C

 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.

 If shock is present, monitor hemodynamic parameters for an increase in pulmonary wedge pressure, an increase in systemic vascular resistance, or a decrease in stroke volume, cardiac output, and cardiac index.

 Titrate inotropic and vasoactive medications within defined parameters to maintain contractility, preload, and afterload per physician’s order.

 When using pulmonary arterial catheter technology, be sure to appropriately level and zero the equipment, use minimal tubing, maintain system patency, perform square wave testing, position the client appropriately, and consider correlation to respiratory and cardiac cycles when assessing waveforms and integrating data into client assessment.

 Observe for worsening signs and symptoms of decreased cardiac output when using positive pressure ventilation.

 Recognize that clients with cardiogenic pulmonary edema may have noninvasive positive pressure ventilation (NPPV) ordered.

 Monitor client for signs and symptoms of fluid and electrolyte imbalance when clients are receiving ultrafiltration or continuous renal replacement therapy (CRRT).

• Recognize that hypoperfusion from low cardiac output can lead to altered mental status and decreased cognition.

• Recognize that elderly clients may demonstrate fatigue and depression as signs of HF and decreased cardiac output.

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

• Observe for syncope, dizziness, palpitations, or feelings of weakness associated with an irregular heart rhythm.

 Observe for side effects from cardiac medications.

• Design educational interventions specifically for the elderly.

• Some of the above interventions may be adapted for home care use. Home care agencies may use specialized staff and methods to care for chronic HF clients.

 Continue to monitor client closely for exacerbation of HF when discharged home.

• Assess for signs/symptoms of cognitive impairment.

• Assess for fatigue and weakness frequently. Assess home environment for safety, as well as resources/obstacles to energy conservation. Instruct client and family members on need for behavioral pacing and energy conservation.

• Help family adapt daily living patterns to establish life changes that will maintain improved cardiac functioning in the client. Take the client’s perspective into consideration and use a holistic approach in assessing and responding to client planning for the future.

• Assist client to recognize and exercise power in using self-care management to adjust to health change. Refer to care plan for Powerlessness.

 Explore barriers to medical regimen adherence. Review medications and treatment regularly for needed modifications. Take complaints of side effects seriously and serve as client advocate to address changes as indicated.

 Refer for cardiac rehabilitation and strengthening exercises if client is not involved in outpatient cardiac rehabilitation.

 Refer to medical social services as necessary for counseling about the impact of severe or chronic cardiac disease.

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

 As the client chooses, refer to palliative care for care, which can begin earlier in the care of the HF client. Palliative care can be used to increase comfort and quality of life in the HF client before end-of-life care.

 If the client’s condition warrants, refer to hospice.

• Identify emergency plan in advance, including whether use of cardiopulmonary resuscitation (CPR) is desired. Encourage family members to become certified in cardiopulmonary resuscitation if the client desires.

• Begin discharge planning as soon as possible upon admission to the emergency department (ED) with case manager or social worker to assess home support systems and the need for community or home health services. Consider referral for advanced practice nurse (APN) follow-up.

 Refer to case manager or social worker to evaluate client ability to pay for prescriptions.

• Include significant others in client teaching opportunities. Include all six areas of discharge instructions for heart failure hospitalizations: daily weight monitoring/reporting, symptoms recognition/reporting/when to call for help, smoking cessation, low-sodium diet, medication use and adherence, and regular follow-up with providers.

• Teach importance of performing and recording daily weights upon arising for the day, and to report weight gain. Ask if client has a scale at home; if not, assist in getting one.

• Teach types and progression patterns of heart failure symptoms, when to call the physician for help, and when to go to the hospital for urgent care.

• Teach importance of smoking cessation and avoidance of alcohol intake. Help clients who smoke stop by informing them of potential consequences and by helping them find an effective cessation method.

• Teach the direct benefits of a low-sodium diet.

 Teach the client importance of consistently taking cardiovascular medications, and include actions, side effects to report.

• Instruct client and family on the importance of regular follow-up care with providers.

• Teach stress reduction (e.g., imagery, controlled breathing, muscle relaxation techniques).

 Refer to an outpatient system of care.

• Provide client/family with advance directive information to consider. Allow client to give advance directions about medical care or designate who should make medical decisions if he or she should lose decision-making capacity.

• Consider atypical presentations for the elderly of possible ACS.

 Ask the prescriber about possible reduced dosage of medications for geriatric clients considering weight and creatinine clearance.

• Consider issues such as quality of life, palliative care, end-of-life care, and differences in sociocultural aspects for clients and families when supporting them in decisions regarding aggressiveness of care.

 Provide information about provider follow-up.

• Teach the client and family to call 911 for symptoms of new angina, existing angina unresponsive to rest and sublingual nitroglycerin tablets, or heart attack. Do not use friends or family for transportation where 911 is available, unless the delay is expected to be longer than 20 to 30 minutes.

• Upon discharge, instruct clients on symptoms of ischemia, when to cease activity, when to use sublingual nitroglycerin, and when to call 911.

• Upon hospital discharge, educate clients and significant others about discharge medications, including nitroglycerin sublingual tablets or spray, with written, easy to understand, culturally sensitive information.

• Provide client teaching related to risk factors for decreased cardiac tissue perfusion, such as hypertension, hypercholesterolemia, diabetes mellitus, tobacco use, advanced age, and gender (female).

• Instruct the client on antiplatelet and anticoagulation therapy about signs of bleeding, need for ongoing medication compliance, and INR monitoring.

• After discharge, continue education and support for client blood pressure and diabetes control, weight management, and resumption of physical activity.

 Provide influenza vaccine prior to discharge.

• Stress the importance of ceasing tobacco use.

• Upon hospital discharge, educate clients about low sodium, low saturated fat diet, with consideration to client education, literacy and health literacy level.

• Teach the importance of exercise.

• 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.

• Assess the health of caregivers, particularly their control over chronic diseases, at regular intervals.

• Assess the presence of and use of social support and encourage the use of secondary caregivers with elderly caregivers.

• To improve the ability to provide safe care: provide skills training related to direct care, perform complex monitoring tasks, supervise and interpret client symptoms, assist with decision-making, assist with medication adherence, provide emotional support and comfort, and coordinate care.

• Teach symptom management techniques (assessment, potential causes, aggravating factors, potential alleviating factors, reassessment), particularly for fatigue, constipation, anorexia, and pain.

• Assess for the influence of cultural beliefs, norms, and values on the client’s ability to modify health behavior.

• Despite the importance of cultural differences in perceptions of caregiver role strain, there are certain characteristics that are distressing to caregivers across multiple cultures.

• Persons with different cultural backgrounds may not perceive the provision of care with equal degrees of distress.

• Recognize that cultures often play a role in identifying who will be recognized as a family caregiver and form partnerships with those groups.

• Encourage spirituality as a source of support for coping.

• Assess for the presence of conflicting values within the culture.

• Recognize that different cultures value and use caregiving resources in different ways.

• Assess the client and caregiver at every visit for quality of relationship, and for the quality of caring that exists.

• Assess preexisting strengths and weaknesses the caregiver brings to the situation, as well as current responses, depression, and fatigue levels.

 Refer the client to home health aide services for assistance with ADLs and light housekeeping. Allow the caregiver to gain confidence in the respite provider.

• Identify client and caregiver factors that necessitate the use of formal home care services, that may affect provision of care, or that need to be addressed before the client can be safely discharged from home care.

• Collaborate with the caregiver and discuss the care needs of the client, disease processes, medications, and what to expect; use a variety of instructional techniques (e.g., explanations, demonstrations, visual aids) until the caregiver is able to express a degree of comfort with care delivery.

• Assess family caregiving skill. The identification of caregiver difficulty with any of a core set of processes highlights areas for intervention.

• Discharge care should be individualized to specific caregiver needs and care situations.

• Assess the caregiver’s need for information such as information on symptom management, disease progression, specific skills, and available support.

• Teach caregivers warning signs for burnout, depression, and anxiety. Help them identify a resource in case they begin to feel overwhelmed.

• Teach the caregiver methods for managing disruptive behavioral symptoms if present. Refer to the care plan for Chronic Confusion.

• Teach the caregiver how to provide the care needed and put a plan in place for monitoring the care provided.

• Provide ongoing support and evaluation of care skills as the care situation and care demands change.

• Provide information regarding the care recipient’s diagnosis, treatment regimen, and expected course of illness.

 Refer to counseling or support groups to assist in adjusting to the caregiver role and periodically evaluate not only the caregiver’s emotional response to care but the safety of the care delivered to the care recipient.

 Obtain a family history of hypertension and stroke to identify persons who may be at increased risk of stroke.

 Monitor BP regularly, as hypertension is a major risk factor for both ischemic and hemorrhagic stroke.

 Teach hypertensive clients the importance of taking their physician-ordered antihypertensive agent to prevent stroke.

 Stress smoking cessation at every encounter with clients, utilizing multimodal techniques to aid in quitting, such as counseling, nicotine replacement, and oral smoking cessation medications.

 Teach clients who experience a transient ischemic attack (TIA) that they are at increased risk for a stroke.

 Teach clients with a history of acute coronary syndromes (unstable angina, non-STEMI [non-ST-elevation myocardial infarction], and STEMI [ST-elevation myocardial infarction]) that they are at risk for stroke.

 Screen clients 65 years of age and older for atrial fibrillation with pulse assessment.

 Call 911 or activate the rapid response team of a hospital immediately in clients displaying the symptoms of stroke as determined by the Cincinnati Stroke Scale (F: facial drooping, A: arm drift on one side, S: speech slurred), being careful to note the time of symptom appearance. Additional symptoms of stroke include sudden numbness/weakness of face, arm or leg, especially on one side, sudden confusion, trouble speaking or understanding, sudden difficulty seeing in one or both eyes, sudden trouble walking, dizziness, loss of balance or coordination, or sudden severe headache.

 Use clinical practice guidelines for glycemic control and BP targets to guide the care of diabetic patients that have had a stroke or TIA.

 Maintain euvolemia.

 Maintain head of bed flat or less than 30 degrees in acute stroke clients.

• Utilize hand massage for elders because most respond well to touch and the provider’s presence.

• Discomfort from cold can be treated with warmed blankets.

• Use complementary touch therapies such as reflexology on clients with dementia to reduce pain and stress.

• Acknowledge any unmet physical, psychological, emotional, spiritual, and environmental needs when attempting to understand the behavior of an elderly client with dementia.

• Provide simple massage.

• Identify and clarify cultural language used to describe pain and other discomforts.

• Assess skin for ashy or yellow-brown appearance.

• Use soap sparingly if the skin is dry.

• Encourage and allow clients to practice their own cultural beliefs and recognize the impact different cultures have on a client’s belief about health care, suffering, and decision-making.

• Assess for cultural and religious beliefs when providing care to clients.

• Teach techniques to use when the client is uncomfortable, including relaxation techniques, guided imagery, hypnosis, and music therapy.

• Instruct the client and family on prescribed medications and therapies that improve comfort.

• Teach the client to follow up with the physician or other practitioner if discomfort persists.

• Encourage clients to utilize the Internet as a means of providing education to complement medical care for those who may be homebound or unable to attend face-to-face education.

• Encourage clients to use guided imagery techniques.

• Provide psychospiritual support and a comforting environment in order to enhance comfort.

• Providing music and verbal relaxation therapy can reduce anxiety.

• Caregivers should not hesitate to use humor when caring for their clients.

• Assess and evaluate child’s level of comfort at frequent intervals.

• Skin-to-skin contact (SSC) and selection of most effective method improves the comfort of newborns during routine blood draws.

• Adjust the environment as needed to enhance comfort.

• Encourage parental presence whenever possible. The same basic principles for managing pain in adults and children apply to neonates.

• Promote use of alternative comforting strategies such as positioning, presence, massage, spiritual care, music therapy, art therapy, and story-telling to enhance comfort when needed. In addition to oral sucrose, other comfort measures should be used to alleviate pain such as swaddling, skin-to-skin contact with mother, nursing, rocking, and holding.

 Support child’s spirituality.

• Identify cultural beliefs, values, lifestyles, practices, and problem-solving strategies when assessing clients.

• Enhance cultural knowledge by actively seeking out information regarding different cultural and ethnic groups.

• Recognize the impact of culture on communication styles and techniques.

• Provide culturally competent care to clients from different cultural groups.

• The nursing interventions described previously in Readiness for enhanced Comfort may be used with clients in the home care setting. When needed, adaptations can be made to meet the needs of specific clients, families, and communities.

 Make appropriate referrals to other organizations or providers as needed to enhance comfort.

 Promote an interdisciplinary approach to home care.

• Evaluate regularly if enhanced comfort is attainable in the home care setting.

• Use music therapy at home.

• Teach client how to regularly assess levels of comfort.

• Instruct client that a variety of interventions may be needed at any given time to enhance comfort.

• Help clients to understand that enhanced comfort is an achievable goal.

• Teach techniques to enhance comfort as needed.

 When needed, empower clients to seek out other health professionals as members of the interdisciplinary team to assist with comforting measures and techniques.

• Encourage self-care activities and continued self-evaluation of achieved comfort levels to ensure enhanced comfort will be maintained.

 All individuals involved in the care and everyday life of children with learning difficulties need to have a collaborate approach to communication.

• See care plan for Impaired verbal Communication.

 Assess for hearing and vision impairments and make appropriate referrals for hearing aids.

• Use touch if culturally acceptable when communicating with older clients and their families.

• Consider singing during caregiving of clients with dementia.

• See care plan for Impaired verbal Communication.

• See care plan for Impaired verbal Communication.

• The interventions described previously may be used in home care.

• See care plan for Impaired verbal Communication.

• See care plan for Impaired verbal Communication.

 Client frequently complains that people mumble, claims that others’ speech is not clear, or client hears only parts of conversations.

 Client often asks people to repeat what they said.

 Client’s friends or relatives state that client doesn’t seem to hear very well, or plays the television or radio too loudly.

 Client does not laugh at jokes due to missing too much of the story.

 Client needs to ask others about the details of a meeting that the client attended.

 Client cannot hear the doorbell or the telephone.

 Client finds it easier to understand others when facing them, especially in a noisy environment.

 Obtain client’s attention before speaking and face toward his or her unaffected side or better ear while allowing client to see speaker’s face at a reasonably close distance.

 Provide sufficient light and do not stand in front of window.

 Remove masks if safe to do so, or use see-through masks and reduce background noise whenever possible.

 Do not raise voice or overenunciate.

 Avoid making assumptions about the communication choice of those with hearing loss or voice impairments.

• Observe behavioral communication cues in infants.

• Identify and define at least two new forms of socially acceptable communication alternatives that may be used by children with significant disabilities.

• Teach children with severe disabilities functional communication skills.

 Refer children with primary speech and language delay/disorder for speech and language therapy interventions.

• Carefully assess all clients for hearing difficulty using an audiometer.

• Avoid use of “elderspeak.”

• Initiate communication with the client with dementia, and give client time to respond.

• Encourage the client to wear hearing aids, if appropriate.

• Facilitate communication and reminiscing with memory boxes that contain objects, photographs, and writings that have meaning for the client.

• Continue to find means to communicate even with those who are nonverbal.

• Nurses should become more sensitive to the meaning of a culture’s nonverbal communication modes, such as eye contact, facial expression, touching, and body language.

• Assess for the influence of cultural beliefs, norms, and values on the client’s communication process.

• 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.

• Assess for how language barriers contribute to health disparities among ethnic and racial minorities.

• Although touch is generally beneficial, there may be certain instances where it may not be advisable due to cultural considerations.

• Modify and tailor the communication approach in keeping with the client’s particular culture.

• Use reminiscence therapy as a language intervention.

• The Office of Minority Health (OMH) of the U.S. Department of Health and Human Services (DHHS) standards on culturally and linguistically appropriate services (CLAS) in health care should be used as needed.

• Teach the client and family techniques to increase communication, including the use of communication devices and tactile touch. Incorporate multidisciplinary recommendations.

 Refer the client to a speech-language pathologist (SLP) or audiologist.

 Hyperactive: delirium characterized by restlessness, agitation, hypervigilance, hallucinations and delusions; may be combative

 Hypoactive: delirium characterized by psychomotor retardation, lethargy, sedation, reduced awareness of surroundings and confusion

 Mixture of both hyper- and hypodelirium: the client fluctuates between periods of hyperactivity and agitation and hypoactivity and sedation.

 Overall appearance, manner, and attitude

 Behavior characteristics and level of psychomotor behavior (activity may be increased or decreased and may include spastic movements or tremors with delirium)

 Mood and affect (may be paranoid or fearful with delirium; may have rapid mood swings)

 Insight and judgment

 Cognition as evidenced by level of consciousness, orientation to time, place, and person, thought process (thinking may be disorganized, distorted, fragmented, slow or accelerated with delirium), and content (perceptual disturbances such as visual, auditory or tactile delusions or hallucinations)

 Level of attention (may be decreased with delirium; may be unable to focus, maintain attention or shift attention, or may be hypervigilant)

 Memory (recent and immediate memory is impaired with delirium; unable to register new information)

 Arousal (may fluctuate with delirium; sleep-wake cycle may be disturbed)

 Language (may have rapid, rambling, slurred, incoherent speech)

 Conduct a medication review and eliminate unnecessary medications. Medications that should be minimized or discontinued include anticholinergics, antihistamines, and benzodiazepines; cholinesterase inhibitors should be continued, as should carbidopa and levodopa for clients with parkinsonism.

 Communicate client status, cognition, and behavioral manifestations to all necessary providers.

 Monitor for any trends occurring in these manifestations, including laboratory tests.

• Recognize admission risk factors for delirium.

• Monitor for delirium in each client in critical care daily. Utilize the Confusion Assessment Method for the ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC).

 Sedate critical care clients carefully; monitor sedation, analgesia, and delirium scores.

• Awaken the client daily.

• Bundle awakening and breathing coordination, choosing the appropriate sedative, monitoring for delirium, and promotion of exercise and early mobility.

• Initiate mobilization, physical therapy, and occupational therapy early in the ICU stay.

• Encourage visits from families.

• Assess older adults upon hospital admission and routinely for risk factors, precipitating factors, and the presence of delirium.

• Avoid the use of restraints.

 Evaluate all medications for potential to cause or exacerbate delirium. Review the Beers Criteria for Potentially Inappropriate Medication Use in Elderly.

• Establish or maintain elimination patterns of urination and defecation.

 Determine if the client is nourished; watch for protein-calorie malnutrition. Consult with physician or dietitian as needed.

• Explain hospital routines and procedures slowly and in simple terms; repeat information as necessary.

• Provide continuity of care when possible, avoid room changes, and encourage visits from family members or significant others.

• If clients know that they are not thinking clearly, acknowledge the concern.

• 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).

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

• Assess and monitor for acute changes in cognition and behavior.

• Delirium is reversible but can become chronic if untreated. The client may be discharged from the hospital to home care in a state of undiagnosed delirium.

• Avoid preconceptions about the source of acute confusion; assess each occurrence on the basis of available evidence.

 Institute case management of frail elderly clients to support continued independent living if possible once delirium has resolved.

 Teach the family to recognize signs of early confusion and seek medical help.

• Counsel the client and family regarding the management of delirium and its sequelae.

 Assess the client for physiological causes, including acute hypoxia, pain, medication effects, malnutrition, and infections such as urinary tract infection, fatigue, electrolyte disturbances, and constipation.

 Assess for psychological causes, including changes in the environment, caregiver, routine, demands to perform beyond capacity, or multiple competing stimuli, including discomfort.

 In clients with agitated behaviors, rather than confronting the client, decrease stimuli in the environment or provide diversional activities such as quiet music, looking through a photo album, or providing the client with textured items to handle.

 If clients with dementia become more agitated, assess for pain.

 Massage the client’s hands or back to relax the client.

 Approach the client in a client-centered framework: utilize respectful, positive statements, give directions one step at a time, provide short and clear cues, utilize verbal praise for successful task completion.

 Involve the family in care of the client.

• Assess for the influence of cultural beliefs, norms, and values on the family’s or caregiver’s understanding of chronic confusion or dementia.

• Inform the client’s family or caregiver of the meaning of and reasons for common behavior observed in clients with dementia.

• 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; refer to social services or other supportive services.

• The interventions described previously may be adapted for home care use.

• Provide information to the family and home care client regarding advance directives.

• Assess the client’s memory and executive function deficits before assuming the inability to make any medical decisions; driving capacity and financial capacity should be assessed for clients with mild cognitive impairment.

• Assess the home for safety features and client needs for assistive devices. Refer to the interventions for Feeding Self-Care deficit, Dressing Self-Care deficit, Bathing Self-Care deficit as needed.

• Promote cognitive stimulation (conversation, singing, dancing, creative activities, games) and memory training exercises for individuals in the early stages of dementia.

• Provide education and support to the family regarding effective communication and ways to manage cognitive and behavioral changes; be prepared to offer support and information to family members who live at a distance as well.

• Use familiar aspects of the environment (smells, music, foods, pictures) to cue the client, capitalizing on habit to remind the client of activities in which the client can participate.

• Instruct the caregiver to provide a balanced activity schedule that does not stress the client or deprive him or her of stimulation; avoid sustained low- or high-stimulation activity.

• Encourage the use of preferred music listening to evoke memories and promote relaxation.

 If the client will require extensive supervision on an ongoing basis, evaluate the client for day care programs. Refer the family to medical social services to assist with this process if necessary.

• Encourage the family to include the client in family activities when possible. Reinforce the use of therapeutic communication guidelines (see Client/Family Teaching and Discharge Planning) and sensitivity to the number of people present.

• Assess family caregivers for caregiver stress, loneliness, and depression.

• Refer to the care plan for Caregiver Role Strain.

 Refer the client to medical social services as necessary to evaluate financial resources and initiate benefits or access to providers.

 Institute case management for frail elderly clients to support continued independent living.

• In the early stages of dementia, provide the caregiver with information on illness processes, needed care, available services, role changes, and the importance of advance directives discussion; facilitate family cohesion.

• Teach the family how to converse with a memory-impaired person and strategies for handling challenging behaviors.

• Teach the family how to provide physical care for the client (bathing, feeding, and ADLs) as well as coping strategies to deal with the burden of caregiving.

• Discuss with the family what to expect as the dementia progresses.

 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 or nursing home in the terminal stages to help the caregiver.

• Assess older adults for the presence of factors that contribute to constipation, including dietary fiber and fluid intake (less than 1.5 L/day), physical activity, use of constipating medications, and diseases that are associated with constipation.

• Explain the importance of adequate fiber intake, fluid intake, activity, and established toileting routines to ensure soft, formed stool.

• Determine the client’s perception of normal bowel elimination and laxative use; promote adherence to a regular schedule.

• Explain why straining (Valsalva maneuver) should be avoided.

• Respond quickly to the client’s call for assistance with toileting.

• Offer food, fluids, activity and toileting opportunities to elderly clients who are cognitively impaired.

• Avoid regular use of enemas in the elderly.

 Use opioids cautiously.

• Position the client on the toilet or commode and place a small footstool under the feet.

• The interventions described previously may be adapted for home care use.

• Take complaints seriously and evaluate claims of constipation in a matter-of-fact manner. Refer to the care plan for Perceived Constipation.

• Assess the self-care management activities the client is already using.

• The following treatment recommendations have been offered:

• Although the use of a 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.

• 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.

 Refer for consideration of the use of polyethylene glycol 3350 (PEG-3350) for constipation.

• Advise the client against attempting to remove impacted feces on his or her own.

• When using a bowel program, establish a pattern that is very regular and allows the client to be part of the family unit.

• 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.

• 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.

• Encourage the client to avoid long-term use of laxatives and enemas and to gradually withdraw from their use if they are used regularly.

• 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.

• The interventions described previously may be adapted for home care use.

• Take complaints seriously and evaluate claims of constipation in a matter-of-fact manner.

• Obtain family and client histories of bowel or other patterned behavior problems.

• Observe family cultural patterns related to eating and bowel habits.

• 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 fatalistic interpretations.

• Instruct the client in a healthy lifestyle that supports normal bowel function (e.g., activity, fluid intake, diet) and encourage progressive inclusion of these elements into daily activities.

• Discuss the client’s self-image. Help the client to reframe the self-concept as capable.

• Instruct the client and family in appropriate expectations for having bowel movements.

• Offer instruction and reassurance regarding explanations for variation from the previous pattern of bowel movements.

• Contract with the client and/or a responsible family member regarding the use of laxatives. Have the client maintain a bowel pattern diary. Observe for diarrhea or frequent evacuation.

 Teach the family to carry out the bowel program per the physician’s orders.

 Refer for home health aide services to assist with personal care, including the bowel program, if appropriate.

• Identify a contingency plan for bowel care if the client is dependent on outside persons for such care.

• Explain normal bowel function and the necessary ingredients for a regular bowel regimen (e.g., fluid, fiber, activity, and regular schedule for defecation).

• Work with the client and family to develop a diet that fits the client’s lifestyle and includes increased fiber.

• 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 each week is considered normal. Explain to the client the harmful effects of the continual use of defecation aids such laxatives and enemas.

• Encourage the client to gradually decrease the use of the usual laxatives and or enemas, and recognize it may take months for the process to do it gradually.

• Determine a method of increasing the client’s fluid intake and fit this practice into client’s lifestyle.

• Explain what Valsalva maneuver is and why it should be avoided.

• Work with the client and family to design a bowel training routine that is based on previous patterns (before laxative or enema abuse) and incorporates the consumption of warm fluids, increased fiber, and increased fluids; privacy; and a predictable routine.

 Use groups that have survived terrorist attacks as useful resource for victims

 Provide accurate information on risks involved, preventive measures, use of antibiotics, and vaccines

 Assist to deal with feelings of fear, vulnerability, and grief

 Encourage individuals to talk to others about their fears

 Assist victims to think positively and to move toward the future

• Help the client identify age-related factors that may affect response to contamination incidents.

• Encourage family members to acknowledge and validate the client’s concerns.

• Advise the elderly to follow public notices related to drinking water.

• Encourage older adults to receive influenza vaccination when it is available beginning as early as late August and continuing through the end of February.

• Provide environmental health hazard information.

• Caution families to avoid having children play in streams following heavy rainfall.

• Ask about use of imported or culture-specific products.

• Assess exposure to multiple pollutants, pre-existing disease, poor nutrition, substandard housing, and limited access to health care.

• Assess current environmental stressors and identify community resources.

• Residential settings may present household-related hazards that impact health such as spread of nosocomial infections and unsanitary, unsafe conditions.

• Provide truthful information to the person or family affected.

• Discuss signs and symptoms of contamination.

• Explain decontamination protocols.

• Explain need for isolation procedures.

• Emphasize the importance of pre- and postexposure treatment of contamination.

 Protect clients from contrast media-induced nephropathy by taking the following actions:

 Monitor the client carefully for symptoms of hypovolemia following use of contrast media including intake and output, blood pressure measurements, and new onset of postural hypotension with dizziness.

 Monitor the client carefully for symptoms of acute failure following use of contrast media including decreased or normal urinary output, and increased creatinine levels.

• Recognize that both allergic and anaphylactoid reactions can occur. Anaphylaxis occurs rapidly, often within 20 minutes of injection, versus a less serious anaphylactoid reaction, which can occur later after an hour.

• Watch carefully for symptoms of a reaction, which can be either mild, moderate, or severe. Report all symptoms to primary care physician because symptoms can advance from mild to severe rapidly.

• After diagnostic testing using contrast media given IV, inspect the IV site used for administration for possible problems such as extravasation, or development of compartment syndrome with excessive amounts of contrast pushed into the tissues under pressure.

• Recognize that a vascular access device utilized for administration of contrast media can rupture from the high pressures utilized to administer the contrast media.

 Screen the elderly client thoroughly before diagnostic testing utilizing contrast media.

• Refer to care plan Ineffective community Coping.

• Review coping skills, power for coping, and the use of power resources.

 Identify problems with alcohol in the elderly with the appropriate tools and make suitable referrals.

• Encourage exercise for positive coping.

• Stimulate individual reminiscence therapy.

• Stimulate group reminiscence therapy.

• Acknowledge racial/ethnic differences at the onset of care.

• Assess an individual’s sociocultural backgrounds in teaching self-management and self-regulation as a means of supporting hope and coping with a diagnosis of type 2 diabetes.

• Encourage the client to use spiritual coping mechanisms such as faith and prayer.

• Encourage spirituality as a source of support for coping.

 Refer the client for a behavioral program that teaches coping skills via “Lifeskills” workshop and/or video.

• Teach coping skills to family caregivers of cancer clients.

• Teach caregivers the COPE intervention (creativity, optimism, planning, expert information) to assist with symptom management.

• Family-based intervention may prevent anxiety disorders in the offspring of parents with anxiety disorders.

• Monitor the client’s risk of harming self or others and intervene appropriately. See care plan for Risk for Suicide.

• Support adolescent and children’s individual coping styles.

• Encourage moderate aerobic exercise (as appropriate).

 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).

• Screen for elder neglect or other forms of elder mistreatment.

• Encourage the client to make choices (as appropriate) and participate in planning care and scheduled activities.

• Target selected coping mechanisms for older persons based on client features, use, and preferences.

• Increase and mobilize support available to older persons by encouraging a variety of mechanisms involving family, friends, peers, and health care providers.

• Actively listen to complaints and concerns.

• Engage the client in reminiscence.

• Assess for the influence of cultural beliefs, norms, and values on the client’s perceptions of effective coping.

• Assess the influence of fatalism on the client’s coping behavior.

• Assess the influence of cultural conflicts that may affect coping abilities.

• Assess for intergenerational family problems that can overwhelm coping abilities.

• Encourage spirituality as a source of support for coping.

• Negotiate with the client with regard to the aspects of coping behavior that will need to be modified.

• Encourage moderate aerobic exercise (as appropriate).

• Identify which family members the client can count on for support.

• Support the inner resources that clients use for coping.

• Use an empowerment framework to redefine coping strategies.

• The interventions described previously may be adapted for home care use.

 Assess for suicidal tendencies. Refer for mental health care immediately if indicated.

• Identify an emergency plan should the client become suicidal.

• Observe the family for coping behavior patterns. Obtain family and client history as possible.

 Assess for effective symptoms after cerebrovascular accident (CVA) in the elderly, particularly emotional lability and depression. Refer for evaluation and treatment as indicated.

• 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.

 Refer the client and family to support groups.

 If monitoring medication use, contract with the client or solicit assistance from a responsible caregiver.

 Institute case management for frail elderly clients to support continued independent living.

 If the client is homebound, refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen.

• Teach the client to problem solve. Have the client define the problem and cause, and list the advantages and disadvantages of the options.

• Provide the seriously ill client and his or her family with needed information regarding the condition and treatment.

• Teach relaxation techniques.

• Work closely with the client to develop appropriate educational tools that address individualized needs.

 Teach the client about available community resources (e.g., therapists, ministers, counselors, self-help groups).

• Encourage exercise for children and adolescents to promote positive self-esteem, to enhance coping, and to prevent behavioral and psychological problems.

• Suggest that parents with children diagnosed with cancer continue with psychosocial support during and after treatment. They may use computer-mediated support groups to exchange messages with other parents.

• Consider the use of telephone support for caregivers of family members with dementia.

• Use technology for social support and to help elders stay connected to family and friends.

• Support a positive sense of humor and social support.

• Refer the older client to self-help support groups. Suggest the “Red Hat Society” for older women.

 Refer the client with Alzheimer’s disease who is terminally ill to hospice.

• Assess an individual’s sociocultural backgrounds in teaching self-management and self-regulation as a means of supporting hope and coping with a diagnosis.

• Encourage spirituality as a source of support for coping.

• Refer to care plan for Ineffective Coping.

• The interventions described previously may be adapted for home care use.

• Provide an Internet-based health coach to encourage self-management for clients with chronic conditions such as depression, impaired mobility and chronic pain.

• Refer the client to mutual health support groups.

• Refer prostate cancer clients and their spouses to family programs that include family-based interventions of communication, hope, coping, uncertainty, and symptom management.

 Refer combat veterans and service members directly involved in combat as well as those providing support to combatants, including nurses for mental health services.

• Teach the client about available community resources (e.g., therapists, ministers, counselors, self-help groups, family-education groups).

• Teach caregivers the COPE intervention (creativity, optimism, planning, expert information) to assist with symptom management.

• Teach expressive writing and education about emotions.

• Acknowledge the stressors unique to racial/ethnic communities.

• Identify community strengths with community members.

• Work with members of the community to prioritize and target health goals specific to the community.

• Establish and sustain partnerships with key individuals within communities when developing and implementing programs.

• Use mentoring strategies for community members.

• Use community church settings as a forum for advocacy, teaching, and program implementation.

• Teach strategies for stress management.

• Explain the relationship between enhancing power resources and coping.

• Assess the adolescent’s perception of support from family and friends during crisis and illness. Also thoroughly assess adolescent’s needs and concerns.

• Provide educational and psychosocial interventions such as coping skills training in treatment for families and their adolescents who have type 1 diabetes.

• Focus on the communication dynamics of families coping with chronic illness. Identify communication barriers and ways in which to enhance the communication process among parents, siblings, and other family members involved.

• Encourage the use of family rituals such as connection, spirituality, love, recreation, and celebration, especially in single-parent families.

• Staff should involve the family in decision-making processes, especially during hospital discharge planning.

• Transitioning into parenthood is a major life event for individuals. Providing effective strategies and education to first-time parents can help them feel more prepared, confident, and supported during this transition.

• Teenage mothers may experience a variety of psychosocial complications during and after their pregnancy, including conflicts due to poor relational boundaries with their own mothers. This type of conflict may exacerbate maternal stress and negatively impact mother-infant interactions.

• Perform a holistic assessment of all needs of informal spousal caregivers.

• Help caregivers believe in themselves and their ability to handle the situation, taking life one day at a time, looking for positive aspects in each situation, and relying on their own individual expertise and experience. Encourage caregivers to establish their priorities and concentrate on caring for their own physical and emotional well-being.

 Refer caregivers of clients with Alzheimer’s disease to a monthly psychoeducational support group (i.e., the Alzheimer’s Association). Incorporate nonpharmacological support programs for caregivers.

 Consider the use of telephone support for caregivers of family members with illnesses such as cancer and dementia.

• Assist in finding transportation to enable family members to visit.

• Acknowledge racial/ethnic differences at the onset of care.

• Assess for the influence of cultural beliefs, norms, and values on the family’s/community’s perceptions of coping.

• Use culturally competent assessment procedures when working with families with different racial/ethnic backgrounds.

• Provide culturally relevant interventions by understanding and utilizing treatment strategies that are acceptable and effective for a particular culture.

• Provide opportunities for families to discuss spirituality.

• Determine how the family’s cultural context impacts their decisions in regard to managing and coping with a child’s illness. Recognize and validate the cultural context.

• The interventions described previously may be adapted for home care use.

• Assess the reason behind the breakdown of family coping.

• During the time of compromised coping, increase visits to ensure the safety of the client, support of the family, and assistance with coping strategies. Provide reassurance regarding expectations for prognosis as appropriate.

 Assess the needs of the caregiver in the home. Intervene to meet needs as appropriate, 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 the caregiver’s fatigue). Encourage caregivers to attend to their own physical, mental, and spiritual health and give more specific information about the client’s needs and ways to meet them.

 Refer the family to medical social services for evaluation and supportive counseling.

 Serve as an advocate, mentor, and role model for caregiving. Write down or contract for the care needed by the client.

 When a terminal illness is the precipitating factor for ineffective coping, offer hospice services and support groups as possible resources.

• Encourage the client and family to discuss changes in daily functioning and routines created by the client’s illness. Validate discomfort resulting from changes.

• Support positive individual and family coping efforts.

 If compromised family coping interferes with the ability to support the client’s treatment plan, refer for psychiatric home health care services for family counseling and implementation of a therapeutic regimen.

• Provide truthful information and support for the family and significant people regarding the client’s specific illness or condition. Address grief issues that arise in the process, including anticipatory grief.

 Refer women with breast cancer and their family caregivers to support groups and other services that provide assistance with daily coping.

• Promote individual and family relaxation and stress-reduction strategies.

 Provide a parent support and education group to provide opportunities for parents to access support, learn new parenting skills, and, ultimately, optimize their relationships with their children in families of children in residential care.

• Siblings of sick children should be considered at risk for emotional disturbances until a full assessment of the family and social support circumstances proves otherwise.

• Recognize predictors of anger in adolescents: anxiety, depression, exposure to violence, and trait anger.

• Assess family members who are caring for clients in long-term care facilities for compassion fatigue: symptoms include the inability to disengage from the suffering of the loved one, a growing feeling of hopelessness or despair, sadness or grief, and inattention to personal care or outside responsibilities. Encourage family members to attend to their own physical, emotional, and social needs. Develop relationships of trust with family caregivers, providing them with a sense of confidence in the level of care their loved ones will be receiving in their absence. Promote therapeutic relationships with family members who are assisting with care, allowing for sharing of concerns and emotions.

• Health care professionals working with African American adolescents who are coping with parental cancer should be sensitive to the potential for post-traumatic growth.

• The interventions described previously may be adapted for home care use.

• Assess for strain in family caregivers.

 Provide psychosocial support to family members dealing with depressed or suicidal clients in the home setting.

• Involve the client and family in the planning of care as often as possible; mutual goal setting is considered part of “client safety.”

• Recognize that family decision-makers may need additional psychological support services.

• Educate family members regarding stress management techniques including massage and alternative therapies.

 Implement family-centered services for children and their caregivers.

• Identify the management styles of families and facilitate the use of more effective ways of coping with childhood illness.

• Provide educational and supportive interventions for families caring for children with illness and disability.

• Encourage family caregivers to participate in counseling and support groups.

 Provide educational interventions to family caregivers that focus on knowledge- and skill-building.

 Older adults should be provided with opportunities to engage their families and their communities.

• Acknowledge the importance of cultural influences in families and ensure that assessments and assessment tools account for such cultural differences.

 Understand and incorporate cultural differences into interventions to enhance the impact of nursing interventions.