C
Decreased Cardiac Output
NANDA-I
Defining Characteristics
Altered Heart Rate/Rhythm
Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardia
Altered Preload
Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge pressure (PAWP); fatigue; increased central venous pressure (CVP); increased pulmonary artery wedge pressure (PAWP); jugular vein distention; murmurs; weight gain
Altered Afterload
Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary vascular resistance (PVR); decreased systemic vascular resistance (SVR); increased pulmonary vascular resistance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary refill; skin color changes; variations in blood pressure readings
NOC (Nursing Outcomes Classification)
Cardiac Pump Effectiveness, Circulation Status, Tissue Perfusion: Abdominal Organs, Peripheral, Vital Signs
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate adequate cardiac output as evidenced by blood pressure, pulse rate and rhythm within normal parameters for client; strong peripheral pulses; maintained level of mentation, lack of chest discomfort or dyspnea, and adequate urinary output; an ability to tolerate activity without symptoms of dyspnea, syncope, or chest pain
• Remain free of side effects from the medications used to achieve adequate cardiac output
• Explain actions and precautions to prevent primary or secondary cardiac disease
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Recognize primary characteristics of decreased cardiac output as fatigue, dyspnea, edema, orthopnea, paroxysmal nocturnal dyspnea, and increased central venous pressure. Recognize secondary characteristics of decreased cardiac output as weight gain, hepatomegaly, jugular venous distention, palpitations, lung crackles, oliguria, coughing, clammy skin, and skin color changes. EBN: A nursing study to validate characteristics of the nursing diagnosis decreased cardiac output in a clinical environment identified and categorized related client characteristics that were present as primary or secondary (Martins, Alita, & Rabelo, 2010).
• Monitor and report presence and degree of symptoms including dyspnea at rest or with reduced exercise capacity, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, distended abdomen, fatigue, or weakness. Monitor and report signs including jugular vein distention, S3 gallop, rales, positive hepatojugular reflux, ascites, laterally displaced or pronounced PMI, heart murmurs, narrow pulse pressure, cool extremities, tachycardia with pulsus alternans, and irregular heartbeat. EB: These are symptoms and signs consistent with heart failure (HF) and decreased cardiac output (Jessup et al, 2009). In a study of primary care clients, breathlessness during exercise, limitations in physical activity, and orthopnea were the three most significant symptoms most often associated with HF (Devroey & Van Casteren, 2011).
• Monitor orthostatic blood pressures and daily weights. EB: These interventions assess for fluid volume status (Jessup et al, 2009). EB: The extent of volume overload is key to deciding on appropriate treatment for HF (Lindenfeld et al, 2010).
• Recognize that decreased cardiac output that can occur in a number of non-cardiac disorders such as septic shock and hypovolemia. Expect variation in orders for differential diagnoses related to the etiology of decreased cardiac output, as orders will be distinct to address primary cause of altered cardiac output. EB: A study of left ventricular function in patients with septic shock identified that 60% developed reversible left ventricular dysfunction that could successfully be hemodynamically supported with IV vasoactive medications (Vieillard-Baron et al, 2008). Obtain a thorough history. EB: It is important to assess for behaviors that might accelerate the progression of HF symptoms such as high sodium diet, excess fluid intake, or missed medication doses (Jessup et al, 2009).
Administer oxygen as needed per physician’s order. Supplemental oxygen increases oxygen availability to the myocardium. EB: Clinical practice guidelines cite that oxygen should be administered to relieve symptoms related to hypoxemia. Supplemental oxygen at night or for exercise is not recommended unless there is concurrent pulmonary disease. Resting hypoxia or oxygen desaturation may indicate fluid overload or concurrent pulmonary disease (Jessup et al, 2009).
• Monitor pulse oximetry regularly, using a forehead sensor if needed. CEB: In a study that compared oxygen saturation values of arterial blood gases to various sensors, it was found that the forehead sensor was significantly better than the digit sensor for accuracy in clients with low cardiac output, while being easy to use and not interfering with client care (Fernandez et al, 2007).
• Place client in semi-Fowler’s or high Fowler’s position with legs down or in a position of comfort. Elevating the head of the bed and legs in down position may decrease the work of breathing and may also decrease venous return and preload.
• During acute events, ensure client remains on short-term bed rest or maintains activity level that does not compromise cardiac output. In severe HF, restriction of activity reduces the workload of the heart (Fauci et al, 2008).
• Provide a restful environment by minimizing controllable stressors and unnecessary disturbances. Schedule rest periods after meals and activities. Rest helps lower arterial pressure and reduce the workload of the myocardium by diminishing the requirements for cardiac output (Fauci et al, 2008).
Apply graduated compression stockings or intermittent sequential pneumatic compression (ISPC) leg sleeves as ordered. Ensure proper fit by measuring accurately. Remove stocking at least twice a day, then reapply. Assess the condition of the extremities frequently. Graduated compression stockings may be contraindicated in clients with peripheral arterial disease (Kahn et al, 2012). EB: A study that assessed effects of ISPC on healthy adults found that there were significant increases in cardiac output, stroke volume, and ejection fraction due to increased preload and decreased afterload (Bickel et al, 2011); EBN: A study that assessed use of knee-length graduated compression stockings found they are as effective as thigh-length graduated compression stockings. They are more comfortable for clients, are easier for staff and clients to use, pose less risk of injury to clients, and are less expensive as recommended in this study (Hilleren-Listerud, 2009). EB: Graduated compression stockings, alone or used in conjunction with other prevention modalities, help promote venous return and reduce the risk of deep vein thrombosis in hospitalized clients (Sachdeva et al, 2010).
Check blood pressure, pulse, and condition before administering cardiac medications such as angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), digoxin, and beta-blockers such as carvedilol. Notify physician if heart rate or blood pressure is low before holding medications. It is important that the nurse evaluate how well the client is tolerating current medications before administering cardiac medications; do not hold medications without physician input. The physician may decide to have medications administered even though the blood pressure or pulse rate has lowered.
• Observe for and report chest pain or discomfort; note location, radiation, severity, quality, duration, associated manifestations such as nausea, indigestion, and diaphoresis; also note precipitating and relieving factors. Chest pain/discomfort may indicate an inadequate blood supply to the heart, which can further compromise cardiac output. EB: Clients with decreased cardiac output may present with myocardial ischemia. Those with myocardial ischemia may present with decreased cardiac output and HF (Jessup et al, 2009; Lindenfeld et al, 2010).
If chest pain is present, refer to the interventions in Risk for decreased Cardiac tissue perfusion care plan.
• Recognize the effect of sleep disordered breathing in HF. EB & CEB: A study assessing effects of OSA physiology on left sided cardiac function found that the increase in negative intrathoracic pressure found in OSA led to a decrease in left ventricular systolic performance (Orban et al, 2008). A study that assessed effectiveness of nasal cannula oxygen supplement for nocturnal obstructive sleep apnea found that 75% of HF clients had sleep apnea, and those who exhibited central sleep apnea had significantly reduced episodes when wearing nasal oxygen during sleep (Sakakibara et al, 2005). Sleep-disordered breathing, including obstructive sleep apnea and Cheyne-Stokes with central sleep apnea, are common organic sleep disorders in clients with chronic HF and are a poor prognostic sign associated with higher mortality (Brostrom et al, 2004).
Closely monitor fluid intake, including intravenous lines. Maintain fluid restriction if ordered. In clients with decreased cardiac output, poorly functioning ventricles may not tolerate increased fluid volumes.
• Monitor intake and output. If client is acutely ill, measure hourly urine output and note decreases in output. EB: Clinical practice guidelines cite that monitoring I&Os is useful for monitoring effects of diuretic therapy (Jessup et al, 2009). Decreased cardiac output results in decreased perfusion of the kidneys, with a resulting decrease in urine output.
Note results of electrocardiography and chest radiography. CEB: Clinical practice guidelines suggest that chest radiography and electrocardiogram are recommended in the initial assessment of HF (Jessup et al, 2009).
Note results of diagnostic imaging studies such as echocardiogram, radionuclide imaging, or dobutamine-stress echocardiography. EB: Clinical practice guidelines state that the echocardiogram is a key test in the assessment of HF (Jessup et al, 2009).
Watch laboratory data closely, especially arterial blood gases, CBC, electrolytes including sodium, potassium and magnesium, BUN, creatinine, digoxin level, and B-type natriuretic peptide (BNP assay). Routine blood work can provide insight into the etiology of HF and extent of decompensation. EB: Clinical practice guidelines recommend that BNP or NTpro-BNP assay should be measured in clients when the cause of HF is not known (Jessup et al, 2009). A study assessed hyponatremia as a prognostic indicator in clients with preserved left ventricular function and found that hyponatremia at first hospitalization is a powerful predictor of long-term mortality in this group (Rusinaru et al, 2009). Serum creatinine levels will elevate in clients with severe HF because of decreased perfusion to the kidneys. Client may be receiving cardiac glycosides, and the potential for toxicity is greater with hypokalemia; hypokalemia is common in heart clients because of diuretic use (Fauci et al, 2008).
• Gradually increase activity when client’s condition is stabilized by encouraging slower paced activities or shorter periods of activity with frequent rest periods following exercise prescription; observe for symptoms of intolerance. Take blood pressure and pulse before and after activity and note changes. Activity of the cardiac client should be closely monitored. See Activity Intolerance.
Serve small, frequent, sodium-restricted, low saturated fat meals. Sodium-restricted diets help decrease fluid volume excess. Low saturated fat diets help decrease atherosclerosis, which causes coronary artery disease. Clients with cardiac disease tolerate smaller meals better because they require less cardiac output to digest. EB: A study that compared cardiac event-free survival between clients who ingested more or less than 3 grams of dietary sodium daily found that those who were NYHA class III or IV clients benefited the most from dietary intake less than 3 grams daily (Lennie et al, 2011); EB: A study that compared HF symptoms with dietary sodium intake found that those with sodium intakes greater than 3 grams per day had more HF symptoms (Son et al, 2011). Emphasis on use of unsaturated fats and less use of saturated fats in the diet is recommended to reduce cardiovascular risk. Polyunsaturates are beneficial to vascular endothelial function, while saturated fats impair vascular endothelial function (Hall et al, 2009; Willett et al, 2011).
• Serve only small amounts of coffee or caffeine-containing beverages if requested (no more than four cups per 24 hours) if no resulting dysrhythmia. CEB: A review of studies on caffeine and cardiac arrhythmias concluded that moderate caffeine consumption does not increase the frequency or severity of cardiac arrhythmias (Hogan, Hornick, & Bouchoux, 2002; Myers & Harris, 1990; Schneider, 1987).
Monitor bowel function. Provide stool softeners as ordered. Caution client not to strain when defecating. Decreased activity, pain medication, and diuretics can cause constipation. The Valsalva maneuver which can be elicited by straining during defecation, cough, lifting self onto the bedpan, or lifting self in bed can be harmful (Moser et al, 2008).
• Have clients use a commode or urinal for toileting and avoid use of a bedpan. Getting out of bed to use a commode or urinal does not stress the heart any more than staying in bed to toilet. In addition, getting the client out of bed minimizes complications of immobility and is often preferred by the client (Winslow, 1992).
• Weigh client at same time daily (after voiding). EB: Clinical practice guidelines state that weighing at the same time daily is useful to assess effects of diuretic therapy (Jessup et al, 2009). Use the same scale if possible when weighing clients. Daily weight is also a good indicator of fluid balance. Increased weight and severity of symptoms can signal decreased cardiac function with retention of fluids.
Provide influenza and pneumococcal vaccines prior to discharge for those who have yet to receive them. EB: Clinical practice guidelines and a Scientific Statement cite that HF hospitalizations are more likely during influenza and winter season, and that having the immunization minimizes that risk (Lindenfeld et al, 2010; Riegel et al, 2009).
• Assess for presence of anxiety and refer for treatment if present. See Nursing Interventions and Rationales for Anxiety to facilitate reduction of anxiety in clients and family. EB: A clinical practice guideline recommends that non-pharmacological techniques for stress reduction are a useful adjunct for reduction of anxiety in HF clients (Lindenfeld et al, 2010). A study that assessed the relationship between anxiety and incidence of death, emergency department visits, or hospitalizations found that those with higher anxiety had significantly worse outcomes than those with lower anxiety (De Jong et al, 2011).
Refer for treatment when depression is present. EBN: A study on combined depression and level of perceived social support found that depressive symptoms were an independent predictor of increased morbidity and mortality, and those with lower perceived social support had 2.1 times higher risk of events than nondepressed clients with high perceived social support (Chung et al, 2011). A qualitative study that described experiences of clients living with depressive symptoms found that negative thinking was present in all participants, reinforcing depressed mood; multiple stressors worsened depressive symptoms; and depressive symptoms were reduced by finding activities from which to distract (Dekker et al, 2009). A study that assessed health-related quality of life found that baseline depression along with perceived control were strongest predictors of physical symptom status (Heo et al, 2008).
Refer to a cardiac rehabilitation program for education and monitored exercise. EB & CEB: Clients with HF should be referred for exercise training when deemed safe, to promote exercise expectations, understanding, and adherence (Lindenfeld et al, 2010). A systematic review of outcomes of exercise based interventions in clients with systolic HF found that hospitalizations and those for systolic HF were reduced for clients in an exercise program and quality of life was improved (Davies et al, 2010). In a study to assess effects of exercise in HF clients, exercise tolerance and left ventricular ejection fraction increased with exercise training (Alves et al, 2012).
Refer to HF program for education, evaluation, and guided support to increase activity and rebuild quality of life. CEB: A study assessing the 6-month outcomes of a nurse practitioner–coordinated HF center found that readmissions, length of stay, and cost per case were all significantly reduced, while quality of life was significantly improved (Crowther et al, 2002).
Critically Ill
Observe for symptoms of cardiogenic shock, including impaired mentation, hypotension with blood pressure lower than 90 mm Hg, decreased peripheral pulses, cold clammy skin, signs of pulmonary congestion, and decreased organ function. If present, notify physician immediately. Cardiogenic shock is a state of circulatory failure from loss from cardiac function associated with inadequate organ perfusion with a high mortality rate. CEB: In a study the defining characteristics of decreased cardiac output were best indicated by decreased peripheral pulses and decreased peripheral perfusion (Oliva & Monteiro da Cruz Dde, 2003).
If shock is present, monitor hemodynamic parameters for an increase in pulmonary wedge pressure, an increase in systemic vascular resistance, or a decrease in stroke volume, cardiac output, and cardiac index. Hemodynamic parameters give a good indication of cardiac function (Fauci et al, 2008).
Titrate inotropic and vasoactive medications within defined parameters to maintain contractility, preload, and afterload per physician’s order. EB: Clinical practice guidelines recommend that intravenous inotropic drugs might be reasonable for HF clients presenting with low BP and low cardiac output to maintain systemic perfusion and preserve end-organ performance (Jessup et al, 2009). By following parameters, the nurse ensures maintenance of a delicate balance of medications that stimulate the heart to increase contractility, while maintaining adequate perfusion of the body.
When using pulmonary arterial catheter technology, be sure to appropriately level and zero the equipment, use minimal tubing, maintain system patency, perform square wave testing, position the client appropriately, and consider correlation to respiratory and cardiac cycles when assessing waveforms and integrating data into client assessment. EB: Clinical practice guidelines recommend that invasive hemodynamic monitoring can be useful in acute HF with persistent symptoms when therapy is refractory, fluid status is unclear, systolic pressures are low, renal function is worsening, vasoactive agents are required, or when considering advanced device therapy or transplantation (Jessup et al, 2009).
Observe for worsening signs and symptoms of decreased cardiac output when using positive pressure ventilation. EB: Positive pressure ventilation and mechanical ventilation are associated with a decrease in preload and cardiac output (Lukacsovitis, Carlussi, & Hill, 2012; Yucel et al, 2011).
Recognize that clients with cardiogenic pulmonary edema may have noninvasive positive pressure ventilation (NPPV) ordered. EB: Clinical practice guidelines for HF state that continuous positive airway pressure improves daily functional capacity and quality of life for those with HF and obstructive sleep apnea (Lindenfeld et al, 2010) and is reasonable for clients with refractory HF not responding to other medical therapies (Jessup et al, 2009). A systematic review of NPPV for cardiogenic pulmonary edema found that use of NPPV significantly reduced mortality and intubation, while decreasing ICU stay by 1 day (Vital et al, 2009).
Monitor client for signs and symptoms of fluid and electrolyte imbalance when clients are receiving ultrafiltration or continuous renal replacement therapy (CRRT). Clients with refractory HF may have ultrafiltration or CRRT ordered as a mechanical method to remove excess fluid volume. EB: Clinical practice guidelines cite that ultrafiltration is reasonable for clients with refractory HF not responsive to medical therapy (Jessup et al, 2009).
• Recognize that hypoperfusion from low cardiac output can lead to altered mental status and decreased cognition. EB & CEB: A study that assessed an association among cardiac index and neuropsychological ischemia found that decreased cardiac function, even with normal cardiac index, was associated with accelerated brain aging (Jefferson et al, 2010). A study that assessed the relationship between hypoperfusion and neuropsychological performance found that among stable geriatric HF clients, executive functions of sequencing and planning were altered (Jefferson et al, 2007).
Geriatric:• Recognize that elderly clients may demonstrate fatigue and depression as signs of HF and decreased cardiac output (Lindenfeld et al, 2010).
If client has heart disease causing activity intolerance, refer for cardiac rehabilitation. EBN: A study that assessed clients’ acceptance of a cardiac rehabilitation program found knowledge and perceived quality of life had increased significantly, and anxiety and depression had been reduced at the end of the program and at 6 month follow-up (Muschalla, Glatz, & Karger, 2011).
• Observe for syncope, dizziness, palpitations, or feelings of weakness associated with an irregular heart rhythm. CEB & EB: Dysrhythmias, particularly atrial fibrillation and ventricular ectopy, and both non-sustained and sustained ventricular tachycardia are common in clients with HF (Hunt et al, 2005; Lindenfeld et al, 2010).
Observe for side effects from cardiac medications. The elderly have difficulty with metabolism and excretion of medications due to decreased function of the liver and kidneys; therefore toxic side effects are more common.
• Design educational interventions specifically for the elderly. EB: Many elderly HF clients have low levels of knowledge about HF self-care and have limitations in function and cognition, low motivation, and low self-esteem. They require skilled assessment of educational level and ability to be successful with self-care (Strömberg, 2005).
Home Care:• Some of the above interventions may be adapted for home care use. Home care agencies may use specialized staff and methods to care for chronic HF clients. CEB: A study assessing HF outcomes over a 10-year period between a multidisciplinary home care intervention and usual care found significantly improved survival and prolonged event-free survival and was both cost- and time-effective (Ingles et al, 2006).
Continue to monitor client closely for exacerbation of HF when discharged home. CEB: Home visits and phone contacts that emphasize client education and recognition of early symptoms of exacerbation can decrease rehospitalization (Gorski & Johnson, 2003).
• After acute hospitalization, the majority of HF clients education is performed, including social support of others, with each session focused on assessment of current knowledge, client learning priorities, and barriers to change (Lindenfeld et al, 2010).
• Assess for signs/symptoms of cognitive impairment. EBN: Impaired cognitive function can affect 25-50% of HF clients and is associated with poorer HF self-care. Etiology of this phenomenon may be poorer regional blood flood to areas of the brain (Riegel et al, 2009).
• Assess for fatigue and weakness frequently. Assess home environment for safety, as well as resources/obstacles to energy conservation. Instruct client and family members on need for behavioral pacing and energy conservation. EBN: Fatigue and weakness limit activity level and quality of life. Assistive devices and other techniques of work simplification can help the client participate in and respond to the health care regimen more effectively (Quaglietti et al, 2004).
• Help family adapt daily living patterns to establish life changes that will maintain improved cardiac functioning in the client. Take the client’s perspective into consideration and use a holistic approach in assessing and responding to client planning for the future. Transition to the home setting can cause risk factors such as inappropriate diet to reemerge.
• Assist client to recognize and exercise power in using self-care management to adjust to health change. EBN: Identified self-care behaviors, barriers to self-care, interventions to promote self-care, and evaluation of effects of self-care are important to maintain the heart failure client’s quality of life and functional status and to reduce mortality from the syndrome (Riegel et al, 2009). Refer to care plan for Powerlessness.
Explore barriers to medical regimen adherence. Review medications and treatment regularly for needed modifications. Take complaints of side effects seriously and serve as client advocate to address changes as indicated. The presence of uncomfortable side effects frequently motivates clients to deviate from the medication regimen.
Refer for cardiac rehabilitation and strengthening exercises if client is not involved in outpatient cardiac rehabilitation.
Refer to medical social services as necessary for counseling about the impact of severe or chronic cardiac disease. Social workers can assist the client and family with acceptance of life changes.
Institute case management of frail elderly to support continued independent living.
As the client chooses, refer to palliative care for care, which can begin earlier in the care of the HF client. Palliative care can be used to increase comfort and quality of life in the HF client before end-of-life care (Buck & Zambroski, 2012).
If the client’s condition warrants, refer to hospice. EB & CEB: End-of-life discussions should occur with clients and family as end-stage heart failure becomes refractory to therapy (Hunt et al, 2005; Lindenfeld et al, 2010). The multidisciplinary hospice team can reduce hospital readmission, increase functional capacity, and improve quality of life in end-stage HF (Coviello, Hricz, & Masulli, 2002).
• Identify emergency plan in advance, including whether use of cardiopulmonary resuscitation (CPR) is desired. Encourage family members to become certified in cardiopulmonary resuscitation if the client desires. EB: A study that assessed the client’s perspective on end-of-life care found that the three most important issues ranked included avoidance of life support if there was no hope of survival, provider communication and reduced family burden (Strachan et al, 2009);
Client/Family Teaching and Discharge Planning:
• Begin discharge planning as soon as possible upon admission to the emergency department (ED) with case manager or social worker to assess home support systems and the need for community or home health services. Consider referral for advanced practice nurse (APN) follow-up. Support services may be needed to assist with home care, meal preparations, housekeeping, personal care, transportation to doctor visits, or emotional support. CEB: A study to assess degree of social support as a predictor of heart failure readmission demonstrated that those without someone living with them had a greater readmission rate in a dose-dependent response, but no correlation to death was found (Rodriguez-Artalejo et al, 2006). Clients often need help on discharge.
Refer to case manager or social worker to evaluate client ability to pay for prescriptions. The cost of drugs may be a factor in filling prescriptions and adhering to a treatment plan.
• Include significant others in client teaching opportunities. Include all six areas of discharge instructions for heart failure hospitalizations: Daily weight monitoring/reporting, symptoms recognition/reporting/when to call for help, smoking cessation, low-sodium diet, medication use and adherence, and regular follow-up with providers. EB: A scientific statement cites social support from family and friends as being positively associated with better medication adherence and self-care maintenance, and lower readmission rates (Riegel et al, 2009). Failure to understand and comply with educational instructions is a major cause of HF exacerbation and hospital readmissions (Jessup et al, 2009). Clinical guidelines recommend that hospitalized heart failure clients be given basic instructions prior to discharge to facilitate self-care and management at home (Jessup et al, 2009).
• Teach importance of performing and recording daily weights upon arising for the day, and to report weight gain. Ask if client has a scale at home; if not, assist in getting one. EB: Clinical practice guidelines suggest that daily weight monitoring leads to early recognition of excess fluid retention, which, when reported, can be offset with additional medication to avoid hospitalization from heart failure decompensation (Jessup et al, 2009). Daily weighing is an essential aspect of self-management. A scale is necessary. Scales vary; the client needs to establish a baseline weight on the home scale.
• Teach types and progression patterns of heart failure symptoms, when to call the physician for help, and when to go to the hospital for urgent care. EB: Inability to recognize or adequately interpret symptom worsening heart failure is common among heart failure clients. Early symptom recognition and early self-help measures or professional evaluation and treatment lead to improved outcomes (Riegel et al, 2009).
• Teach importance of smoking cessation and avoidance of alcohol intake. Help clients who smoke stop by informing them of potential consequences and by helping them find an effective cessation method. EB: Smoking has vasoconstrictor and pro-inflammatory properties that impede effective cardiac output. Discontinuation of smoking leads to reduced adverse consequences, including decreased mortality in HF (Riegel et al, 2009). Smoking cessation advice and counsel given by nurses can be effective and should be available to clients to help stop smoking (Rice & Stead, 2008).
• Teach the direct benefits of a low-sodium diet. EB: A scientific statement and clinical guidelines on heart failure recommend a 2-3 gram/day sodium diet for most stable heart failure clients, and less when heart failure severity warrants (Jessup et al, 2009; Lindenfeld et al, 2010; Riege et al, 2009). Sodium retention leading to fluid overload is a common cause of hospital readmission (Fauci et al, 2008).
Teach the client importance of consistently taking cardiovascular medications, and include actions, side effects to report. EB: A scientific statement cited that adherence to medications ranges from 5% to 90%. In one study 88% adherence was required in heart failure clients to achieve event-free survival. The study cited as reasons for non-adherence, depression, cost, attitudes about taking medication, worrying about or feeling side effects including those on sexual function, receipt of conflicting information about medications from different prescribers, and lack of understanding about discharge instructions (Riegel et al, 2009). Evidence-based guidelines state that taking medication as directed can help prevent HF decompensation, and rehospitalization, and decrease morbidity (Jessup et al, 2009).
• Instruct client and family on the importance of regular follow up care with providers. EB: Post discharge support can significantly reduce hospital readmissions and improve health care outcomes, quality of life, and costs (Hernandez et al, 2010; Jessup et al, 2009).
• Teach stress reduction (e.g., imagery, controlled breathing, muscle relaxation techniques). CEB: A study that assessed effects of relaxation or exercise in heart failure clients versus controls found that those who participated in regular relaxation therapy or exercise training reported greater improvements in psychological outcomes, with the relaxation group significantly improving depression and the exercise training group more improving fatigue (Yu et al, 2007).
Refer to an outpatient system of care. EB: Systems of care such as disease management, telemonitoring, and telehealth promote self-care, facilitating transitions across settings (Riegel et al, 2009).
• Provide client/family with advance directive information to consider. Allow client to give advance directions about medical care or designate who should make medical decisions if he or she should lose decision-making capacity. EB: Heart failure guidelines recommends that clients and families be educated about end-of-life options prior to client decline, and with a change in clinical status (Jessup et al, 2009).
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Risk for decreased Cardiac tissue perfusion
NANDA-I
Risk Factors
Hypertension; hyperlipidemia; cigarette smoking, family history of coronary artery disease; diabetes mellitus; alcohol and drug abuse, obesity, cardiac surgery; hypovolemia; hypoxemia; hypoxia; coronary artery spasm; septic shock, cardiac tamponade; birth control pills, elevated C-reactive protein; lack of knowledge of modifiable risk factors (e.g., smoking, sedentary lifestyle, obesity)
NOC (Nursing Outcomes Classification)
Cardiac Pump Effectiveness, Circulation Status, Tissue Perfusion: Cardiac, Tissue Perfusion: Cellular, Vital Signs
Client Outcomes
Client Will (Specify Time Frame)
• Maintain vital signs within normal range
• Retain a normal cardiac rhythm (have absence of arrhythmias, tachycardia, or bradycardia)
• Be free from chest and radiated discomfort as well as associated symptoms related to acute coronary syndromes
NIC (Nursing Interventions Classification)
Cardiac Care, Cardiac Precautions, Embolus Precautions, Dysrhythmia Management, Vital Signs Monitoring, Shock Management: Cardiac
Nursing Interventions and Rationales
• Be aware that the most common cause of acute coronary syndromes (ACS) [unstable angina (UA), non-ST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial infarction (STEMI)] is reduced myocardial perfusion associated with partially or fully occlusive thrombus development in coronary arteries (Anderson et al, 2011; Antman et al, 2008).
• Assess for symptoms of coronary hypoperfusion and possible ACS including chest discomfort (pressure, tightness, crushing, squeezing, dullness, or achiness), with or without radiation (or originating) in the back, neck, jaw, shoulder, or arm discomfort or numbness; SOB; associated diaphoresis; dizziness, lightheadedness, loss of consciousness; nausea or vomiting with chest discomfort, heartburn or indigestion; associated anxiety. EB: These symptoms are signs of decreased cardiac perfusion and acute coronary syndrome such as UA, NSTEMI, or STEMI. A physical assessment will aid in assessment of the extent, location and presence of, and complications resulting from a myocardial infarction. It will promote rapid triage and treatment. It is also important to assess if the client had a prior stroke (American Heart Association, 2011a; Anderson et al, 2011).
• Consider atypical presentations for women, and diabetic clients of ACS. EB & CEB: Women and diabetic clients may present with atypical findings. A systematic review of differences showed that women had significantly less chest discomfort and were more likely to present with fatigue, neck pain, syncope, nausea, right arm pain, dizziness, and jaw pain (Coventry, Finn, & Bremner, 2011).
• Review the client’s medical, surgical, and social history. EB: A medical history must be concise and detailed to determine the possibility of acute coronary syndromes, and to help determine the possible cause of cardiac symptoms and pathology (Anderson et al, 2011).
• Perform physical assessments for both CAD and non-coronary findings related to decreased coronary perfusion including vital signs, pulse oximetry, equal blood pressure in both arms, heart rate, respiratory rate, and pulse oximetry. Check bilateral pulses for quality and regularity. Report tachycardia, bradycardia, hypotension or hypertension, pulsus alternans or pulsus paradoxus, tachypnea, or abnormal pulse oximetry reading. Assess cardiac rhythm for arrhythmias; skin and mucous membrane color, temperature and dryness; and capillary refill. Assess neck veins for elevated central venous pressure, cyanosis, and pericardial or pleural friction rub. Examine client for cardiac S4 gallop, new heart murmur, lung crackles, altered mentation, pain to abdominal palpation, decreased bowel sounds, or decreased urinary output EB: These indicators help to assess for cardiac and non-cardiac etiologies of symptoms and differential diagnoses (Anderson et al, 2011; Antman et al, 2008).
Administer oxygen as ordered and needed for clients presenting with ACS to maintain a PO2 of at least 90%. EB: Hypoxemia can be under-recognized in the first 6 hours of ACS treatment. Maintaining a SaO2 level of 90% or more may decrease the pain associated with myocardial ischemia by increasing the amount of oxygen delivered to the myocardium (Anderson et al, 2011). EB: Advanced Cardiac Life Support guidelines recommend administering oxygen if the oxygen saturation is less than 94% (O’Connor et al, 2012). A Cochrane review found there was limited evidence to recommend use of oxygen with acute coronary syndrome, more studies are needed (Cabello et al, 2010).
Use continuous pulse oximetry as ordered. EB: Prevention and treatment of hypoxemia includes maintaining arterial oxygen saturation over 90% (Anderson et al, 2011).
Insert one or more large-bore intravenous catheters to keep the vein open. Routinely assess saline locks for patency. Clients who come to the hospital with possible decrease in coronary perfusion or ACS may have intravenous fluids and medications ordered routinely or emergently to maintain or restore adequate cardiac function and rhythm.
Observe the cardiac monitor for hemodynamically significant arrhythmias, ST depressions or elevations, T wave inversions and/or q waves as signs of ischemia or injury. Report abnormal findings. EB: Arrhythmias and electrocardiogram (ECG) changes indicate myocardial ischemia, injury and/or infarction (Anderson et al, 2011; Antman et al, 2008).
• Have emergency equipment and defibrillation capability nearby and be prepared to defibrillate immediately if ventricular tachycardia with clinical deterioration or ventricular fibrillation occurs. EB: Life-threatening ventricular arrhythmias require defibrillation (Anderson et al, 2011).
Perform a 12-lead ECG as ordered, to be interpreted within 10 minutes of emergency department arrival and during episodes of chest discomfort or angina equivalent. EB: A 12-lead ECG should be performed within 10 minutes of emergency department arrival for all clients who are having chest discomfort. Electrocardiograms are used to identify the area of ischemia or injury such as ST depressions or elevations, new left bundle branch block, T wave inversions, and/or q waves and guide treatment (Anderson et al, 2011; Antman et al, 2008).
Administer aspirin as ordered. EB: Aspirin has been shown to prevent platelet clumping, aggregation, and activation that leads to thrombus formation, which in coronary arteries leads to acute coronary syndromes. Contradictions include active peptic ulcer disease, bleeding disorders, and aspirin allergy (Anderson et al, 2011; Antman et al, 2008).
Administer nitroglycerin tablets sublingually as ordered, every 5 minutes until the chest pain is resolved while also monitoring the blood pressure for hypotension, for a maximum of three doses as ordered. Administer nitroglycerin paste or intravenous preparations as ordered. EB: Nitroglycerin causes coronary arterial and venous dilation, and at higher doses arterial dilation, thus reducing preload and afterload and decreasing myocardial oxygen demand while increasing oxygen delivery (Anderson et al, 2011).
• Do not administer nitroglycerin preparations to clients who have received phosphodiesterase type 5 inhibitors, such as sildenafil, tadalafil, or vardenafil, in the last 24 hours (48 hours for long-acting preparations). EB: Synergistic effect causes marked exaggerated and prolonged vasodilation/hypotension (Anderson et al, 2011; Antman et al, 2008).
Administer morphine intravenously as ordered every 5 to 30 minutes while monitoring blood pressure when nitroglycerin alone does not relieve chest discomfort. EB: Morphine has potent analgesic and antianxiolytic effects and causes mild reductions in blood pressure and heart rate that reduce myocardial oxygen consumption. It increases venous capacitance in pulmonary edema associated with decreased coronary perfusion and resultant myocardial dysfunction (Anderson et al, 2011; Antman et al, 2008).
Assess and report abnormal lab work results of cardiac enzymes, specifically troponin Is, chemistries, hematology, coagulation studies, arterial blood gases, finger stick blood sugar, elevated C-reactive protein, or drug screen. Abnormalities can identify the cause of the decreased perfusion and identify complications related to the decreased perfusion such as anemia, hypovolemia, coagulopathy, drug abuse or hyperglycemia. Elevated cardiac enzymes are indicative of a myocardial infarction (Anderson et al, 2011).
• Assess for individual risk factors for coronary artery disease, such as hypertension, dyslipidemia, cigarette smoking, diabetes mellitus, or family history of heart disease. Other risk factors including sedentary life style, obesity, or cocaine or amphetamine use. Note age and gender as risk factors. EB: Certain conditions place clients at higher risk for decreased cardiac tissue perfusion (Anderson et al, 2011).
Administer additional heart medications as ordered including beta blockers, calcium channel blockers, ACE inhibitors, aldosterone antagonists, antiplatelet agents, and anticoagulants. Always check the blood pressure and pulse rate before administering these medications. If the blood pressure or pulse rate is low, contact the physician to see if the medication should be held. Also check platelet counts and coagulation studies as ordered to assess proper effects of these agents. EB: These medications are useful to optimize cardiac function including blood pressure, heart rate, myocardial oxygen demand, intravascular fluid volume and cardiac rhythm (Anderson et al, 2011; Antman et al, 2008).
Administer lipid-lowering therapy as ordered. EB: LDL-C equal to or over 100 mg/dL requires use of LDL lowering drug therapy to prevent progression and possibly cause regression of coronary artery plaques (Anderson et al, 2011). A systematic review of statin use in primary prevention of cardiovascular disease showed reductions in all-cause mortality, major vascular events, and revascularizations (Taylor et al, 2011).
Prepare client with education, withholding meals and/or medications, and intravenous access for cardiac catheterization and possible PCI with door to balloon time of under 90 minutes if STEMI is suspected. EB & CEB: Door to balloon time of under 90 minutes was associated with improved client outcomes (Antman et al, 2008; McNamara et al, 2006).
Prepare clients with education, withholding meals and/or medications, and intravenous access for noninvasive cardiac diagnostic procedures such as 2D echocardiogram, exercise or pharmacological stress test, and cardiac CT scan as ordered. EB: Clients suspected of decreased coronary perfusion should receive these diagnostic procedures as appropriate to evaluate for coronary artery disease (Anderson et al, 2011; Antman et al, 2008).
Maintain bed rest or chair rest as ordered by the physician. EB: Anti-ischemic therapy includes minimizing myocardial oxygen demand in the early hospital phase (Anderson et al, 2011).
• For further medical and nursing interventions used in care of client with an acute coronary event, refer to the reference by Anderson et al (2011).
Request a referral to a cardiac rehabilitation program. EB: Cardiac rehabilitation programs are designed to limit the physiological and psychological effects of cardiac disease, reduce the risk for sudden cardiac death and reinfarction, control symptoms and stabilize or reverse the process of plaque formation, and enhance psychosocial and vocational status of clients (Anderson et al, 2011; Smith et al, 2011).
• Consider atypical presentations for the elderly of possible ACS. CEB: Elderly may present with atypical signs and symptoms such as weakness, stroke, syncope, or change in mental status (Anderson et al, 2007).
Ask the prescriber about possible reduced dosage of medications for geriatric clients considering weight and creatinine clearance. EB: Geriatric clients have reduced pharmacokinetics including reduced muscle mass, renal and hepatic function, and reduced volume of distribution (Anderson et al, 2011).
• Consider issues such as quality of life, palliative care, end-of-life care, and differences in sociocultural aspects for clients and families when supporting them in decisions regarding aggressiveness of care (Anderson et al, 2011).
Client/Family Teaching and Discharge Planning:
Provide information about provider follow-up. EB: Current recommendations suggest that high-risk clients should be seen within 2 weeks and within 2 to 6 weeks for lower risk clients (Antman et al, 2008).
• Teach the client and family to call 911 for symptoms of new angina, existing angina unresponsive to rest and sublingual nitroglycerin tablets, or heart attack. Do not use friends or family for transportation where 911 is available, unless the delay is expected to be longer than 20 to 30 minutes. EB & CEB: Morbidity and mortality from myocardial infarction can be reduced significantly when symptoms are recognized and EMS activated, shortening time to definitive treatment (Anderson et al, 2011).
• Upon discharge, instruct clients on symptoms of ischemia, when to cease activity, when to use sublingual nitroglycerin, and when to call 911. EB: Degree and extent of myocardial ischemia is related to duration of time with inadequate supply of oxygen-rich blood (Anderson et al, 2011).
• Teach client about any medications prescribed. Medication teaching includes the drug name, its purpose, administration instructions such as taking it with or without food, and any side effects to be aware of. Instruct the client to report any adverse side effects to his/her provider.
• Upon hospital discharge, educate clients and significant others about discharge medications, including nitroglycerin sublingual tablets or spray, with written, easy to understand, culturally sensitive information. Clients and significant others need to be prepared to act quickly and decisively to relieve ischemic discomfort (Anderson et al, 2011).
• Provide client teaching related to risk factors for decreased cardiac tissue perfusion, such as hypertension, hypercholesterolemia, diabetes mellitus, tobacco use, advanced age, and gender (female). EB: Those with two or more risk factors should have a 10-year risk screening for development of symptomatic coronary heart disease. Client education is a vital part of nursing care for the client. Start with the client’s base level of understanding and use that as a foundation for further education. It is important to factor in cultural and/or religious beliefs in the education provided (Anderson et al, 2011).
• Instruct the client on antiplatelet and anticoagulation therapy about signs of bleeding, need for ongoing medication compliance, and INR monitoring. EB: A review of client education literature showed a need to prioritize education domains, standardize educational content, and deliver that content efficiently (Wofford, Wells, & Singh, 2008.)
• After discharge, continue education and support for client blood pressure and diabetes control, weight management, and resumption of physical activity. EB: Reduction of risk factors aids as secondary prevention of coronary artery disease (Anderson et al, 2011). ATP III recommends continued efforts to optimize weight and use of regular physical activity (National Institutes of Health, 2011).
Provide influenza vaccine prior to discharge (Anderson et al, 2011; Antman et al, 2008).
• Stress the importance of ceasing tobacco use. Tobacco use can cause or worsen decreased blood flow in the coronaries. Effects of nicotine include increasing pulse and blood pressure and constricting of blood vessels. Tobacco use is a primary factor in heart disease. EBN: Smoking causes vasoconstriction, which can lead to atherosclerotic disease (American Heart Association, 2012c; Anderson et al, 201; Smith et al, 2011).
• Upon hospital discharge, educate clients about low sodium, low saturated fat diet, with consideration to client education, literacy and health literacy level. EB: Reduction of risk factors aid as primary and secondary prevention of coronary artery disease (Anderson et al, 2011). ATP III guidelines recommend that saturated fats be kept to less than 7% of calories and cholesterol under 200 mg/day when LDL is above goal (http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm). A Cochrane review recommended that there be a permanent reduction in saturated fats and replacement with unsaturated fats to decrease atherosclerosis (Hopper et al, 2012).
• Teach the importance of exercise. Exercise helps control blood pressure and weight, which are the most important controlled risk factors for cardiovascular disease (Smith et al, 2011).
References
American Heart Association, Heart attack symptoms and warning signs 2011 http://www.heart.org/HEARTORG/Conditions/Conditions_UCM_305346_SubHomePage.jsp
American Heart Association, Exercise stress test 2011 http://www.heart.org/HEARTORG/Conditions/More/CardiacRehab/Exercise-Stress-Test_UCM_307474_Article.jsp
American Heart Association, Smoking and Cardiovascular Disease 2012 http://www.heart.org/HEARTORG/GettingHealthy/QuitSmoking/QuittingResources/Smoking-Cardiovascular-Disease_UCM_305187_Article.jsp. [Accessed August 29, 2012].
Anderson JL, et al: ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST elevation myocardial infarction, J Am Coll Cardiol 50(7):e1–e157.
Anderson, J.L., et al. 2011 ACCF/AHA focused update incorporated into the ACC/AHA 2007 guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction. J Am Coll Cardiol. 2011;57(19):e215–e330.
Antman, E.M., et al. 2007 Focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial infarction. J Am Coll Cardiol. 2008;51(2):210–247.
Cabello, J., et al. Oxygen therapy for acute myocardial infarction. Cochrane Database Syst Rev. (6):2010. [CD007160].
Coventry, L.L., Finn, J., Bremner, A.P. Sex differences in symptom presentation in acute myocardial infarction: a systematic review and meta-analysis. Heart Lung. 2011;40(6):477–491.
Hooper, L., et al. Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database Syst Rev. (7):2012. [CD002137].
McNamara, R.L., et al. Effect of door-to-balloon time on mortality in patients with ST-segment elevation myocardial infarction. J Am Coll Cardiol. 2006;47(11):2180–2186.
National Institutes of Health. Retrieved November 18, 2011, from http://www.nhlbi.nih.gov/guidelines/cholesterol/index.htm.
O’Connor, R., et al. Part 10: Acute Coronary Syndromes: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122:S787–S817.
Smith, S.C., et al. AHA/ACCF secondary prevention and risk reduction therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation endorsed by the World Heart Federation and the Preventive Cardiovascular Nurses Association. J Am Coll Cardiol. 2011;58:2432–2446.
Taylor, F., et al. Statins for the primary prevention of cardiovascular disease. Cochrane Database Syst Rev. (1):2011. [CD004816].
Wofford, J.L., Wells, M.D., Singh, S. Best strategies for patient education with warfarin: a systematic review. BMC Health Serv Res. 2008;8:40.
Caregiver Role Strain
NANDA-I
Defining Characteristics
Caregiving Activities
Apprehension about recipient’s care if caregiver unable to provide care; apprehension about the future regarding care recipient’s health; apprehension about the future regarding caregiver’s ability to provide care; apprehension about possible institutionalization of care recipient; difficulty completing required tasks; difficulty performing required tasks; dysfunctional change in caregiving activities; preoccupation with care routine
Caregiver Health Status
Physical: Cardiovascular disease; diabetes; fatigue; GI upset; headaches; hypertension; rash; weight change
Behavioral: Poor self-care behaviors; increased smoking; increased alcohol consumption; sleep disturbances
Related Factors (r/t)
Care Recipient Health Status
Addiction; codependence; cognitive problems; dependency; illness chronicity; illness severity; increasing care needs; instability of care recipient’s health; problem behaviors; psychological problems; unpredictability of illness course
Caregiver Health Status
Addiction; codependency; cognitive problems; inability to fulfill one’s own expectations; inability to fulfill others’ expectations; marginal coping patterns; physical problems; psychological problems; unrealistic expectations of self
Caregiver–Care Recipient Relationship
History of poor relationship; mental status of elder inhibiting conversation, presence of abuse or violence; unrealistic expectations of caregiver by care recipient
Caregiving Activities
24-hour care responsibilities; amount of activities (including number of hours and specific activities that are distressful); complexity of activities; discharge of family members to home with significant care needs; ongoing changes in activities; unpredictability of care situation; years of caregiving
Resources
Caregiver is not developmentally ready for caregiver role; deficient knowledge about community resources; difficulty accessing community resources; emotional strength; formal assistance; formal support; inadequate community resources (e.g., respite services, recreational resources); inadequate equipment for providing care; inadequate physical environment for providing care (e.g., housing, temperature, safety); inadequate transportation; inexperience with caregiving; informal assistance; informal support; insufficient finances; insufficient time; lack of caregiver privacy; lack of support; physical energy
NOC (Nursing Outcomes Classification)
Caregiver Adaptation to Patient Institutionalization, Caregiver Emotional Health, Caregiver Home Care Readiness, Caregiver Lifestyle Disruption, Caregiver-Patient Relationship, Caregiver Performance: Direct Care, Caregiver Performance: Indirect Care, Caregiver Physical Health, Caregiver Role Support, Caregiver Role Endurance, Caregiver Stressors, Caregiver Well-Being
Client Outcomes
Throughout the care situation, the caregiver will
• Feel supported by health care professionals, family, and friends
• Report reduced or acceptable feelings of burden or distress
• Take part in self-care activities to maintain own physical and psychological/emotional health
• Identify resources available to help in giving care or to support the caregiver to give care
• Verbalize mastery of the care situation; feel confident and competent to provide care
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Regularly monitor signs of depression, anxiety, burden, and deteriorating physical health in the caregiver throughout the care situation, especially if the marital relationship is poor, the care recipient has cognitive or neuropsychiatric symptoms, there is little social support available, the caregiver becomes enmeshed in the care situation, the caregiver is elderly, female, or has poor preexisting physical or emotional health. Refer to the care plan for Hopelessness when appropriate. EBN: The incidence of depression in family caregivers can be higher than that of the patient with chronic illness (Williams & McCorkle, 2011). EB: Caregiving may weaken the immune system and predispose the caregiver to illness, particularly cardiac illness and poor response to acquired infections in some situations (Gallagher et al, 2008; Gouin, Hantsoo, & Kiecolt-Glaser, 2008; Lovell, Moss, & Wetherell, 2012). Particular subgroups have been shown to be at high risk for becoming distressed as a result of providing care (Schoenmakers, Buntinx, & Delepeleire, 2010).
• The impact of providing care on the caregiver’s emotional health should be assessed at regular intervals using a reliable and valid instrument such as the Caregiver Strain Index, Caregiver Burden Inventory, Caregiver Reaction Assessment, Screen for Caregiver Burden, and the Subjective and Objective Burden Scale (Deeken et al, 2003; Vitaliano et al, 1991). CEB & EBN: Research has validated the effectiveness of a number of evaluation tools for caregiver stress, including the Caregiver Reaction Assessment (Given et al, 1992), Burden Interview (Zarit et al, 1980), the Caregiver Strain Index (Robinson, 1983), and the Caregiver Burden Inventory (Novak & Guest, 1989). Caregiver assessment tools should be multidimensional and evaluate the impact of providing care on multiple aspects of the caregiver’s life (Hudson & Hayman-White, 2006).
• Identify potential caregiver resources such as mastery, social support, optimism, and positive aspects of care. EB & EBN: Research has shown that caregivers can have simultaneous positive and negative responses to providing care. Positive responses may help to buffer the negative effects of providing care on caregivers’ emotional health and may also increase the effectiveness of interventions to reduce strain (Kruithof, Visser-Meily, & Post, 2011).
• Screen for caregiver role strain at the onset of the care situation, at regular intervals throughout the care situation, and with changes in care recipient status and care transitions, including institutionalization. EB & EBN: Care situations that last for several months or years can cause wear and tear that exhaust caregivers’ coping mechanisms and available resources and that may continue after the care recipient has been institutionalized (Paun & Farran, 2011). In addition, changes in the care recipient’s health status necessitate new skills and monitoring from the caregiver and affect the caregiver’s ability to continue to provide care (Given, Sherwood, & Given, 2011). Providing caregiver support throughout the care situation may decrease care recipient institutionalization (Matsuzawa, 2011).
• Watch for caregivers who become enmeshed in the care situation. EBN: Caregivers are at risk for becoming overinvolved or unable to disentangle themselves from the caregiver role, particularly in the absence of adequate social support (Hricik et al, 2011).
• Arrange for intervals of respite care for the caregiver; encourage use if available. EB & EBN: Respite care provides time away from the care situation and can help alleviate distress (Beeber, Thorpe, & Clipp, 2008; Sussman & Regehr, 2009).
• Regularly monitor social support for the caregiver and help the caregiver to identify and utilize appropriate support systems for varying times in the care situation. EBN: Lower levels of perceived support can cause caregivers to feel abandoned and increase their distress (Hwang et al, 2011).
• Encourage the caregiver to grieve over changes in the care recipient’s condition and give the caregiver permission to share angry feelings in a safe environment. Refer to nursing interventions for Grieving. EB: Caregivers grieve the loss of personhood of their loved one, especially when dementia is involved (Holland, Currier, & Gallgher-Thompson, 2009; Kramer et al, 2011).
• Help the caregiver find personal time to meet his or her needs, learn stress management techniques, schedule regular health screenings, and schedule regular respite time. EB: Due to increased risk for poor physical health as a result of providing care, caregivers must feel empowered to maintain self-care activities (Merluzzi et al, 2011). Interventions to provide support for family caregivers have shown improvements in caregiver health (Elliot, Burgio, & Decoster, 2010).
• Encourage the caregiver to talk about feelings, concerns, uncertainties, and fears. Support groups can be used to gain mutual and educational support. EBN: Support groups can improve depressive symptoms and burden, particularly for female caregivers (Chien et al, 2011). EB: Social support groups can be effective over the Internet, using forums such as Facebook (Bender, Jimenez-Marroquin, & Jadad, 2011).
• Observe for any evidence of caregiver or care recipient violence or abuse, particularly verbal abuse; if evidence is present, speak with the caregiver and care recipient separately. EB & CEB: Caregiver violence is possible, particularly when the caregiver has a history of behavioral, emotional, or family problems; screening should be done at regular intervals (Cohen et al, 2006; Cooper et al, 2009).
Involve the family in care transitions; use a multidisciplinary team to provide medical and social services for instruction and planning. EBN: Caregivers who reported involvement in discharge planning, particularly when discharge planning was done by an interdisciplinary team, occurs well before discharge, and includes good communication between the family member and the health care team, report better acceptance of the caregiving role and better health (Bauer et al, 2009).
Encourage regular communication with the care recipient and with the health care team. EB: Caregivers’ preferential communication method and communication needs should be addressed at regular intervals to improve their sense of mastery over the care situation (Moore, 2008). There can be a large discrepancy between what the health care professional feels s/he has communicated and what the caregiver reports hearing (Molinuevo, Hernandez & TRACE, 2011).
• Help caregiver assess his or her financial resources (services reimbursed by insurance, available support through community and religious organizations) and the impact of providing care on his or her financial status. EB & EBN: Low incomes and limited financial resources can cause strain for the caregiver, particularly if there are substantial out-of-pocket costs involved in providing care (Siefert et al, 2008). Prolonged care situations can affect financial resources; assessment of financial distress/strain should occur at regular intervals. Caregivers report needing information regarding financial assistance during the care situation (Sinclair et al, 2010).
• Help the caregiver identify competing occupational demands and potential benefits to maintaining work as a way of providing normalcy. Guide caregivers to seek ways to maintain employment through mechanisms such as job sharing or decreasing hours at work. EB: Employed caregivers report that work can provide a sense of fulfillment, refuge, and satisfaction (Eldh & Carlsson, 2011).
• Help the caregiver problem solve to meet the care recipient’s needs. EBN: Using a psycho-educational or problem-solving intervention can decrease caregiver feelings of strain, although it has not been shown to help with caregivers’ depressive symptoms (Northouse et al, 2010).
• Monitor the caregiver for psychological distress and signs of depression, especially if caring for a mentally impaired elder or if there was an unsatisfactory marital relationship before caregiving. EBN: As the majority of family caregivers are spouses, degree of marital satisfaction is strongly linked with caregiver role strain (Green & King, 2011).
• Assess the health of caregivers, particularly their control over chronic diseases, at regular intervals. CEB: Caregivers who report feeling burdened have an increased risk of mortality, risk that may be particularly high in elderly caregivers with comorbid conditions (Beach et al, 2000; Schulz & Beach, 1999).
• Assess the presence of and use of social support and encourage the use of secondary caregivers with elderly caregivers. EBN: Caregivers are at risk for becoming overinvolved or unable to disentangle themselves from the caregiver role, particularly in the absence of adequate social support (Hricik et al, 2011).
• To improve the ability to provide safe care: provide skills training related to direct care, perform complex monitoring tasks, supervise and interpret client symptoms, assist with decision-making, assist with medication adherence, provide emotional support and comfort, and coordinate care. CEB: Each task demands different skills and knowledge, organizational capacities, role demands, and social and psychological strengths from family members (Schumacher et al, 2000).
• Teach symptom management techniques (assessment, potential causes, aggravating factors, potential alleviating factors, reassessment), particularly for fatigue, constipation, anorexia, and pain. EBN: Caregivers require training in care recipient monitoring symptom management, and interpretation and can benefit from a problem-solving approach (Sherwood et al, 2012).
Multicultural:• Assess for the influence of cultural beliefs, norms, and values on the client’s ability to modify health behavior. EBN: What the client considers normal and abnormal health behavior may be based on cultural perceptions (Giger & Davidhizar, 2008). EBN: Each client should be assessed for ability to modify health behavior based on the phenomenon of communication, time, space, social organization, environmental control, and biological variations (Giger & Davidhizar, 2008).
• Despite the importance of cultural differences in perceptions of caregiver role strain, there are certain characteristics that are distressing to caregivers across multiple cultures. EBN: Social support and care recipients’ behavioral difference have been shown to be an important factor in caregiver distress across multiple cultures (Chiao & Schepp, 2012; Hwang et al, 2011; Zahid & Ohaeri, 2010).
• Persons with different cultural backgrounds may not perceive the provision of care with equal degrees of distress. EB: A group of caregivers in Belize did not report providing care as negative, although they did exhibit physical symptoms of distress (Vroman & Morency, 2011).
• Recognize that cultures often play a role in identifying who will be recognized as a family caregiver and form partnerships with those groups. EB: In a study of American Indians, people who attended and participated in Native events and endorsed traditional healing practices were more likely to be caregivers. The study also reported that gender played a role in identifying caregivers in some tribes, but not all (Goins, 2011).
• Encourage spirituality as a source of support for coping. EBN: Many African Americans and Latinos identify spirituality, religiousness, prayer, and church-based approaches as coping resources. Socioeconomic status, geographical location, and risks associated with health-seeking behavior all influence the likelihood that clients will seek health care and modify health behavior (Giger & Davidhizar, 2008).
• Assess for the presence of conflicting values within the culture. EBN: Whereas sharing and caring is part of the Amish community, females with breast cancer were found to value privacy issues related to their body image and health status and to prefer this was shared in the closed community (Schwartz, 2008).
• Recognize that different cultures value and use caregiving resources in different ways. CEB: When Korean and Caucasian American caregivers were compared, there was more family support in Korean caregivers while Caucasian Americans were more likely to use formal support (Kong, 2007).
• Assess the client and caregiver at every visit for quality of relationship, and for the quality of caring that exists. EB: Quality of the caregiver–care recipient relationship and the impact of the care situation on that relationship can be an important source of distress or support for the caregiver (Quinn, Clare, & Woods, 2009). Chronic illness, especially dementia, can represent a gradual and devastating loss of the marital relationship as it existed formerly. An understanding of the prior relationship is needed before the couple can be helped to anticipate continuing care needs or deterioration, as the dyadic relationship can be expected to change over the care situation (Langer et al, 2010).
• Assess preexisting strengths and weaknesses the caregiver brings to the situation, as well as current responses, depression, and fatigue levels. EB & EBN: Caregivers’ personality type, mastery, self-efficacy, optimism, and social support have all been linked to the amount of distress the caregiver will perceive as a result of providing care (Campbell et al, 2008; Shirai et al, 2009).
Refer the client to home health aide services for assistance with ADLs and light housekeeping. Allow the caregiver to gain confidence in the respite provider. Home health aide services can provide physical relief and respite for the caregiver. EB: Caregiver burden increases as the care recipient’s cognitive and functional ability decline (Ricci et al, 2009).
Client/Family Teaching and Discharge Planning:
• Identify client and caregiver factors that necessitate the use of formal home care services, that may affect provision of care, or that need to be addressed before the client can be safely discharged from home care. EBN: Although home care resources can be useful in decreasing caregiver distress, they are not used with regularity across client populations. Health care practitioners should assess for the need for support resources prior to discharge and at routine intervals throughout the care situation, tailoring community resources to individual caregiver needs (Greene et al, 2011). Interventions prior to discharge may include medication management, identification of medical red flags, identification of community-based resources, and specific caregiver concerns about home care (Hendrix et al, 2011).
• Collaborate with the caregiver and discuss the care needs of the client, disease processes, medications, and what to expect; use a variety of instructional techniques (e.g., explanations, demonstrations, visual aids) until the caregiver is able to express a degree of comfort with care delivery. EB: Knowledge and confidence are separate concepts. Self-assurance in caregiving will decrease the amount of distress the caregiver perceives as a result of providing care (Giovannetti et al, 2012) and may improve the quality of care provided.
• Assess family caregiving skill. The identification of caregiver difficulty with any of a core set of processes highlights areas for intervention. CEB: The ability to engage effectively and smoothly in nine processes has been identified as constituting family caregiving skill: monitoring client behavior, interpreting changes accurately, making decisions, taking action, making adjustment to care, accessing resources, providing hands-on care, working together with the ill person, and negotiating the health care system (Schumacher et al, 2000). EB: Caregiver skills training has been shown to improve caregiver knowledge and skills and may be reimbursable within governmental health care plans (Gitlin, Jacobs, & Earland, 2010).
• Discharge care should be individualized to specific caregiver needs and care situations. EBN: Interventions implemented by advanced practice nurses have been successful in preventing negative outcomes (Bradway et al, 2011).
• Assess the caregiver’s need for information such as information on symptom management, disease progression, specific skills, and available support. EBN: Caregiver interventions should be individualized to meet specific caregiver needs (Greene et al, 2011; Hendrix et al, 2011).
• Teach the caregiver warning signs for burnout, depression, and anxiety. Help them identify a resource in case they begin to feel overwhelmed.
• Teach the caregiver methods for managing disruptive behavioral symptoms if present. Refer to the care plan for Chronic Confusion. CEB: Multicomponent interventions can be particularly effective in caregivers of persons with neurologic sequelae (Pinquart & Sorenson, 2007).
• Teach the caregiver how to provide the care needed and put a plan in place for monitoring the care provided.
• Provide ongoing support and evaluation of care skills as the care situation and care demands change.
• Provide information regarding the care recipient’s diagnosis, treatment regimen, and expected course of illness.
Refer to counseling or support groups to assist in adjusting to the caregiver role and periodically evaluate not only the caregiver’s emotional response to care but the safety of the care delivered to the care recipient.
References
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Goins, R.T., et al. Adult caregiving among American Indians: the role of cultural factors. Gerontologist. 2011;51(3):310–320.
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Risk for Caregiver Role Strain
NANDA-I
Risk Factors
Amount of caregiving tasks, care receiver exhibits bizarre behavior, care receiver exhibits deviant behavior, caregiver health impairment, caregiver is female, caregiver is spouse, caregiver isolation, caregiver not developmentally ready for caregiver role, caregiver’s competing role commitments, co-dependency, cognitive problems in care receiver, complexity of caregiving tasks, congenital defect, developmental delay of caregiver, developmental delay of care receiver, discharge of family member with significant home care needs, duration of caregiving required, family dysfunction before the caregiving situation, family isolation, illness severity of the care receiver, inadequate physical environment for providing care (e.g., housing, transportation, community services, equipment), inexperience with caregiving, instability in the care receiver’s health, lack of recreation for caregiver, lack of respite for caregiver, marginal caregiver’s coping patterns, marginal family adaptation, past history of poor relationship between caregiver and care receiver, premature birth, presence of abuse, presence of situational stressors that normally affect families (e.g., significant loss, disaster or crisis, economic vulnerability, major life events), presence of violence, psychological problems in caregiver, psychological problems in care receiver, substance abuse, unpredictable illness course
Risk for ineffective Cerebral tissue perfusion
NANDA-I
Risk Factors
Abnormal partial thromboplastin time; abnormal prothrombin time; akinetic left ventricular segment; aortic atherosclerosis; arterial dissection; atrial fibrillation; atrial myxoma; brain tumor; carotid stenosis; cerebral aneurysm; coagulopathy (e.g., sickle cell anemia); dilated cardiomyopathy; disseminated intravascular coagulation; embolism; head trauma; hypercholesterolemia; hypertension; infective endocarditis; left atrial appendage thrombosis; mechanical prosthetic valve; mitral stenosis; recent myocardial infarction; sick sinus syndrome; substance abuse; thrombolytic therapy; treatment-related side effects (cardiopulmonary bypass, medications); transient ischemic attack
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Medication Management, Neurologic Monitoring, Positioning: Neurologic, Cerebral Perfusion Promotion, Fall Prevention, Cognitive Stimulation, Environmental Management: Safety
Nursing Interventions and Rationales
To decrease risk of reduced cerebral perfusion r/t stroke or transient ischemic attack:
Obtain a family history of hypertension and stroke to identify persons who may be at increased risk of stroke. EB: A positive family history of stroke increases risk of stroke by approximately 30% (Goldstein et al, 2011).
Monitor BP regularly, as hypertension is a major risk factor for both ischemic and hemorrhagic stroke. EB: Systolic BP should be treated to a goal of less than 140 mm Hg and diastolic BP to less than 90 mm Hg, while clients with diabetes or renal disease have a BP goal of less than 130/80 mm Hg (Goldstein et al, 2011).
Teach hypertensive clients the importance of taking their physician-ordered antihypertensive agent to prevent stroke. EB: Meta-analysis found thiazide diuretics, ACE inhibitors (ACEI), and calcium channel blockers (CCB) all reduced the risk of stroke compared with no treatment or placebo (Wright & Musini, 2009).
Stress smoking cessation at every encounter with clients, utilizing multimodal techniques to aid in quitting, such as counseling, nicotine replacement, and oral smoking cessation medications. EB: Epidemiological studies show a consistent and overwhelming relationship between smoking and both ischemic and hemorrhagic stroke (Goldstein et al, 2011).
Teach clients who experience a transient ischemic attack (TIA) that they are at increased risk for a stroke. CEB: Overall stroke risk in TIA patients is 5.2% at 7 days and 10.3% at 90 days (Giles & Rothwell, 2007; Johnson et al, 2007; Rothwell et al, 2007).
Teach clients with a history of acute coronary syndromes (unstable angina, non-STEMI [non-ST-elevation myocardial infarction], and STEMI [ST-elevation myocardial infarction]) that they are at risk for stroke. CEB: Cardiovascular disease and stroke have the same pathophysiology and therefore the same risk factors. The rate of stroke after a STEMI is markedly increased (Smith et al, 2006; Witt et al 2005).
Screen clients 65 years of age and older for atrial fibrillation with pulse assessment. EB: Atrial fibrillation is associated with a fivefold increase in stroke. Systematic pulse assessment in primary care setting resulted in a 60% increase in the detection of atrial fibrillation (Goldstein et al, 2011).
Call 911 or activate the rapid response team of a hospital immediately in clients displaying the symptoms of stroke as determined by the Cincinnati Stroke Scale (F: facial drooping, A: arm drift on one side, S: speech slurred), being careful to note the time of symptom appearance. Additional symptoms of stroke include sudden numbness/weakness of face, arm or leg, especially on one side, sudden confusion, trouble speaking or understanding, sudden difficulty seeing in one or both eyes, sudden trouble walking, dizziness, loss of balance or coordination, or sudden severe headache (National Stroke Association, 2012). CEB: The Cincinnati Stroke Scale (derived from the NIH Stroke Scale) is used to identify patients having a stroke who may be candidates for thrombolytic therapy (Kothari et al, 1999). EMS activation results in faster physician assessment, computer tomography, and neurological evaluation, which facilitates administering thrombolytics to eligible stroke victims in the required 3-hour time period (Adams et al, 2007).
Use clinical practice guidelines for glycemic control and BP targets to guide the care of diabetic patients that have had a stroke or TIA. CEB: The American Stroke Association recommends that evidence-based guidelines be used in the care of diabetic clients. Good glycemic control has been associated with decreased incidence of strokes (Furie et al, 2011; Handelsman et al, 2011).
To decrease risk of reduced cerebral perfusion pressure: Cerebral perfusion pressure = Mean arterial pressure − intracranial pressure (CPP = MAP − ICP): See care plan for Decreased Intracranial Adaptive Capacity.
Maintain euvolemia. CEB: Infusing intravenous fluids to sustain normal circulating volume helps maintain normal cerebral blood flow (Bullock, Chestnut, & Clifton, 2001).
Maintain head of bed flat or less than 30 degrees in acute stroke clients. CEB: Both mean blood flow velocity in the middle cerebral artery and CPP are increased with lowering head position from 30 degrees to 0 degrees in both ischemic and hemorrhagic stroke clients (Schwarz et al, 2002; Wojner-Alexandrov et al, 2005).
References
Adams, H.P., et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655–1711.
Bullock, R., Chestnut, R., Clifton, G. Management and prognosis of severe traumatic brain injury. J Neurotrauma. 2001;17(6&7):451–627.
Furie, K.L., et al. Guidelines for the prevention of stroke in patients with stroke or transient ischemic attack. Stroke. 2011;42:227–276.
Giles, M.F., Rothwell, P.M. Risk of stroke early after transient ischemic attack: a systematic review and meta-analysis. Lancet Neurol. 2007;6(12):1063–1072.
Goldstein, L.B., et al. Guidelines for the primary prevention of stroke. Stroke. 2011;42:517–584.
Handelsman, Y., et al. American Association of Clinical Endocrinologist medical guidelines for clinical practice for developing a diabetes mellitus comprehensive care plan. Endocr Pract. 2011;17(Suppl 2):1–53.
Johnson, S.C., et al. Validity and refinement of scores to predict early stroke risk after transient ischemic attack. Lancet. 2007;369:283–292.
Kothari, R., et al. Cincinnati prehospital stroke scale: reproducibility and validity. Ann Emerg Med. 1999;33(4):373–378.
National Stroke Association, Warning signs of a stroke 2012 http://www.stroke.org/site/PageServer?pagename=symp [accessed August 27, 2012].
Rothwell, P.M., et al. Effect of urgent treatment of transient ischemic attack and minor stroke on early recurrent stroke (EXPRESS Study): a prospective population based sequential comparison. Lancet. 2007;370:1432–1442.
Schwarz, S., et al. Effects of induced hypertension on intracranial pressure and flow velocities of the middle cerebral arteries in patients with large hemispheric stroke. Stroke. 2002;33(4):998–1004.
Smith, S.C., et al. AHA/ACC guidelines for secondary prevention for patients with coronary and other atherosclerotic valve disease: 2006 update. Circulation. 2006;113:2326–2372.
Witt, B.J., et al. A community-based study of stroke incidence after myocardial infarction. Ann Intern Med. 2005;143:785–792.
Wojner-Alexandrov, A., et al. Heads down: flat positioning improves blood flow velocity in acute ischemic stroke. Neurology. 2005;64:1354–2357.
Wright, J.M., Musini, V.M., First-line drugs for hypertension. Cochrane Database Syst Rev 2009;(3):CD001841.
Ineffective Childbearing Process
NANDA-I
Pregnancy and childbirth process and care of newborn that does not match the environmental context, norms, and expectations
Defining Characteristics
During Pregnancy
• Does not access support systems appropriately
• Does not report appropriate physical preparations
• Does not report appropriate prenatal lifestyle (e.g., diet, elimination, sleep, bodily movement, exercise, personal hygiene)
• Does not report availability of support systems
• Does not report managing unpleasant symptoms in pregnancy
• Does not report a realistic birth plan
• Does not seek necessary knowledge (e.g., of labor and delivery, newborn care)
• Failure to prepare necessary newborn care items
During Labor and Delivery
• Does not demonstrate appropriate baby feeding techniques
• Does not demonstrate attachment behavior to the newborn baby
• Lacks proactivity during labor and delivery
• Does not report lifestyle (e.g., diet, elimination, sleep, bodily movement, personal hygiene) that is appropriate for the stage of labor
• Does not respond appropriately to onset of labor
After Birth
• Does not demonstrate appropriate baby feeding techniques
• Does not demonstrate appropriate breast care
• Does not demonstrate attachment behavior to the baby
• Does not demonstrate basic baby care techniques
• Does not provide safe environment for the baby
• Does not report appropriate postpartum lifestyle (e.g., diet, elimination, sleep, bodily movement, personal hygiene)
Related Factors
• Deficient knowledge (e.g., of labor and delivery, newborn care)
• Inconsistent prenatal health visits
• Lack of appropriate role models for parenthood
• Lack of cognitive readiness for parenthood
• Lack of prenatal health visits
• Lack of a realistic birth plan
• Lack of sufficient support systems
• Maternal psychological distress
NOC Nursing Outcomes Classification
Fetal Status: Antepartum, Intrapartum, Maternal Status: Antepartum, Intrapartum, Depression Level, Family Resiliency, Knowledge: Substance Use Control, Social Support, Spiritual Support
Client Outcomes
Client Will (Specify Time Frame)
• Obtain early prenatal care in the first trimester and maintain regular visits
• Obtain knowledge level needed for appropriate care of oneself during pregnancy including good nutrition and psychological health
• Understand the risks of substance abuse and resources available
• Feel empowered to seek social and spiritual support for emotional well-being during pregnancy
• Utilize support systems for labor and emotional support
• Develop a realistic birth plan taking into account any high risk pregnancy issues
• Be able to understand the labor and delivery process and comfort measures to manage labor pain
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Encourage early prenatal care and regular prenatal visits. EBN: A study compared outcomes of infants born to women who received Medicaid and prenatal care coordination (PNCC) services versus women who received Medicaid but did not receive PNCC. Women who received PNCC services resulted in fewer low-birth-weight infants, fewer preterm infants, and fewer infants transferred to the neonatal intensive care unit. PNCC is an effective strategy for preventing adverse birth outcomes (Van Dijk, Anderko, & Stetzer, 2011).
Identify any high-risk factors that may require additional surveillance such as preterm labor, hypertensive disorders of pregnancy, diabetes, depression, other chronic medical conditions, presence of fetal anomalies, or other high-risk factors. EB: A Cochrane study found that early and regular prenatal care can improve maternal and fetal outcomes by screening for risk factors and providing appropriate intervention and referrals (Dowswell et al, 2010).
Assess and screen for signs and symptoms of depression during pregnancy and in postpartal period including history of depression or postpartum depression, poor prenatal care, poor weight gain, hygiene issues, sleep problems, substance abuse, and preterm labor. If depression is present, refer for behavioral-cognitive counseling, and/or medication (postpartum period only). Both counseling and medication are considered relatively equal to help with depression. EB: Research demonstrates that early screening, treatment, and referral can improve pregnancy outcome by decreasing preterm labor, preterm birth, and low-birth-weight infants. Psychosocial support can improve bonding between mother and infant and allow the mother to appropriately care for infant (Yawn, 2011; Yonkers, Vigod & Ross, 2011).
Observe for signs of alcohol use and counsel women to stop drinking during pregnancy. Give appropriate referral for treatment if needed. EB: Alcohol is teratogenic, and prenatal exposure may result in growth impairment, facial abnormalities, central nervous system and/or intellectual impairment, and behavioral disorders. Evidence suggests women’s past pregnancy, current drinking behavior, and attitude toward alcohol use in pregnancy were the strongest predictors of alcohol consumption in pregnancy (Barclay, 2011; Peadon et al 2011).
Obtain a smoking history and counsel women to stop smoking for the safety of the baby. Give appropriate referral to smoking cessation program if needed. EB: Tobacco smoking in pregnancy remains one of the few preventable factors associated with complications in pregnancy, low birth weight, and preterm birth and has serious long-term health implications for women and babies. Smoking cessation treatment resulted in reduced low-birth-weight infants and decreased preterm births, and there was an increase in mean birth weight (Lumley et al, 2009).
Monitor for substance abuse with recreational drugs. Refer to drug treatment program as needed. Refer opiate-dependent women to methadone clinics to improve maternal and fetal pregnancy outcomes. EB: Opiate-dependent women experience a sixfold increase in maternal obstetric complications and give birth to low-weight babies (Minozzi et al, 2008). The newborn may experience narcotic withdrawal (neonatal abstinence syndrome) have development problems, increased neonatal mortality, and a 74-fold increased risk of sudden infant death syndrome. Maintenance treatment with methadone provides a steady concentration of opiate in the pregnant woman’s blood preventing the adverse effects on the fetus of repeated withdrawals. Buprenorphine may also be prescribed. These treatments can reduce illicit drug use, improve compliance with obstetric care, and improve birth weight but are still associated with neonatal abstinence syndrome (Minozzi et al, 2008).
Monitor for psychosocial issues including lack of social support system, loneliness, depression, lack of confidence, maternal powerlessness, domestic violence, and socioeconomic problems. EB: A study that compared psychosocial assessment versus routine care for pregnant women concluded that the providers who assessed psychosocial factors were more likely to identify psychosocial concerns, including family violence, and to rate the level of concern as high. In two trials, women identified they did not want to feel so alone, be judged, be misunderstood and they wanted to feel an increased sense of their own worth (Austin et al, 2008; Gentry et al, 2010; Small et al, 2011). Social support interventions can improve health. The use of doulas can provide assistance in addressing social-psychological issues and socioeconomic disparities.
Monitor for signs of domestic violence. Refer to a community program for abused women that provides safe shelter as needed. EB: Fear about judgments about their capacity to provide appropriate care for their children often holds women back from disclosing depression and intimate partner violence. Psychological violence during pregnancy by an intimate partner is strongly associated with postnatal depression (Ludermir et al, 2010; Small et al, 2011).
• Provide antenatal education to increase the woman’s knowledge needed to make informed choices during pregnancy, labor, and birth and to promote a healthy lifestyle. EB: The use of doulas and childbirth educators has been shown to reduce medical interventions and improve maternal and infant outcomes in women (Gentry et al, 2010). CEB: A Cochrane review found a lack of quality evidence concerning the effects of antenatal education (Gagnon & Sandall, 2007).
• Encourage expectant parents to prepare a realistic birth plan in order to prepare for the physical and emotional aspects of the birth process and to plan ahead for how they want various situations handled. CEB: A “Discussion Birth Plan” and a “Hospital Birth Plan” can be used to facilitate communication with the expectant parents, their care provider and the hospital staff for events that occur during labor and birth. Both plans can assist expectant parents to make educated and informed decisions (Kaufman, 2007).
• Encourage good nutritional intake during pregnancy to facilitate proper growth and development of the fetus. Women should consume an additional 300 calories per day during pregnancy and achieve a total weight gain of 25 to 30 lb. EB: Low plasma folate concentrations in pregnancy are associated with preterm birth. Preconceptual folate supplementation is associated with a 50% to 70% reduction in preterm birth. Studies revealed that there was little change in dietary patterns in pregnancy, which is of concern because women were not able to improve their overall diets in pregnancy (Bukowski et al, 2009; Crozier et al, 2009). CEB: A study of low and middle income countries showed that supplementation with multi-micronutrients showed a reduction in low birth weight and maternal anemia (Haider & Bhutta, 2006).
Provide depression screening for clients of all ethnicities. EB: Race and ethnicity are important risk factors for antenatal depression. A study found that non-Hispanic white women, black women, and Asian/Pacific Islander women had an increased risk for antenatal depression. The prevalence of antenatal depression was 15.3% in black women, 6.9% in Latinas, and 3.6% in non-Hispanic white women (Gavin et al, 2011).
• Provide obstetrical care that is culturally diverse to ensure a safe and satisfying childbearing experience. EBN: Nurses must acknowledge that the maternity health care system has a unique culture that may clash with the cultures of many of our clients. Women not accustomed to this culture of potential risk in prenatal care, childbirth, and neonatal care may be frightened, overwhelmed, or made to feel guilty if they are not willing to undergo some of the expected interventions (Lewallen, 2011).
References
Austin, M.P., Priest, S.R., Sullivan, E.A., Antenatal psychosocial assessment for reducing perinatal mental health morbidity. Cochrane Database Syst Rev 2008;(4):CD005124.
Barclay, L. ACOG calls for alcohol screen annually and at prenatal visit. Obstet Gynecol. 2011;18:383–388.
Bukowski, R., et al. Preconceptual folate supplementation and the risk of spontaneous preterm birth: a cohort study. PLoS Med. 6(5), 2009.
Crozier, S., et al. Dietary patterns change little from before to during pregnancy. J Nutr. 2009;139(10):1956–1963.
Dowswell, T., et al, Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev 2010;(10):CD000934.
Gagnon, A.J., Sandall, J., Individual or group antenatal education for childbirth or parenthood, or both. Cochrane Database Syst Rev 2007;(3):CD002869.
Gavin, A., et al. Racial differences in the prevalence of antenatal depression. Gen Hosp Psychiatry. 2011;33(2):87–93.
Gentry, Q., et al. “Going beyond the call of doula”: a grounded theory analysis for the diverse roles community-based doulas play in the lives of pregnant and parenting adolescent mothers. J Perinat Educ. 2010;19(4):24–40.
Haider, B.A., Bhutta, Z.A., Multiple-micronutrient supplementation for women during pregnancy. Cochrane Database Syst Rev 2006;(4):CD004905.
Kaufman, T. Evolution of the birth plan. J Perinat Educ. 2007;16(3):47–52.
Lewallen, L.P. The importance of culture in childbearing. J Obstet Gynecol Neonat Nurs. 2011;40:4–8.
Ludermir, A., et al. Violence against women by their intimate partner during pregnancy and postnatal depression: a prospective cohort study. Lancet. 2010;376(9744):903–910.
Lumley, J., et al, Interventions for promoting smoking cessation during pregnancy. Cochrane Database Syst Rev 2009;(3):CD001055.
Minozzi, S., et al, Maintenance agonist treatments for opiate dependent pregnant women. Cochrane Database Syst Rev 2008;(2):CD006318.
Peadon, E., et al. Attitudes and behavior predict women’s intention to drink alcohol during pregnancy: the challenge for health professionals. BMC Public Health. 2011;11:584.
Small, R., et al. The power of social connection and support in improving health: lessons from social support interventions with childbearing women. BMC Public Health. 2011;11(Suppl 5):S4.
Van Dijk, J.W., Anderko, L., Stetzer, F. The impact of prenatal care coordination on birth outcomes. J Obstet Gynecol Neonat Nurs. 2011;40:98–108.
Yawn, B., Recognizing & managing postpartum depression. Am Acad Fam Physician Sci Assemb 2011, Retrieved May 29, 2012, from http://www.medscape.com/viewarticle/749874
Yonkers, K.A., Vigod, S., Ross, L.E. Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women. Obstet Gynecol. 2011;117(4):961–977.
Readiness for enhanced Childbearing Process
NANDA-I
A pattern of preparing for and maintaining a healthy pregnancy, childbirth process, and care of newborn that is sufficient for ensuring well-being and can be strengthened
Defining Characteristics
During Pregnancy
Attends regular prenatal health visits; demonstrates respect for unborn baby; prepares necessary newborn care items; reports appropriate physical preparations; reports appropriate prenatal lifestyle (e.g., nutrition, elimination, sleep, bodily movement, exercise, personal hygiene)
Reports availability of support systems; reports realistic birth plan; reports managing unpleasant symptoms in pregnancy; seeks necessary knowledge (e.g., of labor and delivery, newborn care)
During Labor and Delivery
Demonstrates attachment behavior to the newborn baby; is proactive during labor and delivery; reports lifestyle (e.g., diet, elimination, sleep, bodily movement, personal hygiene) that is appropriate for the stage of labor; responds appropriately to onset of labor; uses relaxation techniques appropriate for the stage of labor; utilizes support systems appropriately
After Birth
Demonstrates appropriate baby feeding techniques; demonstrates appropriate breast care; demonstrates attachment behavior to the baby; demonstrates basic baby care techniques; provides safe environment for the baby; reports appropriate postpartum lifestyle (e.g., diet, elimination, sleep, bodily movement, exercise, personal hygiene); utilizes support system appropriately
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Report appropriate lifestyle choices postpartum
• State normal physical sensations following delivery
• State knowledge of recommended nutrient intake, strategies to balance activity and rest, appropriate exercise, time frame for resumption of sexual activity, strategies to manage stress
• List strategies to bond with infant
• State knowledge of proper handling and positioning of infant/infant safety
• State knowledge of feeding technique and bathing of infant
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
Refer to care plans Risk for impaired Attachment; Readiness for enhanced Breastfeeding; Readiness for enhanced family Coping; Readiness for enhanced Family Processes; Risk for disproportionate Growth; Readiness for enhanced Nutrition; Readiness for enhanced Parenting; Ineffective Role Performance
Prenatal Care
Ensure that pregnant clients have an adequate diet and take multimicronutrient supplements during pregnancy. EB: Nutrition plays an important role in the growth and development of the fetus. Overall, the diet of pregnant women has been reported to be deficient in calories and micronutrients. Prenatal supplementation with multimicronutrients was associated with a significantly reduced risk of low-birth-weight infants and with improved birth weight (Shah et al, 2009).
• Encourage pregnant clients to include enriched cereal grain products in their diets. EB: The number of pregnancies affected by neural tube defects greatly decreased in the United States after the fortification of cereal grain products with folic acid was mandated (CDC, 2010).
• Assess smoking status of pregnant client and offer effective smoking-cessation interventions. EB: Smoking during pregnancy is associated with delivery of preterm infants, low infant birth weight, and increased infant mortality. After delivery, exposure to secondhand smoke can increase an infant’s risk for respiratory tract infections and for dying of sudden infant death syndrome (Tong et al, 2009). Prenatal smoking prevalence remains high in the United States. To reduce prenatal smoking prevalence, efforts should focus on delivering evidence-based cessation interventions to women who are most likely to smoke before pregnancy, younger non-Hispanic white, Alaska Native, and American Indian women, who were identified in this study (Tong et al, 2011).
Assess for signs of depression and make appropriate referral: inadequate weight gain, underutilization of prenatal care, increased substance use, and premature birth. Past personal or family history of depression, single, poor health functioning, and alcohol use. EB: These signs occurring during pregnancy may be associated with depression treatment. Engagement is important, as untreated depression during pregnancy may have unfavorable outcomes for both women and children (Sexton et al, 2012).
Intrapartal Care
• Encourage psychosocial support during labor. EB: In this study at the University College Hospital Ibadan, Nigeria, women with anticipated vaginal delivery were recruited and randomized at the antenatal clinic. The experimental group had companionship in addition to routine care throughout labor until 2 hours after delivery, while the controls had only routine care. The primary outcome measure was cesarean section rate. Women with companionship had better labor outcomes compared to those without (Morhason-Bello et al, 2009).
• Consider using aromatherapy during labor. EB: Aromatherapy has been used in childbirth to reduce anxiety and pain (Horowitz, 2011).
• Offer immersion bath during labor. EBN: The present findings of this study suggest that use of an immersion bath is a suitable alternative form of pain relief for women during labor (da Silva, de Oliveira, & Nobre, 2009).
• Provide massage and relaxation techniques during labor. EB: The findings in this study suggest that regular massage with relaxation techniques from late pregnancy to birth is an acceptable coping strategy for pain relief (Kimber et al, 2008).
• Offer the client in labor a light diet and water. EB: In this study consumption of a light diet during labor did not influence obstetric or neonatal outcomes in participants, nor did it increase the incidence of vomiting. Women who are allowed to eat in labor have similar lengths of labor and operative delivery rates to those allowed water only (O’Sullivan et al, 2009).
• Provide prenatal care for black and white clients. EB: Black-white disparities in infant mortality persist in the United States. In the years 2001 to 2004, Wisconsin had the highest black infant mortality rate (IMR) in the 40 states reporting. IMRs have declined in Wisconsin from 2002 to 2007 despite national trends. Preliminary information suggests contributing factors may include improvement in adequate medical care and prenatal care for all (CDC, 2009).
• Refer the client to a centering pregnancy group (8 to 10 women of similar gestational age receive group prenatal care after initial obstetrical visit) or group prenatal care. EBN: African-American women in group care had significantly fewer preterm births. Women in Centering Pregnancy groups were more likely to initiate breastfeeding, more ready for labor and birth and significantly more satisfied with their prenatal care (Klima, 2009). The majority of perinatal deaths occur in developing countries. In this article we describe the implementation and evaluation of group prenatal care in Iran. Birth weight was greater for the infants of women in group prenatal care compared with those in individual care. We have shown that group prenatal care has improved birth weight. Low birth weight (LBW), preterm birth, and perinatal death, although not significant, were lower in the intervention group (Jafari et al, 2010).
Intrapartal
• Consider the client’s culture when assisting in labor and delivery. EB: This study demonstrated the need for a culturally sensitive, reliable, and valid instrument to better understand the self-efficacy of childbirth as a basis for developing effective interventions to increase normal childbirth among Iranian pregnant women (Khorsandi et al, 2008).
Postpartal
• Provide health and nutrition education for Chinese women after childbirth. Provide information and guidance on contemporary postpartum practices and take away common misconceptions about traditional dietary and health behaviors (e.g., fruit and vegetables should be restricted because of cold nature). Encourage a balanced diet and discourage unhealthy hygiene taboos. EB: “Sitting month” is the Chinese tradition for postpartum customs. Available studies indicate that some of the traditional postpartum practices are potentially harmful for women’s health. Chinese women are advised to follow a specific set of food choices and health care practices. For example, the puerperal women should stay inside and not go outdoors; all windows in the room should be sealed well to avoid wind. Bathing and hair washing should be restricted to prevent possible headache and body pain in later years. Foods such as fruits, vegetables, soybean products, and cold drinks that are considered “cold” should be avoided. In contrast, foods such as brown sugar, fish, chicken, and pig’s trotter, which are considered “hot,” should be encouraged. It is believed that if a woman does not observe these restrictions, she may suffer from poor health later in life. Several studies indicated that the incidences of postpartum health problems are high and these problems may have relation to traditional and unscientific dietary and behavior practices in the postpartum period. Available Chinese data also suggested that the incidences of constipation and hemorrhoids were associated with lack of exercise and a decreased intake of fruit and vegetables; the risk of oral problems was associated with no teethbrushing and excessive intake of sugar during the puerperium (Liu et al, 2009).
• Health and nutrition education should include the Chinese family (particularly the relative who will be staying with the new mother) after the woman gives birth. EB: The results of this study found that increased nutrition and health care knowledge did not lead to parallel dietary and health behavior changes. This lack of change is attributed to the fact that in China, the tradition to support a newly delivered woman and her baby for the first month after childbirth at home is still common. Most of the women had an elder female of the family such as her mother or mother-in-law as the support person. The elder female who takes care of the women may have hindered the changes due to traditional beliefs. The main problematic aspect of the study was the education intervention subjects aimed directly to the study of women, yet “sitting month” was usually recognized as an important event in the family and the postpartum woman has been taken care by her mother or mother-in-law (Liu et al, 2009).
Involve pregnant drug users in drug treatment programs that include coordinated interventions in several areas: drug use, infectious diseases, mental health, personal and social welfare, and gynecological/obstetric care. EB: This literature search revealed that involving pregnant drug users in drug treatment is likely to decrease the chances of prenatal and perinatal complications related to drug use and to increase access to prenatal care. Timely medical intervention can effectively prevent vertical transmission of human immunodeficiency virus and hepatitis B virus, as well as certain other sexually transmitted diseases, and would allow newborns infected with hepatitis C virus during birth to receive immediate treatment (Gyarmathy et al, 2009).
Postpartal
• Provide video conferencing to support new parents. EBN: The findings of this study indicate that VC equipment may be helpful for parents discharged from the hospital early after childbirth (Lindberg, Christensson, & Ohrling, 2009).
• Consider reflexology for postpartum women to improve sleep quality. EBN: In this RCT an intervention involving foot reflexology in the postnatal period significantly improved the quality of sleep in postpartum women (Liet al, 2011).
Client/Family Teaching and Discharge Planning:
• Provide dietary and lifestyle counseling as part of prenatal care to pregnant women. EB: In this study an organized, consistent program of dietary and lifestyle counseling reduced weight gain in pregnancy (Asbee et al, 2009). Community-level interventions of improved perinatal care practices can bring about a reduction in maternal mortality (Kidney et al, 2009).
• Provide the following information in parenting classes, via DVD and Internet: support mechanisms, information and antenatal education, breastfeeding, practical baby care, and relationship changes. Include fathers in the parenting classes. EB: The men felt very involved with their partners’ pregnancy but excluded from antenatal appointments and antenatal classes, and by the literature that was available. Parents had been unaware of, and surprised at, the changes in the relationship with their partners. They would have liked more information on elements of parenting and baby care, relationship changes, and partners’ perspectives prior to becoming parents. Parents suggested that information be provided on a DVD (Deave, Johnson, & Ingram, 2008; St George & Fletcher, 2011).
• Provide group prenatal care to families in the military. EBN: Group PNC offers the potential for continuity of provider, which the women were concerned was lacking. It also offers community with other women. In the process, women gain knowledge and power as health care consumers (Kennedy et al, 2009).
Postpartal
• Encourage physical activity in postpartum women; provide telephone counseling, pedometers, referral to community PA resources, social support, email advice on PA/pedometer goals, and newsletters. EB: In this study these interventions were effective in increasing physical activity in postpartum women (Albright, Maddock, & Nigg, 2009).
• Teach mothers of young children principles of a healthy lifestyle: substitute high-fat foods with low-fat foods such as fruits and vegetables, increase physical activity, consider a community-based self-management intervention to prevent weight gain. EBN: Preventing weight gain rather than treating established obesity is an important economic and public health response to the rapidly increasing rates of obesity worldwide. In this study both a single health education session and interactive behavioral intervention resulted in a similar weight loss in the short term, although more participants in the interactive intervention lost or maintained weight. Self-monitoring appears to enhance weight loss when part of an intervention (Lombard et al, 2009).
References
Albright, C.L., Maddock, J.E., Nigg, C.R. Increasing physical activity in postpartum multiethnic women in Hawaii: results from a pilot study. BMC Womens Health. 2009;9:4.
Asbee, S.M., et al. Preventing excessive weight gain during pregnancy through dietary and lifestyle counseling: a randomized controlled trial. Obstet Gynecol. 2009;113(2 Pt 1):305–312.
Centers for Disease Control and Prevention (CDC). CDC grand rounds: additional opportunities to prevent neural tube defects with folic acid fortification. MMWR Morb Mortal Wkly Rep. 2010;59(31):980–984.
Centers for Disease Control and Prevention (CDC). Apparent disappearance of the black-white infant mortality gap-Dane County, Wisconsin, 1990-2007. MMWR Morb Mortal Wkly Rep. 2009;58(20):561–565.
da Silva, F.M., de Oliveira, S.M., Nobre, M.R. A randomised controlled trial evaluating the effect of immersion bath on labour pain. Midwifery. 2009;25(3):286–294.
Deave, T., Johnson, D., Ingram, J. Transition to parenthood: the needs of parents in pregnancy and early parenthood. BMC Pregnancy Childbirth. 2008;8:30.
Gyarmathy, V.A., et al. Drug use and pregnancy-challenges for public health. Euro Surveill. 2009;4(9):33–36.
Horowitz, S. Aromatherapy: current and emerging applications. Altern Complement Ther. 2011;17(1):26–31.
Ionescu-Ittu, R., et al. Prevalence of severe congenital heart disease after folic acid fortification of grain products: time trend analysis in Quebec, Canada. BMJ. 2009;338:b1673.
Jafari, F., et al. Comparison of maternal and neonatal outcomes of group versus individual prenatal care: a new experience in Iran. Health Care Women Int. 2010;31(7):571–584.
Kennedy, H.P., et al. “I wasn’t alone”—a study of group prenatal care in the military. J Midwifery Womens Health. 2009;54(3):176–183.
Khorsandi, M., et al. Iranian version of childbirth self-efficacy inventory. J Clin Nurs. 2008;17(21):2846–2855.
Kidney, E., et al. Systematic review of effect of community-level interventions to reduce maternal mortality. BMC Pregnancy Childbirth. 2009;9:2.
Kimber, L., et al. Massage or music for pain relief in labour: a pilot randomised placebo controlled trial. Eur J Pain. 2008;12(8):961–969.
Klima, C., Norr, K., Vonderheid, S., Handler, A. Introduction of CenteringPregnancy in a public health clinic. Midwifery. 2009;54(1):27–34.
Li, C.Y., et al. Randomised controlled trial of the effectiveness of using foot reflexology to improve quality of sleep amongst Taiwanese postpartum women. Midwifery. 2011;27(2):181–186.
Lindberg, I., Christensson, K., Ohrling, K. Parents’ experiences of using videoconferencing as a support in early discharge after childbirth. Midwifery. 2009;25(4):357–365.
Liu, N., et al. The effect of health and nutrition education intervention on women’s postpartum beliefs and practices: a randomized controlled trial. BMC Public Health. 2009;9:45.
Lombard, C.B., et al. Weight, physical activity and dietary behavior change in young mothers: short term results of the HeLP-her cluster randomized controlled trial. Nutrition J. 2009;8:17.
Morhason-Bello, I.O., et al. Assessment of the effect of psychosocial support during childbirth in Ibadan, south-west Nigeria: a randomised controlled trial. Aust N Z J Obstet Gynaecol. 2009;49(2):145–150.
O’Sullivan, G., et al. Effect of food intake during labour on obstetric outcome: randomised controlled trial. BMJ. 2009;338:b784.
Sexton, M.B., et al. Predictors of recovery from prenatal depressive symptoms from pregnancy through postpartum. J Womens Health. 2012;21(1):43–49.
Shah, P.S., Ohlsson, A. Knowledge Synthesis Group on Determinants of Low Birth Weight and Preterm Births: Effects of prenatal multimicronutrient supplementation on pregnancy outcomes: a meta-analysis. CMAJ. 2009;180(12):E99–108.
St George, J.M., Fletcher, R.J. Fathers online: learning about fatherhood through the Internet. J Perinat Educ. 2011;20(3):154–162.
Tong, V.T., et al. Trends in smoking before, during, and after pregnancy. Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 31 sites, 2000-2005. MMWR Surveill Summ. 2009;58(4):1–29.
Tong, V.T., et al. Age and racial/ethnic disparities in prepregnancy smoking among women who delivered live births. Prev Chron Dis. 2011;8(6):A121.
Risk for ineffective Childbearing Process
NANDA-I
Risk for a pregnancy and childbirth process and care of newborn that does not match the environmental context, norms, and expectations
Risk Factors
Deficient knowledge (e.g., of labor and delivery, newborn care), domestic violence, inconsistent prenatal health visits, lack of appropriate role models for parenthood, lack of cognitive readiness for parenthood, lack of maternal confidence, lack of prenatal health visits, lack of realistic birth plan, lack of sufficient support systems, maternal powerlessness, maternal psychological distress, suboptimal maternal nutrition, substance abuse, unplanned pregnancy, unwanted pregnancy
Impaired Comfortx
NANDA-I
Perceived lack of ease, relief, and transcendence in physical, psychospiritual, environmental, and sociocultural dimensions
Defining Characteristics
Anxiety; crying; disturbed sleep pattern; fear; illness-related symptoms; inability to relax; insufficient resources (e.g., financial, social support); irritability; moaning; noxious environmental stimuli; reports being uncomfortable; reports being cold; reports being hot; reports distressing symptoms; reports hunger; reports itching; reports lack of ease or contentment in situation; restlessness
NOC (Nursing Outcomes Classification)
Client Satisfaction, Symptom Control, Comfort Status, Coping, Hope, Pain and/or Anxiety Management, Personal Well-Being, Spiritual Health
Client Outcomes
Client Will (Specify Time Frame)
• Provide evidence for improved comfort compared to baseline
• Identify strategies, with or without significant others, to improve and/or maintain acceptable comfort level
• Perform appropriate interventions, with or without significant others, as needed to improve and/or maintain acceptable comfort level
• Evaluate the effectiveness of strategies to maintain/and or reach an acceptable comfort level
NIC (Nursing Interventions Classification)
Calming Techniques, Massage, Healing Touch, Heat/Cold Application, Hope Inspiration, Humor, Meditation Facilitation, Music Therapy, Pain Management, Presence; Progressive Muscle Relaxation, Spiritual Growth Facilitation, Distraction
Nursing Interventions and Rationales∗
• Assess client’s current level of comfort. This is the first step in helping clients achieve improved comfort. Sources of assessment data to determine level of comfort can be subjective, objective, primary, or secondary (Kolcaba, 2012; Wilkinson & VanLeuven, 2007).
• Comfort is a holistic state under which pain management is included. Management of discomforts, however, can be better managed, and with fewer analgesics, by also addressing other comfort needs such as anxiety, insufficient information, social isolation, or financial difficulties. CEB: One randomized study (N = 53) found that female breast cancer clients undergoing radiation therapy rated their overall comfort as being greater than the sum of the hypothesized components of comfort, which provided evidence for the theory of the holistic nature of comfort (Kolcaba & Steiner, 2000, in Kolcaba, 2012).
• Assist clients to understand how to rate their current state of holistic comfort, utilizing institution’s preferred method of documentation. Documentation of comfort prenursing and postnursing interactions is essential to demonstrating the efficacy of nursing activities (Kolcaba, 2003; Kolcaba, Tilton, & Drouin, 2006, in Kolcaba, 2012).
• Enhance feelings of trust between the client and the health care provider. To attain the highest comfort level, clients must be able to trust their nurse (Kolcaba, 2003; Kolcaba et al, 2004). CEB: This randomized design (N = 31) demonstrated the importance of promoting open relationships with clients, which helps to acknowledge their individuality. Knowing the client/significant others is essential in the provision of optimum palliative and terminal care (Kolcaba et al, 2004, in Kolcaba, 2012).
• Manipulate the environment as necessary to improve comfort. CEB: In two experimental studies, the protocol included that all clients be asked about preferences for light, furnishings, body position, television settings, etc. (Kolcaba et al, 2004; Dowd et al, 2007, in Kolcaba, 2012).
• Encourage early mobilization and provide routine position changes to decrease physical discomforts associated with bed rest. CEB: An experimental study of 420 individuals following nonemergency cardiac catheterization found consistently lower scores for back discomfort with no increase in bleeding in the intervention group, when they were turned every hour (Chair et al, 2003). A review comparing the study by Chair et al found its results to be consistent with other studies that have found that backrest elevation, side lying, and early ambulation all improved comfort (Benson, 2004).
• Provide simple massage. CEB: Two experiments, one with 31 and one with 60 clients, demonstrated that hand massage was helpful for reducing discomfort and anxiety and promoting relaxation and sleep (Kolcaba et al, 2004; Kolcaba, Schirm, & Steiner, 2006).
• Provide healing touch, which is well-suited for clients who cannot tolerate more stimulating interventions such as simple massage. EBN: In an experiment (N = 58), college students experienced enhanced comfort immediately after healing touch, compared to their baseline comfort level (Dowd et al, 2007).
• Inform the client of options for control of discomfort such as meditation and guided imagery, and provide these interventions if appropriate. CEB: A study found that female breast cancer clients (N = 53) treated with guided imagery while undergoing radiation therapy had significant improvements in comfort compared with the control group (Kolcaba, 2003).
• Utilize empathy as a response to a client’s negative emotions. EBN: An evaluation interaction analysis found that an accurate empathic response to a client’s expressions of negative emotions can contribute to comfort (Eide, Sibbern, & Johannessen, 2011).
• Encourage clients to use relaxation techniques to reduce pain, anxiety, depression, and fatigue. EBN: In a systematic review of randomized controlled studies, it was found that relaxation training was effective for decreasing pain intensity, anxiety, depression, and fatigue in clients with chronic musculoskeletal pain (Persson et al, 2008).
• Utilize hand massage for elders because most respond well to touch and the provider’s presence. EBN: In an experiment (N = 60), the effects of hand massage on comfort of nursing home residents was found to be significant immediately after the massage compared to residents who did not receive hand massage (Kolcaba, Schirm, & Steiner, 2006, in Kolcaba, 2012).
• Discomfort from cold can be treated with warmed blankets. EBN: This study (N = 126) found significantly increased comfort and decreased anxiety in clients who used self-controlled warming gowns (Wagner, Byrne, & Kolcaba, 2006).
• Use complementary touch therapies such as reflexology on clients with dementia to reduce pain and stress. EBN: In a study conducted on nursing home residents (N = 21), it was found that reflexology was an effective treatment of stress and observed pain in residents with mild to moderate dementia (Hodgson & Andersen, 2008).
• Acknowledge any unmet physical, psychological, emotional, spiritual, and environmental needs when attempting to understand the behavior of an elderly client with dementia. As caregivers, all possible causes for demented elderly clients’ behavior must be considered to maximize comfort (Gallaher & Long, 2011).
• Provide simple massage. EBN: A prospective study design (N = 52) found that providing massage to nursing home residents with dementia was effective in controlling agitation (Holliday-Welsh, Gessert, & Renier, 2009).
• Identify and clarify cultural language used to describe pain and other discomforts. CEB: Clients may interchange words meaning discomfort and pain, may refer to minor discomforts as pain, or may not discuss non-painful discomforts at all (Kolcaba, 2003).
• Assess skin for ashy or yellow-brown appearance. Black skin appears ashy and brown skin appears yellow-brown when clients have pallor sometimes associated with discomfort (Peters, 2007).
• Use soap sparingly if the skin is dry. Black skin tends to be dry, and soap will exacerbate this condition.
• Encourage and allow clients to practice their own cultural beliefs and recognize the impact different cultures have on a client’s belief about health care, suffering, and decision-making. Hindus believe in reincarnation, which gives them comfort during the dying process. Hindus also believe that physical suffering can lead to spiritual growth (Thrane, 2010).
• Assess for cultural and religious beliefs when providing care to clients. EBN: In a hermeneutic phenomenological study conducted in six medical-surgical wards in Iran (N = 22), it was found that family members play an important role in the comfort of the patient. It was also found that caregivers should allow patients to follow religious and traditional principles to facilitate comfort despite physical constraints (Yousefi et al, 2009).
Client/Family Teaching and Discharge Planning:
• Teach techniques to use when the client is uncomfortable, including relaxation techniques, guided imagery, hypnosis, and music therapy. EBN: Interventions such as progressive muscle relaxation training, guided imagery, and music therapy can effectively decrease the perception of uncomfortable sensations, including pain (Kolcaba, 2003). CEB & EBN: Families want to learn how to provide comfort measures to their loved ones who are uncomfortable. (Kolcaba et al, 2004, in Kolcaba, 2012).
• Instruct the client and family on prescribed medications and therapies that improve comfort (Kolcaba, 2003).
• Teach the client to follow up with the physician or other practitioner if discomfort persists (Kolcaba, 2003).
• Encourage clients to utilize the Internet as a means of providing education to complement medical care for those who may be homebound or unable to attend face-to-face education. EBN: In a randomized trial with intervention (N = 41), it was found that the Internet was an effective mode for delivering self-care education to older clients with chronic pain (Berman et al, 2009).
Mental Health
• Encourage clients to use guided imagery techniques. EBN: A quasi-experimental design (N = 60) found that patients who listened to a guided imagery compact disk once a day for 10 days had improved comfort and decreased depression, anxiety, and stress over time (Apùstolo & Kolcaba, 2009, in Kolcaba, 2012).
• Provide psychospiritual support and a comforting environment in order to enhance comfort. EBN: In a cross-sectional descriptive study (N = 98), it was found that cancer patients had lower comfort levels relating to psychospiritual and environmental comfort than to physical and sociocultural comfort. Improvements in psychospiritual and environmental support will enhance overall comfort (Kim & Kwon, 2007).
• Providing music and verbal relaxation therapy can reduce anxiety. EBN: A literature review found that music and verbal relaxation therapy provided reduced chemotherapy-induced anxiety (Lin et al, 2011).
• Caregivers should not hesitate to use humor when caring for their clients. EBN: Analysis of two studies found that humor can be comforting and can contribute to a positive experience for both patient and caregiver (Kinsman-Dean & Major, 2008).
References
Benson, G. Changing patients’ position in bed after non-emergency coronary angiography reduced back pain. Evid Based Nurs. 2004;7(1):19.
Berman, R.L.H., et al. The effectiveness of an online mind-body intervention for older adults with chronic pain. J Pain. 2009;10(1):68–79.
Chair, S.Y., et al. Effect of positioning on back pain after coronary angiography. J Adv Nurs. 2003;42(5):470–478.
Dowd, T., et al. Comparison of healing touch and coaching on stress and comfort in young college students. Holist Nurs Pract. 2007;21(4):194–202.
Eide, H., Sibbern, T., Johannessen, T. Empathic accuracy of nurses’ immediate response to fibromyalgia patients’ expressions of negative emotions: an evaluation using interaction analysis. J Adv Nurs. 2011;67(6):1242–1253.
Gallaher, M., Long, D.O. Demystifying behaviors, addressing pain, and maximizing comfort research and practice: partners in care. J Hospice Palliat Nurs. 2011;13(2):71–78.
Hodgson, N., Andersen, S. The clinical efficacy of reflexology in nursing home residents with dementia. J Altern Complement Med. 2008;14(3):269–275.
Holliday-Welsh, D., Gessert, C., Renier, C. Massage in the management of agitation in nursing home residents with cognitive impairment. Geriatr Nurs. 2009;30(2):108–117.
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Readiness for enhanced Comfort
NANDA
NOC Outcomes (Nursing Outcomes Classification)
Client Satisfaction: Caring, Symptom Control, Comfort Status, Coping, Hope, Motivation, Pain Control, Participation in Health Care Decisions, Spiritual Health
Client Outcomes
Client Will (Specify Time Frame)
NIC Interventions (Nursing Interventions Classification)
Calming Technique, Cutaneous Stimulation, Environmental Management, Comfort, Heat/Cold Application, Hope Inspiration, Humor, Meditation Facilitation, Music Therapy, Pain Management, Presence, Simple Guided Imagery, Simple Massage, Simple Relaxation Therapy, Spiritual Growth Facilitation, Therapeutic Play, Therapeutic Touch, Touch, Distraction
Nursing Interventions and Rationales
• Assess client’s current level of comfort. This is the first step in helping clients to achieve enhanced comfort. Sources of assessment data to determine level of comfort can be subjective, objective, primary, secondary, focused, or even special needs (Wilkinson & VanLeuven, 2007). While clinicians are assessing pain more frequently, this has not resulted in widespread pain reduction. A solution may be to establish comfort-function goals for clients, reminding clients to tell their nurse when pain interferes with function (Pasero & McCaffrey, 2004).
• Help clients understand that enhanced comfort is a desirable, positive, and achievable goal. CEB: Human beings strive to have their basic comfort needs met, but comfort is more than just the absence of pain (Kolcaba, 2003). Comfort is best recognized when a person leaves the state of discomfort and nurses can enhance their client’s comfort in everyday practice (Malinowski & Stamler, 2002).
• Enhance feelings of trust between the client and the health care provider. CEB: To attain the highest comfort level a client must be able to trust the nurse (Hupcey, Penrod, & Morse, 2000) EBN: Patients had greater feelings of emotional comfort when they felt secure, informed and valued (Williams, Dawson, & Kristjanson, 2009). EBN: Trust is an essential element in the nurse-patient relationship (Bell & Duffy, 2009).
• Use therapeutic massage for enhancement of comfort. CEB: This study determined the effects of hand massage on clients near the end of life, with clients reporting feeling special and that the massage felt good. Also, meaningful connectedness was achieved (Kolcaba et al, 2004). Massage is helpful for low back pain and other orthopedic problems (Dryden, Baskwill, & Preyde, 2004). EBN: Women who received massage in the latent labor period prior to delivery had less pain perception than women who did not (Yildirim & Sahin, 2004).
• Teach and encourage use of guided imagery. Guided imagery can be helpful on pain level, physical functional status, and self-efficacy on persons with fibromyalgia (Menzies, Taylor, & Bourguignon, 2006). Visual imagery with mind-body relaxation may be used for symptom control in Hispanic persons diagnosed with fibromyalgia (Menzies & Kim, 2008). EBN: Guided imagery was utilized in a study of psychiatric patients and was found to significantly improve their comfort level (Apùstolo & Kolcaba, 2009). Guided imagery was used to relieve postoperative pain in elderly orthopedic patients.
• Use of heat application to enhance pain relief. EBN: Heat can be helpful with pain management of women with perineal pain during the second stage of labor; 79.9% of women identified relief of perineal pain with the use of warm packs during the second stage of labor. Eighty-five percent of these women found it so effective that they would use it during subsequent births (Dahlen et al, 2009).
• Foster and instill hope in clients whenever possible. EBN: This study was the first to document the effectiveness of a brief hope intervention. The intervention produced a significant effect on pain tolerance. The increase in pain tolerance was stronger for females than males (Berg, Snyder, & Hamilton, 2008). See the care plan for Hopelessness.
• Provide opportunities for and enhance spiritual care activities. The need for comfort and reassurance may be perceived as spiritual needs. To meet these needs, nurses engaged in interaction when they comforted and assured clients. Participants also identified absolution as a spiritual need, and there is evidence that forgiveness may bring one feelings of joy, peace, elation, and a sense of renewed self-worth (Narayanasomy et al, 2004). Individuals who practiced spiritual meditation were found to have a greater increase in pain tolerance (Wachholtz & Pargament, 2008).
Enhance social support and family involvement. EBN: Methods to help terminally ill clients and their families transition from cure to comfort care included spending an increased amount of time with one’s family, appointing one close friend to act as a contact person for other friends, and establishing an email list serve for updates of a client’s status and care (Duggleby & Berry, 2005).
Encourage mind-body therapies such as meditation as an enhanced comfort activity. EB: The most common therapies used were meditation, imagery, and yoga. Research demonstrating the connection between the mind and body has therefore increased interest in the potential use of these therapies (Wolsko et al, 2004). EBN: Meditation has been shown to reduce anxiety, relieve pain, decrease depression, enhance mood and self-esteem, decrease stress, and generally improve clinical symptoms (Bonadonna, 2003). A review of clinical trials for meditation and massage used in end of life found that there was a significant relationship between meditation and pain reduction in the two studies that assessed pain (Lafferty et al, 2006).
Promote participation in creative arts and activity programs. EBN: A creative arts program for caregivers of cancer clients was shown to lower anxiety, and positive emotions were expressed (Walsh, Martin, & Schmidt, 2004). The use of an individualized music protocol program by elderly women was shown to promote and maintain sleep (Johnson, 2003).
Encourage clients to use health information technology (HIT) as needed. Client services can now include management of medications, symptoms, emotional support, health education, and health information (Moody, 2005). EBN: Injured car occupants experienced significantly lower dimensions of pain and discomfort with nursing intervention via telephone (Franzen et al, 2009).
• Evaluate the effectiveness of all interventions at regular intervals and adjust therapies as necessary. It is important for nurses to determine comfort and pain management goals because comfort goals will change with circumstances. Ask questions and ask them frequently, such as “How is your comfort?” Establish guidelines for frequency of assessment and document responses noting if goals are being met (Kolcaba, 2003). EB: A comprehensive palliative care project was conducted at 11 sites. The interdisciplinary review process built trust, endorsed creativity, and ultimately resulted in better meeting the needs of clients, families, and the community (London et al, 2005). Evaluation must be planned for, ongoing, and systematic. Evaluation demonstrates caring and responsibility on the part of the nurse (Wilkinson & VanLeuven, 2007).
Explain all procedures, including sensations likely to be experienced during the procedure. EBN: Patients undergoing abdominal surgery in an experimental group received routine care and a preoperative nursing intervention which included explaining the causes of pain that would occur due to the operation, explaining the influences of postoperative pain and the importance of early out-of-bed activities, teaching how to reduce pain using nonpharmacological methods, encouraging requesting pain medications after surgery, encouraging expression of feelings and concerns, and setting a pain control goal. This group had a significant decrease in postoperative anxiety and a statistically significantly lower postoperative pain intensity 4 hours and 24 hours after the surgical procedure (Lin & Wang, 2004).
Pediatric:• Assess and evaluate child’s level of comfort at frequent intervals. Comfort needs should be individually assessed and planned for. With assessment of pain in children, it is best to use input from the parents or a primary care provider. Use only accepted scales for standardized pain assessment (Remke & Chrastek, 2007).
• Skin-to-skin contact (SSC) and selection of most effective method improves the comfort of newborns during routine blood draws. EB: Premature infants who received skin-to-skin contact demonstrated a decrease in pain reaction during heel lancing (Castral et al, 2008).
• Adjust the environment as needed to enhance comfort. Environmental comfort measures include maintaining orderliness; quiet; minimizing furniture; special attention to temperature, light and sound, color, and landscape (Kolcaba & DeMarco, 2005).
• Encourage parental presence whenever possible. The same basic principles for managing pain in adults and children apply to neonates. In addition to other comfort measures, parental presence should be encouraged whenever possible (Pasero, 2004). EBN: This study reported the effects of co-residence and caregiving on the parents of children dying with AIDS. Although parents who did more caregiving did experience anxiety, insomnia, and fatigue, the caregiving experiences for many parents gave them an opportunity to fulfill their perceived duty as parents before their child died. This in turn resulted in better physical and emotional health outcomes (Kespichayawattana & VanLandingham, 2003).
• Promote use of alternative comforting strategies such as positioning, presence, massage, spiritual care, music therapy, art therapy, and story-telling to enhance comfort when needed. In addition to oral sucrose, other comfort measures should be used to alleviate pain such as swaddling, skin-to-skin contact with mother, nursing, rocking, and holding (Pasero, 2004). EBN: Building on the belief that parents are the primary care providers and health care resource for families, the blended infant massage–parenting program is effective for both mother and infant (Porter & Porter, 2004). EBN: In this study, focus groups were conducted with Moroccan pediatric oncology nurses and physicians to better understand how pain management was achieved in children with cancer. When no medication was available to relieve pain, other techniques were used to comfort clients. These included use of cold therapy, presence, holding a child’s hand, utilizing distraction techniques, playing with them, story-telling, and encouraging parental engagement activities (McCarthy et al, 2004). EB: In a study that examined the effects of music on pain in a pediatric burn unit during nursing procedures, the use of music during procedures reduced pain (Whitehead-Pleaux et al, 2007). EBN: A Talk and Touch intervention by the mothers of PICU infants found that 62 percent of the mothers felt that the intervention made a difference in the pain the infant experienced and 73 percent felt that talk and touch decreased their infant’s distress (Rennick et al, 2011).
Support child’s spirituality. CEB: Children are born with an intrinsic spiritual essence that can be enhanced. Spirituality promotes a sense of hope, comfort, and strength and creates a sense of being loved and nurtured by a higher power (Elkins & Cavendish, 2004).
• Identify cultural beliefs, values, lifestyles, practices, and problem-solving strategies when assessing clients. Cultural sensitivity must always be a component of pain assessment. The nurse must remember that pain expression will vary among clients and that variation must also be acknowledged within cultures (Andrews & Boyle, 2003). EBN: In a qualitative study that identified issues in pain management, cultural beliefs were cited as impediments or barriers to pain management; for example, some Moroccan physicians felt illness-related pain was inevitable, that suffering was normal, and that it had to be endured, especially by boys (McCarthy et al, 2004). EBN: In a qualitative study, Muslim patients, particularly Shiites, expressed feeling more comfortable when they were allowed to practice their religious beliefs (Yousefi et al, 2009).
• Enhance cultural knowledge by actively seeking out information regarding different cultural and ethnic groups. Cultural knowledge is the process of actively seeking information about different cultural and ethnic groups such as their world views, health conditions, health practices, use of home remedies or self-medication, barriers to health care, and risk-taking or health-seeking behaviors (Institute of Medicine, 2002).
• Recognize the impact of culture on communication styles and techniques. Communication and culture are closely intertwined, and communication is the way culture is transmitted and preserved. It influences how feelings are expressed, decisions are made, and what verbal and nonverbal expressions are acceptable. By the age of 5, cultural patterns of communication can be identified in children (Giger & Davidhizar, 2004).
• Provide culturally competent care to clients from different cultural groups. Cultural competency requires health care providers to act appropriately in the context of daily interactions with people who are different from themselves. Providers need to honor and respect the beliefs, interpersonal styles, attitudes, and behaviors of others. This level of cultural awareness requires providers to refrain from forming stereotypes and judgments based on one’s own cultural framework (Institute of Medicine, 2002). EBN: The findings from a review of two studies of Japanese and American women suggest that although there were common ethical concerns between the two cultures, the cultural context of the underlying values may create very different meanings and result in different nursing practices (Wros, Doutrich, & Izumi, 2004).
• The nursing interventions described previously in Readiness for enhanced Comfort may be used with clients in the home care setting. When needed, adaptations can be made to meet the needs of specific clients, families, and communities.
Make appropriate referrals to other organizations or providers as needed to enhance comfort. Referrals should have merit, be practical, timely, individualized, coordinated, and mutually agreed upon by all involved (Hunt, 2005).
Promote an interdisciplinary approach to home care. Members of the interdisciplinary team who provide specialized care to enhance comfort can include the physician, physical therapist, occupational therapist, nutritionist, music therapist, social worker, etc. (Stanhope & Lancaster, 2006).
• Evaluate regularly if enhanced comfort is attainable in the home care setting. Home health agencies monitor client outcomes closely. Evaluation is an ongoing process and is essential for the provision of quality care (Stanhope & Lancaster, 2006).
• Use music therapy at home. EBN: The use of music 30 minutes prior to peak agitation in dementia patients demonstrated that their mean pain levels after listening to music were significantly lower than before the music intervention (Park, 2010).
Client/Family Teaching and Discharge Planning:
• Teach client how to regularly assess levels of comfort.
• Instruct client that a variety of interventions may be needed at any given time to enhance comfort.
• Help clients to understand that enhanced comfort is an achievable goal.
• Teach techniques to enhance comfort as needed.
When needed, empower clients to seek out other health professionals as members of the interdisciplinary team to assist with comforting measures and techniques.
• Encourage self-care activities and continued self-evaluation of achieved comfort levels to ensure enhanced comfort will be maintained.