack of time to meet personal needs; frustration. SOCIOECONOMIC: Withdrawal from social life; changes in leisure activities; low work productivity; refusal of career advancement. RELATIONSHIP: Grief and/or uncertainty regarding changed relationship with care receiver; difficulty watching care receiver go through the illness. Family conflict; concerns about fam Illness severity; illness chronicity; increaing care needs/dependency; unpredictability of illness course; instability of care receiver's health; problem behaviors; psychological or cognitive problems; addiction or codependency. Amount of activities; complexity of activities; 24-hour care responsibilities; ongoing changes in activities; discharge of family members to home w/significant care needs; years of caregiving; unpredictability of care situation. Physical problems; psychological or cognitive problems; addiction or codependency; marginal coping patterns; unrealistic expectations of self; inability to fulfill one's own or others expectations. Isolation from others; competing role commitments; alienation from family, friends, and coworkers; insufficient recreational resources. History of poor relationship; presence of abuse or violence; unrealistic expectations of caregiver by care receiver; mental status of elder that inhibits conversation. History of marginal family coping; etc. Caregiver Emotional Health; Caregiver Lifestyle Disruption; Caregiver Performance: Direct Care, Indirect Care; Caregiver Physical Health; Caregiver Stressors; Caregiver Well-Being; Role Performance (1) Caregiver will maintain physical and psychological health. (2) Caregiver will identify resources available to help in giving care. (3) Care receiver will obtain appropriate care. Caregiver Support (1) Use an evaluation tool to determine caregiver coping and strain. Various instruments have been developed, including the Burden Interview, the Caregiver Strain Index, the Caregiver Burden Inventory, and the Subjective and Objective Burden Scale. (2) Watch for signs of depression in the caregiver, especially if the marital relationship is poor. Intervene to help the caregiver cope. If signs are present, refer to the care plan for Hopelessness. (3) Monitor the quality of care by the caregiver for adequacy and need for improvement. (4) Observe for signs of addiction or codependency in the caregiver or care receiver. (5) Arrange for a home health nurse to provide nursing care and case management following discharge. (6) Arrange intervals of respite care for the caregiver; encourage use if available. (7) Help the caregiver to identify supports and be assertive in using them. (8) Encourage the caregiver to grieve over loss of the care receiver's function. Give the caregiver permission ... (1) Monitor the caregiver for psychological distress and signs of depression, especially if caring for a mentally impaired elder or if there was an unsatisfactory marital relationship before caregiving. (2) Assess the health of the caregiver at intervals, especially if he or she has chronic illness in addition to caregiving role. (3) Recognize that it is hard for the elderly to accept any change in caregivers or in the environment. (1) Assess for the influence of cultural beliefs, norms, values, and expectations on the family's experience of caregiving. (2) Assess for conflicts between the caregiver's cultural obligations to provide care and competing factors like employment. (3) Negotiate with the client regarding the aspects of caregiving that can be modified while still honoring cultural beliefs. (4) Refer the family to social services or other supportive services to assist with the impact of caregiving. (5) Assist the family/caregiver in identifying barriers that would prevent the use of social services or other supportive services that could help reduce the impact of caregiving. (6) Encourage the family to use support groups or other service programs. (7) Encourage caregiver use of spirituality or religion as a source of support for the caregiver. (8) Validate the family's feelings regarding the impact of caregiving on family and personal lifestyle. (1)

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Identify client and caregiver factos that necessitated the use of formal home care services and that may affect provision of care or need to be addressed before the client can be safely discharged. (2) Assess the client and caregiver at every visit for quality of relationship, quality of care provided, functional disability of care recipient, and signs of caregiver stress. Document all observations objectively. (3) Assess perceived level of power experienced by the caregiver in daily activites. (4) Assess preexisting strengths and weaknesses the caregiver brings to the situation, as well as current responses, depression, and fatigue levels. (5) Identify strengths of caregiver and efforts to gain control of unpredictable situations. (6) Help the caregiver to stay connected with the client who may be behaving differently than usual, to make life as routine as possible, to help the client set goals and sustain hope, and to allow the client space to experience progress. (7) ........... (1) Teach the caregiver methods for managing behavioral symptoms if the care receiver has dementia. (2) Teach the caregiver how to provide the physical care needed. (3) Refer to counseling or support groups to assist in adjusting to the caregiver role. Caregiver role strain, risk for 246 Caregiver vulnerability for felt difficulty in performing family caregiver role Lack of developmental readiness on part of caregiver for caregiving role; inadequate physical environment for providing care; unpredictable illness course or instability in care receiver's health; psychological or cognitive problems in care receiver; presence of situational stressors that normally affect families; presence of abuse or violence; premature birth or congenital defect; past history of poor relationship between caregiver and care receiver; marginal family adaptation or dysfunction before caregiving situation; marginal coping patterns on part of caregiver; lack of respite and recreation for caregiver; inexperience with caregiving; female gender of caregiver; addiction or codependency; demonstration of deviant or bizarre behavior by care receiver; competing role commitments of caregiver; high complexity/amount of caregiving tasks; developmental delay or retardation of care receiver or caregiver; discharge of family member w/significant home care needs; ETC. Caregiver Emotional Health; Caregiver Lifestyle Disruption; Caregiver Performance: Direct Care, Indirect Care; Caregiver Physical Health; Caregiver Stressors; Caregiver Well-Being; Role Performance (1)Maintain physical and psychological health. (2) identify resources available to help in giving care. (3) Obtain appropriate care. Caregiver Support; Family Support; Home Maintenance Assistance; Normalization Promotion; Respite Care; Support Group See the care plan for Caregiver Role Strain See the care plan for Caregiver Role Strain See the care plan for Caregiver Role Strain See the care plan for Caregiver Role Strain See the care plan for Caregiver Role Strain Comfort, impaired 247 State in which an individual experiences an uncomfortable sensation in response to a noxious stimulus. Unpleasant sensation of being physically ill at ease that may be localized or generalized but is not described in terms of tissue damage. Verbalization of discomfort (specific examples include aches, pruritis); observed behaviors indicative of discomfort; shifting and/or restlessness; tenseness; shivering and covering up or removing of covers; avoidance; malaise; aching; stiffness; distention; hunger and thirst; reduced mobility; itching; reddened, irritated skin (pruritus). Reaction to chemical irritants (including allergies); dry skin; illness and/or immobility; unmet physical needs (food, fluid, bathing, etc); fever; disease processes; pregnancy; immobility; musculoskeletal disorders; inflammation; intestinal gas, colic; medication side effects; contagious diseases (chickenpox, etc.). Comfort Level; Symptom Control (1) State he or she is comfortable. (2) State that his or her uncomfortable sensations (aches, itching, etc.) are relieved. (3) Explain methods to decrease own discomfort. (4) Display improved physical discomfort. (5) Appear less restless and more at ease. Acupressure; Bathing; Distraction; Exercise promotion; Exercise Promotion: Stretching; Heat/Cold Application; Medication Administration; Music Therapy; Positioning;

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Progressive Muscle Relaxation; Pruritus Management; Simple Guided Imagery; Simple Massage; Simple Relaxation Therapy; Skin Care; Topical Treatments (1) Assess client needs holistically. Physical discomfort often coexists with and is exacerbated by emotional and spiritual discomfort; therefore addressing nonphysical needs can improve the client's perception of physical comfort. The nurse's therapeutic approach and demeanor can have a profound impact on perception of comfort (2) Consult with the physician for medication to reduce discomforting symptoms such as aching. (3) Provide distraction techniques such as music, television, or games. (4) Encourage early mobilization to decrease physical discomforts associated with bed rest. (5) Provide simple massage. (6) Provide gentle, soothing touch, which may be well suited for clients who cannot tolerate more stimulating interventions such as simple massage. (7) Position the client to maximize comfort. (8) Inform the client of options for control of discomfort such as self-hypnosis and guided imagery, and provide these interventions if appropriate. (9) Individualize the timing and........ (1) Comforting touch is helpful for elders because they respond to touch more than to verbal comforting. (2) Frail elderly clients should be protected from cold discomfort. (1) Assess for the influence of cultural beliefs, norms, and values on the client's perceptions of skin and/or hair status and practices. (2) Identify and clarify cultural language used to describe skin and hair. (3) Assess skin for ashy appearance. (4) Encourage the use of lanolin-based lotions for African American clients with dry skin. (5) Offer hair oil and lanolin-based lotion for dry scalp and skin. (6) Use soap sparingly if the skin is dry. (1) Assist the client and family in identifying and avoiding irritants that exacerbate pruritus (e.g., wool, cleansers, allergens). Avoidance of irritants decreases discomfort of pruritus (2) Teach the family to use mild, nonscented, and non-bleach-containing laundry products. Chemical irritants increase the discomfort of pruritus. (3) Keep the temperature of the home moderate to cool. Use a humidifier. Overheated home environments increase sweating, which adds salts to the skin and increases irritation. Raising the moisture in the air helps to keep moisture in the skin (Hardy, 1996). Nursing Research: Cool ambient temperature has been reported to reduce pruritus in some clients (4) Support the use of the client's preferred body lotion, as long as it has not been found to exacerbate pruritus. Have the client apply lotion after bathing before blotting skin dry. Clients are more likely to continue past practices. Applying lotion while the skin is still wet increases the moisturizing..... (1) Teach techniques to use when the client is uncomfortable, including relaxation techniques, guided imagery, hypnosis, and music therapy. (2) Instruct the client and family on prescribed medications and therapies that improve comfort. (3) Perform a complete assessment to determine the cause of pruritus (e.g., dry skin, contact with irritating substance, medication side effect, insect bite, infection, healing burns, underlying systemic disease). (4) Assess for sleep disturbances. (5) Implement soaks with cool or cold washcloths or offer cool baths if appropriate. (6) Keep the client's fingernails short; have the client wear mitts if necessary. (7) Leave pruritic area open to the air if possible. (8) Use nonallergenic mild soap and use it sparingly. (9) Keep skin well lubricated. After bathing, while the skin is still moist, apply nonallergenic moisturizers such as Medilan that are alcohol free and available in cream or ointment form. Apply moisturizers daily. (10) Provide simple ..... Communication, readiness for enhanced 254 Pattern of exchanging information and ideas with others that is sufficient for meeting one's needs and life's goals and can be strengthened. Expresses willingness to enhance communication; able to speak or write a language; forms words, phrases, and language; expresses thoughts and feelings; uses and interprets nonverbal cues appropriately; expresses satisfaction w/ability to sahre information and ideas w/others To be developed Communication; Communication: Expressuve, Receptive (1) Express willingness to enhance communication. (2) Demonstrate ability to speak or write a language. (3) Form

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html words, phrases, and language. (4) Express thoughts and feelings. (5) Use and interpret nonverbal cues appropriately. (6) Express satisfaction with ability to share information and ideas w/others. Active Listening; Communication Enhancement: Hearing Deficit, Speech Deficit (1) Establish a good nurse-client relationship: provide appropriate education for the client, demonstrate caring by being present to the client. (2) Carefully assess the client's readiness to communicate. (3) Assess the client's literacy level. (4) Listen attentively and provide a comfortable environment for communicating; use these practical guidelines to assest in communication: a) slow down and listen to the client's story. b) Use " living room" language. c) use pictures and stories to illustrate important points. d) Repeat instructions; limit the amoundt of info given. e) Have the client "teach back" to confirm understanding. f) Avoid asking, "Do you understand?" g) Be respectful, caring, and sensitive. (5) Provide communication with specialty nurses who have knowledge about the client's situation. (6) Refer couples in maladjusted relationships to psychosocial intervention and social support to strengthen communication nurse specialists. (1) Assess for hearing and vision impairments and make appropriate referrals for hearing aids. (2) Use touch if culturally acceptable when communicating with older clients and thier families. (3) Caregivers may sing when delivering care and instructions. (1) Nurses should become more sensitive to the meaning of a culture's nonverbal communication modes, such as eye contact, facial expression, touching, body language, and distancing practices, in cross-cultural encounters. (2) Nurses should realize that thier good intentions and their usual nonverbal communication style may sometimes be interpreted as offensive and insulting by a specific cultural group. (3) Assess for the influence of cultural beliefs, norms, and values on the client's communication process. (4) Assess personal space needs, acceptable communication styles, acceptable body language, interpretation of eye contact, perception of touch, and use of paraverbal modes when communicating with the client. (5) Take extreme care when using touch. (6) Modify the communication approach in keeping with the client's particular culture. (7) use an interpreter if the client speak a different language. (8) Use therapeutic communication techniques that emphasize acceptance, offer the ... (1) The interventions described previously may be used in home care. (2) Refer to the care plan for Impaired verbal Communication. Communication, verbal, impaired 259 Decreased, delayed, or absent ability to receive, process, transmit, and use a system of symbols. Willful refusal to speak; disorientation in the three spheres of time, space, and person; inability to speak dominant language; failure or inability to speak; speaking or verbalization w/difficulty; inappropriate verbalizations; difficulty forming words ro sentences (e.g., aphonia, dyslalia, dysarthria); difficulty expressing thoughts verbally (e.g., aphasia, dysphasia, apraxia, dyslexia); stuttering; slurring; dyspnea; absence of eye contact or difficulty in selectively attending; difficulty in comprehending and maintaining usual communication pattern; partial or total visual deficit; inability to use or difficulty in using facial or body expressions Decrease in circulation to brain; brain tumor; physical harrier (e.g., tracheostomy, intubation); anatomical defect; cleft palate; alteration of neuromuscular visual system, auditory system, phonatory apparatus; psychological barriers (e.g., psychosis, lack of stimuli); cultural difference; differences related to developmental age; side effects of medication; environmental barriers; absence of significant others; altered perceptions; lack of information; stress; alteration of self-esteem or self-concept; physiological conditions; alteration of CNS; weakening of musculoskeletal system; emotional conditions Communication; Communication: Expressive, Receptive (1) Use effective communication techniques. (2) Use alternative methods of communication effectively. (3) Demonstrate congruency of verbal and nonverbal behavior. (4) Demonstrate understanding even if not able to speak. (5) Express desire for social interactions. Active Listening; Communication Enhancement: Hearing

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

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html role 272 Parent's experience of role confusion and conflict in response to crisis. Expresses concerns about changes in parental role, family functioning, family communication, family health; expresses concerns/feelings of inadequacy with regard to providing for child's physical and emotional needs during hospitalization or at home; shows reluctance to participate in usual caregiving activities, even with encouragement and support; demonstrates disruption in care and caregiving routines; expresses concern about perceived loss of control regarding decisions relating to child; verbalizes or demonstrates feelings of guilt, anger, fear, anxiety, and frustration concerning effect of child's illness on family processes Change in marital status; home care of child w/special needs; interruptions of family life as a result of home care regimens; separation from child as a result of chronic illness; intimidation by invasive or restrictive modalities Acceptance: Health Status; Caregiver Adaptation to Patient Institutionalization; Caregiver Home Care Readiness; Caregiver Lifestyle Disruption; Coping; Grief Resolutioin; Hope; Parent-Infant Attachment; Parenting Performance; Psychosocial Adjustment: Life Change; Role Performance (1) Express feelings and perceptions regarding impacts of illness, disability, and/or hospitalization on parental role. (2) Participate in hospital and home care as much as able to given the availability of resources and support systems. (3) Exhibit assertiveness and responsibility in active family decision making regarding care of the child. (4) Describe and select available resources to support parental management of the child's and family's needs. Abuse Protection Support: Child; Caregiver Support; Counseling; Crisis Intervention; Decision-Making Support; Environmental Management: Attachment Process; Family Process Maintenance; Family Therapy; Role Enhancement (1) Assess parents' previous coping behaviors. (2) Explore parent/family sources of stress, usual methods of coping, and perceptions of illness/condition. Capitalize on the strengths identified. Involve both parents in the assessment. (3) Consider the use of family theory as a framework to help guide intervention. (4) Sustain parental involvement in shard decision making with regard to care by using the following steps: incorporate parents' information concerning the child's condition and progress; normalize the home/hospital environment as much as possible; collaborate in care by providing choices when possible. (5) Seek and support parental participation in care. (6) Provide support for each parent's primary coping strategies. (7) Evaluate the family's perceived strength of its social support system. Encourage the family to use social support to increase its resiliency and to moderate stress. (8) Offer respite care to assist parents in maintaining sufficient energy and personal ..... (1) Acknowledge racial/ethnic differences at the onset of care. (2) Assess for the influence of cutural beliefs, norms, and values on the client' perceptions of the parental role. (3) Acknowledge that value conflicts arising from acculturation stresses may contribute to increased anxiety and significant conflict with parental role. (4) Promote the female parenting role by providing a treatment environment that is culturally based and woman centered. (5) Validate the client's feelings with regard to parental rold confusion and conflict. (1) The interventions described previously may be adapted for home care use. (2) Assess family adjustment prenatally and postpartum; assist new parents to renegotiate behavior around issues such as amount of time spent together, sexual relationship, resolution of disagreements, and provision of sufficient time for leisure/reacreational activities. (3) Assess interference with family functioning. (1) Furnish clear explanations about condition, disease or disability, associated treatments, and prognosis. Describe circumstances involving emotional and physical reactions of the child and types of family member reactions that might be anticipated in response to the condition or crisis. Provide ample time for skill practice. (2) For parents of children with chronic disabilities, tailor educational opportunites based on the experiential phase of the parents (protection, survival, or development of the parent as a central person) as parents develop an identity as the central

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html caregivers for their child. (3) Involve parents in formal and/or informal social support situationis, including parent-to-parent groups, community agencies, and counseling resources. Confusion, acute 278 Abrupt onset of a cluster of global, transient changes, and distribution in attention, cognition, psychomotor activity level, consciousness, or sleep-wake cycle Lack of motivation to initiate and/or follow through with goal-directed or purposeful behavior; fluctuation in psychomotor activity; misperceptions; fluctuation in cognition; increased agitation or restlessness; fluctuation in level of consciousness; fluctuation in sleep-wake cycle; hallucinations Age over 70 years; alcohol abuse; abuse; cognitive impairment; uncontrolled pain; multiple comorbidities; medications; dehydration; infection; sensory deficit; compromised activities of daily living Cognitive Orientation; Distorted Thought Self-Control; Information Processing; Memory; Neurological Status: Consciousness; Sleep (1) Demonstrate restoration of cognitive status to baseline. (2) Obtain adequate amount of sleep. (3) Demonstrate appropriate motor behavior. (4) Maintain functional capacity. (5) Optimize hydration and nutrition Delirium Management; Delusion Management (1) Assess the client's behavior and cognition systematically and continually throughout the day and night, as appropriate.(2)Perform an accurate mental status examination that includes the following: Overall appearance, manner, and attitude Behavior characteristics and level of psychomotor behavior Mood and affect (presence of suicidal or homicidal ideation as observed by others and reported by the client) Insight and judgment Cognition as evidenced by level of consciousness, orientation (to time, place, and person), thought process and content (perceptual disturbances such as illusions and hallucinations, paranoia, delusions, abstract thinking) ....... (1) Mobilize the client as soon as possible; provide active and passive range of motion. (2) Provide sufficient medication to relieve pain. (3) Explain hospital routines and procedures slowly and in simple terms; repeat information as necessary. (4) Provide continuity of care when possible (e.g., provide the same caregivers, avoid room changes). (5) If clients know that they are not thinking clearly, acknowledge the concern. (6) Do not use the intercom to answer a call light. (7) Keep the client's sleep-wake cycle as normal as possible (e.g., avoid letting the client take daytime naps, avoid waking the client at night, give sedatives but not diuretics at bedtime, provide pain relief and back rubs). (8) Maintain normal sleep-wake patterns (treat with bright light for 2 hours in the early evening). (1) Some of the interventions described previously may be adapted for home care use. (2) Assess and monitor for acute changes in cognition and behavior. (3) Delirium is reversible but can become chronic if untreated, and the client may be discharged from the hospital to home care in state of undiagnosed delirium. (4) Assess for treatable causes of changes in cognition and behavior. (5) Assess fluid intake, dementia status, and occurrence of a fall within the past 30 days in evaluating confusion. (6) Avoid preconceptions about the source of acute confusion; assess each occurrence on the basis of available evidence. (7) Institute case management of frail elderly clients to support continued independent living. (1) Teach the family to recognize signs of early confusion and seek medical help. (2) Counsel the client and family regarding the symptoms of delirium, its management, and its sequelae. Confusion, chronic 283 Irreversible, long-standing, and/or progressive deterioration of intellect and personality characterized by decreased ability to interpret environmental stimuli and decreased capacity for intellectual thought processes, and manifested by disturbances of memory, orientation, and behavior Altered interpretation and/or response to stimuli; clinical evidence of organic impairment; altered personality; impaired memory (short and long term); impaired socialization; no change in level of consciousness; decreased ability

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html to participate in self-care; decreased ability for meaningful interaction with the environment Multi-infarct dementia; Karsokoff's psychosis; brain injury; Alzheimer's disease and related dementia Cognition; Cognitive Orientation; Distorted Thought Self-Control (1) Remain content and free from harm. (2) Function at maximal cognitive level. (3) Participate in activities of daily living at the maximum of functional ability Dementia management; Environmental Management; Reality Orientation; Surveillance: Safety (1) Determine the client's cognitive level using a screening tool such as the Mini-Mental State Exam (MMSE). (2) Gather information about the client's predementia functioning, including social situation, physical condition, and psychological functioning. (3) Assess the client for signs of depression: insomnia, poor appetite, flat affect, and withdrawn behavior. (4) Ensure that the client is in a safe environment by removing potential hazards such as sharp objects and harmful liquids. (5) Place an identification bracelet on client. (6) Avoid as much as possible exposing the client to unfamiliar situations and people. Maintain continuity of caregivers. Maintain routines of care by observing established eating, bathing, and sleeping schedules. Send a familiar person with the client when the client goes for diagnostic testing or into unfamiliar environments. (7) Keep the environment quiet and nonstimulating. Avoid or minimize sights and sounds that have a high potential for ........... NOTE: Most of the aforementioned interventions apply to the geriatric client. (1) Use reminiscence and life review therapeutic interventions; ask questions about the client's work, child raising, or time spent in the service. Ask questions such as, "What was really important to you as you look back?" (1) Assess for the influence of cultural beliefs, norms, and values on the family's or caregiver's understanding of chronic confusion or dementia. (2) Inform the client's family or caregiver of the meaning of and reasons for common behavior observed in clients with dementia. (3) Assist the family or caregiver in identifying barriers that would prevent the use of social services or other supportive services that could help reduce the impact of caregiving. (4) Assess the client for the presence of an instrumental activity of daily living (IADL) disability and chronic health conditions. (5) Refer the family to social services or other supportive services to assist in meeting the demands of caregiving for the client with dementia. (6) Encourage the family to make use of support groups or other service programs. (7) Validate the family members' feelings with regard to the impact of the client's behavior on family lifestyle. NOTE: Keeping the client as independent as possible is important. Because communitybased care is usually less structured than institutional care, however, in the home setting the goal of maintaining safety for the client takes on primary importance. (1) Assess and monitor the client for acute changes in cognition and behavior. (2) Assess for treatable causes of changes in cognition and behavior. The mnemonic DEMENTIA can be used to remember potential causes (3) Before providing any home care, assess the client plan for advance directives (living will and power of attorney). If a plan exists, place a copy in the client file. If no plan exists, offer information on advance directives according to agency policy. Refer for assistance in completing advance directives as necessary. Do not witness a living will. (4) Assess the client's memory and executive function deficits before assuming the inability to make any medical decisions. (5) Assess the home for safety features and client needs... (1) In the early stages of confusion (e.g., initial period following stroke), provide the caregiver with information on illness processes, needed care, and likely trajectory of progress. (2) Recommend that the family develop a memory aid wallet or booklet for the client, which contains pictures and text that chronicle the client's life.(3) Teach the family how to set up the environment and use the care techniques/ interventions listed so that cognitive and functional impairments that interact with the client's progressively lowered stress threshold (PLST) will be addressed. Identify stressors and initiate compensatory modifications of the environment. (4) Discuss with the family

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html what to expect as the dementia progresses. (5) Counsel the family about resources available regarding end-of life-decisions and legal concerns. Inform the family that, as dementia progresses, hospice care may be available in the home in the terminal stages to help the caregiver. ........ Constipation 294 Decrease in normal frequency of defecation, accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool Change in bowel pattern; bright red blood with stool; presence of soft, pastelike stool in rectum; distended abdomen; dark, black, or tarry stool; increased abdominal pressure; percussed abdominal dullness; pain with defecation; decreased volume of stool; straining w/defecation; decreased frequency of stool; dry, hard, formed stool; palpable rectal mass; feeling of rectal fullness or pressure; abdominal pain; inability to pass stool; anorexia; headache; change in abdominal growling (borborygmi); indigestion; atypical presentation in older adults (e.g., change in mental status, urinary incontinence, unexplained falls, elevated body temp); severy flatus; generalized fatigue; hypoactive or hyperactive bowel sounds; palpable abdominal mass; abdominal tenderness with or w/o palpable muscle resistance; nausea and/or vomiting; oozing of liquid stool FUNCTIONAL: Recent environmental changes; habitual denial or ignoring of urge to defecate; insufficient physical activity; irregular defecation habits; inadequate toileting; abdominal muscle weakness. PSYCHOLOGICAL: Depression; emotional stress; mental confusion. PHARMACOLOGICAL: Antilipemic agents; overdose of laxatives; calcium carbonate; aluminum-containing antacids; NSAIDS; opiates; anticholinergics; diuretics; iron salts; phenothiazines; sedatives; sympathomimetics; bismuth salts; antidepressants; calcium channel blockers. MECHANICAL: Rectal abscess or ulcer; pregnancy; rectal anal fissure; tumor; megacolon (Hirschprung's disease); electrolyte imbalance; rectal prolapse; prostate enlargement; neurological impairment; reactal anal stricture; rectocele; postsurgical obstruction; hemorrhoids; obesity. PHYSIOLOGICAL: Poor eating habits; decreased motility of GI tract; inadequate dentition or oral hygiene; insufficient fiber intake; insufficient fluid intake; change in usual foods, etc Bowel Elimination; Hydration (1) Maintain passage of soft, formed stool every 1-3 days w/o straining. (2) State relief from discomfort of constipation. (3) Identify measures that prevent or treat constipation. Constipation/Impaction Management (1) Assess usual pattern of defecation, including time of day, amount and frequency of stool, consistency of stool; history of bowel habits or laxative use; diet including fluid intake; exercise patterns; personal remedies for constipation; obstetrical/ gynecological history; surgeries; alterations in perianal sensation; present bowel regimen.(2) Have the client or family keep a diary of bowel habits using a Management of Constipation Assessment Inventory, including information such as time of day; usual stimulus; consistency, amount, and frequency of stool; fluid consumption; and use of any aids to defecation. (3) Review the client's current medications. (4) If the client is receiving opioids, request an order for stool softeners from the primary care practitioner and institute a bowel regimen before the onset of constipation. (5) Palpate for abdominal distention, percuss for dullness, and auscultate bowel sounds. (6) Check for impaction; if present, perform digital removal per ...... (1) Explain the importance of adequate fiber intake, fluid intake, activity, and established toileting routines to ensure soft, formed stool. (2) Determine the client's perception of normal bowel elimination; promote adherence to a regular schedule. (3) Explain Valsalva's maneuver and the reason it should be avoided. (4) Respond quickly to the client's call for help with toileting. (5) Avoid regular use of enemas in the elderly. (6) Use opioids cautiously. If they are ordered, use stool softeners and bran mixtures to prevent constipation. (7) Position the client on the toilet or commode and place a small footstool under the feet. (1) The interventions described previously may be adapted for home care use. (2) Take complaints seriously and evaluate claims of constipation in a matter-of-fact manner. (3) Assess the self-care management activities the client is already using. (4) Although the use of a

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html bedside commode may be necessitated by the client's condition, allow the client to use the toilet in the bathroom when possible and provide assistance. (5) Carefully monitor the bowel patterns of clients under pain management with opioids. In older clients, routinely advise consumption of fluids, fruits, and vegetables as part of the diet, and ambulation if the client is able. Introduce a bowel management program at the first sign of constipation. (6) Refer for consideration of the use of polyethylene glycol 3350 (PEG-3350) for constipation. (7) Advise the client against attempting to remove impacted feces on his or her own. (8) Instruct the client and family in appropriate expectations for having bowel movements..... (1) Instruct the client on normal bowel function and the need for adequate fluid and fiber intake, activity, and a defined toileting pattern in a bowel program. (2) Encourage the client to heed defecation warning signs and develop a regular schedule of defecation by using a stimulus such as a warm drink or prune juice. (3) Encourage the client to avoid long-term use of laxatives and enemas and to gradually withdraw from their use if they are used regularly. (4) If not contraindicated, teach the client how to do bent-leg sit-ups to increase abdominal tone; also encourage the client to contract the abdominal muscles frequently throughout the day. Help the client develop a daily exercise program to increase peristalsis. Constipation, perceived 300 State in which individual makes a self-diagnosis of constipation and ensures daily bowel movement through abuse of laxatives, enemas, and suppositories Expectation of a daily bowel movement that results in overuse of laxatives, enemas, and suppositories; expectation of a bowel movement at same time every day Cultural or family beliefs; faulty appraisals;impaired thought processes Bowel Elimination; Health Beliefs; Health Beliefs: Perceived Threat (1) Regularly defecate soft, formed stool w/o using any aids. (2) Explain the need to decrease or eliminate the use of laxatives, suppositories, and enemas. (3) Identify alternatives to laxatives, enemas, and suppositories for ensuring defecation. (4) Explain that defecation does not have to occur every day. Bowel Management; Medication Management (1) Have the client keep a diary of bowel habits, using a Management of Constipation Assessment Inventory, including information such as time of day, usual stimulus; consistency, amount, and frequency of stool; fluid consumption; and use of any aids to defecation. (2) Determine the client's perception of an appropriate defecation pattern. (3) Monitor the use of laxatives, suppositories, or enemas and suggest replacing them with increased fiber intake along with increased fluids to 2 L/day. (4) Ask the client to keep a food log of the foods eaten for the last 24 hours or recall the usual foods eaten. If necessary, teach the blient the need to eat five to nine fruits and vegetables per day, and at least three servings of whole-grain foods. (5) In place of laxatives, use a mixture of 1 cup of Kellogg's All-Bran cereal, 1 cup of applesauce, and 1 cup of prune juice; begin administration in small amounts and gradually increase amount. Refer to references dor dosing. Keep refrigerated. ..... (1) The interventions described previously may be adapted for home care use. (2) Take complaints seriously and evaluate claims of constipation in a matter-of-fact manner. (3) Obtain family and client histories of bowel or other patterned behavior problems. (4) Observe family cutural patterns related to eating and bowel habits. (5) Encourage a mindset and program of self-care management. Elicit from the client the self-talk he or she uses to describe body perceptions; correct catastrophizing interpretations. Instruct the client in a healthy lifestyle that support normal bowel function and encourage progressive inclusion of these elements into daily activities. (6) Discuss the client's self-image. Help the client to reframe the self-concept as capable. (7) Instruct the client and family in appropraite expectations for having bowel movements. Offer instruction and reassurance regarding explanations for variation from the previous pattern of bowel movements. (8) Contract with the client... Explain normal bowel function and the necessary ingredients for a regular

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html bowerl regimen. (2) Work with the client and family to develop a diet that fits the client's lifestyle and includes increased fiber. (3) Teach the client that it is not necessary to have daily bowel movements and that the passage of anywhere from three stools each day to three stools in a week is considered normal. (4) Explain to the client the harmful effects of the continual use of defecation aids such as laxatives and enemas. (5) Encourage the client to gradually decrease the use of the usual laxative and enemas and to set a date to have eliminated the use of all defecation aids. (6) Explain what Valsalva's maneuver is and why it should be avoided. (7) Work with the client and family to design a bowelr training routine that is based on precious patterns (before laxative or enema abuse) and incorporates the consumption of warm fluids, increased fiber, and increased fluids; privacy; and a predictable routine. Constipation, risk for 304 At risk for decrease in individual's normal frequency of defecation accompanied by difficult or incomplete passage of stool and/or passage of excessively hard, dry stool FUNCTIONAL: Recent environmental changes; habitual denial or ignoring of urge to defecate; insufficient physical activity; irregular defecation habits; inadequate toileting; abdominal muscle weakness. PSYCHOLOGICAL: Emotional stress; mental confusion; depression. PHYSIOLOGICAL: Poor eating habits; decreased motility of GI tract; inadequate dentition or oral hygiene; insufficient fiber intake; insufficient fluid intake; change in usual foods & eating patterns; dehydration. PHARMACOLOGICAL: Phenothiazides; antilipemic agents; overuse of laxatives; calcium carbonate; aluminum-containing antacids; NSAIDS; opiates; anticholinergics; iron salts; sedatives; sympathomimetics; bismuth salts; antidepressants; calcium channel blockers; anticonvulsants. MECHANICAL: Rectal abscess or ulcer; pregnancy; postsurgical obstruction; rectal anal fissure; tumor; megacolon (Hirschsprung's disease) electrolyte imbalance; rectal prolapse; prostate enlargement; neurological impairment; rectal anal stricture... Bowel Elimination (1) Maintain passage of soft, formed stool every 1-3 days w/o straining. (2) Identify measures that prevent constipation. (3) Explain rationale for not using laxatives and enemas. Constipation/Impaction Management See care plan for constipation See care plan for constipation See care plan for constipation Coping, ineffective 306 Inability to form a valid appraisal of internal or external stressors, inadequate choices of practiced responses, and/or inability to access or use available resources Lack of goal-directed behavior or resolution of problem, including inability to attend; difficulty with organized information; sleep disturbance; abuse of chemical agents; depcreased use of social support; use of forms of coping that impede adaptive behavior; poor concentration; fatigue; inadequate problem solving; verbalized inability to cope or ask for help; inability to meet basic needs; destructive behavior toward self or others; inability to meet role expectations; high illness rate; change in usual communication patterns; risk taking Gender differences in coping strategies; inadequate level of confidence in ability to cope; uncertainty; inadequate social support created by characteristics of relationships; inadequate level of perception of control; indequate resource availability; high degree of threat; situational crises; maturational crises; disturbance in pattern of tension release; inadequate opportunity to prepare for stressor; inability to conserve adaptive energies; disturbance in pattern of appraisal of threat; chronic conditions; alteration in body integrity; cultural variables Coping; Decision making; Impulse Self-Control; Information Processing (1) Verbalize ability to cope and ask for help when needed. (2) Demonstrate ability to solve problems r/t current needs. (3) Remain free of destructive behavior toward self or others. (4) Communicate needs and negotiate w/others to meet needs. (5) Discuss how recent life stressors have overwhelmed normal coping strategies. (6) Demonstrate new effective coping strategies. (7) Have illness and accident rates not excessive for age and developmental level Coping Enhancement; Decision-Making Support (1) Observe for causes of ineffective coping such as poor self-concept, grief, lack of problem-solving skills, lack of support, or

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html recent change in life situation. (2) Observe for strengths such as the ability to relate the facts and to recognize the source of stressors. (3) Assess the risk of the client's harming self or others and intervene appropriately. See the care plan forRisk for Suicide. (4) Help the client set realistic goals and identify personal skills and knowledge. (5) Use empathetic communication and encourage the client and family to verbalize fears, express emotions, and set goals. (6) Encourage the client to make choices and participate in the planning of care and scheduled activities. (7) Provide mental and physical activities within the client's ability (e.g., reading, television, radio, crafts, outings, movies, dinners out, social gatherings, exercise, sports, games). (8) If the client is physically able, encourage moderate aerobic exercise. (9) Provide info....... (1) Engage the client in reminiscence. (2) Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, and use of medications with known cognitive and psychotropic side effects). (3) Determine if the individual is displaying a change in personality as a manifestation of difficulty with coping. (4) Increase and mobilize the support available to the elderly client. Encourage interaction with family and friends. (1) Assess for the influence of cultural beliefs, norms, and values on the client's perceptions of effective coping. (2) Assess for intergenerational family problems that can overwhelm coping abilities. (3) Encourage spirituality as a source of support for coping. (4) Negotiate with the client with regard to the aspects of coping behavior that will need to be modified. (5) Identify which family members the client can count on for support. (6) Use an empowerment framework to redefine coping strategies. (7) Assess the influence of fatalism on the client's coping behavior. (8) Assess the influence of cultural conflicts that may affect coping abilities. (1) The interventions described previously may be adapted for home care use. (2) Observe the family for coping behavior patterns. Obtain family and client history as possible. (3) Assess for suicidal tendencies. Refer for mental health care immediately if indicated. Identify an emergency plan should the client become suicidal. (4) Encourage the client to use self-care management to increase the experience of personal control. Identify with the client all available supports and sense of attachment to others. Refer to the care plan for Powerlessness. (5) Refer to medical social services for evaluation and counseling, which will promote adequate coping as part of the medical plan of care. If no primary medical diagnosis has been made, request medical social services to assist with community support contacts. (6) Refer the client and family to support groups. (7) If monitoring medication use, contract with the client or solicit assistance from a responsible caregiver. (8) Institute case.. (1) Teach the client to problem solve. Have the client define the problem and cause, and list the advantages and disadvantages of the options. (2) Provide the seriously ill client and his or her family with needed information regarding the condition and treatment. (3) Teach relaxation techniques. (4) Work closely with the client to develop appropriate educational tools that address individualized needs. (5) Teach the client about available community resources (e.g., therapists, ministers, counselors, self-help groups). Coping, readiness for enhanced 313 Pattern of cognitive and behavioral efforts to manage demands that is sufficient for well-being and can be strengthened Defines stressors as manageable; seeks social support; uses a broad range of problem-oriented emotion-oriented strategies; uses resources; acknowledges power; seeks knowledge of new strategies; is aware of possible environmental changes Coping; Decision Making; Social Support (1) Verbalize ability to cope and ask for help when needed. (2) Demonstrate ability to solve problems r/t current needs. (3) Coomunicate needs and negotiate w/others to meet needs. (4) State that stressors are manageable. (5) Demonstrate new effective coping strategies. (6) Seek social support for problems associated w/coping. (7) Seek spiritual support for personal choice Coping Enhancement; Decision-Making Support (1) Use empathetic communication

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html and encourage the client and family to verbalize fears, express emotions, and set goals. (2) Observe for strengths such as the ability to relate the facts and to recognize the source of stressors. (3) Encourage epxression of positive thoghts and emotions. (4) Encourage the use of cognitive behavioral relaxation. (5) Encouarge the client to use spiritual coping mechanisms such as faith and prayer. (6) help the client set realistic goals and identify personal skills and knowledge. (7) Help the client with depression to maintain social support networks or assist in building new ones. (8) Consider a workplace stress managemetn program to enhance coping skills. (9) Refer for cognitive behavioral therapy. (10) Refer the client with breast cancer to a psychosocial group intervention for coping skills training, stress management, relaxation exercises, and psychosocial support. (1) Refer the client with Alzheimer's disease who is terminally ill to hospice. (2) Refer the widowed older client to self-help support groups. (1) Assess for the influence of cultural beliefs, norms, and values on the client's perceptions of effective coping. (2) Encourage spirituality as a source of support for coping. (3) Identify which family members the client can count on for support. (4) Support the inner resources that clients use for coping. (5) use an empowerment framework to redefine coping strategies. (1) The interventions described previously may be adapted for home care use. (2) Observe the family for coping behavior patterns. Obtain family and client history as possible. (3) Encourage the client to use self-care management to increase the experience of personal control. Identify with the client all available supports and sense of attachment to others. (4)Refer the client and family to support groups. (1) Teach relaxation techniques. (2) Teach the client about available community resources. Coping, community, ineffective 317 Pattern of community activities (for adaptation and problem solving) that is unsatisfactory for meeting the demands or needs of the community Expressed community powerlessness; failure of community to meet its own expectations; deficits of community participation; deficits in communication methods; excessive community conflicts; expressed difficulty in meeting demands for change; expressed vulnerability; high illness rates; stressors perceived as excessive; increased social problems (e.g., homicides, vandalism arson, terrorism, robbery, infanticide, abuse, divorce, unemployment, poverty, militancy, mental illness) Natural or manmade disasters; ineffective or nonexistent community systems (e.g., lack or emergency medical, transportation, or disaster planning systems); deficits in community social support services and resources; inadequate resources for problem solving Community Competence; Community Health Status (1) Participate in community actions to improve power resources. (2) Develop improved communication among community members. (3) Participate in problem solving. (4) Demonstrate cohesiveness in problem solving. (5) Develop new strategies for problem solving. (6) Express power to deal w/change and manage problems. Environmental Management: Community; Health Policy Monitoring NOTE: The diagnosis of Ineffective Coping does not apply and should not be used when stress is being imposed by external sources or circumstances. If the community is a victim of circumstances, using the nursing diagnosis Ineffective Coping is equivalent to blamig the victim. See the care plan for Ineffective community Therapeutic regimen managemed and Readiness for enhanced community Coping. (1) Establish a collaborative partnership with the community (see the care plan for Ineffective community Therapeutic regimen management for references). (2) Participate with community members in the identification of stressors and assessment of distress; for example, observe and participate in community meetings and task forces. (3) Identify community strengths with community members and avoid defining the community in objective terms. (4) Determine the extent of stress proliferation (i.e., primary stressors associated with contextual circumstances such as poverty) and the presence of .......... (1) Acknowledge ths stressors unique to racial/ethnic communities. (2)

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Identify the health services and info resources that are currently available in the community. (3) Work with members of the community to prioritize and target health goals specific to the community. (4) Approach community leaders and members of color with respect, warmth, and professional courtesy. (5) Establish and sustain partnerships with key individuals withing communities when developing and implementing programs. (6) Use community church settings as a forum for advocacy, teaching, and program implementation. (7) Ask political leaders to become part of the partnership process. (8) Protect children from exposure to community conflicts. (1) Teach strategies for stress management. Coping, community, readiness for enhanced 321 Pattern of community activities for adaptation and problem solving that is satisfactroy for meeting the demands or needs of the community but that can also be improved for management of current and future problems and stressors One or more of the following characteristics that indicate effective coping: positive communication between community/aggregates and larger community; availability of programs for recreation and relaxation; sufficiency of resources for managing stressors; agreement that community is responsible for stress management; active planning by community for predicted stressors; active problem solving by community when faced with issues; positive communication among community members Community Competence; Community Health Status (1) Develop enhanced coping strategies. (2) Maintain effective coping strategies for management of stress Environmental Management: Community; Health Policy Monitoring NOTE: Interventions depend on the specific aspects of community coping that can be enhanced (e.g., planning for stress management, communicatioon, development of community power, community perceptions of stress, community coping strategies). (1) Describe the role of the community/public health nurse in working with healthy communities. (2) Help the community to obtain funds for additional programs. (3) Encourage positive attitudes toward the community through the media and other sources. (4) Help community members to colaborate with one another for poewr enhancement and coping skills. (5) Encourage critical thinking. (6) Demonstrate optimum use of the power resources of knowledge, motivation, belief system (hope), physical strength and reserve, psychological stamina and support network, positive self-concept, and energy. (7) Collaborate with community members to improve educational levels within the community. (1) Acknowledge the stresses unique to racial/ethnic communites. (2) Identify what health services and info are currently available in the community. (3) Work with members of the community to prioritize and target health goals specific to the community. (4) Approach community leaders and members of color with respect, warmth, and professional courtesy. (5) Establish and sustain partnerships with key individuals within communities when developing and implementing programs. (6) Use community church settings as a forum for advocacy, teaching, and program implementation. (1) Review coping skills, power for coping, and the use of poewr resources. Coping, defensive 324 Repeated projection of falsely positive self-evaluations based on self-protective pattern that defends against underlying perceived threats to positive self-regard Grandiosity; rationalization of failures; hypersensitivity to slight/criticism; denial of obvious problems/weaknessess; projection of blame/responsibility; lack of follow-through or participation in treatment or therapy; superior attitude toward others; hostile laughter or ridicule of others; difficulty in perception of reality, reality testing; difficulty establishing/maintaining relationships, occurs when a specific pattern of ineffective (defensive) coping is sustained over time Situational crises; psychological impairment; substance abuse; HIV infection Coping; Decision Making; Impulse Self-Control; Information Processing (1) Acknowledge need for change in coping style. (2) Accept responsibility for own behavior. (3) Establish realistic goals with validation from caregivers. (4) Solicit caregiver evaluation in decision making Self-Awareness Enhancement (1) Assess for the presence of denial as a

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html coping mechanism. (2) Do not confront denial if its consequences are not a significant threat to health (3) Determine whether the client has a positive or negative overall appraisal of a given event. (4) Develop a trusting, therapeutic relationship with the client and family. (4) Determine the client's perception of the problem and then provide reality-based examples of the true situation (e.g., witnesses to an accident, blood alcohol levels, problems with alcohol). (5) Help the client identify patterns of response in life that may be maladaptive. (6) Promote the client's feelings of self-worth by using group or individual therapy, role playing, one-to-one interactions, and role modeling. (7) Support strengths and normal observations with "I not that" or "I want you to notice". Tell clients when they do something well. (8) Teach the client to use positive thinking by blocking negative thoughts with the word "Stop!" and inserting positive ..... (1) Assess the client for anger and identify previous outlets for anger. (2) Explore new outlets for anger, including physcial activities within the client's capabilities (e.g., hitting a pillow, woodworking, sanding, scrubbing floors). (3) Assess the client for dementia or depression. (4) If a traumatic event has occurred, support positive religious coping behaviors. ........ (1) Assess for the influence of cultural beliefs, norms, and values on the client's feelings of defensiveness. (2) Acknowledge racial/ethnic differences at the onset of care. (3) Use therapeutic communication techniques that emphasize acceptance, offer the self, validate the client's concerns, and convey respect. (4) Give a rationale when assessing ethnically diverse clients for alcohol use/misuse or other sensitive behaviors. (1) The intervention described previously may be adapted for home care use. (2) Include in the initial assessment client and family histories of mental health problems. (3) Observe family dynamics for dysfunctional and supportive communication. (4) Refer to a mental health professional for possible psychodrama therapy, especially if the client experiences difficulty in coping with a traumatic event. (5) In the absence of primary medical diagnoses, refer to medical social services for assistance in contacting appropriate community services. (6) Refer to a therapist for debriefing if a traumatic or critical event has occurred. (7) Refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen. (1) Teach the client the actions and side effects of meds and the importance of taking them as prescribed, even when the client is feeling good. (2) Work with the client's support group to identify harmful behaviors and to seek help for the client if he or she is unable to control behavior. (3) When a traumatic event has occurred, encourage the use of written disclosure. Instruct the person to write about the event over a period of days. (4) Support family efforts using religious coping behaviors. Coping, family, compromised 330 Situation in which usually supportive primary person provides insufficient, ineffective, or compromised support, comfort, assistance, or encouragement that may be needed by client to manage or master adaptive tasks r/t health challenge OBJECTIVE: Significant person attempts assistive or supportive behaviors with less than satisfactroy results; significant person displays protective behavior disproportionate to client's abilities or need for autonomy; significant person withdraws or enters into limited or temporary personal communication w/client at time of need. SUBJECTIVE: Client expresses or confirms a concern or complaint about significant other's response to his or her health problems; significant person describes or confirms an inadequate understanding or knowledge base, which interferes w/effective assistance or supportive behaviors; significant person describes preoccupatoin w/personal reaction to client's illness, disability, or other situational developmental crisis. Temporary preoccupation of a significant person who tries to manage emotional conflicts and personal suffering and is unable to perceive or act effectively w/regard to client's needs; temporary family disorganization and role changes; prolonged disease or disability progression that exhausts supportive capacity of significant person; other situational or developmental crises or problems significant

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

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html feelings of family members or significant caregivers regarding the impact of the client's illness on family lifestyle. NOTE: This diagnosis prsents the complex and difficult problem of securing an appropriate response by the family to a client's illness and caregiving needs. The same problem in the home setting creates an unusually high risk for abuse of the client. The nurse is cautioned that the margin of time for planning and effectively supporting the family unit to avoid abuse may be minimal or even negligible. Suspected or actual abuse should be reported to adult protective services. (1) The interventions described previously may be adapted for home care use. (2) If the client has been in an institution, establish empathetic contact with the client and family before discharge (3) Assess the family members' ability and willingness to assist in client care. Determine if the family member is an appropriate source of support for the client. (4) Assess the family member's understanding of the client's illness and behavior. Instruct in appropriate expectations of the client and correct any ........... (1) Encourage family members to ask for a break in caregiving and to spend time away from the client. (2) Provide truthful information regarding the client's illness to the family; use anticipatory guidance to prepare for expected outcomes. (3) Involve the client and family in the planning of care as often as possible, mutual goal setting is often an effective strategy. (4) Discuss with the family appropraite ways to demonstrate feelings. (5) Help the family identify the health care needs of the client and family; teach the skills necessary to address health care needs. (6) Promote individual and family relaxation and stress-reduction strategies. Coping, family, readiness for enhanced 343 Effective management of adaptive tasks by family member involved with client' health challenge, who now exhibits desire and readiness for enhanced health and growth with regard to self and in relation to client Individual expresses interest in making contact on a one-to-one basis or through mutual aid group with another person who has experienced a similar situation; attempts to describe growth impact of the crisis on his or her own values, priorities, goals, or relationships; moves in the direction of health promotion and health-enriching lifestyle that supports and monitors maturational processes; audits and negotiates treatment programs and generally chooses experiences that optimize wellness. Needs sufficiently gratified and adaptive tasks effectively addressed to enable goals of self-actualization to surface. Anxiety Self-Control; Caregiver Emotional Health; Caregiver-Patient Relationship; Caregiver Well-Being; Family Coping; Hope; Knowledge: Health Behavior, Health Resources; Participation in Health Care Decisions; Social Support (1) State a plan for growth. (2) Perform tasks needed for change. (3)State positive effects of changes made. Anticipatory Guidance; Caregiver Support; Coping Enhancement; Emotional Support; Family Integrity Promotion; Family Involvement Promotion; Family Mobilization; Family Support; Hope Instillation; Mutual Goal Setting; Normalization Promotion; Support System Enhancement (1) Observe the traits the family possesses that will help initiate change, such as having a positive attitude or stating that change is possible. (2) Consider the use of family theory as a framework to help guide interventions. (3) Allow family members time to verbalize their concerns; provide one-to-one interaction with the family. (4) Provide truthful information and constructive advice about the client's illness and treatment. (5) Evaluate the family's perceived strength of its social support system. Encourage the family to use social support to increase its resiliency and to moderate stress. (6) When a client is having surgery, give the family a 5- to 10-minute progress report about halfway through the surgical procedure. (7) Allow the family to be present during invasive procedures and resuscitation efforts. (8) Have family members share the responsibility for change and encourage all to have input. (9) Explore with the family members way to attain their goals (e.g., adult ...... (1) Encourage family members to reminisce with the older family member. (2) Start and maintain a log of anecdotal stories about the older family member. (3) Encourage children in the family to spend time with and share activities

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html with the older family member. (4) Refer the family to parenting classes and classes for coping with the needs of older parents. (1) Acknowledge racial/ethnic differences at the onset of care. (2) Approach famillies of color with respect, warmth, and professional courtesy. (3) Assess for the influence of cultural beliefs, norms, and values on the family's perceptions of coping. (4) Use a family-centered approach when working with Latino, Asian, African American and Native American clients. (5) Facilitate modeling and role playing for family with regard to healthy ways to communicate and interact. (6) Validate family members' feelings regarding the impact of the client's illness on family lifestyle. (1) The nursing interventions described previously in the care plan for Compromised family Coping should be used in the home environment with adaptations as necessary. (1) Teach that it is normal for changes in family relationships to occur. Work with the family to manage common challenges related to family dynamics. (2) Promote individual and family relaxation and stress-reduction strategies. Death syndrome; sudden infant, risk for 346 Presence of risk factors for sudden death of an infant under 1 year of age MODIFIABLE: Infants placed to sleep in the prone or side-lying position; Prenatal and/or postnatal infant smoke exposure; Infant overheating/overwrapping; Soft underlayment/loose articles in the sleep environment; Delayed or nonattendance of prenatal care. POTENTIALLY MODIFIABLE: Low birth weight; Prematurity; Young maternal age. NONMODIFIABLE: Male gender; ethnicity (e.g., African American, Native American race of mother); seasonality of sudden infant death syndrome (SIDS) deaths (higher in winter and fall months); SIDS mortality peaks between infant age of 2 to 4 months Knowledge: Child Physical Safety; Parenting Performance; Safe Home Environment (1) Explain appropriate measures to prevent SIDS. (2) Demonstrate correct techniques for positioning the infant, protecting the infant from harm. Infant Care; Teaching: Infant Safety (1) Position infant of thier back to sleep, do not position in the prone position. (2) Avoid use of loose bedding such as blankets and sheets for sleeping. (3) Avoid overheating the infant by lightly clothing the child for sleep, and avoiding overbundling. The infant should not feel hot to touch. (4) Provide the infant a certain amount of time in prone position or "tummy time" while the infant is awake and observed. (5) use electronic respiratory or cardiac monitors to detect cardiorespiratory arrest only if ordered. (1) Discuss cultural norms with families in order to provide care that is appropriate for promoting safety for the infant in sleeping arrangements and care. (2) Encourage American Indian mothers to avoid drinking and avoid wrapping infants in excessive blankets or clothing. (3) Encourage African American mothers to find alternatives to bed sharing and to avoid placing pillows, soft toys, and soft bedding in the sleep environment. (1) Most of the interventions above are relevant. (2) Evaluate home for potential safety hazards such as inappropriate cribs, cradles, or strollers. (3) Determine where and how the child sleeps. (1) Teach families to not place the infant in the prone position and to instead position the infant on his or her back for sleep. (2) Teach the parents to place the infant supine to sleep with the head rotated to one side for a week, and then to the other side for a week. (3) Teach parents that the supine position (wholly on the back) confers the lowerst risk of SIDS and is preferred. However, while side sleeping is not as safe as supine, it also has a significantly lower risk than prone. If the sid eposition is used, bring the dependent arm forward to lessen the likelihood of the infant orlling to the prone position. (4) ....... (5) Teach parents the need to obtain a crib that conforms to the safety standards of the Consumer Product Safety Commision. Although many cradles and bassinets also may provide safe sleeping enclosure, safety standards have not been established for these items. (6) Teach parents that sleeping with an infant may be hazardous under certain conditoins, ......... Denial, ineffective 352 The conscious or unconscious attempt to reduce anxiety or fear by disavowing the knowledge or meaning of an event, leading to the detriment of health. Delays seeking or refuses health

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

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

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html pregnancy; refer to treatment programs for substance abuse. (2) Provide support groups and education on the human immunodeficiency virus (HIV) and caring for infants with this diagnosis. (3) Provide developmental care interventions to preterm infants to improve neurodevelopmental outcomes. (4) provide neonatal positioning procedures for preterm infants to prevent extremity malalignment, skull deforities, and gross motor delay. (5) Encourage adequate antepartum and postpartum care for both mother and child. (6) Counsel parents, siblings, and caregivers about the importance of smoking cessation and the necessity of eliminating all second hand smoke exposure. (7) Teach caregivers of children appropriate developmental interactions; use anticipatory guidance to facilitate preparation for developmental milestones. Diarrhea 367 Passage of loose, unformed stools hyperactive bowel sounds; at least three loose liquid stools per day; abdominal pain; cramping PSYCHOLOGICAL: High stress levels and anxiety. SITUATIONAL: Alcohol abuse; toxins; laxative abuse; radiation; tube feedings; adverse effects of medications; contaminants; travel. PHYSIOLOGICAL: Inflammation; malabsorption; infectious processes; irritation; parasites Bowel Elimination; Electrolytes and Acid-Base Balance; Fluid Balance; Hydration; Treatment Behavior: Illness or Injury (1) Defecate formed, soft stool every day to every third day. (2) Maintain a rectal area free of irritation. (3) State relief from cramping and less or no diarrhea. (4) Explain cause of diarrhea and rationale for treatment. (5) Maintain good skin turgor and weight at usual level. (6) Contain stool appropriately (if previously incontinent). Diarrhea Management (1)Assess pattern of defecation or have the client keep a diary that includes the following: time of day defecation occurs; usual stimulus for defecation; consistency, amount, and frequency of stool; type of, amount of, and time food consumed; fluid intake; history of bowel habits and laxative use; diet; exercise patterns; obstetrical/gynecological, medical, and surgical histories; medications; alterations in perianal sensations; and present bowel regimen. (2) Identify cause of diarrhea if possible (e.g., viral, rotavirus, HIV); food; medication effect; radiation therapy; protein malnutrition; laxative abuse; stress). See Related Factors (r/t). (3) If the client has watery diarrhea, a low-grade fever, abdominal cramps, and a history of antibiotic therapy, consider possibility ofClostridium difficileinfection. (4) If the client has diarrhea associated with antibiotic therapy, consult with primary care practitioner regarding the use of probiotics such as yogurt with active cultures...... (1) Evaluate medications the client is taking. Recognize that many medications can result in diarrhea, including digitalis, propranolol, angiotensin-converting enzyme (ACE) inhibitors, histamine-receptor antagonists, NSAIDs, anticholinergic agents, oral hypoglycemia agents, antibiotics, and others. (2) Monitor the client closely to detect whether an impaction is causing diarrhea; remove impaction as ordered. (3) Seek medical attention if diarrhea is severe or persists for more than 24 hours, or if the client has symptoms of dehydration or electrolyte disturbances such as lassitude, weakness, or prostration. (4) Provide emotional support for clients who are having trouble controlling unpredictable episodes of diarrhea. (1) Above interventions may be adapted for home care use. (2) Assess the home for general sanitation and methods of food preparation. Reinforce principles of sanitation for food handling. (3) Assess for methods of handling soiled laundry if the client is bed bound or has been incontinent. Instruct or reinforce Universal Precautions with family and bloodborne pathogen precautions with agency caregivers. (4) When assessing medication history, include over-the-counter drugs, both general and those currently being used to treat the diarrhea. Instruct clients not to mix over-thecounter medications when self-treating. (5) Evaluate current medications for indication that specific interventions are warranted. (6) Consult with physician regarding need for blood work or stool specimens. (7) Evaluate need for home health aide or homemaker service referral. (8) Evaluate need for durable medical equipment in the home.

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html (1) Encourage avoidance of coffee, spices, milk products, and foods that irritate or stimulate the gastrointestinal tract. (2) Teach appropriate method of taking ordered antidiarrheal medications; explain side effects. (3) Explain how to prevent the spread of infectious diarrhea (e.g., careful hand washing, appropriate handling and storage of food). (4) Help the client to determine stressors and set up an appropriate stress reduction plan. (5) Teach signs and symptoms of dehydration and electrolyte imbalance. (6) Teach perirectal skin care. Disuse syndrome, risk for 373 At risk for a deterioration of body systems as the result of prescribed or unavoidable musculoskeletal inactivity Paralysis; altered level of consciouness; mechanical immobilization; prescribed immobilization; severe pain (NOTE: compications from immobility can include pressure ulcer, constipation, stasis of pulmonary secretions, thromosis, urinary tract infection and/or retention, decreased strength or endurance, orthostatic hypotension, decreased range of joint motion, disorientation, disturbed body image, and powerlessness.) Endurance; Immobility Consequences: Physiological; Mobility; Neurological Status: Consciousness; Pain Level (1) Maintain full range of motion in joints. (2) Maintain intact skin, good peripheral blood flow, and normal pulmonary function. (3) Maintain normal bowel and bladder function. (4) Express feelings about imposed immobility. (5) Explain methods to prevent complications of immobility. Energy Management; Exercise Therapy: Joint Mobility, Muscle control (1) Use a functional assessment instrument to evaluate abilities including instruments such as the Barthel Index, the Katz Indext of ADLs, or the FIM instrument. (2) Have the client do exercises in bed if not contraindicated (e.g., flexing and extending feet and quadriceps, performing gluteal and abdominal sitting exercises, lifting small weights to maintain muscle strength). (3) If not contraindicated by the client's condition, obtain referral to physical therapy for use of tilt table to provide weight bearing on long bones. (4) Perform ROM exercises for all possible joints at least twice daily; perform passive or active ROM exercises as appropriate. (5) Use high-top sneakers or specialized boots from the occupational therapy department to prevent footdrop; remove shoes twice daily to provide foot care. (6) Position the client so that joints are in normal anatomical alignment at all times. (7) Get the client up in a chair as soon as appropriate; use a stretcher-chair if necessary... (1) Recognize the importance of keeping elderly clients active if possible. (2) If geriatric, the client is scheduled for an elective surgery that will result in admission into ICU and immobility, or recovery from a knee replacement, initiate a prehabilitation program that includes a warm-up, aerobic strength, flexibility, and functional task work. (3) Refer to physical therapy for an individualized strength training program. Monitor for signs of depression; flat affect, poor appetite, insomnie, many somatic complaints. (4) Keep careful track of bowel function in the elderly; do not allow the client to become constipated. NOTE: Care for all body systems because the immobilized or otherwise at risk client must continue in the home as stated in the previously mentioned interventions. The primary nurse monitors and adjucts the plan of care accordingly per physcian orders. (1) Some of the above interventions may be adapted for home care use. (2) Begin discharge planning as soon as possible with care manager or social worker to assess need for home support systems and community or home health services. (2) Become oriented to all programs of care for the client before discharge from institutional care. (3) Confirm the immediate availability of all necessary assistive devices for the home. (4) Continuity in management of care promotes success in meeting client-centered goals. (5) Perform complete physical assessment and recent history at initial visit. (6) Refer to physical and occupational therapies for immediate evaluations of the client's potential for independence and functioning in the home setting ...... (1) Teach how to perform ROM exercises in bed if not contraindicated. (2) Teach the family how to turn and position the client and provide all care necessary. NOTE: Nursing diagnoses that are commonly relevant when the client

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html is on bed rest include: Constipation, Risk for impaired Skin integrity, Distrubed Sensory perception, Disturbed Sleep pattern, Adult Failure to thrive, and Powerlessness. Diversional activity, deficient 378 Decreased stimulation from or interest or engagement in recreational or leisure activities Usual hobbies cannot be undertaken in hospital; patient's statements regarding boredom and the wish for something to do, to read, etc. Environmental lack or diversional activity as a result of long-term hospitalization or frequent or lengthy treatments Leisure Participation; Play Participation; Social Involvement (1) Engage in personally satisfying diversional activities Recreation Therapy; Self-Responsibility Facilitation (1) Observe for symptoms of deficient diversional activity: yawning, restlessness, flat facial expression, and statements of boredom. (2) Observe ability to engage in activities that require good vision and use of hands. (3) Discuss activities with clients that are interesting and feasible in the present environment. (4) Encourage a mix of physical and mental activities (e.g., crafts, videotapes). Provide activites that are entertaining, such as videotapes, joke books, or a "humor room". (5) Use "bread therapy"--have clients bake bread with a bread maker two times per day or prn. (6) Arrange animal-assisted therapy, with a dog or cat for the client to interact with and care for. (7) Encourage the client to schedule visitors so that they are not all present at once or at inconvenient times. (8) Provide reading material, TV, radio, and books on tape. Provide virtual reality experiences for children, which can be used as distraction techniques during chemotherapy treatments. Recommend... (1) If the client is able, arrange for him or her to attend group senior citizen exercise session for progressive training, even if exercise can only be done while seated. (2) Encourage involvement in senior citizen activities (e.g., AARP, YMCA, church groups, Gray Panthers). Arrange transportation to activities as needed. (3) Encourage clients to use their ability to help others by volunteering. (4) Provide an environment that promotes activity; allow periods of solitude and privacy. (5) Use reminiscence therapy either individually or in groups. (6) Use the Eden Alternaitve with the elderly, bring in appropriate plants for the elderly client to care for, animals such as birds, fish, dogs, and cats as appropriate for the client, and children to visit. (1) Assess for the influence of cultural beliefs, norms, and values on the client's leisure activity interests. (2) Validate the client's feelings and concerns related to lack of stimulation or interest in leisure activities. NOTE: Many of the previosly listed interventions should be administered in the home setting (e.g., modifying the environment to stimulate the client, scheduling visitors to allow for rest and activity). Some adaptations may be necessary. (1) Explore with the client previous interests; consider related activities that are within the client's capabilities. (2) Assess the client for depression. Refer for mental health services as indicated. (3) Refer to occupational therapy to assist the client and family with identifying diversional activities within the capability of the client and family. (4) Assess the family's ability to respond to the client's psychosocial needs for stimulation. (5) Introduce (or continue) friendly volunteer visitors if the client is willing and able to have the company. If transportation is an issue or if the client does not want visitors in the home, consider alternatives (e.g., telephone contacts, computer messaging). (6) In the presence of a psychiatric ...... (1) Work with the client and family on learning diversional activites that the client is interested in (e.g., knitting, hooking rugs, writing memoirs). (2) If the client is in isolation, give the client complete info on why isolation is needed and how it should be accomplished, especially guidelines for visitors. Energy field, disturbed 383 A disruption of the flow of energy surrounding a person's being, which results in a disharmony of mind and spirit Temperature change (warmth/coolness); visual changes (image/color); disruption of the field (vacant/hold/spike/bulge), movement (wave/tingling/dense/flowing), sounds (tone/words) Comfort Level; Spiritual

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Health (1) State sense of well-being. (2) State feeling of relaxation. (3) State decreased pain. (4) State decreased tension. (5) Demonstrate evidence of physical relaxation (e.g., decreased BP, pulse, respiration rate, muscle tension) Therapeutic Touch (1) Refer to care plans for Anxiety, Acute Pain, and Chronic Pain. (2) Administer therapeutic touch (TT) as described in the following discussion (may also include healing touch and Reki practice). (3) Guidelines for Therapeutic Touch..........(4) Administer TT by performing the following steps.............. (1) Assess for the influence of cultural beliefs, norms, and values on the client's sense of disharmony of mind and spirit. (2) Assess for the presence of specific culture-bound syndromes that may manifest as disturbances in energy or spirit. (3) Validate the client's feelings and concerns related to sense of disharmony or energy disturbance. (1) See guidelines for Therapeutic Touch. (2) Help the client and family accept TT as a healing intervention. Consultation and collaboration with a specialist may be the best approach to nursing care. Numberous studies have reported outcomes of Healing Touch as a noninvasive complementary therapy. (3) Assist the family with providing an appropriate space in which TT can be administered. (4) Assess clients with bipolar disorder for the occurence of social rhythm disruption, particulary during periods of stressful life events. Refer for mental health treatment. (5) In the presence of a psychiatric disorder, refer for psychiatric home health care services for client reassurance and implementation of therapeutic regimen. (1) Teach the TT process to family members, TT enables caregivers to embrace their compassion and to touch people with effect. (2) Teach that when working with the very young, old, or ill, or on the head area, TT should be gently and used only for short periods. Exercise caution when using TT with patients who may exhibit an extreme sensitivity to the process (e.g., premature infants, frail elderly, psychotic clients). (3) Teach the client how to use guided imagery. The nurse can facilitate healing by helping the client recontact and reclaim parts of the self (resolve energy disturbance) through guided imagery. (4) Teach the client to use deep breathing to relax. Ask the client to have the disease, affected organ, or symptom assume an image. After the image has been identified, ask the client to speak with the image to address an unresolved issue. By describing a previously unacknowledged part of the self, liberted energy can transform resistance, defenses, and disease in ............. Environmental interpretation syndrome, impaired 387 Consistent lack or orientation to person, place, and time, or circumstances for more than 3 to 6 months, necessitating a protective environment Chronic confusional states; consistent dirorientation in known and unknown environments; loss of occupation or social functioning resulting from memory decline; slow to respond to questions; inability to follow simple directions/instructions, concentrate, or reason Depression; dementia (e.g., Alzheimer's, multi-infarct, Pick's disease, AIDS, Parkinson's disease, alcoholism) Cognitive Orientation; Concentration; Information processing; Memory; Neurological Status: Consciousness (1) Remain content and free from harm. (2) Function at maximal cognitive level. (3) Independently participate in ADLs at the maximum of functional ability. Dementia Managemet; Environmental Management; Reality Orientation; Surveillance: Safety See care plan for Chronic Confusion See care plan for Chronic Confusion See care plan for Chronic Confusion See care plan for Chronic Confusion See care plan for Chronic Confusion Failure to thrive, adult 388 Progressive functional deterioration of a physical and cognitive nature with remarkably diminished ability to live with multisystem diseases, cope with ensuing problems, and manage care Anorexia--does not eat meals when offered; states does not have an appetite, is not hungery, or "I don't want to eat"; inadequate nutritional intake--eating less than body requirements; consumption of minimal to no food at most meals; weight loss--5% unintentional loss in 1 mo or 10% unintentional loss in 6 mo; physical decline--evidence of fatigue,

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

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html chronically disorganized, leading to conflict, denial of problems, resistance to change, ineffective problem solving, and a series of self-perpetuating crises ROLES AND RELATIONSHIPS: Inconsistent parenting/low perception of parental support; ineffective spouse communication/marital problems; intimacy dysfunction; deterioration in family relationships/disturbed family dynamics; altered role function/disruption of family roles; closed communication systems; chronic family problems; family denial; lack of cehesiveness; neglected obligations; lack of skill necessary for relationships; reduced ability of family members to relate to each other for mutual growth and maturation; family unable to meet security needs of its members; disrupted family rituals; economic problems; family does not demonstrate respect for individuality and autonomy of its members; triangulating family relationships; pattern of rejection. BEHAVIORAL: Refusal to get help/inability to accept and receive help appropriately; inadequate understanding or knowledge of alcoholism; ineffective problem-solving skills; loss of control of drinking; manipulation; LOTS MORE; SEE BOOK! Abuse of alcohol; genetic predisposition; lack of problem-solving skills; family history of alcoholism; resistance to treatment; biochemical influences; addictive personality Family Coping; Family Functioning; Family Health Status; Substance Addiction Consequences (1) Develop relatinship with nurse that demonstrates at least minimal level of trust. (2) Demonstrate an understanding of alcoholism as a famiy illness and the severity of the threat to emotional and physical health of family members. (3) Develop and state a belief in feasibility and effectiveness of efforts to address alcoholism. (4) Demonstrate change from dysfunctional patterns by moving from inappropriate to appropriate role relationships, improving cohesion among family members, decreasing conflict and social isolation, and improving coping behaviors. (5) Maintain improvements. Family Process Maintenance; Substance Use Treatment (1) Demonstrate high levels of empathy and expectancy of positive outcomes in interactions with family members. (2) When completing a family assessment, assess behaviors of alcohol abuse, loss of control of drinking, denial, nicotine addiction, impaired communication, inappropriate expression of anger, and enabling behaviors. (2) Screen clients for at-risk drinking during routine primary care visits. At-risk drinking is defined as consuming an average of two or more drinks per day (chronic drinking), or, in the past month, one or more occasion of drining after consuming three or more drinks (drinking and driving) (3) ..... (4) Educate family members about alcoholism, being careful not to label or stigmatize them. (5) Educate family members about available educational and support programs. (6) Stress individual self-focus as a first step in problem resolution. (7) Help family to restructure family patterns of interaction and function to support the development of consistency, a ........ (1) Include assessment of possible alcohol abuse when assessing elderly family members. (2) Use CAGE tool with the population and include drug use along with drinking. An affirmative answer to two or more of the following questions is considered a basis for suspicion of alcohol abuse: C: Have you ever felt you ought to Cut Down on drinking? A: have people every Annoyed you by criticizing your drinking? G: Have you ever felt bad or Guilty about your drinking? E: Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye Opener)? (1) Acknowledge racial/ethnic differences at the onset of care. (2) Approach families of color with respect, warmth, and professional courtesy. (3) Give rationale when assessing black families about alcohol use and misuse. (4) Use a family-centered approach when working with Latino, Asian, African American, and Native American clients. (5) When forking with Asian American clients, provide opportunites for the family to save face. NOTE: In the community setting, alcoholism as an etiology for dysfunctional family porcesses must be considered in two categories. The first is when the client suffers personally from the illness, the second is when a significant other suffers from the illness, that is, the client is not the active alcoholic but may be dependent on the alcoholic for caregiving. The listed considerations apply to both situation with appropriate adaptation for the

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html circumstances. (1) Above interventions may be adapted for home care use. (2) Identify client/family expectations of the home care nurse and nurse expectationsof the client/family by the use of a well-defined contract. Be specific and realistic. Adjust the contract only with clear consent and understanding from client/family. (3) Establish well-defined contingency and emergency plans for the care of the client. (4) Requiest concrete, measurable tasks of the client and family for caregiving and provide concrete, nonjudgmental instruction to ..... Family processes, readiness for enhanced 411 A pattern of family functioning that is sufficient to support the well-being of family members and can be strengthened. Expresses willingness to enhance family dynamics; Family functioning meets physical, social, and psychological needs of family members; Activities support for the safety and growth of family members; Communication is adequate; Relationships are generally positive; interdependent with community; family task are accomplished; Family roles are flexible and appropriate for developmental stages; Respect for family members is evident; Family adapts to change; Boundaries of family members are maintained; Energy level of family supports activities of daily living; Family resilience is evident; Balance exists between autonomy and cohesiveness Family Coping; Family Physical environment; Health Orientation; Health Promoting Behavior; Health Seeking Behavior; Leisure Particpation; Parent-Infant Attachment; Parenting Performance; Psychosocial Adjustment: Life Change; Risk Control; Role Performance; Social Support; Spiritual Health (1) Identify ways to cope effectively and use appropriate support systems (family). (2) Meet physical, psychosocial, and spiritual needs of members or seeks appropriate assistance (family). (3) Demonstrate knowledge of potential environmental, lifestyle, and genetic risks to health and use appropriate measures to decrease possibility of risk (family). (4) Focus on wellness, disease prevention, and maintenance (family and individual). (5) Seek balance among exercise, work, leisure, rest, and nutrition (family and individual). Active Listening; Anticipatory Guidance; Attachment Promotion; Coping Enhancement; Decision-Making Support; Environmental management: Attachment Process; Exercise Promotion; Family Integrity Promotion; Family Involvement Promotion; Family Mobilization; Family Process Maintenance; Health Screening; Mutual Goal Setting; Parent Education: Adolescent, Childrearing Family; Risk Identification; Role Enhancement (1) Assess the family's stress level and coping abilities during the initial nursing assessment. (2) Use family-centered care, and role modeling for holistic care of families. (3) Discuss with the family members how they have handled previous crises. (4) Support family empowerment; strength and resourcefulness. (5) Provide parenting class series based on individual and couple changes in meaning/identity, roles, and relationship/interaction during the transition to parenthood. Address mother/father roles, infant communication abilities, and patterns of the first 3 months of life in a mutually enjoyable, possiblity-focues way. (6) Encourage family members to find meaning in a serious illness like cancer. (7) Have family members participate in client conferences that involve all members of the health care team. (8) Provide family-centered care to explore and use all available resources appropraite for situation (e.g., counseling, social services, self-help groups, pastoral care). (1) Carefully listen to residents and family members in the long-term care facility. (2) Support caregivers' awareness of the positive effects of thier contribution to the well-being of parents. (3) Teach family members about impact of developmental events (e.g., retirement, death, change in health status, and household composition). (4) Encourage social networks, social integration, and social engagement with friends. (1) Assess for the influence of cultural beliefs, norms, and values on the family's perceptions of normal functioning. (2) With the client's consent, facilitate a gorup meeting for family members to discuss how the family is functioning. (3) Facilitate modeling and role-playing for the client and family regarding healthy ways to start a discussion about the client's prognosis. (4) Identify and acknowledge

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

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

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

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Fluid volume, deficient 434 Decreased intravascular, interstitial, and/or intracellular fluid (refers to dehydration, water loss alone without change in sodium level) Decreased urine output; increased urine concentration; weakness; sudden weight loss (except in third-spacing); decreased venous filling; increased body temp; decreased pulse volume/pressure; change in mental state; elevated hematocrit; decreased skin/tongue turgor; dry skin/mucous membranes; thirst; increased pulse rate; decreased blood pressure Active fluid volume loss; failure of regulatory mechanisms Electrolyte and Acid-Base Balance; Fluid Balance; Hydration; Nutritional Status: Food and Fluid Intake (1) Maintain urine output more than 1300 ml/day (or at least 30 ml/hr). (2) Maintain normal BP, pulse, and body temp. (3) Maintain elestic skin turgor; moist tongue and mucous membrances; and orientation to person, place, and time. (4) Explain measures that can be taken to treat or prevent fluid volume loss. (5) Describe symptoms that indicate the need to consult with health care provider. Fluid Management; Hypovolemia Management; Shock Management: Volume (1) Monitor for the existence of factors causing deficient fluid volume (e.g., vomiting, diarrhea, difficulty maintaining oral intake, fever, uncontrolled type 2 diabetes, diuretic therapy). (2)Watch for early signs of hypovolemia, including restlessness, weakness, muscle cramps, and postural hypotension. (3) Monitor total fluid intake and output every 8 hours (or every hour for the unstable client). Recognize that urine output is not always an accurate indicator of fluid balance. (4) Watch trends in output for 3 days; include all routes of intake and output and note color and specific gravity of urine. (5) Monitor daily weight for sudden decreases, especially in the presence of decreasing urine output or active fluid loss. Weigh the client on the same scale with the same type of clothing at same time of day, preferably before breakfast. (6) Monitor vital signs of clients with deficient fluid volume every 15 minutes to 1 hour for the unstable client (every 4 hours for the stable...... (1) Monitor elderly clients for deficient fluid volume carefully, noting new onset of weakness, dizziness, or dry mouth with longitudinal furrows. (2) Check skin turgor of elderly client on the forehead, sternum or inner thigh; also look for the presence of longitudinal furrows on the tongue and dry mucous membranes. (3) Encourage fluid intake by offering fluids regularly to cognitively impaired clients. (4) Incorporate regular hydration into daily routines (e.g., extra glass of fluid with medication or social activities). Consider use of a beverage cart and a hydration assistant to routinely offer increased beverages to clients in extended care. (5) Note the color of urine and compare against a urine color chart to monitor adequate fluid intake. (6) Monitor elderly clients for excess fluid volume during the treatment of deficient fluid volume: listen to lung sounds, watch for edema, and note vital signs. (1) Determine if it is appropriate to intervene for deficient fluid volume or to allow the client to die comfortably without fluids as desired. (2) Teach family members how to monitor output in the home (e.g., use of commode "hat" in the toilet, urinal, or bedpan, or use of catheter and closed drainage). Instruct them to monitor both intake and output (3) When weighing the client, use same scale each day. Be sure scale is on a flat (not cushioned) surface. Do not weigh the client with scale placed on any kind of rug. Use bed or chair scales for clients who are unable to stand. (4) Teach family about complications of deficient fluid volume and when to call physician. (5) If the client is receiving intravenous fluids, there must be a responsible caregiver in thehome. Teach caregiver about administration of fluids, complications of intravenous administration (e.g., fluid volume overload, speed of medication reactions), and when to call for assistance. Assist caregiver with admin..... (1) Instruct the client to avoid rapid position changes, especially from supine to sitting or standing. (2) Teach the client and family about appropriate diet and fluid intake. (3) Teach the client and family how to measure and record intake and output accurately. (4) Teach the client and family about measures instituted to treat hypovolemia and to prevent or treat

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html fluid volume loss. (5) Instruct the client and family about signs of deficient fluid volume that indicate they should contact health care provider. Fluid volume, excess 440 Increased isotonic fluid retention Jugular vein distention; decreased hemoglobin and hematocrit; weight gain over short period; changes in respiratory pattern, dyspnea, or SOB; orthopnea; abnormal breath sounds (rales or crackles); pulmonary congestion; pleural effusion; intake exceeds output; S3 heart sound; change in mental status; restlessness; anxiety; BP changes; pulmonary artery pressure changes; increased central venous pressure; oliguria; azotemia; specific gravity changes; altered electrolytes; edema, may progress to anasarca; positive hepatojugular reflex Compromised regulatory mechanism; excess fluid intake; excess sodium intake Electrolyte and Acid-Base Balance; Fluid Balance; Hydration (1) Remain free of edema, effusion, anasarca; weight appropriate for the client. (2) Maintain clear lung sounds; no evidence of dyspnea or orthopnea. (3) Remain free of jugular vein distention, positive hepatojugular reflex, and gallop heart rhythm. (4) Maintain normal central venous pressure, pulmonary capillary wedge pressure, cardiac output, and vital signs. (5) Maintain urine output within 500 ml of intake and normal urine osmolality and specific gravity. (6) Remain free of restlessness, anxiety, or confusion. (7) Explain measures that can be taken to treat or prevent excess fluid volume, especially fluid and dietary restrictions and medications. (8) Describe symptoms that indicate the need to consult with health care provider. Fluid Management; Fluid Monitoring (1) Monitor location and extent of edema; use a millimeter tape in the same area at the same time each day to measure edema in extremities. (2) Monitor daily weight for sudden increases; use same scale and type of clothing at same time each day, preferably before breakfast. (3) Monitor lung sounds for crackles, monitor respirations for effort, and determine the presence and severity of orthopnea. (4) With head of bed elevated 30 to 45 degrees, monitor jugular veins for distention in the upright position; assess for positive hepatojugular reflex. (5) Monitor central venous pressure, mean arterial pressure, pulmonary artery pressure, pulmonary capillary wedge pressure, and cardiac output; note and report trends indicating increasing pressures over time. (6) Monitor vital signs; note decreasing blood pressure, tachycardia, and tachypnea. Monitor for gallop rhythms. If signs of heart failure are present, see nursing care plan for Decreased Cardiac output. (7) Monitor serum osmolality, .... (1) Recognize that the presence of risk factors for excess fluid volume is particularly serious in the elderly. Decreased cardiac output and stroke volume are normal aging changes that increase the risk for excess fluid volume (1) Assess client and family knowledge of disease process causing excess fluid volume. Teach about disease process and complications of excess fluid volume, including when to contact physician. (2) Assess client and family knowledge and compliance with medical regimen, including medications, diet, rest, and exercise. Assist family with integrating restrictions into daily living. (3) If the client is confined to bed rest or has difficulty reclining, follow previously mentioned positioning recommendations. (4) Teach and reinforce knowledge of medications. Instruct the client not to use over-thecounter medications (e.g., diet medications) without first consulting the physician. Instruct the client to make primary physician aware of medications ordered by other physicians.(5) Identify emergency plan for rapidly developing or critical levels of excess fluid volume when diuresing is not safe at home. (6) Teach about signs and symptoms of both excess and deficient fluid volume and when ...... (1) Describe signs and symptoms of excess fluid volume and actions to take if they occur. (2) Teach the importance of fluid and sodium restrictions. Help the client and family to devise a schedule for intake of fluids throughout entire day. Refer to dietitian concerning implementation of low-sodium diet. (3) Teach how to take diuretics correctly: take one dose in the morning and second dose (if taken) no later than 4 PM. Adjust potassium intake as appropriate for potassiumlosing or potassium-sparing diuretics. Note the

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html especially wedge pressure. (7) If hypotension develops, administer fluid challenge as ordered, giving a specified amount of IV fluids, such as rapidly delivered IV 0.9% normal saline, and monitoring response by observing vital signs, lung sounds, andurine output. (8) Carefully keep track of input and output of fluids during surgery. (9) Measure urine output ........ (1) Monitor the pediatric surgical client closely for signs of fluid loss. (1) Be especially vigilant when monitoring vital signs and fluids in elderly surgical clients. (2) Assess for preoperative dehydration. Gas exchange, impaired 451 Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane Visual disturbance; decreased carbon dioxide; dyspnea; abnormal arterial blood gas levels; hypoxia; irritability; somnolence; restlessness; hypercapnia; tachycardia; cyanosis; abnormal skin color (pale, dusky); hypoxemia; hypercarbia; headache on awakening; abnormal rate, rhythm, depth of breathing; diaphoresis; abnormal arterial pH; nasal flaring Ventilation-perfusion imbalance; alveolar-capillary membrane changes Respiratory Status: Gas Exchange, Ventilation (1) Demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters for that client. (2) Maintain clear lung fields and remain free of signs of respiratory distress. (3) Verbalize understanding of oxygen supplementation and other therapeutic interventions. Acid-Balse Management; Airway Management (1) Monitor respiratory rate, depth, and effort, including use of accessory muscles, nasal flaring, and abnormal breathing patterns. (2) Auscultate breath sounds every 1 to 2 hours. (3) Monitor the client's behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. (4) Monitor oxygen saturation continuously using pulse oximetry. Note blood gas results as available. (5) Observe for cyanosis of the skin; especially note color of the tongue and oral mucous membranes. (6) If the client has unilateral lung disease, alternate semi-Fowler's position with a lateral position (with 10- to 15-degree elevation and "good lung down" for 60 to 90 minutes). This method is contraindicated for clients with pulmonary abscess or hemorrhage or interstitial emphysema. (7) If the client has bilateral lung disease, position the client in either semi-Fowler's or a side-lying position, which increases oxygenation as indicated by pulse oximetry.... (1) Use central nervous system depressants carefully to avoid decreasing respiration rate. (2) Maintain low-flow oxygen therapy. (3) Encourage the client to stop smoking. (1) Assess the home environment for irritants that impair gas exchange. Help the client to adjust the home environment as necessary (e.g., install an air filter to decrease the level of dust). (2) Refer the client to occupational therapy as necessary to assist the client in adaptation to the home and environment and in energy conservation. (3) Assist the client with identifying and avoiding situations that exacerbate impairment of gas exchange (e.g., stress-related situations, exposure to pollution of any kind, proximity to noxious gas fumes such as chlorine bleach). (4) Instruct the client to keep the home temperature above 20 C (68 F) and to avoid cold weather. (5) Instruct the client to limit exposure to persons with respiratory infections. (6) Instruct the family in the complications of the disease and the importance of maintaining the medical regimen, including when to call a physician. (7) Assess nutritional status. Instruct the client to eat several small meals and use...... (1) Teach the client how to perform pursed-lip breathing and controlled diaphragmatic breathing, and how to use the tripod position. Have the client watch the pulse oximeter to note improvement in oxygenation with these breathing techniques. (2) Teach the client energy conservation techniques and the importance of alternating rest periods with activity. See nursing interventions for Fatigue. (3) Teach the importance of not smoking; be aggressive in approach, and ask the client to set a date for smoking cessation. Recommend nicotine replacement therapy (nicotine patch or gum). Refer the client to smoking-cessation programs. Encourage clients who relapse

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html to keep trying to quit. (4) Instruct the family regarding home oxygen therapy if ordered (e.g., delivery system, liter flow, safety precautions). (5) Teach the client relaxation techniques to help reduce stress responses and panic attacks resulting from dyspnea. Grieving 456 State in which an individual or group of individuals reacts to an actual or perceived loss, which may be loss of a person, object, function, status, relationship, or body part. NOTE: Grieving is not an official NANDA diagnosis, but it is included because the authors believe that grieving is part of the normal human response to loss and that nurses can use interventions to help the client grieve. Grieving is a well-ness oriented nursing diagnosis. Verbal expression of distress; anger; sadness; crying; difficulty in expressing loss; alterations in eating habits, sleep patterns, dream patterns, activity levels, or libido; reliving of past experiences; interference with life function; alterations in concentration or pursuit of tasks. Actual or perceived object loss, which may include loss of people, possessions, job, status, home, ideals, or parts and processes of the body Grief Resolution; Hope; Mood Equilibrium; Psychosocial Adjustment: Life Change (1) Express feelings of guilt, fear, anger, or sadness. (2) Identify problems associated with grief (e.g., changes in appetite, insomnia, loss of libido, decreased energy, alteration in activity level). (3) Plan for future one day at a time. (4) Function at normal developmental level and perform activities of daily living Grief Work Facilitation; Grief Work Facilitation: Perinatal Death (1) Use a grief instrument such as the Hogan Grief Reaction Checklist (HGRC) to evaluate the client with regard to the six factors in the normal trajectory of the grieving process: Despair, Panic Behavior, Blame and Anger, Detachment, Disorganization, and Personal Growth. (2) Allow family members to participtae in care of the body of the deceased if desired. Help survivors say goodbye in the most loving and caring way possible. (3) Allow the family "holding" behaviors, including taking photographs of the deceased or clipping a piece of hair. (4) Help the bereaved client survive during times of acute grief. Ensure that the client maintains sufficient nutrtion and help the client determine a routine to make it through each day. (5) Encourage the client to shar memories and tell stories of the person or object of loss by making comments such as, "Tell me about your wife [husband, parent]." Conduct an in-depth personal interview to learn about the client and loved one or loss. (6) ...... (1) Use reminiscence therapy in conjunction with the expression of emotions. (2) Identify pervious losses and assess the client for depression. (3) Monitor an older adult who has been treated for bereavement-related depression for relapse or recurrence. (4) Evaluate the social support system of the elderly client. If the support system is minimal, help the client determine how to increase availabe support. (5) Provide support for the family when the loss is associated with dementia of the family member. (1) Assess for the influence of cultural beliefs, norms, and values on the client's grief and mourning practices. (2) Assess for the influence of cultural beliefs, norms, and values on the client's expressions of grief. (3) Identify whether the client had been notified of the deceased's health status and was able to be present at the deathbed. (4) Validate the client's feelings regarding the loss. NOTE: Grieving may be encountered as the client comes to terms with his or her own loss or heath, or as the family reacts to the client's death. (1) The interventions described previously may be adapted for home care use. (2) Listen actively as the client grieves his or her own death, or real or perceived loss. Normalize the client's expression of grief for himself or herself. (3) If the agency has served the decreased as a client, allow the primary caregivers to attend the services. (4) Plan the first home visit within 10 days after the loss by the client; be guided by the type of loss and the family's schedule following the loss. (5) If the loss of a loved one, allow the client to express feelings about the loss through interaction with the home environment. Symbols of the lost loved one can be comforting and allow the bereaved to accept the loss in stages. (6) A wide range of behaviors and perceptions occurs during the grieving response. Do not react with shock

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html or disbelief at a ... Grieving, anticipatory 463 Intellectual and emotional responses and behaviors by which individuals, families, and communities work through the process of modifying self-concept based on the perception of potential loss. Expression of distress at potential loss; sorrow; guilt; denial of potential loss; anger; altered communication patterns; potential loss of significant object (e.g., people, possessions, job, status, home, ideals, parts and processes of the body); denial of significance of the loss; bargaining; alteration in eating habits, sleep patterns, dream patterns, activity level, or libido; difficulty taking on new or different roles; resolution of grief before the reality of loss Perceived or actual impending loss of people, objects, possessions, job, status, home, ideals, or parts and processes of the body. Coping; Family Coping; Grief Resolution; Psychosocial Adjustment: Life change. (1) Express feelings of guilt, anger, or sorrow. (2) Identify problems associated with anticipatory grief (e.g., changes in activity, eating or libido). (3) Seek help in dealing with anticipated problems. (4) Plan for the future one day at a time. Grief Work Facilitation; Grief Work Facilitation: Perinatal Death (1) If grief results from the impending death of a loved one, allow family members to stay with the loved one during the dying process if desired and help them determine appropriate times to take breaks. (2) Encourage family members to touch the dying client if they are comfortable with doing so. (3) Encourage family members to listen carefully to messages given by the dying lovel one; they may hear symbolic or obscure language referring to the dying process. (4) If the dying client id denying the seriousness of his or her condition, do not negate the denial. (5) Help the dying client to maintain hope by focusing on the moment, reviewing his or her assets, and maintaining important relationships. (6) Use therpeutic communication with open-ended questions such as "What are your thoughts and fears?" (7) Keep family members informed about the clent's condition. (8) Actively listen to the client's and/or family's expression of grief; do not interrup, do not tell your own story, and do .... (1) Assist the client with end-of-life decisions and advance directives. (1) Assess for the influence of cultural beliefs, norms, and values on the clients grief and mourning practices. (2) Assess for the influence of cultural beliefs, norms, and values on the client's expression of grief. NOTE: Hospice care encourages clients and families to experience the client's final days in the setting of choice. All of the previously memtioned interventions can and should be applied to the home setting when that is the setting selected. (1) Listen actively; normalize the client's and family's expression of grief for a loved one who is expected to die. (2) When the potential loss is of a loved one, refer the grieving client to hospice volunteer services for support. (3) When the client has a history of loss of a pregnancy, assess the client's need for a counseling referral during subsequent pregnancies. (1) Teach caregivers that they are doing anticipatory grieving as they care for their loved ones, which is part of the reason care can be so difficult. The grief can become more acute as death approaches. Grieving, disfunctional 468 Extended unsuccessful use of intellectual and emotional responses by which individuals, families, and communities attempt to work through the process of modifying self-concept based on the perception of loss. NOTE: It is now recognized that sometimes what was previously diagnosed as Dysfunctional Grieving might instead be Chronic Sorrow, in which grief lingers and is reactivated at intervals. Refer to the nursing diagnosis Chronic Sorrow is appropriate. Repetitive use of ineffectual behaviors associated with attempts to reinvest in relationships; crying; sadness; reliving of past experiences with little or no reduction (diminishment) of intensity of grief; labile affect; expression of unresolved issues; interference with life functioning; verbal expression of distress at tloss; idealization of lost object (e.g., people, possessions, job, status, home, ideals, parts and processes of the body); difficulty in expressing loss; denial of loss, anger; alterations in eating habits, sleep patterns, dream patterns, activity level,

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

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

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

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

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

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

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

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Provide plant or pet therapy if possible. (8) Provide a safe environment so that the client ....... (1) Provide information regarding the client's condition, treatment plan, and progress. (2) Provide positive reinforcement, praise, and acknowledgment of the challenges of caregiving to family members. (3) Teach the use of stress-reduction techniques, relaxation, and imagery. Many cassette tapes on relaxation and meditation are available. Assist the client and caregivers with relaxation based on their preference from the initial assessment. (4) Encourage families to express love, concern, and encouragement, and allow the client to verbalize feelings. (5) Refer the client to self-help groups such as I Can Cope and Make Today Count. (6) Refer the family to community support groups targeted to the specific needs of the family caregivers. (7) Supply a crisis phone number and negotiate a no-suicide contract with the client stating that the crisis number will be used if thoughts of self-harm occur. Hyperthermia 512 Body temperature elevated above normal range. NOTE: Elevated body temperature can be either fever or hyperthermia. Fever is a normal response in which the core body temperature increases at least 0.8 to 1.1 C (1.5 to 2.0 F) above an individual's normal temp (>38C [>100.5 F]). This elevation is in response to a chemical signal (endogenous pyrogen) released as part of an inflammatory response, such as in infection or tissue injury. Because there is a proportional enhancement of the immune system for each degree of temp elevation, fever is believed to be adaptive to 40 C (104 F). Hyperthermia is an abnormal increase in core body temp, usually above 40 C (104 F), that occurs as a result of disorders of temp control. Causes include brain trauma, heat stroke, drugs (e.g., cocaine, ecstasy), or malignant hyperthermia of anesthesia. Hyperthermia is not adaptive and should be treated as a medical emergency. FEVER: core body temp elevated at least 0.8 to 1.1 C (1.5 to 2.0 F) above individual's normal temp (>38 C [>100.5 F]). HYPERTHERMIA: body temp above 40 C (104 F) with flushed or hot skin, increased respiratory rate, and tachycardia. FEVER: Infection; tissue injury or trauma; dehydration; blood transfusion; medication; neoplasm; increased metabolic rate. HYPERTHERMIA: Exposure to hot environment; vigorous activity; inappropriate clothing; inability or decreased ability to perspire; brain injury; medication; anesthesia; severe illness; trauma Thermoregulation; Thermoregulation: Newborn (1) Maintain oral temp within adaptive levels (below 40 C [104 F]) or lower, depending on the presence of cardiopulmonary illness and client comfort. (2) Remain free of dehydration. Fever Treatment; Malignant Hyperthermia Precautions; Temperature Regulation (1) Assess an afrebile hospitalized client's temp per institutional policy if the client exhibitis signs or symptoms of infection. (2) Measure and record a febrile client's temp at least every 4 to 6 hours or whenever a change in condition occurs (e.g., chills, change in mental status). (3) Temp can be measured with acceptable accuracy using an electronic probe in the mouth or via the external auditory canal (tympanic membrane). Although inconvenient, rectal temp measurement is highly accurate. Use of a glass (mercury) thermometier is also highly accurate but involve increased time (6-7 minutes), risk of mercury contamination, and risk of rectal perofration, although the occurrence is rare. Where equipment is available in ICU settings, temp measurement by intravascular or bladder thermistor is a highly accurate method. Axillary measurements should not be used. (4) Use the same site and method (device) for temp measurement for a given client so that temp trends are assessed ......... (1) An oral temp of 0.8 to 1.1 C (1.5 to 2.0 F) above baseline or above 37.2 C (99.5 F) rectal temp should be considered a fever in the elderly. (2) Rectal temp may be useful to diagnose fever. Nursing judgment must be used to determine if rectal temp measurement is acceptable to the client, especially a client with mental changes or dementia. (3) Assess for other signs and symptoms of infection in additionto or in the absence of fever in the elderly. (4) Help the client seek medical attention immediately if fever is present. To diagnose the fever source, assess for possible precipitating factors, includig

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html rate of 0.6 C [1 F] per hour. NOTE: Hypothermia is not a symptom that appears in the normal course of home care. When it oocurs, it is a clinical emergency and the client/family should access emergency medical services immediately. (1) Some of the interventions described earlier may be adapted for home care use. (2) Before a medical crisis occurs, confirm that the client or family has a thermometer and can read it. Instruct as needed. Verify that the thermometer registers accurately. (3) Instruct the client or family to ake the temp when the client displays cyanosis, pallor, or shivering. (4) Monitor temp every hour, as noted previously. (5) If temp continues to drop, activate the emergency system and notify a physician. (6) If the client is in hospice care, or is terminally ill, follow advance directives, client wishes, and the physician's orders. Keep the client free of pain. (1) Teach the client and family signs of hypothermia and the methods of taking the temp (age-appropriate). (2) Teach the client methods to prevent hypothermia: wearing adequate clothing, including a hat and mittens; heating the environment to a minimum of 20 C [68 F] ; and ingesting adequate food and fluid. (3) Teach the client and family about meds such as sedatives, opioid, and anxiolytics that predispose the client to hypothermia (as appropriate). Identity, personal, disturbed 522 Inability to distinguish between self and nonself Withdrawal from social contact; change in ability to determine relationship of the body to the environment; inappropriate or grandiose behavior. Situational crisis; psychological impairment; chronic illness; pain Identity; Personal Autonomy (1) Show interest in surroundings. (2) Respond to stimuli with appropriate affect. (3) Perform self-care and self-control activities appropriate for age. (4) Acknowledge personal strengths. (5) Engage in interpersonal relationships. (6) Verbalize willingness to change lifestyle and use appropriate community resources. Decision-Making Support; Self-Esteem Enhancement (1) Assess carefully for a history of abuse. (2) Assess for any history of seizure disorders; adhere to the diagnostic criteria for dissociative disorder in the DSM-IV and conduct a structured clinical interview. (3) Avoid labeling the client in terms such as multiple personality disorder (MPD). (4) Offer reassurance to the client and use therapeutic communication at frequent intervals. (5) Work with the client on setting personal goals. (6) Address the client by name. Let the client know who is approaching and orient the client to the surroundings. (7) Have the client describe his or her perceptions of the environment as concretely as possible. (8) Give the client permission to share his or her experiences. The client has always lived in secrecy and is not sure how much it is safe to reveal or who believes that the client's illness is an actual illness. (9) Use touch only after a thorough assessment and as appropriate. (10) Have all team members approach the client in a consistent.... (1) Monitor for signs of depression, grief, and withdrawal and make an appropriate referral. (2) Address the client by his or her full name preceded by the proper title (Mr., Mrs., Ms., Miss); use a nickname or fist name only if suggested by the client, and do not use terms of endearment (e.g., honey). (3) Practice reality orientation principles; ask specifically how the client feels about events that are happening. (4) Ask the client about important past experiences. (5) If the client's symptoms are associated with a stroke, refer the client for longer rehavilitation that inlcudes physical programs addressing psychological as well as neuromuscular issues. (1) Assess for the influence of cultural beliefs, norms, and values on the family's perceptions of infant/child behavior. (2) use a neutral, indirect style when addressing areas in which improvement is needed (such as a need for verbal or oral stimulation) when owrking with Native American clients. (3) Acknowledge and praise parenting strengths noted. (4) Use therapeutic communication techniques that emphasize acceptance, offer the self, validate the client's concerns, and convey respect when discussing infant/child behavior. (1) The interventions described previously may be adapted for home care use. (2) Assess the client's immediate support system and family for relationship patterns and content of communication. (3) Encourage the family to provide support and feedback

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html regarding the client's identity and ego boundaries. (4) If the client is involved in couseling or self-help groups, monitor and encourage attendance. Help the client identify the value of group participation after each group encounter. (5) If the client is taking prescribed psychotropic meds, assess for understanding of possible side effects and the reasons for taking madication. Teach as necessary. (6) Assess meds for effectiveness and side affects and monitor for compliance. (7) If the client is homebound, refer for psychiatirc home health care services for client reassurance and implementation of a therapeutic regimen. (1) Teach stress reduction and relaxation techniques. (2) Refer to community resources or other self-help appropriate for the client's underlying problem. (3) Refer to appropriate treatment as soon as signs of depression are noted. (4) Be a role model for family members: talk to, not around, the client; give choices to the client when family members may be listening; always address the client by name; and do not interrupt when the client is attempting to communicate. Incontinence, urinary, functional 527 Impairment or loss of continence due to functional deficits, including altered mobility, dexterity, or cognition, or environmental barriers. The relationship between functional limitations and urinary incontinence remains controversial. While functional impairment clearly exacerbates the severity of urinary incontinence, the underlying factors that contribute to these functional limitations themselves contribute to abnormal lower urinary tract function and impaired incontinence. Cognitive disorders (delirium, dementia, severe or profound retardation); neuromuscular limitations impairing mobility or dexterity; environmental barriers to toileting Urinary Continence; Urinary Elimination (1) Eliminate or reduce incontinent episodes. (2) Eliminate or overcome environmental barriers to toileting. (3) Use adaptive equipment to reduce or eliminate incontinence related to impaired mobility or dexterity. (4) Use portable urinary collection devices or urine containment devices when access to the toilet is not feasible. Urinary Habit Training; Urinary Incontinence Care (1) Perform a history taking and physical assessment focusing on bothersome lower urinary tract symptoms, cognitive status, functional status (particularly physical mobility and dexterity), frequency and severity of leakage episodes, and alleviating and aggravating factors. (2) Consult with the client and family, the client's physician, and other health care professionals concerning treatment of incontinence in the elderly client undergoing detailed geriatric evaluation. (3) Complete a bladder log of diurnal and nocturnal urine elimination patterns, and patterns of urinary leakage. (4) Assess the client for potentially reversible or modifiable causes of acute/transient urinary incontinence (e.g., urinary tract infection; atrophic urethritis; constipation or impaction; use of sedatives or narcotics interfering with the ability to reach the toilet in a timely fashion, antidepressants or psychotropic medications interfering with efficient detrusor contractions, parasympatholytics, or .... (1) Institute aggressive continence management programs for the cognitively intact, community-dwelling client in consultation with the client and family. (2) Monitor the elderly client in a long-term care facility, acute care facility, or home for dehydration. (1) The interventions described previously may be adapted for home care use. (2) Assess current strategies used to reduce urinary incontinence, including limitation of fluid intake, restriction of bladder irritants, prompted or scheduled toileting, and use of containment devices. (3) Encourage a mind-set and program of self-care management. (4) Implement a bladder training program, including self-monitoring activities (reducing caffeine intake, adjusting amount and timing of fluid intake, decreasing long voiding intervals while awake, instituting dietary changes to promote bowel regularity), bladder training, and pelvic muscle exercise. (5) For a memory-impaired elderly client, implement an individualized scheduled toileting program (on a schedule developed in consultation with the caregiver, approximately every 2 hours, with toileting reminders provided and existing patterns incorporated, such

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html toileting before or after meals). (6) Teach the family the general principles of bladder.... (1) Work with the client, family, and their extended support systems to assist with needed changes in the environment and wardrobe, and other alterations required to maximize toileting access. (2) Work with the client and family to establish a reasonable, manageable prompted voiding program using environmental and verbal cues to remind caregivers of voiding intervals, such as television programs, meals, and bedtime. (3) Teach the family to use an alarm system for toileting or to carry out a check-andchange program and to maintain an accurate log of voiding and incontinence episodes. Incontinence, urinary, reflex 534 Involuntary loss of urine at somewhat predictable intervals when a specific bladder volume is reached. Involuntary loss of urine caused by a defect in the spinal cord between the nerve roots at or below the first cervical segment and those above the second sacral segment. Urine elimination occurs at unpredictable intervals; micturition may be elicited by tactile stimuli, including stroking of inner thigh or perineum. Absent or diminshed sensation or urge to void; incomplete emptying caused by dyssynergia of striated sphincter mechanism, which produces functional outlet obstruction of bladder, may be associated with sweating and acute elevation in BP and pulse rate in clients with spinal cord injury (see the care plan for Autonomic dysreflexia). Paralyzing spinal disorder affecting spinal segments C1 to S2. Urinary Continence; Urinary Elimination (1) Follow prescribed schedule for bladder evacuation. (2) Demonstrate successful use of triggering techniques to stimulate voiding. (3) Have intect perineal skin. (4) Remain clear of symptomatic urinary tract infection. (5) Demonstrate how to apply containment device or inset indwelling catheter or be able to provide caregiver with instructions for performing these procedures. (6) Demonstrate awareness of risk of autonomic dysreflexia, its prevention and management. Urinary Catheterization: intermittent; Urinary Elimination Management; Urinary Incontinence Care (1) Assess the client's neurological status, including the type of neurological disorder, the funcitonal level of neurological impairment, its completeness (effect on motor and sensory function), and the ability to perform bladder management tasks, including tnertmittent catheterization, application of condom catheter, etc. (2) Perform a focused assessment of the urinary system, including perineal skin integrity. (3) Complete a bladder log to determine pattern of urine elimination, incontinence episodes, and current bladder management program. (4) Consult with the physician concerning current bladder function and the potential of the bladder to produce upper urinary tract distress (hydronephrosis, vesicoureteral reflux, febrile urinary tract infection, or compromised renal function). (5) Determine a bladder management program in consultation with the client, family, and rehabilitation team. (6) In consultation with the rehabilitation team, counsel the client and family concerning ..... (1) If difficulties are encouraged in client teaching, refer the elderly client to a nurse who specializes in care of the aging client with urinary incontinence. (1) The interventions described previously may be adapted for home care use. (2) Teach the client what the complications of reflex incontinence are and when to report changes to a physician or primary nurse. (3) If the client is taught intermittent self-catheterization, arrange for contingency care in the event that the client is unable to perform self-catheterization. (4) Assess and instruct the client and family in care of the catheter and supplies in the home. (5) Encourage a mind-set and program of self-care management. (6) Assist the family with arranging care in a way that allows the client to participated in family or favorite activities without embarrassment. Elicit discussion of the client's concerns about the social or emotional burden of incontinence. (7) If meds are ordered, instruct the family or caregivers and the client in medication administration. (1) Teach the client with a spinal injury the signs of autonomic dysreflexia, its relationship to bladder fullness, and management of the condition. (Refer to the care plan for Autonomic dysreflexia.) (2) Teach the client and several

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html videotape if indicated. (2) Teach the client the importance of avoiding dehydration and instruct the client to consume fluid at the rate of 30 ml/kg of body weight daily. (3) Teach the client the importance of avoiding constipation by combination of adequate fluid intake, adequate intake of dietary fiber, and exercise. (4) Teach the client to apply and remove support devices such as bladder neck support prosthesis. (5) Teach the client to select and apply urine containment device. Incontinence, urinary, total 545 State in which the individual experiences continuous and unpredictable loss of urine. NOTE: In this book, the diagnosis Total urinary Incontinence will be used to refer to continuous urine loss due to an extraurethral cause, and the diagnosis Stress urinary Incontinence will be used to refer to leakage caused by urethral sphincter incompetence, regardless of severity. Continuous urine flow varying from dribbling incontinence superimposed on an otherwise identifiable pattern of voiding to severe urine loss without identifiable micturition episodes. Ectopia (ectopic ureter opens into vaginal vault or cutaneously; bladder ectopia with exstrophy/epispadias complex. Fistula (opeing brom bladder or urethra to vagina or skin that bypasses urethral sphincter mechanism, allowing continuous urine loss) Tissue Integrity; Skin and Mucous Membranes; Urinary Continence; Urinary Elimination (1) Experience urine loss that is adequately contained, with clothing remaining unsoiled and odor controlled. (2) Maintain intact perineal skin. (3) Maintain dignity, hide urine containment device in clothing, and minimize bulk and noise related to device. Urinary Incontinence Care (1) Obtain a history of the duration and severity of urine loss, prior management, and aggravating or alleviating features. (2) Perform a focused physical assessment, including inspection of the perineal skin, examination of the vaginal vault, reproduction of the sign of stress incontinence (refer to the care plan for Stress urinary Incontinence), and testing of bulbocavernosus reflex and perineal sensations. (3) Consult a physician concerning the results of colposcopy, cystourethroscopy, intravenous urogram, cystogram, Pyridium pad test, or pelvic examination. (4) Assist the client in selecting and applying a urine containment device(s). Review types of containment products with the client, including advantages and potential complications associated with each type of product. (5) Evaluate disposable vs. reusable products for urine containment, considering the setting (home care vs. acute care vs. long-term care), preferences of the client and caregiver(s), and immediate .............. (1) Provide privacy and support when changing incontinent devices in elderly clients. (2) Avoid brisk scrubbing and use of a washcloth when cleansing the skin of an aging client. (3) Employ meticulous infection control procedures when using an indwelling catheter. (1) The interventions described previously may be adapted for home care use. (2) Encourage a mind-set and program of self-care management. (3) Implement a bladder training program, including self-monitoring activities (reducing caffeine intake, adjusting amount and timing of fluid intake, decreasing long voiding intervals while awake, making dietary changes to promote bowel regularity), bladder training, and pelvic muscle exercise as appropriate. (4) Assist the family with arranging care in a way that allows the client to participate in family or favorite activities without embarrassment. Elicit discussion of the client's concerns about the social or emotional burden of incontinence. (5) Consider the use of an indwelling catheter for continuous drainage in the client with severe urinary incontinence who is homebound, bed-bound, and receiving palliative or end-of-life care (requires a physician's order). (6) When an indwelling catheter is in place, follow the prescribed maintenance..... (1) Teach the family to obtain, apply, and dispose of or clean and reuse urine containment devices. (2) Teach the family a routine perineal skin care regimen, including daily or every other day hygiene and cleansing with containment product changes. (3) Teach the client and family to recognize and manage perineal dermatitis, ammonia contact dermatitis, and monilial rash. (4) Teach the client to maintain adequate fluid intake (30 ml/kg of body weight

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html per day). (5) Teach the client and family to recognize and manage urinary tract infection. Incontinence, urinary, urge 550 State in which the individual experiences involuntary passage of urine with precipitous desire to urinate. Urge incontinence is usually defined within the context of overactive bladder syndrome. The overactive bladder is characterized by bothersome urgency, with or without incontinence, and accompanied by frequent daytime voiding and nocturia. Diurnal urinary frequency (voiding more than once every 2 hours while awake); urgency (subjective report of precipitous or immediate need to urinate when urgency is perceived); years of age and more than once per night to urinate for persons younger than 65 years of age and more than twice per night for persons older than 65 years); symptom of urge incontinence (urine loss associated with desire to urinate); enuresis (involuntary passage of urine while asleep). (1) Neurological disorders (brain disorders, including cerebrovascular accident, brain tumor, normal pressure hydrocephalus, traumatic brain injury). (2) Inflammation of bladder (calculi; tumor, including transitional cell carcinoma and carcinoma in situ; inflammatory lesions of the bladder; urinary tract infection). (3) Bladder outlet obstruction (see Urinary retention). (4) Stress urinary incontinence (mixed urinary incontinence; these conditions often coexist but relationship between them remains unclear). (5) Idiopathic causes (implicated factors include depression, sleep apnea/hypoxia). Tissue Integrity: Skin and Mucous Membranes; Urinary Continence; Urinary Elimination (1) Report relief from urge urinary incontinence or a decrease in the incidence or severity of iincontinent episodes. (2) Identify containment devices that assist in the management of urge urinary incontinence. Urinary Habit Training; Urinary Incontinence Care (1) Take a nursing history focusing on duration of urinary incontinence, diurnal frequency, nocturia, severity of symptoms, and alleviating and aggravating factors. (2) Complete a urinalysis, examining for the presence of nitrites, leukocytes, glucose, or hemoglobin (RBCs). (3) Complete a bladder log, including frequency of diurnal micturition and nocturia, patterns of incontinence, symptoms of accompanying urine loss, and the type and volume of fluids consumed. (4) Review all meds the client is receiving, paying particular attention to sedatives, narcotics, diuretics, antidepressants, psychotropic drugs, and cholinergics. Consult the physician about altering or eliminating these meds if they are suspected of affecting incontinence. (5) Assess the client for urinary retention (see care plan for Urinary Retention). (6) Assess the client for functional limitiations (environmental barriers, limited mobility or dexterity, impaired cognitive function [see care plan for Functional ......... (1) Assess the functional and cognitive status of the elderly client with urge incontinence. (2) Plan care in long-term care facilities based on knowledge of the elderly client's established voiding patterns, paying particular attention to patterns of nocturia. (3) Carefully monitor the elderly client for potential adverse effects of antispasmodic meds, including a severely dry mouth interfering with the use of dentures, eating, or speaking, or confusion, nightmares, constipation, mydriasis, or heat intolerance. (1) The interventions described previously may be adapted for home care use. (2) Teach the importance of avoiding dehydration or excessive fluid consumption and the paradoxical relationship between dehydration and symptoms or urgency. (3) Teach the family and client to identify and correct environmental barriers to toileting iwthin the home. (4) Encourage a mind-set and program of self-care management. (5) Implement a bladder training program as appropriate, including self-monitoring activities (reducing caffeine intake, adjusting amount and timing of fluid intake, decreasing long voiding intervals while awake, making dietary changes to promote bowel regularity), bladder training, and pelvic muscle exercise. (6) Help the client and family to identify and correct environmental barriers to toileting within the home. (1) Teach the client and family to recognize foods and beverages that are unliekly to irritate the bladder. (2) Teach the family and client to recognize and manage side effects of antispasmodic meds used to treat incontinence. (3)

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Help the client and family to recognize and manage side effects of anticholinergic meds used to manage irritative lower urinary tract symptoms. Incontinence, urinary, urge, risk for 555 At risk for involuntary loss of urine associated with a sudden, strong sensation or urinary urgency. Effects of medications, caffeine, alcohol, detrusor hyperreflexia from cystitis, urethritis, tumors, renal calculi, central nervous system disorders above the pontine micturition center; detrusor muscle instability with impaired contractility; involuntary sphincter relaxation; ineffective toileting habits; small bladder capacity. Tissue Integrity: Skin and Mucous Membranes; Urinary Continence; Urinary Elimination (1) Report relief from urge urinary incontinence or a decrease in the incidence or severity of incontinent episodes. (2) Identify containment devices that assist in the management of urge urinary incontinence Urinary Habit Training; Urinary Incontinence Care (1) Take a nursing history focusing on the following lower urinary tract symptoms: daytime voiding frequency, nocturia, presence of bothersome urgency (precipitous desire to urinate that interferes with ADLs), and presence of urine loss. (2) Query the client about specific risk factors for urge urinary incontinence, such as childhood enuresis, depression, prostate enlargement with bladder outlet obstruction, and neurological disorders, including stroke or parkinsonism. (3) Assess the client's functional status, focusing on mobility, dexterity, and cognitive status. (4) Complete a urinalysis, focusing on the presence of nitrates, leukocytes, glucose, or hemoglobin (RBCs). (5) complete bladder log, including frequency of diurnal micturition and nocturia, and the type and volume of fluids consumed. (6) Review with the client the types of beverages consumed, focusing on the intake of bladder irritants, including caffeine and alcohol. Advise the client to reduce or eliminate the intake .... (1) Assess the functional and cognitive status of an elderly client with irritative lower urinary tract symptoms or urge incontinence. (2) Advise a male client with bothersome lower urinary tract symptoms to see his physician or nurse-practitioner, since these symptoms may be related to prostate enlargement. (3) Carefully monitor the elderly client for potential adverse effects of anticholinergic meds, including severe dry mouth interfering with the use of dentures, eating, or speaking, or the occurence of confusion, nightmares, constipation, mydriasis, or heat intolerance. (1) The interventions described previously may be adapted for home care use. (2) Encourage mind-set program of self-care management. (3) Implement a bladder training program, including self-monitoring activites (reducing caffeine intake, adjusting amount and timing of fluid intake, decreasing long voiding intervals while awake, making dietary changes to promote bowel regularity), bladder training, and pelvic muscle exercise. (4) Teach the client and family to recognize foods and beverages that are likely to irritate the bladder. (5) Teach the importance of avoiding dehydration or excessive fluid consumption and the paradoxical relationshiip between dehydration and symptoms of urgency. (6) Teach the family and client to recognize and manage side effects of anticholinergic meds used to treat irritative lower urinary tract symptoms. (7) Teach the family and client to identify and correct environmental barriers to toileting. (8) Assist the family with arranging care in a way that allows... (1) Teach the client and family to recognize foods and beverages that are likely to irritate the bladder. (2) Teach the importance of avoiding dehydration or excessive fluid consumption and the paradoxical relationship between dehydration and symptoms of urgency. Infant behavior, disorganized 560 Disintegrated physiological and neurobehavioral responses to the environment Regulatory problems; instability to inhibit startle; irritability STATE-ORGANIZATION SYSTEM: Active awake (fussy, worried gaze); diffuse/unclear sleep, state-oscillation; quiet-awake (staring, gaze aversion); irritable or panicky crying. ATTENTION-INTERACTION SYSTEM: Abnormal response to sensory stimuli (e.g., difficult to soothe, inability to sustain alert status). MOTOR SYSTEM: Increased, decreased, or limp tone; finger splay,

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

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

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

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

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

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

Intracranial adaptive capacity, decreased 600 Intracranial fluid dynamic mechanisms that normally compensate for increases in intracranial volumes are compromised, resulting in repeated disproportionate increases in intracranial pressure (ICP) in response to a variety of noxious and non-noxious stimuli. Repeated increases in ICP of greater than 10 mm Hg for more than 5 min following a variety of external stimuli; disproportionate increases in ICP following a single environmental or nursing maneuver stimulus; baseline ICP greater than 10 mm Hg; elevated P2 componnt of ICP waveform; wide-amplitude ICP waveform; volume-pressure response test variation

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

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html families. NOTE: Because home care is an intermittent model of care having a goal of safety and optimal wellness of the client between visitis, the importance of teaching (by the nurse) and learning (by the client) should not be understated. All of the previously mentioned interventions are applicable to the home setting. (2) Consider high-tech options for delivery of home-based instruction. Loneliness, risk for 617 At risk for experiencing vague dysphoria Affectional deprivation; social isolation; cathectic deprivation; physical isolation Loneliness Severity; Social Interaction Skills; Social Involvement; Social Support (1) Maintain one or more meaningful relationship (growth enhancing versus codependent or abusive in nature)--relationships allowing self-disclosure--and demonstrate a balance between emotional dependence and independence. (2) Participate in ongoing positive and relevant social activities and interactions that are personally meaningful (3) Demonstrate positive use of time alone when socialization is not possible. Family Integrity Promotion; Socialization Enhancement; Visitation Facilitation (1) Use active listening skills. Establish therapeutic relationship and spend time with client. (2) Assess the client's perception of loneliness (Is the person alone by choice, or do others impose the aloneness?). (3) Assist the client with identifying loneliness as a feeling and the causes related to loneliness. (4) Assess the client's ability and/or inability to meet physcial, psychosocial, spiritual, and financial needs and how unmet needs further challenge the ability to be socially integrated (e.g., loss of job leading to inability to afford usual and familiar social interaction, fatigue; lack of energy necessary for social interaction and personal engagement; impaired skin integument and its relationship to real and/or perceived social isolation). (5) Use active listening skills including assessment and clarification of the client's verbal and nonverbal responses and interactions. (6) Evaluate the client's desire for social interaction in relation to actual social interaction.... ADOLESCENTS: (1) Assess the client's social support system. (2) Evaluate the depth and level of character traits, shyness, and self-esteem, particularly of younger and middle adolescent clients. (3) Evaluate the family stability of younger and middle adolescent clients and advocate and encourage healthy, growth-producing relationships with family and support systems. (4) For older adolescents, encourage close relationships with peers and involvement with groups and organizations. (5) Consider use of pets to cope with loneliness. (1) Assess caregivers for Alzheimer clients for depression related to loneliness. (2) Identify community support systems specific to elderly popluations. (3) Consider a retirement village. (4) Encourage support by friends and family when the decision to stop driving must be made. (5) Assess the client's adaptive sensory functions or any other health deviations that may limit or decrease his or her ability to interact with others. (6) Assess the client's potential or actual hearing loss or hearing impairment and make appropriate referrals if a problem is identified. (7) Encourage physcial activity such as aerobics or stretching and toning in a group. (8) Provide reading materials for clients who are able to read. (1) Acknowledge racial/ethnic differences at the onset of care. (2) Assess for the influence of cultural beliefs, norms, and values on the client's perception of social activity and relationships. (3) Approach individuals of color with respect, warmth, and professional courtesy. (4) Assess the use of personal space needs, communication styles, acceptable body language, eye contact, perception of touch, and use of paraverbals when communicating with the client. (5) Use a family-centered approach when working with Latino, Asian American, Afircan American, and Native American. (6) Promote a sense of ethnic attachment. (7) Validate the client's feelings regarding isolation and loneliness. (1) Above interventions may be adapted for home care use. (2) Assess for depression with lonely elderly client and make appropriate referrals. (3) If the client is experiencing somatic complaints, evaluate client complaints to ensure physcial needs are being met, and then identify relationship between somatic complaints

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html and loneliness. (4) Help the client to identify periods when loneliness is greatest (e.g., certain times of the day, anniversaries of past special events). With the client's permission, refer for services of visiting volunteers. (5) To keep older people independent, interventions to prevent loneliness should be explored. Consider using art as an intervention. (6) Identify alternatives to eating alone. (7) Identify alternative to being alone (e.g., telephone contact). (8) Consider using computers and the Internet to alleviate or reduce loneliness and social isolation. (9) Support religious beliefs. (10) Discuss the meaning of death and fears associated with dying alone. (1) Encourage positive use of solitude to prevent loneliness (e.g., reading, listening to music, enjoying nature and art.). (2) Include the family in all client-teaching activities, and give them accurate info regarding the illness severity. (3) Give family members something to do such as holding a hand, applying lotion, or assisting with feeding. (4) Encourage family members to express caring by telling the client where they will be and sending messages when they cannot be present. Memory, impaired 624 Inability to remember or recall bits of information or behavioral skills; impaired memory may be attributed to pathophysiological or situational causes that are either temporary or permanent. Inability to recal factual information; inability to recall recent or past events; inability to learn or retain new skills or information; inability to determine whether a behavior was performed; observed or reported experiences of forgetting; inability to perform a previously learned skill; forgets to perform a behavior at a scheduled time Fluid and electrolyte imbalance; neurological disturbances; excessive environmental disturbances; anemia; acute or chronic hypoxia; decreased cardiac output Cognitive Orientation; Memory; Neurological Status: Consciousness (1) Demonstrate use of techniques to help with memory loss. (2) State has improved memory Memory Training (1) Assess neurological function; use an assessment tool such as the metamemory in adutlhoos (NIA) questionnaire or the Mini-Mental State Examination (MMSE). (2) Determine whether onset of memory loss is gradual or sudden. If memory loss is sudden, refer the client to a physician for evaluation. (3) Determine amount and pattern of alcohol intake. (4) Note the client's current meds and intake of any mind-altering substances such as benzodiazepines, exstasy, marijuana, cocaine, or glucocorticoids. (5) Note the client's current level of stress. (6) Determine the client's sleep patterns. If insufficient, refer to care plan for Disturbed Sleep pattern. (7) Determine the client's bood sugar levels. If the are elevated, refer to physcian for treatment and encourage a healthy diet and exercise to improve memory. (8) If signs of depression such as weight loss, insomnia, or sad affect are evident, refer the client for psychotherapy. (9) Encourage the client to develop an aerobic exercise ....... (1) Assess for signs of depression. (2) Evaluate all meds that the client is taking to determine whether they are causing the memory loos. (3) Recommend that elderly clients maintain a positive attitude and active involvement with the world around them and that they maintain good nutrition. (4) Encourage the elderly to believe in themselves and to work to improve their memory. (5) refer the client to a memory class that focuses on helping older adults learn membory strategies. (6) Help family develop a memory aid booklet or wallet that contains pictures with a narration. (7) Help family label items such as the bathroom or sock drawer to increase recall. (1) Assess for th einfluence of cultural beliefs, norms, and values on the family or caregiver's understanding of impaired memory. (2) Use bias-free instruments when assessing memory in the culturally diverse client. (3) Inform the client's family or caregiver of meaning of and reasons for common behavior observed in the client with impaired memory. (4) Validate family members' feelings regarding the impact of the client's behavior on family lifestyle. (1) Above interventions may be adapted for home care use. (2) Arrange cures for mdeication taking that are focused around daily events (e.g., meals and bedtimes). (3) Assess the client's need for outside assistance with recall or treatment, med, and

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html willingness/ability of family to provide needed support. (4) Identify a checking-in support system (e.g., Lifeline or significant others). (5) Keep furnitiure placement and household patterns consistent. (6) In the presence of a medical disorder, institute case management of frail elderly to support continued independent living. (1) When teaching the client, determine what the client knows about memory techniques and then build on that knowledge. (2) When teaching a skill to the client, set up a series of practice attempts. Begin with simple tasks so that the client can be positively reinforced and progress to more difficult concepts. (3) Teach clients to use memory techniques such as repeating info they want to remember, making mental associations to remember info, and placing items in strategic places so that they will not be forgotten. Mobility, bed, impaired 630 Limitation of independent movement from one bed position to another. Impaired ability to turn from side to side; impaired ability to move from supine to sitting or sitting to supine; impaired ability to "scoot" or reposition self in bed; impaired ability to move from supine to prone or prone to supine; impaired ability to move from supine to long sitting or long sitting to supine Intolerance to activity; decreased strength and endurance; pain or discomfort; perceptual or cognitive impairment; neuromuscular impairment; musculoskeletal impairment; depression; severe anxiety. Suggested functional level classifications include the following: 0--Completely independent; 1--Requires use of equipment or device; 2--Requires help from another person; 3--Requires help from another person and equipment device; 4--Dependent (does not participate in activity) Mobility; Self-Care: ADLs (1) Demonstrate optimal independence in positioning, exercising, and performing functional activities in bed. (2) Demonstrate ability to direct others on how to do bed positioning, exercising, and functional activities Bed Rest Care (1) Perform accurate physical assessment to determine the client's risk for ICP, respiratory abnormalities, aspiration, pressure ulcer formation, muscle tone abnormalities, and pain levels. (2) Use critical thinking and priority setting to decide the most therapeutic bed positions and frequency of turns based on the client's history, risk profile, and preventative needs. (3) If the client has increased ICP, refer to care plan for Decreased Intracranial adaptive capacity. (4) If the client is dysphagic, assist to sit upright during and after feedings or ingestion of pills. Refer to care plan for Impaired Swallowing. (5) Position the client in an upright position at intervals as tolerated by condition. If possible, elevate HOB incrementally. If vital signs, pulse pattern and oxygen saturation levels are stable, dangle the client or move the client from bed to a "stretcher chair"--a stretcher that turns into a chair--to get out of bed and into a more vertical position. (6) Maintain the... (1) Devleop appropriate strategies for positioning and bed mobility based on the client's multiple chronic and disabling conditions. (2) Assess the family caregivers' strength, health history, and cognitive status to predict ability and risk for helping clients with positioning and bed m obility tasks. Help foamily explore and develop other options if helping clients would place them at too high a risk. (3) Prvent failure by assessing the client's stamina and energy level during exercising and bed mobility activities; give assistance or rest breaks as needed. (4) Spread out bed activities, exercise programs, and ADLs rather than clumping them together. (5) Incorporate memory aids and strategies (e.g., written schedules, directions, sketches, or notes), timers, audiotaped instructions, etc, so that clients with cognitive decline can function independently. (1) Some of the interventions may be adapted for home care use. (2) Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems, assistive devices, and community or home health services. (3) Encourage use of the client's regular bed in the home unless contraindicated for specific medical reasons. (4) Place indented or grooved-out areas in wood pieces under each leg of the bed and set bed against the walls in a corner of the room. (5) Suggest rearranging furniture at thome to make it accessible to meet sleeping,

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html toileting, and living needs. (6) Discuss the psychological and physical benefits of allowing clients to be as self-sufficient as possible in bed mobility and repositioning, even though it may be time consuming. (7) Prepare family members for potential regression in self-care during transition from hospital to home environment. (8) Offer emotional support and suggest community resources and social supports to help ...... (1) Use various sensory modalities to teach the client, family, and caregivers correct techniques for ROM, exercising, repositioning, and bed mobility activities. give info visually (demonstration, sketches, instructional videos, written instructions). Give tactile stimulation (manual guidance, hand-on-hand technique, return deomstrations, note taking). Give auditiory info (verbal instructions, instructional audiotapes, verbal repeating of instructions, self-talk during motor activity, reading aloud written instructions). (2) Schedule time with family and caregivers for client education and practice sessions in addition to sharing info informally. Suggest that family members come prepared with their questions and wearing appropriate clothing and shoes for practice. (3) Teach caregivers proper body mechanics and use of assistive devices (if applicable) while assisting clients with bed mobility activities. Mobility, physical, impaired 643 A limitation in independent, purposeful physical movement of the body or of one or more extremities Postural instability during performance of routine ADLs; limited ability to perform gross motor skills; limited ability to perform fine motor skills; uncoordinated or jerky movements; limited ROM; difficulty turning; decreased reaction time; movement-induced SOB; gait changes; engages in substitutions for movement; slowed movement; movement-induced tremor; Medications; prescribed movement restrictions; discomfort; lack of knowledge regarding value of physical activity; body mass index greater than 30; sensoriperceptual impairments; neuromuscular impairment; pain; musculoskeletal impairment; intolerance to activity/decreased strength and endurance; depressive mood state or anxiety; cognitive impairment; decreased muscle strength, control, and/or mass; reluctance to initiate movement; sedentary lifestyle or disuse or deconditioning; selective or generalized malnutrition; loss of integrity of bone structures; developmental delay; joint stiffness or contractures......see book for more..... SUGGESTED FUNCTIONAL LEVEL CLASSIFICATIONS INCLUDE THE FOLLOWING: 0--Completely independent; 1--Requires use of equipment or device; 2--Requires help from another person for assistance, supervision, or teaching; 3--Requires help from another person and equipment device; 4--Dependent (does not participate in activity) Ambulation; Ambulation: Wheelchair; Mobility; Self-Care: ADLs; Transfer Performance (1) Increase physical activity. (2) Meet mutually defined goals of increased mobility. (3) Verbalize feeling of increased strength and ability to move. (4) Demonstrate use of adaptive equipment to increase mobility Exercise Therapy: Ambulation, Joint Mobility; Positioning (1) Screen for mobility skills in the following order: (1) bed mobility; (2) supported and unsupported sitting; (3) transition movements such as sit to stand, sitting down, and transfers; and (4) standing and walking activities. Use a physical activity tool if available to evaluate mobility. (2) Observe the client for cause of impaired mobility. Determine whether cause is physical or psychological. (3) Monitor and record the client's ability to tolerate activity and use all four extremities; note pulse rate, blood pressure, dyspnea, and skin color before and after activity. See care plan for Activity intolerance. (4) Before activity, observe for and, if possible, treat pain. Ensure that the client is not oversedated. (5) Consult with physical therapist for further evaluation, strength training, gait training, and development of a mobility plan. (6) Obtain any assistive devices needed for activity, such as walking belts, walkers, canes, crutches, or wheelchairs, before the activity..... (1) Help the mostly immobile client achieve mobility as soon as possible, depending on physical condition. (2) Use the Outcome Expectation for Exercise Scale to determine client's self-efficacy expectations and outcomes expectations toward exercise. (3) For a client who is mostly immobile,

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html minimize cardiovascular deconditioning by positioning the client as close to the upright position as possible several times daily. (4) If the client is mostly immobile, encourage him or her to attend a low-intensity aerobic chair exercise class that includes stretching and strengthening chair exercises. (5) Initiate a walking program in which the client walks with or without help every day as part of daily routine. (6) Refer the client to physical therapy for resistance exercise training as able including abdominal crunch, leg press, leg extension, leg curl, calf press, and more. (7) Use the WALC Intervention (Walk; Address pain, fear, fatigue during exercise; Learn about exercise; Cue by self-...... (1) Above interventions may be adapted for home care use. (2) Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems, assistive devices, and community or home health services. (3) Assess home environment for factors that create barriers to physical mobility. Refer to occupational therapy services if needed to assist the client in restructuring home and daily living patterns. (4) Refer to home health aide services to support the client and family through changing levels of mobility. Reinforce need to promote independence in mobility as tolerated. (5) Refer to physical therapy for gait training, strengthening, and balance training. (6) Assess skin condition at every visit. Establish a skin care program that enhances circulation and maximizes position changes. (7) Once the client is able to walk independently, and needs an exercise program, suggest the client enter an exercise program with a friend. (8) Provide support to... (1) Teach the client to get out of bed slowly when transferring from the bed to the chair. (2) Teach the client relaxation techniques to use during activity. (3) Teach the client to use assistive devices such as a cane, a walker, or crutches to increase mobility. (4) Teach family members and caregivers to work with clients during self-care activities such as eating, bathing, grooming, dressing, and transferring rather than having the client be a passive recipient of care. (5) Work with the client using the Transtheoretical Model of behavior change and determine if the client is in the precontemplation, contemplation, preparation, action, or maintenance state of behavior change about exercise. Provide appropriate strategies to support change to exercising based on determined state of change. (6) Develop a series of contracts with mutually agreed on goals of increased activity. Include measurable landmarks of progress, consequences for meeting or not meeting goals, and evaluation dates. Mobility, wheelchair, impaired 650 Limitation of independent movement within the environment using a device equipped with wheels. Impaired ability to operate a manual or power wheelchair on even or uneven surface; impaired ability to operate manual or power wheelchair on an incline or decline; impaired ability to operate wheelchair on curbs Intolerance to activity; decreased strength and endurance; pain or discomfort; perceptual or cognitive impairment; neuromuscular impairment; musculoskeletal impairment; depression; severe anxiety; amputation. SUGGESTED FUNCTIONAL LEVEL CLASSIFICATIONS INCLUDE THE FOLLOWING: 0--Completely independent; 1--Requires use of equipment or device; 2--Requires help from another person for assistance, supervision, or teaching; 3--Requires help from another person and equipment device; 4--Dependent (does not participate in activity) Ambulation: Wheelchair (1) Demonstrate optimal independence in operating and moving a wheelchair or other device equipped with wheels. (2) Demonstrate the ability to direct others in operating and moving a wheelchair or other device equipped with wheels. (3) Demonstrate therapeutic positioning, pressure relief, and safety principles while operating and moving wheelchair or other device equipped with wheels. Exercise Therapy: Muscle Control; Positioning: Wheelchair (1) Assist or remind the client to don appropriate equipment (e.g., braces, corsets, shells, splints, orthoses, immobilizers, and abdominal binders) in bed before wheelchair mobility; loosen or remove equipment after the client returns to bed. (2) Obtain referrals for physcial therapy, occupational therapy, or a wheelchair seating clinic to ensure that the wheelchair and seating system

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html fits the build, abilities, postural support needs, and pressure ulcer prvention of the older client. The seating system should allow the client to propel the chair, safely and ably use the hands to complete ADLs/self-care/job/recreational activities, reach the foot rests and floor with the feet, stand up from the chair without falling, and not be harmed by the wheelchair legs and foot rests. (3) For the client with loss of sensory and motor functioning, emphasize importance of weight shifts every 15 minutes. Reinofrce side leans (leaning toward opposite side of chair), forward leans (leaning forward .... (1) Alternate wheelchair mobility with rest periods when resting pulse rate, respiratory patterns, and BP reading suggest compromised activity tolerance. (2) Avoid using restraints on elderly or confused clients, or those with deformities or spinal curvatures who are at risk for falling because they slide down in a wheelchair or try to reposition self. (3) Ensure proper lower extremity positioning when the client is sitting up. Do not use elevating leg rests as a means to prevent sliding down in the wheelchair. Custom foot rests may be needed. Place both feet either on foot rests or on the floor when wheelchair is stationary. (4) Assess for side effects of meds and potential need for dosage readjustments related to increasing physical activity. (5) Allow the client to move at his or her own speed. Avoid rushing. (1) Assess the client and obtain complete history with references to reasons for impairment. (2) Assess home environment for all barriers to wheelchair access. (3) Assess for skin breakdown. Establish a skin care program to enhance circulation and decrease risk of skin breakdown. (4) Teach advantages, disadvantages, and long-term care involved with various cushions to reduce buttock and sacral pressure during chair sitting. (5) Supply home health aide services as appropriate for assistance with ADLs and skin care. (6) Provide support to clients with long-term impairments and their caregivers. Refer to medical social services or mental health/support groups ervices as necessary. (7) Ensure that the client has info on advocay, options for disability access, and related issues (e.g., education, personnel, and equipment availability) under the Americans with Disabilities Act. (8) Rearrange room functions, furniture, and cupboards so that toileting sleeping, bathing, and preparing and ..... (1) Suggest that the client test-drive wheelchairs and try out cushions and postural supports before purchasing them. (2) Instruct and have the clinet return demonstrate reinflation of pneumatic tires; encoruage the client to monitor tire pressure every 2 to 3 weeks. (3) Teach or secure social services referral to educate clients on financial coverage/regulations of third-party apyers and HCFA for durable medical equipment. Realize that light and ultralight wheelchairs may be easier to propel and may be more comfortable and adjustable than heavier models. They initially are expensive, but over time they cost less to operate than heavier chairs. (4) Supervise and reinforce the client's and family's correct performance of pressure relief techniques (which should be performed every 15 minitues). (5) Teach client to prevent carpal tunnel sungdrome and ulnar neuropathy by not putting pressure on the elbows. Client should reditribute pressure along the entire forearm, especially when ....... Nausea 658 An unpleasant wave-like sensation in the back of the throat, epigastrium, or throughout the abdomen that may or may not lead to vomiting Usually precedes vomiting, but may be experienced after vomiting or when vomiting does not occur; accompanied by pallor, cold and clammy skin, increased salivation, tachycardia, gastric stasis, and diarrhea; accompanied by swallowing movements affected by skeletal muscles; reports "nausea" or "sick to stomach". R/T TREATMENT: Gastric irritation: pharmaceuticals, alcohol, iron, and blood, gastric distention: delayed gastric emptying caused by pharmacological interventions, pharmaceuticals, toxins. BIOPHYSICAL: Biochemical disorders, cardiac pain, cancer of stomach or intra-abdominal tumors, esophageal or pancreatic disease, gastric distention due to delayed gastric emptying, pyloric intestinal obstruction, genitourinary and biliary distension, upper bowel stasis, external compression of the stomach, excess

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html food intake, gastric irritation due to pharyngeal and/or peritoneal inflammation, liver or splenetic capsule stretch, local tumors, motion sickness, Meniere's disease, or labyrinthitis. PHYSICAL: Examples included increased intracranial pressure, meningitis, and toxins. SITUATIONAL: Psychological factors Comfort Level; Hydration; Nutritional Status: Food and Fluid Intake, Nutrient Intake (1) State relief of nausea. (2) Explain methods they can use to decrease nausea and vomiting (N&V) Distraction; Medication Administration; Progressive Muscle Relaxation; Simple Guided Imagery; Therapeutic Touch (1) Determine cause of N&V (e.g., medication effects, viral illness, food poisoning, extreme anxiety, pregnancy). (2) Keep a clean emesis basin and tissues within the client's reach. (3) Provide oral care after the client vomits. (4) Stay with the client to give support, place hand on shoulder, and hold the emesis basin. (5) Provide distraction from sensation of nausea using soft music, television, and videos per the client preference. (6) Maintain a quiet, well-ventilated environment. (7) Avoid sudden movement of the client; allow the client to lie still. (8) After vomiting is controlled and nausea abates, begin feeding the client small amounts of clear fluids such as clear soda or preferably ginger ale, and then crackers; progress to a soft diet. (9) Remove cover of food tray before bringing it into the client's room. (10) Refer HIV-positive clients for management of antiretroviral-related nausea................ (1) Administer antiemetic drugs carefully; watch for side effects. (1) Above interventions may be adapted for home care use. (2) Assist the client and family with identifying and avoiding irritants in the home setting that exacerbates nausea (e.g., strong odors from food, plants, perfume, and room deodorizers). (1) Teach the client techniques to use when uncomfortable, including relaxation techniques, guided imagery, hypnosis, and music therapy. Neglect, unilateral 664 Lack of awareness and attention to one side of the body Consistent inattention to stimuli on an affected side; does not look toward affected side; inadequate positioning and/or safety precautions with regard to the affected side; inadequate self-care; leaves food on plate on the affected side Effects of disturbed perceptual abilities. NOTE: Because the right hemisphere is dominant in directing attention, unilateral neglect is more common if neurological pathology occurs in the right hemisphere of the brain, which results in left-sided neglect. Also, unilateral neglect frequently occurs with damage to the right parietal lobe, the right frontal lobe, the thalamus, and basal ganglia. Body Image; Body Positioning; Self-Care: ADLs (1) Demonstrate techniques that can be used to minimize unilateral neglect. (2) Care for both side of the body appropriately and keep affected side free from harm. Unilateral Neglect Management (1) Monitor the client for signs of unilateral neglect (e.g. not washing, shaving, or dressing one side of the body; sitting or lying inappropriately on affected arm or leg, failing to respond to stimuli on the contralateral side of lesion; eating food only one side of plate; or failing to look to one side of the body). (2) If available, use the "star cancellation test" to evaluate presence of unilateral neglect. (3) Use the Draw-A-Man test as a means of verifying the presence of unilateral neglect. (4) Provdie a safe, well-lighted, and clutter-free environment. Place a call light on unaffected side. Keep side rails up when the client is in bed. Cue the client to environmental hazards when mobile. (5) ..... (6) Refer to a rehabilitation nurse specialist, a neuropsychologist, or an occupational therapiest for continued help in dealing with unilaterl neglect. (1) Many of the listed interventions may be adapted for use in the home care setting. (1) Explain pathology and symptoms of unilateral neglect to both the client and family. Teach the client how to scan regualrly to check the position of body parts and to regularly turn head from side to side for safety when ambulating, using a wheelchair, or doing other tasks. Recommend the client

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html think of self like a horizon-illuminating lighthouse. Noncompliance 667 Behavior of person and/or caregiver that fails to coincide with a health-promoting or therapeutic plan agreed on by the person (and/or family and/or community) and health care professional; in the presence of an agreed-on, health promoting, or therapeurtic plan, person's or caregiver's behavior is fully or partially nonadherent and may lead to clinically ineffective or partially ineffective outcomes Behavior indicative of failure to adhere (directly observed or verbalized by patient or significant others) (critical); objective tests (e.g., physiological measures, detection of markers); evidence of development of complications; evidence of exacerbation of symptoms; failure to keep appointments; failure to progress HEALTH CARE PLAN: Duration; significant others; cost; intensity; complexity. INDIVIDUAL FACTORS: Personal and developmental abilities; health beliefs, cultural influences, spiritual values; individual's value system; knowledge and skill relevant to the regiment behavior; motivational forces. HEALTH SYSTEM: Satisfaction with care; credibility of provider; access and convenience of care; financial flexibility of plan; client-provider relationships; provider reimbursement of teaching and follow-up; provider continuity and regular follow-up individual health coverage; communication and teaching skills of the provider. NETWORK: Involvement of members in health plan; social value regarding plan; perceived beliefs of significant others. NOTE: The nursing diagnosis Noncompliance is judgmental and places blame on the client. The author recommends use of the diagnosis Ineffective Therapeutic regimen management in place of the diagnosis Noncompliance. SEE BOOK FOR MORE!.......... Adherrence Behavior; Compliance Behavior; Pain Level; Symptom Control; Treatment Behavior: Illness or injury (1) Describe consequence of continued noncompliance with treatment regiment. (2) State goals for health and the means by which to obtain them. (3) communicate an understanding of disease and treatment. (4) List treatment regimens and expectations and agree to follow through. (5) List alternative ways to meet goals. (6) Describe the importance of family participation to help achieve goals. Health System Guidance; Self-Modification Assistance (1) Ask the client why he or she has not cimplied with the prescribed treatment. Have the client "tell his or her story". (2) Make the client an active partner in his or her own health care management. Recognize that the client has absolute control over whether he or she follows the health care regimen. (3) Observe for cause of noncompliance (see Related Factors). Recognize that noncompliance is very common. (4) Recognize that behavioral change comes slowly, and often in stages (precontemplation, contemplation, preparation, action, maintenance.....) (5) If the client is in denial; provide info, communicate unconditional positive regard, avoid distancing yourself, and look for opportunities for authentic contact with your client, being present psychologically and physically. (6) Determine the client's and family's knowledge of illness and treatment. Teach them about illness and purpose of the treatment regimen if necessary. (7) Observe whether locus of control is internal or external.. (1) If the client has sensory and coordination deficits, use a med organizer and have the home health nurse or family place the client's meds in daily compartments. (2) Help the client feel like a partner in managing health care condition; use caring, encouragement, written goals, and a "power with" relationship with the nurse. (3) Ask clients if they can afford meds. Refer for financial help from social worker or case manager if needed. (4) Monitor the client for signs of depression associated with noncompliance (e.g., refusing to eat or take meds). Refer the client for treatment of depression as needed. (5) use repetition, verbal cues, and memory aids such as pictures, schedule, or reminder sheet when teaching the health care regimen. Use events such as meals, bedtime, etc. as reminders when to take meds. (6) Consider assistive medication technology: talking reminders, pill dispenser, etc. (1) Assess for the influence of cultural beliefs, norms, and values on the client's ability to modify health behavior. (2) Discuss with the client those aspects of their health behavior/lifestyle that will remain unchanged by their

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html health status. (3) Negotiate with the client regarding the aspects of health behavior that will need to be modified. (4) Assess the role of fatalism on the client's ability to modify health behavior. (5) Validate the client's feelings regarding the impact of health status on current lifestyle. NOTE: Because the home care nurse enters the client's home as a guest, the ability of the nurse to establish a supportive, therapeutic relationship is especially important. (1) Above interventions may be adapted for home care use. (2) Before providing any care, review the Home Health Care Bill of Rights with the client, including the right to refuse treatment. ..... (3) If noncompliance compromises the client's health status, refer for psychiatric home health care services to assess the client's motivation and implement therapeutic regimen. (4) If noncompliant behavior continues and the client chooses not to cooperate with medical regimen, the home health care agency cannot continue to provide services. (5) If care is to be termianted, identify all possible alternatives for the client, and assist with making an informed choice about future health actions. (6) Respect the wishes of terminally ill clients to refuse selected aspects of medical regimen. (1) Teach clients about medication side effects (e.g., mental changes, sexual dysfunction) so that they understand them and feel comfortable discussing them. (2) Teach clients to control their "self-talk" by giving themselves positive messages that will be used to promote desired behaviors, such as taking medications and controlling food intake. Nutrition, readiness for enhanced 675 A pattern of nutrient intake that is sufficient for meeting metabolic needs and can be strengthened. Expresses willingness to enhance nutrition; eats regularly; consumes adequate food and fluid; expresses knowledge of healthy food and fluid choices; follows an appropriate standard for intake; safe preparation and storgae of food and fluids; attitude toward eating and drinking is congruent with health goals. Motivation to improve health through diet Nutritional Status; Nutritional Status: Food and Fluid Intake, Nutrient Intake; Weight Control (1) Explain how to eat according to the US Dietary Guidelines. (2) Design dietary modifications to meet individual long-term goal of health, using principles of variety, balance, and moderation. (3) Weigh within normal range for height and age. Nutrition Management; Nutritional Counseling; Weight Reduction Assistance (1) Ask the client to keep a one day to three day food diary where everything eatin or drank is recorded. (2) Determine the client's knowledge of a nutritious diet and need for supplements. (3) Determine the client's motivation to improve nutrition level, whether for appearance or health benefits. (4) Recommend the client follow the US Dietary Guidelines which can be found at this URL: http://www.health.gov/dietaryguidelines/dga2000/DIETGD.PDF. (5) Help the client determine their body mass index (BMI) Use a chart or one of the formulas in the book on pg 677. (6) Review the client's current exercise level. With the client and primary health care provider, design a long-term exercise program. Encourage the client to adopt an exercise program that involves 45 minutes of exercise five times/week. (7) Explain the value of the Food Pyramid to the client. With the client'sinput, evaluate the client's intake based on the Food Pyramid. (8) Demonstrate the use of food labels to make healthful... (1) Assess changes in lifestyle and eating patterns. (2) Recommend the client discuss the need for a low-dose balanced multiple vitamin and mineral supplement with physician. (3) Assess fluid intake. Recommend routine drinks of water whether thirsty or not. (4) Observe for socioeconomic factors that influence food choices (e.g., funds, cooking facilities). (5) Suggest a variety of seasonings. (1) Assess for dietary intake of essential nutrients. (2) Assess for the influence of cultural beliefs, norms, and values on the client's nutritional knowledge. (3) Discuss with the client those acpects of their diet that will remain unchanged. (4) Determine the motivational factors operating within the client at the present time. (5) Negotiate with the client regarding aspects of his or her diet that will need to be modified. (6) Explore strategies that appeal to the client. (7) Validate the client's

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html feelings regarding the impact of current lifestyle, finances, and transportation on ability to obtain nutritious food. (1) The majority of the interventions above involve teaching. (2) Work with the family members regarding info on how to improve nutritional status. (3) Teach the importance of exercise in a weight control program. Nutrition: less than body requirements, imbalanced 681 Intake of nutrients insufficient to meet metabolic needs. Body weight less than 20% under ideal weight; pale conjunctival and mucous membranes; weakness of muscles required for swallowing or mastication; sore, inflammed buccal cavity; satiety immediately after ingesting food; reported or evidence of lack of food; reported inadequate food intake less than RDA; reported altered taste sensation; perceived inability to ingest food; misconceptions; loss of weight with adequate food intake; aversion to eating; abdominal cramping; poor muscle tone; abdominal pain with or without pathology; lack of interest in food; capillary fragility; diarrhea and/or steatorrhea; excessive loss of hair; hyperactive bowel sounds; lack of information; misinformation Inability to ingest or digest food or absorb nutrients because of biological, psychological, or economic factors. Nutritional Status; Nutritional Status: Food and Fluid Intake, Nutrient Intake; Weight Control (1) Progressively gain weight toward desired goal. (2) Weigh within normal range for height and age. (3) Recognize factors contributing to underweight. (4) Identify nutritional requirements. (5) Consume adequate nourishment. (6) Be free of signs of malnutrition Eating Disorders management; Electrolyte Management: Hypophophatemia; Enteral Tube Feeding; Feeding; Nutrition Management; Nutrition Therapy; Nutritional Counseling; Nutritional Monitoring; Swallowing Therapy; Weight Gain Assistance; Weight Management (1) Determine healthy body weight for age and height. Refer to dietitian for complete nutrition assessment if 10% under healthy body weight or if rapidly losing weight. Legal intervention may be necessary. (2) Compare usual food intake with the U.S. Department of Agriculture Food Pyramid, noting slighted or omitted food groups. (3) If the client is a vegetarian, evaluate vitamin B12 and iron intake. (4) Assess the client's ability to obtain and use essential nutrients. (5) Observe the client's ability to eat (time involved, motor skills, visual acuity, and ability to swallow various textures). (6) If the client lacks endurance, schedule rest periods before meals and open packages and cut up food for the client. (7) Evaluate the client's laboratory studies (serum albumin, serum total protein, serum ferritin, transferrin, hemoglobin, hematocrit, vitamins, and minerals). (8) Maintain a high index of suspicion of malnutrition as a contributing factor in infections and vice versa. (9) Be... (1) Assess for protein-energy malnutrition in elderly clients regardless of setting. (2) Assess for factors contributing to a current acute illness. (3) Implement strategies to prevent recurrence of illness. (4) Interpret laboratory findings cautiously. (5) Offer high protein supplements based on individual needs and capabilities. (6) Give the client a choice of supplements to increase personal control. If the client is unwilling to drink a glass of liquid supplement, offer 30 ml/hr in a medication cup. (7) Offer liquid energy supplements. When given liquid preloads 60 minutes before the next meal, older persons consistently ate a greater total energy load (8) Unless medically contraindicated, permit self-selected seasonings and foods. (9) Play relaxing dinner music during mealtime. (10) Assess components of bone health: calcium intake. (11) Assess components of bone health: vitamin D status. (12) Assess components of bone health: regular exercise. (13) Instruct in wise use of ....... (1) Assess for dietary intake of essential nutrients. (2) Assess for the influence of cultural beliefs, norms, and values on the client's nutritional knowledge. (3) Discuss with the client those aspects of their diet that will remain unchanged. (4) Negotiate with the client regarding the aspects of his or her diet that will need to be modified. (5) Validate the client's feelings regarding the impact of current lifestyle, finances, and transportation on ability to obtain nutritious food. (1) Above interventions

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html may be adapted for home care use. (2) Monitor food intake. Instruct the client in intake of small frequent meals and liquid supplements (e.g., Ensure, Instant Breakfast). (3) Assess the client for depression. Refer for mental health services as indicated. (4) Recognize that older women may continue their younger preoccupation with weight and recurrent dieting, despite being at normal weight. Assess source of low weight or weight loss with this in mind. (5) Monitor and effect total parenteral nutrition (TPN) as ordered by physician. TPN requires monitoring for potential complications and client/caregiver education (6) In the presence of depression diagnosis, refer for psychiatric home health care services for client reassurance and implementation of therapeutic regimen. (1) Build on the strengths in the client's/family's food habits. Adapt changes to their current practices. Accepting the client's/family's preferences shows respect for their culture. (2) Select appropriate teaching aids for the client's/family's background. (3) Implement instructional follow-up to answer the client's/family's questions. (4) Suggest community resources as suitable (food sources, counseling, Meals on Wheels,Senior Centers). (5) Teach the client and family how to manage tube feedings or parenteral therapy at home. Nutrition: more than body requirements, imbalanced 690 Intake of nutrients that exceeds metabolic needs Triceps skin fold of more than 25 mm in women; triceps skin fold of more than 15 mm in men; body weight more than 20% over ideal for height and frame; eating in response to external cues; eating in response to internal cues; reported or observed dysfunctional eating pattern pairing food with other activities; sedentary activity level; concentration of food intake at the end of the day Excessive intake in relation to metabolic needs; deficient knowledge related to desirability of nutritional supplements Nutritional Status: Food and Fluid Intake, Nutrient Intake; Weight control (1) State pertinent factors contributing to weight gain. (2) Identify behaviors that remain under the client's control. (3) Claim ownership for current eating patterns. (4) Design dietary modifications to meet individual long-term goal of weight control, using principles of variety, balance, and moderation. (5) Accomplish desired weight loss in a reasonable period (1-2 lb/week). (6) Incorporate appropriate activities requiring energy expenditure into daily life. (7) Use sound scientific sources to evaluate need for nutritional supplements. Eating Disorders Management; Nutrition Management; Nutritional Counseling; Weight Management; Weight Reduction Assistance (1) Obtain a thorough history. Refer to a dietitian if the client has a medical condition. (2) Evaluate the client's physiological status in relation to weight control. Refer as appropriate. (3) Assess dietary intake through 24-hour recall or questions regarding the usual intake of food groups. (4) Evaluate the client's usual intake of fiber. (5) Determine the client's knowledge of a nutritious diet and need for supplements. (6) Calculate body mass index (BMI) using either of the following formulas. Weight in kilograms divided by height (in meters) squared (kg/m2); Weight in pounds multiplied by 705, divided by height in inches, divided again by height in inches (7) Compute the waist-to-hip ratio (WHR). (8) Determine the client's motivation to lose weight, whether for appearance or health benefits. (9) Observe for situations that indicate a nutritional intake of more than body requirements. (10) Suggest that the client keep a diary of food intake and the circumstances surrounding ..... (1) Assess changes in lifestyle and eating patterns. (2) Assess fluid intake. Recommend routine drinks of water whether thirsty or not. (3) Observe for socioeconomic factors that influence food choices (e.g., inadequate funds or cooking facilities). (4) Suggest a variety of seasonings. (1) Assess for the influence of cultural beliefs, norms, and values on the client's nutritional knowledge and practices. (2) Assess for the influence of cultural beliefs, norms, and values on the client's ideal of acceptable body weight and body size. (3) Discuss with the client those aspects of his or her diet that will remain unchanged, and work with the client to adapt cultural core foods. (4) Negotiate with the client regarding the aspects of his or her diet that will

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html need to be modified. (5) Validate the client's feelings regarding the impact of current lifestyle, finances, and transportation on the ability to obtain and prepare nutritious food. (1) Provide the client and family with information regarding the treatment plan options. (2) Inform the client about the health risks associated with obesity for adults and children in the family. (3) Treatment for childhood obesity should be started when weight gain exceeds established percentiles for age and gender (4) Inform the client and family of the disadvantages of trying to lose weight by dieting alone. (5) Teach the importance of exercise in a weight control program. (6) Teach stress reduction techniques as alternatives to eating. Nutrition: more than body requirements, risk for imbalanced 697 At risk for intake of nutrients that exceeds metabolic needs. Reported use of solid food as major food source before 5 months of age; concentration of food intake at end of day; reported or observed obesity in one or both parents; reported or observed higher baseline weight at beginning of each pregnancy; rapid transition acress growth percentiles in infants or children; pairing of food with other activities; observed use of food as reward or comfort measure; eating in response to internal cues other than hunger; eating in response to external cues; dysfunctional eating patterns Nutritional Status: Food and Fluid Intake, Nutrient Intake; Weight Control (1) Explain concept of a balanced diet. (2) Compare current eating pattern with recommended healthy one. (3) Design dietary modifications to meet individual long-term goal of weight control, using principles of variety, balance, and moderation. (4) Identify role of exercise in weight control. (5) use sound scientific sources to evaluate need for nutritional supplements Nutrition Management; Nutritional Counseling; Weight Management (1) Observe for the presence of risk factors (see Related Factors). (2) Assess nutritional intake, including the use of supplements. (3) Determine the client's knowledge of nutrition. (4) Assess the client's nutritional practices. (5) Assess activity level and motivational factors. (6) Discuss the wise selection, use, and discontinuation of supplements. (7) Clients at risk for milk-alkali syndrome, such as those using thiazides and those with renal failure, should be monitored for hypercalcemia. (8) Vitamin C rebound scurvy has occurred inclients who suddenly discontinued megadoses of vitamin C (ten times the RDA), because the body cannot adjust quickly enough and continues to absorrb a meaher proportion of the now-smaller dose. (9) Establish a plan with the client, using techniques listed in the care plan for Imbalanced Nutrition: more than body requirements. (1) Give the client credit for making enough wise choices to have lived to an advanced age. (2) Encourage the use of varying suppliers of foodstuffs in the unlikely event of contamination. (1) Assess for the influence of cultural beliefs, norms, and values on the client's nutritional knowledge and practices. (2) Assess for influence of cultural beliefs, norms, and values on the client's ideal of acceptable body weight. (3) Disucss with the client those aspects of the diet that will remain unchanged and work with the client to adapt cutlural core foods. (4) negotiate with the client regarding the aspects of his or her diet that will need to be modified. (5) Assess for the influence of the family on patterns of eating. (6) Validate the client's feelings regarding the impact of current lifestyle, finances, and transportation on his her ability to obtain and prepare nutritious food. (1) Analyze the client's nutritional pattern and suggest lower-calorie substitutes for high-calorie dished. (2) Demonstrate the use of food labels to make healthful choices. Alert the client and family to focus on serving size, total fat, and simple carbohydrates. Oral mucous membrane, impaired 701 Disruption of lips and soft tissues of oral cavity Purulent drainage or exudates; gingival recession, pockets deeper than 4 mm; tonsils enlarged beyond what is developmentally appropriate; smooth, atrophic, sensitive tongue; geographic tongue; mucosal denudation; presence of pathogens; difficulty in speech; self-report of bad taste; gingival or mucosal pallor; oral pain/discomfort; xerostomia (dry mouth); vesicles, nodules, or papules;

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

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

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

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

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

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

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html physical punishment; inability to recognize and act on infant cues; see book... Abuse Recovery: Emotional, Physical, Sexual; Abusive Behavior Self-Restraint; Caregiver Emotional Health; Caregiver Stressors; Coping Parent-Infant Attachment; Parenting Performance; Risk Control: Unintended Pregnancy; Social Interaction Skills (1) Successfully establish a nurturing parenting role. (2) Affirm desire to acquire and maintain constuctive parenting skills to support infant/child growth and development. (3) Maintain appropriate measures to develop a safe, nurturing environment. (4) Display attentive, supportive parenting bahaviors. (5) Have knowledge of strategies to protect child from harm and/or neglect. Abuse Protection Support: Child, Attachment Promotion; Caregiver Support; Developmental Enhancement: Adolescent, Child; Environmental Management: Attachment Process; Family Integrity Promotion; Family Support; Family Therapy; Infant Care; Kangaroo Care; Parent Education: Adolescent, childrearing Family, Infant; Risk Identification: Childrearing Family; Role Enhancement NOTE: Management of risk diagnosis necessitates approached using primary and secondary prevention. Primary prevention interventions include activities such as safety instruction and focus on forestalling the development of a disease or condition. Early detection through screening, monitoring, and surveillance is secodnary prevention. (1) Conduct risk identification, noting the presence of a history of abuse, parental/family stressors, strength, and adequacy of social support systems, established coping styles, and other related factors (see Related Factors). (2) Screen for maternal psychiatric-mental health symptoms and negative experiences in the mother's family of origin. (3) Support parents' competence in appraising their infant's behavior and responses. (4) Encourage skin-to-skin care by parents of preterm infants. (5) Provide education to at-risk parents on behavioral management techniques such as looking ahead, giving good instructions, providing positive reinforcement, ......... (1) Assess for the influence of cultrual beliefs, norms, and values on the client's perceptions of parenting. (2) Acknowledge racial/ethnic differences at the onset of care. (3) Approach individuals of color with respect, warmth, and professinal courtesy. (4) Give a rationale when assessing African American individuals about sensitive issues. (5) Acknowledge that value conflicts from acculturation stresses may contribute to increased anxiety and significant conflict with children. (6) Use a neutral, indirect style when addressing areas in which improvement is needed (such as a need for verbal stimulation) when working with Native American clients. (7) Acknowledge the client's feelings regarding parenting. (8) Facilitate modeling and role playing to help the family improve parenting skills. (1) The interventions described previously may be adapted for home care use. (1) Initiate referrals to an appropriate community agency for early follow-up if an actual problem is identified. (2) Refer to the care plan for Impaired Parenting for additional teaching interventions. Peripheral neurovascular dysfunction, risk for 743 At risk for disruption in circulation, sensation, or motion of an extremity Trauma; fractures; mechanical compression (e.g., tourniquet, cast, brace, dressing, restraints); orthopedic surgery; immobilization; burns; vascular obstruction Circulation Status; Joint Movement: Passive; Neurological Status: Spinal Sensory/Motor Function; Risk Detection; Tissue Perfusion: Peripheral (1) Maintain circulation, sensation, and movement of an extremity within client's own normal limits. (2) Explain signs of neurovascular compromise and ways to prevent venous stasis. Exercise Therapy: Joint Movility; Peripheral Sensation Management (1) Perfomr neurovascular assessment every 1-4 hours or every 15 minutes as ordered. Use the six P's of assessment: (Pain.....Pulses... Pallor/Piokilothermia.... Paresthesia..... Paralysis..... Pressure). (2) Monitor the client for symptoms of compartment syndrome evidenced by decreased sensation, weakness, loss of movement, pain with passive movement, pain greater than expected. These symptoms are not always present and can be difficult to assess. (3) Monitor appropriate application and function of corrective device (e.g., cast, splint, traction) every 1 to 4 hours as needed.

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html (4) Position the extremity in correct alignment with each position change; check every hours to ensure appropriate alignment. (5) Get the client out of bed and mobilize the client as soon as possible, after consultation with the physician. (6) Monitor for signs of DVT, especially in high-risk populations, including persons older than 40 years of age; persons with immobility or obesity; persons taking estrogen.... (1) Use heat and cold therapies cautiously; elderly clients often have decreased sensation and circulation. (1) Assess the knowledge base of the client and family following any institutional care. Teach about the disease process and care as necessary. (2) If risk is related to fractures and cast care, teach the family to complete a neurovascular assessment; it may be performed as often as every 4 hours but is more commonly done two to three times per day. (3) If the fracture is peripheral, position the limb for comfort and change position frequently, avoiding dependent positions for extended periods. (4) Refer to physical therapy services as necessary to establish an exercise program and safety in transfers or mobility within limiitations of physical status. (5) Establish an emergency plan. (1) Teach the client and family to recognize signs of neurovascular dysfunction and to report signs immediately to the appropriate person. (2) Emphasize proper nutrition to promote healing. (3) If necessary, refer the client to a rehabilitation facility for instruction in proper use of assistive devices and measures to improve mobility without compromising neurovascular function. Poisoning, risk for 747 Accentuated risk of accidental exposure to, or ingestion of, drugs or dangerous products in doses sufficient to cause poisoning. EXTERNAL: Unprotected contact with heavy metals or chemicals; storage of medicines in unlocked cabinets accessible to children or confused persons; presence of poisonous vegetation; presence of atmospheric pollutants, paint, lacquer, etc., in poorly ventilated areas or without effective protection; flaking, peeling paint or plaster in presence of young children; chemical contamination of food and water; availability of illicit drugs potentially contaminated by poisonous additives; presence of large supplies of drugs in home; placement or storage of dangerous products within reach of children or confused persons. INTERNAL: Verbalization that occupational setting is without adequate safeguards; reduced vision; lack of safety or drug education; lack of proper precautions; insufficient finances; cognitive or emotional difficulties. Knowledge: Child Physical Safety, Medication, Personal Safety; Parenting Performance; Risk Control; Risk Control: Alcohol Use, Drug Use; Risk Detection; Safe Home Environment (1) Prevent inadvertent ingestion of or exposure to toxins or poisonous substances. (2) Explain and undertake appropriate safety measures to prevent ingestion of or exposure to toxins or poisonous substances. Environmental Management: Safety; First Aid; Health Education; Medication management; Surveillance; Surveillance: Safety. (1) Identify risk factors for poisoning, noting special circumstances in which preventive or protective measures are indicated. (2) Evaluate lead exposure risk and cosult the health care provider regarding lead screening measures as indicated (public/ambulatory health). (3) Properly label medications, using large print for the visually impaired. Supply "Mr. Yuk" labels for families with children. (4) Detect possible interactions and cumulative or other adverse effects among prescribed meds, self-administered OTC products, culturally based home treatments, and foods. (5) Prevent iatrogenic harm to client caused by receiving the wrong med or dose by following these guidelines for giving care: (a) Use at least two methods to identify the client, such as name and birth date, before administering meds or blood products. (b) When giving verbal or telephone orders, always require the person taking the orders to verify them by repeating them back. (c) Standardize use of abbreviations and ..... (1) The interventions described previously may be adapted for home care use. (2) Provide the client and/or family with a poison control diagram to be kept on the refrigerator or bulletin board. Ensure that the telephone number for local poison control info is readily available. (3) Prepour meds for a

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html routine as quickly as possible. (13) ... (1) Use environmental assessment skills to identify elderly clients who are traumatized by disaster, loss or both. (2) Observe the client for concurrent losses that may affect copig skills. (3) Allow the lcient more time to establish trust and express anger, guilt, and shame about the trauma. Review past coping skills and give the client positive reinforcement for the successfully dealing with other life crises. (4) Monitor the client for clinical signs of depression and anxiety, refer to a physician for medication if appropriate. (5) Instill hope. (1) Assess for the influence of cultural beliefs, norms, and values on the client's ability to cope with a traumatic experience. (2) Acknowledge racial/ethnic differences at the onset of care. (3) Use a family-centered approach when working with Latino, Asian, African American, and Native American clients. (4) When owrking with an Asian American client, provide opportunities by which the family can save face. (5) Validate the client's feelings regarding the trauma. (1) Assess family support and the response to the client's coping mechanisms. Refer the family for medical social services or other counseling as necessary. (2) Provide a stable routine of day-to-day activites consistent with pretrauma experience. (3) If the client is receiving meds, assess the client's self-medicating ability. Assign a responsible person to administer meds if necessary. (4) Assess the impact of the trauma on significant others (e.g., a father may have to take ovre his partner's parenting responsibility after she has been raped and injured). (1) Explain to the client and family what to expect the first few days after the traumatic event and in the future. (2) Teach positive coping skills and avoidance of negative coping skills. (3) Teach stress reduction methods such as deep breathing, visualization, meditation, and physcial exercise. Encourage their use especially when intrusive thoughts or flashbacks occur. (4) Encourage other healthy living habits of proper diet, adequate sleep, regular exercise, family activites, and spiritual pursuits. (5) Refer the client to peer support groups. (6) Refer the client who has been in an accident to counseling for PTSD (7) Refer the client who has suffered traumatic brain injury (TBI) for counseling for PTSD. (8) Instruct the family in ways to be helpful to and supportive of the traumatized person. Emphasize the importance of listening and being there. Also emphasize that there is no magic phrases capable of easing the person's emotional suffering. (9) consider the use of ............. Post-trauma syndrome, risk for 757 At risk for maladaptive response to a traumatic, overwhelming event. Exaggerated sense of responsibility; perception of event; survivor's role in the event; occupation (e.g., police, fire, rescue, corrections, emergency dept., mental health worker); displacement from home; inadequate social support; nonsupportive environment; diminished ego strength; duration of event Abuse Cessation; Abuse Protection; Abuse Recovery: Emotional; Aggression Self-Control; Anciety Self-Control; Coping; Grief Resolution; Sleep (1) Identify symptoms associated with post-traumatic stress disorder (PTSD) and seek help. (2) Identify the event in realistic, cognitive terms. (3) State that he or she is not to blame for the event. Counsleing; Support System Enhancement (1) Assess for PTSD in a client who has chronic illness, anxiety, or personal disorder; was a witness to serious injury or edeath; or experienced sexual molestation. (2) consider the use of the Standord Acute Stress Reaction Questionnaire to evaluate anxieety and dissociation symptoms after traumatic events. (3) Consider screening for PTSD in a client who is a high utilizer of medical care. (4) Provide peer support to contact co-workers experiencing trauma to remind them that others in the organization are concerned about their welfare; provide an opportunity to discuss the traumatic incident and assess for the need for further post-trauma services. (5) Provide post-trauma debriefing. Effective post-trauma coping skills are taught, and each participant creates a plan for his or her recovery. During the debriefing, the facilitators assess participants to determine their needs for further services in the form of post-trauma cousneling. For maxiamum effectiveness, the debriefing should...

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html (1) Carefully assess the elderly client's response to a traumatic event (e.g., a natural disaster) and use the critical incident stress techniques described previously to prevent symptoms associated with PTSD. (1) Assess for the influence of cultural beliefs, norms, and values on the client's ability to cope with a traumatic experience. (2) Acknowledge racial/ethnic differences at the onset of care. (3) Assure the client of confidentiality. (4) Validate the client's feelings regarding the trauma and allow the client to tell the trauma story. (1) Assess the client's ability to meet primary needs of shelter, nourishment, and safety. Refer to medical social services, state departments of human services, or other organizations as appropriate. (2) Identify other losses or stressors that may affect coping ability (e.g., role or relationship changes, deaths). (3) Assess the family's response to the client's risk. Refer the family to medical social services or mental health services or support groups as necessary. (4) If the client is on medication, assess its effectiveness and the client's compliance with the regimen. Identify who administers the medication. (5) Assist the client in the home in identifying and establishing daily patterns that have meaning for the client. (6) For a client who is displaced from the home, identify internal values that can be maintained while the lcient is displaced, such as respite, contact with specific persons, and honesty. (7) Encourage the client to verbalie feelings of risk and trauma to ...... (1) Instruct the family and friends to use the following critical incident stress management techniques. FOR FAMILY MEMBERS AND FRIENDS: (1) Listen carefully. (2) Spend time with the traumatized person. (3) Offer your assistance and a listening ear, even if the person has not asked for help. (4) Help the person with everyday tasks like clenaing, cooking, caring for the family, and minding children. (5) Give the person some private time. (6) Don't take the individual's anger or other feelings personally. (7) Don't tell the person that he or she is "lucky it wasn't worse"; such statements do not console traumatized people. Instead, tell the person that you are sorry such an event has occurred and you want to understand and assist him or her. (8) Teach the client and family to recognize symptoms of PTSD and to seek treatment when the client does the following: (a) Relives the traumatic event by thinking or dreaming about it frequently. (b) Is unselttled or distressed in other areas of.... Powerlessness 763 Perception that one's own actions will not significantly affect an outcome, perceived lack of control over current situation or immediate happening LOW: Expressions of uncertainty about fluctuating energy levels; passivity. MODERATE: Nonparticpation in care or decision making when opportunities are provided; resentment, anger, and guilt; reluctance to express true feelings; passivity; dependence on others that may result in irritability; fearing alienation from caregivers; expressions of dissatisfaction and frustration because of inability to perform previous tasks/activities; expression of doubt regarding role performance; failure to monitor progress; failure to defend self-care practices when challenged; inability to seek info regarding care. SEVERE: Verbal expressions of having no control over self-care, or influence over situation, or influence over outcome; apathy; depression regarding physical deterioration that occurs despite client's compliance with regimens Health care environment; interpersonal interatctions; lifestyle helplessness; illness-related regimen Depression Self-Control; Health Beliefs; Health Beliefs: Perceived Ability to Perform, Perceived Control, Perceived Resources; Participation in Health Care Decisions (1) State feelings of powerlessness and other feelings related to powerlessness (e.g., anger, sadness, hopelessness) (2) Identify factors that are uncontrollable. (3) Participate in planning and implementing care; make decisions regarding care and treatment when possible. (4) Ask questions about care and treatment. (5) Verbalize hope for the future and sense of participation in planning and implementing care. Cognitive Restructuring; Complex Relationship Building; Mutual Goal Setting; Self-Esteem Enhancement; Self-Responsibility Facilitation NOTE: Prior to implementation of interventions in the face of client powerlessness, nurses should examine their

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html own philosophies of care to ensure that control issues or lack of faith in client capabilities will not bias the ability to intervene sincerely and effectively. (1) Observe for factors contributing to powerlessness (e.g., immobility, hospitalization, unfavorable prognosis, lack of support system, misinformation about situation, inflexible routine, chronic illness). (2) Assess for ineffective therapeutic regimen management or noncompliance. (3) Assess the client's locus of control related to his or her health. (4) Assess for signs/symptoms of hopelessness depression and pay particular attention to the availibility of social support. Hopelessness depression is characterized by a negative cognitive style (e.g., a tendency to perceive negative events as stable and global). (5) Establish a therapeutic relationship with the client by spending one-on-one time with him or her, .... (1)Initiate focused assessment questioning and education regarding syndromes common in elderly. (2) Explore feelings of powerlessness--the feeling that the client's behavior will not affect outcomes. (3) Explore personality resources and inner strengths that the client has used in the past. Incorporate these into the treatment plan. (4) Establish therapeutic relationships by listening; participate with the client in generating choices and incorporate his or her statement of limitations. (5) Emphasize client control in all possible ADLs. (6) Encourage the positive use of solitude--reading, listening to music, enjoying nature--to prevent loneliness. Encourage socialization with others when possible; advocate for the client regarding family visitation if relationships are viewed positively by the client. (7) Monitor the use of alternative therapies but do not intervene unless the therapy interacts negatively with the existing therapeutic regimen. Ensure that all health care providers.... (1) Assess for the influence of cultural beliefs, norms, and values on the client's feelings of powerlessness. The client's expression of powerlessness may be based on cultural perceptions or expectations. (2) Assess the effect of fatalism on the client's expression of powerlessness. (3) Encourage spirituality as a source of support to decrease powerlessness. (4) Validate the client's feelings regarding the impact of health status on current lifestyle. (5) For inner-city clients, help the client to redefine behaviors as ways of coping with a hostile environment and to reconnect with community supports. (1) Include an initial and ongoing assessment and evaluation of potential abuse and neglect. Photograph evidence of abuse or neglect when possible. (2) If neglect or abuse is suspected, identify an emergency plan that addresses the problem immediately, ensures client safety, and includes a report to the appropriate authorities. (3) Develop a therapeutic relationship in the home setting that respects the client's domain. (4) Empower the client by encouraging the client to guide specifics of care such as wound care procedures and dressing and grooming details. Confirm the client's knowledge and document in the chart that the client is able to guide procedures. Document in the home and in the chart the perferred approach to procedures. Orient the family and caregivers to the client's role. (5) Develop a written contract with the client that designates what care will be given and who has responsibility for care elements. Focus should be on care that is controlled by the client. (6) ...... (1) Explain all relevant symptoms, procedures, treatments, and expected outcomes. (2) Procude written instructions for treatments and procedures for which the client will be responsible. (3) Continually assess the client for signs of inappropriate exercise of self-care. Confront such applications of self-care; instruct the client in the dangers that inappropriate care may present and in alternatives for care that would be more effective. (4) Teach stress reduction. relaxation, and imagery. Many cassette tapes are available on relaxation and meditation. Assist the client with relaxation based on the client;s preference indicated in the initial assessment. (5) Teach cognitive-behavioral activities, such as active problem solving, reframing (reappraising the situation from a different perspective), or thought stopping (in response to a negative thought, picturing a large stop sign and replacing the image with a prearranged positive alternative. Teach the client to

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html confront his or her..... Powerlessness, risk for 774 At risk for perceived lack of control over a situation and/or one's ability to significantly affect an outcome. PHSIOLOGICAL: Chronic or acute illness (hospitalization, intubation, ventilator use, suctioning); acute injury or progressive debilitating disease process (e.g., multiple sclerosis); aging (e.g., decreased physical strength, decreased motility); dying. PSYCHOLOGICAL: Lack of knowledge of illness or health care system; lifestyle of dependency with inadequate coping patterns; absence of integrity (e.g., essence of power); decreased self-esteem; low or unstable body image Depression Self-Control; Health Beliefs; Health Beliefs: Perceived Ability to Perform, Perceived Control, Perceived Resources; Participation in Health Care Decisions (1) State feelings of powerlessness and other feelings related to powerlessness (e.g., anger, sadness, hopelessness) (2) Identify factors that are uncontrollable. (3) Participate in planning and implementing care; make decisions regarding care and treatment when possible. (4) Ask questions about care and treatment. (5) Verbalize hope for the future and sense of participation in planning and implementing care. Cognitive Restructuring; Complex Relationship Building; Mutual Goal Setting; Self-Esteem Enhancement; Self-Responsibility Facilitation See care plan for Powerlessness See care plan for Powerlessness See care plan for Powerlessness See care plan for Powerlessness See care plan for Powerlessness Protection, ineffective 776 Decrease in ability to guard self from internal or external threats such as illness or injury Maladaptive stress response; neurosensory alteration; impaired healing; deificient immunity; altered clotting; dyspnea; insomsnia; weakness; restlessness; pressure ulcers; perspiring; itching; immobility; chilling; fatigue; disorientation; cough anorexia Abnormal blood profiles (e.g., leukopenia, thrombocytopenia, anemia, coagulation); extremes of age; inadequate nutrition; alcohol abuse; drug therapies (e.g, antineoplastic, corticosteroid, immune, anticoagulant, thrombolytic); treatments (e.g, surgery, radiation); diseases such as cancer and immune disorders Abuse Protection; Blood Coagulation; Endurance; Immune Status (1) Remain free of infection (2) Remain free of any evidence of new bleeding (3) Explain precautions to take to prevent infection (4) Explain precautions to take to prevent bleeding Bleeding Precautions; Infection Control; Infection Protection (1) Take temperature, pulse, and blood pressure (e.g, q 1 to 4 hrs) (2) Obsreve nutritional status (e.g, weight, serum protein and albumin levels, muscle mass, usual food intake). Work with the dietician to improve nutritional status if needed. All clients diagnosed with HIV should have a dietary consult. (3) Observe the client's sleep pattern; if altered, see Nursing Interventions for Disturbed Sleep patterns. (4) Determine the amount of stress in the client's life. If stress is uncontrollable, see Nursing Interventions for Ineffective Coping. PREVENTION OF INFECTION: (1) Monitor for and report any signs of infection (e.g. fever, chills, flushed skin, drainage, edema, redness, abnormal laboratory values, and pain) and notify the physician. (2) Use appropriate "hand hygiene" (i.e. hand washing, or use of alcohol-based hand rubs). (3) When using an alcohol-based hand rub, apply product to palm of one hand and rub hands together, covering all surfaces of hands and fingers. until ....... (1) If not contraindicated, promote exercise to strengthen the immune system in the elderly. (2) Give elderly client with imbalanced nutrition a nutritional supplement to enhance immune function. (3) See care plan for Risk for Infection for more interventions related to the prevention of infection. (1) Some of the interventions described previously may be adapted for home care use. (2) Consider institution of a nurse-administered mobile care unti for monitoring anticoagulant therapy. (3) For terminally ill clients, teach and institute all of the aformentioned noninvasive precautions that will maintain quality of life. Discuss with the client, family, and physician the consequences of contracting infection. Determine which precautions do not maintain quality of life and should not be used (e.g., physical assessment

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html twice daily, multiple vital sign assessments). DEPRESSED IMMUNE FUNCTION: (1) Teach precautions to take to decrease the chance of infection (e.g, avoiding uncooked fruits or vegetables, using appropriate self-care, ensuring a safe environment). (2) Teach the client and family to notify the physician of elevated temp, even in the absence of other symptoms of infection. (3) teach the client to avoid crowds and contact with persons who have infections. BLEEDING DISORDER: (1) Teach the client to wear a medical alert bracelet and notify all health care personnel of the bleeding disorder. (2) Teach the client and family the signs of bleeding, precautions to take to prevent bleeding, and action to take if bleeding begins. Caution the client to avoid taking over-the-counter meds w/o the permission of the physcian. (3) Teach the client to wear loose-fitting cloths and avoid physical activity that might cause trauma. Rape-trauma syndrome 783 sustained maladaptive response to forced, violent sexual act (penetration may not actually occur) against the victim's will and conset. Fear disorganization; change in relationships; confusion; physical trauma (e.g., bruising, tissue irritation; injjuries identified by use of new technology); suicide attempt; denial; guilt, paranoia; humiliation; embarrassment; aggression; muscle tensoin and/or spasms; mood swings; dependence; powerlessness; nightmares and sleep disturbances; secual dysfrunction; desire for revenge; phobias; loss of self-esteem; inability to make decisions; dissociattive disorders; self-blame; hyperalertness; vulnerability; substance abuse; depression; helplessness; anger; anxiety; agitation; shame; shock Rape; sexual assault; abuse Abuse Cessation; Abuse Protection; Abuse Recovery: Emotional, Sexual; Coping; Impulse Self-Control; Self-Mutilation Restraint (1) Share feelings, concerns, and fears. (2) Recognize that the rape or attempt was not the client's own fault. (3) State that, no matter what the situation, no one has the right to assault another. (4) Describe medical/legal treatment procedures and reasons for treatment. (5) Report absence of physical complications or pain. (6) Identify support people and be able to ask them for help in dealing with this trauma. (7) Function at same level as before crisis, including sexual functioning. (8) Recognize that it is normal for full recovery to take a minimum of 1 year. Couseling; Rape-Trauma Treatment (1) Observe the client's responses, including anger, fear, self-blame, sleep patterns disturbances and phobias. (2) Monitor the client's verbal and nonverbal psychological state (e.g., crying, hand wringing, avoidance of interactions or eye contact with staff, silence and denial). (3) Stay with (or have a trusted person stay with ) the client initially. If a law envrocement interview is permitted, provide support by staying with the client, but only at the client's request. (4) Explain the entire medical/legal examination to the client before beginning any procedures. Obtain written permission to perform the examination but explain that at any time during the exam the client may withdraw consent. Discuss the importance of collection of evidence. The exam will include several procedures that might be unconfortable or painful and the client should know this in advance. Before moving on to each procedure, repeat the explanation and offer the client the right to skip any part of the ...... (1) Build a trusting relationship with the client. (2) Explain reporting and encourage the client to report. (3) Observe for psychosocial distress (e.g., memory impairment, sleep disturbances, regress, changes in bodily function). (4) All examinations should be done on the elderly as they would be done on any adult client after sexual assault. Evidence should be collected and consent for collection, photography, and law enforcement contact should be obtained in all cases. Special attention should be given to the explanation of the genital exam, especially as it related to the use of a speculum. (5) Modify the rape protocol to promote comfor for the geriatric client. Consider positioning female clients with pillows rather than stirrups and consider using a small speculum. (6) Assess for mobility limitations and cognitive impairment. (7) Respect the client's need for privacy. (8) Consider arrangements for temporary housing. Most sexual assaults of older clients

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html occur in the home or ..... (1) Assess for the influence of cultural beliefs, norms, and values on the client's ability to cope with the trauma of the rape experience. (2) Acknowledge racial/ethnic differences at the onset of care. (3) Use a family-centered approach when working with Latino, Asian, African Americans, and native American clients' (4) Provide opportunites by which the family and individual can save face when working with Asian American clients. (5) Assure the client of confidentiality. (6) Validate the client's feelings regarding the rape and allow the client to tell his or her rape story. (7) A culturally sensitive approach should be part of the training of all SARTs and members of the team. (1) Some of the interventions described previously may be adapted for home care use. (2) Interact with the client realistically assessing the home setting for safety and/or selecting a safe environment in which to live. (3) Ensure that the client has a support system in place for long-term support. Instruct the family that recovery may take a long time. Refer for counseling if necessary. (4) Assis the client with realistically assessing the home setting for safety and/or selecting a safe environment in which to live. (5) Make sure that physical symptoms from the rape or other physical conditions are followed up. Follow-up should include a visit to the primary care physician or the local health department in 3-4 weeks for repeat pregnancy testing and STD testing. Explain to the client that additional medication may be necessary for the treatment of STDs or pregnancy. (6) If the client is homebound, refer for psychiatric home health care services for client reassurance and ............ (1) Provide information on prophylactic antibiotic therapy, hep B, and tetanus prophylaxis for nonimmunized clients with trauma. (2) Discharge instructions should be written out for the client. (3) Give instructions to significant others. (4) Explain the purpose of the "morning-after pill". Explain the potential for common side effects related to treatment with norgestrel, such as breast swelling or nausea and vomiting. (Call the emergency department if the client vomits within 1 hour of taking the pill because the pill may need to be taken again.) (Discuss any issues about prophylactic meds at the follow-up visit in 3-4 weeks.) It may take 3-30 days for the menstrual period to start; if menstruation has not begun in 30 days, contact a physician. (5) Explain the potential for severe side effects related to treatment with norgestrel, such as severe leg or chest pain, trouble breathing, coughing up of blood, severe headache or dizziness, and trouble seeing or talking. (6) Advise the .... Rape-trauma syndrome: compound reaction 791 Forced violent sexual act (penetration may not actually occur) against victim's will and consent resulting in a trauma syndrome that includes an acute phase of disorganization of victim's lifestyle and a long-term process or reorganization of lifestyle Change in lifestyle (e.g., changing residence, dealing with repetitive nightmares and phoboias, seeking family support, seeking social network support in long-term phase); emotional reaction (e.g., anger, embarrassment, fear pof physical violence and death, humiliation, desire for revenge, self-blame in acute phase); multiple physical symptoms (e.g., GI irritability, GU discomfort, muscle tension, sleep pattern disturbance in acute phase); reactivated symptoms of previous conditions (i.e., physical illness, psychiatric illness in acute phase); reliance on alcohol and/or drugs (acute phase) Rape; sexual assault; abuse Abuse Cessation; Abuse Protection; Abuse Recovery: Emotional, Sexual; Coping; Impulse Self-Control; Self-Mutilation Restraint (1) Share feelings, concerns, and fears. (2) Recognize that the rape or attempt was not the client's own fault. (3) State that, no matter what the situation, no one has the right to assault another. (4) Describe medical/legal treatment procedures and reasons for treatment. (5) Report absence of physical complications or pain. (6) Identify support people and be able to ask them for help in dealing with this trauma. (7) Function at same level as before crisis, including sexual functioning. (8) Recognize that it is normal for full recovery to take a minimum of 1 year. Couseling; Rape-Trauma Treatment See care plan for Rape-trauma syndrome, Powerlessness, Ineffective Coping, Dysfunctional

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Grieving, Anxiety, Fear, Risk for self-directed Violence, and Sexual dysfunction (1) A new subgroup of rape victims resides in nursing homes. Treatment is necessary. (1) Assess for the influence of cultural beliefs, norms, and values on the client's ability to cope with the trauma of the rape experience. (2) Provide opportunities by which the family and individual can save face when working with Asian American clients. (3) Assure the client of confidentiality. (4) Validate the client's feelings regarding the rape and allow the client to tell his or her rape story. (5) A culturally sensitive approach should be part of the training of all sexual assault response teams and members of teams. (1) If the client has pusued psychiatric counseling, monitor and encourage attendance. (2) If the client is receiving medication, assess the client's knowledge of its purpose, side effects, and interactions with meds for other diagnoses. Monitor for effectiveness, side effeccts, and interations. (3) Establish an emergency plan including hotlines. Contract with the clinet to use the emergency plan. Role play using the hotlines. (4) For other home care and hospics considerations, see care plan for Rape-trauma syndrome. (1) Teach the client what reactions to expect during the acute and long-term phases: acute phase--anger, fear, self-blame, embarrassment, vengeful feelings, physical symptoms, muscle tension, sleeplessness, stomach upset, GU discomfort; long-term phase--changes in lifestyle or residence, nightmares, phobias, seeking of family and social network support. (2) Encourage psychiatric consultation if the client is suicidal, violent, or unable to continue ADLs. (3) Discuss any of the client's current stress-relieving meds that may result in substance abuse. Rape-trauma syndrome: silent reaction 794 Forced violent sexual act (penetration may not actually occur) against victim's will and consent resulting in a trauma syndrome that includes an acute phase ofdisorganization of victim's lifestyle and a long-term process of reorganization of lifestyle Increased anxiety during interview (e.g., blocking of associations. long periods of silience, minor stuttering, phsycial distress); sudden onset of phobic reactions; lack of verbalization about the rape; abrupt changes in relationships with males; increased nightmares; pronounced changes in sexual behavior Rape; sexual assault; abuse Abuse Cessation; Abuse Protection; Abuse Recovery: Emotional, Sexual; Coping; Impulse Self-Control; Self-Mutilation Restraint (1) Resume previous level of relationships with significant others. (2) State improvement in sleep and fewer nightmares. (3) Express feelings about and discusses the rape (Nondisclosure about a sexual assault may arise out of self=protection, but this defensive coing style acts as a pressure cooker and is associated with more intense depressive stymptoms. Clients should be assured that disclosure of an incident of sexual assault to a care provider or advocate has guaranteed confidentiality and does not necessitate notification of law enforcement. (4) Return to usual pattern of sexual behavior (Women who are sexually active after the assault report lower levels of depression. However, being sexually active cannot be construed to mean that the client has adjusted to or resolved the sexual trauma.) (5) Remain free of phobic reactions. See care plan for Rape-trauma syndrome. Counseling; Support System Enhancement (1) See the care plan for Rape-trauma syndrome, Powerlessness, Ineffective Coping, Dysfunctional Grieving, Anxiety, Fear, Risk for self-directed Violence, Sexual dysfunction, and Impaired verbal Communication. (2) Observe for disruption in relationships with significant others. (3) Monitor for signs of increased anxiety (e.g, silence, stuttering, physical distress, irribility, unexplained crying spells). (4) Focus on the client's coping strengths. (5) Observe for changes in sexual behavior. (6) Identify phobic reactions to persons or objects in the environment (e.g, strangers, doorbells, groups of people, knives). (7) Provide support by listening when the client is ready to talk. (8) Be nonjudgmental when feelings are expressed. Explain that anger is normal and needs to be verbalized. (9) Remain with an anxious client even if the client is silent. use gentle speech and actions; move slowly. (10) Evaluate

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html somatic complaints. (1) A new subgroup of rape victims resides in nursing homes. Treatment is necessary. (1) Assess for the influence of cultural beliefs, norms, and values on the client's ability to cope with the trauma of the rape experience. (2) Provide opportunites by which the family and individual can save face when working with Asian American clients' (3) Assure the client of confidentiality. (4) Allow the client to tell is or her rape story without probing. See the care plan for Rape-trauma syndrome. (1) Reassure the client that he or she is not bad and is not at fault. Avoid questions beginning with "why". "Why" questions may sound judgmental and feed into self-blame. (2) Refer the client to a sexual assault counselor. (3) Offer information about testing, treatment, and procedures related to pregnancy, hep B, and STD. Do not wait for the client ot request info. See care plan for Rape-trauma syndrome Relocation stress syndrome 797 Physiological and/or psychosocial disturbances that result from transfer from one environment to another. NOTE: Recent research on the nursing diagnosis of relocation stress syndrome may indicate that the nursing diagnosis is not valid or may not be valied when applied to group moves of clients. More research is needed in this area to validate this nursing intervention. Temporary and/or permanent move; voluntary and/or involuntary move; aloneness, alienation, or loneliness; depression; anxiety (e.g., separation); sleep disturbance; withdrawal; anger; loss of identity, self-worth, or self-esteem; increased verbalization of needs, unwillingness to move or concern over relocation; increased physical symptoms/illness (e.g., GI disturbance, weight change); dependency; insecurity; pessimism; frustration; worry; fear Unpredictability of experience/isolation from family/friends; passive coping; language barrier; decreased health status; impaired psychosocial health; past, concurrent, and recent losses; feeling of powerlessness; lack of adequate support system/group; lack of predeparture counseling Anxiety Self-Control; Child Adaptation to Hospitalization; Coping; Depression Level; Depression Self-Control; Loneliness Severity; Psychosocial Adjustment: Life change; Quality of Life (1) Recognize and know the name of at least one staff member. (2) Express concern about the move when encouraged to do so during individual contacts. (3) Carry out ADLs in usual manner. (4) maintain previous mental and physical health status (e.g., nutrition, elimination, sleep, social interaction). Anxiety Reduction; Coping Enhancement; Discharge Planning; Hope Instillation; Self-Responsibility Facilitation (1) Obtain a history, including the reason for the move, the client's usual coping mechanisms, history of losses, and family support for the client. (2) If the client is an adolescent, try to aviod a move in the middle of the school year, find a newcomer's club for the adolescent ot join and refer for counseling if needed. (3) Provide support for a child and family who must relocate to be near a transplant center. (4) Identify previous routines for ADLs. Try to maintain as much continuity with the previous schedule as possible. (5) bring in familiar items from home. (6) Thoroughly orient the client to the new environment and routines; repeat directions as needed. (7) Spend one-on-one time with the client. Allow the client to express feelings and convey acceptance of them; emphasize that the client's feelings are real and individual and that it is acceptable to be sad or angry about moving. (8) Assign the same staff members to the client; maintain consistency in the personnel the ..... (1) Monitor the need for transfer and transfer only when necessary. (2) Protect the client from injuries such as falls. (3) After the transfer, determine the client's mental status. Document and observe for any new onset of confusion. (4) Refer for music therapy. (5) Use a reality orientation if needed (e.g., "Today is.....", "The date is...," "You are at .....facility"). Repeat the info as needed and provide a clock or calendar. (1) Teach family members about relocation stress syndrome. Encourage them to monitor for signs of the syndrome. (2) help significan others learn how to support the client in the move by setting up a schedule of visits, arranging for holidays, bringing familiar items from home, and establishing a system for

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html contact when the client needs support. Relocation stress syndrome, risk for 801 At risk for physiological and/ro psychosocial disturbances that result from transfer from one environment to another. Moderate to high degree of environmental change (e.g., physical, ethnic, cultural); temporary and/or permanent move; voluntary and/or involuntary move; lack of adequate support system/group; feelings of powerlessness; moderate and mental competence (e.g., alert enough to experience ); unpredictability of experiences; decreased psychosocial or physical health status; lack of predeparture counseling; passive coping; past, current, or recent losses Anxiety Self-Control; Child Adaptation to Hospitalization; Coping; Depression Level; Depression Self-Control; Loneliness Severity; Psychosocial Adjustment: Life change; Quality of Life (1) Recognize and know name of at least one staff member. (2) Express concern about move when encouraged to do so during individual contacts. (3) Carry out ADLs in usual manner. (4) maintain previous mental and physical health (e.g., nutrition, elimination, sleep, social interaction) Anxiety Reduction; Coping Enhancement; Discharge Planning; Hope Instillation; Self-Responsibility Facilitation (1) Adequately prepare the client and family for transfer from the ICU. (2) Assist caregivers with the use of respite care for family members, acknowledge the importance of caregivers' role, and seek their assistance in planning the client's care. (3) Relocation to more supportive housing is a potentially stressful life event for an older adult. Nurses have a critical role to play in helping the family identify the most appropriate housing alternative, assisting in planning the relocation, and helping older adults, especially ethnic elders, adjust to their new homes. (4) Consider 24 hr in-home care as an alternative to nursing home placement. (5) Provide support for spouses who have placed a partner in a care home. Support a continued relationship with the partner. (6) Refer to the care plan for Relocation Stress Syndrome. Refer to the care plan for Relocation Stress Syndrome. Refer to the care plan for Relocation Stress Syndrome. Role performance, ineffective 804 Patterns of behavior and self-expression that do not match the environmental context, norms, and expectations Change in self-perception; role denial; inadequate external support for role enactment; inadequate adaptation to change or transition, system conflict; change in usual patterns of responsibility; discrimination; domestic violence; harassment uncertainty; altered role perceptions; role strain; inadequate self-management; role ambivalence; pessimistic attitude; inadequate motivation; inadequate confidence; inadequate role competency and skills; inadequate knowledge; inappropriate developmental expectations; role conflict; role confusion; powerlessness; inadequate coping; anxeity or depression; role overload; change in other's perception or role; role dissatisfaction; inadequate opportunities for role enactment SOCIAL: Inadequate or inappropriate linkage with the health care system; job schedule demands; young age; developmental level; lack of rewards; poverty; family conflict; inadequate support system; inadequate role socialization; low socioeconomic status; stress and conflict; domestic violence; lack of resources KNOWLEDGE: Inadequate role preparation; lack of knowledge about role, role skills, role transition; lack of opportunity for role rehearsal; developmental transitions; unrealistic role expectations; education attainment level; lack of or inadequate role model. PHYSIOLOGICAL: inadequate/inappropriate linkage with health care system; substance abude; mental illness; body image alteration; physical illness; cognitive deficits; health alterations; depression; low self-esteem; pain; fatigue. NOTE: There is a typology of roles: sociopersonal, home management intimacy, leisure/exercise/recreation, self-management, socialization, community contributor, and religious. Coping; Psychosocial Adjustment: Life Change (1) Identify realistic perception of role. (2) State personal strengths. (3) Acknowledge problems contributing to inability to carry out usual role. (4) Accept physical limitations regarding role responsibility and consider ways to change lifestyle to accomplish goals associated with role performance. (5) Demonstrate knowledge of appropriate

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html behaviors associated with new or changed role. (6) State knowledge of change in responsibility and new behaviors associated with new responsibility. (7) Verbalize acceptance of new responsibility. Role Enhancement (1) Obsreve the client's knowledge of behaviors associated with role. (2) Allow the client to express feelings regarding the role change. (3) Ask the client direct questions regarding new roles and how the health care system can help him or her continue roles. (4) Assis new parents to adjust to changes in workload associated with childbirth. (5) Reinforce the client's strengths, have the client identify past coping skills, and support the continued use of these skills. (6) Have the client make a list of strenths that are needed for the new role. Acknowledge which strengths the client has and which strengths need to be developed. Work with the client to set goals for desired role. (7) Have the client list problems associated with the new role and identify ways of overcoming them. (8) Provide parents with coping skills when the role change is associated with a critically ill child. (8) Assist parents in coping with infants with colic, a condition common in infants. (9) Assist families... (1) Support the client's religious beliefs and activities and provide appropriate spiritual support persons. (2) Encourage the use of humor by family caregivers to describe their role reversal. (3) Explore community needs after assessing the client's strengths. Suggest functional activities. (4) Refer to appropriate support groups for adjustment to role changes. (5) Refer to home health agency for home visits when there is an infant who has excessive crying. (6) Refer to therapy to improve memroy for patients with Alzheimer disease. (1) Assess for the influence of cultural beliefs, norms, values, and expectations on the individual's role. (2) Assess for conflicts between the caregiver's cultural role obligations and competing factors like employment. (3) Negotiate with client regarding the aspects of their role that can be modified and still honor cultural beliefs. (4) Encourage family to use support groups or other service programs to assist with role changes. (5) validate the individual's feelings regarding the impact of role changes on family and personal lifestyle. (1) Above interventions may be adapted for home care use. (2) Determine the anticipated duration of role change. (3) Assess family's ability to physically or psychologically assume responsiblities of decrease or change in the client's role function. (4) Offer a referral to medical social services to assist with assessing the short- and long-term impacts of role change. (1) Teach significant others about health care changes to expect when the client returns home. (2) help the client identify resources for assistance in caring for a disabled or aging parent. (3) Refer to appropriate community agencies to learn skills for functioning in the new or changed role. Self-care deficit, bathing/hygiene 809 Impaired ability to perform or complete bathing/hygiene activities for oneself Inability to: wash body or body parts; obtain or get to water source; regulate temperature or flow of bath water; get bath supplies; dry body; get in and out of bathroom Decreased or lack of motivation; weakness and tiredness; severe anxiety; inability to perceive body part or spatial relationship; perceptual or cognitive impairment; pain; neuromuscular impairment; musculoskeletal impairment; environmental barriers Self-Care: Activities of Daily Living (ADL), Bathing, Hygiene (1) Remain free of body odor and maintain intact skin (2) State satisfaction with ability to use adaptive devices to bathe (3) Bathe with assistance of caregiver as needed without anxiety (4) Explain and use methods to bathe safely and with minimal difficulty Bathing; Self-Care Assistance: Bathing/Hygiene (1) If in a typical bathing setting for the client, assess the client's ability to bathe self via direct observation using physical performance tests for ADLs. (2) Ask the client for input on bathing habits and cultural bathing preferences. (3) Develop a bathing care plan based on the client's own history of bathing practices that addresses skin needs, self-care needs, client response to bathing and equipment needs. (4) Individualize bathing by identifying function of bath (e.g., odor or urine removal), frequency required to achieve function, and best bathing form (e.g.,

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html client's strengths in dressing and grooming to individualize the dressing process. (4) Ask the client for input on clothing choices and how to increase the ease of dressing. (5) Request referrals for occupational and physical therapy. (6) Provide medication for pain 45 minutes before dressing and grooming if needed. (7) Provide privacy and limit people/caregivers in room. (8) Select larger-sized clothing, clothing with elastic waistbands, wide sleeves and pant legs, dresses that....... (1) Assess for grieving resulting from loss of function. (2) Provide medication for pain if needed and plan activities to prevent fatigue before dressing/grooming. (3) Assess tasks the client can complete, noting areas of indepence and difficulty to make adaptations. (4) Assess self-efficacy; assess outcome expections. Based on assessment, promote motivation and self-eficacy for ADL functioning by: role modeling via videotape or partnering; verbal encouragement; individualize care using humor, kindness, joy, and excitement with achievements; social supports; and decrease unpleasant sensations with the ADL function. (5) Allow the client or caregiver adequate time to complete dressing. (6) Telehomecare can be an effective way to assess and monitor ADL performance for older adults. (1) Involve the client in planning of informal care and provide access to health professionals and financial support for the care. (2) Based on functional assessment and rehabilitation capacity, refer for home health aide services to assist with dressing and grooming. (3) Have caregiver view videotape showing caregiver self-care activities followed by a discussion. (4) Cue cognitively impaired clients in steps of dressing and grooming. (5) Respect the preference of the terminally ill client to refuse dressing and limit drooming. (6) If terminally ill client request dressing and grooming, make an extra effort to meet the request and provide care when the client and family will most benefit. (7) Maintain the temp of the home at a comfortable level when dressing terminally ill client. (1) Teach the client to dress the affected side first, then the unaffected side. (2) Teach the simplest step in a task until mastered, and then proceed to more complicated steps. Give praise. (3) Teach the client how to use adaptive devices for dressing and grooming. (4) Teach the client and family to select clothes appropriate for the season, temp, and weather. Self-care deficit, feeding 818 Impaired ability to perform or complete feeding activities Inability to swallow food; inability to prepare food for ingestion; inability to handle utensils; inability to chew food; inability to use assistive device; inability to get food onto utensils; inability to open containers; inability to ingest food safely; inability to manipulate food in mouth; inability to bring food from a receptacle to the mouth; inability to complete a meal; inability to ingest food in a socially acceptable manner; inability to pick up cup or glass; inability to ingest sufficient food Weakness or tiredness; severe anxiety; neuromuscular impairment; pain; perceptual or cognitive impairment; discomfort; environmental barriers; decreased or lack of motivation; musculoskeletal impairment NOTE: See suggested Functional Level Classification in the care plan Impaired physical Mobility (1)Feed self (2) State satisfaction with ability to use adaptive devices for feeding (3) Provide assistance with feeding when necessary (caregiver) Feeding; Self-Care Assistance: Feeding (1) Assess the client's ability to feed self. Test gag reflex bilaterally, and note specific deficits (2) Observe for cause of inability to feed self independently (see Related Factors). (3) Ask the client for input on methods to facilitate eating and feeding (e.g., cultural foods, other food and fluid preferences), and provide four entree choices, including ethnic choice. (4) Request referral for occupational and physical therapy; request a dietician. (5) Ensure that the client has dentures, hearing aids, and glasses in place. (6) Use any necessary adaptive feeding equipment (e.g., rocker knives, plate guards, suction mats, built-up handles on utensils, scoop dishes, large-handled cups). (7) Seat the client at table using name card and place mat with meal in visual range next to role model who can eat, if applicable. (8) Help the client into sitting

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html position; ensure that the client's head is flexed slightly forward and shoulders are supported while eating and for 1 hr after a meal.. (1) Develop client muscle strength building plan to build the client's physiological capacity. (2) Implement Hospital Elder Life Program, a model of care to prevent functional and cognitive decline of older persons during hospitalization. (3) Provide medication for pain before meals if needed and plan activities to prevent fatigue before meals. (4) Assess and maintain documentation about poststroke client's eating and nutrition (include weight) upon admission to long-term care. (5) Serve meals "family-style" with food in serving bowls and an empty plate to be filled by patient. (6) Obtain and value patient's view of agency's food selection and presentation. Present views to administration. (7) Ensure adequate staffing at meal times.(8) Choose soft foods rather than liquids, or use dietary thickeners. (9) Assess for intolerance to food texture and, if found, reverse food texture pattern as tolerated, progressing finally to texture stage of thick liquids.(10) Provide finger foods for.... (1) Based on functional assessment and rehabilitation capacity, refer for home health aide services to assist with feeding. (2) Telehomecare can be an effective way to assess and monitor ADL performance for older adults. (3) Cue cognitively impaired client when feeding. (4) Respect the preference of terminally ill clients to refuse nutrition or assistance with eating. Refer to care plans for Imbalanced Nutrition: less than body requirements and Impaired Swallowing. (5) If terminally ill client requests nutrition, take special care to provide foods and assistive devices that protect the client from aspiration, minimize energy requirements, and meet the client's taste preferences. (1) Teach the client how to use adaptive devices. (2) Teach the client with hemianopsia to turn head so that the plate is in the line of vision. (3) Teach visually impaired client to locate foods according to numbers on a clock. Self-care deficit, toileting 823 Impaired ability to perform or complete own toileting activities. Defining ability to get to toilet or commode; inability to sit on or rise from toilet or commode; inability to manipulate clothing for toileting; inability to carry out proper toilet hygience; inability to flush toilet or commode. Environmental barriers; weakness or tiredness; decreased or lack of motivation; severe anxiety; impaired mobility status; impaired transfer ability; musculoskeletal impairment; neuromuscular impairment; pain; perceptual or cognitive impairment. NOTE: See suggested Functional Level Classification in care plan for Impaired physical Mobility. Self-Care ADLs, Toileting (1) Remain free of incontinence and impaction with no urine or stool on skin. (2) State satisfaction with ability to use adaptive devices for toileting. (3) Explain and use methods to be safe and independent. Environmental management; Self-Care Assistance: Toileting (1) Observe cause ofinability to toilet independently. (2) Assess ability to toilet; not specific deficits. (3) Ask the client for input on toileting methods and timing and how to better provide toileting activity assestance. (4) Assess the client's usual bowel and bladder toileting patterns and the terminology used for toileting. (5) Request referral for occupational and physical therapy for help in working with the client to transfer from bed to commode. (6) use any necessary assistive toiling equipment. (7) Provide privay. (8) Develop toileting schedule using clocks, written schedules, or verbal prompting as cues for the client and provide assistance at scheduled times. (9) Schedule toileting to occur when the defecation urge is strongest or voiding is likely. Assist the client until self-care ability icnreases. (10) Allow the client to particpate as able in toileting, and provide praise for accomplishments. Increase tasks as the client is able, and work with the client to aim ..... (1) Develop client muscle building plan to build the client's physiological capacity. (2) Include exercise and walking program of care. (3) Implement Hospital Elder Life Program, a model of care to prevent functional and cognitive decline of older persons during hospitalization. (4) Assess self-efficacy (The Self-Efficacy for Functional Activities scale); assess outcome expectations (Outcome Expectations for functional Activities scale).

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

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

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html group and structured daily activities. (1) Above interventions may be adapted for home care use (2) Assess current environmental stresses and identify community resources. (3) Assist the client to initiate effective problem solving toward current situation. (4) Encourage family members to acknowledge and validate the client's strengths. (5) Assess the need for establishing an emergency plan. (6) See care plans for Situational low Self-esteem and Chronic low Self-esteem. (1) Refer the client/family to community-based self-help and support groups. (2) Refer to educational classes on stress management, relaxation training, etc.(3) Refer to community agencies that offer support and environmental resources. Self-mutilation 841 Deliberate self-injurious behavior causing tissue damage with the intent of causing non-fatal injury to attain relief of tension Cuts/scratches on body; picking at wounds; self-inflicted burns (e.g., eraser, cigarette); ingestion/inhalation of harmful substances/objects; biting; abrading; severing; insertion of object(s) into body orifice(s); hitting; constricting a body part Psychotic state (command hallucinations); inability to express tension verbally; childhood sexual abuse; violence between parental figures; family divorce; family alcoholism; family history of self-destructive behaviors; adolescence; peers who self-mutilate; isolation from peers; perfectionism; substance abuse; eating disorders; sexual identity crisis; low or unstable self-esteem; low or unstable body image; labile behavior (mood swings); history of inability to plan solutions or see long-term consequences; use of manipulation to obtain nurturing relationship with others; chaotic/disturbed interpersonal relationships; emotionally disturbed, battered child; feels threatened with actual or potential dissociation or depersonalization; mounting tension that is intolerable; impulsivity; inadequate coping; irresistible urge to cut/damage self; needs quick reduction of stress; childhood illness or surgery; foster, group, or institutional care; incarceration; character disorder; borderline.... Aggression Self-Control; Distorted Thought Self-Control; Impulse Self-Control; Mood Equilibrium; Risk Detection; Self-Mutilation Restraint (1) Have injuries treated. (2) Refrain from further self-injury. (3) State appropriate ways to cope with increased psychological or physiological tension. (4) Express feelings. (5) Seek help when having urges to self-mutilate. (6) maintain self-control without supervision. (7) Use appropriate community agencies when caregivers are unable to attend to emotional needs Active Listening; Anger Control Assistance; Behavior Management: Self-Harm; Calming Technique; Environmental Management: Safety; Limit Setting; Mood Management; Mutual Goal Setting; Risk Identification; Self-Responsibility Facilitation NOTE: Prior to implementation of intervention in the face of self-mutilation, nurses should examine their own emotional responses to incidents of self-harm, to ensure that interventions will not be based on countertransference reactions. (1) Provide medical treatment for injuries. (2) Assess for risk of suicide. (3) Assess for signs of depression, anxiety, and impulsivity. (4) Assess for presence of hallucinations Ask specific questions such as, "Do you hear voices that other people do not hear? Are they telling you to hurt yourself?" (5) Assure the client that he or she will not be alone and will be safe during hallucinations. Provide referrals for medication. (6) Monitor the client's behavior using 15-minute checks at irregular times so that the client does not notice a pattern. (7) Establish trust. (8) Be extremely cautious about touching the client when he or she is experiencing abreaction (reenactment of preciptation trauma). Sometimes physically holding a client is necessary ... See care plan for Risk for Self-Mutilation. See care plan for Risk for Self-Mutilation. Self-mutilation, risk for 845 At risk for deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension. Psychotic state (command hallucinations); inability to express tension verbally; childhood sexual abuse; violence between parental figures; family

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

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

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

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html sexually attractive. b) overindulgence in food or alcohol can affect sexual activity. c) Resting and sleep on a firm mattress may augment sexual desire. d) Femininity and musculinity are... (1) Assess for the influence of cultural beliefs, norms, and values on client's perceptions of normal sexual behavior. (2) Discuss with the client those aspects of his or her secxual health/lifestyle that remain unchanged by thier health status. (3) Validate the client's feelings and emotions regarding the changes in sexuality patterns. (1) Above interventions may be adapted for home care use. (2) Help the client and significant other to identify a place and time in the home and daily living for privacy in sharing sexual or relationship activity. If necessary, help the client to communicate the need for privacy to other family members. (3) confirm that physical reasons for dysfunction have been addressed. Encourage participation in support groups or therapy if appropriate. (4) Reinforce or teach about sexual functioning, alternative sexual practices, and necessary sexual precautions. (1) Refer to appropriate community agencies (e.g., certified sex counselor, Reach to Recovery, Ostomy Associatiom). (2) Provude information regarding self-care and sexuality for the woman who has cancer and her partner. (3) Sexuality education is important to all populations, whether hearing or deaf, sighted or blind, disabled, or not disabled. Discuss contraceptive choices. Refer to appropriate health professional (e.g, gynecologist, nurse practitioner). (4) Teach safe sex, which includes using latex condoms, washing with soap immediately after sexual contact, not ingesting semen, avoiding oral-gential contact, not exchanging saliva, avoiding multiple partners, abstaining from sexual activity when ill, and avoiding recreational drugs and alcohol when engaging in sexual activity. Contraty to previously published info, the use of a spermicide containing nonoxynot-9 (N-9) should not be recommmended as a preventative strategy for HIV infection. Skin integrity, impaired 871 Altered epidermis and/or dermis Invasion of body structures; destruction of skin layers (dermis); disruption of skin surface (epidermis) External Hyperthermia; hypothermia; chemical substance (e.g., incontinence); mechanical factors (e.g., friction, shearing forces, pressure, restraint); physical immobilization; humidity; extremes in age; moisture; radiation; medications Internal Altered metabolic state; altered nutritional state (e.g., obesity, emaciation); altered circulation; altered sensation; altered pigmentation; skeletal prominence; developmental factors; immunological deficit; alterations in skin turgor (change in elasticity); altered fluid status Tissue Integrity: Skin and Mucous Membranes; Wound Healing: Primary Intention, Secondary Intention (1) Regain integrity of skin surface (2) Report any altered sensation or pain at site of skin impairment (3) Demonstrate understanding of plan to heal skin and prevent reinjury (4) Describe measures to protect and heal the skin and to care for any skin lesion Incision Site Care; Pressure Ulcer Care; Skin Care: Topical Treatments; Skin Surveillance; Wound Care (1) Assess site of skin impairment and determine etiology (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, skin tear) NOTE: For wounds deeper into subcutaneous tissue, muscle, or bone (stage III or stage IV pressure ulcers), see the care plan for Impaired Tissue integrity. (2) Monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether the client is experiencing changes in sensation or pain. Pay special attention to high-risk areas such as bony prominences, skinfolds, the sacrum, and heels. (3) Monitor the client's skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing. (4) Individualize plan according to the client's skin condition, needs, and preferences. (5) Monitor the client's continence status, and minimize exposure of skin impairment and other areas to moisture from incontinence, ............

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html (1) Instruct and assist the client and caregivers to remove or control impediments to wound healing (e.g., management of underlying disease, improved approach to client positioning, improved nutrition). (2) Initiate a consultation in a case assignment with a wound, ostomy, continence nurse (WOC nurse) to establish a comprehensive plan as soon as possible. (1) Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing. (2) Teach the client to use a topical treatment that is matched to client, wound, and setting. (3) If consistent with overall client management goals, teach how to turn and reposition at least every 2 hours. (4) Teach the client to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury. Skin integrity, impaired, risk for 875 At risk for skin being adversely altered EXTERNAL: Hypothermia; hyperthermia; chemical subtance; exretions and/or secretions; mechanical factors; radiation; physical immobilization; humidity; moisture; extremes of age. INTERNAL: Medication; altered nutritional state; altered metabolic state; altered circulation; altered sensation; altered pigmentation; skeletal prominence; developmental factors; immunological deficit; alterions in skin turgor; psychogenetic, immunological factors. NOTE: Risk should be determined by the use of a risk assessment tool (e.g., Norton scale, Braden scale) Immobility Consequences: Physiological; Tissue Integrity: Skin and Mucous Membranes (1) Report altered sensation or pain at risk areas. (2) Demonstrate understanding of personal risk factors for impaired skin integrity. (3) Verbalize a personal plan for preventing impaired skin integrity. Positioning; Pressure management; Pressure Ulcer Care; Pressure Ulcer Prvention; Skin Surveillance (1) Monitor skin condition at least one a day for color and texture changes, dermatological conditions, or lesions. Determine whether the client is experiencing loss of sensation or pain. (2) Identify clients at risk for impaired integrity as a result of compromised perfusion, immunocompromised status, or chronic medical condition such as diabetes meelitus or renal failure. (3) Monitor the client's skin care practices, noting type of soap or other cleansing agents used, temp of water, and frequency of skin cleansing. (4) Avoid harsh cleansing agents, hot water, extreme friction of force, or too-frequent cleansing. (5) Monitor the client's continence status, and minimize exposure of the site of skin impairment and other areas to moisture from incontinence, perspiration, or wound drainage. (6) If the client is incontinent, implement an incontinence management plan to prevent exposure to chemicals in urine and stool that can strip or erode the skin; refer to a physician for an incontin... (1) Limit number of complete baths to two or three per week, and alternate them with partial baths. Use tepid water temp (between 90 and 105 F) for bathing. (2) Use lotions and moisturizers to prevent skin from drying out, especially in the winter. (3) Increase fluid intake within cardiac and renal limits to a minimum of 1500 ml/day. (4) Increase humidity in the environment, especially during the winter, by using a humidifier or placing a container of water on a warm object. (1) Assess caregiver vigilance and ability. (2) Initiate a consultation in a case assignment with a wound, ostomy, continence nurse (WOC nurse) to establish a comprehensive plan as soon as possible. (3) See the care plan for Impaired Skin Integrity. (1) Teach the client skin assessment and ways to monitor for impending skin breakdown. (2) If consistent with overall client management goals, teach how to turn and reposisiton the client at least every 2 hours. (3) Teach the client to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury. Sleep deprivation 879 Prolonger periods without sleep (sustained natural, periodic suspension of relative unconsciousness) Daytime drowsiness; decreased ability to function; malaise; tiredness; lethargy; restlessness; irritability; heightened sensitivity to pain; listlessness; apathy; slowed reaction; inability to concentrate; perceptual disorders (e.g. disturbed body sensation, delusions, feeling afloat); hallucinations; acute confusion; transient paranoia; agitated or combative; anxious; mild, fleeting nystagmus; hand tremors Prolonged physical discomfor;

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html that includes quiet activites such as reading, television, or crafts. (6) Teach the following sleep hygiene guidelines for improving sleep habits: A) Go to bed only when sleepy. B) When awake in the middle of the night, go to another room, do quiet activites, and go back to bed only when sleepy. C) use the bed only for sleeping--not for reading or snoozing in front of the TV. D)Avoid afternoon and evening naps. E) Get up at the same time every morning ............. Sleep patterns, disturbed 885 Time-limited disruption of sleep (natural periodic suspension of consciousness) Prolonged awakenings; sleep maintenance insomnia; self-induced impairment of normal pattern; sleep onset >30 minutes; early morning insomnia; awakening earlier or later than desired; verbal complaints of difficulty falling asleep; verbal complaints of not feeling well-rested; increased proportion of stage 1 sleep; dissatisfaction with sleep; less than age-normed total sleep time; three or more nighttime awakenings; decreased proportion of Stages 3 and 4 sleep (e.g., hyporesponsiveness, excess sleepiness, decreased motivation); decreased proportion of REM sleep (e.g., REM rebound, hyperactivity, emotional lability, agitation and impulsivity, atypical polysomnographic features); decreased ability to function Ruminative presleep thoughts; daytime activity pattern; thinking about home; body temperature; temperament; dietary; childhood onset; inadequate sleep hygiene; sustained use of antisleep agents; circadian asynchrony; frequently changing sleep-wake schedule; depression; loneliness; frequent travel across time zones; daylight/darkness exposure; grief; anticipation; shift work; delayed or advanced sleep phase syndrome; loss of sleep partner, life change; preoccupation with trying to sleep; periodic gender-related hormonal shifts; biochemical agents; fear; separation from significant others; social schedule inconsistent with chronotype; aging-related sleep shifts; anxiety; medications; fear of insomnia; maladaptive conditioned wakefulness; fatigue; boredom Environmental Noise; unfamiliar sleep furnishings; ambient temperature, humidity; lighting; othergenerated awakening; excessive stimulation; physical restraint; lack of sleep privacy/control; interruptions for therapeutics, monitoring, Comfort Level; Pain Level; Personal Well-Being; Psychosocial Adjustment: Life Change; Quality of Life; Rest; Sleep (1) Wake up less frequently during night (2) Awaken refreshed and not be fatigued during day (3) Fall asleep without difficulty (4) Verbalize plan to implement bedtime routines Sleep Enhancement (1) Obtain a sleep history including bedtime routines, history of sleep problems, changes in sleep with present illness, and use of medications and stimulants. (2) Ask the client to keep a sleep diary for several weeks, which includes bedtime, rise time, number of awakenings, naps, and more. (3) Determine level of anxiety. If the client is anxious, utilize relaxation techniques. See further Nursing Interventions and Rationales forAnxiety. (4) Assess for signs of new onset of depression: depressed mood state, statements of hopelessness, poor appetite. Refer for counseling as appropriate. (5) Observe the client's medication, diet, and caffeine intake. Look for hidden sources of caffeine, such as over-the-counter medications. (6) Provide measures to take before bedtime to assist with sleep (e.g., quiet time to allow the mind to slow down, carbohydrates such as crackers). (7) Provide a back massage before bedtime. (8) Provide pain relief shortly before bedtime and position the client ..... (1) Determine if the client has new onset of a physiological problem that could result in insomnia such as pain, cardiovascular disease, pulmonary disease, neurological problems such as dementia, or urinary problems. (2) Observe elimination patterns. Have the client decrease fluid intake in the evening, and ensure that diuretics are taken early in the morning. (3) Do a careful history of all medications including over-the-counter medications and alcohol intake. (4) If the client is waking frequently during the night, consider the presence of sleep apnea problems and refer to a sleep clinic for

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html evaluation. (5) Evaluate the client for presence of depression or anxiety, which can result in insomnia. Refer for treatment as appropriate. (6) Encourage social activities. Help elderly get outside for increased light exposure and to enjoy nature. (7) Suggest light reading or TV viewing that does not excite as an evening activity. (8) Increase daytime physical activity, and social activities.... (1) Above interventions may be adapted for home care use (2) Provide support to the family of the client with chronic sleep pattern disturbance. (3) Instruct the client/family in expectations for normal sleep. Elicit expectations for sleep, previous sleep patterns; correct misconceptions that influence emotional responses to deviation from expectations. (4) Assess the client for sleep apnea, particularly poststroke (e.g., interview partner regarding the client's sleep pattern and behaviors, have the client maintain sleep log). (5) Assess the client for depression or other psychiatric disorder. Refer for mental health services as indicated. (6) Have the client maintain a sleep diary, describing daily activity levels, use of stimulants, activities or physical sensations around bedtime. Assess diary for potential areas of intervention. (7) Initiate nonpharmacological interventions for insomnia: stimulus control, sleep restriction, relaxation techniques, increasing sunlight exposure,...... (1) Encourage the client to avoid coffee and other caffeinated foods and liquids and also to avoid eating large high-protein or high-fat meals close to bedtime. (2) Advise the client to avoid use of alcohol or hypnotics to induce sleep. Avoid alcohol ingestion 4 to 6 hours before bedtime. (3) Ask the client to keep a sleep diary for several weeks. (4) Teach somatic and cognitive relaxation techniques to induce the relaxation response and facilitate sleep. (5) Teach the client need for increased exercise. Encourage to take a daily walk 5 to 6 hours before retiring. (6) Encourage the client to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts (7) Teach the following guidelines for good sleep hygiene to improve sleep habits: Go to bed only when sleepy. When awake in the middle of the night, go to another room, do quiet activities, and go back to bed only when sleepy. Use the bed only for sleepingnot for reading or snoozing in front...... Sleep, readiness for enhanced 891 A pattern of natural, periodic suspension of consciousness that provides adequate rest, sustains a desired lifestyle, and can be strengthened Expresses willingness to enhance sleep; amount of sleep and REM sleep is congruent with developmental needs; expresses a feeling of being rested after sleep; follows sleep rountines that promote sleep habits, occasional or infrequent use of meds to induce sleep Desire to improve sleep Personal Well-Being; Rest Sleep (1) Awaken refreshed and is not fatigued during day. (2) Fall alseep without difficulty. (3) Verbalize plan to implement improved bedtime routines. Sleep Enhacnement (1) Obtain a sleep history including bedtime routines, sleep patterns, and use of meds and stimulants. (2) Ask the client to keep a sleep diary for several weeks, which includes bedtime, rise time, number of awakenings, naps, and more. (3) Determine level of anxiety. If the client is anxious, use relaxation techniques. See further Nursing Interventions for Anxiety. (4) Observe the client's medication, diet, and caffeine intake. (5) Provide measures to take before bedtime to assist with sleep (e.g., quiet time to allow the mind to slow down, carbohydrates such as crackers). (6) Provide a back massage before bedtime. (7) Initiate nonpharmacological interventions for improved sleep. (1) Encourage the client to develop a bedtime ritual that includes quiet activities such as reading, television, or crafts. (2) Encourage the client take a warm bath in the evening. (3) Observe elimination patterns. Have the client decrease fluid intake in the evening, and ensure that diuretics are taken early in the morning. (4) Encourage social activities. (5) Increase daytime activity. Encourage walking as the client is able. (6) Recommend avoiding use of hypnotics and alcohol to sleep. (7) Reduce daytime napping in the late afternoon; limit naps to short intervals as early in the day as

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html possible. (8) Help the client recognize that there are changes in length of sleep with aging. (1) Teach somatic and cognitive relaxation techniques to induce the realxation response and facilitate sleep. (2) Advise the client to avoid use of alcohol or hypnotics to induce sleep. Avoid alcohol ingestion 4-6 hours before bedtime. (3) Teach the following guidelines for good sleep hygiene to improve sleep habits: A) Go to bed only when sleepy. B) When awake in the middle of the night, go to another room, do quite activities, and go back to bed only when sleepy. C) use the bed only for sleeping, not for reading or snoozing in front of the TV. D) Avoid afternoon and evening naps. E) Get up at the same time every morning. F) Recognize that not everyone needs 8 hours of sleep. G) Move the alarm clock away from the bed so it cannot be seen. H) Do not associate lulls in performance with sleeplessness; sleeplessness should not be blamed for everything that goes wrong during the day. (4) Encourage the client to develop a bedtime ritual that includes quiet activities such as reading, ...... Social interaction, impaired 894 Insufficient or excessive quantity or ineffective quality of social exchange. Verbalized or observed inability to receive or communicate a satisfying sense of belonging, caring, interest, or shared history; verbalized or observed discomfort in social situations; observed use of unsuccessful social interaction behaviors; dysfunctional interaction with peers, family, and/or others; family report of change style or pattern of interaction Knowledge/skill deficit regarding ways to enhance mutuality; therapeutic isolation, sociocultural dissonance; limited physical mobility; environmentl barriers; communication barriers; altered thought processes; absence of available significant others or peers; celf-concept disturbance Child Development: 1 Month, 2 Months, 4 Months, 6 Months, 12 Months, 2 Years, 3 Years, 4 Years, Preschool, Middle Childhood, Adolescence; Play Participation; Role Performance; Social Interaction Skills; Social Involvement (1) Identify barriers that cause impaired social interactions. (2) Discuss feelings that accompany impaired and succesful social interactions. (3) Use available opportunities to practice interactions. (4) Use successful social interaction behaviors. (5) Report increased comfort in social situations. (6) Communicate, state feelings of belonging, demonstrate caring and interest in others. (7) Report effective interactions with others. Socialization Enhancement (1) Observe for cause of discomfort in social situations; ask the client to explain when discomfort began and identify any losses (e.g., loss of health, job, or significant other; aging) and changes (e.g., marriage, birth or adoption of a child, change in body appearance). (2) Assess the client's social support system. (3) Spend time with the client. (4) use active listening skills including assessment and clarification of the client's verbal and nonverbal responses and interactions. (5) Envourage social support for patients with visual impairments. (6) Have the client list behaviors that are associated with being disconnected, and discuss alternative responses that may increase comfort. (7) Monitor the client's use of defense mechanisms, and support healthy defenses (e.g., the client focuses on present and avoids placing blame on others for personal behavior). (8) Have the client list behaviors that cause discomfort. Discuss alternative ways to alleviate discomfort (e.g., focusing ... (1) Avoid assuming that social isolation is normal for elderly client. (2) Assess the client's potential or actual hearing loss or hearing impairment and make appropriate referrals if a problem is identified. (3) Monitor for depression, a particular risk in the elderly. (4) Provide group situations for the client. (5) Encourage physical activity such as aerobics or stretching and toning in a group. (6) Have clients reminisce. (7) Consider the use of language to promote socialization. (1) Acknowledge racial/ethnic differences at the onset of care. (2) Assess for the influence of cultural beliefs, norms, and values on the client's perception of social activity and relationships. (3) Approach individuals of color with respect, warmth, and professional courtesy. (4) Assess the use of personal space needs, communication styles, acceptable body language, eye contact, perception of touch, and paraverbals

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html when communicating with the client. (5) Validate the client's feelings regarding social interaction. (1) Above interventions may be adapted for home care use. (2) Assess family and living environment for social dynamics. Refer for medical social services to assist with family dynamics if appropriate. (3) Assess the client for a psychiatric disorder. Refer for mental health services as indicated. (4) Assess the client social skills; provide feedback regarding maladaptive skills, and opportunities to role play alternative communication styles. (5) Suggest that the client avoid contact with negative persons. (6) Identify activities that the client does alone and assist the client with balancing solitary and social activities. (7) Establish pattern of care and daily activities that involve the client socially (e.g., Meals on Wheels, home health aide visits). Give supportive feedback for positive and appropriate interactions. (8) refer to or support involvement with supportive groups and counseling. (9) In the presence of a psychiatric disorder, refer for psychiatric home health care ..... (1) Help the client accept responsibility for own behavior. Have the client keep a journal, and review it together at prescheduled intervals. Give the client positive feedback for appropriate behaviors, and suggest alternative approached for behaviors that do not enhance social interaction. Positive reinforcement perpetuates appropriate behaviors. Teach social interaction skills for use in actual situations the client is faced with daily. (2) Practice social skills one-to-one and, when the client is ready, in group sessions. (3) Refer to appropriate social agencies for assistance. Social isolation 900 Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatened state. OBJECTIVE: Absence of supportive significant others; projection of hostility in voice and behavior; withdrawal; uncommunicativeness; demonstration of behavior unaccepted by dominant cultural group; desire to be alone or exist in a subculture; repetitive and meaningless actions; preoccupation with own thoughts; lack of eye contact; inappropriate or immature activities for developmental age/stage; evidence of physical/mental handicap or altered state of wellness; sad, dull affect. SUBJECTIVE: Expression of feelings of aloneness imposed by others; expression of feelings of rejection; inappropriate or immature interests for developmental age/stage; inadequate or absent significant purpose in life; inability to meet expectations of others; expression of values acceptable to subculture but unacceptable to dominant cultural group; expression of interest inappropriate to developmental age/stage; feelings of differences from others; insecurity in public Alterations in mental status; inability to engage in satisfying personal relationships; unacceptable social values; unacceptable social behavior; inadequate personal resources; immature interests; factors contributing to absence of satisfying personal relationship; alterations in physical appearance; altered state of wellness Loneliness Severity; Mood Equilibrium; Personal Well-Being; Play Participation; Social Interaction Skills; Social Involvement; Social Support (1) identify feelings of isolation. (2) Practice social and communication skills needed to interact with others. (3) Initiate interactions with others, set and meet goals. (4) Particpate in activities and programs at level of ability and desire. (5) Describe feelings of self-worth. Socialization Enhancement (1) Establish a therapeutic relationship by being emotionally present and authentic. (2) Observe for barriers to social interaction (e.g., illness; incontinence, decreasing ability to form relationships; lack of transportation, money, support system, or knowledge). (3) Note risk factors (e.g., membership in ethnic/cultural minority, chronic physiological or psychological illness or deformities, advanced age). (4) Discuss causes of perceived or actual isolation. (5) Promote social interactions. Support grieving and verbalization of feelings. (6) Establish trust one one one and then gradually introduce the client to others. Allow the client opportunities to introduce issues and to describe his or her daily life. (7) Use active listening skills. Establish therapeutic relationship and spend time with the client. (8) help the client experience success by working

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html together with the client to establish easily attainable goals (e.g., spending 10 minutes conversing with peer). (9) Provide ...... (1) Observe for aggression or other interpersonal problems, poor self-image or signs of powerlessness, confusion of the past with the present, complaints about feeling confined or deserted, or difficulty setting goals and making decisions. (2) Assess for hearing deficit. Provide aids and use adaptive techniques such as facing the individual when speaking, speaking slowly, lowering the pitch of the voice, and enunciating clearly. (3) If the client is in a health care facility, visit him or her for at least 10 minutes every 2-3 hours. (4) Involve nonprofessionals in activities, projects, and goal setting with the client. Practice interdisciplinary management for unit-based activities: engaging in arts and crafts projects, sewing, watching videos, reading large-print books, reading magazines, playing games, playing musical instruments, and using assistive listening devices. (5) Offer the client a choice of activities and persons with whom to sit and socialize. Introductions to stranger.. (1) Acknowledge racial/ethnic differences at the onset of care. (2) Approach individuals of color with respect, warmth, and professional courtesy. (3) Assess personal space needs, communication styles, acceptable body language, attitude toward eye contact, perception of touch, and paraverbal messages when communicating with the client. (4) Use a family-centered approach when working with Latino, Asian, African American, and Native American clients. (5) Promote a sense of ethnic attachment. (1) The interventions described previously may be adapted for home care use. (2) Assess the client for depression or other psychiatric disorder. Refer for mental health services as indicated. (3) Confirm that the home setting has a telephone. Obtain one if necessary for medical safety. If the client lives alone, set up a Lifeline safety system that requires the client to answer the telephone. (4) Consider the use of the computer and Internet to decrease isolation. (5) Encourage family involvement in daily life in small, nonthreatening activities such as short outings, assistance with shipping, and solicitation of input from the isolated person in decision making. (6) Establish a pattern of care and daily activities that involves the client socially (e.g., Meals-on-Wheels, home health aide visitis). (7) have the client keep a diary of social experiences. Discuss the diary during visits. (8) Identify activities that the client does alone. Assist the client with balancing solitary and ... (1) Teach skills related to problem solving, communication, social interaction, activities of daily living, and positive self-esteem. (2) Consider the use of telecommunication and group support via the Internet. (3) Teach role playing (practicing communication skills in specific situations). (4) Encourage the client to initiate contacts with self-help groups, counselors, and therapists. (5) Provide information to the client about senior citizen services, house sharing, pets, day care centers, churches, and community resources. (6) Refer socially isolated caregivers to appropriate support groups as well. (7) Teach caregivers methods to deal with troublesome behaviors related to memory disturbances, restlessness, and agitation, catastrophic reactions, day/night disturbances, delusions, wandering, and physical violence. A general method for clinicians to manage these problems involves the identification of the behavioral problems include fatigue, a change in routine, excessive demands,... Sorrow, chronic 907 Cyclical, recurring, and potentially progressive pattern of pervasive sadness that is experienced (by client, parent or caregiver, or individual with chronic illness or disability) in response to continual loss throught out the trajectory of an illness or disability. Feelings that vary in intensity, are periodic, may progress and intensify over time, and may interfere with client's ability to reach his or her highest level of personal and social well-being; expression of periodic, recurrent feelings of sadness; expression of one or more of the following feelins: anger, being misunderstood, confusion, depression, disappoitment, emptiness, fear, frustration, guilt/self-blame, helplessness, hopelessness, loneliness, low self-esteem,

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html experience previous state of creativity (singing, listening to music, writing), disinterest in nature,and disinterest in reading spiritual literature Connections with power greater than oneself: Demonstrates inability to pray, inability to participate in religious activities, expressions of being abandoned by or having anger toward God; requests to see a religious leader; demonstrates sudden changes in spiritual practices, inability to be introspective/inward turning; expresses being hopeless and suffering Self-alienation; loneliness/social isolation; anxiety; sociocultural deprivation; death and dying of self or others; pain; life change; chronic illness of self or others Acceptance: Health Status Dignified Life Closure Grief Resolution Hope Spiritual Health Suffering Severity (1) Express sense of connectedness with self, others, arts, music, literature, or power greater than oneself (2) Express meaning and purpose in life (3) Express sense of optimism and hope in the future (4) Express ability to forgive (5) Express desire to discuss health state and integrate care in lifestyle (6) Discuss personal response to dying (7) Discuss personal response to grieving Grief Work Facilitation; Hope Instillation; Humor; Music Therapy; Presence; Reminiscence Therapy; Simple Guided Imagery; Simple Massage; Simple Relaxation Therapy; Spiritual Support; Therapeutic Touch ;Touch (1) Observe the client for loss of meaning, purpose, and hope in life. (2) Respect the client's beliefs; avoid imposing your own spiritual beliefs on the client. Be aware of your own belief systems and accept the client's spirituality. Allow for selfdisclosure. Promote a sense of love, caring, and compassion. (3) Monitor and promote supportive social contacts. (4) Refer the client to a support group. (5) Be physically present and actively listen to the client. (6) Support meditation, guided imagery, therapeutic touch, journaling, relaxation, and involvement in art, music, or poetry. Support outdoor activities. (7) Offer or suggest visits with spiritual and/or religious advisors. (8) Help the client make a list of important and unimportant values. (9) Assist the client in identifying and creating his or her own meaningful experiences. Help the client develop skills to deal with illness or lifestyle changes. Include the client in care planning. (10) Ask how to be most helpful; encour... (1) Discuss personal definitions of spiritual wellness with the client. (2) Identify the client's past sources of spirituality. Help the client explore his or her life and identify those experiences that are noteworthy. Clients may want to read the Bible or other religious text or have it read to them. (1) Assess for the influence of cultural beliefs, norms, and values on the client's ability to cope with spiritual distress. (2) Acknowledge the value conflicts from acculturation stresses that may contribute to spiritual distress. (3) Encourage spirituality as a source of support. (4) Validate the client's spiritual concerns and convey respect for his or her beliefs. (1) All of the nursing interventions described previously apply in the home setting. Spiritual distress, risk for 918 At risk for altered sense of harmonious connectedness with all life and the universe in which dimensions that transcend and empower the self may be disrupted Energy-consuming anxiety; low self-esteem; mental illness; physical illness; blocks to self-love; poor relationships; physical or psychological stress; substance abuse; loss of loved one; natural disaster; situational loss; maturational loss; inability to forgive Acceptance: Health Status; Dignified Life Closure; Health Beliefs; Hope; Grief Resolution; Quality of Life; Spiritual Health;

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Counseling; Crisis Intervention; Decision-Making Support; Dying Care; Emotional Support; Forgiveness Facilitation; Grief Work Facilitation; Guilt Work Facilitation; Hope Instillation; Humor; Meditation Faciliitation; Music Therapy; Mutual Goal Setting; Presence; Religious Ritual Enhancement; Reminiscence Therapy; Security Enhancement; Self-Awareness Enhancement; Self-Esteem Enhancement; simple Guided Imagery; Simple Relaxation Therapy; Socialization Enhancement; Spiritual Growth Facilitation; Spiritual Support; Support Group; Support System Enhancement; Touch; Truth Telling; Value Clarification (1) Perform a spiritual assessment that includes the client's relationship with God, meaning and purposeful in life, religious affiliation, and any other significant beliefs. (2) Be present for the client. (3) Listen actively to the client. (4) Encourage the client to pray, setting the example by praying with and for the client. (5) Encourage involvement in group religious social support. (6) Encourage increased quality of life through social support. (7) Assist the client in identifying religious or spiritual beliefs that encourage integration of meaning and purpose in the client's life. (8) Encourage the client to use music as a means of reducing stress. (9) Encourage the client to engage regularly in bibliotherapy. (10) Encourage storytelling. (11) Offer to read to the client. (12) Support involvement in expressive art. (13) Support the use of humor by the client. (14) Encourage the client to practice forgiveness. (15) Support the client in contemplating, viewing, and/or ........... (1) Assess for the influence of cultural beliefs, norms, and values on the client's perception of spirituality. (2) Encourage expressions of spirituality. (3) Validate the client's spiritual concerns and convey respect for his or her beliefs. (1) All of the nursing interventions mentioned previously apply in the home care setting. (2) Refer the client to parish nurses. Suffocation, risk for 927 Accentuated risk of accidental suffocation (inadequate air available for inhalation). EXTERNAL: Vehicle warming in closed garage; use of fuel-burning heaters not vented to outside; smoking in bed; children's playing with plastic bags or inserting small objects into their mouths or nosses; placement of propped bottle in infant's crib; placement of pillow in infant's crib; consumption of large mouthfuls of food; failure to remove doors on discarded or unused refrigerators or freezers; leaving children unattended in bathtubs or pools; household gas leaks; low-strung clothesline;hanging of pacifier around infant's neck. INTERNAL: Reduced olfactory sensation; reduced motor abilities; cognitive or emotional difficulties; disease or injury process; lack of safety education; lack of safety precautions Knowledge: Child Physical Safety, Personal Safety; Parenting: Adolescent Physical Safety, Early/Middle Childhood Physical Safety, Infant/Toddler Physical Safety; Risk Control; Risk Detection; Safe Home Environment; Substance Addiction Consequences (1) Explain and undertake appropriate measures to prevent suffocation. (2) Demonstrate correct techniques for emergency rescue maneuvers (e.g., Heimlich maneuver, rescue breathing, cardiopulmonary resuscitation [CPR]) and describe situations that require them. Aspiration Precautions; Environmental Management: Safety; Infant Care; Positioning; Security Enhancement; Surveillance; Surveillance: Safety; Teaching: Infant Safety NOTE: Management of a risk diagnosis necessitates approached using primary and secondary prevention. Primary prevention interventions, which include activities such as safety instruction, focus on thwarting the development of a disease or condition. Secondary prevention is achieved through screening, monitoring, and surveillance. (1) Conduct risk factor identification, noting special circumstances in which preventive or protective measures are indicated. Note the presence of environmental hazards, including the following: Plastic bags, cribs with slats wider than 2 3/4 inches, ill-fitting mattresses that can allow the infant to become wedged between the mattress and crib, pillows in cribs, abandoned large appliance such as refrigerators, dishwashers, or freezers, clothing with cords or hoods that can become entangled, bibs, pacifiers on a string, drapery

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html cords, pull-toy strings, earth cave-ins, food items. (2) identify hospitalized clients at particular risk for suffocation, .......... (1) Assess the status of the swallow reflex and dentition; offer appropriate foods and beverages accordingly. (2) Observe the client for pocketing food in the side of the mouth; remove food as needed. (3) Position the client in high Fowler's position when eating and for 1 hour afterward. (4) Use care in pillow placement when positioning frail elderly clients who are on bed rest. (1) Assess the home for potential safety hazards in systems that are not likely to be fixed. Assist the family in having these areas assessed and making appropriate safety arrangements. (1) Counsel families on the following: (a) Following general safety practices such as not smoking in bed, properly disposing of large appliances, using properly functioning heating systems and ventilation, having functional smoke detectors, and opening garage doors when warming up a car. (b) Taking safety measures appropriate to the functional developmental age of the client (with emphasis on cirb safety in particular). (c) not placing the infant in the prone position but instead positioning on the back and not placing any soft bedding near the infant's airway. (d) Not allowing the infant or small child to sleep in the same bed as adults and avoiding consuming alcohol or illicit drugs, or smoking if the infant is sleeping with an adult. (2) Advise parents to avoid food that can be inhaled. Non food items smaller than 1 1/4 inches in diameter. (3) Provide information to parents about obtaining the "no-choke test tube" if desired. (4) underscore the necessity of not allowing children ... Suicide, risk for 931 At risk for self-inflicted, life-threatening injury Behavioral: History of previous suicide attempt; impulsiveness; purchase of gun; stockpiling of medicines; making or changing of a will; giving away of possessions; sudden euphoric recovery from major depression; marked changes in behavior, attitude, or school performance. Verbal:Threats of killing oneself; statement of desire to die/end it all .Situational: Living alone; retirement; relocation, institutionalization; economic instability; loss of autonomy/ independence; presence of gun in home; residence of adolescent in nontraditional setting (e.g., juvenile detention center, prison, half-way house, group home) Psychological: Family history of suicide; alcohol and substance use/abuse; psychiatric illness/disorder (e.g., depression, schizophrenia, bipolar disorder); abuse in childhood; guilt; gay or lesbian orientation in youth Demographic: Age: elderly, young adult male, adolescent; race: white, Native American; gender: male; marital status: divorced, widowed Physical........ Depression Level; Distorted Thought Self-Control; Impulse Self-Control; Loneliness Severity; Mood Equilibrium; Risk Detection; Self-Mutilation Restraint; Suicide Self-Restraint (1) Not harm self (2) Maintain connectedness in relationships (3) Disclose and discuss suicidal ideas if present; seek help (4) Express decreased anxiety and control of impulses (5) Talk about feelings; express anger appropriately (6) Refrain from using mood-altering substances (7) Obtain no access to harmful objects (8) Yield access to harmful objects (9) Maintain self-control without supervision Anger Control Assistance; Anxiety Reduction; Calming Technique; Coping Enhancement; Crisis Intervention; Delusion Management; Medication Administration; Mood Management; Substance Use Prevention; Suicide Prevention; Support System Enhancement; Surveillance NOTE: Prior to implementation of interventions in the face of suicidal behavior, nurses should examine their own emotional responses to incidents of suicide to ensure that interventions will not be based on countertransference reactions. Nursing and Clinical Research: Suicidal behavior can lead to stigmatization and discrediting of the client, as it may tap into the nurse's fears about mental illness, concerns about being able to respond effectively, and expectations that persons with mental illness tend toward violence (Joachim and Acorn, 2000; Steadman et al, 1998; Wilson et al, 1999). In one study, medical nurses reported that they could not understand why people harm themselves, and they felt they did not have the skills to deal with suicidal

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html appetite is regained. (3) State that no nausea is present. (4) Demonstrate ability to move about. (5) Demonstrate ability to complete self-care activities. (6) State that no fatigue is present. (7) State that pain is controlled or relieved after nursing interventions. (8) Resume employment activities/ADLs. Incision Site Care; Nutrition Management; Pain Management; Self-Care Assistance (1) Perform a thorough assessment of the client, including risk factors. (2) Assess for the presence of medical conditions and treat appropriately before surgery. If the client is diabetic, maintain normal blood glucose levels before surgery. (3) Provide preoperative teaching by a nurse to decrease postoperative problems of anxiety, pain, nausea, and lack of independence. (4) Provide preoperative information in verbal and written form. (5) Play music of the client's choice before surgery. (6) Consider using healing touch in the perianesthesia setting. (7) For female premenopausal clients, assess the date when the menstrual cycle is mots likely to occur and schedule surgery on alternate dates if possible. (8) Consider the use of an adjustable recliner if not contraindicated for recovery. (9) Do not offer fluids in the immediate postoperative period. (10) In a client with postoperative nausea and vomiting, consider the use of multiple antiemetic meds (double or triple combinations of ... (1) Carefully assess the fluid and electrolyte status and glomerular filtration rate (GFR) of elderly clients before surgery. Provide fluild and electrolyte replacement per the physician's order. (2) Carefully evaluate the client's temp. Know what is normal and abnormal for each client. Check baseline temp and monitor trens. (3) To maximaize the recovery of walking ability in elderly clients with hip fracture, a multidisciplinary approach using skilled medical, nursing, and paramedical care appears to be optimal. (4) Offer spiritual support. (1) To decrease postoperative nausea and vomiting, the client should be instructed to fast before surgery, with the time frame to be determined by the physician. Swallowing, impaired 949 Abnormal functioning of the swallowing mechanism associated with deficits in oral, pharyngeal, or esophageal structure or function Oral phase impairment: Lack of tongue action to form bolus; weak suck resulting in inefficient nippling; incomplete lip closure; pushing of food out of mouth; slow bolus formation; falling of food from mouth; premature entry of bolus; nasal reflux; inability to clear oral cavity; long meals with little consumption; coughing, choking, or gagging before a swallow; abnormality in oral phase of swallow study; piecemeal deglutition; lack of chewing; pooling in lateral sulci; sialorrhea or drooling Pharyngeal phase impairment: Altered head position; inadequate laryngeal elevation; food refusal; unexplained fever; delayed swallow; recurrent pulmonary infections; gurgly voice quality; nasal reflux; choking, coughing, or gagging; multiple swallows; abnormality in pharyngeal phase by swallowing study Esophageal phase impairment: Heartburn or epigastric pain; acidic-smelling breath; unexplained irritability surrounding mealtime; vomitus on pillow; repetitive swallowing or ruminating; ..... Congenital deficits; upper airway anomalies; failure to thrive; protein energy malnutrition; conditions with significant hypotonia; respiratory disorders; history of tube feeding; behavioral feeding problems; self-injurious behavior; neuromuscular impairment (e.g., decreased or absent gag reflex, decreased strength or excursion of muscles involved in mastication, perceptual impairment, or facial paralysis); mechanical obstruction (e.g., edema, tracheotomy tube, or tumor); congenital heart disease; cranial nerve involvement; neurological problems; upper airway anomalies; laryngeal abnormalities; achalasia; gastroesophageal reflux disease; acquired anatomic defects; cerebral palsy; internal or external traumas; tracheal, laryngeal, or esophageal defects; traumatic head injury; developmental delay; nasal or nasopharyngeal cavity defects; oral cavity or oropharynx abnormalities; prematurity

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html decisions regarding methods of integrating therapeutic regimens into ADLs. (3) Provide information on possible illness trajectories to allow planning for future management. (4) Assist the client in resolving ambivalent feelings about illness and management of the therapeutic regimen. (5) Review methods of cotnacting health care provider(s) for changes in therapeutic regimen and/or methods of incorporating therapeutic regimens into ADLs. (6) Record the effectiveness of managing the therapeutic regimens. (1) Assess for the influence of cultural beliefs, norms, and values on the individual's perceptions of the therapeutic regimen. (2) Use a family-centered approach when working with Latino, Asian, African American, and Native American clients. (3) Discuss with the client those aspects of health and lifestyle that will remain unchanged by his or her health status. (4) Validate the client' feelings regarding the ability to manage his or her own care and the impact on current lifestyle. (1) Teach about the disease trajectory and ways to manage disease symptoms as the trajectory changes. Therapeutic regimen management, ineffective 958 Pattern of regulating and integrating into daily living a program for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals Choices of daily living ineffective for meeting goals of a treatment or prevention program; verbalization that client did not take action to reduce risk factors for progression of illness and sequelae; verbalization of desire to manage treatment of illness and prevention of sequelae; verbalization of difficulty with regulation of one or more prescribed regimensfor prevention of complications and treatment of illness or its effects; verbalization that client did not take action to include treatment regimens in daily routines Perceived barriers; social support deficits; powerlessness; perceived susceptibility; perceived benefits; mistrust of regimen and/or health care personnel; knowledge deficit; family patterns of health care; family conflict; excessive demands made on individual or family; economic difficulties; decisional conflicts; complexity of therapeutic regimen; complexity of health care system; faulty perception of illness seriousness; inadequate number and types of cues to action Decision Making; Knowledge: Disease Process, Treatment Regimen; Participation in Health Care Decisions; Symptom Severity; Treatment Behavior: Illness or Injury (1) Describe daily food and fluid intake that meets therapeutic goals (2) Describe activity/exercise patterns that meet therapeutic goals (3) Describe scheduling of medications that meets therapeutic goals (4) Verbalize ability to manage therapeutic regimens (5) Collaborate with health providers to decide on therapeutic regimen that is congruent with health goals and lifestyle Anticipatory Guidance; Health Education; Health Screening; Health System Guidance; Learning Facilitation; Learning Readiness Enhancement; Risk Identification; Self- Modification Assistance NOTE: This diagnosis does not have the same meaning as the diagnosis Noncompliance. This diagnosis is made with the client. If the client does not agree with the diagnosis, it should not be made (Bakker, Kastermans, and Dassen, 1995). The emphasis is on helping the client to direct his or her own life and health, not on the client's compliance with the provider's instructions (1) See the care plans for Effective Therapeutic regimen management andIneffective family Therapeutic regimen management. (2) Establish a collaborative partnership with the client for purposes of meeting healthrelated goals. (3) Discuss all strategies with the client in the context of the client's culture. (4) Assist the client in resolving ambivalent feelings. (5) Review factors of the Health Belief Model with the client (i.e., individual perceptions of seriousness and susceptibility, demographic and other modifying factors, and perceived benefits and barriers). (6) Identify the reasons for actions that are...... (1) Conduct a self-assessment of the relation of culture to ethically based care. (2) Assess the influence of cultural beliefs, norms, values, and attitudes on the client's ability to modify health behavior. (3) Discuss with

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html the client those aspects of his or her health behavior/lifestyle that will remain unchanged by the therapeutic regimen. (4) Assess temporal orientation and its relationship to the management of the therapeuticregimen. (5) Assess the effect of fatalism on the client's ability to adopt the therapeutic regimen. (6) Validate the client's feelings regarding the impact of the therapeutic regimen on current lifestyle. (1) Identify what the client and/or family knows and adjust teaching accordingly. (2) Teach ways to adjust daily activities for inclusion of therapeutic regimens. (3) Teach safety in taking medications. (4) Teach the client to act as a self-advocate with health providers who prescribe therapeutic regimens. Therapeutic regimen management, readiness for enhanced 963 Pattern of regulating and integrating into dauly living a program(s) for treatment of illness and its sequelae that is sufficient for meeting health-related goals and can be strengrthened Expression of desire to manage treatment of illness and prevention of sequelae; choices of daily living that are appropriate for meeting goals of treatment or prevention; expression of little to no difficulty with regulation/integration of one or more prescribed regimens for treatment of illness or preventon of complications; reduction of risk factors for progression of illness and sequelae; lack of unexpected accerleration of illness symptoms Health-Promoting Behavior; Health-Seeking Behavior; Knowledge: Health Behavior, Health Promotion, Health Resources, Illness Care, Medication, Prescribed Activity, Treatment Regimen (1) Describe integration of therapeutic regimen into daily living. (2) Demonstrate continued commitment to integration of therapeutic regimen into daily living routines. Anticipatory Guidelines; Mutal Goal Setting; Patient Contracting; Self-Modification Assistance; Self=Responsiblity Facilitation; Support System Enhancement; Teaching: Disease Process (1) Explore attitudes toward the illness/disease and the need for management of a therapeutic regimen. (2) Review the factors contributing to the likelihood of taking action for health promotion and health protection. Use Pender's Health Promotion Model and Becker's Health Belief Model to identify contributing factors. (3) Further develop and reinforce contributing factors that might change with ongoing management of therapeutic regimen (e.g, knowledge, self-efficacy, self-esteem, and perceived benefits. (4) Reivew the client's strengths in the management of the therapeutic regimen. (5) Collaborate with the client to identify strategies to maintain strengths and develop additional strengths as indicated. (6) Identify contributing factors that may need to be improved now or in the future. (7) Provide knowledge as needed related to the pathophysiology of the disease/illness, prescribed activities, prescribed medications, and nutrition. (8) Use coaching strategies such as educational .... (1) Acknowledge the cultural dimensions of health promotion and protection behaviors. (2) Assist the client in integrating cutlural patterns with prescribed activites, prescribed meds, and prescribed diet. (3) Manipulate community factors that may affect the management of the therapeutic regimen (e.g., barriers, supports, insurance, education about the illness, and provider-client relationships). Community Teaching: (1) Refer therapeutic regimens and their optimum integration with daily living routines. (2) Teach disease processes and therapeutic regimens for managemetn of these disease processes. Therapeutic regimen management, community, ineffective 966 Pattern of regulating and integrating into community processes programs for the treatment of illness and its sequelae that is unsatisfactory for meeting health-related goals Illness symptoms above norm expected for number and type of population; unexpected acceleration of illness(es); number of health care resources insufficient for incidence or prevalence of illness(es); deficits in aggregates for specific groups, deficits in people and programs to be accountable for illness care of specific groups, deficits in community activities for secondary and tertiary prevention; unavailability of health care resources for illness care. To be developed. Decision Making;

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Knowledge: Disease Process, Treatment Regimen; Participation in Health Care Decisions; Symptom Severity; Treatment Behavior: Illness or Injury (1) Secure community members and/or health providers who will be accountable for illness care of specific groups. (2) Remain involved in advocacy for illness care and prevention programs. (3) Develop health care plans for effective prevention and treatment of illnesses. (4) Make resources available for illness care and prevention. (5) Initiate or improve strategies for prevention of the sequelae of illness. Community Health Development; Environmental Management: Community; Health Policy Monitoring; Teaching: Disease Process. NOTE: NIC interventions that were developed for use with individuals can be adapted for use with communites. NOTE: Nursing interventions are conducted in collaboration with key members of the community, community/public health nurses, and members of other disciplines. (1) Seek community leaders who are willing to learn about community assessment data and diagnoses and have potential to work in partnership with nurses and other providers in planning for positive change. (2) Examine the perceptions of community members regarding service needs. (3) Apply the concept of caring to the community as client. (4) Advocate for and with the community in multiple arenas. (5) Provide information to public and private sources about community assessment, diagnosis, and plans of care. (6) Mobilize support for the community to obtain the resources necessary for illness care and prevention. (7) Provide informal helping roles as health educator and/or change agent. (8) Recruit additional health providers as needed. (9) Determine the cultural appropriateness of all programs. (10) Write grant proposals for ...... (1) Identify the health services and information resources that are currently available in the community. (2) Identify cultural barriers such as acculturation issues, lack of community support, and lack of past experience with a health behavior. (3) Work with members of the community to prioritize and target health goals specific to the community. (4) Approach community leaders and members of color with respect, warmth, and professional courtesy. (5) Establish and sustain partnerships with key individuals within the community in developing and implementing programs. (6) Use community church settings as a forum for advocacy, teaching, and program implementation. Therapeutic regiment management, family, ineffective 970 Pattern of regulating and integrating into family processes a program for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals Inappropriate family activities for meeting goals of treatment or prevention program; acceleration of illness symptoms of a family member; lack of attention to illness and its sequelae; verbalization of difficulty with regulation/integration of one or more activites or prevention of complications; verbalization of desire to manage treatment of illness and prevention of its sequelae; verbalization that family did not take action to reduce risk factors for progression of illness and sequelae Complexity of health care system; complexity of therapeutic regimen; decisional conflicts; economic difficulties; excessive demands on individual or family; family conflict Health Orientation; Health-Promoting Behavior; Health-Seeking Behavior; Knowledge: Treatment Regimen; Participation in Health Care Decisions; Treatment Behavior: Illness or Injury (1) Make adjustments in usual activites (e.g., diet, activity, stress management) to incorporate therapeutic regimens of its members. (2) Reduce illness symptoms of family members. (3) Desire to manage therapeutic regimens of its members. (4) Describe a decrease in the difficulties of managing therapeutic regimens. (5) Describe actions to reduce risk factors. Family Involvement Promotion; Family Mobilization; Family Process Maintenance; Teaching: Disease Process (1) Base family interventions on your knowledge of the family, family context, and family function. (2) Use a family approach when helping an individual with a health problem that requires therapeutic management. (3) Ensure that all strategies for working with the family are congruent with the culture of the family. (4) Support religious beliefs and the comfort role of religion. (5) Identify family interactions and their embedded contexts relative to specific

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html health objectives. (6) Review with family members the congruence and incongruence of family behaviors and health-related goals. (7) help family members make decisions regarding ways to integrate therapeutic regimens into daily living. Provide advice or suggestions as solicited and accepted by the family. (8) Demonstrate respect for and trust in family decisions. (9) Acknowledge the challenge of integrating therapeutic regimens with family toward development of greater self-efficacy in relation to these symptoms. (10) Provide ..... (1) Acknowledge racial/ethnic differences at the onset of care. (2) Approach families of color with respect, warmth, and professional courtesy. (3) Assess for the influence of cultural beliefs, norms, and values on the family's perceptions of the therapeutic regimen. (4) Give a rationale when assessing African American families about sensitive issues. (5) Use a family-centered approach when working with Latino, Asian, African American, and Native American. (6) Facilitate modeling and role-playing for the family regarding healthy ways to communicate and interact. (7) Validate family members' feelings regarding the impact of the therapeutic regimen on the family lifestyle. (1) Teach about all aspects of therapeutic regimens. Provide as much knowledge as family members will accept, adjust instructions to account for what the family already knows, and provide information in a culturally congruent manner. (2) Teach ways to adjust family behaviors to include therapeutic regiments. (3) Teach safety in taking meds. (4) Teach family members to act as self-advocates with health providers who prescribe therapeutic regimens. Thermoregulation, ineffective 975 Temperature fluctuation between hypothermia and hyperthermia Fluctuations in body temp above or below normal range; cool skin; cyanotic nail beds; flushed skin; hypertension; increased respiratory rate; pallor (moderate); piloerection; reduction in body temp below normal range; seiquzres/convulsions; shivering (mild); slow capillary refill; tachycardia; warmth to touch Trauma; illness; immaturity; aging; fluctuating environmentla temperature Thermoregulation; Thermoregulation: Newborn (1) Maintain temperature within normal range. (2) Explain measures needed to maintain normal temperature. (3) Explain symptoms of hypothermia or hypethermia. Temperature Regulation; Temperature Reguation: Inoperative (1) Monitor temp every 1-4 hours or use continuous temp monitoring as appropriate. (2) If the client is awake, measure the oral temp, instead of tympanic or axillary temp. (3) Take vital signs every 1-4 hours, noting changes associated with hypothermia: first, increased BP, pulse, and respirations; then, decreased values as hypothermia progresses. (4) Note changes in vital signs associated with hyperthermia: rapid, bounding pulse, increased respiratory rate; and decreased blood pressure accompanied by orthostatic hypotension. (5) Monitor the client for signs of hyperthermia (e.g., headache, nausea, vomiting, weakness, absence of sweating, delirium, and coma). (6) Note vital sign changes associated with hypothermia: first increased and then decreased BP, pulse rate, and respiratory rate. (7) Monitor the client for signs of hypothermia (e.g., shivering, cool sking, piloerection, pallor, slow capillary refill, cyanotic nailbeds, decreased mentation, dysrhythmias). (8) Maintain a ......... (1) Recognize that pediatric clients have a decreased ability to adapt to temp extremes. Take the following actions to maintain body temp in the infant/child: a) Keep the head covered. b) Use blankets to keep the client warm. c) Keep the client covered during procedures, transport, and diagnostic testing. d) Keep the room temp at 22.2 C (72 F). (1) Do not allow an elderly client to become chilled. Keep the client covered when giving a bath and offer socks to wear in bed. (2) Assess the medication profile for the p otential risk of drug-related altered body temperature. (1) Instruct the client to avoid prolonged exposure outdoors. When outdoors, the client should wear gloves and a cap on the head. Wool or fleece clothing can help to maintain body heat. (2) Keep the room temp at 20 to 22.2 C (68 to 72 F). (3) Ensure an adequate source of heat. Refer to social services if the client/family has a low income and heat could be turned off. (4) help the

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html elderly client locate a warm environment to which the client can go for safety in cold weather if the home environment is no longer warm. (5) ........ ......... ......... (1) Teach the client and family the signs of hypothermia and hyperthermia and appropriate actions to take if either condition develops. (2) Teach the client and family an age-appropriate method for taking the temperature. (3) Teach the client to avoid alcohol and meds that depress cerebral function. Thought processes, disturbed 978 Disruption in cognitive operations and activities Cognitive dissonance; memory deficit/problems; inaccurate interpretation of environment; hypovigilance; hypervigilance; distractibility; egocentricity; inappropriate non-reality-based thinking Organic brain changes (specify); changes in physical health (specify); mental illness (specify) Cognition; Cognitive Orientation; Concentration; Decision Making; Distorted Thought Self-Control; Identity; Information Processing; Memory; Neurological Status; Consciousness (1) Demonstrate orientation to time, place, and person; demonstrate imrpoved cognitive function. (2) Be free from physical harm. (3) Perform ADLs appropriately and inedepently. (4) Identify community resources for help. Delusion Management; Dementia Management (1) Observe for causes of altered thought processess (see Related Factors). (2) Monitor, record, and report changes in the client's neurological status (level of consciousness, increased intracranial pressure), mental status (memory, cognition, judgment, concentration), vital signs, laboratory results, and ability to follow commands. (3) Obtain a medical history to rule out physical illness causes for mental status changes. (4) Complete a mental status examination of the client. (5) Report any new onset or sudden increase in confusion. (6) Adjust communication style to the client. (7) Assess pain and promply provide comfort measures. (8) Identify and remove potentially dangerous items from the environement. (9) Limit the use of sedatives and drugs affecting the nervous systms. (10) Use soft restraints with discretion and with a physician's order. (11) Orient the client and call the client by name; introduce yourself on each contact; frequently mention time, date, and place; ........... (1) Monitor for dementia, as evidenced by a gradual onset and a progressive deterioration, or for delirium, as evidence by an acute onset and generally reversible course. (2) Focus on the feelings associated with hallucinations and delusions rather than their content. (1) Assess for the influence of cultural beliefs, norms, and values on the family's or caregiver's understanding of distubred thought processes. (2) Inform the client's family or caregiver of the meaning of and reasons for common behaviors observed in client with disturbed thought processes. (3) Validate the family members' feelings regarding the impact of the client's behavior on family lifestyle. (1) The interventions described previously may be adapted for home care use. (2) Assess the client for the presence of a psychiatric disorder. Refer for mental health services as indicated. (3) Assess the family's knowledge of the disease process and plan of care; teach as necessary. (4) Identify the strengths of the caregiver and the caregiver's efforts to gain control of unpredictable situations. Help the caregiver to stay connected with a client who may be behaving differently than usual, to make life as routine as possible, to help the client set goals and sustain hope, and to allow the client space to experience progress. (5) Assess the client's functional status as it relates to the ability for self-care; refer to a physician for evaluation of medication levels as indicated. (6) Assess the home environment for the availability of distractions from hallucinations, such as playing music over headphones. (7) If the client's condition deteriorates, seek acute medical or mental ...... (1) Teach family member reorientation techniques and the need to repeat instructions frequently. (2) Teach the client distraction techniques to manage hallucinations. (3) Teach family members way to support the client without supporting delusional beliefs. (4) Help the family identify coping skills, environmental supports, and community services for dealing with the chronically mentally ill client. (5) Discuss the caregiver's need for respite.

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Offer support, encouragement, and info for meeting that need. Tissue integrity, impaired 985 Damage to mucous membrane, corneal, integumentary, or subcutaneous tissues Damaged or destroyed tissue (e.g., cornea, mucous membrane, integumentary or subcutaneous tissue) Mechanical factors (e.g., pressure, shear, friction); radiation (including therapeutic radiation); nutritional deficit or excess; thermal factors (temperature extremes); knowledge deficit; chemical irritants (including body excretions, secretions, medications); impaired physical mobility; altered circulation; fluid deficit or excess Tissue Integrity: Skin and Mucous Membranes; Wound Healing: Primary Intention, Secondary Intention (1) Report any altered sensation or pain at site of tissue impairment; (2) Demonstrate understanding of plan to heal tissue and prevent injury; (3) Describe measures to protect and heal the tissue, including wound care; (4) Experience a wound that decreases in size and has increased granulation tissue Incision Site Care; Pressure Ulcer Care; skin Care: Topical Treatments; Skin Surveillance; Wound Care (1) Assess the site of impaired tissue integrity and determine the cause (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer). (2) Determine the size and depth of the wound (e.g., full-thickness wound, stage III or stage IV pressure ulcer). (3) Classify pressure ulcers in the following manner (National Pressure Ulcer Advisory Panel, 1989): Stage III: Full-thickness skin loss involving damage to or necrosis of subcutaneous tissue that may extend down to but not through underlying fascia; ulcer appears as a deep crater with or without undermining of adjacent tissue Stage IV: Full-thickness skin loss with extensive destruction; tissue necrosis; or damage to muscle, bone, or supporting structures (e.g., tendons, joint capsules) (4) Monitor the site of impaired tissue integrity at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether the client is experiencing changes in sensation or pain. .... (1) Some of the interventions described previously may be adapted for home care use.(2) Assess the client's current phase of wound healing (inflammation, proliferation, maturation) and stage of injury; initiate appropriate wound management.(3) Instruct and assist the client and caregivers with removing or controlling impediments to wound healing (e.g., management of underlying disease, improvement in approach to client positioning, improved nutrition). (4) Initiate a consultation in a case assignment with a wound, ostomy, and continence nurse to establish a comprehensive plan as soon as possible. Plan case conferencing to promote optimal wound care. (5) Refer for consideration of treatment options for leg ulcers: (1) Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing. (2) Teach the use of a topical treatment that is matched to the client, wound, and setting. (3) If it is consistent with overall client management goals, teach how to turn and reposition the client at least every 2 hours. (4) Teach the use of pillows, foam wedges, and pressure-reducing devices to prevent pressure injury. Tissue perfusion, ineffective (specify type: renal, cerebral, cardiopulmonary, gastrointestinal, peripheral) 990 Decrease in oxygen resulting in failure to nourish tissues at capillary level Renal Altered blood pressure outside of acceptable parameters; hematuria; oliguria or anuria; elevation in blood urea nitrogen/creatinine ratio Cerebral Speech abnormalities; changes in pupillary reactions; extremity weakness or paralysis; altered mental status; difficult in swallowing; changes in motor response; behavioral changes Cardiopulmonary Altered respiratory rate outside of acceptable parameters; use of accessory

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html muscles; capillary refill longer than 3 seconds; abnormal arterial blood gas levels; chest pain; sense of impending doom; bronchospasms; dyspnea; dysrhythmias; nasal flaring; chest retraction Gastrointestinal Hypoactive or absent bowel sounds; nausea; abdominal distention; abdominal pain or tenderness Peripheral Edema; positive Homans' sign; altered skin characteristics (hair, moisture) or nails; weak or absent pulses; skin discolorations; skin temperature changes; altered sensations; diminished arterial pulsations; pale skin color upon elevation of leg.. Hypovolemia; interruption of arterial flow; hypervolemia; exchange problems; interruption of venous flow; mechanical reduction of venous and/or arterial blood flow; hypoventilation; impaired transport of oxygen across alveolar and/or capillary membrane; mismatch of ventilation with blood flow; decreased hemoglobin concentration in blood; enzyme poisoning; altered affinity of hemoglobin for oxygen Cardiac Pump Effectiveness; Circulation Status; Fluid Balance; Hydration; Tissue Perfusion: Cardiac, Cerebral, Peripheral; Urinary Elimination (1) Demonstrate adequate tissue perfusion as evidenced by palpable peripheral pulses, warm and dry skin, adequate urinary output, and absence of respiratory distress (2) Verbalize knowledge of treatment regimen, including appropriate exercise and medications and their actions and possible side effects (3) Identify changes in lifestyle that are needed to increase tissue perfusion Circulatory Care: Arterial Insufficiency (1) If the client experiences dizziness because of postural hypotension when getting up, teach methods to decrease dizziness, such as remaining seated for several minutes before standing, flexing feet upward several times while seated, rising slowly, sitting down immediately if feeling dizzy, and trying to have someone present when standing. (2) Monitor neurological status; perform a neurological examination; if symptoms of a cerebrovascular accident occur (e.g., hemiparesis, hemiplegia, or dysphasia), call 911 and send the client to the emergency department. (3) If an ischemic stroke is present, consider keeping the head of the bed lower or flat as long as the airway is maintained, after consulting with the physician. (4) See the care plans for Decreased Intracranial adaptive capacity, Risk for Injury, and Acute Confusion. PERIPHERAL PERFUSION: (1) Check the dorsalis pedis, posterior tibial, and popliteal pulses bilaterally. If unable to find them, use a Doppler stethoscope and ...... (1) Change the client's position slowly when getting the client out of bed. (2) Recognize that the elderly have an increased risk of developing pulmonary embolism and that, if it is present, the symptoms are nonspecific and often mimic those of heart failure or pneumonia (1) The interventions described previously may be adapted for home care use. (2) Differentiate between arterial and venous insufficiency. (3) If arterial disease is present and the client smokes, aggressively encourage smoking cessation. See the care plan for Health-seeking behaviors. (4) Examine the feet carefully at frequent intervals for changes and new ulcerations. (5) Assess the client's nutritional status, paying special attention to obesity, hyperlipidemia, and malnutrition. Refer to a dietitian if appropriate. (6) Monitor for development of gangrene, venous ulceration, and symptoms of cellulitis (redness, pain, and increased swelling in an extremity). (1) Explain the importance of good foot care. Teach the client and family to wash and inspect the feet daily. Recommend that the diabetic client wear padded socks, special insoles, and jogging shoes. (2) Teach the diabetic client that he or she should have a comprehensive foot examination at least annually, including assessment of sensation using the Semmes-Weinstein monofilaments. If good sensation is not present, refer to a footwear professional for fitting of therapeutic shoes and inserts, the cost of which is covered by Medicare. (3) For arterial disease, stress the importance of not smoking, following a weight loss program (if the client is obese), carefully controlling a diabetic condition, controlling hyperlipidemia and hypertension,

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html and reducing stress. (4) Teach the client to avoid exposure to cold, to limit exposure to brief periods if going out in cold weather, and to wear warm clothing. (5) Teach the client to recognize the signs and symptoms that should be reported to a... Transfer ability, impaired 996 Limitation of independent movement between two nearby surfaces. Impaired ability to transfer: from bed to chair and chair to bed/on or off toilet or commode/between uneven levels/from chair to car or car to chair/from chair to floor or floor to chair/from standing to floor or floor to standing See defining Characteristics (aeb) Balance; Body Positioning: Self-Initiated (1) Transfer from bed to chair and back successfully. (2) Transfer from chair to chair successfully. (3) Transfer from chair to toilet and back successfully. (4) Transfer from chair to car and back successfully Exercise Promotion: Strength training; Exercise Therapy: Muscle Control (1) Request a consult for PT and/or OT for an upper and lower extremity exercise and strengthening program early in the client's progressive mobilization and recovery. (2) Obtain a consult for a PT, OT, or orthotist to evaluate, prescribe, measure, and fit the client with the proper orthoses, braces, splints, walking aids, raised toilet seats, etc. (3) Inquire about and learn the specific techniques and instructions the OT and PT have taught about and learn the specific techniques and instructions the OT and PT have taught the client to reinforce and assist the client as he or she transfers to various surfaces. (4) Ergonomically assess the client's dependence level, size, weight, strength, movement abilities in bed, balance, tolerance to position change, sensation, behavior, and cognition, as well as equipment availability and staff ratios and experience to decide whether to perform a manual or device-assisted life, transfer, or weighing of the client. (If a PT has already evaluated... (1) Obtain a referral for an OT and/or PT to develop home exercise and transfer regimens aand evaluate the need for home modifications such as wider doorways, safe floor surface, grab bars, clutter elimination, adeuate lighting, adequate seting (proper chair height, stability, support, and firmness), optimum furniture placement (for maneuverability and stability in using to asses in getting up if a fall occurs), fitted bedspreads and blankets so that the client does not trip, etc. (2) Involve a social worker to educate the client and family about equipment costs and financial bnefits and regulations associated with Medicare, Medicaid, and third-party payers, as well as local community options for securing durable medical equipment and home care servies. (3) Coordinate with therapy services to reinforce client and family education regarding safe and effective transfer methods, equipment; application, removal, and care of assistive devices; skin checks and care associated with the use... (1) Begin discharge planning as soon aspossible with the care manager or social worker to assess the need for home support systems, assistive devices, and community or home health services. (2) Obtain referral for an OT and/or PT to develop home exercise and transfer regimes, and evaluate home modification and equipment needs such as wheelchairs, tub seats, hand rails, and raised toilet seats. (3) Involve a social workers to educate the client and family about equipment costs and financela benefits and regulations associated with Medicare, Medicaid, and third-party payers, as well as local community options for seciring durable medical equipment and home care services. (4) coordinate with therapy services to reinforce client and family education regarding safe and effective transfer methods; application, removal, and care of assistive devices; skin checks and care associated with the use of braces, splints, immobiliers, etc. and skin checks and care associated with the use of ........ Trauma, risk for 1004 Accentuated risk of accidental tissue injury (e.g., wound, burn, fracture) EXTERNAL: High-crime neighborhood and client vulnerability; pot handles facing toward front of stove; knives stored combustibles or corrosives; highly flammable children's toys or clothing; obstructed passageways; high beds; large icicles hanging from roof; nonuse or misuse of seat restraints; overexposure to sun, sunlamps, or radiotherapy; overload eletrical outlets; overloaded fuse boxes; play or work near vehicle

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html Urinary Elimination Management (1) Assess the client for readiness for improving urine elimination patterns, focusing on need for physical assistance to access toilet, cognitive awareness of sensations indicating readiness for urine elimination and currect continence status. (2) Complete a bladder diary of diurnal and nocturnal urine elimination patterns and patterns of urinary leakage. (3) Begin a scheduled toileting program (usually every 2-3 hours) for the client who is normally continent (recognizes cues to toilet and expresses readiness to toilet) but requires physcial assistance to access toilet. (4) Remove environmental barriers to toilet access. (5) Provide a urinal or bedside tiolet as indicated. (6) Assist client to remove clothing, transfer to the toilet, cleanse the perineal skin, and redress as indicated. (7) Ensure that toileting opportunities are offered both during daytime hours and during hours of sleep. (8) Ensure that toileting opportunities are offered both during daytime hours and during hrs.... Urinary elimination, impaired 1011 Disturbance in urine elimination. NOTE: This broad diagnosis may be used to describe many dysfunctional coiding conditions. Refer to Functional urinary Incontinence, Reflex urinary incontinence, Stress urinary Incontinence, Total urinary Incontinence, urge urinary Incontinence, and Urinary retention for info on these more specific diagnoses. Too many to list; SEE BOOK !! Bothersome lower urinary tract symptoms (urological disorders, neurological lesions, gynecological conditions, dysfunction of bowel elimination); incontinence (refer to specific diagnosis); urinary retention (refer to specific diagnosis); acute urinary retention (refer to Urinary retention) Urinary Continence; Urinary Elimination; Knowledge: Medication (1) Demonstrate diurnal frequency no more than every 2 hours. (2) Demonstrate nocturia zero to one time per night for adults younger than 70 years and no more than two times per night for persons 70 or older. (3) Be able to postpone voiding until toileting facility is accessed and clothing is removed. (4) Be able to perceive and recognize cues for toileting, move to toilet or use urinal or portable toileting apparatus, and remove clothing as necessary for toileting. (5) Demonstrate postvoidng residual volumes less than 200 ml or 25% of total bladder capacity. (6) State absence of pain or excessive urgency with bladder filling and with urination Urinary Elimination Management (1) Routinele screen all adult women and agins men for urinaryincontinence or lower urinary tract symptoms including bothersome urgency. (2) Complete a more detailed assessment on selected clients including a bladder log and functional/cognitive assessment. (Refer to Functional urinary Incontinence, Reflex urinary Incontinence, Stress urinary Incontinence, Total urianry Incontinence, and Urge urinary Incontinence.) (3) Consult the physician for culture and sensitivity testing and antibiotic treatment in the individual with evidence of a urinary infection. (4) Refer the individual with irritative symptoms; chronic, burning bladder; andurethral pain to a urologist or specialist in the management of pelvic pain. (5) Teach the client to recognize symptoms of UTI (dysuria that crescendos as the bladder nears complete evacuation; urgency to urinate followed by micturition of only a few drips; suprapubic aching; discomfort; malaise; voiding frequency; sudden exacerbation of urinary ......... (1) Provide an environment that encourages toileting for the elderly client cared for in the home or in acute care, long-term care, or critical care units. (2) Perform urinalysis in all elderly person who experience a sudden change in urine elimination patterns, lower abdominal discomfort, acute confusioin, aor a fever of unclear origin. (3) Encourage elderly women to drink at least 10 ounces of cranberry juice daily, regularly consume one to two servings of fresh blueberries, or supplement the diet with cranberry concentrate capsules (usually taken in 500 mg doses with each meal) (1) Provide all clients with the basic principles for optimal bladder function. (2) Teach the community and health care providers that urinary incontinence is not a normal part of aging and that incontinence can be

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html corrected or managed with proper evaluation and care. (3) Provide informaiton to health care providers and the community about the signs, symptoms, and management of urinary tract infections and interstitial cystitis. (4) Teach all persons the signs and symptoms of urinary tract infection and its management. (5) Teach all persons to recognize hematuria and to promptly seek care if this sympom occurs. Urinary retention 1016 Incomplete emptying of the bladder Measured urinary residual greater than 150 to 200 ml or 25% of total bladder capacity; obstructive lower urinary tract symptoms (poor force of stream, intermittency of stream, hesitancy of urination, postvoiding dribbling, feelings of incomplete bladder emptying); irritative lower urinary tract symptoms (urgency to urinate, diurnal frequency of urination, nocturia); overflow incontinence (dribbling urine loss caused when intravesical pressure overwhelms the sphincter mechanism) Bladder outlet obstruction (benign prostatic hyperplasia, prostate cancer, prostatitis, urethral stricture, bladder neck dyssynergia, bladder neck contracture, detrusor striated sphincter dyssynergia, obstructing cystocele or urethral distortion, urethral tumor, urethral polyp, posterior urethral valves, postoperative complication) Deficient detrusor contraction strength (sacral level spinal lesions, cauda equina syndrome, peripheral polyneuropathies, herpes zoster or simplex affecting sacral nerve roots, injury or extensive surgery causing denervation of pelvic plexus, medication side effect, complication of illicit drug use, impaction of stool) Urinary Continence; Urinary Elimination (1( Completely and regularly eliminate urine from the bladder; measured urinary residual volume is less than 150 to 200 ml or 25% of total bladder capacity (voided volume plus urinary residual volume) (2) Experience correction or relief from obstructive symptoms (3) Experience correction or alleviation of irritative symptoms (4) Be free of upper urinary tract damage (renal function remains sufficient; febrile urinary infections are absent) Urinary Retention Care (1)Obtain a focused urinary history emphasizing the character and duration of lower urinary symptoms. Query the client about episodes of acute urinary retention (complete inability to void) or chronic retention (documented elevated postvoid residual volumes). (2) Question the client concerning specific risk factors for urinary retention including: Disorders affecting the sacral spinal cord such as spinal cord injuries of vertebral levels T12 to L2, disk problems, cauda equina syndrome, tabes dorsalis; Acute neurological injury causing sudden loss of mobility such as spinal shock; Metabolic disorders such as diabetes mellitus, chronic alcoholism, and related; conditions associated with polyuria and peripheral polyneuropathies Heavy-metal poisoning (lead, mercury) causing peripheral polyneuropathies; Advanced stage HIV; Medications including antispasmodics/parasympatholytics, alpha-adrenergics, antidepressants, sedatives, narcotics, psychotropic medications, illicit drugs; Recent ...... (1) Aggressively assess elderly clients, particularly those with dribbling urinary incontinence, urinary tract infections, and related condition for urinary retention. (2) Assess elderly clients for impaction when urinary retention is documented or suspected. (3) Assess elderly male clients for retention related to BPH or prostate cancer. (1) The interventions listed previously may be adapted for home care use. (2) Encourage the client to report any inability to void. (3) Maintain an up-to-date medication list; evaluate side-effect profiles for risk of urinary retention. (4) Refer the client for physician evaluation if there is a new occurrence of urinary retention. (1) Teach techniques for intermittent catheterization including use of clean rather than sterile technique, washing using soap and water or a microwave technique, and reuse of the catheter. (2) Teach the client with an indwelling catheter to assess the tube for patency, maintain the drainage system below the level of the symphysis pubis, and routinely cleanse the bedside bag. (3) Teach the client with an indwelling catheter or undergoing intermittent catheterization the symptoms of a significant urinary infection including

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

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html increase in baseline HR (< 20 beats/min); pale; slight cyanosis; slight respiratory accessory muscle use; inability to respond to coaching; inability to cooperate; apprehension; color changes; decreased air entry on auscultation; diaphoresis; eye widening; wide-eyed look; hypervigilance to activities. MILD: Warmth; restlessness; slight increase of respiratory rate from baseline; queries about ..... PHYSIOLOGICAL: Ineffective airway clearance; sleep pattern disturbance; inadequate nutrition; uncontrolled pain or discomfort. PSYCHOLOGICAL: Knowledge deficit of the weaning process and client role; perceived inefficacy about the ability to wean; decreased motivation, decreased self-esteem; moderate or severe anxiety or fear; hopelessness; powerlessness; insufficient trust in nurse. SITUATIONAL: Uncontrolled episodic energy demands or problems; inappropriate pacing of diminished ventilator support; inadequate social support; adverse environment; low nurse-client ratio; extended nurse absence from bedside; unfamiliar nursing staff; history of ventilator dependence for > 4days to 1 week; history of multiple unsuccessful weaning attempts. Respiratory Status: Gas Exchange, Ventilation (1) Wean from ventilator with adequate arterial blood gases. (2) Remain free of unresolved dyspnea or restlessness. (3) Effectively clear secretions. Mechanical Ventilation; Mechanical Ventilatory Weaning (1) Assess client's readiness for weaning as evidenced by the following: a) Hemodynamic stability with adequate heart function. b) Resolution of initial medical problem that led to ventilaor dependence. c) Adequate nutritional status with serum albumin levels > 2.5 g/dl. d) Adequate sleep. e) Psychological readiness. FLUID AND ELECTROLYTE BALANCE: (1) For best results, ensure that the client is in an optimal physiological and psychological state before introducing the stress of weaning. (2) Initiate conditioning for the client including strength training where the client uses a T piece or low intermittent mandatory ventilation for short durations or endurance training where the client uses pressure support ventilation on inspiration to prepare for weaning. (3) Identify reasons for previous unsuccessful weaning attempts, and include that information in development of the weaning plan. (4) Collaborate with an interdisciplinary team to develop a weaning plan with a timeline and goals; .. (1) Recognize that older clients may require longer periods of time to wean. NOTE: Weaning from a ventilator at home should be based on client stability and comfort of the client and caregivers under an intermittent care plan. The client and/or family may be more comfortable having the client rehospitalized for the process. (1) Assess comfort and coping ability of the client and/or family to wean at home, as well as fiscal implications and home care coverage. (2) Establish an emergency plan and methods of implementation. Include emergency aeration and reestablishment of the ventilation assistive device. (3) Obtain orders for alternative routes of medication administration when meds have been administered via a ventilation device. Instruct the client and family in changes. Violence, other-directed, risk for 1033 At risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to others. Body language: rigid posutre, clenching of fists and jaw, hyperactivity, pacing, breathlessness, threatening stances; history of violence against others; history of threats of violence; history of violent antisocial behavior; history of violence, indirect; neurological impairment; cognitive impairment; history of childhood abuse; history of witnessing family violence; cruelty to animals; fire setting; prenatal/perinatal complications or abnormalities; history of drug of alcohol abuse; pathological intoxication; psychotic symptomatology; motor vehicle offenses; suicidal behavior; impulsivity; availability/possession of weapons Abuse Cessation; Abusive Behavior Self-Restraint; Aggression Self-Control; Distorted Though Self-Control; Impulse Self-Control; Parenting: Psyhcosocial Safety; Risk Detectioin (1) Stop all forms of abuse. (2) Have cessation of abuse reported by victim. (3) Display no aggressive activity. (4) Refrain from verbal outbursts. (5) Refrain from violating others' personal

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html space. (6) refrain from antisocial behaviors. (7) Maintain relaxed body language and decreased motor actvity. (8) Identify factors contributing to abusive/aggressive behavior. (9) Demonstrate impulse control or state feelings of control. (10) Identify impulsive behaviors. (11) Identify feelings/behaviors that lead to impulsive actions. (12) Identify consequences of impulsive actions to self and others. (13) Avoid high-risk environments and situations. (14) Identify and talk about feelings; express anger appropriately. (15) Express decreased anxiety and control of hallucinations as applicable. (16) Displace anger to meaningful activities. (17) Communicate needs appropraitely. (18) Identify responsibility to maintain control. (19) Express empathy for victim. (19) Obtain no access or yield access.... Abuse Protection Support; Anger Control Assistance; Behavior Management; Calming Techniqe; Coping Enhancement; Crisis Intervention; Delusion Management; Dementia Management; Distraction; Environmental Management: Violence Prevention; Mood Management; Physical Restraint; Seclusion; Substance Use Prevention (1) MOnitor the environment, evaluate situations that could become violent, and intervene early to de-escalet the situation. Enlist support from other staff rather than attempting to handle the situation alonge. (2) Know and follow instituation's policies and procedures concerning violence. (3) Assess the client for risk factors of violence including those in the following categories: psychiatric disorders; psychological precursors; coping difficulties; and personal history. (4) Assess for potential indicators of impending violence against others: frequent medication change, high use of sedative drugs, past violent behavior, a DSM-IV diagnosis of antisocial personality or borderline personality disorder, and long hospitalization. Other indicators include hypervigilance, hostility, substance sue, and lack of adherence to medication regimen. (5) Assess the client with history of previous assaults. Listen to and acknowledge feelings of anger, observe for increased motor activity, and ... (1) Assess for changes in physiological functions or impairment of the ability to meet basic needs. (2) Observe for dementia and delirium. (3) Assess sensory impairments and the influence they may have on the client's behavior. (4) Observe for signs of fear, anxiety, anger, and agitation, and intervne immediately. (5) Monitor for paradoxical drug reactions, and report any to the physcian. (6) Assess for brain insults such as recent falls or injuries, strokes, or transient ischemic attacks. (7) Decrease environmental stimuli if violence is directed at others. (8) Provide hand or back rubs and calming music when elderly client experiences agitation. (9) If abuse or neglect of an elderly client is suspected, report the suspicion to alocal Adult Protective Services Agency. (1) Assess family members or caregivers for their ability to protect the client and themselves. (2) Include an initial and ongoing assessment and evaluation of potential abuse and neglect. Photograph evidence of abuse or neglect when possible. (3) If neglect of abuse is syspected, identify an emergency plan that addresses the problem immediately, ensures client safety, and includes a report to the appropriate authorities. Discuss when to use hotlines and 911. Role-play access to emergency resources with the client and caregivers. (4) Encourage appropriate safety behaviors in abused women; call the client at intervals during a 6-month period to determine whether safety behaviors are being carried out. (5) Assess the home envirnoment for harmful objects. Have the family remove or lack objects as able. (6) Refer for homemaker or psychiatric home health care services for respite, client reassurance, and implementation of a therapeutic regimen. (7) If the client is taking psychotoropic .... (1) Teach relaxation and exercise as ways to release anger. (2) Teach cognitive-behavioral activities such as active problem solving, reframing, or thought stopping. Teach the client to confront his or her own negative thought patterns such as catastophizing, dichotomous thinking; or unrealistic expectations. (2) For religious couples, encourage the use of prayer. (3) Refer to individual or group therapy. (4) Teach the adolescent client violence prevention and encourage him or her to become involved in community service

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html activities. (5) Teach caregivers and family members of clients with dementia to use expressive physical touch and verbalization (EPT/V) when caring for these clients. (6) Teach the use of appropriate community resources in emergency situations. (7) Inform the client and family about medication actions, side effects, target symptoms, and toxic reactions. Violence, self-directed, risk for 1044 At risk for behaviors in which an individual demonstrates that he or she can be physically, emotionally, and/or sexually harmful to self Body language; rigid posture; clenching of fists and jaw, hyperactivity, pacing, breathlessness, threatening stances; history of violence against others; history of threats of violence; history of violent antisocial behavior; history of violence, indirect; neurological impairment; cognitive impairment; history of childhood abuse; history of witnessing family violence; cruelty to animals; fire setting; prenatal/perinatal complications or abnormalities; history of drug or alcohol abuse; pathological intoxication; psychotic symptomology; motor vehible offenses; suicidal behavior; impulsivity; availability/possession of weapons Depression Self-Control; Distored Thought Self-Control; Impulse Self-Control; Loneliness Severity; Mood Equilibrium; Risk Detection; Self-Mutilation Restraint; Suicide Self-Restraint (1) Refrain from self-injury. (2) State appropriate ways to cope with increased psychological or physiological tension. (3) Talk about feelings, express anger appropriately. (4) Seek help when feeling self-destructive or having urges to self-mutilate. (5) Maintain self-control without supervision. (6) use appropriate community agencies when cargivers are unable to attend to emotional needs. (7) Maintain connectedness in relationships. (8) Express decreased anxiety and control of impulses. (9) Refrain from using mood-altering substances. (10) Obtain no access to harmful objects. (11) Yield access to harmful objects. (12) Maintain self-control without supervision. Anger Control Assistance; Anciety Reduction; Behavior Management: Self-Harm; Calming Technique; Coping Enhancement; Crisis Intervention; Mood Management; Substance Use Prevention; Suicide Prevention Surveillance (1) Refer to the care plan for Risk for Suicide. (2) Refer to the care plans for Self-mutilation and Risk for Self-mutilation. Walking, impaired 1045 Limitation of independent movement within the environment on foot (or artificial limb) Impaired ability to climb stairs; walk on uneven surface; walk required distances; walk on even surfaces; walk on an incline or decline; navigate curbs Intolerance to activity; decreased strength and endurance; pain or discomfort; perceptual or cognictive impairment; neuromuscular impairment; musculoskeletal impairment; depression; severe anxiety; lower extremity amputation. NOTE: These are the same as the etiiologies for Impaired physical Mobility with the addition of lower extremity amputation. Suggested functional level classifications follow: 0--Completely independent, 1--Requires use of equipment or device, 2--Requires help from another person for assistance, supervision, or teaching, 3--Requires help from another person and equipment device, 4--Dependent (does not participate in activity) Ambulation; Mobility (1) Demonstrate optimal independence and safety in walking. (2) Demonstrate the ability to direct others on how to assist with walking. (3) Demonstrate the ability to properly and safely use and care for assistive walking devices. Exercise Therapy: Ambulation (1) Reinforce or request physical therapy consult to teach "bridging"; have client use the technique to move side to side in bed and to raise buttocks off the bed. (2) Apply antiembolic stockings, leg bandage wraps, and abdominal binders; elevate the HOB in small increments to as high a degree as tolerated; change positions slowly and provide adequate hydration to persons who are at risk for or who initially display postural hypotension when standing, sitting, and walking. Assess by comparing lying, sitting, and standing BP changes. If there is a BP discrepancy (lower in upright positions) or symptoms occur, consult the physician for medication review. (3) Remind clients of physician orders regarding weight-bearing limitations during walking. (3) Explain meaning and goals of progressive mobilization (gradual

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html elevation of HOB, tilt table, reclined chair sitting, etc.) to the client who has been on prolonged bed rest and who has poor circulation functioning. (4) Implement the ........... (1) Monitor pulse, respirations, and BP before and 5 minutes after a new activity. Stop activity if any of the following are detected: resting heart rate >100bpm, exercise heart rate that is 35% > resting rate, exercise systolic BP > 25-35 mmHg above resting pressure, or a decrease in systolic BP that is > 20 mm Hg. (2) Recognize that the use of a walking aid increases energy and therefore may raise pulse and BP; however, they are often prescribed to give stability and support for clients with lower extremity weakness, poor balance, or weight-bearing restrictions. (3) For elderly clients use safety and fall precautions such as the following: visual identification (arm bands, etc.), especially in clients at high risk of falling, a call system within reach; client education to call for help before standing and walking; a bed-chair alarm or one-to-one observation, especially for clients with cognitive or memory impairment; obstacle clearance; and assistive devices that are properly ..... (1) Assess the client and obtain a complete history with reference to reasons for impairment. (2) Explain the importance of having adequate lighting both day and night; tacking carpet edges down, removing throw rugs from traffic flow areas, and having nonskid backings on those that are used; applying nonskid wax on floors; and removing clutter, especially small objects, from the floor. (3) Assess the home environment for all barriers to walking. (4) If the client lives alone, assess his or her support system for emergency and contingency care. (5) Use safety devices such as a gait belt when assisting the client in ambulation. (6) Refer to physical and occupational therapists for skills building, strength builing, options for restructuring the environment, and present alternative mobility options. (7) Refer to home health aide services as appropriate for assistance with ADLs. (8) Provide support to the client and caregivers during long-term impairment. Refer to case manager/medical .... (1) Recommend that the client and family check assistive devices to keep them in safe working order. (2) Recommend daily weight-bearing activity and walking, calcium and vitamin D supplementation if dietary intake is low, and avoidance of smoking to prevent osteoporosis and related fractures. Assess for and strongly encourage client not to substitue beverages with caffeine (including cola) and alocohol for milk at meal time. Estrogen-replacement therapy may be helpful; therefore the client may need to consult with a physician. Wandering 1052 Meandering; aimless or repetitive locomotion that exposes the individual to harm; frequently incongruent with boundaries, limits, or obstacles Frequent or continuous movement from place to place, often revisiting the same destinations; persistent locomotion in search of "missing" or unattainable people or places;haphazard locomotion; locomotion in unauthorized or private spaces; locomotion resulting in unintended leaving of a premise; long periods of locomotion without an apparent destination; fretful locomotion or pacing; inability to locate significant landmarks in a familiar setting; locomotion that cannot be easily dissuaded or redirected; following behind or shadowing a caregiver's locomotion; trespassing; hyperactivity; scanning, seeking, or searching behaviors; periods of locomotion interspersed with periods of nonlocomotion (e.g., sitting, standing, sleeping); getting lost Cognitive impairment, specifically memory and recall deficits, disorientation, poor visuoconstructive (or visuospatial) ability, and language (primarily expressive) defects; cortical atrophy; premorbid behavior (e.g., outgoing, sociable personality); premorbid dementia; separation from familiar people and places; sedation; emotional state, especially frustration, anxiety, boredom, or depression (agitation); overstimulating/understimulating social or physical environment; physiological state or need (e.g., hunger/thirst, pain, urination, constipation); time of day Caregiver Home Care Readiness; Fall Prevention Behavior; Falls Occurrence (1) Decrease incidence of falls (preferably free of falls) (2) Decrease incidence of elopements (3) Maintain

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ABC Amber Palm Converter, http://www.processtext.com/abcpalm.html appropriate body weight (4) Be able to explain interventions he or she can use to provide a safe environment for a care receiver who displays wandering behavior Dementia Management (1) Assess and document the amount(frequency and duration), pattern (random, lapping, or pacing), and 24-hour distribution of wandering behavior over a 3-day interval. (2) Document particular aspects of wandering that are troubling. (3) Obtain a history of personality characteristics and behavioral responses to stress. (4) Evaluate for neurocognitive strengths and limitations, particularly language, attention, visuospatial skills, and perseveration. (5) Assess for physical distress or needs such as hunger, thirst, pain, discomfort, or elimination. (6) Assess for emotional or psychological distress such as anxiety, fear, or feeling lost. (7) Observe wandering episodes for antecedents and consequences. (8) Apply observed consequences of wandering such as personal attention, food, and so forth at times when the person is not wandering, and withhold them while the person is wandering. (9) Assess regularly for the presence of or potential for negative outcomes of wandering such as weight... (1) Assess for the influence of cultural beliefs, norms, and values on the family's understanding of wandering behavior. (2) Refer the family to social services or other supportive services to assist with the impact of caregiving for the wandering client. (3) Encourage the family to use support groups or other service programs. (4) Validate the family's feelings regarding the impact of client wandering on family lifestyle. (1) Help the caregiver set up a plan to deal with wandering behavior using the interventions mentioned in Nursing Interventions and Rationales. (2) Assess the home environment for modifications that will protect the client and preventelopement. (3) Enroll wanderers in the Safe Return Program of the Alzheimer's Association, and help the caregiver develop a plan of action to use if the client elopes. (4) Help the caregiver develop a plan of action to use if the client elopes. (5) Institute case management of frail elderly clients to support continued independent living. (6) Refer for homemaker or psychiatric home health care services for respite, client reassurance, and implementation of a therapeutic regimen. Refer to the care plan for Caregiver role strain. (1) Inform the client and family of the meaning of and reasons for wandering behavior. An understanding of wandering behavior will enable the client and family to provide the client with a safe environment. (2) Teach the caregiver/family methods to deal with wandering behavior using the interventions mentioned in Nursing Interventions and Rationales.

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