Watching for closely spaced studies using contrast media and consulting with provider for change in scheduling of studies if needed (Cheung, Ponnusamy & Anderton, 2008). Multiple administration of contrast within 72 hours is considered a risk factor for CIN (O’Donovan, 2010).

 Notifying the provider and the radiology staff if the client has preexisting renal disease. Clients with preexisting impaired renal function are prone to develop acute contrast media induced nephropathy (CIN) (Schilcher et al, 2011; Wong et al, 2011).

 Ensuring that clients having diagnostic testing with contrast are well hydrated with IV saline as ordered before and after the examination. EB: Hydration with crystalloids has been shown to prevent renal insufficiency by diluting the IV contrast. Fluids without salt have been shown to increase acute kidney injury (Rudnick, Goldfarb, & Tumlin, 2008).

 Recognize that many clients with decreased renal function are not aware of their health status, and that a questionnaire checklist administered before testing may not be satisfactory to find clients with impaired renal function that should receive contrast media carefully or who are not a candidate for testing utilizing contrast media because of possible increased renal dysfunction. EB: A study found that use of a pre-procedure checklist was not effective in identifying all the clients with a history of chronic kidney disease to protect them from further kidney damage; instead point-of-care creatine testing was recommended (Kalisz et al, 2011).

 Recognizing that cancer clients are often very vulnerable to contrast induced nephropathy due to frequent imaging examinations. Cancer clients have frequent examinations requiring contrast for tumor staging and assessment of treatment response. In addition the risk is compounded by advancing age, co-administration of nephrotoxic chemotherapy drugs, and dehydration from gastrointestinal complications from drugs and radiation (Heiken, 2008).

• Mild Reactions: Urticaria, pruritus, rhinorrhea, nausea, emesis, diaphoresis, coughing, dizziness

• Moderate Reactions: Persistent emesis, widespread urticaria, headache, edema of the face, laryngeal edema, mild dyspnea, palpitations, tachycardia/bradycardia, hypertension, abdominal cramps

• Severe Reactions: Severe bronchospasm, severe arrhythmias, severe hypotension, pulmonary edema, laryngeal edema, seizures, syncope, death (Wilson, 2011)

• Screen the elderly client thoroughly before diagnostic testing utilizing contrast media. The elderly are more likely to have pre-existing renal failure, along with other comorbidities and are more vulnerable to develop renal damage (Cheung et al, 2008; O’Donovan, 2011).

• Refer to care plan Ineffective community Coping.

• Review coping skills, power for coping, and the use of power resources.

 Identify problems with alcohol in the elderly with the appropriate tools and make suitable referrals. Tools such as the Alcohol Use Disorders Identification Test (AUDIT), Michigan Alcohol Screening Test-Geriatric Version (MAST-G), and the Alcohol-Related Problems Survey (ARPS) may have additional use in this population. Brief interventions have been shown to be effective in producing sustained abstinence or reducing levels of consumption, thereby decreasing hazardous and harmful drinking (Culberson, 2006).

• Encourage exercise for positive coping. CEB: After a 10-week period, the elderly participants in this exercise group reported significant improvements in stress, mood, and several quality-of-life indices (Starkweather, 2007).

• Stimulate individual reminiscence therapy. EB: After eight sessions, an elderly woman had a happier expression on her face, was willing to express herself more verbally, had more interaction with others, and required medication less frequently to help her sleep (Chou, Lan, & Chao, 2008).

• Stimulate group reminiscence therapy. CEB: Participation in reminiscence activities can be a positive and valuable experience for demented older persons. Consequently, the development of a structured care program for elderly persons with cognitive impairment and the need for long-term care is essential. Thus, health providers in long-term care facilities should be trained in reminiscence group therapy and to be able to deliver such a program to the targeted group (Wang, 2007).

• Acknowledge racial/ethnic differences at the onset of care. CEB: Acknowledgment of race/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes (D’Avanzo et al, 2001). African American parents who denied experiences of racism reported higher rates of behavior problems in their children, in contrast to African American parents who actively coped with racism and reported lower levels of behavior problems in their children (Caughy, O’Campo, & Muntaner, 2004).

• Assess an individual’s sociocultural backgrounds in teaching self-management and self-regulation as a means of supporting hope and coping with a diagnosis of type 2 diabetes. EBN: Findings obtained from the themes of this study illustrated that self-management of clients with diabetes is highly related to their own sociocultural environment and experiences (Lin et al, 2008).

• Encourage the client to use spiritual coping mechanisms such as faith and prayer. CEB & EBN: Prayer is a powerful way of coping and is practiced by all Western religions and several Eastern traditions (Mohr, 2006). Spirituality inspired hope among caregivers of stroke clients (Pierce et al, 2008). This study indicates that black American young adult college students may utilize religious coping methods for psychological stress (Kohn-Wood et al, 2012)

• Encourage spirituality as a source of support for coping. EB: The association among spirituality/religiosity, positive appraisals, and internal adaptive coping strategies indicates that the utilization of spirituality/religiosity goes far beyond fatalistic acceptance, but can be regarded as an active coping process (Büssing et al, 2009).

 Refer the client for a behavioral program that teaches coping skills via “Lifeskills” workshop and/or video. CEB: Commercially available, facilitator- or self-administered behavioral training products can have significant beneficial effects on psychosocial well-being in a healthy community sample (Kirby et al, 2006).

• Teach coping skills to family caregivers of cancer clients. CEB: A coping skills intervention was effective in improving caregiver quality of life, reducing burden related to client’s symptoms, and caregiving tasks compared with hospice care alone or hospice plus emotional support (McMillan et al, 2006).

• Teach caregivers the COPE intervention (creativity, optimism, planning, expert information) to assist with symptom management. CEB: Symptom distress, a measure that encompasses client suffering along with intensity, was significantly decreased in the group in which caregivers were trained to better manage client symptoms (McMillan & Small, 2007).

• Family-based intervention may prevent anxiety disorders in the offspring of parents with anxiety disorders. EB: Parental satisfaction with the intervention was high. Findings suggest that a family-based intervention may prevent the onset of anxiety disorders in the offspring of parents with anxiety disorders (Ginsburg, 2009).

• Monitor the client’s risk of harming self or others and intervene appropriately. See care plan for Risk for Suicide. CEB: Adolescents may use self-harming behaviors as a means of communication or way of coping (Murray & Wright, 2006).

• Support adolescent and children’s individual coping styles. EBN: Researchers found that a connection to school could be protective against ineffective coping patterns in a sample of 166 fourth graders (Rice et al, 2008). In a study of coping of 4- to 6-year-olds who were hospitalized, researchers concluded that it was essential to support children’s individual coping strategies with information, guidance, and participation in decisions (Salmela, Salanterä, & Aronen, 2010). EB: In one study of youth with type 1 diabetes, the following coping skills were observed: Younger children used more coping that involved choosing an alternate activity, helping others, and an emotional response (taking personal responsibility), whereas adolescents used more coping that involved persistence, alternate thinking, and talking things over (taking personal responsibility) (Hema, Roper, & Nehring, 2009).

• Encourage moderate aerobic exercise (as appropriate). CEB: Exercise was found to decrease the likelihood of depressive feelings when used as a positive coping strategy for school-age children with angry feelings (Goodwin, 2006).

 Assess and report possible physiological alterations (e.g., sepsis, hypoglycemia, hypotension, infection, changes in temperature, fluid and electrolyte imbalances, and use of medications with known cognitive and psychotropic side effects). EB: A reversible pathophysiological process may be causing symptoms (Rocchiccioli & Sanford, 2009).

• Screen for elder neglect or other forms of elder mistreatment. CEB & EB: Abuse of older people is a serious and growing social problem (Wang, Tseng, & Chen, 2007). In one study of 86 persons with Alzheimer’s disease and their caregivers, researchers found predictors of caregiver abuse behaviors included caregivers who were male, had greater burden, and whose care recipient had greater irritability and cognitive impairment (with less functional impairment)(Cooper et al, 2008).

• Encourage the client to make choices (as appropriate) and participate in planning care and scheduled activities. CEB & EBN: Older persons with heart failure transitioning to home from the hospital made choices about participation in the therapeutic regimen based on their individual goals for community living during a nursing intervention study, which resulted in positive client outcomes and cost savings (McCauley, Bixby, & Naylor, 2006). In a pilot study examining depression care preferences of older home care clients, researchers concluded client preferences during care planning may improve participation in geriatric depression care management (Fyffe et al, 2008).

• Target selected coping mechanisms for older persons based on client features, use, and preferences. CEB: Elders with arthritis reported cognitive efforts, diversional activities, and assertive actions were useful in dealing with daily stress (Tak, 2006). EB: Data from 37 interviews in one study of African American older adults with mild symptoms of depression revealed culturally based coping strategies, which included self-reliance strategies, keeping depressive symptoms from family and friends, denial, use of less stigmatizing emotional expressions, and prayer and relationship with God (Conner et al, 2010).

• Increase and mobilize support available to older persons by encouraging a variety of mechanisms involving family, friends, peers, and health care providers. EBN: Researchers conducted a controlled trial of a nursing intervention to facilitate older adults’ (n = 89) access to community resources to assist them to remain at home. Researchers found the older adults accepted the intervention and had improved health empowerment, purposeful participation in goal attainment, and well-being (Shearer, Fleury, & Belyea, 2010).

• Actively listen to complaints and concerns. EBN: One of the most frequently used strategies by nurses in end-of-life care and communication was active and passive listening (Boyd et al, 2011).

• Engage the client in reminiscence. EBN: In a review of the literature, one author found that while more research is needed, reminiscence was a promising intervention for older adults and proposes a protocol for a structured group reminiscence intervention (Stinson, 2009).

• Assess for the influence of cultural beliefs, norms, and values on the client’s perceptions of effective coping. EBN: The representation of “strength” influences African American women’s conceptualization of depression and coping strategies (Porter & Pacquiao, 2011).

• Assess the influence of fatalism on the client’s coping behavior. EB: While fatalism has been a culturally associated concept, recent studies of Latinos experiencing post-traumatic symptoms and African American women diagnosed with cancer have found no significant findings related to fatalism and traumatic symptoms or fatalism and delay in seeking treatment for breast cancer (Gullatte et al, 2010). More research is needed.

• Assess the influence of cultural conflicts that may affect coping abilities. EBN: In one ethnographic study, the researcher concluded that in the United States, there are differences between nurses’ cultures and those of Syrian Muslims and suggested that improved cultural knowledge can lessen cultural pain and conflicts (Wehbe-Alamah, 2011).

• Assess for intergenerational family problems that can overwhelm coping abilities. EB: While generalization is not possible, in one qualitative case study of intergenerational dynamics in a Euro-American family experiencing the suicide of a father and daughter, areas for assessment were illuminated and included the role of ways of dealing with the initial death, presence of incarceration of family members, and the perceptions of family survivors of suicide (Sandage, 2010).

• Encourage spirituality as a source of support for coping. EBN: In a small qualitative study of Mexican American cancer survivors (n = 5), three themes were uncovered, one of which was the use of spiritual resources to cope with cancer (Campesino, 2009).

• Negotiate with the client with regard to the aspects of coping behavior that will need to be modified. EBN: The use of self-mutilation as a coping behavior or communication of strength has been found in many cultures. One case study reports the care of a Pakistani woman who began self-cutting when she first arrived in the United States. The author identifies the importance of open communication with individualized care, referrals, and support for more effective coping patterns (Williams & Hamilton, 2009).

• Encourage moderate aerobic exercise (as appropriate). CEB: In a group of African American elders with chronic health conditions, exercise was used as a coping strategy for effectively managing chronic health conditions (Loeb, 2006).

• Identify which family members the client can count on for support. EBN: In a study of sources of social support for adults living with HIV (n = 150), researchers found that spouses, friends, siblings, and mothers provided appraisal, belonging, and tangible support (Grant et al, 2009).

• Support the inner resources that clients use for coping. EB: In a qualitative study of 23 Sudanese refugees, participants used a number of coping strategies to deal with pre-immigration, transition, and post-immigration difficulties including reliance on religious beliefs, relying on inner resources, and focus on the future (Khawaja et al, 2008).

• Use an empowerment framework to redefine coping strategies. EBN: In an intervention study of an empowerment intervention in a group (n = 18) of Norwegian women undergoing or recovering from treatment for breast cancer, researchers used empowerment strategies such as reflection on strengths and resources and affirmation of strengths and abilities contributing to the empowerment of the participants (Stang & Mittelmark, 2010). EB: In a qualitative study of deaf people in the United States, researchers found that many participants self-identified as members of an ethno-linguistic minority. Both individual and community empowerment strategies were uncovered in the Internet weblog format, such as the value of using American Sign Language, use of humor, and advocating for social justice (Hamill & Stein, 2011).

• The interventions described previously may be adapted for home care use.

 Assess for suicidal tendencies. Refer for mental health care immediately if indicated.

• Identify an emergency plan should the client become suicidal. Ineffective coping can occur in a crisis situation and can lead to suicidal ideation if the client sees no hope for a solution. A suicidal client is not safe in the home environment unless supported by professional help. Refer to the care plan for Risk for Suicide.

• Observe the family for coping behavior patterns. Obtain family and client history as possible. CEB: Family assessment is necessary to guide interventions and activate appropriate resources (Ellenwood & Jenkins, 2007).

 Assess for effective symptoms after cerebrovascular accident (CVA) in the elderly, particularly emotional lability and depression. Refer for evaluation and treatment as indicated. CEB: In a study of older persons poststroke, researchers found a range of physical and psychological concerns, with some clients expressing fears of getting worse while others expressed hope for recovery. In either case, nurses can assist with the needs and promote the use of effective coping (Popovich, Fox, & Bandagi, 2007).

• Encourage the client to use self-care management to increase the experience of personal control. Identify with the client all available supports and sense of attachment to others. Refer to the care plan for Powerlessness. EBN: In a study of coping strategies of Latino women spouses of stroke survivors, women maintained a sense of spousal obligation to care and used emotion-focused coping to preserve their own physical and psychological health (Arabit, 2008). In a qualitative study of African American women (n = 46) with low incomes trying to lose weight, the women, who were generally had low weight loss self-efficacy, did not set goals regarding weight loss and exercise, and did not have sufficient support from family and friends to make the necessary changes (Mastin, Campo, & Askelson, 2012).

 Refer the client and family to support groups. CEB: Predictors of participation in support groups by cancer clients include trusted others’ views of support groups, support received from special others, and the person’s own beliefs about support groups (Grande, Myers, & Sutton, 2006).

 If monitoring medication use, contract with the client or solicit assistance from a responsible caregiver. Elders with arthritis identified taking medications as an assertive action coping strategy (Tak, 2006).

 Institute case management for frail elderly clients to support continued independent living. EBN: Case management provides home-based care of frail elderly using a process of assessment and medication review leading to new diagnoses, coordination of care, and tailoring of services that match individual needs (Elwyn et al, 2008).

 If the client is homebound, refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen. CEB: Researchers found a therapeutic life review intervention delivered by home care workers enhanced mood in women participants (Symes et al, 2007). CEB: An intervention study of a peer-based and regular case management for community-dwelling adults with severe mental illness demonstrated that improved positive regard at 6 months predicted and sustained treatment motivation for psychiatric, alcohol, and drug use problems and attendance at Alcoholics and Narcotics Anonymous meetings (Sells et al, 2006).

• Teach the client to problem solve. Have the client define the problem and cause, and list the advantages and disadvantages of the options. CEB: A systematic review regarding healthy coping in diabetes management suggested there is evidence from well-controlled intervention studies about coping/problem solving interventions, which support their use (Fisher et al, 2007).

• Provide the seriously ill client and his or her family with needed information regarding the condition and treatment. CEB: Researchers concluded that seriously ill hospitalized clients have poor knowledge of CPR and would benefit from improved understanding of CPR and their role (clients and family) in the decision-making process (Heyland et al, 2006).

• Teach relaxation techniques. EBN: Mindfulness meditation (MBSR) was taught to community-dwelling adults who found the intervention promoted health awareness, personal self-care, and overall well-being (Matchim, Armer, & Stewart, 2008).

• Work closely with the client to develop appropriate educational tools that address individualized needs. EB: Researchers developed a purpose-based information assessment (PIA) tool to evaluate how effective the information met the clients’ individual needs; findings included estimates supporting the validity, reliability, and sensitivity of the PIA. Researchers concluded that the PIA can be used to identify strengths and limitations in meeting an individual’s information needs (Feldman-Stewart, Brennestuhl, & Brundage, 2007).

 Teach the client about available community resources (e.g., therapists, ministers, counselors, self-help groups). EBN: Researchers concluded from a review of the literature regarding couples surviving prostate cancer that in addition to meeting educational needs, nurses must assess for potential concerns and make recommendations and referrals to assist couples with finding appropriate resources for coping with issues related to their relationship (Galbraith, Fink, & Wilkins, 2011). EB: While research suggests that persons needing community services are interested in using them, not all who need services use them, due in part to the need for more information about resources, how to use them more effectively, or availability of services (Janda et al, 2008).

• Encourage exercise for children and adolescents to promote positive self-esteem, to enhance coping, and to prevent behavioral and psychological problems. EBN: Physical activity helped to decrease depression and anxiety and to increase coping skills in adolescents (Beauchemin & Manns, 2008).

• Suggest that parents with children diagnosed with cancer continue with psychosocial support during and after treatment. They may use computer mediated support groups to exchange messages with other parents. EBN: Using computer technology for support was particularly useful for a dispersed group with limited time, helping to decrease depression and anxiety in fathers and mothers (Bragadóttir, 2008)EB: One study shows that continued support for parents is necessary when children complete therapy for cancer (Wakefield et al, 2011).

• Consider the use of telephone support for caregivers of family members with dementia. EBN: Family caregivers of patients with dementia experience caregiver burden and need holistic nursing interventions, such as telephone support (Mason & Harrison, 2008). Another study shows that families provide a considerable amount of informal care and support for older adults. Best practice is to involve families in setting goals and recommendations for plan of care (Bradway & Hirschman KB, 2008).

• Use technology for social support and to help elders stay connected to family and friends. EBN: In one study, elders were able to stay connected with grandchildren via email (Lorenz, 2010).

• Support a positive sense of humor and social support. EBN & EB: Social support and a sense of humor may play an important role in reinforcing self-efficacious approaches to the management of health issues in older adults (Marziali, McDonald, & Donahue, 2008).

• Refer the older client to self-help support groups. Suggest the Red Hat Society for older women. EB: A leisure focused group (Red Hat Society) helped the members to cope with stressors associated with the challenges and losses of old age (Hutchinson et al, 2008).

 Refer the client with Alzheimer’s disease who is terminally ill to hospice. EB: The National Institute of Clinical Excellence (NICE) and the National Council for Palliative Care (NCPC) have highlighted the importance of palliative care for people with dementia (Chatterjee, 2008).

• Assess an individual’s sociocultural backgrounds in teaching self-management and self-regulation as a means of supporting hope and coping with a diagnosis. EBN: Findings obtained from the themes of this study illustrated that self-management of clients with diabetes is highly related to their own sociocultural environment and experiences (Lin et al, 2008). EB: In a study conducted in India, regression analysis showed social support significantly moderated the relations of positive psychological strengths with subjective well-being (Khan & Husain, 2010).

• Encourage spirituality as a source of support for coping. EB: Spirituality and social support are two potentially modifiable determinants of health for older African American women (Paranjape & Kaslow, 2010).

• Foster intergenerational support among African American families. EB: This study describes this as a strength-based model that supports the multigenerational African American family (Waites, 2009). Refer to care plan for Ineffective Coping.

• The interventions described previously may be adapted for home care use.

• Provide an Internet-based health coach to encourage self-management for clients with chronic conditions such as depression, impaired mobility, and chronic pain. EBN: Clients who have higher self-efficacy and participate actively in their care have better disease management. Client-provider Internet portals offer a new venue for empowering and engaging clients in better management of chronic conditions (Allen et al, 2008). Telephone health coaching, along with in-person individual educational sessions and group sessions, was included in a psychoeducation intervention randomized control trial pilot study in women survivors of breast cancer (n = 48); researchers concluded the intervention showed promise to increase overall quality of life and decrease psychological symptom distress (Park et al, 2012). EB: In a randomized control trial of a computerized CBT intervention, researchers found participants (n = 52) enhanced their coping skills (Kiluk, Babuscio, & Carroll, 2010).

• Refer the client to mutual health support groups. EBN: A review of the literature regarding peer support suggests that peer support has the potential for positive outcomes in individuals in recovery (Repper & Carter, 2011). EB: Participating in mutual health support groups led to enhanced coping by improving psychological and social functioning (Pistrang, Barker, & Humphreys, 2008). In a qualitative study of young people engaged in self-help groups for substance use (n = 17), the researcher found that participants valued what the groups offered in terms of connectedness, support, and opportunities for learning (Dadich, 2010).

• Refer prostate cancer clients and their spouses to family programs that include family-based interventions of communication, hope, coping, uncertainty, and symptom management. EBN: Participants in this study reported positive outcomes from a family intervention that offered them information and support (Harden et al, 2009). From a literature review regarding couples surviving prostate cancer, the authors asserted that nurses are in a position to make recommendations and referrals to assist couples to find appropriate resources (Galbraith et al, 2011). EB: Researchers conducted focus groups of female partners (n = 14) of men who received surgical treatment for prostate cancer and found the need for support of the female partners (Evertsen & Wolkenstein, 2010).

 Refer combat veterans and service members directly involved in combat as well as those providing support to combatants, including nurses for mental health services. EBN: Early identification and treatment of mental health problems may decrease the psychosocial impact of combat and thus prevent progression to more chronic and severe psychopathology such as depression and post-traumatic stress disorder (PTSD) (Jones et al, 2008). Veterans’ transition to home life is deeply embedded in the context of relationships. Nurses can use Swanson’s theory of caring to find guidance for ways to provide meaningful support to veterans (Wands, 2011.)

• Teach the client about available community resources (e.g., therapists, ministers, counselors, self-help groups, family-education groups). EB: Families need assistance in coping with health changes (Pickett-Schenk et al, 2008).

• Teach caregivers the COPE intervention (creativity, optimism, planning, expert information) to assist with symptom management EBN: Symptom distress, a measure that encompasses client suffering along with intensity, was significantly decreased in the group in which caregivers were trained to better manage client symptoms (McMillan & Small, 2007).

• Teach expressive writing and education about emotions. EBN: Researchers tested an expressive writing intervention with a sample of rural and urban breast cancer survivors and found it had positive outcomes for physical and psychological well-being (Henry et al, 2010). EB: Researchers used a combination of expressive writing with elements of psychoeducation on emotion regulation with adolescents. It demonstrated that this may be an effective preventive tool, to improve psychosocial adjustment by establishing functional emotion regulation strategies (Horn, Pössel, & Hautzinger, 2011).

• Acknowledge the stressors unique to racial/ethnic communities. EBN: Understanding ethnic interpretations and cultural determinants that contribute to clients’ stress assists the nurse in promoting health within a community (Anderson & McFarlane, 2011).

• Identify community strengths with community members. EB: Latino men from three urban housing communities in the southeastern United States identified Latino community strengths and general community strengths as factors that promote health and prevent risk (Rhodes et al, 2009).

• Work with members of the community to prioritize and target health goals specific to the community. EB: Such prioritization and targeting will increase feelings of control over and sense of ownership of programs (Anderson & McFarlane, 2011; Chinn, 2012).

• Establish and sustain partnerships with key individuals within communities when developing and implementing programs. EB: Health partnerships between collaborating parties are a crucial strategy to optimize the health of a community (Pender, Murdaugh, & Parsons, 2011).

• Use mentoring strategies for community members. EB: In a study of child vaccination in Haiti, it was found that mother’s use of traditional healer services was negatively associated with vaccination of their children, underscoring the potential of enlisting the support of traditional healers in promoting child health by mentoring and educating traditional healers in supporting vaccination efforts (Muula et al, 2009).

• Use community church settings as a forum for advocacy, teaching, and program implementation. EBN: Participant and pastor feedback supported the feasibility of ongoing faith-based screening and education programs as one way to reduce risk factors for diabetes, cardiovascular disease, and stroke in Southern, rural African Americans (Frank & Grubbs, 2008).

• Assess the adolescent’s perception of support from family and friends during crisis and illness. Also thoroughly assess adolescent’s needs and concerns. EB: A qualitative study focusing on the self-identified needs of adolescents living with chronic pain found that the adolescents were experiencing common stressors and concerns, including the struggle to be “normal,” and coping with the pain (Forgeron & McGrath, 2009).

• Provide educational and psychosocial interventions such as coping skills training in treatment for families and their adolescents who have type 1 diabetes. EB: Understanding parent/child dynamics and the influence of anxiety on behalf of the parents may help predict autonomy development and self-management behaviors of adolescents with diabetes (Dashiff et al, 2009).

• Focus on the communication dynamics of families coping with chronic illness. Identify communication barriers and ways in which to enhance the communication process among parents, siblings, and other family members involved. EBN: A recent qualitative study identified four communication themes present among siblings, parents, and others within families of children with chronic illnesses: communication as a reflection of family roles and relationships; giving voice; staying connected; and struggling for normalcy (Branstetter et al, 2008).

• Encourage the use of family rituals such as connection, spirituality, love, recreation, and celebration, especially in single parent families. EBN: Spirituality can play an important role in one’s healing process. Most patients prefer that their health providers address their spiritual needs (Tanyi, McKenzie, & Chapek, 2009).

• Staff should involve the family in decision-making processes, especially during hospital discharge planning. EBN: Increasing parental involvement in caregiving procedures and including them in hospital discharge processes, through written and verbal information, has been identified as an effective way to increase feelings of competence and confidence in family caregivers (Keatinge, Stevenson, & Fitzgerald, 2009).

• Transitioning into parenthood is a major life event for individuals. Providing effective strategies and education to first-time parents can help them feel more prepared, confident, and supported during this transition. EBN: Research indicates that positive experiences during the transitional period into parenthood contribute to parents feeling more confident and educated prior to the postnatal period. Programs such as “Coming Ready or Not!” provide innovative educational and supportive strategies to those preparing for the parenthood role (McKellar, Pincombe, & Henderson, 2009).

• Teenage mothers may experience a variety of psychosocial complications during and after their pregnancy, including conflicts due to poor relational boundaries with their own mothers. This type of conflict may exacerbate maternal stress and negatively impact mother-infant interactions (Stiles, 2008). EBN: Interventions, including cognitive-behavioral therapy interventions, may help improve relational boundaries between teenage mothers and their mothers. This may subsequently improve mother-infant relationships (Stiles, 2008).

• Perform a holistic assessment of all needs of informal spousal caregivers. EBN: The role of informal spousal caregivers has increased as the population ages. Community-based services can positively impact the stress process for family caregivers (Sussman & Regehr, 2009).

• Help caregivers believe in themselves and their ability to handle the situation, taking life one day at a time, looking for positive aspects in each situation, and relying on their own individual expertise and experience. Encourage caregivers to establish their priorities and concentrate on caring for their own physical and emotional well-being. EBN: Using respite care services is an effective coping mechanism for family caregivers (Salin, Kaunonen, & Astedt-Kurki, 2009).

 Refer caregivers of clients with Alzheimer’s disease to a monthly psychoeducational support group (i.e., the Alzheimer’s Association). Incorporate nonpharmacological support programs for caregivers. EB: Nonpharmacological support programs for caregivers have been found to significantly reduce the odds of institutionalization (Spijker et al, 2008).

 Consider the use of telephone support for caregivers of family members with illnesses such as cancer and dementia. EBN: Family caregivers can be helped through a variety of social support mechanisms including telephone support (Radziewicz et al, 2009).

• Assist in finding transportation to enable family members to visit. EB: If a family member is homebound and unable to visit, encourage alternative contact (e.g., telephone, cards and letters, email) to provide ongoing scheduled progress reports and to help reduce loneliness and isolation. Visually impaired elderly, who experience more limitations with driving, have a higher risk for loneliness (Alma et al, 2011).

• Acknowledge racial/ethnic differences at the onset of care. EBN: Acknowledgment of race/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes (Mokuau et al, 2008).

• Assess for the influence of cultural beliefs, norms, and values on the family’s/community’s perceptions of coping. EB: What the family/community considers normal and abnormal coping behavior may be based on cultural perceptions (von Peter, 2009).

• Use culturally competent assessment procedures when working with families with different racial/ethnic backgrounds EB: This study demonstrates that a culturally competent assessment helps to avoid discrepancies and diagnostic errors (Zayas, Torres, & Cabassa, 2009). EBN: This study revealed that significant racial/ethnic disparities were present in regard to recognizing autism spectrum disorders in children. Professionals and clinicians must continue to culturally educate themselves in order to avoid such disparities, and to provide the most effective assessments and interventions needed within the given cultural context (Mandell et al, 2009).

• Provide culturally relevant interventions by understanding and utilizing treatment strategies that are acceptable and effective for a particular culture. EBN: Terminology and therapeutic strategies must reflect and adhere to the values of one’s culture (Hodge & Nadir, 2008). EB: Clinicians have a responsibility to take into consideration the many factors present in culturally diverse situations, including epidemiological knowledge in relation to specific cultures; awareness of how culture influences thoughts and behaviors; taking into consideration one’s cultural and social context; relaying information in an appropriate manner; and recognizing one’s own biases and prejudices toward a specific culture (Seeleman, Suurmond, & Stronks, 2009).

• Provide opportunities for families to discuss spirituality. EB: Results from a recent study revealed that African American young adult males connected and identified with spirituality as a strong form of coping (Page, 2009).

• Determine how the family’s cultural context impacts their decisions in regard to managing and coping with a child’s illness. Recognize and validate the cultural context. EBN: Nurses and other clinicians working with families must include cultural variables when assisting family members with ill children. Demonstrating competency and respect for one’s cultural values helps ensure the good of the patient, as well as patient autonomy (Leever, 2011).

• The interventions described previously may be adapted for home care use.

• Assess the reason behind the breakdown of family coping. Knowledge of the reasons behind compromised coping will assist in identification of appropriate interventions. Refer to the care plan for Caregiver Role Strain.

• During the time of compromised coping, increase visits to ensure the safety of the client, support of the family, and assistance with coping strategies. Provide reassurance regarding expectations for prognosis as appropriate. EBN: Caregivers of heart failure clients require adequate support to help them cope effectively with burden, stress, and poor health outcomes (Pressler et al, 2009).

 Assess the needs of the caregiver in the home. Intervene to meet needs as appropriate, and explore all available resources that may be used to provide adequate home care (e.g., parish nursing as an effective adjunct, home health aide services to relieve the caregiver’s fatigue). Encourage caregivers to attend to their own physical, mental, and spiritual health and give more specific information about the client’s needs and ways to meet them. Meeting the needs of caregivers supports their ability to meet the needs of the client. Assess the client and caregiver separately and in interaction. EBN: Caregivers of individuals with heart failure report poor physical and emotional health. Physical health conditions of the caregivers and the perceived difficulty of caregiving procedures predicted physical health-related quality of life. Depressive symptoms reported by the caregiver were predictors of emotional health-related quality of life. Caregivers of individuals with heart failure may be a vulnerable population of caregivers requiring appropriate interventions and support for enhancing caregiver outcomes (Pressler et al, 2009).

 Refer the family to medical social services for evaluation and supportive counseling. Dedicating time for nurturing the caregivers and reassuring the client allows them to express feelings and feel hope (Dubus, 2010).

 Serve as an advocate, mentor, and role model for caregiving. Write down or contract for the care needed by the client. Therapeutic use of self by the nurse and concrete task definition and assignment reinforce positive coping strategies and allow caregivers to feel less guilty when tasks are delegated to multiple caregivers.

 When a terminal illness is the precipitating factor for ineffective coping, offer hospice services and support groups as possible resources. Nonjudgmental support from helpers with no agenda allows verbalization of feelings. The hospice paradigm addresses the physical, emotional, and spiritual needs of the dying and their family members. EBN: Research suggests that patients and their family members highly value hospice care services and report experiencing beneficial outcomes as a result of utilizing hospice services, including effective pain management, and avoiding death in the hospital setting (Candy et al, 2011).

• Encourage the client and family to discuss changes in daily functioning and routines created by the client’s illness. Validate discomfort resulting from changes. Individuals who live together for a long period tend to become familiar with each other’s patterns: meals are expected at certain times, a spouse becomes accustomed to the client’s sleep habits.

• Support positive individual and family coping efforts. Positive feedback reinforces desired behaviors and supports the family unit.

 If compromised family coping interferes with the ability to support the client’s treatment plan, refer for psychiatric home health care services for family counseling and implementation of a therapeutic regimen. EBN: Psychiatric home care nurses can address issues related to family members’ ability to adjust to changes in the client’s health status. Behavioral interventions in the home can help the family to participate more effectively in the treatment plan (Gaikwad & Warren, 2009).

• Provide truthful information and support for the family and significant people regarding the client’s specific illness or condition. Address grief issues that arise in the process, including anticipatory grief. EB: Family caregivers, especially spouses and adult children, of individuals with Alzheimer’s disease and other forms of dementia often experience anticipatory grief during the caregiving process. Assessing for this type of grief and providing appropriate support and interventions may help improve various aspects of caregiving (Frank, 2008).

 Refer women with breast cancer and their family caregivers to support groups and other services that provide assistance with daily coping. EBN: Many women require emotional, social, cognitive, and physical support following cancer, especially in instances of partial and total mastectomies (Skrzypulec et al, 2009).

• Promote individual and family relaxation and stress-reduction strategies. The immune system weakens in response to stress; persistent relaxation may elicit positive effects on one’s immune system (Kang et al, 2011).

 Provide a parent support and education group to provide opportunities for parents to access support, learn new parenting skills, and, ultimately, optimize their relationships with their children in families of children in residential care. EB: Parent support groups are increasingly utilized to help prevent various forms of child maltreatment. Positive results have been shown in regard to the parental functioning of those who participated in these support groups (Falconer et al, 2008).

• Siblings of sick children should be considered at-risk for emotional disturbances until a full assessment of the family and social support circumstances proves otherwise. EBN: Siblings of sick children frequently suffer from anxiety and depression. Socioeconomic status and parental stress are strong predictors of sibling outcomes (Obrien, Duffy, & Nicholl, 2009).

• Recognize predictors of anger in adolescents: anxiety, depression, exposure to violence, and trait anger. EBN: A meta-analytic study of predictors of anger in adolescents found these traits can forecast moderate to substantial effects in relation to anger (Mahon et al, 2010).

• Assess family members who are caring for clients in long-term care facilities for compassion fatigue: symptoms include the inability to disengage from the suffering of the loved one, a growing feeling of hopelessness or despair, sadness or grief, and inattention to personal care or outside responsibilities. Encourage family members to attend to their own physical, emotional, and social needs. Develop relationships of trust with family caregivers, providing them with a sense of confidence in the level of care their loved ones will be receiving in their absence. Promote therapeutic relationships with family members who are assisting with care, allowing for sharing of concerns and emotions. EBN: This study explored the effects of compassion fatigue in family members caring for loved ones in long-term care facilities, suggesting implications for nursing staff (Perry, 2010).

• Health care professionals working with African American adolescents who are coping with parental cancer should be sensitive to the potential for post-traumatic growth. EB: A qualitative study of African American youths found they are able to attain post-traumatic growth as early as age 11, following the experience of parental cancer. Previous studies of white adolescents found post-traumatic growth only in older adolescents. This study suggests the possibility of a cultural difference in coping abilities found among African American adolescents (Ma, Nino, & Jacobs, 2010).

• The interventions described previously may be adapted for home care use.

• Assess for strain in family caregivers. EBN: Utilizing a tool such as the Modified Caregiver Strain Index gives the nurse information about a caregiver’s abilities. It also could identify a need to evaluate the care recipient’s living situation (Onega, 2008).

 Provide psychosocial support to family members dealing with depressed or suicidal clients in the home setting. EBN: This qualitative study found that depressed or suicidal clients were frequently released to family care without adequate instruction and/or referral for psychosocial support for caregivers (Nosek, 2008).

• Involve the client and family in the planning of care as often as possible; mutual goal setting is considered part of “client safety.” Major changes in the fifth annual issuance of National Patient Safety Goals include home care, assisted living, and disease-specific care programs in 2009. An expectation is to “encourage patients” active involvement in their own care as a patient safety strategy” (TJC, 2009).

• Recognize that family decision-makers may need additional psychological support services. EBN: Family members directly responsible for health care decisions are most at risk for psychological stress (Hickman et al, 2010).

• Educate family members regarding stress management techniques including massage and alternative therapies. EBN: Education, support, psychotherapy, and respite interventions have demonstrated the greatest effect in reducing caregiver strain and burden. A significant decline was observed in the depression and anxiety scores of caregivers in the treatment group receiving massage therapy (Honea et al, 2008).

 Implement family-centered services for children and their caregivers. EBN: Family-centered interventions that individualized to specific needs can lead to higher levels of well-being and care adherence in pediatric settings (Tomlinson, Peden-McAlpine, & Sherman, 2012; Turan, Basbakkal, & Ozbek, 2008).

• Identify the management styles of families and facilitate the use of more effective ways of coping with childhood illness. EBN: Understanding the dominant characteristics of each family’s coping styles and resources and helping them to use more effective management styles can result in better family functioning and treatment outcomes (Conlon et al, 2008).

• Provide educational and supportive interventions for families caring for children with illness and disability. EB & EBN: Providing information, training parents in care management, and offering supportive programs can reduce stress levels in parents and lead to better outcomes for children (Barlow et al, 2008; Cummins, 2008).

• Encourage family caregivers to participate in counseling and support groups. EB & EBN: While a wide variety of programs exist, certain counseling and support group programs have been found to be effective in lowering caregiver burden and depression and decreasing family conflict (Gaugler et al, 2008; Nichols, Martindale-Adams, & Burns, 2011).

 Provide educational interventions to family caregivers that focus on knowledge- and skill-building. EBN: Psychoeducational interventions that are accessible and tailored to individual needs can be highly valued and useful to family caregivers (Coon & Evans, 2009).

 Older adults should be provided with opportunities to engage their families and their communities. EB: Programs that support and facilitate family interaction and intergenerational exchange can be important to the maintenance of family relationships (Dabelko-Schoeny, Anderson, & Spinks, 2010; Heyman & Guthreil, 2008).

• Acknowledge the importance of cultural influences in families and ensure that assessments and assessment tools account for such cultural differences. EBN: Culture may impact the fit, reliability, and validity of family functioning assessment tools (Aarons et al, 2008; Higginbottom et al, 2011).

 Understand and incorporate cultural differences into interventions to enhance the impact of nursing interventions. EBN: Tailoring interventions to the customs, beliefs, preferences, and strengths of specific groups may increase effectiveness (Song et al, 2009).