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 Consider a community-based program for young people that encourages health-related behavior changes, increasing fruit and vegetable intake and engaging in activity.

 Support religious affiliation and positive school climates for adolescents, particularly for lesbian, gay, and bisexual youths in the community.

 Assess homeless elderly veterans in the community for suicidal behavior and make appropriate referrals.

 Provide community-dwelling older women with psychoeducation about aging skills and behaviors and cognitive function that includes group discussion.

• Provide information about the pervasiveness and deadly consequence of HBV for Asians in the United States.

• The above interventions may be adapted for home care and client/family teaching.

• Provide support for establishment of a community garden.

• Encourage visitation of children when family members are in intensive care.

 Refer parents of critically ill children to an intervention program such as COPE, a theory-based intervention program.

• Use visualization and distraction during chest physiotherapy for children with cystic fibrosis.

 Assess for signs of depression resulting from illness-associated changes and make appropriate referrals.

• Use open-ended questions in screening for depression in the elderly.

• Support activities that promote usefulness of older adults.

 Encourage social support.

• Monitor the client for agitation associated with health problems. Support family caring for elders with agitation.

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

• Assess the role of fatalism on the client’s ability to modify health behavior.

• Encourage spirituality as a source of support for coping.

• Negotiate with the client regarding the aspects of health behavior that will need to be modified.

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

• Take the client’s perspective into consideration, and use a holistic approach in assessing and responding to client planning for the future.

• Assist the client to adapt to his/her diagnosis and to live with the disease.

 Refer the client to a counselor or therapist for follow-up care. Initiate community referrals as needed (e.g., grief counseling, self-help groups).

• Refer to care plan for Powerlessness.

• Assess family/caregivers for coping and teaching/learning styles.

• Foster communication between the client/family and medical staff.

• Educate and prepare families regarding the appearance of the client and the environment before initial exposure.

• Help the client to enjoy a sense of “wellness.” Provide support for progress and support enjoyment of the physical, emotional, spiritual, and social aspects of life.

• Teach a client and his or her family relaxation techniques (controlled breathing, guided imagery) and help them practice.

• Allow the client to proceed at own pace in learning; provide time for return demonstrations (e.g., self-injection of insulin).

• If long-term deficits are expected, inform the family as soon as possible.

• Provide clients with information on how to access and evaluate available health information via the Internet.

• Assess the client’s perception of health.

• Assist client to identify both life- and health-related goals.

• Provide information that supports informed decision-making.

• Discuss with the client and support person realistic goal-setting for changes in health maintenance.

• Educate the client about the symptoms of life-threatening illness, such as myocardial infarction (MI), and the need for timeliness in seeking care.

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

• Assess the effect of fatalism on the client’s ability to modify health behavior.

• Assess for use of and reasons for not using health services.

• Clarify culturally related health beliefs and practices.

• Provide culturally targeted education and health care services.

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

 Provide nurse-led case management.

• Include a health-promotion focus for the client with disabilities, with the goals of reducing secondary conditions (e.g., obesity, hypertension, pressure sores), maintaining functional independence, providing opportunities for leisure and enjoyment, and enhancing overall quality of life.

• Encourage a regular routine for health-related behaviors.

• Provide support and individual training for caregivers before the client is discharged from the hospital.

• Assist client to develop confidence in ability to manage the health condition.

• Consider a written contract with the client to follow the agreed-upon health care regimen. Written agreements reinforce the verbal agreement and serve as a reference.

• Using self-care management precepts, instruct the client about possible situations to which he or she may need to respond; include the use of role playing. Instruct in generating hypotheses from available evidence rather than solely from experience.

• Provide the family with website addresses where information can be obtained from the Internet. (Most libraries have Internet access with printing capabilities.)

 Develop collaborative multidisciplinary partnerships.

• Tailor both the information provided and the method of delivery of information to the specific client and/or family.

• Obtain or design educational material that is appropriate for the client; use pictures if possible.

• Teach the client about the symptoms associated with discontinuation of medications, such as a selective serotonin reuptake inhibitor (SSRI).

• Explain nonthreatening aspects before introducing more anxiety-producing information regarding possible side effects of the disease or medical regimen.

• Treat tobacco use as a chronic problem. Tailor the smoking cessation program to the individual. Consider mixed groups of current and past smokers.

• All of the previously mentioned interventions are applicable for the geriatric population.

• Explore community resources to assist with home maintenance (e.g., senior centers, Department of Aging, hospital case managers, the Internet, or church parish nurse).

• Support “aging in place” by providing assistive technology devices: home modification, daily living aids, mobility aids, seating and positioning devices, and sensory aids.

• Focus on the interaction between the older client and the technology, assisting the client to be an active participant in choices and uses.

• See the care plans for Risk for Injury and Risk for Falls.

• Acknowledge the stresses unique to racial/ethnic communities.

• The previously mentioned interventions incorporate these resources.

 Refer clients with mental illness and medical conditions to in-home behavioral health case management.

 Consider referral for new home safety technologies as they become available.

• See care plans Contamination and Risk for Contamination.

• Teach the caregiver the need to set aside some personal time every day to meet his or her own needs.

• Identify support groups within the community to assist families in the caregiver role.

• Provide counseling and support for clients and for caregivers of clients.

• Focus teaching on environmental hazards identified in the nursing assessment. Areas may include, but are not limited to:

• Teach clients to assess their homes for potential environmental health hazards in the home, including risks related to structure, moisture/mold, fire, pets, electrical, ventilation, pests, and lifestyle.

• See care plans Contamination, Risk for Contamination, Risk for Falls, Risk for Infection, and Risk for Injury.

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

• Assess client and family hope prior to teaching.

• Incorporate client and family goal setting with teaching content.

• Provide information to the client and family regarding all aspects of the client’s health condition.

• Previous interventions may be adapted for geriatric clients.

 If depression is suspected; confer with the primary physician regarding referral for mental health services.

• Take threats of self-harm or suicide seriously.

• Use reminiscence and life-review therapies to identify past coping skills.

• Encourage visits from children.

• Consider videoconferencing for elders in nursing homes with relatives as alternative to “live visits.”

• Position the client by a window, take the client outside, or encourage such activities as gardening (if ability allows).

• Provide esthetic forms of expression, such as dance, music, literature, and pictures.

• Consider “biblio and telephone therapy” (BBT).

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

• Assess the effect of fatalism on the client’s expression of hopelessness.

 Assess for depression and refer to appropriate services.

• Encourage spirituality as a source of support for hopelessness.

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

 Assess for isolation within the family unit. Encourage the client to participate in family activities. If the client cannot participate, encourage him or her to be in the same area and watch family activities. Refer for telephone support.

• Reminisce with the client about his or her life.

• Identify areas in which the client can have control.

• If illness precipitated the hopelessness, discuss knowledge of and previous experience with the disease.

 Provide plant or pet therapy if possible.

• Provide information regarding the client’s condition, treatment plan, and progress.

• Teach family caregivers skills to provide care in the home.

• Provide positive reinforcement, praise, and acknowledgment of the challenges of caregiving to family members.

 Refer the client to self-help groups, such as “I Can Cope” and “Make Today Count.”

 When depression is identified by primary care physician in adolescents consider an Internet-based behavior change intervention

 Knowing what they are doing

 Know when it’s necessary to call the medical provider

 Treat me as an individual

 Give my treatments and medications on time

 Check my condition very closely

 Give my pain medication on time

 Know how to handle equipment

 Keep my family informed of my progress

 Don’t give up on me when I am difficult to get along with

• Always ask the client how he or she would like to be addressed. Avoid calling elderly clients “sweetie,” “honey,” “Gramps,” or other terms that can be demeaning unless this is acceptable in the client’s culture, or requested by the client.

• Treat the elderly client with the utmost respect, even if delirium or dementia is present with confusion.

• Avoid use of restraints. Consider all aspects of restraint use including IVs, Foleys, and chemicals.

• Assess for the influence of cultural beliefs, norms, and values on the client’s way of communicating, and follow the client’s lead in communicating in matters of eye contact, amount of personal space, voice tones, and amount of touching. If in doubt, ask the client.

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

• Recognize that the client with the caregiver has complete autonomy in the home.

• Teach family and caregivers the need for the dignity of the client to be maintained at all times.

• Recognize that hyperthermia is a rise in body temperature above 40° C [104° F] that is not regulated by the hypothalamus resulting in an uncontrolled increase in body temperature exceeding the body’s ability to lose heat, and is a medical emergency

• Measure and record a client’s temperature using two modes of temperature monitoring every hour and more frequently as clinically indicated. Continuous temperature monitoring using an indwelling method of temperature measurement is usually indicated to monitor effectiveness of interventions in lowering the body temperature.

• Use the same site and method (device) for temperature measurement for a given client so that temperature trends are assessed accurately; record site of temperature measurement.

 Work with the physician to help determine the cause of the temperature increase, hyperthermia, which will often help direct appropriate treatment.

• Recognize that heat stroke may be separated into two categories: classic and exertional.

• Watch for risk factors for classic heat stroke, which include:

• Risk factors of exertional heat stroke include:

• Recognize signs and symptoms of hyperthermia which include: core body temperature greater than 40° C (104° F), tachycardia, tachypnea, dizziness, weakness, vomiting, headache, confusion, delirium, seizures, coma, acute kidney injury (rhabdomyolysis), hot dry skin (classic heat stroke).

• Recognize that antipyretic agents are of no use in treatment of hyperthermia.

 Assess fluid loss and facilitate oral intake or administer intravenous fluids as ordered to accomplish fluid replacement and support the cardiovascular system. Refer to the care plan for Deficient Fluid Volume.

• Use external cooling measures carefully: loosen or remove excessive clothing, give a tepid water bath, provide cool liquids if the client is alert enough to swallow, fan the client’s face.

• Recognize that cooling with ice packs, cooled intravenous solution, a hypothermia blanket may be required to lower the body temperature. When using a cooling blanket, choose a circulating water cooling device if available and set the temperature regulator to 0.5° to 1° C (1° to 2° F) below the client’s current temperature to prevent shivering.

 Continually assess the client’s neurological and other organ function, especially kidney function, for signs of injury from hyperthermia.

 If the client has just received general anesthesia, especially halothane, sevoflurane, isoflurane, or succinylcholine, recognize that the hyperthermia may be caused by malignant hyperthermia and requires immediate treatment to prevent death.

• Recognize that signs and symptoms of malignant hyperthermia typically occur suddenly after exposure to the anesthetic agent and include rapid rise in core body temperature, muscle rigidity, arrhythmias, tachycardia, tachypnea, hypercarbia, rhabdomyolysis, and acute kidney injury, and elevated serum calcium and potassium, progressing to disseminated intravascular coagulation and cardiac arrest.

 If the client has malignant hyperthermia, begin treatment as ordered, including cessation of the anesthetic agent and intravenous administration of dantrolene sodium, stat, along with antiarrhythmics, and continued support of the cardiovascular system.

• Provide client and family education when malignant hyperthermia occurs, as it is an inherited muscle disorder.

 Recognize that neuroleptic malignant syndrome is a rare condition associated with clients who are taking typical and atypical antipsychotic agents.

• Watch for signs and symptoms that can range from mild to severe and include a sudden change in mental status, rapid rise in body temperature, muscle rigidity, tachycardia, tachypnea, elevated or labile blood pressure, diaphoresis, rhabdomyolysis, and acute kidney injury.

 Begin treatment when diagnosed, including cessation of the neuroleptic or dopamine antagonist agent; ordered administration of dantrolene, bromocriptine, levodopa, amantadine, or nifedipine; and continued support of the cardiovascular and renal systems.

• A client health history that reports extrapyramidal reaction to any medication should be further explored for risk of neuroleptic malignant syndrome, as this syndrome can occur at any time during a client’s treatment with typical and atypical antipsychotic agent.

• Recognize that clients receiving rapid dose escalation of antipsychotic agents (e.g., haloperidol) intramuscularly for acute treatment of delirium may be at increased risk of developing neuroleptic malignant syndrome.

• Assess risk factors of malignant hyperthermia as this has an increased prevalence in the pediatric population.

 Administer dantrolene and oxygen as ordered if malignant hyperthermia is present.

• Help the client seek medical attention immediately if elevated core temperature is present. To diagnose the hyperthermia, assess for possible precipitating factors, including changes in medication, environmental changes, and recent medical interventions or infectious exposures.

• In hot weather, encourage the client to wear lightweight cotton clothing.

• Provide education on the importance of drinking eight glasses of fluid per day (within their cardiac and renal reserves) regardless of whether they are thirsty. Assess for the need for and presence of fans or air conditioning, and also appropriate clothing.

 In hot weather, monitor the elderly client for signs of heat stroke: rising temperature, orthostatic blood pressure drop, weakness, restlessness, mental status changes, faintness, thirst, nausea, and vomiting. If signs are present, move the client to a cool place, have the client lie down, give sips of water, check orthostatic blood pressure, spray with lukewarm water, cool with a fan, and seek medical assistance immediately.

• During warm weather, help the client obtain a fan or an air conditioner to increase evaporation, as needed. Help the elderly client locate a cool environment to which the client can go for safety in hot weather.

• Take the temperature of the elderly client in hot weather.

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

• Determine whether the client or family has a functioning thermometer, and know how to use it. Please refer to the interventions above on taking a temperature.

• Help the client and caregivers prevent and monitor for heat stroke/hyperthermia during times of high outdoor temperatures.

• To prevent heat-related injury in athletes, laborers, and military personnel, instruct them to acclimate gradually to the higher temperatures, increase fluid intake, wear vapor-permeable clothing, and take frequent rests.

• In the event of temperature elevation above the adaptive range, institute measures to decrease temperature (e.g., get the client out of the sun and into a cool place, remove excess clothing, have the client drink fluids, spray the client with lukewarm water, and fan with cool air). Initiate emergency transport.

 Instruct to increase fluids to prevent heat-induced hyperthermia and dehydration in the presence of fever.

• Teach the client to stay in a cooler environment during periods of excessive outdoor heat or humidity. If the client does go out, instruct him or her to avoid vigorous physical activity; wear lightweight, loose-fitting clothing; and wear a hat to minimize sun exposure.

• Recognize hypothermia as a drop in core body temperature below 35° C [95° F].

• Take the temperature at least hourly; if more than mild hypothermia is present (temperature lower than 35° C [95° F]), use a continuous temperature-monitoring device, preferably two of them, one in the rectum, the other in the esophagus.

• Measure and record the client’s temperature hourly and with changes in client condition (e.g., chills, change in metal status) using a core or near core temperature measurement method. Avoid peripheral temperature measurement sites. If client is critically ill, use an indwelling method of temperature measurement.

• Use the same site and method (device) for temperature measurement for a given client so that temperature trends are assessed accurately and record site of temperature measurement.

• Bladder temperature may be used as an indwelling urinary catheter and is often inserted in the management of hypothermia to monitor diuresis.

• See the care plan for Ineffective Thermoregulation as appropriate.

• Recognize that there are three types of accidental hypothermia (environmental causes):

• Remove the client from the cause of the hypothermic episode (e.g., cold environment, cold or wet clothing) and bring into a warm environment. Cover the client with warm blankets and apply a covering to the head and neck to conserve body heat.

• Watch the client for signs of hypothermia: shivering, slurred speech, confusion, clumsy movements, fatigue, dehydration.

 Administer oxygen as ordered.

• Monitor the client’s vital signs every hour and as appropriate. Note changes associated with hypothermia, such as initially increased pulse rate, respiratory rate, and blood pressure as well as diuresis with mild hypothermia, and then decreased pulse rate, respiratory rate, and blood pressure as well as oliguria with moderate to severe hypothermia.

 Attach electrodes and a cardiac monitor. Watch for dysrhythmias.

 Monitor for signs of coagulopathy (e.g., oozing of blood from any open areas or from intravascular catheter sites or mucous membranes). Also note results of clotting studies as available.

• For mild hypothermia (core temperature of 32.2° to 35° C [90° to 95° F]), rewarm client passively:

 For moderate hypothermia (core temperature 28° to 32.1° C [82.4° to 90° F]), use active external rewarming methods. The rewarming rate should not exceed 0.5° to 1° C (1.8° F) per hour. Methods include the following:

 For severe hypothermia (core temperature below 28° C [82.4° F]), use active core-rewarming techniques as ordered:

• Rewarm clients slowly, generally at a rate of 0.5° to 1° C every hour.

• Check blood pressure frequently when rewarming; watch for hypotension.

 Administer IV fluids, using a rapid infuser IV fluid warmer as ordered.

• Determine the factors leading to the hypothermic episode; see Related Factors.

 Request a social service referral to help the client obtain the heat, shelter, and food needed to maintain body temperature.

 Encourage proper nutrition and hydration.

• Recognize that targeted temperature management, also called therapeutic hypothermia, is the active lowering of the client’s body temperature, in a controlled manner, to preserve neurological function after an acute myocardial injury or cardiac arrest.

• Recognize that controlled cooling of clients should be considered for all unconscious survivors of out-of-hospital ventricular tachycardia arrest as well as clients experiencing in-hospital arrests. The optimal targeted temperature for therapy is between 32° and 34° C for up to 48 hours.

• Monitor core or near core temperatures continuously using two methods of temperature monitoring.

• Recognize that cooling may be achieved noninvasively, using fluid-filled cooling devices that are placed next to the client’s skin, or invasively, infusing iced solution.

• Obtain vital signs hourly (or via continuous monitoring) to include continuous electrocardiogram monitoring. Observe for signs of hypotension, bradycardia, and arrhythmias. Mechanical ventilation is required to protect the client’s airway and breathing during treatment.

 Observe for shivering and administer sedation agents or paralytic agents as prescribed.

• Closely inspect the skin prior to and throughout the cooling intervention to prevent skin breakdown associated with the treatment. Implement frequent turning and other pressure reduction interventions as indicated.

 Monitor and treat serum electrolytes (e.g., potassium, magnesium, calcium, and phosphorus) and serum glucose closely during targeted hypothermia and during rewarming of the client. Electrolytes will fluctuate as the client is rewarmed.

 Observe for signs and symptoms of coagulopathy during targeted hypothermia treatment. Hemoconcentration may be noticed as fluids shift during treatment.

• Rewarming should occur in a controlled manner with a rise in body temperature of 0.5° to 1° C per hour and targeted goal of normothermia, 37° C.

 Neurological and cognitive function should be assessed during targeted temperature treatment and after rewarming.

• Recognize that pediatric clients have a decreased ability to adapt to temperature extremes. Take the following actions to maintain body temperature in the infant/child:

 For the preterm or low-birth-weight newborn, use specially designed bags, skin-to-skin care, transwarmer mattresses, and radiant warmers to keep the infant warm.

• Normal aging often includes changes in touch-related sensations, making it harder to differentiate cool and cold.

• Recognize that the elderly can develop indoor hypothermia from air conditioning or ice baths.

• Assess neurological signs frequently, watching for confusion and decreased level of consciousness.

• Recognize that the elderly often wear socks and sweaters to protect themselves from feeling cold, even in warmer weather.

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

• Before a medical crisis occurs, confirm that the client or family has a thermometer and can read it. Instruct as needed. Verify that the thermometer registers accurately.

• Instruct the client or family to take the temperature when the client displays cyanosis, pallor, or shivering.

 Monitor temperature every hour, as noted previously. If the temperature of the client begins dropping below the normal range, apply layers of clothing or blankets, or adjust environmental heat to the comfort level. Do not overheat. Contact a physician.

 If temperature continues to drop, activate the emergency system and notify a physician.

 If the client is in hospice care or is terminally ill, follow advance directives, client wishes, and the physician’s orders. Keep the client free of pain.

• Teach the client and family signs of hypothermia and the method of taking the temperature (age-appropriate).

• Teach the client methods to prevent hypothermia: wearing adequate clothing, including a hat and mittens; heating the environment to a minimum of 20° C (68° F); and ingesting adequate food and fluid.

 Teach the client and family about medications such as sedatives, opioids, and anxiolytics that predispose the client to hypothermia (as appropriate).