• State accurate self-appraisal

• Demonstrate the ability to self-validate

• Demonstrate the ability to make decisions independent of primary peer group

• Express effects of media on self-appraisal

• Express influence of substances on self-esteem

• Identify strengths and healthy coping skills

• State life events and change as influencing self-esteem

Pediatric:

Geriatric:

Home Care:

Client/Family Teaching and Discharge Planning:

Client Will (Specify Time Frame)

• Establish a collaborative partnership with the client for purposes of meeting health-related goals. EB: A telephone link to asthma care, designed to partner with children and parents regarding interventions, had a significant decrease on readmissions and emergency department visits for childhood asthma (Coughey et al, 2010). EB: A community-based partnership was established with youth groups and college student researchers that focused on understanding and promoting policy directed toward decreasing violence and racial conflict at high schools in San Bernardino, California (Peterson, Dolan, & Hanft, 2010).

• Listen to the person’s story about his or her illness self-management. EBN: In a study of successful health management in women with chronic illness, partnership health care providers contributed to positive outcomes. These partnerships were enhanced by careful listening on the part of the health care provider (Cudney, Weinert, & Kinion, 2011).

• Explore the meaning of the person’s illness experience and identify uncertainties and needs through open-ended questions. EB: Understanding the meaning of pain as perceived by clients experiencing chronic pain contributed to their ability to self-manage and develop coping strategies (Roditi & Robinson, 2011).

• Help the client enhance self-efficacy or confidence in his or her own ability to manage the illness. EBN: In a study of women with advanced breast cancer, self-management was related to developing skills and becoming empowered (Schulman-Green et al, 2011).

• Involve family members in knowledge development, planning for self-management, and shared decision-making. EBN: Semistructured interviews of clients suffering from COPD and their family members illuminated themes associated with lack of knowledge about health promotion and community resources, which were identified as barriers to self-health management (Caress, Luker, & Chalmers, 2010).

• Review factors of the Health Belief Model (individual perceptions of seriousness and susceptibility, demographic and other modifying factors, and perceived benefits and barriers) with the client. EBN: Studies using the Health Belief Model support the view that individual perceptions and a variety of modifying factors affect the likelihood of changing health behaviors (Pender, Murdaugh, & Parsons, 2011).

• Use various formats to provide information about the therapeutic regimen, including group education, brochures, videotapes, written instructions, computer-based programs, and telephone contact. EB: The implementation of a telephone-based resource for management of childhood asthma correlated with decreased hospitalizations and emergency room visits (Coughey et al, 2011).

• Help the client identify and modify barriers to effective self-management. EB: A study of 46 overweight and obese adults participating in a behavioral weight loss program concluded that weight bias may interfere with overweight and obese treatment-seeking adults’ ability to achieve optimal health (Carels et al, 2009).

• Help the client self-manage his or her own health through teaching about strategies for changing habits such as overeating, sedentary lifestyle, and smoking. EB: Self-management education helps achieve positive health outcomes such as reductions in systolic blood pressure as well as fewer asthmatic attacks (Govil et al, 2009).

• Develop a contract with the client to maintain motivation for changes in behavior. EBN: The nursing intervention of client contracting provides a concrete means of keeping track of actions to meet health-related goals (Bulechek, Butcher, & Dochterman, 2008).

• Use focus groups to evaluate the implementation of self-management programs. EBN: The use of focus groups to foster decision-making in mental health consumers contributed to greater self-health management (Mahone et al, 2011).

• Refer to the care plan Ineffective family Therapeutic Regimen Management.

Client Will (Specify Time Frame)

• Acknowledge the expertise that the client and family bring to self-health management. EBN: The use of focus groups to acknowledge expertise and foster decision-making in mental health consumers contributed to greater self-health management (Mahone et al, 2011).

• Review factors that contribute to the likelihood of health promotion and health protection. Use Pender’s Health Promotion Model and Becker’s Health Belief Model to identify contributing factors (Pender, Murdaugh, & Parsons, 2010). EBN: Many studies using both the Health Promotion Model and the Health Belief Model support the view that individual perceptions and a variety of modifying factors affect the likelihood of improving health behaviors (Pender, Murdaugh, & Parsons, 2010).

• Further develop and reinforce contributing factors that might change with ongoing management of the therapeutic regimen (e.g., knowledge, self-efficacy, self-esteem, and perceived benefits). EBN: Developing partnerships with community-based programs, health providers, and family fosters ongoing relationships toward enhanced self-health promotion (Coughey et al, 2010; Peterson, Dolan, & Hanft, 2010).

• Support all efforts to self-manage therapeutic regimens. EBN: Ongoing support and assistance from health care providers is needed to identify and enhance factors that contribute to the likelihood of taking action for health promotion and health protection (Pender, Murdaugh, & Parsons, 2010).

• Review the client’s strengths in the management of the therapeutic regimen. EBN: People who are doing the work of managing a therapeutic regimen may not even realize they are doing it well (Lubkin & Larsen, 2009).

• Collaborate with the client to identify strategies to maintain strengths and develop additional strengths as indicated. EB: In a study of clients with chronic pain, identification of strengths regarding pain management, rather than direct elimination of the pain, helped empowered and enabled clients to self-manage their pain (Roditi & Robinson, 2011).

• Identify contributing factors that may need to be improved now or in the future. EBN: Health promotion and protection are complex behaviors that are difficult to implement on a daily basis. Based on the complexity of achieving these behaviors and the perceived barriers to implementation (e.g., time, energy, money), usually one or more contributing factors would benefit from increased focus and attention (Pender, Murdaugh, & Parsons, 2010).

• Provide knowledge as needed related to the pathophysiology of the disease or illness, prescribed activities, prescribed medications, and nutrition. EBN: Knowledge is a factor that contributes significantly to the client’s taking action for health promotion and protection (Pender, Murdaugh, & Parsons, 2010). Remember, however, that knowledge is necessary but not sufficient to explain why people perform or do not perform actions for health promotion and protection (Pender, Murdaugh, & Parsons, 2010).

• Support positive health-promotion and health-protection behaviors. EBN: Ongoing support may be needed to maintain these behaviors (Pender, Murdaugh, & Parsons, 2010).

• Help the client maintain existing support and seek additional supports as needed. EBN: In numerous research studies, social support was shown to be a factor contributing to ongoing maintenance of positive health behaviors (Pender, Murdaugh, & Parsons, 2010). This study demonstrates that peer support programs are a promising approach to enhance social and emotional support, assist clients in daily management and living with diabetes, and promote linkages to clinical care (Funnell, 2010; Heisler, 2010). EB: Clients using Internet discussion boards reported that knowledge and expertise accumulated over many years of self-management was instrumental to participants’ self-reported ability to evaluate information posted and make decisions on its possible use (Armstrong & Powell, 2009).

Community Teaching

Client Will (Specify Time Frame)

• Assess client’s ability to regulate his or her own emotional states. EB: Clients who self-injure are more likely to be lower in emotional self-regulation than persons who do not self-injure. They may use self-harm to increase or decrease feelings (Muehlenkamp et al, 2010).

• Assess client’s degree of self-criticism and use of effective coping skills. Self-harm serves as a coping mechanism for clients. EB: Persecutory self-criticism and limited coping skills are linked with self-harm (Gilbert et al, 2010; Hall & Place, 2010).

• Assess client’s perception of powerlessness. Refer to the care plan for Powerlessness. EB: Testing of the Cry of Pain model of suicidality and repeat self-harm, which identifies defeat, no escape potential, and no rescue as contributory, supports use of this model to understand self-harm (Rasmussen et al, 2010).

• Assessment data from the client and family members may have to be gathered at different times; allowing a family member or trusted friend with whom the client is comfortable to be present during the assessment may be helpful. EB: Self-mutilation sometimes occurs if clients have been victims of abuse or other types of adverse family experiences (Duke et al, 2010; Murray, MacDonald, & Fox, 2008). Clients or family members may be more willing to disclose the presence of abuse if greater privacy is afforded them, or if presence of a trusted family member or friend helps clients to respond more comfortably to the interview situation.

• Assess for risk factors of self-mutilation, including categories of psychiatric disorders (particularly borderline personality disorder, psychosis, eating disorders, autism); psychological precursors (e.g., low tolerance for stress, impulsivity, perfectionism); psychosocial dysfunction (e.g., presence of sexual abuse, divorce or alcoholism in the family, manipulative behavior to gain nurturing, chaotic interpersonal relationships); coping difficulties (e.g., inability to plan solutions or see long-term consequences of behavior); personal history (e.g., childhood illness or surgery, past self-injurious behavior); and peer influences (e.g., friends who mutilate, isolation from peers). These risk factors have been associated with self-mutilation. EB: Self-mutilation has been associated with multiple psychiatric disorders (Murray, MacDonald, & Fox, 2008; Wright et al, 2009). Additional Relevant Research: (Barnes, Eisenberg, & Resnick, 2010; Holm & Severinsson, 2010; Joyce et al, 2010; Peebles, Wilson, & Lock, 2011).

• Assess for co-occurring disorders that require response, specifically childhood abuse, substance abuse, and suicide attempts. Implement reporting or referral as indicated. CEB: A relationship has been found between self-mutilating behavior, substance abuse, childhood abuse, alexithymia, and suicide attempts (Evren & Evren, 2005). EB: (Duke et al, 2010; Murray, MacDonald, & Fox, 2008).

• Assess family dynamics and the need for family therapy and community supports. EBN: Treatment must focus on increasing support for the client, improving family communication, and enhancing the client’s sense of control over the environment. Parents need information to be able to help their children (Rissanen, Kylma, & Laukkanen, 2009).

• Assess for the presence of medical disorders, mental retardation, medication effects, or disorders such as autism that may include self-mutilation. Initiate referral for evaluation and treatment as appropriate. Lesch-Nyhan syndrome is a rare genetic disorder, which is characterized by compulsive self-mutilation (Zilli & Hasselmo, 2008).

• Be alert to other risk factors of self-mutilation in clients with psychosis, including acute intoxication, dramatic changes in body appearance, preoccupation with religion and sexuality, and anticipated or perceived object loss. Many psychiatric disorders have shown a connection with self-mutilation. EB: Command hallucinations occurring with schizophrenia or brief psychotic episodes may direct the client to hurt himself or herself, or others (Barrowcliff & Haddock, 2010).

• Monitor the client’s behavior closely, using engagement and support as elements of safety checks while avoiding intrusive overstimulation. Offer activities that will serve as a distraction. When lack of control exists, client safety is an important issue and close observation is essential. EBN: Clients were found to feel overstimulated by intrusive close observation, resulting in agitation (Ray, Perkins, & Meijer, 2011).

• Assess the client’s ability to enter into a no-suicide or no-self-harm contract. Secure a written or verbal contract from the client to notify staff when experiencing the desire to self-mutilate. A contract places some of the responsibility for safety with the client. CEB: Some clients are not appropriate for a contract: those under the influence of drugs or alcohol or unwilling to abstain from substance use, and those who are isolated or alone without assistance to keep the environment safe (Hauenstein, 2002). The lack of willingness to self-disclose has been shown to discriminate the serious suicide attempter from the client with suicidal ideation or the mild attempter (Apter et al, 2001). EBN: Note: Although contracting is a common practice in psychiatric care settings, research has suggested that self-harm is not prevented by contracts. Thorough, ongoing assessment of suicide risk is necessary, whether or not the client has entered into a no-self-harm contract. Contracts may not be appropriate in community settings (McMyler & Pryjmachuk, 2008).

• Establish trust, listen to client, convey safety, and assist in developing positive goals for the future. EBN & EB: Clients reported that nurses were helpful when they took charge of unsafe situations, performed bodily interventions (e.g., holding hand), conveyed safety, and respected the autonomy of the client (Schoppmann et al, 2007). Clients expressed the need to be listened to and emphasized that staff relationships were important to help cope with strong emotions and daily stresses, to cope with urges to self-injure, and to provide a view of a positive future (Fish & Duperouzel, 2008).

 Refer to mental health counseling. Multiple therapeutic modalities are available for treatment. CEB: Solution-focused brief therapy has been shown to be an effective treatment option for reducing repetitive self-harm (Wiseman, 2003).

• When working with self-mutilative clients who have borderline personality disorder, develop an effective therapeutic relationship by avoiding labeling, seeking to understand the meaning of the self-mutilation, and advocating for adequate opportunities for care. EBN & EB: Clients expressed a need to be respected and treated as an individual, with 1:1 time and awareness of moods. Mutual confidence and trust should be developed before working on issues in depth (Fish & Duperouzel, 2008).

• Maintain a consistent relational distance from the client with borderline personality disorder who self-mutilates: neither too close nor too distant, neither rewarding unacceptable behavior nor trying to control or avoid the client. Clients with borderline personality disorder fear that they will be overwhelmed by or abandoned in relationships, and their reactions can change rapidly. The most effective posture is one that is consistent, allowing clients to react as they need to, while assuring clients that they will not be abandoned.

• Inform the client of expectations for appropriate behavior and consequences within the unit. Emphasize that the client must comply with the rules. Give positive reinforcement for compliance and minimize attention paid to disruptive behavior while setting limits. Clients benefit from clear guidance regarding behavioral expectations and consequences, providing much-needed structure. It is important to reinforce appropriate behavior to encourage repetition. EB: Treatment should involve assisting the client to learn healthier affective regulation skills (Gilbert et al, 2010; Hall & Place, 2010).

• Clients need to learn to recognize distress as it occurs and express it verbally rather than as a physical action against the self. EB: Treatment should involve assisting the client to learn healthier affective regulation skills (Gilbert et al, 2010; Hall & Place, 2010).

• Assist the client to identify the motives/reasons for self-mutilation that have been perceived as positive. Self-harm serves as a defense mechanism. EB: Persecutory self-criticism and limited coping skills are linked with self-harm (Gilbert et al, 2010; Hall & Place, 2010).

• Help the client identify cues that precede impulsive behavior. CEB: Dialectical behavior therapy (DBT) was found to be superior to non-DBT treatment in reducing self-mutilation among individuals with borderline personality disorder (Verheul et al, 2003). CEB: The DBT technique of behavioral chain analysis was found to reduce self-harm behaviors by processing events that precipitate self-mutilation (Alper & Peterson, 2001).

• Assist clients to identify ways to soothe themselves and generate hopefulness when faced with painful emotions. CEB: Women with a history of childhood abuse may not have developed the internal ability to comfort themselves, or self-soothe, resulting in neurobiological disruptions that lead to self-harm as a means of relieving pain (Gallop, 2002). Generating hopefulness is an important self-comforting intervention (Weber, 2002).

• Reinforce alternative ways of dealing with depression and anxiety, such as exercise, engaging in unit activities, or talking about feelings. Goal direction enhances self-efficacy, an important antecedent of empowerment (Self-injury.net, 2011).

• Keep the environment safe; remove all harmful objects from the area. Use of unbreakable glass is recommended for the client at risk for self-injury. Client safety is a nursing priority. Unbreakable glass would eliminate this type of injury.

• Anticipate trigger situations and intervene to assist the client in applying alternatives to self-mutilation. EB: When triggers occur, client stress level may obstruct ability to apply recent learning. Cognitive strategies can be useful to correct irrational beliefs that are part of the trigger (Claes & Vandereycken, 2007).

• If self-mutilation does occur, use a calm, nonpunitive approach. Whenever possible, assist the client to assume responsibility for consequences (e.g., dress self-inflicted wound). Refer to the care plan for Self-Mutilation. This approach does not promote inappropriate attention-getting behavior, may decrease repetition of behavior, and reinforces self-responsibility and self-care management.

• If the client is unable to control self-mutilation behavior, provide interactive supervision, not isolation. Isolation and deprivation take away individuals’ coping abilities and place them at risk for self-harm. Implementing seclusion for clients who have injured themselves in the past may actually facilitate self-injury. Clients are extraordinarily resourceful at identifying environmental objects with which to self-mutilate.

• Involve the client in planning his or her care and problem solving, and emphasize that the client makes choices. CEB: Individuals who self-mutilate were found to use more problem avoidance behaviors and to perceive that they had less control over problem-solving options (Haines & Williams, 2003). EB: Clients reported negative responses to having no input into their treatment plan (Fish & Duperouzel, 2008; Rasmussen et al, 2010).

 Use group therapy to exchange information about methods of coping with loneliness, self-destructive impulses, and interpersonal relationships as well as housing, employment, and health care system issues directly and do not interpret. The group’s focus should be here and now, supportive and psychoeducative, while providing a comforting level of structure.

• Internet groups may provide additional support. CEB: In a study of one web support group (n = 102), many participants reported a decrease in frequency and severity of self-mutilation (Murray & Fox, 2006).

 Refer to protective services if evidence of abuse exists. It is the nurse’s legal responsibility to report abuse.

• Refer to the care plan for Self-Mutilation.

Client Will (Specify Time Frame)

 Provide medical treatment for injuries. Use careful aseptic technique when caring for wounds. Care for the wounds in a matter-of-fact manner. A significant impediment to wound healing is infection. A matter-of-fact approach avoids positive reinforcement and may decrease repetition of behavior.

• Assess for risk of suicide or other self-damaging behaviors. EB: Although self-mutilation should not be viewed simply as failed suicide, it is a significant indicator of suicide risk. Clients may also engage in other self-damaging behaviors, including substance abuse or eating disorders (Buykx et al, 2010). Refer to the care plan for Risk for Suicide.

• Assess for signs of psychiatric disorders, including depression, anxiety, borderline personality disorder, dissociative disorders, eating disorders, and impulsivity. EB: Self-mutilation has been associated with multiple psychiatric disorders (Ahren-Moonga et al, 2008). (Additional research: Holm & Severinsson, 2010; Peebles, Wilson, & Lock, 2011).

• Assess for presence of hallucinations. Ask specific questions such as, “Do you hear voices that other people do not hear? Are they telling you to hurt yourself?” EB: Command hallucinations occurring with schizophrenia or brief psychotic episodes may direct the client to hurt himself or herself, or others (Barrowcliff & Haddock, 2010).

 Assure the client that he or she will be safe during hallucinations, and engage supportively. Provide referrals for medication. EBN: Hallucinations can be very frightening; therefore clients need reassurance that they will be kept safe, while avoiding a sense of intrusion that overstimulates clients (Ray, Perkins, & Meijer, 2011).

 Assess for the presence of medical disorders, mental retardation, medication effects, or disorders such as autism that may include self-mutilation. Initiate referral for evaluation and treatment as appropriate. CEB: Self-mutilation has been reported as a presenting or ongoing symptom with medical disorders, such as the genetic Lesch-Nyhan syndrome (Robey et al, 2003). (Additional relevant research: Singh et al, 2006.)

 Case finding and referral by school nurses for psychological or psychiatric treatment is critical. CEB: Treatment includes starting therapy and medications, increasing coping skills, facilitating decision making, encouraging positive relationships, and fostering self-esteem (McDonald, 2006).

• Monitor the client’s behavior closely, using engagement and support as elements of safety checks while avoiding intrusive overstimulation. When lack of control exists, client safety is an important issue, and close observation is essential. EBN: Clients were found to feel overstimulated by intrusive close observation, resulting in agitation (Ray, Perkins, & Meijer, 2011).

• Establish trust, listen to client, convey safety, and assist in developing positive goals for the future. CEB & EB: Clients reported that nurses were helpful when they took charge of unsafe situations, performed bodily interventions (e.g., holding hand), conveyed safety, and respected the autonomy of the client (Schoppmann et al, 2007). Clients expressed the need to be listened to and emphasized that staff relationships were important to help cope with strong emotions and daily stresses; to cope with urges to self-injure; and to provide a view of a positive future (Fish & Duperouzel, 2008).

• Recognize that self-mutilation may serve a variety of functions for the person. Self-mutilation is identified by clients as a way to help with the regulation of dysphoric affect and cope with dissociative states (Hall & Place, 2010).

• Assess the client’s ability to enter into a no-suicide or no-self-harm contract. Secure a written or verbal contract from the client to notify staff when experiencing the desire to self-mutilate. Discussing feelings of self-harm with a trusted person provides relief for the client. A contract places some of the responsibility for safety with the client. CEB: Some clients are not appropriate for a contract: those under the influence of drugs or alcohol or unwilling to abstain from substance use, and those who are isolated or alone without assistance to keep the environment safe (Hauenstein, 2002). EBN: Note: Although contracting is a common practice in psychiatric care settings, research has suggested that self-harm is not prevented by contracts. Thorough, ongoing assessment of suicide risk is necessary, whether or not the client has entered into a no-self-harm contract. Contracts may not be appropriate in community settings (McMyler & Pryjmachuk, 2008).

 Use a collaborative approach for care. A collaborative approach to care is more helpful to the client.

• Refer to the care plan for Risk for Self-Mutilation for additional information.

Client Will (Specify Time Frame)

Note: Because self-neglect is a culturally framed and socially defined phenomenon, change in a client’s status must occur in such a way that it respects individual rights while ensuring individual health and well-being. This is accomplished through client-nurse partnership, but in some instances, assistance of next of kin and/or adult protective services may be needed (e.g., a state agency or local social services program).

• Monitor individuals with acute or chronic mental and complex physical illness for defining characteristics for self-neglect. EBN & EB: Medical and psychiatric conditions probably underlie most cases of self-neglect, as demonstrated in this sample of impaired older adults (Dyer et al, 2007; Gibbons, Lauder, & Ludwick, 2006; Pavlou & Lachs, 2008).

• Assist individuals with complex mental and physical health issues to adopt positive health behaviors so that they may maintain their health status. EB & CEB: A variety of mental illnesses have been correlated with self-neglect in younger adults. However, in the older adult population, depression has been particularly associated with self-neglecting behavior, with inadequately treated medical disease identified more often in self-neglecters who are also depressed (Burnett et al, 2006; Gibbons, 2007; Lauder, Anderson, & Barclay, 2005; Tomkins, 2008).

• Assess persons with complex health issues for adequate coping abilities, and assist those with coping problems to maintain their health and well-being in the community. EB: Personal control and protecting self are coping strategies seen in community-dwelling self-neglecters and in those identified by adult protective services (APS). Individuals use these strategies to compensate, which sometimes causes them to appear uncooperative or resistant to care and change (Gibbons, 2007).

• Assist individuals whose self-care is failing with managing their medication regimen. EBN: Individuals who exhibit self-neglect may have difficulty managing medication (Gibbons, 2007; Naik et al, 2008).

• Assess individuals with failing self-care for noncompliance (i.e., diagnostic testing, medication regimen, therapeutic regimen, and safety precautions). EBN: Individuals who exhibit self-neglect may demonstrate noncompliance with other therapeutic regimens as well (Gibbons, 2007; Naik et al, 2008).

• Assist persons with self-care deficits due to ADL or IADL impairments. EBN: Individuals with self-care deficits may have difficulty with ADLs. Higher self-neglect severity has been associated with lower levels of physical function among older adults (Dong, Mendes de Leon, & Evans, 2009; Gibbons, 2007; Naik et al, 2008; Pavlou & Lachs, 2008).

• Assess persons with failing self-care for changes in cognitive function (i.e., dementia or delirium). EBN: Individuals with failing self-care may have changes in cognition. Decline in executive function has been associated with risk of reported and confirmed elder self-neglect, and decline in global cognitive function has been associated with risk of greater self-neglect severity (Abrams et al, 2002; Dong et al, 2010b, 2010c; Gibbons, 2007; Tierney et al, 2004).

 Refer persons with failing self-care to appropriate specialists (i.e., psychologist, psychiatrist, social work) and therapists (i.e., physical therapy, occupational therapy, etc.). EBN: Individuals with self-care deficits may need assistance from other health professionals (Gibbons, 2007; Naik et al, 2008; Pavlou & Lachs 2008).

• Utilize behavioral modification as appropriate to bring about client changes that lead to improvement in personal hygiene, environmental hygiene, and adherence to medical regimen. EB: Behavioral modification approaches have been effective in reversing self-neglect in older adults who had triggers or events brought about by the behavior (Fraser, 2006; Thibault, 2008).

• Monitor persons with substance abuse problems (i.e., drugs, alcohol, smoking) for adequate safety. EB: Because mental health and substance use disorders can go unrecognized and untreated in this population, identified self-neglecting clients should be screened as appropriate by nurses and other health professionals (Gibbons, 2007; Paveza, Vande Weerd, & Laumann, 2008; Pavlou & Lachs, 2008).

 Refer persons with failing self-care who are significantly impaired cognitively or functionally and who are suspected victims of abuse to APS. EBN & EB: Self-neglect has been associated with mistreatment in older adults, especially those who live alone (Dyer et al, 2007; NEAIS, 1998; Tierney et al, 2004).

• Monitor clients with changes in cognitive function for adequate safety. EB: Dementia is one of the leading causes for self-neglect (Abrams et al, 2002; NEAIS, 1998).

• Monitor clients with functional impairments for adequate safety. EBN & CEB: Functional impairment, often associated with depression in the older adult, is correlated with self-neglect (Gibbons, 2007; Lachs et al, 2002; NEAIS, 1998).

• Assist individuals with complex mental and physical health needs with maintaining their health and well-being in the community. EB: Those self-neglecters institutionalized in nursing homes have a higher mortality rate than those never identified, and for this reason, maintaining a client’s health and well-being in the community setting is essential to a more positive outcome (Lachs et al, 1998, 2002).

Client Will (Specify Time Frame)

• Gather the client’s sexual history, noting normal patterns of functioning and the client’s vocabulary. EB: Sexual history taking includes assessment of sexual activity and relationship patterns, fertility status/contraception, sexually transmitted infections, sexual practices and beliefs, sexual experiences, sexual satisfaction, and sexual problems (Hatzichristou et al, 2010). EB: Women who reported greater sexual satisfaction and who rated sex as important were less likely to experience low sexual desire; low genital arousal was less likely in those who were taking hormone therapy (Hayes et al, 2008). Other relevant research: (Steinke, 2010).

• Assess duration of sexual dysfunction and explore potential causes such as medications, medical problems, or psychosocial issues. Evaluate sexual dysfunction related to either psychological or medical causes. CEB: In men (N = 1,464), 92.9% had erectile dysfunction (ED) and 50.8% had premature ejaculation; severity of ED was associated with diabetes, hypertension, dyslipidemia, ischemic heart disease, myocardial infarction (MI), and psychological problems (El-Sakka, 2007). CEB: Treatments for cancer contribute to sexual dysfunction, and chemotherapy and surgery contributed to poor sexual functioning in women (Barton-Burke & Gustason, 2007).

• Assess for problems of sexual desire. EB: In a population-based study of women (N = 31,581), the adjusted prevalence of low sexual desire was 38.7%, while sexually related personal distress was 22.8% and the prevalence of any sexual problem was 44.2% (Shifren et al, 2008).

• Assess for history of sexual abuse. EB: Women experiencing sexual violence had greater fear of childbirth after delivery, but not before or during childbirth (Schroll, Tabor, & Kjaergaard, 2011). EB: Sexual abuse was significantly associated with lifetime diagnosis of anxiety disorder, depression, eating disorders, post-traumatic stress disorder, sleep disorders, and suicide (Chen et al, 2010).

• Determine the client and partner’s current knowledge and understanding. EB: A systematic review of randomized trials of interactive, computer-based interventions for sexual health promotion had a moderate effect on sexual knowledge, a small effect on safer sex self-efficacy and safer sex intentions, and an effect on sexual behavior, illustrating that computer-based interventions can positively affect sexual health promotion, as well as other aspects related to sexual behavior (Bailey et al, 2010). EB: In clients with chronic heart failure, 36% believed that sexual intercourse could harm their cardiac condition, and 75% of women and 60% of men reported that no physician had asked about potential sexual problems (Schwarz et al, 2008).

• Assess and provide treatment for sexual dysfunction, involving the person’s partner in the process, and evaluating pharmacological and nonpharmacological interventions. EB: A review of 15 studies of clients with chronic kidney disease showed effectiveness of phosphodiesterase type 5 (PDE-5) inhibitors and zinc in men (Vecchio et al, 2010). EB: Diagnosis and treatment are based on underlying etiologies of sexual dysfunction and treatment options that are client centered and with shared decision-making, as well as being preceded by comprehensive sexual assessment (Hatzichristou et al, 2010). (Other relevant research: Melnik et al, 2011).

• Evaluate symptoms of sexual dysfunction as predictors of other illnesses. EB: Erectile dysfunction can be a useful marker for undiagnosed cardiovascular disease and diabetes (Hackett, 2009). EB: Younger men with ED are at increased risk of cardiovascular events, whereas in older men ED does not seem to be as prognostic (Inman et al, 2009).

• Assess risk factors for sexual dysfunction especially with varying sexual partners. EB: Men having sex with men had sexual dysfunction in progressive HIV infection (Shindel et al, 2011).

• Observe for stress and anxiety as possible causes of dysfunction. CEB: Sexual dysfunction can be attributed to many psychological factors; anxiety is often high with cardiac illness, and decreased sexual satisfaction has been shown to heighten anxiety among MI clients (Steinke & Wright, 2006). EB: General anxiety and sexual anxiety were related in heart failure clients and healthy elders, and sexual self-concept, sexual anxiety, sexual self-efficacy, younger age, and marital status predicted sexual activity (Steinke et al, 2008).

• Assess for depression as a possible cause of sexual dysfunction. Sexual problems and depression are common in chronic disease and chronic pain. EB: Global depression and sexual depression have been linked in heart failure and healthy elders (Steinke et al, 2008). CEB: In diabetes, it is often difficult to determine whether depression or diabetes caused the sexual dysfunction (Grandjean & Moran, 2007). Additional relevant research: (Mosack et al, 2011).

• Observe for grief related to loss (e.g., amputation, mastectomy, ostomy). Change in body image often precedes sexual dysfunction (see care plan for Disturbed Body Image). EB: A study using a psychoeducational group intervention to examine quality of life in breast cancer survivors had improved relationship adjustment and increased satisfaction with sex (Rowland et al, 2011). EB: Those with sexual dysfunction may experience altered self-esteem and coping ability, as well as problems in the relationship (Hatzichristou et al, 2010).

• Explore physical causes such as diabetes, cardiovascular disease, arthritis, or benign prostatic hypertrophy (BPH). EB: Alfuzosin in men with prostatic hyperplasia improved quality of life and BPH progression, with minimal vasodilatory and sexual side effects (Roehrborn & Rosen, 2008). EBN: In women with hypertension, 90% had sexual dysfunction as compared to 41% of healthy women, illustrating the significant effects of hypertension on female sexual function, as well as overall quality of their sexual life (Kutmec & Yurtsever, 2011).

• Certain chronic diseases such as cancer often have significant effects on sexual function, and both the disease process and treatment can contribute to sexual dysfunction. EBN: Chronic pain and related treatment in cancer can contribute to sexual dysfunction, and adequate treatment of pain can improve sex, although partners often fear inflicting more pain or causing fractures (Richards et al, 2011). EB: In 16 focus groups conducted at oncology/hematology clinics (N = 109), the most common cancer- or treatment-related side effects affecting sexual function were fatigue, treatment-related hair loss, weight gain, and organ loss/scarring; intimacy and quality of life was emphasized, and some had improved sex after cancer (Flynn et al, 2011).

• Consider that neurological diseases such as multiple sclerosis (MS) affect sexual function directly, but with secondary effects due to disability related to the illness, social, and emotional effects (Fletcher et al, 2009). EBN: In men with MS, sexual dysfunction and lower-limb and bladder disability were related, and common symptoms were ejaculatory and erectile dysfunction, whereas for women, sexual dysfunction and fatigue and problems with vaginal lubrication and orgasm were strongly correlated (Fraser, Mahoney, & McGurl, 2008). EB: In women with MS, problems with desire was common (57.4%), and abnormal 17β-estradiol (40%) was present, although these factors were not correlated (Lombardi et al, 2011).

• Explore behavioral causes of sexual dysfunction, such as smoking. EB: A small trial of women randomized to receive either nicotine gum or placebo gum revealed that nicotine reduced genital responses to erotic stimuli with 30% attenuation in physiological sexual arousal (Harte & Meston, 2008a). EB: A similar trial of men showed that nicotine reduced erectile function to erotic stimuli with a 23% reduction in physiological sexual arousal (Harte & Meston, 2008b).

• Consider medications as a cause of sexual dysfunction. EB: Long-term treatment with antipsychotic drugs resulted in sexual dysfunction in men (50%) and women (37%), with the severity and tolerance of sexual dysfunction worse in men (Montejo et al, 2010). CEB: Psychotropic drugs are associated with problems with erection, libido, orgasm, lubrication, and sexual satisfaction, and PDE-5 inhibitors may be useful in male sexual dysfunction (Berner et al, 2007).

• Provide privacy and be verbally and nonverbally nonjudgmental. EBN: Sexual counseling ideally occurs in a quiet, private area, such as a conference room (Jaarsma, Steinke, & Gianotten, 2010).

• Provide privacy to allow sexual expression between the client and partner (e.g., private room, “Do Not Disturb” sign for a specified length of time). EBN: The hospital setting has little opportunity for privacy, so the nurse must ensure that it is available (Jaarsma, Steinke, & Gianotten, 2010). EB: Companionship with sharing nearness and love, including both physical and emotional touch, were important to post-MI women (Sundler, Dahlberg, & Ekenstam, 2009).

• Explain the need for the client to share concerns with partner. EB: Women with sexual dysfunction had higher depression scores and more negative feelings for their partner, illustrating the importance of good communication between client and partner (Dennerstein et al, 2008). EB: Addressing client sexual concerns early in neurological disease is important in facilitating partner discussion and in preventing future problems (Clayton & Ramamurthy, 2008).

• Validate the client’s feelings, let the client know that he or she is normal, and correct misinformation. CEB: Women with spinal cord injury often believe they are infertile; however, it is believed that fertility is largely unaffected and approximately 90% of women report a return to their normal menstrual cycle at 1 year after their injury (Ricciardi, Szabo, & Poullos, 2007). EB: There was a high degree of agreement in couples’ perception of the man’s erectile dysfunction, and in their attitudes, and beliefs about erectile dysfunction, although with some differences, illustrating the importance of addressing concerns of both individuals in the relationship (Fisher et al, 2009).

• Refer to appropriate medical providers for consideration of medication for premature ejaculation, erectile dysfunction, or orgasmic problems. EB: Treatment with sildenafil citrate for erectile dysfunction in Parkinson’s disease resulted in a normal erectile function score in 56.9% of the sample versus 8.7% of the placebo group (Safarinejad et al, 2010). CEB: Results of 11 randomized control trials revealed that PDE-5 inhibitors are effective for sexual dysfunction related to prostate cancer (Miles et al, 2007).

• Refer women for possible pharmacological intervention for sexual dysfunction. EB: Therapies for female sexual dysfunction include PDE-5 inhibitors, androgen therapy, tibolone, and prostaglandins (Davis & Nijland, 2008). EB: Hormone therapy improves sexual response and sexual activity frequency; benefits must be weighed against any risks (Dennerstein et al, 2008).

Client Will (Specify Time Frame)

• After establishing rapport or therapeutic relationship, give the client permission to discuss issues dealing with sexuality, for example: “Have you been or are you concerned about functioning sexually because of your health status?” EBN: Start with more general questions and then those more personal; for example, discuss exercise recommendations and then sex as another form of exercise; recognize that some older adults may not be currently sexually active, but may want information for future reference (Steinke, 2005; Steinke & Jaarsma, 2008). EBN: Using the PLISSIT model (giving permission to discuss sexual concerns, providing limited information, providing specific information, referral for intensive therapy) can uncover concerns that might not ordinarily be raised by the client (Hardin, 2007; Jaarsma et al, 2010).

• Use assessment questions and standardized instruments to assess sexual problems, where possible. EB: The Prostate Cancer Index, the International Index of Erectile Function, and the Female Sexual Function Index have been used widely, including in cancer (Jeffrey et al, 2009). EBN: Use specific assessment questions, such as: How important is intimacy in your relationship? Are you satisfied with the amount of intimacy you receive? Are you currently sexually active? Have you noticed any changes in your sexual performance, such as problems with libido, vaginal dryness, orgasmic problems, or erectile problems? Assess current medications to determine effects on sexual function (Steinke & Jaarsma, 2008; Jaarsma et al, 2010).

• Include the client’s partner in discussing sexual concerns and in providing sexual counseling. EBN: Information provided to partners is often inadequate, and discussing sexual issues increases partner understanding and may minimize overprotectiveness by the partner (Ivarsson, Fridlund, & Sjoberg, 2010). EBN: Male partners described altered masculine images and hesitancy in approaching their partners after myocardial infarction, whereas women as partners described a sense of loss and uncertainty (Arenhall et al, 2010, 2011).

• Encourage the client to discuss concerns with his or her partner. EBN: A daily walk together is an ideal time to discuss sexual concerns, while increasing the client’s strength and stamina and promoting health (Steinke & Jaarsma, 2008). EBN: Effective communication with one’s partner includes listening and learning to express one’s feelings and is an important component of self-management for the client (Newman, 2007).

• Explore attitudes about sexual intimacy and changes in sexuality patterns. EBN: Give the client permission to discuss sexual issues, the importance of intimacy, feelings, desires, and attitudes toward intimacy (Jaarsma, Steinke, & Gianotten, 2010). EB: Adults burned as children felt sexually attractive and confident about sexual activity, showing that sexual attitudes and behaviors may not be negatively affected by a condition (Meyer et al, 2011).

• Assess psychosocial function such as anxiety, fear, depression, and low self-esteem. EBN: Sexual depression was greater in heart failure clients who were not sexually active, whereas those who were not depressed had greater sexual satisfaction, particularly when not taking antidepressant medication (Mosack et al, 2011). EB: Sexual anxiety and sexual self-efficacy significantly and independently affected sexual activity in heart failure and healthy elders, illustrating the importance of assessing psychosocial and sexual concerns (Steinke et al, 2008).

• Discuss alternative sexual expressions for altered body functioning or structure, including closeness and touching as other forms of expression. The meaning of sex and sexuality is individually defined, with some engaging in sexual intercourse, whereas others may prefer touching, holding one another, or kissing (Steinke, 2005).

• Some clients choose masturbation for sexual release, an acceptable form of sexual expression, and for some with chronic illnesses, it may be an alternative to sexual intercourse when exercise tolerance is low. EBN: Discuss sexual activities in the context of exercise tolerance and suggest acceptable alternatives to the client when sexual intercourse is not possible (Steinke & Jaarsma, 2008). EBN: For some clients with severe heart failure, activities such as mutual masturbation, oral sex, or sexual intercourse may not be possible if exercise capacity is compromised, making other expressions of intimacy of greater importance (Medina et al, 2009).

• Assess the client’s sexual orientation and usual pattern of sexual activities, and discuss prevention of illnesses for which the client may be at increased risk (e.g., anorectal cancer). EBN: Ask about sexual orientation directly, for example, “Do you have sexual relationships with men, women, or both?” Assess use of safer sex practices (e.g., condom use); the frequency of anal intercourse; number of sexual partners in the last year; last HIV screening/results; and use of medications, alcohol, and illicit drugs (Blackwell, 2008; Ortiz, 2007). EBN: Anal sex in those with myocardial infarction can cause chest pain from vagal stimulation (Steinke & Jaarsma, 2008).

• Specific guidelines for sexual activity for clients who have had total hip replacement (THR) surgery include: Avoid bending the affected leg more than 90 degrees at the hip; when lying on one’s back, turning or rolling the affected leg or turning the toes toward the other leg should be avoided. When side-lying, legs are separated with pillows, avoiding knees touching and toes of the affected leg pointing downward. In an on-bottom sexual position, pillows should be used under the affected thigh for support, with toes pointed upward and slightly outward. Lying on the unaffected side is a preferred position for men with both partners facing the same direction, the man behind the woman in a “spooning” position, with pillows between her legs and the man’s leg resting on top of hers during intercourse. The woman in a side-lying position should place pillows between her legs to support the affected hip, taking care not to bend the affected hip more than 90 degrees or letting toes dangle downward, and with the partner in the “spooning” position behind her. Caution: Hip dislocation during sexual intercourse results in pain; the affected leg will appear shorter, and the foot will turn inward, so direct the client to lie down, not move, and have the partner call an ambulance. CEB: Use of pelvic osteotomy for hip dysplasia in young women resulted in improved sexual satisfaction and quality of life due to reduced hip pain after surgery, and no effect on the ability to deliver a baby vaginally (Masui et al, 2007).

• Specific guidelines for those who have had a myocardial infarction (MI) include: Sexual activity can generally be resumed within a few weeks after MI unless complications are experienced such as arrhythmias or cardiac arrest or if exercise testing reveals that sexual activity is not safe. Sex should occur in familiar surroundings, a comfortable room temperature, with the usual partner, when well rested to minimize cardiac stress, as well as avoiding heavy meals or alcohol for 2 to 3 hours before sexual activity, and choosing a position of comfort to minimize stress of the cardiac client. EB & EBN: Studies of cardiac nurses reveal that increased attention is needed for specific suggestions in resuming sexual activity post-MI, particularly for cardiac rehabilitation nurses (Barnason et al, 2011; Jaarsma et al, 2010; Steinke et al, 2011).

• Specific guidelines for those who have had coronary artery bypass grafting (CABG) are similar to those after MI with the following additions: Incisional pain with sexual activity is generally a dull ache in the midsternal area and does not radiate (unlike prior experiences with chest pain); therefore, reassure the client and partner that sexual activity will not harm the sternum; sexual activity can be generally resumed in 3 to 6 weeks following CABG. EBN: Women, particularly those with large breasts, may report more issues related to pain in the breast, chest numbness, and difficulty healing; therefore, encouraging the woman to choose a position of comfort, support with pillows, and take a pain reliever such as acetaminophen before sexual activity may be helpful (Steinke & Jaarsma, 2008).

• Specific guidelines for those with an implantable cardioverter defibrillator (ICD) include assuring the client and partner that fears about being shocked during sexual activity are normal, and sex can be resumed after the ICD is placed as long as strain on the implant site is avoided; if the ICD discharges with sexual activity, the client should stop, rest, and later notify the physician that the device fired so that a determination can be made if this was an appropriate shock or not; and the client should be instructed to report any dyspnea, chest pain, or dizziness with sexual activity. CEB: Partners are often fearful and overprotective of the client, and some have noted sensations when the client’s ICD fired, though not harmful to the partner (Steinke, 2003; Steinke et al, 2005). EBN: Alteration in sexual activity is common after ICD (Zayac & Finch, 2009).

• Specific guidelines for those with chronic lung disease include planning for sexual activity when energy level is highest; using positions that minimize shortness of breath, such as a semireclining position; engaging in sexual activity when medications are at peak effectiveness; and use of an oxygen cannula, if prescribed, to provide oxygen before, during, or after sex. Also, pulmonary rehabilitation, including exercise and respiratory muscle training, may improve physical and sexual function (Goodell, 2007; Steinke, 2005). CEB: Satisfaction with sexual life was significantly less in those with chronic obstructive pulmonary disease and long-term oxygen therapy when compared to healthy individuals, suggesting that assessment of this aspect of quality of life is important and that support by nurses may be needed (Sturesson & Branholm, 2000). EB: In women living with lung cancer, those who had regular sexual activity had closer couple relationships; satisfaction with information provided by health professionals and psychological support played a role for both men and women (Preau et al, 2011).

• Specific guidelines for those with multiple sclerosis include treatment of symptoms with prescribed medications and supportive therapies to assist with a more satisfying sexual experience. Neuropathic pain may be treated with antiseizure medications, massage therapy, and acupuncture, as well as changing positions for sexual activity and discussing changes in sensation and stimulation with the partner; and exercise, stretching, taking antispasmodic medications 20 minutes before sexual activity, trying alternative positions (e.g., side lying), routine bowel elimination and avoiding a distended bowel, and emptying the bladder can alleviate discomfort with sexual intercourse (Moore, 2007). EB: Clients experiencing pain from MS had reduced sexual function and body image dissatisfaction; therefore, nonpharmacological and pharmacological management of pain may be helpful to enhance sexual function (Knafo et al, 2011). EB: Both positive and negative partner support yielded significant improvements in sexual satisfaction over time in women with systemic sclerosis (Blackmore et al, 2011).

• Those with osteoarthritis, rheumatoid arthritis, or fibromyalgia may fear being in pain or causing pain to their partner; therefore, sexual intercourse may be difficult and may take practice to determine the position of least discomfort, discussing the type of stimulation preferred or trying new positions, allowing plenty of time for sexual foreplay and intercourse, and using touch for sexual stimulation (Newman, 2007). EBN: Fibromyalgia limited sexual activity because of physical symptoms, such as pain, fatigue, and joint stiffness, and caused strain in the sexual relationship (Ryan et al, 2008). CEB: Joint pain with sexual activity occurred in 41% of men and 51% of women (van Berso et al, 2007).

• Refer to the care plan Sexual Dysfunction for additional interventions.

Client Will (Specify Time Frame)

• Review data pertaining to client risk status including age, primary diseases, immunosuppression, antibiotic use, and presence of hemodynamic alterations. EB: Many clients who develop shock have underlying circumstances that predispose them to shock states as evidenced by hypotension and inadequate organ perfusion (Aitken et al, 2011; Pinsky, 2011).

• Review client’s medical and surgical history, noting conditions that place the client at higher risk for shock, including trauma, myocardial infarction, pulmonary embolism, head injury, dehydration, and infection. EB: Certain clinical conditions place clients at higher risk for shock, which requires prompt identification and treatment to improve morbidity and mortality outcomes (AHA, 2011; Dellinger et al, 2008).

• Complete a full nursing physical examination. A full nursing physical examination is crucial in identifying all factors that might place that client at risk for the development of shock, such as hypoperfusion of internal organs (manifesting as decreases in bowel sounds and urinary output, and shortness of breath); tissue hypoperfusion (manifesting as cool, clammy, mottled skin, diminished pulses). EBN: A systematic review found that capillary refill may not be helpful in the assessment of hypoperfusion states; use of vital signs, pulse oximetry, Doppler ultrasound, grading of peripheral pulses, color, and warmth of skin are more sensitive measures (Dufalt et al, 2008).

• Monitor circulatory status (e.g., blood pressure [BP], mean arterial pressure [MAP], skin color, skin temperature, heart sounds, heart rate and rhythm, presence and quality of peripheral pulses, Doppler ultrasound, and pulse oximetry). EB: The initial phase of shock is characterized by decreased cardiac output and tissue perfusion, which results in immediate compensatory changes evidenced by changes in blood pressure, increased heart rate, and shunting of blood away from the periphery, resulting in pale, cooler, damp skin, with reduced peripheral pulses (Dufalt et al, 2008; Pinsky, 2011).

• Maintain IV access and provide isotonic IV fluids such as 0.9% normal saline or Ringer’s lactate as ordered; these fluids are commonly used in the prevention and treatment of shock. EB: Adequate IV access allows for fluid resuscitation and medication delivery to prevent or treat shock (Pinsky, 2011; Wilmont, 2010). EB: Crystalloids or colloids are used to prevent or treat shock targeting a central venous pressure (CVP) of between 8 and 12 mm Hg in nonintubated clients (Dellinger et al, 2008; Pinsky, 2011). EB: A Cochrane review found no difference in risk of dying in the use of colloids compared to crystalloids in trauma, burns, or surgery (Perel & Roberts, 2011).

• Monitor for inadequate tissue oxygenation (e.g., apprehension, increased anxiety, changes in mental status, agitation, oliguria, cool/mottled periphery) and determinants of tissue oxygen delivery (e.g., PaO₂, SpO₂, ScvO₂/SvO₂, MAP, hemoglobin levels, lactate levels, cardiac output [CO]). Assessment of tissue oxygen delivery and oxygenation patterns provides data to assess trends in client’s status and evaluates treatment responses (Pinsky, 2011). EBN: Tissue oxygenation endpoints, including central venous oxygen saturation (ScvO₂), tissue oxygenation (StO₂), and lactate levels, provide data on microcirculation, a key factor in the management of hemodynamic alterations in shock, especially in sepsis (Aitken et al, 2011).

 Maintain vital signs (BP, pulse, respirations, and temperature), and pulse oximetry within normal parameters. EB: Increased heart rate (above 90 beats/min), hypotension (BP below 90 mm Hg systolic), tachypnea (greater than 20 breaths/min), hypoxia (SpO₂ below 90%), and lactate levels (above 2 mmol/L) are indicators of shock (Dellinger et al, 2008; Wilmont, 2010). EB: Temperature greater than 38° C or less than 36° C with white blood cell count greater than 12,000/mm³ or less than 4000/mm³ plus symptoms listed earlier are indicators of SIRS (Dellinger et al, 2008; Wilmont, 2010).

 Administer oxygen immediately to maintain SpO₂ greater than 90% and antibiotics and other medications as prescribed to any client presenting with symptoms of early shock. EB: Administration of high-flow oxygen, hydration, antibiotics, insulin, and vasoactive medications provides early correction of risks for shock and improves survival of shock. Antibiotics as prescribed administered within 1 hour of diagnosis of a sepsis state facilitates a better rate of survival. For each hour in delayed antibiotic administration, survival decreases by 7.6% (Aitken et al, 2011; Bernardi, 2010; Dellinger et al, 2008; Havel, et al, 2011; Wilmot, 2010). EB: A prospective study on compliance with the hemodynamic components of the sepsis resuscitation bundle found that there was a lower mortality rate in clients who were placed on the protocol sooner (Coba et al, 2011). EB: Emergency medical services (EMS) personnel may serve as an important resource for the early diagnosis and treatment of sepsis in the field before hospitalization (Wang et al, 2011).

 Monitor trends in noninvasive hemodynamic parameters (e.g., MAP) as appropriate. EB: Identification of alterations in hemodynamic parameters provides data necessary for early and immediate implementation of prescribed therapies for prompt stabilization, preventing progression of shock. Maintaining MAP at desired levels (above 65 mm Hg) facilitates adequate perfusion to organs (Dellinger et al, 2008; Jones, Treciak, & Dellinger, 2010; Pinsky, 2011). EB: An overarching goal of cardiovascular support is optimization of blood flow to tissues; however, there is no single optimum MAP that can be applied to all (Jones, Treciak, & Dellinger, 2010). EB: Near-infrared spectroscopy and sidestream dark-field imaging have emerged as promising technologies for noninvasively monitoring the microcirculation at the bedside and may provide additional clues to help define adequacy of blood pressure during resuscitation phase of septic shock (Shapiro et al, 2011).

 Monitor hydration status including skin turgor, daily weights, postural blood pressure changes, serum electrolytes (sodium, potassium, chloride, and blood urea nitrogen), and intake and output. Consider insertion of a Foley catheter as ordered to measure hourly output. EBN: Daily weights are an important indicator of fluid status. Skin turgor is a measure of hydration, as are intake and output. Serum electrolyte levels help monitor fluid status (Shepard, 2011).

 Monitor serum lactate levels, interpreting them within the context of each client. EB: Elevations in serum lactate (above 2 mmol/L) may indicate circulatory failure and resultant tissue hypoxia from anaerobic metabolism that results in toxin accumulation, cellular inflammation, and cellular death. Progression to shock may result as characterized by the onset of SIRS. Two or more of the following indicators suggest SIRS: altered temperatures, heart rates above 90 beats/min, tachypnea or hypocarbia, and/or leukocytosis/leukopenia (Nicks, 2011; Wilmont, 2010). EBN: The degree of serum lactate elevation correlates with morbidity and mortality in sepsis; early detection facilitates early treatment and is a more accurate triage tool than vital signs (Aitken et al, 2011). EB: Clients with cirrhosis are at increased risk for infections, especially spontaneous bacterial peritonitis, which may lead to SIRS (Bernardi, 2010).

 Monitor blood glucose levels frequently and administer insulin as prescribed to maintain normal blood sugar levels (blood glucose levels of 70 to 110 mg/dL [3.9 to 6.1 mmol/L]). EB: Research suggests that tight glycemic control decreases mortality and morbidity in surgical clients; the Surviving Sepsis Campaign suggests maintaining blood glucose below 150 mg/dL (8.3 mmol/L) (Dellinger, 2008; Finfer & Delaney, 2008; Nasraway & Rattan, 2010).

Critical Care

External

Chemical substance; extremes in age; humidity; hyperthermia; hypothermia; mechanical factors (e.g., friction, shearing forces, pressure, restraint); medications; moisture; physical immobilization; radiation

Internal

Changes in fluid status; changes in pigmentation; changes in turgor; developmental factors; imbalanced nutritional state (e.g., obesity, emaciation, chronic disease, vascular disease); immunological deficit; impaired circulation; impaired metabolic state; impaired sensation; skeletal prominence