M

Client Will (Specify Time Frame)

• Standardize internal and external transport forms using SBAR format (situation, background, assessment, recommendation) to provide safe and efficient transport of a high-risk pregnant client. QSEN: Using a standardized form throughout the hospital system decreases the risk of errors, miscommunications, and omissions (Edwards & Woodward, 2008; Guise & Lowe, 2008).

 Arrange for psychotherapeutic support when woman expresses intense fear related to high-risk pregnancy and fetal outcomes. EB & EBN: Women with comorbid conditions, such as diabetes or epilepsy, may express intense fear that need to be addressed to ameliorate negative consequences to the woman and her family (DeBackere, Hill, & Kavanaugh, 2008; Hutti, Armstrong, & Myers, 2011; Turner et al, 2008).

• Screen all antepartum clients for depression using a tool that evaluates the biopsychosocial-spiritual dimensions in a culturally sensitive way. EBN: Assessing depression during the antepartum period identifies risks and resources that can be modified to further support the mental health of pregnant women, particularly in women of color (Baisch et al, 2010; Breedlove & Fryzelka, 2011).

• Offer flexible visiting hours; private space for families; and nursing support for management of family stressors, including music and recreation therapy, when a woman is hospitalized with a high-risk pregnancy. CEB & EBN: In qualitative studies of women hospitalized for complications of pregnancy, accommodating individual family needs was recommended, such as flexible visiting hours and private space for family visits, and nursing support for management of family stressors, including identifying family strengths, such as spirituality (Gilbert, 2010; Handley & Stanton, 2006; Price et al, 2007; Richter, Parkes, & Chaw-Kant, 2007).

• Focus on the abilities of a woman with disabilities by encouraging her to identify her support system, resources, and needs for modification of her environment. CEB, EB, & EBN: Concern for safety and limitations for self-care for a woman with physical disabilities can lead nurses to question her desire to bear children and her ability to safely parent. Nurses need to seek knowledge about the physical disabilities their clients have and to provide holistic care to them (Huff, 2010; Smeltzer, 2007; Walsh-Gallagher, Sinclair, & Conkey, 2011).

• Recognize patterns of physical abuse in all pregnant and postpartum women, regardless of age, race, and socioeconomic status. EB & EBN: Studies of women have shown a pattern of abuse despite level of socioeconomic status. The major site of physical abuse during pregnancy is the torso, rather than the head and neck, which are the major sites in nonpregnant women. Recognition of physical injury patterns for assault could aid in better detection of all women experiencing intimate partner violence (Certain, Mueller, & Jagodzinski, 2008; Nannini et al, 2008).

• Perform accurate blood pressure readings at each client’s clinic encounter. EB & EBN: Women who have a history of chronic hypertension and are at risk for preeclampsia (e.g., family history, over 40 years old, first pregnancy, multiple gestation) need to be identified to decrease risk for inadequate placental perfusion or a multisystem shutdown. Choose the correct equipment by measuring a high mid-arm circumference, prepare the client, and record the measurements accurately to identify women at risk for hypertension (Hogan et al, 2011; Peters, 2008).

• Provide educational materials and support for personal autonomy about genetic counseling and testing options prior to pregnancy, that is, preimplantation genetic testing, or during pregnancy, that is, fetal nuchal translucency ultrasound, quadruple screen, cystic fibrosis. EB & EBN: Ethical principles of autonomy, nonmaleficence, and justice must be considered when discussing genetic counseling and testing with a pregnant woman and her family (Lewis, 2011; McCormick, 2011).

• Identify adherence barriers and assist with meal selections to maintain optimal and safe pregnancy weight gain (25 to 35 pounds; 15 to 25 if overweight). EB & EBN: Obesity (body mass index [BMI] above 30) is a common high risk factor that affects 1 in 5 pregnant women. Women can have adequate caloric intake, yet have inadequate nutritional intake. Low protein intake can adversely affect fetal brain development. The sequelae of obesity include gestational diabetes, fetal macrosomia and childhood obesity, congenital anomalies, and increased use of health care services (Chu et al, 2008; Gennaro et al, 2011; Lamont et al, 2011; Walters & Taylor, 2009).

• Use an analogy to explain the pathophysiology of gestational diabetes to teach a pregnant woman about management and treatment. EBN: Teaching using an analogy to explain gestational diabetes can help pregnant women better understand the disorder. Gestational diabetes risk increases with higher BMI. The unique pathophysiology of hyperinsulinemia and hyperglycemia put both mother and baby at higher risk for type 2 diabetes in the future (Irland, 2010).

• Utilize the 5As (tobacco cessation interventions) to treat tobacco use and dependence in pregnant women. EB: According to the USDHHS Clinical Practice Guidelines, health care professionals should at every contact (1) ask if a woman is a tobacco user, (2) advise her to quit, (3) assess her willingness to quit, (4) assist with the quit attempt (such as counseling, medication), and (5) arrange for follow-up (telephone Quitline support) (USDHHS, 2008).

• When questioning at-risk clients regarding recreational drug use, ask if they have used substances such as marijuana or cocaine within the last month, instead of questioning if have used within the last few days. EB: A study demonstrated that the use of these substances correlates best with the toxicology screens if women are asked it they have used these substances within the month (Yonkers et al, 2011).

 Refer clients who self-report drug abuse or have positive toxicology screens to a comprehensive addiction program designed for the pregnant woman. Children born to addicted mothers often have poor neonatal outcomes. EB: A study demonstrated that addicted pregnant women who attended a comprehensive program for addicted moms had better infant and maternal outcomes than addicted pregnant women who did not attend the program, especially if care began early in the pregnancy (Ordean & Kahan, 2011).

• Encourage pregnant women to utilize electronic resources, such as Text4Baby or whattoexpect.com, to track pregnancy progress and provide education and motivation to make healthy lifestyle choices (abstinence from poor nutrition, smoking, alcohol, etc.). EBN: Making education fun, interactive, and personal can encourage women to make behavior modifications for healthier outcomes (Jordan et al, 2011).

Client Will (Specify Time Frame)

• Assess overall cognitive function and memory. The emphasis of the assessment is everyday memory, the day-to-day operations of memory in real-world ordinary situations. Use an assessment tool such as the Mini-Mental State Examination (MMSE). The MMSE can help determine whether the client has cognitive impairment and/or memory loss, delirium and needs to be referred for further evaluation and treatment (Britton & Russel, 2007; Federman et al, 2009).

• Determine whether onset of memory loss is gradual or sudden. If memory loss is sudden, refer the client to a physician or neuropsychologist for evaluation. Acute onset of memory loss may be associated with neurological disease, medication effect, electrolyte disturbances, hypoxia, hypothyroidism, mental illness, or many other physiological factors (Mosconi, Pupi, & De Leon, 2008).

• Determine amount and pattern of alcohol intake. Alcohol intake has been associated with blackouts; clients may function but not remember their actions. Higher average weekly quantity and frequency of alcohol consumed in midlife were associated with lower speech fluency and may impair components of executive function (Gross et al, 2011).

• Note the client’s current medications and intake of any mind-altering substances such as benzodiazepines, ecstasy, marijuana, cocaine, or glucocorticoids. Benzodiazepines, oxybutynin, amitriptyline, fluoxetine, and diphenhydramine can produce memory loss for events that occur after taking the medication; information is not stored in long-term memory (Barton et al, 2008). EB: Glucocorticoid therapy may cause a decrease in memory function that is usually reversible once a person is off the medications (de Quervain & Margraf, 2008). By inhibiting memory retrieval, cortisol may weaken the traumatic memory trace and thus reduce symptoms even beyond the treatment period.

• Note the client’s current level of stress. Ask if there has been a recent traumatic event. Post-traumatic stress and anxiety-inducing general life factors may induce memory problems. Stress or elevated cortisol levels temporarily blocks memory retrieval (van Stegeren, 2009; Wolf, 2009).

• If stress was associated with memory loss, refer to a stress reduction clinic. If not available, suggest that the client meditate, receive massages, and participate in moderate physical activity, all of which may promote stress reduction and reduce anxiety and depression (Peavy et al, 2009).

• Encourage the client to develop an aerobic exercise program. EB: Reviews demonstrated that strength training and aerobic exercise had a positive effect on cognitive function (Ahlskog et al, 2011; Haaland et al, 2008).

• Determine the client’s sleep patterns. If insufficient, refer to care plan for Disturbed Sleep Pattern. EB: A review provided evidence of a range of cognitive deficits identified in untreated obstructive sleep apnea (OSA) clients, from attentional and vigilance to memory and executive functions, and more complex tasks such as simulated driving. Clients reported difficulty in concentrating, increased forgetfulness, an inability to make decisions, and falling asleep at the wheel of a motor vehicle (Jackson, Howard, & Barnes, 2011).

• Determine the client’s blood sugar levels. If they are elevated, refer to physician for treatment and encourage healthy diet and exercise. Baseline fasting glucose levels were NOT associated with memory or executive function (Euser et al, 2010). However, the need to rule out diabetes is a relevant concern for a differential diagnosis.

• If signs of depression such as weight loss, insomnia, or sad affect are evident, refer the client for psychotherapy. Depression can result in source memory errors, in which case the client is not sure if he or she did something or just thought about doing it (Gohier et al, 2008).

 Perform a nutritional assessment. If nutritional status is marginal, confer with a dietitian and primary care practitioner to evaluate whether the client needs supplementation with foods or vitamins. Teach the client the need to eat a healthy diet with adequate intake of whole grains, fruits, and vegetables to decrease cerebrovascular infarcts. Moderate, long-term deficiencies of nutrients may lead to loss of memory. This condition may be preventable or diminished through diet (Shukitt-Hale, Lau, & Joseph, 2008). EB: A study demonstrated that people who had high daily intake of raw fruits and vegetables may be protected from strokes (Griep et al, 2011).

• Question the client about cholesterol level. If it is high, refer to physician or dietitian for help in lowering. Encourage the client to eat a healthy diet, avoiding saturated fats and trans fatty acids. EB: Studies have shown that intake of increased saturated fats has been associated with increased cardiovascular disease including strokes (Hooper et al, 2012; Mahe et al, 2010). A systematic review of studies found that statins should NOT be recommended as a preventive treatment for dementia (Muangpaisan et al, 2010).

• Suggest clients use cues, including alarm watches, electronic organizers, calendars, lists, or pocket computers, to trigger certain actions at designated times. Cues and external cognitive strategies can help remind clients of certain actions, particularly for future intentions known as prospective memory (Kliegel, Jager, & Phillips, 2008).

• Encourage the client to participate in a multicomponent cognitive rehabilitation program that recommends stress and relaxation training, physical activity, external memory devices, such as a calendar for appointments and reminder lists. Using reminders can serve as cues for memory-impaired clients (McDougall et al, 2010b).

• Help the client set up a medication box that reminds the client to take medication at needed times; assist the client with refilling the box at intervals if necessary. Medication boxes are effective because clients will know whether medication has been taken when corresponding compartments are empty.

• If safety is an issue with certain activities (e.g., the client forgets to turn off stove after use or forgets emergency telephone numbers), suggest alternatives such as using a microwave or whistling teakettle for heating water and programming emergency numbers in telephone so that they are readily available.

• Refer the client to a memory clinic (if available), a neuropsychologist, or an occupational therapist. Memory clinics can help the client learn ways to improve memory. Clinics may be more effective for minority elders if work is done in groups because of increased support, reinforcement, and motivation (Harris et al, 2011).

• For clients with memory impairments associated with dementia, see care plan for Chronic Confusion.

Client Will (Specify Time Frame)

• Critically think/set priorities to use the most therapeutic bed positions based on client’s history, risk profile, preventive needs; realize positioning for one condition may negatively affect another. Conditions such as dyspnea, chest injury, pressure ulcer, pain, spinal cord or head injury, fractures, and amputation warrant certain bed positions to prevent complications, and head of bed (HOB) elevations may be contraindicated in certain cardiovascular or neurological conditions (Johnson & Meyenburg, 2009).

• Assess client’s risk for aspiration; if present, elevate HOB to 30 degrees and elevate HOB to 90 degrees during oral intake. Maintaining a sitting position with and after meals can help decrease aspiration pneumonia (Guy & Smith, 2009).

• Raise HOB to 30 degrees for clients with acute increased intracranial pressure (ICP) and brain injury. Refer to care plan for Decreased Intracranial Adaptive Capacity.

 Consult physician for HOB elevation of clients with acute stroke and monitor their response. Refer to care plan for Decreased Intracranial Adaptive Capacity.

• Raise HOB as close to 45 degrees as possible for critically ill, ventilated clients to prevent pneumonia (this height may place clients at higher risk for pressure ulcers). Elevating the HOB decreases regurgitation and risk of aspiration of gastric contents. EB: Researchers reviewed random controlled trials/reviews of prevention of ventilator-associated pneumonia (VAP), and their recommendations included elevating HOB to 45 degrees (Muscedere et al, 2008).

• Assist client to sit as upright as possible during meals/ingestion of pills if dysphagic. Refer to care plan for Impaired Swallowing.

• Periodically sit client as upright as tolerated in bed and dangle client, if vital signs/oxygen saturation levels remain stable. Being vertical reduces the work of the heart, improves circulation/lung ventilation/strength, and stimulates reflexes and awareness of surroundings. EBN: Therapeutic positioning in stationary positions optimizes ventilation and perfusion and promotes effective pulmonary exchange (Johnson & Meyenburg, 2009).

• Maintain HOB at lowest elevation that is medically possible to prevent shear-related injury; check sacrum often. Sacral shearing risk is high when HOB is above 30 degrees; skin may stick to linen if clients slide down, causing skin to pull away from underlying muscle tissue/bone (WOCN, 2010). EBN: A study in surgical ICU clients with HOB elevation above 30 degrees had higher sacral tissue interface pressures than those placed in other positions, regardless of type of pressure redistribution surface used, and these results were confirmed in a study of healthy volunteers (Johnson & Meyenburg, 2009).

• Trial prone positioning for clients with acute respiratory distress syndrome (ARDS), acute lung injury (ALI), and amputation and monitor their tolerance/response. Prone positioning may improve oxygenation; it allows hip extension and thus prevents flexor contractions in amputated lower extremities. EBN: Research demonstrates that prone positioning in critically ill clients with acute lung injury and/or adult respiratory disease improves pulmonary gas exchange (Johnson & Meyenburg, 2009).

• Assess client’s risk for falls using a valid tool, establish individualized fall prevention strategies, and perform postfall assessment to further refine fall prevention interventions. EB: The fall prevention program should include fall prevention interventions as well as assessment of risk and assessment of a fall (Ruddick et al, 2009).

• Lock bed brakes, use low-rise beds at lowest position with floor mats next to them, avoid use of side rails, and apply personal exit alarms on confused clients. Such interventions help prevent falls and reduce injury if fall occurs. EB: Results of a 2008 study by Bowers, Lloyd, and Lee suggested a 25% chance of serious head injury with feet-first falls from about 3 feet onto a tiled floor surface, and that use of an appropriately sized mat (15 cm beyond head/foot boards) significantly reduced risk. Mats seemed to provide “a protective effect” for the pelvis during head-first falls and for the thorax during feet-first falls.

 Avoid use of bedrails and restraints unless ordered by physician.

• Place call light, bedside table, and telephone within reach of clients. Clients won’t fall out of bed reaching for needed items (Gray-Miceli, 2008).

• Use a formalized screening tool to identify persons at high risk for thromboembolism (DVT). Early detection of high risk prompts early initiation of prophylaxis (Kearon et al, 2008).

 Implement thromboembolism prophylaxis/treatment as ordered (e.g., anticoagulants, antiembolic stockings, elastic leg wraps, sequential compression devices, feet/ankle exercises, and hydration). Anticoagulants prevent blood clots; mechanical devices/exercises prevent venous stasis (Kearon et al, 2008). Refer to care plan for Ineffective peripheral Tissue Perfusion.

• Use a formal tool to assess for risk of pressure ulcers. Braden and Norton scales are valid tools along with nursing judgment to assess for risk of pressure ulcer (WOCN, 2010).

• Implement the following interventions to prevent pressure ulcers and complications of immobility:

• Explain importance of exhaling versus holding one’s breath (Valsalva maneuver) and straining during bed activities. Exhaling with movement prevents increased intraabdominal and intrathoracic pressure that elevates blood pressure and impairs myocardial/cerebral perfusion (Weimer & Zadeh, 2009).

• Reassess pain level, especially before movement/exercising, and accept clients’ pain rating and level they think is appropriate for comfort, then administer analgesics based on pain rating. Refer to Acute Pain or Chronic Pain.

• Use special beds/equipment to move bariatric (very obese) clients, such as mattress overlay, sliding/roller board, trapeze, stirrup, and pulley attached to overhead traction system (holds one leg up during pericare). This reduces skin shear and frictional burn, and it decreases resistance for staff to overcome when repositioning obese clients (Cohen et al, 2010).

• Place bariatric clients in free-standing or ceiling-mounted lifts with padded slings while changing bed linen. Less manual lifting reduces staff musculoskeletal injuries (Logan, 2008).

• Place bariatric beds along a corner wall. Helps keep bed from moving during repositioning.

• Identify/modify hospital beds with large gaps between bed rail/mattress that create an entrapment hazard. Ensure that mattresses fit the bed; instill gap fillers/rail inserts, then monitor effectiveness.

Exercise

Bed Positioning

0—Completely independent

1—Requires use of equipment or device

2—Requires help from another person for assistance, supervision, or teaching

3—Requires help from another person and equipment device

4—Dependent (does not participate in activity)

Client Will (Specify Time Frame)

• Screen for mobility skills in the following order: (1) bed mobility; (2) supported and unsupported sitting; (3) transition movements such as sit to stand, sitting down, and transfers; and (4) standing and walking activities. Use a tool such as the Assessment Criteria and Care Plan for Safe Patient Handling and Movement (Sedlak et al, 2009). CEB: Assess for quality of movement, ability to walk and move, gait pattern, ADL function, presence of spasticity, activity tolerance, and activity order (Kneafsey, 2007).

• Screen for additional measures of physical function to assess strength of muscle groups, including unassisted leg stand, use of a balance platform, elbow flexion and knee extension strength, grip strength, timed chair stands, and the 6-minute walk. CEB: The nursing assessment should include factors related to mobility problems (e.g., ability to walk and move), with nursing goals and interventions developed to promote maximum mobility (Kneafsey, 2007). EBN: The abilities of the client should be assessed to determine how best to facilitate movement and protect nurses from injuries and reduce musculoskeletal pain (Sedlak et al, 2009).

• Assess the client for cause of impaired mobility. Determine whether cause is physical, psychological, or motivational. Some clients choose not to move because of psychological factors such as fear of falling or pain; an inability to cope; or depression. EBN: Because fear of falling is associated with immobility and functional dependence, it requires effective assessment and measurement (Greenberg, 2012). Refer to care plans for Risk for Falls, Acute or Chronic Pain, Ineffective Coping, or Hopelessness.

• Use Self-Efficacy for Exercise Scale (Resnick & Jenkins, 2000) and the Outcome Expectation for Exercise Scale (Resnick, Zimmerman, & Orwig, 2001) to determine client’s self-efficacy and outcome expectations toward exercise (Resnick & D’Adamo, 2011). CEB: To optimize mobility and exercise in post-hip fracture older women, self-efficacy and outcome expectations for exercise should be assessed. The impact of fear of falling was greater 1 year post-hip fracture, suggesting that efforts to address fear should be ongoing long after the hip fracture occurs (Resnick et al, 2007). EBN: Use a fear of falling assessment, such as a one-item fear of falling question, Falls Efficacy Scale, or Mobility Efficacy Scale (Messecar, 2008). EBN: An integrative review concluded that fear of falling in high-risk community-dwelling older adults is best measured by the Falls Efficacy Scale-International (Greenberg, 2012).

• Monitor and record the client’s ability to tolerate activity and use all four extremities; note pulse rate, blood pressure, dyspnea, and skin color before and after activity. Refer to the care plan for Activity Intolerance. EB: Use valid and reliable screening procedures and tools to assess the client’s preparticipation in exercise health screening and risk stratification for exercise testing (low, moderate, or high risk) (ACSM, 2010).

 Before activity, observe for and, if possible, treat pain with massage, heat pack to affected area, or medication. Ensure that the client is not oversedated. Pain limits mobility and is often exacerbated by movement.

 Consult with physical therapist for further evaluation, strength training, gait training, and development of a mobility plan. EBN: Prescribing a regimen of regular physical activity that includes both aerobic exercise and muscle strengthening activities is beneficial to minimizing impaired mobility; use exercise diary or log to improve adherence to mobility enhancement recommendations. Develop mobility enhancement programs that are specific to gender and ethnicity and are culturally appropriate (Yeom, Keller, & Fleury, 2009).

• Obtain any assistive devices needed for activity, such as gait belt, weighted vest, walker, cane, crutches, or wheelchair, before the activity begins. Assistive devices can help increase mobility (Yeom, Keller, & Fleury, 2009).

• If the client is immobile, perform passive ROM exercises at least twice a day unless contraindicated; repeat each maneuver three times. EB: Physical rehabilitation interventions were found to be safe, reduced disability, and resulted in few adverse events (Foster et al, 2011).

 If the client is immobile, consult with physician for a safety evaluation before beginning an exercise program; if program is approved, begin with the following exercises:

These exercises help reverse weakening and atrophy of muscles (Fauci et al, 2008).

• If client is immobile, consider use of vertical transfer techniques such as a transfer chair or gait belt pending weight-bearing status and client cooperation. Using a transfer chair that can bend into a stretcher position and then upright can help previously immobile clients get out of bed (Gonzalez et al, 2009). EBN: Critical care clients are high risk for complications related to immobility such as ventilator-associated pneumonia (VAP), atelectasis, and long-lasting functional limitations; therefore, once hemodynamically stable, use progressive mobilization to dangle legs, sit in a chair, stand and bear weight, and walk. Use rotation therapy (kinetic and continuous lateral) to reduce risk of VAP for clients on mechanical ventilation (Rauen et al, 2008).

• Help the client achieve mobility and start walking as soon as possible if not contraindicated. EBN: Early mobilization of orthopedic clients generally prevents medical complications such as deep vein thrombosis, allows clients time to practice using assistive devices or changes in weight-bearing status, and promotes improved function, reduces pain, and facilitates earlier return to independence (Radawiec et al, 2009).

• Use a gait-walking belt when ambulating the client. If the client is able to partially weight bear on one or both lower extremities, use a stand and pivot maneuver with a gait or transfer belt or powered standing assist lift (Gonzalez et al, 2009).

 Apply any ordered brace before mobilizing the client. Braces support and stabilize a body part, allowing increased mobility.

• Initiate a “No Lift” policy where appropriate assistive devices are used for manual lifting. CEB: A “No Lift” policy along with other measures such as the “Back Injury Resource Nurses” and an algorithm on safe client handling resulted in decreased workers’ compensation expenses with reduced lost and modified workdays, along with nurse and client satisfaction (Nelson et al, 2006). EBN: Use the algorithms provided by the National Association of Orthopaedic Nurses for safe client handling and moving during the following high-risk tasks: turning in bed side to side, vertical transfer of postoperative total hip replacement client and extremity cast/splint client, ambulation, and lifting or holding a limb without a cast or splint (Sedlak et al, 2009).

• Increase independence in ADLs, encouraging self-efficacy and discouraging helplessness as the client gets stronger. Providing unnecessary assistance with transfers and bathing activities may promote dependence and a loss of mobility. EBN: A function-focused care intervention (designed to optimize physical activity and function with Parkinson’s disease clients) demonstrated a significant effect on increasing outcome expectations for exercise, improving functional performance and increasing time spent in exercise and physical activity (Pretzer-Abhoff, Galik, & Resnick, 2011).

 If the client has osteoarthritis or rheumatoid arthritis, ask for a referral to a physical therapist to begin an exercise program that includes aerobic exercise, resistance exercise, and flexibility exercise (stretching). EB: Studies of functional outcomes of exercise on older adults and adults with knee arthritis found only a modest beneficial effect of progressive resistance training and cardiorespiratory programs on pain, strength, and function in both groups (Keysor & Brembs, 2011). EB: In a study examining the achievement of physical activity (PA) goals in relation to quality of life and self-reported pain in persons with rheumatoid arthritis (RA), it was found that persons with higher levels of self-efficacy for PA were more likely to achieve personal PA goals. Higher quality of life scores and less perceived arthritis pain were also related to achieving PA goals. Clinicians can therefore support goal achievement by working with clients to foster self-efficacy, set realistic exercise goals with action plans, and provide feedback regarding progress (Knittle, 2011).

 If client has had a cerebrovascular accident (CVA) with hemiparesis, consider use of constraint-induced movement therapy (CIMT), where the functional extremity is purposely constrained and the client is forced to use the involved extremity. CEB: The plasticity of the brain allows the brain to rewire and reroute neural connections to take up the work of the injured area of the brain. Constraint therapy was effective with improved motor function and health-related quality of life (Wu et al, 2007).

• If the client has had a CVA, recognize that balance and mobility are likely impaired, and engage client in fall prevention strategies and protect from falling. EBN: An RCT studied the effects of a 6-month treadmill-training program versus a stretching program for stroke survivors. Both groups experienced increased self-efficacy for exercise and a significant increase in outcome expectations for exercise and activities of daily living on the Stroke Impact Scale (Shaughnessy, Michael, & Resnick, 2012).

• If the client does not feed or groom self, sit side-by-side with the client, put your hand over the client’s hand, support the client’s elbow with your other hand, and help the client feed self; use the same technique to help the client comb hair. EBN: The effectiveness of a restorative care intervention on nursing home resident outcomes included significant improvements in the Tinetti Mobility Score and the subscores for gait and balance, as well as improved walking bathing, and stair climbing (Resnick et al, 2009).

Client Will (Specify Time Frame)

• Assist client to put on and take off equipment (e.g., braces, orthoses, abdominal binders) in bed. These provide stabilization and alignment; abdominal binder prevents postural hypotension and increases vital capacity (for hemodynamic stability, binder must be put on and taken off in bed).

• Inspect skin where orthoses, braces, and other equipment rested, once they are removed. Early detection of pressure allows for early pressure relief strategy implementation and a review of outcomes for preventing the development of pressure ulcers and facilitating wound healing (WOCN, 2010).

 Obtain referrals for physical and occupational therapy, or wheelchair seating clinic. Potential adverse effects of improper fit of wheelchair such as a seat too high can lead to insufficient trunk support, difficulty positioning the knees beneath a table or desk, difficulty propelling the wheelchair because of the difficulty reaching the hand rim on the wheels, and poor overall posture when arms resting on armrests. In addition, seat depth, seat width, armrest height, and leg length for foot plates have to be examined and modified (Pierson & Fairchild, 2008).

• Recognize that use of support surfaces (on chairs and beds ) redistributes pressure and should be used an adjunct to reduce the risk of developing pressure ulcers in addition to repositioning the client on a regular schedule (WOCN, 2010). EB: Sitting-acquired pressure ulcers occur primarily over the ischial tuberosities, and sacral ulcers are primarily the result of excessive loading in bed (Brienza et al, 2010). EB: Skin protection cushions used with fitted wheelchairs lower pressure ulcer incidence in elderly nursing home residents (Brienza et al, 2010). EBN & EB: A randomized clinical trial demonstrated those with high peak pressure indexes using foam cushions acquired more pressure ulcers than those using the pressure-reducing cushions (Brienza, 2009).There are many pressure-relieving cushions. Several that are commonly used are the Roho cushion, Varilite Evolution, and Invacare Matrix cushions.

• Intervene to maintain continence or use absorbent diapers to help prevent skin breakdown due to wet, macerated skin. Some wheelchair cushions have moisture-wicking characteristics.

• Maintain nutrition and hydration, which help to maintain skin integrity (Smith, 2008).

 Obtain physical therapist (PT), occupational therapist (OT), or wheelchair clinic referral for cushion reevaluation if signs of pressure emerge. Professionals assess, problem-solve, and perform pressure mapping to evaluate where peak pressures are and to objectively compare pressures on various cushions (Smith, 2008).

• Emphasize importance of weight shifts every 15 minutes with safety belts in place (leaning forward/laterally) for about 2 minutes for clients with paralysis with ability to move the trunk of their body. CEB: Coggrave and Rose (2003) demonstrated that pressure relief for 1 minute 51 seconds raised transcutaneous oxygen tension enough to unload pressure while sitting.

• Ensure that client and family know how and when to relieve weight bearing and the importance of pressure relief program and demonstrate compliance with it (Pierson & Fairchild, 2008).

• Utilize a passive standing position of wheelchair to relieve weight bearing, or, if applicable, manually stand client or use a sit-to-stand lift with sling for a few minutes. This removes tissue pressure over bony prominences to help prevent pressure ulcers (Baptiste et al, 2008).

• Routinely assess client’s sitting posture and frequently reposition him/her into alignment. EB: A study demonstrated that nursing personnel could reliably use the Resident Ergonomic Assessment Profile for Seating to assess posture of persons in their wheelchair (Gavin-Dreschnack et al, 2009).

• Sit dysphagic clients as upright as possible in individualized wheelchair versus geri-chair when eating. Clients with potential risk for aspiration (dysphagic clients) should have aspiration prevention strategies in place. EBN: During oral intake, the client’s head should be elevated to 90 degrees with hips and knees at the same angle to midline of trunk, and feet should be flat. Each client’s unique situation should determine aspiration prevention interventions (Guy & Smith, 2009).

• Implement use of friction-coated projection hand rims and leather gloves for clients to propel manual wheelchairs. Friction-coated projection rims are less invasive and slippery than aluminum rims; gloves absorb forces of propulsion and help prevent nerve damage/carpal tunnel.

• Manually guide or explain how to push forward on both wheel rims to move ahead, push the right rim to turn left and vice versa, and pull backward on both wheel rims to back up.

• Recommend that clients back wheelchairs into an elevator. If entering face first, instruct them to turn chair around to face the elevator doors. Clients can see the control panel, floor monitor display, and doors opening and can exit wheeling forward. Be aware that feet/legs are at risk for injury if door panels close prematurely or if there is insufficient room to accommodate the wheelchair (Pierson & Fairchild, 2008).

• Reinforce principle of descending a curb backward (“popping a wheelie”) if balance, trunk control, strength, and timing are adequate. Backward descent carries less risk of clients losing control and falling forward out of wheelchair.

• Ascend curbs in a forward position by popping a wheelie or having aide tilt chair back, place front wheels over curb, and roll chair up. If surface is muddy or sandy, ascend backwards. Front casters will not roll on soft surfaces; a backward approach requires less energy and prevents getting stuck or falling forward.

• During assisted wheelies, helper must hold wheelchair until all four wheels are back on the ground and client has control of wheelchair. Releasing one’s grip too soon may alter client’s balance and cause injury.

 Follow therapist’s recommendations for how clients should propel manual wheelchairs to prevent upper extremity pain and joint degeneration. Repetitive stress of manual wheeling has serious negative consequences such as bone and joint injuries with damage to these shoulder joints that do not have time to heal when manual wheeling is the primary means of mobility (Giacobbi et al, 2010).

 Inform clients that ultra-lightweight, pushrim-activated, power-assisted, or electric wheelchairs may be more therapeutic than manual ones. Consider pushrim-activated power-assist wheelchairs, which are manual wheelchairs with a motor linked to the pushrim in each rear hub that can reduce energy needed for propulsion and reserve energy for uneven terrain or obstacle negotiation (Ding et al, 2008).

• Help clients transition from a manual to a powered wheelchair/scooter if progressive disability occurs. EB: If the client does not have sufficient strength or motor control of the extremities to propel a standard wheelchair, the client may need to be evaluated for a power chair (Pierson & Fairchild, 2008).

 Reduce floor clutter and establish safety rules for drivers of electric/power mobility devices; make referrals to PT or OT for driver reevaluations if accidents occur or client’s health deteriorates. Safe driving prevents injury to client, pedestrians, and property. Waist belt restraints are attached to the frame of the wheelchair and are designed to prevent the driver from falling out of or sliding forward in the chair (Pierson & Fairchild, 2008).

• Request and receive client’s permission before moving unoccupied wheelchair in room or out to hallway. Chronic wheelchair users may view chair as part of their identity and independence and may become stressed if it is not readily available (Hollenbeck, 2010).

• Reinforce compensatory strategies for unilateral neglect and agnosia (visual scanning, self-talk, self-questioning as to what could be wrong) as clients propel wheelchair through doorways and around obstacles. Too often nurses physically move wheelchair or obstacle instead of cueing client to detect and solve problems. Refer to care plan for Unilateral Neglect.

• Offer support to help clients cope with issues related to physical disability. Depression and anxiety may occur with physical loss.

• Provide information on support group and Internet resource options.

• Provide information about advocacy, accessibility, assistive technology, and issues under the Americans with Disabilities Act.

 Make social service or wheelchair clinic referral to educate clients on financial coverage/regulations of third-party payers and Health Care Financing Association for wheelchairs. It is wise to recognize cost, advantages, and durability of different wheelchair models before purchasing one.

• Suggest that clients test-drive wheelchairs and try out cushions/postural supports before purchasing them. Equipment is expensive, and different models have different advantages and disadvantages.

Client Will (Specify Time Frame)

• Ask about the nature of the problem and determine that moral distress is present. Expert opinion recommends this as the first step in the 4As to Rise Above Moral Distress model (Ethics Work Group of FY 04, AACN, nd).

• Affirm the distress, commitment, “to take care of yourself” and your obligations. Validate feelings and perceptions with others. Expert opinion recommends this as the second step in the 4As to Rise Above Moral Distress model (Ethics Work Group of FY 04, AACN, nd).

• Prepare to take Action, implement strategies to “initiate the changes you desire. “Anticipate and manage setbacks. Expert opinion recommends this as the third step of the 4As to Rise Above Moral Distress model (Ethics Work Group of FY 04, AACN, nd).

• Assess sources and severity of distress. Expert opinion recommends this as the final step of the 4As to Rise Above Moral Distress model (Ethics Work Group of FY 04, AACN, nd).

Expert opinion suggests that the 4As model can be adapted and applied to noncritical care settings in addition to the critical care setting for which it was originally designed (Epstein & Delgado, 2010).

• Give voice/recognition to moral distress and express concerns about constraints to supportive individuals. EBN: A review/analysis/metasyntheses of 39 qualitative studies revealed that expression of concerns about institutional constraints and involvement in problem solving is essential for nurses (Rittenmeyer & Huffman, 2009). EBN: An exploratory, descriptive study of CRNAs found that spouses and significant others were helpful when ethical issues arose (Radzvin, 2011).

• Engage in problem-solving. EBN: A review/analysis/metasyntheses of 39 qualitative studies revealed that expression of concerns about institutional constraints and involvement in problem solving is essential for nurses (Rittenmeyer & Huffman, 2009).

• Engage in interdisciplinary problem-solving forums including family meeting and/or interdisciplinary rounds. Expert opinion suggests this as a strategy to improve communication and collaboration between client, family, and the health care team (Epstein & Hamric, 2009).

• Implement multidisciplinary interventions/strategies to address moral distress. Expert opinion recommends collaboration to improve a system such as a hospital unit (Epstein & Delgado, 2010).

• Identify/use a support system. EBN: An exploratory, descriptive study of CRNAs found that engaging support of colleagues did not compromise client well-being (Radzvin, 2011). Expert opinion recommends development and use of a network of support including chaplains (Epstein & Delgado, 2010; Ulrich, Hamric, & Grady, 2010).

• Initiate an ethics consult or ethics committee review. EBN: An exploratory, descriptive study of CRNAs suggests increased involvement of ethics committees as a strategy for dealing with ethical dilemmas (Radzvin, 2011). Expert opinion supports utilization of ethics consultants/committees to address moral distress (Ulrich, Hamric, & Grady, 2010).