A
Activity Intolerance
NANDA-I
Insufficient physiological or psychological energy to endure or complete required or desired daily activities
NOC (Nursing Outcomes Classification)
Activity Tolerance, Endurance, Energy Conservation, Self-Care: Instrumental Activities of Daily Living (IADLs)
Client Outcomes
Client Will (Specify Time Frame)
• Participate in prescribed physical activity with appropriate changes in heart rate, blood pressure, and breathing rate; maintain monitor patterns (rhythm and ST segment) within normal limits
• State symptoms of adverse effects of exercise and report onset of symptoms immediately
• Maintain normal skin color, and skin is warm and dry with activity
• Verbalize an understanding of the need to gradually increase activity based on testing, tolerance, and symptoms
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Determine cause of activity intolerance (see Related Factors) and determine whether cause is physical, psychological, or motivational. Determining the cause of a problem can help direct appropriate interventions.
• If mainly on bed rest, minimize cardiovascular deconditioning by positioning the client in an upright position several times daily if possible. Deconditioning of the cardiovascular system occurs within days and involves fluid shifts, fluid loss, decreased cardiac output, decreased peak oxygen uptake, and increased resting heart rate (Fauci et al, 2008). EB: A study found that diabetic clients developed orthostatic hypotension after 48 hours of bed rest, possibly from altered cardiovascular reflexes (Schneider et al, 2009).
• Assess the client daily for appropriateness of activity and bed rest orders. Mobilize the client as soon as it is possible. With bed rest there is a shift of fluids from the extremities to the thoracic cavity from the loss of gravitational stress. Positioning in an upright position helps maintain optimal fluid distribution and maintain orthostatic tolerance (Perme & Chandrashekar, 2009). CEB: A study utilizing tomography demonstrated significant decreased strength in the hip, thigh, and calf muscles in elderly orthopedic clients, as well as bone mineral loss with immobility (Berg et al, 2007).
• If client is mostly immobile, consider use of a transfer chair: a chair that becomes a stretcher. Using a transfer chair where the client is pulled onto a flat surface and then seated upright in the chair can help previously immobile clients get out of bed (Perme & Chandrashekar, 2009).
• When appropriate, gradually increase activity, allowing the client to assist with positioning, transferring, and self-care as possible. Progress from sitting in bed to dangling, to standing, to ambulation. Always have the client dangle at the bedside before trying standing to evaluate for postural hypotension. Postural hypotension is very common in the elderly (Krecinic et al, 2009).
• When getting a client up, observe for symptoms of intolerance such as nausea, pallor, dizziness, visual dimming, and impaired consciousness, as well as changes in vital signs; manual blood pressure monitoring is best. When an adult rises to the standing position, blood pools in the lower extremities; symptoms of central nervous system hypoperfusion may occur, including feelings of weakness, nausea, headache, lightheadedness, dizziness, blurred vision, fatigue, tremulousness, palpitations, and impaired cognition. EBN: Automatic devices cannot reliably detect or rule out orthostatic hypotension, indicating that nurses need to use manual devices to take accurate postural blood pressures for optimal client care (Dind et al, 2011).
• If the client experiences symptoms of postural hypotension, take precautions when getting the client out of bed. Put graduated compression stockings on client or use lower limb compression bandaging, if ordered, to return blood to the heart and brain. Have the client dangle at the side of the bed with legs hanging over the edge of the bed, flex and extend feet several times after sitting up, then stand up slowly with someone holding the client. If client becomes lightheaded or dizzy, return him to bed immediately. Use of compression stockings or leg bandaging can help return fluid from the lower extremities back where it collects from immobility to the heart and brain (Gorelik et al, 2009; Platts et al, 2009).
• Perform range-of-motion (ROM) exercises if the client is unable to tolerate activity or is mostly immobile. See care plan for Risk for Disuse Syndrome.
• Monitor and record the client’s ability to tolerate activity: note pulse rate, blood pressure, monitor pattern, dyspnea, use of accessory muscles, and skin color before, during, and after the activity. If the following signs and symptoms of cardiac decompensation develop, activity should be stopped immediately:
The above are symptoms of intolerance to activity and continuation of activity may result in client harm ( Urden, Stacy, & Lough, 2010; Goldman, 2011).
Instruct the client to stop the activity immediately and report to the physician if the client is experiencing the following symptoms: new or worsened intensity or increased frequency of discomfort; tightness or pressure in chest, back, neck, jaw, shoulders, and/or arms; palpitations; dizziness; weakness; unusual and extreme fatigue; excessive air hunger. These are common symptoms of angina and are caused by a temporary insufficiency of coronary blood supply. Symptoms typically last for minutes as opposed to momentary twinges. If symptoms last longer than 5 to 10 minutes, the client should be evaluated by a physician. Pulse rate and arterial blood oxygenation indicate cardiac/exercise tolerance; pulse oximetry identifies hypoxia (Urden, Stacy, & Lough, 2010; Goldman, 2011).
• Observe and document skin integrity several times a day. Activity Intolerance, if resulting in immobility, may lead to pressure ulcers. Mechanical pressure, moisture, friction, and shearing forces all predispose to their development. Refer to the care plan Risk for impaired Skin Integrity.
• Assess for constipation. If present, refer to care plan for Constipation. Activity Intolerance is associated with increased risk of constipation.
Refer the client to physical therapy to help increase activity levels and strength.
Consider a dietitian referral to assess nutritional needs related to activity intolerance; provide nutrition as needed. If client is unable to eat food, use enteral or parenteral feedings as needed.
• Recognize that malnutrition causes significant morbidity due to the loss of lean body mass. Providing nutrition early helps maintain muscle and immune system function, and reduce hospital length of stay (McClave et al, 2009; Racco, 2009).
• Provide emotional support and encouragement to the client to gradually increase activity. Work with the client to set mutual goals that increase activity levels. Fear of breathlessness, pain, or falling may decrease willingness to increase activity. EB: In clients with Parkinson’s disease motivations for exercising included hope that exercise would slow the disease or prevent a decline in function, feeling better with exercise, belief that exercise is beneficial, and encouragement from family members (Ene, McRae, & Schenkman, 2011).
Observe for pain before activity. If possible, treat pain before activity and ensure that the client is not heavily sedated. Pain restricts the client from achieving a maximal activity level and is often exacerbated by movement.
Obtain any necessary assistive devices or equipment needed before ambulating the client (e.g., walkers, canes, crutches, portable oxygen). Assistive devices can help increase mobility (Yeom, Keller, & Fleury, 2009).
Use a gait walking belt when ambulating the client. Gait belts improve the caregiver’s grasp, reducing the incidence of injuries of clients and nurses (Nelson et al, 2003).
Activity Intolerance Due to Respiratory Disease
• If the client is able to walk and has chronic obstructive pulmonary disease (COPD), use the traditional 6-minute walk distance to evaluate ability to walk. EB: The 6-minute walk test predicted mortality in COPD clients (Celli, 2010).
Ensure that the chronic pulmonary client has oxygen saturation testing with exercise. Use supplemental oxygen to keep oxygen saturation 90% or above or as prescribed with activity. Oxygen therapy can improve exercise ability and long-term administration of oxygen can increase survival in COPD clients (Gold Report, 2011; Stoller et al, 2010).
• Monitor a respiratory client’s response to activity by observing for symptoms of respiratory intolerance such as increased dyspnea, loss of ability to control breathing rhythmically, use of accessory muscles, nasal flaring, appearance of facial distress, and skin tone changes such as pallor and cyanosis (Perme & Chandrashekar, 2009).
• Instruct and assist a COPD client in using conscious, controlled breathing techniques during exercise, including pursed-lip breathing, and inspiratory muscle use. EBN: A systematic review found pursed-lip breathing effective in decreasing dyspnea (Carrieri-Kohlman & Donesky-Cuenco, 2008). EB: A systematic review found that inspiratory muscle training was effective in increasing endurance of the client and decreasing dyspnea (Langer et al, 2009).
Evaluate the client’s nutritional status. Refer to a dietitian if needed. Use nutritional supplements to increase nutritional level if needed. Improved nutrition may help increase inspiratory muscle function and decrease dyspnea. EBN: A study found that almost half of a group of clients with COPD were malnourished, which can lead to an exacerbation of the disease (Odencrants, Ehnfors, & Ehrenbert, 2008).
For the client in the intensive care unit, consider mobilizing the client in a four-phase method if there is sufficient knowledgeable staff available to protect the client from harm. Even intensive care unit clients receiving mechanical ventilation can be mobilized safely if a multidisciplinary team is present to support, protect, and monitor the client for intolerance to activity (Perme & Chandrashekar, 2009).
Refer the COPD client to a pulmonary rehabilitation program. EB: Pulmonary rehabilitation is a highly effective and safe intervention to reduce hospital admissions and mortality and to improve health-related quality of life in COPD clients who have recently suffered an exacerbation of COPD (Puhan et al, 2011).
Activity Intolerance Due to Cardiovascular Disease
• If the client is able to walk and has heart failure, consider use of the 6-minute walk test to determine physical ability. EB: The 6-minute walk test is a simple, safe, and inexpensive exercise test to predict functional capacity (Du et al, 2009).
• Allow for periods of rest before and after planned exertion periods such as meals, baths, treatments, and physical activity. Both physical and emotional rest help lower arterial pressure and reduce the workload of the myocardium (Fauci et al, 2008).
Refer to a heart failure program or cardiac rehabilitation program for education, evaluation, and guided support to increase activity and rebuild life. EB: Exercise-based cardiac rehabilitation is effective in reducing total and cardiovascular mortality and hospital admissions (Heran et al, 2011).
• See care plan for Decreased Cardiac Output for further interventions.
Geriatric:• Slow the pace of care. Allow the client extra time to carry out physical activities. Slow gait in the elderly may be related to fear of falling, decreased strength in muscles, reduced balance or visual acuity, knee flexion contractures, and foot pain.
• Encourage families to help/allow an elderly client to be independent in whatever activities possible. Sometimes families believe they are assisting by allowing clients to be sedentary. Encouraging activity not only enhances good functioning of the body’s systems but also promotes a sense of worth (Fauci et al, 2008). EB: Physical activity and cognitive exercise may improve memory and executive functions in older people with mild cognitive impairment (Teixeira et al, 2012).
Assess for swaying, poor balance, weakness, and fear of falling while elders stand/walk. If present, refer to physical therapy. Fear of falling and repeat falling is common in the elderly population. Balance rehabilitation provides individualized treatment for persons with various deficits associated with balance (Studer, 2008). Refer to the care plan for Risk for Falls and Impaired Walking.
Evaluate medications the client is taking to see if they could be causing activity intolerance. Medications such as beta-blockers; lipid lowering agents, which can damage muscle; antipsychotics, which have a common side effect of orthostatic hypotension; some antihypertensives; and lowering the blood pressure to normal in the elderly can result in decreased functioning. Elderly may need a blood pressure of 140/80 or higher in order to walk without dizziness. It is important that medications be reviewed to ensure they are not resulting in less function of the elderly client. Many of the medications found on the Beers list of medications that are inappropriate to prescribe for elderly clients can result in decreased function from dizziness and delirium (American Geriatrics Society; Molony, 2009).
If the client has heart disease causing activity intolerance, refer for cardiac rehabilitation. EB: A study found that elderly clients with coronary heart disease who participate in cardiac rehabilitation programs had significantly lower mortality rates (Suaya et al, 2009).
Refer the disabled elderly client to physical therapy for functional training including gait training, stepping, and sit-to-stand exercises, or for strength training. EB: Functional decline from hospital-associated deconditioning is common in the elderly, and acute inpatient rehabilitation can be effective in preventing this condition (Kortebein, 2009). CEB: A study found that intensive functional training improved balance and coordination more than strength training (Krebs, Scarborough, & McGibbon, 2007). EB: A Cochrane review found that progressive resistance strength training is effective in elderly clients to improve function (Liu & Latham, 2009).
• When mobilizing the elderly client, watch for orthostatic hypotension accompanied by dizziness and fainting. Postural hypotension is common in elderly clients. Cerebral hypoperfusion is the usual cause of orthostatic intolerance and hypotension (Weimer & Zadeh, 2009). CEB: Insufficient oral fluid intake has been identified as a serious problem in skilled nursing facility residents and has been associated with postural hypotension, acute confusion, and cognitive decline (Zembrzuski, 2006).
Home Care: Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems and the need for community or home health services. EB: Home-based exercise appears more effective in increasing daily ambulatory activity in the community setting than supervised exercise in clients with intermittent claudication (Gardner et al, 2011)
Assess the home environment for factors that contribute to decreased activity tolerance such as stairs or distance to the bathroom. Refer to occupational therapy, if needed, to assist the client in restructuring the home and ADL patterns. During hospitalization, clients and families often estimate energy requirements at home inaccurately because the hospital’s availability of staff support distorts the level of care that will be needed.
Refer to physical therapy for strength training and possible weight training, to regain strength, increase endurance, and improve balance. If the client is homebound, the physical therapist can also initiate cardiac rehabilitation.
• Encourage progress with positive feedback. The client’s experience should be validated as within expected norms. Recognition of progress enhances motivation.
• Teach the client/family the importance of and methods for setting priorities for activities, especially those having a high energy demand (e.g., home/family events). Instruct in realistic expectations.
• Encourage routine low-level exercise periods such as a daily short walk or chair exercises. EB: Older adults participating in low levels of regular exercise can establish and maintain a home-based exercise program that yields immediate and long-term physical and affective benefits (Teri et al, 2011).
• Provide the client/family with resources such as senior centers, exercise classes, educational and recreational programs, and volunteer opportunities that can aid in promoting socialization and appropriate activity. Social isolation can be an outcome of and contribute to activity intolerance. EB: Community-based resistance training and dietary modifications can improve body composition, muscle strength, and physical function in overweight and obese older adults (Straight et al, 2011).
• Instruct the client and family in the importance of maintaining proper nutrition.
• Instruct in use of dietary supplements as indicated. Illness may suppress appetite, leading to inadequate nutrition.
Refer to medical social services as necessary to assist the family in adjusting to major changes in patterns of living because of activity intolerance.
Assess the need for long-term supports for optimal activity tolerance of priority activities (e.g., assistive devices, oxygen, medication, catheters, massage), especially for a hospice client. Evaluate intermittently.
Refer to home health aide services to support the client and family through changing levels of activity tolerance. Introduce aide support early. Instruct the aide to promote independence in activity as tolerated.
• Allow terminally ill clients and their families to guide care. Control by the client or family respects their autonomy and promotes effective coping.
• Provide increased attention to comfort and dignity of the terminally ill client in care planning. Interventions should be provided as much for psychological effect as for physiological support. For example, oxygen may be more valuable as a support to the client’s psychological comfort than as a booster of oxygen saturation.
Institute case management of frail elderly to support continued independent living.
Client/Family Teaching and Discharge Planning:
• Instruct the client on techniques to utilize for avoiding activity intolerance, such as controlled breathing techniques.
• Teach the client techniques to decrease dizziness from postural hypotension when standing up.
• Help client with energy conservation and work simplification techniques in ADLs.
• Describe to the client the symptoms of activity intolerance, including which symptoms to report to the physician.
• Explain to the client how to use assistive devices, oxygen, or medications before or during activity.
• Help client set up an activity log to record exercise and exercise tolerance.
References
American Geriatrics Society. American Geriatrics Society updated Beers Criteria for potentially inappropriate medication use in older adults. Available at http://www.americangeriatrics.org/files/documents/beers/2012BeersCriteria_JAGS.pdf. [Accessed August 2, 2012].
Berg, H.E., et al. Hip, thigh and calf muscle atrophy and bone loss after 5-week bedrest inactivity. Eur J Appl Physiol. 2007;99(3):283–289.
Carrieri-Kohlman, V., Donesky-Cuenco, D. Dyspnea management. An EBP guideline. In: Ackley B., Ladwig G., Swann B.A., et al, eds. Evidence-based nursing care guidelines: medical-surgical interventions. Philadelphia: Mosby, 2008.
Celli, B.R. Predictors of mortality in COPD. Respir Med. 2010;104(6):773–779.
Dind, A. The inaccuracy of automatic devices taking postural measurements in the emergency department. Int J Nurs Pract. 2011;17(5):525–533.
Du, H., et al. A review of the six-minute walk test: its implication as a self-administered assessment tool. Eur J Cardiovasc Nurs. 2009;8(1):2–8.
Ene, H., McRae, C., Schenkman, M. Attitudes toward exercise following participation in an exercise intervention study. J Neurol Phys Ther. 2011;35(1):34–40.
Fauci, A., et al. Harrison’s principles of internal medicine, ed 17. New York: McGraw-Hill; 2008.
Gardner, A., et al. Efficacy of quantified home-based exercise and supervised exercise in patients with intermittent claudication: a randomized controlled trial. Circulation. 2011;123(5):491–498.
Global Initiative for Chronic Obstructive Lung Disease (GOLD Report). Available at http://www.goldcopd.org/guidelines-global-strategy-for-diagnosis-management.html. [Accessed August 2, 2012, 2011].
Goldman, L. Goldman Cecil’s medicine, ed 24. St Louis: Saunders; 2011.
Gorelik, O., et al. Seating-induced postural hypotension is common in older patients with decompensated heart failure and may be prevented by lower limb compression bandaging. Gerontology. 2009;55(2):138–144.
Heran, B.S., et al, Exercise-based cardiac rehabilitation for coronary heart disease. Cochrane Database Syst Rev 2011;(7):CD001800.
Kortebein, P. Rehabilitation for hospital-associated deconditioning. Am J Phys Med Rehabil. 2009;88(1):66–77.
Krebs, D.E., Scarborough, D.M., McGibbon, C.A. Functional vs. strength training in disabled elderly outpatients. Am J Phys Med Rehabil. 2007;86(2):93–103.
Krecinic, T., et al. Orthostatic hypotension in older persons: a diagnostic algorithm. J Nutr Health Aging. 2009;13(6):572–575.
Langer, D., et al. A clinical practice guideline for physiotherapists treating patients with chronic obstructive pulmonary disease based on a systematic review of available evidence. Clin Rehabil. 2009;23(5):445–462.
Liu, C.J., Latham, N.K., Progressive resistance strength training for improving physical function in older adults. Cochrane Database Syst Rev 2009;(3):CD002759.
McClave, S., et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N). JPEN J Parenter Enteral Nutr. 2009;33(3):277–316.
Molony, S.L. Monitoring medication use in older adults. Am J Nurs. 2009;109(1):68–78.
Nelson, A., et al. Safe patient handling and movement. Am J Nurs. 2003;103(3):32.
Odencrants, S., Ehnfors, M., Ehrenbert, A. Nutritional status and patient characteristics for hospitalized older patients with chronic obstructive pulmonary disease. J Clin Nurs. 2008;17(13):1771–1778.
Perme, C., Chandrashekar, R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care. 2009;18(3):212–221.
Platts, S.H., et al. Compression garments as countermeasures to orthostatic intolerance. Aviat Spac Environ Med. 2009;80(5):437–442.
Puhan, M., et al, Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2009;(1):CD005305.
Racco, M. Nutrition in the ICU. RN. 2009;72(1):26–30.
Schneider, S.M., et al. Impaired orthostatic response in patients with type 2 diabetes mellitus after 48 hours of bedrest. Endocr Pract. 2009;15(2):104–110.
Stoller, J.K., et al. Oxygen therapy for patients with COPD: current evidence and the long-term oxygen treatment trial. Chest. 2010;138:179–187.
Straight, C.R., et al. Effects of resistance training and dietary changes on physical function and body composition in overweight and obese older adults. J Phys Act Health. 2011. [Aug 2, Epub ahead of print].
Studer, M. Keep it moving: advances in gait training techniques help clients reduce balance issues. Rehabil Manag. 2008;21(5):10–15.
Suaya, J.A., et al. Cardiac rehabilitation and survival in older coronary patients. J Am Coll Cardiol. 2009;54(1):25–33.
Teixeira, C.V., et al. Non-pharmacological interventions on cognitive functions in older people with mild cognitive impairment (MCI). Arch Gerontol Geriatr. 2012;54(1):175–180.
Teri, L., et al. A randomized controlled clinical trial of the Seattle Protocol for Activity in older adults. J Am Geriatr Soc. 2011;59(7):1188–1196.
Urden, L., Stacy, K., Lough, M. Critical care nursing: diagnosis and management, ed 6. St Louis: Mosby; 2010.
Weimer, L.H., Zadeh, P. Neurological aspects of syncope and orthostatic intolerance. Med Clin North Am. 2009;93(2):427–449.
Yeom, H.A., Keller, C., Fleury, J. Interventions for promoting mobility in community-dwelling older adults. J Am Acad Nurse Pract. 2009;21(2):95–100.
Zembrzuski, C.D. Oral fluid intake and the effect on postural blood pressure and falls in skilled nursing facility residents. NYU doctoral dissertation. 2006:176.
Risk for Activity Intolerance
Ineffective Activity Planning
NANDA-I
Defining Characteristics
Failure pattern of behavior; history of procrastination; lack of plan; lack of resources; lack of sequential organization; reports excessive anxieties about a task to be undertaken; reports fear toward a task to be undertaken; reports worries toward a task to be undertaken; unmet goals for chosen activity
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Anxiety Reduction, Behavior Management, Behavior Modification, Calming Technique, Coping Enhancement, Memory Training, Life Skills Enhancement, Planning Assistance, Sequence Guidance
Nursing Interventions and Rationales
• Establish a contract. EBN: This study of adolescents with Type I diabetes indicated that behavioral contracts may be an important adjunct to reduce nagging and improve outcomes with behavioral changes (Carroll et al, 2011).
Before the first conference/meeting with the client, begin by establishing an agenda and get the assurance that the client will participate. Record the information. Give precise information on the upcoming session. At each session identify precisely the tasks to be accomplished for each session and the upcoming tasks for subsequent session. It is important that the client use a sequential organizational model with the nurse/health care provider (Debray et al, 2005).
Ask the client how he perceives the situation in order to gather his personal vision of the problem and how they envisage their self-involvement. Specify the goals. Clients and caregivers may have different priorities on what is important (Junius-Walker et al, 2011).
Assess the client’s actual level of function (functionality) (at work, in school, at the hospital) by identifying actual dysfunctional behaviors.
Refer the client for cognitive-behavioral therapy. The work for the client begins with the understanding that his thoughts affect his emotions and reactions and therefore the success of meeting his objectives. Suggest that the client change their self-concept, for example, “Stop thinking of yourself as powerless.” The planning of the project (event) will depend in large part on the vision of the client with the problem and on their abilities (perception). Changing this perception may lead to self-confidence and a sense of accomplishment (emotions), which will translate into appropriate actions leading to successful behaviors (Rezvan et al, 2008).
Confront and restructure the following unrealistic idea: “Running away is a better reaction when confronted with a dangerous object.” The true syllogism is “running away is the reaction when confronted with an object that is ‘imagined’ to be dangerous.” Instruct the client to practice and repeat the following statement: “I have the power to change by changing my ideas.” Determine with accuracy the real nature of the danger and the probability that the danger will manifest itself. It is in experimentation that a person will be able to measure their abilities. This is the nature of the contract (Debray et al, 2005).
• Lower the anxiety level tied to the client’s fear of not succeeding. EB: This review of randomized placebo-controlled trials indicates that CBT is efficacious for adult anxiety disorders (Hofmann & Smits, 2008).
Research the client’s rising anxiety behaviors and show evidence of the client’s “catastrophic” thoughts by repeating what negative thoughts the client has expressed, for example, “It would be dreadful if I would not succeed,” “I can never do. . .” Work to change the dramatic interpretation of the situation by the client by using correct words, appropriate to the actual seriousness of the consequences. When assessing for anxiety, it is essential that social, emotional, physical, and cognitive factors are taken into account (McGrandles & McCaig, 2010).
Verify if the lack of success of the project would lower the client’s self-image. Reinforce the idea that making an effort is better than no action (Auger, 2006).
Determine as fairly as possible the success factors needed for the planning and success of the project: financial resources; the family situation; prior medical, psychiatric, and psychosocial conditions; material resources; and the ability to manage stress. EBN: Discussions identifying resources help to handle past resources, the functional solutions of everyday life, favorable changes, exceptions and differences in everyday life, the availability of support and the prospects of future. By noting and providing feedback to families, the nurse offers families a new perspective on themselves (Häggman-Laitila et al, 2010).
Identify the informational needs of the person: understanding of his state of health, supervision of his treatment if he is receiving treatment, diet, and important telephone numbers. EBN: This study of clients with stage 4 chronic kidney disease validated the need for an individual assessment to determine the unique informational needs of each person (Lewis et al, 2010).
Identify and reinforce the elements of the client’s personality that may help him to succeed with his plan. Have the client drill and repeat: “I can change my goals (dreams) with a plan.” Reviews have shown that goal consensus and collaboration between client and therapist are significant for treatment outcome (Mackrill, 2011).
• Assist the client to plan in a realistic way for work, studies, or the choice not to continue a project (determination des objectifs) (Auger, 2006).
Carry out the general objective by using secondary objectives in successive stages and in a logical progression. Remember that the attainment of these objectives may imply a modification of the schedule. Use a schedule, calendar, or agenda to write down the dates. For realistic planning: choose simple tasks, limit long hours of work, protect biopsychosocial well-being, improve techniques (of relaxation, of study, of concentration, of memory, aptitude of reading, writing, the way of taking notes).
• Anticipate the obstacles the client may encounter. This helps the client to increase their motivation and their responsibility to obtain their objectives and develop a plan of action (Auger, 2006).
Establish a safeguard that will be helpful in pursuing the goal. It should be nonpunitive, but help the client to remember the importance of the instrument’s use to attain the micro-objectives, the base of success. It could be written down like this: “I am going to take a 30-minute walk for 2 days. If I do it I will let myself watch TV for 1 hour, otherwise I will take a 1-hour walk for the next 2 days.” Drill and repeat: “I will realize my goals no matter what.”
Ask yourself the following questions: is the person alone, is he capable of attaining his objective in a day or would it be better to get something going with a support team? What is the proof that this person can realistically attain their objectives?
Discuss the resources that the person has already used in order to verify if the changes assert themselves. Identify the potentially pivotal helping people. EBN: This study of families indicated that a resource-enhancing approach typically triggers favorable spontaneous processes of change and solutions (Häggman-Laitila et al, 2010).
Clarify and coordinate the project in collaboration with a multidisciplinary team in the field and with other specialists (doctor, employment center, teacher, technician, etc.).
If necessary, coordinate the orientation of the person towards other structures or treatments that have not been used, for example, individual or group therapy, an educational support person, a financial aid person.
Tackle the client’s fears and worries and encourage him to make a cognitive reconstruction. Use “desire thinking.” Drill and repeat: “I can change false ideas that make me believe that I am unable to carry out (achieve) my plan.” EBN: Desire thinking is a voluntary cognitive process involving verbal and imaginal elaboration of a desired target. Recent research has highlighted the role of desire thinking in the maintenance of addictive, eating, and impulse control disorders (Caselli & Spada, 2011).
Note: The above interventions may be adapted for the geriatric and multicultural client, and for home care and client/family teaching and discharge planning.
• Refer to care plans Anxiety, Readiness for enhanced family Coping, Readiness for enhanced Decision-Making, Fear, Readiness for enhanced Hope, Readiness for enhanced Power, Readiness for enhanced Spiritual Well-Being, Readiness for enhanced Self-Health Management for additional interventions.
References
Auger, L. Vivre avec sa tête ou avec son cœur (Live with your head or with your heart). Quebec: Centre la Pensée Réaliste, republication par Pierre Bovo; 2006.
Carroll, A.E., et al. Contracting and monitoring relationships for adolescents with type 1 diabetes: a pilot study. Diabetes Tech Therapeut. 2011;13(5):543–549.
Caselli, G., Spada, M.M. The Desire Thinking Questionnaire: development and psychometric properties. Addict Behav. 2011;36(11):1061–1067.
Debray, Q., et al. The protocols of treatment of pathological personalities. Cognitive behavioral approach. Paris: Masson; 2005.
Häggman-Laitila, A., Tanninen, H., Pietilä, A. Effectiveness of resource-enhancing family-oriented intervention. J Clin Nurs. 2010;19(17/18):2500–2510.
Hofmann, S.G., Smits, J.A. Cognitive-behavioral therapy for adult anxiety disorders: a meta-analysis of randomized placebo-controlled trials. J Clin Psychiatry. 2008;69(4):621–632.
Junius-Walker, U., et al. Health and treatment priorities of older patients and their general practitioners: a cross-sectional study. Qual Primary Care. 2011;19:67–76.
Lewis, A.L., Stabler, K.A., Welch, J.L. Perceived informational needs, problems, or concerns among patients with stage 4 chronic kidney disease. Nephrol Nurs J. 2010;37(2):143–149.
Mackrill, T. Differentiating life goals and therapeutic goals: expanding our understanding of the working alliance. Brit J Guid Couns. 2011;39(1):25–39.
McGrandles, A., McCaig, M. Diagnosis and management of anxiety in primary care. Nurse Prescribing. 2010;8(7):310. [312–318].
Rezvan, S., et al. A comparison of cognitive-behavior therapy with interpersonal and cognitive behavior therapy in the treatment of generalized anxiety disorder. Couns Psychol Q. 2008;21(4):309–321.
Risk for ineffective Activity Planning
NANDA-I
At risk for an inability to prepare for a set of actions fixed in time and under certain conditions.
Ineffective Airway Clearance
NANDA-I
Defining Characteristics
Absent cough; adventitious breath sounds (rales, crackles, rhonchi, wheezes); changes in respiratory rate and rhythm; cyanosis; difficulty vocalizing; diminished breath sounds; dyspnea; excessive sputum; orthopnea; restlessness; wide-eyed
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate effective coughing and clear breath sounds
• Maintain a patent airway at all times
• Explain methods useful to enhance secretion removal
• Explain the significance of changes in sputum to include color, character, amount, and odor
• Identify and avoid specific factors that inhibit effective airway clearance
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Auscultate breath sounds q 1 to 4 hours. Breath sounds are normally clear or a few scattered fine crackles at bases, which clear with deep breathing. The presence of coarse crackles during inspiration indicates fluid in the airway; wheezing indicates an airway obstruction (Jarvis, 2012).
• Monitor respiratory patterns, including rate, depth, and effort. A normal respiratory rate for an adult without dyspnea is 10 to 20 (Jarvis, 2012). With secretions in the airway, the respiratory rate will increase.
• Monitor blood gas values and pulse oxygen saturation levels as available. An oxygen saturation of less than 90% (normal: 95% to 100%) or a partial pressure of oxygen of less than 80 (normal: 80 to 100) indicates significant oxygenation problems (Schultz, 2011).
Administer oxygen as ordered. Oxygen administration has been shown to correct hypoxemia (Wong & Elliott, 2009).
• Position the client to optimize respiration (e.g., head of bed elevated 30-45 degrees and repositioned at least every 2 hours). An upright position allows for maximal lung expansion; lying flat causes abdominal organs to shift toward the chest, which crowds the lungs and makes it more difficult to breathe. EB: In a mechanically ventilated client, there is a decreased incidence of ventilator-associated pneumonia if the client is positioned at a 30-to 45-degree semirecumbent position as opposed to a supine position (Siela, 2010; Vollman & Sole, 2011).
• Help the client deep breathe and perform controlled coughing. Have the client inhale deeply, hold breath for several seconds, and cough two or three times with mouth open while tightening the upper abdominal muscles. Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective (Gosselink et al, 2008).
• If the client has obstructive lung disease, such as COPD, cystic fibrosis, or bronchiectasis, consider helping the client use the forced expiratory technique, the “huff cough.” The client does a series of coughs while saying the word “huff.” This technique prevents the glottis from closing during the cough and is effective in clearing secretions (Bhowmik et al, 2009; Gosselink et al, 2008).
Encourage the client to use an incentive spirometer if ordered. Recognize that controlled coughing and deep breathing may be just as effective (Gosselink et al, 2008). EBN: A study on care of clients in a medical unit found that use of respiratory bundle that included use of a spirometer and good oral care for ambulatory clients, and oral care, turning, and elevation of the head of the bed for dependent clients, was effective in decreasing the incidence of transfer to critical care for respiratory problems (pneumonia) (Lamar, 2012).
• Encourage activity and ambulation as tolerated. If unable to ambulate the client, turn the client from side to side at least every 2 hours. Body movement helps mobilize secretions. (See interventions for Impaired Gas Exchange for further information on positioning a respiratory client.)
• Encourage fluid intake of up to 2500 mL/day within cardiac or renal reserve. Fluids help minimize mucosal drying and maximize ciliary action to move secretions.
Administer medications such as bronchodilators or inhaled steroids as ordered. Watch for side effects such as tachycardia or anxiety with bronchodilators, or inflamed pharynx with inhaled steroids. Bronchodilators decrease airway resistance, improve the efficiency of respiratory movements, improve exercise tolerance, and can reduce symptoms of dyspnea on exertion (Barnett, 2008). Pharmacologic therapy in COPD is used to reduce symptoms, reduce the frequency and severity of exacerbation, and improve health strategies and exercise tolerance (GOLD, 2011).
Provide percussion, vibration, and oscillation as appropriate (Gosselink et al, 2008).
• Observe sputum, noting color, odor, and volume. Normal sputum is clear or gray and minimal; abnormal sputum is green, yellow, or bloody; malodorous; and often copious. The presence of purulent sputum during a COPD exacerbation can be sufficient indication for starting empirical antibiotic treatment. Notify physician of purulent sputum (GOLD, 2011).
Critical Care
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. For every week of bed rest, muscle strength can decrease 20%; early ambulation also helped clients develop a positive outlook. An early mobility and walking program can promote weaning from ventilator support as a client’s overall strength and endurance improve (Gosselink et al, 2008; Perme & Chandrashekar, 2009).
If the client is intubated, consider use of kinetic therapy, using a kinetic bed that slowly moves the client with 40-degree turns. Rotational therapy may decrease the incidence of pulmonary complications in high risk clients with increasing ventilator support requirements, at risk for ventilator-associated pneumonia, and clinical indications for acute lung injury or acute respiratory distress syndrome (ARDS) with worsening PaO2:FIO2 ratio, presence of fluffy infiltrates via chest radiograph concomitant with pulmonary edema, and refractory hypoxemia (Johnson, 2011).
• Reposition the client as needed. Use rotational or kinetic bed therapy as above in clients for whom side-to-side turning is contraindicated or difficult. EBN: Changing position frequently decreases the incidence of atelectasis, pooling of secretions, and resultant pneumonia (Burns, 2011). EB & EBN: Continuous, lateral rotational therapy has been shown to improve oxygenation and decrease the incidence of VAP (Burns, 2011).
• When suctioning an endotracheal tube or tracheostomy tube for a client on a ventilator, do the following:
Explain the process of suctioning beforehand and ensure the client is not in pain or overly anxious. Suctioning can be a frightening experience; an explanation along with adequate pain relief or needed sedation can reduce stress, anxiety, and pain (Chulay & Seckel, 2011).
Hyperoxygenate before and between endotracheal suction sessions. Studies have demonstrated that hyperoxygenation may help prevent oxygen desaturation in a suctioned client (Chulay & Seckel, 2011; Pedersen et al, 2009; Siela, 2010).
Suction for less than 15 seconds. Studies demonstrated that because of a drop in the partial pressure of oxygen with suctioning, that preferably no more than 10 seconds be used actually suctioning, with the entire procedure taking 15 seconds (Chulay & Seckel, 2011; Pedersen et al, 2009).
Use a closed, in-line suction system. Closed in-line suctioning has minimal effects on heart rate, respiratory rate, tidal volume, and oxygen saturation (Chulay & Seckel, 2011; Seymour et al, 2009).
Avoid saline instillation before suctioning. EBN: Repeated studies have demonstrated that saline instillation before suctioning has an adverse effect on oxygen saturation in both adults and children (Chulay & Seckel, 2011; Pederson et al, 2009; Rauen et al, 2008; Siela, 2010).
With a subglottic suctioning drainage tube in place, be sure to irrigate per manufacturer’s instructions if it becomes clogged (Vollman & Sole, 2011).
Document results of coughing and suctioning, particularly client tolerance and secretion characteristics such as color, odor, and volume (Chulay & Seckel, 2011).
Pediatric:• Educate parents about the risk factors for ineffective airway clearance such as foreign body ingestion and passive smoke exposure.
• See the care plan Risk for Suffocation for more interventions on choking. EB: Passive smoke exposure significantly increases the risk of respiratory infections in children (Chatzimicael et al, 2008).
• Educate children and parents on the importance of adherence to peak expiratory flow (PEF) monitoring for asthma self-management.
• Educate parents and other caregivers that cough and cold medications bought over the counter are not safe for a child under 2 unless specifically ordered by a health care provider. Over-the-counter cold and cough medications are no longer recommended for children under the age of 2 unless recommended by a health care provider. Minimal data exist to support their effectiveness, and overuse can cause harm (Woo, 2008).
• Encourage ambulation as tolerated without causing exhaustion. Immobility is often harmful to the elderly because it decreases ventilation and increases stasis of secretions, leading to atelectasis or pneumonia.
• Actively encourage the elderly to deep breathe and cough. Cough reflexes are blunted, and coughing is decreased in the elderly.
• Ensure adequate hydration within cardiac and renal reserves. The elderly are prone to dehydration, and therefore more viscous secretions, because they frequently use diuretics or laxatives and forget to drink adequate amounts of water.
• Some of the above interventions may be adapted for home care use.
Begin discharge planning as soon as possible with case manager or social worker to assess need for home support systems, assistive devices, and community or home health services.
• Assess home environment for factors that exacerbate airway clearance problems (e.g., presence of allergens, lack of adequate humidity in air, poor air flow, stressful family relationships).
• Assess affective climate within family and family support system. Problems with respiratory function and resulting anxiety can provoke anger and frustration in the client. Feelings may be displaced onto caregiver and require intervention to ensure continued caregiver support. Refer to care plan for Caregiver Role Strain.
• Refer to GOLD guidelines for management of home care and indications of hospital admission criteria (GOLD, 2011).
• When respiratory procedures are being implemented, explain equipment and procedures to family members, and provide needed emotional support. Family members assuming responsibility for respiratory monitoring often find this stressful. They may not have been able to assimilate fully any instructions provided by hospital staff.
• When electrically based equipment for respiratory support is being implemented, evaluate home environment for electrical safety, proper grounding, and so on. Ensure that notification is sent to the local utility company, the emergency medical team, and police and fire departments.
• Provide family with support for care of a client with chronic or terminal illness. Breathing difficulty can provoke extreme anxiety, which can interfere with the client’s ability or willingness to adhere to the treatment plan.
• Refer to care plan for Anxiety. Witnessing breathing difficulties and facing concerns of dealing with chronic or terminal illness can create fear in caregiver. Fear inhibits effective coping. Refer to care plan for Powerlessness.
• Instruct the client to avoid exposure to persons with upper respiratory infections, to avoid crowds of people, and wash hands after each exposure to groups of people, or public places.
Determine client adherence to medical regimen. Instruct the client and family in importance of reporting effectiveness of current medications to physician. Inappropriate use of medications (too much or too little) can influence amount of respiratory secretions.
• Teach the client when and how to use inhalant or nebulizer treatments at home.
• Teach the client/family importance of maintaining regimen and having PRN drugs easily accessible at all times. Success in avoiding emergency or institutional care may rest solely on medication compliance or availability.
• Instruct the client and family in the importance of maintaining proper nutrition, adequate fluids, rest, and behavioral pacing for energy conservation and rehabilitation.
• Instruct in use of dietary supplements as indicated. Illness may suppress appetite, leading to inadequate nutrition. Supplements will allow clients to eat with minimal energy consumption.
• Identify an emergency plan, including criteria for use. Ineffective airway clearance can be life-threatening.
Refer for home health aide services for assistance with ADLs. Clients with decreased oxygenation and copious respiratory secretions are often unable to maintain energy for ADLs.
Assess family for role changes and coping skills. Refer to medical social services as necessary. Clients with decreased oxygenation are unable to maintain role activities and therefore experience frustration and anger, which may pose a threat to family integrity. Family counseling to adapt to role changes may be needed.
For the client dying at home with a terminal illness, if the “ death rattle” is present with gurgling, rattling, or crackling sounds in the airway with each breath, recognize that anticholinergic medications can often help control symptoms, if given early in the process. Anticholinergic medications can help decrease the accumulation of secretions, but do not decrease existing secretions. This medication must be administered early in the process to be effective (Hipp & Letizia, 2009).
For the client with a “death rattle,” nursing care includes turning to mobilize secretions, keeping the head of the bed elevated for postural drainage of secretions, and avoiding suctioning. Suctioning is a distressing and painful event for clients and families, and is rarely effective in decreasing the “death rattle” (Hipp & Letizia, 2009).
Client/Family Teaching and Discharge Planning:
Teach the importance of not smoking. Refer to a smoking cessation program, and encourage clients who relapse to keep trying to quit. Consider using the Motivational Interviewing technique to increase motivation for smoking cessation. Ensure that client receives appropriate medications to support smoking cessation from the primary health care provider. EB: A systematic review of research demonstrated that the combination of medications and an intensive, prolonged counseling program supporting smoking cessation were effective in promoting long-term abstinence from smoking (Fiore et al, 2008). A Cochrane review found that use of the medication varenicline (Chantix) increased the rate of smoking withdrawal two to three times more than smoking withdrawal without use of medications (Cahill, Stead, & Lancaster, 2008). Another Cochrane study showed using motivational interviewing versus brief advice or usual care yielded a modest but significant increase in quitting smoking (Lai et al, 2010).
Teach the client how to use a flutter clearance device if ordered, which vibrates to loosen mucus and gives positive pressure to keep airways open (Bhowmik et al, 2009; Gosselink et al, 2008). CEB & EB: A study demonstrated that use of the mucus clearance device had improved exercise performance compared with COPD clients who use a sham device (Wolkove et al, 2004). A Cochrane review found that there was no clear evidence that oscillation was more or less effective than other forms of physiotherapy for airway clearance in cystic fibrosis (Morrison & Agnew, 2009).
Teach the client how to use peak expiratory flow rate (PEFR) meter if ordered and when to seek medical attention if PEFR reading drops. Also teach how to use metered dose inhalers and self-administer inhaled corticosteroids as ordered following precautions to decrease side effects.
• Teach the client how to deep breathe and cough effectively. EB: Controlled coughing uses the diaphragmatic muscles, making the cough more forceful and effective (Gosselink et al, 2008).
• Teach the client/family to identify and avoid specific factors that exacerbate ineffective airway clearance, including known allergens and especially smoking (if relevant) or exposure to secondhand smoke.
• Educate the client and family about the significance of changes in sputum characteristics, including color, character, amount, and odor. With this knowledge, the client and family can identify early the signs of infection and seek treatment before acute illness occurs.
• Teach the client/family about the need to take ordered antibiotics until the prescription has run out. Taking the entire course of antibiotics helps to eradicate bacterial infection, which decreases lingering, chronic infection.
• Teach the family of the dying client in hospice with a “death rattle,” that rarely are clients aware of the fluid that has accumulated, and help them find evidence of comfort in the client’s nonverbal behavior (Hipp & Letizia, 2009).
References
Barnett, M. Nursing management of chronic obstructive pulmonary disease. Br J Nurs. 2008;17(21):1314–1318.
Bhowmik, A., et al. Improving mucociliary clearance in chronic obstructive pulmonary disease. Respir Med. 2009;103(4):496–502.
Burns, S.M. Invasive mechanical ventilation (through an artificial airway): volume and pressure modes. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Cahill, K., Stead, L.F., Lancaster, T. Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev. 2008;16(3):CD006103.
Chatzimicael, A., et al. Effect of passive smoking on lung function and respiratory infection. Indian J Pediatr. 2008;75(4):335–340.
Chulay, M., Seckel, M. Suctioning: Endotracheal tube or tracheostomy tube. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Fiore, M.C., et al. Treating tobacco use and dependence clinical practice guideline, 2008 update. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service; 2008.
GOLD. Global strategy for the diagnosis, management, and prevention of COPD (revised 2011). Global Initiative for Chronic Obstructive Lung Disease; 2011.
Gosselink, R., et al. Physiotherapy for adult patients with critical illness: recommendations of the European respiratory society and European society of critical care medicine task force on physiotherapy for critically ill patients. Intensive Care Med. 2008;34:1188–1199.
Hipp, B., Letizia, M.J. Understanding and responding to the death rattle in dying patients. Medsurg Nurs. 2009;18(1):17–21.
Jarvis, C. Physical examination and health, ed 6. St Louis: Elsevier Saunders; 2012.
Johnson, S. Pressure redistribution surfaces: continual lateral rotation therapy and Rotorest lateral rotations surface. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Lai, D.T., Cahill, K., Qin, Y., Motivational interviewing for smoking cessation. Cochrane Database Syst Rev 2010;(1):CD006936.
Lamar, J. Relationship of respiratory care bundle with incentive spirometry to reduced pulmonary complications in a medical general practice unit. Medsurg Nurs. 2012;21(1):33–36.
Morrison, L., Agnew, J., Oscillating devices for airway clearance in people with cystic fibrosis. Cochrane Database Syst Rev 2009;(1):CD006842.
Pedersen, C.M., et al. Endotracheal suctioning of the adult intubated patient—what is the evidence? Intensive Crit Care Nurs. 2009;25(1):21–30.
Perme, C., Chandrashekar, R. Early mobility and walking program for patients in intensive care units: creating a standard of care. Am J Crit Care. 2009;18(3):212–220.
Rauen, C.A., et al. Seven evidence-based practice habits: putting some sacred cows out to pasture. Crit Care Nurs. 2008;28(2):98–123.
Schultz, S. Oxygen saturation monitoring with pulse oximetry. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Seymour, C., et al. Physiologic impact of closed-system endotracheal suctioning in spontaneously breathing patients receiving mechanical ventilation. Respir Care. 2009;54(3):367–374.
Siela, D. Evaluation standards for management of artificial airways. Crit Care Nurse. 2010;30(4):76–78.
Vollman, K., Sole, M. Endotracheal tube and oral care. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Wolkove, N., et al. A randomized trial to evaluate the sustained efficacy of a mucus clearance device in ambulatory patients with chronic obstructive pulmonary disease. Can Respir J. 2004;11(8):567.
Wong, M., Elliott, M. The use of medical orders in acute care oxygen therapy. Br J Nurs. 2009;18(8):462–464.
Woo, T. Pharmacology of cough and cold medicines. J Pediatr Health Care. 2008;22(2):73–79.
Risk for Allergy Response
NOC Outcomes (Nursing Outcomes Classification)
NIC Interventions (Nursing Interventions Classification)
Nursing Interventions and Rationales
• A careful history is important in detecting allergens and avoidance of allergen. EB: Spice allergy is rare but spices are widely used and may be in cosmetics. The diagnoses depends on a good history and well-designed testing; treatment is strict avoidance (Chen & Bahna, 2011). Food allergy is among the most common of the allergic disorders. If food allergy or lactose intolerance is suspected, workup should include a detailed allergy-focused clinical history to determine whether the adverse reaction is typically an immediate (IgE mediated) or more delayed-type (nonIgE mediated) allergic reaction, or whether it may be lactose intolerance; a form of non-allergic hypersensitivity (Waddell, 2011).
Carefully assess the client for allergies. Below is information that is important for clients with allergies. Refer for immediate treatment if anaphylaxis is suspected.
Causes
Common allergens include: Animal dander, Bee stings or stings from other insects, Foods, especially nuts, fish, and shellfish, Insect bites, Medications, Plants, Pollens
Symptoms
Common symptoms of a mild allergic reaction include: Hives (especially over the neck and face), Itching, Nasal congestion, Rashes, Watery, red eyes
Symptoms of a moderate or severe reaction include: Cramps or pain in the abdomen, Chest discomfort or tightness, Diarrhea, Difficulty breathing, Difficulty swallowing, Dizziness or light-headedness, Fear or feeling of apprehension or anxiety, Flushing or redness of the face, Nausea and vomiting, Palpitations, Swelling of the face, eyes, or tongue, Weakness, Wheezing, Unconsciousness
First Aid
For a mild to moderate reaction: Calm and reassure the person having the reaction, as anxiety can worsen symptoms.
1. Try to identify the allergen and have the person avoid further contact with it. If the allergic reaction is from a bee sting, scrape the stinger off the skin with something firm (such as a fingernail or plastic credit card). Do not use tweezers; squeezing the stinger will release more venom.
2. If the person develops an itchy rash, apply cool compresses and over-the-counter hydrocortisone cream.
3. Watch the person for signs of increasing distress.
4. Get medical help. For a mild reaction, a physician may recommend over-the-counter medications (such as antihistamines).
For a severe allergic reaction (anaphylaxis):
1. Check the person’s airway, breathing, and circulation (the ABCs of Basic Life Support). A warning sign of dangerous throat swelling is a very hoarse or whispered voice, or coarse sounds when the person is breathing in air. If necessary, begin rescue breathing and CPR.
3. Calm and reassure the person.
4. If the allergic reaction is from a bee sting, scrape the stinger off the skin with something firm (such as a fingernail or plastic credit card). Do not use tweezers—squeezing the stinger will release more venom.
5. If the person has emergency allergy medication on hand, help the person take or inject the medication. Avoid oral medication if the person is having difficulty breathing.
6. Take steps to prevent shock. Have the person lie flat, raise the person’s feet about 12 inches, and cover him or her with a coat or blanket. Do NOT place the person in this position if a head, neck, back, or leg injury is suspected or if it causes discomfort.
Do NOT
• Do NOT assume that any allergy shots the person has already received will provide complete protection.
• Do NOT place a pillow under the person’s head if he or she is having trouble breathing. This can block the airways.
• Do NOT give the person anything by mouth if the person is having trouble breathing.
Prevention
Avoid triggers such as foods and medications that have caused an allergic reaction (even a mild one) in the past. Ask detailed questions about ingredients when you are eating away from home. Carefully examine ingredient labels.
• If you have a child who is allergic to certain foods, introduce one new food at a time in small amounts so you can recognize an allergic reaction.
• People who know that they have had serious allergic reactions should wear a medical ID tag.
• If you have a history of serious allergic reactions, carry emergency medications (such as a chewable form of diphenhydramine and injectable epinephrine or a bee sting kit) according to your health care provider’s instructions.
• Do not use your injectable epinephrine on anyone else. They may have a condition (such as a heart problem) that could be negatively affected by this drug. EB: Although first-time exposure may only produce a mild reaction, repeated exposures may lead to more serious reactions. Once a person has had an exposure or an allergic reaction (is sensitized), even a very limited exposure to a very small amount of allergen can trigger a severe reaction. Most severe allergic reactions occur within seconds or minutes after exposure to the allergen. However, some reactions can occur after several hours, particularly if the allergen causes a reaction after it has been eaten. In very rare cases, reactions develop after 24 hours.
• Anaphylaxis is a sudden and severe allergic reaction that occurs within minutes of exposure. Immediate medical attention is needed for this condition. Without treatment, anaphylaxis can get worse very quickly and lead to death within 15 minutes (Medline Plus, 2012).
Refer for skin testing to confirm IgE-mediated allergic response. EB: Identifying clients who are less sensitive is important, so that they can be started on immunotherapy. An informal survey of low-reacting clients treated with immunotherapy showed a high degree of success (Boyles & John, 2011). Allergy testing serves to confirm an allergic trigger suspected on the basis of history (Sicherer & Wood, 2012).
Note: Do not use serum-specific IgG testing in the diagnosis of food allergy (NICE [National Institute for Health and Clinical Excellence] clinical guideline, 2011).
• See care plans for Latex Allergy Response and Risk for Latex Allergy Response.
Teach parents and children with allergies to peanuts and tree nuts to avoid them and to identify them. EB: Dietary avoidance is the primary management of these allergies and requires the ability to identify peanuts or tree nuts. Treatment of nut allergies with dietary avoidance should include education for both adults and children on identification of peanuts and tree nuts (Hostetler et al, 2012).
Suspect FPIES (food protein-induced enterocolitis syndrome) in formula-fed infants with repetitive emesis, diarrhea, dehydration, and lethargy 1 to 5 hours after ingesting the offending food (the most common are cow’s milk, soy, and rice). Remove the offending food. EB: Early recognition of FPIES and removal of the offending food is important to prevent misdiagnosis and mismanagement of symptoms from other causes. Close follow-up is required to determine when foods may be added back into the diet. FPIES typically occurs before 6 months of age. Diagnosis is made by history and physician-supervised oral food challenges (Leonard & Nowak-Wegrzyn, 2011).
Children should be screened for seafood allergies and avoid seafood and any foods containing seafood if an allergy is detected. EB: Seafood allergy is now a leading cause of anaphylaxis in both the United States and Australia. This study confirmed a seafood as common and important cause of food allergy in Australian children, presenting with a high rate of anaphylaxis (Turner et al, 2011).
References
Boyles, J.H., Jr., John, H. A comparison of techniques for evaluating IgE-mediated allergies. ENT: Ear Nose Throat J. 2011;90(4):164–169.
Chen, J.L., Bahna, S. Spice allergy. Ann Allergy Asthma Immunol. 2011;107(3):191–199.
Hostetler, T.L., et al. The ability of adults and children to visually identify peanuts and tree nuts. Ann Allergy Asthma Immunol. 2012;108(1):25–29.
Leonard, S.A., Nowak-Wegrzyn, A. Food protein-induced enterocolitis syndrome: an update on natural history and review of management. Ann Allergy Asthma Immunol. 2011;107(2):95–100.
Medline Plus. Allergic reactions: causes, symptoms, first aid, prevention. Retrieved May 2012 from http://www.nlm.nih.gov/medlineplus/ency/article/000005.htm.
NICE, CG 116, Food allergy in children and young people: diagnosis and assessment of food allergy in children and young people in primary care and community settings, 2011 Retrieved May 2, 2012, from http://publications.nice.org.uk/food-allergy-in-children-and-young-people-cg116/guidance
Sicherer, S., Wood, R. Allergy testing in childhood: using allergen-specific IgE tests. Pediatrics. 2012;129(1):193–197.
Turner, P., et al. Seafood allergy in children: a descriptive study. Ann Allergy Asthma Immunol. 2011;106(6):494–501.
Waddell, L. Living with food allergy. J Fam Health Care. 2011;21(4):21–28.
Anxiety
NANDA-I
A vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat
Defining Characteristics
Behavioral
Diminished productivity; expressed concerns due to change in life events; extraneous movement; fidgeting; glancing about; insomnia; poor eye contact; restlessness; scanning; vigilance
Affective
Apprehensive; anguish; distressed; fearful; feelings of inadequacy; focus on self; increased wariness; irritability; jittery; overexcited; painful increased helplessness; persistent increased helplessness; rattled; regretful; uncertainty; worried
Physiological
Facial tension; hand tremors; increased perspiration; increased tension; shakiness; trembling; voice quivering
Sympathetic
Anorexia; cardiovascular excitation; diarrhea; dry mouth; facial flushing; heart pounding; increased blood pressure; increased pulse; increased reflexes; increased respiration; pupil dilation; respiratory difficulties; superficial vasoconstriction; twitching; weakness
Parasympathetic
Abdominal pain; decreased blood pressure; decreased pulse; diarrhea; faintness; fatigue; nausea; sleep disturbance; tingling in extremities; urinary frequency; urinary hesitancy; urinary urgency
Cognitive
Awareness of physiological symptoms; blocking of thought; confusion; decreased perceptual field; difficulty concentrating; diminished ability to learn; diminished ability to problem solve; fear of unspecified consequences; forgetfulness; impaired attention; preoccupation; rumination; tendency to blame others
Related Factors (r/t)
Change in: economic status, environment, health status, interaction patterns, role function, role status; exposure to toxins; familial association; heredity; interpersonal contagion; interpersonal transmission; maturational crises; situational crises; stress; substance abuse; threat of death; threat to: economic status, environment, health status, interaction patterns, role function, role status; self-concept; unconscious conflict about essential goals of life; unconscious conflict about essential values; unmet needs
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Identify and verbalize symptoms of anxiety
• Identify, verbalize, and demonstrate techniques to control anxiety
• Verbalize absence of or decrease in subjective distress
• Have vital signs that reflect baseline or decreased sympathetic stimulation
• Have posture, facial expressions, gestures, and activity levels that reflect decreased distress
• Demonstrate improved concentration and accuracy of thoughts
• Demonstrate return of basic problem-solving skills
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Assess the client’s level of anxiety and physical reactions to anxiety (e.g., tachycardia, tachypnea, nonverbal expressions of anxiety). Consider using the Hamilton Anxiety Scale, which grades 14 symptoms on a scale of 0 (not present) to 4 (very severe). Symptoms evaluated are mood, tension, fear, insomnia, concentration, worry, depressed mood, somatic complaints, and cardiovascular, respiratory, gastrointestinal, genitourinary, autonomic, and behavioral symptoms. EBN: Anxiety is a risk factor for major adverse cardiac risk events in persons with stable coronary artery disease (Frasure-Smith & Lesperance, 2008).
• Rule out withdrawal from alcohol, sedatives, or smoking as the cause of anxiety. EB: Military personnel sent to war zones have higher levels of depression that are often exacerbated by alcohol and sedative use (Gale et al, 2010). When withdrawing from either sedatives or alcohol, participants in this study demonstrated elevated levels of anxiety and nervousness (McCabe et al, 2011).
• Use empathy to encourage the client to interpret the anxiety symptoms as normal. EBN: The way a nurse interacts with a client influences his/her quality of life. Providing psychological and social support can reduce the symptoms and problems associated with anxiety (Wagner & Bear, 2009).
• If irrational thoughts or fears are present, offer the client accurate information and encourage him or her to talk about the meaning of the events contributing to the anxiety. EBN: Avoid and suppress painful emotions, thoughts, and sensations, and limit their involvement in meaningful activities (Hayes-Skelton et al, in press).
• Encourage the client to use positive self-talk. EBN: Reducing negative self-talk and increasing positive self-talk can be beneficial for all types of anxiety (Hill, 2010).
• Intervene when possible to remove sources of anxiety. EBN: Removing or reducing sources of stress and anxiety among patients has been shown to decrease hypertension and comorbid conditions (Lobjanidze et al, 2010).
• Explain all activities, procedures, and issues that involve the client; use nonmedical terms and calm, slow speech. Do this in advance of procedures when possible, and validate the client’s understanding. EBN: Effective nurse-client communication is critical to efficient care provision (Finke et al, 2008).
• Provide backrubs/massage for the client to decrease anxiety. EBN: Massage was shown to be an excellent method for reducing anxiety (Labrique-Walusis et al, 2010).
• Use therapeutic touch and healing touch techniques. EBN: Healing touch may be one of the most useful nursing interventions available to reduce anxiety (Maville et al, 2008).
• Guided imagery can be used to decrease anxiety. EBN: Anxiety was decreased with the use of guided imagery during an intervention for postoperative pain (Thomas & Sethares, 2010).
• Suggest yoga to the client. EB: Yoga and massage lessened anxiety in burn patients (Parlak et al, 2010).
• Provide clients with a means to listen to music of their choice or audiotapes. EBN: Music had a positive effect on reducing anxiety in reviewed studies on music listening and postoperative anxiety and pain (Nilsson, 2008).
Monitor the client for depression. Use appropriate interventions and referrals. EB: Anxiety and depression are associated with overall health status, emotional and cognitive functioning, and fatigue (Beaudreau & O’Hara, 2008).
• Older adults report less worry than younger adults. EB: While older adults worry less than their younger counterparts, cognitive-behavioral therapy helped both groups lower levels of worry (Mora et al, 2009).
• Observe for adverse changes if antianxiety drugs are taken. EB: Older adults are notably vulnerable to adverse drug reactions, particularly during unexpected hospitalizations (Bilyeu et al, 2011).
Multicultural:• Assess for the presence of culture-bound anxiety states. EBN: Because of the way in which the African American family has been forced into a structured matrifocal system, African American women in particular have suffered from culture-bound anxiety more often than their male counterparts (Cherry & Giger, 2008).
• Identify how anxiety is manifested in the culturally diverse client. EBN: Cultural and cultural health beliefs are a basic foundation for understanding anxiety in a population (Clear, 2008).
• For diverse clients experiencing preoperative anxiety, provide music of their choice. EBN: This exploratory study demonstrated the positive impact of live music as a holistic patient intervention directed toward reducing pain, anxiety, and muscle tension during the preoperative, intraoperative, and postoperative periods (Sand-Jecklin & Emerson, 2010).
• The above interventions may be adapted for home care use.
Assess for suicidal ideation. Implement emergency plan as indicated. Suicidal ideation may occur in response to co-occurring depression or a sense of hopelessness over severe anxiety symptoms or once antidepressant medications have been started (Mitchell et al, 2009). See care plan for Risk for Suicide.
• Assess for influence of anxiety on medical regimen. EBN: The ability to direct attention is necessary for self-care and independence and was reduced for several months after surgery in older women newly diagnosed with breast cancer (Larsson et al, 2008).
• Assess for presence of depression. Depression and anxiety co-occur frequently (Schoevers et al, 2008).
• Assist family to be supportive of the client in the face of anxiety symptoms. EBN: Supporting the formal and information caregivers of a patient with anxiety as well as the patient may improve overall patient outcomes and allows the family to fully understand the problems the patient is experiencing (Kang et al, 2011).
Consider referral for the prescription of antianxiety or antidepressant medications for clients who have panic disorder (PD) or other anxiety-related psychiatric disorders. EBN: The use of antidepressants, especially SSRI medications, is effective in many cases of anxiety (Katzman, 2009).
Assist the client/family to institute medication regimen appropriately. Instruct in side effects, importance of taking medications as ordered, and effects to report immediately to nurse or physician. Patient interviews revealed that patients’ values and beliefs, barriers to treatment, and prior medication-taking behavior were of primary importance in understanding medication discontinuance (Garavalia et al, 2011).
Refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen. EBN: Providing home health services for patients with anxiety increases self efficacy and reduces symptoms of anxiety, stress, and depression (Shelby et al, 2009).
Client/Family Teaching and Discharge Planning:
Teach use of appropriate community resources in emergency situations (e.g., suicidal thoughts), such as hotlines, emergency departments, law enforcement, and judicial systems. EB: The method of suicide prevention found to be most effective is a systematic, direct-screening procedure that has a high potential for institutionalization (Simon et al, 2007).
• Teach the client/family the symptoms of anxiety. EBN: Teach families to have a general understanding of what is happening to patient with anxiety and help them to accept assistance to overcome their anxiety (Smith et al, 2011).
• Teach the client techniques to self-manage anxiety. EBN: Teaching clients anxiety reduction techniques can help them manage side effects with self-care behaviors (Lu & Wykle, 2007).
• Teach the client to visualize or fantasize about the absence of anxiety or pain, successful experience of the situation, resolution of conflict, or outcome of procedure. EBN: Use of guided imagery has been useful for reducing anxiety (Tyron & McKay, 2009).
• Teach relationship between a healthy physical and emotional lifestyle and a realistic mental attitude. EBN: Some aspects of healthy lifestyle for anxiety disorders include identifying unhealthy relationships, building a strong support system, and adopting general healthy lifestyle habits (Smith et al, 2011).
References
Beaudreau, S., O’Hara, R. Late-life anxiety and cognitive impairment: a review. Am J Geriatr Psychiatry. 2008;16(10):790–803.
Bilyeu, K., et al. Cultivating quality: reducing the use of potentially inappropriate medications in older adults. Am J Nurs. 2011;111(1):47–52.
Cherry, B., Giger, J. African-Americans. In Giger J., Davidhizar R., eds.: Transcultural nursing: assessment and intervention, ed 5, St Louis: Mosby, 2008.
Clear, G. A re-examination of cultural safety: a national imperative. Nurs Prax N Z. 2008;24:2.
Finke, E., Light, J., Kitko, L. A systematic review of the effectiveness of nurse communication with patients with complex communication needs with a focus on the use of augmentative and alternative communication. J Clin Nurs. 2008;17(16):2102–2115.
Frasure-Smith, N., Lesperance, F. Depression and anxiety as predictors of 2-year cardiac events in patients with stable coronary artery disease. Arch Gen Psychiatry. 2008;65(1):62–71.
Gale, C., Wilson, J., Deary, I. Globus sensation and psychopathology in men: the Vietnam experience. Psychosomat Med. 2010;71(9):1026–1031.
Garavalia, L., et al. Medication discussion question: developing a guide to facilitate patient-clinician communication about heart medications. J Cardiovasc Nurs. 2011;26(4):E12–E29.
Hayes-Skelton S, Orsillo S, Roemer L: An acceptance-based behavioral therapy for individuals with generalized anxiety disorder, Cogn Behav Ther, in press.
Hill, J., Less perfection, less stress, 2010 Retrieved November 6, 2011, from http://thestressreliefhandbook.com/2010/02/less-perfection-less-stress
Kang, X., Li, Z., Nolan, M. Informal caregivers’ experiences of caring for patients with chronic heart failure: systematic review and metasynthesis of qualitative studies. J Cardiovasc Nurs. 2011;26(5):386–394.
Katzman, M. Current considerations in the treatment of generalized anxiety disorder. CNS Drugs. 2009;23(2):103–120.
Labrique-Walusis, F., Keister, K., Russell, A. Massage therapy for stress management: Implications for nursing practice. Orthopaedic Nursing. 2010;29(4):254–257.
Larsson, I., et al. Women’s experience of physical activity following breast cancer treatment. Scand J Caring Sci. 2008;22(3):422–429.
Lobjanidze, N., et al. Interaction between depression-anxiety disorders and hypertension. J Hypertension. 2010;28:e94.
Lu, Y., Wykle, M. Relationships between caregiver stress and self-care behaviors in response to symptoms. Clin Nurs Res. 2007;16(1):29–43.
McCabe, S., et al. Medical misuse of controlled medications among adolescents. Arch Pediatr Adolesc Med. 2011;165(8):729–735.
Maville, J., Bowen, J., Benham, G. Effect of healing touch on stress perception and biological correlates. Holist Nurs Pract. 2008;22(2):103–110.
Mora, P., et al. Cognitive-behavioral therapy reduces worry in older adults. J Psychosoc Nurs Ment Health Serv. 2009;47(6):10–11.
Mitchell, A., et al. Depression, anxiety and quality of life in suicide survivors. Arch Psychiatr Nurs. 2009;23(1):2–10.
Nilsson, U. The anxiety and pain reducing effects of music interventions: a systematic review. AORN J. 2008;87(4):780–807.
Parlak, G., Polat, S., Nuran, A. Itching, pain, and anxiety levels are reduced with massage therapy and yoga stretching in burned adolescents. J Burn Care Res. 2010;31(3):429–432.
Sand-Jecklin, K., Emerson, H. The impact of a live therapeutic music intervention on patients’ experience of pain, anxiety, and muscle tension. Holist Nurs Pract. 2010;24(1):7–15.
Schoevers, R., Van, H.L., Koppelmans, V., et al. Managing the patient with co-morbid depression and an anxiety disorder. Drugs. 2008;68(12):1621–1634.
Shelby, R., et al. Pain catastrophizing in patients with noncardiac chest pain: relationships with pain, anxiety, and disability. Psychosomat Med. 2009;71(8):861–868.
Simon, N., et al. The association of comorbid anxiety disorders with suicide attempts and suicidal ideation in outpatients with bipolar disorder. J Psychiatr Res. 2007;41(3-4):255–264.
Smith, M., Jaffe-Gill, E., Segal, J., Generalized anxiety disorder (GAD): symptoms, treatment, and self-help, 2011 Accessed July 25, 2012, at http://helpguide.org/mental/generalized_anxiety_disorder.htm
Thomas, K., Sethares, K. Is guided imagery effective in reducing pain and anxiety in the postoperative total joint arthroplasty patient? Orthopaedic Nursing. 2010;29(6):393–399.
Tyron, W., McKay, D. Memory modification as an outcome variable in anxiety disorder treatment. J Anxiety Disord. 2009;23(4):546–556.
Wagner, D., Bear, M. Patient satisfaction with nursing care: a concept analysis within a nursing framework. J Adv Nurs. 2009;65(3):692–701.
Death Anxiety
NANDA-I
Vague uneasy feeling of discomfort or dread generated by perceptions of a real or imagined threat to one’s existence
Defining Characteristics
Reports concerns of overworking the caregiver; reports deep sadness; reports fear of developing terminal illness; reports fear of loss of mental abilities when dying; reports fear of pain related to dying; reports fear of premature death; reports fear of the process of dying; reports fear of prolonged dying; reports fear of suffering related to dying; reports feeling powerless over dying; reports negative thoughts related to death and dying; reports worry about the impact of one’s own death on significant others
Related Factors (r/t)
Anticipating adverse consequences of general anesthesia; anticipating impact of death on others; anticipating pain; anticipating suffering; confronting reality of terminal disease; discussions on topic of death; experiencing dying process; near-death experience; nonacceptance of own mortality; observations related to death; perceived proximity of death; uncertainty about an encounter with a higher power; uncertainty about the existence of a higher power; uncertainty about life after death; uncertainty of prognosis
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Assess the psychosocial maturity of the individual. EB: As psychosocial maturity and age increase, death anxiety decreases. Findings have shown that psychosocial maturity is a better predictor of death anxiety than is age (Halliday & Boughton, 2008).
Assess clients for pain and provide pain relief measures. EBN: Managing pain takes a multidisciplinary approach in palliative care of the dying client (Ferrell et al, 2008).
• Assess client for fears related to death. EBN: Acknowledging and responding to these fears is the core of end-of-life palliative care (Nadworny, 2007).
• Assist clients with life planning: consider and redefine main life goals, focus on areas of strength and/or goals that will provide satisfaction, adopt realistic goals, and recognize those that are impossible to achieve. EB: Life planning processes affect self-esteem and self-concept by changing unrealistic goals (Ferrell et al, 2008).
• Assist clients with life review and reminiscence. EB: When challenges emerged, the participants implemented “the search to find an acceptable and satisfying completion to this life,” engaging family members, friends, and the hospice team in an effort to relieve discomfort and regain a degree of control (McSherry, 2011).
• Provide music of a client’s choosing. EBN: Traditionally, music has played an important role in human culture and has had a powerful influence on human behavior. Music has a unique capacity for immersing an individual to such a degree that the closeness can be felt and painful aloneness may be alleviated (Chi & Young, 2011).
• Provide social support for families, understanding what is most important to families who are caring for clients at the end of life. EBN: When nurses make the intensive care unit a comfortable place for the dying patients and their loved ones, we also make the patients’ deaths comfortable for us (Millner et al, 2009).
• Encourage clients to pray. EBN: Prayer, scripture reading, and clergy visits were found to comfort some hospice clients, but sometimes specific religious tenets may be troubling and need to be resolved before the client can find peace (Gilbert, 2008).
• Carefully assess older adults for issues regarding death anxiety. EB: Elderly in this study and review revealed higher fear for others than of the dying process. Women showed greater fear for the death of loved ones and for the consequences of their own death on those loved ones than did men (Azaiaz, et al, 2011).
• Provide back massage for clients who have anxiety regarding issues such as death. EBN: Massage significantly decreased anxiety or perception of tension (Frenkel & Shah, 2008).
• Assist clients to identify with their culture and its values. EB/EBN: Christians scored significantly lower for death anxiety than both nonreligious and Muslim groups, and Muslims scored significantly higher than the nonreligious group (Gareth & McAdie, 2009).
• The above interventions may be adapted for home care.
• Identify times and places when anxiety is greatest. Provide for psychological support at those times, using such strategies as personal contact, telephone contact, diversionary activities, or therapeutic self.
• Support religious beliefs; encourage client to participate in services and activities of choice. Belief in a supreme being/higher power provides a feeling of ever-present help (Gilbert, 2008).
Refer to medical social services or mental health services, including support groups as appropriate (e.g., anticipatory grieving groups from hospice, visiting volunteers of hospice. Communication, particularly active listening and attention to spiritual and religious needs, enhances the perceived quality of the dying experience (McWilliam et al, 2008).
• Encourage the client to verbalize feelings to family/caregivers, counselors, and self. Expression of feelings relieves fear burden and allows examination and validation of feelings (Bluck et al, 2008).
• Identify client’s preferences for end-of-life care; provide assistance in honoring preferences as much as practicable. EB: Many changes occur in the final hours of life. Family members of those dying at home need to be prepared for these changes, both to understand what is happening and to provide care (Kehl et al, 2008).
Assist the client in making contact with death-related planning organizations, if appropriate, such as the Cremation Society and funeral homes.
Refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen. Psychiatric home care nurses can address issues relating to client’s death anxiety, including family relationships.
Client/Family Teaching and Discharge Planning:
• Promote more effective communication to family members engaged in the caregiving role. Encourage them to talk to their loved one about areas of concern. Both caregivers and care receivers avoid discussing. EBN: Encouraging loved ones to discuss their wishes and areas of concern will assist the family during the grieving process as they will know the wishes of the dying family member and can carry them out as much as possible (Webb & Guarino, 2011).
• Allow family members to be physically close to their dying loved one, giving them permission, instruction, and opportunities to touch. Keep family members informed. EBN: Helping family to know exactly what is happening and what to expect also eases the process for them and the patient (McWilliam et al, 2008).
• To increase clients’ knowledge about end-of-life issues, teach them and their family members about options for care, such as advance directives. EBN: Educating clients and families about end-of-life options will provide security and reduce anxiety (Kehl et al, 2008).
References
Azaiza, F., et al. Death and dying anxiety among bereaved and nonbereaved elderly parents. Death Stud. 2011;35(7):610–624.
Bluck, S., et al. Life experience with death; related to death attitudes and to the use of death related memories. Death Stud. 2008;32(6):524–549.
Chi, G., Young, A. Selection of music for relaxation and alleviating pain: literature review. Holist Nurs Pract. 2011;25(3):127–135.
Ferrell, B., Levy, M.H., Paice, J. Managing pain from advanced cancer in the palliative care setting. Clin J Oncol Nurs. 2008;12(4):575–581.
Frenkel, M., Shah, V. Complementary medicine can benefit palliative care-part 2. J Palliat Care. 2008;15(6):288–293.
Gareth, J.M., McAdie, T. Are personality, well-being and death anxiety related to religious affiliation? Ment Health Relig Cult. 2009;12(2):115–120.
Gilbert, R.B. More than a parting prayer: lessons in care-giving for the dying. Crisis Loss. 2008;16(3):261–263.
Halliday, L., Boughton, M. The moderating effect of death experience on death anxiety: implications for nursing education. J Hosp Palliat Nurs. 2008;10(2):76–82.
Kehl, K.A., et al. Materials to prepare families for dying at home. J Palliat Med. 2008;11(7):969–972.
McSherry, C. The inner life at the end of life. J Hospice Palliat Care. 2011;13(2):112–120.
McWilliam, C., et al. Living while dying/Dying while living: older clients’ sociocultural experiences of home based palliative care. J Hospice Palliat Care. 2008;10(6):338–349.
Millner, P., Paskiewicz, S., Kautz, D. A comfortable place to say good-bye. Dimen Crit Care Nurs. 2009;28(1):13–17.
Nadworny, S.W. The hospital vigil, fulfilling a patient’s wish not to die alone. Caring. 2007;26(11):52–54.
Webb, J., Guarino, A. Life after death of a loved one: long term distress among surrogate decision makers. J Hospice Palliat Care. 2011;13(6):378–386.
Risk for Aspiration
NANDA-I
At risk for entry of gastrointestinal secretions, oropharyngeal secretions, solids, or fluids into the tracheobronchial passages
Risk Factors
Decreased gastrointestinal motility; delayed gastric emptying; depressed cough; depressed gag reflex; facial surgery; facial trauma; gastrointestinal tubes; incompetent lower esophageal sphincter; increased gastric residual; increased intragastric pressure; impaired swallowing; medication administration; neck trauma; neck surgery; oral surgery; oral trauma; presence of endotracheal tube; presence of tracheostomy tube; reduced level of consciousness; situations hindering elevation of upper body; tube feedings; wired jaws
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Monitor respiratory rate, depth, and effort. Note any signs of aspiration such as dyspnea, cough, cyanosis, wheezing, hoarseness, foul-smelling sputum, or fever. If new onset of symptoms, perform oral suction and notify provider immediately. Signs of aspiration should be detected as soon as possible to prevent further aspiration and to initiate treatment that can be lifesaving (Buckley & Cabrera, 2011). Because of laryngeal pooling and residue in clients with dysphagia, silent aspiration may occur (Guy & Smith, 2009).
• Auscultate lung sounds frequently and before and after feedings; note any new onset of crackles or wheezing. CEB: Auscultation of lung sounds was shown to be specific in identifying clients at risk for aspirating (Shaw et al, 2004).
• Take vital signs frequently, noting onset of a temperature, increased respiratory rate.
• Before initiating oral feeding, check client’s gag reflex and ability to swallow by feeling the laryngeal prominence as the client attempts to swallow. A client can aspirate even with an intact gag reflex (Wieseke, Bantz, & Siktberg, 2008). If client is having problems swallowing, see nursing interventions for Impaired Swallowing.
• If client needs to be fed, feed slowly and allow adequate time for chewing and swallowing. CEB: Multiple studies have found that it takes 35 minutes or more to feed a client who wants to eat (Simmons, 2008; Simmons, Osterweil, & Schnelle, 2001; Simmons & Schnelle, 2004).
• When feeding client, watch for signs of impaired swallowing or aspiration, including coughing, choking, and spitting food.
• Have suction machine available when feeding high-risk clients. If aspiration does occur, suction immediately. A client with aspiration needs immediate suctioning and may need further lifesaving interventions such as intubation.
• Keep the head of bed elevated at 30 to 45 degrees, preferably sitting up in a chair at 90 degrees when feeding. Keep head elevated for an hour afterward. Maintaining a sitting position with and after meals can help decrease aspiration pneumonia (Guy & Smith, 2009).
Note presence of any nausea, vomiting, or diarrhea. Treat nausea promptly with antiemetics.
• If the client shows symptoms of nausea and vomiting, position on side. The side-lying position can help the client expel the vomitus, and decrease possible aspiration.
• Listen to bowel sounds frequently, noting if they are decreased, absent, or hyperactive. Decreased or absent bowel sounds can indicate an ileus with possible vomiting and aspiration; increased high-pitched bowel sounds can indicate a mechanical bowel obstruction with possible vomiting and aspiration (Longo et al, 2012).
• Note new onset of abdominal distention or increased rigidity of abdomen. Abdominal distention or rigidity can be associated with paralytic or mechanical obstruction and an increased likelihood of vomiting and aspiration (Longo et al, 2012).
If client has a tracheostomy, ask for referral to speech pathologist for swallowing studies before attempting to feed. After the evaluation, the decision should be made to have cuff either inflated or deflated when client eats. EB: Studies have shown that use of speaking valves for the client with a tracheostomy may reduce risk of aspiration when the client eats (Baumgartner, Bewyer, & Bruner, 2008). CEB: A study found that a tracheostomy was not associated with increased aspiration (Sharma et al, 2007).
• Provide meticulous oral care including brushing of teeth at least two times per day. Good oral care can prevent bacterial or fungal contamination of the mouth, which can be aspirated. EB: Research has shown that excellent dental care/oral care can be effective in preventing hospital-acquired (or extended care–acquired) pneumonia (Arpin, 2009; Ishikawa et al, 2008; Sarin et al, 2008).
Enteral Feedings
Insert nasogastric feeding tube using the internal nares to distal-lower esophageal-sphincter distance, an updated version of the Hanson method. The ear-to-nose-to-xiphoid-process is often inaccurate. CEB: A study demonstrated that the revised Hanson’s method was more accurate in predicting the correct distance than the traditional method (Ellet et al, 2005).
Tape the feeding tube securely to the nose using a skin protectant under the tape. EBN: A research study found that insertion of the feeding tube into the small intestine and keeping the head of the bed position elevated to at least 30 degrees reduced the incidence of aspiration and aspiration-related pneumonia drastically in critically ill clients (Metheny, Davis-Jackson, & Stewart, 2010). Another study found that aspiration and pneumonia were reduced by feeding the clients in the mid-duodenum or further in the small intestine (Metheny, Stewart, & McClave, 2011).
Check to make sure the initial nasogastric feeding tube placement was confirmed by x-ray, with the openings of the tube in the stomach, not the esophagus, or lungs. This is especially important if a small-bore feeding tube is used, although larger tubes used for feedings or medication administration should be verified by x-ray also. X-ray verification of placement remains the gold standard for determining safe placement of feeding tubes (Bankhead et al, 2009; Guenter, 2010).
• After x-ray verification of correct placement of the tube or the intestines, mark the tube’s exit site clearly with tape or a permanent marker (Simons & Abdallah, 2012)
• Measure and record the length of the tube that is outside of the body at defined intervals to help ensure correct placement. Note the length of the tube outside of the body; it is possible for a tube to slide out and be in the esophagus, without obvious disruption of the tape (Bankhead et al, 2009).
• Note the placement of the tube on any chest or abdominal x-rays that are done on the client. Acutely ill clients receive frequent x-rays. These are available for the nurse to determine continued correct placement of the NG tube (Simons & Abdallah, 2012).
• Check the pH of the aspirate. If the pH reading is 4 or less, the tube is probably in the stomach. Recognize that the pH may not indicate correct placement if the client is receiving continuous tube feedings, is receiving a hydrogen ion blocker or proton pump inhibitor, has blood in the aspirate, or is receiving antacids (Bankhead et al, 2009; Simons & Abdallah, 2012).
• Utilize a number of determinants of correct placement for verification of correct placement before each feeding or every 4 hours if client is on continuous feeding. Measure length of tube outside of body, any recent x-ray results, pH of aspirate if relevant, and characteristic appearance of aspirate. If findings do not ensure correct placement of the tube, obtain an x-ray to verify placement. Do not rely on the air insufflation method. CEB & EBN: The auscultatory air insufflation method is not reliable for differentiating between gastric or respiratory placement; the “whooshing sound can be heard even if the tube is incorrectly placed in the lung (Bankhead et al, 2009; Metheny, 2006; Simons & Abdallah, 2012).
Follow unit policy regarding checking for gastric residual volume during continuous feedings or before feedings, and holding feedings if increased residual feeding is present. CEB & EBN: There is little evidence to support the use of measurement of gastric residual volume, and the practice may or may not be effective in preventing aspiration (Makic et al, 2011; Metheny, 2006; Metheny et al, 2008). It is still done at intervals (Bankhead et al, 2009) especially if there is a question of tube feeding intolerance. The practice of holding tube feedings if there is increased residual reduces the amount of calories given to the client. If the client has a small-bore feeding tube, it is difficult to check gastric residual volume and may be inaccurate. It may be prudent to use large-bore multiple port tubes during the first few days of tube feedings (Metheny et al, 2008).
• Follow unit protocol regarding returning or discarding gastric residual volume. At this time there is not a definitive research base to guide practice. CEB & EBN: A study of the effectiveness of either returning gastric residual volumes to the client or discarding them resulted in inconclusive findings and more research is needed in the area (Booker Niedringhaus & Eden, 2000; Williams & Leslie, 2010).
• Do not use glucose testing to determine correct placement of enteral tube, and to identify aspirated enteral feeding (Guenter, 2010). EB: Glucose was found in tracheal secretions of clients who were not receiving enteral feedings (Bankhead et al, 2009).
• Do not use blue dye to tint enteral feedings (Guenter, 2010). The presence of blue and green skin and urine and serum discoloration from use of blue dye has been associated with the death of clients (Lucarelli et al, 2004). The FDA has reported at least 12 deaths from the use of blue dye in enteral feedings (USFDA, 2009).
• During enteral feedings, position client with head of bed elevated 30 to 45 degrees (Bankhead et al, 2009). CEB: A study of mechanically ventilated clients receiving tube feedings demonstrated there was an increase of the presence of pepsin (from gastric contents) in pulmonary secretions if the client was in a flat position versus being positioned with head elevated (Metheny et al, 2006). Generally do not turn off the tube feeding when repositioning clients. Stopping the tube feeding during repositioning is counterproductive because the client receives less nutrition and the rate of emptying of the stomach is slow. If it is imperative to keep the head of the bed elevated, consider use of reverse Trendelenburg (head higher than feet) when repositioning (Bankhead et al, 2009; Metheny, 2011a).
• Take actions to prevent inadvertent misconnections with enteral feeding tubes into IV lines, and other harmful places. Safety actions that should be taken to prevent misconnections include:
Trace tubing back to origin. Recheck connections at time of client transfer and at change of shift
Use oral syringes for medications through the enteral feeding; do not use IV syringes
Teach nonprofessional personnel “Do Not Reconnect.” If a line becomes dislodged, find the nurse instead of taking the chance of plugging it into the wrong place. Enteral feeding tube lines have been inadvertently plugged into IV peripheral catheters, peritoneal dialysis catheters, central lines, medical gas tubing, and into tracheostomies sometimes resulting in death (Guenter, 2009; Guenter, 2010).
Critical Care
• Recognize that critically ill clients are at an increased risk for aspiration because of severe illness and interventions that compromise the gag reflex. Predisposing causes to aspiration include: sedation, mechanical ventilation, neurological disorders, altered level of consciousness, hemodynamic instability, and sepsis (Makic et al, 2011).
• Recognize that intolerance to feeding as defined by increased gastric residual is more common early in the feeding process. EB: A study found that feeding intolerance in critical care clients happened commonly in the first 5 days of feeding, and feeding intolerance was associated with increased length of both critical care and hospital length of stay (O’Connor et al, 2011).
• Carefully check elderly client’s gag reflex and ability to swallow before feeding. A slowed rate of swallowing is common in older clients (Palmer & Metheny, 2008).
• Watch for signs of aspiration pneumonia in the elderly with cerebrovascular accidents, even if there are no apparent signs of difficulty swallowing or of aspiration. Bedside evaluation for swallowing and aspiration can be inaccurate. EB: Silent aspiration can occur in the elderly population (Butler et al, 2009).
Recognize that the elderly with aspiration pneumonia have fewer symptoms than younger people; repeat cases of pneumonia in the elderly are generally associated with aspiration (Eisenstadt, 2010). Aspiration pneumonia can be undiagnosed in the elderly population because of decreased symptoms; sometimes the only obvious symptom may be new onset of delirium (Metheny, 2011b).
Use central nervous system depressants cautiously; elderly clients may have an increased incidence of aspiration with altered levels of consciousness. Elderly clients have altered metabolism, distribution, and excretion of drugs. Many medications can interfere with the swallowing reflex including antipsychotic drugs, proton pump inhibitors and angiotensin-converting enzyme inhibitors (Gallagher & Naidoo, 2009; van der Maarel-Wierink et al, 2011; Wieseke, Bantz, & Siktberg, 2008).
• Keep an elderly, mostly bedridden client sitting upright for 45 minutes to 1 hour following meals. CEB: A study demonstrated that the number of clients developing a fever was significantly reduced when kept sitting upright after eating (Matsui et al, 2002).
• Recommend to families that enteral feedings may or may not be indicated for clients with advanced dementia. Instead if possible use hand-feeding assistance, modified food consistency as needed, and feeding favorite foods for comfort (Easterling & Robbins, 2008; Sorrell, 2010). EB & CEB: Research has demonstrated that tube feedings in this population do not prevent malnutrition or aspiration, improve survival, reduce infections, or result in other positive outcomes (Kuo et al, 2009; Sampson, Candy & Jones, 2009; Teno et al, 2010). Instead there is an increased risk for aspiration pneumonia (Keithley & Swanson, 2004).
• The above interventions may be adapted for home care use.
• For clients at high risk for aspiration, obtain complete information from the discharging institution regarding institutional management.
• Assess the client and family for willingness and cognitive ability to learn and cope with swallowing, feeding, and related disorders.
• Assess caregiver understanding and reinforce teaching regarding positioning and assessment of the client for possible aspiration.
• Provide the client with emotional support in dealing with fears of aspiration. Fear of choking can provoke extreme anxiety, which can interfere with the client’s ability or willingness to adhere to the treatment plan. Refer to care plan for Anxiety.
• Establish emergency and contingency plans for care of client. Clinical safety of client between visits is a primary goal of home care nursing.
Have a speech and occupational therapist assess client’s swallowing ability and other physiological factors and recommend strategies for working with client in the home (e.g., pureeing foods served to client; providing adaptive equipment for independence in eating). Successful strategies allow the client to remain part of the family.
• Obtain suction equipment for the home as necessary.
• Teach caregivers safe, effective use of suctioning devices. Inform client and family that only individuals instructed in suctioning should perform the procedure.
Institute case management of frail elderly to support continued independent living.
References
Arpin, S. Oral hygiene in elderly people in hospitals and nursing homes. Evid Based Dent. 2009;10(2):46.
Bankhead, R., et al. ASPEN enteral nutrition practice recommendations. J Parenter Enteral Nutr. 2009;33(2):122–167.
Baumgartner, C.A., Bewyer, E., Bruner, D. Management of communication and swallowing in intensive care: the role of the speech pathologist. AACN Adv Crit Care. 2008;19(4):433–443.
Booker, K.J., Niedringhaus, L., Eden, B. Comparison of 2 methods of managing gastric residual volumes from feeding tubes. Am J Crit Care. 2000;9(5):318.
Buckley, L., Cabrera, G. Pneumonia aspiration (anaerobic). CINAHL Information Systems. September 2, 2011.
Butler, S.G., et al. Penetration and aspiration in healthy older adults as assessed during endoscopic evaluation of swallowing. Ann Otol Rhinol Laryngol. 2009;118(3):190–198.
Easterling, C.S., Robbins, E. Dementia and dysphagia. Geriatr Nurs. 2008;29(4):275–285.
Eisenstadt, E.S. Dysphagia and aspiration pneumonia in older adults. J Am Acad Nurse Pract. 2010;22(1):17–22.
Ellett, M.L., et al. Predicting the insertion distance for placing gastric tubes. Clin Nurs Res. 2005;14(1):11.
Gallagher, L., Naidoo, P. Prescription drugs and their effects on swallowing. Dysphagia. 2009;24(2):159–166.
Guenter, P. Enteral feeding misconnections. Safe Pract Patient Care. 2009;4(2):1–8.
Guenter, P. Safe practices for enteral nutrition in critically ill patients. Crit Care Nurs Clin North Am. 2010;22(2):197–208.
Guy, J.L., Smith, L.H. Preventing aspiration: a common and dangerous problem for patients with cancer. Clin J Oncol Nurs. 2009;13(1):105–108.
Ishikawa, A., et al. Professional oral health care reduces the number of oropharyngeal bacteria. J Dent Res. 2008;87(6):594–598.
Keithley, J.K., Swanson, B. Enteral nutrition: an update on practice recommendations. Medsurg Nurs. 2004;13(2):131.
Kuo, S., et al. Natural history of feeding-tube use in nursing home residents with advanced dementia. J Am Med Dir Assoc. 2009;10:264–270.
Longo, D., et al. Harrison’s principles of internal medicine, ed 18. New York: McGraw-Hill; 2012.
Lucarelli, M.R., et al. Toxicity of food drug and cosmetic blue No. 1 dye in critically ill patients. Chest. 2004;125(2):793.
Makic, M.B.F., et al. Evidence-based practice habits: putting more sacred cows out to pasture. Crit Care Nurse. 2011;31:38–62.
Matsui, T., et al. Sitting position to prevent aspiration in bed-bound patients. Gerontology. 2002;48(3):194.
Metheny, N.A. Turning tube feeding off while repositioning patients in bed: ask the experts. Crit Care Nurse. 2011;31(2):96–97.
Metheny, N.A. Preventing respiratory complications of tube feedings: evidence-based practice. Am J Crit Care. 2006;15(4):360–369.
Metheny, N.A. Preventing aspiration in older adults with dysphagia. Med-Surg Matters. 2011;20(5):6–7.
Metheny, N.A., et al. Tracheobronchial aspiration of gastric contents in critically ill tube-fed patients: frequency, outcomes, and risk factors. Crit Care Med. 2006;34(4):1007–1015.
Metheny, N.A., Davis-Jackson, J., Stewart, B. Effectiveness of an aspiration risk-reduction protocol. Nurs Res. 2010;59(1):18–25.
Metheny, N.A., et al. Gastric residual volume and aspiration in critically ill patients receiving gastric feedings. Am J Crit Care. 2008;17(6):512–520.
Metheny, N.A., Stewart, B.J., McClave, S.A. Relationship between feeding tube site and respiratory outcomes. J Parenter Enteral Nutr. 2011;35(3):346–355.
O’Connor, S., et al. Nasogastric feeding intolerance in the critically ill —a prospective observational study. Australian Crit Care. 2011;24(1):22.
Palmer, J.L., Metheny, N.A. Preventing aspiration in older adults with dysphagia: aspiration can lead to aspiration pneumonia, a serious health problem for older adults. AJN. 2008;108(2):40–49.
Sampson, E.L., Candy, B., Jones, L. Enteral tube feeding for older people with advanced dementia. Cochrane Database Syst Rev. 2, 2009. [CD007209].
Sarin, J., et al. Reducing the risk of aspiration pneumonia among elderly patients in long-term care facilities through oral health interventions. J Am Med Dir Assoc. 2008;9(2):128–135.
Sharma, O.P., et al. Swallowing disorders in trauma patients: impact of tracheostomy. Am Surg. 2007;73(11):117–1121.
Shaw, J.L., et al. Bronchial auscultation: an effective adjunct to speech and language therapy bedside assessment when detecting dysphagia and aspiration? Dysphagia. 2004;19(4):211.
Simmons, S.F. Feeding. In: Ackley B., et al, eds. Evidence-based nursing care guidelines. Philadelphia: Mosby, 2008.
Simmons, S.F., Schnelle, J.F. Individualized feeding assistance care for nursing home residents: staffing requirements to implement two interventions. J Gerontol A Biol Sci Med Sci. 2004;59(9):M966–M973.
Simmons, S.F., Osterweil, D., Schnelle, J.F. Improving food intake in nursing home residents with feeding assistance: a staffing analysis. J Gerontol A Biol Sci Med Sci. 2001;56(12):M790–M794.
Simons, S.R., Abdallah, L.M. Bedside assessment of enteral tube placement: aligning practice with evidence. AJN. 2012;112(2):40–48.
Sorrell, J. Use of feeding tubes in patients with advanced dementia. J Psychosoc Nurs. 2010;48(5):15–18.
Teno, J.M., et al. Hospital characteristics associated with feeding tube placement in nursing home residents with advanced cognitive impairment. JAMA. 2010;303:544–550.
U.S. Food and Drug Administration (USFDA), Reports of blue discoloration and death in patients receiving enteral feedings tinted with the dye, FD&C Blue no. 1. FDA Public Health Advisory, 2009 Retrieved March 6, 2012, from www.fda.gov/ForIndustry/ColorAdditives/ColorAdditivesinSpecificProducts/InMedicalDevices/ucm142395.htm
van der Maarel-Wierink, C., et al. Risk factors for aspiration pneumonia in frail older people: a systematic literature review. J Am Med Dir Assoc. 2011;12(5):344–354.
Wieseke, A., Bantz, D., Siktberg, L. Assessment and early diagnosis of dysphagia. Geriatr Nurs. 2008;29(6):376–383.
Williams, T., Leslie, G. Should gastric aspirate be discarded or retained when gastric residual volume is removed from gastric tubes? Aust Crit Care. 2010;23(4):215–217.
Risk for impaired Attachment
NANDA-I
At risk for disruption of the interactive process between parent/significant other and child that fosters the development of a protective and nurturing reciprocal relationship
Risk Factors
Anxiety associated with the parent role; disorganized infant behavior; ill child who is unable effectively to initiate parental contact; inability of parent(s) to meet personal needs; lack of privacy; parental conflict resulting from disorganized infant behavior; parent-child separation; physical barriers; premature infant; substance abuse
NOC (Nursing Outcomes Classification)
Caregiver Adaptation to Patient Institutionalization, Child Development, Parent-Infant Attachment, Parenting Performance
Client Outcomes
Parent(s)/Caregiver(s) Will (Specify Time Frame)
• Be willing to consider pumping breast milk (and storing appropriately) or breastfeeding, if feasible
• Demonstrate behaviors that indicate secure attachment to infant/child
• Provide a safe environment, free of physical hazards
• Provide nurturing environment sensitive to infant/child’s need for nutrition/feeding, sleeping, comfort, and social play
• Read and respond contingently to infant/child’s distress
• Support infant’s self-regulation capabilities, intervening when needed
• Engage in mutually satisfying interactions that provide opportunities for attachment
• Give infant nurturing sensory experiences (e.g., holding, cuddling, stroking, rocking)
• Demonstrate an awareness of developmentally appropriate activities that are pleasurable, emotionally supportive, and growth fostering
• Avoid physical and emotional abuse and/or neglect as retribution for parent’s perception of infant/child’s misbehavior
• State appropriate community resources and support services
NIC (Nursing Interventions Classification)
Anticipatory Guidance, Attachment Process, Attachment Promotion, Coping Enhancement, Developmental Care, Parent Education: Infant
Nursing Interventions and Rationales
• Establish a trusting relationship with parent/caregiver. A literature review identified four nursing behaviors to assist parents in forming a therapeutic relationship with staff: emotional support, parent empowerment, a welcoming environment with supportive unit policies, parent education with opportunities to practice new skills through guided participation (Cleveland, 2008). EBN: Although closeness to vulnerable parents is essential in the therapeutic relationship, the process of parent-nurse detachment is equally vital in making parents gradually more independent and able to take on the responsibilities of caring for their child after discharge (Fegran & Helseth, 2009).
• Encourage mothers to breastfeed their infants and provide support. The Baby Friendly Initiative urges that support should be there for the very first breastfeeding, along with unlimited skin-to-skin contact as soon as possible after delivery (Warren, 2008). EBN: By integrating multi-dimensional social support during the early postpartum period, nurses can promote the long-term health of adolescent mothers and their infants (Grassley, 2010).
• Support mothers of preterm infants in providing pumped breast milk to their babies until they are ready for oral feedings and transitioning from gavage to breast. EBN: Measures that help the infant transition to breast include kangaroo care, nonnutritive sucking, avoidance of bottles, and consistent, supportive staff (Nye, 2008). EBN: A Turkish study found stimulation with breast milk odor effective in decreasing length of transition of preterm infants from gavage to oral feeding and associated with shorter length of hospital stay (Yildiz et al, 2011).
• Identify factors related to postpartum depression (PPD)/major depression and offer appropriate interventions/referrals. EBN: Mothers with PPD have been found to have delayed adaptation to their social role, delayed mastery of parenting skills, and a “mechanical” caregiving style (Barr, 2008). A review of the impact of maternal psychopathology on attachment noted that interventions center on “working with a mother’s caregiving behavior to enhance interactive sensitivity” (Wan & Green, 2009).
• Identify eating disorders/comorbid factors related to depression and offer appropriate interventions/referrals. Combined psychological stressors of new motherhood and body image concerns of pregnancy may predispose exacerbation of eating disorder symptoms and development of postpartum mood disorders, in which mothers can be nonresponsive, inconsistent, or rejecting of the infant (Astrachan-Fletcher, et al, 2008).
• Nurture parents so that they in turn can nurture their infant/child. “Helping the mother to be aware of her emotions, behaviors driven by those emotions, and her capacity to regulate them may improve her ability to respond to the infant” (Velez & Jansson, 2008).
• Offer parents opportunities to verbalize their childhood fears associated with attachment. EB: “Parental lack of resolution concerning loss or trauma has been proposed to result in atypical parenting behaviors, which may have a disorganizing effect on the parent-child relationship” (Bernier & Meins, 2008).
• Suggest journaling or scrapbooking as a way for parents of hospitalized infants to cope with stress and emotions. EBN: While scrapbooking with other NICU families, parents are able to discuss concerns, emotions, and anxieties, in the process receiving support from experienced staff and referrals to other disciplines (Eaton & Mullins, 2010).
• Offer parent-to-parent support to parents of NICU infants. EBN: A cross-sectional survey in tertiary-level NICUs in Karnataka, India, found that nursing support reduced stress in mothers of preterm infants (D’Souza, et al, 2009).
• Encourage parents of hospitalized infants to “personalize the baby” by bringing in clothing, pictures of themselves, toys, and tapes of their voices. CEB: These actions help parents claim the infant as their own and support families’ confidence/competence in caring for their infants at their own pace (Lawhon, 2002).
• Encourage physical closeness using skin-to-skin experiences as appropriate. EB: A South Korean study supported the beneficial effects of kangaroo care on premature infants and their mothers: increased height/head circumference and higher maternal attachment scores (Ahn et al, 2010).
• Plan ways for parents to interact/assist with infant/child caregiving. This literature review cited numerous studies showing that when mothers are involved in giving care, they shift from passive to active role, move to more engaged, confident, and connected parenting and from exclusion to participation in their infant’s care (Obeidat, Bond, & Callister, 2009).
• Educate parents about the importance of the infant-caregiver relationship as a foundation for the development of the infant’s self-regulation capacities. EB: Both contingent responsiveness and emotional-affective support model socialization practices and allow parents to support management of infant arousal states (Lynn et al, 2011).
• Assist parents in developing new caregiving competencies and/or revising/extending old ones. CEB: Five caregiving domains are identified: (1) being with infant, (2) knowing infant as a person, (3) giving care, (4) communicating/engaging with others re: infant/parent needs, (5) problem-solving/decision-making/learning (Pridham et al, 1998).
• Educate parents in reading/responding sensitively to their infant’s unique “body language” (behavior cues) that communicate approach (“I’m ready to play”), avoidance/stress (“I’m unhappy. I need a change.”), and self-calming (“I’m helping myself”). EBN: Mothers with lower competence and more technology-dependent children may perceive their children as more vulnerable and cues as harder to read (Holditch-Davis et al, 2011).
• Educate and support parent’s ability to relieve infant/child’s stress/distress. EBN: In facilitated tucking by parents (FTP), a parent holds the infant in a side-lying, fetal position and offers skin-to-skin contact with the hands during a stressful/painful situation (Axelin et al, 2010). EB: Controlled music stimulation appears safe and effective in ameliorating pain/stress in premature infants after heel-sticks (Tramo et al, 2011).
• Guide parents in adapting their behaviors/activities with infant/child cues and changing needs. EB: “For patterns of positive communication to lead to successful regulation of affect, the caregiver must be receptive to the infant’s cues, appropriately responsive, and motivated to foster further opportunities for interactions”(Lynn et al, 2011).
• Attend to both parents and infant/child to strengthen high-quality interactions. The HUG program focuses on three essential skills: understanding newborn state, reading infant cues, appreciating infant capabilities (Tedder, 2008). EB: A mother’s behavioral and brain responses to her infant’s cues may be important predictors of infant development; in cases of maternal depression or substance abuse, an infant’s smiling face may fail to elicit positive caregiving (Strathearn et al, 2008).
• Assist parents with providing pleasurable sensory learning experiences (i.e., sight, sound, movement, touch, and body awareness). EBN: Using music with preterm infants may enhance neurobehavioral and physiological functioning (Neal & Lindeke, 2008).
• Encourage parents and caregivers to massage their infants and children. EB: Preliminary studies suggest that infant massage combined with kinesthetic stimulation (KS) may have positive effects on preterm infants: greater weight gain, improved bone mineralization, earlier hospital discharge and more optimal behavioral and motor responses compared to controls (Massaro et al, 2009).
• Identify mothers who may need assistance in enhancing maternal role attainment (MRA). EBN: “Mothers with more illness-related distress and less alert infants, and unmarried and less educated mothers may need interventions to enhance MRA” (Miles et al, 2011).
• Recognize that fathers, compared to mothers, may have different starting points in the attachment process in the NICU as nurses encourage parents to have early skin-to-skin contact. EBN: One study showed that after giving birth prematurely, mothers felt powerless, experiencing the immediate postnatal period as surreal and strange; though fathers experienced the birth as a shock, they were ready to become immediately involved (Fegran, Helseth, & Fagermoen, 2008). EB: Specific experiences (e.g., receiving information consistently, speaking to a male physician) may help fathers regain a sense of control to help them fulfill their various roles as protectors/partners/breadwinners (Arockiasamy, Holsti, & Albersheim, 2008).
• Recognize and support infant/child’s capacity for self-regulation and intervene when appropriate. CEB: Infants must learn to take in sensory information while simultaneously managing not to become over-aroused and overwhelmed by stimuli (DeGangi & Breinbauer, 1997; Greenspan, 1992).
• Provide lyrical, soothing music in nursery and home that is age-appropriate (i.e., corrected, in the case of premature infants) and contingent with state/behavioral cues. EB: Exposure to Mozart was found to lower resting energy expenditure (REE) in growing healthy preterm infants (Lubetzky et al, 2010).
• Recognize and support infant/child’s attention capabilities. CEB: “The ability to take an interest in the sights, sounds, and sensations of the world” is a significant developmental milestone (Greenspan & Wieder, 1998).
• Encourage opportunities for mutually satisfying interactions between infant and parent. CEB: The process of attachment involves communication and synchronous and rhythmic patterns of interaction (Rossetti, 1999).
• Encourage opportunities for physical closeness. EB: “Kangaroo mother care” (KMC) has been found to improve growth, reduce morbidities in LBW infants, and be easily continued at home (Suman, Udani, & Nanavati, 2008).
• Provide culturally sensitive parent support to non–English-speaking mothers and families. EBN: In a study contrasting NICU norms in Christchurch, New Zealand, and Tokyo, Japan, areas of difference in parental support needs included (1) establishment of oral feeding, (2) nursing care-related decision-making, (3) parental information/involvement early in hospitalization, (4) visiting regulations, and (5) Western-based interventions (Ichijima, 2009). EB: Congruent parent-to-parent matching is an important way to help non-Anglophone mothers mobilize their strengths; cope with feelings of loss, guilt, helplessness, and anxiety; and increase access to services (Ardal, Sulman, & Fuller-Thompson, 2011).
• Discuss cultural norms with families to provide care that is appropriate for enhancing attachment with the infant/child. EB: Recognition of the NICU norms that may hinder parent-staff communication is important in nursing practice (Ichijima, Kirk, & Hornblow, 2011).
• Promote the attachment process in women who have abused substances by providing a culturally based, women-centered treatment environment. CEB: Pregnant/postpartum Asian/Pacific Islander women identified provisions for the newborn, infant health care, parent education, and infant-mother bonding as conducive to their treatment (Morelli, Fong, & Oliveira, 2001).
• Promote attachment process/development of maternal sensitivity in incarcerated women. EB: Children of female offenders are at risk of developing insecure attachment/attachment disorganization, which may increase risk of poor developmental outcomes (Cassidy et al, 2010).
• Empower family members to draw on personal strengths in which multiple worldviews/values are recognized, incorporated, and negotiated. EBN: According to a Thai study of NICU parents, the need to be strong, to be there, and to care for their infants emerged as main themes in parents’ stories (Sitanon, 2009).
• Encourage positive involvement and relationship development between children and noncustodial fathers to enhance health and development. EB: Research suggests that conflicted parental relationships, usually involving noncustodial fathers, may have profound effects on infant attachment (Finger et al, 2009).
• The above interventions may be adapted for home care use.
• Assess quality of interaction between parent and infant/child. CEB: In a study re: effectiveness of home visiting by paraprofessionals/nurses, outcomes of nurse visitations in particular included more responsive mother-child interaction, less emotional vulnerability in response to fear stimuli among infants, higher infant emotional vitality in response to joy/anger stimuli, and less likelihood of language delays (Olds et al, 2002).
• Use “interaction coaching” (i.e., teaching mother to let the infant lead) so that the mother will match her interaction style to the baby’s cues. EBN: Though delivery of personalized interventions is labor intensive, and testing ways to provide targeted interventions in order to promote sensitive, responsive maternal-infant interactions is challenging, these are supported by current research (Mayberry & Horowitz, 2011).
• Identify community resources/supportive network systems for mothers showing depressive symptoms. EB: A Netherlands home visiting intervention for depressed mothers and their very young infants was found effective (Kersten-Alvarez et al, 2010).
• Provide supportive care for infants and children whose parents have been deployed during wartime. EB: This study’s results—that separation of parent/child influences current and future child development; that a parent’s deployment is associated with maladaptive child behaviors—reinforce the importance of additional support to both children and parents/caregivers remaining at home (Gorman, Eide, & Hisle-Gorman, 2010).
• Provide support to custodial grandparents. EB: Because the health of grandmother caregivers is critical to their ability to parent grandchildren successfully, nurses in a variety of settings are in a unique position to identify/address the health challenges of grandmothers raising grandchildren (Kelley, Whitley, & Campos, 2010). EB: The Family Child Care Network Impact Study found that relationship-based network supports delivered by specially trained staff were associated with higher quality caregiving by childcare providers (Bromer & Bibbs, 2011).
References
Ahn, H.Y., Lee, J., Shin, H.J. Kangaroo care on premature infant growth and maternal attachment and post-partum depression in South Korea. J Trop Pediatr. 2010;56(5):342–344.
Ardal, F., Sulman, J., Fuller-Thompson, E. Support like a walking stick: parent-buddy matching for language and culture in the NICU. Neonat Netw. 2011;30(2):89–98.
Arockiasamy, V., Holsti, L., Albersheim, S. Fathers’ experience in the neonatal intensive care unit: a search for control. Pediatrics. 2008;121(2):e215–e222.
Astrachan-Fletcher, E., et al. The reciprocal effects of eating disorders and the postpartum period: a review of the literature and recommendations for clinical care. J Womens Health. 2008;17(2):227–239.
Axelin, A., et al. Mothers’ different styles of involvement in preterm infant pain care. JOGNN. 2010;39(4):415–424.
Barr, J.A. Postpartum depression, delayed maternal adaptation, and mechanical infant caring: a phenomenological hermeneutic study. Int J Nurs Stud. 2008;45(3):362–369.
Bernier, A., Meins, E. A threshold approach to understanding the origins of attachment disorganization. Dev Psychol. 2008;44(4):969–982.
Bromer, J., Bibbs, T. Improving support services for family child care through relationship-based training. Zero Three. 2011;31(5):22–29.
Cassidy, J., et al. Enhancing attachment security in the infants of woman in a jail-diversion program. Attach Hum Dev. 2010;12(4):333–353.
Cleveland, L.M. Parenting in the neonatal intensive care unit. JOGNN. 2008;37(6):666–691.
DeGangi, G.A., Breinbauer, C. The symptomatology of infants and toddlers with regulatory disorders. J Dev Learning Dis. 1997;1(1):183–215.
D’Souza, S.R.B., et al. Relationship between stress, coping and nursing support of parents of preterm infants admitted to tertiary level neonatal intensive care units of Karnataka, India: a cross-sectional survey. J Neonat Nurs. 2009;15(5):152–158.
Eaton, E., Mullins, A. Using science and having fun. JOGNN. 2010;39(s1):s84–s85.
Fegran, L., Helseth, S. The parent-nurse relationship in the neonatal intensive care unit context: closeness and emotional involvement. Scand J Caring Sci. 2009;23:667–673.
Fegran, L., Helseth, S., Fagermoen, M.S. A comparison of mothers’ and fathers’ experiences of the attachment process in a neonatal intensive care unit. J Clin Nurs. 2008;17(6):810–816.
Finger, B., et al. Parent relationship quality and infant-mother attachment. Attach Hum Dev. 2009;11(3):285–306.
Gorman, G.H., Eide, M., Hisle-Gorman, E. Wartime military deployment and increased pediatric mental health and behavioral health complaints. Pediatrics. 2010;126(6):1058–1066.
Grassley, J.S. Adolescent mothers’ breastfeeding social support needs. JOGNN. 2010;39(6):713–722.
Greenspan, S.I. Infancy and early childhood: the practice of clinical assessment and intervention with emotional and developmental challenges. Madison, CT: International Universities Press; 1992.
Greenspan, S.I., Wieder, S. The child with special needs: encouraging intellectual and emotional growth. Reading, MA: Perseus Books; 1998.
Holditch-Davis, D., et al. Maternal role attainment with medically fragile infants: part 2. Relationship to the quality of parenting. Res Nurs Health. 2011;34(1):35–48.
Ichijima, E. Nursing roles in parental support: a cross-cultural comparison between neonatal intensive care units in New Zealand and Japan. Canterbury, UK: University of Canterbury; 2009.
Ichijima, E., Kirk, R., Hornblow, A. Parental support in neonatal intensive care units: a cross-cultural comparison between New Zealand and Japan. J Pediatr Nurs. 2011;26(3):206–215.
Im, H., Kim, E., Cain, K.C. Acute effects of Yakson and gentle human touch on the behavioral state of preterm infants. J Child Health Care. 2009;13(3):212–226.
Kelley, S.J., Whitley, D.M., Campos, P.E. Grandmothers raising grandchildren: results of an intervention to improve health outcomes. J Nurs Schol. 2010;42(4):379–386.
Kersten-Alvarez, L.E., et al. Long-term effects of a home-visiting intervention for depressed mothers and their infants. J Child Psychol Psychiatry. 2010;51(10):1160–1170.
Lawhon, G. Integrated nursing care: vital issues important in the humane care of the newborn. Semin Neonatol. 2002;7:441–446.
Lubetzky, R., et al. Effect of music by Mozart on energy expenditure in growing preterm infants. Pediatrics. 2010;125(1):e24–e28.
Lynn, L.N., et al. Self-regulation: a new perspective on learning problems experienced by children born extremely preterm. Aust J Educ Dev Psychol. 2011;11:1–10.
Massaro, A.N., et al. Massage with kinesthetic stimulation improves weight gain in preterm infants. J Perinat. 2009;29(5):352–357.
Mayberry, L., Horowitz, J.A. Postpartum depression. In Fitzpatrick J.J., Kazer M., eds.: Encyclopedia of nursing research, ed 3, New York: Springer, 2011.
Miles, M.S., et al. Maternal role attainment with medically fragile infants: part 1. Measurement and correlates during the first year of life. Res Nurs Health. 2011;34(1):20–34.
Morelli, P.T., Fong, R., Oliveira, J. Culturally competent substance abuse treatment for Asian/Pacific Islander women. J Hum Behav Soc Environ. 2001;3(3/4):263.
Neal, D.O., Lindeke, L.L. Music as a nursing intervention for preterm infants in the NICU. Neonat Netw. 2008;27(5):319–327.
Nye, C. Transitioning premature infants from gavage to breast. Neonat Netw. 2008;27(1):7–13.
Obeidat, H.M., Bond, E.A., Callister, L.C. The parental experience of having an infant in the newborn intensive care unit. J Perinat Educ. 2009;18(3):23–29.
Olds, D.L., et al. Home visiting by paraprofessionals and by nurses: a randomized, controlled trial. Pediatrics. 2002;110(3):486–496.
Pridham, K.F., et al. Guided participation and development of care-giving competencies for families of low-birth-weight infants. J Adv Nurs. 1998;28(5):948–958.
Rossetti, L.M. Infant-toddler assessment. Boston: Little, Brown and Company; 1999.
Sitanon, T., Thai parents’ experiences of parenting preterm infants during hospitalization in the neonatal intensive care unit 2009. [unpublished doctoral dissertation, University of Washington, School of Nursing].
Strathearn, L., et al. What’s in a smile? Maternal brain responses to infant facial cues. Pediatrics. 2008;122(1):40–51.
Suman, R.P.N., Udani, R., Nanavati, R. Kangaroo mother care for low birth weight infants: a randomized controlled trial. Indian Pediatr. 2008;45(1):17–23.
Tedder, J.L. Give them the HUG: an innovative approach to helping parents understand the language of their newborn. J Perinat Educ. 2008;17(2):14–20.
Tramo, M.J., et al. Effects of music on physiological and behavioral indices of acute pain and stress in premature infants: clinical trial and literature review. Music Med. 2011;3(2):72–83.
Velez, M., Jansson, L.M. The opioid dependent mother and newborn dyad: non-pharmacologic care. J Addict Med. 2008;2(3):113–120.
Wan, M.W., Green, J. The impact of maternal psychopathology on child-mother attachment. Arch Womens Ment Health. 2009;12(3):123–134.
Warren, R. Breastfeeding in the delivery room. Br J Midwifery. 2008;16(2):119–120.
Yildiz, A., et al. The effect of the odor of breast milk on the time needed for transition from gavage to total oral feeding in preterm infants. J Nurs Schol. 2011;43(3):265–273.
Autonomic Dysreflexia
NANDA-I
Life-threatening, uninhibited sympathetic response of the nervous system to a noxious stimulus after a spinal cord injury at T7 or above
Defining Characteristics
Blurred vision; bradycardia; chest pain; chilling; conjunctival congestion; diaphoresis (above the injury); headache (a diffuse pain in different portions of the head and not confined to any nerve distribution area); Horner’s syndrome; metallic taste in mouth; nasal congestion; pallor (below the injury); paresthesia; paroxysmal hypertension; pilomotor reflex; red splotches on skin (above the injury); tachycardia
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Monitor the client for symptoms of dysreflexia, particularly those with high-level and more extensive spinal cord injuries. See Defining Characteristics. EB: Because some clients are asymptomatic, it is important to recognize risk factors for autonomic dysreflexia (AD), such as higher and more complete injuries and injuries related to trauma (Huang et al, 2011; Schottler et al, 2009). AD has also been associated with lower age groups and less time since injury (Hitzig et al, 2008).
Collaborate with health care practitioners to identify the cause of dysreflexia (e.g., distended bladder, impaction, pressure ulcer, urinary calculi, bladder infection, acute condition in the abdomen, penile pressure, ingrown toenail, or other source of noxious stimuli). EB: Health care practitioners who are not assigned to a specific neuroscience unit may not be aware of potential causes of autonomic dysreflexia (Jackson & Acland, 2011).
If symptoms of dysreflexia are present, place client in high Fowler’s position, remove all support hoses or binders, and immediately determine the noxious stimuli causing the response. If blood pressure cannot be decreased within 1 minute, notify the physician STAT. EB: These steps promote venous pooling, decrease venous return, and decrease blood pressure. The client should be rapidly evaluated by both the physician and nurse to find the possible cause (Krassioukov et al, 2009). Clients in the prone position may be at risk for AD (Yoo et al, 2011).
To determine the stimulus for dysreflexia:
First, assess bladder function. Check for distention, and if present catheterize using an anesthetic jelly as a lubricant. Do not use Valsalva maneuver or Crede’s method to empty the bladder. Ensure existing catheter patency. Also note signs of urinary tract infection. EB: AD is commonly associated with bowel or bladder dysfunction in persons with a spinal cord injury (Furusawa et al, 2011).
Second, assess bowel function. Numb the bowel area with a topical anesthetic as ordered, and once agent is effective (5 minutes), check for impaction. EB: For clients who require manual removal of stool, pretreatment with lidocaine cream may lower blood pressure during removal (Furusawa et al, 2009).
Initiate antihypertensive therapy as soon as ordered and monitor for cardiac dysrhythmias. EB: Due to the large amount of sympathetic discharge following AD, clients in hypertensive crisis are at risk for arrhythmias and myocardial infarction (Ho & Krassioukov, 2010).
Be careful not to increase noxious sensory stimuli. If numbing agent is ordered, use it on anus and 1 inch of rectum before attempting to remove a fecal impaction. Also spray pressure ulcer with it. If necessary to replace an obstructed catheter, use an anesthetic jelly as ordered. EB: Increased noxious sensory stimuli can exacerbate the abnormal response and worsen the client’s prognosis (Furusawa et al, 2009).
• Monitor vital signs every 3 to 5 minutes during acute event; continue to monitor vital signs after event is resolved (symptoms resolve and vital signs return to baseline). EB: It is possible for the client to develop rebound hypotension after the acute event because of the use of antihypertensive medications, or symptoms of dysreflexia may reoccur (Krassioukov et al, 2009).
• Watch for complications of dysreflexia, including signs of cerebral hemorrhage, seizures, MI, or intraocular hemorrhage. EB: Extremely high blood pressure can cause intracranial hemorrhage and death (Krassioukov et al, 2009).
• Accurately and completely record any incidences of dysreflexia; especially note the precipitating stimuli. EB: It is imperative to determine both the causes of the condition and whether the condition is persistent, requiring the client to take medications routinely to prevent repeat incidences (Krassioukov et al, 2009).
• Use the following interventions to prevent dysreflexia:
Ensure that drainage from an indwelling catheter is good and that bladder is not distended.
Ensure a regular pattern of defecation to prevent fecal impaction. EB: AD is commonly associated with bowel or bladder dysfunction in persons with a spinal cord injury (Furusawa et al, 2011).
Frequently change position of client to relieve pressure and prevent the formation of pressure ulcers.
If ordered, apply an anesthetic agent to any wound below level of injury before performing wound care. EB: Stimuli that would cause pain in persons without spinal cord injury can lead to AD (Krassioukov et al, 2009).
Because episodes can recur, notify all health care team members of the possibility of a dysreflexia episode. All health care personnel working with the client should be aware of the condition and how to treat it.
For female clients with spinal cord injury who become pregnant, collaborate with obstetrical health care practitioners to monitor for signs and symptoms of dysreflexia. EB: Autonomic dysreflexia may signal the onset of labor or be a sign of preterm labor. Women undergoing cesarean section should be carefully monitored intra- and postoperatively (Walsh, Grange, & Beale, 2010).
• The above interventions may be adapted for home care use.
• Instruct the client with any known proclivity toward dysreflexia to wear a medical alert bracelet and carry a medical alert wallet card when not in a safe environment (i.e., not with someone who knows client has the condition and can respond appropriately).
Establish an emergency plan: obtain provider/physician orders for medications to be used in situations in which first aid does not work and plans to identify potential stimuli. EB: Medication administered immediately can reverse early stage dysreflexia (Krassioukov et al, 2009).
If orders have not been obtained or client does not have medications, use emergency medical services.
• When episode of dysreflexia is resolved, monitor blood pressure every 30 to 60 minutes for next 5 hours or admit to institution for observation. EB: Autonomic dysreflexia can have a profound effect on vasculature, leading to chronic cardiovascular dysfunction (Alan et al, 2010).
Client/Family Teaching and Discharge Planning:
• Teach recognition of the earliest symptoms of dysreflexia, the actions that should be taken when they occur, and the need to summon help immediately. Give client a written card that contains this information. EB: Clients and families at risk for not understanding the key elements of AD occurrence and management are clients with nontraumatic etiologies, those with T5 or lower injuries, those in the youngest age group at injury, and those who had a shorter duration of injury (Schottler et al, 2009). Clients have reported knowledge gaps regarding AD and having symptoms of AD but not recognizing the condition (McGillivray et al, 2009).
• Teach steps to prevent dysreflexia episodes: care of bladder, bowel, and skin and prevention of other forms of noxious stimuli (i.e., not wearing clothing that is too tight). EB: Data have suggested that despite having symptoms consistent with a diagnosis of AD, there are gaps in clients’ understanding of treatment for the condition, particularly when the spinal cord injury is not a result of trauma (McGillivray et al, 2009).
• Discuss the potential impact of sexual intercourse and pregnancy on autonomic dysreflexia. EB: Autonomic dysreflexia may be triggered by ejaculation and sperm retrieval for men (Ekland et al, 2008; McGuire et al, 2011).
References
Alan, N., et al. Recurrent autonomic dysreflexia exacerbates vascular dysfunction after spinal cord injury. Spine J. 2010;10(12):1108–1117.
Ekland, M.B., et al. Incidence of autonomic dysreflexia and silent autonomic dysreflexia in men with spinal cord injury undergoing sperm retrieval: implications for clinical practice. J Spinal Cord Med. 2008;31(1):33–39.
Furusawa, K., et al. Topical anesthesia blunts the pressor response induced by bowel manipulation in subjects with cervical spinal cord injury. Spinal Cord. 2009;47(2):144–148.
Furusawa, K., et al. Incidence of symptomatic autonomic dysreflexia varies according to the bowel and bladder management techniques in patients with spinal cord injury. Spinal Cord. 2011;49(1):49–54.
Hitzig, S.L., et al. Secondary health complications in an aging Canadian spinal cord injury sample. Am J Phys Med Rehabil. 2008;87(7):545–555.
Ho, C.P., Krassioukov, A.V. Autonomic dysreflexia and myocardial ischemia. Spinal Cord. 2010;48(9):714–715.
Huang, Y.H., et al. Autonomic dysreflexia during urodynamic examinations in patients with suprasacral spinal cord injury. Arch Phys Med Rehabil. 2011;92(9):1450–1454.
Jackson, C.R., Acland, R. Knowledge of autonomic dysreflexia in the emergency department. Emerg Med J. 2011;28(10):866–869.
Krassioukov, A., et al. A systematic review of the management of autonomic dysreflexia after spinal cord injury. Arch Phys Med Rehabil. 2009;90(4):682–695.
McGillivray CF, Evaluating knowledge of autonomic dysreflexia among individuals with spinal cord injury and their
McGuire, C., et al. Electroejaculatory stimulation for male infertility secondary to spinal cord injury. Urology. 2011;77(1):83–87.
Schottler, J., et al. Patient and caregiver knowledge of autonomic dysreflexia among youth with spinal cord injury. Spinal Cord. 2009;47(9):681–686.
Walsh, P., Grange, C., Beale, N. Anaesthetic management of an obstetric patient with idiopathic acute transverse myelitis. Int J Obstet Anesth. 2010;18(1):98–101.
Yoo, K.Y., et al. Fatal cerebral hemorrhage associated with autonomic hyperreflexia during surgery in the prone position in a quadriplegic patient. Minerva Anestesiol. 2010;76(7):554–558.
Risk for Autonomic Dysreflexia
NANDA-I
At risk for life-threatening, uninhibited response of the sympathetic nervous system; post-spinal shock; in an individual with spinal cord injury or lesion at T6 or above (has been demonstrated in clients with injuries at T7 and T8)
Risk Factors
An injury/lesion at T6 or above and at least one of the following noxious stimuli:
• Cardiac/pulmonary problems: pulmonary emboli, deep vein thrombosis
• Gastrointestinal stimuli: bowel distention, constipation, difficult passage of stool, digital stimulation, enemas, esophageal reflux, fecal impaction, gallstones, gastric ulcers, GI system pathology, hemorrhoids, suppositories
• Musculoskeletal: cutaneous stimulations (e.g., pressure ulcer, ingrown toenail, dressings, burns, rash); fractures, heterotrophic bone; pressure over bony prominences or genitalia; range-of-motion exercises, spasm; sunburns, wounds
• Neurological stimuli: painful/irritating stimuli below the level of injury
• Regulatory stimuli: extreme environmental temperatures, temperature fluctuations
• Reproductive stimuli: ejaculation, labor and delivery, menstruation, ovarian cyst, pregnancy, sexual intercourse
• Situational stimuli: constrictive clothing (e.g., straps, stockings, shoes); reactions to pharmaceutical agents (e.g., decongestants, sympathomimetics, vasoconstrictors), opioid withdrawal, positioning, surgical procedures
• Urological stimuli: bladder distention, bladder spasms, calculi, catheterization, cystitis, detrusor sphincter dyssynergia, epididymitis, instrumentation, surgery, urethritis, urinary tract infection
NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family Teaching and Discharge Planning, Rationales, and References
Refer to care plan for Autonomic Dysreflexia.