T

Family Will (Specify Time Frame)

• Base family interventions on knowledge of the family, family context, and family function. EBN: Family research has established that families differ widely from one another, even within cultures (Wright & Leahey, 2009).

• Use a family approach when helping an individual with a health problem that requires therapeutic management. EBN: Family relationships can be a source of support for people with diabetes and may influence self-management behavior (Paddison, 2010).

• Review with family members the congruence and incongruence of family behaviors and health-related goals. EBN: To attain the motivation needed for changes in health habits, family members should understand the relation of daily habits to health-related goals (Wright & Leahey, 2009).

• Acknowledge the challenge of integrating therapeutic regimens with family behaviors. EBN: Therapeutic regimens require modifications of daily activities that have already been established based on family values and beliefs. Acknowledging the difficulty of changing family habits supports families through the process (Wright & Leahey, 2009).

• Review the symptoms of specific illness(es) and work with the family toward development of greater self-efficacy in relation to these symptoms. EBN: Knowledge of symptoms improves the ability of family members to adjust behaviors to prevent and manage symptoms (Lubkin & Larsen, 2007).

• Support family decisions to adjust therapeutic regimens as indicated. EBN: Sometimes families do not have access to health providers and should make independent decisions because of side effects or adverse effects of therapeutic regimens. Family members need to make informed decisions in their best interests (Wright & Leahey, 2009).

• Advocate for the family in negotiating therapeutic regimens with health providers. EB: Illness regimens generally are neither arbitrary nor absolute; therefore, modifications can be discussed as needed to fit with the family lifestyle (Wright & Leahey, 2009).

• Help the family mobilize social supports. EBN: Increased social support helps families to meet health-related goals (Pender, Murdaugh, & Parsons, 2011).

• Help family members modify perceptions as indicated. EBN: Individual perceptions of the seriousness of, susceptibility to, and threat of illness may be distorted or inaccurate and may be modified with new information (Pender, Murdaugh, & Parsons, 2011).

• Use one or more theories of family dynamics to describe, explain, or predict family behaviors (e.g., theories of Bowen, Satir, and Minuchin). EBN: Family systems may not be understood by the nurse without adequate knowledge of family theory (Wright & Leahey, 2009).

 Collaborate with expert nurses or other consultants regarding strategies for working with families. EBN: The family clinical nurse specialist uses components such as time allowance; level of staff’s family theory knowledge; level of experience and comfort; institute policy; and interdisciplinary team commitment to positively influence the delivery of family-centered care (Parker, 2011).

• Coaching methods can be used to help families improve their health. EBN: Coaching is a beneficial tool for families of many children and teens with AD/HD, executive functioning disorders (Sleeper-Triplett, 2008), and/or behavioral concerns. EB: Coaching processes were shown to improve family outcomes related to improved nutrition and physical activity (Heimendinger et al, 2007).

Client Will (Specify Time Frame)

• Teach the following interventions to prevent fires in the home, to handle any possible fire, and to have a readily available exit from the home:

• Teach the following activities to homes with small children:

• Utilize sunscreen when out in the sun. Also use sun-blocking clothing, and stay in the shade if possible. A sunburn predisposes development of skin cancer, in addition to aging of the skin. Up to 50% of children have at least one sunburn by the time they are 11 years of age and generally develop another sunburn 3 years later (Dusza et al, 2012).

• Teach the following interventions from Joyner, 2012, to prevent fires in the home where medical oxygen is in use:

Client Will (Specify Time Frame)

Temperature Measurement

Fever (Pyrexia)

Hypothermia

Hyperthermia

Prevention of Hypothermia in Cold Weather

See the care plan Hypothermia.

Prevention of Hyperthermia in Hot Weather

See the care plan Hyperthermia.

Client Will (Specify Time Frame)

• Assess the site of impaired tissue integrity and determine the cause (e.g., acute or chronic wound, burn, dermatological lesion, pressure ulcer, leg ulcer, skin failure). EB: The etiology or cause of the wound must be determined before appropriate interventions can be implemented. This provides the basis for additional testing and evaluation to start the treatment process (Baranoski & Ayello, 2012).

• Determine the size (length, width) and depth of the wound (e.g., full-thickness wound, deep tissue injury, stage III or IV pressure ulcer). EB: Consistency and accuracy in how the wound (tissue integrity) is measured are important for determining changes in the wound over time and for comparing effectiveness of various treatments (Baranoski & Ayello, 2012).

• Classify pressure ulcers in the following manner. EB: (EPUAP/NPUAP, 2009).

• Inspect and monitor the site of impaired tissue integrity at least once daily for color changes, redness, swelling, warmth, pain, or other signs of infection or per facility/agency policy. Determine whether the client is experiencing changes in sensation or pain. Pay special attention to all high-risk areas such as bony prominences, skin folds, sacrum, and heels. Systematic inspection can identify impending problems early. CEB: Pain secondary to dressing changes can be managed by interventions aimed at reducing trauma and other sources of wound pain (WUWHS, 2007).

• Monitor the status of the skin around the wound. 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 the plan according to the client’s skin condition, needs, and preferences. Avoid harsh cleansing agents, hot water, extreme friction or force, or too-frequent cleansing (Baranoski & Ayello, 2012).

• Monitor the client’s continence status and minimize exposure of the skin impairment site and other areas to moisture from urine or stool, 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. Refer to a continence care specialist, urologist, or gastroenterologist for incontinence assessment (Borchert et al, 2010; WOCN, 2010). EB: Implementing an incontinence prevention plan with the use of a skin or cleanser protectant can significantly decrease skin breakdown and pressure ulcer formation (Borchert et al, 2010).

• Monitor for correct placement of tubes, catheters, and other devices. Assess the skin and tissue affected by the tape that secures these devices. Mechanical damage to skin and tissues as a result of pressure, friction, or shear is often associated with external devices (EPUAP/NPUAP, 2009).

• In an orthopedic client, check every 2 hours for correct placement of foot boards, restraints, traction, casts, or other devices, and assess skin and tissue integrity. Be alert for symptoms of compartment syndrome (refer to the care plan for Risk for Peripheral Neurovascular Dysfunction). Mechanical damage to skin and tissues (pressure, friction, or shear) is often associated with external devices.

• For a client with limited mobility, use a risk-assessment tool to assess immobility-related risk factors systematically. CEB & EBN: 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 (Braden & Maklebust, 2005). Targeting variables (e.g., 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 (Magnan & Maklebust, 2009; WOCN, 2009, 2010).

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

 Identify a plan for debridement if necrotic tissue (eschar or slough) is present and if consistent with overall client management goals. EB: Debride devitalized tissue within the wound bed or edge of pressure ulcers when appropriate to individual’s condition and consistent with overall goals of care (EPUAP/NPUAP, 2009). EB: Do not debride stable, hard, dry eschar in ischemic limbs (EPUAP/NPUAP, 2009).

• Select a topical treatment that maintains a moist, wound-healing environment and also allows absorption of exudate and filling of dead space. No single wound care product provides the optimal environment for healing all wounds. EBN: Choose dressings that provide a moist healing environment, keep periwound skin dry, and control exudate and eliminate dead space (Baranoski & Ayello, 2012; EPUAP/NPUAP, 2009; WOCN, 2009, 2010).

• Do not position the client on the site of impaired tissue integrity. EB: If it is consistent with overall client management goals, reposition the client based on level of tissue tolerance and overall condition, and transfer or reposition the client carefully to avoid adverse effects of external mechanical forces (pressure, friction, and shear) (EPUAP/NPUAP, 2009; WOCN, 2009, 2010).

• Evaluate for the use of support surfaces (specialty mattresses, beds) chair cushion, or devices as appropriate (Brienza et al, 2012).

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

• Avoid massaging around the site of impaired tissue integrity and over bony prominences. EB: (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 EPUAP/NPUAP (2009) endorse the application of reasonable nutritional assessment and treatment for clients at risk for and with pressure ulcers.

 Develop a comprehensive plan of care that includes a thorough wound assessment, treatment interventions, support surfaces, nutritional products, adjunctive therapies, and evaluation of the outcome of care. Documentation of these essential elements is paramount to establishing a framework for quality care.

Client Will (Specify Time Frame)

 Check the brachial, radial, dorsalis pedis, posterior tibial, and popliteal pulses bilaterally. If unable to find them, use a Doppler stethoscope and notify the physician immediately if new onset of absence of pulses along with a cold extremity. Diminished or absent peripheral pulses indicate arterial insufficiency with resultant ischemia (White, 2011).

• Note skin color and feel the temperature of the skin. Skin pallor or mottling, cool or cold skin temperature, or an absent pulse can signal arterial obstruction, which is an emergency that requires immediate intervention (White, 2011). Rubor (reddish blue color accompanied by dependency) indicates dilated or damaged vessels. Brownish discoloration of the skin on the anterior tibia indicates chronic venous insufficiency (Jarvis, 2012). EBN: Cardiac output was a significant predictor for objectively measured skin temperature. Subjective assessment of skin temperature was significantly related to cardiac output, systemic vascular resistance, and serum lactate. These results support the utilization of skin temperature as a noninvasive marker of cardiac output and perfusion (Schey, Williams, & Bucknall, 2009).

• Assess for pain in the extremities, noting severity, quality, timing, and exacerbating and alleviating factors. Differentiate venous from arterial disease. In clients with venous insufficiency, the pain lessens with elevation of the legs and exercise. In clients with arterial insufficiency, the pain increases with elevation of the legs and exercise (Longo et al, 2011). Some clients have both arterial and venous insufficiency. Arterial insufficiency is associated with pain when walking (claudication) that is relieved by rest. Clients with severe arterial disease have pain while at rest, which keeps them awake at night. Venous insufficiency is associated with aching, cramping, and discomfort (White, 2011).

• Check capillary refill. Nail beds usually return to a pinkish color within 1 to 2 seconds after compression; a capillary refilling time greater than 3 seconds is abnormal (Jarvis, 2012). CEB: A study has concluded that capillary refill is age and temperature dependent. The upper limit of normal for adult women should be 3 seconds, and the upper limit of normal for the elderly should be 4.5 seconds (Schrigerr & Baraff, 1988).

• Note skin texture and the presence of hair, ulcers, or gangrenous areas on the legs or feet. Thin, shiny, dry skin with hair loss; brittle nails; and gangrene or ulcerations on toes and anterior surfaces of the feet are seen in clients with arterial insufficiency. If ulcerations are on the side of the leg, they are usually associated with venous insufficiency (Jarvis, 2012).

• Note the presence of edema in the extremities and rate severity on a four-point scale. Measure the circumference of the ankle and calf at the same time each day in the early morning (White, 2011).

Arterial Insufficiency

Venous Insufficiency

Client Will (Specify Time Frame)

 Request consult for a physical and/or occupational therapist (PT and OT) to develop exercise and strengthening program early in the client’s recovery. Leg/trunk strength is key for standing transfers; arm/trunk strength is key for slide-board transfers. EBN: Progressive mobility earlier and more aggressively in the hospital stay, as early as in the ICU, decreases mechanical ventilation days and decreases complications such as weakness from disuse and contractures (Vollman, 2010). EB: Voet and colleagues (2010), via a Cochrane review, reported that strength training and aerobic exercise training for muscle disease may optimize function.

 Obtain a consult for a PT, OT, or orthotist to evaluate and fit clients with proper orthoses, braces, collars, and walking aids before helping them stand. Equipment helps clients move and function safely, comfortably, and independently (Hoeman, Liszner, & Alverzo, 2008).

• Help client put on/take off collars, braces, prostheses in bed, as well as antiembolism stockings and abdominal binders. Apply antiembolism stockings and abdominal binders while the client is in bed, as these appliances may help prevent or reduce hypotension. Collars and braces stabilize and align body parts during motion. EBN: A literature review reported knee-high stockings were as effective as above-the-knee stockings in preventing DVT in immobile medical/surgical inpatients, and compliance was better (McCaffrey & Blum, 2009).

• Assess clients’ dependence, weight, strength, balance, tolerance to position change, cooperation, fatigue level, and cognition plus available equipment and staff ratio/experience to decide whether to do a manual or device-assisted transfer (Nelson et al, 2008b).

 Collaborate with PT and use algorithms to identify technological aids to handle and transfer dependent and obese clients; do not use under-axilla method (Cohen et al, 2010). Powered stand-assist devices, mechanical lifts, stretchers to chairs, and friction-reducing devices prevent musculoskeletal injuries of staff and allow safe client handling (Baptiste et al, 2008). EBN: Results of an exploratory study indicated a safe client handling program (ergonomic assessments, handling assessment criteria, handling devices, etc.) improved client depression, urinary continence, engagement in activities, and morning alertness and lessened risk of falls (Nelson et al, 2008a).

• Implement and document type of transfer (such as slide board, pivot), weight-bearing status (non-weight-bearing, partial), equipment (walker, sling lift), and level of assistance (standby, moderate) on care plan and white board in room.

• Apply a gait belt with handles before transferring clients with partial weight-bearing abilities; keep the belt and client close to provider during the transfer. If used incorrectly, such as at arm’s length, it prevents support of client and places staff at risk for back and arm injuries (Pierson & Fairchild, 2008).

• Help clients don shoes with nonskid soles and socks/hose. Proper shoes help prevent slips/pain/pressure and improve balance. EB: Suggest trying a running shoe that is comfortable and lightweight, as a recent study found that participants unable to see the type of shoe (control shoe, running shoe, or orthopedic shoe) chose the running shoe based on comfort and weight (Riskowski, Dufour, & Hannan, 2011).

• Nursing staff should wear positive-grip shoe covers or nonslip shoes when transferring clients off shower chairs on tile floors.

• Remove or swivel wheelchair armrests, leg rests, and footplates to the side, especially with squat or slide board transfers. This gives clients and nurses feet space to maneuver in and provides fewer obstacles to trip over.

• Adjust transfer surfaces so they are similar in height. For example, lower a hospital bed to about an inch higher than commode height. EB: Similar heights between seat surfaces require less upper extremity muscular effort during transfers (Hoeman, Liszner, & Alverzo, 2008).

• Place wheelchair and commode at a slight angle toward the surface onto which client will transfer. The two surfaces are close together yet allow room for the caregiver to adjust the client’s movements during the transfer (Hoeman, Liszner, & Alverzo, 2008).

• Teach client to consistently lock brakes on wheelchair/commode/shower chair before transferring. Wheels will roll if not locked, thus creating risk for falls. Pneumatic wheelchair tires must be adequately inflated for brakes to lock effectively.

• Give clear, simple instructions, allow client time to process information, and let him or her do as much of the transfer as possible. Overassistance by staff and family may decrease client learning and self-esteem.

 Remind clients to comply with weight-bearing restrictions ordered by their physician. Weight bearing may retard healing in fractured bones.

• Place client in set position before standing him or her—for example, sitting on edge of surface with bilateral weight bearing on buttocks and hips, with knees flexed, balls of feet aligned under knees, and head in midline. This position prepares individuals for bearing weight and permits shifting of weight from pelvis to feet as the center of gravity changes while rising.

• Support and stabilize client’s weak knee(s) by placing one or both of your knees next to or encircling client’s knee(s), rather than blocking them. This allows client to flex his or her knee(s) and lean forward to stand and transfer.

• Position walking aids appropriately so a standing client can grasp and use them once he or she is upright. These aids help provide support, balance, and stability to help client stand and step safely (Pierson & Fairchild, 2008).

• Reinforce to clients who use walkers, to place one hand on walker and push with opposite hand against chair arm or surface from which they are arising to stand up. Placing both hands on the walker may cause it to tip and the client to lose balance and fall.

• Use ceiling-mounted or bedside mechanical bariatric lifts to transfer dependent bariatric (extremely obese) clients. Equipment prevents client/staff injury and is essential for clients who require a moderate/maximum assist transfer (Cohen et al, 2010).

 Assist therapists to transfer bariatric clients who can support their own weight with minimal assistance. Position locked beds against a corner wall. Before sitting client, inflate air mattress overlay if applicable and place a friction-reducing sheet underneath client, then “flat spin” client with the transfer sheet so he/she is lying supine perpendicular to the bed. Deflate all air devices and pad bed edge where posterior thighs will dig in if skin is fragile. Place both knees level with thighs (put feet on a footstool if needed) while client is still supine and assist client to arise to sitting. If client starts sliding, lay client back supine. The wall helps prevent bed movement.

• Use bariatric devices and utilize available safe patient handling equipment for lifting, transferring, positioning, and sliding client (Cohen et al, 2010).

• Place a mechanical lift sling in the wheelchair preventatively. Place two transfer sheets or a slide board under bariatric client. Reinforce that head should be leaning forward and that knees should be level with hips; help hold wheelchair in place as therapist directs/helps client with a scoot transfer. Client may be too fatigued to do a manual transfer back to bed after sitting, so sling/lift can be used.

• Perform initial and subsequent fall risk assessment. Use standardized tools for fall risk assessment and interdisciplinary multifactorial interventions to reduce falls and risk of falling in hospitals (Cameron et al, 2010).

 Collaborate with PT, OT, and pharmacy for individualized preventative/postfall plans, for example, scheduled toileting, balance and strength training, removal of hazards, chair alarms, call system/phone in reach, and review of medications. EB: Results from a study showed low-intensity exercise and incontinence care in residents in nursing homes reduced falls (Cameron et al, 2010). More than five drugs indicates polypharmacy and puts the client at risk for adverse drug reactions, drug-drug interactions, and overall low adherence to drug therapy due to too many drugs to take (Hovstadius et al, 2010).

• Encourage an exercise component such as tai chi, physical therapy, or other exercise for balance, gait, and strength training in group programs or at home.

• Modify environment for safety; recommend vision assessment and consideration for cataract removal.

• Recommend polypharmacy assessment with special consideration to sedatives, antidepressants, and drugs affecting the CNS; recommend evaluation for orthostatic hypotension and irregular heartbeats; and recommend vitamin D supplementation 800 IU per day (Barclay, 2011).

External

Accessibility of guns; bathing in very hot water (e.g., unsupervised bathing of young children); children playing with dangerous objects; children riding in the front seat in car; contact with corrosives; contact with intense cold; contact with rapidly moving machinery; defective appliances; delayed lighting of gas appliances; driving a mechanically unsafe vehicle; driving at excessive speeds; driving while intoxicated; driving without necessary visual aids; entering unlighted rooms; experimenting with chemicals; exposure to dangerous machinery; faulty electrical plugs; flammable children’s toys; frayed wires; grease waste collected on stoves; high beds; high-crime neighborhood; inadequate stair rails; inadequately stored combustibles (e.g., matches, oily rags); inadequately stored corrosives (e.g., lye); inappropriate call-for-aid mechanisms for bed-bound client; knives stored uncovered; lack of gate at top of stairs; lack of protection from heat source; lacks antislip material in bath; lacks antislip material in shower; large icicles hanging from roof; misuse of necessary headgear; misuse of seat restraints; nonuse of seat restraints; obstructed passageways; overexposure to radiation; overloaded electrical outlets; overloaded fuse boxes; physical proximity to vehicle pathways (e.g., driveways, lanes, railroad track); playing with explosives; pot handles facing toward the stove; potential igniting of gas leaks; slippery floor (e.g., wet or highly waxed); smoking in bed; smoking near oxygen; struggling with restraints; throw rugs; unanchored electric wires; unsafe road; unsafe walkways; unsafe window protection in homes with young children; use of cracked dishware; use of unsteady chairs; use of unsteady ladders; wearing flowing clothes around open flame

Internal

Balancing difficulties; cognitive difficulties; deficient knowledge regarding safe procedures; deficient knowledge regarding safety precautions; economically disadvantaged; emotional difficulties; history of previous trauma; poor vision; reduced hand-eye coordination; reduced muscle coordination; reduced sensation; weakness

Client Will (Specify Time Frame)

• Screen clients with a fall risk factor assessment tool to identify those at risk for falls. EBN: A falls risk assessment tool should be easy to utilize so that those at risk for falls will be identified quickly and efficiently (Jones & Whitaker, 2011). EB: The results of this study suggest that recurrent inside fallers and recurrent outside fallers may need a more categorical type of fall risk assessment (Kelsey et al, 2012).

• Provide vision aids for visually impaired clients. EB: This study proposes that a person with diagnosed visual impairments might again have enhanced independence and a better quality of life after rehabilitative efforts using visual aids and training, to restore reading abilities and improve orientation (Trauzettel-Klosinski, 2011).

• Assist the client with ambulation. Encourage the client to use assistive devices in ADLs as needed. EB: The advantages of ambulatory assistive devices (canes, crutches, walkers etc.) include stability, augmentation of muscle action, and lessening of weight-bearing load (Faruqui & Jaeblon, 2010). EB: Assistive devices are commonly used to enhance independent ambulation and participation in societal life for the geriatric population and to better foster stability, promote independence, and increase safety and security (Vogt et al, 2010).

• Educate and provide clients and family with hip protector devices. EBN: Hip protectors are nonpharmaceutical devices that have been shown to prevent hip fractures (Jones, 2011). EB: (Gillespie, Gillespie, & Parker, 2010).

• Have a family member evaluate water temperature for the client. EBN: Because neuropathy can be a companion to decreased tactile sensation, it is crucial to avoid injury to skin integrity related to hot baths and the risk of burns (Nicholas et al, 2010).

• Assess the client for causes of impaired cognition. EB: This study makes the point that successful senior mobility must include appropriate decision-making and those who have reduced physical function and cognitive impairment are more likely to make poor mobility judgments—especially when attempting to multitask (Nagamatsu et al, 2011).

• Provide assistive devices in the home, especially in bathrooms (e.g., hand rails, nonslip decals on the floor of the shower and bathtub). EBN: Clients with chronic conditions, physical difficulties, and cognitive and behavioral deterioration that results from a wide range of disorders can also benefit from today’s assistive technology (Ahrendt & Ranseur, 2010).

• Ensure that call light systems are functioning and that the client is able to use them in conjunction with the nurse making hourly rounds. EBN: In this study, a majority of the clients and their family members surveyed felt that access to call lights mattered to their safety and that answering the call light should be a priority for nursing personnel (Tzeng, 2011).

• Use a nightlight after dark to assist in orientation and improve visual acuity. EBN: This study advises that to help prevent falls, nurses should verify the placement of well-defined visual markers—especially at night—for their elderly clients who ambulate to the bathroom (Saba et al, 2010).

• Teach the client to observe safety precautions, especially in high-crime area neighborhoods (e.g., lock doors, do not leave home at night without a companion; keep entryways well lighted). EB: In this study, older residents residing in low-income areas reported that, along with other neighborhood problems, they had less safety from traffic and less safety from crime (Sallis et al, 2011).

 Instruct the client not to drive under the influence of alcohol or drugs. Assess for a substance abuse problem and refer to appropriate resources for drug and alcohol education. EBN: This study asserts that nursing professionals should be aware of the necessity of educating clients concerning the hazards associated with alcohol consumption (Alameida et al, 2010).

 Review drug profile for potential side effects that may inhibit performance of ADLs. EB: Physicians should assess systemic (e.g., cognition) or drug-specific characteristics such as side effects on a regular basis when dealing with the client on multiple medications (Tsai et al, 2012).

• See care plans for Risk for Aspiration, Impaired Home Maintenance, Risk for Injury, Risk for Poisoning, and Risk for Suffocation.