P

Acute Pain

NANDA-I Definition

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe with an anticipated or predictable end and a duration of less than 6 months

Pain is whatever the experiencing person says it is, existing whenever the person says it does.

Defining Characteristics

Subjective

Pain is a subjective experience, and its presence cannot be proved or disproved. Self-report is the most reliable method of evaluating pain presence and intensity. A client with cognitive ability who is able to speak or provide information about pain in other ways, such as pointing to numbers or words, should use a self-report pain tool (e.g., Numerical Rating Scale [NRS]) to identify the current pain intensity and establish a comfort-function goal.

Objective

Pain is a subjective experience, and objective measurement is impossible. If a client cannot provide a self-report, there is no pain intensity level. Behavioral responses should never serve as the basis for pain management decisions if self-report is possible. However, observation of behavioral responses may be helpful in recognition of pain presence for clients who are unable to provide a self-report. Observable pain responses may include loss of appetite and inability to deep breathe, ambulate, sleep, and perform ADLs. Pain-related behaviors vary widely and are highly individual. They may include guarding, self-protective behavior, and self-focusing; and distraction behavior ranging from crying to laughing, as well as muscle tension or rigidity. Clients may be stoic and lie completely still despite having severe pain. Sudden acute pain may be associated with neurohumoral responses that can lead to increases in heart rate, blood pressure, and respiratory rate. However, physiological responses, such as elevated blood pressure or heart rate, are not sensitive indicators of pain presence and intensity as they do not discriminate pain from other sources of distress, pathological conditions, homeostatic changes, or medications. Behavioral or physiological indicators may be used to confirm other findings; however, the absence of these indicators does not mean that pain is absent.

NOTE: The defining characteristics are modified from the work of NANDA-I.

Related Factors (r/t)

Injury agents (biological, chemical, physical, psychological)

Client Outcomes

Client Will (Specify Time Frame)

For the client who is able to provide a self-report:

• Use a self-report pain tool to identify current pain intensity level and establish a comfort-function goal

• Report that pain management regimen achieves comfort-function goal without side effects

• Describe nonpharmacological methods that can be used to help achieve comfort-function goal

• Perform activities of recovery or ADLs easily

• Describe how unrelieved pain will be managed

• State ability to obtain sufficient amounts of rest and sleep

• Notify member of the health care team promptly for pain intensity level that is consistently greater than the comfort-function goal, or occurrence of side effects

For the client who is unable to provide a self-report:

• Decrease in pain-related behaviors

• Perform activities of recovery or ADLs easily as determined by client condition

• Demonstrate the absence of side effects of analgesics

• No pain-related behaviors will be evident in the client who is completely unresponsive; a reasonable outcome is to demonstrate the absence of side effects related to the prescribed pain treatment plan

Nursing Interventions

• Determine if the client is experiencing pain at the time of the initial interview. If pain is present, conduct and document a comprehensive pain assessment and implement or request orders to implement pain management interventions to achieve a satisfactory level of comfort. Components of this initial assessment include location, quality, onset/duration, temporal profile, intensity, aggravating and alleviating factors, and effects of pain on function and quality of life.

• Assess pain intensity level in a client using a valid and reliable self-report pain tool, such as the 0-10 numerical pain rating scale.

• Assess the client for pain presence routinely; this is often done at the same time as when a full set of vital signs are obtained, and during activity and rest. Also assess for pain with interventions or procedures likely to cause pain.

• Ask the client to describe prior experiences with pain, effectiveness of pain management interventions, responses to analgesic medications including occurrence of side effects, and concerns about pain and its treatment (e.g., fear about addiction, worries, or anxiety) and informational needs.

• Ask the client to identify a comfort-function goal, a pain level, on a self-report pain tool, that will allow the client to perform necessary or desired activities easily. This goal will provide the basis to determine effectiveness of pain management interventions. If the client is unable to provide a self-report, it will not be possible to establish a comfort-function goal.

• Describe the adverse effects of unrelieved pain.

• Use the Hierarchy of Pain Measures as a framework for pain assessment: (1) attempt to obtain the client’s self-report of pain; (2) consider the client’s condition and search for possible causes of pain (e.g., presence of tissue injury, pathological conditions, or exposure to procedures/interventions that are thought to result in pain); (3) observe for behaviors that may indicate pain presence (e.g., facial expressions, crying, restlessness, and changes in activity); (4) evaluate physiological indicators, with the understanding that these are the least sensitive indicators of pain and may be related to conditions other than pain (e.g., shock, hypovolemia, anxiety); and (5) conduct an analgesic trial.

• Assume that pain is present if the client is unable to provide a self-report and has tissue injury, a pathological condition, or has undergone a procedure that is thought to produce pain.

• Conduct an analgesic trial for clients who are unable to provide self-report and have underlying pathology/condition that is thought to be painful, or who demonstrate behaviors that may indicate pain is present. Administer a nonopioid if pain is thought to be mild and an opioid if pain is thought to be moderate to severe. Reassess the client to evaluate intervention effectiveness within a specific period of time based on pharmacokinetics (intravenous [IV] 15 to 30 minutes, subcutaneous 30 minutes, oral 60 minutes).

• Determine the client’s current medication use. Obtain an accurate and complete list of medications the client is taking or has taken.

• Explain to the client the pain management approach, including pharmacological and nonpharmacological interventions, the assessment and reassessment process, potential side effects, and the importance of prompt reporting of unrelieved pain.

• Manage acute pain using a multimodal approach.

• Recognize that the oral route is preferred for pain management interventions. If the client is receiving parenteral analgesia, use an equianalgesic chart to convert to an oral analgesic as soon as possible.

• Provide PCA, perineural infusions, and intraspinal analgesia as ordered, when appropriate and available

• Avoid giving pain medication by the intramuscular (IM) route of administration.

• Obtain a prescription to administer a nonopioid analgesic for mild to moderate pain and an opioid analgesic if indicated for moderate to severe acute pain.

• Treat acute pain in a comprehensive manner.

• Prevent pain by administering analgesia before painful procedures whenever possible (e.g., endotracheal suctioning, wound care, heel puncture, venipunctures, and peripherally inserted IV catheters). Use a topical local anesthetic or IV opioid as determined by individualized client status and severity of associated pain.

• Administer supplemental analgesic doses as ordered to keep the client’s pain level at or below the comfort-function goal, or desired outcome based on clinical judgment or behaviors if client is unable to provide a self-report.

• Perform nursing care when the client is comfortable. This is facilitated when the peak time (maximum serum concentration) of the analgesic is considered.

• Discuss the client’s fears of undertreated pain, side effects, and addiction.

• Assess pain level, sedation level, and respiratory status at regular intervals during opioid administration. Assess sedation and respiratory status every 1 to 2 hours during the first 24 hours of opioid therapy, then every 4 hours if respiratory status has been stable without episodes of hypoventilation, or more frequently as determined by individualized client status. Conduct the respiratory assessment before sedation assessment by evaluating the depth, regularity, and noisiness of respiration, and counting respiratory rate for 60 seconds. Awaken sleeping clients for assessment if the respiration is inadequate (e.g., if respirations are shallow, ineffective, irregular, or noisy [snoring], or periods of apnea occur). Snoring indicates respiratory obstruction and warrants prompt arousal, repositioning, and evaluation of respiratory risk factors. Discontinue titration or continuous opioid infusions immediately, and decrease subsequent opioid doses by 25% to 50% if the client develops excessive sedation.

• Ask the client to report side effects, such as nausea and pruritus, and to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to prevent and improve these conditions and functions. Obtain a prescription for a combination stool softener plus peristaltic stimulant to prevent opioid-induced constipation.

• Review the client’s pain flowsheet and medication administration record to evaluate effectiveness of pain relief, previous 24-hour opioid requirements, and occurrence of side effects.

• Obtain orders to increase or decrease opioid doses as needed; base analgesic and dose on the client’s report of pain severity (clinical judgment of effectiveness if the client is unable to provide a self-report), response to the previous dose in terms of pain relief, occurrence of side effects, and ability to perform the activities of recovery or ADLs.

• When the client is able to tolerate oral intake, obtain a prescription to change analgesics to the oral route of administration; use an equianalgesic chart to determine the initial dose and adjust for incomplete cross tolerance.

• In addition to administering analgesics, support the client’s use of nonpharmacological methods to help control pain, such as distraction, imagery, relaxation, and application of heat and cold.

• Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions.

Pediatric

• Assess for the presence of pain using a valid and reliable pain scale based on age, cognitive development, and the child’s ability to provide a self-report.

• Administer analgesics as prescribed.

• Prevent procedural pain in neonates, infants, and children by using opioid analgesics and anesthetics, as indicated, in appropriate dosages.

• Use a topical local anesthetic such as EMLA cream or LMX-4 before performing venipuncture in neonates, infants, and children.

• For the neonate, use oral sucrose and nonnutritional sucking (NNS) or human milk for pain of short duration such as heel stick or venipuncture.

• Recognize that breastfeeding has been shown to reduce behavioral indicators of pain.

• As with adults, use nonpharmacological interventions to supplement, not replace, pharmacological interventions.

Geriatric

• Please refer to the interventions in the care plan for Chronic Pain.

Multicultural

• Please refer to the care plan on Chronic Pain for multicultural interventions.

Home Care

• Develop the treatment plan with the client and caregivers.

• Develop a full medication profile, including medications prescribed by all physicians and all over-the-counter medications. Assess for drug interactions. Instruct the client to refrain from mixing medications without physician approval.

• Assess the client’s and family’s knowledge of side effects and safety precautions associated with pain medications (e.g., use caution in operating machinery when opioids are first taken or dosage has been increased significantly).

• If medication is administered using highly technological methods, assess the home for the necessary resources (e.g., electricity) and ensure that there will be responsible caregivers available to assist the client with administration.

• Assess the knowledge base of the client and family with regard to highly technological medication administration. Teach as necessary. Be sure the client knows when, how, and whom to contact if analgesia is unsatisfactory.

Client/Family Teaching and Discharge Planning

NOTE: To avoid the negative connotations associated with the words drugs and narcotics, use the term pain medicine when teaching clients.

• Discuss the various discomforts encompassed by the word pain and ask the client to give examples of previously experienced pain. Explain the pain assessment process and the purpose of the pain rating scale.

• Teach the client to use the self-report pain tool to rate the intensity of past or current pain. Ask the client to set a comfort-function goal by selecting a pain level on the self-report tool that will allow performance of desired or necessary activities of recovery with relative ease (e.g., turn, cough, deep breathe, ambulate, participate in physical therapy). If the pain level is consistently above the comfort-function goal, the client should take action that decreases pain or notify a member of the health care team so that effective pain management interventions may be implemented promptly. (See information on teaching clients to use the pain rating scale.)

• Provide written materials on pain control that teach how to use a pain rating scale and how to take analgesics.

• Discuss the total plan for pharmacological and nonpharmacological treatment, including the medication plan for around-the-clock administration and supplemental doses, and the use of supplies and equipment. If PCA is ordered, determine the client’s ability to press the appropriate button. Remind the client and staff that the PCA button is for client use only.

• Reinforce the importance of taking pain medications to maintain the comfort-function goal.

• Demonstrate the use of appropriate nonpharmacological approaches in addition to pharmacological approaches to help control pain, such as application of heat and/or cold, distraction techniques, relaxation breathing, visualization, rocking, stroking, music listening, and television watching).

• Teach nonpharmacological methods when pain is relatively well controlled. Pain interferes with cognition.

Chronic Pain

NANDA-I Definition

Unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage; sudden or slow onset of any intensity from mild to severe, constant or recurring without an anticipated or predictable end. Pain is whatever the experiencing person says it is, existing whenever the person says it does.

Defining Characteristics

Pain is a subjective experience and its presence cannot be proved or disproved. Self-report is the most reliable method of evaluating pain presence and intensity. Please refer to the Defining Characteristics in the Acute Pain care plan for further characteristics of pain.

Related Factors (r/t)

Actual or potential tissue damage; tumor progression and related pathology; diagnostic and therapeutic procedures; central or peripheral nerve injury (neuropathic pain)

NOTE: The cause of chronic (persistent) noncancer (nonmalignant) pain may be unknown. It often involves multiple poorly understood underlying mechanisms and includes a complex interaction of physiological, emotional, cognitive, social, and environmental factors. It is the subject of ongoing research.

Client Outcomes

Client Will (Specify Time Frame)

For the client who is able to provide a self-report:

• Provide a description of the pain experience including physical, social, emotional, and spiritual aspects

• Use a self-report pain tool to identify current pain level and establish a comfort-function goal

• Report that the pain management regimen achieves comfort-function goal without the occurrence of side effects

• Describe nonpharmacological methods that can be used to supplement, or enhance, pharmacological interventions and help achieve the comfort-function goal

• Perform necessary or desired activities at a pain level less than or equal to the comfort-function goal

• Demonstrate the ability to pace activity, taking rest breaks before they are needed

• Describe how unrelieved pain will be managed

• State the ability to obtain sufficient amounts of rest and sleep

• Notify a member of the health care team for pain level consistently greater than the comfort-function goal or occurrence of side effect

For the client who is unable to provide a self-report:

• Demonstrate decrease or resolved pain-related behaviors

• Perform desired activities as determined by client condition

• Demonstrate the absence of side effects

Nursing Interventions

• Assess pain intensity level in a client using a valid and reliable self-report pain tool, such as the 0-10 numerical pain rating scale.

• Describe the adverse effects of persistent unrelieved pain.

• Ask the client to identify the pain level, on a self-report pain tool, that will allow the client to perform desired activities and achieve an acceptable quality of life. This comfort-function goal will provide the basis to determine effectiveness of the individualized pain management plan. If the client is unable to provide a self-report, it will not be possible to establish a comfort-function goal.

• Assess the client for the presence of pain routinely; this is often done at the same time as when a full set of vital signs are obtained in the inpatient setting. Assess pain during both activity and rest.

• Ask the client to maintain a diary (if able) of pain ratings, timing, precipitating events, medications, and effectiveness of pain management interventions.

• Assume that pain is present if the client is unable to provide a self-report and has tissue injury or a pathological condition or has undergone a procedure that is thought to produce pain.

• Determine the client’s current medication use.

• Explain to the client the pain management approach that has been ordered, including therapies, medication administration, side effects, and complications.

• Discuss the client’s fears of undertreated pain, addiction, and overdose.

• Manage chronic pain using a multimodal approach.

• Avoid giving pain medication intramuscularly (IM).

• Recognize that many clients with chronic pain have neuropathic pain. (Please refer to assessment earlier.) Treat neuropathic pain with adjuvant analgesics, such as anticonvulsants, antidepressants, and topical local anesthetics.

• Administer a nonopioid analgesic for mild to moderate chronic pain, such as osteoarthritis or cancer pain.

• Recognize that opioid therapy may be indicated for some clients experiencing chronic pain.

• Treat chronic pain in a comprehensive manner.

• Administer supplemental opioid doses for breakthrough pain as needed to keep pain ratings at or below the comfort-function goal.

• Assess pain level, sedation level, and respiratory status at regular intervals during opioid administration in the inpatient setting. Assess sedation and respiratory status every 1 to 2 hours during the first 24 hours of opioid therapy, then every 4 hours if respiratory status has been stable without episodes of hypoventilation, or more frequently as determined by individualized client status. Conduct the respiratory assessment before sedation assessment by evaluating the depth, regularity, and noisiness of respiration and counting respiratory rate for 60 seconds. Awaken sleeping clients for assessment if the respiration is inadequate (e.g., if respirations are shallow, ineffective, irregular, or noisy [snoring], or periods of apnea occur). Snoring indicates respiratory obstruction and warrants prompt arousal, repositioning, and evaluation of respiratory risk factors. Discontinue titration or continuous opioid infusions immediately, and decrease subsequent opioid doses by 25% to 50% if the client develops excessive sedation.

• Ask the client to describe appetite, bowel elimination, and ability to rest and sleep. Administer medications and treatments to improve these functions. Obtain a prescription for a combination stool softener plus peristaltic stimulant to prevent opioid-induced constipation.

• Question the client about any disruption in sleep.

• Watch for signs of depression in the clients with chronic pain, including sleeplessness, not eating, flat affect, statements of depression, or suicidal ideation.

• Review the client’s pain diary, flow sheet, and medication records to determine the overall degree of pain relief, side effects, and analgesic requirements for an appropriate period (e.g., 1 week).

• In addition to administering analgesics, support the client’s use of nonpharmacological methods to help control pain, such as distraction, imagery, relaxation, and application of heat and cold.

• Teach and implement nonpharmacological interventions when pain is relatively well controlled with pharmacological interventions.

• Encourage the client to plan activities around periods of greatest comfort whenever possible. Pain impairs function.

• Explore appropriate resources for management of pain on a long-term basis (e.g., hospice, pain care center).

• If the client has progressive cancer pain, assist the client and family with handling issues related to death and dying.

Pediatric

• Assess for the presence of pain using a valid and reliable pain scale based on age, cognitive development, and the child’s ability to provide a self-report.

• Administer analgesics as prescribed.

• As with adults, use nonpharmacological interventions to supplement, not replace, pharmacological interventions.

Geriatric

• Always take an older client’s report of pain seriously and ensure that the pain is relieved.

• When assessing pain, speak clearly, slowly, and loudly enough for the client to hear, and if the client uses a hearing aid, be sure it is in place; repeat information as needed. Be sure the client can see well enough to read the pain scale (use an enlarged scale) and written materials.

• Handle the client’s body gently. Allow the client to move at his or her own speed.

• Use nonopioid analgesics for mild to moderate pain.

• Use opioids cautiously in the older client with moderate to severe pain. Initiate opioid therapy with a low dose, and carefully titrate the dose based on pain and sedation assessment. Titrate the dose using a short-acting opioid, and convert to a long-acting opioid as soon as possible for ongoing continuous pain.

• Avoid the use of meperidine (Demerol) in older clients.

• Use nonpharmacological approaches in addition to analgesics.

• Monitor for signs of depression in older clients and refer to specialists with relevant expertise.

Multicultural

• Assess for pain disparities among racial and ethnic minorities.

• Assess for the influence of cultural beliefs, norms, and values on the client’s perception and experience of pain.

• Assess for the effect of fatalism on the client’s beliefs regarding the current state of comfort.

• Incorporate safe and effective folk health care practices and beliefs into care whenever possible.

• Use a family-centered approach to care.

• Teach information about pain medications and their side effects and how to work with health care providers to manage pain, and encourage use of religious faith as desired to cope with pain.

• Use culturally relevant pain scales to assess pain in the client.

• Ensure that directions for medication use are available in the client’s language of choice and are understood by the client and caregiver.

Home Care

• Please refer to the care plan on Acute Pain for interventions on home care.

Client/Family Teaching and Discharge Planning

NOTE: To avoid the negative connotations associated with the words drugs and narcotics, use the term pain medicine when teaching clients and opioids when speaking with colleagues.

• Teach the client to use the self-report pain tool to rate the intensity of past or current pain. Ask the client to set a comfort-function goal by selecting a pain level on the self-report tool that will allow performance of desired or necessary activities of daily living with relative ease (e.g., ambulation, self-care) or achieve acceptable quality of life. If the pain level is consistently above the comfort-function goal, the client should take action that decreases pain or notify a member of the health care team so that effective pain management interventions may be implemented promptly. (See information on teaching clients to use the pain rating scale.)

• Provide written materials on pain control that teach how to use a pain rating scale and how to take analgesics.

• Discuss the total plan for pharmacological and nonpharmacological treatment, including the medication plan for ATC administration and supplemental doses, the maintenance of a pain diary, and the use of supplies and equipment. If PCA is ordered, determine the client’s ability to press the appropriate button. Remind the client and staff that the PCA button is for client use only.

• Reinforce the importance of taking pain medications to maintain the comfort-function goal.

• Explain that some analgesics (e.g., anticonvulsants, antidepressants) must be titrated over an extended period of time to achieve satisfactory pain relief.

• Reinforce that taking opioids for pain relief is not addiction and that addiction is very unlikely to occur.

• Demonstrate the use of appropriate nonpharmacological approaches in addition to pharmacological approaches for helping to control pain, such as application of heat and/or cold, distraction techniques, relaxation breathing, visualization, rocking, stroking, music listening, and television watching. Teach these methods when pain is relatively well controlled, because pain interferes with cognition.

• Suggest the client with chronic pain try having a massage, with aromatherapy if desired.

• Emphasize to the client the importance of pacing activity and taking rest breaks before they are needed.

• Teach nonpharmacological methods when pain is relatively well controlled.

Impaired Parenting

NANDA-I Definition

Inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child

Defining Characteristics

Infant/Child

Behavioral disorders; failure to thrive; frequent accidents; frequent illness; incidence of abuse; incidence of trauma (e.g., physical and psychological); lack of attachment; lack of separation anxiety; poor academic performance; poor cognitive development; poor social competence; runaway

Parental

Abandonment; child abuse; child neglect; frequently punitive; hostility to child; inadequate attachment; inadequate child health maintenance; inappropriate caretaking skills; inappropriate child care arrangements; inappropriate stimulation (e.g., visual, tactile, auditory); inconsistent behavior management; inconsistent care; inflexibility in meeting needs of child; little cuddling; maternal-child interaction deficit; negative statements about child; paternal-child interaction deficit; rejection of child; reports frustration; reports inability to control child; reports role inadequacy; statements of inability to meet child’s needs; unsafe home environment

Related Factors (r/t)

Infant/Child

Altered perceptual abilities; attention deficit hyperactivity disorder; developmental delay; difficult temperament; handicapping condition; illness; multiple births; not desired gender; premature birth; separation from parent; temperamental conflicts with parental expectations

Knowledge

Deficient knowledge about child development; deficient knowledge about child health maintenance; deficient knowledge about parenting skills; inability to respond to infant cues; lack of cognitive readiness for parenthood; lack of education; limited cognitive functioning; poor communication skills; preference for physical punishment; unrealistic expectations

Physiological

Physical illness

Psychological

Closely spaced pregnancies; depression; difficult birthing process; disability; disturbed sleep pattern; high number of pregnancies; history of mental illness; history of substance abuse; lack of prenatal care; sleep deprivation; young parental age

Social

Change in family unit; chronic low self-esteem; economically disadvantaged; father of child not involved; financial difficulties; history of being abused; history of being abusive; inability to put child’s needs before own; inadequate child care arrangements; job problems; lack of family cohesiveness; lack of parental role model; lack of resources; lack of social support networks; lack of transportation; lack of valuing of parenthood; legal difficulties; maladaptive coping strategies; marital conflict; mother of child not involved; poor home environment; poor parental role model; poor problem-solving skills; presence of stress (e.g., financial, legal, recent crisis, cultural move); relocations; role strain; single parent; situational low self-esteem; social isolation; unemployment; unplanned pregnancy; unwanted pregnancy

Client Outcomes

Client Will (Specify Time Frame)

• Initiate appropriate measures to develop a safe, nurturing environment

• Acquire and display attentive, supportive parenting behaviors and child supervision

• Identify appropriate strategies to manage a child’s inappropriate behaviors

• Identify strategies to protect child from harm and/or neglect and initiate action when indicated

Nursing Interventions

• Use the Parenting Sense of Competence (PSOC) scale to measure parental self-efficacy.

• Examine the characteristics of parenting style and behaviors. Consider dysfunctional child-centered and parent-centered cognitions as potentially critical correlates of abusive behavior.

Institute abuse/neglect protection measures if evidence exists of an inability to cope with family stressors or crisis, signs of parental substance abuse are observed, or a significant level of social isolation is apparent.

For a mother with a toddler, assess maternal depression. Make appropriate referral.

• Appraise the parent’s resources and the availability of social support systems. Determine the single mother’s particular sources of support, especially the availability of her own mother and partner. Encourage the use of healthy, strong support systems.

• Provide education to at-risk parents on behavioral management techniques such as looking ahead, giving good instructions, providing positive reinforcement, redirecting, planned ignoring, and instituting time-outs.

• Promotion of better-quality relationships between parents and children is an effective strategy that can lead to enhanced learning. Good-quality parenting leads to improved cognitive and social skills for the children.

• Support parents’ competence in appraising their infant’s behavior and responses.

• Aim supportive interventions at minimizing parents’ experience of strain.

• Model age-appropriate and cognitively appropriate caregiver skills by doing the following: communicating with the child at an appropriate cognitive level of development, giving the child tasks and responsibilities appropriate to age or functional age/level, instituting safety considerations such as the use of assistive equipment, and encouraging the child to perform activities of daily living as appropriate. Encourage mothers to understand and capitalize on their infants’ capacity to interact, particularly in the early months of life.

Provide programs for homeless mothers with severe mental illness who have lost physical custody of their children.

Provide a recovery program that includes instruction in parenting skills and child development for mothers who are addicted to cocaine.

• Refer to Readiness for enhanced Parenting for additional interventions.

Multicultural

• Acknowledge that value conflicts from acculturation stresses may contribute to increased anxiety and significant conflict with children.

• Approach individuals of color with respect, warmth, and professional courtesy

• Clarify parents’ feelings, expectations, perceptions, and availability regarding participation in the care of their sick child.

• Carefully assess meaning of terms used to describe health status when working with Native Americans.

• Provide support for Chinese families caring for children with disabilities.

• Facilitate modeling and role playing to help the family improve parenting skills.

Home Care

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

• Assess parenting stress at each home visit to provide appropriate support and anticipatory guidance to families of children with a chronic disease.

Assess the single mother’s history regarding childhood and partner abuse and current status regarding depressive symptoms, abusive parenting attitudes (lack of empathy, favorable opinion of corporal punishment, parent-child role reversal, and inappropriate expectations). Refer for mental health services as indicated.

• Provide a parenting program of Planned Activities Training (PAT).

• Provide follow-up support for the PAT via cell phone and text messaging.

Client/Family Teaching and Discharge Planning

• Consider individual and/or group-based parenting programs for teenage mothers.

• Consider group-based parenting programs for parents of children younger than 3 years with emotional and behavioral problems.

• Consider group-based parenting programs for parents with anxiety, depression, and/or low self-esteem.

Refer adolescent parents for comprehensive psychoeducational parenting classes.

• Parent training is one of the most effective interventions for behavior problems in young children.

• Encourage positive parenting: respect for children, understanding of normal development, and creative and loving approaches to meet parenting challenges rather than using anger, manipulation, punishment and rewards.

Initiate referrals to community agencies, parent education programs, stress management training, and social support groups. Consider the use of technology and the media.

• Provide information regarding available telephone counseling services and Internet support.

• Refer to the care plans for Delayed Growth and Development, Risk for impaired Attachment, and Readiness for enhanced Parenting for additional teaching interventions.

Readiness for enhanced Parenting

NANDA-I Definition

A pattern of providing an environment for children or other dependent person(s) that is sufficient to nurture growth and development and can be strengthened

Defining Characteristics

Children report satisfaction with home environment; emotional support of children; emotional support of other dependent persons; evidence of attachment; exhibits realistic expectations of children; exhibits realistic expectations of other dependent person(s); expresses willingness to enhance parenting; needs of children are met (e.g., physical and emotional); needs of other dependent person(s) is/are met (e.g., physical and emotional); other dependent person(s) expresses(es) satisfaction with home environment

Client Outcomes

Client/Family Will (Specify Time Frame)

• Affirm desire to improve parenting skills to further support growth and development of children

• Demonstrate loving relationship with children

• Provide a safe, nurturing environment

• Assess risks in home/environment and takes steps to prevent possibility of harm to children

• Meet physical, psychosocial, and spiritual needs or seek appropriate assistance

Nursing Interventions

• Use family-centered care and role modeling for holistic care of families.

• Assess parents’ feelings when dealing with a child who has a chronic illness.

• Encourage positive parenting: respect for children, understanding of normal development, and use of creative and loving approaches to meet parenting challenges.

• Promote low-technology interventions, such as massage and multisensory interventions (maternal voice, eye-to-eye contact, and rocking) and music to reduce maternal and infant stress and improve mother-infant relationship.

• Support kangaroo care for infants at risk at birth; keep infants in an upright position in skin-to-skin contact.

• Provide the parent with the opportunity to assist in the newborn’s first bath, allowing a flexible bath time.

• When the person who is ill is the parent, use family-centered assessment skills to determine the impact of an adult’s illness on the child, and then guide the parent through those topics that are most likely to be of concern.

• Provide practical and psychological assistance for parents of clients with psychiatric diagnoses, such as schizophrenia.

• Refer to the care plan for Impaired Parenting for additional interventions.

Multicultural

• Assess the influence of cultural beliefs, norms, and values on the client’s perception of parenting.

• Acknowledge racial and ethnic differences at the onset of care and provide appropriate health information and social support.

• Support programs for parents of young children in specific cultural communities.

• Clarify parents’ feelings, expectations, perceptions, and availability regarding participation in the care of their sick child.

• Acknowledge and praise parenting strengths noted.

Home Care

• The nursing interventions previously described should be used in the home environment with adaptations as necessary.

Refer to a parenting program to facilitate learning of parenting skills.

Client/Family Teaching and Discharge Planning

• Refer to Client/Family Teaching and Discharge Planning for Impaired Parenting for suggestions that may be used with minor adaptations.

• Teach parents home safety: reduction of hot water temperature, proper poison storage, use of smoke alarms, and installation of safety gates for stairs.

• Teach parents and young teens conflict resolution by using a hypothetical conflict solution with and without a structured conflict resolution guide. Support self-direction of the families with minimal therapist intervention.

• Refer mothers of children with type 1 diabetes for community support in babysitting, child care, or respite.

• Teach families the importance of monitoring television viewing and limiting exposure to violence.

Risk for impaired Parenting

NANDA-I Definition

At risk for inability of the primary caretaker to create, maintain, or regain an environment that promotes the optimum growth and development of the child

Risk Factors

Infant or Child

Altered perceptual abilities; attention deficit hyperactivity disorder; developmental delay; difficult temperament; handicapping condition; illness; multiple births; not gender desired; premature birth; prolonged separation from parent; temperamental conflicts with parental expectation

Knowledge

Deficient knowledge about child development; deficient knowledge about child health maintenance; deficient knowledge about parenting skills; inability to respond to infant cues; lack of cognitive readiness for parenthood; low cognitive functioning; low educational level; poor communication skills; preference for physical punishment; unrealistic expectations of child

Physiological

Physical illness

Psychological

Closely spaced pregnancies; depression; difficult birthing process; disability; high number of pregnancies; history of mental illness; history of substance abuse; sleep deprivation; sleep disruption; young parental age

Social

Change in family unit; chronic low self-esteem; economically disadvantaged; father of child not involved; financial difficulties; history of being abused; history of being abusive; inadequate child care arrangements; job problems; lack of access to resources; lack of family cohesiveness; lack of parental role model; lack of prenatal care; lack of resources; lack of social support network; lack of transportation; lack of valuing of parenthood; late prenatal care; legal difficulties; maladaptive coping strategies; marital conflict; mother of child not involved; parent-child separation; poor home environment; poor parental role model; poor problem-solving skills; relocation; role strain; single parent; situational low self-esteem; social isolation; stress; unemployment; unplanned pregnancy; unwanted pregnancy

Client Outcomes, Nursing Interventions, Client/Family Teaching and Discharge Planning

Refer to care plans Readiness for enhanced Parenting and Impaired Parenting.

Risk for Perioperative Positioning Injury

NANDA-I Definition

At risk for inadvertent anatomical and physical changes as a result of positioning or equipment used during an invasive/surgical procedure

Risk Factors

Disorientation; edema; emaciation; immobilization; muscle weakness; obesity; sensory/perceptual disturbances due to anesthesia. High pressure for short periods of time and low pressure for extended periods of time are risk factors for tissue injury.

Client Outcomes

Client Will (Specify Time Frame)

• Demonstrate unchanged skin condition, with exception of the incision, throughout the perioperative experience

• Demonstrate resolution of redness of the skin at points of pressure within 30 minutes after pressure is eliminated

• Remain injury-free related to surgical positioning, including intact skin and absence of pain and/or numbness associated with surgical positioning

• Demonstrate unchanged or improved physical mobility from preoperative status

• Demonstrate unchanged or improved peripheral sensory integrity from preoperative status

• Maintain sense of privacy and dignity

Nursing Interventions

General Interventions for Any Surgical Client

• Recognize that there is a new accountability for perioperative nurses in the need to maintain skin integrity.

Prevention of Pressure Ulcers

• Complete a preoperative assessment to identify physical alterations that may require additional precautions for procedure-specific positioning, to identify specific procedural positioning needs, type of anesthesia, etc.

• Identify risk factors such as length and type of surgery, potential for intraoperative hypotensive episodes, low core temperatures, and decreased mobility on postoperative day 1.

• Recognize that all surgical clients should be considered at high risk for pressure ulcer development, as pressure ulcers can develop in as little as 20 minutes in the operating room.

• Recognize that clients undergoing cardiac surgical procedures are at increased risk of developing a pressure ulcer, especially below the waist or in the occiput area.

• Protect the heels during surgery by elevating the heels completely.

• Use pressure-reducing devices and pressure-relieving mattresses as necessary to prevent ulcer formation.

• Use gel pads to provide protection against shearing and friction of superficial tissues.

• Avoid using rolled sheets and towels as positioning devices, as they tend to produce high and inconsistent pressures. Special positioning devices are available for use that redistribute pressure.

• Avoid covering positioning devices or placing extra blankets on top of a pressure-reducing surface.

• Recognize that the nurse must demonstrate knowledge not only of the equipment, but also of anatomy and the application of physiological principles in order to properly position the client.

• Monitor pressure being applied to the client intraoperatively by staff, equipment, and/or instruments.

• Pad all bony prominences.

• Recognize that reddened areas or areas injured by pressure should not be massaged.

• Implement measures to prevent inadvertent hypothermia.

• Utilize pressure-relieving devices for the preoperative and postoperative stretcher.

Positioning the Perioperative Client

• Ensure that linens on the OR table are free of wrinkles.

• Lock the OR table, cart, or bed and stabilize the mattress before transfer/positioning of the client. Monitor the client while on the OR table at all times.

• Lift rather than pull or slide the client when positioning to reduce the incidence of skin injury from shearing and/or friction.

• Ensure that appropriate numbers of personnel are present to assist in positioning the client.

• Recognize that optimally, clients (especially those with limited range of motion/mobility) should be asked to position themselves under the nurse’s guidance before induction of anesthesia so that he or she can verify that a position of comfort has been obtained.

• Ensure that nerves are protected by positioning extremities carefully.

• Use slow and smooth movements during positioning to allow the circulatory system to readjust.

• Place a pillow under the back of the knees to relieve lower back pressure.

• Reassess the client after positioning and periodically during the procedure for maintenance of proper alignment and skin integrity.

• Frequently assess the eyes and/or monitor intraocular pressure, especially when client is in prone or knee-chest position, when the client is experiencing significant blood loss, or when the procedure lasts 6½ hours or longer.

• Position hips in proper alignment with knees flexed. Unaligned hips can cause pressure to the low back and hip joints.

• Position the arms extended on armboards so that they do not extend beyond a 90-degree angle. Do not position arms at sides unless surgically necessary.

• Prevent pooling of preparative solutions, blood, irrigation, urine, and feces.

• Keep the client appropriately covered during the procedure.

• When positioning the client prone, care should be taken to ensure the head and neck are properly positioned.

• Recognize that clients positioned in lithotomy position should be kept in this position for as short a time as possible.

• The lowest heel position should be used in the lithotomy position.

• Position the client’s legs parallel and uncrossed.

• Maintain normal body alignment.

• When applying body supports and restraint straps (safety belt), apply loosely and secure over waist or mid-thigh at least 2 inches above knees, avoiding bony prominences by placing a blanket between the strap and the client.

• Check equipment to verify it is in good working order and is used according to manufacturer’s instructions.

• Assess the client’s skin integrity immediately postoperatively.

• Remove client jewelry before surgery because it can cause pressure injury, become entangled in bedding, or catch on equipment during transfer and cause injury

• Recognize that complete, concise, accurate documentation of client assessment and use of positioning devices is imperative.

Risk for Peripheral Neurovascular Dysfunction

NANDA-I Definition

At risk for disruption in circulation, sensation, or motion of an extremity

Risk Factors

Burns; fractures; immobilization; mechanical compression (e.g., tourniquet, cane, cast, brace, dressing, restraint); orthopedic surgery; trauma; vascular obstruction

Client Outcomes

Client Will (Specify Time Frame)

• Maintain circulation, sensation, and movement of an extremity within client’s own normal limits

• Explain signs of neurovascular compromise and ways to prevent venous stasis

• Explain and demonstrate low molecular weight heparin or fondaparinux injections which would be expected to be ordered in orthopedic cases and other high-risk conditions unless contraindicated. These injections may be ordered to continue at home after discharge.

Nursing Interventions

Perform neurovascular assessment every 15 minutes to every 4 hours as ordered or needed based on client’s condition. Use the six P’s of assessment as outlined below.

Pain: Assess severity (on a scale of 1 to 10), quality, radiation, and relief by medications.

Pulses: Check the pulses distal to the injury.

Pallor/Poikilothermia: Check color and temperature changes below the injury site. Check capillary refill.

Paresthesia (change in sensation): Check by lightly touching the skin proximal and distal to the injury. Ask if the client has any unusual sensations such as hypersensitivity, tingling, prickling, decreased feeling, or numbness. Check nerve function (e.g., can the client feel a touch to the area of concern, such as the first web space of the foot [deep peroneal nerve] with tibial fracture).

Paralysis: Ask the client to perform appropriate range-of-motion exercises in the unaffected and then the affected extremity.

Pressure: Check by feeling the extremity; note new onset of firmness or swelling of the extremity.

Monitor the client for symptoms of compartment syndrome evidenced by pain greater than expected, pain with passive movement, decreased sensation, weakness, loss of movement, absence of pulse, and tension in the skin that surrounds the muscle compartment.

• Monitor appropriate application and function of corrective device (e.g., cast, splint, traction) every 1 to 4 hours as needed.

• Position the extremity in correct alignment with each position change; check every hour to ensure appropriate alignment.

Prevention of Deep Vein Thrombosis (DVT), Pulmonary Embolism (PE)

Prevention of fatal pulmonary embolism is top priority for prophylaxis programs, as is the prevention of symptomatic DVT, PE, and postphlebitis syndrome.

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

Monitor for signs of DVT, especially in high-risk populations, including clients of increasing age; clients with immobility or obesity; clients taking estrogen or oral contraceptives; pregnancy and the postpartum period; inherited or acquired thrombophilia (e.g., factor V Leiden); persons with a history of trauma, surgery, or previous DVT; and persons with a cerebrovascular accident, varicose veins, malignancy, or cardiovascular disease.

• Recognize that mechanical methods for DVT prophylaxis, such as graduated compression stockings (GCS), the use of intermittent pneumatic compression (IPC) devices, and the venous foot pump (VFP), increase venous outflow and/or reduce stasis within the leg veins.

Apply graduated compression stockings if ordered; measure carefully to ensure proper fit, removing at least daily to assess circulation and skin condition.

Apply IPC device if ordered.

Watch for and report signs of DVT as evidenced by pain, deep tenderness, swelling in the calf and thigh, and redness in the involved extremity. Take serial leg measurements of the thigh and leg circumferences. In some clients, a tender venous cord can be felt in the popliteal fossa. Do not rely on Homans’ sign.

• Help the client perform prescribed exercises every 4 hours as ordered.

• Provide a nutritious diet and adequate fluid replacement.

Geriatric

• Use heat and cold therapies cautiously.

• Recognize that older clients have an increased risk of developing DVTs.

Home Care

• Assess the knowledge base of the client and family after hospitalization.

• Teach about the disease process and care as necessary.

• If risk is related to fractures and cast care, teach the family to complete a neurovascular assessment; it may be performed as often as every 4 hours but is more commonly done two or three times per day.

• If the fracture is peripheral, position the limb for comfort and change position frequently, avoiding dependent positions for extended periods.

Refer to physical therapy services as necessary to establish an exercise program and safety in transfers or mobility within limitations of physical status.

• Establish an emergency plan.

Client/Family Teaching and Discharge Planning

• Teach the client and family to recognize signs of neurovascular dysfunction and report signs immediately to the appropriate person.

• Teach the client and family to recognize side effects of anticoagulant such as irritation, pain, tenderness, and redness that may occur at the site of injection.

• Teach the client and family to notify the doctor if the client experiences increased bruising, bleeding, or black stools.

• Emphasize proper nutrition to promote healing.

If necessary, refer the client to a rehabilitation facility for instruction in proper use of assistive devices and measures to improve mobility without compromising neurovascular function.

• See Ineffective peripheral Tissue Perfusion (venous insufficiency) for further interventions to prevent DVT.

Risk for Poisoning

NANDA-I Definition

Accentuated risk of accidental exposure to, or ingestion of, drugs or dangerous products in doses sufficient to cause poisoning

Risk Factors

External

Availability of illicit drugs potentially contaminated by poisonous additives; dangerous products placed within reach of children; dangerous products placed within reach of confused individuals or children; large supplies of drugs in house; medicines stored in unlocked cabinets; medicines stored in unlocked cabinets accessible to confused individuals or children; medications not maintained in original containers; breastfeeding mothers who are drug addicted; use of over-the-counter cold and cough medication for children

Internal

Cognitive difficulties; emotional difficulties; lack of drug education; lack of proper precaution; lack of safety education; reduced vision; verbalization that occupational setting is without adequate safeguards

Client Outcomes

Client Will (Specify Time Frame)

• Prevent inadvertent ingestion of or exposure to toxins or poisonous substances

• Explain and undertake appropriate safety measures to prevent ingestion of or exposure to toxins or poisonous substances

• Verbalize appropriate response to apparent or suspected toxic ingestion or poisoning

Nursing Interventions

• When a client comes to the hospital with possible poisoning, begin care following the ABCs and administer oxygen if needed.

It is important for the triage nurse to call the poison control center.

• Obtain a thorough history of what was ingested, how much, and when, and ask to look at the container. Note the client’s age, weight, medications, any medical conditions, and any history of vomiting, choking, coughing, or change in mental status. Also take note of any interventions performed before seeking treatment.

• Carefully inspect for signs of ingestion of poisons, including an odor on the breath, a trace of the substance on the clothing, burns, or redness around the mouth and lips, as well as signs of confusion, vomiting, or dyspnea.

Note results of toxicology screens, arterial blood gases, blood glucose levels, and any other ordered laboratory tests.

Initiate any ordered treatment for poisoning quickly.

Safety Guidelines for Medication Administration

• Prevent iatrogenic harm to the hospitalized client by following these guidelines for administering medications:

Use at least two methods to identify the client before administering medications or blood products, such as the client’s name and medical record number or birth date. Do not use the client’s room number.

When taking verbal or telephone orders, the orders should be written down and then read back for verification to the individual giving the order. The person who gave the orders for the medication then needs to confirm the information that was read back.

Standardize use of abbreviations, acronyms, symbols, and dose designations and eliminate those that are prone to cause errors. (Please refer to The Joint Commission, Critical Access Hospital National Patient Safety goals for list of abbreviations, acronyms, symbols and dose designations that should not be used.)

Be aware of the medications that look/sound alike and ensure that the correct medication is ordered.

Take high-alert medications off the nursing unit, such as potassium chloride. Standardize concentrations of medications such as morphine in PCA pumps.

Label all medications and medication containers or other solutions that are on or off a sterile field for a procedure. Label them when they are first taken out of the original packaging to another container. Label with medication name, strength, amount, and expiration date/time. Review the labels whenever there is a change of personnel.

Use only IV pumps that prevent free flow of IV solution when the tubing is taken out of the pump.

Identify all the client’s current medications on admission to a health care facility and compare the list with the current ordered medications. Reconcile any differences in medications. Reconcile the list of medications if the client is transferred from one unit to another, when there is a handoff to the next provider of care, and when the client is discharged

Detect possible interactions and cumulative or other adverse effects among prescribed medications, self-administered over-the-counter products, culturally based home treatments, herbal remedies, and foods.

Pediatric

Evaluate lead exposure risk and consult the health care provider regarding lead screening measures as indicated (public/ambulatory health).

• Provide guidance for parents and caregivers regarding age-related safety measures, including the following:

Store prescription and over-the-counter medications, vitamins, herbs, and alcohol in a locked cabinet far from children’s reach.

Do not take medications in front of children.

Store cleaning products including things like dishwashing liquids in a high cabinet, out of children’s reach.

Use safety latches on cabinets that contain poisonous substances.

Store potentially harmful substances in the original containers with safety closures intact.

Recognize that no container is completely childproof.

Do not store medications or toxic substances in food containers.

Do not leave alcoholic drinks, cosmetics, or toiletries where children can reach them.

Remove poisonous houseplants from the home. Teach children not to put leaves or berries in their mouths.

Do not suggest that medications are candy.

If interrupted when using a harmful product, take it with you; children can get into it within seconds.

Store poisonous automotive or gardening supplies in a locked area.

Use extreme caution with pesticides and gardening materials close to children’s play areas.

When visitors enter the home, place their handbags or backpacks up high where children are unable to reach them, and obtain poisonous substances.

Advise families that syrup of ipecac is no longer recommended to be kept and used in the home. Vomiting should not be induced following poisoning in the home.

Advise families that over-the-counter cough and cold suppressant medications are not recommended and are no longer considered safe for young children 4 or younger.

• Recognize that some children may have been exposed to methamphetamines or the components used to make methamphetamines.

Geriatric

• Caution the client and family to avoid storing medications with similar appearances close to one another (e.g., nitroglycerin ointment near toothpaste or denture creams).

• Remind the older client to store medications out of reach when young children come to visit.

• Perform medication reconciliation on all elderly clients entering the health care system as well as on discharge.

Home Care

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

• Provide the client and/or family with a poison control poster to be kept on the refrigerator or a bulletin board. Ensure that the telephone number for local poison control information is readily available.

• Pre-pour medications for a client who is at risk of ingesting too much of a given medication because of mistakes in preparation. Delegate this task to the family or caregivers if possible.

• Identify poisonous substances in the immediate surroundings of the home, such as a garage or barn, including paints and thinners, fertilizers, rodent and bug control substances, animal medications, gasoline, and oil. Label with the name, a poison warning sign, and a poison control center number. Lock out of the reach of children.

• Identify the risk of toxicity from environmental activities such as spraying trees or roadside shrubs. Contact local departments of agriculture or transportation to obtain material safety data sheets or to prevent the activity in desired areas.

• To prevent carbon monoxide poisoning, instruct the client and family in the importance of using a carbon monoxide detector in the home, having the chimney professionally cleaned each year, having the furnace professionally inspected each year, ensuring that all combustion equipment is properly vented, and installing a chimney screen and cap to prevent small animals from moving into the chimney.

Multicultural

• Assess housing for pathways of lead poisoning.

• Prompt caregivers to take action to prevent lead poisoning.

If children live in a high-lead environment, teach the need for handwashing before each meal, annual blood testing for lead levels, and avoidance of high lead areas as possible.

• Work with immigrant Mexican families to implement medication, household cleaners, and carbon monoxide safety interventions in the home to prevent accidental poisoning in children. Use the Hispanic social network.

Client/Family Teaching and Discharge Planning

• Teach parents that poison is any substance that is harmful when it enters the body through ingestion, inhalation, injection, or absorption through the skin or mucous membranes. The list of possible poisons is long, including laundry detergent, floor cleaners, antifreeze, fuel, silica gel, and glow-in-the-dark products; drugs; and venom from spider and snake bites.

• Counsel the client and family members regarding the following points of medication safety:

Avoid sharing prescriptions.

Always use good light when preparing medication. Do not dispense medication during the night without a light on.

Read the label before you open the bottle, after you remove a dose, and again before you give it.

Always use child-resistant caps and lock all medications away from your child or confused elder.

Give the correct dose. Never guess.

Do not increase or decrease the dose without calling the physician.

Always follow the weight and age recommendations on the label.

Avoid making conversions. If the label calls for 2 tsp and you have a dosing cup labeled only with ounces, do not use it.

Be sure the physician knows if you are taking more than one medication at a time.

Never let young children take medication by themselves.

Read and follow labeling instructions on all products; adjust dosage for age.

Avoid excessive amounts and/or frequency of doses. (“If a little does some good, a lot should do more.”)

• Advise the family to post first-aid charts and poison control center instructions in an accessible location. Poison control center telephone numbers should be posted close to each telephone and the number programmed into cell phones.

• Advise family when calling the poison control center to do the following:

Give as much information as possible, including your name, location, and telephone number, so that the poison control operator can call back in case you are disconnected or summon help if needed.

Give the name of the potential poison ingested and, if possible, the amount and time of ingestion. If the bottle or package is available, give the trade name and ingredients if they are listed.

Be prepared to tell the person the child’s height, weight, and age.

Describe the state of the poisoning victim. Is the victim conscious? Does he or she have any symptoms? What is the person’s general appearance, skin color, respiration, breathing difficulties, mental status (alert, sleepy, unusual behavior)? Is the person vomiting? Having convulsions?

• Encourage the client and family to take first-aid and other types of safety-related programs.

Initiate referrals to peer group interventions, peer counseling, and other types of substance abuse prevention/rehabilitation programs when substance abuse is identified as a risk factor.

• Teach parents and other caregivers that cough and cold medication bought over-the-counter are not safe for a child under 2 unless specifically ordered by a health care provider.

• Teach parents that bring in a child to ER for possible or actual poisoning, methods to prevent poisoning of the child in the future.

• Teach parents that if a parent is employed in a lead-related occupation, lead contamination as a dust can be transported to the home via worksite clothing, shoes, tools, or vehicles. The dust must be kept away from children.

Post-Trauma Syndrome

NANDA-I Definition

Sustained maladaptive response to a traumatic, overwhelming event

Defining Characteristics

Aggression; alienation; altered mood state; anger; anxiety; avoidance; compulsive behavior; denial; depression; detachment; difficulty concentrating; enuresis (in children); exaggerated startle response; fear; flashbacks; gastric irritability; grieving; guilt; headaches; hopelessness; horror; hypervigilance; intrusive dreams; intrusive thoughts; irritability; neurosensory irritability; nightmares; palpitations; panic attacks; psychogenic amnesia; rage; rape; reports feeling numb; repression; shame; substance abuse

Related Factors (r/t)

Being held prisoner of war; criminal victimization; disasters; epidemics; events outside the range of usual human experience; physical abuse; psychological abuse; serious accidents (e.g., industrial, motor vehicle); serious injury to loved ones; serious injury to self; serious threat to loved ones; serious threat to self; sudden destruction of one’s community; sudden destruction of one’s home; torture; tragic occurrence involving multiple deaths; war witnessing mutilation; witnessing violent death

Client Outcomes

Client Will (Specify Time Frame)

• Return to pre-trauma level of functioning as quickly as possible.

• Acknowledge traumatic event and begin to work with the trauma by talking about the experience and expressing feelings of fear, anger, anxiety, guilt, and helplessness.

• Identify support systems and available resources and be able to connect with them.

• Return to and strengthen coping mechanisms used in previous traumatic event.

• Acknowledge event and perceive it without distortions.

• Assimilate event and move forward to set and pursue life goals.

Nursing Interventions

• Observe for a reaction to a traumatic event in all clients regardless of age or sex.

• After a traumatic event assess for intrusive memories, avoidance and numbing, and hyperarousal.

• Remain with the client and provide support during periods of overwhelming emotions.

• Help the individual try to comprehend the trauma if possible.

• Use touch with the client’s permission (e.g., a hand on the shoulder, holding a hand).

• Explore and enhance available support systems.

• Help the client regain previous sleeping and eating habits.

Provide the client pain medication if he or she has physical pain.

Assess the need for pharmacotherapy.

Refer for appropriate psychotherapy: cognitive therapy, exposure therapy, eye movement desensitization and reprocessing (EMDR), cognitive-behavioral therapy.

• Help the client use positive cognitive restructuring to reestablish feelings of self-worth

• Provide the means for the client to express feelings through therapeutic drawing.

• Encourage the client to return to the normal routine as quickly as possible.

• Talk to and assess the client’s social support after a traumatic event.

Pediatric

• Refer to nursing care plan Risk for Post-Trauma Syndrome.

Carefully assess children exposed to disasters and trauma. Note behavior specific to developmental age. Refer for therapy as needed.

Geriatric

• Carefully screen elderly for signs of PTSD, especially after a disaster.

• Consider using the Horwitz Impact of Event Scale, an appropriate instrument to measure the subjective response to stress in the senior population.

Monitor the client for clinical signs of depression and anxiety; refer to a physician for medication if appropriate.

• Instill hope.

Multicultural

• Assess the influence of cultural beliefs, norms, and values on the client’s ability to cope with a traumatic experience.

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

Carefully assess refugees for PTSD and refer for treatment as appropriate; encourage them to learn the language of their new residence.

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

• When working with Asian American clients, provide opportunities by which the family can save face.

• Incorporate cultural traditions as appropriate.

Home Care

Assess family support and the response to the client’s coping mechanisms. Refer the family for medical social services or other counseling as necessary.

• Assess the impact of the trauma on significant others (e.g., a father may have to take over his partner’s parenting responsibility after she has been raped and injured). Provide empathy and caring to significant others. Refer for additional services as necessary.

Client/Family Teaching and Discharge Planning

• Teach positive coping skills and avoidance of negative coping skills.

• Teach stress reduction methods such as deep breathing, visualization, meditation, and physical exercise. Encourage their use especially when intrusive thoughts or flashbacks occur

• Encourage other healthy living habits of proper diet, adequate sleep, regular exercise, family activities, and spiritual pursuits.

• Refer the client to peer support groups.

• Consider the use of complementary and alternative therapies.

Risk for Post-Trauma Syndrome

NANDA-I Definition

At risk for sustained maladaptive response to a traumatic, overwhelming event

Risk Factors

Diminished ego strength; displacement from home; duration of event; exaggerated sense of responsibility; inadequate social support; occupation (e.g., police, fire, rescue, corrections, emergency room staff, mental health worker); perception of event; survivor’s role in the event; unsupportive environment

Client Outcomes

Client Will (Specify Time Frame)

• Identify symptoms associated with PTSD and seek help

• Acknowledge event and perceive it without distortions

• Identify support systems and available resources and be able to connect with them

• State that he or she is not to blame for the event

Nursing Interventions

• Assess for PTSD in a client who has chronic/critical illness, anxiety, or personality disorder; was a witness to serious injury or death; or experienced sexual molestation.

• Consider the use of a self-reported screening questionnaire.

• Assess for ongoing symptoms of dissociation, avoidant behavior, hypervigilance, and reexperiencing.

• Assess for past experiences with traumatic events.

• Consider screening for PTSD in a client who is a high user of medical care.

Provide deployed combat veterans with previous history of low mental or physical health status before deployment with appropriate referral after deployment.

• Provide peer support to contact co-workers experiencing trauma to remind them that others in the organization are concerned about their welfare.

• Consider implementation of a school-based program for children to decrease PTSD after catastrophic events.

Geriatric and Multicultural

• Refer to the care plan for Post-Trauma Syndrome.

Home Care

Evaluate the client’s response to a traumatic event. If screening warrants, refer to a therapist for counseling/treatment.

• Refer to the care plan for Post-Trauma Syndrome.

Client/Family Teaching and Discharge Planning

• Instruct family and friends to use the following critical incident stress management techniques:

Listen carefully; Spend time with the traumatized person; Offer your assistance and a listening ear, even if the person has not asked for help; Help the person with everyday tasks such as cleaning, cooking, caring for the family, and minding children; Give the person some private time; Do not take the individual’s anger or other feelings personally, and do not tell the person that he or she is “lucky it wasn’t worse”; such statements do not console traumatized people. Instead, tell the person that you are sorry such an event has occurred and you want to understand and assist him or her.

After exposure to trauma teach the client and family to recognize symptoms of PTSD and seek treatment for “recurrent and intrusive distressing recollections of the traumatic event,” insomnia, irritability, difficulty concentrating, hypervigilance.

• Provide education to explain that acute stress disorder symptoms are normal when preparing combatants for their role in deployment. Instruct clients to seek help if the symptoms persist.

• Provide post-trauma debriefings. Effective post-trauma coping skills are taught, and each participant creates a plan for his or her recovery. During the debriefing, the facilitators assess participants to determine their needs for further services in the form of post-trauma counseling. For maximal effectiveness, the debriefing should occur within 2 to 5 days of the incident.

• Provide post-trauma counseling. Counseling sessions are extensions of debriefings and include continued discussion of the traumatic event and post-trauma consequences and the further development of coping skills.

• Consider exposure therapy for civilian trauma survivors following a nonsexual assault or motor vehicle crash.

Things to Try: Critical Incident Stress Debriefing

• Instruct the client to use the following critical incident stress management techniques:

Within the first 24 to 48 hours, engaging in periods of appropriate physical exercise alternated with relaxation to alleviate some of the physical reactions; Structure your time; keep busy; You are normal and are having normal reactions; do not label yourself as “crazy”; Talk to people; talk is the most healing medicine; Be aware of numbing the pain with overuse of drugs or alcohol; you do not need to complicate the stress with a substance abuse problem; Reach out; people do care; Maintain as normal a schedule as possible; Spend time with others; Help your co-workers as much as possible by sharing feelings and checking out how they are doing; Give yourself permission to feel rotten and share your feelings with others; Keep a journal; write your way through those sleepless hours; Do things that feel good to you; Realize that those around you are under stress; Do not make any big life changes; Do make as many daily decisions as possible to give you a feeling of control over your life (e.g., if someone asks you what you want to eat, answer the person even if you are not sure); Get plenty of rest; Recurring thoughts, dreams, or flashbacks are normal; do not try to fight them because they will decrease over time and become less painful; Eat well-balanced and regular meals (even if you do not feel like it).

Assess for a history of life-threatening illness such as cancer and provide appropriate counseling. The physical and psychological impact of having a life-threatening disease, undergoing cancer treatment, and living with recurring threats to physical integrity and autonomy constitute traumatic experiences for many cancer clients.

Pediatric

• Children with cancer should continue to be assessed for PTSD into adulthood.

• Provide protection for a child who has witnessed violence or who has had traumatic injuries. Help the child acknowledge the event and express grief over the event.

• Assess for a medical history of anxiety disorders.

Assess children of deployed parents for PTSD and provide appropriate referrals.

• Consider implementation of a school-based program for children to decrease PTSD after catastrophic events.

Geriatric and Multicultural

• Refer to the care plan for Post-Trauma Syndrome.

Home Care

Evaluate the client’s response to a traumatic or critical event. If screening warrants, refer to a therapist for counseling/treatment.

• Refer to the care plan for Post-Trauma Syndrome.

Client/Family Teaching and Discharge Planning

• Instruct family and friends to use the following critical incident stress management techniques:

• Provide education to explain that acute stress disorder symptoms are normal when preparing combatants for their role in deployment. Instruct clients to seek help if the symptoms persist.

Readiness for enhanced Power

NANDA-I Definition

A pattern of participating knowingly in change that is sufficient for well-being and can be strengthened

Defining Characteristics

Expresses readiness to enhance awareness of possible changes to be made; expresses readiness to enhance freedom to perform actions for change; expresses readiness to enhance identification of choices that can be made for change; expresses readiness to enhance involvement in creating change; expresses readiness to enhance knowledge for participation in change; expresses readiness to enhance participation in choices for daily living; expresses readiness to enhance participation in choices for health; expresses readiness to enhance power

Client Outcomes

Client Will (Specify Time Frame)

• Describe power resources

• Identify realistic perceptions of control

• Develop a plan of action based on power resources

• Seek assistance as needed

Nursing Interventions

• Develop partnerships for shared power.

• Focus on the positive aspects of power, rather than prevention of powerlessness.

• Listen with intent.

• Collaborate with the person to identify resources to put a plan into action.

• Assess the meaning of the event to the person.

• Identify the client’s health literacy in decision-making.

• Facilitate trust in self and others.

• Help client to mobilize social supports, a power resource.

• Support beliefs of power and perceptions of behavioral control.

• Promote the client’s optimum level of physical functioning.

• Reframe professional image, role, and values to incorporate a vision of clients as the experts in their own care.

Home Care

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

Client/Family Teaching and Discharge Planning

• Assess motivation to learn specific content.

Powerlessness

NANDA-I Definition

The lived experience of lack of control over a situation, including a perception that one’s actions do not significantly affect an outcome

Defining Characteristics

Dependence on others; depression over physical deterioration; nonparticipation in care; reports alienation; reports doubt regarding role performance; reports frustration over inability to perform previous activities; reports lack of control; reports shame

Related Factors (r/t)

Illness-related regimen; institutional environment; unsatisfying interpersonal interactions

Client Outcomes

Client Will (Specify Time Frame)

• State feelings of powerlessness and other feelings related to powerlessness (e.g., anger, sadness, hopelessness)

• Identify factors that are uncontrollable

• Participate in planning and implementing care; make decisions regarding care and treatment when possible

• Ask questions about care and treatment

• Verbalize hope for the future and sense of participation in planning and implementing care

Nursing Interventions

NOTE: Before implementation of interventions in the face of client powerlessness, nurses should examine their own philosophies of care to ensure that control issues or lack of faith in client capabilities will not bias the ability to intervene sincerely and effectively.

• Observe for factors contributing to powerlessness (e.g., immobility, hospitalization, unfavorable prognosis, lack of support system, misinformation about situation, inflexible routine, chronic illness). Help clients channel their behaviors in an effective manner.

• Assess the client’s locus of control related to his or her health.

• Establish a therapeutic relationship with the client by spending one-on-one time with him or her, assigning the same caregiver, keeping commitments (e.g., saying, “I will be back to answer your questions in the next hour”), providing encouragement and support, and being empathetic.

• Encourage the client to share his or her beliefs, thoughts, and expectations about his or her illness.

• Help the client assist in planning care and specify the health goals he or she would like to achieve, prioritizing those goals with regard to immediate concerns and identifying actions that will achieve the goals. Goals may need to be small to be attainable (e.g., dangle legs at bedside for 2 days, then sit in chair 10 minutes for 2 days, then walk to window).

• Encourage the client in goal-directed activities that promote a sense of accomplishment, especially regular exercise.

• Recognize the client’s need to experience a sense of reciprocity in dealing with others. Negotiate actions that the client can contribute to the caregiving partnership with both family and nurse (e.g., have the client prepare a cup of tea for the nurse during visits if the client is able.)

• Allow time for questions (15 to 20 minutes each shift). Have the client write down questions, and encourage the client to record a summary of answers received, or provide written material that reinforces answers.

• Encourage the client to take control of as many ADLs as possible; keep the client informed of all care that will be given. Keep items the client uses and needs within reach (e.g., a urinal, tissues, telephone, and television controls).

• Give realistic and sincere praise for accomplishments.

• Consider using one of the measures of powerlessness that are available for general and specific client groups:

Measure of Powerlessness for Adult Patients

Spreitzer’s Psychological Empowerment Questionnaire

Personal Progress Scale—Revised, tested with women

Life Situation Questionnaire—Powerlessness subscale, tested with stroke caregivers

Making Decisions Scale, tested in clients with mental illness

• Refer to the care plans for Hopelessness and Spiritual Distress.

Pediatric

• Two key issues that lead to powerlessness for children and their families are hospitalization and peer victimization or bullying.

• Encourage emotional expression through processes that are appropriate to the child’s level of development.

• Recognize that a sense of powerlessness can prevent children and adolescents from reporting peer victimization. Be supportive, encourage disclosure without pressure, and help the child or adolescent problem solve options to deal with their stressors.

• Provide instruction and visual aids to family members so they may better understand a child’s illness and how the family members can help.

Geriatric

• In addition to the preceding interventions as appropriate:

Initiate focused assessment questioning and education of client and caregivers regarding syndromes common in the elderly, including dementia.

Assess for the presence of elder abuse. Initiate referral to Adult Protective Services and help client regain a sense of safety and control.

Multicultural

• In addition to the preceding interventions as appropriate:

Assess the influence of cultural beliefs, norms, and values on the client’s feelings of powerlessness

Home Care

• In addition to the preceding interventions as appropriate:

Develop a therapeutic relationship in the home setting that respects the client’s domain.

Empower the client by encouraging the client to guide specifics of care such as wound care procedures and dressing and grooming details. Confirm the client’s knowledge and document in the chart that the client is able to guide procedures. Document in the home and in the chart the preferred approach to procedures. Orient the family and caregivers to the client’s role.

Assess the affective climate within the family and family support system, including other caregivers. Instruct the family in appropriate expectations of the client and in the specifics of the client’s illness. Encourage the family and client in efforts toward educating friends and co-workers regarding appropriate expectations for the client.

Evaluate the powerlessness of caregivers to ensure they continue their ability to care for the client. Provide assistance using interventions from this care plan.

• Be aware of and assist clients with potential needs for help in negotiating the health care system.

• Teach stress reduction, relaxation, and imagery. Many audio recordings are available on relaxation and meditation.

• Teach cognitive-behavioral activities, such as active problem solving, reframing (reappraising the situation from a different perspective), or thought stopping (in response to a negative thought, such as picturing a large stop sign and replacing the image with a prearranged positive alternative). Teach the client to confront his or her own negative thought patterns (cognitive distortions).

• Identify the strengths of the caregiver and efforts to gain control of unpredictable situations. Help the caregiver stay connected with a client who may be behaving differently than usual to make life as routine as possible, help the client set goals and sustain hope, and allow the client space to experience progress.

Refer the client to support groups, pastoral care, or social services. These services help decrease levels of stress, increase levels of self-esteem, and reassure clients that they are not alone.

Client/Family Teaching and Discharge Planning

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

Risk for Powerlessness

NANDA-I Definition

At risk for the lived experience of lack of control over a situation including a perception that one’s actions do not significantly affect an outcome

Risk Factors (r/t)

Anxiety; caregiving; chronic low self-esteem; deficient knowledge; economically disadvantaged; illness; ineffective coping patterns; lack of social support; pain; progressive debilitating disease; situational low self-esteem; social marginalization; stigmatized condition; stigmatized disease; unpredictable course of illness

Client Outcomes, Nursing Interventions, Client/Family Teaching and Discharge Planning

Refer to care plans Powerlessness and Readiness for enhanced Power.

Ineffective Protection

NANDA-I Definition

Decrease in the ability to guard self from internal or external threats such as illness or injury

Defining Characteristics

Altered clotting; anorexia; chilling; cough; deficient immunity; disorientation; dyspnea; fatigue; immobility; impaired healing; insomnia; itching; maladaptive stress response; neurosensory alteration; perspiring; pressure ulcers; restlessness; weakness

Related Factors (r/t)

Abnormal blood profiles (e.g., leukopenia, thrombocytopenia, anemia, coagulation); cancer; extremes of age; immune disorders; inadequate nutrition; pharmaceutical agents (e.g., antineoplastic, corticosteroid, immune, anticoagulant, thrombolytic) substance abuse; treatment-related side effects (e.g., surgery, radiation)

Patient Outcomes

Patient Will (Specify Time Frame)

• Remain free of infection

• Remain free of any evidence of new bleeding

• Explain precautions to take to prevent infection

• Explain precautions to take to prevent bleeding

Nursing Interventions

• Take temperature, pulse, and blood pressure (e.g., every 1 to 4 hours)

Observe nutritional status (e.g., weight, serum protein and albumin levels, muscle mass, and usual food intake). Work with the dietitian to improve nutritional status if needed.

• Observe the client’s sleep pattern; if altered, see Nursing Interventions for Disturbed Sleep Pattern.

• Identify stressors in the client’s life. If stress is uncontrollable, see Nursing Interventions for Ineffective Coping.

Prevention of Infection

Monitor for and report any signs of infection (e.g., fever, chills, flushed skin, drainage, edema, redness, abnormal laboratory values, and pain) and notify the physician promptly.

If the client’s immune system is depressed, notify the physician of elevated temperature, even in the absence of other symptoms of infection.

• If white blood cell count is severely decreased (i.e., absolute neutrophil count of less than 1000/mm³), initiate the following precautions:

Take vital signs every 2 to 4 hours.

Complete a head-to-toe assessment twice daily, including inspection of oral mucosa, invasive sites, wounds, urine, and stool; monitor for onset of new reports of pain.

Avoid any invasive procedures, including catheterization, injections, or rectal or vaginal procedures unless absolutely necessary.

• Consider warming the client before elective surgery.

Administer granulocyte growth factor as ordered.

• Take meticulous care of all invasive sites; use chlorhexidine gluconate for cleansing.

• Provide frequent oral care.

Follow Standard Precautions, especially performing hand hygiene to prevent health care–associated infections.

Refer for appropriate prophylactic antifungal treatment and avoid pathogen exposure (through air filtration, regular hand hygiene, and avoidance of plants and flowers).

• Have the client wear a mask when leaving the room.

• Limit and screen visitors to minimize exposure to contagion.

• Help the client bathe daily.

• Practice food safety; a neutropenic diet may not be necessary.

Ensure that the client is well nourished. Provide food with protein, and consider vitamin supplements. If appetite is suppressed, institute a dietary referral. Keep track of serum albumin levels, as well as transferrin and prealbumin levels.

• Help the client to cough and practice deep breathing regularly. Maintain an appropriate activity level.

• Obtain a private room for the client. Use high-energy particulate air filters if available and appropriate. Protective isolation is not recommended. Recognize that cotton cover gowns may not be effective in decreasing infection.

Watch for signs of sepsis, including change in mental status, fever, shaking, chills, and hypotension. If present, notify the physician promptly.

• Refer to care plan for Risk for Infection.

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

Pediatric

• Suggest kangaroo care, frequent and exclusive or nearly exclusive breastfeeding, and early discharge from hospital for low-birth-weight infants.

• Assess postoperative fever in pediatric oncology clients promptly.

• For hand hygiene with low-birth-weight infants, use alcohol hand rub and gloves

Geriatric

• If not contraindicated, promote exercise to promote improved quality of life in the elderly.

• Give elderly clients with imbalanced nutrition a vitamin D supplement to reduce risk of fracture.

• Refer to the care plan for Risk for Infection for more interventions related to the prevention of infection.

Prevention of Bleeding

• Monitor the client’s risk for bleeding; evaluate results of clotting studies and platelet counts.

• Watch for hematuria, melena, hematemesis, hemoptysis, epistaxis, bleeding from mucosa, petechiae, and ecchymoses.

Give medications orally or IV only; avoid giving them IM, subcutaneously, or rectally.

• Apply pressure for a longer time than usual to invasive sites, such as venipuncture or injection sites.

• Take vital signs often; watch for changes associated with fluid volume loss. Excessive bleeding causes decreased blood pressure and increased pulse and respiratory rates.

• Monitor menstrual flow if relevant; have the client use pads instead of tampons.

Have the client use a moistened toothette or a very soft child’s toothbrush instead of an adult toothbrush. Follow the dentist’s recommendation for flossing and appropriate rinses to use. Control gum bleeding by applying pressure to gums with gauze pad soaked in ice water.

• Ask the client either to not shave or to use only an electric razor.

• To decrease risk of bleeding, avoid administering salicylates or nonsteroidal antiinflammatory drugs (NSAIDs) if possible.

Home Care

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

Consider using a nurse-led patient-centered medical home (PCMH) for monitoring anticoagulant therapy.

For terminally ill clients, teach and institute all of the aforementioned noninvasive precautions that maintain quality of life. Discuss with the client, family, and physician the consequences of contracting infection. Determine which precautions do not maintain quality of life and should not be used (e.g., physical assessment twice daily or multiple vital sign assessments).

Client/Family Teaching and Discharge Planning

Depressed Immune Function

• Teach the client and family how to take a temperature. Encourage the family to take the client’s temperature between 3 PM and 7 PM at least once daily.

• Teach precautions to use to decrease the chance of infection (e.g., avoiding uncooked fruits and vegetables, using appropriate self-care including good hand hygiene, and ensuring a safe environment). Teach the client to avoid crowds and contact with persons who have infections. Teach the need for good nutrition, avoidance of stress, and adequate rest to maintain immune system function.

Bleeding Disorder

Teach the client to wear a medical alert bracelet and notify all health care personnel of the bleeding disorder.

Teach the client and family the signs of bleeding, precautions to take to prevent bleeding, and action to take if bleeding begins. Caution the client to avoid taking over-the-counter medications without the permission of the physician.

• Teach the client to wear loose-fitting clothes and avoid physical activity that might cause trauma.