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• Support kangaroo care for infants at risk at birth. Keep infants in an upright position in skin-to-skin contact until they no longer tolerate it.

• Recommend that clients use the “Ask Me 3” program when communicating with their pharmacist (What is my main problem? What do I need to do? Why is it important for me to do this?).

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

• Ensure that all strategies for working with the family are congruent with the culture of the family.

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

• Facilitate modeling and role playing for the family regarding healthy ways to communicate and interact.

• Use the nursing intervention of cultural brokerage to help families deal with the health care system.

• Teach about all aspects of therapeutic regimens. Provide as much knowledge as family members will accept, adjust instruction to account for what the family already knows, and provide information in a culturally congruent manner.

• Teach ways to adjust family behaviors to include therapeutic regimens, such as safety in taking medications and teaching family members to act as self-advocates with health providers who prescribe therapeutic regimens.

 Avoid plugging several appliance cords into the same electrical socket.

 Do not use open candles or allow smoking in the home.

 Keep a fire extinguisher within reach in case a fire should occur.

 Install smoke alarms on every level of the home and in every sleeping area.

 Keep furniture and other heavy objects out of the way of doors and windows.

 Develop a fire escape plan that includes two ways out of every room and an outside meeting place. Practice the escape plan at least twice a year.

 Lock up matches and lighters out of sight and reach.

 Never leave a hot stove unattended.

 Do not allow small children to use the microwave until they are at least 7 or 8 years of age.

 Keep all portable heaters out of children’s reach and at least 3 feet away from anything that can burn.

 Install thermostatic mixer valves in hot water system to prevent extreme hot water causing scalding burns.

 Never smoke in a home where medical oxygen is in use. “No smoking” signs should be posted inside and outside the home.

 All ignition sources—matches, lighters, candles, gas stoves, appliances, electric razors and hair dryers—should be kept at least 10 feet away from the point where the oxygen comes out.

 Do not wear oxygen while cooking. Oils, grease and petroleum products can spontaneously ignite when exposed to high levels of oxygen. Also, do not use oil-based lotions, lip balm, or aerosol sprays.

 Homes with medical oxygen must have working smoke alarms that are tested monthly.

 Keep a fire extinguisher within reach. If a fire occurs, turn off the oxygen and leave the home.

 Develop a fire escape plan that includes two ways out of every room and an outside meeting place. Practice the escape plan at least twice a year.

• Measure and record the client’s temperature using a consistent method of temperature measurement every 1 to 4 hours depending on severity of the situation or whenever a change in condition occurs (e.g., chills, change in mental status)

• Select core, near core, or peripheral temperature monitoring mode based on ability to obtain an accurate temperature from that site and clinical situation dictating the need for mode of temperature monitoring required for clinical treatment decisions.

• Caution should be taken in interpreting extreme values of temperature (less than 35° C or greater than 39° C) from a near core temperature site device.

• Evaluate the significance of a decreased or increased temperature.

 Notify the physician of temperature according to institutional standards or written orders, or when temperature reaches 100.5° F (38.3° C) and above. Also notify the physician of the presence of a change in mental status and temperature greater than 38.3° C or less than 36° C.

• Recognize that fever is characterized as a temporary elevation in internal body temperature 1° to 2° C higher than the client’s normal body temperature.

• Recognize that fever is a normal physiological response to a perceived threat by the body, frequently in response to an infection.

 Review client history to include current medical diagnosis, medications, recent procedures/interventions, and review of laboratory analysis for cause of ineffective thermoregulation.

• Recognize that fever may be low grade (36° C to 38° C) in response to an inflammatory process such as infection, allergy, trauma, illness, or surgery. Moderate to high-grade fever (38° C to 40° C) indicates a more concerted inflammatory response from a systemic infection. Hyperpyrexia (40° C and higher) occurs as a result of damage of the hypothalamus, bacteremia, or an extremely overheated room.

• Recognize that fever has a predictable physiological pattern.

• Monitor and intervene to provide comfort during a fever by:

• Take vital signs frequently, noting changes associated with hypothermia: increased blood pressure, pulse, and respirations which then advance to decreased values as hypothermia progresses.

• Monitor the client for signs of hypothermia (e.g., shivering, cool skin, piloerection, pallor, slow capillary refill, cyanotic nailbeds, decreased mentation, dysrhythmias)

• See the care plan for Hypothermia as appropriate.

• Note changes in vital signs associated with hyperthermia: rapid, bounding pulse; increased respiratory rate; and decreased blood pressure, accompanied by orthostatic hypotension, and signs and symptoms of dehydration.

• Monitor the client for signs of hyperthermia (e.g., headache, nausea and vomiting, weakness, absence of sweating, delirium, and coma).

• Adjust clothing to facilitate passive warming or cooling as appropriate.

• See the care plan for Hyperthermia as appropriate.

• For routine measurement of temperature, use an electronic thermometer in the axilla in infants under the age of 4 weeks; for a child up to 5 years of age, use an electronic thermometer in the axilla, or an infrared tympanic thermometer.

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

• Recognize that the infant and small child are both vulnerable to develop heat stroke in hot weather; ensure that they receive sufficient fluids and are protected from hot environments.

• Antipyretic treatments typically are not indicated unless the child’s temperature is higher than 38.3° C and may be given to provide comfort.

• Do not allow an elderly client to become chilled. Keep the client covered when giving a bath and offer socks to wear in bed. Be aware of factors such as room temperature (heating/air conditioning), clothing (layered/loose), and fluid intake.

• Recognize that the elderly client may have an infection without a significant rise in body temperature.

• Fever does not put the older adult at risk for long-term complications; thus, fever should not be treated with antipyretic agents or other external methods of cooling, unless there is serious heart disease present.

• Ensure that elderly clients receive sufficient fluids during hot days and stay out of the sun.

• Assess the medication profile for the potential risk of drug-related altered body temperature.

Treating Fever

Prevention of Hypothermia in Cold Weather

See the care plan Hypothermia.

Prevention of Hyperthermia in Hot Weather

See the care plan Hyperthermia.

• Teach the client and family the signs of fever, hypothermia, and hyperthermia and appropriate actions to take if either condition develops.

• Teach the client and family an age-appropriate method for taking the temperature.

• Teach the client to avoid alcohol and medications that depress cerebral function.

 Category/Stage III: Full-thickness tissue loss. Subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Category/Stage III pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and can be shallow. In contrast, areas of significant adiposity can develop extremely deep Category/Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

 Category/Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. The depth of a Category/Stage IV pressure ulcer varies by anatomic location. The bridge of the nose, ear, occiput, and malleolus do not have (adipose) subcutaneous tissue and can be shallow. Category IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon, or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable.

 Suspected Deep Tissue Injury: Purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear. The area may be preceded by tissue that is painful, firm, mushy, boggy, warmer, or cooler as compared to adjacent tissue. Deep tissue injury may be difficult to detect in individuals with dark skin tones. Evolution may include a thin blister over a dark wound bed. The wound may further evolve and become covered by thin eschar. Evolution may be rapid, exposing additional layers of tissue even with optimal treatment.

 Unstageable (Depth Unknown): Full-thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed. Until enough slough and/or eschar is removed to expose the base of the wound, the true depth and, therefore, category/stage cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as “the body’s natural cover” and should not be removed.

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

 Assess the client’s current phase of wound healing (inflammation, proliferation, maturation) and stage of injury; initiate appropriate wound management.

• Instruct and assist the client and caregivers in understanding how to change dressings and in the importance of maintaining a clean environment. Provide written instructions and observe them completing the dressing change.

 Initiate a consultation in a case assignment with a wound specialist or wound, ostomy, and continence nurse to establish a comprehensive plan as soon as possible. Plan case conferencing to promote optimal wound care.

 Consult with other health care disciplines to provide a thorough, comprehensive assessment.

• 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. Explain wound bed changes that the caregiver can expect to see. Instruct on when the dressing needs to be changed.

 If it is consistent with overall client management goals, teach how to reposition the client, based on client’s tissue tolerance and condition.

• Teach the use of pillows, foam wedges, and pressure-reducing devices to prevent pressure injury.

 Monitor peripheral pulses. If there is new onset of loss of pulses with bluish, purple, or black areas and extreme pain, notify the physician immediately.

 Measure ankle brachial index (ABI) via Doppler.

• Avoid elevating the legs above the level of the heart.

 For early arterial insufficiency, encourage exercise such as walking or riding an exercise bicycle from 30 to 60 minutes per day as ordered by the physician.

• Keep the client warm and have the client wear socks and shoes or sheepskin-lined slippers when mobile. Do not apply heat.

• Use a variety of leg positions after surgical intervention for PAD (either supine with legs extended, or sitting with legs extended) when getting this population out of bed.

 Pay meticulous attention to foot care.

• If the client has ischemic arterial ulcers, refer to the care plan for Impaired Tissue Integrity.

 If the client smokes, aggressively counsel the client to stop smoking and refer to the physician for medications to support nicotine withdrawal and a smoking withdrawal program.

 Elevate edematous legs as ordered and ensure no pressure under the knee and heels to prevent pressure ulcers.

 Apply graduated compression stockings as ordered. Ensure proper fit by measuring accurately. Remove the stockings at least twice a day, in the morning with the bath and in the evening, to assess the condition of the extremity, then reapply. Knee length is preferred rather than thigh length.

• Encourage the client to walk with compression stockings on and perform toe-up and point-flex exercises.

• If the client is overweight, encourage weight loss to decrease venous disease.

• If the client has venous leg ulcers, encourage the client to avoid prolonged sitting, standing, and elevation of the involved leg. Encourage proper use of compression stockings.

• Discuss lifestyle with the client to determine if the client’s occupation requires prolonged standing or sitting, which can result in chronic venous disease.

 If the client is mostly immobile, consult with the physician regarding use of a calf-high pneumatic compression device for prevention of deep vein thrombosis.

• Observe for signs of deep vein thrombosis, including pain, tenderness, swelling in the calf and thigh, and redness in the involved extremity. Take serial leg measurements of the thigh and calf circumferences. In some clients a tender venous cord can be felt in the popliteal fossa. Do not rely on Homans’ sign.

 Note the results of a D-dimer test and ultrasounds.

• If deep vein thrombosis is present, observe for symptoms of a pulmonary embolism, including dyspnea, pleuritic chest pain, cough, and sometimes hemoptysis, especially with a history of trauma.

 If the client develops deep vein thrombosis, after treatment and hospital discharge recommend client wear below-the-knee elastic compression stockings during the day on the involved extremity.

• Change the client’s position slowly when getting the client out of bed because of possible syncope.

• Recognize that the elderly have an increased risk of developing pulmonary embolism; if it is present, the symptoms are nonspecific and often mimic those of heart failure or pneumonia.

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

• If arterial disease is present and the client smokes, aggressively encourage smoking cessation.

• Examine the feet carefully at frequent intervals for changes and new ulcerations.

 Assess the client’s nutritional status, paying special attention to obesity, hyperlipidemia, and malnutrition. Refer to a dietitian if appropriate.

• Monitor for development of gangrene, venous ulceration, and symptoms of cellulitis (redness, pain, and increased swelling in an extremity).

• Assess pain management strategies and their effectiveness.

• Assess support systems available at home and in the community.

• Explain the importance of good foot care. Teach the client and family to wash and inspect the feet daily. Recommend that the diabetic client wear comfortable shoes and break them in slowly, watching for blisters.

 Teach the diabetic client that he or she should have a comprehensive foot examination at least annually (which includes an analysis for predicting foot ulceration risk), also including assessment of sensation using the Semmes-Weinstein monofilaments. If good sensation is not present, refer to a footwear professional for fitting of therapeutic shoes and inserts, the cost of which is covered by Medicare.

• For arterial disease, stress the importance of not smoking, following a weight loss program (if the client is obese), carefully controlling a diabetic condition, controlling hyperlipidemia and hypertension, maintaining intake of antiplatelet therapy, and reducing stress.

• Teach the client to avoid exposure to cold; limit exposure to brief periods if going out in cold weather and wear warm clothing.

• For venous disease, teach the importance of wearing compression stockings as ordered, elevating the legs at intervals, and watching for skin breakdown on the legs.

• Teach the client to recognize the signs and symptoms that should be reported to a physician (e.g., change in skin temperature, color, or sensation or the presence of a new lesion on the foot).

• Provide clear, simple instructions about plan of care.

 Squat transfer: client leans well forward, slightly raises flexed hips off the surface, pivots, and sits down on new surface.

 Standing pivot transfer: client leans forward with hips flexed and pushes up with hands from seat surface (or arms of chair), then stands erect, pivots, and sits down on new surface.

 Slide board transfer: client should have on pants or have a pillowcase over the board. Remove arm and leg rest from wheelchair on one side, then slightly angle chair toward new surface. Help client lean sideways, thus shifting his or her weight so transfer board can be placed well under the upper thigh of the leg next to new surface. Make sure board is safely angled across both surfaces. Help client to sit upright and place one hand on board and the other hand on surface. Remind and help client perform a series of pushups with arms while leaning slightly forward and lifting (not sliding) hips in small increments across board with each pushup.

 Obtain referral for OT and PT to teach home exercises and balance as well as fall prevention and recovery. They also evaluate for potential modifications such as an entry ramp, elevated toilet seat/toilevator (raised base under toilet), tub seat or shower chair, need for shower stall with built-in seat or wheel-in shower stall without a curb/threshold, handheld flexible shower head, lever-type facets, pull-out drawers with loop handles versus cupboards, standing lift, and so on.

• Assess for adequate lighting and hazards such as throw/area rugs, clutter, cords, and unfitted bedspreads. Suggest safe floor surfaces, such as use of adhesive nonslip strips in tubs/thresholds/areas where floor height changes; removal of wax from slippery floors; and installing low-pile carpet/nonglazed or nonglossy tiles/wood/linoleum coverings. Stress relocating commonly used items to shelves/drawers in reach, applying remote controls to appliances, and optimizing furniture placement for function, maneuverability, and stability.

• Nurses can provide further safety assessments by suggesting installing hand rails in bathrooms and by stairs, ensuring client’s slippers and clothes fit properly, and recommending repairing or discarding broken equipment in the home.

 Involve social worker or case manager to educate clients about potential assistive technology, financial cost and benefits, regulations of payers, and local resources.

 Implement approaches for home care staff and family to safely handle and transfer clients.

• For further information, refer to care plans for Impaired physical Mobility and Impaired Walking.

• Assess for readiness to learn and use teaching modalities conducive to personal learning styles, including written instructions for home use.

• Supervise practice sessions in which client and family apply items such as gait belts, braces, and orthoses. Check skin once aids are removed.

• Teach and monitor client/family for consistent use of safety precautions for transfers (e.g., nonskid shoes, correctly placed equipment/chairs, locked brakes, leg rests swiveled away, and so forth) and for correct performance of transfer or use of lifts/slings.

• Teach client/family how to check brakes on chairs to ensure they engage and how to check tires for adequate air pressure; advise routine inspection and annual tune-up of devices.

• Offer information on safe use of shower and commode chairs to prevent discomfort, pressure, and falls during transfer, transport, care, and hygiene.

• For further information, refer to the care plans for Impaired physical Mobility, Impaired Walking, and Impaired wheelchair Mobility.

• Assess the client’s socioeconomic status.

• Assess family interests in safety topics to identify priority areas for counseling.

• Never leave young children unsupervised around water or cooking areas.

• Keep flammable and potentially flammable articles out of the reach of young children.

• Lock up harmful objects such as guns.

• Assess the geriatric client’s cognitive level of functioning both at admission and periodically.

• Assess for routine eye examinations and use of appropriate prescription glasses.

• Perform a home safety assessment and recommend the following preventive measures: keep electrical cords out of the flow of traffic; remove small rugs or make sure they are slip resistant; increase lighting in hallways and other dark areas; place a light in the bathroom; keep towels, curtains, and other items that might catch fire away from the stove; store harmful products away from food products; provide at least one grab bar in tubs and showers; check prescribed medications for appropriate labels; and store medications in original containers or in a dispenser of some type (e.g., egg carton, 7-day plastic dispenser). If the client cannot administer medications according to directions, secure someone to administer medications.

• Mark stove knobs with bright colors (yellow or red) and outline the borders of steps.

• Discourage driving at night.

• Encourage the client to participate in resistance and impact exercise programs as tolerated.

• Implement fall and injury prevention strategies in residential care facilities.

• Attend a fall prevention screening clinic.

• Educate the family regarding age-appropriate child safety precautions, environmental safety precautions, and intervention in an emergency

• Teach the family to assess the child care provider’s knowledge regarding child safety, environmental safety precautions, and assistance of a child in an emergency.

• Educate the client and family regarding helmet use during recreation and sports activities.

• Encourage the proper use of car seats and safety belts.

• Teach parents to restrict nighttime driving after 10 PM for young drivers.

• Teach how to plan safe prom and graduation parties.

• Teach parents the importance of monitoring youths after school.

• Teach firearm safety. Encourage the family to keep firearms and ammunition in locked storage.

 Educate that the use of psychotropic medications may increase the risk of falls and that withdrawal of psychotropic medications should be considered.

• For further information, refer to care plans for Risk for Aspiration, Impaired Home Maintenance, Risk for Injury, Risk for Poisoning, and Risk for Suffocation.