B

• Use prepackaged medications and prefilled or premixed parenteral therapy as ordered

• Check laboratory tests (i.e., INR) before administration

• Use programmable pumps when using parenteral administration

• Ensure appropriate education for client/family and all staff concerning anticoagulants used

• Notify dietary services when warfarin prescribed (to reduce vitamin K in diet)

• Monitor for any symptoms of bleeding prior to administration.

 Before administering anticoagulants, assess the clotting profile of the client. If the client is on warfarin, assess the INR. Hold the medication if the INR is outside of the recommended parameters and notify the physician or advanced practice nurse.

 Recognize that vitamin K may be given orally or intravenously as ordered for INR levels greater than 5.0. In some circumstances fresh frozen plasma (FFP), prothrombin complex concentrate (PCC), and/or recombinant factor VIIa (rVIIa) may be administered if serious or life-threatening bleeding occurs.

 Manage fluid resuscitation and volume expansion as ordered.

 Consider discussing the co-administration of a proton-pump inhibitor alongside traditional NSAIDs, or with the use of a cyclo-oxygenase 2 inhibitor with the prescriber.

• Ensure adequate nurse staffing in order to be able to provide a high level of surveillance capability.

 Recognize that prophylactic vitamin K administration should be used in neonates for vitamin K deficiency bleeding (VKDB).

 Recognize warning signs of VKDB including minimal bleeds, evidence of cholestasis (icteric sclera, dark urine, irritability), and failure to thrive.

 Use caution in administering NSAIDs in children.

 Monitor children and adolescents for potential bleeding.

 Closely monitor post-cardiotomy clients requiring extracorporeal life support when cardiopulmonary bypass (CPB) duration is prolonged.

• Teach client and family or significant others about any anticoagulant medications prescribed including when to take, how often to have lab tests done, signs of bleeding to report, dietary restrictions needed, and precautions to be followed. Instruct the client to report any adverse side effects to his/her health care provider.

• Instruct the client and family on disease process and rationale for care.

• Provide client and family or significant others with both oral and written educational materials that meet the standards of client education and health literacy.

 Refer parents of children with eating disorders to a support group.

 Refer children and families with severe facial burns for psychosocial support.

 Assess family dynamics and refer parents of adolescents with anorexia or other eating disorders to professional family counseling if indicated.

• Discuss with parents the potentially negative influence media has on younger children as a source of unrealistic ideals of body image.

 Consider using a measurement tool such as the Children’s Body Image Scale (CBIS) if a child is at risk for body image disturbance.

• Focus on remaining abilities. Have client make a list of strengths.

• Encourage regular exercise for the elderly.

• Assess for the influence of cultural beliefs, regional norms, and values on the client’s body image.

• Acknowledge that body image disturbances can affect all individuals regardless of culture, race, or ethnicity.

• Assess client’s level of social support as it is one of the determinants of client’s recovery and emotional health.

• Assess family/caregiver level of acceptance of client’s body changes.

• Encourage client to discuss concerns related to sexuality and provide support or information as indicated. Many conditions that affect body image also affect sexuality.

• Teach all aspects of care. Involve client and caregivers in self-care as soon as possible. Do this in stages if client still has difficulty looking at or touching changed body part.

• Teach appropriate care of surgical site (e.g., mastectomy site, amputation site, ostomy site, etc.).

• Inform client of available community support groups, such as Internet discussion boards.

• Encourage significant others to offer support.

 Refer clients who are having difficulty with personal acceptance, personal and social body image disruption, sexual concerns, reduced self-care skills, and the management of surgical complications to an interdisciplinary team or specialist (e.g., ostomy nurse) if available.

• Provide individualized follow-up with extra home visits or outpatient visits for teen mothers within the first few days after hospital discharge and encourage schools to be more compatible with breastfeeding.

• Provide information and support to mothers on benefits of breastfeeding at antenatal visits.

• Assess whether the client’s concerns about the amount of milk taken during breastfeeding is contributing to dissatisfaction with the breastfeeding process.

• Assess the influence of family support on the decision to continue or discontinue breastfeeding.

• Provide traditional ethnic foods for breastfeeding mothers.

• See care plan for Readiness for enhanced Breastfeeding.

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

• Provide anticipatory guidance in relation to home management of breastfeeding.

• Investigate availability/refer to public health department, hospital home follow-up breastfeeding program, or other postdischarge support.

• Refer to care plan for Risk for impaired Attachment.

• Instruct the client on maternal breastfeeding behaviors/techniques (preparation for, positioning, initiation of/promoting latch-on, burping, completion of session, and frequency of feeding). Consider use of a video.

• Teach the client self-care measures for the breastfeeding woman (e.g., breast care, management of breast/nipple discomfort, nutrition/fluid, rest/activity).

• 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).

• Provide education to father/family/significant others as needed.

• Assess for the influence of cultural beliefs, norms, and values on current breastfeeding practices.

• Assess mothers’ timing preference to begin breastfeeding.

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

• Include the father and other family members in education about breastfeeding.

• Teach the client the importance of maternal nutrition.

• Reinforce the infant’s subtle hunger cues (e.g., quiet-alert state, rooting, sucking, mouthing, hand-to-mouth, hand-to-hand activity) and encourage the client to nurse whenever signs are apparent.

• Review guidelines for frequency (every 2 to 3 hours, or 8 to 12 feedings per 24 hours) and duration (until suckling and swallowing slow down and satiety is reached) of feeding times.

• Provide anticipatory guidance about common infant behaviors.

• Provide information about additional breastfeeding resources.

• Monitor for symptoms of hyperventilation including rapid respiratory rate, sighing breaths, lightheadedness, numbness and tingling of hands and feet, palpitations, and sometimes chest pain.

• Assess cause of hyperventilation by asking client about current emotions and psychological state.

• Ask the client to breathe with you to slow down respiratory rate.

 Consider having the client breathe in and out of a paper bag as tolerated.

 If client has chronic problems with hyperventilation, numbness and tingling in extremities, dizziness, and other signs of panic attacks, refer for counseling.

 Ensure that client in acute dyspneic state has received any ordered medications, oxygen, and any other treatment needed.

• Determine severity of dyspnea using a rating scale such as the modified Borg scale, rating dyspnea 0 (best) to 10 (worst) in severity. An alternative scale is the Visual Analogue Scale (VAS) with dyspnea rated as 0 (best) to 100 (worst).

• Note use of accessory muscles, nasal flaring, retractions, irritability, confusion, or lethargy.

• Observe color of tongue, oral mucosa, and skin for signs of cyanosis.

• Auscultate breath sounds, noting decreased or absent sounds, crackles, or wheezes.

 Monitor oxygen saturation continuously using pulse oximetry. Note blood gas results as available.

• Using touch on the shoulder, coach the client to slow respiratory rate, demonstrating slower respirations; making eye contact with the client; and communicating in a calm, supportive fashion.

• Support the client in using pursed-lip and controlled breathing techniques.

• If the client is acutely dyspneic, consider having the client lean forward over a bedside table, resting elbows on the table if tolerated.

• Position the client in an upright position. An upright position facilitates lung expansion. See Nursing Interventions for Impaired Gas Exchange for further information on positioning.

 Administer oxygen as ordered.

• Increase client’s activity to walking three times per day as tolerated. Assist the client to use oxygen during activity as needed. See Nursing Interventions and Rationales for Activity Intolerance.

• Schedule rest periods before and after activity.

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

• Provide small, frequent feedings.

• Offer a fan to move the air in the environment.

• Encourage the client to take deep breaths at prescribed intervals and do controlled coughing.

• Help the client with chronic respiratory disease to evaluate dyspnea experience to determine if similar to previous incidences of dyspnea and to recognize that he or she made it through those incidences. Encourage the client to be self-reliant if possible, use problem-solving skills, and maximize use of social support.

• See Ineffective Airway Clearance if client has a problem with increased respiratory secretions.

 Refer the COPD client for pulmonary rehabilitation.

• Encourage ambulation as tolerated.

• Encourage elderly clients to sit upright or stand and to avoid lying down for prolonged periods during the day.

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

• Work with the client to determine what strategies are most helpful during times of dyspnea. Educate and empower the client to self-manage the disease associated with impaired gas exchange.

• 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).

• Assess client knowledge of and compliance with medication regimen.

 Refer the client for telemonitoring with a pulmonologist as appropriate, with use of an electronic spirometer, or an electronic peak flowmeter.

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

• 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. Refer to care plan for Anxiety.

• When respiratory procedures (e.g., apneic monitoring for an infant) 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 forth. Ensure that notification is sent to the local utility company, the emergency medical team, police and fire departments.

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

• Support clients’ efforts at self-care. Ensure they have all the information they need to participate in care.

• Identify an emergency plan including when to call the physician or 911.

 Refer to occupational therapy for evaluation and teaching of energy conservation techniques.

 Refer to home health aide services as needed to support energy conservation.

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

• Teach pursed-lip and controlled breathing techniques.

• Teach about dosage, actions, and side effects of medications.

• Using a prerecorded CD, teach client progressive muscle relaxation techniques.

• Teach the client to identify and avoid specific factors that exacerbate ineffective breathing patterns, such as exposure to other sources of air pollution, especially smoking. If client smokes, refer to the smoking cessation section in the Impaired Gas Exchange care plan.