G
Impaired Gas Exchange
Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane
Defining Characteristics
Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing (e.g., rate, rhythm, depth); abnormal skin color (e.g., pale, dusky); confusion; cyanosis; decreased carbon dioxide; diaphoresis; dyspnea; headache upon awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate improved ventilation and adequate oxygenation as evidenced by blood gas levels within normal parameters for that client
• Maintain clear lung fields and remain free of signs of respiratory distress
• Verbalize understanding of oxygen supplementation and other therapeutic interventions
Nursing Interventions
• Monitor respiratory rate, depth, and ease of respiration. Watch for use of accessory muscles and nasal flaring.
• Auscultate breath sounds every 1 to 2 hours. Listen for diminished breath sounds, crackles, and wheezes.
• Monitor the client’s behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy.
Monitor oxygen saturation continuously using pulse oximetry. Correlate arterial oxygen saturation blood gas results with pulse oximetry.
• Observe for cyanosis of the skin; especially note color of the tongue and oral mucous membranes.
• Position the client in a semirecumbent position with the head of the bed at a 30- to 45-degree angle to decrease the aspiration of gastric, oral, and nasal secretions.
• If the client has unilateral lung disease, position with head of bed at 30 to 45 degrees with “good lung down” for about 1 hour at a time.
If the client is acutely dyspneic, consider having the client lean forward over a bedside table, resting elbows on the table if tolerated.
• Help the client deep breathe and perform controlled coughing. Have the client inhale deeply, hold the breath for several seconds, and cough two or three times with the mouth open while tightening the upper abdominal muscles as tolerated. Controlled coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective. If the client has excessive fluid in the respiratory system, refer to the care plan Ineffective Airway clearance.
Monitor the effects of sedation and analgesics on the client’s respiratory pattern; use judiciously.
• Schedule nursing care to provide rest and minimize fatigue.
Administer humidified oxygen through an appropriate device (e.g., nasal cannula or Venturi mask per the physician’s/provider order); aim for an oxygen (O2) saturation level of 90% oxygen saturation or above. Watch for onset of hypoventilation as evidenced by increased somnolence.
• Assess nutritional status including serum albumin level and body mass index (BMI).
• Assist the client to eat small meals frequently and use dietary supplements as necessary.
• If the client is severely debilitated from chronic respiratory disease, consider the use of a wheeled walker to help in ambulation.
Watch for signs of psychological distress including anxiety, agitation, depression, and insomnia. Refer for counseling as needed.
Refer the COPD client to a pulmonary rehabilitation program.
Assess and monitor oxygen indices such as the PF ratio (FIO2:pO2), venous oxygen saturation/oxygen consumption (SVO2 or ScVO2).
Turn the client every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return to baseline promptly, turn the client back into the supine position, check vital signs, and evaluate oxygen status. If the client does not tolerate turning, consider use of a kinetic bed that rotates the client from side to side in a turn of at least 40 degrees.
If the client has adult respiratory distress syndrome with difficulty maintaining oxygenation, consider positioning the client prone with the upper thorax and pelvis supported, allowing the abdomen to protrude. Monitor oxygen saturation and turn back to supine position if desaturation occurs. If the client becomes ventilator dependent, refer to the care plan Impaired spontaneous Ventilation.
Use central nervous system (CNS) depressants carefully to avoid decreasing respiration rate.
• Recognize that the elderly have decreased pulmonary function with age, and that results in decreased gas exchange and pulmonary reserve function. Also, the elderly are more vulnerable to develop pneumonia because of decreased immune function.
• Work with the client to determine what strategies are most helpful during times of dyspnea. Educate and empower the client to self-manage the disease associated with impaired gas exchange.
Collaborate with physicians regarding long-term oxygen administration for chronic respiratory failure clients with severe resting hypoxemia. Administer long-term oxygen therapy greater than 15 hours daily for pO2 less than 55 or SaO2 at or below 88%.
• Assess the home environment for irritants that impair gas exchange. Help the client to adjust the home environment as necessary (e.g., install an air filter to decrease the level of dust).
Refer the client to occupational therapy as necessary to assist the client in adaptation to the home and environment and in energy conservation.
• Assist the client with identifying and avoiding situations that exacerbate impairment of gas exchange (e.g., stress-related situations, exposure to pollution of any kind, proximity to noxious gas fumes such as chlorine bleach).
• Refer to GOLD guidelines for management of home care and indications of hospital admission criteria.
• Instruct the client to keep the home temperature above 68° F (20° C) and to avoid cold weather.
• Instruct the client to limit exposure to persons with respiratory infections.
• Instruct the family in the complications of the disease and the importance of maintaining the medical regimen, including when to call a physician.
Refer the client for home health aide services as necessary for assistance with activities of daily living.
• When respiratory procedures are being implemented, explain equipment and procedures to family members, and provide needed emotional support.
• When electrically based equipment for respiratory support is being implemented, evaluate home environment for electrical safety, proper grounding, and so on. Ensure that notification is sent to the local utility company, the emergency medical team, and police and fire departments.
Watch for family role changes and coping ability. Refer the client to medical social services as appropriate for assistance in adjusting to chronic illness.
Client/Family Teaching and Discharge Planning
• Teach the client how to perform pursed-lip breathing and inspiratory muscle training, and how to use the tripod position. Have the client watch the pulse oximeter to note improvement in oxygenation with these breathing techniques.
• Teach the client energy conservation techniques and the importance of alternating rest periods with activity. See nursing interventions for Fatigue.
Teach the importance of not smoking. Refer to smoking cessation programs, and encourage clients who relapse to keep trying to quit. Ensure that client receives appropriate medications to support smoking cessation from the primary health care provider.
Instruct the family regarding home oxygen therapy if ordered (e.g., delivery system, liter flow, safety precautions, number of tanks needed).
Teach the client the need to receive a yearly influenza vaccine.
• Teach the client relaxation techniques to help reduce stress responses and panic attacks resulting from dyspnea.
Risk for dysfunctional Gastrointestinal Motility
At risk for increased, decreased, ineffective, or lack of peristaltic activity within the gastrointestinal system
Risk Factors
Abdominal surgery; aging; anxiety; change in food; change in water; decreased gastrointestinal circulation; diabetes mellitus; food intolerance (e.g., gluten, lactose); gastroesophageal reflux disease (GERD); immobility; infection (e.g., bacterial, parasitic, viral): pharmaceutical agents (e.g., antibiotics, laxatives, narcotics/opiates, proton pump inhibitors); prematurity; sedentary lifestyle; stress; unsanitary food preparation
Dysfunctional Gastrointestinal Motility
Increased, decreased, ineffective, or lack of peristaltic activity within the gastrointestinal system
Defining Characteristics
Absence of flatus; abdominal cramping; abdominal distention; abdominal pain; accelerated gastric emptying; bile-colored gastric residual; change in bowel sounds (e.g., absent, hypoactive, hyperactive); diarrhea; dry stool; difficulty passing stool; hard stool; increased gastric residual; nausea; regurgitation; vomiting
Related Factors (r/t)
Aging; anxiety; enteral feedings; food intolerance (e.g., gluten, lactose); immobility; ingestion of contaminates (e.g., food, water); malnutrition; pharmaceutical agents (e.g., narcotics/opiates, laxatives, antibiotics, anesthesia); prematurity; sedentary lifestyle; surgery
Client Outcomes
Client Will (Specify Time Frame)
• Be free of abdominal distention and pain
• Pass gas rectally at intervals
Nursing Interventions
• Monitor for abdominal distention, and presence of abdominal pain.
• Auscultate for bowel sounds noting characteristics and frequency, also palpate, and percuss the abdomen.
• Review history noting any anorexia, dyspepsia, nausea/vomiting, abnormal characteristics of bowel movements, including frequency, consistency, and the presence of gas. Other symptoms may include relation of symptoms to meals, especially if aggravated by food, early satiety, postprandial fullness/bloating, and weight loss (more with severe gastroparesis).
• Have client keep a diary of time food and fluid was consumed as it compares to pattern of defecation, including, but not limited to, consistency, amount, and frequency of.
• Monitor for fluid deficits by checking skin turgor, and moisture of tongue. Refer to care plan Deficient Fluid Volume if relevant.
Monitor for nutritional deficits by keeping close track of food intake. Review laboratory studies that affirm nutritional deficits, such as decreased albumin and serum protein levels, liver profile, glucose, and an electrolyte panel. Refer to care plan Imbalanced Nutrition: less than body requirements or Risk for Electrolyte Imbalance as appropriate.
Slowed Gastrointestinal Motility
• Monitor the client for signs and symptoms of decreased gastric motility, which may include delayed emptying, nausea after meals, vomiting, heartburn, diarrhea, feeling full quickly while eating, abdominal bloating and/or pain, anorexia, and reflux.
Monitor daily laboratory studies, ensuring ordered glucose levels are done and evaluated.
If client has nausea and vomiting, provide an antiemetic and intravenous fluids as ordered. Refer to the care plans for Nausea.
Evaluate medications the client is taking.
• Obtain a thorough gastrointestinal history if the client has diabetes, as they are at high risk for gastroparesis and gastric reflux.
Review laboratory and other diagnostic tools, including complete blood count (CBC), amylase, thyroid-stimulating hormone level, glucose with other metabolic studies, upper endoscopy, and gastric-emptying scintigraphy.
Obtain nutritional consult, considering diets lower or higher in liquids or solids, especially fats, depending on gastric motility
Recommend eating small meals and soft (well cooked) foods as they may relieve symptoms of slower motility.
If client is unable to eat or retain food, consult with the registered dietitian and physician, considering further nutritional support in the form of enteral or parenteral feedings for the client with gastroparesis.
If client is receiving gastric enteral nutrition (EN), evaluate gastric residual volume (GRV) per hospital protocol. See the care plan Risk for Aspiration.
Administer prokinetic medications as ordered.
For the client with nausea and vomiting associated with gastroparesis, review use of tricyclics, in addition to the traditional antiemetics and other prokinetic drugs.
Recognize that acupuncture may be an option for both slowed and increased gastric motility.
• Observe for complications of delayed intestinal motility. Symptoms include abdominal pain and distention, nausea, cramping, anorexia, and sometimes bloating. Other signs include tympany to percussion, with absence of flatus, bowel sounds or bowel.
Recommend chewing gum for the routine postoperative patient who is experiencing an ileus, is not at risk for aspiration, and has normal dentition.
• Determine if the client is a smoker.
• Help the client out of bed to walk at least two times per day.
If postoperative ileus is associated with opioid pain medication, request an order for a peripherally acting opioid antagonist.
Note serum electrolyte levels, especially potassium and magnesium.
Increased Gastrointestinal Motility
Observe for complications of gastric surgeries such as dumping syndrome.
• Watch for nausea, vomiting, bloating, cramping, diarrhea, dizziness, and fatigue.
• Monitor for low blood sugar, weakness, sweating, and dizziness 1 to 3 hours after eating as this is when late rapid gastric emptying may occur.
Order a nutritional consult to discuss diet changes. Encourage several small meals per day that are low in carbohydrates, and higher in fiber supplements and fat. Space fluids around meal times, not with them.
Give intravenous fluids as ordered for the client complaining of diarrhea with weakness and dizziness.
Review the client’s medication profile, including current medication list, noting those that may increase gastric motility.
• Offer bathroom, commode, or bedpan assistance, depending on frequency, amount of diarrhea, and condition of client.
• Refer to the care plans for the nursing diagnoses of Deficient Fluid Volume, Nausea, and Diarrhea as relevant.
• Assess infants and children with suspected delayed gastric for fullness and vomiting.
• Continue to encourage the mother of a baby diagnosed with delayed gastric emptying to breastfeed, reinforcing the benefits of breastfeeding.
If the infant is already on a bottle, encourage parents to discuss with the pediatrician a switch to a hypoallergenic formula.
Observe for nutritional and fluid deficits with assessment of skin turgor, mucous membranes, fontanels, furrows of the tongue, electrolyte panel, fluid status, and cardiopulmonary function.
Recommend gentle massage for preterm infants as appropriate.
• Closely monitor diet and medication use/side effects as they affect the gastrointestinal system. Watch for constipation.
Watch for symptoms of dysphagia, gastroesophageal reflux disease, dyspepsia, irritable bowel syndrome, maldigestion, and reduced absorption of nutrients.
If client takes metoclopramide for gastroesophageal reflux disease or slowed gastric motility, assess indication and side effects. Recognize that metoclopramide can cause drug-induced Parkinson’s disease in the elderly, in addition to other neurotoxic side effects
Client/Family Teaching and Discharge Planning
• Teach the client and caregivers about their medications, reinforcing the side effects as they relate to gastrointestinal function.
Recommend possible exercise programs if appropriate.
• Teach client and caregivers to report signs and symptoms that may indicate further complications including increased abdominal girth, projectile vomiting, and unrelieved acute cramping pain (bowel obstruction).
Recommend signs and symptoms of dehydration with client and caregivers.
Risk for ineffective Gastrointestinal Perfusion
Risk Factors
Abdominal aortic aneurysm; abdominal compartment syndrome; abnormal partial thromboplastin time; abnormal prothrombin time; acute gastrointestinal bleed; acute gastrointestinal hemorrhage; age ≥60 years; anemia; coagulopathy (e.g., sickle cell anemia); diabetes mellitus; disseminated intravascular coagulation; female gender; gastric paresis (e.g., diabetes mellitus); gastroesophageal varices; gastrointestinal disease (e.g., duodenal or gastric ulcer, ischemic colitis, ischemic pancreatitis); hemodynamic instability; liver dysfunction; myocardial infarction; poor left ventricular performance; renal failure; stroke; trauma; smoking; treatment-related side effects (e.g., cardiopulmonary bypass, medication, anesthesia, gastric surgery); vascular disease (e.g., peripheral vascular disease, aortoiliac occlusive disease)
Client Outcomes
Client Will (Specify Time Frame)
• Maintain blood pressure within normal limits
• Remain free from abdominal distention
• Tolerate feedings without nausea, vomiting, or abdominal discomfort
• Pass stools of normal color, consistency, frequency, and amount
• Describe prescribed diet regimen
• Describe prescribed medication regimen including medication actions and possible side effects
• Verbalize understanding of treatment regimen including monitoring for signs and symptoms that may indicate problems with gastrointestinal tissue perfusion, the importance of diet and exercise to gastrointestinal health
Nursing Interventions
Complete pain assessment. Assess and document the onset, intensity, character, location, duration, aggravating factors, and relieving factors. Determine whether the pain is exacerbated by eating. Notify the provider for any increase in pain or discomfort or if comfort measures are not effective.
• Monitor vital signs frequently as needed watching for hypotension and tachycardia.
• Encourage the client to eat small, frequent meals rather than three larger meals. Encourage the client to rest after eating to maximize blood flow to the stomach and improve digestion.
• Perform a physical abdominal examination including inspection, auscultation, percussion, and palpation. Complete the assessment in the described order.
• Monitor frequency, consistency, color, and amount of stools.
• Assess for abdominal distention. Measure abdominal girth and compare to client’s accustomed waist or belt size.
Monitor for gastrointestinal side effects from medication administrations, particularly NSAIDs. Discuss the possibility of prescribing a gastroprotective agent such as a proton pump inhibitor with the provider for clients requiring long-term administration of NSAIDs.
• Review the client’s medical and surgical history. Certain conditions place clients at higher risk for ineffective tissue perfusion (e.g., diabetes mellitus, abdominal surgery, cardiothoracic surgery, trauma, mechanical ventilation). In addition to medical or surgical conditions, lifestyle choices such as smoking or cocaine and amphetamine use affect tissue perfusion.
• Recognize that any client who has been in a shock state is vulnerable to decreased gastrointestinal perfusion, and watch for symptoms as just identified.
• Encourage the client to ambulate or perform activity as tolerated, but vigorous activity or heavy lifting should be avoided for several hours after meals.
Monitor intake and output to evaluate fluid and electrolyte balance, and review laboratory data as ordered.
Prepare client for diagnostic or surgical procedures. Diagnostic studies may include abdominal x-ray to rapidly rule out intestinal obstruction, CT, angiography, and abdominal ultrasound. Surgical procedures include exploratory laparotomy, thrombectomy, surgical revascularization, and/or stent placement.
• Recognize that ineffective gastrointestinal perfusion may be an emergency situation necessitating immediate care to save bowel function or life of the client.
• Monitor vital signs frequently. Notify physician if significant deviation from baseline.
• Monitor oxygen saturation and provide oxygen therapy as ordered. Take steps to prevent hypovolemia and hypotensive episodes. Avoid periods of physiological stress, which can lead to hypoxemia. Minimize environmental stressors.
• Monitor tolerance of enteral feedings.
• Monitor patients at risk for abdominal compartment syndrome for signs of increased abdominal pressure.
Client/Family Teaching and Discharge Planning
• Provide client teaching related to risk factors for ineffective gastrointestinal tissue perfusion, signs and symptoms, lifestyle changes that can improve gastrointestinal functioning. Start with the client’s base level of understanding and use that as a foundation for further education.
• Teach client about any medications prescribed. Medication teaching includes the drug name, its purpose, administration instructions such as taking it with or without food, and any side effects to be aware of. Instruct the client to report any adverse side effects to his/her provider.
Risk for unstable blood Glucose level
Risk Factors
Deficient knowledge of diabetes management (e.g., action plan); developmental level; dietary intake; inadequate blood glucose monitoring; lack of acceptance of diagnosis; lack of adherence to diabetes management (e.g., action plan); lack of diabetes management (e.g., action plan); medication management; mental health status; physical activity level; physical health status; pregnancy; rapid growth periods; stress; weight gain; weight loss
Client Outcomes
Client Will (Specify Time Frame)
• Maintain A1C less than 7% (normal level 4% to 6%)
• Maintain less stringent A1C goals than 7% in clients with a history of severe hypoglycemia, advanced diabetes complications, or limited life expectancy
• Maintain outpatient preprandial blood glucose between 70 and 130 mg/dL; consult primary care provider for client-specific goals
• Maintain outpatient postprandial glucose below 180 mg/dL
• In gestational diabetes, maintain preprandial blood glucose ≤ 95 mg/dL, 1-hour pc level at or below 140 mg/dL, and 2-hour pc level at or below 120 mg/dL
• In a pregnant mother with preexisting type 1 or 2 diabetes, maintain premeal, bedtime, and overnight blood glucose 60-99 mg/dL, peak postprandial glucose 100-129 mg/dL, and A1C <6%
• In critically ill hospitalized clients, maintain blood glucose between 140 and 180 mg/dL
• In noncritically ill hospitalized clients, maintain premeal blood glucose values below 140 mg/dL and random blood glucose values below 180 mg/dL. Higher levels may be acceptable in terminally ill patients.
• Demonstrate how to accurately test blood glucose
• Identify self-care actions to take to maintain target glucose levels
• Identify self-care actions to take if blood glucose level is too low or too high
• Demonstrate correct administration of prescribed medications
Nursing Interventions
Check blood glucose three or more times daily.
Evaluate blood glucose levels in hospitalized clients before administering oral hypoglycemic agents or insulin. Adjust timing of medication appropriately with meal times.
Monitor blood glucose every 30 minutes to 2 hours for clients on continuous insulin drips.
Consider continuous glucose monitoring (CGM) in clients with type 1 diabetes on intensive insulin regimens.
Evaluate A1C level for glucose control over previous 2 to 3 months.
• Consider monitoring 1 to 2 hours post meal in individuals who have premeal glucose values within target but have A1C values above target.
• Discuss with provider relaxing goals for clients who have comorbid conditions, shortened life expectancy, frequent hypoglycemia, or hypoglycemia unawareness.
• Monitor for signs and symptoms of hypoglycemia, such as shakiness, dizziness, sweating, hunger, headache, pallor, behavior changes, confusion, or seizures.
Be alert for hypoglycemia in clients receiving 0.6 unit/kg insulin or more daily, and in clients receiving NPH insulin.
If client is experiencing signs and symptoms of hypoglycemia, test glucose and if result is below 70 mg/dL, administer 15 to 20 g glucose (½ cup fruit juice or regular [not diet] soda, 1 cup milk, 1 small piece of fruit, or 3 to 4 glucose tablets). Repeat test in 15 minutes and repeat treatment if indicated. Once SMBG glucose returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia.
Administer intramuscular/subcutaneous glucagon according to agency protocol if client is hypoglycemic and is unable to take oral carbohydrate. For severe hypoglycemia, an IV infusion of 10% dextrose or 25% to 50% IV bolus dextrose may be used.
• Monitor for signs and symptoms of hyperglycemia, such as increased thirst or urination, or high blood or urine glucose levels.
Ensure an acutely ill client is receiving adequate fluids and carbohydrates. Adjustment in oral hypoglycemic or insulin therapy may be required.
Test urine or blood for ketones in ketosis-prone clients during acute illness, trauma, surgery or stress.
Prime IV tubing with 20 mL of diluted IU insulin solution before initiating insulin drip.
Evaluate client’s medication regimen for medications that can alter blood glucose.
Refer client to dietitian for carbohydrate counting instruction.
Refer overweight clients to dietitian for weight loss counseling.
• For interventions regarding foot care, refer to the care plan Ineffective peripheral Tissue Perfusion.
• Watch for age-related cognitive changes that can impair self-management of diabetes.
• Monitor for vision and dexterity impairments that may affect the older client’s ability to accurately measure insulin doses.
• Encourage self-monitoring of blood glucose for residents of extended care facilities who are capable of doing so.
• Assist client to set up pill boxes or a reminder system for taking medications.
• Teach older clients the importance of verifying symptoms with a glucometer reading.
Client/Family Teaching and Discharge Planning
• Provide “survival skills” education for hospitalized clients, including information about (1) diabetes and its treatment, (2) medication administration, (3) nutrition therapy, (4) self-monitoring of blood glucose, (5) symptoms and treatment of hypoglycemia, (6) basic foot care, and (7) follow-up appointments for in-depth training.
• Evaluate clients’ monitoring technique initially at regular intervals.
Refer client to a diabetes treatment and teaching program (DTTP) for training in flexible intensive insulin therapy and dietary freedom.
Refer client for Blood Glucose Awareness Training (BGAT) or web-based training available at http://www.BGAThome.com for instruction in detection, anticipation, avoidance, and treatment of extremes in blood glucose levels.
• Teach client to maintain a blood glucose diary.
• Provide group-based training programs for instruction.
• Teach client the importance of at least 150 minutes/week of moderate-intensity aerobic physical activity (50% to 70% of maximum heart rate).
• Discuss recommending resistance training with client’s provider.
• Teach client with type 1 diabetes to avoid vigorous activity if ketones are present in urine or blood.
• Teach clients who are treated with insulin or insulin-stimulating oral agents to eat added carbohydrates prior to exercise if glucose levels are below 100 mg/dL.
• Teach client and family members regarding sick day management, including importance of early contact with provider, continuing insulin or medication unless instructed otherwise, frequent monitoring, and oral intake.
Grieving
A normal, complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviors by which individuals, families, and communities incorporate an actual, anticipated, or perceived loss into their daily lives
Defining Characteristics
Alteration in activity level; alterations in dream patterns; alterations in immune function; alterations in neuroendocrine function; alteration in sleep patterns; anger; blame; detachment; despair; disorganization; experiencing relief; maintaining connection to the deceased; making meaning of the loss; pain; panic behavior; personal growth; psychological distress; suffering
Related Factors (r/t)
Anticipatory loss of significant object (e.g., possession, job, status, home, parts and processes of body); anticipatory loss of a significant other; death of a significant other; loss of significant object (e.g., possession, job, status, home, parts and processes of body)
Client/Family Outcomes
Client/Family Will (Specify Time Frame)
• Discuss meaning of the loss to his/her life and the functioning of the family
• Identify ways to support family members and articulate methods of support he or she requires from family and friends
• Accept assistance in meeting the needs of the family from friends/extended family
Nursing Interventions
Anticipatory Grieving Interventions
• Grieving of the client, and family/relatives of a critically ill and dying client for the losses experienced during the deteriorating illness, and the future that will be filled with loss.
• Develop a trusting relationship both with the client and with the family by using presence and therapeutic communication techniques.
• Keep the family apprised of the client’s ongoing condition as much as possible. Consult with the family for decision-making as appropriate.
• Keep the family informed on clients’ needs for physical care and support in symptom control, and inform them about health care options at the end of life including palliative care, hospice care, and home care.
• Encourage the family to touch the client as desired; when near death encourage holding the hand, or foot, or wherever can reach and is acceptable to the client and family member.
• Ask family members if receiving sufficient sleep. If a family member desires to be in the room for sleep, provide a reclining chair or portable bed if possible, and bedding to keep the family member comfortable. If needed, find housing for family member from out of town with support of case manager, or social worker.
• Ask family member when last ate if appropriate. Touch family members as appropriate.
• Listen to the family member’s story.
• Encourage family members to show their caring feelings and talk to the client. Recognize and respect different feelings and wishes from both the family members and client.
• If necessary, refer a family member for counseling or minister/priest to help him cope with the existential questions and current overwhelming reality.
• Recognize that one family member may be in a state of caregiver role strain from a long caregiving situation. See the care plan Caregiver Role Strain if appropriate.
• Promote the family roles as appropriate.
• Promote mutual goal setting where decisions are made together that affect the family.
Grieving Interventions When Death of a Loved One Occurs
• Utilize the following activities when interacting with the bereaved person:
Be present and attentive, use active empathetic listening.
Validate the client’s feelings of grief, and feeling hurt, stressful, anxious, out of control, and further symptoms of grieving.
Provide time and space for the person to tell his story of loss.
Offer condolences: “I am sorry that you lost your husband.”
Explain that the feelings will oscillate, as the person does grief work, from coping to accept the loss, to coping to build a new life without the loved one.
Intentionally schedule meetings with the family member(s) to provide support during grieving.
• Help the client utilize a method to give voice to his unique story of loss. Methods to do this include: Keeping a personal journal to record feelings and insights/Retelling of the loss narrative to a caring person/Music therapy techniques with a trained therapist, or listening to music that has significance to the relationship/Use of the “Virtual Dream,” a dreamlike short story written by the grieving person to tell the narrative of the loss.
• Discuss coping methods with the grieving person. Common coping techniques used include exercise, telling the story of grief to a caring person, journaling, pets, and developing a legacy for the deceased.
• Encourage the family to create a quiet and comfortable healing environment, and follow comforting grief rituals such as prayer, interacting with nature, or lighting votive candles.
Refer the family members for spiritual counseling if desired.
• Help the family determine the best way and place to find social support. Encourage family members to continue to use supports as needed for years.
• Identify available community resources, including bereavement groups at local hospitals and hospice centers. Volunteers who provide bereavement support can also be effective.
• Watch for signs of complicated grieving. These include the absence of support in a person’s social network, the presence of a concurrent life crisis, a highly ambivalent marital relationship that preceded the spouse’s death, traumatic circumstances surrounding the death such as suicide, homicide or traffic accident, bereavement with young children, limited economic resources, high self-reproach, high pining, and persistent anger associated with grieving.
• Treat the child with respect, give him or her opportunity to talk about concerns, and answer questions honestly.
• Listen to the child’s expression of grief.
• Help parents recognize that the grieving child does not have to be “fixed”; instead they need support going through an experience of grieving just as adults.
• Consider the use of art for children in hospice care who are dying or dealing with the death of a parent, sibling, or other family member.
Refer grieving children and parents to a program to help facilitate grieving if desired, especially if the death was traumatic.
• Help the adolescent determine sources of support and how to use them effectively.
• Encourage grieving parents to take good care of their own health.
Encourage grieving parents to seek mental health services as needed.
• Recognize that men and women often grieve differently, and explain this to parents if it becomes an issue.
• Recognize that mothers who have a miscarriage grieve and experience sorrow because of loss of the child.
• See Nursing Interventions in care plans for Complicated Grieving and Chronic Sorrow.
• The interventions previously described may be adapted for home care use.
• Assessment of ADLs and IADLs is essential as part of comprehensive care after a home care client has suffered the loss of a loved one.
• Actively listen as the client grieves for his or her own death or for real or perceived loss. Normalize the client’s expressions of grief for self. Demonstrate a caring and hopeful approach.
Refer the client to medical social services as necessary for losses not related to death.
Refer the bereaved to hospice bereavement programs, or an Internet self-help group.
Complicated Grieving
A disorder that occurs after the death of a significant other in which the experience of distress accompanying bereavement fails to follow normative (or cultural) expectations and manifests in functional impairment
Defining Characteristics
Decreased functioning in life roles; decreased sense of well-being; depression; experiencing somatic symptoms of the deceased; fatigue; grief avoidance; longing for the deceased; low levels of intimacy; persistent emotional distress; preoccupation with thoughts of the deceased; rumination; searching for the deceased; self-blame; separation distress; traumatic distress; verbalizes anxiety; verbalizes distressful feelings about the deceased; verbalizes feeling dazed; verbalizes feeling empty; verbalizes feeling in shock; verbalizes feeling stunned; verbalizes feelings of anger; verbalizes feelings of detachment from others; verbalizes feelings of disbelief; verbalizes feelings of mistrust; verbalizes lack of acceptance of the death; verbalizes persistent painful memories; verbalizes self-blame; yearning
Related Factors (r/t)
Death of a significant other; emotional instability; lack of social support; sudden death of a significant other, dementia caregiving, loss of a child
Client Outcomes
Client Will (Specify Time Frame)
• Express appropriate feelings of guilt, fear, anger, or sadness
• Identify somatic distress associated with grief (e.g., anxiety, changes in appetite, insomnia, nightmares, loss of libido, decreased energy, altered activity levels)
• Seek support in dealing with grief-associated issues
• Identify personal strengths and effective coping strategies
• Function at a normal developmental level and begin to successfully and increasingly perform activities of daily living
Nursing Interventions
• Watch for signs of complicated grieving that include symptoms that persist at least 6 months after the death and are experienced at least daily or to a disabling degree. Symptoms include feeling emotionally numb, stunned, shocked, and that life is meaningless; dysfunctional thoughts and maladaptive behaviors; experiencing mistrust and estrangement from others; anger and bitterness over the loss; identity confusion; avoidance of the reality of the loss, or excessive proximity seeking to try to feel closer to the deceased, sometimes focused on wishes to die or suicidal statements and behavior; or difficulty moving on with life. Symptoms must be associated with functional impairment.
Determine the client’s state of grieving. Use a tool such as the Prolonged Grief Disorder Scale, the Grief Support in Health Care Scale, the Hogan Grief Reaction Checklist, and the Beck Depression Inventory.
Determine whether the client is experiencing depression, suicidal tendencies, or other emotional disorders. Refer the client for counseling or therapy as appropriate.
• Educate the client and his or her support systems that grief resolution is not a sequential process and that the positive outcome of grief resolution is the integration of the deceased into the ongoing life of the griever.
Assess caregivers, particularly younger caregivers, for pessimistic thinking and additional stressful life events and refer for appropriate support.
• See the Nursing Interventions in the care plans for Grieving and Chronic Sorrow.
Refer grieving children and parents to a program to help facilitate grieving if desired, especially if the death was traumatic.
• Encourage grieving parents to take good care of their own health.
Encourage grieving parents to seek mental health services as needed.
• Help the adolescent determine sources of support and how to use them effectively. If client is an adolescent exposed to a peer’s suicide, watch for symptoms of traumatic grief as well as PTSD, which include numbness, preoccupation with the deceased, functional impairment, and poor adjustment to the loss.
See the pediatric and parent interventions in the care plans for Grieving and Chronic Sorrow.
• Pay careful attention to the older adult’s self-care.
• Those who have lived with elders with dementia and experienced significant feelings of loss before the loved one’s death may be at risk for more intense feelings of grief after the death of the client with dementia.
Elderly people experience complicated grieving with physical and mental health problems especially when the deceased is a child or spouse.
Risk for complicated Grieving
Risk for disproportionate Growth
At risk for growth above the 97th percentile or below the 3rd percentile for age, crossing two percentile channels
Risk Factors
Environmental
Deprivation; economically disadvantaged; lead poisoning; natural disasters; teratogen; violence
Client Outcomes
Client/Parents/Primary Caregiver Will (Specify Time Frame)
• State information related to possible teratogenic agents
• Identify components of healthy nutrition that will promote growth
• Maintain or improve weight to be within a healthy range for age and sex
Nursing Interventions
• Counsel women who smoke to quit smoking prior to conception if possible and to avoid smoking and secondhand smoke while pregnant.
• Assess alcohol consumption of pregnant women and advise those that drink alcohol to discontinue all use of alcohol through the pregnancy.
• Assess and limit exposure to all drugs (prescription, “recreational,” and over the counter) and give the mother information on known teratogenic agents.
• All women of childbearing age who are capable of becoming pregnant should take 400 mcg of folic acid daily.
Promote a team approach toward preconception and pregnancy glucose control for women with diabetes.
Advise women with mental health disorders to seek appropriate counseling prior to pregnancy.
• Consider regular breast milk and protein-fortified breast milk for low-birth-weight infants in the neonatal intensive care unit.
• Provide tube feedings per physician’s orders when appropriate for clients with neuromuscular impairment.
• Provide for adequate nutrition and nutritional monitoring in clients with medical disorders requiring chronic medication and those with developmental delay.
• Adequate intake of vitamin D is set at 400 IU/day by the National Academy of Sciences. Because adequate sunlight exposure is difficult to determine, a supplement of 400 IU/day is recommended for the following groups to prevent rickets and vitamin D deficiency in healthy infants and children:
All breastfed infants unless they are weaned to at least 500 mL/day of vitamin D–fortified formula or milk
All non-breastfed infants who are ingesting less than 500 mL/day of vitamin D–fortified formula or milk
Children and adolescents who do not receive regular sunlight exposure, do not ingest at least 500 mL/day of vitamin D–fortified milk, or do not take a daily multivitamin supplement containing at least 400 IU of vitamin D
• Provide adequate nutrition to clients with active intestinal inflammation.
• Encourage limiting “screen time” (television, video games, Internet, smart phones, and tablets) to less than 2 hours/day for children.
• Assess the influence of cultural beliefs, norms, values, and expectations on parents’ perceptions of normal growth and development.
• Focus nutritional education on promoting good nutrition and physically active lifestyles for healthy child development as opposed to only for prevention or reduction of overweight.
• Assess for the influence of acculturation.
• Assess whether the parents are concerned about the amount of food eaten.
• Assess the influence of family support on patterns of nutritional intake.
• Negotiate with clients regarding which aspects of healthy nutrition can be modified while still honoring cultural beliefs.
• Encourage parental efforts at increasing physical activity and decreasing dietary fat for their children.
Delayed Growth and Development
Defining Characteristics
Altered physical growth; decreased response time; delay in performing skills typical of age group; difficulty in performing skills typical of age group; flat affect; inability to perform self-care activities appropriate for age; inability to perform self-control activities appropriate for age; listlessness
Related Factors (r/t)
Effects of physical disability; environmental deficiencies; inadequate caretaking; inconsistent responsiveness; indifference; multiple caretakers; prescribed dependence; separation from significant others; stimulation deficiencies
Client Outcomes
Client/Parents/Primary Caregiver Will (Specify Time Frame)
• Describe realistic, age-appropriate patterns of growth and development
• Promote activities and interactions that support age-related developmental tasks
• Display consistent, sustained achievement of age-appropriate behaviors (social, interpersonal, and/or cognitive) and/or motor skills
• Achieve realistic developmental and/or growth milestones based on existing abilities, extent of disability, and functional age
Nursing Interventions
• Counsel women who smoke to quit smoking prior to conception if possible and to avoid smoking and secondhand smoke while pregnant.
• To determine risk for or actual deviations in normal development, consider the use of a screening tool.
• Regularly compare height and weight measurements for the child or adolescent with established age-appropriate norms and previous measurements.
• Provide opportunities for mother-infant skin-to-skin contact (kangaroo care) for preterm infants.
• Provide normal sleep-wake times for clients to promote growth and development.
Engage the child in appropriate play activities. Refer the child to a child life therapist or recreational therapist (if available) for supplemental strategies.
• Assess the influence of cultural beliefs, norms, and values on the client’s perceptions of child development.
• Assess and identify for possible environmental conditions, which may be a contributing factor to altered growth and development.
• Acknowledge racial and ethnic differences at the onset of care.
• Provide information on the effects of environmental risk exposure on growth and development.
• The interventions previously described may be adapted for home care use.
• Assess whether exposure to violence or parental stress is contributing to developmental problems.
Refer premature neonates for follow-up home care and assessment of functional performance.
If possible, refer the family to a program of animal-assisted therapy.
Client/Family Teaching and Discharge Planning
• Encourage parents to take infants and children for routine health visits to the family physician or pediatrician.
• Encourage parents of children with language delays to approach their physician during regular visits regarding the delay.
• Provide parents and/or caregivers realistic expectations for attainment of growth and development milestones. Clarify expectations and correct misconceptions.
• Instruct the client regarding appropriate baby equipment and the importance of buying new equipment rather than used.
• Elicit the involvement of parents and caregivers in social support groups and parenting classes.
• Assess whether parents may benefit from Internet/electronic support groups.
• See care plans Risk for disproportionate Growth/Risk for delayed Development.