D

• Carefully assess clients with dementia regarding ability to make decisions.

 Support previous wishes for clients with dementia.

• If end-of-life discussions are being avoided, nurses can facilitate discussions of health care choices among older adults and their family members.

• Discuss the purpose of a living will, medical power of attorney, and advance directives.

• Discuss choices or changes to be made (e.g., moving in with children, into a nursing home, or into an adult foster care home).

• Assess for the influence of cultural beliefs, norms, and values on the client’s decision-making conflict.

• Provide support for client’s decision-making.

• Identify who will be involved in the decision-making process.

• Use cross-cultural decision aids whenever possible to enhance an informed decision-making process.

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

 Before providing any home care, assess the client plan for advance directives (living will and power of attorney). If a plan exists, place a copy in the client file. If no plan exists, offer information on advance directives according to agency policy. Refer for assistance in completing advance directives as necessary. Do not witness a living will.

• Assess the client and family for consensus (or lack thereof) regarding the issue in conflict.

• Refer to the care plan for Anxiety as indicated.

 Refer to family therapy as needed.

• Instruct the client and family members to provide advance directives in the following areas:

• Inform the family of treatment options; encourage and defend self-determination.

• Identify reasons for family decisions regarding care. Explore ways in which family decisions can be respected.

• Recognize and allow the client to discuss the selection of complementary therapies available, such as spiritual support, relaxation, imagery, exercise, lifestyle changes, diet (e.g., macrobiotic, vegetarian), and nutritional supplementation.

 Provide the Physician Orders for Life-Sustaining Treatment (POLST) form for clients and families faced with end-of-life choices across the health care continuum.

• The above interventions may be adapted for geriatric use. Facilitate collaborative decision-making.

• Use existing decision aids for particular types of decisions, or develop decision aids as indicated.

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

• Develop clinical practice guidelines that include shared decision-making.

• Before teaching clients ages 9 to 20, identify client preferences in involvement with decision-making.

• Allow the client to explain his/her concepts of health care needs, then use reality-focused techniques whenever possible to provide feedback.

• Encourage communication among family members.

• Recognize denial and be aware that grieving may prolong denial.

• Assess for the influence of cultural beliefs, norms, and values involved in the client’s understanding of and ability to acknowledge health status.

• Discuss with the client those aspects of his or her health behavior/lifestyle that will remain unchanged by health status and those aspects of health behavior that will need to be modified to improve health status.

• Assess the role of fatalism in the client’s ability to acknowledge health status.

• Previously mentioned interventions may be adapted for home care utilization.

 Observe family interaction and roles. Refer the client/family for follow-up if prolonged denial is a risk.

• Encourage communication between family members, particularly when dealing with the loss of a significant person.

• Instruct client and family to recognize the signs and symptoms of recurring illness and the appropriate responses to alteration in client’s health status.

• Consider the client’s belief in and use of complementary therapies in self-managing his/her disease.

• Teach family members that denial may continue throughout the adjustment to treatment and they should not be confrontational.

 Inform family of available community support resources.

1. Position the client sitting upright or on side.

2. Use a soft-bristle baby toothbrush.

3. Use fluoride toothpaste and tap water or saline as a solution.

4. Brush teeth in an up-and-down manner.

5. Suction as needed.

• Encourage the expectant mother to eat a healthy, balanced diet that is rich in calcium.

• Advise the pregnant mother not to smoke.

• Advise the expectant mother to practice good care of her teeth, to protect her child’s teeth once born.

• Gently wipe baby’s gums with a washcloth or sterile gauze at least once a day.

• Never allow the child to fall asleep with a bottle containing milk, formula, fruit juice, or sweetened liquids. If the child needs a comforter between regular feedings, at night, or during naps, fill a bottle with cool water or give the child a clean pacifier recommended by the dentist or physician. Never give child a pacifier dipped in any sweet liquid. Avoid filling child’s bottle with liquids such as sugar water and soft drinks.

 When multiple teeth appear, brush with small toothbrush with small (pea-size) amount of fluoride toothpaste. Recommend that child either use a fluoride gel or fluoride varnish.

• Advise parents to begin dental visits at 1 year of age.

 Encourage the family to talk with the dentist about dental sealants, which can help prevent cavities in permanent teeth.

• Recommend the child use dental floss to help prevent gum disease. The dentist will give guidelines on when to start using floss.

• Recommend to parents that they not permit the child to smoke or chew tobacco, and stress the importance of setting a good example by not using tobacco products themselves.

• Recommend the child drink fluoridated water when possible.

• Recommend the child use toothpaste containing fluoride.

• Provide dentists with accurate medication history to avoid drug interactions and client harm. If the client is taking anticoagulants, the INR should be reviewed before providing dental care.

• Help clients brush own teeth, or provide dental care after breakfast and before bed every day.

• If the client has dementia or delirium, and exhibits care-resistant behavior such as fighting, biting, or refusing care, utilize the following method:

 Ensure that dentures are removed and cleaned regularly, preferably after every meal and before bedtime. Soak dentures at night in cold water.

 Support other caregivers providing oral hygiene.

• Assess for the influence of cultural beliefs, norms, and values on the client’s understanding of dental care.

• Assess for barriers to access to dental care, such as lack of insurance.

• Assess client patterns for daily and professional dental care and related patterns (e.g., smoking, nail biting). Assess for environmental influences on dental status (e.g., fluoride).

• Assess client facilities and financial resources for providing dental care.

• Request dietary log from the client, adding column for type of food (i.e., soft, pureed, regular).

• Observe a typical meal to assess first-hand the impact of impaired dentition on nutrition.

• Assist the client with accessing financial or other resources to support optimum dental and nutritional status.

• Teach how to inspect the oral cavity and monitor for problems with the teeth and gums.

• Teach how to implement a personal plan of dental hygiene, including appropriate brushing of teeth and tongue and use of dental floss. Utilize motivational interviewing to facilitate increased compliance in dental care.

• Advise clients to change their toothbrush every 3 to 4 months, because after that toothbrushes are less effective in removing plaque and are a source of bacterial contamination of the mouth and teeth.

• Teach the client the value of having an optimal fluoride concentration in drinking water, and to brush teeth twice daily with toothpaste containing fluoride.

• Teach clients of all ages the need to decrease intake of sugary foods and to brush teeth regularly.

• Inform individuals who are considering tongue piercing of the potential complications such as chipping and cracking of teeth and possible trauma to the gingiva. If piercing is done, teach the client how to care for the wound and prevent complications.

• Assess for alcohol/drug use during pregnancy. Expectant mothers should be instructed that no amount of alcohol consumption is safe during pregnancy.

• Advise expectant mothers to stop smoking and assist with methods of smoking cessation.

• Recommend that women of childbearing age take 400 mcg of folic acid daily in order to reduce the risk of neural tube defects.

• Encourage mother/baby interactions when caring for premature infants.

 Support early advanced developmental screening tests for male infants who are born prematurely or are medically fragile at birth.

 Be aware that socioeconomic factors are predictive of delayed infant development (physical and cognitive) and encourage continued screening along with follow-up care for these infants. Arrange appropriate social services referrals.

 Make arrangements for close follow-up monitoring of opioid-exposed infants.

• Provide support and education to parents of toddlers with developmental disabilities (i.e., Down syndrome, cerebral palsy).

• Encourage parents of toddlers to obtain age-appropriate developmental screenings to detect early problems.

 Discuss advantages of early speech-language intervention with parents of toddlers having delayed development in communication.

• Educate parents on the importance of providing oral care for children with mild/moderate disabilities. Parents may need to assume the responsibility of brushing for the child.

 Encourage mothers with postpartum depression to seek assistance and support as appropriate to ensure normal development of their children.

• Teach new mothers the importance of breastfeeding.

• Recognize cultural risks associated with higher infant mortality.

 Assess for mild or moderate signs of dehydration with both acute and persistent diarrhea: Mild (increased thirst and dry mouth or tongue); Moderate (decreased urination, no wet diapers for 3+ hours, feeling weak or lightheaded, irritability or listlessness, few or no tears when crying). Refer to primary care practitioner for treatment.

 Recommend that the parents give the child oral rehydration fluids to drink in the amounts specified by the physician, especially during the first 4 to 6 hours to replace lost fluid. Once the child is rehydrated, an orally administered maintenance solution should be used along with food. Continue even if child vomits.

• Recommend the mother resume breastfeeding as soon as possible.

• Recommend parents not give the child flat soda, fruit juices, gelatin dessert, or instant fruit drink.

• Recommend parents give children foods with complex carbohydrates, such as potatoes, rice, bread, cereal, yogurt, fruits, and vegetables. Avoid fatty foods, foods high in simple sugars, and milk products.

 Recommend rotavirus vaccine within the child’s vaccination schedule.

 Evaluate medications the client is taking. Recognize that many medications can result in diarrhea, including digitalis, propranolol, angiotensin-converting enzyme (ACE) inhibitors, histamine-receptor antagonists, nonsteroidal antiinflammatory drugs (NSAIDs), anticholinergic agents, oral hypoglycemia agents, antibiotics, and others.

 Monitor the client closely to detect whether an impaction is causing diarrhea; remove impaction as ordered.

 Seek medical attention if diarrhea is severe or persists for more than 24 hours, or if the client has history of dehydration or electrolyte disturbances, such as lassitude, weakness, or prostration.

• Provide emotional support for clients who are having trouble controlling unpredictable episodes of diarrhea.

• Previously mentioned interventions may be adapted for home care use.

• Assess the home for general sanitation and methods of food preparation. Reinforce principles of sanitation for food handling.

• Assess for methods of handling soiled laundry if the client is bed bound or has been incontinent. Instruct or reinforce Universal Precautions with family and blood-borne pathogen precautions with agency caregivers.

• When assessing medication history, include over-the-counter (OTC) drugs, both general and those currently being used to treat the diarrhea. Instruct clients not to mix OTC medications when self-treating.

• Evaluate current medications for indication that specific interventions are warranted.

 Evaluate the need for a home health aide or homemaker service referral.

• Evaluate the need for durable medical equipment in the home.

• Encourage avoidance of coffee, spices, milk products, and foods that irritate or stimulate the gastrointestinal tract.

• Teach appropriate method of taking ordered antidiarrheal medications; explain side effects.

• Explain how to prevent the spread of infectious diarrhea (e.g., careful handwashing, appropriate handling and storage of food, and thoroughly cleaning the bathroom and kitchen).

• Help the client to determine stressors and set up an appropriate stress reduction plan, if stress is the cause of diarrhea.

• Teach signs and symptoms of dehydration and electrolyte imbalance.

• Teach perirectal skin care.

 Consider teaching clients about complementary therapies such as probiotics, after consultation with primary care practitioner.

 Recognize that the client who has been in an intensive care environment may develop a neuromuscular dysfunction acquired in the absence of causative factors other than the underlying critical illness and its treatment, resulting in extreme weakness. The client may need a workup to determine the cause before satisfactory ambulation can begin.

 Consider use of a continuous lateral rotation therapy bed.

 For the stable client in the intensive care unit, consider mobilizing the client in a four-phase method from dangling at the side of the bed to walking if there is sufficient knowledgeable staff available to protect the client from harm.

• Get the client out of bed as early possible and ambulate frequently after consultation with the physician.

• Use the Exercise Assessment and Screening for You (EASY), which was developed to identify benefits of exercise and to assist older adults to select safe and effective exercises. This tool decreases barriers to exercise.

 Refer the client to physical therapy for resistance strength exercise training.

• Monitor for signs of depression: flat affect, poor appetite, insomnia, many somatic complaints.

• Keep careful track of bowel function in the elderly; do not allow the client to become constipated.

• Some of the previous 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 and community or home health services.

 Become oriented to all programs of care for the client before discharge from institutional care.

 Confirm the immediate availability of all necessary assistive devices for home.

• Perform complete physical assessment and recent history at initial home visit.

 Refer to physical and occupational therapies for immediate evaluations of the client’s potential for independence and functioning in the home setting and for follow-up care.

• Allow the client to have as much input and control of the plan of care as possible.

• Assess knowledge of all care with caregivers. Review as necessary.

 Support the family of the client in assumption of caregiver activities. Refer for home health aide services for assistance and respite as appropriate. Refer to medical social services as appropriate.

 Institute case management of frail elderly to support continued independent living, if possible in the home environment.

• Teach client/family how to perform range-of-motion exercises in bed if not contraindicated; this is referred to as a Home Exercise Program.

• Teach the family how to turn and position the client and provide all care necessary.

 Request an order for a child life specialist or, if not available, a play therapist for children.

• Promote a referral to a music therapist.

• Consider art therapy for children living with chronic illness who have activity restrictions.

• Provide activities such as video projects and use of computer-based support groups for children, such as Starbright World, a computer network where teenagers interact virtually, sharing their experiences and escaping hospital routines (www.starbrightworld.org).

• Provide animal-assisted therapy for hospitalized children.

• Provide computer games and virtual reality experiences for children, which can be used as distraction techniques during venipuncture or other procedures.

• Assess the interests of older adults and the types of activities that they enjoy; encourage creative expression such as storytelling, drama, dance, painting, writing, or music.

• If the client is able, arrange for him or her to attend group senior citizen activities.

• Promote activity for older adults through the use of exergames (video games combined with exercise).

• Encourage involvement in dance.

• Encourage involvement in gardening.

• Encourage clients to use their ability to help others by volunteering.

• Provide an environment that promotes activity (e.g., one that has adequate lighting for crafts, large-print books, and adequate acoustics).

• Balance effortful activities with restful activities.

• Provide tai chi as an activity.

• Provide opportunities for storytelling.

 Use reminiscence therapy in conjunction with the expression of emotions. Refer to a reminiscence group if available. Arrange for intergenerational volunteering for individuals with mild to moderate dementia.

• Use the Eden Alternative for older adults; bring in appropriate plants for the elderly client to care for, animals such as birds, fish, dogs, and cats as appropriate for the client and children to visit.

• For clients who love gardening but who may have difficulty being outside, bring in seeds, soil, and pots for indoor gardening experiences. Use seeds such as sunflower, pumpkin, and zinnia that grow rapidly.

• For clients with depressive symptoms, facilitate regular music listening.

• For clients in assisted-living facilities, provide leisure educational programs and pleasant dining experiences.

• For clients who are interested in writing, promote writing groups.

• Prescribe activities to engage passive dementia clients based on their extraversion and openness.

• Initiate opportunities for creative expression such as a TimeSlips storytelling group or Memories in the Making project to foster meaningful activities for clients with dementia.

 Provide recreational therapy exercises in the morning for clients with dementia in the extended care facility, and in geropsychiatric programs.

• Many of the previously listed interventions may be administered in the home setting.

• Explore with the client previous interests; consider related activities that are within the client’s capabilities.

 Assess the client for depression. Refer for mental health services as indicated.

• Assess the family’s ability to respond to the client’s psychosocial needs for stimulation. Assist as able.

 Refer to occupational therapy.

• Introduce (or continue) friendly volunteer visitors if the client is willing and able to have the company. If transportation is an issue or if the client does not want visitors in the home, consider alternatives (e.g., telephone contacts, computer messaging).

• For clients who are interested and capable, suggest involvement in a community gardening experience.

• If the client is dying, and is interested, assist in making a videotape, audiotape, or memory book for family members with treasured stories, memoirs, pictures, and video clips.

• Work with the client and family on learning diversional activities in which the client is interested (e.g., knitting, hooking rugs, writing memoirs).

• If the client is in isolation, give the client complete information on why isolation is needed and how it should be accomplished, especially guidelines for visitors; provide diversional activities and encourage visitation.