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

 Evaluate and refer children and adolescents for eating disorder prevention programs to include medical care, nutritional intervention, and mental health treatment and care coordination.

• Provide gifted children with low self-esteem with appropriate support.

• Suggest that parents with children diagnosed with cancer use computer-mediated support groups to exchange messages with other parents.

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

• Encourage clients to discuss “life history.”

 Refer the older client to self-help support groups, such as the Red Hat Society for older women.

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

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

• Encourage spirituality as a source of support for coping.

• Refer to care plan for Ineffective Coping.

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

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

 Refer the client to mutual health support groups.

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

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

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

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

 Teach coping skills to family caregivers of cancer clients.

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

• Assess barriers to immunization:

• Assess client-provider relationship.

• Assess client/caregiver level of participation in decision-making process.

• Assess sources of information client has previously turned to.

• Assist client/caregiver to find appropriate educational resources.

• Assess cultural or religious beliefs that may relate to either the decision-making process or specific immunizations such as for sexually transmitted diseases.

• Perform comprehensive interview to elicit information regarding the client’s susceptibility to adverse reactions to specific vaccines according to the manufacturer guidelines.

• Identify clients for whom a specific vaccine is contraindicated.

 Report potential or actual adverse effects.

• Inform client/caregiver of the vaccine-specific risks to both women of childbearing age and the fetus.

• Discuss pregnancy planning with appropriate clients considering immunization.

• Identify high-risk individuals for specific vaccine-preventable diseases.

• Identify high-risk groups for specific vaccine-preventable disease.

• Identify high-risk populations for specific vaccine-preventable disease.

• Assess client’s recent travel history and future travel plans.

• Identify vulnerable populations and marginalized populations.

• Tailor educational programs specific to these marginalized and vulnerable populations.

• Adopt recommendations made by national and international professional groups advocating the use of Immunization Central Registries and standing orders.

• Support access to health care that enables clients to access well-preventive care on a walk-in basis during times that are consistent with client schedules.

• Assess cultural beliefs and practices that may have an impact on the educational and decision-making process specific to immunization as well as vaccine-specific illness.

• Actively listen and be sensitive to how communication is shared culturally.

• Employ culturally sensitive educational strategies to maximize the individual, family, or community response.

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

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

• Implement home care strategies that will enhance decision-making and ability to maintain current immunization status.

• Implement mechanisms to contact the client/caregiver at appropriate intervals with reminder literature or phone contact.

• Before teaching, evaluate the client preference for involvement with the decision-making process.

• Use community-based and school-based interventions to teach school-age children and thereby provide vicarious education to the family.

• Develop curricula and media that enhance immunization education.

• Employ media and curricula in office waiting rooms.

• Develop and distribute client log books that provide record-keeping and foster ownership of the responsibility of current immunization status.

• Implement in-situ training to address impulsive behavior followed by role-play, differential reinforcement, corrective feedback and rehearsal in young children and adolescents.

• Refer to mental health treatment for CBT.

• Maintain increased surveillance of the client whenever use of dopamine agonists has been initiated. Implement fall risk screening and precautions for geriatric clients with inattention and impulse control symptoms.

• Monitor caregivers for evidence of caregiver burden.

• Provide families with information about addiction or marriage counseling.

• Families should be encouraged to employ practical measures to manage behavior such as limiting access to credit cards and restricting Internet access gambling and casino websites.

 Distance of the toilet from the bed, chair, and living quarters

 Characteristics of the bed, including presence of side rails and distance of the bed from the floor

 Characteristics of the pathway to the toilet, including barriers such as stairs, loose rugs on the floor, and inadequate lighting

 Characteristics of the bathroom, including patterns of use, lighting, height of the toilet from the floor, presence of handrails to assist transfers to the toilet, and breadth of the door and its accessibility for a wheelchair, walker, or other assistive device

 Determine the frequency of current urination using an alarm system or check-and-change device.

 Record urinary elimination and incontinent patterns in a bladder log to use as a baseline for assessment and evaluation of treatment efficacy.

 Begin a prompted toileting program based on the results of this program; toileting frequency may vary from every 1.5 to 2 hours to every 4 hours.

 Praise the client when toileting occurs with prompting.

 Refrain from any socialization when incontinent episodes occur; change the client and make her or him comfortable.

• Institute aggressive continence management programs for the cognitively intact, community-dwelling client in consultation with the client and family.

• Monitor the elderly client in a long-term care facility, acute care facility, or home for dehydration.

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

• Assess current strategies used to reduce urinary incontinence, including limitation of fluid intake, restriction of bladder irritants, prompted or scheduled toileting, and use of containment devices.

• Encourage a mindset and program of self-care management.

• For a memory-impaired older adult client, implement an individualized, scheduled toileting program (on a schedule developed in consultation with the caregiver, approximately every 2 hours, with toileting reminders provided and existing patterns incorporated, such as toileting before or after meals).

• Teach the family the general principles of bladder health, including avoidance of bladder irritants, adequate fluid intake, and a routine schedule of toileting. (Refer to the care plan for Impaired Urinary Elimination.)

• Teach prompted voiding to the family and client for the client with mild to moderate dementia (refer to previous description).

• Inspect the perineal and perianal skin for evidence of incontinence-associated dermatitis, including inflammation, vesicles in skin exposed to urinary leakage, and especially skin folds or denudation of the skin, particularly when incontinence is managed by absorptive pads or containment briefs.

• Begin a preventive skin care regimen for all clients with urinary and/or fecal incontinence and treat clients with incontinence-associated dermatitis or related skin damage.

• Advise the client about the advantages of using disposable or reusable insert pads, pad-pant systems, or replacement briefs specifically designed for urinary incontinence (or double urinary and fecal incontinence) as indicated.

• Assist the family with arranging care in a way that allows the client to participate in family or favorite activities without embarrassment. Elicit discussion of the client’s concerns about the social or emotional burden of incontinence.

 Refer to occupational therapy for help in obtaining assistive devices and adapting the home for optimal toilet accessibility.

 Consider the use of an indwelling catheter for continuous drainage in the client who is both homebound and bed-bound and is receiving palliative or end-of-life care (requires a physician’s/provider order).

 When an indwelling urinary catheter is in place, follow prescribed maintenance protocols for managing the catheter, taping and replacing the catheter, drainage bag, and care of perineal skin and urethral meatus. Teach infection control measures adapted to the home care setting.

• Assist the client in adapting to the catheter. Encourage discussion of the client’s response to the catheter.

• Work with the client, family, and their extended support systems to assist with needed changes in the environment and wardrobe, and other alterations required to maximize toileting access.

• Work with the client and family to establish a reasonable and manageable prompted voiding program using environmental and verbal cues to remind caregivers of voiding intervals, such as television programs, meals, and bedtime.

• Teach the family to use an alarm system for toileting or to carry out a check-and-change program and to maintain an accurate log of voiding and incontinence episodes.

• Begin intermittent catheterization as ordered using sterile technique; the client may be taught to use clean technique in the home situation.

• Schedule the frequency of intermittent catheterization based on the frequency/volume records of previous catheterizations, functional bladder capacity, and the impact of catheterization on the quality of the client’s life.

• Teach the client managed by intermittent or indwelling catheter to recognize signs of symptomatic urinary tract infection and to seek care promptly when these signs occur. The signs of symptomatic infection are the following:

 Recognize that intermittent catheterization is typically associated with asymptomatic bacteriuria, and the indwelling catheter is routinely associated with asymptomatic colonization.

 Teach intermittent catheterization as the client approaches discharge as directed. Instruct the client and at least one family member in the performance of catheterization. Teach the client with quadriplegia how to instruct others to perform this procedure.

 Teach the client managed by intermittent catheterization to self-administer antispasmodic (parasympatholytic) medications as ordered and to recognize and manage potential side effects as needed.

• For a male client with reflex incontinence who does not have urinary retention and cannot manage the condition effectively with spontaneous voiding, does not choose to perform intermittent catheterization, or cannot perform catheterization, teach the client and his family to obtain, select, and apply an external collective device and urinary drainage system. Assist the client and family to choose a product that adheres to the glans penis or penile shaft without allowing seepage of urine onto surrounding skin or clothing; that avoids provoking hypersensitivity reactions on the skin; and that includes a urinary drainage reservoir that is easily concealed under the clothing and does not cause irritation to the skin of the thigh.

• Teach the client whose incontinence is managed by a condom catheter to routinely inspect the skin with each catheter change for evidence of lesions caused by pressure from the containment device or by exposure to urine, to cleanse the penis thoroughly, and to reapply a new device daily or every other day.

• If difficulties are encountered in client teaching, refer the elderly client to a nurse who specializes in care of the aging client with urinary incontinence.

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

• Teach the client what the complications of reflex incontinence are and when to report changes to a physician or primary nurse.

• If the client is taught intermittent self-catheterization, arrange for contingency care in the event that the client is unable to perform self-catheterization.

• Assess and instruct the client and family in care of the catheter and supplies in the home.

• Encourage a mindset and program of self-care management.

• Assist the family with arranging care in a way that allows the client to participate in family or favorite activities without embarrassment. Elicit discussion of the client’s concerns about the social or emotional burden of incontinence.

• Teach the client to ensure good hydration. Total daily fluid intake should be approximately 2.7 liters per day for women, and 3.7 liters per day for men.

• Teach the client with a spinal injury the signs of autonomic dysreflexia, its relationship to bladder fullness, and management of the condition. Refer to the care plan for Autonomic Dysreflexia.

• Teach the client and several significant others the techniques of intermittent catheterization, indwelling catheter care and removal, or condom catheter management as appropriate.

• Teach the client and family techniques to clean catheters used for intermittent catheterization (if clean technique is ordered, including washing with soap and water and allowing to air dry), and using microwave cleaning techniques.

 Begin a graded exercise program, usually starting with 5 to 10 repetitions and advancing gradually to no more than 35 to 50 repetitions every day or every other day based on baseline and ongoing evaluation of maximal strength and endurance.

 Continue exercise sessions over a period of 3 to 6 months.

 Integrate muscle training into activities of daily living.

 Assess progress every 2 weeks during the first month and every 4 to 6 weeks thereafter.

 Assist the client in completing a bladder diary over a period of a minimum of 3 days or up to 7 days.

 Review the results with the client, determining typical voiding frequency and establishing goals for voiding frequency.

 Using baseline voiding frequency, as determined by the diary, teach the client to urinate by the clock when awake, typically every 30 to 120 minutes.

 Encourage adherence to the program with timing devices, as well as verbal encouragement and support, and address individual reasons for schedule interruption.

 Gradually increase the time between urinations to the negotiated goal. Time intervals between voiding are typically increased in increments of 15 to 30 minutes for clients with a baseline frequency of less than every 60 minutes and increments of 25 to 30 minutes for clients with a baseline frequency of more than every 60 minutes.

• Evaluate the elderly client’s functional and cognitive status to determine the effect of functional limitations on the frequency and severity of urine loss and on plans for management.

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

• Elicit discussion of the client’s concerns about the social or emotional burden of stress incontinence.

• Encourage a mindset and program of self-care management; assist the client to develop an action plan for continence.

• Implement a bladder-training program as outlined previously.

 Consider the use of an indwelling catheter for continuous drainage in the client with severe stress urinary incontinence who is homebound, bed-bound, and receiving palliative or end-of-life care (requires a physician’s order).

 When an indwelling catheter is in place, follow the prescribed maintenance protocols for managing the catheter, drainage bag, and perineal skin and urethral meatus. Teach infection control measures adapted to the home care setting.

• Assist the client in adapting to the catheter. Encourage discussion of the client’s response to the catheter.

• Teach the client to perform pelvic muscle exercise using an audiotape or videotape if indicated.

• Teach the client the importance of avoiding dehydration and instruct the client to consume fluid at the rate of 30 mL/kg of body weight daily (0.5 ounce/pound/day).

• Teach the client the importance of avoiding constipation by a combination of adequate fluid intake, adequate intake of dietary fiber, and exercise.

 Teach the client to apply and remove support devices such as a urethral insert.

• Teach the client to select and utilize incontinence supplies.

 Assist the client in completing a voiding diary over a period of a minimum of 3 days or up to 7 days.

 Review the results with the client, determining typical voiding frequency and establishing goals for voiding frequency based on the longest time interval between voids that is comfortable for the client.

 Using baseline voiding frequency, as determined by the diary, teach the client to void first thing in the morning, every time the predetermined voiding interval passes, and before going to bed at night.

 Encourage adherence to the program with timing devices and verbal encouragement and support, and address individual reasons for schedule interruption.

 Teach distraction and urge suppression techniques (see later discussion) to control urgency while the client postpones urination.

 Gradually increase the time between urinations to the negotiated goal. Time intervals between voiding are typically increased in increments of 15 to 30 minutes for clients with a baseline frequency of less than every 60 minutes and increments of 25 to 30 minutes for clients with a baseline frequency of more than every 60 minutes. The voiding interval should be increased by 15 to 30 minutes each week (based on the client’s tolerance) until a voiding interval of 3 to 4 hours is achieved. Utilize a bladder diary to monitor progress.

• Assess the functional and cognitive status of the elderly client with urge incontinence; utilize interventions to improve mobility.

• Plan care in long-term or acute care facilities based on knowledge of the elderly client’s established voiding patterns, paying particular attention to patterns of nocturia.

• Carefully monitor the elderly client for potential adverse effects of antispasmodic medications, including a severely dry mouth interfering with the use of dentures, eating, or speaking, or confusion, nightmares, constipation, mydriasis, or heat intolerance.

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

• Teach the importance of avoiding dehydration or excessive fluid consumption and the paradoxical relationship between dehydration and symptoms of urgency.

• Teach the family and client to identify and correct environmental barriers to toileting within the home.

• Encourage the client to develop an action plan for of self-care management of incontinence. Implement a bladder-training program as appropriate, including self-monitoring activities (reducing caffeine intake, adjusting amount and timing of fluid intake, decreasing long voiding intervals while awake, making dietary changes to promote bowel regularity), bladder training, and pelvic muscle exercise.

• Help the client and family to identify and correct environmental barriers to toileting within the home.

• Teach the client and family to recognize foods and beverages that are likely to irritate the bladder.

• Teach the family and client to recognize and manage side effects of antispasmodic medications used to treat urge incontinence.

• Help the client and family to recognize and manage side effect of anticholinergic medications used to manage irritative lower urinary tract symptoms.

 Identify usual toileting patterns and plan opportunities for toileting accordingly.

 Provide assistance with toileting for clients with limited access or impaired functional status (mobility, dexterity, access).

 Institute a prompted toileting program for persons with impaired cognitive status.

 Provide adequate privacy for toileting.

 Respond promptly to requests for assistance with toileting.

 Cleansing the bowel of impacted stool if indicated

 Normalizing stool consistency by adequate intake of fluids (30 mL/kg of body weight/day) and dietary or supplemental fiber

 Establishing a regular routine of fecal elimination based on established patterns of bowel elimination (patterns established prior to onset of incontinence)

 Cleanse the bowel of impacted fecal material before beginning the program.

 Implement strategies to normalize stool consistency, including adequate intake of fluid and fiber and avoidance of foods associated with diarrhea.

 Determine a regular schedule for bowel elimination (typically every day or every other day) based on prior patterns of bowel elimination.

 Provide a stimulus before assisting the client to a position on the toilet; digital stimulation, a stimulating suppository, “mini-enema,” or pulsed evacuation enema may be used for stimulation.

 Select a cleanser with a pH range comparable to that of normal skin (usually labeled “pH balanced”).

 Moisturize with an emollient to replace lipids removed with cleansing, and protect with a skin. Products containing petrolatum, dimethicone, or zinc oxide base or a no-sting skin barrier should be used.

 Routine incontinence care should include daily perineal skin cleansing and following each episode of incontinence.

 When feasible, select a product that combines two or all three of these processes into a single step. Ensure that products are available at the bedside when caring for a client with total incontinence in an inpatient facility.

 Teach nursing colleagues, nonprofessional care providers, family, and client the importance of providing toileting opportunities and adequate privacy for the client in an acute or long-term care facility.

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

• Assess and teach a bowel management program to support continence. Address timing, diet, fluids, and actions taken independently to deal with bowel incontinence.

• Instruct caregiver to provide clothing that is nonrestrictive, can be manipulated easily for toileting, and can be changed with ease.

• Evaluate self-care strategies of community-dwelling elders; strengthen adaptive behaviors, and counsel elders about altering strategies that compromise general health.

• Assist the family in arranging care in a way that allows the client to participate in family or favorite activities without embarrassment.

 If the client is limited to bed (or bed and chair), provide a commode or bedpan that can be easily accessed. Involve occupational and physical therapy services as indicated to promote safe transfers.

 If the client is frequently incontinent, refer for home health aide services to assist with hygiene and skin care.

 Refer the family to support services to assist with in-home management of fecal incontinence as indicated.

 Airborne: Isolate the client in a room with monitored negative air pressure, with the room door closed and the client remaining in the room. Always wear appropriate respiratory protection when you enter the room. Limit the movement and transport of the client from the room to essential purposes only. Have the client wear a surgical mask during transport.

 Droplet: Keep the client in a private room, if possible. If not possible, maintain a spatial separation of 3 feet from other beds or visitors. The door may remain open. Wear a surgical mask when you must come within 3 feet of the client. Some hospitals may choose to implement a mask requirement for droplet precautions for anyone entering the room. Limit transport to essential purposes and have the client wear a mask if possible.

 Contact: Place the client in a private room if possible or with someone (cohorting) who has an active infection from the same microorganism. Wear clean, nonsterile gloves when entering the room. When providing care, change gloves after contact with any infective material such as wound drainage. Remove the gloves and clean your hands before leaving the room and take care not to touch any potentially infectious items or surfaces on the way out. Wear a gown if you anticipate your clothing may have substantial contact with the client or other potentially infectious items. Remove the gown before leaving the room. Limit transport of the client to essential purposes and take care that the client does not contact other environmental surfaces along the way. Dedicate the use of noncritical client care equipment to a single client. If use of common equipment is unavoidable, adequately clean and disinfect equipment before use with other clients.

• Suspect pneumonia when the client has symptoms of lethargy or confusion. Assess response to treatment, especially antibiotic therapy.

• Most clients develop HCAP by either aspirating contaminated substances or inhaling airborne particles. Refer to care plan for Risk for Aspiration.

• Carefully screen elderly women with incontinence for urinary tract infections

 Observe and report if the client has a low-grade temperature or new onset of confusion. Use an electronic axillary thermometer.

 Recommend that the geriatric client receive an annual influenza immunization and one-time pneumococcal vaccine.

• Recognize that chronically ill geriatric clients have an increased susceptibility to infection; practice meticulous care of all invasive sites.

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

• Assess and treat wounds in the home.

• Review standards for surveillance of infections in home care.

• Maintain strong infection-prevention policies.

 Monitor for the occurrence of infectious exacerbation of chronic obstructive pulmonary disease (COPD); refer to physician for treatment.

 Refer for nutritional evaluation; implement dietary changes to support recovery and address antibiotic side effects.

• Teach the client risk factors contributing to surgical wound infection (e.g., diabetes and higher body mass index).

• Teach the client and family the importance of hand hygiene in preventing postoperative infections.

• Encourage high-risk persons, including health care workers, to get vaccinated.

• Influenza: Teach symptoms of influenza and importance of vaccination for influenza.

• Teach the client and family how to take a temperature. Encourage the family to take the client’s temperature between 4 PM and 10 PM at least once daily.

 Use at least two methods (e.g., client’s name and medical record number or birth date) to identify the client before administering medications, blood products, treatments, or procedures.

 Prior to beginning any invasive or surgical procedure, have a final verification to confirm the correct client, the correct procedure, and the correct site for the procedure using active communication techniques.

 Label containers used for blood and other specimens in the presence of the client.

 When taking verbal or telephone orders, the orders should be written down and then read back for verification to the individual giving the order.

 Standardize use of abbreviations, acronyms, symbols, and dose designations that are used in the institution.

 Ensure critical test results and values are recorded and reported in a timely manner.

 Utilize a standardized approach of “handing off” communications, including opportunities to ask and answer questions.

 Use only approved abbreviations.

 Standardize and limit the number of drug concentrations utilized by the institution (e.g., concentrations of medications such as morphine in patient-controlled analgesia [PCA] pumps).

 Label all medications and medication containers (e.g., syringes, medication cups, or other solutions on or off the surgical field).

 Identify all of the client’s current medications upon admission to a health care facility, and ensure that all health care staff have access to the information.

 Ensure that accurate medicine information is sent with the client throughout his/her care.

 Reconcile all medication at discharge, and provide list to the client.

 Improve the effectiveness of alarm systems in the clinical area.

 Standardize a list of medications that look alike or sound alike. This list needs to be updated yearly.

 Identify and take extra care with clients who are on blood-thinning medications.

 Reduce the risk of infections by following Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.

 Clients who obtain injuries or die from infectious disease must be documented.

 Utilize proven guidelines to prevent infections that are difficult to treat.

 Utilize proven guidelines to prevent infection of the blood from central lines.

 Utilize safe practices to treat the surgical site of the client.

 Evaluate all clients for fall risk and take appropriate actions to prevent falls.

 Educate the client and family on how to recognize and report concerns about safety issues.

 Identify which clients are at risk for harming themselves.

 Educate staff on how to recognize changes in client condition, how to respond quickly, and how to alert specially trained staff to intervene if needed.

 Prevent errors in surgery.

 Standardize steps to educate staff so documents for surgery are ready prior to surgery.

 Educate staff to mark the body part scheduled for surgery and engage the client in this process as well.

• See care plan for Risk for Falls.

 Avoid use of restraints if at all possible. Restraint-free is now the standard of care for hospitals and long-term care facilities. Obtain a physician’s order if restraints are necessary.

• In place of restraints, use the following:

• For an agitated client, consider providing individualized music of the client’s choice.

• Review drug profile for potential side effects that may increase risk of injury.

• Use one quarter- to one half-length side rails only, and maintain bed in a low position. Ensure that wheels are locked on bed and commode. Keep dim light in room at night.

• If the client has a new onset of confusion (delirium), refer to the care plan for Acute Confusion. If the client has chronic confusion, see the care plan for Chronic Confusion.

• Ask family to stay with the client to prevent the client from accidentally falling or pulling out tubes.

• Remove all possible hazards in environment such as razors, medications, and matches.

• Place an injury-prone client in a room that is near the nurse’s station.

• Help clients sit in a stable chair with armrests. Avoid use of wheelchairs and geri-chairs except for transportation as needed.

 Refer to physical therapy for strengthening exercises and gait training to increase mobility.

 For the agitated psychotic client, use nonphysical forms of behavior management, such as verbal intervention or show of force. If medication is required, use oral medications if at all possible.

• Teach parents the need for close supervision of all young children playing near water.

• If child has epilepsy, recommend showers instead of tub baths, and no unsupervised swimming is ever allowed.

• Assess the client’s socioeconomic status.

• Never leave young children unsupervised around cooking areas.

• Teach parents and children the need to maintain safety for the exercising child, including wearing helmets when biking.

• Encourage parents to insist on using breakaway bases for baseball.

• Provide parents of children with traumatic brain injury with written instruction, emergency phone numbers and ensure that instructions are understood before child is discharged from health care setting. Instruct them to observe for the following symptoms: nausea, mild headache, dizziness, irritability, lethargy, poor concentration, loss of appetite, and insomnia

• Teach both parents and children the need for gun safety.

• Encourage the client to wear glasses and hearing aids and to 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.

• Discourage driving at night.

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

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

• Assess whether exposure to community violence is contributing to risk for injury.

• Use culturally relevant injury prevention programs whenever possible.

• Validate the client’s feelings and concerns related to environmental risks.

• See Risk for Trauma for more Nursing Interventions.

• Assessment of medications used for pain and other symptoms in the elderly is important because pain medications may be interfering with the client’s ability to initiate and maintain sleep.

• Most interventions discussed previously may be used with geriatric clients. Passive body heating via full-immersion or foot baths should be used with great caution in the elderly because of multiple safety issues that are more prevalent with the elderly, including burns, dehydration, and potential for slips/falls in bath area.

• In addition see the Geriatric section of Nursing Interventions for Readiness for enhanced Sleep.

• Assessments and interventions discussed previously may be adapted for use in home care.

• In addition, see the Home Care section of Nursing Interventions for Readiness for enhanced Sleep.

• Teach family about normal sleep and promote adoption of behaviors that enhance it. See Nursing Interventions for Readiness for enhanced Sleep.

• Teach family about sleep deprivation and how to avoid it. See Nursing Interventions for Sleep Deprivation.

• Advise family of importance of not disrupting sleep of others unnecessarily. See Nursing Interventions for Sleep Disruption.

• Advise family of importance of minimizing noise and light in the sleep environment. See Nursing Interventions for Disturbed Sleep Pattern.

• Help family differentiate insomnia from externally caused sleep disruption and resultant sleep deprivation: Family members may have direct control over interruptions in sleep and thus may help limit sleep deprivation directly.

 Maintain and display ICP and CPP continuously as ICP data guide therapy and predict outcome.

 Maintain ICP less than 20 mm Hg and CPP greater than 60 mm Hg.

 Monitor neurological status frequently (hourly in acute situations) using the Glasgow Coma Scale (GCS), noting changes in eye opening, motor response to painful stimuli, and awareness of self, time, and place.

 Monitor pupillary size and reaction to light during all neurological assessments.

 Monitor brain temperature.

 Monitor brain tissue oxygen (PbtO₂).

 Elevate head of bed 30 to 45 degrees with head in midline position.

 Administer sedation per collaborative protocol.

 Administer pain medication per collaborative protocol.

 Maintain glycemic control per collaborative protocol.

 Maintain normothermia.

 Maintain optimal oxygenation and ventilation, applying positive end expiratory pressure (PEEP) as needed and avoiding hyperventilation.

 Premedicate clients with adequate sedation and limit endotracheal suction passes to two in order to limit ICP increases.

 See care plan for Risk for ineffective Cerebral tissue perfusion.

 Remove or loosen rigid cervical collars.

 Administer a bolus dose of mannitol and/or hypertonic saline per collaborative protocol.

 Drain CSF from an intraventricular catheter system per collaborative protocol.

 Administer barbiturates per collaborative protocol, and monitor blood pressure closely during medication administration.

 Induce moderate hypothermia (32° to 35° C) per collaborative protocol.

 Administer norepinephrine to raise MAP per collaborative protocol.

 Administer hypertonic saline per collaborative protocol.