Client Will (Specify Time Frame)

• Establish a therapeutic nurse-client relationship: provide appropriate education for the client, demonstrate caring by being present to the client. CEB: Clients who were nonvocal and ventilated appreciated nursing care that was delivered in an individualized, caring manner (Carroll, 2007).

• Assess the client’s readiness to communicate, using an individualized approach. Avoid making assumptions regarding the client’s preferred communication method. EBN: Using varied communication approaches improved communication efficiency and client engagement (Radtke et al, 2011).

• Assess the client’s literacy level. Screening clients’ literacy levels upon assessment using REALM (Rapid Estimate of Adult Literacy in Medicine) allows providers to tailor information accordingly (Rajda & George, 2009).

• Listen attentively and provide a comfortable environment for communicating; use these practical guidelines to assist in communication: Slow down and listen to the client’s story; use augmentative and alternative communication methods (such as lip-reading, communication boards, writing, body language, and computer/electronic communication devices) as appropriate; repeat instructions if necessary; limit the amount of information given; have the client “teach back” to confirm understanding; avoid asking, “Do you understand?”; be respectful, caring, and sensitive. EB: Multiple augmentative and alternative communication methods, applied with an individualized and creative approach, aid in facilitating communication (Radtke et al, 2011).

 Provide communication with specialty nurses such as clinical nurse specialists or nurse practitioners who have knowledge about the client’s situation. CEB: Clients report being well informed and having high satisfaction with nurse practitioner communication (Hayes, 2007).

 Refer couples in maladjusted relationships for psychosocial intervention and social support to strengthen communication; consider nurse specialists. EB: Being part of a strong dyad may serve as a buffering factor regarding post-traumatic stress related to a cancer diagnosis (Brosseau, McDonald, & Stephen, 2011).

• Consider using music to enhance communication between client who is dying and his/her family. EB: In clients with communication difficulties, music therapy resulted in improvement in communication (Leow, Drury, & Hong, 2010).

• See care plan for Impaired verbal Communication.

Client Will (Specify Time Frame)

• Assess the language spoken, cultural considerations, literacy level, cognitive level, and use of glasses and/or hearing aids. A comprehensive nursing assessment assists in understanding any communication difficulties (Patak et al, 2009).

• Determine client’s own perception of communication difficulties and potential solutions when possible. EB: The Communication Confidence Rating Scale for Aphasia (CCRSA) was found to be an effective tool for assessment of the self-report of communication confidence among clients with aphasia (Babbitt et al, 2011).

• Involve a familiar person when attempting to communicate with a client who has difficulty with communication, if accepted by the client. EBN: Family members recognized clients’ cues and had a deeper understanding of clients’ needs (Dreyer & Nortvedt, 2008).

• Listen carefully. Validate verbal and nonverbal expressions particularly when dealing with pain and utilize nonverbal scales for pain when appropriate. EBN: The revised nonverbal pain scale (NVPS) was found to be superior to the original NVPS in assessing pain in sedated clients receiving mechanical ventilation in the ICU (Kabes, Graves, & Norris, 2009).

• Use therapeutic communication techniques: speak in a well-modulated voice, use simple communication, maintain eye contact at the client’s level, get the client’s attention before speaking, and show concern for the client. EB: Effective communication between clients and health care professionals facilitates positive relations (Wain, Kneebone, & Billings, 2008).

• Avoid ignoring the client with verbal impairment; be engaged and provide meaningful responses to client concerns. EBN: Meaningful responses and emotional support by nurses facilitated organized behavior and initiative in adults with communication impairments as a result of intellectual disabilities and autism (Bakken et al, 2008).

• Use touch as appropriate. Touch has a calming effect on a client who may be frightened due to difficulty with communication (Grossbach, Stranberg, & Chan, 2011).

• Use presence. Spend time with the client, allow time for responses, and make the call light readily available. Relationship-centered care involves the art of nursing, presence, and caring (Finfgeld-Connett, 2008).

• Explain all health care procedures. CEB: Clients who were nonvocal and ventilated were attuned to everything occurring around them, and they appreciated explanations from the nurse (Carroll, 2007). EB: Being understood was described as important by those who were ventilated (Laasko, Hartelius, & Idvall, 2009) and those who were deaf (Andrade et al, 2010).

• Be persistent in deciphering what the client is saying, and do not pretend to understand when the message is unclear. CEB: Persons who were nonvocal and ventilated appreciated persistence on the nurses’ part with respect to being understood, and found it bothersome when others pretended to understand them (Carroll, 2007).

 Utilize an individualized and creative multidisciplinary approach to augmentative and alternative communication assistance and other interventions. EB: A combination of high-technology (with voice output) and low-technology options improved communication efficiency (Radtke et al, 2011). EBN: A story-telling intervention with clients with dementia resulted in improved communication skills and social interaction (Phillips, Reid-Arndt, & Pak, 2010).

• Use consistent nursing staffing for those with communication impairments. CEB: Consistent nursing care increased client-nurse communication and decreased client powerlessness (Carroll, 2007).

 Consult communication specialists as appropriate. Speech language pathologists, audiologists, and interpreters provide more comprehensive communication assistance for those with impaired communication (Patak et al, 2009). LRTs are proficient lipreaders who determine what a nonvocal client is mouthing and then verbalize the client’s words verbatim to others, in order to facilitate communication (Carroll, 2003; Grossbach, Stranberg, & Chan, 2011).

 When the client is having difficulty communicating, assess and refer for audiology consultation for hearing loss. Suspect hearing loss when:

People with hearing loss do not hear sounds clearly. The loss may range from hearing speech sounds faintly or in a distorted way to profound deafness (American Academy of Audiology, 2011).

• When communicating with a client with a hearing loss:

Client Will (Specify Time Frame)

• Assess the client’s behavior and cognition systematically and continually throughout the day and night, as appropriate. Utilize a validated tool to assess presence of delirium such as the Confusion Assessment Method (CAM) or Delirium Observation Screening Scale. EB: The best evidence in a review of the literature supports the use of the CAM (Wong et al, 2010). Delirium is often underrecognized and underdiagnosed (O’Mahoney et al, 2011). EBN: Nurses are missing key symptoms of delirium; use of an objective instrument is essential in guiding assessment and documentation (Steis & Fick, 2008).

• Recognize that delirium may be superimposed on dementia; the nurse must be aware of the client’s baseline cognitive function. EB: Dementia increases the risk and severity of delirium (Voyer et al, 2011b).

• Recognize that there are three distinct types of delirium based on either arousal or motor disturbances (Breitbart & Alici, 2008):

• Identify clients who are at high risk for delirium. EB: Predisposing factors leading to increased vulnerability for delirium include: cognitive impairment, severity of illness, older age, depression, vision and/or hearing impairment, and functional impairment (Sendelbach & Guthrie, 2009) and clients with advanced cancer (Bush & Bruera, et al, 2009), often due to the anticholinergic effects of opioids. Dementia increases the risk and severity of delirium (Voyer et al, 2011b). EBN: There was a significant reduction in delirium in hospitalized elders when a delirium prevention protocol was implemented (Robinson et al, 2008).

• Identify precipitating factors that may precede the development of delirium: use of restraints, indwelling bladder catheter, metabolic disturbances, polypharmacy, pain, infection, dehydration, constipation, electrolyte imbalances, immobility, general anesthesia, hospital admission for fractures or hip surgery, anticholinergic medications, anxiety, sleep deprivation, and environmental factors. Prevention of delirium must be a high priority in light of frequency of occurrence, high treatment costs, longer hospital length of stay, higher rates of functional decline and institutional care, and higher mortality. Delirium may persist and may lead to long-term cognitive decline (O’Mahoney et al, 2011). EB: Recognize that clients who are highly vulnerable for developing delirium require relatively fewer precipitating factors to develop delirium (Sendelbach & Guthrie, 2009). Clients who might benefit from a proactive geriatrics consultation include those over 65 or 70, with baseline cognitive dysfunction, multiple comorbidities, chronic use of psychotropic medications, drug or alcohol dependence, sensory impairment, immobility or functional decline, surgery, prolonged hospital stay, ICU stay, recurrent hospitalizations within the past year, and poor social support (Flinn et al, 2009).

• Perform an accurate mental status examination that includes the following:

 Assess for and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypoxia, hypotension, infection, changes in temperature, fluid and electrolyte imbalance, and use of medications with known cognitive and psychotropic side effects). Delirium is often unrecognized, inappropriately treated, or untreated, especially in terminally ill clients (Breitbart & Alici, 2008). EB: Avoid unnecessary catheterization; utilize infection control protocols to prevent infection, and maintain usual sleep schedule (O’Mahoney et al, 2011).

 Treat the underlying risk factors or the causes of delirium in collaboration with the health care team: establish/maintain normal fluid and electrolyte balance; normal body temperature, normal oxygenation (if the client experiences low oxygen saturation, deliver supplemental oxygen), normal blood glucose levels, normal blood pressure. EB: These factors are common contributors to delirium in the older adult (Flinn et al, 2009).

 Conduct a medication review and eliminate unnecessary medications. Medications that should be minimized or discontinued include anticholinergics, antihistamines, and benzodiazepines; cholinesterase inhibitors should be continued, as should carbidopa and levodopa for clients with parkinsonism (Flinn et al, 2009).

EB: Careful monitoring is needed to identify the potential etiologic factors for delirium (Sendelbach & Guthrie, 2009).

• Identify, evaluate and treat pain quickly and adequately (see care plans for Acute Pain or Chronic Pain). Around the clock acetaminophen may result in less opioid use (Bourne, 2008). EB: There was an association between low doses of analgesia and the development of delirium in hospitalized clients experiencing pain (Robinson & Vollmer, 2010). Untreated pain is a potential cause of delirium, as is excessive opioid administration (Clegg & Young, 2011). Delirium can interfere with pain recognition (Breitbart & Alici, 2008).

• Promote regulation of bowel and bladder function. EB: Constipation may precipitate delirium (O’Mahoney et al, 2011). Catheters should be removed by postoperative day 2 to decrease infection risk (Flinn et al, 2009); urinary retention may precipitate delirium (Waardenburg, 2008).

• Ensure adequate nutritional and fluid intake. Dehydration often precipitates delirium (Thomas et al, 2008). EB: BMI less than 20 is an important risk factor for the development of delirium in postoperative older adult hip fracture clients (Juliebo et al, 2009).

• Promote early mobilization and rehabilitation. EB: Impaired mobility is a risk factor for developing delirium (Brouquet et al, 2010).

• Promote continuity of care; avoid frequent changes in staff and surroundings. EB: Changes may contribute to feelings of disorientation and confusion (O’Mahoney et al, 2011).

• Plan care that allows for an appropriate sleep-wake cycle. Please refer to the care plan for Sleep deprivation. Both delirium and sleep deprivation are associated with disrupted neurotransmitters. It is sometimes difficult to tell which came first. It is known that benzodiazepines deplete melatonin in the body which is needed for normal sleep (Figueroa-Ramos et al, 2009). EB: Sleep deprivation may potentially be a modifiable risk factor for the development of delirium (Weinhouse et al, 2009).

• Facilitate appropriate sensory input by having clients use aids (e.g., glasses, hearing aids) as needed; check for impacted ear wax. Sensory impairment is a predisposing factor for the development of delirium (Voyer et al, 2009). EBN: Clients with hearing loss receive lower doses of pain medication and have a higher incidence of delirium (Robinson et al, 2008).

• Modulate sensory exposure and establish a calm environment. Environments with too much or too little stimulation may precipitate delirium; noise reduction, appropriate lighting based on time of day, reduced clutter, and quiet music are strategies that may impact delirium (Schreier, 2010).

• Provide reality orientation, including identifying self by name at each contact with the client, calling the client by their preferred name, using orientation techniques, providing familiar objects from home such as an afghan, providing clocks and calendars, and gently correcting misperceptions. Facilitate regular visits from family and friends. EB: Persons at risk for delirium should be provided clocks and calendars that are easily visible; family and friends may help with reorientation (O’Mahoney et al, 2011).

• Use gentle, caring communication; provide reassurance of safety; give simple explanations of procedures (Bourne, 2008). Clients with delirium often respond to caring even though they may not understand the verbal message.

• Provide supportive nursing care, including meeting basic needs such as feeding, toileting, and hydration. Delirious clients are unable to care for themselves due to their confusion (Rubin et al, 2011).

 Recognize that delirium is frequently treated with an antipsychotic medication. Administer cautiously as ordered, if there is no other way to keep the client safe. Watch for side effects of the medications. Be aware of paradoxical effects and side effects such as extrapyramidal symptoms, agitation, sedation, and arrhythmias; these may exacerbate the delirium (Bourne, 2008). EB: Haloperidol is recommended as the first-line agent for delirium at the end of life (NCCN Clinical Practice Guidelines in Oncology, 2011); atypical antipsychotics such as risperidone, olanzapine, and quetiapine have been utilized with comparable response (Fong, Tulebaev, & Inouye, 2009).

Critical Care

Client Will (Specify Time Frame)

• Determine the client’s cognitive level using a screening tool such as the Mini-Mental State Exam (MMSE), Mini-Cog (includes a three-item recall and clock drawing test), or Montreal Cognitive Assessment. Age, education, and literacy must be taken into account when interpreting results of the MMSE (Mitchell, 2009) as well as culture and ethnicity (Struble & Sullivan, 2011); an abnormal score necessitates further evaluation. For older adults with mild cognitive impairment, the Short Test of Mental Status and Montreal Cognitive Assessment are more sensitive diagnostic tools than the MMSE (Petersen, 2011). EB: The clock drawing test is useful for detecting moderate to severe dementia; its usefulness in detecting early cases of dementia is limited (Pinto & Peters, 2009).

 In clients who are complaining of memory loss, assess for depression, alcohol use, medication use, sleep, and nutrition. These factors may be implicated in memory loss (Struble & Sullivan, 2011).

 Recognize that pharmacological treatment to slow the progression of Alzheimer’s disease is most effective when used early in the course of the disease. The U.S. Food and Drug Administration has approved five drugs that slow the progression of symptoms for approximately 6 to 12 months; over 75 experimental therapies are being clinically tested in humans (Alzheimer’s Association, 2011).

• If hospitalized, gather information about the client’s pre-admission cognitive functioning, daily routines and care, and decision-making capacity. Establishing continuity of care lessens risk for hospitalized clients. Informed consent may create a dilemma; decision-making capacity will vary depending on the degree of cognitive impairment (Weitzel et al, 2011). EBN & EB: Individuals with a history of cognitive dysfunction are at higher risk for acute confusion during acute illness (Voyer et al, 2011a). Clients with mild cognitive impairment may be able to make decisions regarding their care (Okonkwo et al, 2008).

• Assess the client for signs of depression: anxiety, sadness, irritability, agitation, somatic complaints, tension, loss of concentration, insomnia, poor appetite, apathy, flat affect, and withdrawn behavior. EB: Up to 95% of individuals with dementia have some neuropsychiatric problems (Gauthier et al, 2010), with the most common being apathy, depression, and anxiety; others include aggression, agitation, delusions, and hallucinations (Jalbert, Daiello, & Lapane, 2008). The Cornell Scale is a reliable and valid tool to assess for depression in dementia (Leontjevas, van Hooren, & Mulders, 2009). Approximately 20% of older adults may be affected by significant depressive symptoms (Thielke, Diehr, & Unutzer, 2010).

• Assess the client for anxiety if he or she reports worry regarding physical or cognitive health, reports feelings of being anxious, shortness of breath, dizziness, or exhibit behaviors such as restlessness, irritability, noise sensitivity, motor tension, fatigue, or sleep disturbances. The Rating Anxiety in Dementia (RAID) Scale may be utilized; this may require caregiver input. Recognize that anxiety is common in dementia, is often undiagnosed, and may significantly impact quality of life. CEB: Symptoms of anxiety may progress to more challenging behaviors which negatively impact function and may contribute to discharge from assisted living to nursing home care (Aud, 2004). CEB: The RAID scale is a reliable and valid tool for identifying and measuring anxiety in dementia (Shankar et al, 1999).

 Recognize that clients with Alzheimer’s disease may experience apathy, anxiety and depression, psychomotor agitation, and psychotic or manic syndromes; nonpharmacological interventions for management should be attempted first. EB: More than 75% of clients with Alzheimer’s disease presented with one or more neuropsychiatric syndromes; therapeutic strategies must be planned accordingly (Spaletta et al, 2010). Best practice guidelines recommend psychological interventions as the first approach to treatment (Ballard et al, 2009). Medication for neuropsychiatric symptoms should be prescribed after nonpharmacological interventions have been tried and should be administered at the lowest possible dose and chosen with regard to side effects and adverse reactions (Gauthier et al, 2010).

• Determine client’s normal routines and attempt to maintain them. CEB: Activities that are designed to be consistent with past routines were effective at providing engagement and interest and enhancing quality of life (Cohen-Mansfield & Jensen, 2006).

• Obtain information about the client’s life history from the family; collaborate with family members to provide optimal care. EBN: Knowing the history, interests, needs, and preferences of the individual is essential to person-centered care and helpful when initiating conversation, activities, and routines; the family’s unique knowledge should be incorporated into the plan of care (Edvardsson, Fetherstonhaugh, & Nay, 2010).

• Begin each interaction with the client by gaining and maintaining eye contact, identifying yourself and calling the client by name. Approach the client with a caring, loving, and an accepting attitude, and speak calmly and slowly. EB: Dementia causes a loss of the ability to learn new things and remember people and places (episodic memory); clients will need reassurance and frequent reminding of the identity of caregivers (Yu et al, 2009).

• To enhance communication, use a calm approach, avoid distractions, show interest, keep communication simple, give clear choices, give the client time with word finding, use repetition and rephrasing, and utilize gestures, prompts, and cues or visual aids. Listen attentively to understand nonverbal messages, and engage in topics of interest to the client. EB: These communication techniques assist in focusing attention, incorporate nonverbal means of communication, simplify memory demands, compensate for cognitive slowing, and assist with retrieval and comprehension (Smith et al, 2011).

• Engage the client in scheduled activities that relate to past interests, experiences, and hobbies and are matched to current preferences and abilities. EB: Activities that were once meaningful to the client in terms of self-identity are more likely to result in engagement, even for those with severe cognitive impairment. Residents with current interests in art, music, and pets were more engaged in stimuli that reflected those current interests (Cohen-Mansfield et al, 2010a).

• Promote regular exercise. EB: Exercising regularly may significantly slow the rate of functional decline in individuals with Alzheimer’s disease (Littbrand et al, 2009); a small study demonstrated that a specific walking program for individuals in the later stages of dementia can reduce functional and cognitive decline (Venterelli, Scarsini, & Schena, 2011).

• Provide opportunities for contact with nature or nature-based stimuli, such as facilitating time spent outdoors or indoor gardening. EB: Horticultural-based therapy programs provide positive engagement and may be beneficial for difficult to engage clients with dementia (Jarrott & Gigliotti, 2010). EBN: Individuals with dementia experience more barriers to experiencing nature, which may be an untapped source of pleasure for them (Bossen, 2010).

• Provide animal-assisted therapy. EB: This activity can successfully engage residents with dementia, promoting communication and social interaction regardless of the level of cognitive function (Marx et al, 2010). In a study of animal-assisted therapy with a group of clients with severe Alzheimer’s disease, animal-assisted therapy was associated with a decrease in sadness and anxiety and an increase in motor activity and positive emotions (Mossello et al, 2011).

• Break down self-care tasks into simple steps (e.g., instead of saying, “Take a shower,” say to the client, “Please follow me. Sit down on the bed. Take off your shoes. Now take off your socks.”). Utilize gestures when giving directions; allow for adequate time and model the desired action if needed or possible. EB: Assistance in focusing attention, modeling behavior, and using prompts and cues maximizes communication with individuals with dementia (Smith et al, 2011).

• Promote routines and facilitate success by keeping frequently used items in a visible and consistent location. Consistently practicing routines in an unchanged environment will assist the client in successful maintenance and performance of skills (Bourgeois & Hickey, 2009).

• Use reminiscence and life review therapeutic interventions for clients in the early to middle stages of dementia; ask questions about the client’s past activities, important events and experiences from the past while utilizing photographs, videos, artifacts, music or newspaper clippings or multimedia technology to stimulate memories. EB: In a small preliminary study utilizing YouTube videos, it was found that reminiscence and life review may improve well-being and social engagement (O’Rourke et al, 2011). Memories from childhood or young adulthood are generally intact in the early and middle stages of Alzheimer’s (Smith et al, 2011).

• For clients in the middle to late stages of dementia, engage them in creative expression through the use of TimeSlips story-telling groups. EB: In a study of residents in long-term care settings who were involved in TimeSlips groups, the residents were more alert, socially engaged, had more interactions with staff and others, and staff had more positive views of residents than facilities without the TimeSlips groups (Fritsch, 2009).

• If the client is verbally agitated (repetitive verbalizations, complaints, moaning, muttering, threats, screaming), assess for and address unsatisfied basic needs or environmental factors that may be addressed. EB: Disruptive vocalizations may be an indication that the client with dementia has the need for comfort, attention, or more or less stimulation (Beedard et al, 2011). Behaviors are not solely due to cognitive impairment and may be due to an unmet need or environmental factors that may be overwhelming or understimulating (Gitlin et al, 2009).

• Utilize music as a nonpharmacological approach to managing anxiety. Identify music preferences of the client; interview family members if necessary. For anxious clients who are having problems relaxing enough to eat, try having them listen to music during meals. EBN: Preferred music listening is an effective intervention to decrease anxiety in older adults with dementia (Sung, Chang, & Lee, 2010); utilizing percussion instruments with familiar music was found to be a cost effective method for decreasing anxiety and improving psychological well-being (Sung et al, 2012).

• Assist clients in wayfinding, monitoring them so that they do not get lost in unfamiliar settings. EB: Dementia and some related disorders cause impaired spatial learning; security measures should be unobtrusive, personal surroundings should include familiar objects, and facilities should be designed to have a homelike appearance (Fleming & Purandare, 2010).

• For clients who wander, utilize technologies that monitor but do not restrict. Direct the client who is wandering to a more soothing location with lower light levels and less variation in noise if necessary. EB: Motion detectors may improve quality of life by allowing clients to wander safely without restriction (Wigg, 2010). Modify the environment to reduce wandering if that is the therapeutic goal (Algase et al, 2010).

• Promote sleep by promoting daytime activity, creating a restful sleep environment, decreasing waking, and promoting quiet. EB: Sleep disorders are very common in those with dementia; individuals with Lewy body dementia experience disturbed sleep twice as often (Bliwise et al, 2011). Promoting a dark and quiet nighttime environment, a comfortable sleeping temperature for the client, encouraging physical activity, especially in the afternoon, maintaining a consistent schedule of meals and activities, maintaining a bright daytime environment, and facilitating outdoor activity are all methods of improving sleep (Neikrug & Ancoli-Israel, 2010).

• Provide structured social and physical activities that are individualized for the client. EB: Combined weekly live music and occupational therapy sessions resulted in an improvement in disruptive behavior and depressive symptoms in adults with dementia (Han et al, 2010).

• Provide activities for the client, such as folding washcloths and sorting or stacking activities or other hobbies the individual enjoyed prior to the onset of dementia. EB: The purposeful use of activities tailored to an individual’s abilities may allow the individual to maintain social roles and feelings of connectedness, express themself in a positive way, enhance self-identity, reduce frustration, and prevent boredom, resulting in less agitation (Gitlin et al, 2009).

• Use cues, such as picture boards denoting day, time, and location, to help client with orientation. EBN: Reality orientation, used not when clients are agitated, but as overall reminders of orientation, can help some clients remain more oriented (Yu et al, 2009).

 If the client becomes increasingly confused and/or agitated, perform the following steps:

• Avoid using restraints if at all possible. EB: The use of trunk restraints is associated with higher fall risk for clients with dementia (Luo, Lin, & Castle, 2011).

 Use PRN or low-dose regular dosing of psychotropic or antianxiety drugs only as a last resort; start with the lowest possible dose. They can be effective in managing symptoms of psychosis and aggressive behavior, but have undesirable side effects. EB: Psychotropic medications can cause sedation, orthostatic hypotension and dizziness; use is associated with an increased risk of hospitalization from hip fracture (Jalbert et al, 2010).

 Avoid the use of anticholinergic medications such as diphenhydramine. Anticholinergic medications have a high side-effect profile that includes disorientation, urinary retention, and excessive drowsiness, especially in those with decreased cognition; the anticholinergic side effects outweigh the antihistaminic effects (Artero et al, 2008; Uusvaara et al, 2009).

• For predictable difficult times, such as during bathing and grooming, try the following:

• For care of early dementia clients with primarily symptoms of memory loss, see the care plan for Impaired Memory.

• For clients nearing the end of life, consider a hospice referral. EB: Family members of individuals with dementia reported higher perceptions of the quality of care and quality of dying experience with hospice care (Teno et al, 2011).

• For care of clients with self-care deficits, see the appropriate care plan (Feeding Self-Care deficit; Dressing Self-Care deficit; and Toileting Self-Care deficit).

Functional

Abdominal muscle weakness; habitual denial; habitual ignoring of urge to defecate; inadequate toileting (e.g., timeliness, positioning for defecation, privacy); irregular defecation habits; insufficient physical activity; recent environmental changes

Psychological

Depression, emotional stress, mental confusion

Pharmacological

Aluminum-containing antacids; anticholinergics, anticonvulsants; antidiarrheal agents, antidepressants, antilipemic agents, bismuth salts, calcium carbonate, calcium channel blockers, diuretics, iron salts, laxative overdose, nonsteroidal antiinflammatory drugs (NSAIDs), opioids, phenothiazines, sedatives, and sympathomimetics

Mechanical

Neurological impairment, electrolyte imbalance, hemorrhoids, Hirschsprung’s disease, obesity, postsurgical obstruction, pregnancy, prostate enlargement, rectal abscess, rectal anal fissures, rectal anal stricture, rectal prolapse, rectal ulcer, rectocele, tumors

Physiological

Change in eating patterns, change in usual foods, decreased motility of gastrointestinal tract, defecation disorder, dehydration, inadequate dentition, inadequate oral hygiene, insufficient fiber intake, insufficient fluid intake, poor eating habits

Client Will (Specify Time Frame)

• Assess usual pattern of defecation, including time of day, amount and frequency of stool, consistency of stool; history of bowel habits or laxative use; diet, including fiber and fluid intake; exercise patterns; personal remedies for constipation; obstetrical/gynecological history; surgeries; diseases that affect bowel motility; alterations in perianal sensation; present bowel regimen. Individual bowel habits vary and clients with constipation experience a variety of symptoms (Spinzi et al, 2009).

• Consider emotional influences (e.g., depression and anxiety) on defecation. Emotions influence gastrointestinal function, possibly because control of both emotions and gastrointestinal function is located in the limbic system of the brain. Difficulties with defecation often begin in childhood (e.g., during toilet training), and constipation is also associated with sexual and physical abuse, depression, and anxiety (Whitehead et al, 2009). EBN: In a study, clients with functional constipation were compared to normal controls; subjects with functional constipation had significantly higher anxiety and depression scores (Zhou et al, 2010).

• Have the client or family keep a 7-day diary of bowel habits, including information such as time of day; usual stimulus; consistency, amount, and frequency of stool; difficulty defecating; fluid consumption; and use of any aids to defecation. Health care providers define constipation mainly in terms of frequency, but those affected are more concerned about hard stool and discomfort and straining when attempting to defecate (Wald et al, 2008). CEB: A diary of bowel habits is valuable in treatment of constipation; the use of a diary has proven to be more accurate than client recall in determining the presence of constipation (Andersen et al, 2006).

• Use the Bristol Stool Scale to assess stool consistency. The Bristol Stool scale is widely used as a more objective measure to describe stool consistency (Tack et al, 2011).

 Review the client’s current medications. EB: Many medications are associated with chronic constipation including opioids, anticholinergics, antidepressants, antihypertensives (e.g., clonidine, calcium channel blockers), antispasmodics, diuretics, anticonvulsants, and psychotropics (Eoff & Lembo, 2008; Spinzi et al, 2009).

 If clients are suffering from constipation and are taking constipating medications, consult with the health care provider (with prescriptive powers) about the possibilities of decreasing the medication dosages or finding an alternative medication that is less constipating (Gallagher, O’Mahony, & Quigley, 2008).

 Recognize that opioids cause constipation. If the client is receiving temporary opioids (e.g., for acute postoperative pain), request an order for routine stool softeners from the primary care practitioner, monitor bowel movements, and request a laxative if the client develops constipation. If the client is receiving around-the-clock opiates (e.g., for palliative care), request an order for Senokot-S and institute a bowel regimen. Opioids cause constipation because they decrease propulsive movement in the colon and enhance sphincter tone, making it difficult to defecate. Senokot-S is recommended to prevent constipation when opioids are given around the clock (Kyle, 2007). EB: In a study of hip fracture clients who received opioids following surgery, clients who received prophylactic laxatives were less likely to develop constipation than those who did not (Davies et al, 2008).

 If the client is terminally ill and is receiving around-the-clock opioids for palliative care, speak with the prescribing provider about ordering methylnaltrexone, a drug that blocks opioid effects on the gastrointestinal tract without interfering with analgesia. Methylnaltrexone is FDA approved for clients in palliative care when other laxatives are ineffective (Greenwood-Van Meerveld & Standifer, 2008). Methylnaltrexone does not replace, but is given in addition to, the usual laxative regimen (Kyle, 2009). EB: In an RCT with subjects with opioid-induced constipation, a significantly greater percentage of those who received methylnaltrexone had a bowel movement within 4 hours (without other laxatives) than those who received placebo (Thomas et al, 2008). In a randomized study of clients who took opioids for chronic, nonmalignant pain, those who received subcutaneous methylnaltrexone daily or every other day had significantly more bowel movements than subjects who received the placebo (Michna et al, 2011).

• If new onset of constipation, determine if the client has recently stopped smoking. Constipation is common, but usually transient, when people stop smoking (Wilcox et al, 2010). CEB: In a survey about perceived effects of various foods and beverages on constipation, cigarettes was the item that was most often perceived to have a laxative effect among smokers in all three groups (Müller-Lissner et al, 2005).

• Palpate for abdominal distention, percuss for dullness, and auscultate bowel sounds. In clients with constipation the abdomen is often distended and tender, and stool in the colon produces a dull percussion sound. Bowel sounds will be present.

 Check for impaction; if present, perform digital removal of stool per provider’s order. An impaction is hard stool that is too large to move through the sphincter and must be removed manually. Clients with neurogenic bowel dysfunction (e.g., spinal cord injury) commonly require manual evacuation of stool (Coggrave & Norton, 2009).

• Encourage fiber intake of 20 g/day (for adults) ensuring that the fiber is palatable to the individual and that fluid intake is adequate. Add fiber gradually to decrease bloating and flatus. Larger stools move through the colon faster than smaller stools, and dietary fiber make stools bigger because it is undigested in the upper intestinal tract. Fiber fermentation by bacteria in the colon produces gas. The effectiveness of water-insoluble fibers (e.g., wheat bran) on bowel function is well supported by research, and there is growing evidence that water-soluble fibers (e.g., psyllium) also promote laxation (Vuksan et al, 2008). CEB: The Nurses’ Health Study found that women with a median fiber intake of 20 g/day were less likely to experience constipation than those with a median intake of 7 g/day (Dukas, Willett, & Giovannucci, 2003). In a study of subjects receiving each of 5 treatments in a randomized design, the 5 treatments included: (1) bran cereal, (2) bran with corn cereal, (3) bran with psyllium cereal, (4) a cereal blend of 70% glucomannan and 30% xanthan, and (5) the low-fiber control diet. All four cereals produced significantly greater bowel movement than the low-fiber control diet and all were well tolerated (Vuksan et al, 2008). Researchers found that rye bread shortened intestinal transit time, softened the feces, and eased defecation of women with constipation, and that yogurt lessened the bloating and flatulence resulting from rye bread (Hongisto et al, 2006).

• Use a mixture of bran cereal, applesauce, and prune juice; begin administration in small amounts and gradually increase amount. Keep refrigerated. Always check with the primary care provider before initiating this intervention. It is important that the client also ingest sufficient fluids. CEB: This bran mixture has been shown to be effective even with short-term use in elderly clients recovering from acute conditions; however, it has not been tested with an RCT (Joanna Briggs Institute, 2008). NOTE: Giving fiber without sufficient fluid may result in worsening of constipation. Additional dietary fiber and bulk-forming laxatives are inappropriate for those who have difficulty ingesting adequate fluids, such as clients in palliative care (Kyle, 2007).

• Provide prune or prune juice daily. Each 100 g of prunes contain about 6 g of fiber, 15 g of sorbitol, and 184 mg of polyphenol; all have laxative effects (Attaluri et al, 2011). CEB: In a study about the perceived effects of various foods and beverages on stool consistency, over half of subjects surveyed reported that prunes had a softening effect on their stools (Müller-Lissner et al, 2005). In a randomized study, dried prunes produced significantly more complete spontaneous bowel movements (CSBMs) per week than psyllium, and both treatments produced significantly more CSBMs than at baseline (Attaluri et al, 2011).

• Encourage a fluid intake of 1.5 to 2 L/day (6 to 8 glasses of liquids per day), unless contraindicated because of other health concerns such as renal or heart disease. Cereal fibers such as wheat bran add additional bulk by attracting water to the fiber, so adequate fluid intake is essential. CEB: When dehydrated, the body absorbs additional water from stools, resulting in dry, hard stools that are difficult to pass (Sykes, 2006). Increasing fluid intake is not helpful if the person is already well hydrated.

 If the client is uncomfortable or in pain due to constipation or has acute or chronic constipation that does not respond to increased fiber, fluid, activity, and appropriate toileting, refer the client to the primary care provider for an evaluation of bowel function and health status. There can be multiple causes of constipation, such as endocrine disorders (e.g., hypothyroidism), depression, neurological conditions (e.g., multiple sclerosis and Parkinson’s disease), anorectal disorders, and Hirschsprung’s disease (Eoff & Lembo, 2008).

• Encourage clients to resume walking and activities of daily living as soon as possible if their mobility has been restricted. Encourage turning and changing positions in bed, lifting the hips off the bed, performing range-of-motion exercises, alternately lifting each knee to the chest, doing wheelchair lifts, doing waist twists, stretching the arms away from the body, and pulling in the abdomen while taking deep breaths. Bed rest and decreased mobility lead to constipation, but additional exercise does not help the constipated person who is already mobile. When the client has diminished mobility, even minimal activity increases peristalsis, which is necessary to prevent constipation (Joanna Briggs Institute, 2008). CEB: Twelve weeks of physical activity significantly decreased symptoms of constipation and difficulty defecating in sedentary clients with chronic constipation, but transit time decreased only in subjects who had abnormally long transit time before starting the exercise program (DeSchryver et al, 2005). In a study of 192 hospitalized clients which included daily recording of activity levels, being bedridden for 2 to 3 weeks accounted for a sixfold increase in dissatisfaction with bowel emptying (Cardin et al, 2010).

• Ask clients when they normally have a bowel movement and assist them to the bathroom at that same time every day to establish regular elimination. An optimal time for many individuals is 30 minutes after breakfast because of the gastrocolic reflex (Godfrey & Rose, 2007). CEB: When clients followed a bowel program that included adequate hydration, dietary fiber and regular toileting, most resumed normal bowel elimination patterns without laxatives (Benton et al, 1997). When subjects who had suffered a stroke were randomly scheduled for morning or evening defecation, those defecating in the morning after breakfast returned to regular elimination patterns significantly faster. Subjects whose defecation was scheduled for the same time of day as their normal, pre-stroke patterns also resumed normal elimination patterns significantly faster (Venn, 1992).

• Provide privacy for defecation. If not contraindicated, help the client to the bathroom and close the door. Bowel elimination is a private act in Western cultures, and a lack of privacy can hinder the defecation urge, thus contributing to constipation (Kyle, 2011).

• Help clients onto a bedside commode or toilet so they can either squat or lean forward while sitting. Recognize that it is difficult to impossible to defecate in the lying supine position. Sitting upright allows gravity to aid defecation. CEB: A study of men found that flexing the hip to 90 degrees or more straightens the angle between the anus and the rectum and pulls the anal canal open, to decrease the resistance to the movement of feces from the rectum and the amount of pressure needed to empty the rectum. Hip flexion is greatest when squatting or when leaning forward while sitting (Tagart, 1966). In a study involving volunteers, defecation required significantly less time and was significantly easier when squatting than when sitting (Sikirov, 2003). In another study, researchers found a significant decrease in the ability of subjects to defecate both a water-filled balloon and a silicone device in the lying position versus the sitting position (Rao, Kavolic, & Rao, 2006).

• Teach clients to respond promptly to the defecation urge. CEB: A study of male volunteers determined that the defecation urge can be delayed and that delaying defecation decreased bowel movement frequency, stool weight, and transit time (Klauser et al, 1990).

 Provide laxatives, suppositories, and enemas only as needed if other more natural interventions are not effective, and as ordered only; establish a client goal of eliminating their use. EB & CEB: Moderate evidence exists for the efficacy of lactulose, laxatives containing polyethylene glycol, and bulking agents (e.g., psyllium and bran) for the treatment of constipation in the elderly (Joanna Briggs Institute, 2008). Use of stimulant laxatives should be avoided because they result in laxative dependence and loss of normal bowel function. Laxatives (e.g., bisacodyl) and enemas also damage the surface epithelium of the colon (Schmelzer et al, 2004).

 When giving large volume enema solutions (e.g., soap-suds or tap-water enemas), measure the amount of fluid given and the amount expelled, especially when giving repeated enemas. Use a low concentration of Castile soap in the soap-suds enema. Enema fluid can be retained, and this retained fluid can be harmful for the client prone to fluid overload. CEB: In studies comparing the effectiveness of soap-suds enemas in preoperative liver transplant clients (Schmelzer et al, 2000) and in healthy subjects (Schmelzer et al, 2004), the amount of enema solution given was often larger than the amount of returns, and some subjects retained large amounts of solution. Biopsies taken immediately after soap-suds and tap-water enemas demonstrated damage to the surface epithelium of the colon (Schmelzer et al, 2004).

Client Will (Specify Time Frame)

• Have the client keep a 7-day diary of bowel habits, including information such as time of day; usual stimulus; consistency, amount, and frequency of stool; difficulty defecating; fluid consumption; and use of any aids to defecation. Health care providers define constipation mainly in terms of frequency, but those affected are more concerned about hard stool and discomfort and straining when attempting to defecate (Wald et al, 2008). CEB & EB: A diary of bowel habits is valuable in treatment of constipation; the use of a diary has proven to be more accurate than client recall in determining the presence of constipation (Andersen et al, 2006). A bowel diary was shown to be helpful for clients with opioid-induced constipation (Camilleri et al, 2010).

• Determine the client’s perception of an appropriate defecation pattern. The client may need to be taught that one bowel movement every 1 to 3 days is normal (Mayo Foundation for Medical Education and Research, 2011a).

• Recognize the emotional influences (e.g., depression and anxiety) on defecation. The relationship between emotions and bowel function can be explained as stress-mediated brain-gut dysfunction and can range from altered stress-induced mucosal immune function to impaired ability of the central nervous system to downregulate incoming gut or body afferent signals (Drossman, 2011). Difficulties with defecation often begin in childhood (e.g. during toilet training) (van Dijk et al, 2007), and constipation is also associated with sexual and physical abuse, depression, and anxiety (Whitehead et al, 2009). EBN: In a study, clients with functional constipation were compared to normal controls; subjects with functional constipation had significantly higher anxiety and depression scores (Zhou et al, 2010).

• Monitor the use of laxatives, suppositories, or enemas and suggest replacing them with increased fiber intake along with increased fluids to 2 L/day. Use of stimulant laxatives should be avoided; long-term use can result in dependence on laxative for defecation. In elderly clients with heart failure, use of laxatives containing magnesium can lead to hypermagnesemia and possibly result in increased mortality (Corbi et al, 2008) An increase in fiber intake to 20 to 30 g/day along with an increase in fluid intake can help clients with chronic constipation (Sturtzel & Elmadfa, 2008).

• Encourage fiber intake of 20 g/day (for adults) ensuring that the fiber is palatable to the individual and that fluid intake is adequate. Add fiber gradually to decrease bloating and flatus. Some people with eating disorders do not eat enough fiber to produce stools. Larger stools move through the colon faster than smaller stools, and dietary fiber makes stools bigger because it is undigested in the upper intestinal tract. Fiber fermentation by bacteria in the colon produces gas. The effectiveness of water-insoluble fibers (e.g., wheat bran) on bowel function is well supported by research, and there is growing evidence that water-soluble fibers (e.g., glucomannan and psyllium) also promote laxation (Vuksan et al., 2008). For further information on use of fiber, please refer to care plan Constipation.

• Use a mixture of bran cereal, applesauce, and prune juice; begin administration in small amounts and gradually increase amount. Keep refrigerated. Always check with the primary care practitioner before initiating this intervention. It is important that the client also ingest sufficient fluids. EBN & CEB: This bran mixture has been shown to be effective even with short-term use in elderly clients recovering from acute conditions; however, it has not been tested with an RCT (Joanna Briggs Institute, 2008). NOTE: Giving fiber without sufficient fluid has resulted in worsening of constipation (Müller-Lissner et al, 2005).

• Teach clients to respond promptly to the defecation urge. CEB: A study of male volunteers determined that the defecation urge can be delayed and that delaying defecation decreased bowel movement frequency, stool weight, and transit time (Klauser et al, 1990). The reflex that causes the urge to defecate diminishes after a few minutes and may remain quiet for several hours; as a result, the stool becomes hardened and more difficult to expel.

 Obtain a referral to a dietitian for analysis of the client’s diet and input on how to improve the diet to ensure adequate fiber intake and nutrition.

 Assess for signs of depression, other psychological disorders, and a history of physical or sexual abuse. Often, people with functional constipation have experienced physical or sexual abuse, and symptoms of constipation may arise from psychological problems (O’Brien et al, 2009). EB: A study found that somatic complaints of constipation were common in people with depression (Afridi, Siddiqi, & Ansari, 2009).

• Encourage the client to increase activity, walking for at least 30 minutes at least 5 days a week as tolerated. Decreased mobility leads to constipation, but additional exercise does not help the constipated person who is already mobile. When the client has diminished mobility, even minimal activity increases peristalsis, which is necessary to prevent constipation (Joanna Briggs Institute, 2008). EB: A program of increased toileting assistance, increased exercise, and choice of food and fluid snacks every 2 hours for 8 hours per day over 3 months resulted in increased number of stools for nursing home residents (Schnelle et al, 2010).

 Observe for the presence of an eating disorder, the use of laxatives to control or decrease weight; refer for counseling if needed. People with eating disorders suffer from constipation and other gastrointestinal symptoms, or use laxatives as part of inducing weight loss (Roerig et al, 2010). CEB: Laxative abuse is found in clients with both anorexia and bulimia nervosa and may be associated with worsening of the eating disorder as a form of self-harm (Tozzi et al, 2006).

Pesticides

Dermatological effects of pesticide exposure; gastrointestinal effects of pesticide exposure; neurological effects of pesticide exposure; pulmonary effects of pesticide exposure; renal effects of pesticide exposure; major categories of pesticides: insecticides, herbicides, fungicides, antimicrobials, rodenticides; major pesticides: organophosphates, carbamates, organochlorines, pyrethrum, arsenic, glycophosphates, bipyridyls, chlorophenoxy

Chemicals

Dermatological effects of chemical exposure; gastrointestinal effects of chemical exposure; immunologic effects of chemical exposure; neurological effects of chemical exposure; pulmonary effects of chemical exposure; renal effects of chemical exposure; major chemical agents: petroleum-based agents, anticholinesterases type I agents act on proximal tracheobronchial portion of the respiratory tract, type II agents act on alveoli; type III agents produce systemic effects

Biologicals

Dermatological effects of exposure to biologics; gastrointestinal effects of exposure to biologics; pulmonary effects of exposure to biologics; neurological effects of exposure to biologics; renal effects of exposure to biologics (toxins from organisms [bacteria, viruses, fungi])

Pollution

Neurological effects of pollution exposure; pulmonary effects of pollution exposure (major locations: air, water, soil; major agents: asbestos, radon, tobacco, heavy metal, lead, noise, exhaust)

Waste

Dermatological effects of waste exposure; gastrointestinal effects of waste exposure; hepatic effects of waste exposure; pulmonary effects of waste exposure (categories of waste: trash, raw sewage, industrial waste)

Radiation

External exposure through direct contact with radioactive material; genetic effects of radiation exposure; immunologic effects of radiation exposure; neurological effects of radiation exposure; oncological effects of radiation exposure

External

Chemical contamination of food; chemical contamination of water; exposure to bioterrorism; exposure to disasters (natural or human-made); exposure to radiation (occupation in radiology; employment in nuclear industries and electrical generating plants; living near nuclear industries and/or electrical generating plants); exposure through ingestion of radioactive material (e.g., food/water contamination); flaking, peeling paint in presence of young children; flaking, peeling plaster in presence of young children; floor surface (carpeted surfaces hold contaminant residue more than hard floor surfaces); geographic area (living in area where high level of contaminants exist); household hygiene practices; inadequate municipal services (trash removal, sewage treatment facilities); inappropriate use of protective clothing; lack of breakdown of contaminants once indoors (breakdown is inhibited without sun and rain exposure); lack of protective clothing; lacquer in poorly ventilated areas; lacquer without effective protection; living in poverty (increases potential for multiple exposure, lack of access to health care, poor diet); paint in poorly ventilated areas; paint without effective protection; personal hygiene practices; playing in outdoor areas where environmental contaminants are used; presence of atmospheric pollutants; use of environmental contaminants in the home (e.g., pesticides, chemicals, environmental tobacco smoke); unprotected contact with chemicals (e.g., arsenic); unprotected contact with heavy metals (e.g., chromium, lead)

Internal

Age (children <5 years, older adults); concomitant exposures; developmental characteristics of children; female gender; gestational age during exposure; nutritional factors (e.g., obesity, vitamin and mineral deficiencies); preexisting disease states; pregnancy; previous exposures; smoking

Client Will (Specify Time Frame)

Community Will (Specify Time Frame)

 Help individuals cope with contamination incident by doing the following:

CEB: A crisis situation follows a predictable course in which individuals progress in response to a precipitating stressor and that culminate in a state of acute crisis. Interventions aimed at supporting an individual’s coping help the person deal with feelings of fear, helplessness, and loss of control that are normal reactions in a crisis situation (Boscarino et al, 2006; Caplan, 1964).

• Triage, stabilize, transport, and treat affected community members. CEB: Accurate triage and early treatment provide the best chance of survival to affected persons (Murdoch & Cymet, 2006; Veenema, 2007).

• Utilize approved procedures for decontamination of persons, clothing, and equipment. Victims may first require decontamination prior to entering health facility to receive care in order to prevent the spread of contamination (U.S. Army Medical Research Institute of Infectious Diseases, 2005).

• Utilize appropriate isolation precautions: universal, airborne, droplet, and contact isolation. Proper use of isolation precautions prevents cross-contamination by contaminating agents (U.S. Army Medical Research Institute of Infectious Diseases, 2005).

• Monitor individual for therapeutic effects, side effects, and compliance with postexposure drug therapy. Drug therapy may extend over a long period of time and will require monitoring for compliance as well as therapeutic and side effects (Veenema, 2007).

 Collaborate with other agencies (local health department, emergency medical service [EMS], state and federal agencies). Communication among agencies increases ability to handle crisis efficiently and correctly (CDC, 2009; Veenema, 2007).