G
Risk for Deficient Fluid Volume
NANDA-I
At risk for experiencing decreased intravascular, interstitial, and/or intracellular fluid. This refers to a risk for dehydration, water loss alone without change in sodium.
Risk Factors
Active fluid volume loss; deficient knowledge; deviations affecting absorption of fluids; deviations affecting access of fluids; deviations affecting intake of fluids; excessive losses through normal routes (e.g., diarrhea); extremes of age; extremes of weight; factors influencing fluid needs (e.g., hypermetabolic state); failure of regulatory mechanisms; loss of fluid through abnormal routes (e.g., indwelling tubes); pharmaceutical agents (e.g., diuretics)
Impaired Gas Exchange
NANDA-I
Excess or deficit in oxygenation and/or carbon dioxide elimination at the alveolar-capillary membrane
Defining Characteristics
Abnormal arterial blood gases; abnormal arterial pH; abnormal breathing (e.g., rate, rhythm, depth); abnormal skin color (e.g., pale, dusky); confusion; cyanosis; decreased carbon dioxide; diaphoresis; dyspnea; headache upon awakening; hypercapnia; hypoxemia; hypoxia; irritability; nasal flaring; restlessness, somnolence; tachycardia; visual disturbances
NIC (Nursing Interventions Classification)
Mechanical Ventilation Management: Noninvasive, Oxygen Therapy, Medication Management, Airway Management
Nursing Interventions and Rationales
• Monitor respiratory rate, depth, and ease of respiration. Watch for use of accessory muscles and nasal flaring. Normal respiratory rate is 10 to 20 breaths/min in the adult (Jarvis, 2012). EBN: A study demonstrated that when the respiratory rate exceeds 30 breaths/min, along with other physiological measures, a significant cardiovascular or respiratory alteration exists (Hagle, 2008).
• Auscultate breath sounds every 1 to 2 hours. Listen for diminished breath sounds, crackles, and wheezes. The presence of crackles and wheezes may alert the nurse to airway obstruction, which may lead to or exacerbate existing hypoxia. In severe exacerbations of chronic obstructive pulmonary disease (COPD), lung sounds may be diminished or distant with air trapping (Bickley & Szilagyi, 2009).
• Monitor the client’s behavior and mental status for the onset of restlessness, agitation, confusion, and (in the late stages) extreme lethargy. Changes in behavior and mental status can be early signs of impaired gas exchange. In the late stages the client becomes lethargic and somnolent (Schultz, 2011).
Monitor oxygen saturation continuously using pulse oximetry. Correlate arterial oxygen saturation blood gas results with pulse oximetry An oxygen saturation of less than 90% (normal: 95% to 100%) or a partial pressure of oxygen of less than 80 mm Hg (normal: 80 to 100 mm Hg) indicates significant oxygenation problems. Pulse oximetry is useful for tracking and/or adjusting supplemental oxygen therapy for clients with COPD (GOLD, 2011).
• Observe for cyanosis of the skin; especially note color of the tongue and oral mucous membranes. Central cyanosis of the tongue and oral mucosa is indicative of serious hypoxia and is a medical emergency. Peripheral cyanosis in the extremities may be due to activation of the central nervous system or exposure to cold and may or may not be serious (Bickley & Szilagyi, 2009).
• Position the client in a semirecumbent position with the head of the bed at a 30- to 45-degree angle to decrease the aspiration of gastric, oral, and nasal secretions EBN: Evidence shows that mechanically ventilated clients have a decreased incidence of VAP if the client is placed in a 30- to 45-degree semirecumbent position as opposed to a supine position (Grap, 2009; Siela, 2010; Vollman & Sole, 2011).
• If the client has unilateral lung disease, position with head of bed at 30 to 45 degrees with “good lung down” for about 1 hour at a time (Marklew, 2006).
If the client is acutely dyspneic, consider having the client lean forward over a bedside table, resting elbows on the table if tolerated. Leaning forward can help decrease dyspnea, possibly because gastric pressure allows better contraction of the diaphragm (Langer et al, 2009). This is called the tripod position and is used during times of distress, including when walking, leaning forward on the walker.
• Help the client deep breathe and perform controlled coughing. Have the client inhale deeply, hold the breath for several seconds, and cough two or three times with the mouth open while tightening the upper abdominal muscles as tolerated. Controlled coughing uses the diaphragmatic muscles, which makes the cough more forceful and effective. If the client has excessive fluid in the respiratory system, refer to the care plan Ineffective Airway clearance.
Monitor the effects of sedation and analgesics on the client’s respiratory pattern; use judiciously. Both analgesics and medications that cause sedation can depress respiration at times. However, these medications can be very helpful for decreasing the sympathetic nervous system discharge with physical and psychological distress that accompanies hypoxia (Brennan & Mazanec, 2011).
• Schedule nursing care to provide rest and minimize fatigue. The hypoxic client has limited reserves; inappropriate activity can increase hypoxia.
Administer humidified oxygen through an appropriate device (e.g., nasal cannula or Venturi mask per the physician’s/provider order); aim for an oxygen (O2) saturation level of 90% oxygen saturation or above. Watch for onset of hypoventilation as evidenced by increased somnolence. There is a fine line between ideal or excessive oxygen therapy; increasing somnolence is caused by retention of carbon dioxide (CO2) leading to CO2 narcosis (Wong & Elliott, 2009). Promote oxygen therapy during a COPD exacerbation. Supplemental oxygen should be titrated to improve the client’s hypoxemia with a target of 88% to 92% oxygen saturation (GOLD, 2011).
• Assess nutritional status including serum albumin level and body mass index (BMI).Weight loss in a client with COPD has a negative effect on the course of the disease; it can result in loss of muscle mass in the respiratory muscles, including the diaphragm, which can lead to respiratory failure (Odencrants, Ehnfors, & Ehrenbert, 2008).
• Assist the client to eat small meals frequently and use dietary supplements as necessary. For some clients, drinking 30 mL of a supplement such as Ensure or Pulmocare every hour while awake can be helpful.
• If the client is severely debilitated from chronic respiratory disease, consider the use of a wheeled walker to help in ambulation.
Watch for signs of psychological distress including anxiety, agitation, depression, and insomnia. Refer for counseling as needed (Corbridge et al, 2012). EBN: A study showed that COPD clients were well aware of the stigma associated with having their disease, and the prevalent blaming from others, and health care personnel related to smoking (Berger, Kapella, & Larson, 2011).
Refer the COPD client to a pulmonary rehabilitation program. Pulmonary rehabilitation is now considered a standard of care for the client with COPD (Corbridge et al, 2012; GOLD, 2011; Nici et al, 2009).
Critical Care
Assess and monitor oxygen indices such as the PF ratio (FIO2:pO2), venous oxygen saturation/oxygen consumption (SVO2 or ScVO2) (Burns, 2011; Headley & Guiliano, 2011).
Turn the client every 2 hours. Monitor mixed venous oxygen saturation closely after turning. If it drops below 10% or fails to return to baseline promptly, turn the client back into the supine position, check vital signs, and evaluate oxygen status. If the client does not tolerate turning, consider use of a kinetic bed that rotates the client from side to side in a turn of at least 40 degrees.
If the client has adult respiratory distress syndrome with difficulty maintaining oxygenation, consider positioning the client prone with the upper thorax and pelvis supported, allowing the abdomen to protrude. Monitor oxygen saturation and turn back to supine position if desaturation occurs. EBN & EB: Oxygenation levels have been shown to improve in the prone position, probably due to decreased shunting and better perfusion of the lungs (Vollman & Powers, 2011). Prone ventilation significantly reduced mortality in clients with severe acute hypoxemic respiratory failure, but not in clients with less severe hypoxemia (Sud et al, 2010). If the client becomes ventilator dependent, refer to the care plan Impaired spontaneous Ventilation.
Geriatric: Use central nervous system (CNS) depressants carefully to avoid decreasing respiration rate. An elderly client is prone to respiratory depression.
• Recognize that the elderly have decreased pulmonary function with age, and that results in decreased gas exchange and pulmonary reserve function. Also that the elderly are more vulnerable to develop pneumonia because of decreased immune function. EB: A study demonstrated that frail elderly are more prone to respiratory impairment shown by spirometry, and also have increased mortality (Vaz Fragoso et al, 2012).
Home Care:• Work with the client to determine what strategies are most helpful during times of dyspnea. Educate and empower the client to self-manage the disease associated with impaired gas exchange. EBN & EB: A study found that use of oxygen, self-use of medication, and getting some fresh air were most helpful in dealing with dyspnea (Thomas, 2009). Evidence-based reviews have found that self-management offers COPD clients effective options for managing the illness, leading to more positive outcomes (Kaptein et al, 2008).
Collaborate with physicians regarding long-term oxygen administration for chronic respiratory failure clients with severe resting hypoxemia. Administer long-term oxygen therapy greater than 15 hours daily for pO2 less than 55 or saO2 at or below 88% (Corbridge et al, 2012; GOLD, 2011). Long term oxygen therapy has been shown to increase survival and improve hemodynamics, hematology, exercise capacity, lung mechanics, mental status, motor speed, and hand grip strength (Corbridge et al, 2012).
• Assess the home environment for irritants that impair gas exchange. Help the client to adjust the home environment as necessary (e.g., install an air filter to decrease the level of dust).
Refer the client to occupational therapy as necessary to assist the client in adaptation to the home and environment and in energy conservation.
• Assist the client with identifying and avoiding situations that exacerbate impairment of gas exchange (e.g., stress-related situations, exposure to pollution of any kind, proximity to noxious gas fumes such as chlorine bleach). Irritants in the environment decrease the client’s effectiveness in accessing oxygen during breathing.
• Refer to GOLD guidelines for management of home care and indications of hospital admission criteria (GOLD, 2011).
• Instruct the client to keep the home temperature above 68° F (20° C) and to avoid cold weather. Cold air temperatures cause constriction of the blood vessels, which impairs the client’s ability to absorb oxygen.
• Instruct the client to limit exposure to persons with respiratory infections. Viruses, bacteria, and environmental pollutants are the main causes of exacerbations of COPD (Barnett, 2008).
• Instruct the family in the complications of the disease and the importance of maintaining the medical regimen, including when to call a physician.
Refer the client for home health aide services as necessary for assistance with activities of daily living. Clients with decreased oxygenation have decreased energy to carry out personal and role-related activities.
• When respiratory procedures are being implemented, explain equipment and procedures to family members, and provide needed emotional support. Family members assuming responsibility for respiratory monitoring often find this stressful.
• When electrically based equipment for respiratory support is being implemented, evaluate home environment for electrical safety, proper grounding, and so on. Ensure that notification is sent to the local utility company, the emergency medical team, and police and fire departments. Notification is important to provide for priority service.
Watch for family role changes and coping ability. Refer the client to medical social services as appropriate for assistance in adjusting to chronic illness. Inability to maintain the level of social involvement experienced before illness leads to frustration and anger in the client and may create a threat to the family unit.
• Support the family of the client with chronic illness. Severely compromised respiratory functioning causes fear and anxiety in clients and their families. Reassurance from the nurse can be helpful.
Client/Family Teaching and Discharge Planning:
• Teach the client how to perform pursed-lip breathing and inspiratory muscle training, and how to use the tripod position. Have the client watch the pulse oximeter to note improvement in oxygenation with these breathing techniques. EB: Studies have demonstrated that pursed-lip breathing was effective in decreasing breathlessness and improving respiratory function (Faager, Ståhle, & Larsen, 2008). A systematic review found that inspiratory muscle training was effective in increasing endurance of the client and decreasing dyspnea (Langer et al, 2009).
• Teach the client energy conservation techniques and the importance of alternating rest periods with activity. See nursing interventions for Fatigue.
Teach the importance of not smoking. Refer to smoking cessation programs, and encourage clients who relapse to keep trying to quit. Ensure that client receives appropriate medications to support smoking cessation from the primary health care provider. EB: A systematic review of research demonstrated that the combination of medications and an intensive, prolonged counseling program supporting smoking cessation were effective in promoting long-term abstinence from smoking (Fiore et al, 2008). A Cochrane review found that use of the medication varenicline (Chantix) increased the rate of smoking withdrawal two to three times more than smoking withdrawal without use of medications (Cahill, Stead, & Lancaster, 2008; GOLD, 2011).
Instruct the family regarding home oxygen therapy if ordered (e.g., delivery system, liter flow, safety precautions, number of tanks needed). Long-term oxygen therapy can improve survival, exercise ability, sleep and ability to think in hypoxemic clients (GOLD, 2011). Client education improves compliance with prescribed use of oxygen.
Teach the client the need to receive a yearly influenza vaccine. Receiving a yearly influenza vaccine is helpful to prevent exacerbations of COPD (Black & McDonald, 2009; Corbridge et al, 2012).
• Teach the client relaxation techniques to help reduce stress responses and panic attacks resulting from dyspnea. EB: Relaxation therapy can help reduce dyspnea and anxiety (Langer et al, 2009); teach the client to use music, along with a rest period, to decrease dyspnea and anxiety. CEB & EB: A study demonstrated that use of music along with a resting period was effective in relieving anxiety and exercise-induced dyspnea in clients with COPD (Sidani et al, 2004). Another study demonstrated that music could be more effective than progressive muscle relaxation tapes in decreasing dyspnea and anxiety (Singh & Rao, 2009).
References
Barnett, M. Nursing management of chronic obstructive pulmonary disease. Br J Nurs. 2008;17(21):1314–1318.
Berger, B., Kapella, M., Larson, J. The experience of stigma in chronic obstructive pulmonary disease. West J Nurs Res. 2011;33(7):916–932.
Bickley, L.S., Szilagyi, P. Guide to physical examination, ed 10. Philadelphia: Lippincott Williams & Wilkins; 2009.
Black, P.N., McDonald, C.F. Interventions to reduce the frequency of exacerbations of chronic obstructive pulmonary disease. Postgrad Med J. 2009;85(1001):141–147.
Brennan, C., Mazanec, P. Dyspnea management across the palliative care continuum. J Hosp Palliat Nurs. 2011;13(3):130–139.
Burns, S. Indices of oxygenation. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Cahill, K., Stead, L.F., Lancaster, T., Nicotine receptor partial agonists for smoking cessation. Cochrane Database Syst Rev 2008;(3):CD006103.
Corbridge, S., et al. An evidence-based approach to COPD: part 1. AJN. 2012;112(3):46–59.
Faager, G., Ståhle, A., Larsen, F.F. Influence of spontaneous pursed lips breathing on walking endurance and oxygen saturation in patients with moderate to severe chronic obstructive pulmonary disease. Clin Rehabil. 2008;22(8):675–683.
Fiore, M.C., et al. Treating tobacco use and dependence clinical practice guideline, 2008 update, Rockville, MD. U.S.: Department of Health and Human Services, Public Health Service; 2008.
GOLD, Global strategy for the diagnosis, management, and prevention of COPD revised 2011. [Global Initiative for Chronic Obstructive Lung Disease].
Grap, M. Not-so-trivial pursuit: mechanical ventilation risk reduction. Am J Crit Care. 2009;18(4):299–309.
Hagle, M., et al. Vital signs monitoring. An EBP guideline. In: Ackley B., Ladwig G., Swann B.A., eds. Evidence-based nursing care guidelines: medical-surgical interventions. Philadelphia: Mosby, 2008.
Headley, J., Giuliano, K. Continuous venous oxygen saturation monitoring. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Jarvis, C. Physical examination and health, ed 6. St Louis: Elsevier Saunders; 2012.
Kaptein, A.A., et al. 50 years of psychological research on patients with COPD—road to ruin or highway to heaven? Respir Med. 2008;103:3–11.
Langer, D., et al. A clinical practice guideline for physiotherapists treating patients with chronic obstructive pulmonary disease based on a systematic review of available evidence. Clin Rehabil. 2009;23(5):445–462.
Marklew, A. Body positioning and its effect on oxygenation- a literature review. Br Assoc Crit Care Nurs. 2006;11(1):16–22.
Nici, L., et al. Pulmonary rehabilitation: what we know and what we need to know. J Cardiopulm Rehabil Prev. 2009;29(3):141–151.
Odencrants, S., Ehnfors, M., Ehrenbert, A. Nutritional status and patient characteristics for hospitalized older patients with chronic obstructive pulmonary disease. J Clin Nurs. 2008;17(13):1771–1778.
Schultz, S. Oxygen saturation monitoring with pulse oximetry. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Sidani, S., et al. Evaluating the effects of music on dyspnea and anxiety in patients with COPD: a process-outcome analysis. Int Nurs Perspect. 2004;4(1):5–14.
Siela, D. Evaluation standards for management of artificial airways. Crit Care Nurse. 2010;30(4):76–78.
Singh, V.P., Rao, V. Comparison of the effectiveness of music and progressive muscle relaxation for anxiety in COPD—a randomized controlled pilot study. Chronic Respir Dis. 2009;6(4):209–216.
Sud, S., et al. Prone ventilation reduces mortality in patients with acute respiratory failure and severe hypoxemia: systematic review and meta-analysis. Intensive Care Med. 2010;36:585–599.
Thomas, L. Effective dyspnea management strategies identified by elders with end-stage chronic obstructive pulmonary disease. Appl Nurs Res. 2009;22(2):79–85.
Vas Fragoso, C.A., et al. Frailty and respiratory impairment in older persons. Am J Med. 2012;125(1):79–86.
Vollman, K., Powers, J. Pronation therapy. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Vollman, K., Sole, M. Endotracheal tube and oral care. In Lynn-McHale D.J., ed.: AACN procedure manual for critical care, ed 6, Philadelphia: Saunders Elsevier, 2011.
Wong, M., Elliott, M. The use of medical orders in acute care oxygen therapy. Br J Nurs. 2009;18(8):462–464.
Risk for dysfunctional Gastrointestinal Motility
NANDA-I
At risk for increased, decreased, ineffective, or lack of peristaltic activity within the gastrointestinal system
Risk Factors
Abdominal surgery; aging; anxiety; change in food; change in water; decreased gastrointestinal circulation; diabetes mellitus; food intolerance (e.g., gluten, lactose); gastroesophageal reflux disease (GERD); immobility; infection (e.g., bacterial, parasitic, viral): pharmaceutical agents (e.g., antibiotics, laxatives, narcotics/opiates, proton pump inhibitors); prematurity; sedentary lifestyle; stress; unsanitary food preparation
Dysfunctional Gastrointestinal Motility
NANDA-I
Increased, decreased, ineffective, or lack of peristaltic activity within the gastrointestinal system
Defining Characteristics
Absence of flatus; abdominal cramping; abdominal distention; abdominal pain; accelerated gastric emptying; bile-colored gastric residual; change in bowel sounds (e.g., absent, hypoactive, hyperactive); diarrhea; dry stool; difficulty passing stool; hard stool; increased gastric residual; nausea; regurgitation; vomiting
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Monitor for abdominal distention, and presence of abdominal pain. The acute onset of abdominal distention in conjunction with symptoms of cramping pain, weight loss, nausea, vomiting, obstipation, or diarrhea warrants further evaluation for disorders that cause intestinal obstruction (Camilleri, 2011).
• Auscultate for bowel sounds noting characteristics and frequency, also palpate, and percuss the abdomen. Hypoactive bowel sounds are found with decreased motility as with peritonitis, from paralytic ileus, or from late bowel obstruction. Hyperactive bowel sounds are associated with increased motility (Jarvis, 2012).
• Review history noting any anorexia, dyspepsia, nausea/vomiting, abnormal characteristics of bowel movements, including frequency, consistency, and the presence of gas. Other symptoms may include relation of symptoms to meals, especially if aggravated by food, early satiety, postprandial fullness/bloating, and weight loss (more with severe gastroparesis). These are signs of abnormal gastric motility (Khoo et al, 2009).
• Have client keep a diary of time food and fluid was consumed as it compares to pattern of defecation, including, but not limited to, consistency, amount, and frequency of stool (Holman, Roberts, & Nicol, 2008).
• Monitor for fluid deficits by checking skin turgor, and moisture of tongue. Refer to care plan Deficient Fluid Volume if relevant.
Monitor for nutritional deficits by keeping close track of food intake. Review laboratory studies that affirm nutritional deficits, such as decreased albumin and serum protein levels, liver profile, glucose, and an electrolyte panel. Refer to care plan Imbalanced Nutrition: less than body requirements or Risk for Electrolyte imbalance as appropriate.
Slowed Gastrointestinal Motility
• Monitor the client for signs and symptoms of decreased gastric motility, which may include delayed emptying, nausea after meals, vomiting, heartburn, diarrhea, feeling full quickly while eating, abdominal bloating and/or pain, anorexia, and reflux (Shakil, Church, & Rao, 2008).
Monitor daily laboratory studies, ensuring ordered glucose levels are done and evaluated. Elevated blood glucose levels can cause delayed gastric emptying; therefore, it is important to normalize blood glucose levels (Shakil, Church, & Rao, 2008).
If client has nausea and vomiting, provide an antiemetic and intravenous fluids as ordered. Refer to the care plans for Nausea.
Evaluate medications the client is taking. Recognize that opioids and anticholinergics can cause gastric slowing, along with aluminum hydroxide antacids, beta-adrenergic receptor agonists; calcium channel blockers, diphenhydramine, histamine H2 antagonists, levodopa, proton pump inhibitors, sucralfate, and tricyclic antidepressants (Shakil, Church, & Rao, 2008).
• Obtain a thorough gastrointestinal history if the client has diabetes, as they are at high risk for gastroparesis and gastric reflux. Gastroparesis with delayed emptying of the stomach is a complication of diabetes associated with neuropathy of nerves supplying the stomach (Gregg, 2010).
Review laboratory and other diagnostic tools, including complete blood count (CBC), amylase, thyroid-stimulating hormone level, glucose with other metabolic studies, upper endoscopy, and gastric-emptying scintigraphy. The diagnosis of diabetic gastroparesis is made when other causes are excluded and postprandial gastric stasis is confirmed by gastric emptying scintigraphy, which is considered the gold standard for diagnosing gastroparesis (Shakil, Church, & Rao, 2008).
Obtain nutritional consult, considering diets lower or higher in liquids or solids, especially fats, depending on gastric motility. The person with diminished gastric emptying may be advised to avoid fatty meals while more liquid intake of nutrients may be advised (Shakil, Church, & Rao, 2008).
Recommend eating small meals and soft (well cooked) foods as they may relieve symptoms of slower motility (Dugdale, 2010).
If client is unable to eat or retain food, consult with the registered dietitian and physician, considering further nutritional support in the form of enteral or parenteral feedings for the client with gastroparesis. Some clients require supplementation with either enteral or parenteral nutrition for survival.
If client is receiving gastric enteral nutrition (EN), evaluate gastric residual volume (GRV) per hospital protocol. See the care plan Risk for Aspiration.
Administer prokinetic medications as ordered (Chang et al, 2011; Shakil, Church, & Rao, 2008).
For the client with nausea and vomiting associated with gastroparesis, review use of tricyclics, in addition to the traditional antiemetics and other prokinetic drugs. Tricyclic antidepressants are used in the treatment of many functional gastrointestinal disorders (Stapleton & Wo, 2009).
Recognize that acupuncture may be an option for both slowed and increased gastric motility. EB: Acupuncture stimulation, either mechanical or electrical, placed on abdominal locations of skin or muscle may induce a decrease in gastric motility, while application to a limb caused an increase via supraspinal reflex that activated vagal nerve fibers (Noguchi, 2010).
Postoperative Ileus
• Observe for complications of delayed intestinal motility. Symptoms include abdominal pain and distention, nausea, cramping, anorexia, and sometimes bloating. Other signs include tympany to percussion, with absence of flatus, bowel sounds or bowel movements (Hocevar, Robinson, & Gray, 2010; Woodard, Rastinehad, & Richstone, 2008).
Recommend chewing gum for the routine postoperative patient who is experiencing an ileus, is not at risk for aspiration, and has normal dentition. EBN: Gum chewing may decrease postoperative ileus because it “acts as a sham feeding, potentially stimulating gastric and bowel motility through repetitive stimulation of the cephalic-vagal complex.” It shortens time to passage of flatus and stool (Hocevar, Robinson, & Gray, 2010).
• Determine if the client is a smoker. Smoking increases intestinal motility. Constipation is common, but usually transient, when people stop smoking (Wilcox et al, 2010). CEB: In a survey about perceived effects of various foods and beverages on constipation, cigarette was the item that was most often perceived to have a laxative effect among smokers (Müller-Lissner et al, 2005).
• Help the client out of bed to walk at least two times per day. Exercise may increase gastrointestinal motility (Shakil, Church, & Rao, 2008).
If postoperative ileus is associated with opioid pain medication, request an order for a peripherally acting opioid antagonist. This medication has minimal penetration of the CNS so pain can continue to be relieved, while blocking peripheral sites so that an ileus can be relieved (Rathmell & Fields, 2012).
Note serum electrolyte levels, especially potassium and magnesium. A low potassium level decreases the function of intestinal smooth muscle and can result in an ileus. A low magnesium level makes the body refractory to potassium replacement (Mount, 2012).
Increased Gastrointestinal Motility
Observe for complications of gastric surgeries such as dumping syndrome. This syndrome is the effect of changes in size and function of the stomach, with rapid dumping of hyperosmolar food into the intestines (Alan et al, 2010).
• Watch for nausea, vomiting, bloating, cramping, diarrhea, dizziness, and fatigue. These are common signs and symptoms of early rapid gastric emptying (Alan et al, 2010).
• Monitor for low blood sugar, weakness, sweating, and dizziness 1 to 3 hours after eating as this is when late rapid gastric emptying may occur. Experiencing both early and late forms of gastric emptying is not uncommon (Alan et al, 2010).
Order a nutritional consult to discuss diet changes. Encourage several small meals per day that are low in carbohydrates, and higher in fiber supplements and fat. Space fluids around meal times, not with them (Alan et al, 2010).
Give intravenous fluids as ordered for the client complaining of diarrhea with weakness and dizziness. Severe diarrhea can cause deficient fluid volume with extreme weakness.
Review the client’s medication profile, including current medication list, noting those that may increase gastric motility. Medications such as beta-adrenergic receptor antagonists and prokinetic agents can cause increased gastrointestinal motility (Shakil, Church, & Rao, 2008).
• Offer bathroom, commode, or bedpan assistance, depending on frequency, amount of diarrhea, and condition of client.
• Refer to the care plans for the nursing diagnoses of Deficient Fluid Volume, Nausea, and Diarrhea as relevant.
Pediatric:• Assess infants and children with suspected delayed gastric for fullness and vomiting. Babies and children with delayed gastric emptying take longer to get hungry again and throw up undigested or partially digested food several hours after feeding (Waseem, 2012).
• Continue to encourage the mother of a baby diagnosed with delayed gastric emptying to breastfeed, reinforcing the benefits of breastfeeding. Breast milk moves through the digestive system almost twice as fast as formula (MacLean, 2007).
If the infant is already on a bottle, encourage parents to discuss with the pediatrician a switch to a hypoallergenic formula. Hypoallergenic formula is already partially digested, making the transit time out of the stomach potentially faster (Skillman & Wischmeyer, 2008).
Observe for nutritional and fluid deficits with assessment of skin turgor, mucous membranes, fontanels, furrows of the tongue, electrolyte panel, fluid status, and cardiopulmonary function (Skillman & Wischmeyer, 2008).
Recommend gentle massage for preterm infants as appropriate. EB: With massage, there was increased vagal activity. This was then associated with increased gastric motility and greater weight gain (Field, Diego, & Hernandez-Reif, 2011).
• Closely monitor diet and medication use/side effects as they affect the gastrointestinal system. Watch for constipation. Many gastrointestinal functions are slowed in the elderly (Grassi et al, 2011).
Watch for symptoms of dysphagia, gastroesophageal reflux disease, dyspepsia, irritable bowel syndrome, maldigestion, and reduced absorption of nutrients. These are common gastrointestinal disorders in the elderly (Grassi et al, 2011).
If client takes metoclopramide for gastroesophageal reflux disease or slowed gastric motility, assess indication and side effects. Recognize that metoclopramide can cause drug-induced Parkinson’s disease in the elderly, in addition to other neurotoxic side effects. This medication should be used with great caution in the elderly client because of the increased side effect profile (Esper & Factor, 2008).
Client/Family Teaching and Discharge Planning:
• Teach the client and caregivers about their medications, reinforcing the side effects as they relate to gastrointestinal function.
Recommend possible exercise programs if appropriate. Exercise may increase gastric motility (Shakil, Church, & Rao, 2008).
• Teach client and caregivers to report signs and symptoms that may indicate further complications including increased abdominal girth, projectile vomiting, and unrelieved acute cramping pain (bowel obstruction).
• Review signs and symptoms of dehydration with client and caregivers.
References
Alan, B.R., et al. Dumping syndrome. Medscape reference. Retrieved May 21, 2011, from http://emedicine.medscape.com/article/173594-overview.
Camilleri, M., et al. Disorders of Gastrointestinal motility. In Goldman, ed.: Goldman’s Cecil medicine, ed 24, New York: McGraw Hill, 2011.
Chang, J., et al. Diabetic gastroparesis—backwards and forwards. J Gastroenterol Hepatol. 2011;26:46–57.
Dugdale, D.C. Gastroparesis, Medline Plus. U.S. National Library of Medicine. http://www.nlm.nih.gov/medlineplus/ency/article/000297.htm. [Accessed August 7, 2012].
Esper, C.D., Factor, S.A. Failure of recognition of drug-induced parkinsonism in the elderly. Mov Disord. 2008;23(3):401–404.
Field, T., Diego, M., Hernandez-Reif, M. Potential underlying mechanisms for greater weight gain in massaged preterm infants. Infant Behav Dev. 2011;34(3):383–389.
Grassi, M., et al. Changes, functional disorders, and diseases in the gastrointestinal tract of elderly. Nutr Hosp. 2011;26(4):659–668.
Gregg, K.H. Gastroparesis. MedSurg Nurs. 2010;19(6):345–346.
Hocevar, B.J., Robinson, B., Gray, M. Does chewing gum shorten the duration of postoperative ileus in patients undergoing abdominal surgery and creation of a stoma? J Wound Ostomy Continence Nurs. 2010;37(2):140–146.
Holman, C., Roberts, S., Nicol, M. Preventing and treating constipation in later life. Nurs Older People. 2008;20(5):22–24.
Jarvis, C. Physical examination and health assessment, ed 6. St Louis: Saunders Elsevier; 2012.
Khoo, J., et al. Pathophysiology and management of gastroparesis. Expert Rev Gastroenterol Hepatol. 2009;3(2):167–181.
MacLean, R., Gastroparesis, modified 2007 Retrieved July 23, 2009, from http://infantrefluxdisease.com/gastroparesis.php
Mount, D., et al. Fluid and electrolyte disturbances. In Longo D., ed.: Harrison’s textbook of internal medicine, ed 18, New York: McGraw-Hill, 2012.
Müller-Lissner, S.A., et al. The perceived effect of various foods and beverages on stool consistency. Eur J Gastroenterol Hepatol. 2005;17:109–112.
Noguchi, E. Acupuncture regulates gut motility and secretion via nerve reflexes. Auton Neurosci. 2010;156:15–18.
Rathmell, J., Fields, H., et al. Pain: pathophysiology and management. In Longo D., ed.: Harrison’s textbook of internal medicine, ed 18, New York: McGraw-Hill, 2012.
Shakil, A., Church, R., Rao, S.S. Gastrointestinal complications of diabetes. Am Fam Physician. 2008;77(12):1697–1703.
Skillman, H.E., Wischmeyer, P.E. Nutrition therapy in critically ill infants and children. J Parenter Enteral Nutr. 2008;32(5):520–534.
Stapleton, J., Wo, J.M. Current treatment of nausea and vomiting associated with gastroparesis: antiemetics, prokinetics, tricyclics. J Alt Complement Med. 2009;14(7):833–839.
Waseem, S., et al. Spectrum of gastroparesis in children. J Pediatr Gastroenterol Nutr. 2012;55(2):166–172.
Wilcox, C.S., Oskooilar, N., Erickson, J.S. An open-label study of naltrexone and bupropion combination therapy for smoking cessation in overweight and obese subjects. Addict Behav. 2010;35(3):229–234.
Woodard, E., Rastinehad, A.R., Richstone, L. Management of postoperative ileus. Urol Times. 2008;36(Suppl):S8–S14.
Risk for ineffective Gastrointestinal perfusion
NANDA-I
Risk Factors
Abdominal aortic aneurysm; abdominal compartment syndrome; abnormal partial thromboplastin time; abnormal prothrombin time; acute gastrointestinal bleed; acute gastrointestinal hemorrhage; age ≥ 60 years; anemia; coagulopathy (e.g., sickle cell anemia); diabetes mellitus; disseminated intravascular coagulation; female gender; gastric paresis (e.g., diabetes mellitus); gastroesophageal varices; gastrointestinal disease (e.g., duodenal or gastric ulcer, ischemic colitis, ischemic pancreatitis); hemodynamic instability; liver dysfunction; myocardial infarction; poor left ventricular performance; renal failure; stroke; trauma; smoking; treatment-related side effects (e.g., cardiopulmonary bypass, medication, anesthesia, gastric surgery); vascular disease (e.g., peripheral vascular disease, aortoiliac occlusive disease)
NOC (Nursing Outcomes Classification)
Tissue Perfusion: Abdominal Organs, Gastrointestinal Function, Tissue Perfusion: Cellular, Circulation Status; Knowledge: Treatment Regimen
Client Outcomes
Client Will (Specify Time Frame)
• Maintain blood pressure within normal limits
• Remain free from abdominal distention
• Tolerate feedings without nausea, vomiting, or abdominal discomfort
• Pass stools of normal color, consistency, frequency, and amount
• Describe prescribed diet regimen
• Describe prescribed medication regimen including medication actions and possible side effects
• Verbalize understanding of treatment regimen including monitoring for signs and symptoms that may indicate problems with gastrointestinal tissue perfusion, the importance of diet and exercise to gastrointestinal health
NIC (Nursing Interventions Classification)
Vital Signs Monitoring, Surveillance, Bowel Management, Electrolyte Monitoring, Laboratory Data Interpretation, Medication Management, Teaching: Prescribed Diet, Teaching: Disease Process, Teaching: Prescribed Medication, Nutrition Monitoring
Nursing Interventions and Rationales
Complete pain assessment. Assess and document the onset, intensity, character, location, duration, aggravating factors, and relieving factors. Determine whether the pain is exacerbated by eating. Notify the provider for any increase in pain or discomfort or if comfort measures are not effective. A significant symptom of mesenteric ischemia is pain that is disproportionate to the physical examination findings. Acute arterial mesenteric ischemia often has the most abrupt onset of pain. Clients presenting with acute mesenteric ischemia may have a history of abdominal angina, which is a syndrome of pain starting soon after eating and lasting for several hours (Stamatakos et al, 2008). Acute mesenteric ischemia should be considered with any acute onset of intense abdominal pain. It is an emergent condition and positive outcomes are only possible in the early stages, within 12 hours of onset (Debus et al, 2011; Hauser, 2011).
• Monitor vital signs frequently as needed watching for hypotension and tachycardia. Ischemia or infarction of the gastrointestinal blood supply is a serious situation and can result in death of the client, especially in the elderly (Cangemi, 2009; Hauser, 2011).
• Encourage the client to eat small, frequent meals rather than three larger meals. Encourage the client to rest after eating to maximize blood flow to the stomach and improve digestion. Smaller meals will reduce pressure on the lower esophageal sphincter (O’Malley, 2008).
• Perform a physical abdominal examination including inspection, auscultation, percussion, and palpation. Complete the assessment in the described order. Initially with decreased perfusion there may be increased bowel sounds, and then absence of bowel sounds (Hauser, 2011).
• Monitor frequency, consistency, color, and amount of stools. Clients presenting with sudden cramping, left lower abdominal pain, a strong urge to pass stool and bright red or maroon blood mixed with the stool should be evaluated for colon ischemia (Frishman et al, 2008). Obvious bleeding from the gastrointestinal tract is an ominous sign and often suggests bowel infarction (Hauser, 2011).
• Assess for abdominal distention. Measure abdominal girth and compare to client’s accustomed waist or belt size. Ischemia of the gastrointestinal system can result in decreased motility, and a paralytic ileus with abdominal distention (Urden, Stacey, & Lough, 2010).
Monitor for gastrointestinal side effects from medication administrations, particularly NSAIDs. Discuss the possibility of prescribing a gastroprotective agent such as a proton pump inhibitor with the provider for clients requiring long-term administration of NSAIDs. NSAIDs have significant gastrointestinal toxicity. The mechanisms of damage include disruption of the mucus layer, inhibition of bicarbonate secretion, local tissue hypoxia caused by vasoconstriction, and others. Up to 60%, taking these types of medications have some injury and serious adverse events including gastric and duodenal ulcers, perforation and hemorrhage can occur. The damage may be asymptomatic, especially in the elderly. The relative risk of injury increases with age (Jones et al, 2008).
• Review the client’s medical and surgical history. Certain conditions place clients at higher risk for ineffective tissue perfusion (e.g., diabetes mellitus, abdominal surgery, cardiothoracic surgery, trauma, mechanical ventilation). In addition to medical or surgical conditions, lifestyle choices such as smoking or cocaine and amphetamine use affect tissue perfusion (Hauser, 2011). EB: Gastrointestinal complications following cardiac surgery are rare, but substantially increase morbidity and mortality. Risk factors include age, intraoperative hypoperfusion, and need for high dose vasopressors (Abboud et al, 2008).
• Recognize that any client who has been in a shock state is vulnerable to decreased gastrointestinal perfusion, and watch for symptoms as just identified. In shock the blood flow is preferentially shunted away from the gut to the brain and heart to preserve life. Ischemia of the gut is part of the multiple organ dysfunction syndrome that follows a shock state, especially septic shock (Urden, Stacy, & Lough, 2010).
• Encourage the client to ambulate or perform activity as tolerated, but vigorous activity or heavy lifting should be avoided for several hours after meals. Upper mesenteric ischemia is often associated with upper abdominal pain, which can be elicited by a meal or by physical activity. These symptoms may cause clients to decrease their food intake, leading to weight loss (Hauser, 2011).
Monitor intake and output to evaluate fluid and electrolyte balance, and review laboratory data as ordered.
Prepare client for diagnostic or surgical procedures. Diagnostic studies may include abdominal x-ray to rapidly rule out intestinal obstruction, CT, angiography, and abdominal ultrasound. Surgical procedures include exploratory laparotomy, thrombectomy, surgical revascularization, and/or stent placement (Stamatakos et al, 2008). EB: Elderly clients with serum ferritin concentration in the low normal range should be considered for GI investigation using endoscopy. Anemic clients without evidence of iron deficiency have a low incidence of bleeding GI lesions and should not undergo GI investigation (Powell & McNair, 2008).
• Monitor vital signs frequently. Notify physician if significant deviation from baseline. EBN: Splanchnic hypoperfusion is a common pathophysiological mechanism leading to mucosal ischemia and GI dysfunction. The gastrointestinal vasculature is not able to compensate for reduced systemic blood pressure. Any state of decreased cardiac output, vasopressor usage, or mechanical ventilation can lead to splanchnic hypoperfusion which then leads to ischemia, decreased bicarbonate secretion and decreased upper gastrointestinal motility (Gregory, 2008). Temperature instability, bradycardia, and apnea can be early symptoms of necrotizing enterocolitis in the newborn. Progressive deterioration of vital signs occurs as the disease progresses (Gregory et al, 2011).
• Monitor oxygen saturation and provide oxygen therapy as ordered. Take steps to prevent hypovolemia and hypotensive episodes. Avoid periods of physiological stress, which can lead to hypoxemia. Minimize environmental stressors. EBN: Physiologic stress that is often associated with critical illness can cause the body to initiate protective mechanisms to shunt blood to the vital organs to perfuse the brain and heart and decrease perfusion to the gastrointestinal and other nonvital organs (Gregory, 2008; Singh et al, 2008).
• Monitor tolerance of enteral feedings. EBN: The premature infant’s GI system is less able to absorb nutrients. The unabsorbed nutrients can lead to proliferation of enteral bacteria. The bacteria can produce intestinal gas which leads to distention, increased pressure in the lumen of the intestine, and decreased circulation. Measure gastric residual and note color, consistency (Gregory et al, 2011).
• Monitor patients at risk for abdominal compartment syndrome for signs of increased abdominal pressure. EB: Massive fluid resuscitation is considered a risk factor in development of abdominal compartment syndrome in the critically ill patient population. Administration of large volumes of fluid can cause bowel edema and affect mesenteric vessel function and the lymphatic system (Carlotti & Carvalho, 2009).
Recognize that decreased gastrointestinal perfusion, either acute or chronic, is much more common in the elderly. Risk factors for ischemia of the bowel are primarily older age and increased atherosclerosis (Hauser, 2011).
Be aware that gastrointestinal bleeding that is difficult to control in the elderly may be associated with decreased gastrointestinal perfusion (Hauser, 2011). EB: Elderly clients with serum ferritin concentration in the low normal range should be considered for GI investigation using endoscopy (Powell & McNair, 2008).
Client/Family Teaching and Discharge Planning:
• Provide client teaching related to risk factors for ineffective gastrointestinal tissue perfusion, signs and symptoms, lifestyle changes that can improve gastrointestinal functioning. Start with the client’s base level of understanding and use that as a foundation for further education. Client education is most effective and efficient when the education involves the learner and is individualized to his/her needs including culture-specific needs (London, 2008).
• Teach client about any medications prescribed. Medication teaching includes the drug name, its purpose, administration instructions such as taking it with or without food, and any side effects to be aware of. Instruct the client to report any adverse side effects to his/her provider. EBN: Medication adherence has been identified as a factor in chronic illness management. Poor adherence can lead to complications including medication-related hospitalization, increased health care expenses, and death (Costa, Pone, & Lee, 2011).
References
Abboud, B., et al. Is prompt exploratory laparotomy the best attitude for mesenteric ischemia after cardiac surgery? Interact Cardiovasc Thorac Surg. 2008;7:1079–1083.
Cangemi, J.R. Intestinal ischemia in the elderly. Gastroenterol Clin North Am. 2009;38(3):527–540.
Carlotti, A., Carvalho, W.B. Abdominal compartment syndrome: a review. Pediatr Crit Care Med. 2009;10(1):115–120.
Costa, L., Pone, S., Lee, M. Challenges in posthospital care: nurses as coaches for medication management. Nurs Care Quality. 2011;26(3):243–251.
Debus, E., et al. Intestinal ischemia. Int J Colorect Dis. 2011;26:1087–1097.
Frishman, W., et al. Pharmacologic management of mesenteric occlusive disease. Cardiol Rev. 2008;16(2):59–68.
Gregory, K. Clinical predictors of necrotizing enterocolitis in premature infants. Nurs Res. 2008;57(4):260–270.
Gregory, K., et al. Necrotizing enterocolitis in the premature infant: neonatal nursing assessment, disease pathogenesis, and clinical presentation. Adv Neonat Care. 2011;11(3):155–164.
Hauser, S.C. Vascular diseases of the gastrointestinal tract. In Cecil R.L., Goldman L., Schaefer A.I., eds.: Goldman’s Cecil Medicine, ed 24, Philadelphia: Elsevier Saunders, 2012.
Jones, R., et al. Gastrointestinal and cardiovascular risks of nonsteroidal anti-inflammatory drugs. Am J Med. 2008;121(6):464–474.
London, F. Meeting the challenge: patient education in a diverse America. J Nurse Staff Dev. 2008;24(6):283–285.
O’Malley, P., Screening for GERD in hospitalized patients, 2008 Clinical Updates. Retrieved from http://www.nursingconsult.com/das/stat/view/124538266-4/cup?nid=191270&sid=813547978&SEQNO=2
Powell, N., McNair, A. Gastrointestinal evaluation of anaemic patients without evidence of iron deficiency. Eur J Gastroenterol Hepatol. 2008;20(11):1094–1100.
Singh, H., et al. Gastrointestinal prophylaxis in critically ill patients. Crit Care Nurs Q. 2008;31(4):291–301.
Stamatakos, M., et al. Mesenteric ischemia: still a deadly puzzle for the medical community. Tohoku J Exp Med. 2008;216(3):197–204.
Urden, L., Stacy, K., Lough, M. Critical care nursing: diagnosis and management, ed 6. St Louis: Mosby; 2010.
Risk for unstable blood Glucose level
NANDA-I
Risk Factors
Deficient knowledge of diabetes management (e.g., action plan); developmental level; dietary intake; inadequate blood glucose monitoring; lack of acceptance of diagnosis; lack of adherence to diabetes management (e.g., action plan); lack of diabetes management (e.g., action plan); medication management; mental health status; physical activity level; physical health status; pregnancy; rapid growth periods; stress; weight gain; weight loss
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Maintain A1C less than7% (normal level 4% to 6%) (American Diabetes Association [ADA], 2012a)
• Maintain less stringent A1C goals than 7% in clients with a history of severe hypoglycemia, advanced diabetes complications, or limited life expectancy (ADA, 2012a)
• Maintain outpatient preprandial blood glucose between 70 and 130 mg/dL (ADA, 2012a); consult primary care provider for client-specific goals
• Maintain outpatient postprandial glucose below 180 mg/dL (ADA, 2012a)
• In gestational diabetes, maintain preprandial blood glucose ≤95 mg/dL, 1-hour pc level at or below 140 mg/dL, and 2-hour pc level at or below 120 mg/dL (ADA, 2012a)
• In a pregnant mother with preexisting type 1 or 2 diabetes, maintain premeal, bedtime, and overnight blood glucose 60-99 mg/dL, peak postprandial glucose 100-129 mg/dL, and A1C <6% (ADA, 2012a)
• In critically ill hospitalized clients, maintain blood glucose between 140 and 180 mg/dL (ADA, 2012a; Moghissi et al, 2009)
• In noncritically ill hospitalized clients, maintain premeal blood glucose values below 140 mg/dL and random blood glucose values below 180 mg/dL (ADA, 2012a; Moghissi et al, 2009). Higher levels may be acceptable in terminally ill patients (Moghissi et al, 2009)
• Demonstrate how to accurately test blood glucose
• Identify self-care actions to take to maintain target glucose levels
• Identify self-care actions to take if blood glucose level is too low or too high
• Demonstrate correct administration of prescribed medications
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
Check blood glucose three or more times daily. EB: Clients using multiple insulin injections or insulin pump therapy should do self-monitoring of blood glucose (SMBG) three or more times daily. SMBG is also useful as a guide to therapy in clients on less frequent injections, noninsulin therapies, or medical nutrition therapy alone. “Results of SMBG can be useful in preventing hypoglycemia and adjusting medications (particularly prandial insulin doses), MNT, and physical activity” (ADA, 2012a).
Evaluate blood glucose levels in hospitalized clients before administering oral hypoglycemic agents or insulin. Adjust timing of medication appropriately with meal times. Inappropriately timed insulin can result in hypoglycemia (ADA, 2009).
Monitor blood glucose every 30 minutes to 2 hours for clients on continuous insulin drips (ADA, 2012a). Frequent monitoring guides insulin drip rate changes.
Consider continuous glucose monitoring (CGM) in clients with type 1 diabetes on intensive insulin regimens. EB: “CGM in conjunction with intensive insulin regimens can be a useful tool to lower A1C in selected adults (age ≥25 years) with type 1 diabetes” (ADA, 2012a). In a study of children and adults with type 1 diabetes, CGM was associated with reduced time spent in hypoglycemia and a concomitant decrease in A1C (Battelino et al, 2011).
Evaluate A1C level for glucose control over previous 2 to 3 months. “All clients with diabetes admitted to the hospital should have an A1C obtained if the result of testing in the previous 2 to 3 months is not available” (ADA, 2012a).
• Consider monitoring 1 to 2 hours post meal in individuals who have premeal glucose values within target but have A1C values above target. “Monitoring postprandial plasma glucose (PPG) 1-2 hours after the start of the meal and treatment aimed at reducing PPG values to <180 mg/dL may help lower A1C” (ADA, 2012a).
• Discuss with provider relaxing goals for clients who have comorbid conditions, shortened life expectancy, frequent hypoglycemia, or hypoglycemia unawareness. “Severe or frequent hypoglycemia is an absolute indication for the modification of treatment regimens, including setting higher glycemic goals” (ADA, 2012a).
• Monitor for signs and symptoms of hypoglycemia, such as shakiness, dizziness, sweating, hunger, headache, pallor, behavior changes, confusion, or seizures. Hypoglycemia must be treated quickly to prevent loss of consciousness (ADA, 2012b).
Be alert for hypoglycemia in clients receiving 0.6 unit/kg insulin or more daily, and in clients receiving NPH insulin. EB: “Higher weight-based insulin doses are associated with greater odds of hypoglycemia independent of insulin type . . 0.6 unit/kg seems to be a threshold below which the odds of hypoglycemia are relatively low . . patients who received NPH trended toward greater odds of hypoglycemia compared with those given other insulins” (Rubin et al, 2011).
If client is experiencing signs and symptoms of hypoglycemia, test glucose and if result is below 70 mg/dL, administer 15 to 20 g glucose (1⁄2 cup fruit juice or regular [not diet] soda, 1 cup milk, 1 small piece of fruit, or 3 to 4 glucose tablets). Pure glucose is the preferred treatment, but any form of carbohydrate that contains glucose will suffice. Avoid treating with foods that contain fat. Repeat test in 15 minutes and repeat treatment if indicated. Once SMBG glucose returns to normal, the individual should consume a meal or snack to prevent recurrence of hypoglycemia. “Treatment of hypoglycemia (plasma glucose <70 mg/dL) requires ingestion of glucose- or carbohydrate-containing foods. The acute glycemic response correlates better with the glucose content than with the carbohydrate content of the food. Although pure glucose is the preferred treatment, any form of carbohydrate that contains glucose will raise blood glucose. Added fat may retard and then prolong the acute glycemic response” (ADA, 2012a). “The use of nurse-driven hypoglycemia protocol for any BG levels <70 mg/dL can prevent deterioration of potentially mild events . . to more severe events” (Moghissi et al, 2009).
Administer intramuscular/subcutaneous glucagon according to agency protocol if client is hypoglycemic and is unable to take oral carbohydrate. For severe hypoglycemia, an IV infusion of 10% dextrose or 25% to 50% IV bolus dextrose may be used. Intravenous dextrose or injected glucagon is an alternative to oral carbohydrate in hypoglycemic clients who cannot take oral glucose (ADA, 2012 a; Goldstein, 2009).
• Monitor for signs and symptoms of hyperglycemia, such as increased thirst or urination, or high blood or urine glucose levels. Early recognition and treatment of hyperglycemia can prevent progression to ketoacidosis or hyperosmolar hyperglycemic nonketotic syndrome (ADA, 2012b).
Ensure an acutely ill client is receiving adequate fluids and carbohydrates. Adjustment in oral hypoglycemic or insulin therapy may be required. EB: “The stress of illness, trauma, and/or surgery frequently aggravates glycemic control and may precipitate diabetic ketoacidosis (DKA) or nonketotic hyperosmolar state, life-threatening conditions that require immediate medical care to prevent complications and death” (ADA, 2012a).
Test urine or blood for ketones in ketosis-prone clients during acute illness, trauma, surgery or stress. Ketoacidosis is a life-threatening condition that requires immediate medical care (ADA, 2012a).
Prime IV tubing with 20 mL of diluted insulin solution before initiating insulin drip. CEB: Glucose adsorbs to some IV tubing; priming with 20 mL is enough to minimize this effect (Goldberg et al, 2006; Zahid et al, 2008).
Evaluate client’s medication regimen for medications that can alter blood glucose. Some antipsychotic agents, diuretics, and glucocorticoids, among others, can cause hyperglycemia. Alcohol, aspirin, and beta-blockers are among agents that can cause hypoglycemia (Diabetes in Control, 2011).
Refer client to dietitian for carbohydrate counting instruction. EB: “Monitoring carbohydrate, whether by carbohydrate counting, choices, or experience-based estimation, remains a key strategy in achieving glycemic control” (ADA, 2012a).
Refer overweight clients to dietitian for weight loss counseling. EB: “For individuals with type 2 diabetes, studies have demonstrated that moderate weight loss (5% of body weight) is associated with decreased insulin resistance, improved measures of glycemia and lipemia, and reduced blood pressure” (ADA, 2012a).
• For interventions regarding foot care, refer to the care plan Ineffective peripheral Tissue Perfusion.
• Watch for age-related cognitive changes that can impair self-management of diabetes. EB: “In older people taking insulin, around one quarter of those aged over 75 years had evidence of cognitive impairment which significantly reduced their ability to understand the actions required in the event of low blood glucose” (Phillips & Phillips, 2011).
• Monitor for vision and dexterity impairments that may affect the older client’s ability to accurately measure insulin doses. EB: Medication therapy can present a challenge due to possible visual and dexterity impairments (Pfützner, 2011).
• Encourage self-monitoring of blood glucose for residents of extended care facilities who are capable of doing so. Research has found that more frequent self-monitoring of blood glucose can lead to better glycemic control when used to adjust treatment (Bentley, 2009).
• Assist client to set up pill boxes or a reminder system for taking medications. Many patients do not take medications as prescribed because they forget, or for many other reasons (Kocurek, 2009).
• Teach older clients the importance of verifying symptoms with a glucometer reading. EB: A study of older adults found that they were unable to identify whether symptoms indicated high or low blood glucose. Common symptoms included sensations such as tingling or numbness, lightheadedness, dizziness, lack of energy, and blurred vision (Kirk et al, 2011).
• Be aware that young children (younger than 6 or 7 years) may not be aware of symptoms of hypoglycemia. “Glycemic goals may need to be modified to take into account the fact that most children <6 or 7 years of age have a form of ‘hypoglycemic unawareness,’ including immaturity of and a relative inability to recognize and respond to hypoglycemic symptoms, placing them at greater risk for severe hypoglycemia and its sequelae. In addition . . young children under the age of 5 years may be at risk for permanent cognitive impairment after episodes of severe hypoglycemia” (ADA, 2012a).
Teach adolescents older than 12 years to monitor blood glucose frequently as ordered. EB: An “observational study shows a strong association between more frequent SMBG in the range of 0-5/d and better metabolic control in adolescents above 12 yr of age” (Ziegler, 2011).
• Teach self-efficacy measures to adolescents with type 1 diabetes who are involved in family conflict. EB: The effect of family conflict on frequency of SMBG is reduced when adolescents are taught self-efficacy (Sander, Odell, & Hood, 2010).
Teach family how to use an emergency glucagon kit (if prescribed). Severe hypoglycemia in which client is unable to take oral glucose should be treated with glucagon (ADA, 2012a,b).
• Provide culturally appropriate diabetes health education. EB: A systematic review found that health education “specifically tailored to the cultural needs of a target minority group” improved knowledge level and glucose control in clients with type 2 diabetes (Hawthorne et al, 2008).
• Involve Hispanic community workers (promotoras) when working with Hispanic clients with diabetes. CEB: Improved A1C level was associated with promotora advocacy and participation in promotora-led support groups (Ingram et al, 2007; Lujan, Ostwald, & Ortiz, 2007).
• Encourage involvement of African American clients’ family and friends in diabetes education activities. EB: “Support from family, peers, and health care providers positively influenced adherence behaviors by providing cues to action, direct assistance, reinforcement, and knowledge” (Chlebowy, Hood, & LaJoie, 2010).
Client/Family Teaching and Discharge Planning:
• Provide “survival skills” education for hospitalized clients, including information about (1) diabetes and its treatment, (2) medication administration, (3) nutrition therapy, (4) self-monitoring of blood glucose, (5) symptoms and treatment of hypoglycemia, (6) basic foot care, and (7) follow-up appointments for in-depth training. For the hospitalized patient, diabetes “survival skills” education is generally a feasible approach. Patients and/or family members should receive sufficient information and training to enable safe care at home (ADA, 2012a; Nettles, 2005).
• Evaluate clients’ monitoring technique initially at regular intervals. Accuracy of SMBG is instrument- and user-dependent (ADA, 2012a).
Refer client to a diabetes treatment and teaching program (DTTP) for training in flexible intensive insulin therapy and dietary freedom. Most large hospitals or medical centers offer such programs. Flexible intensive insulin therapy improves quality of life, glucose control, and other parameters (Bendik et al, 2009).
Refer client for Blood Glucose Awareness Training (BGAT) or web-based training available at http://www.BGAThome.com for instruction in detection, anticipation, avoidance, and treatment of extremes in blood glucose levels. CEB: BGAT has been shown to significantly reduce both hypoglycemia and hyperglycemia (Cox et al, 2006), and BGAThome resulted in significant clinical improvements (Cox et al, 2008).
• Teach client to maintain a blood glucose diary. A diary can help clients learn to associate symptoms with actual glucose readings, as well as guide treatment (ADA, 2012b).
• Provide group-based training programs for instruction. CEB: Adults with type 2 diabetes who participate in group-based training programs have improved fasting blood glucose and A1C levels (Deakin et al, 2005).
• Teach client the importance of at least 150 minutes/week of moderate-intensity aerobic physical activity (50% to 70% of maximum heart rate). EB: “Regular exercise has been shown to improve blood glucose control, reduce cardiovascular risk factors, contribute to weight loss, and improve well-being…regular exercise may prevent type 2 diabetes in high-risk individuals” (ADA, 2012a).
• Discuss recommending resistance training with client’s provider. EB: Clinical trials have provided strong evidence for the A1C-lowering value of resistance training in older adults with type 2 diabetes and for an additive benefit of combined aerobic and resistance exercise in adults with type 2 diabetes (ADA, 2012a).
• Teach client with type 1 diabetes to avoid vigorous activity if ketones are present in urine or blood. Exercise can worsen hyperglycemia and ketosis in people deprived of insulin for 12 to 48 hours (ADA, 2012a).
• Teach clients who are treated with insulin or insulin-stimulating oral agents to eat added carbohydrates prior to exercise if glucose levels are below 100 mg/dL. Physical activity can cause hypoglycemia if medication dose or carbohydrate consumption is not altered (ADA, 2012a).
• Teach client and family members regarding sick day management, including importance of early contact with provider, continuing insulin or medication unless instructed otherwise, frequent monitoring, and oral intake. Many cases of DKA and HHS can be prevented by better access to medical care, proper patient education, and effective communication with a health care provider during an illness (Kitabchi, 2009).
References
American Diabetes Association (ADA). 2009 clinical practice recommendations. Diabetes Care. 32(Suppl 1), 2009.
American Diabetes Association (ADA), Living with diabetes. Retrieved August 15, 2011, from 2011 http://www.diabetes.org/living-with-diabetes
American Diabetes Association (ADA). 2012 clinical practice recommendations. Diabetes Care. 34(Suppl 1), 2012.
American Diabetes Association (ADA), Hypoglycemia. Living with diabetes, 2012 Retrieved March 5, 2012, from http://www.diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/hypoglycemia-low-blood.html
Battelino, T., et al. Effect of continuous glucose monitoring on hypoglycemia in type 1 diabetes. Diabetes Care. 2011;34(4):795–800.
Bendik, C.F., et al. Training in flexible intensive insulin therapy improves quality of life, decreases the risk of hypoglycaemia and ameliorates poor metabolic control in patients with type 1 diabetes. Diabetes Res Clin Pract. 2009;83(3):327–333.
Bentley, A. Blood glucose testing in aged care. JBI Database Evid Summ. 2009.
Chlebowy, D.O., Hood, S., LaJoie, A.S. Facilitators and barriers to self-management of type 2 diabetes among urban African American adults: focus group findings. Diabetes Educ. 2010;36(6):897–905.
Cox, D.J., et al. Blood glucose awareness training: what is it, where is it, and where is it going? Diabetes Spectr. 2006;19(1):43–49.
Cox, D.J., et al. Blood glucose awareness training delivered over the Internet. Diabetes Care. 2008;31(8):1527–1528.
Deakin, T., et al, Group-based training for self-management strategies in people with type 2 diabetes mellitus. Cochrane Database Syst Rev 2005;(2):CD003417.
Diabetes in Control, Drugs that can affect glucose levels, 2011 Retrieved August 14, 2011, from http://www.diabetesincontrol.com/images/tools/DrugListAffectingBloodGlucose.pdf
Goldberg, P.A., et al. “Waste not, want not”: determining the optimal priming volume for intravenous insulin infusions. Diabetes Technol Ther. 2006;8(5):598–601.
Goldstein, P.C. Assessment and treatment of hypoglycemia in elders: cautions and recommendations. MedSurg Nurs. 2009;18(4):215–251.
Hawthorne, K., et al, Culturally appropriate health education for type 2 diabetes mellitus in ethnic minority groups. Cochrane Database Syst Rev 2008;(3):CD006424.
Ingram, M., et al. The impact of promotoras on social support and glycemic control among members of a farmworker community on the US-Mexico border. Diabetes Educ. 2007;33(Suppl 6):172S–178S.
Kirk, J.K., et al. Blood glucose symptom recognition: perspectives of older rural adults. Diabetes Educ. 2011;37(3):363–369.
Kitabchi, A., et al. Hyperglycemic crises in adult patients with diabetes. Diabetes Care. 2009;32(7):1335–1343.
Kocurek, B. Promoting medication adherence in older adults… and the rest of us. Diabetes Spectr. 2009;22(2):80–84.
Lujan, J., Ostwald, S.K., Ortiz, M. Promotora diabetes intervention for Mexican Americans. Diabetes Educ. 2007;33(4):660–670.
Moghissi, E.S., et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Endocr Pract. 2009;15(4):353–369.
Nettles, A. Patient education in the hospital. Diabetes Spectr. 2005;18(1):44–48.
Pfützner, J., et al. Evaluation of dexterity in insulin-treated patients with type 1 and type 2 diabetes mellitus. J Diabetes Sci Technol. 2011;5(1):158–165.
Phillips, S., Phillips, A. Diabetes evidence based management: diabetes and older people: ensuring individualized practice. Pract Nurs. 2011;22(4):196–200.
Rubin, D., et al. Weight-based, insulin dose-related hypoglycemia in hospitalized patients with diabetes. Diabetes Care. 2011;34(8):1723–1728.
Sander, E., Odell, S., Hood, K. Diabetes-specific family conflict and blood glucose monitoring in adolescents with type 1 diabetes: mediational role of diabetes self-efficacy. Diabetes Spectr. 2010;23(2):89–94.
Zahid, N., et al. Adsorption of insulin onto infusion sets used in adult intensive care unit and neonatal care settings. Diabetes Res Clin Pract. 2008;80(3):e11–e13.
Ziegler, R., et al. Frequency of SMBG correlates with HbA1c and acute complications in children and adolescents with type 1 diabetes. Pediatr Diabetes. 2011;12(1):11–17.
Grieving
NANDA-I
A normal, complex process that includes emotional, physical, spiritual, social, and intellectual responses and behaviors by which individuals, families, and communities incorporate an actual, anticipated, or perceived loss into their daily lives
Defining Characteristics
Alteration in activity level; alterations in dream patterns; alterations in immune function; alterations in neuroendocrine function; alteration in sleep patterns; anger; blame; detachment; despair; disorganization; experiencing relief; maintaining connection to the deceased; making meaning of the loss; pain; panic behavior; personal growth; psychological distress; suffering
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Grief Work Facilitation, Dying Care, Emotional Support: Perinatal Death, Hope Instillation, Support System Enhancement, Family support, Family Integrity Promotion
Nursing Interventions and Rationales
Anticipatory Grieving Interventions
• Grieving of the client, and family/relatives of a critically ill and dying client for the losses experienced during the deteriorating illness, and the future that will be filled with loss.
• Develop a trusting relationship both with the client and with the family by using presence and therapeutic communication techniques. The use of presence is a significant part of the nurse’s care in palliative care.
• Keep the family apprised of the client’s ongoing condition as much as possible. Consult with the family for decision-making as appropriate. Be aware that surrogate decision making may be a burden to the family when the client was never clear about end-of-life wishes (Sanders & Corley, 2003).
• Keep the family informed on clients’ needs for physical care and support in symptom control, and inform them about health care options at the end of life including palliative care, hospice care, and home care (Wong & Chan, 2007).
• Encourage the family to touch the client as desired; when near death encourage holding the hand, or foot, or wherever can reach and is acceptable to the client and family member.
• Ask family members if receiving sufficient sleep. If a family member desires to be in the room for sleep, provide a reclining chair or portable bed if possible, and bedding to keep the family member comfortable. If needed, find housing for family member from out of town with support of case manager, or social worker. Family members often feel the need for permission to sleep.
• Ask family member when last ate if appropriate. Send to source of food, or provide food as able.
• Touch family members as appropriate. A brief touch on the shoulder can be comforting.
• Listen to the family member’s story. His story may differ from the client’s story, and knowing another reality may change the care given to both the client and family.
• Encourage family members to show their caring feelings and talk to the client. Recognize and respect different feelings and wishes from both the family members and client. Help both parties share feelings and adjust to changes in relationships (Clukey, 2008).
• If necessary, refer a family member for counseling or minister/priest to help him cope with the existential questions and current overwhelming reality.
• Recognize that one family member may be in a state of caregiver role strain from a long caregiving situation. In this situation, the caregiver may be experiencing losing control over his own life, and autonomy being “burdened” with the care for the client (Holley & Mast, 2009). See the care plan Caregiver Role Strain if appropriate.
• Promote the family roles as appropriate. Each family member has a role, and each person differs in interpersonal relationships; recognize these roles and the client’s position in the family. By naming these in conversations, family members and the client recognize roles, and it helps clarify what is happening when they lose track of each other (Holley & Mast, 2009).
• Promote mutual goal setting where decisions are made together that affect the family. “Things” don’t have to be solved at the last minute. Determine with the client and the family what has to be spoken of or has to be realized before death; encourage a life review, as this can help to find perspective in the short term (Mystakidou et al, 2008; 2009). The family’s response to critical illness includes development of psychological outcomes such as anxiety, acute stress disorder, post-traumatic stress, depression, and complicated grief. The response can include a physical withdrawal from the client, with loss of the relationship or an excessive drive to care for the client (Holley & Mast, 2009). In case of caregiver stress a family member might have a hostile attitude to the care delivery system (Clukey, 2008). Adverse psychological outcomes occur in parents of infants, in children, and in family members of adult clients and may be present for more than 4 years after intensive care unit discharge. The way caregivers communicate with the family and include in decision-making may affect long-term outcomes for the family (Davidson, Jones, & Bienvenu, 2012).
Grieving Interventions When Death of a Loved One Occurs
• Utilize the following activities when interacting with the bereaved person:
Be present and attentive, use active empathetic listening. Empathetic listening is a cornerstone of psychological support. It allows the clients’ experiences to count, and themselves to matter (Gamino & Ritter, 2012).
Validate the client’s feelings of grief, and feeling hurt, stressful, anxious, out of control, and further symptoms of grieving. Respectful acknowledgment of the griever’s pain when helping those who have sustained a major loss can be helpful (Gamino & Ritter, 2012).
Provide time and space for the person to tell their story of loss.
Offer condolences: “I am sorry that you lost your husband.”
Explain that the feelings will oscillate, as the person does grief work, from coping to accept the loss, to coping to build a new life without the loved one.
Intentionally schedule meetings with the family member(s) to provide support during grieving.
EBN: A study conducted by White and Ferszt (2009) found the listed interventions to be helpful when helping a grieving person.
• Help the client utilize a method to give voice to his unique story of loss. Methods to do this include: Keeping a personal journal to record feelings and insights/Retelling of the loss narrative to a caring person/Music therapy techniques with a trained therapist, or listening to music that has significance to the relationship/Use of the “Virtual Dream,” a dreamlike short story written by the grieving person to tell the narrative of the loss. Telling the story of the loss is helpful to the bereaved person to make sense of the death experience, find key themes in his life story that has been disrupted, and work his way through a time of overwhelming change (Neimeyer & Torres, 2011).
• Discuss coping methods with the grieving person. Common coping techniques used include exercise, telling the story of grief to a caring person, journaling, pets, and developing a legacy for the deceased. EB: This study identified the uniqueness of the griever, recognized there are multiple factors that influence the grieving process (i.e., culture, personality, and gender), that most bereaved individuals use both cognitive and affective strategies in coping with bereavement, and that bereaved individuals experience both internal and external pressures to grieve in particular ways (Doughty, 2009).
• Encourage the family to create a quiet and comfortable healing environment, and follow comforting grief rituals such as prayer, interacting with nature, or lighting votive candles.
Refer the family members for spiritual counseling if desired. EB: A study that examined the effects of spirituality on grieving found that a more secure style of attachment to God was directly and indirectly associated with lower rates of depression and grief and increased stress-related growth (Kelley & Chan, 2012).
• Help the family determine the best way and place to find social support. Encourage family members to continue to use supports as needed for years. Research has consistently reported that social support from family, friends, and colleagues is an important factor in the bereaved person’s ability to cope after the loss of a loved one (Bath, 2009).
• Identify available community resources, including bereavement groups at local hospitals and hospice centers. Volunteers who provide bereavement support can also be effective. CEB: Social support helps bereaved individuals as they reconstruct their lives and find new meaning in life (Hogan, Worden, & Schmidt, 2004).
• Watch for signs of complicated grieving. These include the absence of support in a person’s social network, the presence of a concurrent life crisis, a highly ambivalent marital relationship that preceded the spouse’s death, traumatic circumstances surrounding the death such as suicide, homicide or traffic accident, bereavement with young children, limited economic resources, high self-reproach, high pining, and persistent anger associated with grieving (Neimeyer & Torres, 2011).
• Treat the child with respect, give him or her opportunity to talk about concerns, and answer questions honestly. Children know much more than adults realize. They are very observant and generally know if a parent or loved one is dying, or cause of death, even if they have not been told (Schuurman, 2012).
• Listen to the child’s expression of grief. The best thing to be done to help a child is to listen with our ears, eyes, hearts, and souls, and recognize that we do not have to have answers (Brown, 2009; Schuurman, 2012).
• Help parents recognize that the grieving child does not have to be “fixed;” instead they need support going through an experience of grieving just as adults. The role of the nurse, parent, and friends is to support and assist, not to help them “get over it” (Schuurman, 2012).
• Consider the use of art for children in hospice care who are dying or dealing with the death of a parent, sibling, or other family member. CEB: The arts are being recognized as a powerful tool for psychological, emotional, and spiritual support. Children learn to use the arts as a healthy and effective coping strategy (Rollins & Riccio, 2002).
Refer grieving children and parents to a program to help facilitate grieving if desired, especially if the death was traumatic. EBN: When a child dies, the parent embarks on a lifelong grief for the loss, and sharing the grief can help the parent (Arnold & Gemma, 2008). EBN: A case study demonstrated that identifying and reinforcing the mother’s strengths in caring for a child with serious health problems helped deal with emotional responses of hopelessness and helplessness (Bettle & Latimer, 2009).
• Help the adolescent determine sources of support and how to use them effectively.
• Encourage grieving parents to take good care of their own health. Research has shown that parents have serious sleep disturbances, loss of appetite, fatigue, and an increased risk of mortality after loss of a child (Alam et al, 2012).
Encourage grieving parents to seek mental health services as needed. The death of a child is regarded as among the most traumatic, incomprehensible, and devastating of losses, with the potential to precipitate a crisis of meaning for the bereaved parent.
• Recognize that men and women often grieve differently, and explain this to parents if it becomes an issue. EB: Mothers and fathers of children who died of cancer grieved differently; mothers were more grief stricken, and generally either stopped working, or worked only part-time. Mothers concentrated on the care of remaining children. Fathers were more task oriented, and went back to work sooner. Also, fathers had more anger, and were reserved in their grieving (Alam et al, 2012). EB: A study found that men were ready to resume sexual activity much sooner than women; some women lost interest in sex and avoided sexual activity in the marriage following loss of a child (Dyregrov & Gjestad, 2012).
• Recognize that mothers who have a miscarriage grieve and experience sorrow because of loss of the child. There is a need for therapeutic interventions given in a caring, compassionate, and culturally sensitive way to help mothers with this significant loss (Wojnar, Swanson, & Adolfsson, 2011).
• Monitor an older adult who has been treated for bereavement-related depression for relapse or recurrence.
• Provide support for the family when the loss is associated with dementia of the family member. EB: Caregivers of persons with Alzheimer’s disease scored high on the Caregiver Grief Inventory. Coping strategies used by this group of caregivers included spiritual faith, social supports, and pets. Caregivers with high levels of grief may benefit from supportive interventions and interventions that facilitate building a supportive network (Sanders et al, 2008).
• Pay careful attention to the older adult’s self-care. EBN: Self-care activities of older adults’ such as exercise, nutrition, and medication management were identified in a study as being essential in overall primary care management when an older adult suffered the loss of a loved one (White & Ferszt, 2009).
• Determine the social supports of older adults. An older adult’s support system may dramatically change after the loss of a loved one, and identifying community supports and perhaps suggesting a family meeting to review an older adult’s need for social support may be beneficial.
Multicultural:• The interventions previously described may be adapted for home care use.
• Assessment of ADLs and IADLs is essential as part of comprehensive care after a home care client has suffered the loss of a loved one. If the deceased had been a caregiver, additional family or formal supports may be needed. Consideration for long-term care placement may also be required depending on the older adult’s health and functional status.
• Actively listen as the client grieves for his or her own death or for real or perceived loss. Normalize the client’s expressions of grief for self. Demonstrate a caring and hopeful approach.
Refer the client to medical social services as necessary for losses not related to death. Support is helpful to grief work for all types of losses. Social workers can help the client plan for financial changes as a result of job losses and help with community referrals as appropriate.
Refer the bereaved to hospice bereavement programs, or an Internet self-help group. Relief of the suffering of clients and families (physical, emotional, and spiritual) is the goal of hospice care (McKay, 2008).
References
Alam, R., et al. Bereavement experiences of mothers and fathers over time after the death of a child due to cancer. Death Stud. 2012;36(1):1–22.
Arnold, J., Gemma, P.B. The continuing process of parental grief. Death Stud. 2008;32(7):658–673.
Bath, D.M. Predicting social support for grieving persons: a theory of planned behavior perspective. Death Stud. 2009;33(10):869–889.
Bettle, A.M., Latimer, M.A. Maternal coping and adaptation: a case study examination of chronic sorrow in caring for an adolescent with a progressive neurodegenerative disease. Can J Neurosci Nurs. 2009;31(4):15–21.
Brown, E. Helping bereaved children and young people. Br J School Nurs. 2009;4(2):69–73.
Clukey, L. Anticipatory mourning: processes of expected loss in palliative care. Int J Palliat Nurs. 2008;14(7):316–325.
Davidson, J.E., Jones, C., Bienvenu, O.J. Family response to critical illness: post–intensive care syndrome—family. Crit Care Med. 2012;40(2):618–624.
Doughty, E.A. Investigating adaptive grieving styles: a Delphi study. Death Stud. 2009;33(5):462–480.
Dyregrov, A., Gjestad, R. Sexuality following the loss of a child. Death Stud. 2011;35(4):289–315.
Gamino, L., Ritter, R.H. Death competence: an ethical imperative. Death Stud. 2012;36(1):23–40.
Hogan, N., Worden, J.W., Schmidt, L. An empirical study of the proposed complicated grief disorder criteria. Omega (Westport). 2004;48(3):263–277.
Holley, C.K., Mast, B.T. The impact of anticipatory grief on caregiver burden in dementia caregivers. Gerontologist. 2009;49(3):388–396.
Kelley, M., Chan, K. Assessing the role of attachment to God, meaning, and religious coping as mediators in the grief experience. Death Stud. 2012;36(3):199–227.
McKay, B. Internet resources for hospice and bereavement. Med Ref Serv Q. 2008;27(2):199–210.
Mystakidou, K., et al. Screening for preparatory grief in advanced cancer patients. Cancer Nurs. 2008;31(4):326–332.
Mystakidou, K., et al. Illness-related hopelessness in advanced cancer: Influence of anxiety, depression, and preparatory grief. Arch Psychiatr Nurs. 2009;23(2):138–147.
Neimeyer, R., Torres, C. The virtual dream: rewriting stories of loss and grief. Death Stud. 2011;35:646–672.
Rollins, J.A., Riccio, L.L. ART is the heART: a palette of possibilities for hospice care. Pediatr Nurs. 2002;28(4):355–363.
Sanders, S., Corley, C.S. Are they grieving? A qualitative analysis examining grief in caregivers of individuals with Alzheimer’s disease. Soc Work Health Care. 2003;37:35–53.
Sanders, S., et al. The experience of high levels of grief in caregivers of persons with Alzheimer’s disease and related dementia. Death Stud. 2008;32(6):495–523.
Schuurman, D.L., The club no one wants to join: a dozen lessons I’ve learned from grieving children and adolescents, 2012 Retrieved May 4, 2012, from http://www.grief.org.au/grief_and_bereavement_support/understanding_grief/supporting_children/the_club_no_one_wants_to_join
White, P., Ferszt, G. Exploration of nurse practitioner practice with clients who are grieving. J Am Acad Nurse Pract. 2009;3(4):231–240.
Wojnar, D.M., Swanson, K.M., Adolfsson A-, S. Confronting the inevitable: a conceptual model of miscarriage for use in clinical practice and research. Death Stud. 2011;35(6):536–558.
Wong, M.S., Chan, S.W. The experiences of Chinese family members of terminally ill patients—a qualitative study. J Clin Nurs. 2007;16(12):2357–2364.
Complicated Grieving
NANDA-I
A disorder that occurs after the death of a significant other in which the experience of distress accompanying bereavement fails to follow normative (or cultural) expectations and manifests in functional impairment
Defining Characteristics
Decreased functioning in life roles; decreased sense of well-being; depression; experiencing somatic symptoms of the deceased; fatigue; grief avoidance; longing for the deceased; low levels of intimacy; persistent emotional distress; preoccupation with thoughts of the deceased; rumination; searching for the deceased; self-blame; separation distress; traumatic distress; verbalizes anxiety; verbalizes distressful feelings about the deceased; verbalizes feeling dazed; verbalizes feeling empty; verbalizes feeling in shock; verbalizes feeling stunned; verbalizes feelings of anger; verbalizes feelings of detachment from others; verbalizes feelings of disbelief; verbalizes feelings of mistrust; verbalizes lack of acceptance of the death; verbalizes persistent painful memories; verbalizes self-blame; yearning
NOC (Nursing Outcomes Classification)
Anxiety Level; Coping; Depression; Grief Resolution; Mood Equilibrium; Personal Well-Being; Psychosocial Adjustment: Life Change, Sleep
Client Outcomes
Client Will (Specify Time Frame)
• Express appropriate feelings of guilt, fear, anger, or sadness
• Identify somatic distress associated with grief (e.g., anxiety, changes in appetite, insomnia, nightmares, loss of libido, decreased energy, altered activity levels)
• Seek support in dealing with grief-associated issues
• Identify personal strengths and effective coping strategies
• Function at a normal developmental level and begin to successfully and increasingly perform activities of daily living
NIC (Nursing Interventions Classification)
Grief Work Facilitation, Grief Work Facilitation: Perinatal Death, Guilt Work Facilitation, Hope Installation
Nursing Interventions and Rationales
• Watch for signs of complicated grieving that include symptoms that persist at least 6 months after the death and are experienced at least daily or to a disabling degree. Symptoms include feeling emotionally numb, stunned, shocked, and that life is meaningless; dysfunctional thoughts and maladaptive behaviors; experiencing mistrust and estrangement from others; anger and bitterness over the loss; identity confusion; avoidance of the reality of the loss, or excessive proximity seeking to try to feel closer to the deceased, sometimes focused on wishes to die or suicidal statements and behavior; or difficulty moving on with life. Symptoms must be associated with functional impairment (Prigerson et al, 2009; Shear et al, 2011).
Determine the client’s state of grieving. Use a tool such as the Prolonged Grief Disorder Scale (Prigerson et al, 2009), the Grief Support in Health Care Scale (Anderson et al, 2010), the Hogan Grief Reaction Checklist (Hogen, Worden, & Schmidt, 2004), and the Beck Depression Inventory. CEB: These tools have been shown to measure grief symptoms effectively and may help differentiate depression from complicated grief (Hogan, Worden, & Schmidt, 2004).
Determine whether the client is experiencing depression, suicidal tendencies, or other emotional disorders. Refer the client for counseling or therapy as appropriate. EB: Counseling, including the use cognitive-behavioral therapy has been shown to be helpful for complicated grieving (Gibson, 2012; Mancini, Griffin, & Bonanno, 2012).
• Educate the client and his or her support systems that grief resolution is not a sequential process and that the positive outcome of grief resolution is the integration of the deceased into the ongoing life of the griever. CEB: Expectation that the griever will in some way “get over” or “get past” the grief is no longer seen as valid; continued involvement with the deceased regularly occurs (Matthews & Marwit, 2004).
Assess caregivers, particularly younger caregivers, for pessimistic thinking and additional stressful life events and refer for appropriate support. EB: A study found that those under 60 years old had higher levels of complicated grief predeath than caregivers 60 and older. There was a significant correlation with levels of complicated grief and pessimistic thinking and severity of stressful life events (Tomarken et al, 2008).
• See the interventions and rationales in the care plans for Grieving and Chronic Sorrow.
Refer grieving children and parents to a program to help facilitate grieving if desired, especially if the death was traumatic. EBN: When a child dies, the parent embarks on a lifelong grief for the loss, and sharing the grief can help the parent (Arnold & Gemma, 2008). EBN: A case study demonstrated that identifying and reinforcing the mother’s strengths in caring for a child with serious health problems helped deal with emotional responses of hopelessness and helplessness (Bettle & Latimer, 2009).
• Encourage grieving parents to take good care of their own health. Research has shown that parents have serious sleep disturbances, loss of appetite, fatigue, and an increased risk of mortality after loss of a child (Alam et al, 2012).
Encourage grieving parents to seek mental health services as needed. The death of child is regarded as among the most traumatic, incomprehensible, and devastating of losses, with the potential to precipitate a crisis of meaning for the bereaved parent (Gerrish & Bailey, 2012). A specialized follow up program for fathers who have lost children, with a focus on social supports has been found to reduce symptoms of complicated grieving (Aho et al, 2011).
• Help the adolescent determine sources of support and how to use them effectively. If client is an adolescent exposed to a peer’s suicide, watch for symptoms of traumatic grief as well as PTSD, which include numbness, preoccupation with the deceased, functional impairment, and poor adjustment to the loss. CEB: Adolescents in this situation are at high risk for depression, anxiety disorder, substance abuse, conduct disorder, and attention deficit-hyperactivity disorder (Melhem et al, 2004).
See the pediatric and parent interventions in the care plans for Grieving and Chronic Sorrow.
• Pay careful attention to the older adult’s self-care. Self-care activities of older adults such as exercise, nutrition, medication management were identified in a study as being essential in overall primary care management when an older adult suffered the loss of a loved one (White & Ferszt, 2009).
• Those who have lived with elders with dementia and experienced significant feelings of loss before the loved one’s death may be at risk for more intense feelings of grief after the death of the client with dementia. Identifying those at-risk clients might assist in tailoring grief counseling (Givens et al, 2011).
Elderly people experience complicated grieving with physical and mental health problems especially when the deceased is a child or spouse (Newson et al, 2011).
• Assess for the influence of cultural beliefs, norms, and values on the client’s grief and mourning practices. EBN: Catholics traditionally have a priest present at the wake that provides a short prayer service. Jewish practices depend on orthodox, conservative, or reformed traditions and are primarily solemn expressions of grief for 7 days, with burial in a wooden coffin the day after death (Franco & Wilson, 2008). EBN: An important aspect of filial piety and family loyalty is an obligation that extends beyond death: observing the anniversary day of the death, gathering at the family home and altar, and cleaning the ancestral tombs. For Buddhists, there typically are special observances, usually with elaborate rites at 100 days, and 1 and 2 years after the death (Stauffer, 2008).
• Encourage discussion of the grief process. EBN: Clients from an ethnic minority group were significantly more likely to report that interviews about death, dying, and bereavement were helpful (Cherry & Giger, 2008). EB: In this study African Americans reported higher levels of complicated grief symptoms than Caucasians, especially when they spent less time speaking to others about their loss experience (Laurie & Neimeyer, 2008).
• Identify whether the client had been notified of the health status of the deceased and was able to be present during illness and death. EBN: Not being present during terminal illness and death can disrupt the grieving process (Giger & Davidhizar, 2008).
• Consider providing support via the Internet. EB: Bereaved parents and individuals bereaved by the sudden, unexpected, or violent death of a loved one are at high risk for developing complicated grief. In this study, an Internet-based intervention led to a significant reduction in symptoms of complicated grief and depression at post treatment (Wagner & Maercker, 2008). CEB: Results of this study of an Internet bereavement support group indicate that the reduction in symptoms of complicated grief observed at post treatment was maintained at 1.5-year follow-up (Wagner & Maercker, 2007).
References
Aho, A.L., et al. Development and implementation of a bereavement follow-up intervention for grieving fathers: an action research. J Clin Nurs. 2011;20(3-4):408–419.
Alam, R., et al. Bereavement experiences of mothers and fathers over time after the death of a child due to cancer. Death Stud. 2012;36(1):1–22.
Anderson, K., et al. The Grief Support in Healthcare Scale: development and testing. Nurs Res. 2010;59(6):372–379.
Arnold, J., Gemma, P.B. The continuing process of parental grief. Death Stud. 2008;32(7):658–673.
Bettle, A.M., Latimer, M.A. Maternal coping and adaptation: a case study examination of chronic sorrow in caring for an adolescent with a progressive neurodegenerative disease. Can J Neurosci Nurs. 2009;31(4):15–21.
Cherry, B., Giger, J. African-Americans. In Giger J., Davidhizar R.E., eds.: Transcultural nursing: assessment and intervention, ed 5, St Louis: Mosby, 2008.
Gerrish, N., Bailey, S. Using the biographical grid method to explore parental grief following the death of a child. Bereavement Care. 2012;31(1):11–17.
Gibson, J. How cognitive behaviour therapy can alleviate older people’s grief. Ment Health Pract. 2012;15(6):12–17.
Giger J., Davidhizar R.E., eds. Transcultural nursing: assessment and intervention, ed 5, St Louis: Mosby, 2008.
Givens, J., et al. Grief among family members of nursing home residents with advanced dementia. Am J Geriatr Psychiatry. 2011;19(6):543–550.
Hogan, N.S., Worden, J.W., Schmidt, L.A. An empirical study of the proposed complicated grief disorder criteria. Omega. 2004;48(3):263–277.
Laurie, A., Neimeyer, R.A. African Americans in bereavement: grief as a function of ethnicity. Omega (Westport). 2008;57(2):173–193.
Mancini, A.D., Griffin, P., Bonanno, G.A. Recent trends in the treatment of prolonged grief. Curr Opin Psychiatry. 2012;25(1):46–51.
Matthews, L., Marwit, S. Complicated grief and the trend toward cognitive-behavioral therapy. Death Stud. 2004;28:849–863.
Melhem, N.M., et al. Traumatic grief among adolescents exposed to a peer’s suicide. Am J Psychiatry. 2004;161(8):1411.
Newson, R.S., et al. The prevalence and characteristics of complicated grief in older adults. J Affect Disord. 2011;132:231–238.
Prigerson, H.G., et al. Prolonged grief disorder: psychometric validation of criteria proposed for DSM-V and ICD-11. PLoS Med. 2009;6(8):e1000121.
Shear, M.K., et al. Complicated grief and related bereavement issues for DSM-5. Depress Anxiety. 2011;28:103–117.
Stauffer, R. Vietnamese. In Giger J., Davidhizar R.E., eds.: Transcultural nursing: assessment and intervention, ed 5, St Louis: Mosby, 2008.
Tomarken, A., et al. Factors of complicated grief pre-death in caregivers of cancer patients. Psychooncology. 2008;17(2):105–111.
Wagner, B., Maercker, A. A 1.5-year follow-up of an Internet-based intervention for complicated grief. J Trauma Stress. 2007;20(4):625–629.
Wagner, B., Maercker, A. An Internet-based cognitive-behavioral preventive intervention for complicated grief: a pilot study. G Ital Med Lav Ergon. 2008;30(3 Suppl B):B47–B53.
White, P., Ferszt, G. Exploration of nurse practitioner practice with clients who are grieving. J Am Acad Nurse Pract. 2009;3(4):231–240.
Risk for complicated Grieving
NANDA-I
At risk for a disorder that occurs after the death of a significant other, in which the experience of distress accompanying bereavement fails to follow normative expectations and manifests in functional impairment
NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family Teaching and Discharge Planning, Rationales, and References
Refer to care plan for Complicated Grieving.
Risk for disproportionate Growth
NANDA-I
At risk for growth above the 97th percentile or below the 3rd percentile for age, crossing two percentile channels
Risk Factors
Caregiver
Abuse; learning difficulties (mental handicap); mental illness; or severe learning disability
Environmental
Deprivation; economically disadvantaged; lead poisoning; natural disasters; teratogen; violence
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Eating Disorders Management, Weight Management, Nutrition Therapy, Nutrition Management, Teaching: Infant Nutrition, Toddler Nutrition
Nursing Interventions and Rationales
Preconception/Pregnancy
• Counsel women who smoke to quit smoking prior to conception if possible and to avoid smoking and secondhand smoke while pregnant. EB: In prospective studies, environmental tobacco smoke exposure was associated with a 33-g reduction in mean birth weight, and in retrospective studies a 40-g reduction in mean birth weight (Bee et al, 2008).
• Assess alcohol consumption of pregnant women and advise those that drink alcohol to discontinue all use of alcohol through the pregnancy. EB: Current research suggests that alcohol intake of seven or more standard drinks (one standard drink = 13.6 grams of absolute alcohol) per week during pregnancy places the fetus at significant risk for the negative effects of ethanol. Effects of alcohol on the fetus are influenced not only by the amount of alcohol consumed, but by the pattern of alcohol (binge drinking versus daily consumption of alcohol) and the exposure threshold amounts of alcohol in the blood, as well as the timing of exposure during gestation (Stade, Bailey, & Dzendoletas, 2009).
• Assess and limit exposure to all drugs (prescription, “recreational,” and over the counter) and give the mother information on known teratogenic agents. EB: According to the National Research Council, 3% of all birth defects and developmental disabilities are caused by environmental exposures. No drug can be considered safe during pregnancy. It should be emphasized that any drug has the potential to cause a birth defect, so no listing of known teratogens is ever complete (CDC, 2011; Florida Birth Defects Registry, 2009).
• All women of childbearing age who are capable of becoming pregnant should take 400 mcg of folic acid daily. EB: Periconceptional use of folic acid reduces the incidence of neural tube defects. Up to 70% of neural tube defects could be prevented if all women who can become pregnant consumed 400 mcg of folic acid from at least 1 month before conception through the first trimester of pregnancy (CDC, 2011; Florida Birth Defects Registry, 2009).
Promote a team approach toward preconception and pregnancy glucose control for women with diabetes. EB: Offspring of women with diabetes mellitus type 1 or type 2 have a two- to fourfold increased risk of birth defects. Available data suggest that excellent preconception and first-trimester glucose control in the mother can greatly reduce, if not eliminate, this risk. Fetal morbidity may still be high in the second and third trimesters if gestational diabetes is not under good control. Programs with a team approach have been the most successful (CDC, 2011; Florida Birth Defects Registry, 2009).
Advise women with mental health disorders to seek appropriate counseling prior to pregnancy. EB: Well-characterized risks are associated with valproate, carbamazepine, lamotrigine, and lithium (Nguyen, Sharma, & McIntyre, 2009).
• Consider regular breast milk and protein-fortified breast milk for low-birth-weight infants in the neonatal intensive care unit. CEB: Observational studies, and meta-analyses of trials comparing feeding with formula milk versus donor breast milk, suggest that feeding with breast milk has major nonnutrient advantages for preterm or low-birth-weight infants (Henderson, Anthony, & McGuire, 2007). In an earlier study it was concluded that protein-enriched breast milk enables low-birth-weight infants requiring especially intensive care to attain growth at discharge comparable to that of healthier infants not given enriched milk (Funkquist et al, 2006).
• Provide tube feedings per physician’s orders when appropriate for clients with neuromuscular impairment. EB: Malnutrition and gastrointestinal disorders are common in children with cerebral palsy. On the other hand, improved nutritional status seems to have a positive effect on motor function in these children (Bekem et al, 2008).
• Provide for adequate nutrition and nutritional monitoring in clients with medical disorders requiring chronic medication and those with developmental delay. EB: One study found a high prevalence of overweight children who had developmental delay. Many factors can contribute to overweight issues in this population, including sedentary lifestyle and medications with weight gain as a side effect (De, Small, & Baur, 2008). Drugs such as SSRIs, (selective serotonin reuptake inhibitors) mood stabilizers, psychostimulants, and antipsychotics can cause weight gain in adolescents. Other medications used to treat chronic conditions, such as stimulants, can cause poor weight gain (Jerrell, 2010).
• Adequate intake of vitamin D is set at 400 IU/day by the National Academy of Sciences. Because adequate sunlight exposure is difficult to determine, a supplement of 400 IU/day is recommended for the following groups to prevent rickets and vitamin D deficiency in healthy infants and children:
All breastfed infants unless they are weaned to at least 500 mL/day of vitamin D-fortified formula or milk
All non-breastfed infants who are ingesting less than 500 mL/day of vitamin D-fortified formula or milk
Children and adolescents who do not receive regular sunlight exposure, do not ingest at least 500 mL/day of vitamin D–fortified milk, or do not take a daily multivitamin supplement containing at least 400 IU of vitamin D
EB: It is now recommended that all infants and children, including adolescents, have a minimum daily intake of 400 IU of vitamin D beginning soon after birth. New evidence supports a potential role for vitamin D in maintaining innate immunity and preventing diseases such as diabetes and cancer (Wagner & Greer, 2008).
• Provide adequate nutrition to clients with active intestinal inflammation. EB: Nutrition plays a role in inflammatory bowel disease (IBD), primarily in prevention and treatment of malnutrition and growth failure. Furthermore, in Crohn disease (CD), nutrition can induce remission, maintain remission, and prevent relapse. Malnutrition is common in IBD and the mechanisms involved include decreased food intake, malabsorption, increased nutrient loss, increased energy requirements, and drug-nutrient interactions (Shamir, 2009).
• Encourage limiting “screen time” (television, video games, Internet, smart phones, and tablets) to less than 2 hours/day for children. EB: High levels of sedentary behaviors, particularly television viewing, are associated with increased risk of overweight and obesity during youth (Hume et al, 2010). The relationship between weight status and time spent in sedentary activities is well documented among older children and adolescents. The formative school years may be an important period when these relationships emerge, providing an opportune time to intervene (Jones et al, 2010).
• Assess the influence of cultural beliefs, norms, values, and expectations on parents’ perceptions of normal growth and development. EBN: One binational study found a Mexican cultural norm toward larger ideal body types for children and showed that the vestiges of this cultural norm persist in Mexican immigrant communities in the United States (Jones et al, 2010).
• Focus nutritional education on promoting good nutrition and physically active lifestyles for healthy child development as opposed to only for prevention or reduction of overweight. EBN: Programs to address overweight among children of Mexican descent in both the United States and Mexico may be more effective if they focus on alternative benefits of weight control strategies (Jones et al, 2010).
• Assess for the influence of acculturation. EB: One study found a marked relationship between acculturation, measured by generational status and language use at home, and failure to meet physical activity recommendations among adolescents aged 10 to 17 (Liu et al, 2009).
• Assess whether the parents are concerned about the amount of food eaten. CEB: Some cultures may add semisolid food within the first month of life because of concerns that the infant is not getting enough to eat and the perception that “big is healthy” (Higgins, 2000). Studies have found that the introduction of solids at less than 4 months is a risk factor for increased infant weight gain (Taveras et al, 2010).
• Assess the influence of family support on patterns of nutritional intake. EBN: In some studies mothers’ pressure on their children to eat has been associated with disinhibited eating and increased child energy intake and body weight (Taveras et al, 2010).
• Negotiate with clients regarding which aspects of healthy nutrition can be modified while still honoring cultural beliefs. CEB: Give and take with clients will lead to culturally congruent care (Leininger & McFarland, 2002). EB: Although black and Hispanic mothers were more likely to initiate breastfeeding, they were less likely to breastfeed their infants exclusively to 6 months of age and were more likely to introduce solid foods before 4 months of age (Taveras et al, 2010).
• Encourage parental efforts at increasing physical activity and decreasing dietary fat for their children. EB: Parental role modeling and parental social support are important elements to consider in designing programs to increase physical activity among underserved adolescents (Wright et al, 2010). Fluctuation of resources affects family food purchase and consumption, resulting in unstable eating patterns and unhealthy eating (Kaufman & Karpati, 2007).
• The interventions previously described may be adapted for home care use.
• Assess parental perception of their child’s weight. EBN: If parents do not recognize their child as at risk for overweight, or overweight, they cannot intervene to diminish the risk factors for pediatric obesity and its related complications (Doolen, Alpert, & Miller, 2009).
• Assess family meal planning and family participation in mealtime activities such as eating together at a scheduled time. EB: Lifestyle assessment is an opportunity to identify potential targets for prevention and increase families’ self-awareness of current behaviors (Daniels et al, 2009).
Client/Family Teaching and Discharge Planning:
• Educate families and children about providing healthy meals and healthy eating to improve learning ability. EB: Using standardized tests, results of one study suggest that a nutritional education program can improve academic performance measured by achievement of specific mathematics and English education standards (Shilts, Lamp, & Horowitz, 2009).
References
Bee, J.L., et al. Environmental tobacco smoke and fetal health: systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed. 2008;93(5):F351–F361.
Bekem, O., et al. Effect of nutritional support in children with spastic quadriplegia. Pediatr Neurol. 2008;39:330–334.
CDC (Centers for Disease Control and Prevention). Birth Defects: Research and tracking. Retrieved Sept 7, 2012, from http://www.cdc.gov/ncbddd/birthdefects/research.html.
Daniels, S.R., et al. American Heart Association Childhood Obesity Research Summit: executive summary. Circulation. 2009;119(15):2114–2123.
De, S., Small, J., Baur, L.A. Overweight and obesity among children with developmental disabilities. J Intellect Devel Disabil. 2008;33(1):43–47.
Doolen, J., Alpert, P.T., Miller, S.K. Parental disconnect between perceived and actual weight status of children: a metasynthesis of the current research. J Am Acad Nurse Pract. 2009;21:160–166.
Florida Birth Defects Registry. Prevention strategies index: strategies to prevent birth defects: limit all drug exposures (prescriptions, “recreational, ” and over-the-counter). Retrieved April 1, 2009, from http://www.fbdr.org.
Funkquist, E.L., et al. Growth and breastfeeding among low birth weight infants fed with or without protein enrichment of human milk. Ups J Med Sci. 2006;111(1):97–108.
Henderson, G., Anthony, M.Y., McGuire, W. Formula milk versus maternal breast milk for feeding preterm or low birth weight infants. Cochrane Database Syst Rev. (4):2007. [CD002972].
Higgins, B. Puerto Rican cultural beliefs: influence on infant feeding practices in western New York. J Transcult Nurs. 2000;11(1):19.
Hume, C., et al. Understanding the correlates of adolescents’ TV viewing: social ecological approach. Int J Pediatr Obes. 2010;1(2):61–168.
Jerrell, J.M. Neuroendocrine-related adverse events associated with antidepressant treatment in children and adolescents. CNS Neurosci Ther. 2010;16(2):3–90.
Jones, R.A., et al. Relationships between child, parent and community characteristics and weight status among young children. Int J Pediatr Obes. 2010;5(3):256–264.
Kaufman, L., Karpati, A. Understanding the sociocultural roots of childhood obesity: food practices among Latino families of Bushwick, Brooklyn. Soc Sci Med. 2007;64(11):2177–2188.
Leininger, M.M., McFarland, M.R. Transcultural nursing: concepts, theories, research and practices, ed 3. New York: McGraw-Hill; 2002.
Liu, J., et al. Acculturation, physical activity, and obesity among Hispanic adolescents. Ethnic Health. 2009;14(5):509–525.
Nguyen, H.T., Sharma, V., McIntyre, R.S. Teratogenesis associated with antibipolar agents. Adv Ther. 2009;26(3):281–294.
Shamir, R. Nutritional aspects in inflammatory bowel disease. J Pediatr Gastroenterol Nutr. 2009;48:S86–S88.
Shilts, M.K., et al. Pilot study: EatFit impacts sixth graders’ academic performance on achievement of mathematics and English education standards. J Nutr Educ Behav. 2009;41(2):127–131.
Stade, B.C., et al. Psychological and/or educational interventions for reducing prenatal alcohol consumption in pregnant women and women planning pregnancy. Cochrane Database Syst Rev. (2):2009. [CD004228].
Taveras, E.M., et al. Racial/ethnic differences in early-life risk factors for childhood obesity. Pediatrics. 2010;125(4):686–695.
Wagner, C.L., Greer, F.R. Prevention of rickets and vitamin D deficiency in infants, children, and adolescents. Pediatrics. 2008;122(5):1142–1152.
Wright, M.S., et al. A qualitative study of parental modeling and social support for physical activity in underserved adolescents. Health Educ Res. 2010;25(2):224–232.
Delayed Growth and Development
NANDA-I
Defining Characteristics
Altered physical growth; decreased response time; delay in performing skills typical of age group; difficulty in performing skills typical of age group; flat affect; inability to perform self-care activities appropriate for age; inability to perform self-control activities appropriate for age; listlessness
NOC (Nursing Outcomes Classification)
Child Development: 1 Month, 2 Months, 4 Months, 6 Months, 12 Months, 2 Years, 3 Years, 4 Years, 5 Years, Middle Childhood, Adolescence, Development: Late Adulthood, Middle Adulthood, Young Adulthood, Growth, Physical Aging, Physical Maturation: Female, Male
Client Outcomes
Client/Parents/Primary Caregiver Will (Specify Time Frame)
• Describe realistic, age-appropriate patterns of growth and development
• Promote activities and interactions that support age-related developmental tasks
• Display consistent, sustained achievement of age-appropriate behaviors (social, interpersonal, and/or cognitive) and/or motor skills
• Achieve realistic developmental and/or growth milestones based on existing abilities, extent of disability, and functional age
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Counsel women who smoke to quit smoking prior to conception if possible and to avoid smoking and secondhand smoke while pregnant. EB: In prospective studies, secondhand smoke exposure during pregnancy has been found to increase the risk of developmental delay (Lee et al, 2011).
• To determine risk for or actual deviations in normal development, consider the use of a screening tool. EB: The early detection of developmental and behavioral problems in children is crucial for early intervention. Among the many tests that can be employed for this purpose, the DENVER II and the Alberta Infant Motor Scale are the most often used. Also, the Movement Assessment of Infants is starting to be used. Two other tests are recommended in the literature because of their high sensitivity and specificity: the Test of Infant Motor Performance and the General Movements (Santos, Araújo, & Porto, 2008).
• Regularly compare height and weight measurements for the child or adolescent with established age-appropriate norms and previous measurements. EB: The revised growth charts provide an improved tool for evaluating the growth of children in clinical and research settings. It is recommended to use the WHO growth standards for infants and children 2 years old and less. It is recommended to use the CDC growth charts for children over the age of 2 (CDC, 2007).
• Provide opportunities for mother-infant skin-to-skin contact (kangaroo care) for preterm infants. EB: Preterm babies exposed to skin-to-skin contact showed a better mental development and better results in motor tests. It also improves thermal care (Thukral et al, 2008).
• Provide normal sleep-wake times for clients to promote growth and development. EB: Children who have more nighttime sleep have better neurocognitive performance and attention control (Lam et al, 2011).
Engage the child in appropriate play activities. Refer the child to a child life therapist or recreational therapist (if available) for supplemental strategies. EBN: Play is a very important part of children’s lives and is necessary to help children through stressful events including hospitalization (Li, Chung, & Ho, 2011).
• Assess the influence of cultural beliefs, norms, and values on the client’s perceptions of child development. EBN: What the client considers normal and abnormal child development may be based on cultural perceptions (Giger & Davidhizar, 2008).
• Assess and identify for possible environmental conditions, which may be a contributing factor to altered growth and development. CEB: Insecticide exposures were widespread among minority women in New York City during pregnancy, and high levels were associated with lower birth weight and length (Whyatt et al, 2004).
• Acknowledge racial and ethnic differences at the onset of care. CEB: Acknowledgment of race and ethnicity issues enhances communication, establishes rapport, and promotes treatment outcomes (D’Avanzo & Naegle, 2001).
• Provide information on the effects of environmental risk exposure on growth and development. CEB: Minority children with prenatal environmental tobacco smoke exposure were twice as likely to be classified as significantly cognitively delayed when compared with unexposed children (Rauh et al, 2004). Data suggest that environmental exposure may lead to delayed growth and pubertal development in African American and Mexican American girls (Shevell et al, 2003).
• The interventions previously described may be adapted for home care use.
• Assess whether exposure to violence or parental stress is contributing to developmental problems. EB: Children and young people may be significantly affected by living with domestic violence, and impact can endure even after measures have been taken to secure their safety (Holt, Buckley, & Whelan, 2008). EB: Mothers that report high levels of stress or low levels of parenting satisfaction were significantly more likely to have a child with a developmental delay (Slykerman et al, 2007).
Refer premature neonates for follow-up home care and assessment of functional performance. EBN: Functional performance is a useful clinical measure to understand how well preterm children perform age-expected daily activities as well as the family burden of preterm sequelae (Sullivan & Msall, 2007).
If possible, refer the family to a program of animal-assisted therapy. EB: AAT helps the client by diminishing anxiety, stress, and pain. Positive changes have been reported in blood pressure, mobility, and muscular strength. Human contact with animals, including visual attention, has a “substantial calming effect” on the heart rate and blood pressure (Hastings et al, 2008).
Client/Family Teaching and Discharge Planning:
• Encourage parents to take infants and children for routine health visits to the family physician or pediatrician. Family physicians play a major role in the early recognition and referral of children with developmental delays or mental retardation. Once the physician has recognized a possible developmental problem, she or he can help determine whether neurological, audiological, or ophthalmological evaluations or rehabilitative services are needed (Moeschler & Shevell, 2006).
• Encourage parents of children with language delays to approach their physician during regular visits regarding the delay. EB: Language delay (LD) at 2 years proved to represent a sensitive marker for various developmental problems. Adequate early intervention requires a clear distinction between specific expressive or receptive-expressive LD and LD associated with other neurodevelopmental problems (Buschmann et al, 2008).
• Provide parents and/or caregivers realistic expectations for attainment of growth and development milestones. Clarify expectations and correct misconceptions. EBN: Learning about the growth and developmental differences between children with congenital heart defects and normal children may help parents of the former to detect problems associated with delayed growth and development earlier (Chen, Li, & Wang, 2004).
• Instruct the client regarding appropriate baby equipment and the importance of buying new equipment rather than used. EB: 190 auctions contained or were suspected to contain a recalled children’s item from a target list. Most of the recalled items were listed for sale from addresses within the United States, with sellers from Canada, Australia, Great Britain, and Ireland also represented. On average, six bids were placed on each recalled item, with 70% of auctions eventuating in a sale (Kirschman & Smith, 2007).
• Elicit the involvement of parents and caregivers in social support groups and parenting classes. Postnatal services that included parenting classes had a positive impact on children’s health and supported development (Miller, 2006). Women in particular geographical areas can use asynchronous mail systems to share information with and obtain support from other mothers. Cohort-based electronic communication could be particularly important in rural areas where travel is restricted for women and access to professional support is limited (Hall & Irvine, 2009).
• Assess whether parents may benefit from Internet/electronic support groups. EBN: The majority of participants in an Internet parent support group not only obtained what they sought, but found more than expected in terms of insight and people to trust. The strongest outcome factor related to satisfaction was improved caregiver-child relationship, and nearly 90% of the sample suggested participating in an Internet parent support group as soon as possible. Nurses may want to consider Internet parent support groups as an adjunct for social support in this population (Baum, 2004).
• See care plans: Risk for disproportionate Growth/Risk for delayed Development.
References
Baum, L.S. Internet parent support groups for primary caregivers of a child with special health care needs. Pediatr Nurs. 2004;30(5):381–388. [401].
Buschmann, A., et al. Children with developmental language delay at 24 months of age: results of a diagnostic work-up. Dev Med Child Neurol. 2008;50(3):223–229.
Centers for Disease Control and Prevention (CDC). National Center for Health Statistics clinical growth charts. Retrieved September 26, 2011, from http://www.cdc.gov/nchs/about/major/nhanes/growthcharts/clinical_charts.htm.
Chen, C., Li, C., Wang, J. Growth and development of children with congenital heart disease. J Adv Nurs. 2004;47(3):260–269.
D’Avanzo, C.E., Naegle, M.A. Developing culturally informed strategies for substance-related interventions. In: Naegle M.A., D’Avanzo C.E., eds. Addictions and substance abuse: strategies for advanced practice nursing. St Louis: Mosby, 2001.
Giger, J.N., Davidhizar, R.E. Transcultural nursing: assessment and intervention, ed 4. St Louis: Mosby; 2008.
Hall, W., Irvine, V. E-communication among mothers of infants and toddlers in a community-based cohort: a content analysis. J Adv Nurs. 2009;65(1):175–183.
Hastings, T., et al. Pet therapy: a healing solution. J Burn Care Res. 2008;29(6):874–876.
Holt, S., Buckley, H., Whelan, S. The impact of exposure to domestic violence on children and young people: a review of the literature. Child Abuse Negl. 2008;32(8):797–810.
Kirschman, K.B., Smith, G.A. Resale of recalled children’s products online: an examination of the world’s largest yard sale. Inj Prev. 2007;13(4):228–231.
Lam, J.C., et al. The effects of napping on cognitive function in preschoolers. J Dev Behav Pediatr. 2011;32(2):90–97.
Lee, B.E., et al. Secondhand smoke exposure during pregnancy and infantile neurodevelopment. Environ Res. 2011;111(2011):539–544.
Li, W.H.C., Chung, J.O.K., Ho, E.K.Y. The effectiveness of therapeutic play, using virtual reality computer games, in promoting the psychological well-being of children hospitalized with cancer. J Clin Nurs. 2011;20(15/16):2135–2143.
Miller, K. Interventions for child health and parenting practices. Am Fam Physician. 2006;74(12):2112–2113.
Moeschler, J., Shevell, M. American Academy of Pediatrics Committee on Genetics: clinical genetic evaluation of the child with mental retardation or developmental delays. Pediatrics. 2006;117(6):2304–2316.
Rauh, V.A., et al. Developmental effects of exposure to environmental tobacco smoke and material hardship among inner-city children. Neurotoxicol Teratol. 2004;26(3):373–385.
Santos, R.S., Araújo, A.P., Porto, M.A. Early diagnosis of abnormal development of preterm newborns: assessment instruments. J Pediatr. 2008;84(4):289–299.
Shevell, M., et al. Practice parameter: evaluation of the child with global developmental delay: report of the Quality Standards Subcommittee of the American Academy of Neurology and The Practice Committee of the Child Neurology Society. Neurology. 2003;60(3):367–380.
Slykerman, R.F., et al. Determinants of developmental delay in infants aged 12 months. Paediatr Perinat Epidemiol. 2007;21:121–128.
Sullivan, M.C., Msall, M.E. Functional performance of preterm children at age 4. J Pediatr Nurs. 2007;22(4):297–309.
Thukral, A., et al. Kangaroo mother care—an alternative to conventional care. Indian J Pediatr. 2008;75(5):497–503.
Whyatt, R.M., et al. Prenatal insecticide exposures and birth weight and length among an urban minority cohort. Environ Health Perspect. 2004;112(10):1125.