H
Deficient community Health
NANDA-I
Presence of one or more health problems or factors that deter wellness or increase the risk of health problems experienced by an aggregate
Defining Characteristics
Incidence of risks relating to hospitalization experienced by aggregates or populations; incidence of risks relating to physiological states experienced by aggregates or populations; incidence of risks relating to psychological states experienced by aggregates or populations; incidence of health problems experienced by aggregates or populations; no program available to enhance wellness for an aggregate or population; no program available to prevent one or more health problems for an aggregate or population; no program available to reduce one or more health problems for an aggregate or population; no program available to eliminate one or more health problems for an aggregate or population
Related Factors
Lack of access to public health care providers; lack of community experts; limited resources; program has inadequate budget; program has inadequate community support; program has inadequate consumer satisfaction; program has inadequate evaluation plan; program has inadequate outcome data; program partly addresses health problem
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Community Health Development: Identify health concerns, strengths, and priorities with community partners, Assist community members in raising awareness of health problems and concerns
Nursing Interventions and Rationales
Refer to care plans: Readiness for enhanced Community Coping, Ineffective Community Coping, Ineffective Health Maintenance, Impaired Home Maintenance, Risk for Other-directed Violence
• Encourage healthy nutrition and exercise among community members using the resources available to the community. EB: Community-based health communication interventions must address the realities of the community including literacy levels and existing networks of providers and consumers (Martinez et al, 2012). Community-belonging was strongly related to health behavior change in Canada and may be an important component of population health prevention strategies (Hystad & Carpiano, 2012).
• Facilitate goal setting in the community for behavior change related to diet and exercise for overweight and obese adults. EB: In this study goal setting shows promise as a community-based intervention to change behavior specific to diet and exercise (Pearson, 2012).
Pediatric:
Consider a community-based program for young people that encourages health-related behavior changes, increasing fruit and vegetable intake and engaging in activity. EB: This program for overweight and obese young people helped implement behavior and lifestyle changes that were associated with significant reductions in self-reported weight and Body Mass Index Z-score (standard deviation), without compromising growth in height (Stubbs et al, 2012).
Support religious affiliation and positive school climates for adolescents, particularly for lesbian, gay, and bisexual youths in the community. EB: Although religious climate was also associated with health behaviors among heterosexual youths, it was more strongly associated with the health behaviors of lesbian, gay, and bisexual youths. Among LGB youths, a supportive religious climate was significantly associated with fewer alcohol abuse symptoms and fewer sexual partners (Hatzenbuehler, Pachankis, & Wolff, 2012).
Geriatric: Assess homeless elderly veterans in the community for suicidal behavior and make appropriate referrals. EB: This study documented the increased prevalence of suicidal behavior in homeless elderly veterans (Schinka et al, 2012).
Provide community-dwelling older women with psychoeducation about aging skills and behaviors and cognitive function that includes group discussion. EB: This new comprehensive educational group intervention reduces negative emotional reactions toward cognitive functioning. It can potentially contribute the well-being of an important and large group of older adults (Hoogenhout et al, 2012).
Multicultural:• Provide information about the pervasiveness and deadly consequence of HBV for Asians in the United States. EB: Asians in San Francisco are disproportionately affected by chronic hepatitis B virus (HBV) infection and its fatal consequences. This information was most likely to drive clients to seek education and testing (Shiau et al, 2012).
Home Care, Client/Family Teaching, and Discharge Planning:
• The above interventions may be adapted for Home Care and Client/Family Teaching.
• Provide support for establishment of a community garden. EB: In this study, community garden participants consumed fruits and vegetables 5.7 times per day. Community gardeners met national recommendations to consume fruits and vegetables at least 5 times per day, compared with 37% of home gardeners and 24% of non-gardeners (Litt et al, 2011).
References
Hatzenbuehler, M., Pachankis, J., Wolff, J. Religious climate and health risk behaviors in sexual minority youths: a population-based study. Am J Public Health. 2012;102(4):657–663.
Hoogenhout, E.M., et al. Effects of a comprehensive educational group intervention in older women with cognitive complaints: a randomized controlled trial. Aging Ment Health. 2012;16(2):135–144.
Hystad, P., Carpiano, R. Sense of community-belonging and health-behaviour change in Canada. J Epidemiol Community Health. 2012;66(3):277–283.
Litt, J., et al. The influence of social involvement, neighborhood aesthetics, and community garden participation on fruit and vegetable consumption. Am J Public Health. 2011;101(8):1466–1473.
Martinez, J., et al. Formative Research for a community-based message-framing intervention. Am J Health Behav. 2012;36(3):335–347.
Pearson, E.S. Goal setting as a health behavior change strategy in overweight and obese adults: a systematic literature review examining intervention components. Patient Educ Couns. 2012;87(1):32–42.
Schinka, J.A., et al. Suicidal behavior in a national sample of older homeless veterans. Am J Public Health. Mar, 2012;102(Suppl 1):S147–S153.
Shiau, R., et al. Using survey results regarding hepatitis B knowledge, community awareness and testing behavior among Asians to improve the San Francisco Hep B Free Campaign. J Community Health. 2012;37(2):350–364.
Stubbs, J., et al. Weight, body mass index and behaviour change in a commercially run lifestyle programme for young people. J Hum Nutr Diet. 2012;25:161–166.
Risk-prone Health behavior
NANDA-I
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• State acceptance of change in health status
• Request assistance in altering behaviors to adapt to change
• State personal goals for dealing with change in health status and means to prevent further health problems
• State experience of a period of grief that is proportional to the actual or perceived effect of the loss
• Report and/or demonstrate behavior changes mutually agreed upon with nurse as evidence of positive adaptation
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Assess the client’s definitions of health and wellness and major barriers to health and wellness. EBN: Each person has unique, individual perceptions of well-being and illness (Kiefer, 2008).
• Use motivational interviewing to help the client identify and change unhealthy behaviors. EB: In these studies of smokers and substance abusers, MI (motivational interviewing) was helpful in promoting smoking cessation and reduction of substance use (Lai et al, 2010; Smedslund et al, 2011).
• Allow the client adequate time to express feelings about the change in health status. EBN: This is an important intervention for the client with a serious illness such as a malignant brain tumor (Khalili, 2007).
• Use open-ended questions to allow the client free expression (e.g., “Tell me about your last hospitalization” or “How does this time compare?”). EBN: Effective questioning facilitates a better understanding of the client and enables the development of a deeper nurse-client relationship (Jasmine, 2009).
• Help the client work through the stages of grief that occur as part of a psychological adaptation to illness. All clients will go through different stages in a different order. Encourage support from family and friends to help them focus their energy outward; people do best when they are focused on others rather than themselves (Schwartz, 2009).
• Encourage visitation and communication with family/close relatives of clients including during episodes of critical illness. EBN: The presence of close relatives is of great importance for the ill person and must be facilitated by staff. Close relatives can help with the change brought about by critical illness (Engström & Söderberg, 2007).
• Discuss the client’s current goals. If appropriate, have the client list goals so that they can be referred to and steps can be taken to accomplish them. Support hope that the goals will be accomplished. CEB: Clarification of the client/family goals and expectations will allow the nurse to clarify what is possible and to identify measures that can facilitate achievement of the goals (Northouse et al, 2002). “Hope theory” may facilitate recovery and clearer and more sustainable goals (Snyder et al, 2006).
Encourage participation in appropriate wellness programs associated with health changes. EB: In this study of clients with multiple sclerosis, a wellness program facilitating positive health choices demonstrated gains in functional status and decreased anxiety and depression (Hart et al, 2011).
• Provide assistance with activities as needed. EBN: Clients’ feelings of personal control increased when assistance was available to help them do things they could not do by themselves; they felt insecure and experienced emotional discomfort when assistance was lacking (Lauck, 2009).
• Give the client positive feedback for accomplishments, no matter how small. Support the client and family and promote their strengths and coping skills. EB: Support is necessary to help the client and family throughout the illness (Khalili, 2007).
• Manipulate the environment to decrease stress; allow the client to display personal items that have meaning. CEB: Appraisal uncertainty is a risk factor for a negative adaptation to health change (Dudley-Brown, 2002).
• Maintain consistency and continuity in daily schedule. When possible, provide the same caregiver. CEB: The predictability of interaction with the same nurses as a part of treatment facilitates trust, confidence, and positive adaptation (Richer & Ezer, 2002).
• Promote use of positive spiritual influences. Spirituality is an innate aspect of being human, and every client has the potential for spiritual growth through suffering from an illness (Tu, 2006).
Refer to community resources. Provide general and contact information for ease of use. EB: Participating with a group of peers in a relevant activity appears to be an important factor in effectively changing behavior (Boldy & Silfo, 2006). In this study in Canada, community-belonging was strongly related to health-behavior change (Hystad & Carpiano, 2012).
• Encourage visitation of children when family members are in intensive care. Visitation of children should be supported to facilitate expression of feelings associated with major health changes in family members (Knutsson et al, 2008).
Refer parents of critically ill children to an intervention program such as COPE, a theory-based intervention program. EBN: Research findings indicate that this program reduces short- and long-term stress, anxiety, and post-traumatic stress disorder symptoms often experienced by parents with critically ill children (Peek & Melnyk, 2010).
• Use visualization and distraction during chest physiotherapy for children with cystic fibrosis. Although chest physiotherapy is central to the management of cystic fibrosis (CF), adherence among children is problematic. Visualization and distraction may improve compliance (Williams et al, 2007).
Assess for signs of depression resulting from illness-associated changes and make appropriate referrals. EBN: Depression may be a consequence of aging. Assessments of the spouse’s perception as well as of the client’s factual situation may identify risk factors that are leading to a depressed state (Franzen-Dahlin, 2008).
• Use open-ended questions in screening for depression in the elderly (Magnil, Gunnarsson, & Björkelund, 2011).
• Support activities that promote usefulness of older adults. EB: Older adults with persistently low perceived usefulness or feelings of uselessness may be a vulnerable group with increased risk for poor health outcomes in later life (Gruenewald et al, 2009; Rozanova, Keating, & Eales, 2012).
Encourage social support. EBN: In this study, social support demonstrated a positive relation with perceived well-being in older adults (Kiefer, 2011).
• Monitor the client for agitation associated with health problems. Support family caring for elders with agitation. EB: The findings in this study suggest that some symptoms, such as agitation/aggression and irritability/lability, may affect the caregivers significantly, although the symptoms’ frequency and severity are low (Matsumoto et al, 2007).
• Assess for the influence of cultural beliefs, norms, and values on the client’s ability to modify health behavior. CEB: What the client considers normal and abnormal health behavior may be based on cultural perceptions (Leininger & McFarland, 2002; Richardson, 2004; Van Bruggen, 2008).
• Assess the role of fatalism on the client’s ability to modify health behavior. EB: Fatalistic perspectives, which involve the belief that you cannot control your own fate, may influence health behaviors in some cultures. EB: Fatalism has been identified as a dominant belief among Latinos and is believed to act as a barrier to cancer prevention (Espinosa de los Monteros & Gallo, 2011). Some African American women experience a fatalistic attitude about breast cancer (McQueen et al, 2011).
• Encourage spirituality as a source of support for coping. CEB: Many African Americans and Latinos identify spirituality, religiousness, prayer, and church-based approaches as coping resources (Giger et al, 2008).
• Negotiate with the client regarding the aspects of health behavior that will need to be modified. CEB: Give-and-take with the client will lead to culturally congruent care (Leininger & McFarland, 2002).
• The above interventions may be adapted for home care use.
• Take the client’s perspective into consideration, and use a holistic approach in assessing and responding to client planning for the future. EBN: Clients with newly diagnosed diabetes do not want to become their illness (Johansson, Dahlberg, & Ekebergh, 2009).
• Assist the client to adapt to his/her diagnosis and to live with the disease. EBN: Despite being diagnosed with diabetes, clients still want to continue the same life and be the same persons as before, although they now carry a disease (Johansson, Dahlberg, & Ekebergh, 2009).
Refer the client to a counselor or therapist for follow-up care. Initiate community referrals as needed (e.g., grief counseling, self-help groups). EBN: Families need assistance and support in coping with health change and caregiving (Honea et al, 2008).
Client/Family Teaching and Discharge Planning:
• Assess family/caregivers for coping and teaching/learning styles. CEB: The degree of optimism and pessimism influences the coping and health outcomes of caregivers of clients with Parkinson’s disease (Lyons et al, 2004).
• Foster communication between the client/family and medical staff. EBN: Family members of individuals undergoing cardiopulmonary resuscitation expressed a need to be involved and present or informed at all times during the process (Wagner, 2004). EB: Psychotherapeutic interventions should not only address the clients’ problems but also the support-givers’ questions, needs, and psychosocial burdens (Frick et al, 2005).
• Educate and prepare families regarding the appearance of the client and the environment before initial exposure. EBN: Families indicated that knowing what to expect was helpful (Clukey, 2008).
• Help the client to enjoy a sense of “wellness.” Provide support for progress and support enjoyment of the physical, emotional, spiritual, and social aspects of life. EBN: Nurses provide information and support to facilitate the individual in his/her progress toward a achieving a sense of wellness and recognizing that healing will take time (White et al, 2012).
• Teach a client and his or her family relaxation techniques (controlled breathing, guided imagery) and help them practice. EBN: Guided imagery with relaxation may be an easy-to-use self-management intervention to improve the quality of life of older adults with osteoarthritis (Baird & Sands, 2006).
• Allow the client to proceed at own pace in learning; provide time for return demonstrations (e.g., self-injection of insulin). CEB: Use clear and distinct language free of medical jargon and meaningless values (Wagner, 2004).
• If long-term deficits are expected, inform the family as soon as possible. CEB: An honest assessment shared by the nurse of a particular situation is important to the family’s sense of what is expected of them in adapting to a health care change (Weiss & Chen, 2002).
• Provide clients with information on how to access and evaluate available health information via the Internet. Client access to health information and personal health records is becoming increasingly important in today’s health care society. MedlinePlus, NIH Senior Health, and ClinicalTrials.gov are designed to get medical information directly into the hands of clients (Koonce et al, 2007).
References
Baird, C.L., Sands, L.P. Effect of guided imagery with relaxation on health-related quality of life in older women with osteoarthritis. Res Nurs Health. 2006;29(5):442–451.
Boldy, D., Silfo, E. Chronic disease self-management by people from lower socio-economic backgrounds: action planning and impact. J Integr Care. 2006;4(4):19–25.
Clukey, L. Anticipatory mourning: processes of expected loss in palliative care. Int J Palliat Nurs. 2008;14(7):316. [318–325].
Dudley-Brown, S. Prevention of psychological distress in persons with inflammatory bowel disease. Issues Ment Health Nurs. 2002;23:403.
Engström, A., Söderberg, S. Receiving power through confirmation: the meaning of close relatives for people who have been critically ill. J Adv Nurs. 2007;59(6):569–576.
Espinosa de los Monteros, K., Gallo, L. The relevance of fatalism in the study of Latinas’ cancer screening behavior: a systematic review of the literature. In J Behav Med. 2011;18(4):310–318.
Franzen-Dahlin, A. Predictors of life situation among significant others of depressed or aphasic stroke patients. J Clin Nurs. 2008;17(12):1574–1580.
Frick, E., et al. Social support, affectivity, and the quality of life of patients and their support-givers prior to stem cell transplantation. J Psychosoc Oncol. 2005;23(4):15–34.
Giger, J., et al. Church and spirituality in the lives of the African American community. J Transcult Nurs. 2008;19(4):375–383.
Gruenewald, T.L., et al. Increased mortality risk in older adults with persistently low or declining feelings of usefulness to others. J Aging Health. 2009;21(2):398–425.
Hart, D., et al. Developing a wellness program for people with multiple sclerosis. Int J MS Care. 2011;13(4):154–162.
Honea, N.J., et al. Putting evidence into practice: nursing assessment and interventions to reduce family caregiver strain and burden. Clin J Oncol Nurs. 2008;12(3):507–516.
Hystad, P., Carpiano, R. Sense of community-belonging and health-behaviour change in Canada. J Epidemiol Community Health. 2012;66(3):277–283.
Jasmine, T.J.X. The use of effective therapeutic communication skills in nursing practice. Singapore Nurs J. 2009;36(1):35–38. [40].
Johansson, A., Dahlberg, K., Ekebergh, M. A lifeworld phenomenological study of the experience of falling ill with diabetes. Int J Nurs Stud. 2009;46(2):197–203.
Kiefer, R.A. An integrative review of the concept of well-being. Holist Nurs Pract. 2008;22(5):244–252.
Kiefer, R.A. The effect of social support on functional recovery and well-being in older adults following joint arthroplasty. Rehabil Nurs. 2011;36(3):120–126.
Khalili, Y. Ongoing transitions: the impact of a malignant brain tumour on patient and family. Axone. 2007;28(3):5–13.
Knutsson, S., et al. Children’s experiences of visiting a seriously ill/injured relative on an adult intensive care unit. J Adv Nurs. 2008;61(2):154–162.
Koonce, T., et al. Toward a more informed patient: bridging health care information through an interactive communication portal. J Med Libr Assoc. 2007;95(1):77.
Lai, D.T., et al, Motivational interviewing for smoking cessation. Cochrane Database Syst Rev Jan 20, 2010;(1):CD006936.
Lauck, S. Patients felt greater personal control and emotional comfort in hospital when they felt secure, informed, and valued. Evid Based Nurs. 2009;12(1):29.
Leininger, M.M., McFarland, M.R. Transcultural nursing: concepts, theories, research and practices, ed 3. New York: McGraw-Hill; 2002.
Lyons, K.S., et al. Pessimism and optimism as early warning signs for compromised health for caregivers of patients with Parkinson’s disease. Nurs Res. 2004;53(6):354–362.
Magnil, M., Gunnarsson, R., Björkelund, C. Using patient-centred consultation when screening for depression in elderly patients: a comparative pilot study. Scand J Prim Health Care. 2011;29(1):51–56.
Matsumoto, N., et al. Caregiver burden associated with behavioral and psychological symptoms of dementia in elderly people in the local community. Dement Geriatr Cogn Disord. 2007;23(4):e219–224.
McQueen, A., et al. Understanding narrative effects: the impact of breast cancer survivor stories on message processing, attitudes, and beliefs among African American women. Health Psychol. 2011;30(6):674–682.
Northouse, L.A., et al. A family-based program of care for women with recurrent breast cancer and their family members. Oncol Nurs Forum. 2002;29(10):1411–1419.
Peek, G., Melnyk, B.M. Coping interventions for parents of children newly diagnosed with cancer: an evidence review with implications for clinical practice and future research. Pediatr Nurs. 2010;36(6):306–313.
Richardson, P. How cultural ideas help shape the conceptualization of mental illness and mental health. Occup Ther. 2004;9(1):5–8.
Richer, M.C., Ezer, H. Living in it, living with it, and moving on: dimensions of meaning during chemotherapy. Oncol Nurs Forum. 2002;29(1):113–119.
Rozanova, J., Keating, N., Eales, J. Unequal social engagement for older adults: constraints on choice. Can J Aging. 2012;31(1):25–36.
Schwartz, J.C. Psychological adaptation to illness: a personal odyssey and suggestions for physicians. Proc (Bayl Univ Med Cent). 2009;22(3):242–245.
Smedslund, G., et al, Motivational interviewing for substance abuse. Cochrane Database Syst Rev 2011;(5):CD008063.
Snyder, C.R., et al. Hope for rehabilitation and vice versa. Rehab Psychol. 2006;51(2):89–112.
Tu, M. Illness: an opportunity for spiritual growth. J Altern Complement Med. 2006;12(10):1029–1033.
Van Bruggen, H. Mental health as social construct. In Creek J., Lougher L., eds.: Occupational health and mental health, ed 4, London: Churchill Livingstone, 2008.
Wagner, J.M. Lived experience of critically ill patients’ family members during cardiopulmonary resuscitation. Am J Crit Care. 2004;13(5):416–420.
Weiss, S.J., Chen, J.L. Factors influencing maternal mental health and family functioning during the low birthweight infant’s first year of life. J Pediatr Nurs. 2002;17(2):114–125.
White, M., et al. In the shadows of family-centered care: parents of ill adult children. Detail only available. Hospice Palliative Nurs. 2012;14(1):53–60.
Williams, B., et al. Problems and solutions: accounts by parents and children of adhering to chest physiotherapy for cystic fibrosis. Disabil Rehabil. 2007;29(14):1097–1105.
Ineffective Health Maintenance
NANDA-I
Defining Characteristics
Demonstrated lack of adaptive behaviors to environmental changes; demonstrated lack of knowledge about basic health practices; history of lack of health-seeking behavior; inability to take responsibility for meeting basic health practices; impairment of personal support systems; lack of expressed interest in improving health behaviors
Related Factors (r/t)
Cognitive impairment; complicated grieving; deficient communication skills; diminished fine motor skills; diminished gross motor skills; inability to make appropriate judgments; ineffective family coping; ineffective individual coping; insufficient resources (e.g., equipment, finances); lack of fine motor skills; lack of gross motor skills; perceptual impairment; spiritual distress; unachieved developmental tasks
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Assess the client’s feelings, values, and reasons for not following the prescribed plan of care. See Related Factors. EB: Patients often want to have more influence on decision-making in the care than they actually are afforded (Tariman et al, 2010).
• Assess for family patterns, economic issues, and cultural patterns that influence compliance with a given medical regimen. EB: There are marked differences in use of health care services among different cultural groups (Hall, Rubin, & Charnock, 2009).
• Help the client to choose a healthy lifestyle and to have appropriate diagnostic screening tests. EBN: Healthy lifestyle measures, such as exercising regularly, maintaining a healthy weight, not smoking, and limiting alcohol intake, help reduce the risk of cancer and other chronic illnesses (Thompson, 2010).
• Assist the client in reducing stress. EB: Individuals with high perceived stress are significantly more likely to be nonadherent with treatment regimens. This happens with individuals with cardiovascular disease (Smith & Blumenthal, 2011), clients who are opioid dependent (Passik & Lowery, 2011), and those who are living with HIV (Nugent et al, 2010).
• Help the client determine how to manage complex medication schedules (e.g., HIV/AIDS regimens or polypharmacy). EBN: Components of successful self-management of medications include establishing habits, adjusting routines, tracking, simplifying, and managing costs (Swanlund, 2010). Simplifying treatment regimens and tailoring them to individual lifestyles encourages adherence to treatment (Steinman & Hanlon, 2010).
• Identify complementary healing modalities, such as herbal remedies, acupuncture, healing touch, yoga, or cultural shamans that the client uses in addition to or instead of the prescribed allopathic regimen. EB: Use of complementary healing modalities among clients with chronic disease is relatively high. The person’s beliefs about complementary and alternative therapies may negatively influence medical adherence (Villagran et al, 2012).
Refer the client to appropriate services as needed. EB: When appropriate referrals are missed or delayed, clients often experience poor outcomes, including complications, psychological distress, and hospital readmissions (Lebecque et al, 2009).
• Identify support groups related to the disease process. EBN: Individuals who attend support groups demonstrate improved disease management and enhanced quality of life (Song et al, 2011).
• Use technology such as text messaging to remind clients of scheduled appointments. EB: “No show” rates are reduced when appointment reminders are sent as text messages to clients’ mobile telephones (Koshy, Car, & Majeed, 2008).
• Assess the client’s perception of health. EB: Perceived ill health in older clients is associated with lower self-care ability and sense of control (Söderhamn, Bachrach-Lindström, & Ek, 2008). Older clients with diabetes or metabolic syndrome often underestimate their cardiovascular risk (Martell-Claros et al, 2011).
• Assist client to identify both life- and health-related goals. EB: Older individuals endorse health goals and disease management that are congruent with their life goals (Morrow et al, 2008).
• Provide information that supports informed decision-making. EBN: Encouraging independence and enhancing social networks can enhance client autonomy (Rosland, Heisler, & Choi, 2010).
• Discuss with the client and support person realistic goal-setting for changes in health maintenance. EBN: The Modified Caregiver Strain Index can be given to family members of older adults to help determine the level of stress/burden and the consequences for the caregiver’s overall health. Often the caregiver is an older adult as well. The index can act as a guide to select interventions that will help the older adult but also reduce caregiver strain and improve the lives of both (Onega, 2008; Wolff et al, 2010).
• Educate the client about the symptoms of life-threatening illness, such as myocardial infarction (MI), and the need for timeliness in seeking care. EBN: Women, especially those of advanced age, wait longer before seeking treatment for signs and symptoms of acute MI (Higginson, 2008).
• Assess influence of cultural beliefs, norms, and values on the client’s ability to modify health behavior. EB: Awareness of the cultural importance of family and social relationships, symbolic and social meanings of food, and the spiritual dimensions of disease are key in encouraging self-management of disease (Sowattanangoon, Kotchabhakdi, & Petrie, 2011).
• Assess the effect of fatalism on the client’s ability to modify health behavior. EB: Fatalistic beliefs about cancer may hamper screening and delay help-seeking for symptoms (Beeken, Simon, & von Wagner, 2011).
• Assess for use of and reasons for not using health services. EBN: Compared with Caucasians, women of color had later initiation of prenatal care and fewer prenatal visits overall (Park, Vincent, & Hastings-Tolsma, 2007). Language and cultural barriers were identified as barriers to utilization of mental health services for Latino children (Lopez, Bergren, & Painter, 2008).
• Clarify culturally related health beliefs and practices. EBN: Language, culture, and ethnicity influence the choice of a health care provider and participation in health management strategies (Hjelm, Berntorp, & Apelqvist, 2012). Use of trained medical interpreters and familiarity with folk illness beliefs treatments positively affects the client’s health outcomes (Brotanek, Seeley, & Flores, 2008).
• Provide culturally targeted education and health care services. EB: A culturally sensitive diabetes education program produced improvement in HbA1c, fasting plasma glucose, cholesterol/HDL ratio, and HDL in Hispanic clients (Metghalchi et al, 2008). Hispanic individuals with diabetes who participated in a lifestyle awareness program reported a sense of empowerment and increased self-efficacy (McCloskey & Flenniken, 2011).
• The interventions described previously may be adapted for home care use.
Provide nurse-led case management. EBN: Individualized, systematic, and guideline-based nurse case management promotes cardiovascular risk reduction in home-based, primary care, and community settings (Berra, 2011). A home care service model utilizing nurse-led case management facilitates access to services and resources and has a positive impact on the client’s functional ability (Morales-Asencio et al, 2008).
• Include a health-promotion focus for the client with disabilities, with the goals of reducing secondary conditions (e.g., obesity, hypertension, pressure sores), maintaining functional independence, providing opportunities for leisure and enjoyment, and enhancing overall quality of life. EB: Individuals living with physical disabilities or cognitive impairment receive fewer preventive services and have higher rates of chronic illness (Reichard, Stolzle, & Fox, 2011). Community-based physical activity and educational programs provide fitness and psychosocial benefits for individuals with intellectual (Heller et al, 2011) or developmental (Bazzano et al, 2009) disabilities.
• Encourage a regular routine for health-related behaviors. EBN: Individuals who establish a regular routine for exercise are more likely to be compliant over time than those who use an ad hoc approach to exercise (Hines, Seng, & Messer, 2007).
• Provide support and individual training for caregivers before the client is discharged from the hospital. EBN: Caregivers are very interested in receiving instruction and hands-on practice of procedures they would need to perform at home. They report increased confidence in their ability to provide such care and to help their loved ones manage symptoms at home (Hendrix et al, 2009).
• Assist client to develop confidence in ability to manage the health condition. EB: Self-management education targeted at self-efficacy improves physiological outcomes, enhances coping techniques, and reduces health care use (Labrecque et al, 2011).
• Consider a written contract with the client to follow the agreed-upon health care regimen. Written agreements reinforce the verbal agreement and serve as a reference. EB: Written agreement between health care providers and clients may promote adherence (Bosch-Capblanch et al, 2007).
• Using self-care management precepts, instruct the client about possible situations to which he or she may need to respond; include the use of role playing. Instruct in generating hypotheses from available evidence rather than solely from experience. EBN: Interventions that focus on increasing self-awareness of cues relative to health increase the client’s ability to recognize and respond to changes in symptoms and health status (Hernandez, Hume, & Roger, 2008).
Client/Family Teaching and Discharge Planning:
• Provide the family with website addresses where information can be obtained from the Internet. (Most libraries have Internet access with printing capabilities.) EB: Internet/video-delivered interventions are successful in increasing physical activity and fruit and vegetable intake in adolescents (Mauriello et al, 2010). Online information gathering can promote client engagement in health maintenance and care (Iverson, Howard, & Penney, 2008).
Develop collaborative multidisciplinary partnerships. EBN: Multidisciplinary and multifactorial interventions are likely to be more effective in achieving desired outcomes (Norlund, Ropponen, & Alexanderson, 2009).
• Tailor both the information provided and the method of delivery of information to the specific client and/or family. EBN: Client-centered educational interventions that focus on individualization have a positive impact on the client’s sense of well-being and optimism that therapy will be effective (Radwin, Cabral, & Wilkes, 2009).
• Obtain or design educational material that is appropriate for the client; use pictures if possible. EB: The use of materials tailored to the individual has a strong effect on dietary behavior (Enwald & Huotari, 2010) and physical activity (Wanner et al, 2009).
• Teach the client about the symptoms associated with discontinuation of medications, such as a selective serotonin reuptake inhibitor (SSRI). EB: Educate client about SSRI discontinuation syndrome, which may include lightheadedness, dizziness, headaches, GI disturbances, diaphoresis, lethargy, vivid dreams, and flu-like symptoms. A 3- to 4-week graded dosage tapering is encouraged with short-acting SSRIs to avoid this syndrome (Hosenbocus & Chahal, 2011).
• Explain nonthreatening aspects before introducing more anxiety-producing information regarding possible side effects of the disease or medical regimen. EBN: Anxiety may interfere with concentration and the ability to understand and remember (Lachman & Agrigoroaei, 2012).
• Treat tobacco use as a chronic problem. Tailor the smoking cessation program to the individual. Consider mixed groups of current and past smokers. EB: Flexible smoking cessation programs that are tailored to the individual’s culture and life situation and offer support to a range of smokers are perceived by participants as both beneficial and valued (Ritchie, Schulz, & Bryce, 2007).
References
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Impaired Home Maintenance
NANDA-I
Defining Characteristics
Objective
Disorderly surroundings; inappropriate household temperature; insufficient clothes; insufficient linen; lack of clothes; lack of linen; lack of necessary equipment; offensive odors; overtaxed family members; presence of vermin; repeated unhygienic disorders; repeated unhygienic infections; unavailable cooking equipment; unclean surroundings
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Assess the concerns of family members, especially the primary caregiver, about long-term home care. EBN: Caregivers express frustration with health care providers’ lack of awareness of circumstances at home (Honea et al, 2008). Poor family support increases the risk of adverse outcomes for caregivers (Etters, Goodall, & Harrison, 2008).
Consider a predischarge home assessment referral to determine the need for accessibility and safety-related environmental changes. EB: Predischarge home assessments reveal a significant number of environmental changes that are necessary, including the need for equipment changes, home modifications and furniture changes, and can be instrumental in decreasing falls postdischarge (Johnston, Barras, & Grimmer-Somers, 2010).
• Use an assessment tool to identify environmental safety hazards in the home. EB: Use of assessment tools such as the Cougar Home Safety Assessment provide structure in the identification of key environmental hazards in the home (Fisher et al, 2008).
• Establish a plan of care with the client and family based on the client’s needs and the caregiver’s capabilities. EBN: Collaborative identification of health-related concerns, goals, determination of ways to enhance facilitators of change and overcome barriers and obstacles is effective in engaging the family in home care that is feasible for the particular family’s situation (Tyler & Horner, 2008).
• Assist family members to develop realistic expectations of themselves in the performance of their caregiving roles. EB: Interventions for caregivers positively affect client and caregiver general mental health as well as caregiver burden and distress for caregivers of people with dementia (Signe & Elmståhl, 2008) and stroke (Wood, Connelly, & Maly, 2010).
• Set up a system of relief for the main caregiver in the home, and plan for sharing of household duties. EBN: Respite care provides decreased burden and improved quality of life for the caregiver (Salin, Kaunonen, & Åstedt-Kurki, 2009; Shaw et al, 2009).
Initiate referral to community agencies as needed, including housekeeping services, Meals on Wheels (MOW), wheelchair-compatible transportation services, and oxygen therapy services. EBN: Improved access to food and nutrition programs improves dietary intake of recipients (Kamp et al, 2010).
Obtain adaptive equipment and telemedical equipment, as appropriate, to help family members continue to maintain the home environment. EB: The provision of adaptive equipment, implementation of environmental modifications and in-home telemonitoring and education keeps persons with chronic illnesses out of inpatient facilities without increasing the cost of care (Bendixen et al, 2009).
• Ask the family to identify support people. EB: Mothers’ abilities to safeguard their children against injury are influenced by many contextual factors, including relationships with neighbors and trust in community services (Olsen et al, 2008).
• All of the previously mentioned interventions are applicable for the geriatric population.
• Explore community resources to assist with home maintenance (e.g., senior centers, Department of Aging, hospital case managers, the Internet, or church parish nurse). CEB: Older adults often attempt to do home maintenance and repairs themselves because of lack of awareness of available services and their fears related to personal safety, or being overcharged or sold services they do not need (Ashby, Ozanne-Smith, & Fox, 2007).
• Support “aging in place” by providing assistive technology devices: home modification, daily living aids, mobility aids, seating and positioning devices, and sensory aids. EB: Accessibility problems in the home affect both life satisfaction and perceived health of community-dwelling older adults. Assessment for risk and incorporation of compensatory strategies, home modification for access and safety, and exercises to promote balance and muscle strength in programs such as Advancing Better Living for Elders (ABLE) is a cost-effective way to delay functional decline and mortality in elders (Gitlin et al, 2009; Jutkowitz et al, 2012).
• Focus on the interaction between the older client and the technology, assisting the client to be an active participant in choices and uses. EBN: When users of technologies are active in the technological process, assessed in interaction with technology in their everyday practices, the technology can be more efficiently used to meet the needs of the client (Rodeschini, 2011).
• See the care plans for Risk for Injury and Risk for Falls.
• Acknowledge the stresses unique to racial/ethnic communities. Minority adults who moved from low-poverty neighborhoods were less likely to be exposed to violence and disorder, experience health problems, abuse alcohol, and receive cash assistance (Fauth, Leventhal, & Brooks-Gunn, 2008). Adolescents who are in the ethnic minority in a given community are more likely to use alcohol and to get drunk (Swaim & Stanley, 2011).
• The previously mentioned interventions incorporate these resources.
Refer clients with mental illness and medical conditions to in-home behavioral health case management. EBN: Intensive community-based services can be as effective as inpatient care for some groups of adults and children with mental illness (Lamb, 2009; Sjølie, Karlsson, & Kim, 2010).
Consider referral for new home safety technologies as they become available. Technologies designed for functional monitoring, safety monitoring, physiological monitoring, cognitive support, sensory aids, monitoring security, and increasing social interaction are available and cost-effective (Gitlin et al, 2009; Martin et al, 2008).
• See care plans Contamination and Risk for Contamination.
Client/Family Teaching and Discharge Planning:
• Teach the caregiver the need to set aside some personal time every day to meet his or her own needs. EBN: Family needs and need for relief are important (Smits et al, 2007).
• Identify support groups within the community to assist families in the caregiver role. EBN: A nurse-led support group may have a positive effect on the well-being of spouses of stroke clients (Franzén-Dahlin et al, 2008). Caregivers are most in need of effective communication, emotional support, education and advocacy (Macleod, Skinner, & Low, 2012).
• Provide counseling and support for clients and for caregivers of clients. EBN: Individual counseling and support including risk assessment, education, and referrals decreases lighting and other hazards related to falls in the home (Elley et al, 2008). Providing social support to the caregivers of adolescents with diabetes enhances the support these parents can provide to their child (Idalski Carcone et al, 2011).
• Focus teaching on environmental hazards identified in the nursing assessment. Areas may include, but are not limited to:
Home Safety. Identify the need for and use of common safety devices in the home. EB: Environmental hazards are commonly found in the homes of community-dwelling older adults (Leung et al, 2010). An intervention to reduce exposure to injury hazards (including installing smoke detectors, stair gates, and cabinet locks) in homes of young children led to a 70% reduction in injury (Phelan et al, 2011).
Biological and Chemical Contaminants. Assess for and reduce the presence of allergens, contaminants, and pollutants in the home. EB: Biological and chemical sensitizers including dust mites, mold, tobacco smoke, and pollen are implicated in the exacerbation of chronic conditions such as asthma (Dixon et al, 2009; Nambu et al, 2008). Health improvements are seen in children with asthma with simple, low-cost environmental changes, including dehumidification, use of room air cleaners, and regular service of heating and air conditioning units (Johnson et al, 2009).
Food Safety. Instruct client to avoid microbial food-borne illness by regularly washing hands, food contact surfaces, and fruits and vegetables. Meat and poultry should not be washed or rinsed. Separate raw, cooked, and ready-to-eat foods while shopping, preparing, or storing foods. Cook foods to a safe temperature to kill microorganisms. Chill (refrigerate) perishable food promptly and defrost foods properly. Avoid raw (unpasteurized) milk or any products made from unpasteurized milk, raw or partially cooked eggs, foods containing raw eggs, raw or undercooked meat and poultry, unpasteurized juices, and raw sprouts (USDHHS, 2010).
Environmental Stressors. Assist clients and families with decision-making regarding potential conflicts in home maintenance priorities, given financial constraints. EB: Many families encounter conflicts prioritizing the allocation of scarce financial resources among the regulation of heating and cooling, provision of adequate food, and access to and use of health care services (Cook et al, 2008).
• Teach clients to assess their homes for potential environmental health hazards in the home, including risks related to structure, moisture/mold, fire, pets, electrical, ventilation, pests, and lifestyle. EB: The housing-based hazard index (HHI) is a promising measure of overall home hazards with good reliability and validity and the ability to discriminate between healthy and nonhealthy homes. It requires more testing (Nriagu, Smith, & Socier, 2011).
• See care plans Contamination, Risk for Contamination, Risk for Falls, Risk for Infection, and Risk for Injury.
References
Ashby, K., Ozanne-Smith, J., Fox, B. Investigating the over-representation of older persons in do-it-yourself home maintenance injury and barriers to prevention. Inj Prev. 2007;13(5):328–333.
Bendixen, R.M., et al. Cost effectiveness of a telerehabilitation program to support chronically ill and disabled elders in their homes. Telemed J E Health. 2009;15(1):31–38.
Cook, J.T., et al. A brief indicator of household energy security: associations with food security, child health, and child development in US infants and toddlers. Pediatrics. 2008;122(4):e867–e875.
Dixon, S.L., et al. An examination of interventions to reduce respiratory health and injury hazards in homes of low-income families. Environ Res. 2009;109(1):123–130.
Elley, C.R., et al. Effectiveness of a falls-and-fracture nurse coordinator to reduce falls: a randomized, controlled trial of at-risk older adults. J Am Geriatr Soc. 2008;56(8):1383–1389.
Etters, L., Goodall, D., Harrison, B.E. Caregiver burden among dementia patient caregivers: a review of the literature. Am Acad Nurse Pract. 2008;20(8):423–428.
Fauth, R.C., Leventhal, T., Brooks-Gunn, J. Seven years later: effects of a neighborhood mobility program on poor Black and Latino adults’ well-being. J Health Soc Behav. 2008;49(2):119–130.
Fisher, G.S., et al. Home modification outcomes in the residences of older people as a result of Cougar Home Safety Assessment (Version 4.0) recommendations. Cal J Health Prom. 2008;6(1):87–110.
Franzén-Dahlin, A., et al. A randomized controlled trial evaluating the effect of a support and education programme for spouses of people affected by stroke. Clin Rehabil. 2008;22(8):722–730.
Gitlin, L.N., et al. Long-term effect on mortality of a home intervention that reduces functional difficulties in older adults: results from a randomized trial. J Am Geriatr Soc. 2009;57(3):476–481.
Honea, N.J., et al. Putting evidence into practice: nursing assessment and interventions to reduce family caregiver strain and burden. Clin J Oncol Nurs. 2008;12(3):507–516.
Idalski Carcone, A., et al. Social support for diabetes illness management: supporting adolescents and caregivers. J Dev Behav Pediatr. 2011;32(8):581–590.
Johnson, L., et al. Low-cost interventions improve indoor air quality and children’s health. Allergy Asthma Proc. 2009;30(4):377–385.
Johnston, K., Barras, S., Grimmer-Somers, K. Relationship between pre-discharge occupational therapy home assessment and prevalence of post-discharge falls. J Eval Clin Pract. 2010;16(6):1333–1339.
Jutkowitz, E., et al. Cost effectiveness of a home-based intervention that helps functionally vulnerable older adults age in place at home. J Aging Res. 2012:680265. [2012].
Kamp, B.J., et al. Food and nutrition programs for community-residing older adults. J Am Diet Assoc. 2010;110(3):463–472.
Lamb, C.E. Alternatives to admission for children and adolescents: providing intensive mental healthcare services at home and in communities: what works? Curr Opin Psychiatry. 2009;22(4):345–350.
Leung, A., et al. Psychosocial risk factors associated with falls among Chinese community-dwelling older adults in Hong Kong. Health Soc Care Community. 2010;18(3):272–281.
Macleod, A., Skinner, M.W., Low, E. Supporting hospice volunteers and caregivers through community-based participatory research. Health Soc Care Community. 2012;20(2):190–198.
Martin, S., et al, Smart home technologies for health and social care support. Cochrane Database Syst Rev 2008;(4):CD006412.
Nambu, M., et al. The effect of dust mite-free pillow on clinical course of asthma and IgE level—a randomized, double-blind, controlled study. Pediatr Asthma Allergy Immunol. 2008;21(3):137–143.
Nriagu, J., Smith, P., Socier, D. A rating scale for housing-based health hazards. Sci Total Environ. 2011;409(24):5423–5431.
Olsen, L., et al. An ethnography of low-income mothers’ safeguarding efforts. J Safety Res. 2008;39(6):609–616.
Phelan, K.J., et al. A randomized controlled trial of home injury hazard reduction: the HOME injury study. Arch Pediatr Adolesc Med. 2011;165(4):339–345.
Rodeschini, G. Gerotechnology: a new kind of care for aging? An analysis of the relationship between older people and technology. Nurs Health Sci. 2011;13(4):521–528.
Salin, S., Kaunonen, M., Åstedt-Kurki, P. Informal carers of older family members: how they manage and what support they receive from respite care. J Clin Nurs. 2009;18(4):492–501.
Shaw, C., et al. Systematic review of respite care in the frail elderly. Health Technol Assess. 2009;13(20):1–224. [iii].
Signe, A., Elmståhl, S. Psychosocial intervention for family caregivers of people with dementia reduces caregiver’s burden: development and effect after 6 and 12 months. Scand J Caring Sci. 2008;22(1):98–109.
Sjølie, H., Karlsson, B., Kim, H.S. Crisis resolution and home treatment: structure, process, and outcome—a literature review. J Psychiatr Ment Health Nurs. 2010;17(10):881–892.
Smits, C.H., et al. Effects of combined intervention programmes for people with dementia living at home and their caregivers: a systematic review. Int J Geriatr Psychiatry. 2007;22(12):1181–1193.
Swaim, R.C., Stanley, L.R. Rurality, region, ethnic community make-up and alcohol use among rural youth. J Rural Health. 2011;27(1):91–102.
Tyler, D.O., Horner, S.D. Collaborating with low-income families and their overweight children to improve weight-related behaviors: an intervention process evaluation. Spec Pediatr Nurs. 2008;13(4):263–274.
U.S. Department of Health and Human Services and U.S. Department of Agriculture: Dietary guidelines for Americans 2010, ed 7. Washington, DC: U.S. Government Printing Office; 2010.
Wood, J.P., Connelly, D.M., Maly, M.R. “Getting back to real living”: a qualitative study of the process of community reintegration after stroke. Clin Rehabil. 2010;24(11):1045–1056.
Readiness for enhanced Hope
NANDA-I
A pattern of expectations and desires for mobilizing energy on one’s own behalf that is sufficient for well-being and can be strengthened
Defining Characteristics
Expresses desire to enhance ability to set achievable goals; expresses desire to enhance belief in possibilities; expresses desire to enhance congruency of expectations with desires; expresses desire to enhance hope; expresses desire to enhance interconnectedness with others; expresses desire to enhance problem solving to meet goals; expresses desire to enhance sense of meaning to life; expresses desire to enhance spirituality
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Develop an open and caring and empathetic relationship that enables the client to discuss hope. EBN: Time nurses spend with patients can inspire hope (Montana & Kautz, 2011). In this study of patients in palliative care, hope was increased when empathy was used (Richardson, MacLeod, & Kent, 2012).
• Screen the client for hope using a valid and reliable instrument as indicated. EB: The HHI is a brief instrument with good psychometric properties that has been developed for clinical use. It has been designed to facilitate the examination of hope at various intervals so that changes in levels of hope can be identified (Van Gestel-Timmermans et al, 2010).
• Focus on the positive aspects of hope, rather than the prevention of hopelessness. Hope is essential to life and is therefore a fundamental human need. Without hope, despair and depression take hold with devastating effects (O’Hara, 2010).
• Provide emotional support and encourage hope. EB: This study illustrates how reestablishment of a hopeful attitude can strengthen a patient even with end-stage pulmonary disease and passive suicidal ideation (Anbar & Murthy, 2010).
• Help the person to identify his or her desires and expectations. EBN: This study indicates that nurses working with patients with serious conditions such as cancer listen carefully to the patients’ metaphors and reflect on the implicit meaning of them, helping the patients to see the light in the horizon and helping them to realize that hope and hopelessness are two sides of the same coin (Hammer, Mogensen, & Hall, 2009).
• Use a family-oriented approach when discussing hope. EB: Adaptation is an issue for the whole family and is facilitated by being able to stay close to the patient and receive supportive unambiguous information from the staff both during the ICU stay and after discharge (Söderström et al, 2009).
• Review internal and external resources to enhance hope. EBN: In a concept analysis of hope, based on a review of 17 research studies of terminally ill clients, the 10 attributes of hope were identified as “positive expectation, positive qualities, spirituality, goals, comfort, help/caring, interpersonal relationships, control, legacy, and life review” (Johnson, 2007).
• Identify spiritual beliefs and practices. CEB: Hope is a spiritual need, as identified in a study of 683 individuals (Flannelly, Galek, & Flannelly, 2006). EB: Spirituality was identified as a factor in increasing hope in clients with mental illness (Schrank et al, 2012).
• Assist the person to consider possible adaptations to changes. EBN: A grounded theory study of 41 women looked at refocusing hope after having a diagnosis of fetal abnormality identified by ultrasound. It identified four phases they experienced as “assume normal,” “shock,” “gaining meaning,” and “rebuilding.” It showed that they maintained hope by attaching their hopes to reality and adapting to changes as needed (Lalor, Begley, & Galavan, 2009).
Client/Family Teaching and Discharge Planning:
• Assess client and family hope prior to teaching. CEB: The degree and type of client and family hope may differ from each other, which may interfere with learning and use of knowledge for problem solving (Benzein & Berg, 2005).
• Incorporate client and family goal setting with teaching content. EBN: Realistic goal setting fosters and supports hope (Lalor, Begley, & Galavan, 2009).
• Provide information to the client and family regarding all aspects of the client’s health condition. EBN: Accurate and complete information sharing empowers, which is more likely to support hope than the perceptions that might occur without accurate and complete information (Forbat et al, 2009; Lalor, Begley, & Galavan, 2009). The most important need identified in the Critical Care Family Needs Inventory was “hope,” followed by the need for adequate and honest information (Linnarsson, Bubini, & Perseius, 2010).
References
Anbar, R.D., Murthy, V.V. Reestablishment of hope as an intervention for a patient with cystic fibrosis awaiting lung transplantation. J Altern Complement Med. 2010;16(9):1007–1010.
Benzein, E.G., Berg, A.C. The level of and relation between hope, hopelessness and fatigue in patients and family members in palliative care. Palliat Med. 2005;19:234–240.
Flannelly, K.J., Galek, K., Flannelly, L.T. A test of the factor structure of the Patient Spiritual Needs Assessment Scale. Holist Nurs Pract. 2006;20(4):187–190.
Forbat, L., et al. The use of technology in cancer care: applying Foucault’s ideas to explore the changing dynamics of power in health care. J Adv Nurs. 2009;65(2):306–315.
Hammer, K., Mogensen, O., Hall, E.O.C. The meaning of hope in nursing research: a meta-synthesis. Scand J Caring Sci. 2009;23(3):549–557.
Johnson, S. Hope in terminal illness: an evolutionary concept analysis. Int J Palliat Nurs. 2007;13(9):451–459.
Lalor, J., Begley, C.M., Galavan, E. Recasting hope: a process of adaptation following fetal anomaly diagnosis. Soc Sci Med. 2009;68(3):362–372.
Linnarsson, J.R., Bubini, J., Perseius, K. Review: a meta-synthesis of qualitative research into needs and experiences of significant others to critically ill or injured patients. J Clin Nurs. 2010;19(21/22):3102–3111.
Montana, C., Kautz, D.D. Turning the nightmare of complex regional pain syndrome into a time of healing, renewal, and hope. MedSurg Nurs. 2011;20(3):139–142.
O’Hara, D. Hope—the neglected common factor. Ther Today. 2010;21(9):1748–7846.
Richardson, K., MacLeod, R., Kent, B. A Steinian approach to an empathic understanding of hope among patients and clinicians in the culture of palliative care. J Adv Nurs. 2012;68(3):686–694.
Schrank, B., et al. Determinants, self-management strategies and interventions for hope in people with mental disorders: systematic search and narrative review. Soc Sci Med. 2012;74(4):554–564.
Söderström, I.K., et al. Family adaptation in relation to a family member’s stay in ICU. Intensive Crit Care Nurs. 2009;25(5):250–257.
Van Gestel-Timmermans, H., et al. Hope as a determinant of mental health recovery: a psychometric evaluation of the Herth Hope Index—Dutch version. Scand J Caring Sci. Dec 2010;24(Suppl):67–74.
Hopelessness
NANDA-I
Subjective state in which an individual sees limited or no alternatives or personal choices available and is unable to mobilize energy on own behalf
Defining Characteristics
Closing eyes; decreased affect; decreased appetite; decreased response to stimuli; decreased verbalization; lack of initiative; lack of involvement in care; passivity; shrugging in response to speaker; sleep pattern disturbance; turning away from speaker; verbal cues (e.g., despondent content, “I can’t,” sighing)
NOC (Nursing Outcomes Classification)
Decision-Making, Hope, Mood Equilibrium, Nutritional Status: Food and Fluid Intake, Quality of Life, Sleep
Client Outcomes
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
Monitor and document the potential for suicide. (Refer the client for appropriate treatment if a potential for suicide is identified.) Refer to the care plan Risk for Suicide for specific interventions. EB: In this study of men who had attempted suicide, hopelessness was identified as an important risk factor in suicide, and thus it is important to be identified by nurses (Hinkkurinen, Isola, & Kylmä, 2011).
Monitor potential for depression. (Refer the client for appropriate treatment if depression is identified.) EB: Hopelessness is a potential predictor for depressive symptoms for breast cancer clients (Brothers & Andersen, 2008).
• Monitor family caregivers for symptoms of hopelessness. EB: Caregivers of advanced cancer clients are at risk for experiencing hopelessness (Mystakidou et al, 2007a). EBN: Parents of children with cancer are at risk for hopelessness (Bayat, Erdem, & Kuzucu, 2008). EB: Caregivers of persons with dementia were more hopeless than non-caregivers (Bandera, Pawlowski, & Goncalves, 2007).
• Determine appropriate approaches based on the underlying condition or situation that is contributing to feelings of hopelessness. EB: Understanding the source of the hopelessness, such as negative life events, will indicate the approaches that may be most beneficial to the person (Toussaint et al, 2008). EBN: Women with advanced breast cancer and their families and men with prostate cancer and their families benefit from specific strategies of intervention (Northouse et al, 2007).
• Assess for pain and respond with appropriate measures for pain relief. EB: Pain that interferes with mood and enjoyment in life results in feelings of hopelessness for clients with advanced cancer (Mystakidou et al, 2007b).
• Facilitate access to resources to support spiritual well-being. EB: Low spiritual well-being is a risk factor for hopelessness (Rodin, Lo, & Mikulincer, 2009). EB: Strategies to enhance spiritual well-being may decrease hopelessness (Toussaint et al, 2008).
• Assist the client in looking at alternatives and setting goals that are important to him or her. Use of the nurse’s knowledge along with the client’s experience within the context of a supportive relationship stimulates an unfolding of possibilities (Kylma, 2005). EBN: When health professionals work with men with prostate cancer and their family caregivers, they should help them replace avoidant coping strategies with alternate strategies (Northouse et al, 2007).
• Discussion of hope may be helpful in increasing hope. Entering into discussion of hope may be helpful in increasing hope (Cutcliff & Koehn, 2007). EBN: Health-promoting conversations about hope and suffering with couples in palliative care has potential for improving hope (Benzein & Savemant, 2008).
• Provide accurate information. EBN: Accurate information allows the redefining and transforming of hope (Duggleby & Wright, 2005; Duggleby, Williams, & Wright, 2009). EB: Educational interventions may decrease hopelessness related to the threat of breast cancer in young women (Fry & Prentice-Dunn, 2006).
• Encourage decision-making and problem solving. EBN: Hopelessness may be an outgrowth of a perceived loss of control and/or self-efficacy. As changes occur, the nurse interacts with the client to evaluate their impact on life goals and assists in making adaptations that support hopefulness and decrease hopelessness (Kylma, 2005). EB: Problem-solving therapy decreased depression and suicide in adolescents and young adults (Eskin, Ertekin, & Demir, 2007).
• Spend one-on-one time with the client. Use empathy; try to understand what the client is saying and communicate this understanding to the client to create a nonjudgmental trusting environment to develop therapeutic relationships with the client. The therapeutic relationship is an essential component of interventions to address hopelessness (Koehn & Cutcliff, 2007).
• Teach alternative coping strategies such as physical activity. EBN: As the number of minutes of exercise increased, hopelessness decreased in prison inmates (Cashin, Potter, & Butler, 2008). EB: In college students, physical activity each week was associated with decreased feelings of hopelessness (Taliaferro, Rienzo, & Pigg, 2008).
• Review the client’s strengths and resources with the client. EBN: Working with the client to identify positive experiences, resources, and personal strengths facilitates the development of hopefulness (Kylma, 2005).
• Involve family and significant others in the plan of care. EBN: Social support decreased hopelessness and anxiety in parents of children with cancer (Bayat, Erdem, & Kuzucu, 2008).
• For additional interventions, see the care plans for Readiness for enhanced Hope, Spiritual Distress, Readiness for enhanced Spiritual Well-Being, and Disturbed Sleep Pattern.
• Previous interventions may be adapted for geriatric clients.
If depression is suspected; confer with the primary physician regarding referral for mental health services. EB: This study of older adults identified hopelessness as a major risk factor for suicide (Neufeld, O’Rourke, & Donnelly, 2010).
• Take threats of self-harm or suicide seriously. EB: This study of older adults identified hopelessness as a major risk factor for suicide (Neufeld, O’Rourke, & Donnelly, 2010). Older adults have the highest risk of death by suicide in the United States (Cukrowicz et al, 2011).
• Use reminiscence and life-review therapies to identify past coping skills. Older people in residential facilities benefit from this therapy (Wang, 2004). CEB: Life review produced a positive outcome when used with individuals with right hemisphere cerebrovascular accidents (Davis, 2004).
• Encourage visits from children. Social relationships foster hopefulness (Duggleby, 2001).
• Consider videoconferencing for elders in nursing homes with relatives as alternative to “live visits.” Once-a-week videoconferencing effectively improved the nursing home residents’ emotional and appraisal social support, depressive status, and loneliness (Tsai et al, 2010).
• Position the client by a window, take the client outside, or encourage such activities as gardening (if ability allows). Using nature can help older people expand their perspectives, connect with strength, and expand their coping strategies, while gaining a wider sense of acceptance and completion in life (Berger, 2009).
• Provide esthetic forms of expression, such as dance, music, literature, and pictures. EBN: Esthetic experiences are related to feelings of timelessness and spacelessness and serve as sources of gratification (Wikstrom, 2004).
• Consider “biblio and telephone therapy”(BTT). EB: The results of this study of older adults demonstrated that the clients benefited from BTT and that depressive symptoms lessened (Brenes et al, 2010).
• Assess for the influence of cultural beliefs, norms, and values on the client’s feelings of hopelessness. EB: In some Latino cultures, talking about depression (depresión) may be taboo. Hopelessness (desanimo) may be understood differently by clients of various cultural backgrounds and may have a more normative and culturally specific, comfortable sound for clients (Marsiglia et al, 2011).
• Assess the effect of fatalism on the client’s expression of hopelessness. EBN: Fatalistic perspectives, which involve the belief that one cannot control one’s own fate, may influence health behaviors in some Asian, African American, and Latino populations (Marsiglia et al, 2011). This study of African Americans with multiple sclerosis identified fatalism, defined as a surrender of power to external forces in life leading to hopelessness, as being common among some African Americans (Holland, Gray, & Pierce, 2011).
Assess for depression and refer to appropriate services. EBN: Older Taiwanese American adults with depressive symptoms report hopelessness as a symptom associated with depression (Suen & Tusaie, 2004).
• Encourage spirituality as a source of support for hopelessness. EBN: African Americans and Latinos may identify spirituality, religiousness, prayer, and church-based approaches as coping resources (Samuel-Hodge et al, 2000). EBN: Spiritual beliefs, the role of prayer, and the role of family in caregiving were predominant aspects of the end-of-life experience in Mexican Americans. There is a need to focus on the role of religious institutions in Mexican American culture, where spirituality and religion are strong influences in the life experience (Johnston, 2007).
• Previously mentioned interventions may be adapted for home care use.
Assess for isolation within the family unit. Encourage the client to participate in family activities. If the client cannot participate, encourage him or her to be in the same area and watch family activities. Refer for telephone support. Hope is facilitated by meaningful interpersonal relationships (Koehn & Cutcliff, 2007). EB: Clients show significant improvements in depression and positive affect during the 16 weeks of telephone-administered treatment (Mohr, Hart, & Julian, 2005).
• Reminisce with the client about his or her life. EBN: The process of remembering past activities helps find meaning and purpose in life and inspires hope (Duggleby & Wright, 2005). EB: Older people in residential facilities benefit from life review (Chin, 2007).
• Identify areas in which the client can have control. Allow the client to set achievable goals in these areas. Assist the client when necessary to negotiate desirable outcomes. EBN: Mobilization of resources to promote self-efficacy promotes hope (Kylma, 2005).
• If illness precipitated the hopelessness, discuss knowledge of and previous experience with the disease. Help the client to identify past coping strengths. EBN: Knowledge of the disease and previous positive coping experience with the illness provide hope for the future (Duggleby & Wright, 2005).
Provide plant or pet therapy if possible. EBN: Caring for pets or plants helps to find meaning and purpose and foster hope (Holtslander & Duggleby, 2009). EB: Pet therapy has been reported to have a positive effect on psychological well-being (Colombo et al, 2006).
Client/Family Teaching and Discharge Planning:
• Provide information regarding the client’s condition, treatment plan, and progress. EBN: Clear, direct communication of the potential of an intervention to overcome a threat along with honest discussion of negative aspects fosters hope for clients and their families (Duggleby & Wright, 2005; Holtslander et al, 2005).
• Teach family caregivers skills to provide care in the home. EBN: Family caregivers find hope in giving skilled care to their family members (Duggleby et al, 2009). EBN: A psychoeducational program preparing family caregivers for caring for a dying relative at home increased their feeling of caregiving competence and rewards (Hudson et al, 2008).
• Provide positive reinforcement, praise, and acknowledgment of the challenges of caregiving to family members. EBN: Positive comments and praise foster hope in family caregivers (Holtslander et al, 2005).
Refer the client to self-help groups, such as “I Can Cope” and “Make Today Count.” EBN: Self-help and/or professionally led curriculum-based support programs for families are effective in reducing stress and facilitating coping and hope (Northouse et al, 2007).
When depression is identified by primary care physician in adolescents consider an Internet-based behavior change intervention EB: In this study, a primary care/Internet-based intervention model among adolescents demonstrated reductions in depressed mood over 6 months and may result in fewer depressive episodes (Hoek et al, 2011).
References
Bandera, D.R., Pawlowski, J., Goncalves, T.R. Psychological distress in Brazilian caregivers of relatives with dementia. Aging Ment Health. 2007;11(1):14–19.
Bayat, M., Erdem, E., Kuzucu, E.G. Depression, anxiety, hopelessness and social support levels of the parents of children with cancer. J Pediatr Oncol Nurs. 2008;25:247–253.
Benzein, E.V., Savemant, B.I. Health-promoting conversation about hope and suffering with couples in palliative care. Int J Palliat Nurs. 2008;14(9):409–445.
Berger, R. Being in nature: an innovative framework for incorporating nature in therapy with older adults. J Holist Nurs. 2009;27(1):45–50.
Brenes, G., et al. Feasibility and acceptability of bibliotherapy and telephone sessions for the treatment of late-life anxiety disorders. Clin Gerontol. 2010;33:62–68.
Brothers, B.M., Andersen, B.L. Hopelessness as a predictor of depressive symptoms for breast cancer patients coping with recurrence. Psychooncology. 2008;18(3):267–275.
Cashin, A., Potter, E., Butler, T. The relationship between exercise and hopelessness in prison. J Psychiatr Ment Health Nurs. 2008;15:66–71.
Chin, A. Clinical effects of reminiscence therapy in older adults: a meta-analysis of controlled trials. Hong Kong J Occupat Ther. 2007;17(1):10–22.
Colombo, G., et al. Pet therapy and institutionalized elderly: a study on 144 cognitively unimpaired subjects. Arch Gerontol Geriatr. 2006;42(2):207–216.
Cukrowicz, K.C., et al. Perceived burdensomeness and suicide ideation in older adults. Psychol Aging. 2011;26(2):331–338.
Cutcliff, J.R., Koehn, C.V. Hope and interpersonal psychiatric/mental health nursing: a systematic review of the literature—part two. J Psychiatr Ment Health Nurs. 2007;14:141–147.
Davis, M.C. Life review therapy as an intervention to manage depression and enhance life satisfaction in individuals with right hemisphere cerebral vascular accidents. Issues Ment Health Nurs. 2004;25(5):503–515.
Duggleby, W. Hope at the end of life. J Hosp Palliat Nurs. 2001;3(2):51.
Duggleby, W., et al. Renewing everyday hope: the hope experience of family caregivers of persons with dementia. Issues Ment Health Nurs. 2009;30(8):514–521.
Duggleby, W., Wright, K. Transforming hope: how elderly palliative patients live with hope. Can J Nurs Res. 2005;37(2):70–84.
Eskin, M., Ertekin, K., Demir, H. Efficacy of a problem-solving therapy for depression and suicide potential in adolescents and young adults. Cogn Ther Res. 2007;32(2):227–245.
Fry, R.B., Prentice-Dunn, S. Effects of psychosocial intervention on breast self-examination attitudes and behaviors. Health Educ Res 21. 2006;2:287–295.
Hinkkurinen, J., Isola, A., Kylmä, J. Experiences of self-destruction and related hopelessness in men who have attempted suicide [Finnish]. Hoitotiede. 2011;23(3):230–239.
Hoek, W., et al. Randomized controlled trial of primary care physician motivational interviewing versus brief advice to engage adolescents with an Internet-based depression prevention intervention: 6-month outcomes and predictors of improvement. Transl Res. 2011;158(6):315–325.
Holland, B.E., Gray, J., Pierce, T.G. The client experience model: synthesis and application to African Americans with multiple sclerosis. J Theory Constr Test. 2011;15(2):36–40.
Holtslander, L., Duggleby, W. The hope experience of older bereaved women who cared for a spouse with terminal cancer. Qual Health Res. 2009;19:388–400.
Holtslander, L., et al. The experience of hope for informal caregivers of palliative patients. J Palliat Care. 2005;21(4):285–291.
Hudson, P., et al. Evaluation of a psycho-educational group program for family caregivers in home-based palliative care. Palliat Med. 2008;22:270–280.
Johnston, R. Religions in society, ed 7. Upper Saddle River, NJ: Pearson Prentice Hall; 2007.
Koehn, C.V., Cutcliff, J.R. Hope and interpersonal psychiatric/mental health nursing: a systematic review of the literature—part one. J Psychiatr Ment Health Nurs. 2007;14:134–140.
Kylma, J. Despair and hopelessness in the context of HIV: a meta-synthesis on qualitative research findings. J Clin Nurs. 2005;14:813–821.
Marsiglia, F.F., et al. Hopelessness, family stress, and depression among Mexican-heritage mothers in the Southwest. Health Soc Work. 2011;36(1):7–18.
Mohr, D., Hart, S., Julian, L. Telephone administered psychotherapy for depression. Arch Gen Psychiatry. 2005;62(9):1007–1014.
Mystakidou, K., et al. Caregivers of advanced cancer patients: feelings of hopelessness and depression. Cancer Nurs. 2007;30(5):412–418.
Mystakidou, K., et al. Exploring the relationships between depression, hopelessness, cognitive status, pain and spirituality in patients with advanced cancer. Arch Psychiatr Nurs. 2007;21(3):150–161.
Neufeld, E., O’Rourke, N., Donnelly, M. Enhanced measurement sensitivity of hopeless ideation among older adults at risk of self-harm: reliability and validity of Likert-type responses to the Beck Hopelessness Scale. Aging Ment Health. 2010;14(6):752–756.
Northouse, L., et al. Randomized clinical trial of a family intervention for prostate cancer patients and their spouses. Cancer. 2007;110:2809–2811.
Rodin, G., Lo, C., Mikulincer, M. Pathways to distress: the multiple determinants of depression, hopelessness and the desire for hastened death in metastatic cancer patients. Soc Sci Med. 2009;68(3):562–569.
Samuel-Hodge, C.D., et al. Influences on day-to-day self-management of type 2 diabetes among African American women: spirituality, the multi-caregiver role, and other social context factors. Diabetes Care. 2000;23(7):928.
Suen, L.J., Tusaie, K. Is somatization a significant depressive symptom in older Taiwanese Americans? Geriatr Nurs. 2004;25(3):157–163.
Taliaferro, L.S., Rienzo, B.A., Pigg, M. Associations between physical activity and reduced rates of hopelessness, depression and suicidal behavior among college students. J Am Coll Health. 2009;57(4):427–436.
Toussaint, L., et al. Why forgiveness may protect against depression: hopelessness as an explanatory mechanism. Pers Ment Health. 2008;2:89–103.
Tsai, H.H., et al. Videoconference program enhances social support, loneliness, and depressive status of elderly nursing home residents. Aging Ment Health. 2010;14(8):947–954.
Wang, J. The comparative effectiveness among institutionalized and non-institutionalized elderly people in Taiwan of reminiscence therapy as a psychological measure. J Nurs Res. 2004;12(3):237–244.
Wikstrom, B. Older adults and the arts: the importance of aesthetic forms of expression in later life. J Gerontol Nurs. 2004;30(9):30–36.
Risk for compromised Human Dignity
NANDA-I
At risk for perceived loss of respect and honor
Honoring an individual’s dignity is imperative and consists of the following elements:
• Physical comfort (bathing, positioning, pain and symptom relief, touch, and a peaceful environment). Encompasses aspects of privacy, respect, and autonomy. Also includes staff expertise, effectiveness, and safety of care
• Psychosocial comfort (listening, sharing fears, giving permission, presence, not dying alone, family support and presence). Includes elements of client participation and choice. Clients feel at ease, safe, and protected; neither intimidated nor threatened
• Spiritual comfort (sharing love and caring words, being remembered, validating their lives, praying with and for, reading scripture and Bible, clergy and referral to other providers [i.e., hospice]) (Groenewoud et al, 2008)
Risk Factors
Cultural incongruity; disclosure of confidential information; exposure of the body; inadequate participation in decision-making; loss of control of body functions; perceived dehumanizing treatment; perceived humiliation; perceived intrusion by clinicians; perceived invasion of privacy; stigmatizing label; use of undefined medical terms
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Be authentically present when with the client, try to limit extraneous thoughts of self or others, and concentrate on the well-being of the client. Helping the client feel important is a core value in the nursing profession. Respect for human dignity includes self-worth, autonomy, self-determination, individuality, and client rights (Uei & Wu, 2010). The nurse attempts to enter into and stay within the other’s frame of reference to connect with the inner life world of meaning and spirit of the other; together they join in a mutual search for meaning and wholeness of being and becoming to potentiate comfort measures, pain control, a sense of well-being, wholeness, or even spiritual transcendence of suffering. EBN: Presence is described as transformative to the client care experience, having the potential to facilitate the healing process (Tavernier, 2009). EBN: Results of this study on presencey found that it can facilitate healing and promote dignity: maintaining dignity includes privacy for the body, cleanliness, independence and being able to exert control, sufficient time from staff, attitudes toward older people, and communication (Webster & Bryan, 2009).
• Accept the client as is, with unconditional positive regard. The person is viewed as whole and complete, regardless of illness or social situation. Dignity is an inherent characteristic of being human. Being treated with unconditional love is a healing experience in itself. Essential to the client-centered relationship are unconditional regard, empathy, and genuineness (Dossey & Keegan, 2009).
• Use loving, appropriate touch based on the client’s culture. When first meeting the client, shake hands with younger clients; touch the arm or shoulder of older clients. Ideally the caring relationship with client and family begins on hospital admission and is carried through to discharge and into the home if possible. EBN: Touch can lower anxiety (Maville, Bowen, & Benham, 2008). EBN: Nurses need to be creative and realize the potential for complementary interventions such as touch and massage to assist with improving quality of life, self-esteem, comfort, confidence, dignity, and peace (Fenton, 2011). CEB: Touch can help build interpersonal relationships (Salzmann-Erikson & Eriksson, 2005).
• Determine the client’s perspective about his/her health. Example questions include: “Tell me about your health.” “What is it like to be in your situation?” “Tell me how you perceive yourself in this situation.” “What meaning are you giving to this situation?” “Tell me about your health priorities.” “Tell me about the harmony you wish to reach.” Such questions usually contribute to helping people find meaning to the crisis in their life (Watson, 2008). EBN: Clients are vulnerable to loss of dignity due to their impaired health, which is further threatened by lack of privacy, and curt or authoritarian staff behavior (Baillie, 2009).
• Create a loving, healing environment for the client to help meet physical, psychological, and spiritual needs as possible. The goal is to develop a healing environment where wholeness, beauty, comfort, dignity, and peace are potentiated (Dossey & Keegan, 2009).
• Determine the client’s preferences for when and how nursing care is needed and follow the client’s guidelines if at all possible. The client’s autonomy must be recognized as part of dignified nursing care. CEB: A summary of older adults’ perceptions of the most important nurse caring behaviors is (Marini, 1999):
Know when it’s necessary to call the medical provider
Give my treatments and medications on time
Check my condition very closely
Give my pain medication on time
• Include the client in all decision-making; if the client does not choose to be part of the decision, or is no longer capable of making a decision, use the named surrogate decision maker. The Patient Self-Determination Act, effective in 1991, requires that all individuals receiving medical care also receive written information about their right to accept or refuse medical or surgical treatment and their right to initiate advance directives. Advance directives are instructions that indicate health care interventions to initiate or withhold or that designate someone who will act as a surrogate in making such decisions in the event that decision-making capacity is lost (Dossey & Keegan, 2009).
• Encourage the client to share his or her feelings, both positive and negative as appropriate and as the client is willing. Being present to and supportive of the expression of positive and negative feelings is a connection with deeper spirit of self and the one being cared for (Watson, 2008). EBN: Nurses play a fundamental role in caring for those who suffer. Suffering is associated with loss, intense emotions, spiritual distress, and inability to express those experiences. The basic tenets of caring for those who are suffering include listening, intimate care of the body, and presence (Ferrell & Coyle, 2008).
• Ask the client what he/she would like to be called and use that name consistently.
• Maintain privacy at all times.
• Avoid authoritative care when the nurse knows what should be done, and the client is powerless. EBN: Nursing care must be focused on protecting and maintaining clients’ dignity to the greatest extent possible, so that clients are not exposed to suffering during their nursing care (Heijkenskjold, Ekstedt, & Lindwall, 2010). CEB: Fewer visits, less eye contact, and increasingly meaningless conversations reflect emotional abandonment; community is denied. Suffering is devaluing and causes people to retreat from dehumanizing experiences (Stanley, 2002). EBN: Nurses dedicate personal time to clients. When nurses see that clients are sad, they give them personal time by sitting down with them and finding out what is wrong (Heijkenskjold, Ekstedt, & Lindwall, 2010)
• Actively listen to what the client is saying both verbally and nonverbally. CEB: We must quiet our “inner dialogue” so that we may hear more clearly, allow others to tell the whole story, listen without judgment or advice, and bear witness to the experience. Attentive silence is a communicative act in its own right, an act of compassion. It signifies respect, legitimizes what is said, and creates an atmosphere in which self-discovery can occur (Stanley, 2002).
• Encourage the client to share thoughts about spirituality as desires. The care of the soul remains the most powerful aspect of the art of caring in nursing. The caring occasion becomes “transpersonal” when “it allows for the presence of the spirit of both—then the event of the moment expands the limits of openness and has the ability to expand human capabilities” (Watson, 2008).
• Utilize interventions to instill increased hope; see the care plan Readiness for enhanced Hope. CEB: When hope for a cure is no longer possible, help clients to recognize that the relationships change between clients, families, and caregivers but do not end. Hope continues, but now has a different focus (Erlen, 2003). Caring does not end but is rather transformed when intensive treatment ends. EB: The findings indicated that some professionals may struggle with fears of providing “false hope,” a fear of litigation and a lack of training, when considering providing hope. However, the research also identified positive and hopeful messages that are not in conflict with providing honest and realistic communication. These include acknowledging the dignity and worth of the individual, indicating that there is help available, and informing families about the spectrum of possible outcomes for their loved one rather than the worst case scenario (Harnett, Tierney, & Guerin, 2009).
• For further interventions on spirituality, see the care plan for Readiness for enhanced Spiritual Well-Being.
• Always ask the client how he or she would like to be addressed. Avoid calling elderly clients “sweetie,” “honey,” “Gramps,” or other terms that can be demeaning unless this is acceptable in the client’s culture, or requested by the client. Appropriate forms of address must be used with the elderly to maintain dignity. EBN & CEB: A respectful form of address has positive effects, whereas overfamiliarity tends to have a negative impact on self-respect, physical and mental health, and recovery from disease, particularly with older people and those with dementia (Williams et al, 2008; Woolhead et al, 2006).
• Treat the elderly client with the utmost respect, even if delirium or dementia is present with confusion. Confused clients respond positively to caregivers who approach gently, with positive regard, and treat the confused client with respect and dignity.
• Avoid use of restraints. Consider all aspects of restraint use including IVs, Foleys, and chemicals. The paternalistic use of physical restraints is morally unjustified and a violation of the client’s autonomy. Dignity is not maintained. EBN: Research on clients with dementia suggests that unmet needs such as anxiety or pain can manifest in wandering or aggressive behavior. This can be time consuming to manage and, depending on how staff respond—for example, by the use of restraint or sedatives has been found to be not in the clients’ best interests (Bridges & Wilkinson, 2011).
• Assess for the influence of cultural beliefs, norms, and values on the client’s way of communicating, and follow the client’s lead in communicating in matters of eye contact, amount of personal space, voice tones, and amount of touching. If in doubt, ask the client. What the client considers normal and appropriate communication that maintains and facilitates dignity is based on cultural perceptions. EBN: Client dignity is promoted when staff provide privacy and use interactions that help clients feel comfortable, in control and valued. Individual staff behavior has a major impact on whether threats to client dignity actually lead to its loss (Baillie, 2009).
Client/Family Teaching and Discharge Planning:
• Teach family and caregivers the need for the dignity of the client to be maintained at all times. How an individual cognitively perceives and emotionally deals with the illness can depend on the person’s family and social relationships and ultimately can affect the ability to heal.
Note: Caring is integral to maintaining dignity. According to Jean Watson (2008), a caring occasion is the moment (focal point in space and time) when the nurse and another person come together in such a way that an occasion for human caring is created. Both the one cared for and the one caring can be influenced by the caring moment through the choices and actions decided within the relationship, thereby influencing and becoming part of their own life history (Watson, 2008).
References
Baillie, L. Patient dignity in an acute care hospital setting: a case study. Int J Nurs Stud. 2009;46:23–37.
Bridges, J., Wilkinson, C. Achieving dignity for older people with dementia in hospital. Nurs Stand. 2011;25(29):42–47. [quiz 48].
Dossey, B., Keegan, L. Holistic nursing: a handbook for practice, ed 5. Sudbury, MA: Jones & Bartlett; 2009.
Erlen, J. Caring doesn’t end. Orthop Nurs. 2003;22(5):446–449.
Fenton, S. Reflections on lymphoedema, fungating wounds and the power of touch in the last weeks of life. Int J Palliat Nurs. 2011;17(2):60–66.
Ferrell, B., Coyle, N. The nature of suffering and the goals of nursing. Oncol Nurs Forum. 2008;35(2):241–247.
Groenewoud, A., et al. Building quality report card for geriatric care in the Netherlands: using concept mapping to identify the appropriate “building blocks” from the consumer’s perspective. Gerontologist. 2008;48(1):79–92.
Harnett, A., Tierney, E., Guerin, S. Convention of hope—communicating positive realistic messages to families at the time of a child’s diagnosis with disabilities. Br J Learn Disabil. 2009;37:257–264.
Heijkenskjold, K.B., Ekstedt, M., Lindwall, L. The patient’s dignity from the nurse’s perspective. Nurs Ethics. 2010;17(3):313–324.
Marini, B. Institutionalized older adults’ perception of nursing caring behaviors: a pilot study. J Gerontol Nurs. 1999;25(5):10–16.
Maville, J., Bowen, J., Benham, G. Effect of healing touch on stress perception and biological correlates. Holist Nurs Pract. 2008;22(2):103–110.
Salzmann-Erikson, M., Eriksson, H. Encouraging touch: a path to affinity in psychiatric care. Issues Ment Health Nurs. 2005;26(8):843–852.
Stanley, K. The healing power of presence: respite from the fear of abandonment. Oncol Nurs Forum. 2002;39(6):935–940.
Tavernier, S. An evidence-based conceptual analysis of presence. In Dossey B., et al, eds.: Holistic nursing: a handbook for practice, ed 5, Sudbury, MA: Jones and Bartlett, 2009.
Uei, S., Wu, S. Promoting dignity in long term care. Macau J Nurs. 2010;9(2):20–24.
Watson, J. Nursing: the philosophy and science of caring. Boulder: University Press of Colorado; 2008.
Webster, C., Bryan, K. Older people’s views of dignity and how it can be promoted in a hospital environment. J Clin Nurs. 2009;18(12):1784–1792.
Williams, K., et al. Elderspeak communication: impact on dementia care. Am J Alzheimers Dis Other Demen. 2008;24(1):11–20.
Woolhead, G., et al. “Tu” or “vous”? A European qualitative study of dignity and communication with older people in health and social care settings. Patient Educ Couns. 2006;61(3):363–371.
Hyperthermia
NANDA-I
Body temperature elevated above normal range
Elevated body temperature can be either fever (pyrexia) or hyperthermia. Fever is a regulated rise in the core body temperature to 1° to 2° C higher than the client’s normal body temperature as an innate immune response to a perceived threat and is regulated by the hypothalamus. Hyperthermia is an unregulated rise in body temperature that occurs when a client either gains heat through an increase in the body’s heat production or has developed an inability to effectively dissipate heat (Becker & Wu, 2010; Pitoni, Sinclair, & Andrews, 2011; Scrase & Tranter, 2011). Hyperthermia is not adaptive and should be treated as a medical emergency.
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Maintain core body temperature within adaptive levels (less than 104° F, 40° C)
• Remain free of complications of malignant hyperthermia (MH)
• Remain free of complication of neuroleptic malignant syndrome (NMS)
• Verbalize signs and symptoms of heat stroke and actions to prevent heat stroke
• Verbalize personal risks for malignant hyperthermia and neuroleptic malignant syndrome to be reported during health history reviews to all health care professionals including pharmacists
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
Temperature Measurement
• Recognize that hyperthermia is a rise in body temperature above 40° C [104° F] that is not regulated by the hypothalamus resulting in an uncontrolled increase in body temperature exceeding the body’s ability to lose heat, and is a medical emergency (Beard & Day, 2008; Dinarello & Porat, 2011).
• Measure and record a client’s temperature using two modes of temperature monitoring every hour and more frequently as clinically indicated. Continuous temperature monitoring using an indwelling method of temperature measurement is usually indicated to monitor effectiveness of interventions in lowering the body temperature. EBN & EB: Hyperthermia is a life-threatening crisis that requires accurate temperature measurement. Core temperature is obtained by a pulmonary artery catheter, from the distal esophagus, or from the tympanic membrane; near core temperature measurements include oral, bladder, rectal, and temporal artery, and peripheral measurements are obtained by skin surface measurements and in the axilla (Davie & Amoore 2010; Frommelt, Ott, & Hays, 2008; Hooper et al, 2009). Research is limited on accuracy of temporal artery measurements outside normal ranges; axillary temperature is accurate in neonates but is not well supported in adults; tympanic membrane measurements and chemical dot thermometers are least accurate and should be avoided in caring for the acutely ill adult client (Calonder et al, 2010; Davie & Amoore, 2010; Hooper et al, 2009; Makic et al, 2011; O’Grady et al, 2008).
• Use the same site and method (device) for temperature measurement for a given client so that temperature trends are assessed accurately; record site of temperature measurement. EBN & EB: There are differences in temperature depending on the site from which temperature measurement is obtained; however, differences between sites should not be greater than 0.3° to 0.5° C (Bridges & Thomas, 2009; Davie & Amoore, 2010; Dinarello & Porat, 2011; Frommelt, Ott, & Hays, 2008; Hooper et al, 2009; Makic et al, 2011).
Work with the physician to help determine the cause of the temperature increase, hyperthermia, which will often help direct appropriate treatment. It is important to treat the underlying cause of the temperature to preserve neurological function of the client as well as implement interventions to rapidly lower the core temperature (Beard & Day, 2008; Dinarello & Porat, 2011; Leon & Helwig, 2010).
• Refer to care plan Ineffective Thermoregulation for interventions managing fever (pyrexia).
Heat Stroke
• Recognize that heat stroke may be separated into two categories: classic and exertional. Classic heat stroke usually involves the very young and older client during environmental heat waves. Exertional heat stroke occurs in young adults performing strenuous exercise in hot climates (Beard& Day, 2008; Leon & Helwig, 2010).
• Watch for risk factors for classic heat stroke, which include (Leon & Helwig, 2010):
EB: Physiological effects of aging lower onset of sweating and rate of sweating needed to help with dissipation of body heat. Medications can dehydrate the client as well as blunt physiological responses necessary to assist with heat dissipation, increasing the risk of heat stroke in older clients (Beard & Day, 2008; Brege, 2009; Leon & Helwig, 2010).
• Risk factors of exertional heat stroke include (Leon & Helwig, 2010):
Drug use (e.g., alcohol, amphetamines, ecstasy)
Wearing protective clothing (uniforms and athletic gear) that limits heat dissipation
• Recognize signs and symptoms of hyperthermia which include: core body temperature greater than 40° C (104° F), tachycardia, tachypnea, dizziness, weakness, vomiting, headache, confusion, delirium, seizures, coma, acute kidney injury (rhabdomyolysis), hot dry skin (classic heat stroke) (Beard & Day, 2008; Brege, 2009; Dinarello & Porat, 2011; Leon & Helwig, 2010).
• Recognize that antipyretic agents are of no use in treatment of hyperthermia. EB: Because the cause of the hyperthermia does not involve the hypothalamus, antipyretic agents are ineffective and not indicated in treatment of clients with hyperthermia (Beard & Day, 2008; Dinarello & Porat, 2011).
Assess fluid loss and facilitate oral intake or administer intravenous fluids as ordered to accomplish fluid replacement and support the cardiovascular system. Increased metabolic rate, diuresis, and diaphoresis-associated exertional hyperthermia, cause loss of body fluids (Beard & Day, 2008; Brege, 2009; CDC, 2012). Refer to the care plan for Deficient Fluid Volume.
• Use external cooling measures carefully: loosen or remove excessive clothing, give a tepid water bath, provide cool liquids if the client is alert enough to swallow, fan the client’s face. EB & EBN: Hyperthermia must be treated aggressively to lower the body temperature. However, interventions to cool the client should not be so aggressive that the patient shivers. Shivering increases heat production, oxygen consumption, and cardiorespiratory effort (Beard & Day, 2008; Brege, 2009; CDC, 2012; Pitoni, Sinclair, & Andrews, 2011).
• Recognize that cooling with ice packs, cooled intravenous solution, a hypothermia blanket may be required to lower the body temperature quickly (Dinarello & Porat, 2011; Leon & Helwig, 2010). When using a cooling blanket, choose a circulating water cooling device if available and set the temperature regulator to 0.5° to 1° C (1° to 2° F) below the client’s current temperature to prevent shivering. EB: A review examined cooling methods found that skin surface cooling methods using ice and fans provided inconsistent cooling; hydrogel-coated water circulating pads placed on the chest and legs provided better targeted cooling than water circulating cooling blankets that can be placed over or under the patient; and intravascular core cooling is an invasive technique that may be used to rapidly cool the body (Polderman & Herold, 2009).
Continually assess the client’s neurological and other organ function, especially kidney function, for signs of injury from hyperthermia. EB & EBN: Hyperthermia can cause permanent neurological injury, acute kidney injury, electrolyte imbalances, and coagulation disorders. Continuous assessment of neurological and other organ function is essential as the client’s body temperature is rapidly lowered (Beard & Day, 2008; Dinarello & Porat, 2011; Leon & Helwig, 2010).
Malignant Hyperthermia
If the client has just received general anesthesia, especially halothane, sevoflurane, isoflurane, or succinylcholine, recognize that the hyperthermia may be caused by malignant hyperthermia and requires immediate treatment to prevent death. Malignant hyperthermia is often a fatal disease and must be treated promptly. As more surgeries are done in ambulatory surgery centers, it is important that the medication dantrolene be stocked for rapid administration as ordered (AORN, 2008; Dinarello and Porat, 2011; Hopkins, 2011).
• Recognize that signs and symptoms of malignant hyperthermia typically occur suddenly after exposure to the anesthetic agent and include rapid rise in core body temperature, muscle rigidity, arrhythmias, tachycardia, tachypnea, hypercarbia, rhabdomyolysis, and acute kidney injury, and elevated serum calcium and potassium, progressing to disseminated intravascular coagulation and cardiac arrest (Hopkins, 2011).
If the client has malignant hyperthermia, begin treatment as ordered, including cessation of the anesthetic agent and intravenous administration of dantrolene sodium, stat, along with antiarrhythmics, and continued support of the cardiovascular system. Dantrolene helps decrease the increased muscle activity associated with malignant hyperthermia and can be life-saving (Dinarello & Porat, 2011).
• Provide client and family education when malignant hyperthermia occurs, as it is an inherited muscle disorder. Obtaining a thorough health history to include family history of adverse experiences with anesthesia is important in identifying clients at risk for malignant hyperthermia. Genetic testing may also be indicated (Malignant Hyperthermia Association of the United States, 2011).
Neuroleptic Malignant Syndrome
Recognize that neuroleptic malignant syndrome is a rare condition associated with clients who are taking typical and atypical antipsychotic agents (Gillman, 2010; Trollor, Chen, & Sachdev, 2009). EB & EBN: The most common agents associated with the condition are dopamine-2 inhibiting agents (e.g., haloperidol, fluphenazine, chlorpromazine, quetiapine, risperidone, and olanzapine). Dopamine antagonist agents have also been found to trigger the syndrome as well (e.g., metoclopramide, promethazine, prochlorperazine) (Dinarello & Porat, 2011; Gillman, 2010; Harrison & McErlane, 2008; Seitz & Gill, 2009; Trollor, Chen, & Sachdev, 2009).
• Watch for signs and symptoms that can range from mild to severe and include a sudden change in mental status, rapid rise in body temperature, muscle rigidity, tachycardia, tachypnea, elevated or labile blood pressure, diaphoresis, rhabdomyolysis, and acute kidney injury (Harrison & McErlane, 2008; Seitz & Gill, 2009).
Begin treatment when diagnosed, including cessation of the neuroleptic or dopamine antagonist agent; ordered administration of dantrolene, bromocriptine, levodopa, amantadine, or nifedipine; and continued support of the cardiovascular and renal systems (Dinarello & Porat, 2011).
• A client health history that reports extrapyramidal reaction to any medication should be further explored for risk of neuroleptic malignant syndrome, as this syndrome can occur at any time during a client’s treatment with typical and atypical antipsychotic agents (Harrison & McErlane, 2008; Seitz & Gill, 2009; Trollor, Chen, & Sachdev, 2009).
• Recognize that clients receiving rapid dose escalation of antipsychotic agents (e.g., haloperidol) intramuscularly for acute treatment of delirium may be at increased risk of developing neuroleptic malignant syndrome (Seitz & Gill, 2009).
• Assess risk factors of malignant hyperthermia as this has an increased prevalence in the pediatric population. The administration of inhalation anesthesia and succinylcholine is common in this age group. Risk assessment includes a personal or family history of anesthesia-related complications or death (Malignant Hyperthermia Association of the United States, 2011).
Administer dantrolene and oxygen as ordered if malignant hyperthermia is present. Dantrolene and oxygen should administered as treatment of malignant hyperthermia (Dinarello & Porat, 2011).
• Help the client seek medical attention immediately if elevated core temperature is present. To diagnose the hyperthermia, assess for possible precipitating factors, including changes in medication, environmental changes, and recent medical interventions or infectious exposures. The elderly are more susceptible to environmentally and medication-induced hyperthermia, due to the greater incidence of underlying chronic medical conditions that impair thermal regulation or prevent removal from a hot environment (Beard & Day, 2008).
• In hot weather, encourage the client to wear lightweight cotton clothing.
• Provide education on the importance of drinking eight glasses of fluid per day (within their cardiac and renal reserves) regardless of whether they are thirsty. Assess for the need for and presence of fans or air conditioning, and also appropriate clothing. The elderly are more susceptible to a hot environment than are younger adults because of a decreased sensitivity to heat, decreased sweat gland function, decreased thirst, and decreased mobility (Beard & Day, 2008; Brege, 2009).
In hot weather, monitor the elderly client for signs of heat stroke: rising temperature, orthostatic blood pressure drop, weakness, restlessness, mental status changes, faintness, thirst, nausea, and vomiting. If signs are present, move the client to a cool place, have the client lie down, give sips of water, check orthostatic blood pressure, spray with lukewarm water, cool with a fan, and seek medical assistance immediately. The elderly are predisposed to heat exhaustion and should be watched carefully for its occurrence; if it is present, it should be treated promptly (Beard & Day, 2008; Brege, 2009).
• During warm weather, help the client obtain a fan or an air conditioner to increase evaporation, as needed. Help the elderly client locate a cool environment to which the client can go for safety in hot weather.
• Take the temperature of the elderly client in hot weather. Elderly clients may not be able to tell that they are hot because of decreased sensation.
• Some of the interventions described previously may be adapted for home care use.
• Determine whether the client or family has a functioning thermometer, and know how to use it. Please refer to the interventions above on taking a temperature.
• Help the client and caregivers prevent and monitor for heat stroke/hyperthermia during times of high outdoor temperatures. Preventive measures include minimizing time spent outdoors, use of air conditioning or fans, increasing fluid intake, and taking frequent rest periods (Beard & Day, 2008; CDC, 2012).
• To prevent heat-related injury in athletes, laborers, and military personnel, instruct them to acclimate gradually to the higher temperatures, increase fluid intake, wear vapor-permeable clothing, and take frequent rests (Beard & Day, 2008; CDC, 2012).
• In the event of temperature elevation above the adaptive range, institute measures to decrease temperature (e.g., get the client out of the sun and into a cool place, remove excess clothing, have the client drink fluids, spray the client with lukewarm water, and fan with cool air). Initiate emergency transport. Hyperthermia is an acute and possibly life-threatening situation (Beard & Day, 2008; CDC, 2012).
Client/Family Teaching and Discharge Planning:
Instruct to increase fluids to prevent heat-induced hyperthermia and dehydration in the presence of fever. Liberal fluid intake replaces fluid lost through perspiration and respiration (Pinto & Walsh, 2011).
• Teach the client to stay in a cooler environment during periods of excessive outdoor heat or humidity. If the client does go out, instruct him or her to avoid vigorous physical activity; wear lightweight, loose-fitting clothing; and wear a hat to minimize sun exposure. Such methods reduce exposure to high environmental temperatures, which can cause heat stroke and hyperthermia (Beard & Day, 2008; CDC, 2012).
References
Association of Perioperative Registered Nurses (AORN). Malignant hyperthermia guideline. Perioperative standards and recommended practices. Denver: Author; 2008.
Beard, R.M., Day, M.W. Fever and hyperthermia: learn to beat the heat. Nursing. 2008;38(6):28–31.
Becker, J.H., Wu, S.C. Fever: an update. J Am Podiatr Med Assoc. 2010;100(4):281–290.
Brege, D.J. Red flags: recognizing and treating heatstroke. Nurs Made Incred Easy. 2009;7(4):13–18.
Bridges, E., Thomas, K. Noninvasive measurement of body temperature in critically ill patients. Crit Care Nurse. 2009;29(3):94–97.
Calonder, E.M., et al. Temperature measurement in patients undergoing colorectal surgery and gynecology surgery: a comparison of esophageal core, temporal artery, and oral methods. J Perianesth Nurs. 2010;25(2):71–78.
Centers for Disease Control and Prevention (CDC), Heat stress, 2012 NIOSH workplace safety and health tips. Retrieved September 3, 2012, from http://www.cdc.gov/niosh/topics/heatstress, 2012
Davie, A., Amoore, J. Best practice in the measurement of body temperature. Nurs Stand. 2010;24(42):42–50.
Dinarello, C., Porat, R. Fever and hyperthermia. In Fauci A.S., et al, eds.: Harrison’s principles of internal medicine, ed 18, New York: McGraw-Hill, 2012.
Frommelt, T., Ott, C., Hays, V. Accuracy of different devices to measure temperature. MedSurg Nurs. 2008;17(3):171–177.
Gillman, P.K. Neuroleptic malignant syndrome: mechanisms, interactions and causality, a review. Move Disord. 2010;25(12):1780–1790.
Harrison, P.A., McErlane, K.S. Neuroleptic malignant syndrome. Am J Nurs. 2008;108(7):35–38.
Hooper, V.D., et al. ASPAN’s evidence-based clinical practice guideline for the promotion of perioperative normothermia. J Perianesth Nurs. 2009;24(5):217–287.
Hopkins, P.M. Malignant hyperthermia: pharmacology of triggering. BR J Anaesth. 2011;107(1):48–56.
Leon, L.R., Helwig, B.G. Heat stroke: role of the systemic inflammatory response. J Appl Physiol. 2010;109:1980–1988.
Makic, M.B.F., et al. Evidence-based practice habits: putting more sacred cows out to pasture. Crit Care Nurse. 2011;31:38–62.
Malignant Hyperthermia Association of the United States, Website, 2011 Retrieved September 3, 2012, from http://www.mhaus.org, 2011
O’Grady, N.P., et al. Guidelines for evaluation of new fever in critically ill adult patients: 2008 update from the American College of Critical Care Medicine and the Infectious Diseases Society of America. Crit Care Med. 2008;36(4):1330–1349.
Pinto, S., Walsh, K., Heart stroke. CINAHL Information Systems, Dec 23, 2011 (2p) http://web.ebscohost.com/ehost/pdfviewer/pdfviewer?sid=40ac8537-a3d4-4e3b-b632-5214cbd9402d%40sessionmgr11&vid=12&hid=21 [Accessed August 5, 2012].
Pitoni, S., Sinclair, H.L., Andrews, P.J.D. Aspects of thermoregulation physiology. Curr Opin Crit Care. 2011;17:115–121.
Polderman, K.H., Herold, I. Therapeutic hypothermia and controlled normothermia in the intensive care unit: practical considerations, side effects, and cooling methods. Crit Care Med. 2009;37(3):1101–1120.
Scrase, W., Tranter, S. Improving evidence-based care for patients with pyrexia. Nurs Stand. 2011;25(29):37–41.
Seitz, D.P., Gill, S.S. Neuroleptic malignant syndrome complicating antipsychotic treatment of delirium or agitation in medical and surgical patients: case reports and a review of the literature. Psychosomatics. 2009;50(1):8–15.
Trollor, J.N., Chen, X., Sachdev, P.S. Neuroleptic malignant syndrome associated with atypical antipsychotic drugs. CNS Drugs. 2009;23(6):477–492.
Hypothermia
NANDA-I
Defining Characteristics
Body temperature below normal range; cool skin; cyanotic nail beds; hypertension; pallor; piloerection; shivering; slow capillary refill; tachycardia
Related Factors (r/t)
Aging; consumption of alcohol; damage to hypothalamus; decreased ability to shiver; decreased metabolic rate; evaporation from skin in cool environment; exposure to cool environment; illness; inactivity; inadequate clothing; malnutrition; medications; trauma; drowning; medically induced targeted temperature hypothermia (Adapted from NANDA-I, 2012-2014)
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Maintain body temperature within normal range
• Identify risk factors of hypothermia
• State measures to prevent hypothermia
• Identify symptoms of hypothermia and actions to take when hypothermia is present
• If hypothermia is medically induced client/family will state goals for hypothermia treatment
NIC (Nursing Interventions Classification)
Hypothermia Treatment, Temperature Regulation, Temperature Regulation: Intraoperative, Vital Signs Monitoring
Nursing Interventions and Rationales
Temperature Measurement
• Recognize hypothermia as a drop in core body temperature below 35° C [95° F] (Danzl, 2011; Turk, 2010).
• Take the temperature at least hourly; if more than mild hypothermia is present (temperature lower than 35° C [95° F], use a continuous temperature-monitoring device, preferably two of them, one in the rectum, the other in the esophagus (Danzl, 2011).
• Measure and record the client’s temperature hourly and with changes in client condition (e.g., chills, change in metal status) using a core or near core temperature measurement method. Avoid peripheral temperature measurement sites. If client is critically ill, use an indwelling method of temperature measurement. EBN & EB: Core temperature is obtained by a pulmonary artery catheter and distal esophagus; near core temperature measurements include: oral, bladder, rectal, temporal artery, and peripheral measurements are obtained by skin surface measurements, axilla (Davie & Amoore, 2010; Frommelt, Ott, & Hays, 2008; Hooper et al, 2009; Makic et al, 2011). Tympanic temperature measurement has been found to be inaccurate in hypothermic states and is not recommended in practice (Danzl, 2011; Hooper et al 2009; O’Grady et al, 2008). Evidence is lacking regarding accuracy of temporal artery monitoring devices during states of hypothermia (Hooper et al, 2009; Makic et al, 2011).
• Use the same site and method (device) for temperature measurement for a given client so that temperature trends are assessed accurately and record site of temperature measurement. EBN & EB: There are differences in temperature depending on the site (esophageal, oral, bladder, rectal, axillary, or temporal artery); however, differences should not be greater than 0.3° to 0.5° C (Bridges & Thomas, 2009; Davie & Amoore, 2010; Frommelt, Ott, & Hays, 2008; Hooper et al 2009; Makic et al, 2011; Polderman & Herold, 2009).
• Bladder temperature may be used as an indwelling urinary catheter and is often inserted in the management of hypothermia to monitor diuresis. CEB & EB: Bladder temperature probes have been shown to be accurate during states of increased diuresis, but measurements may be less accurate when urine volume is low (low rate of diuresis) (Fallis, 2005; Polderman & Herold, 2009). Temperatures obtained by this method may lag, up to 20 minutes during targeted temperature hypothermia interventions (Polderman & Herold, 2009).
• See the care plan for Ineffective Thermoregulation as appropriate.
Accidental Hypothermia
• Recognize that there are three types of accidental hypothermia (environmental causes):
Acute hypothermia, also called immersion hypothermia, often from sudden exposure to cold through immersion in cold water or snow
Exhaustion hypothermia, caused by exposure to cold in association with lack of food and exhaustion
Chronic hypothermia that occurs over days or weeks and primarily affects the elderly (Guly, 2011)
• Remove the client from the cause of the hypothermic episode (e.g., cold environment, cold or wet clothing) and bring into a warm environment. Cover the client with warm blankets and apply a covering to the head and neck to conserve body heat. Layering of dry clothing, including wearing a hat, can be effective in warming a client with mild hypothermia; the goal is also to prevent any further heat loss (Lasater, 2008; Mulligan, 2009).
• Watch the client for signs of hypothermia: shivering, slurred speech, confusion, clumsy movements, fatigue, dehydration. As hypothermia progresses, the skin becomes pale, muscles are tense, fatigue and weakness progress, breathing is decreased, and pulmonary congestion is present, compromising oxygenation; pulses are decreased and blood pressure and heart rate decrease, progressing to lethal arrhythmias (e.g., ventricular fibrillation) (Danzl, 2011).
Administer oxygen as ordered. Oxygenation is hampered by the change in the oxyhemoglobin curve caused by hypothermia (Danzl, 2011).
• Monitor the client’s vital signs every hour and as appropriate. Note changes associated with hypothermia, such as initially increased pulse rate, respiratory rate, and blood pressure as well as diuresis with mild hypothermia, and then decreased pulse rate, respiratory rate, and blood pressure as well as oliguria with moderate to severe hypothermia. With mild hypothermia, there is activation of the sympathetic nervous system, which can increase the values of vital signs. As hypothermia progresses, decreased circulating volume develops, which results in decreased cardiac output and depressed oxygen delivery. Hypoxia, metabolic acidosis, and intrinsic irritability of a cold myocardium result in dysrhythmias (Danzl, 2011; Turk, 2010).
Attach electrodes and a cardiac monitor. Watch for dysrhythmias. With hypothermia, the client is prone to dysrhythmias because of the cold myocardium; dysrhythmias may include atrial fibrillation, ventricular fibrillation, or asystole (Danzl, 2011).
Monitor for signs of coagulopathy (e.g., oozing of blood from any open areas or from intravascular catheter sites or mucous membranes). Also note results of clotting studies as available. Coagulopathy is a common occurrence during hypothermia (Thorsen et al, 2011).
• For mild hypothermia (core temperature of 32.2° to 35° C [90° to 95° F]), rewarm client passively:
Set room temperature to 21° to 24° C (70° to 75° F)
Keep the client dry; remove any damp or wet clothing
Layer clothing and blankets and cover the client’s head; use insulated metallic blankets
For mild hypothermia, allow the client to rewarm at his or her own pace. Heat is regained through the body’s ability to generate heat (Danzl, 2011; Lasater, 2008; Mulligan, 2009). Passive rewarming is not encouraged for clients with temperatures lower than 32.2° C (90° F) because it is a slow process, requires sufficient glycogen stores to be utilized by the client’s body, and may increase oxygen consumption, increasing the risk of adverse cardiac events (Danzl, 2011).
For moderate hypothermia (core temperature 28° to 32.1° C [82.4° to 90° F]), use active external rewarming methods. The rewarming rate should not exceed 0.5° to 1° C (1.8° F) per hour. Methods include the following (Danzl, 2011; Galvao, Liang, & Clark, 2010):
For severe hypothermia (core temperature below 28° C [82.4° F]), use active core-rewarming techniques as ordered (Danzl, 2011; Lasater, 2008; Mulligan, 2009):
Recognize that extracorporeal blood rewarming methods, such as coronary artery bypass, are most effective
Use of an intravascular countercurrent in-line heat exchange to deliver warmed fluid or blood (Danzl, 2011)
Use of heated and humidified oxygen through the ventilator as ordered
Administering heated intravenous (IV) fluids at prescribed temperature
Heated irrigation of the gastrointestinal tract (nasogastric lavage) or bladder irrigations as ordered.
Severe hypothermia is associated with acidosis, ventricular fibrillation, apnea, thrombocytopenia, impaired clotting, oliguria, loss of cerebrovascular autoregulation, coma, and increased mortality in trauma clients and requires prompt core body rewarming (Danzl, 2011; Lasater, 2008; Thorsen et al, 2011).
• Rewarm clients slowly, generally at a rate of 0.5° to 1° C every hour. Slow rewarming helps prevent a phenomenon called “afterdrop,” where cold, hyperkalemic blood from the periphery returns to the heart, resulting in a biochemical injury leading to dysrhythmias and severe hypotension (Danzl, 2011; Lasater, 2008).
• Check blood pressure frequently when rewarming; watch for hypotension. As the body warms, formerly vasoconstricted vessels dilate, which results in hypotension (Mulligan, 2009).
Administer IV fluids, using a rapid infuser IV fluid warmer as ordered. Fluids are often needed to maintain adequate fluid volume. If the client develops untreated fluid depletion, hypotension with decreased cardiac output and acute renal failure can result. A rapid infuser warmer is needed to keep IV fluids warmed sufficiently to be effective in raising the body temperature (Danzl, 2011).
• Determine the factors leading to the hypothermic episode; see Related Factors. It is important to assess risk factors and precipitating events to prevent another incident of hypothermia and to direct treatment (Guly, 2011; Mulligan, 2009).
Request a social service referral to help the client obtain the heat, shelter, and food needed to maintain body temperature. A preventive approach that includes adequate food and fluid intake, shelter, heat, and clothing decreases the risk of hypothermia.
Encourage proper nutrition and hydration. Request a referral to a dietitian to identify appropriate dietary needs. Insufficient calorie and fluid intake predisposes the client to hypothermia, especially the elderly (Danzl, 2011).
Targeted Temperature Hypothermia
• Recognize that targeted temperature management, also called therapeutic hypothermia, is the active lowering of the client’s body temperature, in a controlled manner, to preserve neurological function after an acute myocardial injury or cardiac arrest. EB: In the event the client is successfully resuscitated after an acute myocardial injury/arrest, medically induced targeted temperature management has been shown to provide neurological protection against ischemic neuronal injury post cardiac arrest (Azmoon et al, 2011; Neumer et al, 2011; Nunnally et al, 2011). Target temperature management is becoming standard of care, nationwide, with out-of-hospital cardiac arrest (Neumer et al, 2011). Evidence to support targeted temperature management for treatment of clients with traumatic brain injury or stroke and neonates remains an area of active research (Nunnally et al, 2011; Varon & Acosta, 2008).
• Recognize that controlled cooling of clients should be considered for all unconscious survivors of out-of-hospital ventricular tachycardia arrest as well as clients experiencing in-hospital arrests (Hazinski et al, 2010; Neumer et al, 2011). The optimal targeted temperature for therapy is between 32° and 34° C for up to 48 hours (Azmoon et al, 2011; Hazinski et al, 2010; Neumer et al, 2011). EB: The American Heart Association and the International Liaison Committee on Resuscitation have included therapeutic hypothermia as an intervention to be considered in the management of cardiac arrest patients to optimize neurological outcomes (Neumer et al, 2011).
• Monitor core or near core temperatures continuously using two methods of temperature monitoring. EB: To ensure that the targeted temperature is achieved and maintained closely within the prescribed temperature range, two methods of core or near core temperature monitoring are recommended (McKean, 2009; Niklasch, 2010; Polderman & Herold, 2009).
• Recognize that cooling may be achieved noninvasively, using fluid-filled cooling devices that are placed next to the client’s skin, or invasively, infusing iced solution. EB & EBN: Invasive cooling provides a more predictable cooling; however, current research has found air- or fluid-filled external devices to provide effective cooling as well. Less optimal methods of cooling include the use of fans, ice packs, or blankets that do not provide temperature regulation feedback between the machine and client (Galvao, Liang, & Clark, 2011; McKean, 2009; Morita et al, 2011).
• Obtain vital signs hourly (or via continuous monitoring) to include continuous electrocardiogram monitoring. Observe for signs of hypotension, bradycardia, and arrhythmias. Mechanical ventilation is required to protect the client’s airway and breathing during treatment. EB: Diuresis is more pronounced during the induction of hypothermia. Hypotension may be more prominent as the client is rewarmed because of vasodilatation, requiring close monitoring and interventions to support blood pressure. Bradycardia associated with hypothermia is often not responsive to atropine. If the client is overcooled (temperature drops below 32° C), the risk of arrhythmias will increase; ventricular fibrillation refractory to defibrillation may occur at temperatures below 30° C (McKean, 2009; Polderman & Herold, 2009).
Observe for shivering and administer sedation agents or paralytic agents as prescribed. EB: Shivering significantly increases the body’s metabolic rate and oxygen consumption (McKean, 2009; Polderman & Herold, 2009).
• Closely inspect the skin prior to and throughout the cooling intervention to prevent skin breakdown associated with the treatment. Implement frequent turning and other pressure reduction interventions as indicated. EBN: Lowering the body temperature causes vasoconstriction and can compromise perfusion to the skin, increasing the client’s risk of skin breakdown (McKean, 2009).
Monitor and treat serum electrolytes (e.g., potassium, magnesium, calcium, and phosphorus) and serum glucose closely during targeted hypothermia and during rewarming of the client. Electrolytes will fluctuate as the client is rewarmed. EB & EBN: Diuresis, acid-base imbalances, and metabolic responses are responsible for fluctuations of electrolytes and glucose. As the client is rewarmed, electrolyte replacements, especially potassium replacements, should be closely monitored to prevent rebound hyperkalemia that may occur as the body temperature rises (McKean, 2009; Polderman & Herold, 2009; Turk, 2010).
Observe for signs and symptoms of coagulopathy during targeted hypothermia treatment. Hemoconcentration may be noticed as fluids shift during treatment. EB: For every 1° C decline in temperature, the hematocrit may increase by approximately 2%, requiring monitoring but not treatment. Platelet counts decrease during hypothermic states, but research has not found a significant risk of bleeding during targeted hypothermia treatment (McKean, 2009; Polderman & Herold, 2009; Thorsen et al, 2011; Turk, 2010).
• Rewarming should occur in a controlled manner with a rise in body temperature of 0.5° to 1° C per hour and targeted goal of normothermia, 37° C. EB: Aggressive rewarming may cause rebound hyperthermia, cerebral edema, seizures, hypotension, and ventricular fibrillation (McKean, 2009; Niklasch, 2010; Polderman & Herold, 2009).
Neurological and cognitive function should be assessed during targeted temperature treatment and after rewarming. EB: The goal of targeted temperature treatment is neurological protection; close monitoring of neurological function post intervention and serial assessments are indicated (Nunnally et al, 2011; Polderman & Herold, 2009).
• Recognize that pediatric clients have a decreased ability to adapt to temperature extremes. Take the following actions to maintain body temperature in the infant/child:
Use blankets to keep the client warm.
Keep the client covered during procedures, transport, and diagnostic testing.
The combination of a relatively smaller body surface area, smaller body fluid volume, less well-developed temperature control mechanisms, and smaller amount of protective body fat limits the infant’s and child’s ability to maintain normal temperatures (Pio, Kirkwood, & Gove, 2010).
For the preterm or low-birth-weight newborn, use specially designed bags, skin-to-skin care, transwarmer mattresses, and radiant warmers to keep the infant warm. EB & EBN: These methods can help keep the vulnerable newborn warm in the delivery room (McCall et al, 2010). Parents should be taught how to wrap neonates/infants to maintain body temperature (Bissinger & Annibale, 2010), yet there is a need for more studies in this area (McCall et al, 2010).
• Normal aging often includes changes in touch-related sensations, making it harder to differentiate cool and cold. Decreased temperature sensitivity increases the risk of hypothermia in the older adult (Dugdale, 2012).
• Recognize that the elderly can develop indoor hypothermia from air conditioning or ice baths. Clients present with vague complaints of mental and/or other skill deterioration (Heller, 2012).
• Assess neurological signs frequently, watching for confusion and decreased level of consciousness. EB: Mechanisms to control body temperature decrease with age; coupled with a slower counterregulatory response, lower rate of metabolism, and less effective vascular response, this will make hypothermia less obvious. Early signs of hypothermia are subtle (Danzl, 2011; Polderman & Herold, 2009).
• Recognize that the elderly often wear socks and sweaters to protect themselves from feeling cold, even in warmer weather (McLafferty, Farley, & Hendry, 2009).
Home Care: Hypothermia is not a symptom that appears in the normal course of home care. When it occurs, it is a clinical emergency, and the client/family should access emergency medical services immediately.
• Some of the interventions described earlier may be adapted for home care use.
• Before a medical crisis occurs, confirm that the client or family has a thermometer and can read it. Instruct as needed. Verify that the thermometer registers accurately.
• Instruct the client or family to take the temperature when the client displays cyanosis, pallor, or shivering.
Monitor temperature every hour, as noted previously. If the temperature of the client begins dropping below the normal range, apply layers of clothing or blankets, or adjust environmental heat to the comfort level. Do not overheat. Contact a physician. Passive rewarming is the only method of rewarming that is appropriate for home care under normal circumstances.
If temperature continues to drop, activate the emergency system and notify a physician. Hypothermia is a clinically acute condition that cannot be managed safely in the home.
If the client is in hospice care or is terminally ill, follow advance directives, client wishes, and the physician’s orders. Keep the client free of pain. The goal of terminal care is to provide dignity and comfort during the dying process.
Client/Family Teaching and Discharge Planning:
• Teach the client and family signs of hypothermia and the method of taking the temperature (age-appropriate).
• Teach the client methods to prevent hypothermia: wearing adequate clothing, including a hat and mittens; heating the environment to a minimum of 20° C (68° F); and ingesting adequate food and fluid. Simple measures such as layering clothes, wearing a hat, and avoiding extremes in temperature prevent significant heat loss (Mulligan, 2009).
Teach the client and family about medications such as sedatives, opioids, and anxiolytics that predispose the client to hypothermia (as appropriate). If the client has had hypothermia in the past, using alternative medications is an option if there is no contraindication (Danzl, 2011).
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