B
Risk for Bleeding
NOC (Nursing Outcomes Classification)
Blood Coagulation, Blood Loss Severity, Circulation Status, Fall Prevention Behavior, Gastrointestinal Function; Knowledge: Personal Safety, Maternal Status, Physical Injury Severity, Risk Control, Safe Home Environment, Vital Signs
Client Outcomes
Client Will (Specify Time Frame)
• Discuss precautions to prevent bleeding complications
• Explain actions that should be taken if bleeding happens
• Maintain adherence to agreed upon anticoagulant medication and lab work regimens
• Monitor for signs and symptoms of bleeding
• Maintain a mean arterial pressure above 70 mm Hg, a heart rate between 60 and 100 with a normal rhythm, and urine output greater than 0.5 mL/kg/hr
NIC (Nursing Interventions Classification)
Admission Care, Bleeding Precautions, Bleeding Reduction, Blood Product Administration, Circumcision Care, Fluid Management, Health Screening, Hemorrhage Control, Neurologic Monitoring, Postpartum Care, Risk Identification, Teaching: Disease Process, Teaching: Prescribed Medication, Oxygen Therapy, Shock Prevention, Surveillance, Vital Signs Monitoring
Nursing Interventions and Rationales
• Perform admission risk assessment for falls and for signs of bleeding. Safety precautions should be implemented for all at risk patients. EBN: Upon admission to any health care facility nurses should assess for fall risk factors that could increase the risk of bleeding (Gray-Micelli, 2008; Holmes, 2011).
• Monitor the client closely for hemorrhage especially in those at increased risk for bleeding. Watch for any signs of bleeding including: bleeding of the gums, blood in sputum, emesis, urine or stool, bleeding from a wound, bleeding into the skin with petechiae, and purpura. EB: Clients at increased risk for bleeding may include older individuals (>60 years of age), individuals with active gastroduodenal ulcer, postpartum women, previous bleeding episode, hypertension, labile INRs, low platelet count, active malignancy, renal or liver failure, ICU stay, drug or alcohol use, co-administered antiplatelets with nonsteroidal antiinflammatory drugs, clients receiving antithrombotic and anticoagulant therapies (Chen et al, 2011; Chua et al, 2011; Decousus et al, 2011). Additional relevant research: Gupta et al, 2010; Hochholzer et al, 2011; Lane et al, 2011; Pisters et al, 2010; Tay, Lip & Lane, 2011. Individuals who take selective serotonin reuptake inhibitors (SSRIs) with or without a history of gastrointestinal bleeding may be at increased risk for bleeding especially if concurrently taking NSAIDs or low-dose aspirin (Andrade et al, 2010). Use of aspirin and clopidogrel in the treatment of clients with image verified “small” subcortical strokes demonstrated higher rates of bleeding when compared to treatment with aspirin alone (Stiles, 2011).
• If bleeding develops, apply pressure over the site as needed or appropriate, on the appropriate pressure site over an artery, and use pressure dressings as needed (Matteucci, Schub, & Pravikoff, 2011).
Monitor coagulation studies, including prothrombin time (PT), international normalized ratio (INR), activated partial thromboplastin time (aPTT), fibrinogen, fibrin degradation/split products, and platelet counts as appropriate. EB: INR is the preferred method to evaluate warfarin therapy, typically at least 16 hours after the last dose is administered. Dose adjustments will not result in a steady-state INR value for up to 3 weeks (ICSI, 2011).The aPTT is most commonly used to assess unfractionated heparin (UH) therapy but some clients may require additional testing to assess for heparin resistance (Russo, 2010). Replacement of UH with low molecular weight heparin and other new anticoagulants may be forthcoming but UH is still a drug of choice due to ability to rapidly reverse effect with protamine sulfate (Lehman & Frank, 2009).
Assess vital signs at frequent intervals to assess for physiological evidence of bleeding such as tachycardia, tachypnea, and hypotension. Symptoms may include dizziness, shortness of breath, and fatigue. Carefully assess for compensatory changes associated with bleeding including increased heart rate and respiratory rate. Initially blood pressure may be stabile and then begin to decrease. Assess for orthostatic blood pressure changes (drop in systolic by >20 mm Hg and/or a drop in diastolic by >10 mm Hg in 3 minutes) by taking the blood pressure in lying, sitting, and standing positions (Matteucci, Schub, & Pravikoff, 2011; Urden, Stacy, & Lough, 2009). Prospective identification of clients at risk for massive transfusion is an imprecise science (Vandromme et al, 2011).
Monitor all medications for the potential to increase bleeding including aspirin, NSAIDs, SSRIs, and complementary and alternative therapies such as coenzyme Q (10) and ginger. CEB: Antiplatelet medications can increase the risk of bleeding in high-risk clients (ICSI, 2011). In a study of adults receiving warfarin, CoQ (10) and ginger appeared to increase the risk of bleeding (Shalansky et al, 2007). Ginger, when taken with medicines that slow clotting, may increase the chances for bruising and bleeding (Medline Plus, 2011). Aspirin use has been shown to reduce myocardial infarcts in men, and women receiving aspirin experienced fewer ischemic strokes; however, aspirin does increase the risk for major bleeding events, primarily those of gastrointestinal origin (Wolff, Miller, & Ko, 2009).
Safety Guidelines for Anticoagulant Administration: Joint Commission National Patient Safety Goals 2011: Follow approved protocol for anticoagulant administration:
• Use prepackaged medications and prefilled or premixed parenteral therapy as ordered
• Check laboratory tests (i.e., INR) before administration
• Use programmable pumps when using parenteral administration
• Ensure appropriate education for client/family and all staff concerning anticoagulants used
• Notify dietary services when warfarin prescribed (to reduce vitamin K in diet)
• Monitor for any symptoms of bleeding prior to administration. Standard defined protocols can decrease errors in administration (Joint Commission, 2011). Anticoagulation therapy is complex. Risk of bleeding is reduced in clients who receive appropriate education in anticoagulant therapy use (Metlay et al, 2008).
Before administering anticoagulants, assess the clotting profile of the client. If the client is on warfarin, assess the INR. Hold the medication if the INR is outside of the recommended parameters and notify the physician or advanced practice nurse. EB: Target INR for warfarin is between 2.0 and 3.0 for nonvalvular atrial fibrillation and between 2.5 and 3.5 for valvular atrial fibrillation. Risk of bleeding is increased when INR is >4.0 and risk for thromboembolism increases when INR is <1.7. A 2% to 4% risk for bleeding remains in individuals within therapeutic range of INR. Dose adjustments of 15% usually change the INR level by 1.0 (ICSI, 2011). A safety advisory was issued by the Australian regulatory authority for the anticoagulant dabigatran (Pradaxa) due to an increase in the number of bleeding-related adverse events (Hughes, 2011).
Recognize that vitamin K may be given orally or intravenously as ordered for INR levels greater than 5.0. In some circumstances fresh frozen plasma (FFP), prothrombin complex concentrate (PCC), and/or recombinant factor VIIa (rVIIa) may be administered if serious or life-threatening bleeding occurs. EB: With INR levels above 5.0 it is recommended to give vitamin K rather than just holding the warfarin; administration of vitamin K is through the oral or intravenous route as subcutaneous or intramuscular routes result in erratic absorption (ICSI, 2011).
Manage fluid resuscitation and volume expansion as ordered. CEB: Blood products (including human albumin), non-blood products or combinations can be used to restore circulating blood volume in individuals at risk for blood losses from trauma, burns, or surgery. Administration of albumin over normal sterile saline does not alter survival rates (The Albumin Reviewers, 2004).
Consider discussing the co-administration of a proton-pump inhibitor alongside traditional NSAIDs, or with the use of a cyclo-oxygenase 2 inhibitor with the prescriber. EB: Risk of NSAID-related bleeding may be reduced with the use of a proton-pump inhibitor or cyclo-oxygenase 2 inhibitor (Chua et al, 2011; Rahme & Bernatsky, 2011; Wu et al, 2011).
• Ensure adequate nurse staffing in order to be able to provide a high level of surveillance capability. CEB: The size and mix of nurse staffing in hospitals has been demonstrated to have a direct impact on client outcomes. Lower levels of nurse staffing have been associated with higher rates of poor client outcomes including those outcomes caused by gastrointestinal bleeding and “failure to rescue” (Needleman et al, 2002).
Recognize that prophylactic vitamin K administration should be used in neonates for vitamin K deficiency bleeding (VKDB). CEB: Hemorrhagic disease of the newborn (HDN) is due to vitamin K deficiency resulting in life-threatening bleeding within the first hours of life (Clarke et al, 2006). A single oral or parenteral administration of vitamin K prevents early VKDB (birth to 2 weeks of age) in contrast to late VKDB (2-12 weeks of age) that is prevented by parenteral administration (Miller, 2003).
Recognize warning signs of VKDB including minimal bleeds, evidence of cholestasis (icteric sclera, dark urine, irritability), and failure to thrive. CEB: Warning signs are often present but may be overlooked (Sutor, 2003).
Use caution in administering NSAIDs in children. EB: A study of children aged 2 months to 16 years found that although upper gastrointestinal bleeding is rare, one third of the cases seen were attributable to exposure to NSAID at doses used for analgesia or antipyretic purposes (Grimaldi-Bensouda et al, 2010).
Monitor children and adolescents for potential bleeding. EB: Children and adolescents who take SSRIs need to be closely monitored as the potential for bleeding exists across age groups (Andrade et al, 2010).
Closely monitor post-cardiotomy clients requiring extracorporeal life support when cardiopulmonary bypass (CPB) duration is prolonged. EB: In a retrospective study of clients excessive bleeding was found to occur more frequently in children who had been on CPB for more than 3 hours (Nardell et al, 2009). Excessive bleeding occurred predominantly within 6 hours postoperatively. Incidence of bleeding increased when the client had lower platelet counts (Nardell et al, 2009).
Client/Family Teaching and Discharge Planning:
• Teach client and family or significant others about any anticoagulant medications prescribed including when to take, how often to have lab tests done, signs of bleeding to report, dietary restrictions needed, and precautions to be followed. Instruct the client to report any adverse side effects to his/her health care provider. Medication teaching includes the drug name, purpose, administration instructions (e.g., with or without food), necessary lab tests, and any side effects to be aware of. Provision of such information using clear communication principles and an understanding of the client’s health literacy level may facilitate appropriate adherence to the therapeutic regimen by enhancing knowledge base (Joint Commission, 2011; National Institutes of Health (NIH), 2011; Nurit et al, 2009). EB: Education of the client reduces the risk of bleeding (Metlay et al, 2008).
• Instruct the client and family on disease process and rationale for care. When clients and their family members have sufficient understanding of their disease process they can participate more fully in care and healthy behaviors. Knowledge empowers clients and family members allowing them to be active participants in their care. EBN: Use of written and verbal education enhances client retention of information needed when managing potent medications (Nurit et al, 2009).
• Provide client and family or significant others with both oral and written educational materials that meet the standards of client education and health literacy. EB: The use of clear communication, materials written at a fifth grade level, and the teach-back method enhances the client’s ability to understand important health related information and improves self-care safety (NIH, 2011).
References
Alderson, P., et al, The Albumin Reviewers Human albumin solution for resuscitation and volume expansion in critically ill patients. Cochrane Database Syst 2004;(4):CD001208.
Andrade, C., et al. Serotonin reuptake inhibitor antidepressants and abnormal bleeding: a review for clinicians and a reconsideration of mechanisms. J Clin Psychiatry. 2010;71(12):1565–1575.
Chen, W., et al. Association between CHADS2 risk factors and anticoagulation-related bleeding: a systematic literature review. Mayo Clin Proc. 2011;86(6):509–521.
Chua, S., et al. Gastrointestinal bleeding and outcomes after percutaneous coronary intervention for ST-segment elevation myocardial infarction. Am J Crit Care. 2011;20(3):218–225.
Clarke, P., et al. Vitamin K prophylaxis for preterm infants: a randomized controlled trial of 3 regimens. Pediatrics. 2006;118:e1657–e1666.
Decousus, H., et al. Factors at admission associated with bleeding risk in medical patients: findings from the IMPROVE investigators. Chest. 2011;139(1):69–79.
Gray-Micelli, D. Preventing falls in acute care. In Capezuti E, et al, eds.: Evidence-based geriatric nursing protocols for best practice, ed 3, New York: Springer, 2008.
Grimaldi-Bensouda, L., et al. Clinical features and risk factors for upper gastrointestinal bleeding in children: a case-crossover study. Eur J Clin Pharmacol. 2010;66(8):831–837.
Gupta, N., et al. Defining patients at high risk for gastrointestinal hemorrhage after drug-eluting stent placement: a cost utility analysis. J Interv Cardiol. 2010;23(2):179–187.
Hochholzer, W., et al. Predictors of bleeding and time dependence of association of bleeding with mortality: insights from the Trial to Assess Improvement in Therapeutic Outcomes by Optimizing Platelet Inhibition with Prasugrel-Thrombolysis in Myocardial Infarction 38 (TRITON-TIMI 38). Circulation. 2011;123(23):2681–2689.
Holmes, S. Risk for bleeding. In Ackley B., Ladwig G., eds.: Nursing diagnosis handbook, ed 9, St Louis: Mosby, 2011.
Hughes, S. Dabigatran: Australia issues bleeding warning, Heartwire. Retrieved October 9, 2011;2011;10, from http://www.medscape.com/viewarticle/751161_print
Institute for Clinical Systems Improvement (ICSI). Antithrombotic therapy supplement. Bloomington, MN: ICSI; 2011.
Joint Commission, Hospital national patient safety goals—effective July 1, 2011 Retrieved October 10, 2011, from http://www.jointcommission.org/hap_2011_npsgs/
Lane, D., et al. Bleeding risk in patients with atrial fibrillation: the AMADEUS study. Chest. 2011;140(1):146–155.
Lehman, C., Frank, E. Laboratory monitoring of heparin therapy: partial thromboplastin time or anti-Xa assay? Labmed. 2009;40(1):47–51.
Matteucci, R., Schub, T., Pravikoff, D. Shock, hypovolemic. In: CINAHL nursing guide. Nursing Reference Center; 2011.
Medline Plus, Ginger. MedLine Plus 2011;11, Accessed November 11, 2011 http://www.nlm.nih.gov/medlineplus/druginfo/natural/961.html
Metlay, J., et al. Patient reported receipt of medication instructions for warfarin is associated with reduced risk of serious bleeding events. J Gen Intern Med. 2008;23(10):1589–1594.
Miller, C. Controversies concerning vitamin K and the newborn: policy statement of the American Academy of Pediatrics. Pediatrics. 2003;112(1):191–192.
Nardell, K., et al. Risk factors for bleeding in pediatric post-cardiotomy patients requiring ECLS. Perfusion. 2009;24(3):191–197.
National Institutes of Health, Clear communication: An NIH health literacy initiative, 2012 Retrieved August 3, 2012, from http://www.nih.gov/clearcommunication/plainlanguage.htm
Needleman, J., et al. Nurse staffing and quality of care in hospitals in the United States. Policy Polit Nurs Pract. 2002;3(40):306–308.
Nurit, P., et al. Evaluation of a nursing intervention project to promote patient medication education. J Clin Nurs. 2009;18(17):2530–2536.
Pisters, R., et al. A novel user friendly score (HAS-BLED) to assess 1-year risk of major bleeding in patients with atrial fibrillation: the Euro heart study. Chest. 2010;138:1093–1100.
Rahme, E., Bernatsky, S. NSAIDs and risk of lower gastrointestinal bleeding. Lancet. 2011;376:7.
Russo, W., Laboratory monitoring of heparin therapy. UTMB Health 2011;11, Retrieved November 12, 2011, from http://www.utmb.edu/lsg/hem/HEPARIN_THERAPY.htm
Shalansky, S., et al. Risk of warfarin-related bleeding events and supratherapeutic international normalized ratios associated with complementary and alternative medicine: a longitudinal analysis. Pharmacotherapy. 2007;27(9):1237–1247.
Stiles, S., Clopidogrel-aspirin arm halted in SPS3 stroke trial. Heartwire 2011;10, Retrieved October 7, 2011, from http://www.medscape.com/viewarticle/751011_print
Sutor, A. New aspects of vitamin K prophylaxis. Semin Thromb Hemost. 2003;29(4):373–376.
Tay, K., Lip, G., Lane, D. Can we IMPROVE bleeding risk assessment for acutely ill, hospitalized medical patients? Chest. 2011;139:10–13.
Urden, L.D., Stacy, K.M., Lough, M.E. Thelan’s critical care nursing: diagnosis and management, ed 6. Philadelphia: Mosby; 2009.
Vandromme, M., et al. Prospective identification of patients at risk for massive transfusion: an imprecise endeavor. Am Surg. 2010;77:155–161.
Wolff, T., Miller, T., Ko, S. Aspirin for the primary prevention of cardiovascular events: an update of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2009;150(6):405–410.
Wu, H., et al. Pantoprazole for the prevention of gastrointestinal bleeding in high-risk patients with acute coronary syndromes. J Crit Care. 26(4), 2011. [434.e1-6].
Disturbed Body Image
NANDA-I
Defining Characteristics
Behaviors of acknowledgment of one’s body; behaviors of avoidance of one’s body; behaviors of monitoring one’s body; nonverbal response to actual change in body (e.g., appearance, structure, function); nonverbal response to perceived change in body (e.g., appearance, structure, function); reports feelings that reflect an altered view of one’s body (e.g., appearance, structure, function); reports perceptions that reflect an altered view of one’s body in appearance
Objective
Actual change in function; actual change in structure; behaviors of acknowledging one’s body; behaviors of monitoring one’s body; change in ability to estimate spatial relationship of body to environment; change in social involvement; extension of body boundary to incorporate environmental objects; intentional hiding of body part; intentional overexposure of body part; missing body part; not looking at body part; not touching body part; trauma to nonfunctioning part; unintentional hiding of body part; unintentional overexposing of body part
Subjective
Depersonalization of loss by use of impersonal pronouns; depersonalization of part by use of impersonal pronouns; emphasis on remaining strengths; focus on past appearance; focus on past function; focus on past strength; heightened achievement; personalization of loss by name; personalization of body part by name; preoccupation with chance; preoccupation with loss; refusal to verify actual change; reports change in lifestyle; reports fear of reaction by others; reports negative feelings about body (e.g., feelings of helplessness, hopelessness, powerlessness)
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate adaptation to changes in physical appearance or body function as evidenced by adjustment to lifestyle change
• Identify and change irrational beliefs and expectations regarding body size or function
• Recognize health-destructive behaviors and demonstrate willingness to adhere to treatments or methods that will promote health
• Verbalize congruence between body reality and body perception
• Describe, touch, or observe affected body part
• Demonstrate social involvement rather than avoidance and utilize adaptive coping and/or social skills
• Utilize cognitive strategies or other coping skills to improve perception of body image and enhance functioning
• Utilize strategies to enhance appearance (e.g., wig, clothing)
NIC (Nursing Interventions Classification)
Body Image Enhancement, Eating Disorder Management, Referral, Self-Awareness Enhancement, Self-Esteem Enhancement, Support Group Weight Gain Assistance
Nursing Interventions and Rationales
• Incorporate psychosocial questions related to body image as part of nursing assessment to identify clients at risk for body image disturbance (e.g., body builders; cancer survivors; clients with eating disorders, burns, skin disorders, polycystic ovary disease; or those with stomas/ostomies/colostomies or other disfiguring conditions). EB: Assessment of psychosocial issues can help to identify clients at risk for body image concerns as a result of a disfiguring condition (Borwell, 2009). Nurses, caring for patients during their hospital stay, are in the ideal position to assess how they are emotionally adapting to having a disfigurement (Bowers, 2008).
• If client is at risk for body image disturbance, consider using a tool such as the Body Image Quality of Life Inventory (BIQLI) or Body Areas Satisfaction Scale (BASS), which quantifies both the positive and negative effects of body image on one’s psychosocial quality of life. EBN: Using a body image scale can help nurses to identify possible body image disturbances and to plan individual nursing interventions (Giovannelli et al, 2008).
Assess for history of childhood maltreatment in clients suffering from body dissatisfaction, anorexia, or other eating disorders and make appropriate psychosocial referrals if indicated. EB: The results from this study indicate specific forms of childhood maltreatment (emotional and sexual abuse) are significantly associated with body dissatisfaction, depressive symptoms, and eating disorders (Dunkley et al, 2010).
Assess for body dysmorphic disorder (BDD) (pathological preoccupation with muscularity and leanness; occurs more often in males than in females) and refer to psychiatry or other appropriate provider. EB: Body dysmorphic disorder (BDD) is a prevalent and disabling preoccupation with a slight or imagined defect in appearance. Results from the small number of available randomized controlled trials (RCTs) suggest that serotonin reuptake inhibitors (SRIs) and cognitive behavioral therapy (CBT) may be useful in treating clients with BDD (Ipser, Sander, & Stein, 2009).
Assess for steroid use, if BDD is identified. EB: The current evidence from this literature review suggests that anabolic androgenic steroid (AAS) abuse is possibly a perpetuating factor in the evolution of muscle dysmorphia (MD). Psychiatric complications of AAS include mood and behavior changes, perceptual abnormalities, and withdrawal symptoms (Rohman, 2009).
• Assess for lipodystrophy (an abnormal redistribution of adipose tissue) in clients receiving antiretroviral therapy as a treatment for HIV/AIDS. This condition is common and can be a source of distress to clients. EBN: Lipodystrophy is often an unavoidable side effect of antiretroviral therapy. Clients suffering from this syndrome are often ignored when expressing concerns about body changes. Nurses are uniquely qualified to assess these clients as well as provide education and psychosocial support (Gagnon & Holmes, 2011).
If client is at risk for anorexia nervosa, consider investigation of emotional qualifiers, using a tool to assess emotional intelligence such as the EQ-1. EB: A study of female university students ages 18 to 30 found a significant correlation between disordered eating behaviors and lower levels of emotional intelligence, particularly in the areas of emotional self-awareness, interpersonal relationships, stress management, and happiness (Costarelli, Demerzi, & Stamou, 2009).
• Discuss expectations for weight loss and anticipated body changes with clients planning to undergo bariatric surgery for morbid obesity. Assist the client in identifying realistic goals. EB: Morbidly obese clients often set unrealistic goals for ideal body weight and appearance following bariatric surgery. Guidance is necessary to help them understand limitations of the surgery (Munoz et al, 2010).
Use cognitive-behavioral therapy (CBT) to assist the client to express his emotions and feelings. EBN: This study of clients with bulimia used CBT and helped the clients to disentangle themselves regarding body image and weight (Huang & Hsieh, 2010).
• Help client describe ideal self, identify self-criticisms, and give suggestions to support acceptance of self. EBN: Job rehabilitation and body image should be incorporated into the daily care of head and neck cancer clients. For example, participants could learn how to use cosmetic strategies to improve their facial appearance during otopalatodigital (OPD) syndrome follow-up. Thus, the negative impact might be reduced (Liu, 2008).
• Discuss spirituality as an adjunct to improving body satisfaction. EB: Qualitative data reported improvements in body satisfaction and lower occurrences of disordered eating associated with the practice of yoga and its related spirituality (Dittmann & Freedman, 2009).
• Provide education and support for clients receiving treatments or medications that have the potential to alter body image. Discuss alternatives if available. EBN: Men receiving androgen-deprivation therapy as a treatment for prostate cancer may be at greater risk of body image dissatisfaction (Harrington, Jones, & Badger, 2009).
• Encourage the clients to write a narrative description of their changes. EBN: Expressive writing has therapeutic benefits with feelings of greater psychological well-being and fewer posttraumatic intrusion and avoidance symptoms (Atkinson et al, 2009).
• Take cues from clients regarding readiness to look at wound (may ask if client has seen wound yet) and utilize clients’ questions or comments as way to teach about wound care and healing. CEB: Tailoring interventions to individual clients and reading their nonverbal cues likely contributes to clients’ ability to heal emotionally from impact of wound on body image (Birdsall & Weinberg, 2001).
Encourage client to participate in regular aerobic and/or non-aerobic exercise when feasible. EB: Participants of this study demonstrated higher levels of body satisfaction following the very first exercise session (Vocks et al, 2009).
Provide client with a list of appropriate community support groups (e.g., Reach to Recovery, Ostomy Association). EB: This study of three different cancer groups (a group for women with metastatic cancer, a colorectal cancer support group, and a group for Chinese cancer patients) showed their perceived benefits were similar; the groups provided information, acceptance, and understanding (Bell et al, 2010).
Pediatric: Note: Many of the above interventions are appropriate for the pediatric client.
Refer parents of children with eating disorders to a support group. EB: Parents indicated that it assisted them in understanding eating disorder symptoms and treatment and supporting their child struggling with an eating disorder. Additionally, the group was a source of emotional support. Results suggest that inclusion of a parent support group in the outpatient treatment of children and adolescents with eating disorders has important implications for parents (Pasold, Boateng, & Portilla, 2010).
Refer children and families with severe facial burns for psychosocial support. EB: Severe facial burn influences health-related quality of life (HRQOL) in children. Additional psychosocial support is suggested to enhance recovery for patients with severe face burns and their families during the years following injury (Stubbs et al, 2011).
Assess family dynamics and refer parents of adolescents with anorexia or other eating disorders to professional family counseling if indicated. EB: This study indicated that when adolescents’ basic psychological needs are met, they are less likely to worry about the adequacy of body appearance and engage in unhealthy weight control behaviors. Parenting practices such as lack of emotional support or demanding conformity have negative impacts on adolescents suffering from eating disorders (Thøgersen-Ntoumani, Ntoumanis, & Mikitaras, 2010).
• Discuss with parents the potentially negative influence media has on younger children as a source of unrealistic ideals of body image. EB: Results of this study suggest that more frequent viewing of programming such as music videos and soap operas promotes higher levels of body dissatisfaction and restrained eating in young girls (Anschutz, et al, 2009).
Consider using a measurement tool such as the Children’s Body Image Scale (CBIS) if a child is at risk for body image disturbance. EB: The CBIS has produced stable results for measurements of children’s body size perception and satisfaction (Truby & Paxton, 2008).
Geriatric:• Focus on remaining abilities. Have client make a list of strengths. CEB: Results from unstructured interviews with women aged 61 to 92 years regarding their perceptions and feelings about their aging bodies suggest that women exhibit the internalization of ageist beauty norms, even as they assert that health is more important to them than physical attractiveness and comment on the “naturalness” of the aging process (Hurd, 2000).
• Encourage regular exercise for the elderly. EBN: This study of 85-year-olds in Sweden emphasized the importance of activities and exercises in staying fit and having a good quality of life and better perceived health (Fischer et al, 2008).
Multicultural:• Assess for the influence of cultural beliefs, regional norms, and values on the client’s body image. EB: A study of young adults living in Hawaii and Australia demonstrated a tolerance for body sizes that are significantly larger than the size (BMI) considered healthy (Knight, Latner, & Illingworth, 2010). EBN: Each client should be assessed for body image based on the phenomenon of communication, time, space, social organization, environmental control, and biological variations (Giger & Davidhizar, 2008). EB: A study of Muslim women found that the strength of their religious faith was inversely related to body dissatisfaction (Mussap, 2009).
• Acknowledge that body image disturbances can affect all individuals regardless of culture, race, or ethnicity. EB: Results in this study suggest that gender and cultural differences in body image among adolescents are significant (Ceballos & Czyzewska, 2010). Body image disorders are becoming increasingly prevalent in developing non-Western countries such as China (Xu et al, 2010).
Home Care:• The above interventions may be adapted for home care use.
• Assess client’s level of social support as it is one of the determinants of client’s recovery and emotional health. CEB: Females who perceived they have good social support were found to adapt better to changes in body image after stoma surgery (Brown & Randle, 2005).
• Assess family/caregiver level of acceptance of client’s body changes. CEB: Family members’ expressions and reactions were found to impact women’s coping, and negative reactions in particular increased the women’s level of anxiety (Brown & Randle, 2005).
• Encourage client to discuss concerns related to sexuality and provide support or information as indicated. Many conditions that affect body image also affect sexuality. CEB: Brown and Randle (2005) found that clients (particularly females) with stomas often believe they are less sexually attractive after surgery, though their sexual partner may not share that view. However, clients who underwent urostomy surgery often experienced a decrease in sexual functioning.
• Teach all aspects of care. Involve client and caregivers in self-care as soon as possible. Do this in stages if client still has difficulty looking at or touching changed body part. EB: Prostate cancer clients need interventions that assist them to manage the effects of their disease. Programs need to include spouses because they also are negatively affected by the disease and can influence client outcomes (Kershaw et al, 2008).
Client/Family Teaching and Discharge Planning:
• Teach appropriate care of surgical site (e.g., mastectomy site, amputation site, ostomy site, etc.). EBN: Integration of a cosmetic program into the routine nursing care for oral cancer clients is highly recommended. This study confirmed that cosmetic rehabilitation had positive effects on the body image of oral cancer clients (Huang & Liu, 2008).
• Inform client of available community support groups, such as Internet discussion boards. EB: Many people living with long-term conditions would like to be in contact with their peers, and Internet discussion boards represent a cost-effective and interactive way of achieving this (Armstrong & Powell, 2009).
• Encourage significant others to offer support. EB: Clients in this study with heart failure managed depressive symptoms that affect health-related quality of life by engaging in activities such as exercise and reading, and by using positive thinking, spirituality, and social support. Helping clients find enhanced social support is important (Dekker et al, 2009).
Refer clients who are having difficulty with personal acceptance, personal and social body image disruption, sexual concerns, reduced self-care skills, and the management of surgical complications to an interdisciplinary team or specialist (e.g., ostomy nurse) if available. EBN: There is sufficient research-based evidence to conclude that intestinal ostomy surgery exerts a clinically relevant impact on health-related quality of life (HRQOL), and that nursing interventions can ameliorate this effect (Pittman, Kozell, & Gray, 2009).
References
Anschutz, D., et al. Watching your weight? The relation between watching soaps and music television and body dissatisfaction and restrained eating in young girls. Psychol Health. 2009;24(9):1035–1050.
Armstrong, N., Powell, J. Patient perspectives on health advice posted on internet discussion boards: a qualitative study. Health Expect. 2009;12(3):313–320.
Atkinson, R., et al. Therapeutic benefits of expressive writing in an electronic format. Nurs Admin Q. 2009;33(3):212–215.
Bell, K., et al. Is there an “ideal cancer” support group? Key findings from a qualitative study of three groups. J Psychosoc Oncol. 2010;28(4):432–449.
Birdsall, C., Weinberg, K. Adult clients looking at their burn injuries for the first time. J Burn Care Rehabil. 2001;22(5):360–364.
Borwell, B. Rehabilitation and stoma care: addressing the psychological needs. Br J Nurs. 18(4), 2009. [S20–2-S24-5].
Bowers, B. Providing effective support for patients facing disfiguring surgery. Br J Nurs. 2008;17(2):94–98.
Brown, H., Randle, J. Living with a stoma: a review of the literature. J Clin Nurs. 2005;14(1):74–81.
Ceballos, N., Czyzewska, M. Body image in Hispanic/Latino vs. European American adolescents: implications for treatment and prevention of obesity in underserved populations. J Health Care Poor Underserv. 2010;21(3):823–838.
Costarelli, V., Demerzi, M. Stamou D: Disordered eating attitudes in relation to body image and emotional intelligence in young women. J Human Nutr Dietetics. 2009;22:239–245.
Dekker, R.L., et al. Living with depressive symptoms: patients with heart failure. Am J Crit Care. 2009;18(4):310–318.
Dittmann, D.A., Freedman, M.R. Body awareness, eating attitudes, and spiritual beliefs of women practicing yoga. Eat Disord. 2009;17:273–292.
Dunkley, D.M., Masheb, R.M., Grilo, C.M. Childhood maltreatment, depressive symptoms, body dissatisfaction in patients with binge eating disorder: the mediating role of self-criticism. Int J Eat Disord. 2010;43(3):274–281.
Fischer, R.S., et al. Still going strong: perceptions of the body among 85-year-old people in Sweden. Int J Older People Nurs. 2008;3(1):14–21.
Gagnon, M., Holmes, D. Bodies in mutation: understanding lipodystrophy among women living with HIV/AIDS. Res Theory Nurs Pract. 2011;25(1):23–39.
Giger, J., Davidhizar, R. Transcultural nursing: assessment and intervention, ed 4. St Louis: Mosby; 2008.
Giovannelli, T.S., et al. The measurement of body-image dissatisfaction-satisfaction: is rating importance important? Body Image. 2008;5(2):216–223.
Harrington, J.M., Jones, E.G. Badger T: Body image perceptions in men with prostate cancer. Oncol Nurs Forum. 2009;36(2):167–172.
Huang, C., Hsieh, C. Treating bulimia nervosa: a nurse’s experience using cognitive behavior therapy [Chinese]. J Nurs (China). 2010;57(Suppl 2):29–34.
Huang, S., Liu, H.E. Effectiveness of cosmetic rehabilitation on the body image of oral cancer patients in Taiwan. Support Care Cancer. 2008;16(9):981–986.
Hurd, L.C. Older women’s body image and embodied experience: an exploration. J Women Aging. 2000;12(3-4):77–97.
Ipser, J.C., Sander, C., Stein, D.J. Pharmacotherapy and psychotherapy for body dysmorphic disorder. Cochrane Database Syst Rev. 2009;1:CD005332.
Kershaw, T.S., et al. Longitudinal analysis of a model to predict quality of life in prostate cancer patients and their spouses. Ann Behav Med. 2008;36(2):117–128.
Knight, T., Latner, J.D., Illingworth, D. Tolerance of larger body sizes by young adults living in Australia and Hawaii. Eat Disord. 2010;18:425–434.
Liu, H.E. Changes of satisfaction with appearance and working status for head and neck tumor patients. J Clin Nurs. 2008;17(14):1930–1938.
Munoz, D., et al. Changes in desired body shape after bariatric surgery. Eat Disord. 2010;18:347–354.
Mussap, A.J. Strength of faith and body image in Muslim and non-Muslim women. Ment Health Relig Cult. 2009;12(2):121–127.
Pasold, T.L., Boateng, B.A., Portilla, M.G. The use of a parent support group in the outpatient treatment of children and adolescents with eating disorders. Eat Disord. 2010;18(4):318–332.
Pittman, J., Kozell, K., Gray, M. Should WOC nurses measure health-related quality of life in patients undergoing intestinal ostomy surgery? J Wound Ostomy Continence Nurs. 2009;36(3):254–265.
Rohman, L. The relationship between anabolic androgenic steroids and muscle dysmorphia: a review. Eat Disord. 2009;17(3):187–199.
Stubbs, T.K., et al. Psychosocial impact of childhood face burns: a multicenter, prospective, longitudinal study of 390 children and adolescents. Burns. 2011;37(3):387–394.
Thøgersen-Ntoumani, C., Ntoumanis, N., Mikitaras, N. Unhealthy weight control behaviors in adolescent girls: a process model based on self-determination theory. Psychol Health. 2010;25(5):535–550.
Truby, H., Paxton, S.J. The children’s body image scale: reliability and use with international standards for body mass index. Br J Clin Psychol. 2008;47:119–128.
Vocks, S., et al. Effects of a physical exercise session on state body image: the influence of pre-experimental body dissatisfaction and concerns about weight and shape. Psychol Health. 2009;24(6):713–729.
Xu, X., et al. Body dissatisfaction, engagement in body change behaviors and sociocultural influences on body image among Chinese adolescents. Body Image. 2010;7(2):156–164.
Insufficient Breast Milk
NANDA-I
Defining Characteristics
Infant
Constipation; does not seem satisfied after sucking time; frequent crying; long breastfeeding time; refuses to suck; voids small amounts of concentrated urine (less than four to six times a day); wants to suck very frequently; weight gain is lower than 500 g in a month (comparing two measures)
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Initiate skin-to-skin contact at birth and undisturbed contact for the first hour following birth; the mother should be encouraged to watch the baby, not the clock. These behaviors are associated with an abundant milk supply (Noonan, 2011).
• Encourage postpartum women to start breastfeeding based on infant need as early as possible and reduce formula use to increase breastfeeding frequency. Use nonnarcotic analgesics as early as possible. EBN: These interventions are suggested to decrease early weaning in this study of women who had cesarean births and perceived insufficient milk supply (Lin et al, 2011).
• Provide suggestions for mothers on how to increase milk production and how to determine if there is insufficient milk supply. EBN: Teach mothers to know if there is low intake of breast milk by checking baby’s wet diapers (fewer than 6 to 8) and monitoring the frequency and amount of baby’s bowel movements. Provide suggestions to women on how to increase milk production, such as improving latch-on, increasing the frequency of feeding, offering both breasts during each breastfeeding session, and drinking enough fluids (Yen-Ju & McGrath, 2011).
• Instruct mothers that breastfeeding frequency, sucking times, and amounts are variable and normal. Assist mothers in optimal milk removal frequency. EBN: Breastfeeding rates may be affected by a maternal perception of insufficient milk production and less than optimal milk removal frequency (Kent, Prime, & Garbin, 2012)
Consider the use of medication for mothers of preterm infants with insufficient expressed breast milk. EBN: Breast milk remains the optimal form of enteral nutrition for term and preterm infants until up to 6 months postnatal age. In these studies there was modest improvement in EBM values with the use of a galactogogue medication (Donovan & Buchanan, 2012).
• Provide individualized follow-up with extra home visits or outpatient visits for teen mothers within the first few days after hospital discharge and encourage schools to be more compatible with breastfeeding. Adolescent mothers in the United States are much less likely to imitate breastfeeding than older mothers. This study indicated that these interventions may be helpful for teens who desire to breastfeed (Tucker, Wilson, & Samandari, 2011).
• Provide information and support to mothers on benefits of breastfeeding at antenatal visits EB: This study of mothers of infants in Bhaktapur, Nepal, supported that although proper breastfeeding is the most cost-effective intervention for reducing childhood morbidity and mortality, adherence to breastfeeding recommendations in developing countries is not satisfactory. Although many mothers instituted breastfeeding within 1 hour of delivery, continuation for up to six months was not common. Very few mothers received any information on breastfeeding during the antenatal visit (Ulak et al, 2012).
• Refer to care plans Interrupted Breastfeeding, Readiness for enhanced Breastfeeding for additional interventions.
References
Donovan, T.J., Buchanan, K., Medications for increasing milk supply in mothers expressing breastmilk for their preterm hospitalised infants. Cochrane Database Syst Rev 2012;(3):CD005544.
Kent, J., Prime, D., Garbin, C. Principles for maintaining or increasing breast milk production. J Obstet Gynecol Neonat Nurs. 2012;41(1):114–121.
Lin, S.Y., et al. Factors related to milk supply perception in women who underwent cesarean section. J Nurs Res. 2011;19(2):94–101.
Noonan, M. Breastfeeding: is my baby getting enough milk? Br J Midwifery. 2011;19(2):82–89.
Tucker, C.M., Wilson, E.K., Samandari, G. Infant feeding experiences among teen mothers in North Carolina: findings from a mixed-methods study. Int Breastfeed J. 2011;6:14.
Ulak, M., et al. Infant feeding practices in Bhaktapur, Nepal: a cross-sectional, health facility based survey. Int Breastfeed J. 2012;7(1):1–8.
Yen-Ju, H., McGrath, J. Predicting breastfeeding duration related to maternal attitudes in a Taiwanese sample. J Perinat Educ. 2011;20(4):188–199.
Ineffective Breastfeeding
NANDA-I
Defining Characteristics
Inadequate milk supply; infant arching at the breast; infant crying at the breast; infant inability to latch on to maternal breast correctly; infant exhibiting crying within the first hour after breastfeeding; infant exhibiting fussiness within the first hour after breastfeeding; insufficient emptying of each breast per feeding; insufficient opportunity for suckling at the breast; no observable signs of oxytocin release; nonsustained suckling at the breast; observable signs of inadequate infant intake; perceived inadequate milk supply, persistence of sore nipples beyond first week of breastfeeding; resisting latching on; unresponsive to other comfort measures; unsatisfactory breastfeeding process
Related Factors (r/t)
Infant anomaly; infant receiving supplemental feedings with artificial nipple; interruption in breastfeeding; knowledge deficit; maternal ambivalence; maternal anxiety; maternal breast anomaly; nonsupportive family; nonsupportive partner; poor infant sucking reflex; prematurity; previous breast surgery; previous history of breastfeeding failure
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Achieve effective breastfeeding (dyad)
• Verbalize/demonstrate techniques to manage breastfeeding problems (mother)
• Manifest signs of adequate intake at the breast (infant)
• Manifest positive self-esteem in relation to the infant feeding process (mother)
• Explain alternative method of infant feeding if unable to continue exclusive breastfeeding (mother)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Identify women with risk factors for lower breastfeeding initiation and continuation rates (age less than 20 years, low socioeconomic status) as well as factors contributing to ineffective breastfeeding as early as possible in the perinatal experience. EBN: Nurses should support the development of breastfeeding skills which have been shown to predict attitude, positive commitment and confidence in breastfeeding (Avery et al, 2009).
• Provide time for clients to express expectations and concerns and give emotional support. CEB: Lactation consultants and nurses play a key role in the establishment of breastfeeding (Lewallen et al, 2006).
• Use valid and reliable tools to measure breastfeeding performance and to predict early discontinuance of breastfeeding whenever possible/feasible. EBN: Ho and McGrath (2010) compared and contrasted the clinical usefulness and psychometric properties of seven self-report instruments and found that they each contribute to our understanding of breastfeeding in various ways.
• Promote comfort and relaxation to reduce pain and anxiety. CEB: Discomfort and increased tension are factors associated with reduced let-down reflex and premature discontinuance of breastfeeding. Anxiety and fear are associated with decreased milk production (Mezzacappa & Katkin, 2002).
• Avoid supplemental feedings. EB: A correlation exists between hospital staff providing formula and/or water supplements and failure to succeed with exclusive breastfeeding (Declercq et al, 2009).
• Monitor infant behavioral cues and responses to breastfeeding. EBN: Monitor and assess the mom and baby for several breastfeeding sessions to evaluate maternal and infant cues, latch, nipple condition, and response to breastfeeding (Ladewig et al, 2010).
• Provide necessary equipment/instruction/assistance for milk expression as needed. EBN: Expressing breast milk by hand may be more effective in the removal of colostrum in the immediate postpartum period than the use of electric pumps. Mothers should be taught the technique of hand expressing breast milk so engorgement can be addressed when electrical pumps are not available (Ladewig et al, 2010).
Provide referrals and resources: lactation consultants, nurse and peer support programs, community organizations, and written and electronic sources of information. EBN: Evidence-based guidelines and systematic reviews support the use of professionals with special skills in breastfeeding and other support programs to promote continued breastfeeding (Association of Women’s Health Obstetric and Neonatal Nurses, 2007). If a newborn is having difficulty breastfeeding beyond 24 hours a lactation consultant should be contacted (Shannon et al, 2007).
• See care plan for Readiness for enhanced Breastfeeding.
• Assess whether the client’s concerns about the amount of milk taken during breastfeeding is contributing to dissatisfaction with the breastfeeding process. CEB: Some cultures may add semisolid food within the first month of life as a result of concerns that the infant is not getting enough to eat and the perception that “big is healthy” (Higgins, 2000).
• Assess the influence of family support on the decision to continue or discontinue breastfeeding. EBN: Family members may have different impressions and ideas about breastfeeding that can cause maternal misunderstanding and influence the length of time she breastfeeds (Purdy, 2010).
• Provide traditional ethnic foods for breastfeeding mothers. EBN: One barrier to breastfeeding is a lack of hospital foods that allow women to follow a traditional diet postpartum. After a staff training program on breastfeeding, and the creation of a Cambodian menu, initiation rates increased significantly more in Cambodians than in non-Cambodians. Postintervention, there was no significant difference between breastfeeding initiation rates among Cambodian women (66.7%) compared to non-Cambodians (68.9%) (Galvin et al, 2008).
• See care plan for Readiness for enhanced Breastfeeding.
• The above interventions may be adapted for home care use.
• Provide anticipatory guidance in relation to home management of breastfeeding. CEB: Since many women maintain a career after having children, nurses should initiate teaching about pumping, maintaining milk supply, and feeding the infant while the mother is at work. Women can continue to breastfeed while working if provided education and support (Lewallen et al, 2006).
• Investigate availability/refer to public health department, hospital home follow-up breastfeeding program, or other postdischarge support. CEB: Some hospitals and public health departments have follow-up breastfeeding programs, particularly for high-risk mothers (e.g., older mothers, history of substance use, risk of physical abuse) (McNaughton, 2004).
• See care plan for Risk for impaired Attachment.
Client/Family Teaching and Discharge Planning:
• Instruct the client on maternal breastfeeding behaviors/techniques (preparation for, positioning, initiation of/promoting latch-on, burping, completion of session, and frequency of feeding). Consider use of a video. EBN: Breastfeeding mothers should be evaluated to determine knowledge deficits, provide teaching, assist with breastfeeding, and address any concerns the mother might have (Ladewig et al, 2010).
• Teach the client self-care measures for the breastfeeding woman (e.g., breast care, management of breast/nipple discomfort, nutrition/fluid, rest/activity). EBN: Painful nipples, mastitis, adequate hydration, and fatigue are some of the problems a breastfeeding woman may experience (Ladewig et al, 2010).
• Provide information regarding infant cues and behaviors related to breastfeeding and appropriate maternal responses (e.g., cues that infant is ready to feed, behaviors during feeding that contribute to effective breastfeeding, measures of infant feeding adequacy). Teach the mother signs of infant readiness to feed (lusty cry, rooting and sucking behaviors when nipple is placed near baby’s lips) (Ladewig et al, 2010).
• Provide education to father/family/significant others as needed. EBN: Family members may have different impressions and ideas about breastfeeding that can cause maternal misunderstanding and influence the length of time she breastfeeds (Purdy, 2010).
See Readiness for enhanced Breastfeeding for additional references.
Galvin, S., et al. A practical intervention to increase breastfeeding initiation among Cambodian women in the U.S. Matern Child Health J. 2008;12(4):545–547.
Higgins, B. Puerto Rican cultural beliefs: influence on infant feeding practices in western New York. J Transcult Nurs. 2000;11(1):19–30.
Ho, Y.J., McGrath, J.M. A review of the psychometric properties of breastfeeding assessment tools. J Obstet Gynecol Neonat Nurs. 2010;39(4):386–400.
Lewallen, L.P., et al. Breastfeeding support and early cessation. J Obstet Gynecol Neonatal Nurs. 2006;35(2):166–172.
McNaughton, D.B. Nurse home visits to maternal-child clients: a review of intervention research. Public Health Nurs. 2004;21(3):207–219.
Mezzacappa, E.S., Katkin, E.S. Breast-feeding is associated with reduced perceived stress and negative mood in mothers. Health Psychol. 2002;21(2):187–193.
Shannon, T., O’Donnell, M.J., Skinner, K. Breastfeeding in the 21st century: overcoming barriers to help women and infants. Nurs Women Health. 2007;11(6):569–575.
Interrupted Breastfeeding
NANDA-I
Break in the continuity of the breastfeeding process as a result of inability or inadvisability to put baby to breast for feeding
Defining Characteristics
Infant receives no nourishment at the breast for some or all feedings; lack of knowledge about expression of breast milk; lack of knowledge about storage of breast milk; maternal desire to eventually provide breast milk for child’s nutritional needs; maternal desire to maintain breastfeeding for child’s nutritional needs; maternal desire to provide breast milk for child’s nutritional needs; separation of mother and child
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Discuss mother’s desire/intention to begin or resume breastfeeding. EBN: Nurses should support the development of breastfeeding skills which have been shown to predict attitude, positive commitment and confidence in breastfeeding (Avery et al, 2009).
• Provide anticipatory guidance to the mother/family regarding potential duration of the interruption when possible/feasible. EBN: One way to enhance involvement and reduce stress for mothers interested in resuming breastfeeding is to begin breast pumping to stimulate milk production and provide essential nutrition for the infant when stable (Hadsell, 2010-2011).
• Reassure mother/family that early measures to sustain lactation and promote parent-infant attachment can make it possible to resume breastfeeding when the condition/situation requiring interruption is resolved. EBN: Observation and validation of breastfeeding technique should be confirmed to help avoid difficulties (Kronborg & Vaeth, 2009).
• Reassure the mother/family that the infant will benefit from any amount of breast milk provided. EBN: One of the most common reasons mothers supplement or stop breastfeeding is their perception of the baby not getting milk (Noonan, 2011).
Collaborate with the mother/family/health care providers/employers (as needed) to develop a plan for expression of breast milk/infant feeding/kangaroo care/skin-to-skin contact (SSC). Nurses should collaborate with the mother and teach her the skill of hand expression even if she plans on using a breast pump because a pump may not always be available (Ladewig et al, 2010).
• Monitor for signs indicating infant’s ability to breastfeed and interest in breastfeeding. EBN: Teach the mother to recognize and respond to her baby’s feeding cues and signs that her breasts are filling (Noonan, 2011).
• Observe mother performing psychomotor skills (expression, storage, alternative feeding, kangaroo care, and/or breastfeeding) and assist as needed. EBN: Observation and validation of breastfeeding technique should be confirmed to help avoid difficulties (Kronborg & Vaeth, 2009).
Use supplementation only as medically indicated. EB: A correlation exists between hospital staff providing formula and/or water supplements and failure to succeed with exclusive breastfeeding (Declercq et al, 2009).
• Provide anticipatory guidance for common problems associated with interrupted breastfeeding (e.g., incomplete emptying of milk glands, diminishing milk supply, infant difficulty with resuming breastfeeding, or infant refusal of alternative feeding method). EBN: One measure to decrease interruption of breastfeeding due to perceived inadequate milk supply (PIM) is teaching by the clinician because many women perceive crying, fussiness, and wakefulness as signs that their baby is not receiving enough milk (Gatti, 2008).
Initiate follow-up and make appropriate referrals.
• Assist the client to accept and learn an alternative method of infant feeding if effective breastfeeding is not achieved. CEB: If it is clear that breastfeeding cannot be achieved after the interruption and an alternative feeding method must be instituted, the mother needs support and education (Mozingo et al, 2000).
• See care plans for Readiness for enhanced Breastfeeding and ineffective Breastfeeding.
• Teach culturally appropriate techniques for maintaining lactation. CEB: The Oketani method of breast massage is used by Japanese and other Asian women. Oketani breast massage improved quality of human milk by increasing total solids, lipids, casein concentration, and gross energy (Foda et al, 2004).
• Validate the client’s feelings with regard to the difficulty of or her dissatisfaction with breastfeeding. EBN: Many women stop breastfeeding because of a misconception that they do not have enough milk to feed their infant (Davis, 2011).
• See care plans for Readiness for enhanced Breastfeeding and ineffective Breastfeeding.
Client/Family Teaching and Discharge Planning:
• Teach mother effective methods to express breast milk. EBN: Expressing breast milk by hand may be more effective in the removal of colostrum in the immediate postpartum period than the use of electric pumps (Ladewig, London, & Davidson, 2010). Mothers should be taught the technique of hand expressing breast milk so engorgement can be addressed when electrical pumps are not available (Ladewig et al, 2010).
• Teach mother/parents about kangaroo care. EBN: Parents can use skin-to-skin care to promote attachment and provide closeness to their infant (Ladewig et al, 2010).
• Instruct mother on safe breast milk handling techniques. EB: Breastfeeding mothers can retain the high quality of breast milk and the health of their infant by using safe preparation guidelines and storage methods (CDC, 2011).
• See care plans for Readiness for enhanced Breastfeeding and ineffective Breastfeeding.
See Readiness for enhanced Breastfeeding for additional references.
Davis, C. Breastfeeding support: students are taking the lead in encouraging new mothers to bond with their babies. Nurs Stand. 2011;25(24):61.
Foda, M.I., et al. Composition of milk obtained from unmassaged versus massaged breasts of lactating mothers. J Pediatr Gastroenterol Nutr. 2004;38(5):484–487.
Gatti, L. Maternal perceptions of insufficient milk supply in breastfeeding. J Nurs Scholarsh. 2008;40(4):355–363.
Hadsell, C.A. Assessing psychological readiness for learning about breastfeeding in mothers of NICU infants: a guide for postpartum nurses. J N Y State Nurs Assoc. 2010-2011:8–12.
Mozingo, J.N., et al. “It wasn’t working.” Women’s experiences with short-term breastfeeding. MCN Am J Matern Child Nurs. 2000;25(3):120–126.
Noonan, M. Breastfeeding: Is my baby getting enough milk? Br J Midwifery. 2011;19(2):82–89.
Readiness for enhanced Breastfeeding∗
NANDA-I
A pattern of proficiency and satisfaction of the mother-infant dyad that is sufficient to support the breastfeeding process and can be strengthened
Defining Characteristics
Adequate infant elimination patterns for age; appropriate infant weight pattern for age; eagerness of infant to nurse; effective mother-infant communication patterns; infant content after feeding; mother reports satisfaction with the breastfeeding process; mother able to position infant at breast to promote a successful latching-on response; regular suckling at the breast; regular swallowing at the breast; signs of oxytocin release; sustained suckling at the breast; sustained swallowing at the breast; symptoms of oxytocin release are present
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Encourage expectant mothers to learn about breastfeeding during pregnancy. EBN: Nurses should support the development of breastfeeding skills which have been shown to predict attitude, positive commitment, and confidence in breastfeeding (Avery et al, 2009).
• Encourage and facilitate early skin-to-skin contact (SSC) (position includes contact of the naked baby with the mother’s bare chest within 2 hours after birth). EBN: Early skin-to-skin contact led to statistically significant breastfeeding performance at 1 to 4 months of age and improved length of breastfeeding (Caruana, 2008).
• Encourage rooming-in and breastfeeding on demand. EBN: Mothers who room-in with their infants have greater percentages of exclusive breastfeeding when released from the hospital (Zuppa et al, 2009).
• Monitor the breastfeeding process and identify opportunities to enhance knowledge and experience regarding breastfeeding. EB: While mothers and babies are in the hospital it is essential that hospital personnel support their effort to learn to breastfeed (CDC, 2011).
• Give encouragement/positive feedback related to breastfeeding mother-infant interactions. EBN: “Confident commitment” has been associated as an essential factor for sustained breastfeeding (Avery et al, 2009).
• Monitor for signs and symptoms of nipple pain and/or trauma. EBN: Women should be instructed on proper positioning and infant attachment to the breast to prevent nipple pain and/or trauma during breastfeeding (The Joanna Briggs Institute, 2009).
• Discuss prevention and treatment of common breastfeeding problems. EBN: Moms who learn to distinguish the challenges associated with establishing breastfeeding and realize that is it a learning process for both mother and baby can attain confidence in their abilities and lead to successful breastfeeding (Avery et al, 2009).
• Monitor infant responses to breastfeeding. EBN: Monitor and assess the mom and baby for several breastfeeding sessions to evaluate maternal and infant cues, latch, nipple condition, and response to breastfeeding (Ladewig, London, & Davidson, 2010).
• Identify current support-person network and opportunities for continued breastfeeding support. EB: Education and support to breastfeeding mothers increases the length of breastfeeding and helps to promote exclusive breastfeeding (Anonymous, 2008).
• Avoid supplemental bottle feedings and pacifiers and do not provide samples of formula on discharge. EB:A correlation exists between hospital staff providing formula and/or water supplements and failure to succeed with exclusive breastfeeding (Declercq et al, 2009). EBN: The use of pacifiers is independently related to a reduction in the amount of time an infant is exclusively breastfed (Kronborg & Vaeth, 2009).
Provide follow-up contact; as available provide home visits and/or peer counseling. EB:Professional support is that is accessible to women at all times during the antenatal and postpartal periods influences breastfeeding outcomes (Kervin, Kemp, & Pulver, 2010).
• Assess for the influence of cultural beliefs, norms, and values on current breastfeeding practices. EBN: The Hispanic mother may believe stress and anger make bad milk, which makes a breastfeeding infant ill. Some Hispanic women neutralize the bowel when weaning from breast to bottle by feeding only anise tea for 24 hours (Gonzalez, Owens, & Esperat, 2008). EBN: Each client should be assessed for ability to breastfeed based on a culturally competent assessment of the phenomenon of communication, time, space, social organization, environmental control, and biological variations (Giger & Davidhizar, 2008).
• Assess mothers’ timing preference to begin breastfeeding. Women from different cultures may have different beliefs about the best time to begin breastfeeding (Purnell & Paulanka, 2008). EBN:Although usual hospital practice is to begin breastfeeding immediately, some cultures (e.g., Arab heritage) do not regard colostrum as appropriate for newborns and may prefer to wait until milk is present at about 3 days of age (Purnell & Paulanka, 2008).
Client/Family Teaching and Discharge Planning:
• Include the father and other family members in education about breastfeeding. EBN: Family members may have different impressions and ideas about breastfeeding that can cause maternal misunderstanding and influence the length of time she breastfeeds (Purdy, 2010).
• Teach the client the importance of maternal nutrition. EB: Consumption or avoidance of specific foods or drinks is generally not necessary. Breastfeeding mothers should consume 500 calories more than a nonpregnant, nonnursing women. Adequate protein intake is important with 65 g/day during the first 6 months and 62 g/day during the second 6 months recommended (Ladewig, London, & Davidson, 2010).
• Reinforce the infant’s subtle hunger cues (e.g., quiet-alert state, rooting, sucking, mouthing, hand-to-mouth, hand-to-hand activity) and encourage the client to nurse whenever signs are apparent. Parents should be taught feeding cues that suggest it is a good time to breastfeed their infant.EBN: Evidence-based practice guidelines support the teaching/reinforcement of these skills as important to effective breastfeeding (Association of Women’s Health Obstetric and Neonatal Nurses, 2007).
• Review guidelines for frequency (every 2 to 3 hours, or 8 to 12 feedings per 24 hours) and duration (until suckling and swallowing slow down and satiety is reached) of feeding times. In the first few days, frequent and regular stimulation of the breasts is important to establish an adequate milk supply; after breastfeeding is established, feeding lasts until the breasts are drained (Association of Women’s Health Obstetric and Neonatal Nurses, 2007). EBN: Evidence-based guidelines recommend assessment of infant satisfaction/satiety including infant cues and patterns of weight (Association of Women’s Health Obstetric and Neonatal Nurses, 2007).
• Provide anticipatory guidance about common infant behaviors. EBN: Being able to anticipate and manage behaviors and problems promotes parental confidence (Association of Women’s Health Obstetric and Neonatal Nurses, 2007).
• Provide information about additional breastfeeding resources. EBN: Evidence-based clinical practice guidelines suggest that breastfeeding books, materials, websites, and breastfeeding support groups, which provide current and accurate information, can enhance maternal success and satisfaction with the breastfeeding process (Association of Women’s Health Obstetric and Neonatal Nurses, 2007).
References
Anonymous. Breastfeeding support helps reduce child mortality. Aust Nurs J. 2008;16(3):16.
Avery, A., et al. Confident commitment is a key factor for sustained breastfeeding. Birth. 2009;36(2):141–148.
Association of Women’s Health Obstetric and Neonatal Nurses. Evidence-based clinical practice guideline: breastfeeding support: pre-natal care through the first year (practice guideline), ed 2. Washington, DC: Author; 2007.
Caruana, E. Early skin-to-skin contact for mothers and their healthy newborn infants. J Adv Nurs. 2008;62(4):439–440.
Centers for Disease Control and Prevention (CDC), Breastfeeding report card—United States. Atlanta, GA: U.S. Department of Health and Human Services, CDC; 2011 Retrieved October 12, 2011, from http://www.cdc.gov/breastfeeding/data/reportcard.htm
Declercq, E., et al. Hospital practices and women’s likelihood of fulfilling their intention to exclusively breastfeed. Am J Public Health. 2009;99(5):929–935.
Giger, J., Davidhizar, R. Transcultural nursing: assessment and intervention. St Louis: Mosby; 2008.
Gonzalez, E., Owens, D., Esperat, C. Mexican Americans. In: Giger J., Davidhizar R., eds. Transcultural nursing: assessment and intervention. St Louis: Mosby, 2008.
Kervin, B.E., Kemp, L., Pulver, L.J. Types and timing of breastfeeding support and its impact on mothers’ behaviours. J Paediatr Child Health. 2010;46:85–91.
Kronborg, H., Vaeth, M. How are effective breastfeeding technique and pacifier use related to breastfeeding problems and breastfeeding duration? Birth. 2009;36(1):34–42.
Ladewig, A.P., London, M.L., Davidson, M.R. Breastfeeding nutrition and newborn nutrition. In Davidson M., London M., Ladewig P., eds.: Contemporary maternal-newborn nursing care, ed 7, Upper Saddle River, NJ: Pearson, 2010.
Purdy, I.B. Social, cultural, and medical factors that influence maternal breastfeeding. Issues Ment Health Nurs. 2010;31:365–367.
Purnell, L.D., Paulanka, B.J. Transcultural health care: a culturally competent approach, ed 4. Philadelphia: FA Davis; 2008.
The Joanna Briggs Institute. The management of nipple pain and/or trauma associated with breastfeeding,. Aust Nurs J. 2009;17(2):32–35.
Zuppa, A.A., et al. Weight loss and jaundice in healthy term newborns in partial and full rooming-in. J Matern Fetal Neonat Med. 2009;22(9):801–805.
Ineffective Breathing Pattern
NANDA-I
Defining Characteristics
Alterations in depth of breathing; altered chest excursion; assumption of three-point position; bradypnea; decreased expiratory pressure; decreased inspiratory pressure; decreased minute ventilation; decreased vital capacity; dyspnea; increased anterior-posterior diameter; nasal flaring; orthopnea; prolonged expiration phase; pursed-lip breathing; tachypnea; use of accessory muscles to breathe
Related Factors (r/t)
Anxiety; body position; bony deformity; chest wall deformity; cognitive impairment; fatigue; hyperventilation; hypoventilation syndrome; musculoskeletal impairment; neurological immaturity; neuromuscular dysfunction; obesity; pain; perception impairment; respiratory muscle fatigue; spinal cord injury
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate a breathing pattern that supports blood gas results within the client’s normal parameters
• Report ability to breathe comfortably
• Demonstrate ability to perform pursed-lip breathing and controlled breathing
• Identify and avoid specific factors that exacerbate episodes of ineffective breathing patterns
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Monitor respiratory rate, depth, and ease of respiration. Normal respiratory rate is 10 to 20 breaths/min in the adult (Jarvis, 2012). EBN: When the respiratory rate exceeds 30 breaths/min, along with other physiological measures, a study demonstrated that a significant physiological alteration existed (Hagle, 2008).
• Note pattern of respiration. If client is dyspneic, note what seems to cause the dyspnea, the way in which the client deals with the condition, and how the dyspnea resolves or gets worse.
• Note amount of anxiety associated with the dyspnea. A normal respiratory pattern is regular in a healthy adult. To assess dyspnea, it is important to consider all of its dimensions, including antecedents, mediators, reactions, and outcomes.
• Attempt to determine if client’s dyspnea is physiological or psychological in cause. EB: Maximal respiratory work is less unpleasant than moderately intense air hunger, and unpleasantness of dyspnea can vary independently from perceived intensity, consistent with pain. Separate dimensions should be measured (Banzett et al, 2008). A study found that when the cause was psychological (medically unexplained dyspnea), there was affective dyspnea, anxiety, and tingling in the extremities, whereas when the dyspnea was physiological, there was associated wheezing, cough, sputum, and palpitations (Han et al, 2008).
Psychological Dyspnea—Hyperventilation
• Monitor for symptoms of hyperventilation including rapid respiratory rate, sighing breaths, lightheadedness, numbness and tingling of hands and feet, palpitations, and sometimes chest pain (Bickley & Szilagyi, 2009).
• Assess cause of hyperventilation by asking client about current emotions and psychological state.
• Ask the client to breathe with you to slow down respiratory rate. Maintain eye contact and give reassurance. By making the client aware of respirations and giving support, the client may gain control of the breathing rate.
Consider having the client breathe in and out of a paper bag as tolerated. This simple treatment helps associated symptoms of hyperventilation, including helping to retain carbon dioxide, which will decrease associated symptoms of hyperventilation (Bickley & Szilagyi, 2009).
If client has chronic problems with hyperventilation, numbness and tingling in extremities, dizziness, and other signs of panic attacks, refer for counseling.
Physiological Dyspnea
Ensure that client in acute dyspneic state has received any ordered medications, oxygen, and any other treatment needed.
• Determine severity of dyspnea using a rating scale such as the modified Borg scale, rating dyspnea 0 (best) to 10 (worst) in severity. An alternative scale is the Visual Analogue Scale (VAS) with dyspnea rated as 0 (best) to 100 (worst).
• Note use of accessory muscles, nasal flaring, retractions, irritability, confusion, or lethargy. These symptoms signal increasing respiratory difficulty and increasing hypoxia.
• Observe color of tongue, oral mucosa, and skin for signs of cyanosis. Cyanosis of the tongue and oral mucosa is central cyanosis and generally represents a medical emergency. Peripheral cyanosis of nail beds or lips may or may not be serious (Bickley & Szilagyi, 2009).
• Auscultate breath sounds, noting decreased or absent sounds, crackles, or wheezes. These abnormal lung sounds can indicate a respiratory pathology associated with an altered breathing pattern.
Monitor oxygen saturation continuously using pulse oximetry. Note blood gas results as available. An oxygen saturation of less than 90% (normal: 95% to 100%) or a partial pressure of oxygen of less than 80 mm Hg (normal: 80 to 100 mm Hg) indicates significant oxygenation problems.
• Using touch on the shoulder, coach the client to slow respiratory rate, demonstrating slower respirations; making eye contact with the client; and communicating in a calm, supportive fashion. The nurse’s presence, reassurance, and help in controlling the client’s breathing can be beneficial in decreasing anxiety. CEB: A study demonstrated that anxiety is an important indicator of severity of client’s disease with chronic obstructive pulmonary disease (COPD) (Bailey, 2004).
• Support the client in using pursed-lip and controlled breathing techniques. Pursed-lip breathing results in increased use of intercostal muscles, decreased respiratory rate, increased tidal volume, and improved oxygen saturation levels (Faager, Stahle, & Larsen, 2008). EBN: A systematic review found pursed-lip breathing effective in decreasing dyspnea (Carrieri-Kohlman & Donesky-Cuenco, 2008).
• If the client is acutely dyspneic, consider having the client lean forward over a bedside table, resting elbows on the table if tolerated. Leaning forward can help decrease dyspnea (Brennan & Mazanec, 2011), possibly because gastric pressure allows better contraction of the diaphragm (Langer et al, 2009). This is called the tripod position and is used during times of distress, including when walking.
• Position the client in an upright position (Brennan & Mazanec, 2011). An upright position facilitates lung expansion. See Nursing Interventions and Rationales for Impaired Gas Exchange for further information on positioning.
Administer oxygen as ordered. Oxygen administration has been shown to correct hypoxemia which causes dyspnea (Wong & Elliott, 2009).
• Increase client’s activity to walking three times per day as tolerated. Assist the client to use oxygen during activity as needed. See Nursing Interventions and Rationales for Activity Intolerance. Supervised exercise has been shown to decrease dyspnea and increase tolerance to activity (Reilly, Silverman, & Shapiro, 2012).
• Schedule rest periods before and after activity. Respiratory clients with dyspnea are easily exhausted and need additional rest.
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).
• Provide small, frequent feedings. Small feedings are given to avoid compromising ventilatory effort and to conserve energy. Clients with dyspnea often do not eat sufficient amounts of food because their priority is breathing.
• Offer a fan to move the air in the environment. EBN & EB: A systematic review found that the movement of cool air on the face can be effective in relieving dyspnea in pulmonary clients (Carrieri-Kohlman & Donesky-Cuenco, 2008). A study found a significant decrease in dyspnea with use of a fan directed at the nose and mouth (Galbraith et al, 2010)
• Encourage the client to take deep breaths at prescribed intervals and do controlled coughing.
• Help the client with chronic respiratory disease to evaluate dyspnea experience to determine if similar to previous incidences of dyspnea and to recognize that he or she made it through those incidences. Encourage the client to be self-reliant if possible, use problem-solving skills, and maximize use of social support. The focus of attention on sensations of breathlessness has an impact on judgment used to determine the intensity of the sensation.
• See Ineffective Airway Clearance if client has a problem with increased respiratory secretions.
Refer the COPD client for pulmonary rehabilitation. EB: A Cochrane study found pulmonary rehabilitation programs highly effective and safe for a client who has an exacerbation of COPD (Puhan et al, 2009).
• Encourage ambulation as tolerated. Immobility is harmful to the elderly because it decreases ventilation and increases stasis of secretions.
• Encourage elderly clients to sit upright or stand and to avoid lying down for prolonged periods during the day. Thoracic aging results in decreased lung expansion; an erect position fosters maximal lung expansion.
• The above interventions may be adapted for home care use.
• Work with the client to determine what strategies are most helpful during times of dyspnea. Educate and empower the client to self-manage the disease associated with impaired gas exchange. EBN & EB: A study found that use of oxygen, self use of medication, and getting some fresh air were most helpful in dealing with dyspnea (Thomas, 2009). Evidence-based reviews have found that self-management offers COPD clients effective options for managing the illness, leading to more positive outcomes (Kaptein et al, 2008).
• Assist the client and family with identifying other factors that precipitate or exacerbate episodes of ineffective breathing patterns (i.e., stress, allergens, stairs, activities that have high energy requirements). Awareness of precipitating factors helps clients avoid them and decreases risk of ineffective breathing episodes.
• Assess client knowledge of and compliance with medication regimen. Client/family may need repetition of instructions received at hospital discharge and may require reiteration as fear of a recent crisis decreases. Fear interferes with the ability to assimilate new information.
Refer the client for telemonitoring with a pulmonologist as appropriate, with use of an electronic spirometer, or an electronic peak flowmeter. EB: A systematic review of home telemonitoring for conditions such as COPD, asthma, and lung transplantation found that use of telemonitoring resulted in early detection of deterioration of clients’ respiratory status, and positive client receptiveness to the approach (Jaana, Paré, & Sicotte, 2009).
• Teach the client and family the importance of maintaining the therapeutic regimen and having PRN drugs easily accessible at all times. Appropriate and timely use of medications can decrease the risk of exacerbating ineffective breathing.
• Provide the client with emotional support in dealing with symptoms of respiratory difficulty. Provide family with support for care of a client with chronic or terminal illness. 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.
• When respiratory procedures (e.g., apneic monitoring for an infant) 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 forth. Ensure that notification is sent to the local utility company, the emergency medical team, police and fire departments. Notification is important to provide for priority service.
• Refer to GOLD guidelines for management of home care and indications of hospital admission criteria (GOLD, 2011).
• Support clients’ efforts at self-care. Ensure they have all the information they need to participate in care.
• Identify an emergency plan including when to call the physician or 911. Having a ready emergency plan reassures the client and promotes client safety.
Refer to occupational therapy for evaluation and teaching of energy conservation techniques.
Refer to home health aide services as needed to support energy conservation. Energy conservation decreases the risk of exacerbating ineffective breathing.
Institute case management of frail elderly to support continued independent living.
Client/Family Teaching and Discharge Planning:
• Teach pursed-lip and controlled breathing techniques. EB: Studies have demonstrated that pursed-lip breathing was effective in decreasing breathlessness and improving respiratory function (Faager, Stahle, & Larsen, 2008).
• Teach about dosage, actions, and side effects of medications. Inhaled steroids and bronchodilators can have undesirable side effects, especially when taken in inappropriate doses.
• Using a prerecorded CD, teach client progressive muscle relaxation techniques. EB: Relaxation therapy can help reduce dyspnea and anxiety (Langer et al, 2009).
• Teach the client to identify and avoid specific factors that exacerbate ineffective breathing patterns, such as exposure to other sources of air pollution, especially smoking. If client smokes, refer to the smoking cessation Section in the Impaired Gas Exchange care plan.
References
Bailey, P.H. The dyspnea-anxiety-dyspnea cycle—COPD patient’s stories of breathlessness. Qual Health Res. 2004;14(6):760–778.
Banzett, R., et al. The affective dimension of laboratory dyspnea. Am J Respir Crit Care Med. 2008;177:1384–1390.
Bickley, L.S., Szilagyi, P. Guide to physical examination, ed 10. Philadelphia: Lippincott; 2009.
Brennan, C., Mazanec, P. Dyspnea management across the palliative care continuum. J Hosp Palliat Nurs. 2011;13(3):130–139.
Carrieri-Kohlman, V., Donesky-Cuenco, D. Dyspnea management. An EBP guideline. In: Ackley B., et al, eds. Evidence-based nursing care guidelines: medical-surgical interventions. Philadelphia: Mosby, 2008.
Faager, G., Stahle, A., Larsen, F.F. Influence of spontaneous pursed lips breathing on walking endurance and oxygen saturation in patients with moderate to severe chronic obstructive pulmonary disease. Clin Rehabil. 2008;22(8):675–683.
Galbraith, S., et al. Does the use of a handheld fan improve chronic dyspnea? A randomized controlled, crossover trial. J Pain Symptom Manage. 2010;39(5):831–838.
GOLD. Global strategy for the diagnosis, management, and prevention of COPD (revised 2011). Global Initiative for Chronic Obstructive Lung Disease; 2011.
Hagle, M. Vital signs monitoring. An EBP guideline. In: Ackley B., et al, eds. Evidence-based nursing care guidelines: medical-surgical interventions. Philadelphia: Mosby, 2008.
Han, J., et al. The language of medically unexplained dyspnea. Chest. 2008;133(4):961–968.
Jaana, M., Paré, G., Sicotte, C. Home telemonitoring for respiratory conditions: a systematic review. Am J Manage Care. 2009;15(5):313–320.
Jarvis, C. Physical examination and health, ed 6. St. Louis: Saunders; 2012.
Kaptein, A.A., et al. 50 years of psychological research on patients with COPD—road to ruin or highway to heaven? Respir Med. 2008;103:3–11.
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.
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.
Puhan, M., et al. Pulmonary rehabilitation following exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. (1):2009. [CD005305].
Reilly, J., Silverman, E., Shapiro, S. Chronic obstructive pulmonary disease. In Longo D., et al, eds.: Harrison’s principles of internal medicine, ed 18, New York: McGraw-Hill, 2012.
Thomas, L. Effective dyspnea management strategies identified by elders with end-stage chronic obstructive pulmonary disease. Appl Nurs Res. 2009;22(2):79–85.
Wong, M., Elliott, M. The use of medical orders in acute care oxygen therapy. Br J Nurs. 2009;18(8):462–464.
∗Formerly effective breastfeeding.