F

• Elderly clients who have failure to thrive (FTT) should be evaluated by review of their ADLs, cognitive function, and mood; a comprehensive history and physical examination; selected laboratory studies and screening for alcohol and substance abuse.

• Assess for depression with a geriatric depression scale. Be alert for depression in clients newly admitted to nursing homes.

• Screen for depression in persons with adult macular degeneration (AMD) and low vision or vision loss.

 Carefully assess for elder abuse and refer for treatment.

• Encourage the client to make decisions independently; offer choices.

• Instill hope; assist client to manage chronic conditions through education and social support.

• Provide music for clients with dementia, pain, acute confusion, and functional deficits.

 Consider the use of light therapy.

 Provide opportunities for visitation from animals.

• Encourage clients to reminisce and share and compile life histories.

• Complete a spiritual assessment and support the client’s spirituality; encourage clients to connect with their preferred faith community, and to pray if they wish.

• Evaluate the social support system and help the client to identify ways he might increase social support.

• Encourage older adult clients to take part in activities and social relationships according to their capacity and wishes.

• Help clients identify and practice activities that promote usefulness.

• Provide physical touch or massage for clients. Touch the client’s hand or arm when speaking with him or her; offer hugs with permission.

 Assess possible causes for adult FTT and treat or alleviate any underlying problems such as dysphagia, malnutrition, dehydration, depression, infection, diarrhea, renal failure, polypharmacy, sensory impairments, and illnesses caused by physical and cognitive changes.

• Assess for signs of fatigue and mental status changes that may indicate an infection is present.

• Monitor weight loss, food intake (leaving 25% or more of food uneaten at most meals), psychiatric/mood diagnoses, and decreased ability to participate in ADLs.

• Assess for signs of dehydration; the Dehydration Risk Appraisal Checklist is a potential tool for determining this risk in nursing home residents.

• Play soothing music during mealtimes to increase the amount of food eaten and promote decreased agitation.

• Decrease noise and increase lighting in the dining area.

• Serve “family-style” meals.

 Refer to a dietitian for individualized nutrition therapy; include the older adult in food choice decisions.

• Refer to care plan Readiness for enhanced Nutrition for additional interventions.

• Assess how often the frail older adult goes outdoors; encourage outside activities.

• Provide creative opportunities for interaction with the natural environment.

• Assess grip strength periodically and monitor for a decline in strength.

• Assess and monitor physical function in terms of the client’s ability to complete with tools such as the Katz Index or Lawton Scale.

• Assess frailty with a tool such as the Edmonton Frail Scale.

• Provide strength and resistance training.

• Promote participation in an exercise-based balance program.

• Implement dance therapy.

 Refer for possible pharmacological intervention.

• Refer to care plans for Imbalanced Nutrition: less than body requirements, Hopelessness, Spiritual Distress, Readiness for enhanced Spiritual Well-Being, Social Isolation, Chronic Sorrow, Chronic low Self-Esteem.

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

• Actively listen and be sensitive to how communication is shared culturally; some cultures combine communication with eye contact, and some avoid eye contact.

 Refer culturally diverse clients to appropriate social, medical, mental health, and spiritual services.

• Refer to a dietitian who can suggest the least restrictive diet that considers ethnic and cultural preferences.

• Promote participation in a community-based exercise program that focuses on strength, endurance, and balance.

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

• If FTT is attributable to a dementing illness, refer to care plan for Chronic Confusion.

 Institute case management or coordinated care of frail elders in the community.

 Consider use of a nurse-managed telehealth system with clients who have been discharged early from the hospital to monitor symptoms, provide education, and make referrals if necessary.

 Refer for medical evaluation when cognitive changes are noticed.

• Encourage family to provide and encourage social interaction with the client.

• Instruct the family to monitor the elder person’s weight.

 Provide referral for evaluation of hearing and appropriate hearing aids.

 Refer for psychotherapy and possible medication if the etiology is depression.

 Well-staffed and educated nursing personnel with frequent client contact with careful consideration during shift changes

 Nursing units designed to care for clients with cognitive or functional impairments

 Nonskid footwear, sneakers preferable

 Adequate lighting, night-light in bathroom

 Toilet frequently

 Frequently assess need for invasive devices, tubes, IVs

 Hide tubes with bandages to prevent pulling of tubes

 Consider alternative IV placement site to prevent pulling out IV

 Alarm systems with ankle, above-the-knee, or wrist sensors

 Bed or wheelchair alarms

 Wedge cushions on chairs to prevent slipping

 Increased observation of the client

 Locked doors to unit

 Low or very low height beds

 Border-defining pillow/mattress to remind the client to stay in bed

• Assess fall risk using a falls risk assessment tool such as the Hendrich II Fall Risk Model, Stratify Tool, or Morse Falls Scale.

• Complete a post-fall assessment for older adults.

 If new onset of falling, assess for lab abnormalities, and signs and symptoms of infection and dehydration, and check blood pressure and pulse rate supine, sitting, and standing for hypotension and orthostatic hypotension. If the client has a borderline high blood pressure, the risk of falling due to administration of antihypertensives may outweigh the benefits of the antihypertensive medication. Discuss with the health care provider on a client-to-client basis.

• Complete a fear of falling assessment for older adults. This includes measuring fear of falling, or the level of concern about falling, and falls self-efficacy, the degree of confidence a person has in performing common activities of daily living without falling.

• Encourage the client to wear glasses and use walking aids when ambulating.

• If the client experiences dizziness because of orthostatic hypotension when getting up, teach methods to decrease dizziness, such as rising slowly, remaining seated several minutes before standing, flexing feet upward several times while sitting, sitting down immediately if feeling dizzy, and trying to have someone present when standing.

 Refer to physical therapy for strength training, using free weights or machines, and suggest participation in exercise programs.

 Implement evidence-based interventions to prevent falls. These include:

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

• Implement evidence-based fall prevention practices to older adults in community settings and home health care programs.

 If delirium is present, assess for cause of delirium and/or falls with the use of an interdisciplinary team. Consult with the physician immediately. Assess and monitor for acute changes in cognition and behavior.

• Assess home environment for threats to safety including clutter, slippery floors, scatter rugs, and other potential hazards. Additionally, assess external environment (e.g., uneven pavement, unleveled stairs/steps).

 Instruct the client and family or caregivers on how to correct identified hazards for those with visual impairment. Refer to physical and occupational therapy services for assistance if needed.

 Use a multifactorial assessment along with interventions targeted to the identified risk factors. Key components of the interventions include evaluating need for all medications; balance, gait and strength training; use of strategies to deal with postural hypotension, if present; home safety evaluation with needed modifications; and any needed cardiovascular treatment.

• Encourage the client to eat a balanced diet, with particular inclusion of vitamin D and calcium.

• If the client lives alone or spends a lot of time alone, teach the client what to do if he or she falls and cannot get up, and suggest he or she have a personal emergency response system or a mobile phone that is available from the floor.

• Ensure appropriate nonglare lighting in the home. Ask the client to install indoor strip or “runway” type of lighting to baseboards to help clients vision. Install motion-sensitive lighting that turns on automatically when the client gets out of bed to go to the bathroom.

• Have the client wear supportive, low-heeled shoes with good traction when ambulating. Avoid use of slip-on footwear. Wear appropriate footwear in inclement weather.

• Provide a signaling device for clients who wander or are at risk for falls.

• Provide medical identification bracelet for clients at risk for injury from dementia, diabetes, seizures, or other medical disorders.

• Suggest a tai chi class designed for the elderly to selected clients who have sufficient balance to participate.

• Safety guidelines. Teach the client and the family about the fall reduction measures that are being used to prevent falls.

• Teach the client how to safely ambulate at home, including using safety measures such as hand rails in bathroom, and need to avoid carrying things or performing other tasks while walking.

• Teach the client the importance of maintaining a regular exercise program. If the client is afraid of falling while walking outside, suggest he or she walks the length of a local mall.

• Use closed-ended questions when questioning adolescents about drinking behavior.

• Provide a brief motivational interviewing and cognitive-behavioral‒based alcohol intervention group program for young people at risk of developing a problem with alcohol.

• Encourage parent communication about alcohol use with adolescents.

 Consider the Community Reinforcement Approach (CRA) that encourages clients to become progressively involved in alternative nonsubstance-related pleasant social activities, and to work on enhancing the enjoyment they receive within the “community” of their family and job.

 Educate family members about available educational and support programs and encourage no/limited alcohol use in the home.

• Work at strengthening adolescents’ relationships in and out of the home.

• Provide school-based prevention programs using peer leaders at an early age.

• Provide a school-based drug-prevention program to junior high students.

• Include assessment of possible alcohol abuse when assessing elderly family members.

 Provide alcohol treatment programs for geriatric clients in primary care settings.

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

• Use a family-centered approach when working with Latino, Asian American, African American, and Native American clients.

• Some less-acculturated Latino families may be unwilling to discuss family issues with health care providers until they perceive a close personal relationship with the provider.

• Use family strengthening interventions such as behavioral parent training, family skills training, in-home family support, brief family therapy, and family education when working with culturally diverse families.

• Work with families in a way that incorporates cultural elements.

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

• Work with family members to support a sense of valued fit on their part; include them in treatment planning and identify the importance of their roles in the client’s care. At the same time, encourage their pursuit of positive outside activities that enhance their sense of belonging.

• Educate client and family regarding the interactions of alcohol use with medications and the therapeutic regimen.

• Alcoholism is a family disease.

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

• Provide telephone prompting for clients to start alcohol treatment.

• Suggest the client complete a confidential Internet self-screening test for identification of problems and suggestions for treatment if a problem with alcohol is suspected. Many tools are available.

• Provide education for family.

• Facilitate participation in mutual help groups.

• Carefully assess potential for reunifying children placed in foster care with their birth parents.

• Allow and encourage family to assist in the client’s care.

 Refer children and mothers exposed to violence in the home to Theraplay: an attachment-based intervention that uses the four core elements of nurturing, engagement, structure, and challenge in interactions between mother and her child.

• Encourage family members to be involved in the care of relatives who are in residential care settings.

• Support group problem solving among family members and include the older member.

 Refer family for counseling with a psychotherapist who is knowledgeable about gerontology.

• Refer to care plan for Readiness for enhanced Family Processes for additional interventions.

• Refer to the care plan Readiness for enhanced Family Processes for additional interventions.

• The nursing interventions described in the care plan for Compromised family Coping should be used in the home environment with adaptations as necessary.

• Encourage family members to find meaning in a serious illness.

• Refer to Client/Family Teaching and Discharge Planning in Compromised family Coping and Readiness for enhanced family Coping for suggestions that may be used with minor adaptations.

• Provide a parenting class series based on individual and couple changes in meaning and identity, roles, and relationships and interaction during the transition to parenthood. Address mother and father roles, infant communication abilities, and patterns of the first 3 months of life in a mutually enjoyable, possibility focused manner.

• Encourage families with adolescents to have family meals.

 Consider the use of adventure therapy for adolescents with cancer.

• Carefully listen to residents and family members in the long-term care facility.

• Support caregivers’ awareness of the positive effects of their contribution to the well-being of parents.

• Teach family members about the impact of developmental events (e.g., retirement, death, change in health status, and household composition).

• Encourage social networks; social integration; and social engagement with friends, children, and relatives of the elderly.

• Evaluate fatigue in elderly clients routinely, particularly in clients with limited physical function and lower levels of social support.

• Review comorbid conditions that may contribute to fatigue, such as congestive heart failure, arthritis, obesity, and cancer.

• Identify recent losses; monitor for depression as a possible contributing factor to fatigue.

 Review medications for side effects.

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

• Assess the client’s history and current patterns of fatigue as they relate to the home environment and environmental and behavioral triggers of increased fatigue.

 Refer to occupational and/or physical therapy if substantial intervention is needed to assist the client in adapting to home and daily patterns.

• For clients receiving chemotherapy, intervene to:

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

• Assess effect of fatigue on the client’s relatedness; recognize that the client’s fatigue affects the whole family. Initiate the following interventions:

 Refer for family therapy in the event the client’s fatigue interferes with normal family functioning.

• Help client to reframe cognitively; share information about fatigue and how to live with it, including need for positive self-talk.

• Teach strategies for energy conservation (e.g., sitting instead of standing during showering, storing items at waist level).

• Teach the client to carry a pocket calendar, make lists of required activities, and post reminders around the house.

• Teach the importance of following a healthy lifestyle with adequate nutrition, fluids, and rest; pain relief; insomnia correction; and appropriate exercise to decrease fatigue (i.e., energy restoration).

• See Hopelessness care plan if appropriate.

• Use drawing and artistic expression to assist children express fear.

• Explore coping skills previously used by the client to deal with fear.

• Teach parents to use cognitive-behavioral strategies such as positive coping statements (“I am a brave girl [boy]. I can take care of myself in the dark”) and rewards of bravery tokens for appropriate behavior.

• Screen for depression in clients who report social or school fears.

• Teach relaxation techniques to children to induce calmness.

• Establish a trusting relationship so that all fears can be identified.

• Monitor for dementia and use appropriate interventions.

• Provide a protective and safe environment, use consistent caregivers, and maintain the accustomed environmental structure.

• Observe for untoward changes if antianxiety drugs are taken.

• Assess for fear of falls in hospitalized clients with hip fractures to determine risk of poor health outcomes.

• Encourage exercises to improve physical skills and levels of mobility to decrease fear of falling.

• Assist the client in identifying and reducing risk factors of falls, including environmental hazards in and out of the home, the importance of good nutrition and activity, proper footwear, and how to stand up after a fall.

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

• Assess for the influence of cultural beliefs, norms, and values on the client’s perspective of a stressful situation.

• Identify what triggers fear response.

• Identify how the client expresses fear.

• Validate the client’s feelings regarding fear.

• Assess for fears of racism in culturally diverse clients.

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

• Assess to differentiate the presence of fear versus anxiety.

• Refer to care plan for Anxiety.

• During initial assessment, determine whether current or previous episodes of fear relate to the home environment (e.g., perception of danger in the home or neighborhood or of relationships that have a history in the home).

• Identify with the client what steps may be taken to make the home a “safe” place to be.

 Encourage the client to seek or continue appropriate counseling to reduce fear associated with stress or resolve alterations in irrational thought processes.

 Encourage the client to have a trusted companion, family member, or caregiver present in the home for periods when fear is most prominent. Pending other medical diagnoses, a referral to homemaker or home health aide services may meet this need.

 Offer to sit quietly with a terminally ill client as needed by the client or family, or provide hospice volunteers to do the same.

• Teach the client the difference between warranted and excessive fear.

• Teach clients to use guided imagery when they are fearful; have them use all senses to visualize a place that is “comfortable and safe” for them.

• Teach use of appropriate community resources in emergency situations (e.g., hotlines, emergency departments, law enforcement, judicial systems).

• Encourage use of appropriate community resources in nonemergency situations (e.g., family, friends, neighbors, self-help and support groups, volunteer agencies, churches, recreation clubs and centers, seniors, youths, others with similar interests).

• If fear is associated with bioterrorism, provide accurate information and ensure that health care personnel have appropriate training and preparation.

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

 Infants with risk factors and clinical indicators of feeding problems present prior to hospital discharge should be referred to appropriate community early-intervention service providers (e.g., community health nurses), early learning programs (individualized per states), occupational therapy, (speech pathologists, feeding specialists) to facilitate adequate weight gain for optimal growth and development.

• Provide anticipatory guidance for infant’s expected feeding course.

• Teach various effective feeding methods and strategies to parent(s).

• Teach parents how to read, interpret, and respond contingently to infant cues.

• Help parents identify support systems prior to hospital discharge.

• Provide anticipatory guidance for the infant’s discharge.

• Encourage the elderly client to develop a pattern of drinking water regularly.

• Ensure that when food intake is reduced or limited, it is compensated with an increase in water/fluid intake.

• Incorporate regular hydration into daily routines, such as providing an extra glass of fluid with medication or during social activities. Consider using a beverage cart to routinely offer beverages to clients in extended care facilities.

• Monitor central venous pressure, right atrial pressure, and pulmonary capillary wedge pressure for decreases.

• Monitor serum and urine osmolality, serum sodium, BUN/creatinine ratio, and hematocrit for elevations.

 Insert an indwelling urinary catheter if ordered and measure urine output hourly. Notify physician if urine output is less than 0.5 mL/kg/hr.

 When ordered, initiate a fluid challenge of crystalloids (0.9% normal saline or lactated Ringer’s) for replacement of intravascular volume; monitor the client’s response to prescribed fluid therapy and fluid challenge, especially noting central venous pressure and pulmonary capillary wedge pressure readings, vital signs, urine output, blood lactate concentrations, and lung sounds.

• Position the client flat with legs elevated when hypotensive, if not contraindicated.

 Monitor trends in serum lactic acid levels and base deficit obtained from blood gases as ordered.

 Consult physician/provider if signs and symptoms of deficient fluid volume persist or worsen.

• Monitor the child for signs of deficient fluid volume, including sunken eyes, decreased tears, dry mucous membranes, poor skin turgor, and decreased urine output.

 Reinforce the physician’s recommendation for the parents to give the child oral rehydration fluids to drink in the amounts specified, especially during the first 4 to 6 hours to replace fluid losses. Consider using diluted oral rehydration fluids. Once the child is rehydrated, an orally administered maintenance solution should be used along with food.

• Recommend that the mother resume breastfeeding as soon as possible.

• Recommend that parents not give the child decarbonated soda, fruit juices, gelatin dessert, or instant fruit drink mix. Instead give child the oral rehydration fluids ordered, and when tolerated, food.

• Once the child has been rehydrated, begin feeding regular food other than avoiding milk products.

• Monitor elderly clients for deficient fluid volume carefully, noting new onset of weakness, dizziness, and postural hypotension.

• Evaluate the risk for dehydration using the Dehydration Risk Appraisal Checklist.

• Check skin turgor of elderly client on the forehead, subclavian area, or inner thigh; also look for the presence of longitudinal furrows on the tongue and dry mucous membranes.

• Encourage fluid intake by offering fluids regularly to cognitively impaired clients.

• Incorporate regular hydration into daily routines (e.g., extra glass of fluid with medication or social activities). Because of their low water reserves, it may be prudent for the elderly to learn to drink regularly when not thirsty. Consider use of a beverage cart and a hydration assistant to routinely offer increased beverages to clients in extended care.

• If client is identified as having chronic dehydration, flag the food tray to indicate to caregivers he should finish 75% to 100% of his food and fluids.

• Recognize that lower blood pressures and a higher BUN/creatinine ratio can be significant signs of dehydration in the elderly.

• Note the color of urine and compare against a urine color chart to monitor adequate fluid intake.

• Monitor elderly clients for excess fluid volume during the treatment of deficient fluid volume: listen to lung sounds, watch for edema, and note vital signs.

• Teach family members how to monitor output in the home (e.g., use of commode “hat” in the toilet, urinal, or bedpan, or use of catheter and closed drainage). Instruct them to monitor both intake and output. Use common terms such as “cups” or glasses of water a day when providing education.

• When weighing the client, use same scale each day. Be sure scale is on a flat, not cushioned, surface. Do not weigh the client with scale placed on any kind of rug.

• Teach family about complications of deficient fluid volume and when to call physician.

• If the client is receiving IV fluids, there must be a responsible caregiver in the home. Teach caregiver about administration of fluids, complications of IV administration (e.g., fluid volume overload, speed of medication reactions), and when to call for assistance. Assist caregiver with administration for as long as necessary to maintain client safety.

• Identify an emergency plan, including when to call 911.

• Support the family/client in a palliative care situation to decide if it is appropriate to intervene for deficient fluid volume or to allow the client to die without fluids.

• Instruct the client to avoid rapid position changes, especially from supine to sitting or standing.

• Teach the client and family about appropriate diet and fluid intake.

• Teach the client and family how to measure and record intake and output accurately.

• Teach the client and family about measures instituted to treat hypovolemia and to prevent or treat fluid volume loss.

• Instruct the client and family about signs of deficient fluid volume that indicate they should contact health care provider.

 Insert an indwelling urinary catheter if ordered and measure urine output hourly. Notify physician if less than 0.5 mL/kg/hr.

 Monitor central venous pressure, mean arterial pressure, pulmonary capillary wedge pressure, and cardiac output/index; note and report trends indicating increasing or decreasing pressures over time.

 Monitor the effects of infusion of diuretic drips. Perform continuous renal replacement therapy (CRRT) as ordered if the client is critically ill, hemodynamically unstable, and excessive fluid must be removed.

• Recognize that the presence of fluid volume excess is particularly serious in the elderly.

• Monitor electrolyte levels carefully, including sodium levels and potassium levels, with both increased and decreased levels possible. Refer to the care plan for Risk for Electrolyte imbalance.

• Assess client and family knowledge of disease process causing excess fluid volume.

 Teach about disease process and complications of excess fluid volume, including when to contact the physician/provider.

• Assess client and family knowledge and compliance with medical regimen, including medications, diet, rest, and exercise. Assist family with integrating restrictions into daily living.

 Teach and reinforce knowledge of medications. Instruct the client not to use over-the-counter (OTC) medications (e.g., diet medications) without first consulting the physician/provider.

 Instruct the client to make the primary physician/provider aware of medications ordered by other physicians.

• Identify emergency plan for rapidly developing or critical levels of excess fluid volume when diuresing is not safe at home.

 Teach about signs and symptoms of both excess and deficient fluid volume such as darker urine and when to call physician.

• Describe signs and symptoms of excess fluid volume and actions to take if they occur.

 Teach client on diuretics to weigh self daily in the morning, and notify the physician/provider if there is a 2.2 lb (1.0 kg) or more weight gain.

 Teach the importance of fluid and sodium restrictions. Help the client and family to devise a schedule for intake of fluids throughout entire day. Refer to dietitian concerning implementation of low-sodium diet.

• Teach clients how to measure and document intake and output with common household measurements such as cups.

 Teach how to take diuretics correctly: take one dose in the morning and second dose (if taken) no later than 4 PM. Adjust potassium intake as appropriate for potassium-losing or potassium-sparing diuretics. Note the appearance of side effects such as weakness, muscle cramps, hypertension, palpitations, or irregular heartbeat.

• For the client undergoing hemodialysis, teach client the required restrictions in dietary electrolytes, protein and fluid. Spend time with the client to detect any factors that may interfere with the client’s compliance with the fluid restriction or restrictive diet.