• Express hope

• Express sense of meaning and purpose in life

• Express peace and serenity

• Express love

• Express acceptance

• Express surrender

• Express forgiveness of self and others

• Express satisfaction with philosophy of life

• Express joy

• Express courage

• Describe being able to cope

• Describe use of spiritual practices

• Describe providing service to others

• Describe interaction with spiritual leaders, friends, and family

• Describe appreciation for art, music, literature, and nature

Geriatric:

Pediatric:

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

Home Care:

Client Will (Specify Time Frame)

• Assist client in identification of stress overload during vulnerable life events. EB: In a systematic review of 40 studies it was found that at least 33% of surrogates experience stressful emotional burden on making treatment decisions for others (Wendler & Rid, 2011).Women with breast cancer who were involved in group therapy focusing on stress reduction and muscle relaxation were 56% less likely to succumb to the disease and 45% less likely to experience a recurrence (Andersen et al, 2008). Men with high stress have higher all-cause mortality, the effects being more pronounced among middle-aged men (Nielsen et al, 2008).

• Listen actively to descriptions of stressors and the stress response. CEB: Developing nurse-client partnerships is the best way to obtain valid and reliable information related to stress overload (Lunney, 2006). EBN: In a recent longitudinal study of clients with heart failure, researchers found that clients with high anxiety experienced sorter periods of event-free (hospitalization, mortality) survival than those with lower anxiety (P = .03) (Dejong et al, 2011). Stress neuropeptide levels may be altered in critical illness mediating immunity, endothelial responses, and oxidative stress (Papathanassoglou et al, 2011).

• In younger adult women, assess interpersonal stressors. EB: A systematic review and meta-analysis of 30 studies found that maternal exposure to the stress of domestic violence results in significantly increased risk of low birth weight and preterm birth (Shah & Shah, 2010). Complex post-traumatic stress disorders and related extreme stress were assessed in a qualitative/quantitative study of 14 assaulted women with a mean age of 38. A high sense of coherence enabled these women to leave their abusive relationships (Scheffer & Renck, 2008).

• Categorize stressors as modifiable or nonmodifiable. EBN: Removing or minimizing some stressors, changing responses to stressors, and modifying the long-term effects of stress are all actions that can assist those with chronic illnesses and stress (Upton & Solowiej, 2010).

• Help clients modify or mitigate stressors identified as modifiable. CEB: There are numerous possible strategies to modify stressors, including time management, improved organizational skills, problem solving, changing perceptions of stress, breathing, relaxation techniques, visual imagery, and soothing rituals (Lloyd, Smith, & Weinger, 2005). Interventions that are person-directed (cognitive-behavioral approaches) versus work-directed may result in reductions in stress, burnout, and anxiety in health care workers (Marine et al, 2006).

• Help clients distinguish among short-term, chronic, and secondary stressors. EBN: A study of 108 mothers with children diagnosed with autistic spectrum disorder found that managing demanding behavior and upset feelings, discipline, and managing behavior in public places were the highest sources of overall parenting stress (Phetrasuwan & Shandor Miles, 2009). Caregiver role overload exacerbates secondary stressors, whereas socioeconomic support may ameliorate those stressors (Gaugler et al, 2008). Social support is a critical dimension of health and health promotion and serves as a buffer in the stress response (Pender, Murtaugh & Parsons, 2010). EB: The frequency of stressful health-related events, not health-unrelated events, is associated with all-cause mortality (Phillips, Der, & Carroll, 2008).

• Provide information as needed to reduce stress responses to acute and chronic illnesses. EBN: Information provided to critical care clients through the use of tactile touch interventions led to significantly lower levels of anxiety as evident by reductions in circulatory parameters (Henricson et al, 2008). CEB: Supporting the individual adaptation through facilitation of cognitive processes that help the person achieve congruence in meaning mediates the threatening effects of incongruence between situational and global meaning (Skaggs, Barron, 2006).

• Explore possible therapeutic approaches such as cognitive-behavioral therapy, biofeedback, neurofeedback, acupuncture, pharmacological agents, and complementary and alternative therapies. CEB: Neurofeedback promotes optimum functioning of the central nervous system, induces relaxation, and supports healthy balance, flexibility, and resilience (Brown, 2007). Adults who had experienced hospitalizations of at least 5 days said that spirituality strengthened their coping ability (Cavendish et al, 2006). Therapeutic techniques such as acupuncture may improve levels of wellness through direct homeostatic stabilization of the autonomic nervous system (Walling, 2006).

• Help the client to reframe his or her perceptions of some of the stressors. EBN: Researchers found that nursing students with higher anxiety states were 62% less optimistic, findings supporting that individuals with pessimistic outlooks perceive situations as more threatening (Warning, 2011). EB: Study findings of 73 people with rheumatoid arthritis suggest that individuals high in personal mastery may be more susceptible to the effects of stress, experiences of pain, and fatigue (Younger et al, 2008). An association was found between leader behaviors, relationship between employee and leader, and specific leader styles on employee stress and affective well-being (Skakon et al, 2010).

• Assist the client to mobilize social supports for dealing with recent stressors. EBN: Emotional support in Taiwanese caregivers is suggested as a moderator of stressors experienced by caregivers of clients with Alzheimer’s disease or stroke, particularly in caregivers with lower household incomes (Huang et al, 2009). EB: In a secondary analysis of data, caregivers who maintained balance in their lives by taking breaks from the caregiving role experience a decrease in caregiving stressors (Knussen et al, 2008).

Modifiable

Delayed prenatal care; infant overheating; infant overwrapping; infants placed to sleep in the prone position; infants placed to sleep in the side-lying position; bed sharing; lack of prenatal care; postnatal infant smoke exposure; prenatal infant smoke exposure; soft underlayment (loose articles in the sleep environment)

Potentially Modifiable

Low birth weight, prematurity, young maternal age

Nonmodifiable

Ethnicity (e.g., African American or Native American), male gender, seasonality of SIDS deaths (e.g., winter and fall months), infant age of 2-4 months, possible gene mutation resulting in Brugada (QT) syndrome

Client Will (Specify Time Frame)

• Position the infant supine to sleep; do not position in the prone position or side-lying position. EB: In a retrospective review of hundreds of SIDS cases, more than 70% of the incidences happened when the infant was in a prone or side-lying position (Ostfeld et al, 2010).

• Avoid use of loose bedding, such as blankets and sheets for sleeping. If blankets are used, they should be tucked in around the crib mattress so the infant’s face is less likely to become covered by bedding. One strategy is to make up the bedding so that the infant’s feet are able to reach the foot of the crib with the blankets tucked in around the crib mattress and reaching only the level of the infant’s chest, or put the child in a sleep sack instead of a blanket (AAP, 2011a).

• Lightly clothe the infant for sleep. Avoid overbundling and overheating the infant. The infant should not feel hot to touch. EB: Overheating the infant has been associated with increased risk of SIDS. “Head covering precedes the death and is causally related to SIDS” (Mitchell et al, 2008).

• Provide the infant a certain amount of time in prone position while the infant is awake and observed. Change the direction that your baby lies in the crib from one week to the next; and avoid too much time in car seats, carriers, and bouncers. Prolonged time in the supine position can result in a flat head shape, and delayed motor development. Utilizing “tummy time” with the infant can prevent these problems (AAP, 2011a; Miller, 2011).

• Consider offering the infant a pacifier during sleep times. EB: Use of a pacifier was associated with decreased incidence of SIDS (Moon et al, 2012; Vennemann et al, 2009).

 Use electronic respiratory or cardiac monitors to detect cardiorespiratory arrest only if ordered. There is no evidence that use of such home monitors decreases the incidence of SIDS (AAP, 2010).

External

Discarding refrigerators without removing doors; eating large mouthfuls of food; hanging a pacifier around infant’s neck; household gas leaks; inserting small objects into airway; leaving children unattended in water; low-strung clothesline; pillow placed in infant’s crib; playing with plastic bags; propped bottle placed in infant’s crib; smoking in bed; use of fuel-burning heaters not vented to outside; vehicle warming in closed garage

Internal

Cognitive difficulties; disease process; emotional difficulties; injury process; lack of safety education; lack of safety precautions; reduced motor abilities; reduced olfactory sensation

Client Will (Specify Time Frame)

• Identify hospitalized clients at particular risk for suffocation, including the following:

Institute safety measures such as proper positioning and feeding precautions. See the care plans for Risk for Aspiration and Impaired Swallowing for additional interventions. Vigilance and special protective measures are necessary for clients at greater risk for suffocation. CEB: Mental health clients have an increased incidence of choking and suffocation incidents (Corcoran & Walsh, 2003).

Behavioral

Buying a gun; changing a will; giving away possessions; history of prior suicide attempt; impulsiveness; making a will; marked changes in attitude; marked changes in behavior; marked changes in school performance; stockpiling medicines; sudden euphoric recovery from major depression

Demographic

Age (e.g., elderly people, young adult males, adolescents); divorced; male gender; race (e.g., white, Native American); widowed

Physical

Chronic pain; physical illness; terminal illness

Psychological

Childhood abuse; family history of suicide; guilt; homosexual youth; psychiatric disorder; psychiatric illness; substance abuse

Situational

Adolescents living in nontraditional settings (e.g., juvenile detention center, prison, halfway house, group home); economic instability; institutionalization; living alone; loss of autonomy; loss of independence; presence of gun in home; relocation; retired

Social

Cluster suicides; disciplinary problems; disrupted family life; grieving; helplessness; hopelessness; legal problems; loneliness; loss of important relationship; poor support systems; social isolation

Verbal

States desire to die; threats of killing oneself

Client Will (Specify Time Frame)

• Assess for suicidal ideation when the history reveals the following: depression, substance abuse; bipolar disorder, schizophrenia, anxiety disorders, post-traumatic stress disorder, dissociative disorder, eating disorders, substance use disorders, antisocial or other personality disorders; attempted suicide, current or past; recent stressful life events (divorce and/or separation, relocation, problems with children); recent unemployment; recent bereavement; adult or childhood physical or sexual abuse; gay, lesbian, or bisexual gender orientation; family history of suicide, history of chronic trauma. Clinicians should be alert for suicide when the aforementioned factors are present in asymptomatic persons (APA, 2011; Li et al, 2011). EBN & EB: Persons who commit suicide often see their physician shortly beforehand. Primary care providers could be effective in preventing suicide, particularly among older adults and women (Davidsen, 2011). First episode psychosis is a particular risk factor for suicide; early intervention has been shown to be helpful (Ceskova, Prikryl, & Kasparek, 2011). (Additional relevant research: Dutra et al, 2008; Hardt et al, 2008; Innamorati et al, 2008.)

• Assess all medical clients and clients with chronic illnesses, traumatic injuries, or pain for their perception of health status and suicidal ideation. Medical clients who perceived their health to be poor or who were in chronic pain were significantly more likely to report current suicidal ideation. EB: Myocardial infarction has been connected with higher suicide rates, especially during the first month after discharge; the risk remained high for at least 5 years (Larsen et al, 2010). Persons living with HIV/AIDS who had depressive symptoms and low life satisfaction were at significantly higher risk of suicide (Davis et al, 2011).(Additional relevant research: Brenner et al, 2009; Ratcliffe et al, 2008; Robson et al, 2010; Schneider & Shenassa, 2008; Woolley et al, 2008.)

• Assess the client’s ability to enter into a no-suicide contract. Contract (verbally or in writing) with the client for no self-harm if the client is appropriate for a contract; recontract at appropriate intervals. Discussing feelings of self-harm with a trusted person provides relief for the client. A contract gets the subject out in the open and places some of the responsibility for safety with the client. CEB: Some clients are not appropriate for a contract: those under the influence of drugs or alcohol or unwilling to abstain from substance use, and those who are isolated or alone without assistance to keep the environment safe (Hauenstein, 2002). If the client will not contract, the risk of suicide should be considered higher. EBN: Note: Although contracting is a common practice in psychiatric care settings, research has suggested that self-harm is not prevented by contracts. Thorough, ongoing assessment of suicide risk is necessary, whether or not the client has entered into a no-self-harm contract. Contracts may not be appropriate in community settings (McMyler & Pryjmachuk, 2008).

• Be alert for warning signs of suicide: making statements such as, “I can’t go on,” “Nothing matters anymore,” “I wish I were dead”; becoming depressed or withdrawn; behaving recklessly; getting affairs in order and giving away valued possessions; showing a marked change in behavior, attitudes, or appearance; abusing drugs or alcohol; suffering a major loss or life change. Suicide is rarely a spontaneous decision. In the days and hours before people kill themselves, clues and warning signs usually appear.

• Take suicide notes seriously and ask if a note was left in any previous suicide attempts. Consider themes of notes in determining appropriate interventions. Clients who leave a suicide note may be at higher risk of future completed suicide in the future. A note should be viewed as indication of a failed but serious attempt.

• Question family members regarding the preparatory actions mentioned. Clinicians should be alert for suicide when these factors are present in asymptomatic persons (APA, 2011).

• Determine the presence and degree of suicidal risk. A number of questions will elicit the necessary information: Have you been thinking about hurting or killing yourself? How often do you have these thoughts and how long do they last? Do you have a plan? What is it? Do you have access to the means to carry out that plan? How likely is it that you could carry out the plan? Are there people or things that could prevent you from hurting yourself? What do you see in your future a year from now? Five years from now? What do you expect would happen if you died? What has kept you alive up to now? CEB: Using the acronym SAL, the nurse can evaluate the client’s suicide plan for its Specificity (how detailed and clear is the plan?), Availability (does the client have immediate access to the planned means?), and Lethality (could the plan be fatal, or does the client believe it would be fatal?). Assessment of reasons for living is another important part of evaluating suicidal clients (Malone et al, 2000).

• Observe, record, and report any changes in mood or behavior that may signify increasing suicide risk and document results of regular surveillance checks. EB: Suicidal ideation often is not continuous; it may decrease, then increase in response to negative thinking or exposure to stressors (e.g., family visits). Documentation of surveillance will alert all members of the health care team to changes in the clients’ potential risk for suicide so they may be prepared to respond in the event of suicidal behavior (McNiel et al, 2008; Neuner et al, 2008).

• Develop a positive therapeutic relationship with the clients; do not make promises that may not be kept. Be aware that some clients may offer to self-disclose if the nurse will promise not to tell anyone what they have said. Clarify with the clients that anything they share will be communicated only to other staff but that secrets cannot be kept. EBN: Nurses reconnect suicidal clients with humanity by guiding the client, helping them learn how to live, and helping them connect appropriately with others. Positive support can buffer against suicide, whereas conflictual interactions can increase suicide risk (Hirsch & Barton, 2011; Lakeman & FitzGerald, 2008).

 Refer for mental health counseling and possible hospitalization if evidence of suicidal intent exists, which may include evidence of preparatory actions (e.g., obtaining a weapon, making a plan, putting affairs in order, giving away prized possessions, preparing a suicide note). EB: Clients vary in the preparation for suicide attempts, and professional assessment is required to determine the need for hospitalization (APA, 2011). The following interventions may be instituted.

• Assign a hospitalized client to a room located near the nursing station. Close assignment increases ease of observation and availability for a rapid response in the event of a suicide attempt.

• Search the newly hospitalized client and the client’s personal belongings for weapons or potential weapons and hoarded medications during the inpatient admission procedure, as appropriate. Remove dangerous items. Clients intent on suicide may bring the means with them. Action is necessary to maintain a hazard-free environment and client safety.

• Limit access to windows and exits unless locked and shatterproof, as appropriate. Suicidal behavior may include attempts to jump out of windows or to escape the unit to find other means of suicide (e.g., gaining roof access for a jump). Hospitals should ensure that exits are secure.

• Monitor the client during the use of potential weapons (e.g., razor, scissors). Clients with suicidal intent may take advantage of any opportunity to harm themselves.

• Increase surveillance of a hospitalized client at times when staffing is predictably low (e.g., staff meetings, change of shift report, periods of unit disruption). Clients who remain intent on suicide will be watchful of periods when staff surveillance lessens to permit completion of a suicide plan.

 If imminent suicide is suspected or an attempt has occurred, call for assistance and do not leave the client alone. Client and staff safety will be served by assistance in the response. The client may attempt additional self-harm if left alone.

• Place the client in the least restrictive, safe, and monitored environment that allows for the necessary level of observation. Assess suicidal risk at least daily and more frequently as warranted. Close observation of the client is necessary for safety as long as intent remains high. Suicide risk should be assessed at frequent intervals to adjust suicide precautions and limitations on the client’s freedom of movement and to ensure that restrictions continue to be appropriate. EB: Inpatient root cause analyses of suicide attempts and environmental safety checklists for units can be helpful in maintaining safety (Mills et al, 2008).

• Consider strategies to decrease isolation and opportunity to act on harmful thoughts (e.g., use of a sitter). CEB: Clients have reported feeling safe and having their hope restored in response to close observation (Bowers & Park, 2001).

• Explain suicide precautions and relevant safety issues to the client and family (e.g., purpose, duration, behavioral expectations, and behavioral consequences). CEB: Suicide precautions may be viewed as restrictive. Clients have reported the loss of privacy as distressing (Bowers & Park, 2001).

 Refer for treatment and participate in the management of any psychiatric illness or symptoms that may be contributing to the client’s suicidal ideation or behavior. Psychiatric disorders have been associated with suicidal behavior. Symptoms of the disorder may require treatment with antidepressant, antipsychotic, or antianxiety medications. EB: A systematic review has shown a highly significant effect for cognitive behavior therapy in reducing suicidal behavior (Tarrier, Taylor, & Gooding, 2008).

 Verify that the client has taken medications as ordered (e.g., conduct mouth checks after medication administration). The client may attempt to hoard medications for a later suicide attempt.

 Maintain increased surveillance of the client whenever use of an antidepressant has been initiated or the dose increased. Antidepressant medications take anywhere from 2 to 6 weeks to achieve full efficacy. During that period the client’s energy level may increase, although the depression has not yet lifted, which increases the potential for suicide.

• Involve the client in treatment planning and self-care management of psychiatric disorders. Self-care management promotes feelings of self-efficacy, particularly for clients with depression. Suicidal ideation may occur in response to a sense of hopelessness, a sense that the client has no control over life circumstances. The more clients participate in their own care, the less powerless and hopeless they feel. Refer to the care plan for Powerlessness.

• Explore with the client all circumstances and motivations related to the suicidality. Listen to the client’s own views on his or her problems. EB: Primary reasons for suicide attempts were found to be feelings of loneliness or hopelessness, and mental illness/psychological problems (APA, 2011).

• Explore with the client all perceived consequences that could act as a barrier to suicide (e.g., effect on family, religious beliefs). CEB: The most common barrier to suicide is consequences to family members (Bell, 2000).

• Keep discussion oriented to the present and future. Clients under stress have difficulty focusing their thoughts, which leads to a sense of being overwhelmed by problems. Focusing on the present and future helps the client to address problem solving with regard to current stressors.

• Discuss plans for dealing with suicidal ideation in the future (e.g., how to identify precipitating factors, whom to contact, where to go for help, how to respond to desire for self-harm). Clients are supported in self-care management when they are helped to identify actions they can take if suicidal ideation recurs.

• Assist the client in identifying a network of supportive persons and resources (e.g., clergy, family, care providers). EB: Clients who are suicidal often feel alienated from others and benefit from actions that facilitate support of the client by family and friends (deCastro & Guterman, 2008).

 Refer family members and friends to local mental health agencies and crisis intervention centers if the client has suicidal ideation or a suspicion of suicidal thoughts exists. Clients at risk should receive evaluation and help (APA, 2011).

 Document client behavior in detail to support outpatient commitment or an overnight psychiatric observation program for an actively suicidal client. Involuntary outpatient commitment can improve treatment, reduce the likelihood of hospital readmission, and reduce episodes of violent behavior in persons with severe psychiatric illnesses. Overnight psychiatric observation followed by outpatient referral also can be an effective alternative to traditional hospitalization without leading to an increase in suicide gestures or attempts.

• Utilize cognitive-behavioral techniques that help the client to modify thinking styles that promote depression, hopelessness, and a belief that suicide is a valid means of escaping the current situation. Suicide has been shown to be associated with constriction in cognitive style, leading to decreased problem solving and information processing. Cognitive-behavioral techniques and the promotion of problem-solving skills, combined with the therapeutic relationship, have been posited as key interventions when dealing with the hopelessness inherent to suicidal ideation.

• Engage the client in group interventions that can be useful to address recurrent suicide attempts. Group therapy was shown to decrease suicidality.

• With the client’s consent, facilitate family-oriented crisis intervention. Family-oriented crisis intervention can clarify stresses and allow assessment of family dynamics. EBN: Families of suicidal clients reported potential burnout from being on guard day and night, maintaining ADLs, and trying to create a nurturing environment. Families need support in preparing to accept clients back into the home (Nosek, 2008; Sun & Long, 2008).

• Involve the family in discharge planning (e.g., illness/medication teaching, recognition of increasing suicidal risk, client’s plan for dealing with recurring suicidal thoughts, community resources). Suicidal clients often are ambivalent about hurting themselves; they may not want to die so much as to escape an intolerable situation. Consequently they often leave clues about their state of mind. EBN: Family members must learn before clients leave the hospital how to respond to clues early, support the treatment regimen, and encourage the client to initiate the emergency plan. Nurses help in guiding families through the process (Nosek, 2008; Sun & Long, 2008).

 Before discharge from the hospital, ensure that the client has a supply of ordered medications, has a plan for outpatient follow-up, understands the plan or has a caregiver able and willing to follow the plan, and has the ability to access outpatient treatment. Clients may be discharged before they have recovered substantial functional ability and may have difficulty concentrating on the plan for follow-up. They may need the assistance of others to ensure that prescriptions are filled, that they attend appointments, or that they have transportation to the outpatient care setting.

 In the event of successful suicide, refer the family to a therapy group for survivors of suicide. Recommended clinical interventions include addressing psychological distress, normalizing denial as an effective coping strategy, working with concerns about family disintegration, and helping families deal with stigmatization. EB: Psychoeducational support group participants found relief in sharing a personal narrative of their suicide bereavement with others (Feigelman & Feigelman, 2011a,b). Internet support groups for suicide survivors may also be helpful for bereavement (Feigelman et al, 2008; Jones & Meier, 2011).

• See the care plans for Risk for self-directed Violence, Hopelessness, and Risk for Self-Mutilation. Clients with suicidal ideation often are reacting to a feeling of hopelessness.

Client Will (Specify Time Frame)

• Perform a thorough assessment of the client, including risk factors. Allow time to be with the client. EBN: Assessment of clients preoperatively by nursing and medical staff is an important part of the surgical experience to ensure that appropriate interventions are used and recovery from surgery is as quick as possible (Layzell, 2008). EB: Clients with higher presurgery levels of emotional distress appear to be at greater risk for experiencing higher levels of postsurgery side effects (Montgomery et al, 2010).

• Assess for the presence of medical conditions and treat appropriately before surgery. If the client is diabetic, maintain normal blood glucose levels before surgery. CEB: High blood-glucose levels slow healing and increase risk of infection. The American Diabetes Association recommends that blood glucose should be less than 180 mg/dL for people in the hospital or having surgery. For some, the goal is less than 110 mg/dL (ADA, 2005). EB: In some cases, complications and poor client satisfaction and joint function can be directly attributable to obesity (Choong & Dowsey, 2011).

• Carefully assess client’s use of dietary supplements such as feverfew, ginkgo biloba, garlic, ginseng, ginger, valerian, kava, St. John’s wort, ephedra (Ma huang or metabolite), and echinacea. It is recommended that all clients be advised to stop all dietary supplements at least 1 week before major surgical or diagnostic procedures. EB: Most medications, herbal preparations, and nutraceutical supplements have notable effects on biochemical pathways and may influence wound healing, coagulation, and cardiovascular function. They can also interact with other drugs (Rowe & Baker, 2009). EB: Herbal remedies are common in clients presenting for anesthesia. Because of the potential interactions between anesthetic drugs or techniques and such medication, it is important for anesthetists to be aware of their use (Baillard et al, 2007).

• Assess and treat for depression and anxiety in a client complaining of continuing fatigue after surgery. EB: Fatigue is common after major surgery and delays recovery. The results of this study indicate that psychological processes may well be relevant in the etiology of postoperative fatigue (Rubin, Cleare, & Hotopf, 2004).

• Play music of the client’s choice preoperatively, intraoperatively, and postoperatively. EBN: Listening to self-selected music during the preoperative period can effectively reduce anxiety levels and should be a useful tool for preoperative nursing (Arslan, Özer, & Özyurt, 2008). EBN: Results of this research provide evidence to support the use of music and/or a quiet rest period to decrease pain and anxiety. The interventions pose no risks and have the benefits of improved pain reports and decreased anxiety (Allred, Byers, & Sole, 2010).

• Consider using healing touch and other mind-body-spirit interventions such as stress control and imagery in the perianesthesia setting. EBN: Research showed that stress management, imagery, and touch therapy all produced reductions in reported worry, as compared with standard therapy (Seskevich, Crater, & Lane, 2004). EB: Therapeutic Touch was effective in decreasing pain intensity and depressive attitudes and symptoms, as well as for improving sleep quality (Marta et al, 2010).

• Use warmed cotton blankets to reduce heat loss during surgery. EB: Monitoring of body temperature and avoidance of unintended perioperative hypothermia through active and passive warming measures are the keys to preventing its complications (Hart et al, 2011).

• Use careful aseptic technique when caring for wounds. CEB: Handwashing continues to be the most important factor in reducing health care–associated infection, but the use of an aseptic technique will further cut the risk of infection (Hart, 2007).

• Suggest the use of a semipermeable dressing and suction drainage for selected orthopedic clients. EB: This form of postoperative wound management appears to retain the nursing and hygiene advantages of suction drainage while preventing client discomfort and possibilities of wound infection associated with deep internal drainage (Panousis, Grigoris, & Strover, 2004).

• Clients should be allowed to shower after surgery to maintain cleanliness if not contraindicated because of the presence of pacemaker wires. EB: In a prospective randomized study, early water contact was allowed in order to test postoperative wound healing, regardless of whether the wounds were kept dry or had water contact with or without shower foam from the second postoperative day; no infection was registered (Neues & Haas, 2000). EB: Postoperative hair-washing resulted in no increase in incision infection scores or decrease in health-related quality of life scores when compared to no hair-washing (Ireland et al, 2007).

• Promote early ambulation and deep breathing. Consider use of a transcutaneous electrical nerve stimulation (TENS) unit for pain relief. EBN: Both high- and low-frequency TENS significantly decreased postoperative pain intensity using the numeric rating scale, pain rating index, and number of words chosen compared with placebo TENS (Desantana, Sluka, & Lauretti, 2009). When looking across all of the intervention types, the most frequently reported positive outcomes were associated with measures of ambulatory ability (Chudyk et al, 2009). Deep breathing clears the lungs and prevents pneumonia.

• The client should be provided with a complete, balanced therapeutic diet after the immediately postoperative period (24 to 48 hours). EB: Optimal wound healing requires adequate nutrition. Nutrition deficiencies impede the normal processes that allow progression through stages of wound healing. Malnutrition has also been related to decreased wound tensile strength and increased infection rates (Stechmiller, 2010).

• Provide 20-minute foot and hand massage (5 minutes to each extremity), 1 to 4 hours after a dose of pain medication. EBN: This pretest-posttest design study reported that the reduction in pain intensity was significantly meaningful in both intervention groups, who received massages, when compared to the control group (Degirmen et al, 2010).

 Carefully consider the use of alternative therapy with a physician’s order, such as application of aloe vera or aqueous cream to promote wound healing. EBN: It [aloe vera] can be effective for genital herpes, psoriasis, human papillomavirus, seborrheic dermatitis, aphthous stomatitis, xerosis, lichen planus, frostbite, burn, wound healing and inflammation (Feily & Namazi, 2009).

• Consider the use of noetic therapies: stress management, imagery, and touch therapy. EBN: Studies of Therapeutic Touch, healing touch, and Reiki are quite promising; however, at this point, they can only suggest that these healing modalities have efficacy in reducing anxiety; improving muscle relaxation; aiding in stress reduction, relaxation, and sense of well-being; promoting wound healing; and reducing pain (Engebretson & Wardell, 2007). EB: Touch therapies may have a modest effect in pain relief (So, Jiang, & Qin, 2008).

• Encourage the client to use prayer as a form of spiritual coping if this is comfortable for the client. EB: Prayer frequencies were associated with reduced complications but not hospitalization. Sense of reverence (respecting clients spiritual practices) in secular contexts predicted fewer complications and shorter hospitalization (Ai et al, 2009).

• See the care plans for Anxiety, Acute Pain, Fatigue, Risk for deficient Fluid Volume, Risk for Perioperative Positioning Injury, Impaired physical Mobility, and Nausea.

Esophageal Phase Impairment

Abnormality in esophageal phase by swallow study; acidic-smelling breath; bruxism; complaints of “something stuck”; epigastric pain; food refusal; heartburn or epigastric pain; hematemesis; hyperextension of head (e.g., arching during or after meals); nighttime awakening; nighttime coughing; observed evidence of difficulty in swallowing (e.g., stasis of food in oral cavity, coughing/choking); odynophagia; regurgitation of gastric contents (wet burps); repetitive swallowing; unexplained irritability surrounding mealtime; volume limiting; vomiting; vomitus on pillow

Oral Phase Impairment

Abnormality in oral phase of swallow study; choking, coughing, or gagging before a swallow; drooling; food falls from mouth; food pushed out of mouth; inability to clear oral cavity; incomplete lip closure; lack of chewing; lack of tongue action to form bolus; long meals with little consumption; nasal reflux; piecemeal deglutition; pooling in lateral sulci; premature entry of bolus; sialorrhea; slow bolus formation; weak suck resulting in inefficient nippling

Pharyngeal Phase Impairment

Abnormality in pharyngeal phase by swallowing study; altered head position; choking, coughing, or gagging; delayed swallow; food refusal; gurgly voice quality; inadequate laryngeal elevation; multiple swallows; nasal reflux; recurrent pulmonary infections; unexplained fevers

Congenital Defects

Behavioral feeding problems; conditions with significant hypotonia; congenital heart disease; failure to thrive; history of tube feeding; mechanical obstruction (e.g., edema, tracheostomy tube, tumor); neuromuscular impairment (e.g., decreased or absent gag reflex, decreased strength or excursion of muscles involved in mastication, perceptual impairment, facial paralysis); protein energy malnutrition; respiratory disorders; self-injurious behavior; upper airway anomalies

Neurological Problems

Achalasia; acquired anatomic defects; cerebral palsy; cranial nerve involvement; developmental delay; esophageal defects; gastroesophageal reflux disease; laryngeal abnormalities; laryngeal defects; nasal defects; nasopharyngeal cavity defects; oropharynx abnormalities; prematurity; tracheal defects; traumas; traumatic head injury; upper airway anomalies

Client Will (Specify Time Frame)

 If the client has impaired swallowing, do not feed orally until an appropriate diagnostic workup is completed. Feeding a client who cannot adequately swallow results in aspiration and possibly death (Wieseke, Bantz, & Siktberg, 2008).

 Ensure proper nutrition by consulting with a physician regarding alternative nutrition and hydration when oral nutrition is not safe/adequate.

 Refer to a speech-language pathologist for bedside evaluation, and videofluoroscopy or fiberoptic endoscopic evaluation of swallowing (FEES) to determine swallowing problems and solutions as soon as oral and/or pharyngeal dysphagia is suspected. Early referral of CVA clients to a speech pathologist, along with early initiation of nutritional support, can result in decreased length of hospital stay, shortened recovery time, and reduced overall health costs (Runions, Rodrigue, & White, 2004) and is indicated in preventing aspiration pneumonia (Hammond & Goldstein, 2006).

 To manage impaired swallowing, use a dysphagia team composed of a rehabilitation nurse, speech pathologist, dietitian, physician, and radiologist. The dysphagia team can help the client learn to swallow safely and maintain a good nutritional status (Wieseke, Bantz, & Siktberg, 2008).

 Observe the following feeding guidelines:

• During meals and all oral intake, observe for signs associated with swallowing problems such as coughing, choking, spitting of food, drooling, difficulty handling oral secretions, double swallowing or delay in swallowing, watering eyes, nasal discharge, wet or gurgly voice, decreased ability to move the tongue and lips, decreased mastication of food, decreased ability to move food to the back of the pharynx, slow or scanning speech (Wieseke, Bantz, & Siktberg, 2008). EB: Perceptual judgments of a clear post-swallow voice quality provided reasonable evidence that aspiration and dysphagia were absent as measured by videofluoroscopy (Waito et al, 2011).

 Watch for uncoordinated chewing or swallowing; coughing immediately after eating or delayed coughing; pocketing of food; wet-sounding voice; sneezing when eating; delay of more than 1 second in swallowing; or a change in respiratory patterns. If any of these signs is present, remove all food from the oral cavity, stop feedings, and consult with speech and language pathologist and dysphagia team. These are signs of impaired swallowing and possible aspiration (Wieseke, Bantz, & Siktberg, 2008). Placing a client with suspected dysphagia on NPO status is the strongest measure that can be taken to prevent choking and aspiration (Tanner, 2010).

 If signs of aspiration or pneumonia are present, auscultate lung sounds after feeding. Note new onset of crackles or wheezing, and note elevated temperature. CEB: Auscultation of bronchial lung sounds was shown to be specific in identifying clients at risk for aspirating (Shaw et al, 2004).

• Watch for signs of malnutrition and dehydration and keep a record of food intake. Malnutrition is common in dysphagic clients (Wieseke, Bantz, & Siktberg, 2008). Clients with dysphagia are at serious risk for malnutrition and dehydration, which can lead to aspiration pneumonia resulting from depressed immune function and weakness, lethargy, and decreased cough.

 Evaluate nutritional status daily. Weigh the client weekly to help evaluate nutritional status. If the client is not adequately nourished, work with the dysphagia team to determine whether the client needs therapeutic feeding only or needs enteral feedings until the client can swallow adequately. CEB: Dysphagic stroke clients who received thickened fluid dysphagia diets failed to meet their needs for fluids, whereas a group receiving enteral feeding and IV fluid did meet fluid requirements (Finestone et al, 2001).

• If client is not eating a sufficient amount of food, recognize that the immune system may be impaired with resultant increased risk of infection. CEB: In a study comparing elderly clients with dysphagia who were tube fed versus others who were orally fed, the orally fed clients had much lower CD4 cell counts, as well as a low CD4/CD8 ratio (Leibovitz et al, 2004).

 Document and notify the physician and dysphagia team of changes in medical, nutritional, or swallowing status. Health care professionals are responsible for accurate, complete, and coordinated communication with other team members, facilities, and the client and his or her family (Tanner, 2010).

 Work with the client on swallowing exercises prescribed by the dysphagia team. CEB: Clients who received a high-intensity swallowing intervention versus usual care or a low-intensity swallowing intervention were more likely to return to a normal diet and recover swallowing ability by 6 months (Carnaby, Hankey, & Pizzi, 2006).

• If needed, provide meals in a quiet environment away from excessive stimuli, such as a community dining room for some clients who are easily distracted. A noisy environment can be an aversive stimulus and can decrease effective chewing and swallowing.

 For many adult clients, if recommended by the speech therapist, avoid the use of straws if recommended by the speech pathologist. Use of straws can increase the risk of aspiration, because straws can result in spilling of a bolus of fluid rapidly in the posterior pharynx. CEB: A reduction in airway protection with use of a straw was shown for drinking in older men as compared with younger men (Daniels et al, 2004).

• Recognize that the client can aspirate oral feedings, even if there are no symptoms of coughing or distress. This phenomenon is called silent aspiration and is common (Easterling & Robbins, 2008). It is estimated that up to 60% of stroke clients with dysphagia have silent aspiration (Ickenstein et al, 2011).

• Ensure that oral hygiene is maintained. Studies have shown that most individuals aspirate their own saliva during sleep. What determines whether the client develops pneumonia is the ability of the immune system to control bacteria and the amount of contamination of the oropharynx (Campbell-Taylor, 2008).

• Check the oral cavity for proper emptying after the client swallows and after the client finishes the meal. Provide oral care at the end of the meal. It may be necessary to manually remove food from the client’s mouth. If this is the case, use gloves and keep the client’s teeth apart with a padded tongue blade. Food may become pocketed on the affected side and cause stomatitis, tooth decay, and possible later aspiration.

• Praise the client for successfully following directions and swallowing appropriately. Praise reinforces behavior and sets up a positive atmosphere in which learning takes place.

• Keep the client in an upright position for 45 minutes to an hour after a meal. CEB: A study demonstrated that the number of elderly clients developing a fever was significantly reduced when clients were kept sitting upright after eating (Matsui et al, 2002).

• Recognize that impaired swallowing may be caused by the medications the client is taking. Side effects of medications include xerostomia (antidepressants, anticholinergics, antihistamines, bronchodilators, antineoplastic, anti-parkinson), CNS depression (anticonvulsants, benzodiazepines, antispasmodics, antidepressants, antipsychotics), myopathy (corticosteroids, lipid-lowering agents, colchicines), and esophageal sphincter tone decrease (antihistamines, diuretics, opiates, antipsychotics, antihypertensives, anticholinergics). Medications can cause impaired swallowing in multiple ways. For more information about medications, refer to these references (Wieseke, Bantz, & Siktberg, 2009).

 If client has a tracheostomy, ask for referral to speech pathologist for swallowing studies before attempting to feed. After evaluation, the decision should be made to have cuff either inflated or deflated when client eats. EB: Studies have shown that use of speaking valves for the client with a tracheostomy may reduce risk of aspiration when the client eats (Baumgartner, Bewyer, & Bruner, 2008).