Risk for urge urinary Incontinence
NANDA-I
At risk for involuntary passage of urine occurring soon after a sudden, strong sensation of urgency to void
Risk Factors
Atrophic urethritis, atrophic vaginitis, effects of alcohol; effects of caffeine; effects of pharmaceutical agents, detrusor hyperactivity with impaired bladder contractility, fecal impaction, impaired bladder contractility, ineffective toileting habits, involuntary sphincter relaxation, small bladder capacity
Bowel Incontinence
NANDA-I
Defining Characteristics
Constant dribbling of soft stool, fecal odor; inability to delay defecation; fecal staining of bedding; fecal staining of clothing; inability to recognize urge to defecate; inattention to urge to defecate; recognizes rectal fullness but reports inability to expel formed stool; red perianal skin; self-report of inability to recognize rectal fullness; urgency
Related Factors (r/t)
Abnormally high abdominal pressure; abnormally high intestinal pressure; chronic diarrhea; colorectal lesions; dietary habits; environmental factors (e.g., inaccessible bathroom); general decline in muscle tone; immobility; impaired cognition; impaired reservoir capacity; incomplete emptying of bowel; laxative abuse; loss of rectal sphincter control; lower motor nerve damage; medications; rectal sphincter abnormality; impaction; stress; toileting self-care deficit; upper motor nerve damage
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Have regular, complete evacuation of fecal contents from the rectal vault (pattern may vary from every day to every 3 days)
• Have regulation of stool consistency (soft, formed stools)
• Reduce or eliminate frequency of incontinent episodes
• Exhibit intact skin in the perianal/perineal area
• Demonstrate the ability to isolate, contract, and relax pelvic muscles (when incontinence related to sphincter incompetence or high-tone pelvic floor dysfunction)
• Increase pelvic muscle strength (when incontinence related to sphincter incompetence)
• Identify triggers that precipitate change in bowel continence
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• In a private setting, directly question client about the presence of fecal incontinence. If the client reports altered bowel elimination patterns, problems with bowel control, or “uncontrollable diarrhea,” complete a focused nursing history including previous and present bowel elimination routines, dietary history, frequency and volume of uncontrolled stool loss, and aggravating and alleviating factors. Unless questioned directly, clients are often hesitant to report the presence of fecal incontinence (Fisher, Bliss, & Savik, 2008). The nursing history determines the patterns of stool elimination, to characterize involuntary stool loss and the likely etiology of the incontinence (Bliss & Norton 2010).
• Recognize that risk factors for fecal incontinence include older individuals, female sex, impaired mobility, cognitive impairment, and structural or functional impairment of bowel function (Aitola et al, 2011; Langemo et al, 2011). Although fecal incontinence is more common in women, it is also a problem for men and should not be overlooked when obtaining a health history (Aitola et al, 2011). EBN: Double incontinence, defined as urinary and fecal incontinence, was found to be 10.3% in a large cross-sectional study of 1869 community-dwelling women aged 45 to 85; thus, if a client is suffering from one form of incontinence, ask the client if he/she suffers from double incontinence as well (Slieker-ten Hove et al, 2010).
• Recognize that additional risk factors for bowel incontinence in hospitalized clients include antibiotic therapy, medications, nasogastric feeding, immobility, inability to communicate elimination needs, acute disease processes and procedures (e.g., cancer, abdominal surgery), sedation, and mechanical ventilation (Hurnauth, 2011; Makic et al, 2011).
Conduct a health history assessment that includes a review of current bowel patterns/habits to include constipation and use of laxatives; pelvic floor injury with childbirth; acute trauma to organs, muscles, or nerves involved in defecation; gastrointestinal inflammatory disorders; functional disability; and medications (Bliss & Norton, 2010; Nurko & Scott, 2011; Roach & Christie, 2008).
Closely inspect the perineal skin and skin folds for evidence of skin breakdown in clients with incontinence. EBN: A recent expert consensus statement defined moisture-associated skin damage (MASD) as inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture (Black et al, 2011). Incontinence-associated dermatitis (IAD) is a form of skin irritation that develops from chronic exposure to urine or liquid stool (Black et al, 2011).
In close consultation with a physician or advanced practice nurse, consider routine use of a validated tool that focuses on bowel elimination patterns. More than 23 validated symptom questionnaires have been developed and validated for the evaluation of urinary and fecal incontinence (Avery et al, 2007). Similarly, a variety of tools are available to assess risk for perineal skin breakdown (Langemo et al, 2011).
Complete a focused physical assessment, including inspection of perineal skin, pelvic muscle strength assessment, digital examination of the rectum for presence of impaction and anal sphincter strength, and evaluation of functional status (mobility, dexterity, visual acuity).
• Complete an assessment of cognitive function; explore for a history of dementia, delirium, or acute confusion (Bliss & Norton, 2011). EBN: A study found that critically ill clients who were less cognitively aware were more likely to develop incontinence-associated dermatitis than clients who were more cognitively aware (Bliss et al, 2011).
• Document patterns of stool elimination and incontinent episodes through a bowel record, including frequency of bowel movements, stool consistency, frequency and severity of incontinent episodes, precipitating factors, and dietary and fluid intake. Documented patterns of elimination are used to narrow the likely etiology of stool incontinence and serve as a baseline to evaluate treatment efficacy (Nurko & Scott, 2011).
• Assess stool consistency and its influence on risk for stool loss. Several classification systems for stool exist and may assist the nurse and client to differentiate among normal soft, formed stool, hardened stools associated with constipation, and liquid stools associated with diarrhea. CEB: A study of stool consistency found good reliability when evaluated by nurses and clients. Word-only descriptors yielded equivocal consistency when assessed by subjects, as did tools that combined words with illustrations of various stool consistencies (Bliss et al, 2001). Less well-formed (loose or liquid) stool is associated with an increased severity and frequency of fecal incontinence episodes and potential for compromised skin integrity (Bharucha et al, 2008; Black et al, 2011; Langemo et al, 2011).
• Identify conditions contributing to or causing fecal incontinence. Fecal incontinence is frequently multifactorial. Accurate assessment of the probable etiology of fecal incontinence is necessary to select a treatment plan likely to control or eliminate the condition (Lazarescu, Turnbull, & Vanner, 2009).
• Improve access to toileting:
Identify usual toileting patterns and plan opportunities for toileting accordingly.
Provide assistance with toileting for clients with limited access or impaired functional status (mobility, dexterity, access).
Institute a prompted toileting program for persons with impaired cognitive status.
Provide adequate privacy for toileting.
Respond promptly to requests for assistance with toileting.
CEB: Acute or transient fecal incontinence frequently occurs in the acute care or long-term care facility because of inadequate access to toileting facilities, insufficient assistance with toileting, or inadequate privacy when attempting to toilet (Bliss et al, 2000).
• Review the client’s nutritional history and evaluate methods to normalize stool consistency with dietary adjustments (e.g., avoiding high-fat content foods) and use of fiber (Nurko & Scott, 2011; Ostaszkiewicz et al, 2010). EBN: Diet modifications found to be helpful in the management of fecal incontinence for community-living adults included restrictions of some foods, adding fiber to the diet, and establishing consistent eating patterns (Croswell, Bliss, & Savik, 2010). EB: A study found that dried plums (prunes) were also effective in improving defecation patterns in adults when compared to psyllium (Attaluri et al, 2011).
• Encourage the client to keep a nutrition log to track foods that irritate the bowel (Nurko & Scott, 2011).
• For hospitalized clients receiving tube feeding–associated fecal incontinence, involve the nutrition specialist to evaluate the formula composition, osmolality, and fiber content.
• For the client with intermittent episodes of fecal incontinence related to acute changes in stool consistency, begin a bowel reeducation program consisting of:
Cleansing the bowel of impacted stool if indicated
Normalizing stool consistency by adequate intake of fluids (30 mL/kg of body weight/day) and dietary or supplemental fiber
Establishing a regular routine of fecal elimination based on established patterns of bowel elimination (patterns established prior to onset of incontinence)
Education on bowel patterns and strategies to establish normal defecation patterns and stool consistency to reduce or eliminate the risk of recurring fecal incontinence have been found to be beneficial in controlling fecal incontinence associated with changes in stool consistency (Ostaszkiewicz et al, 2010).
Implement a scheduled stimulation defecation program for persons with neurological conditions causing fecal incontinence:
Cleanse the bowel of impacted fecal material before beginning the program.
Implement strategies to normalize stool consistency, including adequate intake of fluid and fiber and avoidance of foods associated with diarrhea.
Determine a regular schedule for bowel elimination (typically every day or every other day) based on prior patterns of bowel elimination.
Provide a stimulus before assisting the client to a position on the toilet; digital stimulation, a stimulating suppository, “mini-enema,” or pulsed evacuation enema may be used for stimulation.
The scheduled, stimulated program relies on consistency of stool and a mechanical or chemical stimulus to produce a bolus contraction of the rectum with evacuation of fecal material (Penn, 2011).
Begin a reeducation or pelvic floor muscle exercise program for the person with sphincter incompetence or high-tone pelvic floor muscle dysfunction of the pelvic muscles, or refer persons with fecal incontinence related to sphincter dysfunction to a nurse specialist or other therapist with clinical expertise in these techniques of care. CEB: There is insufficient evidence to conclude that bowel reeducation or pelvic floor muscle exercise programs are effective for the management of fecal incontinence in adults. However, the existing evidence does provide adequate support to consider implementing this intervention in selected clients, particularly given the potential for benefit in the absence of harmful side effects (Norton, Hosker, & Brazzelli, 2006).
Consider a pelvic muscle training program or radiofrequency stimulation program in clients with urgency to defecate and fecal incontinence related to recurrent diarrhea or fecal incontinence associated with myogenic disorders affecting the pelvic floor muscles. Data suggest that although pelvic floor muscle training improves anorectal squeeze and related factors, its effect on fecal incontinence may be modest. Clients undergoing pelvic floor muscle training tend to have perceptions of control over bowel function (Sun et al, 2008). EB: Early results from a study that explored radiofrequency procedures to reduce fecal incontinence found improvement in the client’s quality of life for 12 months post intervention (Ruiz et al, 2010).
• Institute a structured skin care regimen that incorporates three essential steps: cleanse, moisturize, and protect:
Select a cleanser with a pH range comparable to that of normal skin (usually labeled “pH balanced”).
Moisturize with an emollient to replace lipids removed with cleansing, and protect with a skin. Products containing petrolatum, dimethicone, or zinc oxide base or a no-sting skin barrier should be used (Langemo et al, 2011; Makic et al, 2011).
Routine incontinence care should include daily perineal skin cleansing and following each episode of incontinence.
When feasible, select a product that combines two or all three of these processes into a single step. Ensure that products are available at the bedside when caring for a client with total incontinence in an inpatient facility.
Use of absorptive pads or adult containment briefs that are applied next the client’s skin increases the risk of incontinence-associated dermatitis. Absorbent underpads that wick moisture away from skin may be used with immobile clients. EBN: A structured skin care regimen based on a three-step process (cleanse, moisturize, and protect) is effective for the prevention of incontinence-associated dermatitis (Black et al, 2011; Langemo et al, 2011; Makic et al, 2011).
Consult the physician or advanced practice nurse if a fungal infection is suspected. An antifungal cream or powder beneath a protective ointment may be indicated (Black et al 2011; Langemo et al, 2011; Makic et al, 2011).
• Assist the client to select and apply a containment device for occasional episodes of fecal incontinence. A fecal containment device will prevent soiling of clothing and reduce odors in the client with uncontrolled stool loss. EBN: A study of community persons with fecal incontinence who used an absorptive dressing to contain mucus and stool leakage after surgery revealed that the device was preferred over traditional pads in 92% (Bliss & Savik, 2008).
• In the client with frequent episodes of fecal incontinence and limited mobility, monitor the sacrum and perineal area for pressure ulcerations. CEB: Limited mobility, particularly when combined with fecal incontinence, increases the risk of pressure ulceration. Routine cleansing, pressure reduction techniques, and management of fecal and urinary incontinence reduce this risk (Johanson, Irizarry, & Doughty, 1997; Junkin & Selekof, 2007; Schnelle et al, 1997).
• With acutely ill clients, anticipate and evaluate the cause of acute diarrhea. Anticipate diarrhea associated with treatment or specific interventions (e.g., medications, initiation of tube feedings). Interventions to manage acute diarrhea include use of absorbent pads and skin protectant moisturizers or fecal collector/pouch (Makic et al, 2011; Langemo et al, 2011).
Consult a physician or advanced practice nurse about insertion of a bowel management system in the critically ill client when conservative measures have failed and fecal incontinence is excessive and/or produces perianal skin injury or incontinence-associated dermatitis. Indwelling bowel management systems (BMSs), also called fecal management systems, are commercially available and designed to direct, collect, and contain liquid stool in immobile clients. BMS devices are approved by the Food and Drug Administration for up to 29 days for management of liquid stool (Langemo et al, 2011; Makic et al, 2011). EBN: Devices other than BMSs should not be used for indwelling bowel/feces diversion (Beekman et al, 2009; Wishin, Gallagher, & McCann, 2008).
Geriatric:• Evaluate all elderly clients for established or acute fecal incontinence when the elderly client enters the acute or long-term care facility and intervene as indicated. The prevalence of fecal incontinence, which often coexists with urinary incontinence, is approximately 50% in long-term care and 20% in acute care facilities (Junkin & Selekof, 2007). EBN: A recent study found a reduction in incontinence and constipation in nursing home residents who were offered frequent toileting assistance, exercise, and choice of food snacks to improve defecation patterns (Schnelle et al, 2010).
• Determine the client’s cognitive level using a screening tool such as the Mini-Mental State Exam (MMSE), the CAM, or Mini-Cog. CEB: Use of a standard evaluation tool such as the MMSE can help determine the client’s abilities and assist in planning appropriate nursing interventions. Acute or established dementias increase the risk of fecal incontinence among the elderly (Borson et al, 2006).
• The preceding interventions may be adapted for home care use.
• Assess and teach a bowel management program to support continence. Address timing, diet, fluids, and actions taken independently to deal with bowel incontinence. Identifying factors that change level of incontinence may guide interventions. If client has been taking over-the-counter medications or home remedies, it is important to consider their influence.
• Instruct caregiver to provide clothing that is nonrestrictive, can be manipulated easily for toileting, and can be changed with ease. Avoidance of complicated maneuvers increases the chance of success in toileting programs and decreases the client’s risk for embarrassing incontinent episodes.
• Evaluate self-care strategies of community-dwelling elders; strengthen adaptive behaviors, and counsel elders about altering strategies that compromise general health.
• Assist the family in arranging care in a way that allows the client to participate in family or favorite activities without embarrassment. Careful planning can both help client retain dignity and maintain integrity of family patterns.
If the client is limited to bed (or bed and chair), provide a commode or bedpan that can be easily accessed. Involve occupational and physical therapy services as indicated to promote safe transfers.
If the client is frequently incontinent, refer for home health aide services to assist with hygiene and skin care.
Refer the family to support services to assist with in-home management of fecal incontinence as indicated.
Note: Refer to nursing diagnoses Diarrhea and Constipation for detailed management of these related conditions.
References
Aitola, P., et al. Prevalence of fecal incontinence in adults aged 30 years or more in general population. Colorect Dis. 2010;12(7):687–691.
Attaluri, A., et al. Randomized clinical trail: dried plums vs psyllium for constipation. Aliment Pharmacol Ther. 2011;33(7):822–828.
Avery, K.N., et al. Questionnaires to assess urinary and anal incontinence: review and recommendations. J Urol. 2007;177(1):39–49.
Beekman, D., et al. Prevention and treatment of incontinence-associated dermatitis: literature review. J Adv Nurs. 2009;65(6):1141–1154.
Bharucha, A.E., et al. Relation of bowel habits to fecal incontinence in women. Am J Gastroenterol. 2008;103(6):1470–1475.
Black, J.M., et al. MASD part 2: incontinence-associated dermatitis and intertriginous dermatitis. J Wound Ostomy Continence Nurs. 2011;38(4):359–370.
Bliss, D.Z., Norton, C. Conservative management of fecal incontinence. Am J Nurs. 2010;110(9):30–40.
Bliss, D.Z., Savik, K. Use of an absorbent dressing specifically for fecal incontinence. J Wound Ostomy Continence Nurs. 2008;35(2):221–228.
Bliss, D.Z., et al. Fecal incontinence in hospitalized clients who are acutely ill. Nurs Res. 2000;49(2):101–108.
Bliss, D.Z., et al. Supplementation with dietary fiber improves fecal incontinence. Nurs Res. 2001;50(4):203–213.
Bliss, D.Z., et al. Incontinence-associated dermatitis in critically ill adults. J Wound Ostomy Continence Nurs. 2011;38(4):433–445.
Borson, S., et al. Improving identification of cognitive impairment in primary care. Int J Geriatr Psychiatry. 2006;21(4):349–355.
Croswell, E., Bliss, D.Z., Savik, K. Diet and eating pattern modifications used by community-living adults to manage their fecal incontinence. J Wound Ostomy Continence Nurs. 2010;37(6):677–682.
Fisher, K., Bliss, D.Z., Savik, K. Comparison of recall and daily self-report of fecal incontinence severity. J Wound Ostomy Continence Nurs. 2008;35(5):515–520.
Hurnauth, C. Management of faecal incontinence in acutely ill patients. Nurs Stand. 2011;25(2):48–56.
Johanson, J.F., Irizarry, F., Doughty, A. Risk factors for fecal incontinence in a nursing home population. J Clin Gastroenterol. 1997;24:156.
Junkin, J., Selekof, J. Prevalence of incontinence and associated skin injury in an acute care population. J Wound Ostomy Continence Nurs. 2007;34(3):260–269.
Langemo, D., et al. Incontinence and incontinence-associated dermatitis. Adv Skin Wound Care. 2011;24(3):126–140.
Lazarescu, A., Turnbull, G.K., Vanner, S. Investigating and treating fecal incontinence: when and how. Can J Gastroenterol. 2009;23(4):301–308.
Makic, M.B.F., et al. Evidence-based practice habits: putting more sacred cows out to pasture. Crit Care Nurse. 2011;31:38–62.
Norton, C., Hosker, G., Brazzelli, M., Biofeedback and/or sphincter exercises for the treatment of faecal incontinence in adults. Cochrane Database Syst Rev 2006;(2):CD002111.
Nurko, S., Scott, S.M. Coexistence of constipation and incontinence in children and adults. Best Pract Res Clin Gastroenterol. 2011;25:29–41.
Ostaszkiewicz, J., et al. The effects of conservative treatment for constipation on symptom severity and quality of life in community-dwelling adults. J Wound Ostomy Continence Nurs. 2010;37(2):193–198.
Penn, R. Not having the right bowel care is demeaning. Nurs Times. 2011;107(12):16–18.
Roach, M., Christie, J.A. Fecal incontinence in the elderly. Geriatrics. 2008;63(2):13–21.
Ruiz, D., et al. Does the radiofrequency procedure for fecal incontinence improve quality of life and incontinence at 1 year follow up? Dis Colon Rectum. 2010;53(7):1041–1046.
Schnelle, J.F., et al. Skin disorders and moisture in incontinent nursing home residents: intervention implications. J Am Geriatr Soc. 1997;45(10):1182–1188.
Schnelle, J.F., et al. A controlled trial of an intervention to improve urinary and fecal incontinence and constipation. J Am Geriatr Soc. 2010;58(8):1504–1511.
Slieker-ten Hove, M.C., et al. Prevalence of double incontinence, risks and influence on quality of life in a general female population. Neurourol Urodyn. 2010;29(4):454–550.
Sun, D., et al. Results of biofeedback therapy together with electrical stimulation in faecal incontinence with myogenic lesions. Acta Chirurg Belg. 2008;108(3):313–317.
Wishin, J., Gallagher, J., McCann, E. Emerging options for the management of fecal incontinence in hospitalized patients. J Wound Ostomy Continence Nurs. 2008;35(1):104–110.
Disorganized Infant behavior
NANDA-I
Defining Characteristics
Attention-Interaction System
Abnormal response to sensory stimuli (e.g., difficult to soothe, unable to sustain alert status)
Motor System
Altered primitive reflexes; changes to motor tone; finger splaying; fisting; hands to face; hyperextension of extremities; jitteriness,; startles; tremors; twitches; uncoordinated movement
Physiological
Arrhythmias; bradycardia; oxygen de-saturation; feeding intolerances; skin color changes; tachycardia; time-out signals (e.g., gaze, grasp, hiccough, cough, sneeze, sigh, slack jaw, open mouth, tongue thrust)
State-Organization System
Active-awake (fussy, worried gaze); diffuse sleep; irritable crying; quiet-awake (staring, gaze aversion); state-oscillation
Caregiver
Cue misreading; deficient knowledge regarding behavioral cues; environmental stimulation contribution
Environmental
Lack of containment within environment; physical environment inappropriateness; sensory deprivation; sensory inappropriateness; sensory overstimulation
NOC (Nursing Outcomes Classification)
Child Development, Neurological Status, Preterm Infant Organization, Sleep, Thermoregulation: Newborn, Infant Nutritional Status
Client Outcomes
Client Will (Specify Time Frame)
• Display physiological/autonomic stability: cardiopulmonary, digestive functioning
• Display signs of organized motor system (Wyngarden, DeWys, & Padnos, 1999)
• Display signs of organized state system: ability to achieve and maintain a state, and transition smoothly between states (Wyngarden, DeWys, & Padnos, 1999)
• Demonstrate progress toward effective self-regulation (Wyngarden, DeWys, & Padnos, 1999)
• Demonstrate progress toward or ability to maintain calm attention
• Demonstrate progress or ability to engage in positive interactions
• Demonstrate ability to respond to sensory information in an adaptive way
• Recognize infant/child behaviors as complex communication system that express specific needs and wants (e.g., hunger, pain, stress desire to engage or disengage)
• Educate parents/caregivers to recognize infant’s four avenues of communication: autonomic/physiological, motor, state, attention/interaction
• Recognize how infants respond to environmental sensory input through stress/avoidance and approach/engagement behaviors
• Recognize and support infant’s self-regulatory, coping behaviors used to regain or maintain homeostasis
• Teach parents to “tune in” to their own interactive style and how that affects their infant’s behavior
• Teach parents ways to adapt their interactive style in response to infant’s style of communication
• Identify appropriate positioning and handling techniques that will enhance normal motor development (Wyngarden, DeWys, & Padnos, 1999)
• Promote infant/child’s attention capabilities that support visual and auditory development (Wyngarden, DeWys, & Padnos, 1999)
• Engage in pleasurable parent-infant interactions that encourage bonding and attachment (Wyngarden, DeWys, & Padnos, 1999)
• Structure and modify the environment in response to infant/child’s behavior and personal needs (Wyngarden, DeWys, & Padnos, 1999)
• Identify available community resources that provide early intervention services, emotional support, community health nursing, and parenting classes (Wyngarden, DeWys, & Padnos, 1999)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Recognize the five neuro-behavior systems through which infants communicate organization and/or disorganization/stress (i.e., physiological/autonomic, motor, states, attention/interactional, self-regulatory). The Assessment of Preterm Infants’ Behavior (APIB) is based on theory that each subsystem functions independently and yet functions in relation to the other subsystems. Infant’s physiologic/autonomic subsystem has to be stable/organized related to respiratory and heart rate, enabling infant to attend and/or interact with someone or something (Als et al, 2005).
• Recognize behavior used to communicate stress/avoidance and approach/engagement. The neuro-behavior system theory provides a framework for reading, interpreting, and responding to cues and values the infant’s importance and ability to affect the environment (Als et al, 2005).
• Individualized developmental care for low-birth-weight, preterm infants has been shown to positively influence neurodevelopmental outcomes. EB: Randomized controlled trials in this study demonstrated positive effect that favors developmental interventions (Gardner & Famuyide, 2009).
• Provide optimal physical (inanimate) environment, social (animate) environment including caregiver-infant interactions for premature and medically fragile infants. EB: “For babies the environment is crucial for brain growth and development, for families defining the moment for relationships—with their baby, each other, health care system, spiritual” (White, 2010).
• Provide infants with adequate pain management during stressful and painful procedures. EB: Parents who were shown infant pain cues and comforting techniques were better prepared to take an active role in infant pain management and felt more positive about their parenting role in the postdischarge period (Franck et al, 2011). EB: Effective and inexpensive ways of helping newborns recover from painful procedures include nonnutritive sucking, breastfeeding, skin-to-skin mother care, swaddling, and tucking, which are the best ways to enhance parent involvement in pain management (Walter-Nicolet et al, 2010). EB: A combination of 24% sucrose and nonnutritive sucking is clinically effective and safe in relieving pain during simple procedures such as venipuncture or heel stick in both preterm and term infants (Elserafy et al, 2009).
• Identify appropriate body positions that optimize body alignment (neck, trunk, semiflexed, and midline orientation of extremities, with spine in straight alignment). EB: Positioning and use of blanket rolls and gel pillows help to compensate for the preterm infant’s immature motor system (Bobish & Stanger, 2008).
• Identify and use best positions that encourage longer periods of sleep. EB: This study showed that swaddling helped supine-positioned infants spend more time in NREM sleep. Infants had less spontaneous awakening than when not swaddled (Franco et al, 2005). EB: Three positions—swaddled prone nested, prone unnested, or side-lying nested—showed the fewest stress behaviors (Grenier et al, 2003).
• Provide care that encourages infant state organization—ability to achieve and maintain quiet-sleep and quiet-awake states, and transition smoothly between sleep and awake states. EB: Skin-to-skin holding (kangaroo care) was found to increase quiet sleep time compared to sleeping (Scher et al, 2009). This study found that infants with smooth shifts between quiet sleep and awake states had more positive emotions and better cognitive and verbal skills at 5 years of age than those with abrupt shifts between states of high arousal, active sleep, and short episodes of active and quiet sleep (Weisman et al, 2011).
• Provide infants opportunities for nonnutritive sucking. EB: Infants receiving nonnutritive sucking during tube feeding exhibited less defensive behaviors, were less fussy, and fell asleep more easily (Pinelli & Symington, 2005). EB: Music-reinforced nonnutritive sucking affected the state of preterm low-birth-weight infants during heel stick (Whipple, 2008).
• Encourage parents to identify and support infant’s attention capabilities. EBN: Help parents to identify their infant’s attention, structure the environment, and adapt their interactions to support attention capabilities for acquiring longer attention capability (Davis et al, 2005).
• Provide parents opportunities to experience physical closeness through loving touch, massage, cuddling, skin-to-skin (kangaroo care), and rocking that enhances parent-infant attachment. EBN: Gentle human touch versus usual care reduced infant stress as evidenced by urine stress hormones (Im & Kim, 2009). EB: NICU nurses have an essential role in facilitating maternal confidence necessary for maternal attachment (Johnson, 2008).
• Encourage parents to be active collaborators in their infant’s care. EB: Kangaroo care is an effective way for parents to actively engage by decreasing infant pain during invasive procedures (Akcan et al, 2009). EBN: If possible, time intramuscular injections during kangaroo care (Kashaninia et al, 2008). EBN: Fathers often hide emotions and need encouragement to express feeling and physically touch (Johnson, 2008).
• Provide infants with positive sensory experiences (i.e., visual, auditory, tactile, vestibular, proprioceptive) to enhance development of sensory pathways. EBN: This study found that maternal voice along with other sensory events helps develop and maturate the sensory system (Krueger, 2010). EB: Infants listening to mothers’ singing gave mothers more assurance and infants were discharged from hospital earlier (Cevasco, 2008).
Provide information or refer to community-based follow-up programs for preterm/at-risk infants and their families. Seamless communication between NICU staff and community agencies enhances parents’ feelings of confidence during the difficult transition from NICU discharge to home (Sherman, Aylward, & Shoemaker, 2009).
Multicultural:• Assess for the influence of cultural beliefs, norms, and values on the family’s perceptions of infant/child behavior. EBN: The theory of hot and cold espoused by many Mexican Americans has symbolic significance for the nature and process of reproduction and for the relationship between mother and child (Giger & Davidhizar, 2008). Beliefs related to the phenomena of communication, time, space, social organization, environmental control, and biological variations influence the family’s perceptions of infant behavior (Giger & Davidhizar, 2008).
Client/Family Teaching and Discharge Planning:
• Ask parents what they need to help them care for their premature infant. EB: Article identifies what parents express as the tips that were most helpful in caring for their premature infant (Morrissette, 2010).
• Educate parents on the positive effects of pacifier use after NICU discharge, including breastfed infants EB: Pacifier use contributed to safer sleep patterns and decreased incidence of sudden infant death syndrome (Jenik & Vain, 2009).
• Provide information on techniques to promote sleep for infants. EB: Education on sleep enhancement appears to increase length of infant sleep patterns (Gagnon & Bryanton, 2009).
• Nurture parents so that they in turn can nurture their infant/child. The most difficult and overlooked aspect of care of the high-risk neonate is effective, timely, and compassionate information delivery to parents and family by the medical staff (Sherman, Aylward, & Shoemaker, 2009).
• Have knowledge of community early intervention services and follow-up programs for preterm and at-risk infants and families (Akers et al, 2007).
• The preceding interventions may be adapted for home care use.
• Educate families in ways of preparing the home environment. Patterns of sound, light, and caregiving tasks should minimize stress, conserve energy, and protect the developing neonate from inappropriate environmental stimuli (Akers et al, 2007).
• Prepare families for realistic challenges of caring for preterm and at-risk infants prior to discharge. EBN: Nurses care can provide emotional support, parent empowerment and a welcoming environment that encourages parents and provides opportunities to practice new skills for parents preparing for NICU discharge (Cleveland, 2008). NICU education and support program for parents and infants prepares families for caring for preterm infants and at-risk infants (2007, COPE for Parents NICU Program for parents of premature infants).
• Encourage families to teach friends/visitors to recognize and respond to infant’s unique behavioral cues. It is important for families to feel comfortable obtaining support from their regular support systems; therefore, supportive persons need to be taught how to interact in the environment in a way that supports both the family and the infant (Als et al, 2005).
• Provide families information about community resources, developmental follow-up services, and parent-to-parent support programs. Primary care physician (PCP) follow-up should include all infants born prematurely for early identification of adverse neurological development. EB: Infants born at 34 to 36 weeks continually can be at risk for neurodevelopmental problems and should have close follow-up (Woythaler, McCormick, & Smith, 2011). EB: Provide families with available published resources (Sherman, Aylward, & Shoemaker, 2009, updated September 21, 2010).
References
Akcan, E., et al. The effect of kangaroo care on pain in premature infants during invasive procedures,. Turk J Pediatr. 2009;51(1):14–18.
Akers, A.L., et al. InReach: connecting NICU infants and their parents with community early intervention services. Zero Three. 27(3), 2007.
Als, H., et al. The Assessment of Preterm Infants’ Behavior (APIB): furthering the understanding and measurement of neurodevelopmental competence in preterm and full-term infants. Ment Retard Dev Disabil Res Rev. 2005;11(1):94–102.
Bobish, T., Stanger, M. Providing services in the clinical setting neonatal intensive care unit and inpatient. In: Drnach M., ed. The clinical practice of pediatric physical therapy. Baltimore: Lippincott Williams & Wilkins, 2007.
Cevasco, A.M. The effects of mothers’ singing on full-term and preterm and maternal emotional responses. J Music Ther. 2008;45(3):273–306.
Cleveland, L.M. Parenting in the neonatal intensive care unit. J Obstet Neonat Nurs. 2008;37(6):666–691.
COPE NICU, Program for Parents of Premature Infants 2007 info@copeforhope.com or call 1-607-664-6157. Retrieved September, 11, 2012, from http://www.copeforhope.com/cop_nicu.html
Davis, W.D., et al. Parent-child interaction and attention regulation in children born prematurely. J Spec Pediatr Nurs. 2005;9(3):85–94.
Elserafy, F.A., et al. Oral sucrose and a pacifier for pain relief during simple procedures in preterm infants: a randomized controlled trial. Ann Saudi Med. 2009;29(3):184–188.
Franck, L.S., et al. Parent involvement in pain management for NICU infants: a randomized controlled trial. Pediatrics. 2011;128(3):510–518.
Franco, P., et al. Influence of swaddling on sleep and arousal characteristics of healthy infants. Pediatrics. 2005;115(5):1307–1311.
Gagnon, A.J., Bryanton, J., Postnatal parental education for optimizing infant general health and parent-infant relationships. Cochrane Database Syst Rev 2009;(1):CD004068.
Gardner, E.H., Famuyide, M. Developmental interventions in the NICU: what are the developmental benefits? NeoReviews. 2009;10(3):113–120.
Giger, J., Davidhizar, R. Transcultural nursing: assessment and intervention. St Louis: Mosby; 2008.
Grenier, I.R., et al. Comparison of motor self-regulatory and stress behaviors of preterm infants across body positions. Am J Occup Ther. 2003;57(3):290–294.
Im, H., Kim, D. Effect of Yakson and gentle human touch versus usual care on urine stress hormones and behaviors in preterm infants: a quasi-experimental study. Int J Nurs Stud. 2009;46(4):450–458.
Jenik, A.G., Vain, N. The pacifier debate. Early Hum Dev. 2009;85(10):621–626.
Johnson, A. Engaging fathers in NICU: taking down the barriers to the baby. J Perinat Neonat Nurs. 2008;22(4):302–306.
Kashaninia, Z., et al. The effect of kangaroo care on behavioral responses to pain of an intramuscular injection in neonates. J Spec Pediatr Nurs. 2008;13(4):275–280.
Krueger, C. Exposure to maternal voice in preterm infants: review. Adv Neonat Care. 2010;10(1):13–20.
Morrissette, C., What are your best NICU parenting tips?, 2010 Retrieved September 7, 2012, from http://preemies.about.com/od/parentingyourpreemie/f/NICUCare.htm
Pinelli, J., Symington, A.J., Non-nutritive sucking calming effect for promoting physiologic stability and nutritive in preterm infants. Cochrane Database Syst Rev 2005;(4):CD001071. [updated April 2010].
Scher, M.S., et al. Neurophysiologic assessment of brain maturation after an eight-week trial of skin-to-skin contact with preterm infants. Clin Neurophysiol. 2009;120(10):1812–1818.
Sherman, M.P., Aylward, G.P., Shoemaker, C.T. Follow-up of the NICU patient. updated July 1, 2009. Retrieved October 28, 2009, from http://emedicine.medscape.com/article/977318-overview.
Walter-Nicolet, E., et al. Pain management in newborns: from prevention to treatment. Paediatr Drugs. 2010;12(6):353–365.
Weisman, O., et al. Sleep-wake transitions in premature neonates predict early development. Pediatrics. 2011;128(4):706–714.
Whipple, J. The effect of music-reinforced nonnutritive sucking on state of preterm, low birthweight infants experiencing heelstick. J Music Ther. 2008;45(3):227–272.
White R: NICU design—why it matters. Presentation at Millennium Neonatal Symposium, April 10, 2010, Providence, RI.
Woythaler, M.S., McCormick, M.C., Smith, V.C. Late preterm infants have worse 24 month neurodevelopmental outcomes than term infants. Pediatrics. 2011;127(3):622–629.
Wyngarden, K., DeWys, M., Padnos, P. Learnings from the field: the impact of using two new nursing diagnoses, organized infant behavior and disorganized infant behavior [abstract]. In: Classification of Nursing Diagnoses: Proceedings of the Thirteenth Conference. NANDA; 1999.
Readiness for enhanced organized infant behavior
NANDA-I
A pattern of modulation of the physiological and behavioral systems of functioning (i.e., autonomic, motor, state-organization, self-regulatory, and attentional-interactional systems) in an infant that is sufficient for well-being and can be strengthened
Risk for disorganized Infant behavior
NANDA-I
Risk for alteration in integrating and modulation of the physiological and behavioral systems of functioning (i.e., autonomic, motor, state, organizational, self-regulatory, and attentional-interactional systems)
Risk for Infection
NANDA-I
Risk Factors
Chronic disease (diabetes mellitus, obesity); deficient knowledge to avoid exposure to pathogens; inadequate primary defenses (altered peristalsis, broken skin) (e.g., intravenous catheter placement, invasive procedures), change in pH of secretions, decrease in ciliary action, premature rupture of amniotic membranes, prolonged rupture of amniotic membranes, smoking, stasis of body fluids, traumatized tissue (e.g., trauma, tissue destruction); inadequate secondary defenses: decreased hemoglobin, immunosuppression (e.g., inadequate acquired immunity, pharmaceutical agents including immunosuppressants, steroids, monoclonal antibodies, immunomodulators), leukopenia, suppressed inflammatory response); inadequate vaccination; increased environmental exposure to pathogens, outbreaks; invasive procedures; malnutrition
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Consider targeted surveillance for methicillin-resistant Staphylococcus aureus (MRSA) (screen clients at risk for MRSA on admission). EB: After universal MRSA surveillance, more than 5000 clients underwent surgical procedures. The rate of MRSA surgical site infection (SSI) identified decreased from 0.23% to 0.09% (Pofahl et al, 2009). The incidence of MRSA central line–associated bloodstream infections reported from hundreds of different intensive care units have decreased 50% to 70% between 2001 and 2007 (Burton, Edwards, & Horan, 2009).
Observe and report signs of infection such as redness, warmth, discharge, and increased body temperature. EBN: Change in mental status, fever, shaking, chills, and hypotension are indicators of sepsis (Risi, 2009).
Assess temperature of neutropenic clients; report a single temperature of greater than 100.5° F. CEB: Fever is often the first sign of an infection (NCCN, 2006). EBN: The immunocompromised host may present with a very different clinical picture when compared to an immunocompetent host. The progress of the infection may be more rapid, and the infection may quickly become life-threatening; report temperature elevation from baseline (Risi, 2009).
• Oral or tympanic thermometers may be used to assess temperature in adults and infants. EBN: The use of tympanic thermometers in addition to oral thermometers in obtaining temperatures is supported (Dzarr, Karmal, & Baba, 2009; Mains 2008). Rectal and oral temperature measurements are more accurate than other methods of temperature measurement such as temporal or axillary measurement (Makic et al, 2011).
Note and report laboratory values (e.g., white blood cell count and differential, serum protein, serum albumin, and cultures). EBN: While the white blood cell count may be in the normal range, an increased number of immature bands may be present (Risi, 2009). EBN: A neutropenic client with fever represents an absolute medical emergency (Mahtani, 2010).
• Assess skin for color, moisture, texture, and turgor (elasticity). Keep accurate, ongoing documentation of changes. EB: Hospital-acquired pressure areas, skin tears, and infections are associated with pain, reduced mobility, increased risk of in-hospital complications, and increased health care costs (AHRQ, 2010).
• Carefully wash and pat dry skin, including skinfold areas. Use hydration and moisturization on all at-risk surfaces. EBN: Moisturizers result in an increase of skin hydration and restoration of the skin barrier function and play a prominent role in the long-term management of atopic dermatitis (Lawton, 2009; Miller, Koch, & Yentzer, 2011).
• Refer to care plan for Risk for impaired Skin Integrity.
• Monitor client’s vitamin D level. EB: Vitamin D deficiency has been correlated with increased rates of infection. The recent discovery that vitamin D induces antimicrobial peptide gene expression explains, in part, the “antibiotic” effect of vitamin D and has greatly renewed interest in the ability of vitamin D to improve immune function (Gombart, 2009).
• Refer to care plan Readiness for enhanced Nutrition for additional interventions.
• Use strategies to prevent health care–acquired pneumonia (CDC/HICPAC, 2004): assess lung sounds, and sputum color and characteristics; use sterile water rather than tap water for mouth care of immunosuppressed clients; use sterile technique when suctioning; suction secretions above tracheal tube before suctioning; drain accumulated condensation in ventilator tubing into a fluid trap or other collection device before repositioning the client; assess patency and placement of nasogastric tubes; elevate the client’s head to 30 degrees or higher to prevent gastric reflux of organisms in the lung. EB: Ventilator-associated pneumonia is the most common health care–acquired infection seen in the intensive care unit (Kollef, Morrow, & Baughman, 2008).
• Encourage fluid intake. EB: Fluid intake helps thin secretions and replace fluid lost during fever (Guppy et al, 2011).
• Use appropriate “hand hygiene” (i.e., handwashing or use of alcohol-based hand rubs). EBN: Meticulous infection prevention precautions are required to prevent health care–associated infection, with particular attention to hand hygiene and standard precautions (CDC, 2011). In this study a lower rate of MRSA was linked to good hand hygiene (Mears et al, 2009). EB: Handwashing is currently the recommended strategy for reducing transmission of C. difficile. Alcohol gels do not inactivate C. difficile spores (Macleod-Glover, Sadowski, 2010).
• When using an alcohol-based hand rub, apply ample amount of product to palm of one hand and rub hands together, covering all surfaces of hands and fingers, until hands are dry. Note that the volume needed to reduce the number of bacteria on hands varies by product. EBN: Adequate hand antisepsis has proven to result in reduced infection rates. The use of alcohol-based hand rub is particularly effective; in contrast with handwashing, it kills susceptible bacteria more rapidly and to a greater extent, is less time-consuming, and skin health is better preserved when moisturizers are added (Aitken et al, 2011).
• Follow standard precautions and wear gloves during any contact with blood, mucous membranes, nonintact skin, or any body substance except sweat. Use goggles and gowns when appropriate. Standard precautions apply to all clients. You must assume all clients are carrying blood-borne pathogens (CDC/HICPAC, 2007). EBN: Hands of health care workers are the most common cause of health care–associated infections (Heath, 2009).
• Follow transmission-based precautions for airborne-, droplet-, and contact-transmitted microorganisms:
Airborne: Isolate the client in a room with monitored negative air pressure, with the room door closed and the client remaining in the room. Always wear appropriate respiratory protection when you enter the room. Limit the movement and transport of the client from the room to essential purposes only. Have the client wear a surgical mask during transport (CDC, 2005; Lambert, Iademarco, & Ridzon).
Droplet: Keep the client in a private room, if possible. If not possible, maintain a spatial separation of 3 feet from other beds or visitors. The door may remain open. Wear a surgical mask when you must come within 3 feet of the client. Some hospitals may choose to implement a mask requirement for droplet precautions for anyone entering the room. Limit transport to essential purposes and have the client wear a mask if possible.
Contact: Place the client in a private room if possible or with someone (cohorting) who has an active infection from the same microorganism. Wear clean, nonsterile gloves when entering the room. When providing care, change gloves after contact with any infective material such as wound drainage. Remove the gloves and clean your hands before leaving the room and take care not to touch any potentially infectious items or surfaces on the way out. Wear a gown if you anticipate your clothing may have substantial contact with the client or other potentially infectious items. Remove the gown before leaving the room. Limit transport of the client to essential purposes and take care that the client does not contact other environmental surfaces along the way. Dedicate the use of noncritical client care equipment to a single client. If use of common equipment is unavoidable, adequately clean and disinfect equipment before use with other clients.
• Standard precautions are based on the likely routes of transmission of pathogens. The second tier of the CDC guidelines is Transmission-Based Precautions. This replaces many old categories of isolation precautions and disease-specific precautions with three simpler sets of precautions. These three sets of precautions are designed to prevent airborne transmission, droplet transmission, and contact transmission (CDC/HICPAC, 2007).
• Use alternatives to indwelling catheters whenever possible (external catheters, incontinence pads, bladder control techniques). Sterile technique must be used when inserting urinary catheters. EB: Urinary tract infections (UTIs) account for almost half of all health care–associated infection (HAI), and a significant number of these infections are related to the insertion of urinary catheters (Conway, Larson, 2012; Saint et al, 2008).
• If a urinary catheter is necessary, follow catheter management practices: All indwelling catheters should be connected to a sterile, closed drainage system (i.e., not broken), except for good clinical reasons. Cleanse the perineum and meatus twice daily using soap and water. EBN: A nurse-driven protocol achieved a 32% reduction in the use of catheters [from 0.22 to 0.15 catheters/client-day] and a 45% reduction in CAUTI [from 4.78 to 2.64 infections/1000 catheter-days] (Parry & Srinivasan, 2011).
• Use evidence-based practices and educate personnel in care of peripheral catheters: use aseptic technique for insertion and care, label insertion sites and all tubing with date and time of insertion, inspect every 8 hours for signs of infection, record, and report. EB: Use of chlorhexidine gluconate for vascular catheter site care reduces catheter-related bloodstream infections and catheter colonization (CDC, 2011a).
• Use sterile technique wherever there is a loss of skin integrity. EBN: Infectious agents can invade when a treatment damages the skin or mucous membranes, which are natural barriers against infection (Risi, 2009).
• Ensure the client’s appropriate hygienic care with handwashing; bathing; oral care; and hair, nail, and perineal care performed by either the nurse or the client. Daily showers or baths can help to reduce the number of bacteria on the client’s skin. The oral cavity is a common site for infection (Coughlan & Healy, 2008).
• Recommend responsible use of antibiotics; use antibiotics sparingly. EB: Use and misuse of antibiotics results in several problems, the most significant of which are increases in resistance, C. difficile–associated disease (CDAD), and health care costs. National surveillance data show that the proportion of health care–associated infections due to multidrug-resistant organisms (MDROs) is increasing. Antibiotic stewardship is essential in reducing current and future resistance in bacteria (Jacob & Gaynes, 2010).
• Carefully screen and treat women with infertility who may have female genital tuberculosis. EB: Female genital tuberculosis is a symptomless disease inadvertently uncovered during investigation for infertility (Temporado Cookson, Brachman, & Ladele, 2008).
Pediatric: Note: Many of the preceding interventions are appropriate for the pediatric client.
• Follow meticulous hand hygiene when working with premature infants. EB: Cross-transmission through transient hand carriage of a health care worker appeared to be the probable route of transmission in NICU (Borghesi & Stronati, 2008).
• Cluster nursing procedures to decrease number of contacts with infants, allowing time for appropriate hand hygiene. EBN: Audit programs to track compliance with hand hygiene identified a drop in the incidence of health care–associated infections in very low-birth-weight infants in the NICU (Capretti et al, 2008).
• Avoid the prophylactic use of topical cream in premature infants. CEB: Prophylactic application of topical ointment increases the risk of coagulase-negative staphylococcal infection and any health care–acquired infection. A trend toward increased risk of any bacterial infection was noted in infants prophylactically treated (Conner, Soll, & Edwards, 2004).
• Encourage early enteral feeding with human milk. Human milk enhances immune defenses of the infant (Borghesi & Stronati, 2008).
• Monitor recurrent antibiotic use in children. Instruct parents on appropriate indicators for medical visits and the risks associated with overuse of antibiotics. EB: Guidelines addressing treatment of asthma in children state that antibiotics should not be used as part of chronic asthma therapy or for acute exacerbations, with the exception of clients with comorbid bacterial infections such as pneumonia or sinusitis (Paul et al, 2011).
• Suspect pneumonia when the client has symptoms of lethargy or confusion. Assess response to treatment, especially antibiotic therapy. EB: An observational study of a large database of 54,620 adult cases of CAP showed that the use of antibiotics as recommended by guidelines was found to be associated with statistically significant reductions in hospital mortality and length of stay (McCabe et al, 2009).
• Most clients develop HCAP by either aspirating contaminated substances or inhaling airborne particles. Refer to care plan for Risk for Aspiration.
• Carefully screen elderly women with incontinence for urinary tract infections. EB: Consider alternatives to chronic indwelling catheters, such as intermittent catheterization. Catheter-associated urinary tract infection (CAUTI) has been associated with increased morbidity, mortality, hospital cost, and length of stay (CDC/HICPAC, 2009).
Observe and report if the client has a low-grade temperature or new onset of confusion. Use an electronic axillary thermometer. CEB: Those caring for elderly clients must be alerted to the potential presence of infection when even low-grade temperature elevations appear for short periods (Holtzclaw, 2003). In the majority of acute confusion in the elderly, the etiology was multifactorial infections and dehydration as the most common causes (Cacchione et al, 2003)EB: The electronic axillary thermometer is safe and accurate for geriatric clients (Giantin et al, 2008).
Recommend that the geriatric client receive an annual influenza immunization and one-time pneumococcal vaccine. EB: Immunization against influenza is an effective intervention that reduces serologically confirmed cases (CDC, 2011b).
• Recognize that chronically ill geriatric clients have an increased susceptibility to infection; practice meticulous care of all invasive sites. EB: A successful infection prevention program can provide the foundation for expanding performance improvement throughout the long-term care facility (Smith, Bennett, & Bradley, 2008).
• Some of the above interventions may be adapted for home care use.
• Assess and treat wounds in the home. EBN: Home-based wound care, when combined with comprehensive nursing assessment, can be effective while reducing costs. Success can be achieved through the implementation of multiple clinical, educational, and operational strategies simultaneously (McIsaac, 2007).
• Review standards for surveillance of infections in home care. EBN: Home care has expanded in the United States, but infection surveillance, prevention, and control have lagged behind. In this article, it is recommended that infectious disease control principles form the basis of training for home care providers to assess infection risk and develop prevention strategies (Young, 2009).
• Maintain strong infection-prevention policies. EBN: Strong guidelines are important to avoid infection in the home setting, especially addressing such issues as storage and use of irrigation solutions and supplies (Young, 2009).
Monitor for the occurrence of infectious exacerbation of chronic obstructive pulmonary disease (COPD); refer to physician for treatment. EB: There is increasing evidence that implicates viral infections as a major risk factor for exacerbations of COPD (Varkey & Varkey, 2008).
• Refer for nutritional evaluation; implement dietary changes to support recovery and address antibiotic side effects. EB: Several randomized controlled trials and meta-analyses suggested that probiotics are effective in primary and secondary prevention of gastroenteritis and in its treatment (Guarino, Lo Vecchio, & Berni Canani, 2009).
Client/Family Teaching and Discharge Planning:
• Teach the client risk factors contributing to surgical wound infection (e.g., diabetes and higher body mass index). EB: These are some of the factors associated with risk of surgical wound infection (Uckay et al, 2010).
• Teach the client and family the importance of hand hygiene in preventing postoperative infections. EB: Two thirds of wound infections occur after discharge. Using good hand hygiene practices is effective for preventing these infections (Alexander 2011).
• Encourage high-risk persons, including health care workers, to get vaccinated (CDC, 2011).
• Influenza: Teach symptoms of influenza and importance of vaccination for influenza. EB: Influenza is caused by a virus and is readily spread by coughing, sneezing, and nasal secretions. Getting vaccinated protects your clients from health care–acquired influenza (CDC, 2011c).
• Teach the client and family how to take a temperature. Encourage the family to take the client’s temperature between 4 pm and 10 pm at least once daily. EBN: The lowest body temperature usually occurs between 0400h and 0500h, with highest readings being recorded between 1600 h and 2000 h (Hastings, 2009 in Peate & Wild, 2012).
References
Agency for Healthcare Quality and Research (AHRQ). Using tools and guidelines to significantly reduce hospital-acquired pressure ulcers. Medscape News. April 25, 2010.
Aitken, L., et al. Nursing considerations to complement the Surviving Sepsis Campaign guidelines. Crit Care Med. 2011;39(7):1800–1818.
Alexander, J.W. Updated recommendations for controlling surgical site infections. Ann Surg. 2011;253(96):1082–1093.
Borghesi, A., Stronati, M. Strategies for the prevention of hospital-acquired infections in the neonatal intensive care unit. J Hosp Infect. 2008;68(4):293–300.
Burton, D., Edwards, J., Horan, T. Methicillin-resistant Staphylococcus aureus central line–associated bloodstream infections in U.S. intensive care units, 1997-2007. JAMA. 2009;301(7):727–736.
Cacchione, P.Z., et al. Clinical profile of acute confusion in the long-term care setting. Clin Nurs Res. 2003;12(2):145–158.
Capretti, M.G., et al. Impact of a standardized hand hygiene program on the incidence of nosocomial infection in very low birth weight infants. Am J Infect Control. 2008;36(6):430–435.
Centers for Disease Control and Prevention (CDC), Guideline for hand hygiene in health-care settings. Recommendations of the Healthcare Infection Control Practices Advisory Committee and the HICPAC/SHEA/APIC/IDSA Hand Hygiene Task Force. MMWR: Recomm RepMay 19, 2011;51(RR-16:):1–45 Retrieved Sept 12, 2012, from http://www.cdc.gov/handhygiene/Guidelines.html
Centers for Disease Control and Prevention, Guideline for the prevention of intravascular catheter related infections, 2011 Retrieved from http://www.cdc.gov/hicpac
Centers for Disease Control and Prevention. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP), 2011. MMWR Recomm Rep. 2011;60(33):1128–1132.
Centers for Disease Control and Prevention: Vaccine information Statement (VIS) Influenza, July 2011c.
Centers for Disease Control and Prevention, Immunization of Health-Care Personnel Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm RepNov 25, 2011;60(RR-7:):1–45 Retrieved Sept 13, 2012 from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6007a1.htm
Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee (HICPAC): guidelines for preventing health-care-associated pneumonia, 2003 recommendations of the CDC and the Healthcare Infection Control Practices Advisory Committee. Respir Care. 2004;49(8):926–939.
Centers for Disease Control and Prevention. Healthcare Infection Control Practices Advisory Committee: 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. Retrieved September 12, 2011, from http://www.cdc.gov/ncidad/dh9p/pdf/guidelines/isolation2007.pdf.
Centers for Disease Control and Prevention, Healthcare Infection Control Practices Advisory Committee: 2009 guideline for prevention of catheter-associated urinary tract infections, 2009 Retrieved September 15from http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
Conner, J.M., Soll, R.F., Edwards, W.H., Topical ointment for preventing infection in preterm infants. Cochrane Database Syst Rev 2004;(1):CD001150.
Conway, L.J., Larson, E.L. Guidelines to prevent catheter-associated urinary tract infection: 1980 to 2010. Heart & Lung. 2012;41(3):271–283.
Coughlan, M., Healy, C. Nursing care, education and support for patients with neutropenia. Nurs Stand. 2008;22(46):35–41.
Dzarr, A.A., et al. A comparison between infrared tympanic thermometry, oral and axilla with rectal thermometry in neutropenic adults. Eur J Oncol Nurs. Sep 13, 2009;4:250–254.
Giantin, V., et al. Reliability of body temperature measurements in hospitalised older patients. J Clin Nurs. 2008;17(11):1518–1525.
Gombart, A. The vitamin D-antimicrobial peptide pathway and its role in protection against infection. Future Microbiol. 2009;4(9):1151–1165.
Guarino, A. Probiotics as prevention and treatment for diarrhea. Curr Opin Gastroenterol. 2009;25(1):18–23.
Guppy, M.P.B., et al, A. Advising patients to increase fluid intake for treating acute respiratory infections. Cochrane Database Syst Rev 2011;(2):CD0044193.
Heath, J. Infection prevention measures for immune compromised populations. In APIC text of infection control and epidemiology, ed 3. Washington, DC: Association for Professionals in Infection Control and Epidemiology; 2009.
Holtzclaw, B.J. Use of thermoregulatory principles in patient care: fever management. Online J Clin Innovat. 2003;5(5):1–23.
Jacob, J., Gaynes, R. Emerging trends in antibiotic use in U.S. hospitals: quality, quantification and stewardship. Expert Rev Anti Infect Ther. 2010;8(8):893–902.
Jensen, P.A., et al. Guidelines for preventing the transmission of Mycobacterium tuberculosis in health-care settings, 2005. MMWR Recomm Rep. Dec, 2005;54(RR-17):1–141.
Kollef, M.H., Morrow, L.E., Baughman, R.P. Health care-associated pneumonia (HCAP): a critical appraisal to improve identification, management, and outcomes—proceedings of the HCAP Summit. Clin Infect Dis. 2008;46(Suppl 4):S296–S334.
Lawton, S. Practical issues for emollient therapy in dry and itchy skin. Br J Nurs. 2009;18(16):978–984.
Mahtani, R. Neutropenia and infection. Retrieved July 29, 2010, from http://www.caring4cancer.
Mains, J.A. Measuring temperature. Nurs Stand. 2008;22(39):44–47.
Makic, M.B., et al. Evidence-based practice habits: putting more sacred cows out to pasture. Am Assoc Crit Care Nurse. 2011;31(2):38–63.
McCabe, C., et al. Guideline-concordant therapy and reduced mortality and length of stay in adults with community acquired pneumonia: playing by the rules. Arch Intern Med. 2009;169:1525–1531.
Macleod-Glover, N. Sadowski C: Efficacy of cleaning products for C. difficile: environmental strategies to reduce the spread of Clostridium difficile-associated diarrhea in geriatric rehabilitation. Can Fam Physician. May 2010;56(5):417–423.
McIsaac, C. Closing the gap between evidence and action: how outcome measurement informs the implementation of evidence-based wound care practice in home care. Wounds. 2007;19(11):299–309.
Mears, A., et al. Healthcare-associated infection in acute hospitals: which interventions are effective? J Hosp Infect. 2009;71(4):307–313.
Miller, D.W., Koch, S.B., Yentzer, B.A. An over-the-counter moisturizer is as clinically effective as, and more cost-effective than, prescription barrier creams in the treatment of children with mild-to-moderate atopic dermatitis: a randomized, controlled trial. J Drugs Dermatol. 2011;10(6):531–537.
National Comprehensive Cancer Network (NCCN), Fever and neutropenia treatment guidelines for patients with cancer—version II, March 2006 Retrieved September 9, 2011, from http://www.nccn.org/patients/patient_gls/_english/_fever_and_neutropenia/1_introduction.asp
Parry M, Srinivasan A: Protocol reduces use of urinary catheters, infections [Abstract 357]. Presented April 3, 2011, at the Society for Healthcare Epidemiology of America (SHEA) 20th Annual Scientific Meeting.
Paul, I., et al. Antibiotic prescribing during pediatric ambulatory care visits for asthma. Pediatrics. 2011;127:1014–1021.
Peate, I., Wild, K. Clinical observations 1/6: assessing body temperature. Br J Healthcare Assist. 2012;6(5):215–219.
Pofahl, W.E., et al. Active surveillance screening of MRSA and eradication of the carrier state decreases surgical-site infections caused by MRSA. J Am Coll Surg. 2009;208(5):981–986.
Risi, G.F. The immunocompromised host. In APIC text of infection control and epidemiology, ed 3. Washington, DC: Association for Professionals in Infection Control and Epidemiology; 2009.
Saint, S., et al. Preventing hospital-acquired urinary tract infection in the United States: a national study. Clin Infect Dis. 2008;46(2):243–250.
Smith, P., Bennett, G., Bradley, S. SHEA/APIC guideline: infection prevention and control in the long-term care facility. Am J Infect Control. 2008;36(7):504–534.
Temporado Cookson, S., Brachman, P., Jr., Ladele, O. Infertility in a U.S. resettled African refugee: a case report of genital tuberculosis. South Med J. 2008;101(12):1258–1260.
Uckay, I., et al. Preventing surgical site infections. Expert Rev Anti Infect Ther. 2010;8(6):657–670.
Varkey, J., Varkey, B. Viral infections in patients with chronic obstructive pulmonary disease. Curr Opin Pulm Med. 2008;14(2):89–94.
Young, C. Home care. In APIC text of infection control and epidemiology, ed 3. Washington, DC: Association for Professionals in Infection Control and Epidemiology; 2009.
Risk for Injury
NANDA-I
At risk for injury as a result of environmental conditions interacting with the individual’s adaptive and defensive resources
Note: This nursing diagnosis overlaps with other diagnoses such as Risk for Falls, Risk for Trauma, Risk for Poisoning, Risk for Suffocation, Risk for Aspiration, and if the client is at risk of bleeding, Ineffective Protection. Refer to care plans for these diagnoses if appropriate.
Risk Factors
External
Biological (e.g., immunization level of community, microorganism); chemical (e.g., poisons, pollutants, drugs, pharmaceutical agents, alcohol, nicotine, preservatives, cosmetics, dyes); human (e.g., nosocomial agents; staffing patterns; cognitive, affective, psychomotor factors); mode of transport; nutritional (e.g., vitamins, food types); physical (e.g., design, structure, and arrangement of community, building, and/or equipment)
Internal
Abnormal blood profile (e.g., leukocytosis/leukopenia, altered clotting factors, thrombocytopenia, sickle cell, thalassemia, decreased hemoglobin); biochemical dysfunction; developmental age (physiological, psychosocial); effector dysfunction; immune/autoimmune dysfunction; integrative dysfunction; malnutrition; physical (e.g., broken skin, altered mobility); psychological (affective orientation); sensory dysfunction; tissue hypoxia
NOC (Nursing Outcomes Classification)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Prevent iatrogenic harm to the hospitalized client by following the National Patient Safety goals:
Accuracy of Client Identification
Use at least two methods (e.g., client’s name and medical record number or birth date) to identify the client before administering medications, blood products, treatments, or procedures.
Prior to beginning any invasive or surgical procedure, have a final verification to confirm the correct client, the correct procedure, and the correct site for the procedure using active communication techniques.
Label containers used for blood and other specimens in the presence of the client.
Effectiveness of Communication Among Care Staff
When taking verbal or telephone orders, the orders should be written down and then read back for verification to the individual giving the order.
Standardize use of abbreviations, acronyms, symbols, and dose designations that are used in the institution.
Ensure critical test results and values are recorded and reported in a timely manner.
Utilize a standardized approach of “handing off” communications, including opportunities to ask and answer questions.
Medication Safety
Standardize and limit the number of drug concentrations utilized by the institution (e.g., concentrations of medications such as morphine in patient-controlled analgesia [PCA] pumps).
Label all medications and medication containers (e.g., syringes, medication cups, or other solutions on or off the surgical field).
Identify all of the client’s current medications upon admission to a health care facility, and ensure that all health care staff have access to the information.
Ensure that accurate medicine information is sent with the client throughout their care.
Reconcile all medication at discharge, and provide list to the client.
Improve the effectiveness of alarm systems in the clinical area.
Standardize a list of medications that look alike or sound alike. This list needs to be updated yearly.
Identify and take extra care with clients who are on blood-thinning medications.
Infection Control
Reduce the risk of infections by following Centers for Disease Control and Prevention (CDC) hand hygiene guidelines.
Clients who obtain injuries or die from infectious disease must be documented.
Utilize proven guidelines to prevent infections that are difficult to treat.
Utilize proven guidelines to prevent infection of the blood from central lines.
Utilize safe practices to treat the surgical site of the client.
Identify Clients Who Are Susceptible to Changes in Health Status
Educate staff on how to recognize changes in client condition, how to respond quickly, and how to alert specially trained staff to intervene if needed.
Standardize steps to educate staff so documents for surgery are ready prior to surgery.
Educate staff to mark the body part scheduled for surgery and engage the client in this process as well.
These actions have been shown to increase client safety and are required actions for accreditation by The Joint Commission (2011).
• See care plan for Risk for Falls.
Avoid use of restraints if at all possible. Restraint-free is now the standard of care for hospitals and long-term care facilities. Obtain a physician’s order if restraints are necessary. CEB: The use of restraints has been associated with serious injuries, including rhabdomyolysis, brachial plexus injury, neuropathy, and dysrhythmias, as well as strangulation, traumatic brain injuries, and all the consequences of immobility (Park & Tang, 2007). A current research study has shown a significant reduction in falls in a group that use quarter bedrails as a restraint versus a group that were using bedrails times four as a restraint (Capezuti et al, 2007).
• In place of restraints, use the following:
Well-staffed and educated nursing personnel with frequent client contact
Continuity of care with familiar staff
Nursing units designed to care for clients with cognitive or functional impairments
Avoiding use of IVs or tubes that are susceptible to being removed
Alarm systems with ankle, above-the-knee, or wrist sensors
Increased observation of the client
Providing exercise to diffuse and deflect client behavior
Border-defining pillow/mattress to remind the client to stay in bed
These alternatives to restraints can be helpful to prevent falls (Capezuti et al, 2007; Park & Tang, 2007).
• For an agitated client, consider providing individualized music of the client’s choice. EBN: Sung, Chang, and Lee (2010) found that preferred music listening had a positive impact by reducing the level of anxiety in older adults with dementia. Park and Pringle Specht completed a study in 2009 which found that the mean agitation levels of people with dementia were significantly lower while and after listening to preferred music than they were before listening to preferred music.
• Review drug profile for potential side effects that may increase risk of injury. EB: Medication-related admissions are common in older people, and more than half are preventable (Rogers et al, 2009). Clients’ fall rates were directly related to the number of psychotropic medications they were receiving (Cooper et al, 2007).
• Use one quarter- to one half-length side rails only, and maintain bed in a low position. Ensure that wheels are locked on bed and commode. Keep dim light in room at night. EBN: Use of full side rails can result in the client climbing over the rails, leading with the head, and sustaining a head injury. Side rails with widely spaced vertical bars and side rails not situated flush with the mattress have been associated with asphyxiation deaths because of rail and in-bed entrapment and should not be used (Capezuti et al, 2007).
• If the client has a new onset of confusion (delirium), refer to the care plan for Acute Confusion. If the client has chronic confusion, see the care plan for Chronic Confusion.
• Ask family to stay with the client to prevent the client from accidentally falling or pulling out tubes. Geriatric clients with chronic conditions and activity limitations had higher rates of fall injuries compared with older adults without chronic conditions (Schiller, Bramarow, & Dey, 2007).
• Remove all possible hazards in environment such as razors, medications, and matches.
• Place an injury-prone client in a room that is near the nurse’s station. EB: A pilot study has shown a slight decrease in fall rates due to the nurse’s ability to check on the client more frequently and react to call lights more quickly by placing the client closer to the nurse’s station (Nazarko, 2007).
• Help clients sit in a stable chair with armrests. Avoid use of wheelchairs and geri-chairs except for transportation as needed. Falling from a wheelchair can result in a serious injury or even death (Opalek, Graymire, & Redd, 2009).
Refer to physical therapy for strengthening exercises and gait training to increase mobility. EB: Physical activity (exercise) serves primary, secondary, and tertiary roles in the prevention of falls among older adults (Rose, 2008).
For the agitated psychotic client, use nonphysical forms of behavior management, such as verbal intervention or show of force. If medication is required, use oral medications if at all possible. EBN: The nurse should encourage strict schedules in the client’s activities of daily living. The nurse should communicate with the client in a calm and encouraging voice and use distraction with activities that the client enjoys. Given the likelihood of multiple medications being prescribed to the psychiatric population, the nurse should be aware of drug interactions, half-lives, and preferred route of administration (Sharer, 2008).
• Teach parents the need for close supervision of all young children playing near water. EB: Data available for low- and middle-income countries (LMICs) indicate that the burden of drowning in children is significant and becoming a leading public health problem (Hyder et al, 2008).
• If child has epilepsy, recommend showers instead of tub baths, and no unsupervised swimming is ever allowed. CEB: Most drowning accidents involving children are preventable if basic safety measures are taken (Bolte, 2000).
• Assess the client’s socioeconomic status. EB: Pediatric clients are at a greater risk for injury in lower versus higher income families (Laursen & Nielsen, 2008).
• Never leave young children unsupervised around cooking areas. EB: Some identified hazards to young children include burns and scalds, water temperatures set at greater than 54° C, kettles or appliances with dangling wires, or no stove guards to prevent a child from grabbing pots (Leblanc et al, 2006).
• Teach parents and children the need to maintain safety for the exercising child, including wearing helmets when biking. EB: More than 100 children are treated in each day for bicycle-related head injuries (Mehan, 2010).
• Encourage parents to insist on using breakaway bases for baseball. CEB: Use of breakaway bases was shown to reduce the number of injuries in baseball and softball by 96% (Janda, Bir, & Kedroske, 2001).
• Provide parents of children with traumatic brain injury with written instruction, emergency phone numbers and ensure that instructions are understood before child is discharged from health care setting. Instruct them to observe for the following symptoms: nausea, mild headache, dizziness, irritability, lethargy, poor concentration, loss of appetite, and insomnia. Symptoms of concussion may occur up to 2 weeks after injury, and need prompt treatment to prevent further injury (Bethel, 2012).
• Teach both parents and children the need for gun safety. According to the Centers for Disease Control, in 2005 there were 3006 firearm-related deaths among children 15 years and younger (Obeng, 2010).
• Encourage the client to wear glasses and hearing aids and to use walking aids when ambulating.
• If the client experiences dizziness because of orthostatic hypotension when getting up, teach methods to decrease dizziness, such as rising slowly, remaining seated several minutes before standing, flexing feet upward several times while sitting, sitting down immediately if feeling dizzy, and trying to have someone present when standing. EBN: In a 2009 study, Hiitola et al found that of 653 geriatric study participants, two thirds experienced a drop in blood pressure of some amount, whereas the other third experienced orthostatic hypotension.
• Discourage driving at night. A decline in depth perception, slower recovery from glare, and night blindness are common in the elderly and make night driving a difficult and unsafe task.
• Acknowledge racial/ethnic differences at the onset of care. EB: Death by violence has increased significantly among Alaska Natives, who have a suicide rate, frequently related to alcohol and self-inflicted gunshot wounds, three times that of the general U.S. population (National Center for Health Statistics, 2008). Apfelbaum, Sommers, and Norton (2008) found the avoidance of race predicted decrements in nonverbal friendliness during interracial interaction.
• Assess for the influence of cultural beliefs, norms, and values on the client’s perceptions of risk for injury. EBN: What the client considers risky behavior may be based on cultural perceptions (Giger & Davidhizar, 2008).
• Assess whether exposure to community violence is contributing to risk for injury. EBN: Exposure to community violence has been associated with increases in aggressive behavior and depression (Balter & Tamis-LeMonda, 2006). Minority students, especially African American and Hispanic students in lower grades, may participate in and may more often be victims of school violence (Wright & Fitzpatrick, 2004).
• Use culturally relevant injury prevention programs whenever possible.
• Validate the client’s feelings and concerns related to environmental risks. CEB: Ethnic minority families were less likely to engage in some safety practices and have less access to information regarding the availability and fitting of safety equipment (Mulvaney & Kendrick, 2004). Injuries were identified as the third leading cause of death among Hispanics and the leading cause for those Hispanic individuals 1 to 44 years of age (Mallonee, 2003).
Home Care and Client/Family Teaching and Discharge Planning:
• See Risk for Trauma for interventions and rationales.
Websites
CDC: Center for Injury Prevention and Control: http://www.cdc.gov/injury/index.html.
National Institute for Occupational Safety and Health: http://www.cdc.gov/niosh.
References
Apfelbaum, E.P., Sommers, S.R., Norton, M.I. Seeing race and seeming racist? Evaluating strategic colorblindness in social interaction. J Personality Soc Psychol. 2008;95(4):918–932.
Balter, L., Tamis-LeMonda, C. Child psychology: a handbook of contemporary issues. New York: Psychology Press; 2006.
Bethel, J. Emergency care of children and adults with head injury. Nurs Stand. 2012;26(43):49–56.
Bolte, R. Drowning: a preventable cause of death. Patient Care. 2000;34(7):129.
Capezuti, E., et al. Consequences of an intervention to reduce restrictive side rail use in nursing homes. J Am Geriatr Soc. 2007;55:334–341.
Cooper, J., et al. Assessment of psychotropic and psychoactive drug loads and falls in nursing facility residents. Consult Pharm. 2007;22:483–489.
Giger, J., Davidhizar, R. Transcultural nursing: assessment and intervention. St Louis: Mosby; 2008.
Hiitola, P.P., et al. Postural changes in blood pressure and the prevalence of orthostatic hypotension among home-dwelling elderly aged 75 years or older. J Hum Hypertens. 2009;23(1):33–39.
Hyder, A.A., et al. Childhood drowning in low- and middle-income countries: urgent need for intervention trials. J Paediatr Child Health. 2008;44(4):221–227.
Janda, D.H., Bir, C., Kedroske, B. A comparison of standard versus breakaway bases: an analysis of a preventative intervention for softball and baseball foot and ankle injuries. Foot Ankle Int. 2001;22:810.
The Joint Commission. 2011 national patient safety goals. Retrieved December 15, 2011, from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_npsg_facts.htm.
Laursen, B., Nielsen, J.W. Influence of socioeconomic factors on the risk of unintentional childhood injuries. Eur J Public Health. 2008;18(4):366–370.
Leblanc, J., et al. Home safety measures and the risk of unintentional injury among young children: a multi-centre case control study. Can Med Assoc J. 2006;175(8):883–887.
Mallonee, S. Injuries among Hispanics in the United States: implications for research. J Transcult Nurs. 2003;14(3):217–226.
Mehan, T.J. Bicycle-related injuries. Pediatr Parents. 2010;26(1-2):24.
Mulvaney, C., Kendrick, D. Engagement in safety practices to prevent home injuries in preschool children among white and non-white ethnic minority families. Inj Prev. 2004;10(6):375.
National Center for Health Statistics. Health: United States, 2002 with urban and rural chartbook. Washington DC: U.S. Government Printing Office; 2008.
Nazarko, L. Reducing the risk of falls in the care home. Nurs Residential Care. 2007;9(11):524–526.
Obeng, C. Should gun safety be taught in schools? Perspectives of teachers. J Sch Health. 2010;80(8):394–398.
Opalek, J., Graymire, V., Redd, D. Wheelchair falls: 5 years of data from a level 1 trauma center. J Trauma Nurs. 2009;16(2):98–102.
Park, H. Pringle Specht J: Effect of individualized music on agitation in individuals with dementia who live at home. J Gerontol Nurs. 2009;35(8):47–55.
Park, M., Tang, J.H. Changing the practice of physical restraint use in acute care. J Gerontol Nurs. 2007;33(2):9–16.
Rogers, S., et al. Medication-related admissions in older people. Drugs Aging. 2009;26(11):951–961.
Rose, D. Preventing falls among older adults: no “one size suits all” intervention strategy. J Rehabil Res Dev. 2008;45(8):1153–1166.
Schiller, J., Bramarow, E., Dey, A. Fall injury episodes among noninstitutionalized older adults, United States 2001-2003. Adv Data. 2007;392:1–16.
Sharer, J. Tackling sundowning in a patient with Alzheimer’s disease. Medsurg Nursing. 2008;17(1):27–29.
Sung, H., Chang, A., Lee, W. A preferred music listening intervention to reduce anxiety in older adults with dementia in nursing homes. J Clin Nurs. 2010;19(7-8):1056–1064.
The Joint Commission. 2011 National patient safety goals. Retrieved December 15, 2011, from http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/07_npsg_facts.htm.
Wright, D., Fitzpatrick, K. Psychosocial correlates of substance use behaviors among African American youth. Adolescence. 2004;39(156):653–667.
Insomnia
Judith A. Floyd, PhD, RN, FAAN, Jean D. Humphries, PhD(c), MS, RN and Elizabeth S. Jenuwine, PhD, MLIS
NANDA-I
Defining Characteristics
Observed changes in affect, observed lack of energy, increased work/school absenteeism, reports changes in mood, reports decreased health status, reports decreased quality of life, reports difficulty concentrating, reports difficulty falling asleep, reports difficulty staying asleep, reports dissatisfaction with sleep (current), reports increased accidents, reports lack of energy, reports nonrestorative sleep, reports sleep disturbances that produce next-day consequences, reports waking up too early
Related Factors (r/t)
Activity pattern (e.g., timing, amount), anxiety, depression, environmental factors (e.g., ambient noise, daylight/darkness exposure, ambient temperature/humidity, unfamiliar setting), fear, frequent daytime naps, gender-related hormonal shifts, grief, inadequate sleep hygiene (current), intake of stimulants, intake of alcohol, impairment of normal sleep pattern (e.g., travel, shift work), interrupted sleep, pharmaceutical agents, parental responsibilities, physical discomfort (e.g., pain, shortness of breath, cough, gastroesophageal reflux, nausea, incontinence/urgency), stress (e.g., ruminative pre-sleep pattern)
NOC (Nursing Outcomes Classification)
Comfort Level; Pain Level; Personal Well-Being; Psychosocial Adjustment: Life Change; Quality of Life; Rest; Sleep
Client Outcomes
Client Will (Specify Time Frame)
• Verbalize plan to implement sleep-promoting routines
• Fall asleep with less difficulty a minimum of four nights out of seven
• Wake up less frequently during night a minimum of four nights out of seven
• Sleep a minimum of 6 hours most nights and more if needed to meet next stated outcome
• Awaken refreshed and not be fatigued during day most of the time
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Obtain a sleep history including time needed to initiate sleep, duration of awakenings after the first sleep onset, total nighttime sleep amounts, and satisfaction with sleep amounts. Also explore bedtime routines, use of medications and stimulants, and use of complementary/alternative therapies for stress management and relaxation before bedtime. Assessment of sleep behavior and patterns is an important part of any health status examination (Humphries, 2008; Salas & Gamaldo, 2011).
• From the history, assess the degree and chronic nature of insomnia. Adults can be considered to have insomnia if their daytime tiredness and sleepiness is accompanied by one or more or the following several nights/week: (a) inability to initiate sleep; (b) awakening during the night with inability to reinitiate sleep; and/or (c) short nighttime sleep; insomnia is considered chronic if it continues beyond 4 weeks (Morgan et al, 2011).
• Avoid negative associations with ability to sleep. EB: Fear of not sleeping can interfere with sleep initiation and maintenance (Morin et al, 2009).
• If feasible, have client arise from bed to participate in calming activities whenever anxious about failure to fall asleep. CEB: Restricting use of bed to sleeping promoted sleep initiation (Wang et al, 2005).
• Avoid a focus on the clock and subsequent worry about sleep time lost to sleeplessness. CEB: Controlling negative stimuli promoted sleep initiation (Wang et al, 2005).
• Focus on positive aspects of life. EB: Subjects’ focus on gratitude was related to other positive presleep cognitions, shorter times to fall asleep, longer nighttime sleep, and better daytime function (Wood et al, 2009). Consider use of full-immersion baths or foot baths in the evening in client settings with close supervision. CEB: A systematic review showed that passive heating by use of warm baths relaxed sleepers and increased deep sleep in the elderly (Liao, 2002). EB: Small manipulations of core body and skin temperature were found to affect sleep onset in adults including normal older sleepers and elderly insomniacs (Raymann & VanSomeren, 2008). Passive body heating via full-immersion or foot baths should be used with caution in the elderly because of multiple safety issues including burns, dehydration, and potential for slips/falls in bath area.
Assist clients with chronic insomnia to select nights for sleeping pill use if complete discontinuance of sleeping pills is not feasible. EB: An effective early phase of treatment for chronic insomnia included use of sleeping pills 2 to 3 nights per week while subjects simultaneously learned cognitive-behavioral strategies for relaxing the mind and body before sleep and during the night (Morin et al, 2009).
For clients with chronic insomnia, refer to a nurse practitioner or other professional trained in cognitive-behavioral therapies. EB: Advanced practice nurses trained in cognitive-behavioral therapies are effective providers of behavioral sleep medicine (Buysse et al, 2011; Järnefelt et al, 2012).
Assess pain medication use and, when feasible, recommend pain medications that promote rather than interfere with sleep (see Acute Pain and Chronic Pain care plans). EB: Some pain medications also promote sleep, whereas others promote alertness and thus interfere with falling and staying asleep (Sateia, 2009).
Assess level of anxiety. If chronic insomnia is accompanied by anxiety, use relaxation techniques. (See further Nursing Interventions and Rationales for Anxiety.) CEB: A systematic review showed that the use of relaxation techniques to promote sleep in people with chronic insomnia is effective (Wang et al, 2005).
Assess for signs of depression: depressed mood state, statements of hopelessness, poor appetite. Refer for counseling as appropriate. EB: Many symptoms associated with sleep disruption arise from central nervous system hyperarousal in the depressed client (Sateia, 2009).
Assess for signs of sleep apnea and restless leg syndrome; if present, refer to an accredited sleep clinic for evaluation. If the client is waking frequently during the night, other primary sleep disorders may be the cause (Lamm et al, 2008; Sheldon et al, 2009-2010).
Assess for signs of substance overuse/abuse including prescription, OTC, and illicit drugs, as well as alcohol, caffeine, and theophylline use. Suggest lifestyle change and refer for addiction counseling as appropriate. Stimulants and mood alternators can greatly disrupt the circadian rhythm of sleep and waking (Matthews, 2011).
• Supplement other interventions with teaching about sleep and sleep promotion. (See further Nursing Interventions and Rationales for Readiness for enhanced Sleep.) CEB: A systematic review found that sleep education alone is not an effective treatment for chronic insomnia, but is a necessary component of effective treatment of insomnia whether short term or chronic (McCurry et al, 2007).
• Assessment of medications used for pain and other symptoms in the elderly is important because pain medications may be interfering with the client’s ability to initiate and maintain sleep (Matthews, 2011; Sateia, 2009).
• Most interventions discussed previously may be used with geriatric clients. Passive body heating via full-immersion or foot baths should be used with great caution in the elderly because of multiple safety issues that are more prevalent with the elderly, including burns, dehydration, and potential for slips/falls in bath area.
• In addition see the Geriatric Section of Nursing Interventions and Rationales for Readiness for enhanced Sleep.
• Assessments and interventions discussed previously may be adapted for use in home care.
• In addition, see the Home Care Section of Nursing Interventions and Rationales for Readiness for enhanced Sleep.
• Teach family about normal sleep and promote adoption of behaviors that enhance it. See Nursing Interventions and Rationales for Readiness for enhanced Sleep.
• Teach family about sleep deprivation and how to avoid it. See Nursing Interventions and Rationales for Sleep deprivation.
• Advise family of importance of not disrupting sleep of others unnecessarily. See Nursing Interventions and Rationales for Disturbed Sleep Pattern.
• Advise family of importance of minimizing noise and light in the sleep environment. See Nursing Interventions and Rationales for Disturbed Sleep Pattern.
• Help family differentiate insomnia from externally caused sleep disruption and resultant sleep deprivation: Family members may have direct control over interruptions in sleep and thus may help limit sleep deprivation directly. Insomnia is generally a stress-related, medication-related, or disease related psycho-physiological activation that interferes with the client’s ability to calm the mind and body adequately for initiation and maintenance of sleep. Family members can support clients’ attempts to manage their health and relax at bedtime, thus having an indirect effect.
References
Buysse, D.J., et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011;171(10):887–895.
Humphries, J.D. Sleep disruption in hospitalized adults. Medsurg Nurs. 2008;17(6):391–395.
Järnefelt, H., et al. Cognitive behavior therapy for chronic insomnia in occupational health services. J Occup Rehabil. 2012. [Mar 30. Epub ahead of print].
Lamm, J., et al. Obtaining a thorough sleep history and routinely screening for obstructive sleep apnea. J Am Acad Nurs Pract. 2008;20:225–229.
Liao, W.C. Effects of passive body heating on body temperature and sleep regulation in the elderly: a systematic review. Int J Nurs Stud. 2002;39(8):803–810.
Matthews, E.E. Sleep disturbances and fatigue in critically ill patients. AACN Adv Crit Care. 2011;22(3):204–224.
McCurry, S.M., et al. Evidence-based psychological treatments for insomnia in older adults. Psychol Aging. 2007;22(1):18–27.
Morgan, K., et al. Insomnia: evidence-based approaches to assessment and management. Clin Med. 2011;11(3):278–281.
Morin, C.M., et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial. JAMA. 2009;301(19):2005–2215.
Raymann, R.J., VanSomeren, E.J. Diminished capability to recognize the optimal temperature for sleep initiation may contribute to poor sleep in elderly people. Sleep. 2008;31(9):1301–1309.
Salas, R.E., Gamaldo, C.E. Diagnostic and therapeutic considerations in sleep disorders: case studies and commentary. J Clin Outcomes Manage. 2011;18(3):129–144.
Sateia, M.J. Update on sleep and psychiatric disorders. Chest. 2009;135(5):1370–1379.
Sheldon, A., et al. Nursing assessment of obstructive sleep apnea in hospitalised adults: a review of risk factors and screening tools. Contemporary Nurse. 2009-2010;34(1):19–33.
Wang, M., et al. Cognitive behavioural therapy for primary insomnia: a systematic review. J Adv Nurs. 2005;50(5):553–564.
Wood, A.M., et al. Gratitude influences sleep through the mechanism of pre-sleep cognitions. J Psychosom Res. 2009;66(1):43–48.
Decreased Intracranial Adaptive Capacity
NANDA-I
Intracranial fluid dynamic mechanisms that normally compensate for increases in intracranial volumes are compromised, resulting in repeated disproportionate increases in intracranial pressure (ICP) in response to a variety of noxious and nonnoxious stimuli
Defining Characteristics
Baseline ICP greater than 10 mm Hg; disproportionate increases in ICP following a single environmental or nursing maneuver stimulus; repeated increases in ICP of greater than 10 mm Hg for more than 5 minutes following any of a variety of external stimuli; volume-pressure response test variation (volume-pressure ratio of 2, pressure-volume index of less than 10); wide-amplitude ICP waveform (Kirkness, Burr, & Cain, 2006)
NIC (Nursing Interventions Classification)
Cerebral Edema Management, Cerebral Perfusion Promotion, Intracranial Pressure (ICP) Monitoring, Neurological Monitoring
Nursing Interventions and Rationales
To assess ICP and CPP effectively:
Maintain and display ICP and CPP continuously as ICP data guide therapy and predict outcome. The only way to determine CPP is to continuously monitor ICP and blood pressure (CPP = MAP − ICP). CEB: Continuous monitoring of CPP improves odds of survival at hospital discharge in clients with traumatic brain injury (TBI) (Brain Trauma Foundation et al, 2007; Fan et al, 2008; Kirkness, Burr, & Cain, 2006).
Maintain ICP less than 20 mm Hg and CPP greater than 60 mm Hg. CEB: The Guidelines for the Management of Severe Brain Injury established the treatment threshold for ICP as greater than 20 mm Hg and CPP less than 60 mm Hg (Brain Trauma Foundation et al, 2007).
Monitor neurological status frequently (hourly in acute situations) using the Glasgow Coma Scale (GCS), noting changes in eye opening, motor response to painful stimuli, and awareness of self, time, and place. CEB: A decrease of 2 points in a GCS score without identifiable cause (administration of sedation, narcotics, or anesthetic agents) should be reported to the physician (McNett, 2007).
Monitor pupillary size and reaction to light during all neurological assessments. EB: Pupil size and reactivity are predictive of outcome; nonreactive and dilated pupils are associated with a mortality as high as 80% compared to a mortality of 24% in traumatic brain–injured clients with pupils that react to light (Chamoun, Robertson, & Gopinath, 2009).
Monitor brain temperature. CEB: Hyperthermia is prevalent in clients with acute brain injury, contributes to increased length of stays, and has been strongly associated with poor outcomes in severe TBI. Brain temperature has been found higher than core temperatures in all published studies; therefore, fever may not be detectable in the absence of brain temperature monitoring (McIlvoy, 2007).
Monitor brain tissue oxygen (PbtO2). EB & CEB: Low brain PbtO2 has been significantly correlated with poor outcomes and increased mortality in clients with severe TBI (Chang et al, 2009; Vespa, 2006).
To prevent harmful increases in ICP:
Elevate head of bed 30 to 45 degrees with head in midline position. EBN & CEB: Elevating the head of the bed allows for increased venous drainage that decreases ICP. However, if client is suffering acute stroke, CPP may be compromised with head elevation (Blissitt et al, 2006; Fan, 2004; Ledwith et al, 2010; Schulz-Stubner & Thiex, 2006; Wojner-Alexandrov et al, 2005).
Administer sedation per collaborative protocol. CEB: Propofol infusions, compared with morphine sulfate infusions, lower ICP, especially during endotracheal suctioning (Gemma et al, 2002; Ghori et al, 2007).
Administer pain medication per collaborative protocol. CEB: Narcotics do not adversely affect ICP in postcraniotomy clients (Englehard et al, 2004).
Maintain glycemic control per collaborative protocol. EB: Maintain glucose levels between 140 and 180 mg/dL utilizing insulin therapy in brain-injured clients (Bilotta et al, 2009; Finfer et al, 2009; Moghissi et al, 2009; Yang et al, 2009).
Maintain normothermia. CEB: Elevation in brain temperature is associated with a rise in ICP (McIlvoy, 2007; Ogden, Mayer, & Connolly, 2005).
Maintain optimal oxygenation and ventilation, applying positive end expiratory pressure (PEEP) as needed and avoiding hyperventilation. CEB: PEEP levels of 10 cm H2O have been found to produce no significant changes in ICP, especially when combined with head of bed elevation of 30 degrees. Hyperventilation has been found to worsen outcomes in TBI clients and should be avoided, especially in the first 24 hours post injury (Brain Trauma Foundation et al, 2007; Huynh et al, 2002; Videtta et al, 2002).
Premedicate clients with adequate sedation and limit endotracheal suction passes to two in order to limit ICP increases. CEB: In well-sedated or paralyzed clients, elevations in ICP are attenuated, but increases in ICP may be cumulative with each suction pass (Gemma et al, 2002; Kerr et al, 2001).
To prevent harmful decreases in CPP:
See care plan for Risk for ineffective Cerebral tissue perfusion.
To treat sustained intracranial hypertension (ICP greater than 20 mm Hg):
Remove or loosen rigid cervical collars. CEB: Loosening or removing these collars allows for unrestricted venous drainage that lowers ICP (Hunt, Hallworth, & Smith, 2001; Mobbs, Stoodley, & Fuller, 2002).
Administer a bolus dose of mannitol and/or hypertonic saline per collaborative protocol. EB: Osmotic diuretics provide immediate plasma-expanding effects that increase cerebral blood flow and cause diuresis that decreases cerebral edema. A meta-analysis of five trials concluded that hypertonic saline is more effective than mannitol in the treatment of elevated ICP (Brain Trauma Foundation et al, 2007; Kamel et al, 2011).
Drain CSF from an intraventricular catheter system per collaborative protocol. CEB: CSF drainage has been found to be as effective as osmotic diuretics in severe TBI (Kerr et al, 2001; Kinoshita et al, 2006).
Administer barbiturates per collaborative protocol, and monitor blood pressure closely during medication administration. EB: Barbiturates decrease ICP but are associated with clinically significant hypotension that produces detrimental decreases in MAP and CPP and should only be used in clients who are hemodynamically stable and monitored closely for decreases in blood pressure (Chen et al, 2008; Marshall et al, 2010; Thorat et al, 2008).
Induce moderate hypothermia (32° to 35° C) per collaborative protocol. CEB: A recent meta-analysis suggests that hypothermia maintained for 48 hours reduces mortality and results in favorable neurological outcomes, but only in clients who do not receive barbiturates (Peterson et al, 2008; Tokutomi et al, 2003).
To treat decreased CPP (sustained CPP <60 mm Hg):
Administer norepinephrine to raise MAP per collaborative protocol. CEB: Norepinephrine is effective in raising MAP and CPP and may be more effective than dopamine (Johnston et al, 2004; Steiner et al, 2004).
Administer hypertonic saline per collaborative protocol. CEB: Infusions of hypertonic saline have been found to raise CPP while decreasing ICP (Al-Rawl et al, 2005; Bentsen et al, 2004).
References
Al-Rawl, P., et al. Cerebral blood flow augmentation in patients with severe subarachnoid haemorrhage. Acta Neurochir Suppl. 2005;95:123–127.
Bentsen, G., et al. Predictable reduction of intracranial hypertension with hypertonic saline hydroxyethyl starch: a prospective clinical trial in critically ill patients with subarachnoid haemorrhage. Acta Anaesthesiol Scand. 2004;48(9):1089–1095.
Bilotta, F., et al. Glycemic management in neurocritical care patients: a review. J Neurosurg Anesthesiol. 2009;21(1):2–9.
Blissitt, P., et al. Cerebrovascular dynamics with head-of-bed elevation in patients with mild or moderate vasospasm after aneurysmal subarachnoid hemorrhage. Am J Crit Care. 2006;15(2):206–210.
Brain Trauma Foundation. American Association of Neurological Surgeons, and Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS: Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24(Suppl 1):S1–S106. [ed 3].
Chamoun, R.B., Robertson, C.S., Gopinath, S.P. Outcome in patients with blunt head trauma and a Glasgow Coma Scale score of 3 at presentation. J Neurosurg. 2009;111(4):683–687.
Chang, J., et al. Physiologic and functional outcome correlates of brain tissue hypoxia in traumatic brain injury. Crit Care Med. 2009;37:283–290.
Chen, H., et al. Barbiturate infusion for intractable intracranial hypertension and its effect on brain oxygenation. Neurosurgery. 2008;63(5):880–887.
Englehard, K., et al. Effect of remifentanil on intracranial pressure and cerebral blood flow velocity in patients with head trauma. Acta Anaesthesiol Scand. 2004;48(4):396–399.
Fan, J. Effect of backrest position on intracranial pressure and cerebral perfusion pressure in individuals with brain injury: a systematic review. J Neurosci Nurs. 2004;36(5):278–288.
Fan, J., et al. Intracranial pressure waveform morphology and intracranial adaptive capacity. Am J Crit Care. 2008;17(6):545–554.
Finfer, S., et al. Intensive versus conventional glucose control in critically ill patients. N Engl J Med. 2009;360:1283–1297.
Gemma, M., et al. Intracranial effects of endotracheal suctioning in the acute phase of head injury. J Neurosurg Anesthesiol. 2002;14(1):50–54.
Ghori, K., et al. Effect of midazolam versus propofol sedation on markers of neurological injury and outcome after isolated head injury: a pilot study. Crit Care Resusc. 2007;9(2):166–171.
Hunt, K., Hallworth, S., Smith, M. The effects of rigid collar placement on intracranial and cerebral perfusion pressures. Anaesthesia. 2001;56(6):511–513.
Huynh, T., et al. Positive end-expiratory pressure alters intracranial and cerebral perfusion pressure in severe traumatic brain injury. J Trauma. 2002;53(3):488–493.
Johnston, J., et al. Effect of cerebral perfusion pressure augmentation with dopamine and norepinephrine on global and focal brain oxygenation after traumatic brain injury. Intensive Care Med. 2004;30(5):791–797.
Kamel, H., et al. Hypertonic saline versus mannitol for the treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care Med. 2011;39(3):554–559.
Kerr, M., et al. Dose response to cerebrospinal fluid drainage on cerebral perfusion in traumatic brain-injured adults. Neurosurg Focus. 2001;11(4):E1.
Kinoshita, K., et al. Importance of CPP management using cerebrospinal drainage in severe TBI. Acta Neurochirurg. 2006;96(Suppl):S37–S39.
Kirkness, C., Burr, R., Cain, K. Effect of continuous display of cerebral perfusion pressure on outcomes in patients with traumatic brain injury. Am J Crit Care. 2006;15(6):600–610.
Ledwith, M., et al. Effect of body position on cerebral oxygenation and physiological parameters in patients with acute neurological conditions. J Neurosci Nurs. 2010;42(5):280–287.
Marshall, G., et al. Pentobarbital coma for refractory intra-cranial hypertension after severe traumatic brain injury: Mortality predictions and one-year outcomes in 55 patients. J Trauma. 2010;69(2):275–283.
Mcilvoy, L.H. Impact of brain temperature and core temperature on ICP and CPP. J Neurosci Nurs. 2007;39(6):324–331.
McNett, M. A review of the predictive ability of Glasgow Coma Scale scores in head-injured patients. J Neurosci Nurs. 2007;39(2):68–75.
Mobbs, R., Stoodley, M., Fuller, J. Effect of cervical hard collar on intracranial pressure after head injury. Aust N Z J Surg. 2002;72(6):389–391.
Moghissi, E., et al. American Association of Clinical Endocrinologists and American Diabetes Association consensus statement on inpatient glycemic control. Diabetes Care. 2009;32(6):1119–1131.
Ogden, A., Mayer, S., Connolly, E. Hyperosmolar agents in neurosurgical practice: the evolving role of hypertonic saline. Neurosurgery. 2005;57(2):207–215.
Peterson, K., et al. Hypothermia treatment for TBI: a systematic review and meta-analysis. J Neurotrauma. 2008;25:62–71.
Schulz-Stubner, S., Thiex, R. Raising the head-of-bed by 30 degrees reduces ICP and improves CPP without compromising cardiac output in euvolemic patients with traumatic brain injury and subarachnoid hemorrhage: a practice audit. Eur J Anaesthesiol. 2006;23:177–180.
Steiner, L., et al. Direct comparison of cerebrovascular effects of norepinephrine and dopamine in head-injured patients. Crit Care Med. 2004;32(4):1049–1054.
Thorat, J., et al. Barbiturate therapy for patients with refractory intracranial hypertension following severe TBI: its effects on tissue oxygenation, brain temperature, and autoregulation. J Clin Neurosci. 2008;15(2):143–148.
Tokutomi, T., et al. Optimal temperature for the management of severe traumatic brain injury: effect of hypothermia on intracranial pressure, systemic and intracranial hemodynamics, and metabolism. Neurosurgery. 2003;52(1):102–111.
Vespa, P. Brain tissue oxygen monitoring: a measure of supply and demand. Crit Care Med. 2006;35(6):1850–1852.
Videtta, W., et al. Effects of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure. Acta Neurochir Suppl. 2002;81:93–97.
Wojner-Alexandrov, A., et al. Heads down: flat positioning improves blood flow velocity in acute ischemic stroke. Neurology. 2005;64:1354–2357.
Yang, M., et al. Intensive insulin therapy on infection rate, days in NICU, in-hospital mortality and neurology outcome in severe traumatic brain injury patients: a randomized controlled trial. Int J Nurs Stud. 2009;46(6):753–758.