A

 Onset of chest discomfort or pain

 Dyspnea

 Palpitations

 Excessive fatigue

 Lightheadedness, confusion, ataxia, pallor, cyanosis, nausea, or any peripheral circulatory insufficiency

 Dysrhythmia

 Exercise hypotension

 Excessive rise in blood pressure

 Inappropriate bradycardia

 Increased heart rate

• If the client is able to walk and has chronic obstructive pulmonary disease (COPD), use the traditional 6-minute walk distance to evaluate ability to walk.

 Ensure that the chronic pulmonary client has oxygen saturation testing with exercise. Use supplemental oxygen to keep oxygen saturation 90% or above or as prescribed with activity.

• Instruct and assist a COPD client in using conscious, controlled breathing techniques during exercise, including pursed-lip breathing, and inspiratory muscle use.

 Evaluate the client’s nutritional status. Refer to a dietitian if needed. Use nutritional supplements to increase nutritional level if needed.

 For the client in the intensive care unit, consider mobilizing the client in a four-phase method if there is sufficient knowledgeable staff available to protect the client from harm.

 Refer the COPD client to a pulmonary rehabilitation program.

• If the client is able to walk and has heart failure, consider use of the 6-minute walk test to determine physical ability.

• Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity.

 Refer to a heart failure program or cardiac rehabilitation program for education, evaluation, and guided support to increase activity and rebuild life.

• See care plan for Decreased Cardiac Output for further interventions.

• Slow the pace of care. Allow the client extra time to carry out physical activities.

• Encourage families to help/allow an elderly client to be independent in whatever activities possible.

 Assess for swaying, poor balance, weakness, and fear of falling while elders stand/walk. If present, refer to physical therapy. Refer to the care plan for Risk for Falls and Impaired Walking.

 Evaluate medications the client is taking to see if they could be causing activity intolerance. Medications such as beta-blockers; lipid lowering agents, which can damage muscle; antipsychotics, which have a common side effect of orthostatic hypotension; some antihypertensives; and lowering the blood pressure to normal in the elderly can result in decreased functioning.

 If the client has heart disease causing activity intolerance, refer for cardiac rehabilitation.

 Refer the disabled elderly client to physical therapy for functional training including gait training, stepping, and sit-to-stand exercises, or for strength training.

• When mobilizing the elderly client, watch for orthostatic hypotension accompanied by dizziness and fainting.

 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.

 Assess the home environment for factors that contribute to decreased activity tolerance such as stairs or distance to the bathroom. Refer to occupational therapy, if needed, to assist the client in restructuring the home and ADL patterns.

 Refer to physical therapy for strength training and possible weight training, to regain strength, increase endurance, and improve balance. If the client is homebound, the physical therapist can also initiate cardiac rehabilitation.

• Encourage progress with positive feedback.

• Teach the client/family the importance of and methods for setting priorities for activities, especially those having a high energy demand (e.g., home/family events). Instruct in realistic expectations.

• Encourage routine low-level exercise periods such as a daily short walk or chair exercises. Provide the client/family with resources such as senior centers, exercise classes, educational and recreational programs, and volunteer opportunities that can aid in promoting socialization and appropriate activity.

 Refer to medical social services as necessary to assist the family in adjusting to major changes in patterns of living because of activity intolerance.

 Assess the need for long-term supports for optimal activity tolerance of priority activities (e.g., assistive devices, oxygen, medication, catheters, massage), especially for a hospice client. Evaluate intermittently.

 Refer to home health aide services to support the client and family through changing levels of activity tolerance. Introduce aide support early. Instruct the aide to promote independence in activity as tolerated.

• Allow terminally ill clients and their families to guide care.

• Provide increased attention to comfort and dignity of the terminally ill client in care planning.

 Institute case management of frail elderly to support continued independent living.

• Instruct the client on techniques to utilize for avoiding activity intolerance, such as controlled breathing techniques.

• Teach the client techniques to decrease dizziness from postural hypotension when standing up.

• Help client with energy conservation and work simplification techniques in ADLs.

• Describe to the client the symptoms of activity intolerance, including which symptoms to report to the physician.

• Explain to the client how to use assistive devices, oxygen, or medications before or during activity.

• Help client set up an activity log to record exercise and exercise tolerance.

 Before the first conference/meeting with the client, begin by establishing an agenda and get the assurance that the client will participate. Record the information. Give precise information on the upcoming session. At each session identify precisely the tasks to be accomplished for each session and the upcoming tasks for subsequent session.

 Ask the client how he perceives the situation in order to gather his personal vision of the problem and how he envisages his self-involvement. Specify the goals.

 Assess the client’s actual level of function (functionality) (at work, in school, at the hospital) by identifying actual dysfunctional behaviors.

 Verify if the lack of success of the project would lower the client’s self-image.

 Identify the informational needs of the person: understanding of their state of health, supervision of their treatment if they are receiving treatment, diet, and important telephone numbers.

 Identify and reinforce the elements of the client’s personality that may help him to succeed with his plan. Have the client drill and repeat: “I can change my goals (dreams) with a plan.”

 Carry out the general objective by using secondary objectives in successive stages and in a logical progression. Remember that the attainment of these objectives may imply a modification of the schedule. Use a schedule, calendar, or agenda to write down the dates. For realistic planning: choose simple tasks, limit long hours of work, protect biopsychosocial well-being, improve techniques (of relaxation, of study, of concentration, of memory, aptitude of reading, writing, the way of taking notes).

 Establish a safeguard that will be helpful in pursuing the goal. It should be nonpunitive, but help the client to remember the importance of the instrument’s use to attain the micro-objectives, the base of success. It could be written down like this: “I am going to take a 30-minute walk for 2 days. If I do it I will let myself watch TV for 1 hour, otherwise I will take a 1-hour walk for the next 2 days.” Drill and repeat: “I will realize my goals no matter what.”

 Ask yourself the following questions: is the person alone, is he capable of attaining his objective in a day or would it be better to get something going with a support team? What is the proof that this person can realistically attain his objectives?

 If necessary, coordinate the orientation of the person toward other structures or treatments that have not been used, for example: individual or group therapy, an educational support person, a financial aid person.

 Tackle the client’s fears and worries and encourage him to make a cognitive reconstruction. Use “desire thinking.” Drill and repeat: “I can change false ideas that make me believe that I am unable to carry out (achieve) my plan.”

 If the client is intubated and is stable, consider getting the client up to sit at the edge of the bed, transfer to a chair, or walk as appropriate, if an effective interdisciplinary team is developed to keep the client safe.

 If the client is intubated, consider use of kinetic therapy, using a kinetic bed that slowly moves the client with 40-degree turns.

• Reposition the client as needed. Use rotational or kinetic bed therapy as above in clients for whom side-to-side turning is contraindicated or difficult.

• When suctioning an endotracheal tube or tracheostomy tube for a client on a ventilator, do the following:

• Educate parents about the risk factors for ineffective airway clearance such as foreign body ingestion and passive smoke exposure.

• See the care plan Risk for Suffocation for more interventions on choking.

• Educate children and parents on the importance of adherence to peak expiratory flow (PEF) monitoring for asthma self-management.

• Educate parents and other caregivers that cough and cold medications bought over the counter are not safe for a child under 2 unless specifically ordered by a health care provider.

• Encourage ambulation as tolerated without causing exhaustion.

• Actively encourage the elderly to deep breathe and cough.

• Ensure adequate hydration within cardiac and renal reserves.

• Some of the above interventions may be adapted for home care use.

 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.

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

• Assess affective climate within family and family support system. Refer to care plan for Caregiver Role Strain.

• Refer to GOLD guidelines for management of home care and indications of hospital admission criteria.

• When respiratory procedures are being implemented, explain equipment and procedures to family members, and provide needed emotional support.

• When electrically based equipment for respiratory support is being implemented, evaluate home environment for electrical safety, proper grounding, and so on. Ensure that notification is sent to the local utility company, the emergency medical team, and police and fire departments.

• Provide family with support for care of a client with chronic or terminal illness.

• Refer to care plan for Anxiety. Refer to care plan for Powerlessness.

• Instruct the client to avoid exposure to persons with upper respiratory infections, to avoid crowds of people, and wash hands after each exposure to groups of people, or public places.

 Determine client adherence to medical regimen. Instruct the client and family in importance of reporting effectiveness of current medications to physician.

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

• Teach the client/family importance of maintaining regimen and having PRN drugs easily accessible at all times.

• Instruct the client and family in the importance of maintaining proper nutrition, adequate fluids, rest, and behavioral pacing for energy conservation and rehabilitation.

• Instruct in use of dietary supplements as indicated.

• Identify an emergency plan, including criteria for use.

 Refer for home health aide services for assistance with ADLs.

 Assess family for role changes and coping skills. Refer to medical social services as necessary.

 For the client dying at home with a terminal illness, if the “death rattle” is present with gurgling, rattling, or crackling sounds in the airway with each breath, recognize that anticholinergic medications can often help control symptoms, if given early in the process.

 For the client with a “death rattle,” nursing care includes turning to mobilize secretions, keeping the head of the bed elevated for postural drainage of secretions, and avoiding suctioning.

 Teach the importance of not smoking. Refer to a smoking cessation program, and encourage clients who relapse to keep trying to quit. Consider using the Motivational Interviewing technique to increase motivation for smoking cessation. Ensure that client receives appropriate medications to support smoking cessation from the primary health care provider.

 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.

 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-administer inhaled corticosteroids as ordered following precautions to decrease side effects.

• Teach the client how to deep breathe and cough effectively.

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

• Educate the client and family about the significance of changes in sputum characteristics, including color, character, amount, and odor.

• Teach the client/family about the need to take ordered antibiotics until the prescription has run out.

• Teach the family of the dying client in hospice with a “death rattle,” that rarely are clients aware of the fluid that has accumulated, and help them find evidence of comfort in the client’s nonverbal behavior.

Causes

Common allergens include: animal dander, bee stings or stings from other insects, foods, especially nuts, fish, and shellfish, insect bites, medications, plants, pollens

Symptoms

Common symptoms of a mild allergic reaction include: Hives (especially over the neck and face), itching, nasal congestion, rashes, watery, red eyes

Symptoms of a moderate or severe reaction include: Cramps or pain in the abdomen, chest discomfort or tightness, diarrhea, difficulty breathing, difficulty swallowing, dizziness or light-headedness, fear or feeling of apprehension or anxiety, flushing or redness of the face, nausea and vomiting, palpitations, swelling of the face, eyes, or tongue, weakness, wheezing, unconsciousness

First Aid

For a mild to moderate reaction: Calm and reassure the person having the reaction, as anxiety can worsen symptoms.

For a severe allergic reaction (anaphylaxis):

Do Not

When to Contact a Medical Professional

Call for immediate medical emergency assistance if:

Prevention

NOTE: Do not use serum-specific IgG testing in the diagnosis of food allergy.

See care plans for Latex Allergy Response and Risk for Latex Allergy Response.

 Teach parents and children with allergies to peanuts and tree nuts to avoid them and to identify them.

 Suspect FPIES (food protein-induced enterocolitis syndrome) in formula-fed infants with repetitive emesis, diarrhea, dehydration, and lethargy 1 to 5 hours after ingesting the offending food (the most common are cow’s milk, soy, and rice). Remove the offending food.

 Children should be screened for seafood allergies and avoid seafood and any foods containing seafood if an allergy is detected.

• The above interventions may be adapted for the pediatric client.

 Monitor the client for depression. Use appropriate interventions and referrals.

• Older adults report less worry than younger adults.

• Observe for adverse changes if antianxiety drugs are taken.

• Provide a quiet environment with diversion.

• Assess for the presence of culture-bound anxiety states.

• Identify how anxiety is manifested in the culturally diverse client.

• For diverse clients experiencing preoperative anxiety, provide music of their choice.

• The above interventions may be adapted for home care use.

 Assess for suicidal ideation. Implement emergency plan as indicated. Suicidal ideation may occur in response to co-occurring depression or a sense of hopelessness over severe anxiety symptoms or once antidepressant medications have been started. See care plan for Risk for Suicide.

• Assess for influence of anxiety on medical regimen.

• Assess for presence of depression.

• Assist family to be supportive of the client in the face of anxiety symptoms.

 Consider referral for the prescription of antianxiety or antidepressant medications for clients who have panic disorder (PD) or other anxiety-related psychiatric disorders.

 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.

 Refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen.

 Teach use of appropriate community resources in emergency situations (e.g., suicidal thoughts), such as hotlines, emergency departments, law enforcement, and judicial systems.

• Teach the client/family the symptoms of anxiety.

• Teach the client techniques to self-manage anxiety.

• Teach the client to visualize or fantasize about the absence of anxiety or pain, successful experience of the situation, resolution of conflict, or outcome of procedure.

• Teach relationship between a healthy physical and emotional lifestyle and a realistic mental attitude.

• Carefully assess older adults for issues regarding death anxiety.

• Provide back massage for clients who have anxiety regarding issues such as death.

• Refer to care plan for Grieving.

• Assist clients to identify with their culture and its values.

• Refer to care plans for Anxiety and Grieving.

• The above interventions may be adapted for home care.

• Identify times and places when anxiety is greatest. Provide for psychological support at those times, using such strategies as personal contact, telephone contact, diversionary activities, or therapeutic self.

• Support religious beliefs; encourage client to participate in services and activities of choice.

 Refer to medical social services or mental health services, including support groups as appropriate (e.g., anticipatory grieving groups from hospice, visiting volunteers of hospice).

• Encourage the client to verbalize feelings to family/caregivers, counselors, and self.

• Identify client’s preferences for end-of-life care; provide assistance in honoring preferences as much as practicable.

 Assist the client in making contact with death-related planning organizations, if appropriate, such as the Cremation Society and funeral homes.

 Refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen.

• Refer to care plan for Powerlessness.

• Promote more effective communication to family members engaged in the caregiving role. Encourage them to talk to their loved one about areas of concern. Both caregivers and care receivers avoid discussing.

• Allow family members to be physically close to their dying loved one, giving them permission, instruction, and opportunities to touch. Keep family members informed.

• To increase clients’ knowledge about end-of-life issues, teach them and their family members about options for care, such as advance directives.

 Insert nasogastric feeding tube using the internal nares to distal-lower esophageal-sphincter distance, an updated version of the Hanson method.

 Tape the feeding tube securely to the nose using a skin protectant under the tape.

 Check to make sure the initial nasogastric feeding tube placement was confirmed by x-ray, with the openings of the tube in the stomach, not the esophagus, or lungs. This is especially important if a small-bore feeding tube is used, although larger tubes used for feedings or medication administration should be verified by x-ray also.

• After x-ray verification of correct placement of the tube or the intestines, mark the tube’s exit site clearly with tape or a permanent marker.

• Measure and record the length of the tube that is outside of the body at defined intervals to help ensure correct placement.

• Note the placement of the tube on any chest or abdominal x-rays that are done on the client.

• Check the pH of the aspirate. If the pH reading is 4 or less, the tube is probably in the stomach.

• Utilize a number of determinants of correct placement for verification of correct placement before each feeding or every 4 hours if client is on continuous feeding. Measure length of tube outside of body, any recent x-ray results, pH of aspirate if relevant, and characteristic appearance of aspirate. If findings do not ensure correct placement of the tube, obtain an x-ray to verify placement. Do not rely on the air insufflation method.

 Follow unit policy regarding checking for gastric residual volume during continuous feedings or before feedings, and holding feedings if increased residual feeding is present.

• Follow unit protocol regarding returning or discarding gastric residual volume.

• Do not use glucose testing to determine correct placement of enteral tube, and to identify aspirated enteral feeding.

• Do not use blue dye to tint enteral feedings.

• During enteral feedings, position client with head of bed elevated 30 to 45 degrees.

• Take actions to prevent inadvertent misconnections with enteral feeding tubes into IV lines, and other harmful places. Safety actions that should be taken to prevent misconnections include:

• Recognize that critically ill clients are at an increased risk for aspiration because of severe illness and interventions that compromise the gag reflex.

• Recognize that intolerance to feeding as defined by increased gastric residual is more common early in the feeding process.

• Carefully check elderly client’s gag reflex and ability to swallow before feeding.

• 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.

 Recognize that the elderly with aspiration pneumonia have fewer symptoms than younger people; repeat cases of pneumonia in the elderly are generally associated with aspiration.

 Use central nervous system depressants cautiously; elderly clients may have an increased incidence of aspiration with altered levels of consciousness.

• Keep an elderly, mostly bedridden client sitting upright for 45 minutes to 1 hour following meals.

• Recommend to families that enteral feedings may or may not be indicated for clients with advanced dementia. Instead if possible use hand-feeding assistance, modified food consistency as needed, and feeding favorite foods for comfort.

• The above interventions may be adapted for home care use.

• For clients at high risk for aspiration, obtain complete information from the discharging institution regarding institutional management.

• Assess the client and family for willingness and cognitive ability to learn and cope with swallowing, feeding, and related disorders.

• Assess caregiver understanding and reinforce teaching regarding positioning and assessment of the client for possible aspiration.

• Provide the client with emotional support in dealing with fears of aspiration. Refer to care plan for Anxiety.

• Establish emergency and contingency plans for care of client.

 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).

• Obtain suction equipment for the home as necessary.

• Teach caregivers safe, effective use of suctioning devices. Inform client and family that only individuals instructed in suctioning should perform the procedure.

 Institute case management of frail elderly to support continued independent living.

• Teach the client and family signs of aspiration and precautions to prevent aspiration.

• Teach the client and family how to safely administer tube feeding.

• Recognize and support infant/child’s capacity for self-regulation and intervene when appropriate.

• Provide lyrical, soothing music in nursery and home that is age-appropriate (i.e., corrected, in the case of premature infants) and contingent with state/behavioral cues.

• Recognize and support infant/child’s attention capabilities.

• Encourage opportunities for mutually satisfying interactions between infant and parent.

• Encourage opportunities for physical closeness.

• Provide culturally sensitive parent support to non‒English-speaking mothers and families.

• Discuss cultural norms with families to provide care that is appropriate for enhancing attachment with the infant/child.

• Promote the attachment process in women who have abused substances by providing a culturally based, women-centered treatment environment.

• Promote attachment process/development of maternal sensitivity in incarcerated women.

• Empower family members to draw on personal strengths in which multiple worldviews/values are recognized, incorporated, and negotiated.

• Encourage positive involvement and relationship development between children and noncustodial fathers to enhance health and development.

• The above interventions may be adapted for home care use.

• Assess quality of interaction between parent and infant/child.

• Use “interaction coaching” (i.e., teaching mother to let the infant lead) so that the mother will match her interaction style to the baby’s cues.

• Identify community resources/supportive network systems for mothers showing depressive symptoms.

• Provide supportive care for infants and children whose parents have been deployed during wartime.

• Provide support to custodial grandparents.

 First, assess bladder function. Check for distention, and if present catheterize using an anesthetic jelly as a lubricant. Do not use Valsalva maneuver or Crede’s method to empty the bladder. Ensure existing catheter patency. Also note signs of urinary tract infection.

 Second, assess bowel function. Numb the bowel area with a topical anesthetic as ordered, and once agent is effective (5 minutes), check for impaction.

 Third, assess the skin, looking for any points of pressure.

 Ensure that drainage from an indwelling catheter is good and that bladder is not distended.

 Ensure a regular pattern of defecation to prevent fecal impaction.

 Frequently change position of client to relieve pressure and prevent the formation of pressure ulcers.

• The above interventions may be adapted for home care use.

• Instruct the client with any known proclivity toward dysreflexia to wear a medical alert bracelet and carry a medical alert wallet card when not in a safe environment (i.e., not with someone who knows client has the condition and can respond appropriately).

 Establish an emergency plan: obtain provider/physician orders for medications to be used in situations in which first aid does not work and plans to identify potential stimuli.

 If orders have not been obtained or client does not have medications, use emergency medical services.

• When episode of dysreflexia is resolved, monitor blood pressure every 30 to 60 minutes for next 5 hours or admit to institution for observation.

• 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 information.

• Teach steps to prevent dysreflexia episodes: care of bladder, bowel, and skin and prevention of other forms of noxious stimuli (i.e., not wearing clothing that is too tight).

• Discuss the potential impact of sexual intercourse and pregnancy on autonomic dysreflexia.