R
Rape-Trauma Syndrome
NANDA-I
Sustained adaptive response to a forced, violent sexual penetration against the victim’s will and consent
Defining Characteristics
Aggression; agitation; anger; anxiety; change in relationships; confusion; denial; dependence; depression; disorganization; dissociative disorders; embarrassment; fear; guilt; helplessness; humiliation; hyperalertness; impaired decision-making; loss of self-esteem; mood swings; muscle spasms; muscle tension; nightmares; paranoia; phobias; physical trauma; powerlessness; revenge; self-blame; sexual dysfunction; shame; shock; sleep disturbances; substance abuse; suicide attempts; vulnerability
NOC (Nursing Outcomes Classification)
Abuse Cessation, Abuse Protection, Abuse Recovery: Emotional, Sexual, Coping, Impulse Self-Control, Self-Mutilation Restraint
Client Outcomes
Client Will (Specify Time Frame)
• Share feelings, concerns, and fears
• Recognize that the rape or attempt was not client’s own fault
• State that, no matter what the situation, no one has the right to assault another
• Describe medical/legal treatment procedures and reasons for treatment
• Report absence of physical complications or pain
• Identify support resources and attend psychotherapy/group assistance in coping with the trauma and effects of the traumatic experience
• Function at same level as before crisis, including sexual functioning
• Recognize that it is normal for full recovery to take a minimum of 1 year
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Escort the client to a treatment room immediately on arrival to the emergency department. Avoid interruptions during contact with the client. Stay with (or have a trusted person stay with) the client initially. EBN: In many medical facilities, sexual assault victims meet with long waits and trauma-insensitive care that might be considered a “second assault” (Keller & Lechner, 2010). Persons who have endured a sexual assault often feel traumatized by the care received in hospital emergency departments (Fehler-Capral, Campbell, & Patterson, 2011).
• Provide a sexual assault response team (SART), if available, that includes a sexual assault nurse examiner (SANE), rape counseling advocate, and representative of law enforcement for best possible outcomes. EB: A need for a comprehensive management approach to sexual assault is evident and should include prescriptive guidelines; workforce training and development; equitable access to services; and community education (Jancey, Meuleners, & Phillips, 2011). EBN: A study of the available literature demonstrates that SANE/SART programs provide emotional and mental support that allows a victim of sexual assault to take control over her/his options and choices and also assists the client in navigating the criminal justice system and accessing health services (Henry & Force, 2011; Lewis-O’Connor et al, 2010).
• Observe for signs of physical injury. EBN: Assessment and documentation of injuries and physical findings are all-important, both in furnishing a baseline for determining intervention priorities and for any possible legal action (Carter-Snell, 2011).
• Ask the client if she/he is in pain. If further clarification is needed, ask the client to point to areas that were injured or touched. EBN: Description of the appearance, distribution, and combination of genital injuries is imperative to evidence-based practice (Keller & Lechner, 2010).
• Document the client’s chief complaint and request an event history of the sexual assault in her/his own words. EB: It is agreed that awareness of the client’s sexual victimization history is invaluable in personalizing cases and determining treatment interventions (Probst, Turchek, & Zimak, 2011). EBN: The manner in which the client’s descriptions of the event are documented is up to the health care professional in accordance with policy (quotes, phrases of the victim’s description of the event, etc.). However it is done, the history should be documented as it is stated (Spears & Faugno, 2009).
• Monitor the client’s verbal and nonverbal affect. Encourage the client to verbalize his/her feelings. EB: There is widely accepted documentation that early intervention in cases of trauma significantly lessens the risk of anxiety, depression, self-harm, addiction issues, eating disorders, and suicide (Marshall, 2012). Individuals at risk for developing long-term problems after an assault should be identified during the initial assessment (Campbell, 2008).
• Explain everything you are doing. EBN: Clarify the medical aspects of the forensic examination for the victim and obtain consent, but ensure that the client is aware that although he has given consent for the exam, he can stop it at any point (Learner, 2012). EB: Ensure that a forensic examination is performed with an appreciation of the victim’s wishes and needs at all times (McGregor et al, 2009).
• Explain to the client that all or some of the client’s clothing may be kept for evidential purposes and photographs may be taken (with consent) to document the client’s injuries. EBN: For the victims of sexual assault, the forensic examination is the inaugural step in the advancement of justice. Assessment and treatment of victims, as well as the precise collection and documentation of evidence, are critical for a solid case (Fitzpatrick et al, 2012).
• If a law enforcement interview is permitted, provide support by staying with the client on her/his request. EB: By keeping the victim of sexual assault calm and comfortable, the nurse’s actions at the bedside may benefit the legal investigation and leave the victim less traumatized and better able to give a complete report of the assault (Campbell, Greeson, & Patterson, 2011).
• Utilize the sexual assault evidence collection kits that have been reviewed by the SART members and provided by your state to collect adequate and accurate evidence for analysis by a forensic laboratory. EB: Standardized evidence-collection kits usually contain forms for documentation to assist examiners. Evidence collection requires the victim’s permission during each of the necessary steps, and the client should be given the opportunity to set the tempo of the exam and to be aware that she/he may decline any part of the examination (Linden, 2011). EB: Proper evidence collection and quality laboratory services are the keys to obtaining the full value of collected DNA in sexual assault cases (Burg, Kahn, & Welch, 2011).
• Discuss the possibility of pregnancy and sexually transmitted infections (STIs) and the treatments available. EB: Immediate care for victims of sexual assault should include the treatment of injuries, prophylaxis for sexually transmitted infections, the possible administration of emergency contraception to prevent pregnancy, and the sensitive management of psychological issues (Luce, Schrager, & Gilchrist, 2010).
• Encourage the client to report the rape to a law enforcement agency. EB: Rape survivors’ decisions to assist in legal actions are influenced by three social groups: family/friends, service providers, and police (Anders & Christopher, 2011). EB: This study suggests that shame is a barrier for not reporting a sexual assault to law enforcement and was also associated with physical injury, victimization by a relative, and self-blame (Wolitsky-Taylor et al, 2011; Zinzow & Thompson, 2011). EBN: Victims may display postdecisional regret after reporting a sexual assault (Marchetti, 2012).
• Involve the support system if appropriate and if the client grants permission. EB: Research strongly suggests the kind of reactions survivors of sexual assault receive from others in their social circle (family, friends, and partners) may have a profound effect on their health and well-being; the results appear to depend on the caliber of the relationship before the sexual assault (Ahrens & Albana, 2012).
• For those interested in a spiritual connection, make the appropriate recommendation. EB: An increasing body of literature documents the benefits that religious coping provides for the victim of sexual assault, including higher levels of psychological well-being and lower levels of depression (Ahrens et al, 2010).
• Stress the necessity of follow-up care with a mental health professional to recognize and intervene with problems associated with the effects of rape-trauma. EB: In the aftermath of rape, victims often experience evidence of depression, anxiety, post-traumatic stress disorder (PTSD), self-harm, and increased risk of suicide (Marshall, 2012).
• Stress the importance of awareness throughout the community of the scope and severity of the effects of sexual abuse as a means of additional healing empowerment. EB: This study suggests that given characteristic societal victim-blaming following rape, self-blame is expected to be considerably more intense among survivors of rape than in other victims and prognostic of elevated post-trauma symptoms (Moor & Farchi, 2011). EB: Rape myth acceptance (RMA) was associated with offensive attitudes and behaviors toward women, but it was also found that RMA correlated with other “isms,” such as racism, heterosexism, classism, and ageism; consequently, it would seem that rape prevention programs could be broadened to add interventions to address other myths concurrent with RMA (Jordan, 2011; Suarez & Gadalla. 2010).
Geriatric:• Build a trusting relationship with the client. EBN: Trust begins by acting with integrity and caring, which then conveys investment in another’s welfare (Laskowski-Jones, 2011).
• All examinations should be done on the elderly as they would be done on any adult client after sexual assault with modifications for comfort if necessary. EB: The clinician has the responsibility to the client to document a competent history and perform an appropriate forensic examination, interpret the findings, and recognize patterns of harm (Fox, 2012). EBN: Sexual abuse in the elderly can present with symptoms of a sexually transmitted disease (STD) and/or reddened, swollen, bruised, or bleeding genitalia/breasts (Caple & Schub, 2011).
• Assess for mobility limitations and cognitive impairment. EB: Studies suggest that adults with possible mild cognitive impairment (MCI) display declines in everyday functioning. These results suggest that mobility declines could be features of MCI, and changes in mobility may be particularly important (O’Connor et al, 2010).
• Explain and encourage the client to report sexual abuse. EB: In this study, it was found that the caseworker and the elderly victims might hold contradictory views regarding the perpetrators’ motivations for abuse and what would be the likely outcomes of reporting it; this was most likely to occur when the perpetrator was a family member. Adjusting these differences can raise the likelihood of effective interventions (Jackson & Hafemeister, 2011). EBN: The extent of the problem of sexual abuse in the elderly is difficult to evaluate due to underreporting and the vulnerability and reluctance of the elderly to discuss the issue with health care providers, which may be due to the fact that perpetrators are frequently family members with the resulting issues of dependency, family loyalty, and fear of the consequences (Joubert & Posenelli, 2009).
• Observe for psychosocial distress. EBN: Changes in behavior, such as becoming more withdrawn, depressed, confused, fearful, or agitated, may be the consequences of sexual abuse in the elderly (Nazarko, 2011).
• Consider arrangements for temporary housing. EB: Practical implications—collaboration and an integrated community response are vital to enhancing the safety and quality of life of the older victim of abuse (Brandl & Dawson, 2011). EBN: Nurses need to consider the circumstance of an older person’s social well-being and the general risk factors for abuse (Ebutt, 2009).
Male Rape
• Encourage men who are raped to report the assault. EB: Sexual assault among males, compared with females, has not been extensively studied and may also be significantly underreported (Choudhary et al, 2012). EB: This study indicates that all things being equal in sexual assault between men and women’s experiences, men who had been penetrated had significantly lower likelihood of seeking counseling (Monk-Turner & Light, 2010). EB: This study suggests that male victims of sexual assault are more likely to be depressed and consider suicide, but less likely to seek health services; efforts should be made to reach these victims (Masho & Anderson, 2009).
Multicultural:• Assess for the influence of cultural beliefs, norms, and values on the client’s ability to cope with the trauma of the rape experience. EBN: It is suggested that divergences among minority women in the frequency of rape, reports of rape, and use of available resources will vary based on ethnicity, race, cultural standards, help-seeking behaviors, and availability of accessible services (Lawson, 2011). Assess to determine if physically abused women are also victims of sexual assault. EB: Care for those victims of sexual assault and domestic violence should include crisis services—legal advocacy, medical advocacy, counseling, support group, and shelter (Macy et al, 2011). EB: Sexual assault is experienced by most physically abused women and associated with significantly higher levels of PTSD compared with women physically abused only. The risk of re-assault is decreased if contact is made with health or justice agencies (Moreland et al, 2007).
• Assure the client of confidentiality. EB: It is suggested that not all criminal justice and medical professionals understand the statutory provision of privilege to communications between rape victim advocates and victims (Cole, 2011).
Home Care:• Some of the interventions described previously may be adapted for home care use.
• Corroborate the client’s feelings of self-worth. This study proposes that the feeling of self-worth moderates the effects of violence—especially violent loss—on PTSD and depression (Mancini, Prati, & Black, 2011).
• Assist the client with realistically assessing the home setting for safety and/or selecting a safe environment in which to live. EBN: The protection or safeguarding of vulnerable adults must be an integral part of everyday nursing practice (Straughair, 2011).
Ensure that the client has systems in place for long-term support. EB: Survivors of abuse noted that a cooperative model of health care, particularly between mental health and physical health professionals, was an asset to their recovery (Dunleavy & Slowik, 2012).
Design a practical discharge plan to include a safe shelter if needed, follow-up care for physical injury and follow-up referral for psychological support. EB: Safety, medical, and psychological plans for discharge are critical to the victim of sexual assault (Linden, 2011).
Assess for other client vulnerabilities such as mental health issues or addiction and refer client to social agencies for implementation of a therapeutic regimen. EB: Client support should be in response to the whole person; the assault should be addressed in both its social and cultural elements, with sensitivity to the client’s distinct needs and by sharing information with other social services, if so allowed by the client (Marshall, 2012).
Client/Family Teaching and Discharge Planning:
Discuss the need for prophylactic antibiotic therapy, hepatitis B vaccination, tetanus prophylaxis, and emergency contraception as needed. EB: The CDC has noted that there is poor compliance for follow-up visits among survivors of sexual assault; therefore, routine preventive therapy should be encouraged (CDC, 2010). EB: This study suggests that female sexual assault victims seen in the emergency department are often not offered comprehensive care including prophylaxis against pregnancy (Bakhru, Malinger, & Fox, 2010).
• Emphasize the client’s needs for safety and to decrease the opportunities for repeat attacks. EBN: The client should be made aware that the results of continued abuse may include more abuse, chronic pain, physical and emotional illness, and even death (Symes, 2011). EB: Safety and support programs have been shown to reduce sexual assaults (Luce, Schrager, & Gilchrist, 2010). EB: This study suggests that victims who have suffered sexual and/or physical assault identified the real supports of food, housing, financial assistance, and religious and spiritual counseling as most helpful to them (Postmus et al, 2009).
• Recognize the vulnerability of the client. EB: Conceptualizations of present control over the recovery process were related to lower levels of psychological distress (Walsh & Bruce, 2011). EB: Sexual assault could result in long-term mental and physical health problems, which may include self-destructive behaviors, chronic pelvic pain, and difficulty with pelvic exams (Luce et al, 2010).
Note: Post-traumatic stress disorder has a high probability of being a psychological sequela to rape. Research demonstrated two effective treatments for improvement of PTSD in rape victims—prolonged exposure and stress inoculation training. Prolonged exposure involves reliving the rape experience by imagining it as vividly as possible, describing it aloud in the present tense, taping this description, and listening to the tape at least once daily. Stress inoculation training uses breathing exercises to diminish anxiety and instruction in coping skills, thought stopping, cognitive restructuring, self-dialogue, and role playing. Research suggests that a combination of both treatments may provide the optimal effect. Furthermore, for those who reported the assault to police, lower levels of legal system success and satisfaction were linked to higher levels of perceived control over present recovery.
References
Ahrens, C., Albana, E. The ties that bind: understanding sexual assault disclosures on survivors’ relationships with friends, family and partners. J Trauma Dissoc. 2012;13(2):226–243.
Ahrens, C., et al. Spirituality and well being: the relationship between religious coping and recovery from sexual assault. J Interpers Violence. 2010;25(7):1242–1263.
Anders, M., Christopher, F. A socioecological model of rape survivors’ decisions to aid in case prosecution. Psychol Women Q. 2011;35(1):92–106.
Bakhru, A., Malinger, J., Fox, M. Postexposure prophylaxis for victims of sexual assault: treatments and attitudes of emergency department physicians. Contraception. 2010;82(2):168–173.
Brandl, B., Dawson, L. Responding to victims of abuse in later life in the United States. J Adult Protect. 2011;13(6):315–322.
Burg, A., Kahn, R., Welch, K. DNA testing of sexual assault evidence: the laboratory perspective. J Forensic Nurs. 2011;7(3):145–152.
Campbell, R. The psychological impact of rape victims. Am Psychol. 2008;63(8):702–717.
Campbell, R., Greeson, M., Patterson, D. Defining the boundaries: how sexual assault nurse examiners (SANEs) balance patient care and law enforcement collaboration. J Forensic Nurs. 2011;7(1):17–26.
Caple, C., Schub, T., Pravikoff, D. Elder abuse. CINAHL Information Systems. 2p, Dec 23, 2011.
Carter-Snell, C. Injury documentation: using the BALD STEP mnemonic and the RCMP sexual assault kit. Outlook. 2011;34(1):15–20.
Centers for Disease Control and Prevention (CDC), Sexually transmitted diseases: treatment guidelines, 2010 Retrieved Feb 6, 2012, from http://www.cdc.gov/std/treatment/2010/sexual-assault.htm
Choudhary, E., et al. Epidemiological characteristics of male sexual assault in a criminological database. J Interpers Violence. 2012;27(3):523–546.
Cole, J. Victim confidentiality on sexual assault response teams (SART). J Interpers Violence. 2011;26(2):360–376.
Dunleavy, K., Slowik, A. Emergence of delayed posttraumatic stress disorder symptoms related to sexual trauma: patient-centered and trauma-cognizant management by physical therapists. Phys Ther. 2012;95(2):339–351.
Ebutt, A. Abuse of older people. Nurs Stand. 2009;24(8):59.
Fehler-Capral, G., Campbell, R., Patterson, D. Adult sexual assault survivors’ experiences with sexual assault nurse examiners (SANEs). J Interpers Violence. 2011;26(18):3618–3639.
Fitzpatrick, M., et al. Sexual assault forensic examiners’ training and assessment using simulation technology. J Emerg Nurs. 2012;38(1):85–90.
Fox, A.W. Elder abuse. Med Sci Law. 2012;52(3):128–136.
Henry, D., Force, L. From our readers. Strategies for implementing an effective sexual assault nurse examiners program (SANE). Am Nurse Today. 2011;6(8):3.
Jackson, S., Hafemeister, T. Lessons learned from APS caseworkers and elderly victims they serve. Victimization Elderly Disabled. 2011;14(1):1–15.
Jancey, J., Meuleners, L., Phillips, M. Health professionals’ perceptions of sexual assault management: a Delphi Study. Health Educ. 2011;70(3):249–259.
Jordan, J. Here we go round the review-go-round: rape investigation and prosecution-are things getting worse not better? J Sex Aggression. 2011;17(3):234–249.
Joubert, L., Posenelli, S. Responding to a “window of opportunity”: the detection and management of aged abuse in an acute and subacute health care setting. Soc Work Health Care. 2009;48(7):702–714.
Keller, P., Lechner, M. Injuries to the cervix in sexual assault victims. J Forensic Nurs. 2012;6(4):196–202.
Laskowski-Jones, L. Building a foundation of trust. Nursing. 2011;41(9):6.
Lawson, S. Sexual assault: disparities within health care and the criminal justice system for minority women. Hispanic Health Care Int. 2011;9(2):58–60.
Learner, S. Compassion in time of crisis. Nurs Stand. 2012;27(18):22–30.
Lewis-O’Connor, A. The evolution of SANE/SART―are there differences? Sexual Assault Nurse Examiner/Sexual Assault Response Team. J Forensic Nursing. 2010;6(1):53.
Linden, J. Care of the adult patient after sexual assault. N Engl J Med. 2011;365(9):834–841.
Luce, H., Schrager, S., Gilchrist, V. Sexual assault of women. Am Fam Physician. 2010;81(4):489–495.
Macy, R., et al. Domestic violence and sexual assault service goal priorities. J Interpers Violence. 2011;26(16):3361–3382.
Mancini, A., Prati, G., Black, S. Self worth mediates the effects of violent loss on PTSD symptoms. J Trauma Stress. 2011;24(1):116–120.
Marchetti, C. Regret and police reporting among individuals who have experienced sexual assault. J Am Psychiatr Nurs. 2012;18(1):32–39.
Marshall, D. Twenty-four-hour sexual assault care—incorporating courtesy, dignity, privacy and respect. Healthcare Counsel Psychotherapy Journal. 2012;2(1):15–20.
Masho, S., Anderson, L. Sexual assault in men: a population-based study in Virginia. Violence Victims. 2009;24(1):98–110.
McGregor, J., et al. Examination for sexual assault: evaluating the literature for indicators of women-centered care. Health Care Women Int. 2009;30(3):22–40.
Monk-Turner, E., Light, D. Male sexual assault and rape: who seeks counseling? Sex Abuse. 2010;22(3):255–265.
Moor, A., Farchi, M. Is rape-related self blame distinct from other post traumatic attributions of blame? A comparison of severity and implications for treatment. Women Ther. 2011;34(4):447–460.
Moreland, L., et al. Posttraumatic stress disorder and pregnancy health: preliminary update and implications. Psychosomatics. 2007;48:304–308.
Nazarko, L. Nursing & Residential Care. 2011;13(6):264–268.
O’Connor, M., et al. Changes in mobility among older adults with psychometrically defined mild cognitive impairment. J Gerontol B Psychol Sci Soc Sci. 2010;65B(3):306–316.
Postmus, J., et al. Women’s experiences of violence and seeking help. Violence Against Women. 2009;15(7):852–868.
Probst, D., Turchek, J., Zimak, E. Assessment of sexual assault in clinical practice: available screening tools for use with different adult populations. J Aggression Maltreat Trauma. 2011;20(2):199–226.
Spears, T., Faugno, D. Tips of the trade. On Edge. 2009;15(3):2.
Straughair, C. Safeguarding vulnerable adults: the role of the registered nurse. Nurs Stand. 2011;25(45):49–56.
Suarez, E., Gadalla, T. Stop blaming the victim: a meta-analysis on rape myths. J Interpers Violence. 2010;25(11):2010–2035.
Symes, L. Abuse across the lifespan: prevalence, risk, and protective factors. Nurs Clin North Am. 2011;46(4):391–411.
Walsh, R., Bruce, S. The relationships between perceived levels of control, psychological distress, and legal system variables in a sample of sexual assault survivors. Violence Against Women. 2011;22(3):603–618.
Wolitsky-Taylor, K., et al. Is reporting of rape on the rise? A comparison of women with reported versus unreported rape experiences in the National Women’s Study—replication. J Interpers Violence. 2011;26(4):804–832.
Zinzow, H., Thompson, M. Barriers to reporting sexual victimization: prevalence and correlates among undergraduate women. J Aggression Maltreat Trauma. 2011;20(7):711–725.
Ineffective Relationship
NANDA-I
Defining Characteristics
Does not identify partner as a key person; does not meet developmental goals appropriate for family life-cycle stage; inability to communicate in a satisfying manner between partners; no demonstration of mutual respect between partners; no demonstration of mutual support in daily activities between partners; no demonstration of understanding of partner’s insufficient (physical, social, psychological) functioning; no demonstration of well-balanced autonomy between partners; no demonstration of well-balanced collaboration between partners; reports dissatisfaction with complementary relation between partners; reports dissatisfaction with fulfilling physical needs between partners; reports dissatisfaction with sharing of ideas between partners; reports dissatisfaction with sharing of information between partners
Readiness for enhanced Relationship
NANDA-I
A pattern of mutual partnership that is sufficient to provide for each other’s needs and can be strengthened
Defining Characteristics
Demonstrates mutual respect between partners; demonstrates mutual support in daily activities between partners; demonstrates understanding of partner’s insufficient (physical, social, psychological) function; demonstrates well-balanced autonomy between partners; demonstrates well-balanced collaboration between partners; identifies each other as a key person; meets developmental goals appropriate for family life-cycle stage; reports desire to enhance communication between partners; reports satisfaction with complementary relationship between partners; reports satisfaction with fulfilling emotional needs by one’s partner; reports satisfaction with fulfilling physical needs by one’s partner; reports satisfaction with sharing of ideas between partners; reports satisfaction with sharing of information between partners.
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
Assess for signs of depression in the family when one partner is depressed, and make appropriate referrals. EB: Depressive symptoms affect functioning of the whole family (Hinton et al, 2009).
• Support “relationship talk” between couples (talking with a partner about the relationship, what one needs from one’s partner, and/or the relationship implications of a shared stressor). Such discussions in couples with lung cancer have been shown to help partners better define their relationships and repair relationships that are functioning poorly (Badr, Acitelli, & Taylor, 2008). EB: These discussions may help alleviate the negative impact that sexual problems have on prostate cancer patients’ and their partners’ marital adjustment (Badr & Taylor, 2009).
• Encourage couples to participate and share in exciting and satisfying leisure activities and to share stories. EB: This study demonstrated that couples feel connected with their partners and more satisfied with their relationships when they engage in these types of activities (Graham, 2008). When stories are used as a way to understand the lives of couples, they have the potential for enhancing individual and relational growth (Skerrett, 2010).
• Assist couples in establishing boundaries between work and home. This study demonstrates that for both men and women, job demands foster their own work-family conflict (WFC), which in turn contributes to their partners’ home demands, family-work conflict (FWC), and exhaustion. In addition, social undermining mediates the relationship between individuals’ WFC and their partners’ home demands (Bakker, Demerouti, & Dollard, 2008).
• Assist couples in regulating negative emotions. EB: The results of this study of newlyweds support theories suggesting that the ability to regulate negative emotions may help intimates avoid perpetrating intimate partner violence (IPV), particularly when faced with a partner’s IPV perpetration (McNulty & Hellmuth, 2008).
• Assist couples in dealing with anger and communication when the diagnosis is cancer. EB: The anger-expression styles of both clients and their partners seem to modify the family atmosphere, and together, they are important determinants of the long-term quality of life of the cancer clients. Interventions for couples facing cancer should include a focus on ways of dealing with anger and thereby support dyadic coping with cancer (Julkunen, Gustavsson-Lilius, & Hietanen, 2009). Couples who are survivors of prostate cancer are faced with interruptions in their intimate relationships, communication, and overall quality of life. They need recommendations for appropriate resources (Galbraith, Fink, & Wilkins, 2011).
• Refer to care plans Readiness for enhanced Family Processes and Readiness for enhanced family Coping.
Pediatric:• Provide guidance and information on communication techniques for teenagers, especially those involved in intimate relationships. EBN: The findings of this study suggest that many female adolescents desired the love of a male partner and were willing to concede to his request of practicing unprotected sex. Findings support the urgent need for interventions that will promote skill-building techniques to negotiate safer sex behaviors among youth who are most likely to be exposed to STIs through risky behaviors (Bralock & Koniak-Griffin, 2009).
• Encourage supportive relationships among parents and teenagers EB: This study suggests that parenting may be associated with multiple benefits to teenagers’ sexual relationships including delayed intercourse and greater condom use (Parkes et al, 2011).
Assess for spousal depression when one partner has cardiovascular disease, and make appropriate referrals. EB: Exposure to spousal suffering is an independent and unique source of distress in married couples that contributes to psychiatric and physical morbidity (Schulz et al, 2009).
Assess for depression and anxiety and make appropriate referrals for “prewidows” caring for spouses with chronic life-limiting conditions. EB: In this study health deficits associated with spousal bereavement may be evident earlier in the marital transition than previously thought, warranting attention to the health of elderly persons whose spouses have chronic/life-limiting conditions (Williams et al, 2008).
• Support older couples’ positive collaborative communication. EB: In this study of older couples, the couples displayed a unique blend of warmth and control during collaborative communication, suggesting that a greater focus on emotional and social concerns during problem solving is important (Smith et al, 2009).
• Encourage collaborative coping (i.e., spouses pooling resources and problem solving jointly) among older adults. EB: This study of older adults whose husbands had prostate cancer suggested that collaborative coping may be associated with better daily mood and greater marital satisfaction because of heightened perceptions of efficacy in coping with stressful events and problems surrounding illness (Berg et al, 2008).
• Provide culturally tailored community-level interventions to raise awareness about HIV and bisexuality, and decrease HIV and sexual orientation stigma. EB: Culturally tailored interventions may increase African American and Latino MSMW’s (men who have sex with men and women) comfort in communicating with their female partners about sexuality, HIV, and condoms (Mutchler et al, 2008). Sociocultural factors and HIV-related misinformation contribute to the increasing number of Chilean women living with HIV. Future HIV prevention should stress partner communication, empowerment, and improving the education of women vulnerable to HIV (Cianelli, Ferrer, & McElmurry, 2008).
• Provide home-based psychoeducation to assist new parent couples with parenting and their couple relationship. EB: The best outcomes for psychoeducational interventions for effective parenting of infants and sustaining a mutually satisfying couple relationship seem to be achieved when programs are accessible by couples at home, when skill training is provided, and possibly when programs target couples at high risk of maladjustment to parenthood (Petch & Halford, 2008).
Client/Family Teaching and Discharge Planning:
• Encourage clients and spouses to participate together in interventions to lower low-density lipoprotein cholesterol (LDL-C). Teach spouses how to provide emotional and instrumental support, allow clients to decide which component of the intervention they would like to receive, and have clients determine their own goals and action plans. Provide telephone calls to clients and spouses separately. During each client telephone call, client progress is reviewed, and clients create goals and action plans for the upcoming month. During spouse telephone calls, which occur within 1 week of client calls, spouses are informed of clients’ goals and action plans and devise strategies to increase emotional and instrumental support. EB: The behaviors required to lower LDL-C levels may be difficult to adhere to if they are inconsistent with spouses’ health practices, and, alternatively, may be enhanced by enlisting support from the spouse. Interventions that teach spouses to provide instrumental and emotional support may help clients initiate and adhere to behaviors that lower their LDL-C levels. Moreover, allowing clients to retain autonomy by deciding which behaviors they would like to change and how may improve adherence and clinical outcomes (Voils et al, 2009). Interventions to reduce cardiovascular risk factors should be addressed jointly to both members of a marital couple (Di Castelnuovo et al, 2009).
References
Badr, H., Acitelli, L.K., Taylor, C.L. Does talking about their relationship affect couples’ marital and psychological adjustment to lung cancer? J Cancer Surviv. 2008;2(1):53–64.
Badr, H., Taylor, C.L. Sexual dysfunction and spousal communication in couples coping with prostate cancer. Psycho-Oncology. 2009;18(7):735–746.
Bakker, A.B., Demerouti, E., Dollard, M.F. How job demands affect partners’ experience of exhaustion: integrating work-family conflict and crossover theory. J Appl Psychol. 2008;93(4):901–911.
Berg, C.A., et al. Collaborative coping and daily mood in couples dealing with prostate cancer. Psychol Aging. 2008;23(3):505–516.
Bralock, A., Koniak-Griffin, D. What do sexually active adolescent females say about relationship issues? J Pediatr Nurs. 2009;24(2):131–140.
Cianelli, R., Ferrer, L., McElmurry, B.J. HIV prevention and low-income Chilean women: machismo, marianismo and HIV misconceptions. Cult Health Sex. 2008;10(3):297–306.
Di Castelnuovo, A., et al. Spousal concordance for major coronary risk factors: a systematic review and meta-analysis. Am J Epidemiol. 2009;169(1):1–8.
Galbraith, M.E., Fink, R., Wilkins, G.G. Couples surviving prostate cancer: challenges in their lives and relationships. Semin Oncol Nurs. 2011;27(4):300–308.
Graham, J.M. Self-expansion and flow in couples’ momentary experiences: an experience sampling study. J Pers Soc Psychol. 2008;95(3):679–694.
Hinton, L., et al. Longitudinal influences of partner depression on cognitive functioning in Latino spousal pairs. Dement Geriatr Cogn Disord. 2009;27(6):491–500.
Julkunen, J., Gustavsson-Lilius, M., Hietanen, P. Anger expression, partner support, and quality of life in cancer patients. J Psychosom Res. 2009;66(3):235–244.
McNulty, J.K., Hellmuth, J.C. Emotion regulation and intimate partner violence in newlyweds. J Fam Psychol. 2008;22(5):794–797.
Mutchler, M.G., et al. Psychosocial correlates of unprotected sex without disclosure of HIV-positivity among African-American, Latino, and white men who have sex with men and women. Arch Sex Behav. 2008;37(5):736–747.
Parkes, A., et al. Is parenting associated with teenagers’ early sexual risk-taking, autonomy and relationship with sexual partners? Perspect Sexual Reproduct Health. 2011;43(1):30–40.
Petch, J., Halford, W.K. Psycho-education to enhance couples’ transition to parenthood. Clin Psychol Rev. 2008;28(7):1125–1137.
Schulz, R., et al. Spousal suffering and partner’s depression and cardiovascular disease: the Cardiovascular Health Study. Am J Geriatr Psychiatry. 2009;17(3):246–254.
Skerrett, K. “Good Enough Stories”: Helping couples invest in one another’s growth. Fam Process. 2010;49(4):503–516.
Smith, T.W., et al. Conflict and collaboration in middle-aged and older couples: I. Age differences in agency and communion during marital interaction. Psychol Aging. 2009;24(2):259–273.
Voils, C.I., et al. Study protocol: couples partnering for lipid enhancing strategies (CouPLES)—a randomized, controlled trial. Trials. 2009;6(10):10.
Williams, B.R., et al. Marital status and health: exploring pre-widowhood. J Palliat Med. 2008;11(6):848–856.
Risk for ineffective Relationship
Impaired Religiosity
NANDA-I
Impaired ability to exercise reliance on beliefs and/or participate in rituals of a particular faith tradition
Defining Characteristics
Difficulty adhering to prescribed religious beliefs; difficulty adhering to prescribed religious rituals (e.g., religious ceremonies, dietary regulations, clothing, prayer, worship/religious services, private religious behaviors/reading religious materials/media, holiday observances, meetings with religious leaders); questions religious belief patterns; questions religious customs; reports a need to reconnect with previous belief patterns; reports a need to reconnect with previous customs; reports emotional distress because of separation from faith community
Related Factors (r/t)
Psychological
Anxiety; fear of death; ineffective coping; ineffective support; lack of security; personal crisis; use of religion to manipulate
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Express satisfaction with the ability to express religious practices
• Express satisfaction with access to religious materials and rituals
• Demonstrate balance between religious practices and healthy lifestyles
• Avoid high-risk, controlling religious relationships that inflict physical, sexual, or emotional harm and/or exploitation
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Recognize when clients integrate religious practices in their life. EB: In a cross-sectional descriptive study of 85 individuals with visual impairment, religious well-being predicted 7% of coping behaviors (Yampolsky et al, 2008). In patients with traumatic brain injury, religious well-being (personal connection to a Higher Power) predicted life satisfaction, whereas public religious practice did not (Waldron-Perrine et al, 2011).
• Encourage and/or coordinate the use of and participation in usual religious rituals or practices that support coping. EB: In a cross-sectional descriptive study of 85 individuals with visual impairment, religious well-being predicted 7% of coping behaviors (Yampolsky et al, 2008). In a prospective study of antepartal women, participating in organized religious activities was associated with less postpartum depression (Mann et al, 2008).
• Encourage the use of prayer or meditation as appropriate. CEB: A controlled study of 84 college students revealed that those who participated in a religious spiritual meditation exercise experienced significantly less anxiety and more positive mood, spiritual health, and spiritual experiences and higher pain tolerance (Wachholtz & Pargament, 2005).
• Promote family coping using religious practices to help cope with loss, as appropriate. EB: In a cross-sectional, retrospective survey of parents of children who have died, participants identified spirituality and religion as shaping their perspective of the grief process (Arnold & Gemma, 2008).
Refer to religious leader, professional counseling, or support group as needed. EBN: In a grounded theory study, it was found that chaplains promoted spirituality, which was validated in a psychometric study (Burkhart & Hogan, 2008; Burkhart, Schmidt, & Hogan, 2011).
• Promote established religious practices in the elderly. EB: In a sample of chronically ill older adults, self-reported religiosity and closeness to God significantly predicted acceptance of death attitudes (Daaleman & Dobbs, 2010).
Promote religious practices that are culturally appropriate:
African American. EBN: In a sample of 203 African American professional women, 69% rated attending church as a coping mechanism to deal with stress (Bacchus, 2008).
Hawaiian women. EBN: In a semistructured interview with Hawaiian women in churches, integrating religious and spiritual practices in health promotion was viewed as important in promoting breast cancer screening (Ka’opua, 2008).
African. EBN: In a phenomenological study, Nigerian-born immigrants treated depression with spirituality and religion, rather than health care professionals (Ezeobele et al, 2009). EB: In Uganda, 85% of African women with HIV/AIDS use spirituality as a coping mechanism, including support from other believers, prayer, and trusting in God (Hodge & Roby, 2010).
Aborigine. EB: Within Aboriginal communities, using traditional healers and elders can effectively address domestic violence victims (Puchala et al, 2010).
References
Arnold, J., Gemma, P.B. The continuing process of parental grief. Death Stud. 2008;32:658–673.
Bacchus, D.N. Coping with work-related stress: a study of the use of coping resources among professional black women. J Ethnic Cultur Divers Soc Work. 2008;17(1):60–81.
Burkhart, L., Hogan, N. An experiential theory of spiritual care in nursing practice. Qual Health Res. 2008;18(7):928–938.
Burkhart, L., Schmidt, L., Hogan, N. Development and psychometric testing of the spiritual care inventory instrument. J Adv Nurs. 2011;67(11):2463–2472.
Daaleman, T.P., Dobbs, D. Religiosity, spirituality, and death attitudes in chronically ill older adults. Res Aging. 2010;32(2):224–243.
Ezeobele, I., et al. Depression and Nigerian-born immigrant women in the United States: a phenomenological study. J Psychol Ment Health Nurs. 2009;17:193–201.
Hodge, D.R., Roby, J. Sub-Sahara African women living with HIV/AIDS: an exploration of general and spiritual coping strategies. Soc Work. 2010;55(1):27–37.
Ka’opua, L.S. Developing a culturally responsive breast cancer screening promotion with native Hawaiian women in churches. Health Soc Work. 2008;33(3):169–177.
Mann, J.R., et al. Do antenatal religious and spiritual factors impact the risk of postpartum depressive symptoms? J Womens Health. 2008;17(5):745–755.
Puchala, C., et al. Using traditional spirituality to reduce domestic violence within Aboriginal communities. J Alt Compl Med. 2010;16(1):89–96.
Wachholtz, A.B., Pargament, K.I. Is spirituality a critical ingredient of meditation? Comparing the effects of spiritual meditation, secular meditation, and relaxation on spiritual, psychological, cardiac, and pain outcomes. J Behav Med. 2005;28(4):367–384.
Waldron-Perrine, B., et al. Religion and spirituality in rehabilitation outcomes among individuals with traumatic brain injury. Rehab Psychol. 2011;56(2):107–116.
Yampolsky, M.A., et al. The role of spirituality in coping with visual impairment. J Vis Impair Blind. 2008;102(1):28–39.
Readiness for enhanced Religiosity
NANDA-I
A pattern of reliance on religious beliefs and/or participation in rituals of a particular faith tradition that is sufficient for well-being and can be strengthened
Defining Characteristics
Expresses desire to strengthen belief patterns that have provided religion in the past; expresses desire to strengthen religious belief patterns that have provided comfort in the past; expresses desire to strengthen religious customs that have provided comfort in the past; questions belief patterns that are harmful; questions customs that are harmful; rejects belief patterns that are harmful; rejects customs that are harmful; requests assistance to expand religious options; request assistance to increase participation in prescribed religious beliefs (e.g., religious ceremonies, dietary regulations/rituals, clothing, prayer, worship/religious services, private religious behaviors, reading religious materials/media, holiday observances); requests forgiveness; requests meeting with religious leaders/facilitators; requests reconciliation; requests religious experiences; requests religious materials
NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family and Discharge Planning, Rationales, and References
See care plan for Impaired Religiosity.
• Provide spiritual care for children based on developmental level. CEB: When nurses are comfortable providing spiritual care, they can implement numerous spiritual care activities and interventions to meet the spiritual needs of the child and family. After determining the child’s spiritual beliefs and spiritual needs, a plan of care is developed based on the child’s developmental age (Burkhart, 2011; Elkins & Cavendish, 2004; Fowler, 1981, 1987).
Infants: Have the same nurse care for the child on a daily basis. Encourage holding, cuddling, rocking, playing with, and singing to the infant. Continuity of care will promote the establishment of trust because nurses provide much of the needed ongoing support. The infant who is ill or dying still needs to be sung to, talked to, played with, held, cuddled, and rocked (Elkins & Cavendish, 2004).
Toddlers: Provide consistency in care and familiar toys, music, stories, clothing blankets, pillows, and any other individual object of contentment. Schedule home religious routines into the plan of care, and support home routines regarding good and bad behavior. The importance of consistency in care and routine with this age group cannot be overemphasized. The nurse should support parents’ home routines during hospitalization as much as possible and encourage them to continue to have the same expectations regarding good and bad behavior. If particular religious routines are carried out at certain times of the day, the nurse should schedule them in the care plan (Elkins & Cavendish, 2004).
School-age children and adolescents: Encourage both groups to express their feelings regarding spirituality. Ask them, “Do you wish to pray, and what do want to pray about?” Offer age-appropriate complementary therapies such as music, art, videos, and connectedness with peers through cards, letters, and visits. School-age children and adolescents should be encouraged to express their feelings, concerns, and needs regarding spirituality. For adolescents, nurses need to accept their beliefs and wishes even if they are different from their caregiver’s. The nurse needs to facilitate the child’s participation in religious rituals and spiritual practices. Referrals to clergy and other spiritual support may be necessary (Elkins & Cavendish, 2004). In a literature review, reflection and storytelling with adolescents helps find meaning in bereavement therapy and can lead to spiritual growth (Leighton, 2008).
ReferenceS
Burkhart, L. Religious/spiritual influences on health in the family. In: Craft-Rosenberg M., Pehler S., eds. Encyclopedia of family health. Washington, DC: Sage, 2011.
Elkins, M., Cavendish, R. Developing a plan for pediatric spiritual care. Holist Nurs Pract. 2004;18(4):179–184.
Fowler, J.W. Stages of faith: the psychology of human development and quest for meaning. San Francisco: Harper & Row; 1981.
Fowler, J.W. Faith development and pastoral care. Philadelphia: Fortress Press; 1987.
Leighton, S. Bereavement therapy with adolescents: facilitating a process of spiritual growth. J Child Adolesc Psychol Nurs. 2008;21(1):24–34.
Risk for impaired Religiosity
NANDA-I
At risk for an impaired ability to exercise reliance on religious beliefs and/or participate in rituals of a particular faith tradition
Related Factors (r/t)
NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family and Discharge Planning, Rationales, and References
Refer to care plan for Impaired Religiosity.
Relocation Stress Syndrome
NANDA-I
Physiological and/or psychosocial disturbances that result from transfer from one environment to another
Defining Characteristics
Alienation; aloneness; anger; anxiety (e.g., separation); concern over relocation; dependency; depression; fear; frustration; increased illness; increased physical symptoms; increased verbalization of needs; insecurity; loneliness; loss of identity; loss of self-esteem; loss of self-worth; pessimism; sleep disturbance; verbalizes unwillingness to move; withdrawal; worry
NOC (Nursing Outcomes Classification)
Relocation Adaptation, Anxiety Self-Control, Child Adaptation to Hospitalization, Coping, Depression Level, Depression Self-Control, Loneliness Severity, Psychosocial Adjustment: Life Change, Quality of Life
Client Outcomes
Client Will (Specify Time Frame)
• Recognize and know the name of at least one staff member
• Express concern about move when encouraged to do so during individual contacts
• Carry out activities of daily living (ADLs) in usual manner
• Maintain previous mental and physical health status (e.g., nutrition, elimination, sleep, social interaction, physical activity)
NIC (Nursing Interventions Classification)
Anxiety Reduction, Coping Enhancement, Discharge Planning, Hope Instillation, Self-Responsibility Facilitation, Animal-Assisted Therapy, Art Therapy, Music Therapy, Massage, Mood Management
Nursing Interventions and Rationales
• Be aware that relocation to supportive housing may be a positive change. CEB: Relocation stress syndrome is not a universally occurring phenomenon. Relocation was found to be no more stressful than other life changes (Walker, Curry, & Hogstel, 2007).
• Begin relocation planning as early in the decision process as possible. CEB & EBN: Having a well-organized plan for the move with support and advocacy through the process may reduce anxiety (Davis, 2005; Johnson, 2008; Kao, Travis, & Acton, 2004).
• Obtain a history, including the reason for the move, the client’s usual coping mechanisms, history of losses, and family support for the client. A history helps the nurse determine the amount of support needed and appropriate interventions to decrease relocation stress.
• Identify to what extent the client can participate in the relocation decisions and advocate for this participation. EBN: Older adults with poor mental functioning may be less able to be involved in the decisions and more vulnerable to disempowerment by others (Johnson, Radina & Popejoy, 2010).
• Assess client’s readiness to relocate and relocation self-efficacy. CEB: A validated relocation readiness instrument was used successfully with older adults (Rossen, 2007; Rossen & Gruber, 2007).
• Consult an evidence-based practice guide for relocation. EBN: Researchers compiled latest findings to develop a protocol to assist in relocating elders (Hertz et al, 2007).
• Assess family members’ perceptions of clients’ ability to participate in relocation decisions. Particularly in cases of dementia, be alert to care worker’s involvement in making the decision to relocate. They may need support and encouragement through the process. EB: Care workers were found to be highly stressed during the relocation decision-making process and “walking a tightrope” between the older adult’s needs and those of the person’s family members (Hortana, Fahlstrom, & Ahlstrom, 2010).
• Consider the clients’ and families’ cultural and ethnic values as much as possible when choosing roommates, foods, and other aspects of care. CEB & EBN: Nurses need to be aware of the differences in values and practices of different cultures and ensure that they give culturally appropriate care that is respectful of elders and family caregivers’ beliefs about elder care (Caron & Bowers, 2003; Johnson, 2008; Johnson & Tripp-Reimer, 2001a, 2001b).
• Promote clear communication between all participants in the relocation process. CEB: Case studies revealed the importance of using integrated approach to planning with clear communication among practitioners (LeClerc & Wells, 2001).
• Observe the following procedures if the client is being transferred to an extended care facility or assisted living facility:
Facilitate the client’s participation in decisions and choice of placement and arrange a preadmission visit if possible. CEB & EBN: Clients who are more involved in the decision-making process appear to have fewer problems adjusting to the new environment (Newson, 2008b). Research has shown a link between the loss of independence with transfer to a nursing home and depression (Johnson, 2008; Loeher et al, 2004). Decreased relocation control was significantly related to poorer adjustment (Bekhet, Zauszniewski, & Wykle, 2008).
If the client cannot visit the new facility, arrange for a visit or telephone call by a member of the staff to welcome the client and show a videotape or at least provide pictures of the new care facility.
Have a familiar person accompany the client to the new facility. This lessens client and family anxiety, confusion, and dissatisfaction.
Recommend that the caregiver write a journal of thoughts and feelings regarding the relocation of his or her loved one. CEB: Writing has been found to improve physical and emotional health among caregivers of older adults (Dellasega & Haagen, 2004).
Continue to assess caregiver psychological distress during a 6-month period following relocation. Caregivers experience distress because of the responsibility of moving loved one. EB: Caregivers may begin to resolve conflicted feelings during this time and need support (Smit et al, 2011).
• Identify previous routines for ADLs. Try to maintain as much continuity with the previous schedule as possible. CEB: Continuity of routines has been shown to be a crucial factor in positively influencing adjustment to a new environment (Kao, Travis, & Acton, 2004).
• Bring in familiar items from home (e.g., pictures, clocks, afghans).
• Establish the way the client would like to be addressed (Mr., Mrs., Miss, first name, nickname). Calling clients by their desired name shows respect.
• Thoroughly orient the client and the family to the new environment and routines; repeat directions as needed. CEB: The stress of the move may interfere with the client’s ability to remember directions. A progressive introduction and orientation for both the client and the family should be done (Kao, Travis, & Acton, 2004).
• Spend one-to-one time with the client. Allow the client to express feelings and convey acceptance of them; emphasize that the client’s feelings are real and individual and that it is acceptable to be sad or angry about moving. CEB: Expressing feelings can help the client deal with the change and facilitate grief work that accompanies loss of independence (Tracy & DeYoung, 2004).
• Allocate a caring staff member to help the client adjust to the move. Assign the same staff members to the client for care if compatible with client; maintain consistency in the personnel the client interacts with. CEB & EB: Consistency hastens adjustment and increases quality of care (Iwasiw et al, 2003). A caring practitioner can support the client through the journey of adapting to a new environment (Newson, 2008b).
• Ask the client to state one positive aspect of the new living situation each day. Helping the client focus on the positive aspects of the move can help change attitude and reframe the situation in a positive fashion. EBN: Learned resourcefulness through positive thinking significantly affected relocation adjustment (Bekhet, Zauszniewski, & Wykle, 2008).
• Monitor the client’s health status and provide appropriate interventions for problems with social interaction, nutrition, sleep, new onset of infection, or elimination problems. CEB & EBN: Health problems may appear first as declines in ADLs (e.g., bathing, eating, and dressing) (Chen & Wilmoth, 2004). Older adults who moved in the previous year reported increased comorbidity, disability, functional limitation, and worse self-rated health (Hong & Chen, 2009).
• If the client is being transferred within a facility, have staff members from the new unit visit the client before transfer.
• Work with the caregivers and family members helping them deal with stages of “making the best of it,” “making the move,” and “making it better.” EBN: A study demonstrated that relatives of clients entering a nursing home can work in partnership with health care staff to ease the transition for their loved one more effectively (Newson, 2008b).
• If a client is being transferred from the intensive care unit (ICU), have previous staff make occasional visits until the client is comfortable in the new surroundings. Ensure that the family is told relevant information. CEB: Leaving the ICU staff may be the most negative component of transfer (McKinney & Deeny, 2002). A review of the literature in this area demonstrated that information needs were most important to families of clients transferred out of ICU (Mitchell, Courtney, & Coyer, 2003).
• Watch for coping problems (e.g., withdrawal, regression, angry behavior, impaired sleeping, refusal to eat, flat affect) and intervene immediately. EBN: Research has shown a link between the loss of independence with transfer to a nursing home and depression (Johnson, 2008).
• Encourage the client to express grief for the loss of the old situation; explain that it is normal to feel sadness over change and loss. CEB & EB: Older adults in long-term care grieve loss of home, possessions, and independence (Newson, 2008a; Pilkington, 2005).
• Pay special attention to assessing and giving psychosocial care. EB: Although physical care may predicate the relocation, meeting psychosocial care needs must be individualized via careful assessment (Salarvand et al, 2008).
• Encourage the client to participate in care as much as possible and make own decisions when possible (e.g., placement of the bed, choice of roommate, bathing routines). Having choices helps prevent feelings of powerlessness that may lead to depression. CEB: Research showed that residents who viewed the nursing home move negatively after 3 months felt powerless, vulnerable, and isolated (Iwasiw et al, 2003).
• Assess family history and contact information from children relocated to rescue shelters. EB: No unified system exists in the United States to reunite children with their families after natural disaster or terrorist attack, so nursing has a major role to play in locating children’s families and facilitating reunification (Chung & Shannon, 2007).
• Be aware that community relocation may be beneficial for children, and assess community resources of new location. EB: African American children who relocated from an inner city to a suburb benefitted especially from available institutional resources (Keels, 2008).
• Provide support for a child and family who must relocate to be near a transplant center. CEB: Recognizing the unique needs of parents who must relocate for a child’s transplantation procedure supports the delivery of individualized nursing care and the effective allocation of program resources (Stubblefield & Murray, 2002).
• In divorce situations, recommend alternative dispute resolution versus traditional litigated settlement. EBN: This nonadversarial approach may mitigate some of the trauma of divorce experienced by children (Stein & Oler, 2010).
• Encourage child to verbalize concerns in divorce situations when they and/or a parent relocate. CEB: Relocation of a parent in divorce has been linked with children’s financial concerns, hostility toward parents, views of parents as not socially supportive, and poorer self-perceived health (Braver, Ellman, & Fabricius, 2003).
• Assess presence of allergies before and after relocation. EB: Six-year-old children who relocated were found to have significant allergy sensitization over those who did not relocate (Herberth et al, 2007).
• If the client is an adolescent, try to avoid a move in the middle of the school year, find a newcomers’ club for the adolescent to join, and refer for counseling if needed. CEB: Most adolescents who relocate suffer a brief period of loss of companionship and intimacy with close friends (Vernberg, Greenhoot, & Biggs, 2006).
• Assess adolescents’ perceptions of their acceptance by peers. CEB: Poor perceptions of peer acceptance have been related to less initiation of social interactions in new settings (Aikins, Bierman, & Parker, 2005).
• Help parents recognize that relocation stress syndrome may persist for prolonged periods (e.g., 2 years) in adolescents. EB: Adolescents were found to commonly express their ideology of the relocation (Nuttman-Shwartz, Huss & Altman, 2010).
• Monitor the need for transfer and transfer only when necessary. CEB: Older adults often experience loss of function after relocation (Chen & Wilmoth, 2004). EBN: Relocation has been associated with death (Laughlin et al, 2007).
• Implement discharge planning early so that it is not rushed. CEB: Early discharge planning enhanced elders’ information levels and decreased their concerns (Kleinpell, 2004).
• Protect the client from injuries such as falls. CEB: Older adults who fell were more likely to be admitted to a nursing home (Seematter-Bagnoud et al, 2006). Having one fall increases the likelihood of additional falls (Quadri et al, 2005).
• After the transfer, determine the client’s mental status. Document and observe for any new onset of confusion. Confusion can follow relocation because of the overwhelming stress and sensory overload.
• Facilitate visits from companion animals. CEB: A randomized trial of 6 weeks of animal-assisted therapy (dog visits) decreased loneliness among nursing home residents (Banks & Banks, 2002).
• Encourage reminiscence of happy times. EB: Nine weeks of group reminiscence therapy enhanced self-esteem among 24 nursing home residents in a two-group, nonrandomized study (Chao et al, 2006).
• Refer for music therapy. CEB: One case study indicated that music therapy may facilitate a resident’s adjustment to life in a long term-care facility (Kydd, 2001).
• Monitor for neuroleptic prescriptions. CEB: A cohort study showed that 60% of older adults admitted to nursing homes were prescribed these drugs (most commonly haloperidol) and 10% in doses over recommended levels within 100 days of admission (Bronskill et al, 2004).
Client/Family Teaching and Discharge Planning:
• Teach family members and remind direct care staff about relocation stress syndrome. Encourage them to monitor for signs of the syndrome. CEB: Relocation stress syndrome begins to ease at approximately 4 weeks after the move (Hodgson et al, 2004).
• Help significant others learn how to support the client in the move by setting up a schedule of visits, arranging for holidays, bringing familiar items from home, and establishing a system for contact when the client needs support. EBN: Social support of family and friends was significantly related to relocation adjustment (Bekhet, Zauszniewski, & Wykle, 2008).
• Assist family members and the relocating older adult to use webcam technology for interaction to supplement in-person visits. EB: When older adults in a care facility have less than one visitor per week, interaction can be supplemented with technological “visits” (Meyer, Marx, & Ball-Saiter, 2011).
References
Aikins, J.W., Bierman, K.L., Parker, J.G. Navigating the transition to junior high school: the influence of pre-transition friendship and self-system characteristics. Soc Dev. 2005;14:42–60.
Banks, M., Banks, W. The effects of animal-assisted therapy on loneliness in an elderly population in long-term care facilities. J Gerontol A Biol Sci Med Sci. 2002;57A(7):M428–M432.
Bekhet, A.K., Zauszniewski, J.A., Wykle, M.L. Milieu change and relocation adjustment in elders. West J Nurs Res. 2008;30:113–129.
Braver, S.L., Ellman, I.M., Fabricius, W.V. Relocation of children after divorce and children’s best interests: new evidence and legal considerations. J Fam Psychol. 2003;17(2):206–219.
Bronskill, S.E., et al. Neuroleptic drug therapy in older adults newly admitted to nursing homes: incidence, dose, and specialist contact. J Am Geriatr Soc. 2004;52(5):749–755.
Caron, C.D., Bowers, B.J. Deciding whether to continue, share, or relinquish caregiving: caregiver views. Qual Health Res. 2003;13(9):1252–1271.
Chao, S., et al. Effects of group reminiscence therapy on depression, self-esteem and life satisfaction of elderly nursing home residents. J Nurs Res. 2006;14(1):36–45.
Chen, P.C., Wilmoth, J. The effects of residential mobility on ADL and IADL limitations among the very old living in the community. J Gerontol B Soc Sci. 2004;59B(3):S164–S172.
Chung, S., Shannon, M. Reuniting children with their families during disasters: a proposed plan for greater success. Am J Disaster Med. 2007;2(3):113–117.
Davis, S. Meleis’ theory of nursing transitions and relatives’ experiences of nursing home entry. J Adv Nurs. 2005;52:658–671.
Dellasega, C., Haagen, B. A different kind of caregiving support group. J Psychosoc Nurs Ment Health Serv. 2004;42(8):46–55.
Herberth, G., et al. The stress of relocation and neuropeptides: an epidemiological study in children. J Psychosomatic Res. 2007;63:451–452.
Hertz, J.E., et al. Management of relocation in cognitively intact older adults. J Gerontol Nurs. 2007;33(11):12–18.
Hodgson, N., et al. Biobehavioral correlates of relocation in the frail elderly: salivary cortisol, affect, and cognitive function. J Am Geriatr Soc. 2004;52(11):1856–1862.
Hong, S.I., Chen, L.M. Contribution of residential relocation and lifestyle to the structure of health trajectories. J Aging Health. 2009;21:244–265.
Hortana, B., Fahlstrom, G., Ahlstrom, G. Experiences of relocation in dementia care workers. Int J Older People Nurs. 2010;6(2):93–101.
Iwasiw, C., et al. Resident and family perspectives: the first year in a long-term care facility. J Gerontol Nurs. 2003;29(1):45.
Johnson, R.A. Relocation stress syndrome guideline. In: Ackley B., et al, eds. Evidence-based nursing care guidelines: medical-surgical interventions. Philadelphia: Mosby, 2008.
Johnson, R.A., Radina, M., Popejoy, L. Older adults’ participation in nursing home placement decisions. Clin Nurs Res. 2010;19(4):358–375.
Johnson, R.A., Tripp-Reimer, T. Aging, ethnicity and social support: a review—part 1. J Gerontol Nurs. 2001;27(6):15–21.
Johnson, R.A., Tripp-Reimer, T. Relocation among ethnic elders: a review—part 2. J Gerontol Nurs. 2001;27(6):22–27.
Kao, H.F., Travis, S.S., Acton, G.J. Relocation to a long-term care facility: working with patients and families before, during, and after. J Psychos Nurs Ment Health Serv. 2004;42(3):10.
Keels, M. Neighborhood effects examined through the lens of residential mobility programs. Am J Comm Psychol. 2008;42(3-4):235–250.
Kleinpell, R. Randomized trial of an intensive care-based early discharge planning intervention for critically ill elderly patients. Am J Crit Care. 2004;13:335–345.
Kydd, P. Using music therapy to help a client with Alzheimer’s disease adapt to long-term care. Am J Alzheimers Dis Other Demen. 2001;16(2):103.
Laughlin, A., et al. Predictors of mortality following involuntary interinstitutional relocation. J Gerontol Nurs. 2007;33(9):20–26.
LeClerc, M., Wells, D.L. Process evaluation of an integrated model of discharge planning. Can J Nurs Leadersh. 2001;14(2):19–26.
Loeher, K.E., et al. Nursing home transition and depressive symptoms in older medical rehabilitation patients. Clin Gerontol. 2004;27(1-2):59–70.
McKinney, A.A., Deeny, P. Leaving the intensive care unit: a phenomenological study of the patients’ experience. Intens Crit Care Nurs. 2002;18(6):320.
Meyer, D., Marx, T., Ball-Seiter, V. Social isolation and telecommunication in the nursing home: a pilot study. Gerontechnology. 2011;10(1):51–58.
Mitchell, M.L., Courtney, M., Coyer, F. Understanding uncertainty and minimizing families’ anxiety at the time of transfer from intensive care. Nurs Health Sci. 2003;5(3):207.
Newson, P. Relocation to a care home, part one: exploring reactions. Nurs Resident Care. 2008;10(7):321–324.
Newson, P. Relocation to a care home, part two: exploring helping strategies. Nurs Resident Care. 2008;10(8):373–377.
Nuttman-Shwartz, O., Huss, E., Altman, A. The experience of forced relocation as expressed in children’s drawings. Clin Soc Work J. 2010;38:397–407.
Pilkington, F.B. Grieving a loss: the lived experience for elders residing in an institution. Nurs Sci Q. 2005;18(3):233–242.
Quadri, P., et al. Lower limb function as predictor of falls and loss of mobility with social repercussions one year after discharge among elderly inpatients. Aging Clin Exper Res. 2005;17(2):82–89.
Rossen, E.J. Assessing older persons’ readiness to move to independent congregate living. Clin Nurs Spec. 2007;21:292–296.
Rossen, E.J., Gruber, K.J. Development and psychometric testing of the Relocation Self-Efficacy Scale. Nurs Res. 2007;56:244–251.
Salarvand, S., et al. The emotional experiences of elderly people living in nursing homes. Ann Gen Psych. 2008;7(Suppl1):1.
Seematter-Bagnoud, L., et al. Healthcare utilization of elderly persons hospitalized after a noninjurious fall in a Swiss academic medical center. J Am Geriatr Soc. 2006;54(6):891–897.
Smit, D., et al. The long-term effect of group living homes versus regular nursing homes for people with dementia on psychological distress of informal caregivers. Ageing Ment Health. 2011;15(5):557–561.
Stein, S., Oler, C. Emotional and legal considerations in divorce and relocation: a call for alternative dispute resolution. J Individual Psychol. 2010;66(3):290–301.
Stubblefield, C., Murray, R.L. Waiting for lung transplantation: family experiences of relocation. Pediatr Nurs. 2002;28(5):501.
Tracy, J.P., DeYoung, S. Moving to an assisted living facility: exploring the transitional experience of elderly individuals. J Gerontol Nurs. 2004;30(10):26.
Vernberg, E., Greenhoot, A., Biggs, B. Intercommunity relocation and adolescent friendships: who struggles and why? J Consult Clin Psychol. 2006;74(3):511–523.
Walker, C.A., Curry, L.C., Hogstel, M.O. Relocation stress syndrome in older adults transitioning from home to a long-term care facility: myth or reality? J Psychosoc Nurs. 2007;45:35–45.
Risk for Relocation Stress Syndrome
NANDA-I
At risk for physiological and/or psychosocial disturbances following transfer from one environment to another
Risk for ineffective Renal Perfusion
NANDA-I
Risk Factors
Abdominal compartment syndrome; advanced age; bilateral cortical necrosis; burns; cardiac surgery; cardiopulmonary bypass; diabetes mellitus; exposure to toxins; female glomerulonephritis; hyperlipidemia; hypertension; hypovolemia; hypoxemia; hypoxia; infection (e.g., sepsis, localized infection); malignancy; malignant hypertension; metabolic acidosis; multitrauma; polynephritis; renal artery stenosis; renal disease (polycystic kidney); smoking; systemic inflammatory response syndrome; treatment-related side effects (medications); vascular embolism; vasculitis
NIC (Nursing Interventions Classification)
Medication Management, Acid-Base Monitoring, Fluid/Electrolyte Management, Laboratory Data Interpretation, Electrolyte Management.
Nursing Interventions and Rationales
• Measure intake and output on a regular basis. Calculate intake against the output to monitor fluid retention. Oliguria and/or anuria are generally associated with onset of acute renal failure, but up to 60% of clients can be in renal failure with almost normal urine output (nonoliguric acute renal failure) (Workeneh et al, 2012). Urine output normally should be 0.5 mL/kg/hr (Lab Tests Online, 2011a; Workeneh, et al, 2012).
• Monitor for edema. Edema may be present with increased fluid retention due to impaired renal function related to decreased renal perfusion (Kellicker & Schub, 2011; Lab Tests Online, 2011a).
• Assess client for history of risk factors for decreased renal perfusion, which can result in renal insufficiency, renal artery stenosis, and acute renal failure. These factors can be classified into three categories (Workeneh et al, 2012):
Prerenal: The cause of renal damage comes before the kidneys, from decreased renal perfusion. Causes include renal arterial disease, shock states, cardiac and thoracoabdominal surgeries, hypovolemia, heart failure, and decreased cardiac output.
Intrinsic (Intrarenal): There is structural damage to the kidney, something directly toxic to the kidney. Causes include hypertension, diabetes, glomerulonephritis, kidney infection, lupus, Goodpasture syndrome, nephrotoxic drugs, and IV contrast.
Postrenal: The cause of renal disease is a mechanical obstruction of the urinary collecting system. Causes include benign prostatic hypertrophy, cancer of the kidney, obstruction of ureters and the urethra, and strictures. The goal is to recognize what can cause kidney damage and prevent the damage from happening or worsening if possible (Workeneh et al, 2012). Clients who have undergone cardiac and thoracoabdominal surgeries are at risk for acute renal failure due to renal damage possibly related to such factors as hypovolemia, inflammation, ischemia-reperfusion, and other factors (Kellicker & Schub, 2011; Nigwekar & Kandula, 2009; Spinowitz & Rodriguez, 2010).
• Assess for signs of dehydration. Dehydration may cause decreased renal perfusion and lead to renal failure (Kellicker, & Schub, 2011). Refer to care plan for Deficient Fluid Volume.
• Ensure that clients are receiving appropriate amounts of fluids to prevent dehydration. A guideline is 1 to 1.5 mL of fluid per calorie needed, so an average intake would be between 2000 and 3000 mL/day, or at least 8 cups of fluid. EB: The previous general health recommendation of intake of eight 8-oz glasses of water per day is currently found to have no scientific basis, but is used as a recommendation (McCartney, 2011).
• Monitor vital signs carefully. Especially note new onset of hypertension from onset of kidney dysfunction, or decreased mean arterial pressure (MAP). Chronic hypertension can lead to atherosclerosis, the most common cause of renal artery stenosis. Hypotension may lead to poor renal perfusion and acute renal failure (Kellicker & Schub, 2011; Spinowitz & Rodriguez, 2010).
Utilize continuous cardiac monitoring as needed. Monitor for dysrhythmias due to possible increased serum potassium and phosphorus, or low hemoglobin due to poor kidney function (Kellicker & Schub, 2010, 2011).
• Listen to lung sounds, noting presence of adventitious lung sounds. Crackles or rales are signs of fluid overload due to acute or chronic renal failure (Kellicker & Schub, 2011). Refer to care plan for Excess Fluid Volume.
• Monitor for changes in mental status and headache. Changes in mental status from impaired renal function can range from difficulty in concentration, confusion, seizures, and coma as the result of uremic toxins and electrolyte imbalances that can cause encephalopathy (Kellicker & Schub, 2010). Refer to care plan for Acute Confusion.
• Weigh the client daily. Fluid retention related to decreased renal perfusion will cause weight to increase (Kellicker & Schub, 2011).
Monitor peak and trough blood levels carefully in clients receiving nephrotoxic antibiotics, including vancomycin and aminoglycosides. The antibiotics are excreted via the renal system and are nephrotoxic. Peak and trough testing reflects antibiotic levels in the serum; elevated levels can cause renal impairment (Decker & Molitoris, 2009; Drew, 2009).
Ensure that clients having diagnostic testing with contrast are well hydrated with IV saline as ordered before and after the examination. EB: Hydration with crystalloids has been shown to prevent renal insufficiency by diluting the IV contrast. Fluids without salt have been shown to increase acute renal failure (Rudnick & Tumlin, 2009). Refer to care plan Risk for adverse reaction to iodinated Contrast media.
Collect a 24-hour urine specimen for examination as ordered; place on ice to preserve the quality of the urine. Collection of urine over a 24-hour time period allows better assessment of kidney function, rather than a random urine sample (Lab Tests Online, 2011b).
Note the results of diagnostic studies as available: renal ultrasound, radionuclide scanning, abdominal/pelvic CT, MRA, arteriography. These tests are commonly done for diagnosing renal failure (Spinowitz & Rodriguez, 2010).
Perform a complete pain assessment. Assess and document the onset, intensity, character, location, duration, aggravating factors, and relieving factors. Notify the provider of any increase in pain or discomfort or if comfort measures are not effective. EBN: Generalized pain and muscle spasms can be caused by electrolyte imbalances and metabolite accumulation due to renal failure (Kellicker & Schub, 2010).
Monitor laboratory data as ordered or per protocol. Laboratory data could include BUN, serum creatinine, inulin clearance, glomerular filtration rate, serum and urine electrolytes, calcium, phosphate, complete blood count, urine total protein, albumin, alkaline phosphatase, and urinalysis. Report abnormalities to attending provider. EB: The foregoing laboratory studies are used in the diagnosis and monitoring of renal insufficiency and renal failure. Monitoring these labs will help direct therapy (Lab Tests Online, 2011a; White et al, 2011).
Client/Family Teaching and Discharge Planning:
• Provide client teaching related to risk factors for renal insufficiency or acute renal failure, including signs and symptoms of acute renal failure, and lifestyle changes that can improve renal function. Client education is a vital part of nursing care for the client with possible renal disease. Start with the client’s base level of understanding and use that as a foundation for further education (National Kidney Foundation, 2009).
Teach client about any medications prescribed. Medication teaching includes the drug name, its purpose, administration instructions such as taking it with or without food, and any side effects to be aware of. Instruct the client to report any adverse side effects to his/her provider (Kellicker & Schub, 2010).
Stress the importance of stopping smoking. Effects of nicotine include increasing pulse and blood pressure and constricting of blood vessels. Smoking causes vasoconstriction and atherosclerosis that can exacerbate problems with tissue perfusion, including perfusion of the kidneys (Spinowitz & Rodriguez, 2010).
References
Decker, B.S., Molitoris, B.A., Manifestations of and risk factors for aminoglycoside nephrotoxicity, 2009 Retrieved April 9, 2011, from http://www.uptodate.com/online/content/topic.do?topicKey=renlfail/10385&selectedTitle=2~150&source=search_result#
Drew, R.H., Vancomycin dosing and serum concentration monitoring in adults, 2009 Retrieved April 9, 2011, from http://www.uptodate.com/online/content/topic.do?topic.Key=antibiot/7122&selectedTitle=2~150&source=search_result
Kellicker, P.G., Schub, T., Renal failure, acute: an overview, 2010 Nursing reference center. Retrieved April 9, 2011, from http://0-search.ebscohost.com.topcat.switchinc.org/login.aspx?direct=true&db=nrc&AN=5000004704&site=nrc-live
Kellicker, P.G., Schub, T., Renal failure, acute: in older adults, 2011 Nursing reference center. Retrieved April 9, 2011, from http://0-search.ebscohost.com.topcat.switchinc.org/login.aspx?direct=true&db=nrc&AN=5000004691&site=nrc-live
Lab Tests Online, Kidney and urinary tract function, disorders, and diseases, 2011 Retrieved October 11, 2011, from http://labtestsonline.org/understanding/conditions/kidney#
Lab Tests Online, 24-hour urine sample, 2011 Retrieved October 11, 2011, from http://labtestsonline.org/glossary/urine-24
McCartney, M. Waterlogged? BMJ. 2011;343:d4280.
National Kidney Foundation, Chronic kidney disease, 2009 Retrieved October 11, 2011, from http://www.kidney.org/kidneyDisease/ckd/index.cfm
Nigwekar, S., Kandula, P. N-Acetylcysteine in cardiovascular surgery associated renal failure: a meta-analysis. Ann Thorac Surg. 2009;87:139–147.
Rudnick, M.R., Tumlin, J.A., Prevention of radiocontrast media-induced acute kidney injury (acute renal failure), 2009 Retrieved September 29, 2012, from http://www.uptodate.com/contents/prevention-of-contrast-induced-nephropathy
Spinowitz, B., Rodriguez, J., Renal artery stenosis, 2010 Retrieved October 11, 2011, from http://emedicine.medscape.com/article/245023-overview
White, M.T., et al. The significance of a serum creatinine in defining renal function in seriously injured and septic patients. J Trauma. 2011;70(2):421–427.
Workeneh, B.T., et al, Acute renal failure, 2012 Medscape Reference. Retrieved February 11, 2012, from http://emedicine.medscape.com/article/243492-overview
Impaired individual Resilience
NANDA-I
Defining Characteristics
Decreased interest in academic activities; decreased interest in vocational activities; depression; guilt; isolation; lower perceived health status; low self-esteem; renewed elevation of distress; shame; social isolation; using maladaptive coping skills (i.e., drug use, violence, etc.)
Related Factors (r/t)
Demographics that increase chance of maladjustment; gender; inconsistent parenting; large family size; low intelligence; low maternal education; minority status; neighborhood violence; parental mental illness; poor impulse control; poverty; psychological disorders; substance abuse; violence; vulnerability factors which encompass indices that exacerbate the negative effects of the risk condition
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Demonstrate reduced or cessation of drug and alcohol usage
• State effective life events on feelings about self
• Will seek help when necessary
• Verbalize or demonstrate cessation of abuse
• Adapt to unexpected crises or challenges
• Verbalize positive outlook on illness, family, situation, and life
• Use available resources to meet coping needs
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Encourage positive, health-seeking behaviors. EBN: Promoting health will provide a foundation for enhancing the abilities of individuals to cope, find resources, use resources, and evaluate resources for appropriate decision making (Landau, 2010).
• Ensure access to biological psychological and spiritual resources. EBN: Identifying and linking persons to available resources will foster engagement in resources that enhance protective factors and resilience (Landau, 2010).
• Foster communication skills through basic communication skill training. EBN: Individuals who are skilled communicators have fewer problems with family relationships and are able to articulate their own viewpoint (Szanton & Gill, 2010).
• Foster cognitive skills in decision-making. EB: Assist in the identification of problems and situational factors that contribute to problems, offering options for resolution (Burton, Pakenham, & Brown, 2010).
• Assist client in cognitive restructuring of negative thought processes. EBN: Positive thinking has been associated with increased feelings of coherence and resourcefulness when dealing with adversity (Zauszniewski, Bekhet, & Suresky, 2010).
• Facilitate supportive family environments and communication. EBN: Individuals found to be resilient if raised in families with greater levels of parental supervision and consistent expectations, rules, and consequences for problem behaviors, and effective systems for monitoring children and adolescents (Scudder, Sullivan, & Copeland-Linder, 2008).
• Promote engagement in positive social activities. EB: Facilitating involvement with positive peers decreases the potential for involvement in risky behavior (Veselska et al, 2009).
• Assist client to identify strengths, and reinforce these. EBN: Positive self-esteem can be seen as an essential feature of mental health, and also a facilitator of social engagement (Veselska et al, 2009).
• Help the client to identify positive emotions in the midst of adverse situations. EBN: Recovering from negative emotions in the midst of adverse situations and focusing on positive emotions helps to buffer against life adversity (Szanton & Gill, 2010).
• Build on supportive counseling and therapy. EB: Facilitating and mobilizing supportive systems external to individuals and families promote social connectedness, problem solving, resource accessing, and cognitive restructuring (Burton, Pakenham, & Brown, 2010).
• Identify protective factors such as assets and resources to enhance coping. EB: According to the protective factor model of resilience, a protective factor that interacts with a stressor reduces the likelihood of negative outcomes (Vahia et al, 2011).
• Provide positive reinforcement and emotional support during the learning process. EBN: Positive outcomes and adherence to interventions are attained when clients are supported and reinforced for positive behavior or steps in the learning process (Tetlie, Heimsnes, & Almvik, 2009). EB: Clients with positive, supportive educational environments show self-efficacy to attaining goals in the midst of adverse situations (Rigby, Thornton, & Young, 2008).
• Encourage mindfulness, a conscious attention and awareness of self. EB: This will help the client identify strengths, as well as promote relaxation and stress reduction (Coholic, 2011).
• Assist the client to have an optimistic worldview. EBN: Promoting positive thinking and empowering individuals to address adverse situations in a positive frame has been associated with reduced mortality and improved psychological well-being (Szanton & Gill, 2010).
• The preceding interventions may be adapted for the pediatric client.
• Support the seeking of opportunities to improve cognitive abilities, such as tutoring and other resources; the development of positive and supportive relations such as family, community members, or mentors; and the improvement of general health. EBN: These activities help to encourage the promotion of protective factors of adolescent resilience such as positive coping and positive self-esteem (Lau & van Niekerk, 2011).
• Promote the development of positive mentor relationships. EB: Avoidance of risk-taking behavior is linked to attachment with caring adults (Yadav, O’Reilly, & Karim, 2010). EB: Children exposed early to caring adults experienced support, encouragement, guidance, and admonishment (Anthony, Alter, & Jenson, 2009).
References
Anthony, E.K., Alter, C.F., Jenson, J.M. Development of a risk and resilience-based out-of-school time program for children and youths. Soc Work. 2009;54(1):45–55.
Burton, N.W., Pakenham, K.I., Brown, W.J. Feasibility and effectiveness of psychosocial resilience training: a pilot study of the READY program… REsilience and Activity for every DaY. Psychol Health Med. 2010;15(3):266–277.
Coholic, D. Exploring the feasibility and benefits of arts-based mindfulness-based practices with young people in need: aiming to improve aspects of self-awareness and resilience. Child Youth Care Forum. 2011;40(4):303–317.
Landau, J. Communities that care for families: the LINC model for enhancing individual, family, and community resilience. Am J Orthopsychiatry. 2010;80(4):516–524.
Lau, U., van Niekerk, A. Restorying the self: an exploration of young burn survivors’ narratives of resilience. Qual Health Res. 2011;21(9):1165–1181.
Rigby, S.A., Thornton, E.W., Young, C.A. A randomized group intervention trial to enhance mood and self-efficacy in people with multiple sclerosis. Br J Health Psychol. 2008;13(Pt 4):619–631.
Scudder, L., Sullivan, K., Copeland-Linder, N. Adolescent resilience: lessons for primary care. J Nurse Pract. 2008;4(7):535–543.
Szanton, S.L., Gill, J.M. Facilitating resilience using a society-to-cells framework: a theory of nursing essentials applied to research and practice. Adv Nurs Sci. 2010;33(4):329–343.
Tetlie, T., Heimsnes, M.C., Almvik, R. Using exercise to treat patients with severe mental illness: how and why? J Psychosoc Nurs Mental Health Serv. 2009;47(2):32–40.
Vahia, I.V., et al. Psychological protective factors across the lifespan: implications for psychiatry. Psychiatr Clin North Am. 2011;34(1):231–248.
Veselska, Z., et al. Self-esteem and resilience: the connection with risky behavior among adolescents. Addict Behav. 2009;34:287–291.
Yadav, V., O’Reilly, M., Karim, K. Secondary school transition: does mentoring help “at-risk” children? Community Pract. 2010;83(4):24–28.
Zauszniewski, J.A., Bekhet, A.K., Suresky, M.J. Resilience in family members of persons with serious mental illness. Nurs Clin North Am. 2010;45(4):613.
Readiness for enhanced Resilience
NANDA-I
A pattern of positive responses to an adverse situation or crisis that is sufficient for optimizing human potential and can be strengthened
Defining Characteristics
Access to resources; demonstrates positive outlook; effective use of conflict management strategies; enhances personal coping skills; expressed desire to enhance resilience; identifies available resources; identifies support systems; increases positive relationships with others; involvement in activities; makes progress toward goals; presence of a crisis; reports enhanced sense of control; reports self-esteem; safe environment is maintained; sets goals; takes responsibilities for actions; use of effective communication skills
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Listen to and encourage expressions of feelings and beliefs. EBN: Communication assists individuals and families to resolve conflicts and to facilitate potential for growth, to identify inherent strengths, and to problem solve effectively (Black & Lobo, 2008).
• Establish a therapeutic relationship based on trust and respect. EBN: Therapeutic relationships between therapists, nurses, and clients are essential to help individuals establish goals to communicate concerns, and to empower the client (Halldorsdottir, 2008).
• Assist client to identify strengths and reinforce these. EBN: Fostering the use of protective factors will promote the ability of an individual to overcome adverse situations (Black & Lobo, 2008).
• Provide positive reinforcement and emotional support during implementation of care. EB: Providing positive reinforcement and emotional support will enhance a client’s self-esteem, which is a key component of physical and mental health; individuals with higher self-esteem are more likely to be resilient than peers with less self-esteem (Veselska et al, 2008).
Facilitate the development of mentorship opportunities. EB: Mentoring programs have been shown to prevent negative outcomes and to improve adolescents’ transition to young adulthood (Yadav, O’Reilly, & Karim, 2010).
• Determine how family behavior affects the client. EB: The model of resilience is based on the presupposition that individuals and families are connected to each other and their community and have collective strengths, which will help them to compensate for their adversity (Swanson et al, 2011).
• Provide assistance in decision-making. CEB: Decision-making helps individuals to feel more in control of their situation, and nurses can create an atmosphere that helps clients participate in activities that develop life skills (Karapetian-Alvord & Grados, 2005).
• Establish individual/family/community goals. EBN: Individuals, families, and communities that set goals will focus on attaining or achieving positive outcomes despite adversity (Black & Lobo, 2008).
• The preceding interventions may be adapted for the pediatric client.
• Encourage the promotion of protective factors by fostering the seeking of opportunities to improve cognitive abilities such as tutoring and other resources; the development of positive and supportive relations such as family, community members, or mentors; and the improvement of general health. EBN: These factors are associated with adolescent resilience and promote positive coping and positive self-esteem (Ahern, Ark, & Byers, 2008).
• Use teaching strategies that are culturally and age appropriate. EB: Nurses who use currently existing family and community resources will promote a context that allows solutions to emerge in a culturally appropriate and sustainable way (Ungar, 2010).
References
Ahern, N.R., Ark, P., Byers, J. Resilience and coping strategies in adolescents. Paediatr Nurs. 2008;20(10):32–36.
Black, K., Lobo, M. A conceptual review of family resilience. J Family Nurs. 2008;14(1):33–55.
Halldorsdottir, S. The dynamics of the nurse-patient relationship: introduction of a synthesized theory from the patient’s perspective. Scand J Caring Sci. 2008;22(4):643–652.
Karapetian-Alvord, M., Grados, J.J. Enhancing resilience in children: a proactive approach. Prof Psychol Res Pract. 2005;36(3):238–245.
Swanson, J., et al. Predicting early adolescents’ academic achievement, social competence, and physical health from parenting, ego resilience, and engagement coping. J Early Adolesc. 2011;31(4):548–576.
Ungar, M. Families as navigators and negotiators: facilitating culturally and contextually specific expressions of resilience. Family Process. 2010;49(3):421–435.
Veselska, Z., et al. Self-esteem and resilience: the connection with risky behaviors among adolescents. Addict Behav. 2008;34:287–291.
Yadav, V., O’Reilly, M., Karim, K. Secondary school transition: does mentoring help “at-risk” children? Community Pract. 2010;83(4):24–28.
Risk for compromised Resilience
NANDA-I
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
• Determine how family behavior affects client. EBN: The model of resilience is based on the presupposition that individuals and families are connected to each other and their community and have collective strengths, which will help them to compensate for their adversity (West, Usher, & Foster, 2011).
• Help to identify personal rights, responsibilities, and conflicting norms. EB: Maintaining a sense of control and positive perspective about one’s environment helps individuals to positively cope with adversity (Kia-Keating et al, 2011).
• Encourage consideration of values underlying choices and consequences of the choice. EB: Improving social skills, enhancing self-efficacy and considering values behind choices will promote character building and life satisfaction (Kia-Keating et al, 2011).
• Help client to practice conversational and social skills. EB: Social competence and social support have been shown to improve academic achievement for minority, low-income school children; cognitive skills are protective factors to assist individuals with resilience (Elias & Haynes, 2008).
• Assist client to prioritize values. EB: Nurses can help individuals to prioritize positive values, in order to resist engagement in risky behaviors such as smoking, drinking, or violence (Veselska et al, 2009).
• Create an accepting, nonjudgmental atmosphere. EB: Assisting families and individuals to create stable and positive communication skills helps to minimize unreasonable expectations and concentrate on positive outcomes (Anthony, Alter, & Jenson, 2009).
• Help identify self-defeating thoughts. EB: Self-esteem increases the potential for optimism; women with high self-esteem are more likely to adjust to changing life situations and transitions (Lee et al, 2008).
Refer to community resources as appropriate. EB: Attending community resources, such as support groups, helps to disseminate and develop health promotion activities that improve well-being and quality of life (Landau, 2010).
• Help clarify problem areas in interpersonal relationships. EBN: Individuals who were socially connected to their environment, family, and sense of self are able to maintain a supportive mindset and experience a good quality of life despite compromising health conditions, serious diagnosis, and poor prognosis (Denz-Penhey & Murdoch, 2008).
• Identify and enroll high-risk families in follow-up programs. EBN: Families with adequate resources and positive relationships have a better chance of managing stress and restoring balance in the presence of adversity and limited resources (West, Usher, & Foster, 2011).
References
Anthony, E.K., Alter, C.F., Jenson, J.M. Development of a risk and resilience-based out-of-school time program for children and youths. Soc Work. 2009;54(1):45–55.
Denz-Penhey, H., Murdoch, J.C. Personal resiliency: serious diagnosis and prognosis with unexpected quality outcomes. Qual Health Res. 2008;18(3):391–404.
Elias, J., Haynes, N.M. Social competence, social support, and academic achievement, in minority low income urban elementary school children. School Psychol Q. 2008;32(4):474–495.
Kia-Keating, M., et al. Protecting and promoting: an integrative conceptual model for healthy development of adolescents. J Adolesc Health. 2011;48(3):220–228.
Landau, J. Communities that care for families: the LINC model for enhancing individual, family, and community resilience. Am J Orthopsychiatry. 2010;80(4):516–524.
Lee, H., et al. Correlates of resilience in the face of adversity for Korean women immigrants to the US. J Immigr Minor Health. 2008;10:415–422.
Veselska, Z., et al. Self-esteem and resilience: the connection with risky behavior among adolescents. Addict Behav. 2009;34:287–291.
West, C., Usher, K., Foster, K. Family resilience: towards a new model of chronic pain management. Collegian. 2011;18(1):3–10.
Parental Role Conflict
NANDA-I
Defining Characteristics
Anxiety; demonstrated disruption in caretaking routines; fear; reluctant to participate in usual caretaking activities; reports concern about changes in parental role; reports concern about family (e.g., functioning, communication, health); reports concern about perceived loss of control over decisions relating to child; reports feelings of frustration; reports feelings of guilt; reports feeling of inadequacy to provide for child’s needs (e.g., physical, emotional)
Related Factors (r/t)
Change in marital status; home care of a child with special needs; interruptions of family life due to home care regimen (e.g., treatments, caregivers, lack of respite); intimidation with invasive modalities (e.g., intubation); intimidation with restrictive modalities (e.g., isolation); parent-child separation due to chronic illness; specialized care center
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Express feelings and perceptions regarding impacts of illness, disability, and/or hospitalization on parental role
• Participate in hospital and home care as much as able given the availability of resources and support systems
• Exhibit assertiveness and responsibility in active family decision-making regarding care of the child
• Describe and select available resources to support parental management of the child’s and family’s needs
NIC (Nursing Interventions Classification)
Caregiver Support, Counseling, Decision-Making Support, Family Process Maintenance, Family Therapy, Role Enhancement
Nursing Interventions and Rationales
• Assess and support parents’ previous coping behaviors. EBN: Understanding what experience a parents has with coping will enable the nurse support the parents in the current situation (Dashiff et al, 2011).
• Determine parent/family sources of stress, usual methods of coping, and perceptions of illness/condition. Maximize on the strengths identified. EBN: Parents of children with chronic illnesses/diseases find significant improvement to diminish stress and anxiety by utilizing support groups (Bragadottir, 2008). EB: Clinical assessment of parental stress and acknowledging a difference in parenting experiences for mothers and fathers are needed (Davis & Carter, 2008).
• Evaluate the family’s perceived strength of its social support system, including religious beliefs. Encourage the family to use social support. EBN: A strong relationship has been identified between religiosity and positive coping behaviors (Elkin et al, 2007).
• Determine the older childbearing woman’s support systems and expectations for motherhood. EBN: Nurses caring for the older childbearing woman must not forget that they need support and additional education during the peripartum period (Suplee, Dawley, & Bloch, 2007).
• Consider the use of family-centered theory as the conceptual foundation to help guide interventions. EB: The concept of family-centered care stresses the importance of the family in children’s well-being (Bamm & Rosenbaum, 2008).
• Be available to accept and support parents, listening and discussing concerns. EBN: When parents feel accepted, supported, and not blamed by the health care professionals, their ability to reflect and make sense of their own thoughts, feelings, and behaviors seems to have a positive influence on the process of change (Levac et al, 2008).
Maintain parental involvement in shared decision-making with regard to care by using the following steps: Incorporate parents’ information concerning the child’s typical routines, behaviors, fears, likes, and dislikes; provide clear and direct firsthand information concerning the child’s condition and progress; normalize the home/hospital environment as much as possible; collaborate in care by providing choices when possible. EBN: Developing an understanding of decision-making within families before the informed consent process will increase health care knowledge of how to improve the health care experience for all families (Snethen et al, 2006).
• Seek and support parental participation in care. EBN: Environments that facilitate continual parental presence may reduce parental stress related to child’s hospitalization (Smith, Hefley, & Anand, 2007). Promoting family-centered care enhances the overall quality of NICU, resulting in less stress; parents become more informed and confident with the care of the infant (Cooper et al, 2007).
• Provide support for each parent’s primary coping strategies and needs. EB: In this study of parents of ADHD children, mothers reported greater psychological distress and perceived less support from their families (Gau, 2007). EBN: Parent support in a neonatal unit found nurses used more concrete guidance when dealing with fathers, while focusing on the emotional side with mothers (Inberg, Axelin, & Salantera, 2008).
Inform parents of financial resources, respite care, and home support to assist them in maintaining sufficient energy and personal resources to continue caregiving responsibilities. EBN: If health professionals can make parents aware of the financial resources, respite care, and home support that are available to them early on in diagnosis, it may help to alleviate some of the emotional anxieties (Narramore, 2008).
• Encourage the parent to meet his or her own needs for rest, nutrition, and hygiene. Provide parent bed spaces so that the parent may stay with the sick child. EBN: Because of the potential for parental fatigue, it is essential for staff to promote parent self-care (Smith, Hefley, & Anand, 2007).
• Provide family-centered care: allowing parents to touch and talk to the child, assisting in the handling of medical equipment, and offering a comfortable chair, preferably a rocking chair. Provide opportunities and offer praise for successful caregiving. EBN: Establishing an emotionally safe and supportive neonatal unit where a trusting bond exits between parents and nurses may help decrease parents’ stress level and their need to remain vigilant for the safety of their infant (Cleveland, 2008).
• Refer parents to available telephone and/or Internet support groups. EBN: The Internet has changed the way parents can research an illness, and it also empowers them to look for support groups in their area (Sullivan, 2008).
• Involve new mothers’ partners or parents in clinical encounters and invite family members to discuss their expectations and parenting experiences. EBN: Clinicians realize the importance of involving partners and family members in the care of the infant to help the mother caring for the infant (Palmer, 2010).
• Acknowledge racial/ethnic differences at the onset of care. EBN: Acknowledgment of race/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes (Giger & Davidhizar, 2008).
• Assess for the influence of cultural beliefs, norms, and values on the client’s perceptions of the parental role. CEB: What the client considers normal or abnormal when caring for other members of the family is culturally related (Villarruel & Leininger, 2004). EBN: Including the client’s culture in care will have a huge impact on the health of the client and their family (Fornons Fontdevila, 2010).
• Acknowledge that value conflicts arising from acculturation stresses may contribute to increased anxiety and significant conflict with the parental role. EBN: Helping family members retain traditional values may be protective for family functioning. Clinical intervention efforts geared toward preventing and reducing conflict relations among family members appears key to promoting adolescents’ well-being (Pasch et al, 2006). EBN: This study looks at the anxiety of parents with a child with chronic illness that affects their development and parents with a normally developed child. There can be conflict for parents, and this needs to be evaluated and incorporated in nursing care (Parker et al, 2011).
• Promote the female parenting role by providing a treatment environment that is culturally based and woman-centered. EBN: The study shows the importance of including the mother in procedures to benefit maternal-child bonding (Pinto & Barbosa, 2007).
• Support the client’s parenting role in her usual setting via social exchange. EBN: Social exchange is a useful theory in support of the nurse-client relationship and is useful in accomplishing client outcomes (Byrd, 2006).
• The interventions described previously may be adapted for home care use.
• Assess family adjustment prenatally and postpartum; assist new parents to renegotiate parenting roles and responsibilities with co-parenting. Encourage the father to take an active role in infant care with the mother’s support. EB: Fathers’ but not mothers’ withdrawal during co-parenting negotiations was associated with greater disengagement and less warmth during triadic play and with fathers’ feeling that mothers did not respect their parenting (Elliston et al, 2008).
Client/Family Teaching and Discharge Planning:
• Offer family-led education interventions to improve participants’ knowledge about their condition and its treatment and decreasing their information needs. EB: Family-led education interventions may provide families with the information they need to better cope with their relative’s mental illness (Pickett-Schenk et al, 2008).
• For children and their parents involved in bereavement support groups, identify the family’s positive way of coping. EBN: When assessing their group experiences, children and parents most appreciated the support and understanding they received, the freedom to express themselves, a diminished sense of isolation, and the normalization of their emotions (Davies et al, 2007).
Refer parents of children with behavioral problems to parenting programs. EB: Parenting programs reduced disruptive behaviors in children with these improvements being maintained well over time, and further improvements in long-term follow-up (de Graaf et al, 2008).
• Involve parents in formal and/or informal social support situations, such as Internet support groups. EBN: In this study, clients viewed Internet cancer support groups (ICSGs) positively as an excellent source of social support. Participants wanted to use ICSGs for emotional support, information, and interactions; they were able to reach out to other clients with cancer without traveling and without interrupting their busy schedules (Im et al, 2007).
• Teach the client about available community resources (e.g., therapists, ministers, counselors, self-help groups). EB: Supporting caregivers over time and following up to ensure that they access needed services are critical ways to help them cope with care of a loved one (Dobrof et al, 2006).
• Encourage parents with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) to implement custody plans for their children. EBN: In this study, more than half of the children were not in custody of their HIV-infected parent at some time during the study period. Pediatricians and others taking care of children with HIV-infected parents may be able to offer counseling or referrals to assist parents with child custody issues (Cowgill et al, 2007).
References
Bamm, E.L., Rosenbaum, P. Family-centered theory: origins, development, barriers, and supports to implementation in rehabilitation medicine. Arch Phys Med Rehabil. 2008;89(8):1618–1624.
Bragadottir, H. Computer-mediated support group intervention for parents. J Nurs Scholarsh. 2008;40(1):32–38.
Byrd, M.E. Social exchange as a framework for client-nurse interaction during public health nursing maternal-child home visits. Public Health Nurs. 2006;23(3):271–276.
Cleveland, L.M. Parenting in the neonatal intensive care unit. J Obstet Gynecol Neonatal Nurs. 2008;37(6):666–691.
Cooper, L.G., et al. Impact of family-centered care initiative on NICU care, staff and families. J Perinatol. 2007;27(2 Suppl):S32–37.
Cowgill, B.O., et al. Children of HIV-infected parents: custody status in a nationally representative sample. Pediatrics. 2007;120(3):e494–503.
Dashiff, C., et al. Parents’ experiences supporting self-management of middle adolescents with type 1 diabetes mellitus. Pediatr Nurs. 2011;37(6):304–310.
Davies, B., et al. Parents’ and children’s perspectives of a children’s hospice bereavement program. J Palliat Care. 2007;23(1):14–23.
Davis, N., Carter, A. Parenting stress in mothers and fathers of toddlers with autism spectrum disorders: associations with child characteristics. J Autism Dev Disord. 2008;38(7):1278–1291.
de Graaf, I., et al. Effectiveness of the Triple P Positive Parenting Program on behavioral problems in children: a meta-analysis. Behav Modif. 2008;32(5):714–735.
Dobrof, J., et al. Social work series. Caregivers and professionals partnership caregiver resource center: assessing a hospital support program for family caregivers. J Palliat Med. 2006;9(1):196–205.
Elkin, T.D., et al. Religiosity and coping in mothers of children diagnosed with cancer: an exploratory analysis. J Pediatr Oncol Nurs. 2007;24(5):274–278.
Elliston, D., et al. Withdrawal from co-parenting interactions during early infancy. Fam Process. 2008;47(4):481–499.
Fornons, Fontdevila D. Madeleine Leininger: clear and dark transcultural [sic] [Spanish]. Index Enfermería. 2010;19(2-3):172–176.
Gau, S.S. Parental and family factors for attention-deficit hyperactivity disorder in Taiwanese children. Aust N Z J Psychiatry. 2007;41(8):688–696.
Giger, J., Davidhizar, R. Social organization. In: Giger J., Davidhizar R., eds. Transcultural nursing: assessment and intervention. St Louis: Mosby, 2008.
Im, E., et al. Patient’s attitudes toward internet cancer support groups. Oncol Nurs Forum. 2007;34(3):705–712.
Inberg, E., Axelin, A., Salantera, S. Supporting the early interaction between a premature baby and its parents with the help of nursing methods. Hoitotiede. 2008;20(4):192–202.
Levac, A.M., et al. Exploring parent participation in a parent training program for children’s aggression: understanding and illuminating mechanisms of change. J Child Adolesc Psychiatr Nurs. 2008;21(2):78–88.
Narramore, N. Meeting the emotional needs of parents who have a child with complex needs. J Child Young Peoples Nurs. 2008;2(3):103–107.
Palmer, A. It takes a village to mother the new mother: development of a support program to address the mental health needs of women along the continuum of perinatal care. J Obstet Gynecol Neonatal Nurs. 39, 2010. [S33–S33].
Parker, J.A., et al. Religiosity, Spirituality, and marital relationships of parents raising a typically developing child or a child with a disability. J Fam Nurs. 2011;17(1):82–104.
Pasch, L.A., et al. Acculturation, parent-adolescent conflict, and adolescent adjustment in Mexican American families. Fam Process. 2006;45(1):75–86.
Pickett-Schenk, S.A., et al. Improving knowledge about mental illness through family-led education: the journey of hope. Psychiatr Serv. 2008;59(1):49–56.
Pinto, J.P., Barbosa, V.L. Maternal-infant bonding and the mother’s participation during venipuncture: a psychoanalytic perspective. Rev Latino-Am Enfermagem. 2007;15(1):150–155.
Smith, A.B., Hefley, G.C., Anand, K.J.S. Parent bed spaces in the PICU: effect on parental stress. Pediatr Nurs. 2007;33(3):215–221.
Snethen, J.A., et al. Family patterns of decision-making in pediatric clinical trials. Res Nurs Health. 2006;29(3):223–232.
Sullivan, C.F. Cybersupport: empowering asthma caregivers. Pediatr Nurs. 2008;34(3):217–224.
Suplee, P.D., Dawley, K., Bloch, J.R. Tailoring peripartum nursing care for women of advanced maternal age. J Obstet Gynecol Neonatal Nurs. 2007;36(6):616–623.
Villarruel, A., Leininger, M. Culture care of Mexican Americans. In Leininger M., ed.: Transcultural nursing, ed 3, New York: McGraw-Hill, 2004.
Ineffective Role Performance
NANDA-I
Patterns of behavior and self-expression that do not match the environmental context, norms, and expectations
Defining Characteristics
Altered role perceptions; anxiety; change in capacity to resume role; change in other’s perception of role; change in self-perception of role; change in usual patterns of responsibility; deficient knowledge; depression; discrimination; domestic violence; harassment; inadequate adaptation to change; inadequate confidence; inadequate external support for role enactment; inadequate motivation; inadequate opportunities for role enactment; inadequate self-management; inadequate skills; inappropriate developmental expectations; ineffective coping; ineffective role performance; pessimism; powerlessness; role ambivalence; role conflict; role confusion; role denial; role dissatisfaction; role overload; role strain; system conflict; uncertainty
Related Factors (r/t)
Knowledge
Inadequate role model; inadequate role preparation (e.g., role transition, skill rehearsal, validation); lack of education; lack of role model; unrealistic role expectations
NOC (Nursing Outcomes Classification)
Client Outcomes
Client Will (Specify Time Frame)
• Identify realistic perception of role
• Acknowledge problems contributing to inability to carry out usual role
• Accept physical limitations regarding role responsibility and consider ways to change lifestyle to accomplish goals associated with role performance
• Demonstrate knowledge of appropriate behaviors associated with new or changed role
• State knowledge of change in responsibility and new behaviors associated with new responsibility
NIC (Nursing Interventions Classification)
Nursing Interventions and Rationales
Social
• Ask the client direct questions regarding new roles and how the health care system can help him or her continue in roles. EBN: All participants in this study of clients who had had a stroke described the loss of valued roles that they had previously enjoyed. Health care professionals need to recognize and provide psychological support for clients and significant others who are adjusting to these changes (Thompson, 2008).
Allow the client to express feelings regarding the role change; refer for support as needed. EBN: For women with cancer and with children living at home, the demands of being a good mother while undergoing treatments and recovering from illness have been described as a difficult life process. All of the women included in this study expressed the need for professional support to help them endure treatment procedures as well as to sustain their moral responsibility as good mothers (Elmberger et al, 2008).
Refer for support as needed for home caregivers of military families during the deployment of spouses. EBN: Caregivers affiliated with the National Guard and those with more months of deployment reported significantly poorer emotional well-being and more household and relationship hassles. Given the important effect that maternal well-being has on child and family functioning, it is critical to understand how the stress of deployment is affecting mothers in their daily routines, especially during potentially high-stress periods (Lara-Cinisomo et al, 2012).
• Reinforce the client’s strengths and internalized values. CEB: Participants in this study whose intentions were more aligned with their moral norm were more likely to perform healthy behaviors (driving within speed limit, applying universal precautions, exercising, not smoking) (Godin, Conner, & Sheehan, 2005).
• Have the client make a list of strengths that are needed for the new role. Acknowledge which strengths the client has and which strengths need to be developed. Work with the client to set goals for desired role. EBN: Adversity can be an opportunity to focus on strengths and nurture resiliency. Clients should not subscribe to “victim” labels. Resilience should be celebrated (Engel, 2007).
• Support the client’s religious practices. EBN: Clients dealing with role change associated with health crisis may be at risk for spiritual crisis and need an interdisciplinary approach to assist them through this time (Agrimson & Taft, 2009).
Physiological
• Identify ways to compensate for physical disabilities (e.g., have a ramp built to provide access to house, put household objects within the client’s reach from wheelchair) and provide technological assistance when available. CEB: Among people with disability, use of assistive technology was associated with use of fewer hours of personal assistance (Hoenig, Taylor, & Sloan, 2003).
• Refer to the care plans for Readiness for enhanced family Coping, Readiness for enhanced Decision-Making, Impaired Home Maintenance, Impaired Parenting, Risk for Loneliness, Readiness for enhanced community Coping, Readiness for enhanced Self-Care, and Ineffective Sexuality Pattern.
• Assist new parents to adjust to changes in workload associated with childbirth. Mothers may need additional support. EB: In most cases, mothers are the primary caregivers and are, therefore, responsible for the majority of the work related to infant care tasks (Barkin et al, 2010).
Refer teen parents and families to a community-based, multifamily group (MFG) intervention strategy (e.g., Families and Schools Together [FAST] babies). EB: This program showed statistically significant increases in parental self-efficacy for the teenage mothers, improved parent-child bonds, reduced stress and family conflict, and increased social support (McDonald et al, 2009).
Refer to home health agency for home visits when there is an infant who has excessive crying. EBN: Mother-infant relationships can be improved through early home visiting interventions by trained nursing staff (Geçkil, Sahin, & Ege, 2009). The crying baby is the most common presentation in every clinician’s office in the first 16 weeks of life (Kvitvær, Miller, & Newell, 2012).
• Provide parents with coping skills when the role change is associated with a critically and chronically ill child. CEB: Results from mothers who received the Creating Opportunities for Parent Empowerment (COPE) program indicate the need to educate parents regarding their children’s responses as they recover from critical illness and how they can assist their children in coping with the stressful experience (Melnyk, Feinstein, & Fairbanks, 2006). Involving parents of chronically ill children in ongoing discussions about their positions in management may help promote their active and informed participation (Swallow, 2008).
Assist families how to manage day-to-day needs of a child with cerebral palsy (CP). Teach family members to value the small things children do, connect with other families, locate community resources, and understand the short- and long-term needs of the child. CEB: In families of children with CP, strategies for optimizing caregiver physical and psychological health include supports for behavioral management and daily functional activities as well as stress management and self-efficacy techniques. These data support clinical pathways that require biopsychosocial frameworks that are family centered (Raina et al, 2005).
• Consider the use of media-based behavioral treatments for children with behavioral disorders. EBN: Behaviors problems in children are quite common. For straightforward cases, media-based interventions may be enough to make clinically significant changes in a child’s behavior. Media-based therapies appear to have both clinical and economic implications for the treatment of children with behavioral problems (Montgomery, 2005). EB: This paper discussed using media-based strategies for delivery of parenting interventions (Barlow & Calam, 2011).
• Assess older adults’ choices regarding their care and enable them to live as they wish and receive the help they want by carefully listening to their stories. EB: In this study “appreciative inquiry” was used to enable older adults, some with dementia, to tell their stories and describe their choices for care (Seebohm et al, 2010). This study showed an association of perceived control and successful aging (Infurna et al, 2010).
• Provide support and practice for the elderly to use assistive devices. EB: This study indicates that frail elderly people need specifically developed support in the process of becoming assistive device users (Skymne et al, 2012).
• Support the client’s religious beliefs and activities and provide appropriate spiritual support persons. EB: For individuals like most participants in this study (Christians), incorporating spirituality/religion into counseling for anxiety and depression was desirable (Stanley et al, 2011).
• Explore community needs after assessing the client’s strengths. Encourage elders to participate in volunteer programs. EB: Engagement in social and generative activities has benefits for the well-being of older adults; programs such as Experience Corps Baltimore provide a social model for health promotion for older adult volunteers in public schools (Martinez et al, 2006).
• Provide educational materials for older clients who are recovering from hip surgery or fractures to promote early mobility. EBN: The results of this study of older adults suggest that the provision of basic information is essential for successful recovery (early mobility) from hip surgery. Hip fracture clients should be provided with an educational booklet containing basic information on mobility to promote optimal recovery (Murphy et al, 2011).
Refer to appropriate support groups for mental stress related to role changes. EB: Within this sample, caregivers of clients with Parkinson’s disease reported far greater burden from “mental stress” (e.g., worrying about individual’s safety) than from “physical stress” (e.g., lifting individual into bed) (Roland, Jenkins, & Johnson, 2010).
Refer clients to therapeutic recreation programs that use humor. EB: Older adults’ life satisfaction showed significant improvement when participating in “the happiness and humor group” (Mathieu, 2008).
Refer to therapy to improve memory for clients with Alzheimer’s disease. EB: Facing an inevitable decline, persons with early-stage dementia and their care partners found it helpful to talk with one another and with peers in the same circumstances about the disease and its effects in this memory club (Zarit et al, 2004).
• Provide music of choice for clients with Alzheimer’s. EB: The findings in this study suggest that music enhances autobiographical recall for clients with Alzheimer’s by promoting positive emotional memories (El Haj, Postal, & Allain, 2012).
• Provide support for grandparents raising grandchildren. EBN: Grandparent caregivers are at risk for multiple physical, mental, and emotional problems due to the stresses and strains of care provision (Lo & Liu, 2009).
• Assess for the influence of cultural beliefs, norms, values, and expectations on the individual’s role. CEB: The individual’s role may be based on cultural perceptions (Leininger & McFarland, 2002). EBN: It is important to gain an understanding of cultural beliefs and traditional practices relating to the postpartum care of women and their babies (Geçkil, Sahin, & Ege, 2009).
• Assess for conflicts between the caregiver’s cultural role obligations and competing factors such as employment or school. CEB: Mexican immigrant children provide essential help to their families, including translating, interpreting, and caring for siblings (Orellana, 2003). A recent study found that African-American caregivers experienced a wide range of caregiver role strain (Wallace Williams, Dilworth-Anderson, & Goodwin, 2003).
• Negotiate with the client regarding the aspects of their role that can be modified and still honor cultural beliefs. CEB: Give-and-take with the client will lead to culturally congruent care (Leininger & McFarland, 2002).
• Encourage family to use support groups or other service programs to assist with role changes. EB: Black clients have a history of not participating in support groups (Seebohm, Munn-Giddings, & Brewer, 2010).
• Refer new moms to a new mothers’ Internet-based social support network. EBN: Many single, low-income African-American mothers lack social support, experience psychological distress, and encounter difficulties caring for their infants during the transition to parenthood. The New Mothers Network may be an effective social support nursing intervention for improving single, low-income, African American mothers’ psychological health outcome, parenting outcome, and health care utilization outcomes (Hudson et al, 2008).
• The preceding interventions may be adapted for home care use.
Offer a referral to medical social services to assist with assessing the short- and long-term impacts of role change. EB: The discharge planner’s role, especially with the elderly, is important (Preyde, Macaulay, & Dingwall, 2009).
Client/Family Teaching and Discharge Planning:
• Provide educational materials to family members on client behavior management plus caregiver stress-coping management. EB: The capacity for caregivers to rate mild cognitive change in PD may be useful to assist in early screening and intervention approaches (Naismith et al, 2011).
• Help the client identify resources for assistance in caring for a disabled or aging parent (e.g., adult day care, nursing home placement). EBN: There is a need for support when a family member is placed in a nursing home (Wilkes, Jackson, & Vallido, 2008). In this study day care was effective in reducing behavioral and psychological symptoms of dementia clients and in alleviating caregivers’ burden (Mossello et al, 2008).
Refer to appropriate community agencies to learn skills for functioning in the new or changed role (e.g., vocational rehabilitation, parenting classes, hospice, respite care). EB: Program Without Walls (PWW) is a person-centered, community-based approach for state rehabilitation counselors to provide vocational rehabilitation (VR) services to people with traumatic brain injury (TBI). This study demonstrated that the PWW showed promise as a systems change effort to improve VR services for people with TBI (O’Neill et al, 2004).
• Consider pet therapy for college students in a new role, their first semester away from home. EBN: In this study, students away from home for the first time felt that a pet therapy program could temporarily fill the absence of previous support systems and be a catalyst for establishing new social relationships (Adamle, Riley, & Carson, 2009).
References
Adamle, K.N., Riley, T.A., Carlson, T. Evaluating college student interest in pet therapy. J Am Coll Health. 2009;57(5):545–548.
Agrimson, L.B., Taft, L.B. Spiritual crisis: a concept analysis. J Adv Nurs. 2009;65(2):454–461.
Barkin, J.L., et al. Development of the Barkin Index of Maternal Functioning. J Womens Health (Larchmt). 2010;19(12):2239–2246.
Barlow, J., Calam, R. A public health approach to safeguarding in the 21st century. Child Abuse Rev. 2011;20(4):238–255.
El Haj, M., Postal, V., Allain, P. Music enhances autobiographical memory in mild Alzheimer’s disease. Educ Gerontol. 2012;38(1):30–41.
Elmberger, E., et al. Being a mother with cancer: achieving a sense of balance in the transition process. Cancer Nurs. 2008;31(1):58–66.
Engel, B. Eagle soaring: the power of the resilient self. J Psychosoc Nurs Ment Health Serv. 2007;45(2):44–49.
Geçkil, E., Sahin, T., Ege, E. Traditional postpartum practices of women and infants and the factors influencing such practices in South Eastern Turkey. Midwifery. 2009;25(1):62–71.
Godin, G., Conner, M., Sheeran, P. Bridging the intention-behavior “gap”: the role of moral norm. Br J Soc Psychol. 2005;44(Pt 4):497–512.
Hoenig, H., Taylor, D.H., Jr., Sloan, F.A. Does assistive technology substitute for personal assistance among the disabled elderly? Am J Public Health. 2003;93(2):330–337.
Hudson, D.B., et al. New Mothers Network: the development of an Internet-based social support intervention for African American mothers. Iss Comprehen Pediatr Nurs. 2008;31(1):23–35.
Infurna, F.J., et al. The nature and cross-domain correlates of subjective age in the oldest old: Evidence from the OCTO Study. Psychol Aging. 2010;25(2):470–476.
Kvitvær, B.G., Miller, J., Newell, D. Improving our understanding of the colicky infant: a prospective observational study. J Clin Nurs. 2012;21(1-2):63–69.
Lara-Cinisomo, S., et al. A mixed-method approach to understanding the experiences of non-deployed military caregivers. Matern Child Health J. 2012;16(2):374–384.
Leininger, M.M., McFarland, M.R. Transcultural nursing: concepts, theories, research and practices, ed 3. New York: McGraw-Hill; 2002.
Lo, M., Liu, Y.H. Quality of life among older grandparent caregivers: a pilot study. J Adv Nurs. 2009;65(7):1475–1484.
Martinez, I.L., et al. Engaging older adults in high impact volunteering that enhances health: recruitment and retention in The Experience Corps Baltimore. J Urban Health. 2006;83(5):941–953.
Mathieu, S.I. Happiness and Humor Group promotes life satisfaction for the senior center participants. Activities Adapt Aging. 2008;32(2):134–148.
McDonald, L., et al. An evaluation of a groupwork intervention for teenage mothers and their families. Child Fam Soc Work. 2009;14(1):45–57.
Melnyk, B.M., Feinstein, N., Fairbanks, E. Two decades of evidence to support implementation of the COPE program as standard practice with parents of young unexpectedly hospitalized/critically ill children and premature infants. Pediatr Nurs. 2006;32(5):475–481.
Montgomery, M. Media-based behavioral treatments for behavioral disorders in children. Cochrane Database Syst Rev. (1):2005. [CD002206].
Mossello, E., et al. Day care for older dementia patients: favorable effects on behavioral and psychological symptoms and caregiver stress. Int J Geriatr Psychiatry. 2008;23(10):1066–1072.
Murphy, S., et al. An intervention study exploring the effects of providing older adult hip fracture patients with an information booklet in the early postoperative period. J Clin Nurs. 2011;20(23-24):3404–3413.
Naismith, S.L., et al. How well do caregivers detect mild cognitive change in Parkinson’s disease? Mov Disord. 2011;26(1):161–164.
O’Neill, J.H., et al. The Program Without Walls: innovative approach to state agency vocational rehabilitation of persons with traumatic brain injury. Arch Phys Med Rehabil. 2004;85(4 Suppl 2):S68–S72.
Orellana, M.F., Responsibilities of children in Latino immigrant homes. New Dir Youth Dev 2003;(100):25–39.
Preyde, M., Macaulay, C., Dingwall, T. Discharge planning from hospital to home for elderly patients: a meta-analysis. J Evid Based Soc Work. 2009;6(2):198–216.
Raina, P., et al. The health and well-being of caregivers of children with cerebral palsy. Pediatrics. 2005;115(6):e626–e636.
Roland, K.P., Jenkins, M.E., Johnson, A.M. An exploration of the burden experienced by spousal caregivers of individuals with Parkinson’s disease. Mov Disord 30. 2010;25(2):189–193.
Seebohm, P., et al. Using Appreciative Inquiry to promote choice for older people and their carers. Ment Health Soc Inclusion. 2010;14(4):13–21.
Seebohm, P., Munn-Giddings, C., Brewer, P. What’s in a name? A discussion paper on the labels and location of self-organising community groups, with particular reference to mental health and Black groups. Ment Health Soc Inclusion. 2010;14(3):23–29.
Skymne, C., et al. Getting used to assistive devices: ambivalent experiences by frail elderly persons. Scand K Occup Ther. 2012;19(2):194–203.
Stanley, M.A., et al. Older adults’ preferences for religion/spirituality in treatment for anxiety and depression. Aging Ment Health. 2011;15(3):334–343.
Swallow, V., An exploration of mothers’ and fathers’ views of their identities in chronic-kidney-disease management: parents as students? J Clin Nurs 2008;(23):3177–3186.
Thompson, H.S. A review of the psychosocial consequences of stroke and their impact on spousal relationships. Br J Neurosci Nurs. 2008;4(4):177–184.
Wallace Williams, S., Dilworth-Anderson, P., Goodwin, P.Y. Caregiver role strain: the contribution of multiple roles and available resources in African-American women. Aging Ment Health. 2003;7(2):103–112.
Wilkes, L., Jackson, D., Vallido, T. Placing a relative into a nursing home: family members’ experiences after the move. A review of the literature. Geriaction. 2008;26(1):24–29.
Zarit, S.H., et al. Memory Club: a group intervention for people with early-stage dementia and their care partners. Gerontologist. 2004;44(2):262–269.