Nursing Diagnosis Handbook: An Evidence-Based Guide to Planning Care

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Tissue Integrity: Skin and Mucous Membranes, Wound Healing: Primary Intention, Secondary Intention

Example NOC Outcome with Indicators

Tissue Integrity: Skin and Mucous Membranes will be intact as evidenced by the following indicators: Skin integrity/Skin lesions not present/Tissue perfusion/Skin temperature/Skin thickness. (Rate the outcome and indicators of Tissue Integrity: Skin and Mucous Membranes: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes

Client Will (Specify Time Frame)

• Regain integrity of skin surface

• Report any altered sensation or pain at site of skin impairment

• Demonstrate understanding of plan to heal skin and prevent reinjury

• Describe measures to protect and heal the skin and to care for any skin lesion

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Incision Site Care, Pain Management, Pressure Ulcer Care, Pressure Ulcer Prevention, Risk Identification, Skin Care: Topical Treatments, Skin Surveillance, Wound Care, Wound Irrigation

Example NIC Activities—Pressure Ulcer Care

Monitor color of wound bed, temperature, edema, erythema, moisture, and appearance of surrounding skin; Note characteristics of any drainage

Nursing Interventions and Rationales

• Assess site of skin impairment and determine cause (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, skin tear). EB: The cause of the wound must be determined before appropriate interventions can be implemented. This will provide the basis for additional testing and evaluation to start the assessment process (Baranoski & Ayello, 2012; McCulloch & Kloth, 2010).

• For clients with limited mobility, use a risk assessment tool to systematically assess immobility-related risk factors (EPUAP/NPUAP, 2009). A validated risk assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown (EPUAP/NPUAP, 2009). EB & CEB: Targeting variables (such as age and Braden Scale Risk Category) can focus assessment on particular risk factors (e.g., pressure) and help guide the plan of prevention and care (EPUAP/NPUAP, 2009; Magnan, & Maklebust, 2009; McCulloch & Kloth 2010; Sussman & Bates-Jensen, 2012; WOCN, 2009).

• Determine that skin impairment involves skin damage only (e.g., partial-thickness wound, stage I or stage II pressure ulcer). The following classification system is for pressure ulcers:

Category/Stage I: Intact skin with nonblanchable erythema of a localized area, usually over a bony prominence. Darkly pigmented skin may not have visible blanching. The area may be painful, firm, soft, warmer, or cooler as compared to adjacent tissue. Category/Stage I may be difficult to detect in individuals with dark skin tones. May indicate “at risk” persons (EPUAP/NPUAP, 2009; NPUAP, 2009).

Category/Stage II: Partial-thickness skin loss of dermis presenting as a shallow open ulcer with a red- pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled. Presents as a shiny or dry shallow ulcer without slough or bruising.^∗ This category/stage should not be used to describe skin tears, tape burns, incontinence-associated dermatitis, maceration, or excoriation (EPUAP/NPUAP, 2009).

• Inspect and monitor site of skin impairment at least once a day for color changes, redness, swelling, warmth, pain, or other signs of infection. Determine whether the client is experiencing changes in sensation or pain. Pay special attention to high-risk areas such as bony prominences, skin folds, the sacrum, and heels. Systematic inspection can identify impending problems early (Baranoski & Ayello, 2012; EPUAP/NPUAP, 2009).

• Monitor the client’s skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing. Cleansing should not compromise the skin (Baranoski & Ayello, 2012).

• Consider using normal saline to clean the pressure ulcer or as ordered by physician (EPUAP/NPUAP 2009).

• Individualize plan according to the client’s skin condition, needs, and preferences. EBN & CEB: Avoid harsh cleansing agents, hot water, extreme friction or force, or cleansing too frequently (EPUAP/NPUAP, 2009; WOCN, 2010).

• Monitor the client’s continence status, and minimize exposure of skin impairment to other areas of moisture from perspiration or wound drainage. EBN: Moisture from incontinence may contribute to pressure ulcer development by macerating the skin (Borchert et al, 2010; WOCN, 2010).

If the client is incontinent, implement an incontinence management plan to prevent exposure to chemicals in urine and stool that can strip or erode the skin. Utilize a skin protectant or cleanser protectant. Refer to a continence care specialist, urologist, or gastroenterologist for incontinence assessment (Borchert et al, 2010). EB: Implementing an incontinence prevention plan with the use of a skin protectant or a cleanser protectant can significantly decrease skin breakdown and pressure ulcer formation (Borchert et al, 2010).

• Do not position the client on site of skin impairment. If consistent with overall client management goals, reposition the client as determined by individualized tissue tolerance and overall condition. Reposition and transfer the client with care to protect against the adverse effects of external mechanical forces such as pressure, friction, and shear. EB: Do not position an individual directly on a pressure ulcer. Continue to turn/reposition the individual regardless of the support surface in use. Establish turning frequency based on the characteristics of the support surface and the individual’s response (EPUAP/NPUAP, 2009). If the goal of care is to keep the client (e.g., a terminally ill client) comfortable, turning and repositioning may not be appropriate (NPUAP, 2009).

• Evaluate for use of support surfaces (specialty mattresses, beds), chair cushions, or devices as appropriate. Maintain the head of the bed at the lowest possible degree of elevation to reduce shear and friction, and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed (EPUAP/ NPUAP, 2009; WOCN, 2010).

• Implement a written treatment plan for topical treatment of the site of skin impairment. A written plan ensures consistency in care and documentation (Baranoski & Ayello, 2012).

• Select a topical treatment that will maintain a moist wound-healing environment (stage II) and that is balanced with the need to absorb exudate. Stage I pressure ulcers may be managed by keeping the client off of the area and using a protective dressing (Baranoski & Ayello, 2012). EBN: Choose dressings that provide a moist environment, keep periwound skin dry, and control exudate and eliminate dead space (EPUAP/NPUAP, 2009; WOCN, 2009, 2010).

• Avoid massaging around the site of skin impairment and over bony prominences. EB: Research suggests that massage may lead to deep-tissue trauma (EPUAP/NPUAP, 2009).

Assess the client’s nutritional status. Refer for a nutritional consult and/or institute dietary supplements as necessary. Optimizing nutritional intake, including calories, fatty acids, protein, and vitamins, is needed to promote wound healing (EPUAP/NPUAP, 2009). The wound care organizations endorse the application of reasonable nutritional assessment and treatment for clients at risk for and with pressure ulcers.

• Identify the client’s phase of wound healing (inflammation, proliferation, maturation) and stage of injury. EBN: The selection of the dressing is based on the tissue in the ulcer bed (wound bed), the condition of the skin around the ulcer bed, and the goals of the person with the ulcer. Generally, maintaining a moist ulcer bed is the ideal when the ulcer bed is clean and granulating to promote healing and closure (EPUAP/NPUAP, 2009). No single wound dressing is appropriate for all phases of wound healing.

Home Care:

• The interventions described previously may be adapted for home care use.

• Instruct and assist the client and caregivers in how to change dressings and maintain a clean environment. Provide written instructions and observe them completing the dressing change.

• Educate client and caregivers on proper nutrition, signs and symptoms of infection, and when to call the agency and/or physician with concerns.

It may be beneficial to initiate a consultation in a case assignment with a wound, ostomy, continence (WOC) nurse (or wounds specialist) to establish a comprehensive plan for complex wounds.

Client/Family Teaching and Discharge Planning:

Teach skin and wound assessment and ways to monitor for signs and symptoms of infection, complications, and healing. Early assessment and intervention help prevent serious problems from developing.

Teach the client why a topical treatment has been selected. EBN: The type of dressing needed may change over time as the wound heals and/or deteriorates (EPUAP/NPUAP, 2009; WOCN, 2010).

If consistent with overall client management goals, teach how to reposition as client condition warrants. CEB & EB: If the goal of care is to keep a client (e.g., terminally ill client) comfortable, turning and repositioning may not be appropriate (EPUAP/NPUAP, 2009).

Teach the client to use pillows, foam wedges, chair cushions, and pressure-redistribution devices to prevent pressure injury. EB: The use of effective pressure-reducing seat cushions for elderly wheelchair users significantly prevented sitting-acquired pressure ulcers (Brienza et al, 2012).

Risk for impaired Skin Integrity

Sharon Baranoski, MSN, RN, CWCN, APN-CCNS, FAAN

NANDA-I

Definition

At risk for alteration in epidermis and/or dermis

Risk Factors

External

Chemical substance; excretions and/or secretions; extremes of age; humidity; hyperthermia; hypothermia; mechanical factors (e.g., friction, shearing forces, pressure, restraint); moisture; physical immobilization; radiation

Internal

Alterations in skin turgor (change in elasticity); altered circulation; altered metabolic state; altered nutritional state (e.g., obesity, emaciation); altered pigmentation; altered sensation; chronic disease, developmental factors; history of pressure ulcers, immunological deficit; medication; psychogenetic, immunological factors; skeletal prominence, vascular disease

NOTE: Risk should be determined by the use of a risk assessment tool (e.g., Norton scale, Braden scale).

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Immobility Consequences: Physiological, Tissue Integrity: Skin and Mucous Membranes

Example NOC Outcome with Indicators

Tissue Integrity: Skin and Mucous Membranes will be intact as evidenced by the following indicators: Skin intactness/Skin lesions not present/Tissue perfusion/Skin temperature. (Rate the outcome and indicators of Tissue Integrity: Skin and Mucous Membranes: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes

Client Will (Specify Time Frame)

• Report altered sensation or pain at risk areas as soon as noted

• Demonstrate understanding of personal risk factors for impaired skin integrity

• Verbalize a personal plan for preventing impaired skin integrity

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Positioning: Pressure Management, Pressure Ulcer Care, Pressure Ulcer Prevention, Skin Surveillance

Example NIC Activities—Pressure Ulcer Care

Monitor color of wound bed, temperature, edema, erythema, moisture, and appearance of surrounding skin; Note characteristics of any drainage

Nursing Interventions and Rationales

• Inspect and monitor skin condition at least once a day for color or texture changes, redness, localized heat, edema or induration, pressure damage, dermatological conditions, or lesions and any incontinence-associated dermatitis. Determine whether the client is experiencing loss of sensation or pain. Systematic inspection can identify impending problems early (Baranoski & Ayello, 2012; EPUAP/NPUAP, 2009).

• Identify clients at risk for impaired skin integrity as a result of immobility, chronological age, malnutrition, incontinence, compromised perfusion, immunocompromised status, or chronic medical condition, such as diabetes mellitus, spinal cord injury, or renal failure. CEB & EBN: These client populations are known to be at high risk for impaired skin integrity (Baranoski & Ayello, 2012). Targeting variables (such as age and Braden Scale Risk Category) can focus assessment on particular risk factors (e.g., pressure) and help guide the plan of prevention and care (EPUAP/NPUAP, 2009; Magnan & Maklebust, 2009).

• Monitor the client’s skin care practices, noting type of soap or other cleansing agents used, temperature of water, and frequency of skin cleansing. Individualize plan according to the client’s skin condition, needs, and preferences (Baranoski & Ayello, 2012).

• Cleanse the skin gently with pH-balanced cleansers. Avoid harsh cleansing agents, hot water, extreme friction or force, or too-frequent cleansing (WOCN, 2010).

Monitor the client’s continence status and minimize exposure of the site of skin impairment (incontinence-associated dermatitis) and other areas to moisture from incontinence, perspiration, or wound drainage. If the client is incontinent, implement an incontinence management plan to prevent exposure to chemicals in urine and stool that can strip or erode the skin. Use a barrier product to reduce risk of exposure; refer to a physician (e.g., continence care specialist, urologist, gastroenterologist) for an incontinence assessment (WOCN, 2009). EB & CEB: Implementing an incontinence prevention plan with the use of a skin protectant or a cleanser protectant can significantly decrease skin breakdown and pressure ulcer formation (Baranoski & Ayello, 2012; Borchert et al, 2010; EPUAP/NPUAP 2009; WOCN, 2010).

• For clients with limited mobility, inspect and monitor condition of skin covering bony prominences. Pressure ulcers usually occur over bony prominences, such as the sacrum, coccyx, trochanter, and heels, as a result of unrelieved pressure between the prominence and support surface, or with shearing and friction (Baranoski & Ayello, 2012; EPUAP/NPUAP, 2009; Magnan & Maklebust, 2009; WOCN, 2009, 2010).

• Use a risk assessment tool to systematically assess immobility-related risk factors. A validated risk assessment tool such as the Norton or Braden scale should be used to identify clients at risk for immobility-related skin breakdown (EPUAP/NPUAP, 2009; Magnan & Maklebust, 2009; WOCN, 2010).

• Implement a written prevention plan. EB: A written plan ensures consistency in care and documentation (Baranoski & Ayello, 2012).

• The use of repositioning should be considered in all at-risk individuals. Frequency of repositioning will be influenced by variables concerning the individual and the support surface in use. Frequency of repositioning should be determined by the individual’s tissue tolerance and medical condition (EPUAP/NPUAP, 2009). Reposition the client with care to protect against the adverse effects of external mechanical forces (e.g., pressure, friction, shear) (EPUAP/NPUAP, 2009; WOCN, 2009, 2010).

• Evaluate for use of specialty mattresses, beds, or devices as appropriate (Brienza et al, 2012). If the goal of care is to keep the client (e.g., a terminally ill client) comfortable, turning and repositioning may not be appropriate. Maintain the head of the bed at the lowest possible degree of elevation to reduce shear and friction and use lift devices, pillows, foam wedges, and pressure-reducing devices in the bed (EPUAP/NPUAP, 2009; WOCN, 2009, 2010).

• Avoid massaging over bony prominences. Research suggests that massage may lead to deep-tissue trauma (EPUAP/NPUAP, 2009; WOCN, 2010).

Assess the client’s nutritional status; refer for a nutritional consult, and/or institute dietary supplements. The National Pressure Ulcer Advisory Panel (EPUAP/NPUAP, 2009) endorses the application of reasonable nutritional assessment and treatment for clients at risk for and with pressure ulcers.

Geriatric:

• Limit number of complete baths to two or three per week, and alternate them with partial baths. Use a tepid water temperature (between 90° and 105° F) for bathing. EB: Excessive bathing, especially in hot water, depletes aging skin of moisture and increases dryness. The ability to retain moisture is decreased in aging skin because of diminished amounts of dermal proteins. One of the most common age-related changes to the skin is damage to the stratum corneum (Baranoski & Ayello, 2012).

• Use lotions and moisturizers to prevent skin from drying out, especially in the winter. Avoid skin care products that contain allergens such as lanolin, latex, and dyes (Baranoski & Ayello, 2012).

• Increase fluid intake within cardiac and renal limits to a minimum of 1500 mL per day. Dry skin is caused by loss of fluid; increasing fluid intake hydrates the skin (Baranoski & Ayello, 2012).

• Increase humidity in the environment, especially during the winter, by using a humidifier or placing a container of water on a warm object. Increasing the moisture in the air helps keep moisture in the skin.

Home Care:

• Assess caregiver vigilance and ability CEB: In a limited study of the Braden scale, caregiver vigilance and ability were recognized as potentially significant variables for determining the risk of developing pressure sores (Braden & Maklebust, 2005).

Initiate a consultation in a case assignment with a wound care specialist or wound, ostomy, and continence (WOC) nurse to establish a comprehensive plan as soon as possible.

• See the care plan for Impaired Skin Integrity.

Client/Family Teaching and Discharge Planning:

• Teach the client skin assessment and ways to monitor for impending skin breakdown. Early assessment and intervention help prevent the development of serious problems. EB: Basic elements of a skin assessment are assessment of temperature, color, moisture, turgor, and intact skin (Baranoski & Ayello, 2012).

• If consistent with overall client management goals, teach how to turn and reposition the client. EB: If the goal of care is to keep the client (e.g., a terminally ill client) comfortable, turning and repositioning may not be appropriate (EPUAP/NPUAP, 2009). Do not position an individual directly on a pressure ulcer. Continue to turn/reposition the individual regardless of the support surface in use. Establish turning frequency based on the characteristics of the support surface and the individual’s response (EPUAP/NPUAP, 2009).

• Teach the client and or caregivers to use pillows, foam wedges, and pressure-reducing devices to prevent pressure injury (EPUAP/NPUAP, 2009; WOCN, 2009, 2010). EB: The use of effective pressure-reducing seat cushions for elderly wheelchair users may significantly prevent sitting-acquired pressure ulcers (Brienza & Geyer, 2012; EPUAP/NPUAP, 2009).

References

Baranoski, S., Ayello, E.A. Skin an essential organ. In Baranoski S., Ayello E.A., eds.: Wound care essentials: practice principles, ed 3, Ambler, PA: Lippincott Williams & Wilkins, 2012.

Borchert, K., et al. The incontinence-associated dermatitis and its severity instrument. J Wound Ostomy Continence Nurs. 2010;37(5):527–535.

Braden, B., Maklebust, J. Wound wise: preventing pressure ulcers with the Braden scale. Am J Nurs. 2005;105(6):70–72.

Brienza, D.M., et al. Pressure redistribution: seating, positioning, and support surfaces. In Baranoski S., Ayello E.A., eds.: Wound care essentials: practice principles, ed 3, Ambler, PA: Lippincott Williams & Wilkins, 2012.

European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel (EPUAP/NPUAP). Prevention and treatment of pressure ulcers. Washington, DC: National Pressure Ulcer Advisory Panel; 2009.

Magnan, M.A., Maklebust, J. The nursing process and pressure ulcer prevention: making the connection. Adv Skin Wound Care. 2009;22(2):83–91.

Wound, Ostomy, and Continence Nurses Society (WOCN). Pressure ulcer assessment: best practice for clinicians. Mt Laurel, NJ: Author; 2009.

Wound, Ostomy, and Continence Nurses Society (WOCN). Guideline for prevention and management of pressure ulcers, WOCN clinical practice guideline series no 2. Mount Laurel, NJ: Author; 2010.

Sleep deprivation

Judith A. Floyd, PhD, RN, FAAN, Jean D. Humphries, MSN, PhD(c), MS, RN and Elizabeth S. Jenuwine, PhD, MLIS

NANDA-I

Definition

Prolonged periods of time without sleep (sustained natural, periodic suspension of relative consciousness)

Defining Characteristics

Acute confusion, agitation, anxiety, apathy, combativeness, daytime drowsiness, decreased ability to function, fatigue, fleeting nystagmus, hallucinations, hand tremors, heightened sensitivity to pain, inability to concentrate, irritability, lethargy, listlessness, malaise, perceptual disorders (i.e., disturbed body sensation, delusions, feeling afloat), restlessness, slowed reaction, transient paranoia

Related Factors (r/t)

Aging-related sleep stage shifts, dementia, familial sleep paralysis, inadequate daytime activity, idiopathic central nervous system hypersomnolence, narcolepsy, nightmares, non–sleep-inducing parenting practices, periodic limb movement (e.g., restless leg syndrome, nocturnal myoclonus), prolonged discomfort (e.g., physical, psychological), sustained inadequate sleep hygiene, prolonged use of pharmacological or dietary antisoporifics, sleep apnea, sleep terror, sleep walking, sleep-related enuresis, sleep-related painful erections, sundowner’s syndrome, sustained circadian asynchrony, sustained environmental stimulation, sustained uncomfortable sleep environment

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Rest, Sleep, Symptom Severity

Example NOC Outcome with Indicators

Sleep as evidenced by the following indicators: Hours of sleep/Sleep pattern/Sleep quality/Sleep efficiency/Feels rejuvenated after sleep/Sleeps through the night consistently. (Rate the outcome and indicators of Sleep: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes

Client Will (Specify Time Frame)

• Verbalize plan that provides adequate time for sleep

• Identify actions that can be taken to ensure adequate sleep time

• Awaken refreshed as soon as adequate time is spent sleeping

• Be less sleepy during the day as soon as adequate time is spent sleeping

NIC (Nursing Interventions Classification)

Suggested NIC Intervention

Sleep Enhancement

Example NIC Activities—Sleep Enhancement

Monitor/record client’s sleep pattern and number of sleep hours; Encourage client to establish a bedtime routine to facilitate transition from wakefulness to sleep

Nursing Interventions and Rationales

• Obtain a sleep history including amount of sleep obtained each night, use of medications and stimulants that may interfere with sleep amount, medical conditions and their treatment that limits sleep time, work and family responsibilities that limit sleep time, and daytime sequelae suggestive of sleep deprivation (e.g., drowsiness, inability to concentrate, slowed reactions). Assessment of sleep-wake behavior and patterns is an important part of any health status examination (Humphries, 2008; Salas & Gamaldo, 2011).

From the history, assess degree of sleep deprivation. Most healthy adults require 7.5 to 9 hours sleep per night to function optimally; children, adolescents, and the ill require additional hours of sleep (Carskadon & Dement, 2011).

From the history, identity factors leading to sleep deprivation. Factors that most frequently limit sleep time for outpatients are work demands (including extended work hours and shift work), social activities, and domestic responsibilities (including childcare and other family caregiving); for inpatients, the most frequent causes of sleep loss are medical conditions, their treatment, and excessive hospital noise and lighting (Banks & Dinges, 2011; Matthews, 2011).

Assess evening pain medication use and, when feasible, administer pain medications that promote rather than interfere with sleep. (See further Nursing Interventions and Rationales for Pain.) Some pain medications also promote sleep, whereas others promote alertness (Sateia, 2009).

Assess hypersensitivity to pain. EB: Sleep deprivation leads to increased sensitivity to pain (Roehrs, 2009).

Assess for underlying physiological illnesses causing sleep loss (e.g., cardiovascular, pulmonary, gastrointestinal, hyperthyroidism, nocturia occurring with benign hypertrophic prostatitis or pain). Symptomatology of physical disease states can interrupt and shorten sleep (Matthews, 2011; Sateia, 2009).

Assess for underlying psychiatric illnesses causing sleep loss (e.g., bipolar depression, anxiety disorders, schizophrenia). EB: Symptomatology of mental disease states can deprive the client of sleep (Sateia, 2009).

Monitor for nocturnal panic attacks. Refer for treatment as appropriate. EB: Numerous nocturnal events and symptoms such as panic attacks can contribute to sleep loss (Sateia, 2009).

Monitor for sleep disordered breathing (e.g., apneas and hypopneas) and accompanying daytime sleepiness. Refer for diagnosis by sleep specialists as appropriate. EBN: Sleep apnea often goes undiagnosed and deprives the client of deep sleep (Lamm et al, 2008; Sheldon et al, 2009-2010).

Monitor for presence of nocturnal symptoms of restless leg syndrome with uncomfortable restless sensations in legs that occur before sleep onset or during the night. Refer for treatment as appropriate. EB: Numerous nocturnal events and symptoms can contribute to sleep loss (Sateia, 2009).

Monitor for symptoms of overactive bladder. EBN: Women who self-report symptoms of overactive bladder have been found to experience sleep deficits (Newman & Koochaki, 2011).

Assess for chronic insomnia. See further Nursing Interventions and Rationales for Insomnia. Chronic insomnia leads to sleep deprivation (Matthews, 2011).

• Monitor caffeine intake. EB: Sleep-deprived persons often use stimulants to overcome negative effects of sleep deprivation; caffeine may be helpful in the temporary management of sleepiness, but overuse and late-day use can contribute to subsequent sleep disruption (Roehrs & Roth, 2008).

• Encourage napping as a way to compensate for sleep deprivation when severely restricted nighttime sleep cannot be avoided. Set a regular schedule for napping. EB: Regular sleep schedules that include strategically placed nap periods can supplement total amounts of sleep obtained per circadian period (Walsh et al, 2011).

• Minimize factors that disturb the client’s sleep by consolidating care. See Nursing Interventions and Rationales for Disturbed Sleep Pattern.

• Keep the sleep environment quiet (e.g., avoid use of intercoms, lower the volume on radio and television, keep beepers on nonaudio mode, anticipate alarms on intravenous [IV] pumps, talk quietly on unit). See Nursing Interventions and Rationales for Disturbed Sleep Pattern.

• Mask noise in sleep area if noise cannot be eliminated. See Nursing Interventions and Rationales for Readiness for enhanced Sleep.

Geriatric:

• Interventions identified previously may be adapted for use with geriatric clients.

• In addition, see the Geriatric Section of Nursing Interventions and Rationales for Disturbed Sleep Pattern.

Home Care:

• Interventions identified previously may be adapted for home care use. See the Home Care section of Nursing Interventions and Rationales for Disturbed Sleep Pattern.

• Teach family about the short-term and long-term consequences of inadequate amounts of sleep. EB: Insufficient sleep is associated with poor attention, decreased performance, increases in mortality and morbidity, and cardiovascular risk factors including hypertension, insulin resistance, hormonal deregulation, and inflammation (Mullington et al, 2009).

• Teach client/family about the need for those with chronic conditions to avoid schedules and commitments that interfere with obtaining adequate amounts of sleep. EBN: Clients with left ventricular assist devices obtained inadequate sleep persisting up to 6 months after surgery (Casida et al, 2011). EBN: Clients with poorly controlled asthma had less total sleep time and lower sleep efficiency than the person with well-controlled asthma (Babcock & Krouse, 2010).

• Promote adoption of behaviors that ensure adequate amounts of sleep for all family members. See Nursing Interventions and Rationales for Readiness for enhanced Sleep.

• Teach family about signs of sleep deprivation and how to avoid chronic sleep loss. See Nursing Interventions and Rationales for Disturbed Sleep Pattern.

• Advise against the sleep deprived person’s chronic use of stimulants (e.g., caffeine) to overcome daytime sequelae of sleep deprivation; focus on elimination of factors that lead to chronic sleep loss. EB: Caffeine may be helpful in the temporary management of sleepiness, but overuse and late-day use can contribute to subsequent sleep disruption and caffeine habituation (Roehrs & Roth, 2008).

References

Babcock, J., Krouse, H.J. Evaluating the sleep/wake cycle in persons with asthma: three case scenarios. J Am Acad Nurs Pract. 2010;22:270.

Banks, S., Dinges, D.F. Chronic sleep deprivation. In Kryger M.H., Roth T., Dement W.C., eds.: Principles and practice of sleep medicine, ed 5, St Louis: Saunders, 2011.

Carskadon, M.A., Dement, W.C. Normal human sleep. In Kryger M.H., Roth T., Dement W.C., eds.: Principles and practice of sleep medicine, ed 5, St Louis: Saunders, 2011.

Casida, J.M., et al. Sleep and daytime sleepiness of patients with left ventricular assist devices: a longitudinal pilot study. Prog Transplantation. 2011;21(2):131–136.

Humphries, J.D. Sleep disruption in hospitalized adults. Medsurg Nurs. 2008;17(6):391–395.

Lamm, J., et al. Obtaining a thorough sleep history and routinely screening for obstructive sleep apnea. J Am Acad Nurs Pract. 2008;20:225–229.

Matthews, E.E. Sleep disturbances and fatigue in critically ill patients. AACN Adv Crit Care. 2011;22(3):204–224.

Mullington, J.M., et al. Cardiovascular, inflammatory, and metabolic consequences of sleep deprivation. Prog Cardiovasc Dis. 2009;51(4):294–302.

Newman, D.K., Koochaki, P.E. Characteristics and impact of interrupted sleep in women with overactive bladder. Urologic Nurs. 2011;31(5):304–312.

Roehrs, T.A. Does effective management of sleep disorders improve pain symptoms? Drugs. 2009;69(Suppl 2):5–11.

Roehrs, T., Roth, T. Caffeine: sleep and daytime sleepiness. Sleep Med Rev. 2008;12(2):153–162.

Salas, R.E., Gamaldo, C.E. Diagnostic and therapeutic considerations in sleep disorders: case studies and commentary. J Clin Outcomes Manage. 2011;18(3):129–144.

Sateia, M.J. Update on sleep and psychiatric disorders. Chest. 2009;135(5):1370–1379.

Sheldon, A., et al. Nursing assessment of obstructive sleep apnea in hospitalised adults: a review of risk factors and screening tools. Contemp Nurse. 2009;34(1):19–33. [2010].

Walsh, J.K., et al. Sleep medicine, public policy, and public health. In Kryger M.H., Roth T., Dement W.C., eds.: Principles and practice of sleep medicine, ed 5, St Louis: Saunders, 2011.

Readiness for enhanced Sleep

Judith A. Floyd, PhD, RN, FAAN, Jean D. Humphries, PhD, MS, RN and Elizabeth S. Jenuwine, PhD, MLIS

NANDA-I

Definition

A pattern of natural, periodic suspension of consciousness that provides adequate rest, sustains a desired lifestyle, and can be strengthened

Defining Characteristics

Expresses willingness to enhance sleep; amount of sleep is congruent with developmental needs; reports being rested after sleep; follows sleep routines that promote sleep habits; occasional use of pharmaceutical agents to induce sleep

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Personal Well-Being, Rest, Sleep

Example NOC Outcome with Indicators

Sleep as evidenced by the following indicators: Hours of sleep/Sleep pattern/Sleep quality/Sleep efficiency/Feels rejuvenated after sleep/Napping appropriate for age. (Rate each indicator of Sleep: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes

Client Will (Specify Time Frame)

• Verbalize an interest in what constitutes normal sleep

• Verbalize an interest in nonpharmacological approaches to sleep promotion

• Establish an environment conducive to sleep initiation and maintenance throughout the night

NIC (Nursing Interventions Classification)

Suggested NIC Intervention

Sleep Enhancement

Example NIC Activities—Sleep Enhancement

Assess client’s sleep/activity pattern; Assist/encourage client to create an environment that facilitates sleep; Assist/encourage client to adopt personal practices that enhance sleep.

Nursing Interventions and Rationales

• Obtain a sleep history including bedtime routines, sleep patterns, use of medications and stimulants, and use of complementary/alternative medical practices for stress management and relaxation prior to bedtime. Assessment of sleep behavior and patterns is an important part of any health status examination (Humphries, 2008; Salas & Gamaldo, 2011).

From the history, assess the client’s ability to initiate and maintain sleep, obtain adequate amounts of sleep, and manage daytime responsibilities free from fatigue and sleepiness. CEB: Most adults who are satisfied with nighttime sleep average 7.5 to 9.0 hours of sleep per night (range of 6.5 to 10.0 hours) and fall asleep within 20 minutes initially and more quickly if awakened during the night; daytime is characterized by no naps or regularly scheduled brief naps, and little fatigue or sleepiness (Floyd, 2002). EBN: Gender and cultural beliefs influenced sleep patterns and sleep preferences (Sok, 2008). Difficulty sleeping is a side effect of psychoactive substances contained in foodstuffs, as well as prescription and OTC medications (Kloss et al, 2011; Woodward, 2012). CEB: Cigarette smokers took longer to fall asleep and had shorter and lighter nighttime sleep than nonsmokers; however, acute nicotine withdrawal caused even more sleep disruption (Zhang et al, 2006).

• Based on assessment, teach one or more of the listed sleep promotion practices as appropriate. EBN: In adult acute care settings, improved sleep quality and less use of sleeping medication was reported when multicomponent sleep promotion protocols were tested (Lareau et al, 2008).

Establish a regular schedule for sleep, exercise, napping, and mealtimes. Regular schedules are believed to promote sleep initiation and sleep maintenance by maintaining a circadian rhythm of alertness/drowsiness (Kloss et al, 2011; Woodward, 2012).

Avoid long periods of daytime sleep. CEB: Whereas regular, short napping in the morning or early afternoon improved mood and performance in older adults, long periods of sleep during the day appeared to replace nighttime sleep (Campbell et al, 2005).

Arise at the same time each day even if sleep was poor during the previous night. Although many factors can interfere with falling and staying asleep, forcing a regular arise time helps establish a circadian rhythm and ensure better sleep the following night (Kloss et al, 2011; Woodward, 2012).

If not contraindicated have high-glycemic-index carbohydrate dinner and/or bedtime snack. CEB: High-glycemic-index carbohydrate meals shortened sleep onset in adults (Afaghi et al, 2007).

Limit caffeine. Caffeine is one of the most widely consumed psychoactive substances and it has profound effects on sleep-wake function; there are several hidden sources of caffeine such as over-the-counter medications, soft drinks, and chocolate (Roehrs & Roth, 2008). EBN: Caffeine abstinence improves sleep quality (Sin et al, 2009).

Limit alcohol use. EBN: Limited alcohol use (one to two drinks) shortened time needed to fall asleep and increased depth of sleep the first 2 hours, but also suppressed REM sleep, which sometimes led to REM-rebound, that is, lighter, more fragmented sleep later in the night (Dean et al, 2010).

Avoid long-term use of sleeping pills. Long-term use of sleeping pills can be habit forming, and typically dependence and withdrawal symptoms occur while the therapeutic effect diminishes over time (Woelk et al, 2010; Woodward, 2012).

Engage in relaxing activities before bed. EBN: Several systematic reviews show that all forms of relaxation improve quantity and quality of sleep to some extent (Hellstrom et al, 2011).

Provide backrub or other forms of massage. EBN: Use of a back massage has been shown effective for promoting relaxation (Hellstrom et al, 2011).

Teach relaxation techniques. CEB: A systematic review showed both cognitive and behavioral relaxation techniques have shortened time to fall asleep (Wang et al, 2005). EBN: A meta-analysis of five RCTs showed that music-assisted relaxation led to a moderate improvement in sleep quality in clients with sleep complaints (de Niet et al, 2009).

Teach complementary and alternative interventions as culturally congruent. There is a growing body of research using complementary and alternative medicine that shows modalities such as tai chi, acupuncture, acupressure, yoga, and meditation have improved sleep in clinical populations (Gooneratne, 2008).

Lower lighting in sleep area. EB: Light affects hormonal secretions related to circadian rhythms of sleepiness (Bjorvatn & Pallesen, 2009).

Mask noise in sleep area when it cannot be eliminated. EBN: “White noise” (i.e., sounds covering the entire range of human hearing, e.g., ocean sounds) and music decrease time needed to fall asleep and nighttime awakenings (Hellstrom et al, 2011).

For anxious clients consider use of a lavender oil preparation in the health care setting. EB: A multisite clinical trial found scent of lavender lowered anxiety and improved self-reported sleep (Woelk et al, 2010).

Geriatric:

• Interventions discussed previously may be adapted for use with geriatric clients.

• Counsel the older adult regarding normal age-related changes in sleep: EB: As people age, increased time is needed to fall asleep; frequency and duration of waking after sleep onset increases; and, nighttime sleep amount tends to decrease (Woodward, 2012).

• Elicit the older adult’s expectations for sleep and correct misconceptions. The elderly person may be unduly concerned by normal age-related changes in sleep patterns; lighter sleep and occasional awakenings may be misconstrued as sleep disorders (Morin, 2011).

• Assess and refer as appropriate if coexisting conditions may be disrupting sleep. EBN: Depression, sleep apnea, and restless leg syndrome are commonly missed coexisting conditions in the elderly (Lamm et al, 2008; Woodward, 2012).

• Discuss appropriate and inappropriate self-help measures for improving sleep. EB: Older adults have been found to choose sleep interventions that can worsen rather than improve sleep (Gooneratne et al, 2011).

• Encourage walking and other exercise outdoors unless contraindicated. Exercise and exposure to natural light reinforce circadian rhythms that control sleep (Bjorvatn & Pallesen, 2009).

• Help elderly clients engage with others who enjoy similar events. Social interactions reinforce circadian rhythms that control sleep (Bjorvatn & Pallesen, 2009).

• Combine strength training, walking, and social activities when feasible. EBN: Nursing home residents had longer nighttime sleep when in combined exercise and social activity programs than when in either exercise or social activity programs alone (Richards et al, 2011).

Home Care:

• Interventions discussed previously may be adapted for home care use.

• Some complementary and alternative medicine interventions may be more easily tried at home than in health care facilities. EB: A multisite clinical trial found scent of lavender lowered anxiety and improved self-reported sleep (Woelk et al, 2010).

• Assess the conduciveness of the home environment for both caregivers and clients’ sleep. Many factors in the home environment can promote or interfere with the sleep readiness of clients/family members (Kloss et al, 2011; Woodward, 2012). EBN: A multicomponent sleep promotion program improved sleep quality in family caregivers of persons with dementia (Simpson & Carter, 2010). EB: Medium-firm bedding systems have been found to reduce pain and stiffness and improve sleep quality in the home (Jacobson et al, 2008).

References

Afaghi, A., et al. High-glycemic-index carbohydrate meals shorten sleep onset. Am J Clin Nutr. 2007;85(2):426–430.

Bjorvatn, B., Pallesen, S. A practical approach to circadian rhythm sleep disorders. Sleep Med Rev. 2009;13(1):47–60.

Campbell, S.S., et al. Effects of a nap on nighttime sleep and waking function in older subjects. J Am Geriatr Soc. 2005;53(1):48–53.

Dean, G.E., et al. Sleep in lung cancer: the role of anxiety, alcohol and tobacco. J Addict Nurs. 2010;21:130–137.

de Niet, G., et al. Music-assisted relaxation to improve sleep quality: meta-analysis. J Adv Nurs. 2009;65(7):1356–1364.

Floyd, J.A. Sleep and aging. Nurs Clin North Am. 2002;37:719–731.

Gooneratne, N.S. Complementary and alternative medicine for sleep disturbances in older adults. Clin Geriatr Med. 2008;24(1):121–138.

Gooneratne, N.S., et al. Perceived effectiveness of diverse sleep treatments in older adults. J Am Geriatr Soc. 2011;59:297–303.

Hellstrom, A., et al. Promoting sleep by nursing interventions in health care settings: a systematic review. Worldviews EBN (3rd quarter). 2011:128–142.

Humphries, J.D. Sleep disruption in hospitalized adults. Medsurg Nurs. 2008;17(6):391–395.

Jacobson, B.H., et al. Grouped comparisons of sleep quality for new and personal bedding systems. Appl Ergon. 2008;29(2):247–254.

Kloss, J.D., et al. The delivery of behavioral sleep medicine to college students. J Adolesc Health. 2011;48:553–561.

Lamm, J., et al. Obtaining a thorough sleep history and routinely screening for obstructive sleep apnea. J Am Acad Nurs Pract. 2008;20:225–229.

Lareau, R., et al. Examining the feasibility of implementing specific nursing interventions to promote sleep in hospitalized elderly patients. Geriatr Nurs. 2008;29(3):197–206.

Morin, C.M. Psychological and behavioral treatments for insomnia 1: approaches and efficacy. In Kryger M.H., Roth T., Dement W.C., eds.: Principles and practice of sleep medicine, ed 5, St Louis: Saunders, 2011.

Richards, K.C., et al. Strength training, walking, and social activity improve sleep in nursing home and assisted living residents: randomized controlled trial. J Am Geriatr Soc. 2011;59:214–223.

Roehrs, T., Roth, T. Caffeine: sleep and daytime sleepiness. Sleep Med Rev. 2008;12(2):153–162.

Simpson, C., Carter, P.A. Pilot study of a brief behavioral sleep intervention for caregivers of individuals with dementia. Res Gerontol Nurs. 2010;3(1):19–29.

Sin, C.M., et al. Systematic review on the effectiveness of caffeine abstinence on the quality of sleep. J Clin Nurs. 2009;18(1):13–21.

Sok, S.R. Sleep patterns and insomnia management in Korean-American older adult immigrants. J Clin Nurs. 2008;17(1):135–143.

Wang, M., et al. Cognitive behavioural therapy for primary insomnia: a systematic review. J Adv Nurs. 2005;50(5):553–564.

Woelk, H., et al. A multi-center, double-blind, randomised study of the lavender oil preparation Silexan in comparison to lorazepam for generalized anxiety disorder. Phytomedicine. 2010;17(2):94–99.

Woodward, M. Sleep in older people. Rev Clin Gerontol. 2012;22(2):130–149.

Zhang, L., et al. Cigarette smoking and nocturnal sleep architecture. Am J Epidemiol. 2006;164(6):529–537.

Disturbed Sleep Pattern

Judith A. Floyd, PhD, RN, FAAN, Jean D. Humphries, PhD, MS, RN and Elizabeth S. Jenuwine, PhD, MLIS

NANDA-I

Definition

Time-limited interruptions of sleep amount and quality due to external factors

Defining Characteristics

Change in normal sleep pattern, reports not feeling well rested, dissatisfaction with sleep, decreased ability to function, reports being awakened, reports no difficulty falling asleep

Related Factors

Ambient temperature, ambient humidity, caregiving responsibilities, change in daylight-darkness exposure, interruptions (e.g., for therapeutics, monitoring, lab tests), lack of sleep privacy/control, lighting, noise, noxious odors, physical restraint, sleep partner, unfamiliar sleep furnishings

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Personal Well-Being, Rest, Sleep

Example NOC Outcome with Indicators

Sleep as evidenced by the following indicators: Hours of sleep/Sleep pattern/Sleep quality/Sleep efficiency/Feels rejuvenated after sleep. (Rate the outcome and indicators of Sleep: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes

Client Will (Specify Time Frame)

• Verbalize plan to implement sleep promotion routines

• Maintain a regular schedule of sleep and waking

• Fall asleep without difficulty

• Remain asleep throughout the night

• Awaken naturally, feeling refreshed and is not fatigued during day

NIC (Nursing Interventions Classification)

Suggested NIC Intervention

Sleep Enhancement

Example NIC Activities—Sleep Enhancement

Determine client’s sleep/activity pattern; Encourage client to establish a bedtime routine to facilitate transition from wakefulness to sleep

Nursing Interventions and Rationales

• Obtain a sleep history including bedtime routines, number of times awakened during the night, noise and light levels in the sleep environment, and activities occurring in the sleep environment during hours of sleep. Assessment of sleep-wake behavior and patterns is an important part of any health status examination (Humphries, 2008; Salas & Gamaldo, 2011).

From the history, assess whether client has an opportunity for normal sleep. During a normal night of sleep, sleepers cycle from light sleep to deep sleep to dream (i.e., REM) sleep several times. Cycles take approximately 90 to 110 minutes each. The deepest sleep is obtained during the first two to three cycles or the first 3 to 4 hours of sleep. The amount of REM sleep obtained per cycle increases over the night. Both deep sleep and REM sleep are needed for the sleeper to have adequate sleep and feel refreshed on awakening. To obtain adequate deep sleep, the sleeper requires 3 to 4 hours of uninterrupted sleep at the beginning of the sleep period; to obtain adequate REM sleep, the sleeper needs additional 90-minute blocks of sleep the second half of the night (Carskadon & Dement, 2011).

From the history, assess environmental factors that interrupt sleep. Environmental factors that most frequently interrupt sleep in all settings are related to (a) the physical sleep environment and/or (b) activities of others in the sleep environment (Fontana & Pittiglio, 2010; Humphries, 2008).

• Assess level of pain. (See further Nursing Interventions and Rationales for Pain.) EB: Chronic pain leads to chronic sleep disruption (Zhang, 2012).

• If client has recurring pain, provide pain relief shortly before bedtime and position client comfortably for sleep. EB: If sleep disruption is not prevented, sleep deprivation will occur and increased hypersensitivity to pain may result (Roehrs, 2009).

• Keep environment quiet, room lighting dim, and bedding supportive of comfortable body alignment. See Nursing Interventions and Rationales for Readiness for enhanced Sleep.

• Offer earplugs and eye masks if feasible. CEB: Although not all clients found these aids comfortable to use and earplugs did not block all noise, some clients in critical care reported these aids improved their sleep quality (Richardson et al, 2007).

• Establish a sleeping and waking routine with regular times for sleeping and waking, including routines for preparing for sleep. See Nursing Interventions and Rationales for Readiness for enhanced Sleep.

• For hospitalized stable clients, consider instituting the following sleep protocol to a regular sleep-wake routine:

Night shift: Give the client the opportunity for uninterrupted sleep the first 3 to 4 hours of the sleep period. Keep environmental noise and light to a minimum. After major sleep period, allow 80 to 90 minutes between interruptions. (If client must be disturbed the first 3 to 4 hours, attempt to protect 90- to 110-minute blocks of time in between awakenings.) EBN: Several researchers have found that the high frequency of nocturnal care interaction allows clients few uninterrupted periods for sleep that are long enough for them to complete even one 90- to 110-minute sleep cycle (Missildine, 2008; Missildine et al, 2010).

Day shift: Encourage short morning and/or after-lunch naps as needed. Promote a physical activity regimen as appropriate. Schedule newly ordered medications to avoid the need to wake the client the first few hours of the night. EBN: Effective sleep promotion protocols have been developed for minimizing sleep disruption in intensive care settings (Matthews, 2011; Patel et al, 2008).

Evening shift: Limit napping. Encourage a suitable bedtime routine. At sleep time, lower intensity of room and unit lights and keep noise and conversation on the unit to a minimum. EBN: Spence et al (2011) found the top three noise-making events in a surgical unit were (a) overhead paging, (b) alarms on equipment, and (c) people talking in the hallway. EBN: A review of 10 studies conducted from 1995 to 2007 indicated that control of ambient stressors (e.g., lighting, noise, and sleep interruptions for care) improved sleep quality (Fontana & Pittiglio, 2010). EBN: Hospital noise was reduced following introduction of noise-reduction protocols (Richardson et al, 2009).

Geriatric:

• Most interventions identified previously are suitable for use with geriatric clients; however, be cautious about introducing earplugs and eye masks with ataxic clients and dementia clients, given that they may contribute to disorientation. Elderly clients should also be observed for nighttime safety risk due to increased incidence of sleep apnea with nocturia (Lamm et al, 2008; Phillips, 2011).

• Assessments for pain, anxiety, depression, sleep apnea, restless leg syndrome, and substance use/abuse are especially important in the elderly because sleep disruption is more common with the elderly and is made worse by these conditions (Matthews, 2011; Sateia, 2009).

• In addition see the Geriatric section of Nursing Interventions and Rationales for Readiness for enhanced Sleep.

Home Care:

• Interventions identified previously may be adapted for home care use.

• In addition, see the Home Care section of Nursing Interventions and Rationales for Readiness for enhanced Sleep.

Client/Family Teaching and Discharge Planning:

• Teach family about sleep and the importance of uninterrupted sleep during treatment and recovery.

• Teach family about signs of sleep deprivation, which may result from several environmental factors. See Nursing Interventions and Rationales for Sleep deprivation.

References

Carskadon, M.A., Dement, W.C. Normal human sleep: an overview. In Kryger M.H., Roth T., Dement W.C., eds.: Principles and practice of sleep medicine, ed 5, St Louis: Saunders, 2011.

Fontana, C.J., Pittiglio, L.I. Sleep deprivation among critical care patients. Crit Care Nurs Q. 2010;33(1):75–81.

Humphries, J.D. Sleep disruption in hospitalized adults. Medsurg Nurs. 2008;17(6):391–395.

Lamm, J., et al. Obtaining a thorough sleep history and routinely screening for obstructive sleep apnea. J Am Acad Nurs Pract. 2008;20:225–229.

Matthews, E.E. Sleep disturbances and fatigue in critically ill patients. AACN Adv Crit Care. 2011;22(3):204–224.

Missildine, K. Sleep and the sleep environment of older adults in acute care settings. J Gerontol Nurs. 2008;34(6):15–21.

Missildine, K., et al. Sleep in hospitalized elders: a pilot study. Geriatric Nurs. 2010;31(4):263–272.

Patel, M., et al. Sleep in the intensive care unit setting. Crit Care Nurs Q. 2008;31(4):309–320.

Phillips, B.A. Obstructive sleep apnea in the elderly. In Kryger M.H., Roth T., Dement W.C., eds.: Principles and practice of sleep medicine, ed 5, St Louis: Saunders, 2011.

Richardson, A., et al. Earplugs and eye masks: do they improve critical care patients’ sleep? Nurs Crit Care. 2007;12(6):278–286.

Richardson, A., et al. Development and implementation of a noise reduction intervention programme: a pre- and post-audit of three hospital wards. J Clin Nurs. 2009;18:3316–3324.

Roehrs, T., Roth, T. Caffeine: sleep and daytime sleepiness. Sleep Med Rev. 2008;12(2):153–162.

Salas, R.E., Gamaldo, C.E. Diagnostic and therapeutic considerations in sleep disorders: case studies and commentary. J Clin Outcomes Manage. 2011;18(3):129–144.

Sateia, M.J. Update on sleep and psychiatric disorders. Chest. 2009;135(5):1370–1379.

Spence, J., et al. Nighttime noise issues that interrupt sleep after cardiac surgery. J Nurs Care Qual. 2011;26(1):88–95.

Zhang, J. Insomnia, sleep quality, pain, and somatic symptoms: sex differences and shared genetic components. Pain. 2012;153:666–673.

Impaired Social Interaction

Gail B. Ladwig, MSN, RN

NANDA-I

Definition

Insufficient or excessive quantity or ineffective quality of social exchange

Defining Characteristics

Discomfort in social situations; dysfunctional interaction with others; family report of changes in interaction (e.g., style, pattern); inability to communicate a satisfying sense of social engagement (e.g., belonging, caring, interest, or shared history); inability to receive a satisfying sense of social engagement (e.g., belonging, caring, interest, or shared history); use of unsuccessful social interaction behaviors

Related Factors (r/t)

Absence of significant others; communication barriers; deficit about ways to enhance mutuality (e.g., knowledge, skills); disturbed thought processes; environmental barriers; limited physical mobility; self-concept disturbance; sociocultural dissonance; therapeutic isolation

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Child Development: Middle Childhood, Adolescence, Play Participation, Role Performance, Social Interaction Skills, Social Involvement

Example NOC Outcome with Indicators

Social Involvement as evidenced by the following indicator: Interacts with close friends, neighbors, family members, and members of work groups. (Rate the outcome and indicators of Social Involvement: 1 = never demonstrated, 2 = rarely demonstrated, 3 = sometimes demonstrated, 4 = often demonstrated, 5 = consistently demonstrated [see Section I].)

Client Outcomes

Client Will (Specify Time Frame)

• Identify barriers that cause impaired social interactions

• Discuss feelings that accompany impaired and successful social interactions

• Use available opportunities to practice interactions

• Use successful social interaction behaviors

• Report increased comfort in social situations

• Communicate, state feelings of belonging, demonstrate caring and interest in others

• Report effective interactions with others

NIC (Nursing Interventions Classification)

Suggested NIC Intervention

Socialization Enhancement

Example NIC Activities—Socialization Enhancement

Encourage patience in developing relationships, Help patient increase awareness of strengths and limitations in communicating with others

Nursing Interventions and Rationales

• Consider using a self-rating scale to assess social functioning. Social functioning is an important dimension to assess. EB: This scale seems to be a valuable instrument for the monitoring of social functioning in psychiatric clients (Zanello et al, 2006).

• Monitor the client’s use of defense mechanisms and support healthy defenses (e.g., the client focuses on present and avoids placing blame on others for personal behavior). EBN: Solution-focused techniques have been demonstrated to be beneficial. Therapy focuses on client’s present and future, capitalizing on the strengths and resources of the client and significant others around them (Wand, 2010).

• Spend time with the client. EBN: In this study of spirituality at end of life, presence was identified as important in itself. By his or her caring presence, the nurse identifies with the client in his or her suffering and conveys dignity, respect, and compassion (Milligan, 2011).

• Use active listening skills, including assessment and clarification of the client’s verbal and nonverbal responses and interactions. EBN: The best practice with regard to communication in palliative care could be achieved by using a sensitive assessment of how each client chooses to cope with his or her situation rather than by adopting a uniform approach to care (Lunney, 2006).

• Identify client strengths. Have the client make a list of strengths and refer to it when experiencing negative feelings. He or she may find it helpful to put the list on a note card to carry at all times. EB: Instillation of hope helps the client to see that his or her future can be better (Ruddick, 2008).

• Have group members support each other in a group setting. EB: Assertive community treatment (ACT) is beneficial in reestablishing or maintaining bonds between family, friends, and acquaintances (Tempier et al, 2012).

• Model appropriate social interactions. Give positive verbal and nonverbal feedback for appropriate behavior (e.g., make statements such as, “I’m proud that you made it to work on time and did all the tasks assigned to you without saying that your supervisor was picking on you”; make eye contact). If not contraindicated, touch the client’s arm or hand when speaking. CEB: Shared feelings increased communication with stroke and aphasia clients without words (Sundin, Jansson, & Norberg, 2000).

• Use role playing to increase social skills. EB: Role playing has been demonstrated to increase social functioning in clients with schizophrenia (Bellack, Brown, & Thomas-Lohrman, 2006).

• Use client-centered humor as appropriate. EB: Humor may be helpful in working with clients with depression (Bokarius et al, 2011).

• Consider use of animal therapy; arrange for visitation. EB: Equine-facilitated therapy (working with horses) is described as a parallel experience to working in groups, “social interaction” (Akaltun & Banning, 2012).

• Consider the use of the Internet and email to promote socialization. EBN: Use of the Internet was effective in providing social support and education for isolated rural women with chronic illness (Hill & Weinert, 2004). Email enabled engagement with a teenager with a mood disorder who had been difficult to communicate with (Roy & Gillett, 2008).

Refer client for behavioral interventions (life skills program) to increase social skills. EB: A commercially available, facilitator-administered or self-administered behavioral training product can have significant beneficial effects on psychosocial well-being in a healthy community sample (Kirby et al, 2006).

• Refer to care plans for Risk for Loneliness and Social Isolation for additional interventions.

Pediatric:

• Encourage social support for clients with visual and hearing impairments. EB: Research on Dutch adolescents with visual impairments indicates that social support, especially the support of peers, is important to adolescents with visual impairments (Kef, 2002). Social support is needed for mothers of children with hearing impairment, as it is a “hidden” disability (Dehkordi et al, 2011).

• Provide computers and Internet access to children with chronic disabilities that limit socialization. EB: Parents who had a child with Duchenne’s muscular dystrophy and were provided with a personal computer and email and Internet connectivity indicated that social isolation was felt to have been reduced, and an occupation, interest, and enjoyment provided for the boys and their families (Soutter, Hamilton, & Russell, 2004).

• Consider use of RAP therapy (therapy using rap music) in groups to advance social skills of urban adolescents. EB: Findings were unequivocally in favor of the RAP therapy as a tool for advancing prosocial behavior in three adolescent groups: violent offenders, status offenders, and a control condition of high school students with no criminal history (DeCarlo & Hockman, 2003).

• Consider residential wilderness treatment programs for adolescents with unsuccessfully treated mental health issues and antisocial behavior. In this study, 13 male adolescents in a 4-month residential wilderness program demonstrated increased self-esteem, improved social and problem-solving skills, and less aggressive behavior (Cook, 2008).

Geriatric:

• Encourage socialization through education, support groups, and programs for the elderly in the community. EB: Social participation has been found to be related to better functional skills, well-being, health-related quality of life, and survival (Dahan-Oliel, Gélinas, & Mazer, 2008). Neighborhood social cohesion may be protective against stroke mortality (Clark et al, 2011).

Assess the client’s potential or actual sensory problems with hearing and vision and make appropriate referrals if a problem is identified. EB: Sensory problems are common experiences within the older U.S. population, and there is substantial difficulty sustaining social participation activities (Crews & Campbell, 2004).

• Monitor for depression, a particular risk in the elderly. Depression is one of the most common mental health problems in later life that can often stop people from enjoying spending time with their families (Sims, 2009).

• Encourage group physical activity, such as aerobics or stretching and toning. EB: Where appropriate, the development of sport and physical activity opportunities for service users should be considered by mental health professionals (Carter-Morris & Faulkner, 2003).

• Consider having clients participate in playing Wii. EB: This study of elderly who played with the Wii experienced well-being, particularly social connection and enjoyment (Kahlbaugh et al, 2011).

• Have clients reminisce. EBN: This study demonstrated that reminiscence offers a possible intervention in treatment for older women (Stinson & Kirk, 2006).

• Refer to care plans for Adult Failure to Thrive, Risk for Loneliness, and Social Isolation for additional interventions.

Multicultural:

• Assess for the effect of racism on the client’s perceptions of social interactions. EB: In this study of clients in group drug treatment plans, women, but not men, of different races acted differently in mixed-race, mixed-gender cocaine treatment groups, with African-American women exhibiting fewer of several behaviors (Johnson, Connolly Gibbons, & Crits-Christoph, 2011).

• Approach individuals of color with respect, warmth, and professional courtesy. EBN: Physicians engaged in less client-centered communication with African-American clients than with Caucasian clients (Johnson et al, 2004). Minorities were significantly more likely to report being treated with disrespect or being looked down on in the client-provider relationship (Blanchard & Lurie, 2004).

• Validate the client’s feelings regarding social interaction. EBN: Research suggests that an increased risk of health pessimism among African American adults is due in part to race differences in the perception of interpersonal maltreatment (Boardman, 2004).

• Use interpreters as needed. EB: Primary care nurses act as gatekeepers to interpreting services (Gerrish et al, 2004).

• Refer to care plan Social Isolation for additional interventions.

Home Care:

• Previously discussed interventions may be adapted for home care use.

Refer to or support involvement with supportive groups and counseling. EB: Group settings provide the opportunity to practice new skills (Alfano & Rowland, 2006).

Client/Family Teaching and Discharge Planning:

Refer to appropriate social agencies for assistance (e.g., family therapy, self-help groups, creative activities, crisis intervention), especially individuals who are seriously ill. EB: Intensive psychotherapy may be most applicable to severely ill clients with bipolar disorder, whereas briefer treatments may be adequate for less severely ill clients (Miklowitz, 2006). Active involvement in creative activities promotes well-being and quality of life and increases social engagement (Bungay & Clift, 2010). Music therapy as an addition to standard care helps people with schizophrenia to improve their global state, mental state (including negative symptoms), and social functioning, if a sufficient number of music therapy sessions are provided by qualified music therapists (Mössler et al, 2011).

References

Akaltun, E., Banning, N. When the therapist is a horse. Ther Today. 23(2), 2012.

Alfano, C.M., Rowland, J.H. Recovery issues in cancer survivorship: a new challenge for supportive care. Cancer J. 2006;12(5):432–443.

Bellack, A.S., Brown, C.H., Thomas-Lohrman, S. Psychometric characteristics of role-play assessments of social skill in schizophrenia. Behav Ther. 2006;37(4):339–352.

Blanchard, J., Lurie, N. R-E-S-P-E-C-T: patient reports of disrespect in the health care setting and its impact on care. J Fam Pract. 2004;53(9):721–730.

Boardman, J.D. Health pessimism among black and white adults: the role of interpersonal and institutional maltreatment. Soc Sci Med. 2004;59(12):2523–2533.

Bokarius, A., et al. Attitude toward humor in patients experiencing depressive symptoms. Innov Clin Neurosci. 2011;8(9):20–23.

Bungay, H., Clift, S. Arts on prescription: a review of practice in the U.K. Perspect Public Health. 2010;130(6):277–281.

Carter-Morris, P., Faulkner, G. A football project for service users: the role of football in reducing social exclusion. J Ment Health Promot. 2003;2(1):7.

Clark, C.J., et al. Neighborhood cohesion is associated with reduced risk of stroke mortality. Stroke. 2011;42(5):1212–1217.

Cook, E.C. Residential wilderness programs: the role of social support in influencing self-evaluations of male adolescents. Adolescence. 2008;43(172):751–774.

Crews, J.E., Campbell, V.A. Vision impairment and hearing loss among community-dwelling older Americans: implications for health functioning. Am J Public Health. 2004;94(5):823–829.

Dahan-Oliel, N., Gélinas, I., Mazer, B. Social participation in the elderly: what does the literature tell us? Crit Rev Phys Rehabil Med. 2008;20(2):159–176.

DeCarlo, A., Hockman, E. RAP therapy: a group work intervention method for urban adolescents. Soc Work Groups. 2003;26(3):45–59.

Dehkordi, M., et al. Stress in mothers of hearing impaired children compared to mothers of normal and other disabled children. Audiology. 2011;20(1):128.

Gerrish, K., et al. Bridging the language barrier: the use of interpreters in primary care nursing. Health Soc Care Community. 2004;12(5):407–413.

Hill, W.G., Weinert, C. An evaluation of an online intervention to provide social support and health education. Comput Inform Nurs. 2004;22(5):282–288.

Johnson, J.E., et al. Gender, race, and group behavior in group drug treatment. Drug Alcohol Depend. 2011;119(3):e39–e45.

Johnson, R.L., et al. Patient race/ethnicity and quality of patient-physician communication during medical visits. Am J Public Health. 2004;94(12):2084–2090.

Kahlbaugh, P., et al. Effects of playing Wii on well-being in the elderly: physical activity, loneliness, and mood. Activ Adapt Aging. 2011;35(4):331–344.

Kef, S. Psychosocial adjustment and the meaning of social support for visually impaired adolescents. J Visual Impair Blind. 2002;96(1):22.

Kirby, E.D., et al. Psychosocial benefits of three formats of a standardized behavioral stress management program. Psychosom Med. 2006;68(6):816–823.

Lunney, M. Stress overload: a new diagnosis. Int J Nurs Terminol Classif. 2006;17(4):165–175.

Miklowitz, D.J. An update on the role of psychotherapy in the management of bipolar disorder. Curr Psychiatry Rep. 2006;8(6):498–503.

Milligan, S. Addressing the spiritual care needs of people near the end of life. Nurs Stand. 2011;26(4):47–56.

Mössler, K., et al. Music therapy for people with schizophrenia and schizophrenia-like disorders. Cochrane Database Syst Rev. (12):2011. [CD004025].

Roy, H., Gillett, T., E-mail: a new technique for forming a therapeutic alliance with high-risk young people failing to engage with mental health services? A case study, Clin Child Psychol Psychiatry 2008;(1):95–103.

Ruddick, F. Hope, optimism and expectation. Ment Health Pract. 2008;12(1):33–35.

Sims, B. New resources fight depression. Nurs Resident Care. 2009;11(2):59.

Soutter, J., Hamilton, N., Russell, P. The golden freeway: a preliminary evaluation of a pilot study advancing information technology as a social intervention for boys with Duchenne muscular dystrophy and their families. Health Soc Care Community. 2004;12(1):25–33.

Stinson, C.K., Kirk, E. Structured reminiscence: an intervention to decrease depression and increase self-transcendence in older women. J Clin Nurs. 2006;15(2):208–218.

Sundin, K., et al. Communicating with people with stroke and aphasia: understanding through sensation without words. J Clin Nurs. 2000;9(4):481.

Tempier, R., et al. Does assertive community outreach improve social support? Results from the Lambeth study of early-episode psychosis. Psychiatr Serv. 2012;63(3):216–222.

Wand, T. Mental health nursing from a solution focused perspective. Int J Ment Health Nurs. 2010;19(3):210–219.

Zanello, A., et al. Validation of the QFS measuring the frequency and satisfaction in social behaviours in psychiatric adult population. Encephale. 2006;32(1 Pt 1):45–59.

Social Isolation

Julianne E. Doubet, BSN, RN, CEN, NREMT-P

NANDA-I

Definition

Aloneness experienced by the individual and perceived as imposed by others and as a negative or threatening state

Defining Characteristics

Objective

Absence of supportive significant other(s); developmentally inappropriate behaviors; dull affect; evidence of handicap (e.g., physical, mental); exists in a subculture; illness; meaningless actions; no eye contact; preoccupation with own thoughts; projects hostility; repetitive actions; sad affect; seeks to be alone; shows behavior unaccepted by dominant cultural group; uncommunicative; withdrawn

Subjective

Developmentally inappropriate interests; experiences feelings of differences from others; inability to meet expectations of others; insecurity in public; reports feelings of aloneness imposed by others; reports feelings of rejection; reports inadequate purpose in life; reports values unacceptable to the dominant cultural group

Related Factors (r/t)

Alterations in mental status; alterations in physical appearance; altered state of wellness; factors contributing to the absence of satisfying personal relationships (e.g., delay in accomplishing developmental tasks); immature interests; inability to engage in satisfying personal relationships; inadequate personal resources; unaccepted social behavior; unaccepted social values

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Loneliness Severity, Mood Equilibrium, Personal Well-Being, Play Participation, Social Anxiety Level, Social Interaction Skills, Social Involvement, Social Support

Example NOC Outcome with Indicators

Client Outcomes

Client Will (Specify Time Frame)

• Identify feelings of isolation

• Practice social and communication skills needed to interact with others

• Initiate interactions with others; set and meet goals

• Participate in activities and programs at level of ability and desire

• Describe feelings of self-worth

NIC (Nursing Interventions Classification)

Suggested NIC Intervention

Socialization Enhancement

Example NIC Activities—Socialization Enhancement

Encourage patience in developing relationships; Help patient increase awareness of strengths and limitations in communicating with others

Nursing Interventions and Rationales

• Establish a therapeutic relationship with the client. EBN: Effective communication will increase the ability of the nurse to meet the individual needs of the client (Weaver, 2011). EBN: Nurses are one of the fundamental client advocate groups that promotes the prevention of social isolation (Wilson, Harris, & Hollis, 2011).

• Observe for barriers to social interaction: physical, emotional, and environmental. EBN: In determining the extent of a client’s social isolation, it is important to include the observation of his/her number of contacts, feelings of belonging, fulfilling relationships, and the quality of their engagement with others (Nicholson, 2009).

• Note risk factors. EB: Clients with social isolation and loneliness are at a greater risk for inactivity, smoking, and multiple health-endangering behaviors (Shankar et al, 2011). EB: Social isolation has been shown to be damaging to health (Fiorello & Sabatini, 2011). Individuals recovering from a stroke often experience social isolation (Hinojosa, Haun, & Hinojosa, 2011).

• Discuss/assess causes of perceived or actual isolation. EB: Aging causes a natural tendency to become detached from the activities and places that defined him/her; this disconnect may be accentuated by loss of a spouse, retirement, relocation, illness, and other factors (Schum & Sjolander, 2011).

• Allow the client opportunities to describe his or her daily life and to introduce any issues that may be of concern. EBN: This will assist in the determination of specific health care interventions necessary for the individual client—especially in the isolated and aging populations—the trend seems to be moving toward community-based health care (Greaves & Rogers-Clark, 2011).

• Promote social interactions. Support the expression of feelings. EBN: Social rehabilitation was identified as an active process, in which the client’s environment, activities, social interaction, self-recognition, awareness of social problems, coping strategies, and satisfaction play an important role (Portillo & Cowley, 2011).

• Assist the client in identifying specific health and social problems and involve them in their resolution. EBN: The outcome of a client’s disclosures may include resolution, reassurance, and assistance gained, but may also open the client to rejection and/or negative repercussions; nurses must recognize the significance of disclosed subject matter and act on these disclosures with sensitivity (Saiki & Lobo, 2011).

• Assist the client in identifying acceptable activities that encourage socialization. Studies have shown that people with regular social connections present with significantly less cognitive decline when compared to those who are lonely and/or isolated (Ristau, 2011).

• Identify available personal support systems and involve those individuals in the client’s care. EB: Both professional medical and client groups have called for increased participation of clients’ informal support networks in chronic disease care, as a means to help improve both clinical status and disease self-management (Rosland et al, 2011).

Refer clients to support groups as necessary. EBN: This study extended prior research that indicated the intervention of a nurse practitioner (NP) and social worker, together with a geriatrics disciplinary team, bettered the quality of care offered home-based, low-income elderly (Ganz, Koretz, & Bail, 2010).

• Encourage liberal visitation for a client who is hospitalized or in an extended care facility (ECF). EBN: This study proposes that a volunteer “befriending” service for older people confined to an extended care facility has positive effects for the residents who appreciated the chance to discuss personal issues significant to them—including loneliness—with another adult (Downey, 2011). EBN: Visits from those who are in a close socially connected network were associated with perceived support, and this was associated with a decrease in isolation (Wilkinson & McAndrew, 2008).

• Help the client identify role models and encourage interactions with others with similar interests. Technology may be helpful in finding others with similar interests. As technology becomes an increasing component in the formation of social skills, literature supports the use of video-modeling interventions through the use of electronic communication devices to model sought-after behaviors that can be imitated (Whalen, Franke, & Brady, 2011).

• See the care plan for Risk for Loneliness.

Pediatric:

Refer obese adolescents for diet, exercise, and psychosocial support. EB: Obese adolescent females are at greater risk for smoking addiction in young adulthood than their normal-weight peers (Hussaini, Nicholson, & Shera, 2011). Adolescents who are overweight may experience the harmful effects of obesity on psychological constructs, including concepts of beauty, body image, and satisfaction, which all add to the psychological attitudes and impressions about personal worth and self-image (Pratt, 2009).

Assess socially isolated adolescents for substance abuse. Refer to appropriate organizations for support and treatment. EB: Psychological therapy is the chief method of adolescent substance abuse management, with pharmacological interventions as an adjunct (Greydanus, Feucht, & Patel, 2010). Adolescent substance abuse is a public health problem that requires more effective treatment options and approaches (Killeen, McCrae-Clark, & Waldrop, 2012; McCay, Cole, & Sumnall, 2011).

Geriatric:

• Assess physical and mental status to establish a firm basis for planning social activities. EB: Older people who are less able, or unable, to adapt to the changes that come with aging have been found to be more susceptible to poor physical and mental health (Schum & Sjolander, 2011). This study involving older adults in a problem-solving therapy group demonstrated that clients were at least twice as likely as the health care professional to identify their problems (Enguidanos et al, 2011).

• Assess for hearing deficit. Provide aids and use adaptive techniques. EBN: Because hearing loss is more prevalent with aging, it is important that the nurse be aware of options open to older adults with hearing loss; early detection is essential (Harkin & Kelleher, 2011).

• Encourage physical closeness if appropriate. EBN: Empathetic touch, when used with a particular purpose, conveys the nurse’s concern and becomes a potent means of intervention (Playfair, 2010). EBN: Touch helps with integration and fosters social relatedness. Tactile stimulation benefits the older adult’s psychological well-being (Routasalo et al, 2009).

• Involve client in goal-setting and planning activities. EBN: Assessment of an older person’s goals, as identified by the individual in need of home care, allows the health care provider to personalize the client’s activities, which then leads to betterment of the client’s quality of life (Parsons, Rouse, & Robinson, 2012). EBN: Involvement in participation of goal setting and planning of social activities enhanced both their anticipation and their participation in the activities (Toofany, 2008).

• Involve nonprofessionals in activities, projects, and goal setting with the client. Activities might include engaging in arts and crafts, reading, playing games, and music therapy. EBN: Group music therapy relieved agitated activity in the elderly who suffer from dementia and promoted emotional relaxation, encouraged interpersonal interactions, and appeared to reduce further agitated episodes (Lin et al, 2011). EBN: A recognized intervention for loneliness is to provide opportunities and assistance for making choices, setting goals, and making decisions. Cognitively impaired clients may require several repetitions (Routasalo et al, 2009).

• Suggest varied social activities that would decrease isolation and encourage participation. EB: Social activity is positively associated with reduced risks of impairment in activities of daily living; mobility; and the utilization of agents involved in the activities of daily life, among community-living elderly (James, Boyle, & Bennett, 2011). EB: Social encounters and significant relationships are vital determining factors for the quality of life that the elderly experience (Brownie & Horstmanshof, 2011).

• Position clients in group interventions according to abilities, age, life situations, preferences, and personal and cultural characteristics. EB: In this study, psychosocial group rehabilitation was associated with lower mortality and less use of health services (Pitkala et al, 2009).

• Consider the use of simulated presence therapy (see the care plan for Hopelessness) for clients with cognitive distress. EB: Video of the simulated presence of a family member appeared to reduce unwillingness of the adult with dementia to involve himself in basic, everyday self-care tasks (O’Connor et al, 2011).

Consider using computers and the Internet to alleviate or reduce loneliness and social isolation. EB: The results of this study showed that that Internet and computer activity can increase the quality of life in older, isolated persons, particularly in regard to life satisfaction, well-being, and empowerment, while decreasing depression and feelings of loneliness (McComish, Peura, & Richardson, 2010). EBN: Internet use was found to decrease loneliness and depression significantly, while perceived social support and self-esteem increased significantly (Sum et al, 2009).

Multicultural:

• Acknowledge racial/ethnic differences at the onset of care. EBN: It is necessary for nurses to be aware of cultural differences, be responsive to clients’ needs, and include them in the plan of care (Kwok & White, 2011).

• Assess for the influence of cultural beliefs, norms, and values. EB: This study defines “cultural loneliness” as a state where one is lonely in a foreign culture and does not feel understood or able to explain cultural meanings; culture helps shape loneliness and in turn is shaped by it (van Staden & Coetzee, 2010). EB: This review of literature reemphasizes the key factors that should be in the forefront when assessing the needs of Latinos; immigration and migration concerns, work experience, acculturalization, and health inequities (Furman, Negi, & Iwamoto, 2009).

• Assess personal space needs, communication styles, acceptable body language, attitude toward eye contact, perception of touch, and paraverbal messages when communicating with the client. EBN: This study concludes that nurses who had positive experiences with people from other cultures were motivated to gain deeper understanding of that culture and more profound awareness of cultural diversity so that they might meet the cultural needs of their clients, but it was also admitted that the nurse’s past experiences may have led to preconceived ideas about specific cultures and their practices (Huang, Yates, & Prior, 2010).

• Use a culturally competent, professional approach when working with clients of various ethnic groups. EBN: Health care professionals must first acknowledge their own beliefs, then be open-minded to the cultural and religious differences of their clients and the effect that illness and/or surgery can have on those clients (Black, 2011).

• Promote a sense of ethnic attachment. EBN: Provide care in a way that respects and considers the client’s cultural and religious needs (Black, 2011).

• Assess the client’s feelings regarding social isolation. EBN: In this study of African American women with breast cancer, it is suggested that personal stress can be measured by the level of the client’s isolation and proposed that nurses should generate interventions to decrease that isolation and assist clients in developing supportive bonds with other clients and community members (Heiney et al, 2011).

• Assist those ethnic minorities who are underserved to access essential health care. EB: This study demonstrates that for successful breast cancer screening of underserved women to occur, it is important to take into consideration their racial and/or ethnic backgrounds, socioeconomic status, command of English, and basic access to health care (Pruthi, Schmidt, & Sherman, 2010).

Home Care:

• The interventions described previously may be adapted for home care use.

• Confirm that the home setting has a health-safety communication system that is user friendly. EB: Those older persons who are socially isolated and have no support are especially vulnerable in an emergency, and their preparation to react to a disaster is questionable (Staley, Alemagno, & Straffer-King, 2011).

• Consider the use of the computer and Internet to decrease isolation. EB: Computer and Internet use appears to be a significant part of leisure time among older adults, and satisfaction with Internet usage may be contributory to their well-being (Heo, Kim, & Won, 2011). EB: This study illustrates the connection between computer and Internet use and the older adults’ feelings of well-being; their cognitive abilities; and sense of independence (Shapira, Barak, & Gal, 2007).

• Assess options for living that allow the client privacy, but not isolation. EB: In this study it was reported that older women living alone not only were lonely, but also had fewer years of education, increased mobility problems, and were more frail than those living with others (Bergland & Engedal, 2011). EB: In this Scandinavian study, it was found that affordable, decent, and appropriate noninstitutional housing, along with the availability of service stipulations, played an indispensable role in the lives of older adults (van Bilsen et al, 2008).

• Assist clients to interact with neighbors in the community when they move to supported housing. EB: The participants in this study, residents of supported housing, reported that it was important to them to feel a part of the community when interacting with their neighbors, especially in regard to neighbor relations, community safety, neighborhood satisfaction, and tolerance of mental illness (Townley & Kloos, 2011).

Client/Family Teaching and Discharge Planning:

• Assist the client in initiating contacts with self-help groups, counselors, and therapists. EBN: Appropriate interventions are needed to educate the client concerning the problems caused by loneliness; the proper management of chronic disease; referrals, not only to monitor physical status, but also to enhance social networking; and referrals to social services to address personal needs (Jarve & Dool, 2011; Theeke, 2010).

• Provide information to the client about senior citizen services and community resources. EB: Many older adults rely on senior centers and other aspects of aging services and social service programs for their basic needs, to maintain their health and independence, and to decrease the effects of social isolation (Barios-Paoli, 2011). EB: This study indicated that accomplishment of social roles is, for the majority of participants, more significant than daily activities (Levasseur, St-Cyr Tribble, & Desrosiers, 2009).

• Refer socially isolated caregivers to appropriate support groups as well. EBN: Nurses demonstrate a keen knowledge of the needs of relatives and reported efficacious interventions in supporting those needs (Buckley & Andrews, 2011).

• See the care plan for Caregiver Role Strain.

References

Barios-Paoli, L. Innovative senior centers. Care Manag J. 2011;12(2):50–53.

Bergland, A., Engedal, K. Living arrangements, social networks, health, mobility, and balance of older women. Phys Occup Ther Geriatr. 2011;29(2):90–101.

Black, P. Understanding religious beliefs of patients needing a stoma. Gastrointest Nurs. 2011;9(10):17–22.

Brownie, S., Horstmanshof, L. The management of loneliness in aged care residents: an important therapeutic target for gerontological nursing. Geriatr Nurs. 2011;32(5):318–325.

Buckley, P., Andrews, T. Intensive care nurses’ knowledge of critical care family needs. Intensive Crit Care Nurs. 2011;27(5):263–272.

Downey, J. Befriending in care homes: the results of a pilot study. Nurs Residential Care. 2011;13(8):395–397.

Enguidanos, S., et al. Patient-centered approach to building problem solving skills among older primary care patients: problems identified and resolved. J Gerontol Soc Work. 2011;54(3):276–291.

Fiorello, D., Sabatini, F. Quality and quantity: the role of social interactions in self-reported individual health. Soc Sci Med. 2011;73(11):1644–1652.

Furman, R., Negi, N., Iwamoto, D. Social work practice with Latinos: key issues for social workers. Soc Work. 2009;54(2):167–174.

Ganz, D., Koretz, B., Bail, K. Nurse practitioner comanagement for patients in an academic geriatric practice. Am J Manage Care. 2011;16(12):343–355.

Greaves, M., Rogers-Clark, C. “Once I became a pensioner I became a nobody—a non-entity”: the story of one woman’s experience of the health care system. Contemp Nurs. 2011;37(2):204–212.

Greydanus, D., Feucht, C., Patel, D. Pharmacologic management of substance abuse disorders in adolescents: current concepts. Int J Adolesc Health. 2010;3(2):255–264.

Harkin, H., Kelleher, C. Caring for older adults with hearing loss. Nurs Older People. 2011;23(9):22–28.

Heiney, S., et al. Antecedents and mediators of community connection in African American women with breast cancer. Res Theory Nurs Pract. 2011;25(4):252–270.

Heo, J., Kim, J., Won, Y.S. Exploring the relationship between Internet use and leisure satisfaction among older adults. Activities Adapt Aging. 2011;35(1):43–54.

Hinojosa, R., Haun, J., Hinojosa, M. Social isolation poststroke: relationship between race/ethnicity, depression, and functional independence. Top Stroke Rehabil. 2011;18(1):79–86.

Huang, Y., Yates, P., Prior, D. Factors influencing oncology nurses’ approaches to accommodating cultural needs in palliative care. J Clin Nurs. 2010;19(7-8):1179–1181.

Hussaini, A., Nicholson, L., Shera, D. Adolescent obesity as a risk factor for high-level nicotine addiction in young women. J Adolesc Health. 2011;18(5):511–517.

James, B., Boyle, P., Bennett, D. Relation of late-life social activity with incident disability among community-dwelling older adults. J Gerontol A Biol Sci Med Sci. 2011;66(4):467–473.

Jarve, R., Dool, D. Simple tools to increase patient satisfaction with the referral process. Fam Pract Manage. 2011;18(6):9–14.

Killeen, T., McCrae-Clark, A., Waldrop, A. Contingency management in community programs treating adolescent substance abuse: a feasibility study. J Child Adolesc Psychiatr Nurs. 2012;25(1):33–41.

Kwok, C., White, K. Cultural and linguistic isolation: the breast cancer experience of Chinese-Australian women—a qualitative study. Contemp Nurse. 2011;30(1):85–94.

Levasseur, M., St-Cyr Tribble, D., Desrosiers, J. Meaning of quality of life for older adults: importance of human functioning components. Arch Gerontol Geriatr. 2009;49(2):e91–e100.

Lin, Y., et al. Effectiveness of group music intervention against agitated behavior in elderly persons with dementia. Int J Geriatr Psychiatry. 2011:670–678.

McCay, M., Cole, J., Sumnall, H. Teenage thinking on teenage drinking: 15 to 16-year olds’ experiences of alcohol in Northern Ireland. Drugs Educ Prev Policy. 2011;18(5):323–332.

McComish, H., Peura, C., Richardson, N. Computer and Internet engagement for older adults. Activ Dir Q Alzheimers Other Demen Patient. 2010;11(3):43–46.

Nicholson, N. Social isolation in older adults: an evolutionary concept analysis. J Adv Nurs. 2009;65(6):1342–1350.

O’Connor, C., et al. Using video simulated presence to reduce resistance to care and increase participation of adults with dementia. Am J Alzheimers Dis Other Demen. 2011;26(4):317–325.

Parsons, J., Rouse, P., Robinson, M. Goal setting as a feature of homecare services for older people: does it make a difference? Age Ageing. 2012;40(1):24–29.

Pitkala, K., et al. Effects of psychosocial group rehabilitation on health, use of health care services, and mortality of older persons suffering from loneliness: a randomized, controlled trial. J Gerontol A Biol Sci Med Sci. 2009;64(7):792–800.

Playfair, C. Human relationships: an exploration of loneliness and touch. Br J Nurs. 2010;19(2):122. [124–126].

Portillo, M., Cowley, S. Social rehabilitation in long-term conditions: learning about the process. J Adv Nurs. 2011;67(6):1329–1340.

Pratt, H. Psychological issues in obesity. Int J Child Health Hum Dev special issue. 2009:369–376.

Pruthi, S., Schmidt, E., Sherman, M. Promoting a breast cancer screening clinic for underserved women: a community collaboration. Ethnicity Dis. 2010;20(4):463–466.

Ristau, S. People do need people: social interaction boosts brain health in older age. Generations. 2011;35(2):70–76.

Rosland, A., et al. Family and friend participation in primary care visits of patients with diabetes or heart failure: patient and physician determinants and experiences. Med Care. 2011;49(1):37–45.

Routasalo, P., et al. Effects of psychosocial group rehabilitation on social functioning, loneliness and well-being of lonely, older people: randomized controlled trial. J Adv Nurs. 2009;65(2):297–305.

Saiki, L., Lobo, M. Disclosure: a concept analysis. J Adv Nurs. 2011;67(12):2713–2722.

Schum, D., Sjolander, M. The impact of connectivity for the older patient. Hear J. 2011;64(6):44. [46, 48–50].

Shankar, A., et al. Loneliness, social isolation, and behavioral and biological health indicators in older adults. Health Psychol. 2011;4:377–385.

Shapira, J., Barak, A., Gal, I. Promoting older adults’ well-being through Internet training and use. Aging Ment Health. 2007;11(5):477–484.

Staley, J., Alemagno, S., Straffer-King, P. Senior adult emergency preparedness: what does it really mean? J Emerg Manage. 2011;9(6):47–55.

Sum, S., et al. Internet use as a predictor of sense of community in older people. Cyberpsychol Behav. 2009;12(2):235–239.

Theeke, L. Sociodemographic and health-related risks for loneliness and outcome differences by loneliness status in a sample of U.S. older adults. Res Gerontol Nurs. 2010;3(2):113–125.

Toofany, S. How to promote a healthier tomorrow. Nurs Older People. 2008;20(2):17–20.

Townley, G., Kloos, B. Examining the psychological sense of community for individuals with serious mental illness residing in supported housing environments. Community Ment Health. 2011;47(2):436–446.

van Bilsen, P., et al. Sheltered housing compared to independent housing in the community. Scand J Caring Sci. 2008;22(2):265–274.

van Staden, W., Coetzee, K. Conceptual relations between loneliness and culture. Curr Opin Psychiatry. 2010;23(6):524–527.

Weaver, D. Introduction to communication in social care. Nurs Residential Care. 2011;13(2):60–64.

Whalen, C., Franke, L., Brady, L. Teaching social skills using video modeling interventions. Perspect Sch Based Issues. 2011;12(2):41–48.

Wilkinson, C., McAndrew, S. “I’m not an outsider, I’m his mother!” A phenomenological enquiry into carer experiences of exclusion from acute psychiatric settings. Int J Ment Health Nurs. 2008;17(6):392–401.

Wilson, D., Harris, A., Hollis, V. Upstream thinking and health promotion planning for older adults at risk of social isolation. Int J Older People Nurs. 2011;6(4):282–288.

Chronic Sorrow

Patricia White, PhD, ANP-BC and Betty Ackley, MSN, EdS, RN

NANDA-I

Definition

Cyclical, recurring, and potentially progressive pattern of pervasive sadness experienced (by parent, caregiver, individual with chronic illness or disability) in response to continual loss throughout the trajectory of an illness or disability

Defining Characteristics

Reports feelings of sadness (e.g., periodic, recurrent); reports feelings that interfere with ability to reach highest level of personal well-being; reports feelings that interfere with ability to reach highest level of social well-being; reports negative feelings (e.g., anger, being misunderstood, confusion, depression, disappointment, emptiness, fear, frustration, guilt, helplessness, hopelessness, low self-esteem, being overwhelmed, recurring loss, self-blame)

Related Factors (r/t)

Crisis in management of the disability; crises in management of the illness; crises related to developmental stages; death of a loved one; experiences chronic disability (e.g., physical or mental); experiences chronic illness (e.g., physical or mental); missed opportunities; missed milestones; unending caregiving

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Acceptance: Health Status, Depression Level, Depression Self-Control, Grief Resolution, Hope, Mood Equilibrium

Example NOC Outcome with Indicators

Grief Resolution with plans for a positive future as evidenced by the following indicators: Describes meaning of loss or death/Reports decreased preoccupation with loss/Reports adequate nutritional intake/Reports adequate sleep/Expresses positive expectations about the future.

(Rate the outcome and indicators of Grief Resolution: 1 = never demonstrated, 2 = rarely demonstrated, 3 = sometimes demonstrated, 4 = often demonstrated, 5 = consistently demonstrated [see Section I].)

Client Outcomes

Client Will (Specify Time Frame)

• Express appropriate feelings of guilt, fear, anger, or sadness

• Identify problems associated with sorrow (e.g., changes in appetite, insomnia, nightmares, loss of libido, decreased energy, alteration in activity levels)

• Seek help in dealing with grief-associated problems

• Plan for future one day at a time

• Function at normal developmental level

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Grief Work Facilitation, Grief Work Facilitation: Perinatal Death

Example NIC Activities—Grief Work Facilitation

Encourage client to verbalize memories of loss, both past and current; Assist client in identifying personal coping strategies

Nursing Interventions and Rationales

• Determine the client’s degree of sorrow. Use the Burke/NCRS Chronic Sorrow Questionnaire for the individual or caregiver as appropriate. This questionnaire is designed to determine the occurrence of chronic sorrow, cues that trigger sorrow, coping strategies, and factors that direct health care personnel to deal with the sorrowful client or caregiver (Isaksson & Ahlstrom, 2008).

• Identify problems of eating and sleeping; ensure that basic human needs are being met. Bereaved individuals are at a risk for poor nutrition.

• Develop a trusting relationship with the client by using empathetic therapeutic communication techniques. EB: An empathetic person who takes the time to listen, offers support and reassurance, recognizes and focuses on feelings, and appreciates the uniqueness of each individual and family is helpful to clients experiencing chronic sorrow (Isaksson & Ahlstrom, 2008).

• Help the client to understand that sorrow may be ongoing. No timetable exists for grieving, despite popular thought. After loss, life is characterized by good times and bad times when sorrow is triggered by events. EBN: Loss of a child results in lifelong grief (Arnold & Gemma, 2008). Studies have demonstrated that feelings of sadness, guilt, anger, frustration, and fear occur periodically throughout the lives of people experiencing chronic loss resulting in chronic sorrow (Isaksson & Ahlstrom, 2008).

• Help the client recognize that, although sadness will occur at intervals for the rest of his or her life, it will become bearable. CEB: In time the client may develop a relationship with grief that is lifelong but livable, and as much filled with comfort as it is with sorrow (Moules et al, 2007). CEB: A study showed that the common belief about the need for resolving grief is not helpful to the bereaved, but rather, grief’s presence may contribute to a new relationship with the deceased over time (Moules et al, 2004). As the grief resolves, there can be times of satisfaction and even happiness (Clements et al, 2004).

• Give anticipatory guidance about life events when the families might experience renewed feelings of loss. Chronic sorrow triggers (Masterson, 2010) might include developmental milestones such as when the loved one would have graduated from school, birthdays, when same-aged family members are getting married and having children.

• Encourage the use of positive coping techniques:

Taking action: Suggested strategies include keeping busy, keeping personal interests, going away, getting out of the house, doing something to gain a feeling of control over life.

Cognitive coping: Techniques include concentrating on the positive aspects of life, having a “can do” attitude, taking one day at a time, and taking responsibility for the quality of one’s own life. Encourage the client to write about the experience.

Interpersonal coping: Techniques include talking to a close friend, a health care professional, or someone with the same condition or circumstance. Joining a support group can also help the sorrowful person to cope.

Emotional coping: Encourage the client to express feelings both to other people and to write out feelings, cry as desired, give thanks, and pray if desired.

EBN: Clients with chronic sorrow have found these coping techniques helpful (Isaksson & Ahlstrom, 2008).

• Expect the client to meet responsibilities; give positive reinforcement for planning how to meet responsibilities, and for accomplishing responsibilities.

Encourage the client to make time to talk to family members about the loss with the help of professional support as needed and without criticizing or belittling each other’s feelings about the loss. Once these feelings are shared, family members can better begin to accept the chronic loss, hopefully develop coping strategies, and begin collaborative goal setting (Lowden & Fabijan, 2010). EBN: A study found that supportive family members were very helpful to clients with chronic sorrow from multiple sclerosis (Isaksson & Ahlstrom, 2008).

• Help the client determine the best way and place to find social support. EBN: Social support is shown to help bereaved individuals as they put their lives back together and find new meaning in life (Isaksson & Ahlstrom, 2008).

• Monitor for symptoms of exhaustion, isolation, and, potentially, loss of hope and dreams as potential indicators of caregiving burden and burnout (Masterson, 2010). EBN: Caregivers for chronically ill spouses and children commonly experience symptoms of sorrow (Hewetson & Singh, 2009). See care plan for Caregiver Role Strain.

Identify available community resources, including grief counselors or support groups available for specific losses (e.g., Multiple Sclerosis Society). CEB: Psychoeducational, group activity and self-assessment caused suicide rates to decrease among elderly females in a Japanese culturally sensitive intervention study (Oyama et al, 2005).

Identify whether the client is experiencing depression, suicidal tendencies, or other emotional disorders. Refer for counseling as appropriate.

Pediatric:

• Treat the child with respect, give him or her the opportunity to talk about concerns, and answer questions honestly. Children know much more than adults realize. They are very observant and generally know if a parent or loved one is dying, or cause of death, even if they have not been told (Schuurman, 2012).

• Listen to the child’s expression of grief. The best thing to be done to help a child is to listen with our ears, eyes, hearts, and souls, and recognize that we do not have to have answers (Brown, 2009; Schuurman, 2012).

• Help parents recognize that the grieving child does not have to be “fixed”; instead, he needs support going through an experience of grieving just as adults do. The role of the nurse, parent, and friends is to support and assist, not to help him or her “get over it” (Schuurman, 2012).

• Consider the use of art for children in hospice care who are dying or dealing with the death of a parent, sibling, or other family member.

Refer grieving children and parents to a program to help facilitate grieving if desired, especially if the death was traumatic. EBN: When a child dies, the parent embarks on a lifelong grief for the loss, and sharing the grief can help the parent (Arnold & Gemma, 2008). EBN: A case study demonstrated that identifying and reinforcing the mother’s strengths in caring for a child with serious health problems helped in dealing with emotional responses of hopelessness and helplessness (Bettle & Latimer, 2009).

• Help the adolescent determine sources of support and how to use them effectively.

Encourage parents in chronic sorrow to seek mental health services as needed, learn stress reduction, and take good care of their health. EB: Parents of children with intellectual disabilities and mental health problems often experienced helplessness and despair (Faust & Scior, 2008). CEB: A study analyzing the grief and coping of mothers who had lost children under the age of 7 years found that the spouse, remaining children, grandparents, next of kin, friends, and colleagues were the main sources of support (Laakso & Paunonen-Ilmonen, 2002).

• Recognize that mothers who have a miscarriage grieve and experience sorrow because of loss of the child. There is a need for therapeutic interventions given in a caring, compassionate and culturally sensitive way to help mothers with this significant loss (Wojnar, Swanson, & Adolfsson, 2011).

Geriatric:

• Identify previous losses and assess the client for depression. In older age, losses and changes often occur in rapid succession without adequate recovery time.

• Evaluate the social support system of the elderly client. If the support system is minimal, help the client determine how to increase available support. The elderly who have a minimal support system are more vulnerable to depression from grief. The support of family (especially children) and friends is a common way for elderly people to cope with a loss.

Home Care:

• The interventions described previously may be adapted for home care use.

Assess the client for depression. Refer for mental health services as indicated. Sadness is part of the syndrome of depression. Increase in mood is unlikely unless the underlying depression is treated. Counseling services provide an opportunity for expression of feelings, increase coping skills, and provide respite for caregivers.

When sorrow is focused around loss of a pregnancy, encourage the client to follow through on a counseling referral. CEB: Parents with a history of perinatal loss are at higher risk for depressive symptoms and pregnancy-specific anxiety during subsequent pregnancies, particularly before the third trimester. Mothers had a higher level of symptoms than fathers (Armstrong, 2002).

• Encourage the client to participate in activities that are diversionary and uplifting as tolerated (e.g., outdoor activities, hobby groups, church-related activities, pet care). Diversionary activities decrease the time spent in sorrow, can give meaning to life, and provide a sense of well-being.

• Encourage the client to participate in support groups appropriate to the area of loss or illness (e.g., Crohn’s disease support group or Widow to Widow). Support groups can increase an individual’s sense of belonging. Group activity helps the client to identify alternative ways to problem solve.

• Provide psychological support for family/caregivers. Family/caregivers who feel supported are often able to provide greater and more consistent support to the affected person.

In the presence of a psychiatric disorder, refer for psychiatric home health care services for client reassurance and implementation of a therapeutic regimen.

See the care plans for Chronic low Self-Esteem, Risk for Loneliness, and Hopelessness.

References

Armstrong, D.S. Emotional distress and prenatal attachment in pregnancy after perinatal loss. J Nurs Scholarsh. 2002;34:339–345.

Arnold, J., Gemma, P.B. The continuing process of parental grief. Death Stud. 2008;32:658–673.

Bettle, A.M., Latimer, M.A. Maternal coping and adaptation: a case study examination of chronic sorrow in caring for an adolescent with a progressive neurodegenerative disease. Can J Neurosci Nurs. 2009;31(4):15–21.

Brown, E. Helping bereaved children and young people. Br J School Nurs. 2009;4(2):69–73.

Clements, P.T., et al. Life after death: grief therapy after the sudden traumatic death of a family member. Perspect Psychiatr Care. 2004;40(4):149–154.

Faust, H., Scior, K. Mental health problems in young people with intellectual disabilities: the impact on parents. J Appl Res Intellect Disabil. 2008;21(5):414–424.

Hewetson, R., Singh, S. The lived experience of mothers of children with chronic feeding and/or swallowing difficulties. Dysphagia. 2009;24(3):322–332.

Isaksson, A., Ahlstrom, G. Managing chronic sorrow: experiences of patients with multiple sclerosis. J Neurosci Nurs. 2008;40(3):180–192.

Laakso, H., Paunonen-Ilmonen, M. Mothers’ experience of social support following the death of a child. J Clin Nurs. 2002;11(2):176–185.

Lowden, Fabijan L. Interventions with families experiencing chronic sorrow related to multiple sclerosis. Can J Neurosci Nurs. 2010;32(1):21.

Masterson, M., Chronic sorrow in mothers of adult children with cerebral palsy: an exploratory study 2010. [Unpublished dissertation].

Moules, N.J., et al. The soul of sorrow work: grief and therapeutic interventions with families. J Fam Nurs. 2007;13(1):114–141.

Moules, N.J., et al. Making room for grief: walking backwards and living forward. Nurs Inq. 2004;11(2):99–107.

Oyama, H., et al. Community-based suicide prevention through group activity for the elderly successfully reduced the high suicide rate for females. Psychiatry Clin Neurosci. 2005;59(3):337–344.

Schuurman, D.L., The club no one wants to join: a dozen lessons I’ve learned from grieving children and adolescents, 2012 Retrieved May 4, 2012, from http://www.grief.org.au/grief_and_bereavement_support/understanding_grief/supporting_children/the_club_no_one_wants_to_join

Wojnar, D.M., Swanson, K.M., Adolfsson A-, S. Confronting the inevitable: a conceptual model of miscarriage for use in clinical practice and research. Death Stud. 2011;35(6):536–558.

Spiritual Distress

Lisa Burkhart, PhD, RN

NANDA-I

Definition

Impaired ability to experience and integrate meaning and purpose in life through connectedness with self, others, art, music, literature, nature, and/or a power greater than oneself

Defining Characteristics

Connections to Self

Anger; expresses lack of acceptance; expresses lack of courage; expresses lack of hope; expresses lack of love; expresses lack of meaning in life; expresses lack of purpose in life; expresses lack of self-forgiveness; expresses lack of serenity (e.g., peace); guilt; ineffective coping

Connections with Others

Expresses alienation; refuses interactions with significant others; refuses interactions with spiritual leaders; verbalizes being separated from support system

Connections with Art, Music, Literature, Nature

Disinterest in nature; disinterest in reading spiritual literature; inability to express previous state of creativity (e.g., singing/listening to music/writing)

Connections with Power Greater Than Oneself

Expresses anger toward power greater than self; expresses being abandoned; expresses hopelessness; expresses suffering; inability for introspection; inability to experience the transcendent; inability to participate in religious activities; inability to pray; requests to see a spiritual leader; sudden changes in spiritual practices

Related Factors (r/t)

Active dying; anxiety; chronic illness; death; life change; loneliness; pain self-alienation; social alienation; sociocultural deprivation

NOC (Nursing Outcomes Classification)

Suggested NOC Outcomes

Coping, Dignified Life Closure, Grief Resolution, Hope, Spiritual Health, Stress Level

Example NOC Outcome with Indicators

Spiritual Health as evidenced by the following indicators: Quality of faith, hope, meaning, and purpose in life/Connectedness with inner-self and with others to share thoughts, feelings, and beliefs. (Rate each indicator of Spiritual Health: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Section I].)

Client Outcomes

Client Will (Specify Time Frame)

• Express meaning and purpose in life

• Express sense of hope in the future

• Express sense of connectedness with self

• Express sense of connectedness with family/friends

• Express ability to forgive

• Express acceptance of health status

• Find meaning in relationships with others

• Find meaning in relationship with Higher Power

• Find meaning in personal and health care treatment choices

NIC (Nursing Interventions Classification)

Suggested NIC Interventions

Active Listening, Forgiveness Facilitation, Grief Work Facilitation, Hope Inspiration, Humor, Music Therapy, Presence, Referral, Reminiscence Therapy, Self-Awareness Enhancement, Simple Guided Imagery, Simple Massage, Simple Relaxation Therapy, Spiritual Support, Therapeutic Touch, Touch

Example NIC Activities—Spiritual Support

Encourage use of spiritual resources if desired; Be available to listen to client’s feelings

Nursing Interventions and Rationales

• Observe clients for cues indicating difficulties in finding meaning, purpose, or hope in life. EBN: In a grounded theory study, spiritual care begins by recognizing a client cue for needing spiritual care (Burkhart & Hogan, 2008). CEB: In a quantitative study of 156 clients with cancer and 68 caregivers, Taylor (2006) found that one of the most prevalent spiritual needs was finding meaning.

• Observe clients with chronic illness, poor prognosis, or life-changing conditions for loss of meaning, purpose, and hope in life. EBN: In a phenomenological study, spirituality is one theme for women undergoing breast biopsy (Demir et al, 2008). Prince-Paul (2008) found that spiritual well-being and social well-being accounted for 52.6% of the variance of quality of life for those at end-of-life.

• Offer spiritual care in disaster relief. EB: In a case study of Hurricane Katrina survivors, spirituality and religion were found to be important sources of resilience and coping in disaster relief, particularly for the African American community (Alawiyah et al, 2011).

• Promote a sense of love, caring, and compassion in nursing encounters. CBE: In a quantitative study of 156 clients with cancer and 68 caregivers, Taylor (2006) found that one of the most prevalent spiritual needs was giving love to others.

• Be physically present and actively listen to the client. EBN: In a grounded theory study, spiritual care included promoting client connectedness with self (Burkhart & Hogan, 2008). EB: A qualitative study of young adult daughters with parents experiencing cancer identified being present as a theme (Puterman & Cadell, 2008). In a meta-analysis of qualitative research on spirituality/spiritual care in palliative care, spiritual care includes presence, journeying together, listening, connecting, creating openings, and engaging in reciprocal sharing (Edwards et al, 2010).

• Help the client find a reason for living, be available for support and promote hope. EBN: In a quantitative study of 156 clients with cancer and 68 caregivers, Taylor (2006) found that one of the most prevalent spiritual needs was keeping a positive perspective. EB: A qualitative study of young adult daughters with parents experiencing cancer identified hope and spirituality as themes (Puterman & Cadell, 2008).

• Listen to the client’s feelings about suffering and/or death. Be nonjudgmental and allow time for grieving. EBN: In a cross-sectional, retrospective survey of parents of children who have died, participants identified spirituality and religion as shaping their perspective of the grief process (Arnold & Gemma, 2008).

• Respect the client’s beliefs; avoid imposing your own spiritual beliefs on the client. Be aware of your own belief systems and accept the client’s spirituality. EBN: A program evaluating an end-of-life integrated care pathway found that spiritual care involves individualizing interventions based on spiritual practices (Lhussier, Carr, & Wilcockson, 2007). CEB: Taylor and Mamier (2005) reported that most cancer clients and caregivers welcomed interventions that were less intimate, commonly used, and not overtly religious.

• Monitor and promote supportive social contacts. EBN: In a qualitative study of stroke caregivers, interacting with family and friends emerged as a theme (Pierce et al, 2008).

• Integrate family into spiritual practices as appropriate. EBN: In a qualitative study of stroke caregivers, interacting with family and friends emerged as a theme (Pierce et al, 2008). In a phenomenological study, lung cancer clients identified maintaining contact with family and friends for support and prayer as helpful self-care strategies (John, 2010). EB: In a meta-analysis of qualitative research, family relationships were an integral part of spiritual care (Edwards et al, 2010).

• Assist family in searching for meaning in client’s health care situation. EBN: A qualitative study of young adult daughters with parents experiencing cancer identified exploring meaning as a theme (Puterman & Cadell, 2008). A qualitative study of family/caregivers for those in hospice identifies the search for meaning and caring presence as part of the mourning process (Clukey, 2008). EB: In a descriptive study, spirituality predicted better quality of life for younger and lower-income family caregivers of cancer clients (Kim & Spillers, 2009).

• Offer spiritual support to caregivers. EBN: In a qualitative study of stroke caregivers, interacting with family and friends emerged as a theme (Pierce et al, 2008).

Refer the client to a support group or counseling. EBN: Pierce et al (2008) qualitatively studied a Web-based support and education intervention.

• Support meditation, guided imagery, journaling, relaxation, and involvement in art, music, or poetry. Support outdoor activities. EBN: In a qualitative study of stroke caregivers, being one with nature emerged as a theme (Pierce et al, 2008). In a qualitative survey of chronically ill individuals, participants wanted access to a garden, a quiet space available in hospital to think through decisions, spiritual help or guidance, swimming, and a choice of genres of music available (Dale & Hunt, 2008). EB: In a randomized controlled trial, a spiritual meditation intervention was associated with fewer migraine headaches, less anxiety and a greater pain tolerance, headache-related self-efficacy, daily spiritual experiences, and existential well-being (Wachholtz & Pargament, 2008).

• Offer or suggest visits with spiritual and/or religious advisors. EBN: In a qualitative study of stroke caregivers, feeling the presence of a greater power and practicing rituals emerged as two themes (Pierce et al, 2008). In a grounded theory study, spiritual care included promoting connectedness with others, including chaplains (Burkhart & Hogan, 2008).

• Provide privacy or a “sacred space.” EBN: In a qualitative survey of chronically ill individuals, participants wanted access to a garden and a quiet space available in the hospital to think through decisions (Dale & Hunt, 2008).

• Allow time and a place for prayer. EBN: In a qualitative survey of chronically ill individuals, religious participants wanted prayer over meditation (Dale & Hunt, 2008). In a grounded theory study, spiritual care included promoting religious rituals and prayer and was validated in a psychometric study (Burkhart & Hogan, 2008; Burkhart, Schmidt, & Hogan, 2011). CEB: In a quantitative study of 156 clients with cancer and 68 caregivers, Taylor (2006) found that one of the most prevalent spiritual needs was understanding or relating to God.

• Coordinate or encourage attending spiritual retreats, courses, or programming. EB: In a study with 128 male clients who expressed interest in attending an informational intervention, topics included spirituality (Manii & Ammerman, 2008).

Geriatric:

• Identify the client’s past spiritual practices that have been helpful. Help the client explore his or her life and identify those experiences that are noteworthy. EB: A cross-sectional study of individuals living in the community revealed that as people age, spirituality is more important (Trouillet & Gana, 2008.) A large survey of community-dwelling older adults indicated that a majority of participants had spiritual experiences daily, with African Americans and women having higher scores than Caucasians and men (Skarupski et al, 2010).

• Offer opportunities to practice one’s religion. EB: In a cross-sectional study of older adults, religious attendance was associated with positive general health perception and inversely associated with pack/year smoked and severity of illness (Yohannes et al, 2008). The geriatric population utilizes religious services in naturally occurring retirement communities (Lun, 2010).

Pediatric:

• Offer adolescents opportunities for reflection and storytelling to express their spirituality. EBN: In a literature review, reflection and storytelling with adolescents help find meaning in bereavement therapy and can lead to spiritual growth (Leighton, 2008).

Multicultural:

• Recognize the importance of spirituality and provide culturally competent spiritual care to specific populations:

Arab Americans. EB: Arab American immigrants are fatalistic in that they believe that cancer is a punishment from God and prognosis was determined by God (Shah et al, 2008).

Hawaiians. EB: In a semistructured interview with Hawaiian women in churches, integrating religious and spiritual practices in health promotion was viewed as important in promoting breast cancer screening (Ka’opua, 2008).

Latinos. CEB: Latinos may identify spirituality, religiousness, prayer, and church-based approaches as coping resources (Simoni, Frick, & Huang, 2006).

African Americans. EBN: A descriptive study with 178 low-income, abused African American women revealed that spiritual well-being was associated with readiness to change (Bliss et al, 2008). EB: A large survey of community dwelling older adults indicated that a majority of participants had spiritual experiences daily, with African Americans and women having higher scores than Caucasians and men (Skarupski et al, 2010).

Domestic violence survivors. EBN: In a meta-analysis of qualitative research on domestic violence survivors, spirituality and religiosity plays an important role, and that role may differ based on culture (Yick, 2008).

African women. EB: In Uganda, 85% of African women with HIV/AIDS use spirituality as a coping mechanism, including support from other believers, prayer, and trusting in God (Hodge & Roby, 2010). EBN: In a phenomenological study, Nigerian-born immigrants treated depression with spirituality and religion, rather than health care professionals (Ezeobele et al, 2009).

Aborigine. EB: Within Aboriginal communities, using traditional healers and elders can effectively address domestic violence victims (Puchala et al, 2010).

Home Care:

• All of the nursing interventions described previously apply in the home setting.

References

Alawiyah, T., et al. Spirituality and faith-based interventions: pathways to disaster resilience for African American hurricane Katrina survivors. J Relig Spiritual Soc Work Soc Thought. 2011;30:294–319.

Arnold, J., Gemma, P.B. The continuing process of parental grief. Death Stud. 2008;32:658–673.

Bliss, J.J., et al. African American women’s readiness to change abusive relationships. J Fam Violence. 2008;23:161–171.

Burkhart, L., Hogan, N. An experiential theory of spiritual care in nursing practice. Qual Health Res. 2008;18(7):928–938.

Burkhart, L., Schmidt, L., Hogan, N. Development and psychometric testing of the spiritual care inventory instrument. J Adv Nurs. 2011;67(11):2463–2472.

Clukey, L. Anticipatory mourning: processes of expected loss in palliative care. Int J Palliat Nurs. 2008;14(7):316–325.

Dale, H., Hunt, J. Perceived need for spiritual and religious treatment options in chronically ill individuals. J Health Psychol. 2008;13:712–718.

Demir, F., et al. Patients’ lived experiences of excisional breast biopsy: a phenomenological study. J Clin Nurs. 2008;17:744–751.

Edwards, A., et al. The understanding of spirituality and the potential role of spiritual care in end-of-life and palliative care: a meta-study of qualitative research. Palliat Med. 2010;24(8):753–770.

Ezeobele, I., et al. Depression and Nigerian-born immigrant women in the United States: a phenomenological study. J Psychol Ment Health Nurs. 2009;17:193–201.

Hodge, D.R., Roby, J. Sub-Sahara African women living with HIV/AIDS: an exploration of general and spiritual coping strategies. Soc Work. 2010;55(1):27–37.

John, L.D. Self-care strategies used by patients with lung cancer to promote quality of life. Oncol Nurs Forum. 2010;37(3):339–347.

Ka’opua, L.S. Developing a culturally responsive breast cancer screening promotion with native Hawaiian women in churches. Health Soc Work. 2008;33(3):169–177.

Kim, Y., Spillers, R.L. Quality of life of family caregivers at 2 years after a relative’s cancer diagnosis. Psycho-Oncology. 2010;19:431–440.

Leighton, S. Bereavement therapy with adolescents: facilitating a process of spiritual growth. J Child Adolesc Psychol Nurs. 2008;21(1):24–34.

Lhussier, M., Carr, S.M., Wilcockson, J. The evaluation of an end-of-life integrated care pathway. Int J Palliat Nurs. 2007;13(2):74–81.

Lun, M.W.A. The correlate of religion involvement and formal service use among community-dwelling elders: an explorative case of naturally occurring retirement community. J Relig Spiritual Soc Work Soc Thought. 2010;29:207–217.

Manii, D., Ammerman, D. Men and cancer: a study of the needs of male cancer patients in treatment. J Psychosoc Oncol. 2008;26(2):87–102.

Pierce, L.L., et al. Spirituality expressed by caregivers of stroke survivors. West J Nurs Res. 2008;30(5):606–619.

Prince-Paul, M. Relationships among communicative acts, social well-being, and spiritual well-being on the quality of life at the end of life in patients with cancer enrolled in hospice. J Palliat Med. 2008;11(1):20–25.

Puchala, C., et al. Using traditional spirituality to reduce domestic violence within Aboriginal communities. J Altern Complement Med. 2010;16(1):89–96.

Puterman, J., Cadell, S. Timing is everything: the experience of parental cancer for young adult daughters—a pilot study. J Psychosoc Oncol. 2008;26(2):103–121.

Shah, S.M., et al. Arab American immigrants in New York: health care and cancer knowledge, attitudes, and beliefs. J Immigr Minor Health. 2008;10:429–436.

Simoni, J.M., Frick, P.A., Huang, B.A. Longitudinal evaluation of a social support model of medication adherence among HIV-positive men and women on antiretroviral therapy. Health Psychol. 2006;25(1):74–81.

Skarupski, K.A., et al. Daily spiritual experiences in a biracial, community-based population of older adults. Aging Ment Health. 2010;14(7):779–789.

Taylor, E.J. Prevalence and associated factors of spiritual needs among patients with cancer and family caregivers. Oncol Nurs Forum. 2006;33(4):729–735.

Taylor, E.J., Mamier, I. Spiritual care nursing: what cancer patients and family caregivers want. J Adv Nurs. 2005;49(3):260–267.

Trouillet, R., Gana, K. Age differences in temperament, character and depressive mood: a cross-sectional study. Clin Psychol Psychother. 2008;1:266–275.

Wachholtz, A.B., Pargament, K.I. Migraines and meditation: does spirituality matter? J Behav Med. 2008;31(4):351–366.

Yick, A.G. A metasynthesis of qualitative findings on the role of spirituality and religiosity among culturally diverse domestic violence survivors. Qual Health Res. 2008;18(9):1289–1306.

Yohannes, A.M., et al. Health behaviour, depression and religiosity in older patients admitted to intermediate care. Int J Geriatr Psychiatry. 2008;23:735–740.