S
Sedentary lifestyle
Defining Characteristics
Chooses a daily routine lacking physical exercise; demonstrates physical deconditioning; verbalizes preference for activities low in physical activity
Related Factors (r/t)
Deficient knowledge of health benefits of physical exercise; lack of training for accomplishment of physical exercise; lack of resources (time, money, companionship, facilities); lack of motivation; lack of interest
Client Outcomes
Client Will (Specify Time Frame)
• Engage in purposeful moderate-intensity cardiorespiratory (aerobic) exercise for 30 to 60 minutes per day on greater/equal to 5 days per week for a total of 2 hours and 30 minutes (150 minutes) per week.
• Increase exercise to 20 minutes per day (less than 150 minutes per week). Light to moderate intensity exercise may be beneficial in deconditioned persons.
• Increase pedometer step counts by 1000 steps per day every 2 weeks to reach a daily step count of at least 7000 steps per day, with a daily goal for most healthy adults of 10,000 steps per day.
• Perform resistance exercises that involve all major muscle groups (legs, hips, back, chest, abdomen, shoulders, and arms) performed on 2 to 3 days per week.
• Perform flexibility exercise (stretching) for each of the major muscle-tendon groups 2 days per week for 10 to 60 seconds to improve joint range of motion; greatest gains occur with daily exercise.
• Engage in neuromotor exercise 20 to 30 minutes per day including motor skills (e.g., balance, agility, coordination, and gait), proprioceptive exercise training, and multifaceted activities (e.g., tai chi and yoga) to improve and maintain physical function and reduce falls in those at risk for falling (older persons).
• Meet mutually defined goals of exercise that include individual choice, preference and enjoyment in the exercise prescription.
Nursing Interventions
• Observe the client for cause of sedentary lifestyle. Determine whether cause is physical, psychological, social, or ecological. See care plans for Ineffective Coping or Hopelessness.
Assess for reasons why the client would be unable to participate in an exercise program; refer for evaluation by a primary care provider as needed.
• Use the Self-Efficacy for Exercise Scale and the Outcome Expectation for Exercise Scale to determine client’s self-efficacy and outcome expectations toward exercise.
• Recommend the client enter an exercise program with a person who supports exercise behavior (e.g., friend or exercise buddy).
• Recommend using fitness smartphone applications for customizing, cueing, tracking, and analyzing an exercise program.
• Recommend the client begin a walking program using the following criteria:
Obtain a pedometer by purchase or from community/public health resources
Determine common times when brisk walking for at least 10-minute intervals can be incorporated into lifestyle and daily activities.
Set incremental walking goal and increase it by 1000 steps per day every 2 weeks for a minimum of 7000 steps per day with a daily goal for most healthy adults of 10,000 steps per day (approximately 5 miles).
Toward the end of day, if have not met walking goal, look for opportunities to increase activity level (e.g., park further from destination; use stairs) or go for a walk indoors or outdoors until reach designated goal of 7000 to 10,000 steps per day.
• Recommend client begin performing resistance exercises for additional health benefits of increased bone strength and muscular fitness.
Encourage prescriptive resistance exercise of each major muscle group (hips, thighs, legs, back, chest, shoulders, and abdomen) using a variety of exercise equipment such as free weights, bands, stair climbing, or machines 2 to 3 days per week. Involve the major muscle groups for 8 to 12 repetitions to improve strength and power in most adults; 10 to 15 repetitions to improve strength in middle-aged and older persons starting exercise; 15 to 20 repetitions to improve muscular endurance. Intensity should be between moderate (5 to 6) and hard (7 to 8) on a scale of 0 to 10
Encourage to use a gradual progression of greater resistance, and/or more repetitions per set, and/or increasing frequency using concentric, eccentric, and isometric muscle actions. Perform bilateral and unilateral single and multiple joint exercises. Optimize exercise intensity by working large before small muscle groups, multiple joint exercises before single-joint exercises, and higher intensity before lower intensity exercises.
• Encourage child to increase the amount of walking done per day; if child is willing, ask him or her to wear a pedometer to measure number of steps.
• Recommend the child decrease television viewing, watching movies, and playing video games. Ask parents to limit television to 1 to 2 hours per day maximum.
• Use valid and reliable criterion-referenced standards for fitness testing (e.g., Senior Fitness Test) designed for older adults that can predict the level of capacity associated with maintaining physical independence into later years of life (e.g., get up and go test).
• Recommend the client begin a regular exercise program, even if generally active.
Refer the client to physical therapy for resistance exercise training as able involving all major muscle groups.
• Use the Function-Focused Care (FFC) rehabilitative philosophy of care with older adults in residential nursing facilities to prevent avoidable functional decline.
• Recommend the client begin a tai chi practice.
• If client is scheduled for an elective surgery that will result in admission into the intensive care unit (ICU) and immobility, or recovery from a joint replacement, for example, initiate a prehabilitation program that includes a warm-up followed by aerobic, strength, flexibility, neuromotor, and functional task work.
• The preceding interventions may be adapted for home care use.
Assess home environment for factors that create barriers to mobility. Refer to physical and occupational therapy services if needed to assist the client in restructuring home environment and daily living patterns. Use home safety assessment tool to prevent falls and improve mobility and function such as the tool found at http://agingresearch.buffalo.edu/hssat/index.htm.
Client/Family Teaching and Discharge Planning
• Work with the client using theory-based interventions (e.g., social cognitive theoretical components such as self-efficacy; transtheoretical model).
• Recommend the client use the Exercise Assessment and Screening for You (EASY) tool to help determine appropriate exercise for the older adult client. This tool is available online at http://www.easyforyou.info.
• Consider using motivational interviewing techniques when working with both children and adult clients to increase their activity.
Readiness for enhanced Self-Care
A pattern of performing activities for oneself that helps to meet health-related goals and can be strengthened
Defining Characteristics
Expresses desire to enhance independence in maintaining health; expresses desire to enhance independence in maintaining life; expresses desire to enhance independence in maintaining personal development; expresses desire to enhance independence in maintaining well-being; expresses desire to enhance knowledge of strategies for self-care; expresses desire to enhance responsibility for self-care; expresses desire to enhance self-care
Client Outcomes
Client Will (Specify Time Frame)
• Evaluate current levels of self-care as optimum for abilities
• Express the need or desire to continue to enhance levels of self-care
• Seek health-related information as needed
• Identify strategies to enhance self-care
• Perform appropriate interventions as needed
• Evaluate the effectiveness of self-care interventions at regular intervals
Bathing Self-Care deficit
Defining Characteristics
Inability to access bathroom; inability to dry body; inability to get bath supplies; inability to obtain water source; inability to regulate bath water; inability to wash body
Related Factors (r/t)
Cognitive impairment; decreased motivation; environmental barriers; inability to perceive body part; inability to perceive spatial relationship; musculoskeletal impairment; neuromuscular impairment; pain; perceptual impairment; severe anxiety; weakness
NOTE: Specify level of independence using a standardized functional scale.
Client Outcomes
Client Will (Specify Time Frame)
• Remain free of body odor and maintain intact skin
• State satisfaction with ability to use adaptive devices to bathe
• Use methods to bathe safely with minimal difficulty
• Bathe with assistance of caregiver as needed and report satisfaction, and dignity maintained during bathing experience
• Bathe with assistance of caregiver as needed without exhibiting defensive (aggressive) behaviors
Nursing Interventions
• QSEN (Safety): Warm bathing area above 25.1° C (77.18° F) while bathing, especially on cold days.
• QSEN (Safety): Consider using chlorhexidine-impregnated cloths rather than soap and water for daily client bathing.
• QSEN (Safety): Consider using a prepackaged bath, especially for high-risk clients (elderly, immunocompromised, invasive procedures, wounds, catheters, drains), to avoid client exposure to pathogens from contaminated bath basin, water source, and release of skin flora into bath water.
• Establish the goal of client’s bathing as being a pleasant experience, especially for cognitively impaired clients, without the symptoms of unmet needs—hitting, biting, kicking, screaming, resisting—and plan for client preferences in timing, type and length of bathing, water temperature, and with silence or music.
• QSEN (Patient-Centered): Role model and teach the sequence of behaviors for client-centered care: greet client, orient client to task, offer client choices and input, converse with client, and exhibit interest in client and convey approval of client as a person.
• QSEN (Patient-Centered): Use client-centered bathing interventions: plan for client’s comfort and bathing preferences, show respect in communications, critically think to solve issues that arise, and use a gentle approach.
• Provide a 41° C footbath for 40 minutes before bedtime.
Provide pain relief measures, such as ice packs, heat, and analgesics for sore joints 45 minutes before bathing; move extremities slowly and carefully; and inform the client before movements associated with pain occur (walking; transferring to a new location; moving joints; and washing genitals, face, and between toes and under arms). Have the client wash painful areas, recognize indicators of pain, and apologize for any pain caused.
• Consider environmental and human factors that may limit bathing ability, such as bending to get into the tub, reaching for bathing items, grasping faucets, and lifting oneself. Adapt environment by placing items within easy reach, installing grab bars, lowering faucets, and using a handheld shower.
• Use a comfortable padded shower chair with foot support, or adapt a chair: pad it with towels/washcloths, cover the cold back with dry towels, and cover the arms with foam pipe insulation.
• Ensure that bathing assistance preserves client dignity through use of privacy with a traffic-free bathing area and posted privacy signs, timeliness of personal care, and conveyance of honor and recognition of the deservedness of respect and esteem of all persons.
• QSEN (Safety): If the client is bathing alone, place the assistance call light within reach.
• For cognitively impaired clients, avoid upsetting factors associated with bathing: instead of using the terms bath, shower, or wash, use comforting words, such as warm, relaxing, or massage. Start at the client’s feet and bathe upward; bathe the face last after washing hands and using a clean cloth. Use a beautician/barber or wash hair at another time to avoid water dripping in the face.
• Use towel bathing to bathe client in bed, a bath blanket, and warm towels to keep the client covered the entire time. Warm and moisten towels/washcloths and place in plastic bags to keep them warm. Use the towels to massage large areas (front, back) and one washcloth for facial areas and another one for genital areas. No rinsing or drying is needed as is commonly thought for bathing.
• QSEN (Patient-Centered): For shower bathing: use client-centered techniques, keep client covered with towels and cleanse under the towels, use no-rinse products, use favorite bathing items, and use a handheld shower with adjustable spray.
• QSEN (Patient-Centered): Assess older clients’ preferences for bathing and their responses to bathing difficulties.
• Design the bathing environment for comfort: Visual. Reduce clutter and use partitions to hide equipment storage. Laminate and put artwork or decorative objects in bather’s view, or place cue cards to bathing process (wall, ceiling, shower). Stand or sit in bather’s position to experience what he/she sees. Decrease glare from tiles, white walls, and artificial lights. Use contrasting colors and soft but adequate lighting on a dimming switch for adjustment.
• Arrange the bathing environment to promote sensory comfort: Auditory. Reduce noise of voices and water. Do not allow traffic into bathing room. Add fabric to absorb sound (three to four times the width of the opening for sound-absorbing folds). Play soft music.
• Design the bathing environment for comfort: Tactile. Use heat lamps or radiant heat panels to keep the room warm. Use powder-coated grab bars in decorative colors with nonslip grip. Provide a soft rug to stand on. Ensure that flooring is not slippery (a high coefficient of friction, ideally above 80, is desired and obtained through flooring coatings).
• When bathing a cognitively impaired client, have all bathing items ready for the client’s needs before bathing begins.
• Train caregivers bathing clients with dementia to avoid behaviors that can trigger assault: confrontational communication, invalidation of the resident’s feelings, failure to prepare a resident for a task, initiating shower spray or touch during bathing without verbal prompts beforehand, washing the hair/face, speaking disrespectfully to the client, and hurrying the pace of the bath.
• QSEN (Safety): Test water temperature before use with a thermometer to prevent scalding.
• Use a prepackaged bath for older adults to prevent skin dryness.
• Focus on the abilities of the client with dementia to obtain client’s participation in bathing.
• Encourage client to perform bathing tasks and allow adequate time for performance of tasks.
• If in a typical bathing setting for the client, assess the client’s ability to bathe self via direct observation using physical performance tests for ADLs.
Request referrals for occupational therapy for clients who have experienced a stroke.
Based on functional assessment and rehabilitation capacity, refer for home health aide services to assist with bathing and hygiene.
• QSEN (Safety): Turn down temperature of water heater and recommend use of a water temperature‒sensing shower valve to prevent scalding.
Dressing Self-Care deficit
Defining Characteristics
Impaired ability to fasten clothing; impaired ability to obtain clothing; impaired ability to put on necessary items of clothing; impaired ability to put on shoes; impaired ability to put on socks; impaired ability to take off necessary items of clothing; impaired ability to take off shoes; impaired ability to take off socks; inability to choose clothing; inability to maintain appearance at a satisfactory level; inability to pick up clothing; inability to put clothing on lower body; inability to put clothing on upper body; inability to put on shoes; inability to put on socks; inability to remove clothes; inability to remove shoes; inability to remove socks; inability to use assistive devices; inability to use zippers
Related Factors (r/t)
Cognitive impairment; decreased motivation; discomfort; environmental barriers; fatigue; musculoskeletal impairment; neuromuscular impairment; pain; perceptual impairment; severe anxiety; weakness
NOTE: Specify level of independence using a standardized functional scale.
Client Outcomes
Client Will (Specify Time Frame)
• Dress and groom self to optimal potential
• Use assistive technology to dress and groom
• Explain and use methods to enhance strengths during dressing and grooming
Nursing Interventions
• Assess a client’s range of movement, upper limb strength, balance, coordination, functional grip, dexterity, sensation, and ability to detect limb position.
Provide pain medication 45 minutes before dressing and grooming as needed.
• Select adaptive clothing: loose clothing; elastic waistbands and cuffs; square, large arm holes; no seam lines; dresses that open down the back and short coats (for wheelchair users); Velcro fasteners; larger or magnetic buttons; zipper pulls for grasping; and for drooling, absorbent scarves that can be easily changed.
• For clients with limited arm and shoulder movement, use clothing that fastens at the front, such as for blouses, bras, and shirts.
• QSEN (Safety): Allow client with poor balance or postural hypotension to sit rather than stand when dressing, for safety.
• Dress the affected side first, then the unaffected side; undressing the affected side is done last.
• Use adaptive dressing and grooming equipment as needed (e.g., long-handled brushes, long grasping devices, button hooks, elastic shoelaces, Velcro shoes, soap-on-a-rope, suction holders).
• For clients with a fine hand tremor, use weighted handles on grooming items or stabilize the client’s arm on a table; for a weak or painful grip, use lightweight, large-grip handles.
• Maintain individuality with hairstyle, jewelry, and clothing.
• QSEN (Patient-Centered): Determine the client’s personal preferences for dressing and grooming by using the Self-maintenance Habits and Preferences in Elderly (SHAPE) questionnaire and focus on items most preferred by the client.
• Assist residents with goal setting and their highest ADL performance level rather than providing the care for them.
• Ensure clients can see clothing to select what to wear by administering annual vision testing and having client wear clean glasses.
• Consider individualized smart machine-based prompting for dressing task completion for dementia clients.
• Use clocks, routines, and explanations for the client with dementia to convey that it is morning and time to get ready for the day’s activities by dressing.
• Lay clothing out (with label in back facing up) in the order that it will be put on by the client, either one item at a time or in piles with first item on top of pile (dress bottom half first: underwear, then slacks, socks; then dress top half: bra, shirt, sweater).
Involve the client in planning of informal care and provide access to health professionals and financial support for the care.
Client/Family Teaching and Discharge Planning
• Teach caregivers to see dressing as an opportunity to promote independence and a better quality of life for clients who are able, and as a time to increase social talk for others.
Consider referral for use of assistive technology to prompt independent learning of self-care skills such as dressing.
Feeding Self-Care deficit
Defining Characteristics
Inability to bring food from a receptacle to the mouth; inability to chew food; inability to complete a meal; inability to get food onto utensil; inability to handle utensils; inability to ingest food in a socially acceptable manner; inability to ingest food safely; inability to ingest sufficient food; inability to manipulate food in mouth; inability to open containers; inability to pick up cup or glass; inability to prepare food for ingestion; inability to swallow food; inability to use assistive device
Related Factors (r/t)
Cognitive impairment; decreased motivation; discomfort; environmental barriers; fatigue; musculoskeletal impairment; neuromuscular impairment; pain; perceptual impairment; severe anxiety; weakness
NOTE: Specify level of independence using a standardized functional scale.
Client Outcomes
Client Will (Specify Time Frame)
Nursing Interventions
• QSEN (Safety): Assess for choking and swallowing risk for clients with learning disability and note condition of teeth, medication side effects, and abnormal eating behaviors.
QSEN (Safety): Consult speech-language therapist to assess swallowing and identify safe feeding plan for client with a stroke.
• QSEN (Safety): Consider assessment of ICU and stepdown clients’ readiness for an oral diet with a 3-oz water swallow challenge by a trained provider.
• QSEN (Patient-Centered): Individualize assisted feeding for those who are completely dependent.
• QSEN (Teamwork and Collaboration): Give priority to continuity in the cooperation between the parties involved in assisted feeding for those who are completely dependent.
• QSEN (Patient-Centered): Consult client on the benefit or desire to use assistive devices for feeding.
• QSEN (Safety): Presentation of feeding: provide 1 teaspoon of solid food or 10 to 15 mL of liquid at a time; wait until client has swallowed prior food/liquid.
• QSEN (Safety): Individualize nutritional plan to promote a positive mealtime experience for clients after surgical and radiotherapy treatment for tongue cancer.
• QSEN (Patient-Centered): Assist clients with cancer to plan self-care strategies to promote control (choosing foods), self-worth (food value for survival), and positive relationships (family meal interactions), and use distraction (humor) to manage eating problems.
• QSEN (Safety): Ensure oral care is provided to all clients regardless of type of feeding.
• QSEN (Patient-Centered): Obtain and incorporate the client’s view of the agency’s food selection and presentation into agency food service.
• QSEN (Patient-Centered): Assess the ability of clients with dementia to self-feed, and supervise the feeding of those with moderate dependency by providing verbal or physical assistance.
• QSEN (Patient-Centered): Use the Edinburgh Feeding Evaluation in Dementia scale to assess eating and feeding problems in clients with late-stage dementia.
• QSEN (Patient-Centered): Consider “comfort-only feeding” for clients with dementia using careful hand feeding.
• QSEN (Patient-Centered): Allow a resident an average of 42 minutes of staff time per meal and 13 minutes per between-meal snack to improve oral intake.
• QSEN (Patient-Centered): Promote family visits at mealtimes for clients with dementia to encourage eating.
• QSEN (Patient-Centered): Play familiar music during meals for clients with Alzheimer’s disease.
• Use aromatherapy with the smell of baking bread for those with dementia.
QSEN (Safety): Provide targeted feeding with trained feeding assistants to older clients with dysphagia who are on texture modified diets.
QSEN (Safety): Provide CNAs with information on techniques to feed clients with dementia.
• QSEN (Patient-Centered): Provide individualized dining experience for those with dementia through consistent routine, such as same seat placed for limited distractions, preferred dining companions, presentation of one food item at a time, use of a Plexiglas barrier around place setting to prevent reaching.
Toileting Self-Care deficit
Defining Characteristics
Inability to carry out proper toilet hygiene; inability to flush toilet or commode; inability to get to toilet or commode; inability to manipulate clothing for toileting; inability to rise from toilet or commode; inability to sit on toilet or commode
Related Factors (r/t)
Cognitive impairment; decreased motivation; environmental barriers; fatigue; impaired mobility status; impaired transfer ability; musculoskeletal impairment; neuromuscular impairment; pain; perceptual impairment; severe anxiety; weakness
Client Outcomes
Client Will (Specify Time Frame)
• Remain free of incontinence and impaction with no urine or stool on skin
• State satisfaction with ability to use adaptive devices for toileting
• Explain and use methods to be safe and independent in toileting
Nursing Interventions
• QSEN (Patient-Centered): Assess client’s usual toileting patterns and preferences, and factors contributing to impaired toileting leading to constipation or urinary incontinence.
• QSEN (Patient-Centered): Ask client to participate in recovery preference exploration (RPE) to assist in defining client’s recovery preferences and treatment goals.
• QSEN (Patient-Centered): Before use of a bedpan, discuss its use with clients.
• QSEN (Patient-Centered): Use necessary assistive toileting equipment (e.g., raised toilet seat, bedside commode, suction mats, spill-proof urinals, support rails next to toilet, toilet safety frames, female urinal, fracture bedpans, long-handled toilet paper holders).
• QSEN (Patient-Centered): Assess client’s prior use of incontinence briefs and avoid use for hospitalized continent but limited mobility client.
• QSEN (Safety): Make assistance call button readily available to the client and answer call light promptly.
• QSEN (Safety): Provide folding commode chairs in patient bathrooms.
• QSEN (Patient-Centered): For residents who show occasional/frequent bowel/bladder incontinence on the Minimum Data Set, plan an individualized toileting schedule.
• QSEN (Patient-Centered): Assess the client’s functional ability to manipulate clothing for toileting, and if necessary modify clothing with Velcro fasteners, elastic waists, drop-front underwear, or slacks.
• QSEN (Safety): Avoid the use of indwelling catheters if possible, and use condom catheters in men without dementia.
• QSEN (Patient-Centered): Provide clients with dementia access to regular exercise.
Readiness for enhanced Self-Concept
A pattern of perceptions or ideas about the self that is sufficient for well-being and can be strengthened
Defining Characteristics
Accepts limitations; accepts strengths; actions are congruent with verbal expression; expresses confidence in abilities; expresses satisfaction with body image; expresses satisfaction with personal identity; expresses satisfaction with role performance; expresses satisfaction with sense of worthiness; expresses satisfaction with thoughts about self; expresses willingness to enhance self-concept
Client Outcomes
Client Will (Specify Time Frame)
• State willingness to enhance self-concept
• State satisfaction with thoughts about self, sense of worthiness, role performance, body image, and personal identity
• Demonstrate actions that are congruent with expressed feelings and thoughts
Nursing Interventions
• Assess and support activities that promote self-concept developmentally.
• Refer to nutritional and exercise programs to support weight loss.
• Refer clients to massage therapy as an adjunct treatment.
• Support establishing church-based community health promotion programs (CBHPPs) with the following key elements: partnerships, positive health values, availability of services, access to church facilities, community-focused interventions, health behavior change, and supportive social relationships.
• Offer client choices in clothing when client is hospitalized.
Refer clients with history of childhood sexual abuse for intensive therapy that uses narrative life stories to promote positive sense of self.
• Consider the development of a Healthy Kids Mentoring Program that has four components: (1) relationship building, (2) self-esteem enhancement, (3) goal setting, and (4) academic assistance (tutoring). Mentors met with students twice each week for 1 hour each session on school grounds. During each meeting, mentors devoted time to each program component.
Assess and provide referrals to mental health professionals for clients with unresolved worries associated with terrorism.
• Provide an alternative school-based program for pregnant and parenting teenagers.
• Encourage clients to consider a web-based support program when they are in a caregiving situation.
• Encourage activity and a strength, mobility, balance, and endurance training program.
• Provide opportunities for clients to engage in life skills (themed collections of everyday items based upon general activities that residents may have previously carried out).
• Carefully assess each client and allow families to participate in providing care that is acceptable based on the client’s cultural beliefs.
• Provide education and support for health-promoting behaviors and self-concept for clients from diverse cultures.
• Refer to the care plans Disturbed Body Image, Readiness for enhanced Coping, Chronic low Self-Esteem, and Readiness for enhanced Spiritual Well-Being.
Chronic low Self-Esteem
Defining Characteristics
Dependent on others’ opinions; evaluation of self as unable to deal with events; exaggerates negative feedback about self; excessively seeks reassurance; frequent lack of success in life events; hesitant to try new situations; hesitant to try new things; indecisive behavior; lack of eye contact; nonassertive behavior; overly conforming; passive; rejects positive feedback about self; reports feelings of guilt; reports feelings of shame
Related Factors (r/t)
Ineffective adaptation to loss; lack of affection; lack of approval; lack of membership in group; perceived discrepancy between self and cultural norms; perceived discrepancy between self and spiritual norms; perceived lack of belonging; perceived lack of respect from others; psychiatric disorder; repeated failures; repeated negative reinforcement; traumatic event; traumatic situation
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate improved ability to interact with others (e.g., maintains eye contact, engages in conversation, expresses thoughts/feelings)
• Verbalize increased self-acceptance through positive self-statements about self
• Identify personal strengths, accomplishments, and values
• Identify and work on small, achievable goals
• Improve independent decision-making and problem-solving skills
Nursing Interventions
• Actively listen to and respect the client.
• Assess the client’s environmental and everyday stressors, including physical health concerns and the potential for abusive relationships.
• Assess existing strengths and coping abilities, and provide opportunities for their expression and recognition.
• Reinforce the personal strengths and positive self-perceptions that a client identifies.
• Identify client’s negative self-assessments.
• Encourage realistic and achievable goal setting and resources and identify impediments to achievement.
• Demonstrate and promote effective communication techniques; spend time with the client.
• Encourage independent decision-making by reviewing options and their possible consequences with client.
• Assist client to challenge negative perceptions of self and performance.
• Use failure as an opportunity to provide valuable feedback.
• Promote maintaining a level of functioning in the community.
• Assist client with evaluating the effect of family and peer group on feelings of self-worth.
• Support socialization and communication skills.
• Encourage journal/diary writing as a safe way of expressing emotions.
• Support client in identifying and adapting to functional changes.
• Use reminiscence therapy to identify patterns of strength and accomplishment.
• Encourage participation in peer group activities.
• Encourage activities in which a client can support/help others.
• Assess a client’s immediate support system/family for relationship patterns and content of communication.
Refer to medical social services to assist the family in pattern changes that could benefit the client.
If a client is taking prescribed psychotropic medications, assess for knowledge of medication side effects and reasons for taking medication. Teach as necessary.
Assess medications for effectiveness and side effects and monitor client for compliance.
Situational low Self-Esteem
Defining Characteristics
Evaluation of self as unable to deal with events; evaluation of self as unable to deal with situations; indecisive behavior; nonassertive behavior; reports current situational challenge to self-worth; reports helplessness; reports uselessness; self-negating verbalizations
Related Factors (r/t)
Behavior inconsistent with values; developmental changes; disturbed body image; failures; functional impairment; lack of recognition; loss; rejections; social role changes
Client Outcomes
Client Will (Specify Time Frame)
• State effect of life events on feelings about self
• Acknowledge presence of guilt and not blame self if an action was related to another person’s appraisal
• Demonstrate self-perceptions are accurate given physical capabilities
• Demonstrate separation of self-perceptions from societal stigmas
Nursing Interventions
Assess the client for signs and symptoms of depression and potential for suicide and/or violence. If present, immediately notify the appropriate personnel of symptoms. See care plans for Risk for other-directed Violence and Risk for Suicide.
• Assess the client’s environmental and everyday stressors, including evidence of abusive relationships.
• Assist in the identification of problems and situational factors that contribute to problems, offering options for resolution.
• Mutually identify strengths, resources, and previously effective coping strategies.
• Accept client’s own pace in working through grief or crisis situations.
• Accept the client’s own defenses in dealing with the crisis.
• Provide information about support groups of people who have common experiences or interests.
• Teach the client mindfulness techniques to cope more effectively with strong emotional responses.
• Support client’s decisions in health care treatment.
• Encourage objective appraisal of self and life events and challenge negative or perfectionist expectations of self.
• Provide psychoeducation to client and family.
• Validate confusion when feeling ill but looking well.
• Acknowledge the presence of societal stigma. Teach management tools.
• Validate the effect of negative past experiences on self-esteem and work on corrective measures.
• See care plan for Chronic low Self-Esteem.
• Establish an emergency plan and contract with the client for its use.
• Access supplies that support a client’s success at independent living.
• See care plan for Chronic low Self-Esteem.
Client/Family Teaching and Discharge Planning
• Assess the person’s support system (family, friends, and community) and involve them if desired.
• Educate client and family regarding the grief process.
• Teach client and family that the crisis is temporary.
Refer to appropriate community resources or crisis intervention centers.
Refer to resources for handicap and/or disability services.
• Refer to illness-specific consumer support groups.
• See care plan for Chronic low Self-Esteem.
Risk for chronic low Self-Esteem
Risk Factors
Ineffective adaptation to loss; lack of affection; lack of membership in group; perceived discrepancy between self and cultural norms; perceived discrepancy between self and spiritual norms; perceived lack of belonging; perceived lack of respect from others; psychiatric disorder; repeated failures; repeated negative reinforcement; traumatic event; traumatic situation
Risk for situational low Self-Esteem
Risk Factors
Behavior inconsistent with values; decreased control over environment; developmental changes; disturbed body image; failures; functional impairment; history of abandonment; history of abuse; history of learned helplessness; history of neglect; lack of recognition; loss; physical illness; rejections; social role changes; unrealistic self-expectations
Client Outcomes
Client Will (Specify Time Frame)
• State accurate self-appraisal
• Demonstrate the ability to self-validate
• Demonstrate the ability to make decisions independent of primary peer group
• Express effects of media on self-appraisal
• Express influence of substances on self-esteem
Nursing Interventions
• Identify environmental and/or developmental factors that increase risk for low self-esteem, especially in children/adolescents, to make needed referrals.
• Assess the client’s previous experiences with health care and coping with illness to determine the level of education and support needed.
• Assess for low and negative affect (expression of feelings).
• Encourage client to maintain highest level of community functioning.
• Treat the client with respect and as an equal to maintain positive self-esteem.
• Help the client to identify the resources and social support network available at this time. Encourage the client to find a self-help or therapy group that focuses on self-esteem enhancement.
• Encourage the client to create a sense of competence through short-term goal setting and goal achievement.
Assess the client for symptoms of depression and anxiety. Refer to specialist as needed. Prompt and effective treatment can prevent exacerbation of symptoms or safety risks.
• See care plans for Disturbed personal Identity, Situational low Self-Esteem, and Chronic low Self-Esteem.
• Support humor as a coping mechanism.
• Assist the client in life review and identifying positive accomplishments.
• Help client to establish a peer group and structured daily activities.
• See care plans for Situational low Self-Esteem and Chronic low Self-Esteem.
• Assess current environmental stresses and identify community resources.
• Encourage family members to acknowledge and validate the client’s strengths.
• Assess the need for establishing an emergency plan.
• See care plans for Situational low Self-Esteem and Chronic low Self-Esteem.
Client/Family Teaching and Discharge Planning
Refer the client/family to community-based self-help and support groups.
Refer the client to educational classes on stress management, relaxation training, and so on.
Refer the client to community agencies that offer support and environmental resources.
• See care plans for Situational low Self-Esteem and Chronic low Self-Esteem.
Ineffective Self-Health Management
Pattern of regulating and integrating into daily living a therapeutic regimen for treatment of illness and its sequelae that is unsatisfactory for meeting specific health goals
Defining Characteristics
Failure to include treatment regimens in daily living; failure to take action to reduce risk factors; ineffective choices in daily living for meeting health goals; reports desire to manage the illness; reports difficulty with prescribed regimens
Related Factors (r/t)
Complexity of health care system; complexity of therapeutic regimen; decisional conflicts; deficient knowledge; economic difficulties; excessive demands made (e.g., individual, family); family conflict; family patterns of health care; inadequate number of cues to action; perceived barriers; perceived benefits; perceived seriousness; perceived susceptibility; powerlessness; regimen; social support deficit
Client Outcomes
Client Will (Specify Time Frame)
• Describe daily food and fluid intake that meets therapeutic goals
• Describe activity/exercise patterns that meet therapeutic goals
• Describe scheduling of medications that meets therapeutic goals
• Verbalize ability to manage therapeutic regimens
• Collaborate with health providers to decide on a therapeutic regimen that is congruent with health goals and lifestyle
Nursing Interventions
NOTE: This diagnosis does not have the same meaning as the diagnosis Noncompliance. This diagnosis is made with the client, so if the client does not agree with the diagnosis, it should not be made. The emphasis is on helping the client direct his or her own life and health, not on the client’s compliance with the provider’s instructions.
• Establish a collaborative partnership with the client for purposes of meeting health-related goals.
• Listen to the person’s story about his or her illness self-management.
• Explore the meaning of the person’s illness experience and identify uncertainties and needs through open-ended questions.
• Help the client enhance self-efficacy or confidence in his or her own ability to manage the illness.
• Involve family members in knowledge development, planning for self-management, and shared decision-making.
• Review factors of the Health Belief Model (individual perceptions of seriousness and susceptibility, demographic and other modifying factors, and perceived benefits and barriers) with the client.
• Use various formats to provide information about the therapeutic regimen, including group education, brochures, videotapes, written instructions, computer-based programs, and telephone contact.
• Help the client identify and modify barriers to effective self-management.
• Help the client self-manage his or her own health through teaching about strategies for changing habits such as overeating, sedentary lifestyle, and smoking.
• Develop a contract with the client to maintain motivation for changes in behavior.
• Use focus groups to evaluate the implementation of self-management programs.
• Refer to the care plan Ineffective family Therapeutic Regimen Management.
• Assess the influence of cultural beliefs, norms, and values on the individual’s perceptions of the therapeutic regimen.
• Discuss all strategies with the client in the context of the client’s culture.
• Provide health information that is consistent with the health literacy of clients.
• Assess for barriers that may interfere with client follow-up of treatment recommendations.
• Use electronic monitoring to improve management of medications.
• Validate the client’s feelings regarding the ability to manage his or her own care and the impact on current lifestyle.
• Prepare and instruct clients and family members in the use of a medication box. Set up an appropriate schedule for filling of the medication box, and post medication times and doses in an accessible area (e.g., attached by a magnet to the refrigerator).
• Monitor self-management of the medical regimen.
Refer to health care professionals for questions and self-care management.
Client/Family Teaching and Discharge Planning
• Identify what the client and/or family know and adjust teaching accordingly. Teach the client and family about all aspects of the therapeutic regimen, providing as much knowledge as the client and family will accept, in a culturally congruent manner.
• Teach ways to adjust ADLs for inclusion of therapeutic regimens.
• Teach safety in taking medications.
• Teach the client to act as a self-advocate with health providers who prescribe therapeutic regimens.
Readiness for enhanced Self-Health Management
A pattern of regulating and integrating into daily living a therapeutic regimen for treatment of illness and its sequelae that is sufficient for meeting health-related goals and can be strengthened
Defining Characteristics
Choices of daily living are appropriate for meeting goals (e.g., treatment, prevention); describes reduction of risk factors; expresses desire to manage the illness (e.g., treatment, prevention of sequelae); expresses little difficulty with prescribed regimens; no unexpected acceleration of illness symptoms
Risk for Self-Mutilation
At risk for deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension
Risk Factors
Adolescence; autistic individuals; battered child; borderline personality disorders; character disorders; childhood illness; childhood sexual abuse; childhood surgery; depersonalization; developmentally delayed individuals; dissociation; disturbed body image; disturbed interpersonal relationships; eating disorders; emotional disorder; family divorce; family history of self-destructive behaviors; family substance abuse; feels threatened with loss of significant relationship; history of inability to plan solutions; history of inability to see long-term consequences; history of self-directed violence; impulsivity; inability to express tension verbally; inadequate coping; incarceration; irresistible urge for self-directed violence; isolation from peers; living in nontraditional setting (e.g., foster group, or institutional care); loss of control over problem-solving situations; loss of significant relationship(s); low self-esteem; mounting tension that is intolerable; need for quick reduction of stress; peers who self-mutilate; perfectionism; psychotic state (e.g., command hallucinations); reports negative feelings (e.g. depression, rejection, self-hatred, separation anxiety, guilt); sexual identity crisis; substance abuse; unstable self-esteem; use of manipulation to obtain nurturing relationship with others; violence between parental figures
Client Outcomes
Client Will (Specify Time Frame)
• Identify triggers to self-mutilation
• State appropriate ways to cope with increased psychological or physiological tension
• Seek help when having urges to self-mutilate
• Maintain self-control without supervision
• Use appropriate community agencies when caregivers are unable to attend to emotional needs
Nursing Interventions
NOTE: Before implementing interventions in the face of self-injury, nurses should examine their own emotional responses to incidents of self-injury to ensure that interventions will not be based on countertransference reactions.
• Assess client’s ability to regulate his or her own emotional states.
• Assess client’s degree of self-criticism and use of effective coping skills. Self-harm serves as a coping mechanism for clients.
• Assess client’s perception of powerlessness. Refer to the care plan for Powerlessness.
• Assessment data from the client and family members may have to be gathered at different times; allowing a family member or trusted friend with whom the client is comfortable to be present during the assessment may be helpful.
• Assess for risk factors of self-mutilation, including categories of psychiatric disorders (particularly borderline personality disorder, psychosis, eating disorders, autism); psychological precursors (e.g., low tolerance for stress, impulsivity, perfectionism); psychosocial dysfunction (e.g., presence of sexual abuse, divorce or alcoholism in the family, manipulative behavior to gain nurturing, chaotic interpersonal relationships); coping difficulties (e.g., inability to plan solutions or see long-term consequences of behavior); personal history (e.g., childhood illness or surgery, past self-injurious behavior); and peer influences (e.g., friends who mutilate, isolation from peers).
• Assess for co-occurring disorders that require response, specifically childhood abuse, substance abuse, and suicide attempts. Implement reporting or referral as indicated.
• Assess family dynamics and the need for family therapy and community supports.
• Assess for the presence of medical disorders, mental retardation, medication effects, or disorders such as autism that may include self-mutilation. Initiate referral for evaluation and treatment as appropriate.
• Be alert to other risk factors of self-mutilation in clients with psychosis, including acute intoxication, dramatic changes in body appearance, preoccupation with religion and sexuality, and anticipated or perceived object loss.
• Monitor the client’s behavior closely, using engagement and support as elements of safety checks while avoiding intrusive overstimulation. Offer activities that will serve as a distraction.
• Assess the client’s ability to enter into a no-suicide or no-self-harm contract. Secure a written or verbal contract from the client to notify staff when experiencing the desire to self-mutilate.
• Establish trust, listen to client, convey safety, and assist in developing positive goals for the future.
Refer to mental health counseling. Multiple therapeutic modalities are available for treatment.
• When working with self-mutilative clients who have borderline personality disorder, develop an effective therapeutic relationship by avoiding labeling, seeking to understand the meaning of the self-mutilation, and advocating for adequate opportunities for care.
• Maintain a consistent relational distance from the client with borderline personality disorder who self-mutilates: neither too close nor too distant, neither rewarding unacceptable behavior nor trying to control or avoid the client.
• Inform the client of expectations for appropriate behavior and consequences within the unit. Emphasize that the client must comply with the rules. Give positive reinforcement for compliance and minimize attention paid to disruptive behavior while setting limits.
• Clients need to learn to recognize distress as it occurs and express it verbally rather than as a physical action against the self.
• Assist the client to identify the motives/reasons for self-mutilation that have been perceived as positive. Self-harm serves as a defense mechanism.
• Help the client identify cues that precede impulsive behavior.
• Assist clients to identify ways to soothe themselves and generate hopefulness when faced with painful emotions.
• Reinforce alternative ways of dealing with depression and anxiety, such as exercise, engaging in unit activities, or talking about feelings.
• Keep the environment safe; remove all harmful objects from the area. Use of unbreakable glass is recommended for the client at risk for self-injury.
• Anticipate trigger situations and intervene to assist the client in applying alternatives to self-mutilation.
• If self-mutilation does occur, use a calm, nonpunitive approach. Whenever possible, assist the client to assume responsibility for consequences (e.g., dress self-inflicted wound). Refer to the care plan for Self-Mutilation.
• If the client is unable to control self-mutilation behavior, provide interactive supervision, not isolation.
• Involve the client in planning his or her care and problem solving, and emphasize that the client makes choices.
Use group therapy to exchange information about methods of coping with loneliness, self-destructive impulses, and interpersonal relationships as well as housing, employment, and health care system issues directly and do not interpret.
• Internet groups may provide additional support.
• The same dynamics described previously apply to adolescents.
• Conduct a thorough physical examination, being alert for superficial scars that may be patterned, although in most cases scabbing or infection is not evident. This should be done also with children and adolescents who have a chronic medical condition.
• Maintaining a therapeutic relationship with teens requires explicit assurances of confidentiality, consistency of clinical routines, and a nonjudgmental communication style.
• Attend to behavioral clues of self-mutilation; a brief self-report assessment can be useful.
• Encourage expression of painful experiences and provide supportive counseling.
• Multiple treatment modalities may be used in addressing the themes of young people who self-harm.
• Teaching coping skills can be an important intervention for adolescents.
• Assess for the presence of an eating disorder or substance abuse. Attend to the themes that preoccupy teens with eating disorders who self-mutilate.
• Evaluate for suicidal ideation/suicide risk. Refer to the care plan for Risk for Suicide for additional information.
• Be aware that there is not complete overlap between self-mutilation and suicidal behavior. The motivation may be different (coping with difficult feelings rather than ending life), and the method is usually different.
• Use treatment approaches detailed previously, with modifications as appropriate for this age group.
• Provide hand or back rubs and calming music when elderly clients experience anxiety.
• Provide soft objects for elderly clients to hold and manipulate when self-mutilation occurs as a function of delirium or dementia. Apply mitts, splints, helmets, or restraints as appropriate.
• Older adults who show self-destructive behaviors should be evaluated for dementia.
• Communicate degree of risk to family/caregivers; assess the family and caregiving situation for ability to protect the client and to understand the client’s self-mutilative behavior. Provide family and caregivers with guidelines on how to manage self-harm behaviors in the home environment.
• Establish an emergency plan, including when to use hotlines and 911. Develop a contract with the client and family for use of the emergency plan. Role-play access to the emergency resources with the client and caregivers.
• Assess the home environment for harmful objects. Have family remove or lock objects as able.
If client behaviors intensify, institute an emergency plan for mental health intervention.
Refer for homemaker or psychiatric home health care services for respite, client reassurance, and implementation of therapeutic regimen.
If the client is on psychotropic medications, assess client and family knowledge of medication administration and side effects.
Client/Family Teaching and Discharge Planning
• Explain all relevant symptoms, procedures, treatments, and expected outcomes for self-mutilation that is illness based (e.g., borderline personality disorder, autism).
• Assist family members to understand the complex issues of self-mutilation. Provide instruction on relevant developmental issues and on actions parents can take to avoid media that glorify self-harm behaviors.
• Provide written instructions for treatments and procedures for which the client will be responsible.
• Instruct the client in coping strategies (assertiveness training, impulse control training, deep breathing, progressive muscle relaxation).
• Role play (e.g., say, “Tell me how you will respond if someone ignores you”).
• 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, picture a large stop sign and replace the image with a prearranged positive alternative). Teach the client to confront his or her own negative thought patterns (or cognitive distortions), such as catastrophizing (expecting the very worst), dichotomous thinking (perceiving events in only one of two opposite categories), or magnification (placing distorted emphasis on a single event).
Provide the client and family with phone numbers of appropriate community agencies for therapy and counseling.
Give the client positive things on which to focus by referring to appropriate agencies for job-training skills or education.
Self-Mutilation
Deliberate self-injurious behavior causing tissue damage with the intent of causing nonfatal injury to attain relief of tension
Defining Characteristics
Abrading; biting; constricting a body part; cuts on body; hitting; ingestion of harmful substances; inhalation of harmful substances; insertion of object into body orifice; picking at wounds; scratches on body; self-inflicted burns; severing
Related Factors (r/t)
Adolescence; autistic individual; battered child; borderline personality disorder; character disorder; childhood illness; childhood sexual abuse; childhood surgery; depersonalization; developmentally delayed individual; dissociation; disturbed body image; disturbed interpersonal relationships; eating disorders; emotional disorder; family divorce; family history of self-destructive behaviors; family substance abuse; feels threatened with loss of significant relationship; history of inability to plan solutions; history of inability to see long-term consequences; history of self-directed violence; impulsivity; inability to express tension verbally; incarceration; ineffective coping; irresistible urge to cut self; irresistible urge for self-directed violence; isolation from peers; labile behavior; lack of family confidant; living in nontraditional setting (e.g., foster, group institutional care); low self-esteem; mounting tension that is intolerable; needs quick reduction of stress; peers who self-mutilate; perfectionism; poor communication between parent and adolescent; psychotic state (e.g., command hallucinations); report negative feelings (e.g., depression, rejection, self-hatred, separation anxiety, guilt, depersonalization); sexual identity crisis; substance abuse; unstable body image; unstable self-esteem; use of manipulation to obtain nurturing relationship with others; violence between parental figures
Client Outcomes
Client Will (Specify Time Frame)
• Refrain from further self-injury
• State appropriate ways to cope with increased psychological or physiological tension
• Seek help when having urges to self-mutilate
• Maintain self-control without supervision
• Use appropriate community agencies when caregivers are unable to attend to emotional needs
Nursing Interventions
NOTE: Before implementing interventions in the face of self-mutilation, nurses should examine their own emotional responses to incidents of self-harm to ensure that interventions will not be based on countertransference reactions.
Provide medical treatment for injuries. Use careful aseptic technique when caring for wounds. Care for the wounds in a matter-of-fact manner.
• Assess for risk of suicide or other self-damaging behaviors. Refer to the care plan for Risk for Suicide.
• Assess for signs of psychiatric disorders, including depression, anxiety, borderline personality disorder, dissociative disorders, eating disorders, and impulsivity.
• Assess for presence of hallucinations. Ask specific questions such as, “Do you hear voices that other people do not hear? Are they telling you to hurt yourself?”
Assure the client that he or she will be safe during hallucinations, and engage supportively. Provide referrals for medication.
Assess for the presence of medical disorders, mental retardation, medication effects, or disorders such as autism that may include self-mutilation. Initiate referral for evaluation and treatment as appropriate.
Case finding and referral by school nurses for psychological or psychiatric treatment is critical.
• Monitor the client’s behavior closely, using engagement and support as elements of safety checks while avoiding intrusive overstimulation.
• Establish trust, listen to client, convey safety, and assist in developing positive goals for the future.
• Recognize that self-mutilation may serve a variety of functions for the person.
• Assess the client’s ability to enter into a no-suicide or no-self-harm contract. Secure a written or verbal contract from the client to notify staff when experiencing the desire to self-mutilate.
Use a collaborative approach for care.
• Refer to the care plan for Risk for Self-Mutilation for additional information.
Home Care and Client/Family Teaching and Discharge Planning
• See the care plan for Risk for Self-Mutilation.
Self-Neglect
A constellation of culturally framed behaviors involving one or more self-care activities in which there is a failure to maintain a socially accepted standard of health and well-being
Defining Characteristics
Inadequate environmental hygiene; inadequate personal hygiene; nonadherence to health activities
Related Factors (r/t)
Capgras syndrome; cognitive impairment (e.g., dementia); depression; executive processing ability; fear of institutionalization; frontal lobe dysfunction; functional impairment; learning disability; lifestyle choice; maintaining control; major life stressor; malingering; obsessive-compulsive disorder; paranoid personality disorders; schizotypal personality disorders; substance abuse
Client Outcomes
Client Will (Specify Time Frame)
• Show improvement in mental health problems
• Show improvement in chronic medical problems
• Reveal improvement in cognition (e.g., if reversible and treatable)
• Demonstrate improvement in functional status (e.g., basic and instrumental activities of daily living)
• Demonstrate adherence to health activities
• Exhibit improved personal hygiene
• Exhibit improved environmental hygiene
• Have fewer hospitalizations and emergency room visits
• Increase safety of community in which client lives
• Agree to necessary personal and environmental changes that eliminate risk/endangerment to self or others (i.e., neighbors)
NOTE: Because self-neglect is a culturally framed and socially defined phenomenon, change in a client’s status must occur in such a way that it respects individual rights while ensuring individual health and well-being. This is accomplished through client-nurse partnership, but in some instances, assistance of next of kin and/or adult protective services may be needed (e.g., a state agency or local social services program).
Nursing Interventions
• Monitor individuals with acute or chronic mental and complex physical illness for defining characteristics for self-neglect.
• Assist individuals with complex mental and physical health issues to adopt positive health behaviors so that they may maintain their health status.
• Assess persons with complex health issues for adequate coping abilities, and assist those with coping problems to maintain their health and well-being in the community.
• Assist individuals whose self-care is failing with managing their medication regimen.
• Assess individuals with failing self-care for noncompliance (i.e., diagnostic testing, medication regimen, therapeutic regimen, and safety precautions).
• Assist persons with self-care deficits due to ADL or IADL impairments.
• Assess persons with failing self-care for changes in cognitive function (i.e., dementia or delirium).
Refer persons with failing self-care to appropriate specialists (i.e., psychologist, psychiatrist, social work) and therapists (i.e., physical therapy, occupational therapy, etc.).
• Utilize behavioral modification as appropriate to bring about client changes that lead to improvement in personal hygiene, environmental hygiene, and adherence to medical regimen.
• Monitor persons with substance abuse problems (i.e., drugs, alcohol, smoking) for adequate safety.
Refer persons with failing self-care who are significantly impaired cognitively or functionally and who are suspected victims of abuse to APS.
• Monitor clients with changes in cognitive function for adequate safety.
• Monitor clients with functional impairments for adequate safety.
• Assist individuals with complex mental and physical health needs with maintaining their health and well-being in the community.
Assess client’s socioeconomic status and refer for appropriate support.
Refer persons demonstrating a significant decline in self-care abilities (i.e., posing a threat to themselves or to their community) for evaluation of capacity and executive function.
Obtain the assistance of APS in the case of refusal of professional health care services when there is a clear indication of self-endangerment.
Sexual Dysfunction
The state in which an individual experiences a change in sexual function during the sexual response phases of desire, excitation, and/or orgasm, which is viewed as unsatisfying, unrewarding, or inadequate
Defining Characteristics
Actual limitations imposed by disease; actual limitations imposed by therapy; alterations in achieving perceived sex role; alterations in achieving sexual satisfaction; change of interest in others; change of interest in self; inability to achieve desired satisfaction; perceived alteration in sexual excitation; perceived deficiency of sexual desire; perceived limitations imposed by disease; perceived limitations imposed by therapy; seeking confirmation of desirability; verbalization of problem
Related Factors (r/t)
Absent role models; altered body function (e.g., pregnancy, recent childbirth, drugs, surgery, anomalies, disease process, trauma, radiation); altered body structure (e.g., pregnancy, recent childbirth, surgery, anomalies, disease process, trauma, radiation); biopsychosocial alteration of sexuality; deficient knowledge; ineffectual role models; lack of privacy; lack of significant other; misinformation; physical abuse; psychosocial abuse (e.g., harmful relationships); values conflict; vulnerability
Client Outcomes
Client Will (Specify Time Frame)
• Identify individual cause of sexual dysfunction
• Identify stressors that contribute to dysfunction
• Discuss alternative, satisfying, and acceptable sexual practices for self and partner
• Identify the degree of sexual interest by the client and partner
• Adapt sexual technique as needed to cope with sexual problems
• Discuss with partner concerns about body image and sex role
Ineffective Sexuality Pattern
Defining Characteristics
Alterations in achieving perceived sex role; alteration in relationship with significant other; reports changes in sexual activities; reports changes in sexual behaviors; reports difficulties with sexual activities; reports difficulties in sexual behaviors; reports limitations in sexual activities; reports limitations in sexual behaviors; values conflict
Related Factors (r/t)
Absent role model; conflicts with sexual orientation; conflicts with variant preferences; deficient knowledge about alternative responses to health-related transitions, altered body function or structure, illness or medical treatment; fear of acquiring a sexually transmitted infection; fear of pregnancy; impaired relationship with a significant other; ineffective role model; lack of privacy; lack of significant other; skill deficit about alternative responses to health-related transitions, altered body function or structure, illness, or medical treatment
Client Outcomes
Client Will (Specify Time Frame)
• State knowledge of difficulties, limitations, or changes in sexual behaviors or activities
• State knowledge of sexual anatomy and functioning
• State acceptance of altered body structure or functioning
• Describe acceptable alternative sexual practices
• Identify importance of discussing sexual issues with significant other
• Describe practice of safe sex with regard to pregnancy and avoidance of STDs
Risk for Shock
At risk for an inadequate blood flow to the body’s tissues which may lead to life-threatening cellular dysfunction
Risk Factors
Advanced age (greater than 65 years); comorbidities (e.g., angina, prior stroke, peripheral vascular disease, diabetes, cancer, renal insufficiency); emergency procedures related to traumatic events; hypotension; hypovolemia; hypoxemia; hypoxia; infection; sepsis; systemic inflammatory response syndrome (SIRS)
Client Outcomes
Client Will (Specify Time Frame)
• Discuss precautions to prevent complications of disease
• Maintain adherence to agreed upon medication regimens
• Monitor for infection signs and symptoms
• Maintain a mean arterial pressure above 65 mm Hg
• Maintain a heart rate between 60 and 100 with a normal rhythm
Nursing Interventions
• Review data pertaining to client risk status including age, primary diseases, immunosuppression, antibiotic use, and presence of hemodynamic alterations.
• Review client’s medical and surgical history, noting conditions that place the client at higher risk for shock, including trauma, myocardial infarction, pulmonary embolism, head injury, dehydration, and infection.
• Complete a full nursing physical examination.
• Monitor circulatory status (e.g., blood pressure [BP], mean arterial pressure [MAP], skin color, skin temperature, heart sounds, heart rate and rhythm, presence and quality of peripheral pulses, Doppler ultrasound, and pulse oximetry).
• Maintain IV access and provide isotonic IV fluids such as 0.9% normal saline or Ringer’s lactate as ordered; these fluids are commonly used in the prevention and treatment of shock.
• Monitor for inadequate tissue oxygenation (e.g., apprehension, increased anxiety, changes in mental status, agitation, oliguria, cool/mottled periphery) and determinants of tissue oxygen delivery (e.g., PaO2, SpO2, ScvO2/SvO2, MAP, hemoglobin levels, lactate levels, cardiac output [CO]).
Maintain vital signs (BP, pulse, respirations, and temperature), and pulse oximetry within normal parameters.
Administer oxygen immediately to maintain SpO2 greater than 90% and antibiotics and other medications as prescribed to any client presenting with symptoms of early shock.
Monitor trends in noninvasive hemodynamic parameters (e.g., MAP) as appropriate.
Monitor hydration status including skin turgor, daily weights, postural blood pressure changes, serum electrolytes (sodium, potassium, chloride, and blood urea nitrogen), and intake and output. Consider insertion of a Foley catheter as ordered to measure hourly output.
Monitor serum lactate levels, interpreting them within the context of each client.
Monitor blood glucose levels frequently and administer insulin as prescribed to maintain normal blood sugar levels (blood glucose levels of 70 to 110 mg/dL [3.9 to 6.1 mmol/L]).
Prepare the client for the placement of an additional IV line, central line, and/or a pulmonary artery catheter as prescribed.
Monitor trends in hemodynamic parameters (e.g., CVP, CO, CI, SVR, PAOP, and MAP) as appropriate.
Monitor arterial blood gases, coagulation, chemistries, point-of-care blood glucose, cardiac enzymes, blood cultures, and hematology.
Administer vasopressor agents as prescribed. If the client is in shock, refer to the care plan Risk for ineffective Renal Perfusion as needed. If the client is in shock, refer to the care plan Risk for ineffective Gastrointestinal Perfusion as needed. If the client is in shock, refer to the care plan Impaired Gas Exchange as needed. If the client is in shock and develops heart failure, refer to the care plan Decreased Cardiac Output as needed.
Client/Family Teaching and Discharge Planning
Teach client and family or significant others about any medications prescribed. Instruct the client to report any adverse side effects to his/her health care provider.
• Instruct the client and family on disease process and rationale for care.
• Instruct clients and their family members on the signs and symptoms of low blood pressure to report to their health care provider (dizziness, lightheadedness, fainting, dehydration and unusual thirst, lack of concentration, blurred vision, nausea, cold, clammy, pale skin, rapid and shallow breathing, fatigue, depression).
• Implement educational initiatives to reduce health care–associated infections (HAIs).
• Promote a culture of client safety and individual accountability.
Impaired Skin Integrity
Defining Characteristics
Destruction of skin layers; disruption of skin surface; invasion of body structures
Related Factors (r/t)
Chemical substance; extremes in age; humidity; hyperthermia; hypothermia; mechanical factors (e.g., friction, shearing forces, pressure, restraint); medications; moisture; physical immobilization; radiation
Internal
Changes in fluid status; changes in pigmentation; changes in turgor; developmental factors; imbalanced nutritional state (e.g., obesity, emaciation, chronic disease, vascular disease); immunological deficit; impaired circulation; impaired metabolic state; impaired sensation; skeletal prominence
Client Outcomes
Client Will (Specify Time Frame)
• Regain integrity of skin surface
• Report any altered sensation or pain at site of skin impairment
• Demonstrate understanding of plan to heal skin and prevent reinjury
• Describe measures to protect and heal the skin and to care for any skin lesion
Nursing Interventions
• Assess site of skin impairment and determine cause (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, skin tear).
• For clients with limited mobility, use a risk assessment tool to systematically assess immobility-related risk factors.
• Determine that skin impairment involves skin damage only (e.g., partial-thickness wound, stage I or stage II pressure ulcer). The following classification system is for pressure ulcers:
Category/Stage I: Intact skin with nonblanchable erythema of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue.
Category/Stage II: Partial-thickness skin loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled. Presents as a shiny or dry shallow ulcer without slough or bruising.∗
• Inspect and monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether the client is experiencing changes in sensation or pain. Pay special attention to high-risk areas such as bony prominences, skin folds, the sacrum, and heels.
• Monitor the client’s skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing.
• Consider using normal saline to clean the pressure ulcer or as ordered by physician.
• Individualize plan according to the client’s skin condition, needs, and preferences.
• Monitor the client’s continence status, and minimize exposure of skin impairment to other areas of moisture from perspiration or wound drainage.
If the client is incontinent, implement an incontinence management plan to prevent exposure to chemicals in urine and stool that can strip or erode the skin. Utilize a skin protectant or cleanser protectant. Refer to a continence care specialist, urologist, or gastroenterologist for incontinence assessment.
• For clients with limited mobility, use a risk assessment tool to systematically assess immobility-related risk factors
• Do not position the client on site of skin impairment. If consistent with overall client management goals, reposition the client as determined by individualized tissue tolerance and overall condition. Reposition and transfer the client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear.
• Evaluate for use of support surfaces (specialty mattresses, beds), chair cushions, or devices as appropriate. Maintain the head of the bed at the lowest possible degree of elevation to reduce shear and friction, and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed.
• Implement a written treatment plan for topical treatment of the site of skin impairment.
• Select a topical treatment that will maintain a moist wound-healing environment (stage II) and that is balanced with the need to absorb exudate. Stage I pressure ulcers may be managed by keeping the client off of the area and using a protective dressing.
• Avoid massaging around the site of skin impairment and over bony prominences.
Assess the client’s nutritional status. Refer for a nutritional consult and/or institute dietary supplements as necessary.
• Identify the client’s phase of wound healing (inflammation, proliferation, maturation) and stage of injury.
• The interventions described previously may be adapted for home care use.
• Instruct and assist the client and caregivers in how to change dressings and maintain a clean environment. Provide written instructions and observe them completing the dressing change.
• Educate client and caregivers on proper nutrition, signs and symptoms of infection, and when to call the agency and/or physician with concerns.
It may be beneficial to initiate a consultation in a case assignment with a wound, ostomy, continence (WOC) nurse (or wounds specialist) to establish a comprehensive plan for complex wounds.
Client/Family Teaching and Discharge Planning
Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing.
Teach the client why a topical treatment has been selected.
If consistent with overall client management goals, teach how to reposition as client condition warrants.
Teach the client to use pillows, foam wedges, chair cushions, and pressure-redistribution devices to prevent pressure injury.
∗Bruising indicates suspected deep tissue injury. For wounds deeper into subcutaneous tissue; muscle, or bone (category/stage III or stage IV pressure ulcers), see the care plan for Impaired Tissue Integrity.
Risk for impaired Skin Integrity
Risk Factors
Chemical substance; excretions and/or secretions; extremes of age; humidity; hyperthermia; hypothermia; mechanical factors (e.g., friction, shearing forces, pressure, restraint); moisture; physical immobilization; radiation
Internal
Alterations in skin turgor (change in elasticity); altered circulation; altered metabolic state; altered nutritional state (e.g., obesity, emaciation); altered pigmentation; altered sensation; chronic disease, developmental factors; history of pressure ulcers, immunological deficit; medication; psychogenetic, immunological factors; skeletal prominence, vascular disease
NOTE: Risk should be determined by the use of a risk assessment tool (e.g., Norton scale, Braden scale).
Client Outcomes
Client Will (Specify Time Frame)
• Report altered sensation or pain at risk areas as soon as noted
• Demonstrate understanding of personal risk factors for impaired skin integrity
• Verbalize a personal plan for preventing impaired skin integrity
Nursing Interventions
• Inspect and monitor skin condition at least once a day for color or texture changes, redness, localized heat, edema or induration, pressure damage, dermatological conditions, or lesions and any incontinence-associated dermatitis. Determine whether the client is experiencing loss of sensation or pain.
• Identify clients at risk for impaired skin integrity as a result of immobility, chronological age, malnutrition, incontinence, compromised perfusion, immunocompromised status, or chronic medical condition, such as diabetes mellitus, spinal cord injury, or renal failure.
• Monitor the client’s skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing.
• Cleanse the skin gently with pH-balanced cleansers. Avoid harsh cleansing agents, hot water, extreme friction or force, or too-frequent cleansing.
Monitor the client’s continence status and minimize exposure of the site of skin impairment (incontinence-associated dermatitis) and other areas to moisture from incontinence, perspiration, or wound drainage. If the client is incontinent, implement an incontinence management plan to prevent exposure to chemicals in urine and stool that can strip or erode the skin. Use a barrier product to reduce risk of exposure; refer to a physician (e.g., continence care specialist, urologist, gastroenterologist) for an incontinence assessment.
• For clients with limited mobility, inspect and monitor condition of skin covering bony prominences.
• Use a risk assessment tool to systematically assess immobility-related risk factors.
• Implement a written prevention plan.
• The use of repositioning should be considered in all at-risk individuals. Frequency of repositioning will be influenced by variables concerning the individual and the support surface in use. Frequency of repositioning should be determined by the individual’s tissue tolerance and medical condition. Reposition the client with care to protect against the adverse effects of external mechanical forces (e.g., pressure, friction, shear).
• Evaluate for use of specialty mattresses, beds, or devices as appropriate.
• Avoid massaging over bony prominences.
Assess the client’s nutritional status; refer for a nutritional consult, and/or institute dietary supplements.
• Limit number of complete baths to two or three per week, and alternate them with partial baths. Use a tepid water temperature (between 90° and 105° F) for bathing.
• Use lotions and moisturizers to prevent skin from drying out, especially in the winter.
• Increase fluid intake within cardiac and renal limits to a minimum of 1500 mL per day.
• Increase humidity in the environment, especially during the winter, by using a humidifier or placing a container of water on a warm object.
• Assess caregiver vigilance and ability
Initiate a consultation in a case assignment with a wound care specialist or wound, ostomy, and continence (WOC) nurse to establish a comprehensive plan as soon as possible.
• See the care plan for Impaired Skin Integrity.
Client/Family Teaching and Discharge Planning
• Teach the client skin assessment and ways to monitor for impending skin breakdown.
• If consistent with overall client management goals, teach how to turn and reposition the client. Teach the client and or caregivers to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury.
Sleep deprivation
Prolonged periods of time without sleep (sustained natural, periodic suspension of relative consciousness)
Defining Characteristics
Acute confusion, agitation, anxiety, apathy, combativeness, daytime drowsiness, decreased ability to function, fatigue, fleeting nystagmus, hallucinations, hand tremors, heightened sensitivity to pain, inability to concentrate, irritability, lethargy, listlessness, malaise, perceptual disorders (i.e., disturbed body sensation, delusions, feeling afloat), restlessness, slowed reaction, transient paranoia
Related Factors (r/t)
Aging-related sleep stage shifts, dementia, familial sleep paralysis, inadequate daytime activity, idiopathic central nervous system hypersomnolence, narcolepsy, nightmares, non–sleep-inducing parenting practices, periodic limb movement (e.g., restless leg syndrome, nocturnal myoclonus), prolonged discomfort (e.g., physical, psychological), sustained inadequate sleep hygiene, prolonged use of pharmacological or dietary antisoporifics, sleep apnea, sleep terror, sleep walking, sleep-related enuresis, sleep-related painful erections, sundowner’s syndrome, sustained circadian asynchrony, sustained environmental stimulation, sustained uncomfortable sleep environment
Client Outcomes
Client Will (Specify Time Frame)
• Verbalize plan that provides adequate time for sleep
• Identify actions that can be taken to ensure adequate sleep time
• Awaken refreshed as soon as adequate time is spent sleeping
• Be less sleepy during the day as soon as adequate time is spent sleeping
Nursing Interventions
• Obtain a sleep history including amount of sleep obtained each night, use of medications and stimulants that may interfere with sleep amount, medical conditions and their treatment that limits sleep time, work and family responsibilities that limit sleep time, and daytime sequelae suggestive of sleep deprivation (e.g., drowsiness, inability to concentrate, slowed reactions).
From the history, assess degree of sleep deprivation.
From the history, identity factors leading to sleep deprivation.
Assess evening pain medication use and, when feasible, administer pain medications that promote rather than interfere with sleep. (See further Nursing Interventions for Pain.)
Assess hypersensitivity to pain.
Assess for underlying physiological illnesses causing sleep loss (e.g., cardiovascular, pulmonary, gastrointestinal, hyperthyroidism, nocturia occurring with benign hypertrophic prostatitis or pain).
Assess for underlying psychiatric illnesses causing sleep loss (e.g., bipolar depression, anxiety disorders, schizophrenia).
Monitor for nocturnal panic attacks. Refer for treatment as appropriate.
Monitor for sleep disordered breathing (e.g., apneas and hypopneas) and accompanying daytime sleepiness. Refer for diagnosis by sleep specialists as appropriate.
Monitor for presence of nocturnal symptoms of restless leg syndrome with uncomfortable restless sensations in legs that occur before sleep onset or during the night. Refer for treatment as appropriate.
Monitor for symptoms of overactive bladder.
Assess for chronic insomnia. See further Nursing Interventions for Insomnia.
• Encourage napping as a way to compensate for sleep deprivation when severely restricted nighttime sleep cannot be avoided. Set a regular schedule for napping.
• Minimize factors that disturb the client’s sleep by consolidating care. See Nursing Interventions for Disturbed Sleep Pattern.
• Keep the sleep environment quiet (e.g., avoid use of intercoms, lower the volume on radio and television, keep beepers on nonaudio mode, anticipate alarms on intravenous [IV] pumps, talk quietly on unit). See Nursing Interventions for Disturbed Sleep Pattern.
• Mask noise in sleep area if noise cannot be eliminated. See Nursing Interventions for Readiness for enhanced Sleep.
• Interventions identified previously may be adapted for use with geriatric clients.
• In addition, see the Geriatric section of Nursing Interventions for Disturbed Sleep Pattern.
• Interventions identified previously may be adapted for home care use. See the Home Care section of Nursing Interventions for Disturbed Sleep Pattern.
• Teach family about the short-term and long-term consequences of inadequate amounts of sleep.
• Teach client/family about the need for those with chronic conditions to avoid schedules and commitments that interfere with obtaining adequate amounts of sleep.
• Promote adoption of behaviors that ensure adequate amounts of sleep for all family members. See Nursing Interventions for Readiness for enhanced Sleep.
• Teach family about signs of sleep deprivation and how to avoid chronic sleep loss. See Nursing Interventions for Disturbed Sleep Pattern.
• Advise against the sleep deprived person’s chronic use of stimulants (e.g., caffeine) to overcome daytime sequelae of sleep deprivation; focus on elimination of factors that lead to chronic sleep loss.
Readiness for enhanced Sleep
A pattern of natural, periodic suspension of consciousness that provides adequate rest, sustains a desired lifestyle, and can be strengthened
Defining Characteristics
Expresses willingness to enhance sleep; amount of sleep is congruent with developmental needs; reports being rested after sleep; follows sleep routines that promote sleep habits; occasional use of pharmaceutical agents to induce sleep
Client Outcomes
Client Will (Specify Time Frame)
• Verbalize an interest in what constitutes normal sleep
• Verbalize an interest in nonpharmacological approaches to sleep promotion
• Establish an environment conducive to sleep initiation and maintenance throughout the night
Nursing Interventions
• Obtain a sleep history including bedtime routines, sleep patterns, use of medications and stimulants, and use of complementary/alternative medical practices for stress management and relaxation prior to bedtime.
From the history, assess the client’s ability to initiate and maintain sleep, obtain adequate amounts of sleep, and manage daytime responsibilities free from fatigue and sleepiness.
• Based on assessment, teach one or more of the listed sleep promotion practices as appropriate.
Establish a regular schedule for sleep, exercise, napping, and mealtimes.
Avoid long periods of daytime sleep.
Arise at the same time each day even if sleep was poor during the previous night.
If not contraindicated have high-glycemic-index carbohydrate dinner and/or bedtime snack.
Avoid long-term use of sleeping pills.
Engage in relaxing activities before bed.
Provide backrub or other forms of massage.
Teach complementary and alternative interventions as culturally congruent.
Mask noise in sleep area when it cannot be eliminated.
For anxious clients consider use of a lavender oil preparation in the health care setting.
• Interventions discussed previously may be adapted for use with geriatric clients.
• Counsel the older adult regarding normal age-related changes in sleep:
• Elicit the older adult’s expectations for sleep and correct misconceptions.
• Assess and refer as appropriate if coexisting conditions may be disrupting sleep.
• Discuss appropriate and inappropriate self-help measures for improving sleep.
• Encourage walking and other exercise outdoors unless contraindicated.
• Help elderly clients engage with others who enjoy similar events.
• Combine strength training, walking, and social activities when feasible.
Disturbed Sleep Pattern
Defining Characteristics
Change in normal sleep pattern; reports not feeling well rested; dissatisfaction with sleep; decreased ability to function; reports being awakened; reports no difficulty falling asleep
Related Factors
Ambient temperature; ambient humidity; caregiving responsibilities; change in daylight-darkness exposure; interruptions (e.g., for therapeutics, monitoring, lab tests), lack of sleep privacy/control; lighting; noise, noxious odors; physical restraint; sleep partner; unfamiliar sleep furnishings
Client Outcomes
Client Will (Specify Time Frame)
• Verbalize plan to implement sleep promotion routines
• Maintain a regular schedule of sleep and waking
• Fall asleep without difficulty
• Remain asleep throughout the night
• Awaken naturally, feeling refreshed and is not fatigued during day
Nursing Interventions
• Obtain a sleep history including bedtime routines, number of times awakened during the night, noise and light levels in the sleep environment, and activities occurring in the sleep environment during hours of sleep.
From the history, assess whether client has an opportunity for normal sleep.
From the history, assess environmental factors that interrupt sleep.
• Assess level of pain. (See further Nursing Interventions for Pain.)
• If client has recurring pain, provide pain relief shortly before bedtime and position client comfortably for sleep.
• Keep environment quiet, room lighting dim, and bedding supportive of comfortable body alignment. See Nursing Interventions for Readiness for enhanced Sleep.
• Offer earplugs and eye masks if feasible.
• Establish a sleeping and waking routine with regular times for sleeping and waking, including routines for preparing for sleep. See Nursing Interventions for Readiness for enhanced Sleep.
• For hospitalized stable clients, consider instituting the following sleep protocol to a regular sleep-wake routine:
Night shift: Give the client the opportunity for uninterrupted sleep the first 3 to 4 hours of the sleep period. Keep environmental noise and light to a minimum. After major sleep period, allow 80 to 90 minutes between interruptions. (If client must be disturbed the first 3 to 4 hours, attempt to protect 90- to 110-minute blocks of time in between awakenings.)
Day shift: Encourage short morning and/or after-lunch naps as needed. Promote a physical activity regimen as appropriate. Schedule newly ordered medications to avoid the need to wake the client the first few hours of the night.
Evening shift: Limit napping. Encourage a suitable bedtime routine. At sleep time, lower intensity of room and unit lights and keep noise and conversation on the unit to a minimum.
• Most interventions identified previously are suitable for use with geriatric clients; however, be cautious about introducing earplugs and eye masks with ataxic clients and dementia clients, given that they may contribute to disorientation. Elderly clients should also be observed for nighttime safety risk due to increased incidence of sleep apnea with nocturia.
• Assessments for pain, anxiety, depression, sleep apnea, restless leg syndrome, and substance use/abuse are especially important in the elderly because sleep disruption is more common with the elderly and is made worse by these conditions.
• In addition see the Geriatric section of Nursing Interventions for Readiness for enhanced Sleep.
• Interventions identified previously may be adapted for home care use.
• In addition, see the Home Care section of Nursing Interventions for Readiness for enhanced Sleep.
Client/Family Teaching and Discharge Planning
• Teach family about sleep and the importance of uninterrupted sleep during treatment and recovery.
• Teach family about signs of sleep deprivation, which may result from several environmental factors. See Nursing Interventions for Sleep deprivation.
Impaired Social Interaction
Defining Characteristics
Discomfort in social situations; dysfunctional interaction with others; family report of changes in interaction (e.g., style, pattern); inability to communicate a satisfying sense of social engagement (e.g., belonging, caring, interest, or shared history); inability to receive a satisfying sense of social engagement (e.g., belonging, caring, interest, or shared history); use of unsuccessful social interaction behaviors
Related Factors (r/t)
Absence of significant others; communication barriers; deficit about ways to enhance mutuality (e.g., knowledge, skills); disturbed thought processes; environmental barriers; limited physical mobility; self-concept disturbance; sociocultural dissonance; therapeutic isolation
Client Outcomes
Client Will (Specify Time Frame)
• Identify barriers that cause impaired social interactions
• Discuss feelings that accompany impaired and successful social interactions
• Use available opportunities to practice interactions
• Use successful social interaction behaviors
• Report increased comfort in social situations
• Communicate, state feelings of belonging, demonstrate caring and interest in others
Nursing Interventions
• Consider using a self-rating scale to assess social functioning.
• Monitor the client’s use of defense mechanisms and support healthy defenses (e.g., the client focuses on present and avoids placing blame on others for personal behavior).
• Use active listening skills, including assessment and clarification of the client’s verbal and nonverbal responses and interactions.
• Identify client strengths. Have the client make a list of strengths and refer to it when experiencing negative feelings. He or she may find it helpful to put the list on a note card to carry at all times.
• Have group members support each other in a group setting.
• Model appropriate social interactions. Give positive verbal and nonverbal feedback for appropriate behavior (e.g., make statements such as, “I’m proud that you made it to work on time and did all the tasks assigned to you without saying that your supervisor was picking on you”; make eye contact). If not contraindicated, touch the client’s arm or hand when speaking.
• Use role playing to increase social skills.
• Use client-centered humor as appropriate.
• Consider use of animal therapy; arrange for visitation.
• Consider the use of the Internet and email to promote socialization.
Refer client for behavioral interventions (life skills program) to increase social skills.
• Refer to care plans for Risk for Loneliness and Social Isolation for additional interventions.
• Encourage social support for clients with visual and hearing impairments.
• Provide computers and Internet access to children with chronic disabilities that limit socialization.
• Consider use of RAP therapy (therapy using rap music) in groups to advance social skills of urban adolescents.
• Consider residential wilderness treatment programs for adolescents with unsuccessfully treated mental health issues and antisocial behavior.
• Encourage socialization through education, support groups, and programs for the elderly in the community.
Assess the client’s potential or actual sensory problems with hearing and vision and make appropriate referrals if a problem is identified.
• Monitor for depression, a particular risk in the elderly.
• Encourage group physical activity, such as aerobics or stretching and toning.
• Consider having clients participate in playing Wii.
• Refer to care plans for Adult Failure to Thrive, Risk for Loneliness, and Social Isolation for additional interventions.
Social Isolation
Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state
Defining Characteristics
Absence of supportive significant other(s); developmentally inappropriate behaviors; dull affect; evidence of handicap (e.g., physical, mental); exists in a subculture; illness; meaningless actions; no eye contact; preoccupation with own thoughts; projects hostility; repetitive actions; sad affect; seeks to be alone; shows behavior unaccepted by dominant cultural group; uncommunicative; withdrawn
Subjective
Developmentally inappropriate interests; experiences feelings of differences from others; inability to meet expectations of others; insecurity in public; reports feelings of aloneness imposed by others; reports feelings of rejection; reports inadequate purpose in life; reports values unacceptable to the dominant cultural group
Related Factors (r/t)
Alterations in mental status; alterations in physical appearance; altered state of wellness; factors contributing to the absence of satisfying personal relationships (e.g., delay in accomplishing developmental tasks); immature interests; inability to engage in satisfying personal relationships; inadequate personal resources; unaccepted social behavior; unaccepted social values
Client Outcomes
Client Will (Specify Time Frame)
• Identify feelings of isolation
• Practice social and communication skills needed to interact with others
• Initiate interactions with others; set and meet goals
• Participate in activities and programs at level of ability and desire
Nursing Interventions
• Establish a therapeutic relationship with the client.
• Observe for barriers to social interaction: physical, emotional, and environmental.
• Discuss/assess causes of perceived or actual isolation.
• Allow the client opportunities to describe his or her daily life and to introduce any issues that may be of concern.
• Promote social interactions. Support the expression of feelings.
• Assist the client in identifying specific health and social problems and involve them in their resolution.
• Assist the client in identifying acceptable activities that encourage socialization.
• Identify available personal support systems and involve those individuals in the client’s care.
Refer clients to support groups as necessary.
• Encourage liberal visitation for a client who is hospitalized or in an extended care facility (ECF).
• Help the client identify role models and encourage interactions with others with similar interests. Technology may be helpful in finding others with similar interests.
• See the care plan for Risk for Loneliness.
• Assess physical and mental status to establish a firm basis for planning social activities.
• Assess for hearing deficit. Provide aids and use adaptive techniques.
• Encourage physical closeness if appropriate.
• Involve client in goal-setting and planning activities.
• Involve nonprofessionals in activities, projects, and goal setting with the client. Activities might include engaging in arts and crafts, reading, playing games, and music therapy.
• Suggest varied social activities that would decrease isolation and encourage participation.
• Position clients in group interventions according to abilities, age, life situations, preferences, and personal and cultural characteristics.
• Consider the use of simulated presence therapy (see the care plan for Hopelessness) for clients with cognitive distress.
Consider using computers and the Internet to alleviate or reduce loneliness and social isolation.
• Acknowledge racial/ethnic differences at the onset of care.
• Assess for the influence of cultural beliefs, norms, and values.
• Assess personal space needs, communication styles, acceptable body language, attitude toward eye contact, perception of touch, and paraverbal messages when communicating with the client.
• Use a culturally competent, professional approach when working with clients of various ethnic groups.
• Promote a sense of ethnic attachment.
• Assess the client’s feelings regarding social isolation.
• Assist those ethnic minorities who are underserved to access essential health care.
• The interventions described previously may be adapted for home care use.
• Confirm that the home setting has a health-safety communication system that is user friendly.
• Consider the use of the computer and Internet to decrease isolation.
• Assess options for living that allow the client privacy, but not isolation.
• Assist clients to interact with neighbors in the community when they move to supported housing.
Client/Family Teaching and Discharge Planning
• Assist the client in initiating contacts with self-help groups, counselors, and therapists.
• Provide information to the client about senior citizen services and community resources.
• Refer socially isolated caregivers to appropriate support groups as well.
• See the care plan for Caregiver Role Strain.
Chronic Sorrow
Cyclical, recurring, and potentially progressive pattern of pervasive sadness experienced (by parent, caregiver, individual with chronic illness or disability) in response to continual loss throughout the trajectory of an illness or disability
Defining Characteristics
Reports feelings of sadness (e.g., periodic, recurrent); reports feelings that interfere with ability to reach highest level of personal well-being; reports feelings that interfere with ability to reach highest level of social well-being; reports negative feelings (e.g., anger, being misunderstood, confusion, depression, disappointment, emptiness, fear, frustration, guilt, helplessness, hopelessness, low self-esteem, being overwhelmed, recurring loss, self-blame)
Related Factors (r/t)
Crisis in management of the disability; crises in management of the illness; crises related to developmental stages; death of a loved one; experiences chronic disability (e.g., physical or mental); experiences chronic illness (e.g., physical or mental); missed opportunities; missed milestones; unending caregiving
Client Outcomes
Client Will (Specify Time Frame)
• Express appropriate feelings of guilt, fear, anger, or sadness
• Identify problems associated with sorrow (e.g., changes in appetite, insomnia, nightmares, loss of libido, decreased energy, alteration in activity levels)
• Seek help in dealing with grief-associated problems
Nursing Interventions
• Determine the client’s degree of sorrow. Use the Burke/NCRS Chronic Sorrow Questionnaire for the individual or caregiver as appropriate.
• Identify problems of eating and sleeping; ensure that basic human needs are being met.
• Develop a trusting relationship with the client by using empathetic therapeutic communication techniques.
• Help the client to understand that sorrow may be ongoing. No timetable exists for grieving, despite popular thought. After loss, life is characterized by good times and bad times when sorrow is triggered by events.
• Help the client recognize that, although sadness will occur at intervals for the rest of his or her life, it will become bearable.
• Give anticipatory guidance about life events when the families might experience renewed feelings of loss.
• Encourage the use of positive coping techniques:
Taking action: Suggested strategies include keeping busy, keeping personal interests, going away, getting out of the house, doing something to gain a feeling of control over life.
Cognitive coping: Techniques include concentrating on the positive aspects of life, having a “can do” attitude, taking one day at a time, and taking responsibility for the quality of one’s own life. Encourage the client to write about the experience.
Interpersonal coping: Techniques include talking to a close friend, a health care professional, or someone with the same condition or circumstance. Joining a support group can also help the sorrowful person to cope.
Emotional coping: Encourage the client to express feelings both to other people and to write out feelings, cry as desired, give thanks, and pray if desired.
• Expect the client to meet responsibilities; give positive reinforcement for planning how to meet responsibilities, and for accomplishing responsibilities.
Encourage the client to make time to talk to family members about the loss with the help of professional support as needed and without criticizing or belittling each other’s feelings about the loss.
• Help the client determine the best way and place to find social support.
• Monitor for symptoms of exhaustion, isolation, and, potentially, loss of hope and dreams as potential indicators of caregiving burden and burnout.
Identify available community resources, including grief counselors or support groups available for specific losses (e.g., Multiple Sclerosis Society).
Identify whether the client is experiencing depression, suicidal tendencies, or other emotional disorders. Refer for counseling as appropriate.
• Treat the child with respect, give him or her the opportunity to talk about concerns, and answer questions honestly.
• Listen to the child’s expression of grief.
• Help parents recognize that the grieving child does not have to be “fixed”; instead, he needs support going through an experience of grieving just as adults do.
• Consider the use of art for children in hospice care who are dying or dealing with the death of a parent, sibling, or other family member.
Refer grieving children and parents to a program to help facilitate grieving if desired, especially if the death was traumatic.
• Help the adolescent determine sources of support and how to use them effectively.
Encourage parents in chronic sorrow to seek mental health services as needed, learn stress reduction, and take good care of their health.
• Recognize that mothers who have a miscarriage grieve and experience sorrow because of loss of the child.
• The interventions described previously may be adapted for home care use.
Assess the client for depression. Refer for mental health services as indicated.
When sorrow is focused around loss of a pregnancy, encourage the client to follow through on a counseling referral.
• Encourage the client to participate in activities that are diversionary and uplifting as tolerated (e.g., outdoor activities, hobby groups, church-related activities, pet care).
• Encourage the client to participate in support groups appropriate to the area of loss or illness (e.g., Crohn’s disease support group or Widow to Widow).
• Provide psychological support for family/caregivers.
In the presence of a psychiatric disorder, refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen.
See the care plans for Chronic low Self-Esteem, Risk for Loneliness, and Hopelessness.
Spiritual Distress
Impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself
Defining Characteristics
Anger; expresses lack of acceptance; expresses lack of courage; expresses lack of hope; expresses lack of love; expresses lack of meaning in life; expresses lack of purpose in life; expresses lack of self-forgiveness; expresses lack of serenity (e.g., peace); guilt; ineffective coping
Connections with Others
Expresses alienation; refuses interactions with significant others; refuses interactions with spiritual leaders; verbalizes being separated from support system
Connections with Art, Music, Literature, Nature
Disinterest in nature; disinterest in reading spiritual literature; inability to express previous state of creativity (e.g., singing/listening to music/writing)
Connections with Power Greater Than Oneself
Expresses anger toward power greater than self; expresses being abandoned; expresses hopelessness; expresses suffering; inability for introspection; inability to experience the transcendent; inability to participate in religious activities; inability to pray; requests to see a spiritual leader; sudden changes in spiritual practices
Related Factors (r/t)
Active dying; anxiety; chronic illness; death; life change; loneliness; pain self-alienation; social alienation; sociocultural deprivation
Client Outcomes
Client Will (Specify Time Frame)
• Express meaning and purpose in life
• Express sense of hope in the future
• Express sense of connectedness with self
• Express sense of connectedness with family/friends
• Express acceptance of health status
• Find meaning in relationships with others
• Find meaning in relationship with Higher Power
• Find meaning in personal and health care treatment choices
Nursing Interventions
• Observe clients for cues indicating difficulties in finding meaning, purpose, or hope in life.
• Observe clients with chronic illness, poor prognosis, or life-changing conditions for loss of meaning, purpose, and hope in life.
• Offer spiritual care in disaster relief.
• Promote a sense of love, caring, and compassion in nursing encounters.
• Be physically present and actively listen to the client.
• Help the client find a reason for living, be available for support and promote hope.
• Listen to the client’s feelings about suffering and/or death. Be nonjudgmental and allow time for grieving.
• Respect the client’s beliefs; avoid imposing your own spiritual beliefs on the client. Be aware of your own belief systems and accept the client’s spirituality.
• Monitor and promote supportive social contacts.
• Integrate family into spiritual practices as appropriate.
• Assist family in searching for meaning in client’s health care situation.
• Offer spiritual support to caregivers.
Refer the client to a support group or counseling.
• Support meditation, guided imagery, journaling, relaxation, and involvement in art, music, or poetry. Support outdoor activities.
• Offer or suggest visits with spiritual and/or religious advisors.
• Provide privacy or a “sacred space.”
• Allow time and a place for prayer.
• Coordinate or encourage attending spiritual retreats, courses, or programming.
Risk for Spiritual Distress
At risk for an impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself
Readiness for enhanced Spiritual Well-Being
A pattern of experiencing and integrating meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself that is sufficient for well-being and can be strengthened
Defining Characteristics
Expresses desire for enhanced acceptance; expresses desire for enhanced coping; expresses desire for enhanced courage; expresses desire for enhanced hope; expresses desire for enhanced joy; expresses desire for enhanced love; expresses desire for enhanced meaning in life; expresses desire for enhanced purpose in life; expresses desire for enhanced satisfying philosophy of life; expresses desire for enhanced self-forgiveness; expresses desire for enhanced serenity (e.g., peace); expresses desire for enhanced surrender; meditation
Connections with Others
Provides service to others; requests forgiveness of others; requests interactions with significant others; requests interaction with spiritual leaders
Client Outcomes
Client Will (Specify Time Frame)
• Express sense of meaning and purpose in life
• Express forgiveness of self and others
• Express satisfaction with philosophy of life
• Describe use of spiritual practices
• Describe providing service to others
• Describe interaction with spiritual leaders, friends, and family
• Describe appreciation for art, music, literature, and nature
Nursing Interventions
• Perform a spiritual assessment that includes the client’s relationship with God, meaning and purpose in life, religious affiliation, and any other significant beliefs.
• Be present and actively listen to the client.
• Encourage the client to pray or engage in other spiritual meditative practices.
• Coordinate or encourage attending spiritual retreats or courses.
• Encourage clients to reflect on what is meaningful to them in life.
• Encourage increased quality of life through social support and family relationships.
• Assist the client in identifying religious or spiritual beliefs that encourage integration of meaning and purpose in the client’s life.
• Support meditation, guided imagery, journaling, relaxation, and involvement in art, music, or poetry. Support outdoor activities.
• Encourage outdoor activities.
• Encourage expressions of spirituality.
• Encourage integration of spirituality in healthy lifestyle choices.