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• Encourage child to increase the amount of walking done per day; if child is willing, ask him or her to wear a pedometer to measure number of steps. EB: A study demonstrated that the recommended number of steps per day to have a healthy body composition for the 6- to 12-year-old is 10,000 to 13,000 steps for a girl and 12,000 to 16,000 steps for a boy. Evidence shows that adolescents steadily decrease steps/day until approximately 8000 to 9000 steps/day are observed in 18-year-olds (Tudor-Locke et al, 2011).

• Recommend the child decrease television viewing, watching movies, and playing video games. Ask parents to limit television to 1 to 2 hours per day maximum. EB: A study demonstrated that watching television was not connected to an increased BMI, but watching television advertising, including food advertisements, was associated with obesity in children (Zimmerman & Bell, 2010).

• Use valid and reliable criterion-referenced standards for fitness testing (e.g., Senior Fitness Test) designed for older adults that can predict the level of capacity associated with maintaining physical independence into later years of life (e.g., get up and go test). Interventions can subsequently be designed to target weak areas and therefore help reduce the risk of immobility and dependence (Rikli & Jones, 2012).

• Recommend the client begin a regular exercise program, even if generally active. Walking is an effective exercise in the elderly (Resnick, 2009). EB: A meta-analysis to determine the effect sizes of exercise on physical function, activities of daily living (ADLs), and quality of life of frail older adults found exercise beneficial in increasing gait speed and improving balance and ADL performance (Chou, Hwang, & Wu, 2012).

 Refer the client to physical therapy for resistance exercise training as able involving all major muscle groups. EB: A Cochrane review found that progressive resistance-strength training for physical disability in older clients resulted in increased strength and positive improvements in some limitations (Liu & Latham, 2009).

• Use the Function-Focused Care (FFC) rehabilitative philosophy of care with older adults in residential nursing facilities to prevent avoidable functional decline. EBN: The primary goals of FFC are to alter how direct care workers (DCWs) provide care to residents to maintain and improve time spent in physical activity and improve or maintain function. Residents receiving FFC had less functional decline, and a greater percentage who were not ambulating returned to ambulatory status for short functional distances (Resnick et al, 2011).

• Recommend the client begin a tai chi practice. EB: Tai chi resulted in increased function and quality of life for clients with osteoarthritis of the knee (Lee et al, 2009). Another study demonstrated that clients performing tai chi had better balance (Wong et al, 2009).

• If client is scheduled for an elective surgery that will result in admission into the intensive care unit (ICU) and immobility, or recovery from a joint replacement, for example, initiate a prehabilitation program that includes a warm-up followed by aerobic, strength, flexibility, neuromotor, and functional task work. EBN: A study of FFC with hospitalized older adults found physical functional declines in both study groups, but less decline was associated with the group receiving FFC. The role of the gerontological rehabilitation nurse is essential throughout the hospital stay and during transitional care (Boltz et al, 2011).

• The preceding interventions may be adapted for home care use.

 Assess home environment for factors that create barriers to mobility. Refer to physical and occupational therapy services if needed to assist the client in restructuring home environment and daily living patterns. Use home safety assessment tool to prevent falls and improve mobility and function such as the tool found at http://agingresearch.buffalo.edu/hssat/index.htm. EBN: Assess person-environment fit (P-E fit) using a reliable and valid instrument such as the Housing Enabler (http://www.enabler.nu/) to evaluate the impact of the relationship between the person and his or her environment and subsequently how P-E fit affects physical activity and function (Pomeroy et al, 2011).

• Work with the client using theory-based interventions (e.g., social cognitive theoretical components such as self-efficacy; transtheoretical model). EBN: In a behavioral validity study that examined the evidence for physical activity stage of change across nine studies, physical activity stage of change was found to be behaviorally valid, evidenced by self-reported exercise, physical activity, pedometers, sedentary behaviors, and physical functioning. Physical fitness and weight indicators were not related to physical activity stage of change (Hellsten et al, 2008).

• Recommend the client use the Exercise Assessment and Screening for You (EASY) tool to help determine appropriate exercise for the older adult client. This tool is available online at http://www.easyforyou.info (Resnick, 2009). EBN: A study found an association between higher EASY cumulative scores with decreased days limited from usual activity and decreased unhealthy physical health outcomes (Smith et al, 2011).

• Consider using motivational interviewing techniques when working with both children and adult clients to increase their activity. EBN: A study found that use of motivational interviewing along with evidence-based nutritional guidelines and exercise prescriptions was effective in decreasing the BMI and size of waistline in children (Tripp et al, 2011). EB: Another study found that clients with low back pain who received motivational interviewing were more compliant with performing ordered exercises and had improved physical function (Vong et al, 2011). EB: A study that evaluated compliance of diabetic clients with prescribed exercise found that use of motivational interviewing resulted in increased oxygenation and improved muscle strength and lipid profile (Lohmann, Siersma, & Olivarius, 2010).

• Assess and evaluate a child’s level of self-care and adjust strategies as needed. EBN: Parents of children with asthma needed to be able to detect, interpret, and monitor meaningful symptoms to adequately control them. When barriers exist for enhanced self-care activities, treatment in an emergency room is the consequence even if the parents are well intended (Cox & Taylor, 2005). Interventions that incorporate cognitive-behavioral skills building may be a key factor for promoting physical activity as well as fruit and vegetable intake in adolescents (Kelly et al, 2012). Nurses must adopt, recognize, and assess a child’s readiness to learn diabetes care and bear responsibility for it. A balance between diabetes care requirements and a child’s maturity must be assessed (Kelo, Martikainen, & Eriksson, 2011).

• Assist families to engage in and maintain social support networks. EBN: Children with cancer are competent agents, performing many practices in the area of universal and developmental self-care requisites (Moore & Beckwitt, 2004). EBN: Improved caregiver-child relationship suggests participation in an Internet support group as soon as possible for primary caregivers of a child with special health care needs (Baum, 2004). EB: Social support was effective in promoting psychological well-being in this study of AIDS orphans (Okawa et al, 2011).

• Encourage activities that support or enhance spiritual care. CEB: Spiritual growth is significantly related to an adolescent’s initiation and responsibility for self-care (Callaghan, 2005). EBN: Children’s care will be enhanced when children are given the opportunity to express their spiritual and relational concerns (Kamper, Van Cleve, & Savedra, 2010).

• Identify cultural beliefs, values, lifestyle practices, and problem-solving strategies when assessing the client’s level of self-care. For common minor illnesses, many people use self-care with medicines, vitamins, herbs, exercise, or foods that they believe have healing powers. Many self-care practices are handed down from generation to generation (Andrews & Boyle, 2003). EB: The importance of cultural and religious traditions was identified for self-management in this study of Thai Buddhist people with type 2 diabetes (Lundberg & Thrakul, 2012).

• Enhance cultural knowledge by seeking out information regarding different cultural or ethnic groups. The transcultural nurse must be guided by acquired knowledge in the assessment, diagnosis, planning, implementation, and evaluation of the client’s needs, based on culturally relevant information (Giger & Davidhizar, 2004). Cultural self-assessment is the first step in providing culturally competent care (Andrews & Boyle, 2003).

• Recognize the impact of culture on self-care behaviors. EB: Self-care practices play a critical role in the management of chronic illness, yet little is known about the self-care practices of chronically ill African Americans or how lack of access to health care affects health. Self-care practices are culturally based (Becker, Gates, & Newsom, 2004). EB: In noting the factors that influence self-efficacy in HlV risk reduction among Asian and Pacific Islanders, variations in reported self-efficacy for female respondents are explained by acculturation and comfort in asking medical practitioners about HIV/AIDS (Takahashi et al, 2006). EBN: Cultural beliefs play an important role in attitudes toward diabetes among people of South Asian origin. Understanding these beliefs assists in promoting self-management (Osman & Curzio, 2012).

• Provide culturally competent care. Cultural competence is a continuous process of awareness, knowledge, skill, interaction, and sensitivity that is demonstrated among those who render care and the services they provide (Giger & Davidhizar, 2004). EB: In this study of Latino women, a culturally based adaptation of a program to promote physical activity significantly improved both self-reported readiness to engage in physical activity and vigorous physical activity (Coleman et al, 2012).

• Support independent self-care activities. EB: In a study of self-care practices of migrant and seasonal farm workers, a majority of self-care practices were judged as appropriate for the health problem (Anthony et al, 2010).

• The nursing interventions described previously may also be used in home care settings.

• Support the new sense of self that may occur with complex health problems. EBN: In this review it was shown that a new sense of self permeated clients’ attempts to deal with the day-to-day management (self-care) of the health problems associated with heart disease (Welstand, Carson, & Rutherford, 2009).

• Assist individuals and families to prevent exacerbations of chronic illness symptoms so rehospitalization is not necessary. EBN: In a database analysis of OASIS, of 145,191 people with heart failure in home care, 15% experienced rehospitalization (Madigan, 2008).

• In complex chronic illnesses such as heart failure, help individuals and families to accept continued functional disabilities and work toward maintenance of optimum functional status, considering the reality of illness status. EBN: In the database analysis of 145,191 cases in OASIS of people with heart failure at home, there was only a small improvement in functional status over an average of 44 home care visits (Madigan, 2008).

• Use educational guidelines for stroke survivors. EBN: Evidence-based educational guidelines were developed and tested in 1150 home visits (Ostwald et al, 2008).

• Ensure appropriate interdisciplinary communication to support client safety. EBN: Health care providers can best facilitate self-management by coordinating self-management activities, by recognizing that different self-management processes vary in importance to clients over time, and by having ongoing communication with clients and providers to create appropriate self-management plans (Schulman-Green et al, 2012).

• Enhance individual and family coping with chronic illnesses. EBN: In a study of 113 adults 3 weeks after hospital discharge, many difficulties with coping were identified (Fitzgerald Miller, Placentine, & Weiss, 2008).

• Implement a community care management program. EBN: For 12 years, a community care management program in Colorado with a focus on improving the quality of life and facilitating the self-efficacy of elderly chronically ill individuals and families has successively achieved its goals and demonstrated an 81% reduction in financial losses during 2006 for emergency and inpatient services (Luzinski et al, 2008). EB: This study demonstrated a significant increase in self-management goal setting in clients with diabetes after the addition of community health workers to the team (Hargraves et al, 2012)

• Teach clients how to regularly assess their level of self-care.

• Instruct clients that a variety of interventions may be needed to enhance self-care.

• Help clients to understand that enhanced self-care is an achievable goal.

• Empower clients.

• Teach clients about the decision-making process and self-care activities needed to manage their illness state and promote well-being.

• Continuously stress that all self-care activities must be regularly evaluated to ensure that enhanced levels of self-care can be maintained.

• QSEN (Patient-Centered): Assess older clients’ preferences for bathing and their responses to bathing difficulties. EB: Bathing for older clients is important, personal, varied in preferences for assistance and aids, and results in modification of the bathing routine for disabilities (Ahluwalia et al, 2010).

• Design the bathing environment for comfort: Visual. Reduce clutter and use partitions to hide equipment storage. Laminate and put artwork or decorative objects in bather’s view, or place cue cards to bathing process (wall, ceiling, shower). Stand or sit in bather’s position to experience what he/she sees. Decrease glare from tiles, white walls, and artificial lights. Use contrasting colors and soft but adequate lighting on a dimming switch for adjustment. Bathing rooms are sterile, institutional, and frightening spaces filled with unfamiliar equipment—tubs with sides that open up and look like they might swallow you, or gurneys with arms that look like construction cranes. Overhead lights can be bright and shine into the bather’s eyes. Glare can cause visual discomfort, especially in clients with visual changes or cataracts (Calkins, 2005).

• Arrange the bathing environment to promote sensory comfort: Auditory. Reduce noise of voices and water. Do not allow traffic into bathing room. Add fabric to absorb sound (three to four times the width of the opening for sound-absorbing folds). Play soft music. Noise discomfort can result from high-echo tiled walls, loud voices, and running water. Traffic can compromise privacy. Absorb negative sounds, and add positive sounds through music (Calkins, 2005).

• Design the bathing environment for comfort: Tactile. Use heat lamps or radiant heat panels to keep the room warm. Use powder-coated grab bars in decorative colors with nonslip grip. Provide a soft rug to stand on. Ensure that flooring is not slippery (a high coefficient of friction, ideally above 80, is desired and obtained through flooring coatings). If the caregiver is warm to the point of sweating, room temperature is about right for an older person being bathed. Appealing, stable grab bars are needed for balance. Preventing the floor from becoming slippery from water is essential (Calkins, 2005).

• When bathing a cognitively impaired client, have all bathing items ready for the client’s needs before bathing begins. Injury often occurs when a cognitively impaired client is left alone while forgotten items are obtained.

• Train caregivers bathing clients with dementia to avoid behaviors that can trigger assault: confrontational communication, invalidation of the resident’s feelings, failure to prepare a resident for a task, initiating shower spray or touch during bathing without verbal prompts beforehand, washing the hair/face, speaking disrespectfully to the client, and hurrying the pace of the bath. CEB: During bathing, assaults (defensive behavior) by nursing home residents with dementia are frequently triggered by caregiver actions that startle, frighten, hurt, or upset the resident. This might happen when caregivers spray water on a resident without warning or when they touch a resident’s feet, axilla, or perineum, possibly due to the startle reflex (Somboontanont et al, 2004).

• QSEN (Safety): Test water temperature before use with a thermometer to prevent scalding. With assistive bathing, temperature changes are not felt by the person controlling the temperature (Fathers, 2004).

• Use a prepackaged bath for older adults to prevent skin dryness. CEB: A prepackaged bath regimen proved much more effective than the traditional soap and water method in preventing flaking and scaling and improving overall skin condition (Joanna Briggs Institute, 2007).

• Focus on the abilities of the client with dementia to obtain client’s participation in bathing. EBN: The use of an abilities-focused approach increases the ability of people with dementia to participate in their care (Sidani, Streiner, & LeClerc, 2012).

• Encourage client to perform bathing tasks and allow adequate time for performance of tasks. EBN: Use of a restorative care approach that engages clients in physical activity and in performing ADLs, rather than doing the tasks for them, maintains their independence and avoids further disability (Resnick et al, 2009).

• QSEN (Patient-Centered): Ask the client for input on bathing habits and cultural bathing preferences. EB: Bathing is a personal experience with variability in attitudes, preferences, and adaptations to disability to be considered when developing interventions for bathing (Ahluwalia et al, 2010).

• If in a typical bathing setting for the client, assess the client’s ability to bathe self via direct observation using physical performance tests for ADLs. Observation of bathing performed in an atypical bathing setting may result in false data.

 Request referrals for occupational therapy for clients who have experienced a stroke. CEB: After stroke, those receiving occupational therapy preserve more function and therefore are more likely to be independent in performing activities of daily living (Legg, Drummond, & Langhorne, 2006).

 Based on functional assessment and rehabilitation capacity, refer for home health aide services to assist with bathing and hygiene. Support by home health aides preserves the energy of the client and provides respite for caregivers.

• QSEN (Safety): Turn down temperature of water heater and recommend use of a water temperature‒sensing shower valve to prevent scalding. Older or disabled people have slower reflexes to respond to hot water and may be unable to regulate water temperature, yet they may be left unattended. Water at 130° F produces a first-degree burn in 20 seconds; at 135° to 140° F, exposure for 5 to 6 seconds causes third-degree burns (Fathers, 2004).

• Teach the client and family a client-centered bathing routine that includes a frequency schedule, privacy, skin inspection, no-rinse products, skin lubricants, chill prevention, bathing options such as sponge or towel, and safety methods such as checking water temperature. CEB: Families and caregivers who are taught methods to meet the client’s bathing needs can increase the client’s satisfaction with the bathing experience in a quicker, easier, and less anxious manner (Rader et al, 2006).

• QSEN (Patient-Centered): Determine the client’s personal preferences for dressing and grooming by using the Self-maintenance Habits and Preferences in Elderly (SHAPE) questionnaire and focus on items most preferred by the client. CEB: The SHAPE questionnaire measures a client’s customary daily routines to plan for personal preferences in dressing and grooming during self-care (Cohen-Mansfield & Jensen, 2007a).

• Assist residents with goal setting and their highest ADL performance level rather than providing the care for them. Participation in self-care improves functioning, self-esteem, and family and caregiver satisfaction while reducing functional decline and disability (Resnick et al, 2008).

• Ensure clients can see clothing to select what to wear by administering annual vision testing and having client wear clean glasses. Older adults’ visual problems or dirty glasses impair clothing and color choices (Nazarko, 2008).

• Consider individualized smart machine-based prompting for dressing task completion for dementia clients. EB: Dressing independence can be increased with machine-based prompting devices (Bewernitz et al, 2009).

• Use clocks, routines, and explanations for the client with dementia to convey that it is morning and time to get ready for the day’s activities by dressing. Clients with dementia often do not know the reason for needing to dress (Nazarko, 2008).

• Lay clothing out (with label in back facing up) in the order that it will be put on by the client, either one item at a time or in piles with first item on top of pile (dress bottom half first: underwear, then slacks, socks; then dress top half: bra, shirt, sweater). Clients with dementia may have difficulty recognizing what a clothing item is and in what order and how to put it on (Nazarko, 2008).

 Request referral for physical therapy. EB: Physical rehabilitation for long-term care residents reduces disability to promote independence in ADLs (Forster et al, 2009).

• Consider use of assistive technology versus personal care assistance for Native Americans. EB: Older American Indians use more assistive technology for assistance with ADLs than the general same-age population (Goins, et al, 2010).

 Involve the client in planning of informal care and provide access to health professionals and financial support for the care. CEB: To maintain self-care in dressing/grooming, it is important to have continuity between past and present practices, so staff needs to be aware of and be sensitive to an individual’s preferences and prior routines (Cohen-Mansfield & Jensen, 2007b).

• Teach caregivers to see dressing as an opportunity to promote independence and a better quality of life for clients who are able, and as a time to increase social talk for others. CEB: The dressing process should not be viewed as a race for efficiency but rather a time to retain independence in dressing skills, and for social interaction that reduces isolation and loneliness by allowing residents to experience social contact and exercise (Cohen-Mansfield et al, 2006).

 Consider referral for use of assistive technology to prompt independent learning of self-care skills such as dressing. CEB: Those with disabilities may be taught to dress independently with use of preferred stimuli—prompting assistive technology (visual—lights, auditory—music/verbal, vibratory) delivered on failure to respond to a dressing task (Lancioni et al, 2007).

• QSEN (Patient-Centered): Obtain and incorporate the client’s view of the agency’s food selection and presentation into agency food service. CEB: The FoodEx-LTC, a 28-item questionnaire that measures food and food service satisfaction, can be used to promote the resident’s enjoyment and increased nutritional intake of food (Crogan & Evans, 2006).

• QSEN (Patient-Centered): Assess the ability of clients with dementia to self-feed, and supervise the feeding of those with moderate dependency by providing verbal or physical assistance. EBN: Although low-dependency clients can self-feed, and those with severe dependency are fed, food intake among residents with moderate dependence is often ignored (Lin, Watson, & Wu, 2010).

• QSEN (Patient-Centered): Use the Edinburgh Feeding Evaluation in Dementia scale to assess eating and feeding problems in clients with late-stage dementia. Identifying client behaviors during feeding allows development of an effective plan for feeding (Stockdell & Amella, 2008).

• QSEN (Patient-Centered): Consider “comfort-only feeding” for clients with dementia using careful hand feeding. Comfort-only feeding reframes the focus to feeding a client as long as it is not distressing and is comfort oriented by being the least invasive and most satisfying means for nutrition with careful hand feeding (Palecek et al, 2010).

• QSEN (Patient-Centered): Allow a resident an average of 42 minutes of staff time per meal and 13 minutes per between-meal snack to improve oral intake. EB: When these time frames are provided for staff to assist with meals and snacks, improved oral intake and weight gain in residents at risk for weight loss results (Simmons et al, 2008).

• QSEN (Patient-Centered): Promote family visits at mealtimes for clients with dementia to encourage eating. EBN: Family encouragement may reactivate eating skills to delay onset of eating difficulty in clients with dementia (Lin, Watson, & Wu, 2010).

• QSEN (Patient-Centered): Play familiar music during meals for clients with Alzheimer’s disease. EB: Familiar background music played during meals increased caloric intake in adults with Alzheimer’s by 20% (Thomas & Smith, 2009).

• Use aromatherapy with the smell of baking bread for those with dementia. EB: The smell of baking bread increased intake of food and self-feeding in those with dementia (Cleary et al, 2008).

 QSEN (Safety): Provide targeted feeding with trained feeding assistants to older clients with dysphagia who are on texture modified diets. EB: Clients with dysphagia who received individualized feeding assistance increased their nutritional intake (Wright, Cotter, & Hickson, 2008).

 QSEN (Safety): Provide CNAs with information on techniques to feed clients with dementia. EB: This study indicated that nursing assistants stated they needed more training to address feeding difficulty in residents with dementia (Chang & Roberts, 2008).

• QSEN (Patient-Centered): Provide individualized dining experience for those with dementia through consistent routine, such as same seat placed for limited distractions, preferred dining companions, presentation of one food item at a time, use of a Plexiglas barrier around place setting to prevent reaching. EB: Environmental manipulations can be successful in reducing barriers and improving eating and swallowing in those with dementia (Cleary, 2009).

• QSEN (Patient-Centered): For those who use chopsticks with impaired hand function, suggest adapted chopsticks. CEB: Adapted chopsticks can be inexpensive and easily constructed, for those with lower cervical spinal cord injury and residual gross grasp (Chang et al, 2006).

• Avoid wasting food with those of Chinese culture. EB: Wasted food in the Chinese culture is seen as an offense to God, as God provides food (Chang & Roberts, 2008).

 QSEN (Teamwork and Collaboration): Request referral for occupational therapy to provide client and caregiver support with feeding. EB: Support, provision of adequate information, and sharing responsibility assisted caregivers in adapting to their care giving roles with relatives who have eating difficulties (Johansson & Johansson, 2009).

• QSEN (Patient-Centered): Provide clients with nutritional food tasting samples and recipes. EB: Sampling new foods can promote a continued interest in food and enjoyment of eating (Manilla, Keller, & Hedley, 2010).

• QSEN (Patient-Centered): Educate family members about the benefits of hand feeding as long as possible, and the risks versus benefits of tube feeding for clients with dementia. EB: Studies show that PEG tube feeding does not decrease aspiration or prolong survival for those with dementia and may cause complications (Sampson, Candy, & Jones, 2009).

• QSEN (Patient-Centered): For residents who show occasional/frequent bowel/bladder incontinence on the Minimum Data Set, plan an individualized toileting schedule. EBN: Assessment makes individualized planning possible and accurate and reduces incontinence (Morgan et al, 2008).

• QSEN (Patient-Centered): Assess the client’s functional ability to manipulate clothing for toileting, and if necessary modify clothing with Velcro fasteners, elastic waists, drop-front underwear, or slacks. For clients with impaired dexterity or weakness, wearing dresses, athletic bottoms, or skirts with a stretch waistband makes it easier to use the toilet than wearing clothing with buttons and zippers (Cohen, 2008).

• QSEN (Safety): Avoid the use of indwelling catheters if possible, and use condom catheters in men without dementia. EB: Using a condom catheter rather than an indwelling urinary catheter can reduce infection or death, especially in men without dementia (Saint, Kaufman, & Rodgers, 2006).

• QSEN (Patient-Centered): Provide clients with dementia access to regular exercise. EBN: ADL performance improved with a regular exercise program of stretching, walking and leg weight bearing (Chang et al, 2011).

• QSEN (Patient-Centered): Remove barriers to toileting, support client’s cultural beliefs, and preserve dignity. CEB: The physical and sociocultural environments in long-term care require older clients to overcome greater physical and cognitive challenges to maintain their participation, autonomy, and dignity in toileting than if they were at home (Sacco-Peterson & Borell, 2004).

 QSEN (Teamwork and Collaboration): Request referral for home physical therapy when client is recovering from illness or surgery. EB: Toileting, transferring, and ambulation/locomotion function were improved in clients with orthopedic diagnoses after home physical therapy (Kim, Gordes, & Alon, 2010).

• QSEN (Patient-Centered): To design a bathroom for an older adult, consider adaptable bath fixtures/furniture and safety needs. EB: Poor bathroom design requires use of assistive adaptive devices, reduces quality of life, and contributes to safety concerns such as falls (Burton, Reed, & Chamberlain, 2011).

• Teach client and family to wash hands after toileting. EB: Interventions that promote handwashing can reduce diarrhea episodes by about one third in children and adults (Ejemot et al, 2008).

• Have the family install a toilet seat of a contrasting color. CEB: Visualization of the toilet is aided by installing a toilet seat of a contrasting color (Gerdner, Buckwalter, & Reed, 2002).

• Consider the development of a Healthy Kids Mentoring Program that has four components: (1) relationship building, (2) self-esteem enhancement, (3) goal setting, and (4) academic assistance (tutoring). Mentors met with students twice each week for 1 hour each session on school grounds. During each meeting, mentors devoted time to each program component. CEB: The Healthy Kids Mentoring Program results indicated that students’ overall self-esteem, school connectedness, peer connectedness, and family connectedness were significantly higher at posttest than at pretest (Kelly et al, 2011).

 Assess and provide referrals to mental health professionals for clients with unresolved worries associated with terrorism. EBN: The National Association of Pediatric Nurse Practitioners (NAPNAP) initiated a national campaign titled Keep Your Children/Yourself Safe and Secure (KySS). Interventions are urgently needed to assist children and teens in coping with the multitude of stressors related to growing up in today’s society (Melnyk et al, 2002).

• Provide an alternative school-based program for pregnant and parenting teenagers. CEB: The girls who attended this program developed close relationships with their peers and teachers. Many of them experienced academic success for the first time and reported that pregnancy and impending motherhood motivated them to do better in school (Spear, 2002).

• Encourage clients to consider a web-based support program when they are in a caregiving situation. EBN: Technology, such as telephone networks and the Internet, helps in supporting isolated and lonely older people. It helps to alleviate anxiety and increase self-confidence (Cattan, Kime, & Bagnall, 2011).

• Encourage activity and a strength, mobility, balance, and endurance training program. EB: Participants in this physical activity program demonstrated increased self-worth (Huberty et al, 2008).

• Provide opportunities for clients to engage in life skills (themed collections of everyday items based upon general activities that residents may have previously carried out). Life-skill centers offer residents a means of purposeful occupation in tasks that they have undertaken for decades using skills that are inherent and not forgotten (Swann, 2009).

• Provide information on advance directives. EBN: In this study elders stated that the optimal time for advance care planning was during periods of wellness. They are ready and eager to discuss advance planning (Malcomson & Bisbee, 2009).

• Carefully assess each client and allow families to participate in providing care that is acceptable based on the client’s cultural beliefs. EBN: An understanding of client suffering that is shaped by traditional cultural values helps nurses communicate empathy in a culturally sensitive manner to facilitate the therapeutic relationship and clinical outcomes (Hsiao et al, 2006). Spiritual well-being, the perception of health and wholeness, can boost self-confidence and self-esteem. These behaviors were demonstrated by the elderly Amish in this study. This information will assist nurses in serving this population (Sharpnack et al, 2011).

• Provide education and support for health-promoting behaviors and self-concept for clients from diverse cultures. EB: This study of older adults in Korea demonstrated significant changes in self-esteem, depression, and social network after completing the Older Paraprofessional Training Program (Lee & Choi, 2012).

• Refer to the care plans Disturbed Body Image, Readiness for enhanced Coping, Chronic low Self-Esteem, and Readiness for enhanced Spiritual Well-Being.

• Previously discussed interventions may be used in the home care setting.

 Provide bully prevention programs and include information on cyberbullying. EBN: This study supported those students who were victims or offenders of bullying and demonstrated low self-esteem. Technology, computers, and cell phones are means for bullying so prevention programs need to address these issues (Patchin & Hinduja, 2010).

• Support client in identifying and adapting to functional changes. EBN: The ability to adjust goals was shown to be critical as a way of preventing the development of depressive symptoms following negative life events in older adults (Bailly et al, 2012).

• Use reminiscence therapy to identify patterns of strength and accomplishment. Identifying strengths and accomplishments counteracts pervasive negativity.

• Encourage participation in peer group activities. CEB: Withdrawal and social isolation are detrimental to feelings of self-worth (Stuart-Shor et al, 2003).

• Encourage activities in which a client can support/help others. EB: The findings of this study reveal that late-life productive engagement is widespread, with the majority of older individuals involved in multiple forms of activity concurrently. Non‒market-based activities such as caregiving, informal assistance, and volunteering are most prevalent (Hinterlong, 2008).

• Assess for the influence of cultural beliefs, norms, and values on the client’s sense of self-esteem. CEB: How the client values self may be based on cultural perceptions (Giger & Davidhizar, 2008). Asian American youths demonstrate lower levels of self-esteem than their non-Asian peers (Rhee, Chang, & Rhee, 2003).

• Assess socioeconomic issues. EB: Racial minorities and those who are economically disadvantaged are up to three times more likely to experience disability than are whites and those who are not economically disadvantaged, respectively (Louie & Ward, 2011).

• Assess for drug and alcohol use in individuals with low self-esteem. EB: Among Mexican American female adolescents, poor self-confidence predicts higher levels of alcohol use (Swaim & Wayman, 2004).

• Validate the client’s feelings regarding ethnic or racial identity. CEB: Individuals with strong ethnic affiliation have higher levels of self-esteem than others (Greig, 2003).

• Assess a client’s immediate support system/family for relationship patterns and content of communication. EBN: Family strength assessments help the nurse to incorporate family strengths into nursing care, especially in times of crisis (Sittner, Hudson, & DeFrain, 2007).

• Encourage the client’s family to provide support and feedback regarding client value or worth. EBN: There are significant relationships between adolescents’ practice of healthy behaviors, self-efficacy of those behaviors, self-care abilities, and their support systems, among other factors (Callaghan, 2006).

 Refer to medical social services to assist the family in pattern changes that could benefit the client. The best nursing plan may be to access specialty services for the client and family.

 If a client is involved in counseling or self-help groups, monitor and encourage attendance. Help the client identify the value of group participation after each group encounter. Discussion about group participation clarifies and reinforces group feedback and support.

 If a client is taking prescribed psychotropic medications, assess for knowledge of medication side effects and reasons for taking medication. Teach as necessary. EBN: Education that helps clients understand their illness, particular symptoms, and how medications help them may be beneficial in promoting adherence (Wu et al, 2008).

 Assess medications for effectiveness and side effects and monitor client for compliance. EBN: A positive working relationship with the health care provider may result in improved adherence to taking medications to assist with problems (Wu et al, 2008).

 Refer to community agencies for psychotherapeutic counseling. EB: Family-led programs are an effective resource for families with mental illness (Pickett-Schenk et al, 2008). Cognitive-behavioral therapy (CBT) has a unique role in realizing and overcoming negative core beliefs and feelings of low self-worth (Johnson, 2012).

 Refer to psychoeducational groups on stress reduction and coping skills. EB: CBT, psychoeducation for anxiety disorder appears to be helpful for a number of clients and largely acceptable for most clients who attend (Houghton & Saxon, 2007).

 Refer to self-help support groups specific to needs. EB: Participation in mutual mental health groups leads to improved psychological and social functioning (Pistrang, Barker, & Humphreys, 2008).

• See care plan for Chronic low Self-Esteem.

• Establish an emergency plan and contract with the client for its use. Having an emergency plan is reassuring to the client. Establishing a contract validates the worth of the client and provides a caring link between the client and society.

• Access supplies that support a client’s success at independent living.

• See care plan for Chronic low Self-Esteem.

• Assess the person’s support system (family, friends, and community) and involve them if desired. CEB: Family strength assessments help the nurse to incorporate family strengths into nursing care, especially in times of crisis (Sittner, Hudson, & DeFrain, 2007).

• Educate client and family regarding the grief process. Understanding this process normalizes responses of sadness, anger, guilt, and helplessness. Recommended therapeutic communication skills such as eye contact, use of therapeutic touch, and active listening can be enhanced by an understanding of the grief process (Wright & Hogan, 2008).

• Teach client and family that the crisis is temporary. Knowing that the crisis is temporary provides a sense of hope for the future.

 Refer to appropriate community resources or crisis intervention centers.

 Refer to resources for handicap and/or disability services.

• Refer to illness-specific consumer support groups. Mutual help support groups aid the client with chronic illness to cope with their illness (Chen, Pai, & Li, 2008).

• See care plan for Chronic low Self-Esteem.