V

 Verify objective and estimate duration of treatment. Check physician’s order.

• Assess client’s clinical situation when venous infusion is indicated.

• Assess if client is prepared for an IV procedure. Explain the procedure if necessary to decrease stress.

• Provide privacy and make the client comfortable during the intravenous insertion.

• Teach the client what symptoms of possible vascular trauma he should be alert to and to immediately inform staff if they notice any of these symptoms.

• Wash hands before and after touching the client, as well as when inserting, replacing, accessing, repairing, or dressing an intravascular catheter.

• Maintain aseptic technique for the insertion and care of intravascular catheters. Use gloves and always reduce the number of staff present in the environment during the procedure if possible.

• Assess the condition of the client’s veins, possible age-related influence, and previous intravenous site use.

• In cases of hard-to-access veins, consider strategies such as the use of ultrasound (US) to assist in vein localization and safe venipuncture.

• Avoid areas of joint flexion or bony prominences.

• Choose an appropriate vascular access device (VAD) based on the types and characteristics of the devices and insertion site. Consider the following:

 Choose a device with consideration of the nature, volume, and flow of prescribed solution.

• If possible, choose the venous access site considering the client’s preference.

• Select the gauge of the venous device according to the duration of treatment, purpose of the procedure, and size of the vein.

• Verify if client is allergic to fixation or device material.

• Disinfect the venipuncture site.

• Provide a comfortable, safe, hypoallergenic, easily removable stabilization dressing, allowing for visualization of the access site.

• Use either sterile gauze or sterile, transparent, semipermeable dressing to cover catheter site. Replace dressing used on short-term CVC sites every 2 days for gauze dressings and replace it at least every 7 days for transparent dressings.

• Document insertion date, site, type of VAD, number of punctures performed, other occurrences, and measures/arrangements taken.

• Always decontaminate the device before infusing medication or manipulating IV equipment.

 Verify the sequence of drugs to be administrated

• Monitor permeability and flow rate at regular intervals.

• Monitor catheter-skin junction and surrounding tissues at regular intervals, observing possible appearance of burning, pain, erythema, altered local temperature, infiltration, extravasation, edema, secretion, tenderness, or induration. Remove promptly.

 Replace device according to institution protocol.

 Flush vascular access according to organizational policies and procedures, and as recommended by the manufacturer.

• Remove catheter on suspected contamination, if the client develops signs of phlebitis, infection, or a malfunctioning catheter, or when no longer required.

• Clients need to be encouraged to report any discomfort such as pain, burning, swelling, or bleeding.

• The preceding interventions may be adapted for the pediatric client.

• Inform the client and family about the IV procedure, obtain permissions, maintain client’s comfort, and perform appropriate assessment prior to venipuncture. Assess the client for any allergies or sensitivities to tape, antiseptics, or latex. Choose a healthy vein and appropriate site for insertion of selected device.

• The use of an appropriate device to obtain blood samples reduces discomfort in the pediatric client. However, this procedure needs to be effective and safe.

• Avoid areas of joint flexion or bony prominences.

 Consider if sedation or the use of local anesthetic is suitable for insertion of a catheter, taking into consideration the age of the pediatric client.

• Use diversion while carrying out the procedure

• The preceding interventions may be adapted for the geriatric client.

• Consider the physical, emotional, and cognitive changes related to older adults.

• Use strict aseptic technique for venipuncture of older clients.

• Some devices can be kept after discharge. Inform client and family members about care of the selected device.

• Help in the choice of actions that support self-care.

• Select, with the client, the insertion site most compatible with the development of activities of daily living.

• Avoid the use of the dominant hands as an IV placement site.

• Minimize the use of continuous IV therapy whenever possible.

 Explain the intubation and mechanical ventilation process to the client and family as appropriate, and during intubation administer sedation for client comfort according to the physician’s orders.

• Secure the endotracheal tube in place using either tape or a commercially available device, auscultate bilateral breath sounds, use a CO₂ detector, and obtain a chest radiograph to confirm endotracheal tube placement.

• Ensure that ventilator settings are appropriate to meet the client’s minute ventilation requirements.

 Suction as needed and hyperoxygenate according to unit policy. Refer to the care plan Ineffective Airway Clearance for further information on suctioning.

• Check that monitor alarms are set appropriately at the start of each shift.

• Respond to ventilator alarms promptly. If unable to immediately locate the source/cause of an alarm, use a manual self-inflating resuscitation bag to ventilate the client while waiting for assistance.

• Prevent unplanned extubation by maintaining stability of endotracheal tube with careful taping or use of a device for stabilization of the tube, also use of restraints if needed with physician’s order.

• Drain collected fluid from condensation out of ventilator tubing as needed.

• Note ventilator settings of flow of inspired oxygen, peak inspiratory pressure, tidal volume, and alarm activation at intervals and when removing the client from the ventilator for any reason.

 Administer analgesics and sedatives as needed to facilitate client comfort and rest. Pain and sedation scales provide a consistent way of monitoring sedation levels and ensuring that therapeutic outcomes are being met.

 Initiate a “sedation vacation” daily, with lightening of analgesics and sedatives until the client becomes awake. During this time carefully monitor the client to protect from inadvertent self-extubation, pain and anxiety, and periods of desaturation from asynchrony of breathing with the ventilator.

• Utilize tools such as the Riker Sedation-Agitation Scale, the Motor Activity Assessment Scale, the Ramsey Scale, or the Richmond Agitation-Sedation Scale because they can be useful in monitoring levels of sedation.

• Alternatives to medications for decreasing anxiety should be attempted, such as music therapy with selections of the client’s choice played on headphones at intervals.

• Analyze and respond to arterial blood gas results, end-tidal CO₂ levels, and pulse oximetry values.

• Use an effective means of verbal and nonverbal communication with the client such as an alphabet board, picture board, electronic voice output communication aids, computers, and writing slates. Ask the client for input into his or her care as appropriate. Barriers to communication include endotracheal tubes, sedation, and general weakness associated with a critical illness.

• Move the endotracheal tube from side to side every 24 hours, and tape it or secure it with a commercially available device. Assess and document client’s skin condition, and ensure correct tube placement at lip line.

• Implement steps to prevent ventilator-associated pneumonia (VAP), including continuous removal of subglottic secretions, elevation of the head of bed to 30 to 45 degrees unless medically contraindicated, change of the ventilator circuit no more than every 48 hours, and handwashing before and after contact with each client. See details in the sections that follow.

 Use endotracheal tubes that allow for the continuous aspiration of subglottic secretions.

• Position the client in a semirecumbent position with the head of the bed at a 30- to 45-degree angle to decrease the aspiration of gastric, oral, and nasal secretions.

• Consider use of kinetic therapy, using a kinetic bed that slowly moves the client with 40-degree turns.

• Perform handwashing using both soap and water and alcohol-based solution before and after all mechanically ventilated client contact to prevent VAP.

• Provide routine oral care using toothbrushing and oral rinsing with an antimicrobial agent if needed.

• Maintain proper cuff inflation for both endotracheal tubes and cuffed tracheostomy tubes with minimal leak volume or minimal occlusion volume to decrease risk of aspiration and reduce incidence of ventilator-associated pneumonia.

• Reposition the client as needed. Use rotational bed or kinetic bed therapy in clients for whom side-to-side turning is contraindicated or difficult.

 If the client is intubated and is stable, consider getting the client up to sit at the edge of the bed, transfer to a chair, or walk as appropriate, if an effective interdisciplinary team is developed to keep the client safe.

• Assess bilateral anterior and posterior breath sounds every 2 to 4 hours and PRN; respond to any relevant changes.

• Assess responsiveness to ventilator support; monitor for subjective complaints and sensation of dyspnea.

 Collaborate with the interdisciplinary team in treating clients with acute respiratory failure. Collaborate with the health care team to meet ventilator care needs and avoid complications.

• Recognize that critically ill older adults have a high rate of morbidity when mechanically ventilated.

 Some of the interventions listed previously may be adapted for home care use. Begin discharge planning as soon as possible with the case manager or social worker to assess the need for home support systems, assistive devices, and community or home health services.

 With help from a medical social worker, assist the client and family to determine the fiscal effect of care in the home versus an extended care facility.

• Assess the home setting during the discharge process to ensure the home can safely accommodate ventilator support (e.g., adequate space and electricity).

• Have the family contact the electric company and place the client’s residence on a high-risk list in case of a power outage.

• Assess the caregivers for commitment to supporting a ventilator-dependent client in the home.

• Be sure that the client and family or caregivers are familiar with operation of all ventilation devices, know how to suction secretions if needed, are competent in doing tracheostomy care, and know schedules for cleaning equipment. Have the designated caregiver or caregivers demonstrate care before discharge.

• Assess client and caregiver knowledge of the disease, client needs, and medications to be administered via ventilation-assistive devices. Avoid analgesics. Assess knowledge of how to use equipment. Teach as necessary.

• Establish an emergency plan and criteria for use. Identify emergency procedures to be used until medical assistance arrives. Teach and role play emergency care.

• Explain to the client the potential sensations that will be experienced, including relief of dyspnea, the feeling of lung inflations, the noise of the ventilator, and the reality of alarms.

• Explain to the client and family about being unable to speak, and work out an alternative system of communication. See previously mentioned interventions.

• Demonstrate to the family how to perform simple procedures, such as suctioning secretions in the mouth with a tonsil-tip catheter, providing range-of-motion exercises, and reconnecting the ventilator immediately if it becomes disconnected.

• Offer both the client and family explanations of how the ventilator works and answer any questions.

 Physiological readiness

 Resolution of initial medical problem that led to ventilator dependence

 Hemodynamic stability

 Normal hemoglobin levels

 Absence of fever

 Normal state of consciousness

 Metabolic, fluid, and electrolyte balance

 Adequate nutritional status with serum albumin levels >2.5 g/dL

 Adequate sleep

 Adequate pain management and sedation

 Tachypnea, dyspnea, or chest and abdominal asynchrony

 Agitation or mental status changes

 Decreased oxygen saturation: SaO₂ less than 90%

 Increased PaCO₂ or ETCO₂

 Change in pulse rate or blood pressure or onset of new dysrhythmias

• Recognize that older clients may require longer periods to wean.

• Weaning from a ventilator at home should be based on client stability and comfort of the client and caregivers under an intermittent care plan.

 Monitor the environment, evaluate situations that could become violent, and intervene early to deescalate the situation. Know and follow institution’s policies and procedures concerning violence. Consider that family members or other staff may initiate violence in all settings. Enlist support from other staff rather than attempting to handle the situation alone.

• Assess causes of aggression: social versus biological.

• Assess the client for risk factors of violence, including those in the following categories: personal history (e.g., past violent behavior); psychiatric disorders (particularly psychoses, paranoid or bipolar disorders, substance abuse, PTSD, antisocial personality or borderline personality disorder); neurological disorders (e.g., head injury, temporal lobe epilepsy, CVA, dementia or senility), medical disorders (e.g., hypoxia, hypo- or hyperglycemia), psychological precursors (e.g., low tolerance for stress, impulsivity), coping difficulties (e.g., inability to plan solutions or see long-term consequences of behavior), and childhood or adolescent disorders (e.g., conduct disorders, hyperactivity, autism, learning disability).

• Measures of violence may be useful in predicting or tracking behavior, and serving as outcome measures.

• Assess the client with a history of previous assaults. Listen to and acknowledge feelings of anger, observe for increased motor activity, and prepare to intervene if the client becomes aggressive.

• Assess the client for physiological signs and external signs of anger.

• Assess for the presence of hallucinations.

• Apply STAMPEDAR as an acronym for assessing the immediate potential for violence.

• Determine the presence and degree of homicidal or suicidal risk. A number of questions will elicit the necessary information. “Have you been thinking about harming someone? If yes, who? How often do you have these thoughts, and how long do they last? Do you have a plan? What is it? Do you have access to the means to carry out that plan? What has kept you from hurting the person until now?” Refer to the care plan for Risk for Suicide.

• Take action to minimize personal risk: Use nonthreatening body language. Respect personal space and boundaries. Maintain at least an arm’s length distance from the client; do not touch the client without permission (unless physical restraint is the goal). Do not allow the client to block access to an exit. If speaking with the client alone, keep the door to the room open. Be aware of where other staff is at all times. Notify other staff of where you are at all times. Take verbal threats seriously and notify other staff. Wear clothing and accessories that are not restricting and that will not be dangerous (e.g., sandals or shoes with heels can lead to twisted ankles; necklaces or dangling earrings could be grabbed).

• Remove potential weapons from the environment. Be prepared to remove obstructions to staff response from the environment. Search the client and his or her belongings for weapons or potential weapons on admission to the hospital as appropriate.

• Inform the client of unit expectations for appropriate behavior and the consequences of not meeting these expectations. Emphasize that the client must comply with the rules of the unit. Give positive reinforcement for compliance. Increase surveillance of the hospitalized client at smoking, meal, and medication times.

• Assign a single room to the client with a potential for violence toward others.

• Maintain a calm attitude in response to the client. Provide a low level of stimulation in the client’s environment; place the client in a safe, quiet place, and speak slowly and quietly.

• Redirect possible violent behaviors into physical activities (e.g., walking, jogging) if the client is physically able.

• Provide sufficient staff if a show of force is necessary to demonstrate control to the client.

• Protect other clients in the environment from harm. Remove other individuals from the vicinity of a violent or potentially violent client. Follow safety protocols of the department.

• Maintain a secluded area for the client to be placed when violent. Ensure that staff are continuously present and available to client during seclusion.

 Recognize legal requirements that the least restrictive alternative of treatment should be used with aggressive clients. The hierarchy of intervention is: promote a milieu that provides structure and calmness, with negotiation and collaboration taking precedence over control; maintain vigilance of the unit and respond to behavioral changes early; talk with client to calm and promote understanding of emotional state; use chemical restraints as ordered; increase to manual restraint if needed; increase to mechanical restraint and seclusion as a last resort.

 Use mechanical restraints if ordered and as necessary. Physical restraint can be therapeutic to keep the client and others safe.

 Follow the institution’s protocol for releasing restraints. Observe the client closely, remain calm, and provide positive feedback as the client’s behavior becomes controlled.

 After a violent event on a unit, debriefing and support of both staff and clients should be made available.

• Form a therapeutic alliance with the client, remaining calm, identifying the source of anger as external to both nurse and client, and using the therapeutic relationship to prevent the need for seclusion or restraint.

• Allow, encourage, and assist the client to verbalize feelings appropriately either one-on-one or in a group setting. Actively listen to the client; explore the source of the client’s anger, and negotiate resolution when possible. Teach healthy ways to express feelings/anger, appropriate gender roles, and how to communicate needs appropriately.

• Identify with client the stimuli that initiate violence and the means of dealing with the stimuli. Have the client keep an anger diary and discuss alternative responses together. Teach cognitive-behavioral techniques.

 Initiate and promote staff attendance at aggression management training programs.

• Screen for possible abuse in women or children with a pattern of multiple injuries, particularly if any suspicion exists that the physical findings are inconsistent with the explanation of how the injuries were incurred.

 Report suspected child abuse to Child Protective Services.

 Refer women suspected of being in a spousal abuse situation to an area crisis center and provide phone number of area crisis hotline.

• Assess for physical and mental concerns of women, including risk of HIV.

• Assist the client in negotiating the health care system and overcoming barriers.

• With women who repeatedly experience injuries from domestic violence, maintain a nonjudgmental approach and continue to offer resources/referrals. If the woman voices a willingness to leave her situation, assist with developing an emergency plan that will consider all contingencies possible (e.g., safe location, financial resources, care of children, when to leave safely).

• Maintain a nonjudgmental response when clients return to husbands or refuse to leave them.

• Focus on providing support, ensuring safety, and promoting self-efficacy while encouraging disclosure about IPV events.

• Screen pregnant women for the potential for domestic violence during pregnancy, especially with teenage pregnancies.

• Screen women and children for effects of domestic violence during the postpartum period.

• Women with physical or mental disabilities require extended assessment, including a comprehensive functional assessment, with attention to cultural issues, the nature of the disability, and needed resources. Women with disabilities may experience abuse from multiple sources, and particular attention should be paid to the additional emotional stressors present.

 Referral for spiritual counseling may be considered, but be aware that clergy vary in their helpfulness.

• Identify risk factors such as ongoing mental illness of a parent, and monitor family closely.

 In cases where spouse or child abuse accompanies substance abuse, refer the abusive client to a substance abuse treatment program. Refer the spouse receiving abuse to Al-Anon and the children to Alateen.

 In cases where an adult reveals a history of unresolved/untreated sexual abuse as a child, referral to a local Adults Molested as Children (AMAC) group may be helpful.

 Referral of women for psychiatric/psychological treatment or parenting classes should be considered as an appropriate intervention.

 Referral of children for psychiatric/psychological treatment should be considered as an appropriate intervention.

 Batterer intervention programs are often available and may be court mandated.

• Assess for acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) among victims of violence.

 Assess the support network of women who become victims of violent crime and refer for appropriate levels of assistance.

• Be aware that hate crime is increasing, particularly toward gay and transgendered individuals, and it requires support and advocacy for victims.

 Victims of violence seen in the ED should receive an assessment for needed services and assignment to case management.

• Assist client to cope with potential stalking activity.

• Approach client with sensitivity.

 Monitor for paradoxical drug reactions, and report any to the physician.

• Assess for brain insults, such as recent falls or injuries, strokes, or transient ischemic attacks.

• Decrease environmental stimuli if violence is directed at others.

• Assess holistic needs of the client.

• Discuss with client her wishes regarding use of an emergency contraceptive.

 If abuse or neglect of an elderly client is suspected, report the suspicion to an adult protective services agency with jurisdiction over the geographical area where the client lives.

• Assess for predictors of anger that can lead to violent behavior.

• Be alert for both shaken baby syndrome and exposure of children to violence.

• Pregnant teens should be assessed for abuse, particularly if they are with an older partner.

 In the case of child abuse or neglect, refer for early childhood home visitation.

• Be alert to the potential for elder abuse in clients, including the possibility of psychological abuse.

• Assess for changes in physiological functions (e.g., constipation, dehydration) or impairment of the ability to meet basic needs (e.g., inadequate toileting, decreased mobility). Observe for signs of fear, anxiety, anger, and agitation, and intervene immediately.

• Observe for dementia and delirium.

• Be aware that IPV may arise or continue under circumstances of medical illness.

• Be alert for the potential of sexual abuse of elders.

• Exercise cultural competence when dealing with domestic violence.

• Identify and respond to unique needs of immigrant women who experience IPV.

• Assist with acculturation and activating social support.

• Be alert to the potential for violent behavior in the home setting. Respond to verbal aggression with interventions to deescalate negative emotional states.

• Assess family members or caregivers for their ability to protect the client and themselves.

• Include an initial and ongoing assessment and evaluation of potential abuse and neglect. Photograph evidence of abuse or neglect when possible.

 If neglect or abuse is suspected, identify an emergency plan that addresses the problem immediately, ensures client safety, and includes a report to the appropriate authorities. Discuss when to use hotlines and 911. Role-play access to emergency resources with the client and caregivers.

• Encourage appropriate safety behaviors in abused women; call the client at intervals during a 6-month period to determine whether safety behaviors are being carried out.

• Assess the home environment for harmful objects. Have the family remove or lock objects as able.

 Refer for homemaker or psychiatric home health care services for respite, client reassurance, and implementation of a therapeutic regimen.

 If the client is taking psychotropic medications, assess client and family knowledge of medication and its administration and side effects. Teach as necessary.

 Evaluate effectiveness and side effects of medications.

• If client displays mildly intensifying aggressive behavior, attempt to diffuse anger or violence (e.g., ask for a glass of water to distract client). Later in the visit, explain that aggressive behavior is not acceptable and present consequences of continued aggressive behavior (i.e., right of agency to discontinue services).

• Document all acts or verbalizations of aggression.

 If client verbalizes or displays threatening behavior, notify your supervisor and plan to make joint visits with another staff person or a security escort.

• If the client’s behavior is not overtly threatening but makes the nurse uncomfortable, a meeting may be held outside the home in sight of others (e.g., front porch).

• Never enter a home or remain in a home if aggression threatens your well-being.

 Never challenge a show of force, such as a gun threat. Leave and notify your supervisor and the appropriate authorities. Document the incident.

 If client behaviors intensify, refer for immediate mental health intervention.

• Instruct victims of IPV in the dynamics and prognosis of domestic violence behavior.

• Instruct victims of IPV in the outcomes for children who witness or are victims of domestic violence.

• Teach relaxation and exercise as ways to release anger and deal with stress.

• 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), magnification (placing distorted emphasis on a single event), or unrealistic expectations (e.g., “I should get what I want when I want it”).

 Refer to individual or group therapy.

• Teach the adolescent client violence prevention, and encourage him or her to become involved in community service activities.

• Teach the use of appropriate community resources in emergency situations (e.g., hotline, community mental health agency, ED, 911 in most places in the United States, the toll-free National Domestic Violence Hotline [1-800-799-SAFE]).

• Encourage the use of self-help groups in nonemergency situations.

• Inform the client and family about medication actions, side effects, target symptoms, and toxic reactions.