D

Client Will (Specify Time Frame)

• Observe for factors causing or contributing to conflict (e.g., value conflicts, fear of outcome, poor problem-solving skills). EB: When studying client-provider dyads, it was found that the more unclear one member’s expressed values, the greater their interpretation that the other member has made an ineffective choice, and this also correlated with both members experiencing personal uncertainty (Leblanc et al, 2009).

• Provide emotional support. EBN: Clients with values-sensitive health decisions frequently experience decisional conflict and require support (Stacey et al, 2008b).

• Give the client time and permission to express feelings associated with decision-making. EB: Decision aids in practice influence client trust in the clinician, which may be mediated through improvements in knowledge, reductions in decisional conflict, values clarification, and increased client participation in clinical decision-making (Nannenga et al, 2009).

 Use decision aids or computer-based decision aid to assist clients in making decisions. EB: Learning assessment tools are beneficial in optimizing family outcomes when it is evident that decisions will need to be made for children with life-limiting illnesses (Knapp et al, 2010). Online tutorials, computerized decision-support tools, workshops, and educational outreach can help to reduce parental decisional conflict related to place of care, place of death, and treatment regimens (Knapp et al, 2010).

 Initiate health teaching and referrals when needed. EB: Male cancer clients who viewed a computerized education tool about sperm banking before their cancer treatment had significantly less decisional conflict about banking sperm than those who had not viewed it (Huyghe et al, 2008). EBN: Nurses may provide support via helplines. They can provide decision support that helps callers in understanding cancer information, as well as assisting in the clarification of their values that were associated with their options, and ultimately reduced decisional conflict (Stacey et al, 2008).

• Facilitate communication between the client and family members regarding the final decision; offer support to the person actually making the decision. EB: Family/HIV-positive adolescent-centered advance care planning demonstrated improved communication quality and congruence as well as decreased decisional conflict. Adolescents who received the intervention reported feeling significantly better informed about end-of-life decisions. Families were more willing to engage in end-of-life discussions (Lyon et al, 2009).

• Provide detailed information on benefits and risks using functional terms and probabilities tailored to clinical risk, plus steps for considering the issues and means for making a decision, including values clarification and decision aids, when clients are faced with difficult treatment choices. EBN: A study of 176 post-menopausal women who were exposed to either the tailored decision support booklet or the standard North American Menopause Society Menopause Guidebook significantly increased their knowledge and decreased their decisional conflict and uncertainty about hormone therapy use (Becker, Stuifbergen, & Dormire, 2009).

Client Will (Specify Time Frame)

• Support and encourage clients and their representatives to engage in health care decisions. EB: In order to support meaningful decision-making for palliative care patients and their families, perceived risks must be acknowledged as factors that shape and constrain end-of-life choices (Wilson, Gott, & Ingleton, 2011).

• Respect personal preferences, values, needs, and rights. EB: “Denial of this right of autonomy and self-determination may worsen the individual’s physical and existential suffering” (Soriano & Lagman, 2012).

• Determine the degree of participation desired by the client. EB: “Ultimately, a patient must be able to understand the information given to him, evaluate the consequences of the options presented, deliberate on these options based on his values, communicate this choice, and maintain consistency overtime” (Soriano & Lagman, 2012).

• Provide information that is appropriate, relevant, and timely. EB: Use of a “labor decision aid” demonstrated an improvement in women’s labor analgesia knowledge. The group using the decision aid was more informed of analgesia options and considered the opinions of providers in making analgesia decisions and demonstrated improved informed decision making (Raynes-Greenow et al, 2010).

• Determine the health literacy of clients and their representatives prior to helping with decision-making. EB: Communication skills are crucial in shared decision-making, especially for clients with low literacy. Tailoring information and communication to clients’ individual needs is beneficial (Shaw et al, 2009).

• Tailor information to the specific needs of individual clients, according to principles of health literacy. EB: Tailored decision support information was effective in supporting adults with low levels of education in making informed choices and increased involvement in decisions about treatment for presence of fecal occult blood (Smith et al, 2010).

• Motivate clients to be as independent as possible in decision-making. EB: According to Smith et al (2010), clarifying to the participants that they have a choice about screening, informing them of the limitations of screening, and discussing how they value each outcome encouraged some participants to share or prefer to share the decision with their provider.

• Identify the client’s level of choice in decision-making. EB: Women’s expectations of the duration and level of pain suffered, quality of her caregiver support, and involvement in labor decision-making are the most commonly reported factors in birthing satisfaction (Raynes-Greenow et al, 2010).

• Focus on the positive aspects of decision-making, rather than decisional conflicts. EBN: Numerous studies conducted during development of the health promotion model show that promotion differs from prevention and requires a positive rather than negative approach (Pender, Murdaugh, & Parsons, 2011).

• Design educational interventions for decision support. EBN: Using specific educational and institutional interventions decreased barriers for Helpline nurses in providing decision support (Stacey et al, 2008).

• Provide clients with the benefits of decisions at the same time as helping them to identify strategies to reduce the barriers for healthful decisions. EB: This study demonstrated that attrition in programs for the prevention of mother-to-child-transmission of HIV was partially due to the attitude of the male partner toward involvement and a low participation rate, suggesting that external barriers play a large role in this decision-making process and that partners’ needs should be addressed more specifically when providing services (Theuring et al, 2009).

• Acknowledge the complexity of everyday self-care decisions related to self-management of chronic illnesses. EB: The results of this study demonstrated that individuals’ participation in day-to-day life is influenced by personal characteristics as well as the environment, and these influence a person’s decision to return to walking in the community after stroke (Corrigan & McBurney, 2008).

Client Will (Specify Time Frame)

• Assess the client’s and family’s understanding of the illness, the treatments, and expected outcomes. EBN: Effective communication between client and health care provider in relation to health promotion, disease prevention, and disease management is key to optimal health outcomes (Heinrich & Karner, 2011). EBN: It has been found that a significant number of older adults and/or their agents may not understand the client’s discharge instructions when released from the ED; this lack of information may have a negative effect on health outcomes (Hastings, Barrett, & Weinberger, 2011).

• Allow client time for adjustment to his/her situation. EBN: Health care providers could recognize and actively assist those clients who are unable to accept their disabilities by helping to develop effective modes of adjustment to their disease; especially in those recently diagnosed (Chao et al, 2010).

• Spend time with the client: listen and allow time for response. EB: Clinician-patient communication has been shown to be a determining factor in health outcomes (Street et al, 2009).

• Aid the client in making choices regarding treatment and actively involve him/her in the decision-making process. EB: A study of a current program that introduced nurse “care managers” into the primary health care system showed the program to be most effective in increasing patients’ cognition; self-management skills; and readiness to make changes in their health care decisions (Ciccone, Ambrogio, & Cortese, 2010).

• Explain the necessity of adherence to the prescribed treatment plan to promote feelings of wellness. EB: Health care professionals must be part of the solution to better adherence through communication and education (Scott & McClure, 2010).

• Allow the client to express and use denial as a coping mechanism if appropriate to treatment. EB: Denial in lung cancer patients may be an adaptive mechanism and must be respected by clinicians (Vos et al, 2010). EBN: To meet health requirements, assess the coping mechanism of denial of illness and support the client in examining/developing appropriate strategies in order to assist in their implementation of self-management (McGann, Sexton, & Chyun, 2008).

• Avoid confrontation and consider the client as an equal partner in health care. EBN: Current focus is on the person as the primary decision maker in his or her health care and is apropos in relation to the key concept of quality of life as defined by the person, or community and expressed in the nursing theory of Human Becoming (Marshall, Sahm, & McCarthy, 2012; Poirier, 2012).

• Support the client’s spiritual coping measures. EBN: The clinician should be aware of the religious methods of coping employed by terminally ill patients as they discuss prognosis and treatment (Phelps et al, 2009). It is suggested that unless clinicians recognize spirituality as an element of life, there is little chance that they will form an efficacious working relationship with their clients (Trevino & Pargament, 2008).

• Develop a trusting, therapeutic relationship with the client/family. EBN: Early interventions(i.e., routine family meetings) to address the ongoing needs of family members of—and patients with—chronic critical illnesses (CCI) is seen as instrumental in reducing the psychological impact of the patient’s ill health for the family and to incorporate their (patient’s and family’s) preferences into the plan of care (Hickman & Douglas, 2011).

 Assist the client in utilizing existing and additional sources of support. EBN: Health care providers should recognize the individual needs, including emotional, psychosocial, sexual, and relational, of those who suffer from chronic illness and provide suitable information and support—especially for those who are isolated from the mainstream (Spring et al, 2011). EBN: It is important for health care providers to identify and satisfy each patient’s unique situational needs; group education should be considered as an option (Ivarsson, Klefgard, & Nillsen, 2011).

• Refer to care plans Defensive Coping and Dysfunctional Family Processes.

Client Will (Specify Time Frame)

 Inspect oral cavity/teeth at least once daily and note any discoloration, presence of debris, amount of plaque buildup, presence of lesions such as white lesions or patches, edema, or bleeding, and intactness of teeth. Refer to a dentist or periodontist as appropriate. Systematic inspection can identify impending problems. White lesions are often leukoplakia, which is a precursor to squamous cell carcinoma. If the lesion is cancerous, prompt treatment is needed (Engelke & Pravikoff, 2010).

• If the client is free of bleeding disorders and is able to swallow, encourage the client to brush teeth with a soft toothbrush using fluoride-containing toothpaste at least two times per day. Do not use foam swabs or lemon glycerin swabs to clean the teeth. EB: Oral bacteria cause caries and periodontal disease. Plaque is a biofilm of bacteria, which often becomes contaminated with antibiotic-resistant bacteria in the hospitalized client (Roberts & Mullany, 2010). CEB: The toothbrush is the most important tool for oral care; toothbrushing is the most effective method of reducing plaque and controlling periodontal disease; a nursing study demonstrated that foam swabs are not effective in removing plaque (Pearson & Hutton, 2002). Lemon glycerin swabs dry the oral mucosa and can erode the tooth enamel (Foss-Durant & McAffee, 1997; Meurman et al, 1996; Poland, 1987). Inspect the gingiva for signs of gingivitis. Normally the gums should be pink and firm; gingivitis is likely when the gums are red and loose. Bleeding from the gums in an indication of gingivitis, and the client should see a dentist (Bissett, 2011).

• Encourage the client to floss the teeth at least once per day if free of a bleeding disorder, or if the client is unable, floss the teeth for the client. EB: A Cochrane review found that there is some evidence that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. Also, there is some evidence that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months (Sambunjak et al, 2011). Utilize a rotation-oscillation power toothbrush for removal of dental plaque. EB: Multiple studies have found a rotation-oscillation power toothbrush more effective than an ultrasonic toothbrush (Biesbrock, Walters, & Bartizek, 2008; He et al, 2008; Williams et al, 2008). A systematic review found that the powered toothbrush was safe to use on both hard and soft dental tissues (Robinson, 2011).

• Determine the client’s mental status and manual dexterity; if the client is unable to care for self, nursing personnel must provide dental hygiene. The nursing diagnosis Bathing/Hygiene Self-Care deficit is then applicable.

• If the client is unable to brush own teeth, follow this procedure:

Each client must receive oral care including toothbrushing two times every day to maintain healthy teeth and mouth, and to prevent complications associated with periodontitis (the advanced form of gum disease that can cause tooth loss), which is associated with health problems such as cardiovascular disease, stroke, and bacterial pneumonia (ADA, 2009).

• Monitor the client’s nutritional and fluid status to determine if adequate. Recommend the client eat a balanced diet and limit between-meal snacks. Poor nutrition predisposes clients to dental disease (ADA, 2009).

• Recommend the client stop or at least decrease intake of soft drinks. Sugar-containing soft drinks can cause cavities, and the low pH of the drink can cause erosion in teeth (ADA, 2009). EB: A study demonstrated a much higher incidence of caries in children who drank soft drinks, as well as increased intake of processed foods (Llena & Forner, 2008).

• Instruct the client with halitosis to clean the tongue when performing oral hygiene. Brush tongue with a tongue scraper or toothbrush and follow with a mouth rinse. EB: A Cochrane review found that tongue cleaning was effective for short-term control of halitosis (Van der Sleen et al, 2010).

• Determine the client’s usual method of oral care. Whenever possible, build on the client’s existing knowledge base and current practices to develop an individualized plan of care.

• Tell the client to direct the toothbrush at a 45-degree angle toward the tooth surfaces, not horizontally (ADA, 2009).

• Use an antimicrobial mouthwash as ordered or tap water or saline only for a mouth rinse. Avoid the use of hydrogen peroxide, or alcohol-based mouthwashes. Some antimicrobial mouthwashes have demonstrated effective action in decreasing bacterial counts in plaque and decreasing gingivitis (ADA, 2009). CEB: Hydrogen peroxide can cause mucosal damage and is extremely foul tasting to clients (Tombes & Gallucci, 1993).

 Recommend client see a dentist at prescribed intervals, generally two times per year if teeth are in satisfactory condition. It is important to see a dentist at regular intervals for preventive dental care (ADA, 2009).

 If there are any signs of bleeding when the teeth are brushed, refer the client to a dentist or, if obvious signs of inflamed gums, a periodontist. Bleeding along with halitosis is associated with gingivitis. Beginning gingivitis can often be reversed with good oral hygiene; with more advanced cases a periodontist may be needed to correct the condition. If platelet numbers are decreased, or if the client is edentulous, use moistened Toothettes or a specially made very soft toothbrush for oral care. A regular toothbrush can cause soft tissue injury and bleeding in clients with low numbers of platelets.

• Recognize that good dental care/oral care can be effective in preventing hospital acquired (or extended care acquired) pneumonia. CEB & EB: Many references have found that dental/oral care was effective in preventing new onset of pneumonia (Arpin, 2009; Ishikawa et al 2008; Sarin et al, 2007).

• Provide scrupulous dental care to critically ill clients, including ventilated clients to prevent ventilator-associated pneumonia. EB & EBN: Numerous studies have demonstrated decreased incidence of ventilator-associated pneumonia with good oral care (Fields, 2008; Panchabhai et al, 2009).

• If teeth are nonfunctional for chewing, modification of oral intake (e.g., edentulous diet, soft diet) may be necessary. The nursing diagnosis Imbalanced Nutrition: less than body requirements may apply.

• If the client is unable to swallow, keep suction nearby when providing oral care.

• See care plan for Impaired Oral Mucous Membrane.

Pregnant Client

Infant Oral Hygiene

Older Children

Prenatal

Economically disadvantaged; endocrine disorders; genetic disorders; illiteracy; inadequate nutrition; inadequate prenatal care; infections; lack of prenatal care; late prenatal care; maternal age <15 years; maternal age >35 years; substance abuse; unplanned pregnancy; unwanted pregnancy

Individual

Adopted child; behavior disorders; brain damage (e.g., hemorrhage in postnatal period, shaken baby, abuse, accident); chronic illness; congenital disorders; failure to thrive; foster child; frequent otitis media; genetic disorders; hearing impairment; inadequate nutrition; lead poisoning; natural disasters; positive drug screen(s); prematurity; seizures; substance abuse; technology-dependent; treatment-related side effects (e.g., chemotherapy, radiation therapy, radiation therapy, pharmaceutical agents); vision impairment

Environmental

Economically disadvantaged; violence

Caregiver

Abuse; learning disabilities; mental illness; severe learning disability

Client/Parents/Primary Caregiver Will (Specify Time Frame)

Preconception/Pregnancy

Neonate/Infant

Toddler/Preschooler/School-age

Psychological

Anxiety; high stress levels

Situational

Adverse effects of pharmaceuticals; alcohol abuse; contaminants; travel; laxative abuse; radiation; toxins; tube feedings

Physiological

Infectious processes; inflammation; irritation; malabsorption; parasites

Client Will (Specify Time Frame)

• Assess pattern of defecation, or have the client keep a diary that includes the following: time of day defecation occurs; usual stimulus for defecation; consistency, amount, and frequency of stool; type of, amount of, and time food consumed; fluid intake; history of bowel habits and laxative use; diet; exercise patterns; obstetrical/gynecological, medical, and surgical histories; medications; alterations in perianal sensations; and present bowel regimen. Assessment of defecation pattern will help direct treatment. Nurses are important in the early recognition, diagnosis, and prompt treatment if clients have C. difficile. Recognition can prevent life-threatening complications such as colitis, toxic megacolon, perforations, and sepsis (Keske & Letizia, 2010).

• Recommend use of standardized tool both to consistently assess and then treat diarrhea. Stool classification systems include the Hart and Dobb Diarrhea Scale, the Guenther and Sweed Stool Output Assessment Tool, and the Bristol Stool scale (Kyle, 2007; Sabol & Carlson, 2007). EBN: One such tool, the Diarrhea Assessment and Treatment Tool, when used in a oncology institution, resulted in positive outcomes for clients (Bisanz et al, 2010).

• Inspect, auscultate, palpate, and percuss the abdomen in that order. Expect increased frequency of bowel sounds with diarrhea (Jarvis, 2012).

 Use an evidence-based bowel management protocol which includes obtaining a stool specimen, immediate cessation of any ordered laxative, use of soluble fiber supplement, and if continued diarrhea, use of loperamide. Consistently monitor and report bowel activity during this time. CEB: After the protocol was implemented, diarrhea was decreased in an Australian ICU setting with fewer ICU day occurrences of diarrhea (Ferrie & East, 2007).

 Identify cause of diarrhea if possible based on history (e.g., rotavirus or norovirus exposure; HIV infection; food poisoning; medication effect; radiation therapy; protein malnutrition; laxative abuse; stress). See Related Factors (r/t). Identification of the underlying cause is important, because the treatment often is determined based on the cause of diarrhea.

 Recognize that a workup for diarrhea will consist of laboratory work such as a complete blood count with differential and blood cultures if the client is febrile. Also obtain stool specimens as ordered, to either rule out or diagnose an infectious process (e.g., ova and parasites, C. difficile infection, bacterial cultures for food poisoning). The three most commonly used diagnostic test for C. difficile include stool cytotoxic assay, enzyme-linked immunosorbent assay (ELISA), and stool culture, with the assay considered the gold standard (Keske & Letizia, 2010).

 If the client has watery diarrhea, a low-grade fever, abdominal cramps, and a history of antibiotic therapy, especially clindamycin, cephalosporins, and fluoroquinoline antibiotics, consider possibility of C. difficile infection. C. difficile infections have become common because of the frequent use of broad-spectrum antibiotics, and now there is a hypervirulent form of C. difficile causing increased morbidity and mortality (Gravel et al, 2009; Makic et al, 2011). Antibiotics can change normal gut flora, allowing proliferation of C. difficile and causing antibiotic-associated diarrhea and colitis (Higginson, 2009).

• Review other factors such as increased age, extended use of enteral feedings, and gastrointestinal procedures and surgeries that increase the risk of diarrhea (Keske & Letizia, 2010).

• Use standard precautions when caring for clients with diarrhea to prevent spread of infectious diarrhea; use gloves and handwashing. C. difficile and viruses causing diarrhea have been shown to be highly contagious. C. difficile is difficult to eradicate because of spore formation (Keske & Letizia, 2010). CEB & EB: A review of client care related to C. difficile summarizes care to include contact isolation, soap and water handwashing (alcohol rubs are not effective), use of disposable equipment, and environmental room decontamination (Makic, 2011). A medical review of prevention of spread of C. difficile recommended additional guidelines of avoiding rectal temperatures, placing clients in private rooms, and using full barrier precautions (Dubberke et al, 2008). Bacterial spores, such as C. difficile, are not destroyed by alcohol, chlorhexidine, or triclosan products. Even vigorous handwashing is minimally effective. Vegetative cells of C. difficile can survive for at least 24 hours on inanimate surfaces, and spores can survive for months on objects such as toilets, sinks, and bed rails (Keske & Letizia, 2010; Makic, 2011).

 If the client has diarrhea associated with antibiotic therapy, consult with the primary care practitioner regarding the use of probiotics, such as yogurt with active cultures, to treat diarrhea, or probiotic dietary supplements; or preferably use probiotics to prevent diarrhea when first beginning antibiotic therapy. EB: Probiotics have been shown to be helpful to prevent antibiotic-associated diarrhea in some clients (Guarino, Lo Vecchio, & Canani, 2009). Probiotics are used in an attempt to balance intestinal flora and restrict the colonization of C. difficile (Keske & Letizia, 2010; Rohde, Bartolini, & Jones, 2009).

 If a probiotic is ordered, administer it with food. Recommend that it be taken through the antibiotic course and 10 to 14 days after it has finished. Food tends to buffer the stomach acids, allowing more of the probiotic ingredients to pass through the stomach for absorption in the intestines. Beginning this therapy early helps to prevent antibiotic-associated diarrhea (Koivula, 2010).

 Recognize that C. difficile can commonly recur after treatment, and that reculturing of stool should be done before initiating retreatment. High reinfection rates up to 12% to 24% have been reported within the first 2 months of initial diagnosis if symptoms do recur (Keske & Letizia, 2010).

• Ask the client to examine intake of high fructose corn syrup and fructose sweeteners in relation to onset of diarrhea symptoms. If diarrhea is associated with fructose ingestion, intake should be limited or eliminated. CEB: High fructose corn syrup or fructose sweeteners from fruit juices can cause gastrointestinal symptoms of bloating, rumbling, flatulence, and diarrhea at amounts of 25 to 50 g. Malabsorption is demonstrated in clients after 25 g fructose, and most clients develop symptoms with 50 g fructose (Beyer, Caviar, & McCallum, 2005).

 If the client has infectious diarrhea, consider avoiding use of medications that slow peristalsis. If an infectious process is occurring, such as C. difficile infection or food poisoning, medication to slow peristalsis should generally not be given. The increase in gut motility helps eliminate the causative factor, and use of antidiarrheal medication could result in a toxic megacolon (Sunenshine & McDonald, 2006).

• Assess for dehydration by observing skin turgor over sternum and inspecting for longitudinal furrows of the tongue. Watch for excessive thirst, fever, dizziness, lightheadedness, palpitations, excessive cramping, bloody stools, hypotension, and symptoms of shock. Severe diarrhea can cause deficient fluid volume with extreme weakness and a possible shock state (Higginson, 2009; Thorson, Bliss, & Savik, 2008).

 Refer to the care plans Deficient Fluid Volume and Risk for Electrolyte Imbalance if appropriate.

 If the client has chronic diarrhea causing fecal incontinence at intervals, consider suggesting use of dietary fiber from psyllium or gum arabic after consultation with primary practitioner. CEB: Use of a fiber supplement decreases the number of incontinent stools and improves stool consistency (Bliss et al, 2001). Soluble dietary fiber is useful for controlling diarrhea and normalizing the intestinal flora (Nakao et al, 2002).

 If diarrhea is chronic and there is evidence of malnutrition, consult with primary care practitioner for a dietary consult and possible use of a hydrolyzed formula (a clear liquid supplement containing increased protein and calories) such as Ensure Alive, Resource Breeze Fruit Beverage, or Citrotein (Lutz & Przytulski, 2010) to maintain nutrition while the gastrointestinal system heals.

• Encourage the client to eat small, frequent meals, eating foods that are easy to digest at first (e.g., bananas, crackers, pretzels, rice, potatoes, clear soups, applesauce), but switch to a regular diet as soon as tolerated. Also recommend avoiding milk products, foods high in fiber, and caffeine (dark sodas, tea, coffee, chocolate). The BRAT diet has been traditionally recommended but is nutritionally incomplete and should be avoided (Shapiro et al, 2010).

• Provide a readily available bathroom, commode, or bedpan.

• Thoroughly cleanse and dry the perianal and perineal skin daily and as needed (PRN) using a cleanser capable of stool removal. Refer to perirectal skin care in the care plan Bowel Incontinence.

 If the client has enteral tube feedings and diarrhea, consider infusion rate, position of feeding tube, tonicity of formula, possible formula contamination, and excessive intake of hyperosmolar medications, such as sorbitol commonly found in the liquid version of medications (Makic, 2011). Consider changing the formula to a lower osmolarity, lactose-free, or high-fiber feeding. Determination of the cause of diarrhea should include an abdominal examination, fecal leukocytes, quantification of stool, stool culture for C. difficile (and/or toxin assay), serum electrolyte panel, and review of medications (Guenter, 2010). EBN: A significant relationship was found between diarrhea, duration of enteral tube feedings, glucose control, albumin and white cell counts (Jack et al, 2010).

• Do not administer bolus enteral feedings into the small bowel. The stomach has a larger capacity for large fluid volumes, whereas the small bowel can usually only tolerate up to 150 mL/hr (Sabol & Carlson, 2007).

 Dilute liquid medications before administration through the enteral tube and flush the enteral feeding tube with sufficient water before and after medication administration. Since many liquid medications contain sorbitol or are hyperosmotic, diluting the medication may help decrease occurrence of diarrhea (Sabol & Carlson, 2007; Thorson, Bliss, & Savik, 2008).

• Teach clients with cancer the types of diarrhea they may encounter, emphasizing not only chemotherapy and radiation induced diarrhea, but also C. difficile, along with associated signs and symptoms, and treatments. C. difficile must be identified early in the cancer client because of their weakened immune systems and difficulty with C. difficile infection treatment (Winkeljohn, 2010).

 For chemotherapy induced diarrhea (CID) and radiation induced diarrhea (RID), review rationale for pharmacological interventions selected such as loperamide and octreotide, along with soluble fiber and probiotic supplements. Consult a registered dietitian to assist with recommendations to alleviate diarrhea, decrease dehydration, and maintain nutritional status. EBN: Both CID and RID can occur as often a or more than 50% of the time, dependent on the chemotherapy regimen or if it is in combination with radiation (Muehlbauer et al, 2009; Visich & Pluth, 2010).

Client Will (Specify Time Frame)

• When client’s condition is stable, screen for mobility skills in the following order: (1) bed mobility; (2) supported and unsupported sitting; (3) transition movements such as sit to stand, sitting down, and transfers; and (4) standing and walking activities. Use a tool such as the Assessment Criteria and Care Plan for Safe Patient Handling and Movement (Sedlak et al, 2009). EB: In healthy adults, muscle strength declines by 1% per day of strict bed rest (De Jonghe et al, 2009).

• Assess the level of assistance needed by the client and express in terms of amount of effort expended by the person assisting the client. The range is as follows: total assist, meaning client performs 0% to 25% of task and, if client requires the help of more than one caregiver, it is referred to as a dependent transfer; maximum assist, meaning client gives 25% of effort while caregiver performs majority of the work; moderate assist, meaning client gives 50% of effort; minimal assist, meaning client gives 75% of effort; contact guard assist, meaning no physical assist is given but caregiver is physically touching client for steadying, guiding, or in case of loss of balance; stand by assist, meaning caregiver’s hands are up and ready in case needed; supervision, meaning supervision of task is needed even if at a distance; modified independent, meaning client needs assistive device or extra time to accomplish task; and independent, meaning client is able to complete task safely without instruction or assistance. EB & CEB: There are guideliness on how to determine the amount of care the client will need (Granger, 2011; Uniform Data System, 1997).

 Request a referral to a physical therapist as needed so that client’s range of motion, muscle strength, balance, coordination, and endurance can be part of the initial evaluation.

• Incorporate bed exercises such as flexing and extending feet and quadriceps or use of Thera-Bands for upper extremities into nursing care to help maintain muscle strength and tone (Koenig, Teixeira, & Yetzer, 2012).

 If not contraindicated by the client’s condition, obtain a referral to physical therapy for use of tilt table to help determine the cause of syncope. Use of the tilt table can help determine if the cause of syncope is autonomic or from another cause (Low & Engstrom, 2012).

• Perform range of motion exercises for all possible joints at least twice daily; perform passive or active range of motion exercises as appropriate. If not used, muscles weaken and shorten from fibrosis of the muscle (Wagner et al, 2008). EBN: Range of motion exercises are effective in maintaining joint mobility and muscle integrity (Gillis & MacDonald, 2008; Summers et al, 2009).

• Use specialized boots to prevent pressure ulcers on the heels and footdrop; remove boots twice daily to provide foot care. Boots hopefully help keep the foot in normal anatomical alignment to prevent footdrop and prevent pressure ulcer formation on the heel. EB: A Cochrane review found that there is not a good evidence base to determine which boots or pressure redistribution system is most effective in preventing heel pressure ulcers (McGinnis & Stubbs, 2011). EBN: A study found that use of a wedge-shaped viscoelastic bed-sized support surface was more effective than use of a pillow to prevent heel ulcers (Heyneman et al, 2009).

• When positioning a client on the side, tilt client 30 degrees or less while lying on side. Full (versus tilt) side-lying position places higher pressure on trochanter, predisposing to skin breakdown although more evidence is needed to fully determine the impact of full versus tilted positioning (van Rijswijk, 2009).

• Assess skin condition at least daily and more frequently if needed. Utilize a risk assessment tool such the Braden Scale or the Norton Scale to predict the risk of developing pressure ulcers. EBN: Use of a risk assessment tool is possibly effective to predict the risk of developing a pressure ulcer (Gillis & MacDonald, 2008). Refer to care plan for Risk for impaired Skin Integrity.

• Discuss with staff and management a “safe handling” policy that may include a “no lift” policy. Benefits of a safe handling policy include decreased injury to workers, increased safety and comfort for clients, decreased litigation related to injuries, and decreased lost work and wages due to injury, as well as decreased workers’ compensation claims (Nelson et al, 2008).

• Turn clients at high risk for pressure/shear/friction frequently. Turn clients at least every 2 to 4 hours on a pressure-reducing mattress/every 2 hours on standard foam mattress. These are general guidelines given for turning, but they do not have a good evidence base. Preferably base the turning schedule on close assessment of the client’s condition and predisposing conditions (Krapfl & Gray, 2008; van Rijswijk, 2009).

• Provide the client with a pressure-relieving horizontal support surface. For further interventions on skin care, refer to the care plan for Impaired Skin Integrity.

• Help the client out of bed as soon as able. Early mobilization reduces risk of atelectasis, pneumonia, venous thromboembolism (VTE) and pulmonary embolism, and decreases orthostatic hypotension (Summers et al, 2009) as well as reducing risk of skeletal muscle atrophy, joint contractures, insulin resistance, microvascular dysfunction, systemic inflammation, and pressure ulcers (Brower, 2009). Bed rest is almost always harmful to clients; early mobilization is better than bed rest for most health conditions (Perme & Chandrashekar, 2009).

• When getting the client up after bed rest, do so slowly and watch for signs of postural (orthostatic) hypotension, tachycardia, nausea, diaphoresis, or syncope. Take the blood pressure lying, sitting, and standing, waiting 2 minutes between each reading. Consequences of bed rest are increased systemic vascular resistance, muscle atrophy, joint contracture, thromboembolic disease, and insulin resistance as well as microvascular dysfunction (Brower, 2009). Suggest waist-high elastic hosiery such as an elastic “belly binder” and/or bilateral lower extremity ace wraps over TED hose to facilitate venous return if hypotension is an issue (McPhee & Papadakis, 2009).

• Obtain assistive devices such as braces, crutches, or canes to help the client reach and maintain as much mobility as possible. Assistive devices can help increase mobility (Yoem, Keller, & Fleury, 2009).

 Apply graduated compression stockings as ordered. Ensure proper fit by measuring accurately. Remove the stockings at least twice a day, in the morning with the bath and in the evening to assess the condition of the extremity, then reapply. Knee length is preferred rather than thigh length. EBN & EB: Effectiveness of knee-high compression stockings is equal to thigh-high compression stockings, and knee-high stockings are more comfortable and fit better, adding to client compliance as stockings are most effective when worn continuously during the at-risk period; on during day and off at night (Hilleren-Listerud, 2009; McCaffrey & Blum, 2009). The American College of Chest Physicians (ACCP, 2012) recommends pharmacological or mechanical prophylaxis such as the use of graduated compression stockings to reduce the incidence of venous thromboembolism in clients who have undergone high-risk orthopedic surgical procedures clients older than 70 years of age or are at high risk for VTE for multiple reasons (Kahn et al, 2012). Please refer to the ACCP guidelines for use of mechanical prophylaxis for specific client situations.

• Observe for signs of VTE, including pain, tenderness, and swelling in the calf and thigh. Also observe for new onset of breathlessness. Clients commonly complain of a cramp in their lower calf that persists and becomes more painful with time. Symptoms of existing deep vein thrombosis are nonspecific and cannot be used alone to determine the presence of VTE. New onset of breathlessness is commonly associated with development of a pulmonary embolism (Goldhaber, 2012).

• Have the client cough and deep breathe or use incentive spirometry every 2 hours while awake. Bed rest compromises breathing because of decreased chest expansion, decreased cilia activity, pooling of mucus, the effects of organ shift (such the diaphragm and heart as well as pressure on the esophagus when in the supine position) and leads to partial or complete atelectasis usually of the left lower lobe (Brower, 2009).

• Monitor respiratory functions, noting breath sounds and respiratory rate. Percuss for new onset of dullness in lungs.

• Note bowel function daily. Provide increased fluids, fiber, and natural laxatives such as prune juice as needed. Constipation is common in immobilized clients because of decreased activity and fluid and food intake. Refer to care plan Constipation.

• Increase fluid intake to 2000 mL/day within the client’s cardiac and renal reserve. Adequate fluids helps prevent kidney stones and constipation, both of which are associated with bed rest.

• Encourage intake of a balanced diet with adequate amounts of fiber and protein. Consider recommending Practical Interventions to Achieve Therapeutic Lifestyle Changes (TLC), which includes monounsaturated and polyunsaturated fats, oils, margarines, beans, peas, lentils, soy, skinless poultry, lean fish, trimmed cuts of meat, fat-free and low-fat daily foods, omega-3 polyunsaturated fat sources, and whole grains including soluble fiber sources such as oats, oat bran, and barley (Tucker, 2010).

Critical Care

Client Will (Specify Time Frame)

• Observe for signs of deficient diversional activity: restlessness, unhappy facial expression, and statements of boredom and discontent. EBN: In a study of residents living in long-term care in Turkey, 67% of the residents were diagnosed with deficient diversional activity (Güler et al, 2012).

• Observe ability to engage in activities that require good vision and use of hands. Diversional activities must be tailored to the client’s capabilities.

• Discuss activities with clients that are interesting and feasible in the present environment.

• Encourage the client to share feelings about situation of inactivity. Work and hobbies provide structure and continuity to life; the client may feel a sense of loss.

• Encourage the client to participate in any available social or recreational opportunities in the health care environment. EB: Resilience, which is defined as flourishing despite adversity, is promoted with quality relationships and integration into the community (Hildon et al, 2010). A creative art-making experience helped women with chronic disease develop increased satisfaction in daily life, a positive self-image, increased hope, and contact with the outside world (Reynolds, Vivat, & Prior, 2008).

• Encourage a mix of physical and mental activities if possible (e.g., crafts, crossword puzzles).

• Provide videos and/or DVDs of movies for recreation and distraction.

• Provide magazines of interest, books of interest.

• Provide books on CD and CD player, and electronic versions of books for listening or reading as available.

• Set up a puzzle in a community space, or provide individual puzzles as desired.

• Provide access to a portable computer so that the client can access email and the Internet. Give client a list of interesting websites, including games and directions on how to perform Web searches if needed.

• Help client find a support group for the appropriate condition on the Internet if interested. EBN: A study found that individuals dealing with low survival rate cancers desire online informational support (Buin & Whitten, 2011).

 Arrange animal-assisted therapy if desired, with a dog, cat, or bird for the client to interact with and care for, if possible. EBN: A study demonstrated decreased passivity and improved mood in extended care clients (Kawamura, Niiyama, & Niiyama, 2009). EB: Animal-assisted therapy has been associated with enhanced socialization, stress reduction, improvement in mood and well-being, a decrease in anxiety and loneliness, and the development of leisure and recreational skills (Munoz et al, 2011).

• Encourage the client to schedule visitors so that they are not all present at once or at inconvenient times. A schedule prevents the client from becoming exhausted from frequent company.

• If clients are able to write, help them keep journals or engage them in opportunities for creative writing in a group; if clients are unable to write, have them record thoughts on tape, or on videotape. EB: A professional writer led creative writing workshops for a small group of older women in a nursing home; these workshops provided enjoyment, promoted the development of personal relationships within the community, and allowed staff to gain deeper insight into the lives of the residents (Wilson et al, 2011).

 Request recreational or art therapist to assist with activities. EB: In a study of women with breast cancer who were undergoing radiation, those who participated in weekly art therapy experienced a significant improvement in physical and psychological health and quality of life (Svensk et al, 2009).

 Refer to occupational therapy. EB: Occupational therapists are able to assist persons with compensatory strategies to assist with activities (Arbesman & Lieberman, 2011).

• Provide a change in scenery; get the client out of the room as possible. A lack of sensory stimulation has significant adverse effects on clients.

• Help the client to experience nature through looking at a nature scene from a window, or walking through a garden if possible. Nature can have an important effect on health, well-being, and quality of life (Bossen, 2010).

• Structure the environment as needed to promote optimal comfort and sensory diversity (e.g., have family bring in posters, banners, or a sound system; change lighting; change direction bed faces). EBN: For hospitalized clients needing close observation, consider the use of a S.A.F.E. unit that uses trained “diversional partners” rather than sitters; diversional activities were promoted through the use of TVs and VCRs on rolling carts, radios and CD players with music from various genres, movies, rocking chairs, a storage cabinet stocked with games and art supplies, stuffed animals, soft balls, and towels for folding (Nadler-Moodie et al, 2009).

• Work with family to provide music that is enjoyable to the client. CEB: Music can help decrease anxiety in clients before surgery (Cooke et al, 2005), after surgery (Sendelbach et al, 2006), and in clients with an acute myocardial infarction (Winters, 2008). EB: Music played in a major mode as opposed to a minor mode induced an emotional response similar to happiness and decreased stress as evidenced by the reduction of cortisol levels (Miyuki et al, 2008).

• Structure the client’s schedule around personal wishes for time of care, relaxation, and participation in fun activities. Increased client control fosters increased client self-esteem.

• Spend time with the client when possible, giving the client full attention and being present in the moment, or arrange for a friendly visitor.