F

• Assess for the influence of cultural beliefs, norms, and values on the family’s or caregiver’s understanding of FTT. EBN: What the family considers normal and abnormal health behavior may be based on cultural perceptions (Giger & Davidhizar, 2008).

• Actively listen and be sensitive to how communication is shared culturally; some cultures combine communication with eye contact, and some avoid eye contact. EBN: Understanding cultural differences in communication will enhance understanding of interactions (Suh, Kagan, & Strumpf, 2009).

 Refer culturally diverse clients to appropriate social, medical, mental health, and spiritual services. EB: In a study of health care transitions of ethnically diverse older adults, assessments of informal care available, bilingual information and services, partnerships with culturally competent agencies, and expansion of services were recommendations for improving outcomes after hospital discharge (Graham, Ivey, & Neuhauser, 2009).

• Refer to a dietitian who can suggest the least restrictive diet that considers ethnic and cultural preferences. EB: Food selections are influenced by religious beliefs, ethnic values, and traditions (Dorner, Friedrich, & Posthauer, 2010).

• Promote participation in a community-based exercise program that focuses on strength, endurance, and balance. EB: Older African-Americans who had experienced falls and participated in an on-site exercise program demonstrated better adherence to the on-site classes than to the follow-up exercising at home (Stineman et al, 2011).

• The above interventions may be adapted for home care use.

• If FTT is attributable to a dementing illness, refer to care plan for Chronic Confusion.

 Institute case management or coordinated care of frail elders in the community. EB: Coordinated care of frail elders may decrease health care utilization (Eklund & Wilhelmson, 2009).

 Consider use of a nurse-managed telehealth system with clients who have been discharged early from the hospital to monitor symptoms, provide education, and make referrals if necessary. EBN: Videophones were useful in educating clients with Parkinson’s disease about complicated medication regimens (Fincher et al, 2009).

 Refer for medical evaluation when cognitive changes are noticed. EB: When signs of cognitive impairment are noted, the client should be referred for a diagnostic workup, including lab values to rule out other causes, depression screening and cognitive screening tests (Perry et al, 2010).

• Encourage family to provide and encourage social interaction with the client. EB: A decline in social activity is associated with a more rapid loss of motor function in older adults (Buchman et al, 2009).

• Instruct the family to monitor the elder person’s weight. EBN: Changes in weight may reflect challenges in maintaining homeostasis; monitoring for fluctuations, gains, and losses is an important aspect of care for the older adult (Arnold et al, 2010).

 Provide referral for evaluation of hearing and appropriate hearing aids. Even mild hearing loss can affect the ability to process speech when there is background noise or multiple speakers; this can lead to social isolation, depression, diminished cognitive function, and a decrease in quality of life (Shargorodsky et al, 2010).

 Refer for psychotherapy and possible medication if the etiology is depression. Geriatric depression is a common but frequently unrecognized or inadequately treated condition in the elderly population; it is more prevalent with stroke, hearing loss, vision loss, chronic cardiac and lung disease (Huang et al, 2010).

• Safety guidelines. Complete a fall-risk assessment for older adults in acute care using a valid and reliable tool such as the Hendrich II model. Recognize that risk factors for falling include recent history of falls, fear of falling, confusion, depression, altered elimination patterns, cardiovascular/respiratory disease impairing perfusion or oxygenation, postural hypotension, dizziness or vertigo, primary cancer diagnosis, and altered mobility (Gray-Miceli, 2008). The Hendrich II Fall Risk Model is quick to administer and provides a determination of risk for falling based on gender, mental and emotional status, symptoms of dizziness, and known categories of medications increasing risk (Hendrich, 2006). This tool screens for primary prevention of falls and is integral in a post-fall assessment for the secondary prevention of falls (Gray-Miceli, 2007).

• Screen all clients for balance and mobility skills (supine to sit, sitting supported and unsupported, sit to stand, standing, walking and turning around, transferring, stooping to floor and recovering, and sitting down). Use tools such as the Balance Scale by Tinetti or the Get Up and Go Scale. It is helpful to determine the client’s functional abilities and then plan for ways to improve problem areas or determine methods to ensure safety (Gray-Miceli, 2008).

• Recognize that when people attend to another task while walking, such as carrying a cup of water, clothing, or supplies, they are more likely to fall. CEB: Those who slow down when given a carrying task are at a higher risk for subsequent falls (Lundin-Olsson, Nysberg, & Gustafson, 1998).

• Carefully assist a mostly immobile client up. Be sure to lock the bed and wheelchair and have sufficient personnel to protect the client from falls. When rising from a lying position, have the client change positions slowly, dangle legs, and stand next to the bed prior to walking to prevent orthostatic hypotension.

• Use a “high-risk fall” armband/bracelet and fall risk room sign to alert staff for increased vigilance and mobility assistance. These steps alert the nursing staff of the increased risk of falls (Gray-Miceli & Quigley, 2011).

 Evaluate the client’s medications to determine whether medications increase the risk of falling; consult with physician regarding the client’s need for medication if appropriate. Polypharmacy, or taking more than four medications, has been associated with increased falls. Medications such as benzodiazepines, antidepressants, neuroleptics, sedatives and hypnotics, antiarrhythmics, and diuretics increase risk for falls (Gray-Miceli & Quigley, 2011). EB: Short- to intermediate-acting benzodiazepine and tricyclic antidepressants may produce ataxia, impaired psychomotor function, syncope, and additional falls (Fick et al, 2003). Side effects of these medications include drowsiness, confusion, loss of balance, orthostatic hypotension (Gray-Miceli & Quigley, 2011).

• Orient the client to environment. Place the call light within reach and show how to call for assistance; answer call light promptly.

• Use one quarter- to one half-length side rails only, and maintain bed in a low position. Ensure that wheels are locked on bed and commode. Keep dim light in room at night. CEB: Use of full side rails can result in the client climbing over the rails, leading with the head, and sustaining a head injury. Side rails with widely spaced vertical bars and side rails not situated flush with the mattress have been associated with asphyxiation deaths because of rail and in bed entrapment and should not be used (Capezuti et al, 2002).

• Routinely assist the client with toileting on his or her own schedule. Always take the client to bathroom on awakening and before bedtime. Keep the path to the bathroom clear, label the bathroom, and leave the door open. EBN: A study found that falls were most commonly associated with toileting, especially falling on the way from bed or chair to the bathroom (Tzeng, 2010).

 Avoid use of restraints if at all possible. Obtain a physician’s order if restraints are deemed necessary, and use the least restrictive device. The use of restraints has been associated with serious injuries including rhabdomyolysis, brachial plexus injury, neuropathy, and dysrhythmias, as well as strangulation, asphyxiation, traumatic brain injuries, and all the consequences of immobility (Evans & Cotter, 2008). CEB & EB: A study demonstrated that there was no increase in falls or injuries in a group of clients who were not restrained, versus a similar group that was restrained in a nursing home (Capezuti et al, 1999, 2002). A study in two acute care hospitals demonstrated that when restraints were not used, there was no increase in client falls, injuries, or therapy disruptions (Mion et al, 2001). EBN: A large study of hospitalized clients demonstrated that use of restraints was associated with an increase in the rate of falling of two or more times, compared with those who did not receive restraints (Titler et al, 2011).

• In place of restraints, use the following:

These alternatives to restraints can be helpful to prevent falls (Cotter & Evans, 2012).

• If the client has an acute change in mental status (delirium), recognize that the cause is usually physiological and is a medical emergency. Consider possible causes for delirium. Consult with the physician or health care provider immediately. Note: See Fick and Mion (2007); Flanagan and Fick (2010). See interventions for Acute Confusion.

• If the client has chronic confusion due to dementia, implement individualized strategies to enhance communication. Assessment of specific receptive and expressive language abilities is needed in order to understand the client’s communication difficulties and facilitate communication. NOTE: See interventions for Chronic Confusion. See Flanagan and Fick (2010).

• Ask family to stay with the client to assist with ADLs and prevent the client from accidentally falling or pulling out tubes.

 If the client is unsteady on feet, have two nursing staff members alongside when walking the client. Consider referral to physical therapy for gait training and strengthening. The client can walk independently, but the nurse can rapidly ensure safety if the knees buckle. Interdisciplinary care is most comprehensive and beneficial to the client.

• Place a fall-prone client in a room that is near the nurses’ station. Such placement allows more frequent observation of the client.

 Refer to physical therapy or other programs for exercise programs that target strength, balance, flexibility, or endurance. EB: Programs with at least two of these components have been shown to decrease the rate of falling and number of people falling (Gillespie et al, 2009).

• Assess fall risk using a falls risk assessment tool such as the Hendrich II Fall Risk Model, Stratify Tool, or Morse Falls Scale. These falls risk assessment tools have predictive properties for anticipated physiological falls (Gray-Miceli & Quigley, 2011).

• Complete a post-fall assessment for older adults. This is integral for the secondary prevention of falls (Gray-Miceli & Quigley, 2011).

 If new onset of falling, assess for lab abnormalities, and signs and symptoms of infection and dehydration, and check blood pressure and pulse rate supine, sitting, and standing for hypotension and orthostatic hypotension. If the client has a borderline high blood pressure, the risk of falling due to administration of antihypertensives may outweigh the benefits of the antihypertensive medication. Discuss with the health care provider on a client-to-client basis. If orthostatic hypotension is present and there is minimal change in the heart rate, most likely the baroreceptors are not working to maintain blood pressure on arising. This is common in the elderly and may be caused by hypovolemia resulting from the excessive use of diuretics, vasodilators, or other types of drugs; dehydration; or prolonged bed rest as well as cardiovascular disease, neurological disease, or another medication’s adverse effect (NINDS, 2007). Insertion of a pacemaker can reduce falls in people with frequent falls associated with carotid sinus hypersensitivity, a condition that may cause changes in heart rate and blood pressure (Gillespie, 2009).

• Complete a fear of falling assessment for older adults. This includes measuring fear of falling, or the level of concern about falling, and falls self-efficacy, the degree of confidence a person has in performing common activities of daily living without falling. Fear of falling may be measured by a single item question asking about the presence of fear of falling or rating severity of fear of falling on a 1-4 Likert scale as is commonly done in studies. Falls self-efficacy may be measured using a valid and reliable tool such as the Falls Efficacy Scale-International (Greenberg, 2011; Yardley et al, 2005).

• Encourage the client to wear glasses and use walking aids when ambulating.

• If the client experiences dizziness because of orthostatic hypotension when getting up, teach methods to decrease dizziness, such as rising slowly, remaining seated several minutes before standing, flexing feet upward several times while sitting, sitting down immediately if feeling dizzy, and trying to have someone present when standing. CEB: Always have the client dangle at the bedside before trying standing to evaluate for postural hypotension. Watch the client closely for dizziness during increased activity. Postural hypotension can be detected in up to 30% of elderly clients. These methods can help prevent falls as well as maintain adequate fluid intake (Tinetti, 2003).

 Refer to physical therapy for strength training, using free weights or machines, and suggest participation in exercise programs. Exercise can prevent falls in older people. Greater relative effects are seen in programs that include exercises that challenge balance, use a higher dose of exercise, and do not include a walking program. Service providers can use these findings to design and implement exercise programs for falls prevention (AGS, 2011).

 Implement evidence-based interventions to prevent falls. These include:

• Some of the above interventions may be adapted for home care use.

• Implement evidence-based fall prevention practices to older adults in community settings and home health care programs (Fortinsky et al, 2008).

 If delirium is present, assess for cause of delirium and/or falls with the use of an interdisciplinary team. Consult with the physician immediately. Assess and monitor for acute changes in cognition and behavior. An acute and fluctuating change in cognition and behavior is the classic presentation of delirium. Delirium is reversible and should be considered a medical emergency. Delirium can become chronic if untreated, and clients may be discharged from hospitals to home care in states of undiagnosed delirium. EBN: Falls may be a precipitating event consistent with acute confusion (Gray-Miceli & Quigley, 2011).

• Assess home environment for threats to safety including clutter, slippery floors, scatter rugs, and other potential hazards. Additionally, assess external environment (e.g., uneven pavement, unleveled stairs/steps). CEB: Clients suffering from impaired mobility, impaired visual acuity, and neurological dysfunction, including dementia and other cognitive functional deficits, are at risk for injury from common hazards. These recommendations were shown to be effective to reduce falls (Tinetti, 2003).

 Instruct the client and family or caregivers on how to correct identified hazards for those with visual impairment. Refer to physical and occupational therapy services for assistance if needed. EB: Interventions to improve home safety were shown to be effective in people at high risk, such as those with severe visual impairment (Gillespie et al, 2009).

 Use a multifactorial assessment along with interventions targeted to the identified risk factors. Key components of the interventions include evaluating need for all medications; balance, gait and strength training; use of strategies to deal with postural hypotension, if present; home safety evaluation with needed modifications; and any needed cardiovascular treatment. EB: As people age, they may fall more often for a multiple of reasons including problems with balance, poor vision, and dementia. Fear of falling can result in self-restricted activity levels (Gillespie et al, 2009).

• Encourage the client to eat a balanced diet, with particular inclusion of vitamin D and calcium. Vitamin D deficiency and hypocalcemia are common in older adults, contributing to falls, musculoskeletal complaints, and functional and mobility deficits. Results show that vitamin D and calcium were superior to calcium supplementation alone in regard to fall prevention, musculoskeletal function, and bone metabolism, especially in recurrent falls and frail, older women with vitamin D deficiency (Bischoff et al, 2003). Older adults with unexplained falls, pain, and gait imbalance may have osteomalacia due to vitamin D deficiency (Dharmarajan, 2005).

• If the client lives alone or spends a lot of time alone, teach the client what to do if he or she falls and cannot get up, and suggest he or she have a personal emergency response system or a mobile phone that is available from the floor. CEB: If the client is at risk for falls, use gait belt and additional persons when ambulating. Gait belts decrease the risk of falls during ambulation (Tinetti, 2003). EBN: Be aware that clients may react ambivalently to a personal emergency response system. A study showed that while the system alleviated some anxiety about ability to receive help, concern was also expressed about being shocked by hearing strangers enter the home (Porter, 2003).

• Ensure appropriate nonglare lighting in the home. Ask the client to install indoor strip or “runway” type of lighting to baseboards to help clients vision. Install motion-sensitive lighting that turns on automatically when the client gets out of bed to go to the bathroom.

• Have the client wear supportive, low-heeled shoes with good traction when ambulating. Avoid use of slip-on footwear. Wear appropriate footwear in inclement weather. Supportive shoes provide the client with better balance and protect the client from instability on uneven surfaces. Antislip shoe devices worn in icy conditions have been shown to reduce falls (Gillespie et al, 2009).

• Provide a signaling device for clients who wander or are at risk for falls. Orienting a vulnerable client to a safety net relieves anxiety of the client and caregiver and allows for rapid response to a crisis situation.

• Provide medical identification bracelet for clients at risk for injury from dementia, diabetes, seizures, or other medical disorders.

• Suggest a tai chi class designed for the elderly to selected clients who have sufficient balance to participate. EB: Participation in tai chi classes may prevent falls in relatively healthy community-dwelling older people (AGS, 2011).

• Safety guidelines. Teach the client and the family about the fall reduction measures that are being used to prevent falls (TJC, 2009).

• Teach the client how to safely ambulate at home, including using safety measures such as hand rails in bathroom, and need to avoid carrying things or performing other tasks while walking. Safe use of walking aids and assistive devices is crucial to safety and prevention of future falls (Gray-Miceli & Quigley, 2011).

• Teach the client the importance of maintaining a regular exercise program. If the client is afraid of falling while walking outside, suggest he or she walk the length of a local mall. Exercise can prevent falls in older people. Greater relative effects are seen in programs that include exercises that challenge balance and use a higher dose of exercise than just walking programs (AGS, 2011).

• Use closed-ended questions when questioning adolescents about drinking behavior. Student reports of specific beverage type use were higher when using closed-ended questions compared with open-ended questions. The adolescent drinking amount self-reports seem reasonably reliable and valid both on a population and individual level (Lintonen, Ahlstro, & Metso, 2004).

• Provide a brief motivational interviewing and cognitive-behavioral–based alcohol intervention group program for young people at risk of developing a problem with alcohol. EB: Participants showed an increase in readiness to reduce their alcohol consumption and a reduction in their frequency of drinking at post treatment and the first follow-up assessment (Bailey et al, 2004).

• Encourage parent communication about alcohol use with adolescents. EB: Findings from the current study indicate parent-adolescent communication has been identified as important in delaying the onset and escalation of alcohol use (Abar, Fernandez, & Wood, 2011).

 Consider the Community Reinforcement Approach (CRA) that encourages clients to become progressively involved in alternative nonsubstance-related pleasant social activities, and to work on enhancing the enjoyment they receive within the “community” of their family and job. EB: CRA, originally developed for individuals with alcohol use disorders, has been successfully employed to treat a variety of substance use disorders for more than 35 years. Based on operant conditioning, CRA helps adolescents rearrange their lifestyles so that healthy, drug-free living becomes rewarding and thereby competes with alcohol and drug use (Meyers, Roozen, & Smith, 2010).

 Educate family members about available educational and support programs and encourage no/limited alcohol use in the home. EBN: Both individual and multiperson interventions exert an influential role in family-based therapy for treatment of adolescent drug abuse (Hoque et al, 2006).

• Work at strengthening adolescents’ relationships in and out of the home. Prevention interventions focusing on increasing socially conforming attitudes and on strengthening relationships both in and out of the home during adolescence are likely to be effective in reducing aspects of alcohol involvement for women in the general community (Locke & Newcomb, 2004).

• Provide school-based prevention programs using peer leaders at an early age. EB: Targeting middle school–aged children and designing programs that can be delivered primarily by peer leaders will increase the effectiveness of school-based substance-use prevention programs (Gottfredson & Wilson, 2003).

• Provide a school-based drug-prevention program to junior high students. EB: Students who received the drug-prevention program during junior high school were less likely to have violations and points on their driving records (Warner, White, & Johnson, 2007).

• Include assessment of possible alcohol abuse when assessing elderly family members. EB: Alcohol abuse and dependence in older people are important problems that frequently remain undetected by health services (Beullens & Aertgeerts, 2004). The majority of elderly alcoholics are married, have low education levels, and do not belong to high social classes (Shahpesandy et al, 2006).

 Provide alcohol treatment programs for geriatric clients in primary care settings. EB: Older primary care clients were more likely to accept collaborative mental health treatment within primary care than in mental health/substance abuse clinics. These results suggest that integrated service arrangements improve access to mental health and substance abuse services for older adults who underuse these services (Bartels et al, 2004).

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

• Use a family-centered approach when working with Latino, Asian American, African American, and Native American clients. EBN: American Indian families may be extended structures that could exert powerful influences over functioning (Kopera-Frye, 2009). Family therapy is important in addressing the needs of Hispanic families with adolescent substance abusers (Kopera-Frye, 2009). EBN: Involve the entire family structure in working through the problem. This is essential because some Asian-American families are perceived as patriarchal. For example, Sue (2004) described the family lifestyle of Chinese and Japanese Americans as patriarchal, with authority and communication exercised from the top down. Sue (2004) also noted that within these families there is a need for interdependent roles, strict adherence to traditional norms, and minimization of conflict by suppression of overt emotion.

• Some less-acculturated Latino families may be unwilling to discuss family issues with health care providers until they perceive a close personal relationship with the provider. EBN: Some Latino families may believe that personal problems should be kept private and may not respond to the health care provider until there is an established personal relationship (Kopera-Frye, 2009).

• Use family strengthening interventions such as behavioral parent training, family skills training, in-home family support, brief family therapy, and family education when working with culturally diverse families. EB: Comprehensive prevention programs combining multiple approaches produced large positive effects when used with different cultural groups and with different ages of children (Kumpfer, Alvarado, & Whiteside, 2003).

• Work with families in a way that incorporates cultural elements. EB: Activities such as tundra walks and time with elders supported in treatment were used successfully for substance abuse treatment with Yup’ik and Cup’ik Eskimos (Mills, 2003).

• The previous interventions may be adapted for home care use.

• Work with family members to support a sense of valued fit on their part; include them in treatment planning and identify the importance of their roles in the client’s care. At the same time, encourage their pursuit of positive outside activities that enhance their sense of belonging. EBN: Sense of belonging (valued fit) has been identified as a buffer to depression among both depressed and nondepressed individuals with a family history of alcoholism. A buffering effect was not found for individuals with a family history of drug abuse (Sargent et al, 2002).

• Educate client and family regarding the interactions of alcohol use with medications and the therapeutic regimen. Increased awareness of drug interactions decreases the chance of relapse due to over-the-counter and other medications (Weisberg & Hawes, 2005).

• Alcoholism is a family disease. If everyone participates in recovery everyone can be healed (Buddy, 2007).

 Refer for psychiatric home health care services for client reassurance and implementation of therapeutic regimen. EB: Twelve studies (five randomized controlled trials, one quasi-experimental study, and six uncontrolled cohort studies) found that home and community-based treatment of psychiatric symptoms of socially isolated older adults with mental illness was associated with improved or maintained psychiatric status. All randomized controlled trials reported improved depressive symptoms, and one reported improved overall psychiatric symptoms (Van Citters & Bartells, 2004).

• Provide telephone prompting for clients to start alcohol treatment. EB: This study demonstrated that telephone prompting was a simple and effective way to improve attendance for the start of treatment and retention in alcohol treatment (Jackson et al, 2009).

• Suggest the client complete a confidential Internet self-screening test for identification of problems and suggestions for treatment if a problem with alcohol is suspected. Many tools are available. The website www.AlcoholScreening.org helps individuals assess their own alcohol consumption patterns to determine if their drinking is likely harming their health or increasing their risk for future harm. Through education and referral, the site urges those whose drinking is harmful or hazardous to take positive action and informs all adults who consume alcohol about guidelines and caveats for lower risk drinking (Boston University School of Public Health, 2005).

• Provide education for family. EB: Family education facilitates understanding of the disease and its causes, effects, and treatment (U.S. Department of Health and Human Services, 2005).

• Facilitate participation in mutual help groups (MHGs). EB: Mutual help groups appear to mobilize the same change processes such as coping, motivation and self-efficacy that are mobilized by many different types of professionally led groups (Kelly, Magill, & Stout, 2009; Moos, 2008).

• Carefully assess potential for reunifying children placed in foster care with their birth parents. EB: Reunifying children placed in foster care with their birth parents is a primary goal of the child welfare system (Lewis, 2011).

• Allow and encourage family to assist in the client’s care. EBN: Parents need to be able to negotiate with health staff what this participation will involve and negotiate new roles for themselves in sharing care of their sick child. Parents should be involved in the decision-making process (Corlett & Twycross, 2006).

 Refer children and mothers exposed to violence in the home to Theraplay: an attachment-based intervention that uses the four core elements of nurturing, engagement, structure, and challenge in interactions between mother and her child. EBN: This family connections program improves the quality of life for mothers and children during a short shelter stay; it has the potential to improve the long-term quality of life (Bennett, Shiner, & Ryan, 2006).

• Encourage family members to be involved in the care of relatives who are in residential care settings. EB: Family involvement in residential long-term care is important especially when preparing for end-of-life care (Daaleman et al, 2009).

• Support group problem solving among family members and include the older member. EB: Support groups either in person or by telephone are important for all members of the family (Shanley, 2008).

 Refer family for counseling with a psychotherapist who is knowledgeable about gerontology.

• Refer to care plan for Readiness for enhanced Family Processes for additional interventions.

• Refer to the care plan Readiness for enhanced Family Processes for additional interventions.

• The nursing interventions described in the care plan for Compromised family Coping should be used in the home environment with adaptations as necessary.

• Encourage family members to find meaning in a serious illness. EBN: Letting go before the death of a loved one involves a shift in thinking in which there is acknowledgment of impending loss without impeding its natural progression (Lowey, 2008).

• Refer to Client/Family Teaching and Discharge Planning in Compromised family Coping and Readiness for enhanced family Coping for suggestions that may be used with minor adaptations.

• Provide a parenting class series based on individual and couple changes in meaning and identity, roles, and relationships and interaction during the transition to parenthood. Address mother and father roles, infant communication abilities, and patterns of the first 3 months of life in a mutually enjoyable, possibility focused manner. EBN: Parents who took part in this U.S. Navy New Parent program improved their perceptions of their parenting and coping skills, enhanced the family’s quality of life (Kelley et al, 2007). EB: This study demonstrated that a psychoeducational program with modest dosage (eight sessions) had a positive impact on observed family interaction and child behavior at 6-month follow-up (child age 1 year) (Feinberg, Kan, & Goslin, 2009).

• Encourage families with adolescents to have family meals. Eating family meals may enhance the health and well-being of adolescents. Public education on the benefits of family mealtime is recommended (Fruh et al, 2012).

 Consider the use of adventure therapy for adolescents with cancer. EBN: Adventure therapy is considered a strategy to promote health and in this study cancer survival (Wynn, Frost, & Pawson, 2012).

• Carefully listen to residents and family members in the long-term care facility. EBN: Nurses can improve life and dignity for residents by listening to residents and family members (“Listen to your elderly patients for plan of care,” 2010).

• Support caregivers’ awareness of the positive effects of their contribution to the well-being of parents. EBN: Using a partnership approach to caregiving will enhance the well-being of both the parent and child taking care of them (Lèvesque et al, 2010).

• Teach family members about the impact of developmental events (e.g., retirement, death, change in health status, and household composition). Knowledge regarding normative developmental challenges of aging can reduce the stress such challenges place on families (Diwan & Wertheimer, 2007).

• Encourage social networks; social integration; and social engagement with friends, children, and relatives of the elderly. EB: The study shows that social engagement is important to help enhance health for the elderly (Golden, Conroy, & Lawler, 2009).

• Assess for the influence of cultural beliefs, norms, and values on the family’s perceptions of normal functioning. EBN: Cultural beliefs will have a considerable impact on a client’s functioning (Brittain, 2010).

• Identify and acknowledge the stresses unique to racial/ethnic families. EBN: Understanding a client’s unique racial/ethnic background may help the nurse identify stressors that the client and the family may be experiencing (Pang & Suen, 2008).

• Assess and support spiritual needs of families. EBN: Assessing the supporting the spiritual needs of the client and the family can enhance their perception of care and healing (Tanyi, McKenzie, & Chapek, 2009).

• With the client’s consent, facilitate a group meeting for family members to discuss how the family is functioning. EBN: A family meeting opens communication and lets each family member know it is okay to talk about what is happening (Sharma & Dy, 2011).

• Facilitate modeling and role playing for the client and family regarding healthy ways to start a discussion about the client’s prognosis. EBN: It is helpful to practice communication skills in a safe environment before trying them in a real-life situation (Fisher, Taylor, & High, 2012).

• Encourage family mealtimes. EB: Encouraging family mealtimes enhances the communication between the family and health and well-being (Fruh et al, 2012).

• The previous nursing interventions should be used in the home environment with adaptations as necessary.

 Encourage virtual support groups to family caregivers. EB: Positive participant responses were identified as learning to use computers, negotiating the website links, obtaining disease-specific information from the website, using technology to communicate, bonding with group members, providing mutual guidance and support, and benefiting in terms of coping with the stresses of caregiving (Marziali, Damianakis, & Donahue, 2006).

 Encourage caregivers of elderly clients with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy (LTOT) to seek additional services such as social services, respite care, and additional home health visits. EB: More convenient family resources for severe COPD clients may improve the stress among caregivers (Takata et al, 2008).

• Refer to Client/Family Teaching and Discharge Planning in Readiness for enhanced family Coping for suggestions that may be used with minor adaptations.