Ineffective Breathing Pattern

Ineffective breathing pattern
175
Ineffective Breathing Pattern
NANDA-I
Debra Siela, PhD, RN, CCNS,ACNS-BC, CCRN, CNE, RRT
B
De?nition
Inspiration and/or expiration that does not provide adequate ventilation
De?ning Characteristics
Alterations in depth of breathing; altered chest excursion; assumption of threepoint position; bradypnea;
decreased expiratory pressure; decreased inspiratory pressure; decreased minute
ventilation; decreased vital
capacity; dyspnea; increased anterior-posterior diameter; nasal ?aring; o
rthopnea; prolonged expiration
phase; pursed-lip breathing; tachypnea; use of accessory muscles to breathe
Related Factors (r/t)
Anxiety; body position; bony deformity; chest wall deformity; cognitive impairme
nt; fatigue; hyperventilation; hypoventilation syndrome; musculoskeletal impairment; neurological i
mmaturity; neuromuscular
dysfunction; obesity; pain; perception impairment; respiratory muscle fatigue; s
pinal cord injury
NOC
(Nursing Outcomes Classi?cation)
Suggested NOC Outcomes
Respiratory Status: Airway Patency, Ventilation; Vital Signs
Example NOC Outcome with Indicators
Respiratory Status as evidenced by the following indicators: Respiratory rate/Re
spiratory rhythm/Depth of inspiration/Auscultated breath sounds/Airway patency/Oxygen saturation//Ease of breathing/Vital
capacity. (Rate each indicator of Respiratory
Status: 1 = severe deviation from normal range, 2 = substantial deviation from n
ormal range, 3 = moderate deviation from
normal range, 4 = mild deviation from normal range, 5 = no deviation from normal
range [see Section I].)
Client Outcomes
Client Will (Specify Time Frame):
Demonstrate a breathing pattern that supports blood gas results within the clie
nt s normal parameters
Report ability to breathe comfortably
Demonstrate ability to perform pursed-lip breathing and controlled breathing
Identify and avoid speci?c factors that exacerbate episodes of ineffective brea
thing patterns
NIC
(Nursing Interventions Classi?cation)
Suggested NIC Interventions
Airway Management, Respiratory Monitoring
Example NIC Activities Airway Management
Encourage slow, deep breathing; turning; and coughing; Monitor respiratory and o
xygenation status as appropriate
Nursing Interventions and Rationales
Monitor respiratory rate, depth, and ease of respiration. Normal respiratory ra
te is 10 to 20 breaths/
min in the adult (Jarvis, 2012). EBN: When the respiratory rate exceeds 30 breat
hs/min, along with other
physiological measures, a study demonstrated that a signi?cant physiolog
ical alteration existed (Hagle,
2008).
= Independent
CEB = Classic Research

B = Evidence-Based
176
? = Collaborative
EBN = Evidence-Based Nursing
Note pattern of respiration. If client is dyspneic, note what seems to cause th

e dyspnea, the way in which
the client deals with the condition, and how the dyspnea resolves or gets worse.
B
Note amount of anxiety associated with the dyspnea. A normal respiratory patter
n is regular in a healthy
adult. To assess dyspnea, it is important to consider all of its dimensions, inc
luding antecedents, mediators,
reactions, and outcomes.
Attempt to determine if client s dyspnea is physiological or psychological in cau
se. EB: Maximal respiratory work is less unpleasant than moderately intense air hunger, and unpleasantn
ess of dyspnea can vary
independently from perceived intensity, consistent with pain. Separate dimension
s should be measured (Banzett et al, 2008). A study found that when the cause was psychological (medicall
y unexplained dyspnea), there
was affective dyspnea, anxiety, and tingling in the extremities, whereas when th
e dyspnea was physiological,
there was associated wheezing, cough, sputum, and palpitations (Han et al, 2008)
.
Psychological Dyspnea Hyperventilation
Monitor for symptoms of hyperventilation including rapid respiratory rate, sigh
ing breaths, lightheadedness,
numbness and tingling of hands and feet, palpitations, and sometimes chest pain
(Bickley & Szilagyi, 2009).
Assess cause of hyperventilation by asking client about current emotions and ps
ychological state.
Ask the client to breathe with you to slow down respiratory rate. Maintain eye
contact and give reassurance.
By making the client aware of respirations and giving support, the client may ga
in control of the breathing rate.
? Consider having the client breathe in and out of a paper bag as tolerated. Th
is simple treatment helps associated symptoms of hyperventilation, including helping to retain carbon dioxide,
which will decrease associated symptoms of hyperventilation (Bickley & Szilagyi, 2009).
? If client has chronic problems with hyperventilation, numbness and tingling i
n extremities, dizziness, and
other signs of panic attacks, refer for counseling.
Physiological Dyspnea
? Ensure that client in acute dyspneic state has received any ordered medicatio
ns, oxygen, and any other
treatment needed.
Determine severity of dyspnea using a rating scale such as the modi?ed Borg sca
le, rating dyspnea 0 (best)
to 10 (worst) in severity. An alternative scale is the Visual Analogue Scale (VA
S) with dyspnea rated as 0
(best) to 100 (worst).
Note use of accessory muscles, nasal ?aring, retractions, irritability, confus
ion, or lethargy. These symptoms signal increasing respiratory dif?culty and increasing hypoxia.
Observe color of tongue, oral mucosa, and skin for signs of cyanosis. Cyanosis
of the tongue and oral
mucosa is central cyanosis and generally represents a medical emergency. Periphe
ral cyanosis of nail beds or
lips may or may not be serious (Bickley & Szilagyi, 2009).
Auscultate breath sounds, noting decreased or absent sounds, crackles, or wheez
es. These abnormal lung
sounds can indicate a respiratory pathology associated with an altered breathing
pattern.
? Monitor oxygen saturation continuously using pulse oximetry. Note blood gas r
esults as available. An
oxygen saturation of less than 90% (normal: 95% to 100%) or a partial pressure o
f oxygen of less than 80 mm
Hg (normal: 80 to 100 mm Hg) indicates signi?cant oxygenation problems.
Using touch on the shoulder, coach the client to slow respiratory rate, demons
trating slower respirations;
making eye contact with the client; and communicating in a calm, supportive fash
ion. The nurse s presence, reassurance, and help in controlling the client s breathing can be bene?cial
in decreasing anxiety. CEB:
A study demonstrated that anxiety is an important indicator of severity of clien
t s disease with chronic obstructive pulmonary disease (COPD) (Bailey, 2004).
Support the client in using pursed-lip and controlled breathing techniques. Pu
rsed-lip breathing results in
increased use of intercostal muscles, decreased respiratory rate, increased tida
l volume, and improved oxygen
saturation levels (Faager, Stahle, & Larsen, 2008). EBN: A systematic review fou
nd pursed-lip breathing effective in decreasing dyspnea (Carrieri-Kohlman & Donesky-Cuenco, 2008).
If the client is acutely dyspneic, consider having the client lean forward ove
r a bedside table, resting elbows
on the table if tolerated. Leaning forward can help decrease dyspnea (Brennan &
Mazanec, 2011), possibly
because gastric pressure allows better contraction of the diaphragm (Langer et a
l, 2009). This is called the tripod position and is used during times of distress, including when walking.
Position the client in an upright position (Brennan & Mazanec, 2011). An uprig
ht position facilitates lung
expansion. See Nursing Interventions and Rationales for Impaired Gas Exchange fo
r further information
on positioning.
= Independent
B = Evidence-Based
? = Collaborative

? Administer oxygen as ordered. Oxygen administration has been shown to correct
hypoxemia which causes
dyspnea (Wong & Elliott, 2009).
Increase client s activity to walking three times per day as tolerated. Assist th
e client to use oxygen during
activity as needed. See Nursing Interventions and Rationales for Activity Intole
rance. Supervised exercise
has been shown to decrease dyspnea and increase tolerance to activity (Reilly, S
ilverman, & Shapiro, 2012).
Schedule rest periods before and after activity. Respiratory clients with dysp
nea are easily exhausted and
need additional rest.
? Evaluate the client s nutritional status. Refer to a dietitian if needed. Use n
utritional supplements to
increase nutritional level if needed. Improved nutrition may help increase inspi
ratory muscle function and
decrease dyspnea. EBN: A study found that almost half of a group of clients with
COPD were malnourished,
which can lead to an exacerbation of the disease (Odencrants, Ehnfors, & Ehrenbe
rt, 2008).
Provide small, frequent feedings. Small feedings are given to avoid compromisi
ng ventilatory effort and to conserve energy. Clients with dyspnea often do not eat suf?cient amounts of food be
cause their priority is breathing.
Offer a fan to move the air in the environment. EBN & EB: A systematic review
found that the movement of
cool air on the face can be effective in relieving dyspnea in pulmonary clients
(Carrieri-Kohlman & DoneskyCuenco, 2008). A study found a signi?cant decrease in dyspnea with use of a fan
directed at the nose and
mouth (Galbraith et al, 2010)

Encourage the client to take deep breaths at prescribed intervals and do contr
olled coughing.
Help the client with chronic respiratory disease to evaluate dyspnea experienc
e to determine if similar to previous incidences of dyspnea and to recognize that he or she made it through those
incidences. Encourage the client
to be self-reliant if possible, use problem-solving skills, and maximize use of
social support. The focus of attention
on sensations of breathlessness has an impact on judgment used to determine the
intensity of the sensation.
See Ineffective Airway Clearance if client has a problem with increased respir
atory secretions.
? Refer the COPD client for pulmonary rehabilitation. EB: A Cochrane study foun
d pulmonary rehabilitation
programs highly effective and safe for a client who has an exacerbation of COPD
(Puhan et al, 2009).
Geriatric
Encourage ambulation as tolerated. Immobility is harmful to the elderly because
it decreases ventilation and
increases stasis of secretions.
Encourage elderly clients to sit upright or stand and to avoid lying down for p
rolonged periods during the
day. Thoracic aging results in decreased lung expansion; an erect position foste
rs maximal lung expansion.
Home Care
The above interventions may be adapted for home care use.
Work with the client to determine what strategies are most helpful during times
of dyspnea. Educate and
empower the client to self-manage the disease associated with impaired gas excha
nge. EBN & EB: A study
found that use of oxygen, self use of medication, and getting some fresh air wer
e most helpful in dealing with
dyspnea (Thomas, 2009). Evidence-based reviews have found that self-management o
ffers COPD clients effective options for managing the illness, leading to more positive outcomes (Kaptei
n et al, 2008).
Assist the client and family with identifying other factors that precipitate o
r exacerbate episodes of ineffective breathing patterns (i.e., stress, allergens, stairs, activities that have h
igh energy requirements). Awareness of precipitating factors helps clients avoid them and decreases risk of ine
ffective breathing episodes.
Assess client knowledge of and compliance with medication regimen. Client/fami
ly may need repetition of
instructions received at hospital discharge and may require reiteration as fear
of a recent crisis decreases. Fear
interferes with the ability to assimilate new information.
? Refer the client for telemonitoring with a pulmonologist as appropriate, with
use of an electronic spirometer,
or an electronic peak ?owmeter. EB: A systematic review of home telemonitoring f
or conditions such as COPD,
asthma, and lung transplantation found that use of telemonitoring resulted in ea
rly detection of deterioration of
clients respiratory status, and positive client receptiveness to the approach (Ja
ana, Par, & Sicotte, 2009).
Teach the client and family the importance of maintaining the therapeutic regi
men and having PRN drugs
easily accessible at all times. Appropriate and timely use of medications can de
crease the risk of exacerbating
ineffective breathing.
Provide the client with emotional support in dealing with symptoms of respirat
ory dif?culty. Provide
family with support for care of a client with chronic or terminal illness. Refer
to care plan for Anxiety.
Witnessing breathing dif?culties and facing concerns of dealing with chronic or
terminal illness can create fear
in caregiver. Fear inhibits effective coping.
177
B
= Independent
B = Evidence-Based
178
? = Collaborative
When respiratory procedures (e.g., apneic monitoring for an infant) ar

e being implemented, explain
equipment and procedures to family members, and provide needed emotional support
. Family members
B
REFERENCES
assuming responsibility for respiratory monitoring often ?nd this stressful. The
y may not have been able to
assimilate fully any instructions provided by hospital staff.
When electrically based equipment for respiratory support is being implemented
, evaluate home environment for electrical safety, proper grounding, and so forth. Ensure that noti?cat
ion is sent to the local
utility company, the emergency medical team, police and ?re departments. Noti?ca
tion is important to
provide for priority service.
Refer to GOLD guidelines for management of home care and indications of hospit
al admission criteria
(GOLD, 2011).
Support clients efforts at self-care. Ensure they have all the information they
need to participate in care.
Identify an emergency plan including when to call the physician or 911. Having
a ready emergency plan
reassures the client and promotes client safety.
? Refer to occupational therapy for evaluation and teaching of energy conservat
ion techniques.
? Refer to home health aide services as needed to support energy conservation.
Energy conservation decreases
the risk of exacerbating ineffective breathing.
? Institute case management of frail elderly to support continued independent l
iving.
Client/Family Teaching and Discharge Planning
Teach pursed-lip and controlled breathing techniques. EB: Studies have
demonstrated that pursed-lip
breathing was effective in decreasing breathlessness and improving respiratory f
unction (Faager, Stahle, &
Larsen, 2008).
Teach about dosage, actions, and side effects of medications. Inhaled steroids
and bronchodilators can have
undesirable side effects, especially when taken in inappropriate doses.
Using a prerecorded CD, teach client progressive muscle relaxation techniques.
EB: Relaxation therapy
can help reduce dyspnea and anxiety (Langer et al, 2009).
Teach the client to identify and avoid speci?c factors that exacerbate ineffect
ive breathing patterns, such
as exposure to other sources of air pollution, especially smoking. If client smo
kes, refer to the smoking
cessation section in the Impaired Gas Exchange care plan.
Bailey PH: The dyspnea-anxiety-dyspnea cycle COPD patient s stories
of breathlessness, Qual Health Res 14(6):760 778, 2004.
Banzett R, et al: The affective dimension of laboratory dyspnea, Am J
Respir Crit Care Med 177:1384 1390, 2008.
Bickley LS, Szilagyi P: Guide to physical examination, ed 10, Philadelphia, 2009, Lippincott.
Brennan C, Mazanec P: Dyspnea management across the palliative care
continuum, J Hosp Palliat Nurs 13(3):130 139, 2011.
Carrieri-Kohlman V, Donesky-Cuenco D: Dyspnea management. An

EBP guideline. In Ackley B et al, editors: Evidence-based nursing
care guidelines: medical-surgical interventions, Philadelphia, 2008,
Mosby.
Faager G, Stahle A, Larsen FF: In?uence of spontaneous pursed lips
breathing on walking endurance and oxygen saturation in patients
with moderate to severe chronic obstructive pulmonary disease,
Clin Rehabil 22(8):675 683, 2008.
Galbraith S, et al: Does the use of a handheld fan improve chronic
dyspnea? A randomized controlled, crossover trial, J Pain Symptom
Manage 39(5):831 838, 2010.
GOLD: Global strategy for the diagnosis, management, and prevention of
COPD (revised 2011), 2011, Global Initiative for Chronic Obstructive Lung Disease.
Hagle M: Vital signs monitoring. An EBP guideline. In Ackley B
et al, editors: Evidence-based nursing care guidelines: medical-surgical
interventions, Philadelphia, 2008, Mosby.
Han J, et al: The language of medically unexplained dyspnea, Chest
133(4):961 968, 2008.
Jaana M, Par G, Sicotte C: Home telemonitoring for respiratory conditions: a systematic review, Am J Manage Care 15(5):313 320, 2009.
Jarvis C: Physical examination and health, ed 6, St. Louis, 2012,
Saunders.
Kaptein AA, et al: 50 years of psychological research on patients with
COPD road to ruin or highway to heaven? Respir Med 103:3 11,
2008.
Langer D, et al: A clinical practice guideline for physiotherapists treating
patients with chronic obstructive pulmonary disease based on a
systematic review of available evidence, Clin Rehabil 23(5):445 462,
2009.
Odencrants S, Ehnfors M, Ehrenbert A: Nutritional status and patient
characteristics for hospitalized older patients with chronic obstructive pulmonary disease, J Clin Nurs 17(13):1771 1778, 2008.
Puhan M, et al: Pulmonary rehabilitation following exacerbations of
chronic obstructive pulmonary disease, Cochrane Database Syst
Rev(1), CD005305:2009.
Reilly J, Silverman E, Shapiro S: Chronic obstructive pulmonary disease.
In Longo D et al, editors: Harrison s principles of internal medicine,
ed 18, New York, 2012, McGraw-Hill.
Thomas L: Effective dyspnea management strategies identi?ed by elders
with end-stage chronic obstructive pulmonary disease, Appl Nurs
Res 22(2):79 85, 2009.
Wong M, Elliott M: The use of medical orders in acute care oxygen
therapy, Br J Nurs 18(8):462 464, 2009.
= Independent
B = Evidence-Based
Decreased cardiac output
? = Collaborative
179
Decreased Cardiac Output
NANDA-I
Maryanne Crowther, DNP, APN, CCRN
De?nition
Inadequate volume of blood pumped by the heart per minute to meet metabolic dema
nds of the body
C
Altered Heart Rate/Rhythm
Arrhythmias; bradycardia; electrocardiographic changes; palpitations; tachycardi
a
Altered Preload
Edema; decreased central venous pressure (CVP); decreased pulmonary artery wedge
pressure (PAWP);
fatigue; increased central venous pressure (CVP); increased pulmonary artery wed
ge pressure (PAWP); jugular vein distention; murmurs; weight gain
Altered Afterload
Clammy skin; dyspnea; decreased peripheral pulses; decreased pulmonary v
ascular resistance (PVR);
decreased systemic vascular resistance (SVR); increased pulmonary vascular resis
tance (PVR); increased systemic vascular resistance (SVR); oliguria, prolonged capillary re?ll; skin color
changes; variations in blood
pressure readings
Altered Contractility
Crackles; cough; decreased ejection fraction; decreased left ventricular stroke
work index (LVSWI); decreased
stroke volume index (SVI); decreased cardiac index; decreased cardiac output; or
thopnea; paroxysmal nocturnal dyspnea; S3 sounds; S4 sounds
Behavioral/Emotional
Anxiety; restlessness
Altered heart rate; altered heart rhythm; altered stroke volume: altered preload
, altered afterload, altered
contractility
NOC
Cardiac Pump Effectiveness, Circulation Status, Tissue Perfusion: Abdominal Orga
ns, Peripheral, Vital Signs
Cardiac Pump Effectiveness as evidenced by the following indicators: Blood press
ure/Heart rate/Cardiac index/Ejection

fraction/Activity tolerance/Peripheral pulses/Neck vein distention not present/H
eart rhythm/Heart sounds/Angina not present/Peripheral edema not present/Pulmonary edema not present. (Rate the outcome and indica
tors of Cardiac Pump Effectiveness:
1 = severe deviation from normal range, 2 = substantial deviation from normal ra
nge, 3 = moderate deviation from normal
range, 4 = mild deviation from normal range, 5 = no deviation from normal range
[see Section I].)
Client Outcomes
Demonstrate adequate cardiac output as evidenced by blood pressure, pulse rate
and rhythm within normal parameters for client; strong peripheral pulses; maintained level of mentati
on, lack of chest discomfort or dyspnea, and adequate urinary output; an ability to tolerate activity wi
thout symptoms of dyspnea,
syncope, or chest pain
= Independent
B = Evidence-Based
180
? = Collaborative
Remain free of side effects from the medications used to achieve adequate cardi
ac output
Explain actions and precautions to prevent primary or secondary cardiac disease
NIC
C
Cardiac Care, Cardiac Care: Acute
Example NIC Activities Cardiac Care
Evaluate chest pain (e.g., intensity, location, radiation, duration, and precipi
tating and alleviating factors); Document cardiac
dysrhythmias
Recognize primary characteristics of decreased cardiac output as fatigue, dyspn
ea, edema, orthopnea,
paroxysmal nocturnal dyspnea, and increased central venous pressure. Recognize s
econdary characteristics of decreased cardiac output as weight gain, hepatomegaly, jugular venous di
stention, palpitations,
lung crackles, oliguria, coughing, clammy skin, and skin color changes. EBN: A n
ursing study to validate
characteristics of the nursing diagnosis decreased cardiac output in a clinical

environment identi?ed and categorized related client characteristics that were present as primary or secondar
y (Martins, Alita, & Rabelo,
2010).
Monitor and report presence and degree of symptoms including dyspnea at rest o
r with reduced exercise
capacity, orthopnea, paroxysmal nocturnal dyspnea, nocturnal cough, distended ab
domen, fatigue, or
weakness. Monitor and report signs including jugular vein distention, S3 gallop,
rales, positive hepatojugular re?ux, ascites, laterally displaced or pronounced PMI, heart murmurs, na
rrow pulse pressure,
cool extremities, tachycardia with pulsus alternans, and irregular heartbeat. EB
: These are symptoms and
signs consistent with heart failure (HF) and decreased cardiac output (Jessup et
al, 2009). In a study of primary care clients, breathlessness during exercise, limitations in physical activ
ity, and orthopnea were the
three most signi?cant symptoms most often associated with HF (Devroey & Van Cast
eren, 2011).
Monitor orthostatic blood pressures and daily weights. EB: These interventions
assess for ?uid volume status (Jessup et al, 2009). EB: The extent of volume overload is key to deciding o
n appropriate treatment for HF
(Lindenfeld et al, 2010).
Recognize that decreased cardiac output that can occur in a number of non-card
iac disorders such as
septic shock and hypovolemia. Expect variation in orders for differential diagno
ses related to the etiology
of decreased cardiac output, as orders will be distinct to address primary cause
of altered cardiac output.
EB: A study of left ventricular function in patients with septic shock identi?ed
that 60% developed reversible
left ventricular dysfunction that could successfully be hemodynamically supporte
d with IV vasoactive medications (Vieillard-Baron et al, 2008). Obtain a thorough history. EB: It is import
ant to assess for behaviors that
might accelerate the progression of HF symptoms such as high sodium diet, excess
?uid intake, or missed medication doses (Jessup et al, 2009).
? Administer oxygen as needed per physician s order. Supplemental oxygen increase
s oxygen availability to
the myocardium. EB: Clinical practice guidelines cite that oxygen should be admi
nistered to relieve symptoms
related to hypoxemia. Supplemental oxygen at night or for exercise is not recomm
ended unless there is concurrent pulmonary disease. Resting hypoxia or oxygen desaturation may indicate ?uid
overload or concurrent
pulmonary disease (Jessup et al, 2009).
Monitor pulse oximetry regularly, using a forehead sensor if needed. CEB: In a
study that compared oxygen
saturation values of arterial blood gases to various sensors, it was found that
the forehead sensor was signi?cantly better than the digit sensor for accuracy in clients with low cardiac out
put, while being easy to use and
not interfering with client care (Fernandez et al, 2007).
Place client in semi-Fowler s or high Fowler s position with legs down or in a pos
ition of comfort. Elevating the head of the bed and legs in down position may decrease the work of breat
hing and may also decrease

venous return and preload.
During acute events, ensure client remains on short-term bed rest or maintains
activity level that does not
compromise cardiac output. In severe HF, restriction of activity reduces the wor
kload of the heart (Fauci
et al, 2008).
= Independent
B = Evidence-Based
? = Collaborative

Provide a restful environment by minimizing controllable stressors and unnecess
ary disturbances. Schedule rest periods after meals and activities. Rest helps lower arterial pressure
and reduce the workload of the
myocardium by diminishing the requirements for cardiac output (Fauci et al, 2008
).
? Apply graduated compression stockings or intermittent sequential pneumatic com
pression (ISPC) leg
sleeves as ordered. Ensure proper ?t by measuring accurately. Remove stocking at
least twice a day, then
reapply. Assess the condition of the extremities frequently. Graduated compressi
on stockings may be
contraindicated in clients with peripheral arterial disease (Kahn et al, 2012).
EB: A study that assessed
effects of ISPC on healthy adults found that there were signi?cant increases in
cardiac output, stroke volume,
and ejection fraction due to increased preload and decreased afterload (Bickel e
t al, 2011); EBN: A study that
assessed use of knee-length graduated compression stockings found they are as ef
fective as thigh-length graduated compression stockings. They are more comfortable for clients, are easier fo
r staff and clients to use, pose
less risk of injury to clients, and are less expensive as recommended in this st
udy (Hilleren-Listerud, 2009). EB:
Graduated compression stockings, alone or used in conjunction with other prevent
ion modalities, help promote venous return and reduce the risk of deep vein thrombosis in hospitalized c
lients (Sachdeva et al, 2010).
? Check blood pressure, pulse, and condition before administering
cardiac medications such as
angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (A
RBs), digoxin, and
beta-blockers such as carvedilol. Notify physician if heart rate or blood pressu
re is low before holding
medications. It is important that the nurse evaluate how well the client is tole
rating current medications
before administering cardiac medications; do not hold medications without physic
ian input. The physician
may decide to have medications administered even though the blood pressure or pu
lse rate has lowered.
Observe for and report chest pain or discomfort; note location, radiation, seve
rity, quality, duration, associated manifestations such as nausea, indigestion, and diaphoresis; also note pr
ecipitating and relieving
factors. Chest pain/discomfort may indicate an inadequate blood supply to the he
art, which can further compromise cardiac output. EB: Clients with decreased cardiac output may present wi
th myocardial ischemia.
Those with myocardial ischemia may present with decreased cardiac output and HF
(Jessup et al, 2009; Lindenfeld et al, 2010).
? If chest pain is present, refer to the interventions in Risk for decreased Car
diac tissue perfusion care
plan.
Recognize the effect of sleep disordered breathing in HF. EB & CEB: A study ass
essing effects of OSA physiology on left sided cardiac function found that the increase in negative intrath
oracic pressure found in OSA led
to a decrease in left ventricular systolic performance (Orban et al, 2008). A st
udy that assessed effectiveness of
nasal cannula oxygen supplement for nocturnal obstructive sleep apnea found that
75% of HF clients had sleep
apnea, and those who exhibited central sleep apnea had signi?cantly reduced epis
odes when wearing nasal
oxygen during sleep (Sakakibara et al, 2005). Sleep-disordered breathing, includ
ing obstructive sleep apnea
and Cheyne-Stokes with central sleep apnea, are common organic sleep disorders i
n clients with chronic HF
and are a poor prognostic sign associated with higher mortality (Brostrom et al,
2004).
? Closely monitor ?uid intake, including intravenous lines. Maintain ?uid restri
ction if ordered. In clients
with decreased cardiac output, poorly functioning ventricles may not tolerate in
creased ?uid volumes.
Monitor intake and output. If client is acutely ill, measure hourly urine outpu
t and note decreases in
output. EB: Clinical practice guidelines cite that monitoring I&Os is useful for
monitoring effects of diuretic
therapy (Jessup et al, 2009). Decreased cardiac output results in decreased perf
usion of the kidneys, with a
resulting decrease in urine output.
? Note results of electrocardiography and chest radiography. CEB: Clinic
al practice guidelines suggest
that chest radiography and electrocardiogram are recommended in the initial asse
ssment of HF (Jessup et al,
2009).
? Note results of diagnostic imaging studies such as echocardiogram, radionuclid
e imaging, or dobutamine-stress echocardiography. EB: Clinical practice guidelines state that the ec
hocardiogram is a key test in
the assessment of HF (Jessup et al, 2009).
? Watch laboratory data closely, especially arterial blood gases, CBC, electroly
tes including sodium, potassium and magnesium, BUN, creatinine, digoxin level, and B-type natriuretic pepti
de (BNP assay). Routine blood work can provide insight into the etiology of HF and extent of decomp
ensation. EB: Clinical practice
guidelines recommend that BNP or NTpro-BNP assay should be measured in clients w
hen the cause of HF is

not known (Jessup et al, 2009). A study assessed hyponatremia as a prognostic in
dicator in clients with preserved left ventricular function and found that hyponatremia at ?rst hospitaliza
tion is a powerful predictor of
long-term mortality in this group (Rusinaru et al, 2009). Serum creatinine level
s will elevate in clients with
severe HF because of decreased perfusion to the kidneys. Client may be receiving
cardiac glycosides, and the
181
C
= Independent
B = Evidence-Based
182
? = Collaborative
potential for toxicity is greater with hypokalemia; hypokalemia is common in hea

rt clients because of diuretic
use (Fauci et al, 2008).
Gradually increase activity when client s condition is stabilized by encouraging
slower paced activities or
shorter periods of activity with frequent rest periods following exercise prescr
iption; observe for sympC
toms of intolerance. Take blood pressure and pulse before and after activity and
note changes. Activity of
the cardiac client should be closely monitored. See Activity Intolerance.
? Serve small, frequent, sodium-restricted, low saturated fat meals. Sodium-rest
ricted diets help decrease
?uid volume excess. Low saturated fat diets help decrease atherosclerosis, which
causes coronary artery disease. Clients with cardiac disease tolerate smaller meals better because they re
quire less cardiac output to
digest. EB: A study that compared cardiac event-free survival between clients wh
o ingested more or less than 3
grams of dietary sodium daily found that those who were NYHA class III or IV cli
ents bene?ted the most from
dietary intake less than 3 grams daily (Lennie et al, 2011); EB: A study that co
mpared HF symptoms with
dietary sodium intake found that those with sodium intakes greater than 3 grams
per day had more HF symptoms (Son et al, 2011). Emphasis on use of unsaturated fats and less use of satu
rated fats in the diet is recommended to reduce cardiovascular risk. Polyunsaturates are bene?cial to vascular
endothelial function, while
saturated fats impair vascular endothelial function (Hall et al, 2009; Willett e
t al, 2011).
Serve only small amounts of coffee or caffeine-containing beverages if requeste
d (no more than four cups
per 24 hours) if no resulting dysrhythmia. CEB: A review of studies on caffeine
and cardiac arrhythmias
concluded that moderate caffeine consumption does not increase the frequency or
severity of cardiac arrhythmias (Hogan, Hornick, & Bouchoux, 2002; Myers & Harris, 1990; Schneider, 1987).
? Monitor bowel function. Provide stool softeners as ordered. Caution client not
to strain when defecating.
Decreased activity, pain medication, and diuretics can cause constipation. The V
alsalva maneuver which can
be elicited by straining during defecation, cough, lifting self onto the bedpan,
or lifting self in bed can be harmful (Moser et al, 2008).
Have clients use a commode or urinal for toileting and avoid use of a bedpan. G
etting out of bed to use a
commode or urinal does not stress the heart any more than staying in bed to toil
et. In addition, getting the
client out of bed minimizes complications of immobility and is often preferred b
y the client (Winslow, 1992).
Weigh client at same time daily (after voiding). EB: Clinical practice guidelin
es state that weighing at the
same time daily is useful to assess effects of diuretic therapy (Jessup et al, 2
009). Use the same scale if possible
when weighing clients. Daily weight is also a good indicator of ?uid balance. In
creased weight and severity of
symptoms can signal decreased cardiac function with retention of ?uids.
? Provide in?uenza and pneumococcal vaccines prior to discharge for those who ha
ve yet to receive them.
EB: Clinical practice guidelines and a Scienti?c Statement cite that HF hospital
izations are more likely during
in?uenza and winter season, and that having the immunization minimizes that risk
(Lindenfeld et al, 2010;
Riegel et al, 2009).
Assess for presence of anxiety and refer for treatment if present. See Nursing
Interventions and Rationales
for Anxiety to facilitate reduction of anxiety in clients and family. EB: A clin
ical practice guideline recommends that non-pharmacological techniques for stress reduction are a useful adju
nct for reduction of anxiety
in HF clients (Lindenfeld et al, 2010). A study that assessed the relationship b
etween anxiety and incidence of
death, emergency department visits, or hospitalizations found that those with hi
gher anxiety had signi?cantly
worse outcomes than those with lower anxiety (De Jong et al, 2011).
? Refer for treatment when depression is present. EBN: A study on combined depre
ssion and level of perceived
social support found that depressive symptoms were an independent predictor of i
ncreased morbidity and
mortality, and those with lower perceived social support had 2.1 times higher ri
sk of events than nondepressed

clients with high perceived social support (Chung et al, 2011). A qualitative st
udy that described experiences
of clients living with depressive symptoms found that negative thinking was pres
ent in all participants, reinforcing depressed mood; multiple stressors worsened depressive symptoms;
and depressive symptoms were
reduced by ?nding activities from which to distract (Dekker et al, 2009). A stud
y that assessed health-related
quality of life found that baseline depression along with perceived control were
strongest predictors of physical
symptom status (Heo et al, 2008).
? Refer to a cardiac rehabilitation program for education and monitored exercise
. EB & CEB: Clients with HF
should be referred for exercise training when deemed safe, to promote exercise e
xpectations, understanding, and
adherence (Lindenfeld et al, 2010). A systematic review of outcomes of exercise
based interventions in clients
with systolic HF found that hospitalizations and those for systolic HF were redu
ced for clients in an exercise
program and quality of life was improved (Davies et al, 2010). In a study to ass
ess effects of exercise in HF clients, exercise tolerance and left ventricular ejection fraction increased with e
xercise training (Alves et al, 2012).
= Independent
B = Evidence-Based
? = Collaborative

? Refer to HF program for education, evaluation, and guided support to increase
activity and rebuild quality of life. CEB: A study assessing the 6-month outcomes of a nurse practitioner c
oordinated HF center found
that readmissions, length of stay, and cost per case were all signi?cantly reduc
ed, while quality of life was signi?cantly improved (Crowther et al, 2002).
Critically Ill
? Observe for symptoms of cardiogenic shock, including impaired mentation, hypo
tension with blood pressure lower than 90 mm Hg, decreased peripheral pulses, cold clammy skin, signs o
f pulmonary congestion, and decreased organ function. If present, notify physician immediately. Ca
rdiogenic shock is a state of
circulatory failure from loss from cardiac function associated with inadequate o
rgan perfusion with a high
mortality rate. CEB: In a study the de?ning characteristics of decreased cardiac
output were best indicated by
decreased peripheral pulses and decreased peripheral perfusion (Oliva & Monteiro
da Cruz Dde, 2003).
? If shock is present, monitor hemodynamic parameters for an increase in pulmona
ry wedge pressure, an
increase in systemic vascular resistance, or a decrease in stroke volume, cardia
c output, and cardiac index.
Hemodynamic parameters give a good indication of cardiac function (Fauci et al,
2008).
? Titrate inotropic and vasoactive medications within de?ned parameters to maint
ain contractility, preload, and afterload per physician s order. EB: Clinical practice guidelines recomm
end that intravenous inotropic drugs might be reasonable for HF clients presenting with low BP and low c
ardiac output to maintain
systemic perfusion and preserve end-organ performance (Jessup et al, 2009). By f
ollowing parameters, the
nurse ensures maintenance of a delicate balance of medications that stimulate th
e heart to increase contractility, while maintaining adequate perfusion of the body.
? When using pulmonary arterial catheter technology, be sure to appropriately le
vel and zero the equipment, use minimal tubing, maintain system patency, perform square wave testing,
position the client
appropriately, and consider correlation to respiratory and cardiac cycles when a
ssessing waveforms and
integrating data into client assessment. EB: Clinical practice guidelines recomm
end that invasive hemodynamic monitoring can be useful in acute HF with persistent symptoms when therapy
is refractory, ?uid status
is unclear, systolic pressures are low, renal function is worsening, vasoactive
agents are required, or when considering advanced device therapy or transplantation (Jessup et al, 2009).
? Observe for worsening signs and symptoms of decreased cardiac output when usin
g positive pressure
ventilation. EB: Positive pressure ventilation and mechanical ventilation are as
sociated with a decrease in
preload and cardiac output (Lukacsovitis, Carlussi, & Hill, 2012; Yucel et al, 2
011).
? Recognize that clients with cardiogenic pulmonary edema may have noninvasive p
ositive pressure ventilation (NPPV) ordered. EB: Clinical practice guidelines for HF state that contin
uous positive airway pressure
improves daily functional capacity and quality of life for those with HF and obs
tructive sleep apnea (Lindenfeld et al, 2010) and is reasonable for clients with refractory HF not respondin
g to other medical therapies
(Jessup et al, 2009). A systematic review of NPPV for cardiogenic pulmonary edem
a found that use of NPPV
signi?cantly reduced mortality and intubation, while decreasing ICU stay by 1 da
y (Vital et al, 2009).
? Monitor client for signs and symptoms of ?uid and electrolyte imbalance when c
lients are receiving ultra?ltration or continuous renal replacement therapy (CRRT). Clients with refractor
y HF may have ultra?ltration or CRRT ordered as a mechanical method to remove excess ?uid
volume. EB: Clinical practice
guidelines cite that ultra?ltration is reasonable for clients with refractory HF
not responsive to medical therapy
(Jessup et al, 2009).
Recognize that hypoperfusion from low cardiac output can lead to altered mental
status and decreased
cognition. EB & CEB: A study that assessed an association among cardiac index an
d neuropsychological isch-
emia found that decreased cardiac function, even with normal cardiac index, was
associated with accelerated
brain aging (Jefferson et al, 2010). A study that assessed the relationship betw
een hypoperfusion and neuropsychological performance found that among stable geriatric HF clients, executive f
unctions of sequencing and
planning were altered (Jefferson et al, 2007).
Geriatric
Recognize that elderly clients may demonstrate fatigue and depression as signs
of HF and decreased cardiac output (Lindenfeld et al, 2010).
? If client has heart disease causing activity intolerance, refer for cardiac r
ehabilitation. EBN: A study that
assessed clients acceptance of a cardiac rehabilitation program found knowledge a
nd perceived quality of life
had increased signi?cantly, and anxiety and depression had been reduced at the e
nd of the program and at 6
month follow-up (Muschalla, Glatz, & Karger, 2011).
183
C
= Independent
B = Evidence-Based
184
? = Collaborative
Observe for syncope, dizziness, palpitations, or feelings of weakness associate

d with an irregular heart
rhythm. CEB & EB: Dysrhythmias, particularly atrial ?brillation and ventr
icular ectopy, and both nonsustained and sustained ventricular tachycardia are common in clients with HF (H
unt et al, 2005; Lindenfeld
et al, 2010).
C
? Observe for side effects from cardiac medications. The elderly have dif?culty
with metabolism and excretion
of medications due to decreased function of the liver and kidneys; th
erefore toxic side effects are more
common.
Design educational interventions speci?cally for the elderly. EB: Many elderly
HF clients have low levels of
knowledge about HF self-care and have limitations in function and cognition, low
motivation, and low selfesteem. They require skilled assessment of educational level and ability to be s
uccessful with self-care (Strmberg, 2005).
Home Care
Some of the above interventions may be adapted for home care use. Home care age
ncies may use specialized staff and methods to care for chronic HF clients. CEB: A study assessing HF
outcomes over a 10-year
period between a multidisciplinary home care intervention and usual care found s
igni?cantly improved survival and prolonged event-free survival and was both cost- and time-effective (I
ngles et al, 2006).
? Continue to monitor client closely for exacerbation of HF when discharged home
. CEB: Home visits and
phone contacts that emphasize client education and recognition of early symptoms
of exacerbation can decrease
rehospitalization (Gorski & Johnson, 2003).
After acute hospitalization, the majority of HF clients education is performed,
including social support
of others, with each session focused on assessment of current knowledge, client
learning priorities, and
barriers to change (Lindenfeld et al, 2010).
Assess for signs/symptoms of cognitive impairment. EBN: Impaired cognitive func
tion can affect 25-50% of
HF clients and is associated with poorer HF self-care. Etiology of this phenomen
on may be poorer regional
blood ?ood to areas of the brain (Riegel et al, 2009).
Assess for fatigue and weakness frequently. Assess home environment for safety,
as well as resources/
obstacles to energy conservation. Instruct client and family members on need for
behavioral pacing and
energy conservation. EBN: Fatigue and weakness limit activity level and quality
of life. Assistive devices and
other techniques of work simpli?cation can help the client participate in and re
spond to the health care regimen more effectively (Quaglietti et al, 2004).
Help family adapt daily living patterns to establish life changes that will mai
ntain improved cardiac functioning in the client. Take the client s perspective into consideration and use a
holistic approach in assessing and responding to client planning for the future. Transition to the home set
ting can cause risk factors
such as inappropriate diet to reemerge.
Assist client to recognize and exercise power in using self-care management to
adjust to health change.
EBN: Identi?ed self-care behaviors, barriers to self-care, interventions to prom
ote self-care, and evaluation of effects of self-care are important to maintain the heart failure client s
quality of life and functional
status and to reduce mortality from the syndrome (Riegel et al, 2009)
. Refer to care plan for
Powerlessness.
? Explore barriers to medical regimen adherence. Review medications and treatmen
t regularly for needed
modi?cations. Take complaints of side effects seriously and serve as client advo
cate to address changes as

indicated. The presence of uncomfortable side effects frequently motivates clien
ts to deviate from the medication regimen.
? Refer for cardiac rehabilitation and strengthening exercises if client is not
involved in outpatient cardiac
rehabilitation.
? Refer to medical social services as necessary for counseling about the impact
of severe or chronic cardiac
disease. Social workers can assist the client and family with acceptance of life
changes.
? Institute case management of frail elderly to support continued independent li
ving.
? As the client chooses, refer to palliative care for care, which can begin earl
ier in the care of the HF client.
Palliative care can be used to increase comfort and quality of life in the HF cl
ient before end-of-life care
(Buck & Zambroski, 2012).
? If the client s condition warrants, refer to hospice. EB & CEB: End-of-life disc
ussions should occur with
clients and family as end-stage heart failure becomes refractory to therapy (Hun
t et al, 2005; Lindenfeld et al,
2010). The multidisciplinary hospice team can reduce hospital readmission, incre
ase functional capacity, and
improve quality of life in end-stage HF (Coviello, Hricz, & Masulli, 2002).
= Independent
B = Evidence-Based
? = Collaborative

Identify emergency plan in advance, including whether use of cardiopulmonary re
suscitation (CPR) is
desired. Encourage family members to become certi?ed in cardiopulmonary resuscit
ation if the client
desires. EB: A study that assessed the client s perspective on end-of-life care fo
und that the three most important issues ranked included avoidance of life support if there was no hope of su
rvival, provider communication
and reduced family burden (Strachan et al, 2009);
Begin discharge planning as soon as possible upon admission to the emergency de
partment (ED) with
case manager or social worker to assess home support systems and the need for co
mmunity or home
health services. Consider referral for advanced practice nurse (APN) follow-up.
Support services may be
needed to assist with home care, meal preparations, housekeeping, personal care,
transportation to doctor
visits, or emotional support. CEB: A study to assess degree of social support as
a predictor of heart failure
readmission demonstrated that those without someone living with them had a great
er readmission rate in a
dose-dependent response, but no correlation to death was found (Rodriguez-Artale
jo et al, 2006). Clients often
need help on discharge.
? Refer to case manager or social worker to evaluate client ability to pay for
prescriptions. The cost of drugs
may be a factor in ?lling prescriptions and adhering to a treatment plan.
Include signi?cant others in client teaching opportunities. Include all six ar
eas of discharge instructions for
heart failure hospitalizations: Daily weight monitoring/reporting, symptoms reco
gnition/reporting/when
to call for help, smoking cessation, low-sodium diet, medication use and adheren
ce, and regular follow-up
with providers. EB: A scienti?c statement cites social support from family and f
riends as being positively associated with better medication adherence and self-care maintenance, and lower readm
ission rates (Riegel et al,
2009). Failure to understand and comply with educational instructions is a major
cause of HF exacerbation and
hospital readmissions (Jessup et al, 2009). Clinical guidelines recommend that h
ospitalized heart failure clients
be given basic instructions prior to discharge to facilitate self-care and manag
ement at home (Jessup et al, 2009).
Teach importance of performing and recording daily weights upon arising for th
e day, and to report
weight gain. Ask if client has a scale at home; if not, assist in getting one. E
B: Clinical practice guidelines
suggest that daily weight monitoring leads to early recognition of excess ?uid r
etention, which, when reported,
can be offset with additional medication to avoid hospitalization from heart fai
lure decompensation (Jessup
et al, 2009). Daily weighing is an essential aspect of self-management. A scale
is necessary. Scales vary; the client needs to establish a baseline weight on the home scale.
Teach types and progression patterns of heart failure symptoms, when to call th
e physician for help, and
when to go to the hospital for urgent care. EB: Inability to recognize or adequa
tely interpret symptom worsening heart failure is common among heart failure clients. Early symptom recogni
tion and early self-help
measures or professional evaluation and treatment lead to improved outcomes (Rie
gel et al, 2009).
Teach importance of smoking cessation and avoidance of alcohol intake. Help cl
ients who smoke stop by
informing them of potential consequences and by helping them ?nd an effective ce
ssation method. EB:
Smoking has vasoconstrictor and pro-in?ammatory properties that impede effective
cardiac output. Discontinuation of smoking leads to reduced adverse consequences, including decreased
mortality in HF (Riegel et al,
2009). Smoking cessation advice and counsel given by nurses can be effective and
should be available to clients
to help stop smoking (Rice & Stead, 2008).
Teach the direct bene?ts of a low-sodium diet. EB: A scienti?c statement and c
linical guidelines on heart
failure recommend a 2-3 gram/day sodium diet for most stable heart failure clien
ts, and less when heart failure
severity warrants (Jessup et al, 2009; Lindenfeld et al, 2010; Riege et al, 2009
). Sodium retention leading to
?uid overload is a common cause of hospital readmission (Fauci et al, 2008).

? Teach the client importance of consistently taking cardiovascular medications
, and include actions, side
effects to report. EB: A scienti?c statement cited that adherence to medications
ranges from 5% to 90%. In
one study 88% adherence was required in heart failure clients to achieve event-f
ree survival. The study cited
as reasons for non-adherence, depression, cost, attitudes about taking medicatio
n, worrying about or feeling
side effects including those on sexual function, receipt of con?icting informati
on about medications from different prescribers, and lack of understanding about discharge instructions (Rieg
el et al, 2009). Evidence-based
guidelines state that taking medication as directed can help prevent HF decompen
sation, and rehospitalization, and decrease morbidity (Jessup et al, 2009).
Instruct client and family on the importance of regular follow up care with pr
oviders. EB: Post discharge
support can signi?cantly reduce hospital readmissions and improve health care ou
tcomes, quality of life, and
costs (Hernandez et al, 2010; Jessup et al, 2009).
185
C
= Independent
B = Evidence-Based
186
? = Collaborative
Teach stress reduction (e.g., imagery, controlled breathing, muscle relaxation

techniques). CEB: A study
that assessed effects of relaxation or exercise in heart failure clients versus
controls found that those who participated in regular relaxation therapy or exercise training reported greater improv
ements in psychological outcomes, with the relaxation group signi?cantly improving depression and the exerc
ise training group more
C
REFERENCES
improving fatigue (Yu et al, 2007).
? Refer to an outpatient system of care. EB: Systems of care such as disease ma
nagement, telemonitoring, and
telehealth promote self-care, facilitating transitions across settings (Riegel e
t al, 2009).
Provide client/family with advance directive information to consider. Allow cli
ent to give advance directions about medical care or designate who should make medical decisions if he or
she should lose decision-making capacity. EB: Heart failure guidelines recommends that clients and f
amilies be educated about
end-of-life options prior to client decline, and with a change in clinical statu
s (Jessup et al, 2009).
Alves AJ, et al: Exercise training improves diastolic function in heart
failure patients, Med Sci Sports Exerc 44(5):776 785, 2012.
Bickel A, et al: The physiological impact of intermittent sequential
pneumatic compression (ISPC) leg sleeves on cardiac activity, Am J
Surg 202:15 22, 2011.
Brostrom A, et al: Sleep dif?culties, daytime sleepiness, and healthrelated quality of life in patients with chronic heart failure, J Cardiovasc Nurs 19(4):234 242, 2004.
Buck HG, Zambroski CH: Upstreaming palliative care for patients with
heart failure, J Cardiovasc Nurs 27(2):147 153, 2012.
Chung ML, et al: Depressive symptoms and poor social support have a
synergistic effect on event-free survival in patients with heart failure,
Heart Lung 40(6):492 501, 2011.
Coviello JS, Hricz L, Masulli PS: Client challenge: accomplishing quality of life in end-stage heart failure: a hospice multidisciplinary
approach, Home Healthc Nurse 20:195 198, 2002.
Crowther M, et al: Evidence-based development of a hospital-based
heart failure center, Re?ect Nurs Leadersh 28(2):32 33, 2002.
Davies EJ, et al: Exercise based rehabilitation for heart failure, Cochrane
Database Syst Rev(4), CD003331:2010.
De Jong MJ: Linkages between anxiety and outcomes in heart failure,
Heart Lung 40(5):393 404, 2011.
Dekker RL, et al: Living with depressive symptoms: patients with heart
failure, Am J Crit Care 18(4):310 318, 2009.
Devroey D, Van Casteren V: Signs for early diagnosis of heart failure in
primary health care, Vasc Health Risk Manag 7:591 596, 2011.
Fauci A, et al: Harrison s principles of internal medicine, ed 17, New
York, 2008, McGraw-Hill.
Fernandez M, et al: Evaluation of a new pulse oximeter sensor, Am J
Crit Care 16(2):146 152, 2007.
Gorski LA, Johnson K: A disease management program for heart failure:
collaboration between a home care agency and a care management
organization, Home Healthc Nurse 21(11):734, 2003.
Hall WL: Dietary saturated and unsaturated fats as determinants of
blood pressure and vascular function, Nutr Res Rev 22(1):18 38,
2009.
Heo S, et al: Predictors and effect of physical symptom status on healthrelated quality of life in patients with heart failure, Am J Crit Care
17:124 132, 2008.
Hernandez AF, et al: Relationship between early physician follow-up
and 30-day readmission among Medicare bene?ciaries hospitalized
for heart failure, JAMA 303(17):1716 1722, 2010.
Hilleren-Listerud AE: Graduated compression stocking and intermittent pneumatic compression device length selection, Clin Nurse Spec
23(1):21 24, 2009.
Hogan E, Hornick B, Bouchoux A: Communicating the message: clarifying the controversies about caffeine, Nutr Today 37(1):28, 2002.
Hunt SA, et al: ACC/AHA 2005 guideline update for the diagnosis and
management of chronic heart failure in the adult, J Am Coll Cardiol
46(6):e1 82, 2005.
Ingles SC, et al: Extending the horizon in chronic heart failure: effects
of multidisciplinary, home-based intervention relative to usual care,
Circulation 114(23):2466 2473, 2006.
Jefferson AL, et al: Systemic hypoperfusion is associated with executive
dysfunction in geriatric cardiac patients, Neurobiol Aging 28(3):477
483, 2007.
Jefferson AL, et al: Cardiac index is associated with brain aging: the
Framingham Heart study, Circulation 122(7):690 697, 2010.
Jessup M, et al: 2009 focused update: ACCF/AHA guidelines for the
diagnosis and management of heart failure in adults: a report of
the American College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines: developed in
collaboration with the International Society for Heart and Lung
Transplantation, Circulation 119(14):1977 2016, 2009.
Kahn S, et al: Antithrombotic therapy and prevention of thrombosis, ed
9, American College of Chest Physician Evidence-Based Clinical
Practice Guidelines Online Only Articles, Chest 141(suppl 2):e195S
e226S, 2012:doi.10.1378.
Lennie TA, et al: Three gram sodium intake is associated with longer
event-free survival only in patients with advanced heart failure,
J Card Fail 17(4):325 330, 2011.
Lindenfeld J, et al: Executive summary: HFSA comprehensive heart
failure practice guidelines, J Card Fail 16(6):475 539, 2010.
Lukacsovitis J, Carlussi A, Hill N: Physiological changes during low
and high intensity non-invasive ventilation, Eur Respir J 39(4):869
875, 2012.
Martins QC, Alita G, Rabelo ER: Decreased cardiac output: clinical
validation in patients with decompensated heart failure, Int J Nurs
Terminol Classif 21(4):156 165, 2010.
Moser DK, et al: Cardiac precautions. In Ackley B, et al, editors:
Evidence-based nursing care guidelines, Philadelphia, 2008, Mosby.
Muschalla B, Glatz J, Karger G: Cardiac rehabilitation with a structured
education programme for patients with chronic heart failure
illness-related knowledge, mental wellbeing and acceptance in
participants, Rehabilitation 50(2):103 110, 2011.
Myers MG, Harris L: High dose caffeine and ventricular arrhythmias,
Can J Cardiol 6(3):95 98, 1990.
Oliva AP: Monteiro da Cruz Dde A: Decreased cardiac output: validation with postoperative heart surgery patients, Dimens Crit Care
Nurs 22(1):39 44, 2003.
Orban M, et al: Dynamic changes of left ventricular performance and
left atrial volume induced by the Mueller maneuver in healthy
young adults and implications for obstructive sleep apnea, atrial
?brillation and heart failure, Am J Cardiol 102:1557 1561, 2008.
= Independent
B = Evidence-Based
? = Collaborative
Risk for decreased cardiac tissue perfusion
187
Quaglietti S, et al: Management of the patient with congestive heart
failure in the home care and palliative care setting, Ann Long Term
Care 12(1):33, 2004.
Rice VH, Stead LF: Nursing interventions for smoking cessation,
Cochrane Database Syst Rev(2), CD001188:2008.
Son YJ, Lee Y, Song EK: Adherence to a sodium-restricted diet is associated with lower symptom burden and longer cardiac event-free survival in patients with heart failure, J Clin Nurs 20(21/22):3029 3038,
2011.
Strachan PH, et al: Mind the gap: opportunities for improving end
Riegel B, et al: State of the science: promoting self-care in persons with
heart failure: a scienti?c statement from the American Heart Association, Circulation 120:1141 1163, 2009.
Rodriguez-Artalejo F, et al: Social network as a predictor of hospital
readmission and mortality among older patients with heart failure,
J Card Fail 12(8):621 627, 2006.
Rusinaru D, et al: Relation of serum sodium level to long term outcome
after a ?rst hospitalization for heart failure with preserved ejection
fraction, Am J Cardiol 103:405 410, 2009.
Sachdeva A, et al: Elastic compression stockings for prevention of deep
vein thrombosis, Cochrane Database Syst Rev(7), CD001484:2010.
Sakakibara M, et al: Effectiveness of short-term treatment with nocturnal oxygen therapy for central sleep apnea in patients with congestive heart failure, J Cardiol 46(2):53 61, 2005.
Schneider JR: Effects of caffeine ingestion on heart rate, blood pressure,
myocardial oxygen consumption, and cardiac rhythm in acute myocardial infarction patients, Heart Lung 16:167, 1987.
of life care for patients with advanced heart failure, Can J Cardiol
25(11):635 640, 2009.
Strmberg A: The crucial role of patient education in heart failure, Eur J
Heart Fail 7(3):363 369, 2005.
Vital FMR, et al: Non-invasive positive pressure ventilation (CPAP or
bilevel NPPV) for cardiogenic pulmonary edema, Cochrane Data-
base Syst Rev(3), 2009. CD005351.

Willett WC, et al: The Great Fat Debate: a close look at the
controversy questioning the validity of age-old dietary guidance,
J Am Dietetic Assoc 11(5):655 658, 2011.
Winslow EH: Panning bedpans, Am J Nurs 92:16G, 1992.
Yu DS, et al: Non-pharmacological interventions in older people with
heart failure: effects of exercise training and relaxation therapy,
Gerontology 53(2):74 81, 2007.
Yucel S, et al: Nursing diagnoses in patients having mechanical ventilation support in a respiratory intensive care unit in Turkey, Int J Nurs
Pract 17(5):502 508, 2011.
C
Risk for decreased Cardiac tissue perfusion
Maryanne Crowther, DNP, APN, CCRN

NANDA-I
De?nition
Risk for a decrease in cardiac (coronary) circulation
Risk Factors
Hypertension; hyperlipidemia; cigarette smoking, family history of coronary arte
ry disease; diabetes mellitus; alcohol and drug abuse, obesity, cardiac surgery; hypovolemia; hypoxemia; h
ypoxia; coronary artery
spasm; septic shock, cardiac tamponade; birth control pills, elevated C-reactive
protein; lack of knowledge of
modi?able risk factors (e.g., smoking, sedentary lifestyle, obesity)
NOC
Cardiac Pump Effectiveness, Circulation Status, Tissue Perfusion: Cardiac, Tissu
e Perfusion: Cellular, Vital Signs
Tissue Perfusion: Cardiac as evidenced by the following indicators: Angina/Arrhy
thmia/Tachycardia/Bradycardia/Nausea/
Vomiting/Profuse diaphoresis. (Rate the outcome and indicators of Tissue Perfusi
on: Cardiac: 1 = severe, 2 = substantial,
3 = moderate, 4 = mild, 5 = none [see Section I].)
Client Outcomes
Maintain vital signs within normal range
Retain a normal cardiac rhythm (have absence of arrhythmias, tachycardia, or br
adycardia)
Be free from chest and radiated discomfort as well as associated symptoms relat
ed to acute coronary
syndromes
Deny nausea and be free of vomiting
Have skin that is dry and of normal temperature
= Independent

B = Evidence-Based
188
? = Collaborative
NIC
C
Cardiac Care, Cardiac Precautions, Embolus Precautions, Dysrhythmia Management,
Vital Signs Monitoring, Shock Management: Cardiac
Example NIC Activity Cardiac Precautions
Avoid causing intense emotional situations; Avoid overheating or chilling the cl
ient; Provide small frequent meals; Substitute arti?cial
salt and limit sodium intake if appropriate; Promote effective techniques for re
ducing stress; Restrict smoking
Be aware that the most common cause of acute coronary syndromes (ACS) [unstable
angina (UA), nonST-elevation myocardial infarction (NSTEMI), and ST-elevation myocardial
infarction (STEMI)] is
reduced myocardial perfusion associated with partially or fully occlusive thromb
us development in coronary arteries (Anderson et al, 2011; Antman et al, 2008).
Assess for symptoms of coronary hypoperfusion and possible ACS including chest
discomfort (pressure,
tightness, crushing, squeezing, dullness, or achiness), with or without radiatio
n (or originating) in the
back, neck, jaw, shoulder, or arm discomfort or numbness; SOB; associated diapho
resis; dizziness, lightheadedness, loss of consciousness; nausea or vomiting with chest discomfort, hea
rtburn or indigestion;
associated anxiety. EB: These symptoms are signs of decreased cardiac perfusion
and acute coronary syndrome
such as UA, NSTEMI, or STEMI. A physical assessment will aid in assessment of th
e extent, location and presence of, and complications resulting from a myocardial infarction. It will promo
te rapid triage and treatment.
It is also important to assess if the client had a prior stroke (American Heart
Association, 2011a; Anderson
et al, 2011).
Consider atypical presentations for women, and diabetic clients of ACS. EB & C
EB: Women and diabetic
clients may present with atypical ?ndings. A systematic review of differences sh
owed that women had signi?cantly less chest discomfort and were more likely to present with fatigue, neck
pain, syncope, nausea, right arm
pain, dizziness, and jaw pain (Coventry, Finn, & Bremner, 2011).
Review the client s medical, surgical, and social history. EB: A medical history
must be concise and detailed
to determine the possibility of acute coronary syndromes, and to help determine
the possible cause of cardiac
symptoms and pathology (Anderson et al, 2011).
Perform physical assessments for both CAD and non-coronary ?ndings related to d
ecreased coronary
perfusion including vital signs, pulse oximetry, equal blood pressure in both ar
ms, heart rate, respiratory
rate, and pulse oximetry. Check bilateral pulses for quality and regularity. Rep
ort tachycardia, bradycardia, hypotension or hypertension, pulsus alternans or pulsus paradoxus, tachypne
a, or abnormal pulse
oximetry reading. Assess cardiac rhythm for arrhythmias; skin and mucous membran
e color, temperature
and dryness; and capillary re?ll. Assess neck veins for elevated central venous
pressure, cyanosis, and
pericardial or pleural friction rub. Examine client for cardiac S4 gallop, new h
eart murmur, lung crackles,
altered mentation, pain to abdominal palpation, decreased bowel sounds, or decre
ased urinary output
EB: These indicators help to assess for cardiac and non-cardiac etiologies of sy
mptoms and differential diagnoses (Anderson et al, 2011; Antman et al, 2008).
? Administer oxygen as ordered and needed for clients presenting with ACS to ma
intain a PO2 of at least
90%. EB: Hypoxemia can be under-recognized in the ?rst 6 hours of ACS treatment.
Maintaining a SaO2 level
of 90% or more may decrease the pain associated with myocardial ischemia by incr
easing the amount of oxygen delivered to the myocardium (Anderson et al, 2011). EB: Advanced Cardiac Lif
e Support guidelines recommend administering oxygen if the oxygen saturation is less than 94% (O Connor et
al, 2012). A Cochrane
review found there was limited evidence to recommend use of oxygen with acute co
ronary syndrome, more
studies are needed (Cabello et al, 2010).
? Use continuous pulse oximetry as ordered. EB: Prevention and treatment of hyp
oxemia includes maintaining arterial oxygen saturation over 90% (Anderson et al, 2011).
? Insert one or more large-bore intravenous catheters to keep the vein open. Ro
utinely assess saline locks
for patency. Clients who come to the hospital with possible decrease in coronary
perfusion or ACS may have
= Independent
B = Evidence-Based
? = Collaborative

intravenous ?uids and medications ordered routinely or emergently to maintain or
restore adequate cardiac

function and rhythm.
? Observe the cardiac monitor for hemodynamically signi?cant arrhythmias, ST dep
ressions or elevations,
T wave inversions and/or q waves as signs of ischemia or injury. Report abnormal
?ndings. EB: Arrhythmias and electrocardiogram (ECG) changes indicate myocardial ischemia, injury an
d/or infarction (Anderson
et al, 2011; Antman et al, 2008).
Have emergency equipment and de?brillation capability nearby and be prepared to
de?brillate immediately if ventricular tachycardia with clinical deterioration or ventricu
lar ?brillation occurs. EB: Lifethreatening ventricular arrhythmias require de?brillation (Anderson et al, 2011)
.
? Perform a 12-lead ECG as ordered, to be interpreted within 10 minutes of emerg
ency department arrival
and during episodes of chest discomfort or angina equivalent. EB: A 12-lead ECG
should be performed
within 10 minutes of emergency department arrival for all clients who are having
chest discomfort. Electrocardiograms are used to identify the area of ischemia or injury such as ST depressi
ons or elevations, new left
bundle branch block, T wave inversions, and/or q waves and guide treatment (Ande
rson et al, 2011; Antman
et al, 2008).
? Administer aspirin as ordered. EB: Aspirin has been shown to prevent platelet
clumping, aggregation, and
activation that leads to thrombus formation, which in coronary arteries leads to
acute coronary syndromes.
Contradictions include active peptic ulcer disease, bleeding disorders, and aspi
rin allergy (Anderson et al,
2011; Antman et al, 2008).
? Administer nitroglycerin tablets sublingually as ordered, every 5 minutes unti
l the chest pain is resolved
while also monitoring the blood pressure for hypotension, for a maximum of three
doses as ordered.
Administer nitroglycerin paste or intravenous preparations as ordered. EB: Nitro
glycerin causes coronary
arterial and venous dilation, and at higher doses arterial dilation, thus reduci
ng preload and afterload and
decreasing myocardial oxygen demand while increasing oxygen delivery (Anderson e
t al, 2011).
Do not administer nitroglycerin preparations to clients who have recei
ved phosphodiesterase type 5
inhibitors, such as sildena?l, tadala?l, or vardena?l, in the last 24 hours (48
hours for long-acting preparations). EB: Synergistic effect causes marked exaggerated and prolonged vasodilat
ion/hypotension (Anderson
et al, 2011; Antman et al, 2008).
? Administer morphine intravenously as ordered every 5 to 30 minutes while monit
oring blood pressure
when nitroglycerin alone does not relieve chest discomfort. EB: Morphine has pot
ent analgesic and antianxiolytic effects and causes mild reductions in blood pressure and heart rate t
hat reduce myocardial oxygen
consumption. It increases venous capacitance in pulmonary edema associated with
decreased coronary perfusion and resultant myocardial dysfunction (Anderson et al, 2011; Antman et al, 2
008).
? Assess and report abnormal lab work results of cardiac enzymes, speci?cally tr
oponin Is, chemistries,
hematology, coagulation studies, arterial blood gases, ?nger stick blood sugar,
elevated C-reactive
protein, or drug screen. Abnormalities can identify the cause of the decreased p
erfusion and identify
complications related to the decreased perfusion such as anemia, hypovolemia, co
agulopathy, drug abuse
or hyperglycemia. Elevated cardiac enzymes are indicative of a myocardial infarc
tion (Anderson et al,
2011).
Assess for individual risk factors for coronary artery disease, such as hyperte
nsion, dyslipidemia, cigarette
smoking, diabetes mellitus, or family history of heart disease. Other risk facto
rs including sedentary life
style, obesity, or cocaine or amphetamine use. Note age and gender as risk facto
rs. EB: Certain conditions
place clients at higher risk for decreased cardiac tissue perfusion (Anderson et
al, 2011).
? Administer additional heart medications as ordered including beta blockers, ca
lcium channel blockers,
ACE inhibitors, aldosterone antagonists, antiplatelet agents, and anticoagulants
. Always check the blood
pressure and pulse rate before administering these medications. If the blood pre
ssure or pulse rate is low,
contact the physician to see if the medication should be held. Also check platel
et counts and coagulation
studies as ordered to assess proper effects of these agents. EB: These medicatio
ns are useful to optimize
cardiac function including blood pressure, heart rate, myocardial oxygen demand,
intravascular ?uid volume
and cardiac rhythm (Anderson et al, 2011; Antman et al, 2008).
? Administer lipid-lowering therapy as ordered. EB: LDL-C equal to or over 100 m
g/dL requires use of LDL
lowering drug therapy to prevent progression and possibly cause regression of co
ronary artery plaques (Anderson et al, 2011). A systematic review of statin use in primary prevention of car
diovascular disease showed
reductions in all-cause mortality, major vascular events, and revascularizations
(Taylor et al, 2011).
? Prepare client with education, withholding meals and/or medications, and intra
venous access for cardiac
catheterization and possible PCI with door to balloon time of under 90 minutes i
f STEMI is suspected.
189
C
= Independent

B = Evidence-Based
190
? = Collaborative
EB & CEB: Door to balloon time of under 90 minutes was associated with improved
client outcomes (Antman
et al, 2008; McNamara et al, 2006).
? Prepare clients with education, withholding meals and/or medications, and int
ravenous access for noninvasive cardiac diagnostic procedures such as 2D echocardiogram, exercise or phar
macological stress test,
C
and cardiac CT scan as ordered. EB: Clients suspected of decreased coronary perf
usion should receive these
diagnostic procedures as appropriate to evaluate for coronary artery disease (An
derson et al, 2011; Antman
et al, 2008).
? Maintain bed rest or chair rest as ordered by the physician. EB: Anti-ischemi
c therapy includes minimizing
myocardial oxygen demand in the early hospital phase (Anderson et al, 2011).
For further medical and nursing interventions used in care of client with an a
cute coronary event, refer to
the reference by Anderson et al (2011).
? Request a referral to a cardiac rehabilitation program. EB: Cardiac rehabilit
ation programs are designed to
limit the physiological and psychological effects of cardiac disease, reduce the
risk for sudden cardiac death and
reinfarction, control symptoms and stabilize or reverse the process of plaque fo
rmation, and enhance psychosocial and vocational status of clients (Anderson et al, 2011; Smith et al, 2011
).
Geriatric
Consider atypical presentations for the elderly of possible ACS. CEB: Elderly m
ay present with atypical
signs and symptoms such as weakness, stroke, syncope, or change in mental status
(Anderson et al, 2007).
? Ask the prescriber about possible reduced dosage of medications for geriatric
clients considering weight
and creatinine clearance. EB: Geriatric clients have reduced pharmacokin
etics including reduced muscle
mass, renal and hepatic function, and reduced volume of distribution (Anderson e
t al, 2011).
Consider issues such as quality of life, palliative care, end-of-life care, an
d differences in sociocultural
aspects for clients and families when supporting them in decisions reg
arding aggressiveness of care
(Anderson et al, 2011).
? Provide information about provider follow-up. EB: Current recommendations sug
gest that high-risk clients
should be seen within 2 weeks and within 2 to 6 weeks for lower risk clients (An
tman et al, 2008).
Teach the client and family to call 911 for symptoms of new angina, existing an
gina unresponsive to rest
and sublingual nitroglycerin tablets, or heart attack. Do not use friends or fam
ily for transportation where
911 is available, unless the delay is expected to be longer than 20 to 30 minute
s. EB & CEB: Morbidity and
mortality from myocardial infarction can be reduced signi?cantly when symptoms a
re recognized and EMS
activated, shortening time to de?nitive treatment (Anderson et al, 2011).
Upon discharge, instruct clients on symptoms of ischemia, when to cease activit
y, when to use sublingual
nitroglycerin, and when to call 911. EB: Degree and extent of myocardial ischemi
a is related to duration of
time with inadequate supply of oxygen-rich blood (Anderson et al, 2011).
Teach client about any medications prescribed. Medication teaching includes the
drug name, its purpose,
administration instructions such as taking it with or without food, and any side
effects to be aware of. Instruct
the client to report any adverse side effects to his/her provider.
Upon hospital discharge, educate clients and signi?cant others about discharge
medications, including
nitroglycerin sublingual tablets or spray, with written, easy to understand, cul
turally sensitive information. Clients and signi?cant others need to be prepared to act quickly and decis
ively to relieve ischemic discomfort (Anderson et al, 2011).
Provide client teaching related to risk factors for decreased cardiac tissue pe
rfusion, such as hypertension,
hypercholesterolemia, diabetes mellitus, tobacco use, advanced age, and gender (
female). EB: Those with
two or more risk factors should have a 10-year risk screening for development of
symptomatic coronary heart
disease. Client education is a vital part of nursing care for the client. Start
with the client s base level of understanding and use that as a foundation for further education. It is important to
factor in cultural and/or religious beliefs in the education provided (Anderson et al, 2011).
Instruct the client on antiplatelet and anticoagulation therapy about signs of
bleeding, need for ongoing
medication compliance, and INR monitoring. EB: A review of client education lite
rature showed a need to
prioritize education domains, standardize educational content, and deliver that
content ef?ciently (Wofford,
Wells, & Singh, 2008.)
After discharge, continue education and support for client blood pressure and d
iabetes control, weight
management, and resumption of physical activity. EB: Reduction of risk factors a
ids as secondary prevention
= Independent
B = Evidence-Based
? = Collaborative
REFERENCES
Caregiver role strain

of coronary artery disease (Anderson et al, 2011). ATP III recommends continued
efforts to optimize weight
and use of regular physical activity (National Institutes of Health, 2011).
? Provide in?uenza vaccine prior to discharge (Anderson et al, 2011; Antman et
al, 2008).
Stress the importance of ceasing tobacco use. Tobacco use can cause or worsen
decreased blood ?ow in the
coronaries. Effects of nicotine include increasing pulse and blood pressure and
constricting of blood vessels.
Tobacco use is a primary factor in heart disease. EBN: Smoking causes vasoconstr
iction, which can lead to
atherosclerotic disease (American Heart Association, 2012c; Anderson et al, 201;
Smith et al, 2011).
Upon hospital discharge, educate clients about low sodium, low saturated fat d
iet, with consideration to
client education, literacy and health literacy level. EB: Reduction of risk fact
ors aid as primary and secondary
prevention of coronary artery disease (Anderson et al, 2011). ATP III guidelines
recommend that saturated
fats be kept to less than 7% of calories and cholesterol under 200 mg/day when L
DL is above goal (http://www.
nhlbi.nih.gov/guidelines/cholesterol/index.htm). A Cochrane review recommended t
hat there be a permanent
reduction in saturated fats and replacement with unsaturated fats to decrease at
herosclerosis (Hopper et al,
2012).
Teach the importance of exercise. Exercise helps control blood pressure and we
ight, which are the most
important controlled risk factors for cardiovascular disease (Smith et al, 2011)
.
191
C
American Heart Association: Heart attack symptoms and warning signs,
2011a. http://www.heart.org/HEARTORG/Conditions/Conditions_
UCM_305346_SubHomePage.jsp.
American Heart Association: Exercise stress test, 2011b. http://
www.heart.org/HEARTORG/Conditions/More/CardiacRehab/
Exercise-Stress-Test_UCM_307474_Article.jsp.
American Heart Association. Smoking and Cardiovascular Disease
2012 C. http://www.heart.org/HEARTORG/GettingHealthy/
QuitSmoking/QuittingResources/Smoking-CardiovascularDisease_UCM_305187_Article.jsp. Accessed August 29, 2012.
Anderson JL, et al: ACC/AHA 2007 guidelines for the management of
patients with unstable angina/non-ST elevation myocardial infarction, J Am Coll Cardiol 50(7):e1 e157.
Anderson JL, et al: 2011 ACCF/AHA focused update incorporated into
the ACC/AHA 2007 guidelines for the management of patients with
unstable angina/non-ST-elevation myocardial infarction, J Am Coll
Cardiol 57(19):e215 e330, 2011.
Antman EM, et al: 2007 Focused update of the ACC/AHA 2004 guidelines for the management of patients with ST-elevation myocardial
infarction, J Am Coll Cardiol 51(2):210 247, 2008.
Cabello J, et al: Oxygen therapy for acute myocardial infarction,
Cochrane Database Syst Rev(6), CD007160:2010.
Coventry LL, Finn J, Bremner AP: Sex differences in symptom presentation in acute myocardial infarction: a systematic review and metaanalysis, Heart Lung 40(6):477 491, 2011.
Hooper L, et al: Reduced or modi?ed dietary fat for preventing cardiovascular disease, Cochrane Database Syst Rev(7), CD002137:2012.
McNamara RL, et al: Effect of door-to-balloon time on mortality in
patients with ST-segment elevation myocardial infarction, J Am Coll
Cardiol 47(11):2180 2186, 2006.
National Institutes of Health. Retrieved November 18, 2011, from http:
//www.nhlbi.nih.gov/guidelines/cholesterol/index.htm.
O Connor R, et al: Part 10: Acute Coronary Syndromes: 2010 American
Heart Association guidelines for cardiopulmonary resuscitation and
emergency cardiovascular care, Circulation 122:S787 S817, 2010.
Smith SC, et al: AHA/ACCF secondary prevention and risk reduction
therapy for patients with coronary and other atherosclerotic vascular disease: 2011 update: a guideline from the American Heart Association and American College of Cardiology Foundation endorsed
by the World Heart Federation and the Preventive Cardiovascular
Nurses Association, J Am Coll Cardiol 58:2432 2446, 2011.
Taylor F, et al: Statins for the primary prevention of cardiovascular
disease, Cochrane Database Syst Rev(1), CD004816:2011.
Wofford JL, Wells MD, Singh S: Best strategies for patient education
with warfarin: a systematic review, BMC Health Serv Res 8:40, 2008.
Caregiver Role Strain
Paula Sherwood, RN, PhD, CNRN, FAAN, and Barbara A. Given, PhD, RN, FAAN
NANDA-I
De?nition
Dif?culty in performing family caregiver role
Caregiving Activities
Apprehension about recipient s care if caregiver unable to provide care;
apprehension about the future
regarding care recipient s health; apprehension about the future regarding caregiv
er s ability to provide care;
apprehension about possible institutionalization of care recipient; dif?culty co
mpleting required tasks; dif?culty performing required tasks; dysfunctional change in caregiving act
ivities; preoccupation with care
routine
= Independent
B = Evidence-Based
192
? = Collaborative
Caregiver Health Status

Physical
Cardiovascular disease; diabetes; fatigue; GI upset; headaches; hypertension; ra
sh; weight change
Behavioral
C
Poor self-care behaviors; increased smoking; increased alcohol consumption; slee
p disturbances
Emotional
Anger; anxiety; disturbed sleep; feeling depressed; frustration; impaired
individual coping; impatience;
increased emotional lability; increased nervousness; lack of time to me
et personal needs; somatization;
stress
Socioeconomic
Changes in leisure activities; low work productivity; quitting work or refusing
career advancement to provide care, withdrawing from social life; ?nancial distress including, b
ut not limited to, poverty and
bankruptcy
Caregiver Care Recipient Relationship
Dif?culty watching care recipient go through the illness; grief regarding change
d relationship with care recipient; uncertainty regarding changed relationship with care recipient
Family Processes
Concerns about family members; family con?ict; family cohesion; family dysfuncti
on
Care Recipient Health Status
Addiction; codependence; cognitive problems; dependency; illness chronicit
y; illness severity; increasing
care needs; instability of care recipient s health; problem behaviors; psychologic
al problems; unpredictability
of illness course
Caregiver Health Status
Addiction; codependency; cognitive problems; inability to ful?ll one s own expecta
tions; inability to ful?ll
others expectations; marginal coping patterns; physical problems; psycholo
gical problems; unrealistic
expectations of self
Caregiver Care Recipient Relationship
History of poor relationship; mental status of elder inhibiting conversation, pr
esence of abuse or violence;
unrealistic expectations of caregiver by care recipient
Caregiving Activities
24-hour care responsibilities; amount of activities (including number of hours a
nd speci?c activities that are
distressful); complexity of activities; discharge of family members to home with
signi?cant care needs; ongoing changes in activities; unpredictability of care situation; years of caregivi
ng
Family Processes
History of family dysfunction; history of marginal family coping
Resources
Caregiver is not developmentally ready for caregiver role; de?cient knowledge ab
out community resources;
dif?culty accessing community resources; emotional strength; formal assistance;
formal support; inadequate
community resources (e.g., respite services, recreational resources); inadequate
equipment for providing
care; inadequate physical environment for providing care (e.g., housing, tempera
ture, safety); inadequate
transportation; inexperience with caregiving; informal assistance; informal supp
ort; insuf?cient ?nances;
insuf?cient time; lack of caregiver privacy; lack of support; physical energy
Socioeconomic
Alienation from others; competing role commitments; insuf?cient recreation; isol
ation from others; ?nancial distress including potential loss of loss of home and savings
= Independent

B = Evidence-Based
? = Collaborative

NOC
Caregiver Adaptation to Patient Institutionalization, Caregiver Emotional Health
, Caregiver Home Care
Readiness, Caregiver Lifestyle Disruption, Caregiver-Patient Relationship, Careg
iver Performance: Direct
Care, Caregiver Performance: Indirect Care, Caregiver Physical Health, Caregiver
Role Support, Caregiver
Role Endurance, Caregiver Stressors, Caregiver Well-Being
Caregiver Emotional Health with plans for a positive future as evidenced by the
following indicators: Satisfaction with
life/Sense of control/Self-esteem/Perceived social connectedness/Perceived spiri
tual well-being. (Rate the outcome and indicators of
Caregiver Emotional Health: 1 = severely compromised, 2 = substantially compromi
sed, 3 = moderately compromised,
4 = mildly compromised, 5 = not compromised [see Section I].)
Client Outcomes
Throughout the care situation, the caregiver will:
Feel supported by health care professionals, family, and friends
Report reduced or acceptable feelings of burden or distress
Take part in self-care activities to maintain own physical and psychological/em
otional health
Identify resources available to help in giving care or to support the caregiver
to give care
Verbalize mastery of the care situation; feel con?dent and competent to provide
care
Throughout the care situation, the care recipient will:
Obtain quality and safe care
NIC
Suggested NIC Intervention
Caregiver Support
Example NIC Activities Caregiver Support
Determine caregiver s acceptance of role; Accept expressions of negative emotion
Regularly monitor signs of depression, anxiety, burden, and deteriorating physi
cal health in the caregiver
throughout the care situation, especially if the marital relationship is poor, t
he care recipient has cognitive
or neuropsychiatric symptoms, there is little social support available, the care
giver becomes enmeshed in
the care situation, the caregiver is elderly, female, or has poor preexisting ph
ysical or emotional health.
Refer to the care plan for Hopelessness when appropriate. EBN: The incidence of
depression in family
caregivers can be higher than that of the patient with chronic illness (Williams
& McCorkle, 2011). EB: Caregiving may weaken the immune system and predispose the caregiver to illness, par
ticularly cardiac illness and
poor response to acquired infections in some situations (Gallagher et al, 2008;

Gouin, Hantsoo, & KiecoltGlaser, 2008; Lovell, Moss, & Wetherell, 2012). Particular subgroups have been s
hown to be at high risk for
becoming distressed as a result of providing care (Schoenmakers, Buntinx, & Dele
peleire, 2010).
The impact of providing care on the caregiver s emotional health should be assess
ed at regular intervals
using a reliable and valid instrument such as the Caregiver Strain Index, Caregi
ver Burden Inventory,
Caregiver Reaction Assessment, Screen for Caregiver Burden, and the Subjective a
nd Objective Burden
Scale (Deeken et al, 2003; Vitaliano et al, 1991). CEB & EBN: Research has valid
ated the effectiveness of
a number of evaluation tools for caregiver stress, including the Caregiver React
ion Assessment (Given et al,
1992), Burden Interview (Zarit et al, 1980), the Caregiver Strain Inde
x (Robinson, 1983), and the
193
C
= Independent
B = Evidence-Based
194
? = Collaborative
Caregiver Burden Inventory (Novak & Guest, 1989). Caregiver assessment tools sho
uld be multidimensional and evaluate the impact of providing care on multiple aspects
of the caregiver s life (Hudson &
Hayman-White, 2006).
C
Identify potential caregiver resources such as mastery, social support, optimis
m, and positive aspects of
care. EB & EBN: Research has shown that caregivers can have simultaneous positiv
e and negative responses to
providing care. Positive responses may help to buffer the negative effects of pr
oviding care on caregivers emotional health and may also increase the effectiveness of interventions to reduce
strain (Kruithof, Visser-Meily, &
Post, 2011).
Screen for caregiver role strain at the onset of the care situation, at regula
r intervals throughout the care
situation, and with changes in care recipient status and care transitions, inclu
ding institutionalization.
EB & EBN: Care situations that last for several months or years can cause wear a
nd tear that exhaust caregivers coping mechanisms and available resources and that may continue after the car
e recipient has been institutionalized (Paun & Farran, 2011). In addition, changes in the care recipient s h
ealth status necessitate new
skills and monitoring from the caregiver and affect the caregiver s ability to con
tinue to provide care (Given,
Sherwood, & Given, 2011). Providing caregiver support throughout the care situat
ion may decrease care recipient institutionalization (Matsuzawa, 2011).
Watch for caregivers who become enmeshed in the care situation. EBN: Caregiver
s are at risk for becoming
overinvolved or unable to disentangle themselves from the caregiver role, partic
ularly in the absence of adequate social support (Hricik et al, 2011).
Arrange for intervals of respite care for the caregiver; encourage use if avai
lable. EB & EBN: Respite care
provides time away from the care situation and can help alleviate distress (Beeb
er, Thorpe, & Clipp, 2008;
Sussman & Regehr, 2009).
Regularly monitor social support for the caregiver and help the caregiver to i
dentify and utilize appropriate support systems for varying times in the care situation. EBN: Lower levels o
f perceived support can cause
caregivers to feel abandoned and increase their distress (Hwang et al, 2011).
Encourage the caregiver to grieve over changes in the care recipient s condition
and give the caregiver
permission to share angry feelings in a safe environment. Refer to nursing inter
ventions for Grieving. EB:
Caregivers grieve the loss of personhood of their loved one, especially when dem
entia is involved (Holland,
Currier, & Gallgher-Thompson, 2009; Kramer et al, 2011).
Help the caregiver ?nd personal time to meet his or her needs, learn stress ma
nagement techniques,
schedule regular health screenings, and schedule regular respite time. EB: Due t
o increased risk for poor
physical health as a result of providing care, caregivers must feel empowered to
maintain self-care activities
(Merluzzi et al, 2011). Interventions to provide support for family caregivers h
ave shown improvements in
caregiver health (Elliot, Burgio, & Decoster, 2010).
Encourage the caregiver to talk about feelings, concerns, uncertainties, and f
ears. Support groups can be
used to gain mutual and educational support. EBN: Support groups can improve dep
ressive symptoms and
burden, particularly for female caregivers (Chien et al, 2011). EB: Social suppo
rt groups can be effective over
the Internet, using forums such as Facebook (Bender, Jimenez-Marroquin, & Jadad,
2011).
Observe for any evidence of caregiver or care recipient violence or abuse, par
ticularly verbal abuse; if
evidence is present, speak with the caregiver and care recipient separately. EB
& CEB: Caregiver violence is
possible, particularly when the caregiver has a history of behavioral, emotional
, or family problems; screening
should be done at regular intervals (Cohen et al, 2006; Cooper et al, 2009).
? Involve the family in care transitions; use a multidisciplinary team to provi
de medical and social services
for instruction and planning. EBN: Caregivers who reported involvement in discha
rge planning, particularly
when discharge planning was done by an interdisciplinary team, occurs well befor
e discharge, and includes
good communication between the family member and the health care team, report be
tter acceptance of the
caregiving role and better health (Bauer et al, 2009).
? Encourage regular communication with the care recipient and with the health c
are team. EB: Caregivers
preferential communication method and communication needs should be addressed at
regular intervals to
improve their sense of mastery over the care situation (Moore, 2008). There can
be a large discrepancy between
what the health care professional feels s/he has communicated and what the careg
iver reports hearing (Molinuevo, Hernandez & TRACE, 2011).
Help caregiver assess his or her ?nancial resources (services reimbursed by in
surance, available support
through community and religious organizations) and the impact of providing care
on his or her ?nancial
status. EB & EBN: Low incomes and limited ?nancial resources can cause strain fo
r the caregiver, particularly
if there are substantial out-of-pocket costs involved in providing care
(Siefert et al, 2008). Prolonged
= Independent
B = Evidence-Based
? = Collaborative

care situations can affect ?nancial resources; assessment of ?nancial distress/s
train should occur at regular
intervals. Caregivers report needing information regarding ?nancial assistance d
uring the care situation (Sinclair et al, 2010).
Help the caregiver identify competing occupational demands and potential bene?t
s to maintaining work
as a way of providing normalcy. Guide caregivers to seek ways to maintain employ
ment through mechanisms such as job sharing or decreasing hours at work. EB: Employed caregivers r
eport that work can provide a sense of ful?llment, refuge, and satisfaction (Eldh & Carlsson, 2011).
Help the caregiver problem solve to meet the care recipient s needs. EBN: Using a
psycho-educational or
problem-solving intervention can decrease caregiver feelings of strain, although

it has not been shown to help
with caregivers depressive symptoms (Northouse et al, 2010).
Geriatric
Monitor the caregiver for psychological distress and signs of depression, espec
ially if caring for a mentally
impaired elder or if there was an unsatisfactory marital relationship before car
egiving. EBN: As the majority of family caregivers are spouses, degree of marital satisfaction is strongly
linked with caregiver role strain
(Green & King, 2011).
Assess the health of caregivers, particularly their control over chronic diseas
es, at regular intervals. CEB:
Caregivers who report feeling burdened have an increased risk of mortality, risk
that may be particularly high
in elderly caregivers with comorbid conditions (Beach et al, 2000; Schulz & Beac
h, 1999).
Assess the presence of and use of social support and encourage the use of secon
dary caregivers with elderly
caregivers. EBN: Caregivers are at risk for becoming overinvolved or unable to d
isentangle themselves from the
caregiver role, particularly in the absence of adequate social support (Hricik e
t al, 2011).
To improve the ability to provide safe care: provide skills training related to
direct care, perform complex
monitoring tasks, supervise and interpret client symptoms, assist with decisionmaking, assist with medication adherence, provide emotional support and comfort, and coordinate care. CE
B: Each task demands
different skills and knowledge, organizational capacities, role demands, and soc
ial and psychological strengths
from family members (Schumacher et al, 2000).
Teach symptom management techniques (assessment, potential causes, aggra
vating factors, potential
alleviating factors, reassessment), particularly for fatigue, constipation, anor
exia, and pain. EBN: Caregivers require training in care recipient monitoring symptom management, and interp
retation and can bene?t
from a problem-solving approach (Sherwood et al, 2012).
Multicultural
Assess for the in?uence of cultural beliefs, norms, and values on the client s ab
ility to modify health
behavior. EBN: What the client considers normal and abnormal health behavior may
be based on cultural
perceptions (Giger & Davidhizar, 2008). EBN: Each client should be assessed for
ability to modify health
behavior based on the phenomenon of communication, time, space, social organizat
ion, environmental control, and biological variations (Giger & Davidhizar, 2008).
Despite the importance of cultural differences in perceptions of caregiver role
strain, there are certain
characteristics that are distressing to caregivers across multiple cultures. EBN
: Social support and care
recipients behavioral difference have been shown to be an important factor in car
egiver distress across multiple
cultures (Chiao & Schepp, 2012; Hwang et al, 2011; Zahid & Ohaeri, 2010).
Persons with different cultural backgrounds may not perceive the provision of c
are with equal degrees of
distress. EB: A group of caregivers in Belize did not report providing care as n
egative, although they did exhibit
physical symptoms of distress (Vroman & Morency, 2011).

Recognize that cultures often play a role in identifying who will be recognized
as a family caregiver and
form partnerships with those groups. EB: In a study of American Indians, people
who attended and participated in Native events and endorsed traditional healing practices were more like
ly to be caregivers. The study
also reported that gender played a role in identifying caregivers in some tribes
, but not all (Goins, 2011).
Encourage spirituality as a source of support for coping. EBN: Many African Ame
ricans and Latinos identify spirituality, religiousness, prayer, and church-based approaches as coping
resources. Socioeconomic status,
geographical location, and risks associated with health-seeking behavior all in?
uence the likelihood that clients
will seek health care and modify health behavior (Giger & Davidhizar, 2008).
Assess for the presence of con?icting values within the culture. EBN: Whereas s
haring and caring is part of
the Amish community, females with breast cancer were found to value privacy issu
es related to their body
image and health status and to prefer this was shared in the closed community (S
chwartz, 2008).
195
C
= Independent
B = Evidence-Based
196
? = Collaborative
Recognize that different cultures value and use caregiving resources in differe
nt ways. CEB: When Korean
and Caucasian American caregivers were compared, there was more family support i
n Korean caregivers while
Caucasian Americans were more likely to use formal support (Kong, 2007).
C
Home Care
Assess the client and caregiver at every visit for quality of relationship, and
for the quality of caring that
exists. EB: Quality of the caregiver care recipient relationship and the impact of
the care situation on that
relationship can be an important source of distress or support for the caregiver
(Quinn, Clare, & Woods, 2009).
Chronic illness, especially dementia, can represent a gradual and devastating lo
ss of the marital relationship as
it existed formerly. An understanding of the prior relationship is needed before
the couple can be helped to
anticipate continuing care needs or deterioration, as the dyadic relationship ca
n be expected to change over the
care situation (Langer et al, 2010).
Assess preexisting strengths and weaknesses the caregiver brings to t
he situation, as well as current
responses, depression, and fatigue levels. EB & EBN: Caregivers personality type,
mastery, self-ef?cacy,
optimism, and social support have all been linked to the amount of distress the
caregiver will perceive as a
result of providing care (Campbell et al, 2008; Shirai et al, 2009).
? Refer the client to home health aide services for assistance with ADLs and li
ght housekeeping. Allow the
caregiver to gain con?dence in the respite provider. Home health aide services c
an provide physical relief
and respite for the caregiver. EB: Caregiver burden increases as the care recipi
ent s cognitive and functional
ability decline (Ricci et al, 2009).
Identify client and caregiver factors that necessitate the use of formal home c
are services, that may affect
provision of care, or that need to be addressed before the client can be safely
discharged from home care.
EBN: Although home care resources can be useful in decreasing caregiver distress
, they are not used with regularity across client populations. Health care practitioners should assess for th
e need for support resources prior
to discharge and at routine intervals throughout the care situation, tailoring c
ommunity resources to individual caregiver needs (Greene et al, 2011). Interventions prior to discharge may i
nclude medication management, identi?cation of medical red ?ags, identi?cation of community-based resour
ces, and speci?c caregiver
concerns about home care (Hendrix et al, 2011).
Collaborate with the caregiver and discuss the care needs of the client, diseas
e processes, medications, and
what to expect; use a variety of instructional techniques (e.g., explanations, d
emonstrations, visual aids)
until the caregiver is able to express a degree of comfort with care delivery. E
B: Knowledge and con?dence
are separate concepts. Self-assurance in caregiving will decrease the amount of
distress the caregiver perceives
as a result of providing care (Giovannetti et al, 2012) and may improve the qual
ity of care provided.
Assess family caregiving skill. The identi?cation of caregiver dif?culty with a
ny of a core set of processes
highlights areas for intervention. CEB: The ability to engage effectively and sm
oothly in nine processes has
been identi?ed as constituting family caregiving skill: monitoring client behavi
or, interpreting changes accurately, making decisions, taking action, making adjustment to care, accessing re
sources, providing hands-on

care, working together with the ill person, and negotiating the health care syst
em (Schumacher et al, 2000). EB:
Caregiver skills training has been shown to improve caregiver knowledge and skil
ls and may be reimbursable
within governmental health care plans (Gitlin, Jacobs, & Earland, 2010).
Discharge care should be individualized to speci?c caregiver needs and care sit
uations. EBN: Interventions
implemented by advanced practice nurses have been successful in preventing negat
ive outcomes (Bradway
et al, 2011).
Assess the caregiver s need for information such as information on symptom manage
ment, disease progression, speci?c skills, and available support. EBN: Caregiver interventions sh
ould be individualized to
meet speci?c caregiver needs (Greene et al, 2011; Hendrix et al, 2011).
Teach the caregiver warning signs for burnout, depression, and anxiety. Help th
em identify a resource in
case they begin to feel overwhelmed.
Teach the caregiver methods for managing disruptive behavioral symptoms if pres
ent. Refer to the care
plan for Chronic Confusion. CEB: Multicomponent interventions can be particularl
y effective in caregivers
of persons with neurologic sequelae (Pinquart & Sorenson, 2007).
Teach the caregiver how to provide the care needed and put a plan in place for
monitoring the care
provided.
Provide ongoing support and evaluation of care skills as the care situation and
care demands change.
= Independent
B = Evidence-Based
? = Collaborative
REFERENCES

Provide information regarding the care recipient s diagnosis, treatment regimen,
and expected course of
illness.
? Refer to counseling or support groups to assist in adjusting to the caregiver
role and periodically evaluate
not only the caregiver s emotional response to care but the safety of
the care delivered to the care
recipient.
197
C
Bauer M, et al: Hospital discharge planning for frail older people and
their family, J Clin Nurs 18(18):2539 2546, 2009.
Beach SJ, et al: Negative and positive health effects of caring for a disabled spouse: longitudinal ?ndings from the caregiver health effects
study, Psychol Aging 15(2):259 271, 2000.
Beeber AS, Thorpe JM, Clipp EC: Community-based service use by
elders with dementia and their caregivers: a latent class analysis,
Nurs Res 57(5):312 321, 2008.
Bender JL, Jimenez-Marroquin MC, Jadad AR: Seeking support on
Facebook: a content analysis of breast cancer groups, J Med Internet
Res 13(1):e16, 2011.
Bradway C, et al: A qualitative analysis of an advanced practice
nurse-directed transitional care model intervention, Gerontologist
52(3):394 407, 2012.
Campbell P, et al: Determinants of burden in those who care for
someone with dementia, Int J Geriatr Psychiatry 23(10):1078 1085,
2008.
Chien LY, et al: Caregiver support groups in patients with dementia: a
meta-analysis, Int J Geriatr Psychiatry 26(10):1089 1098, 2011.
Chiao CY, Schepp KG: The impact of foreign caregiving on depression among older people in Taiwan: model testing, J Adv Nurs
68(5):1090 1099, 2012.
Cohen M, et al: Development of a screening tool for identifying elderly
people at risk of abuse by their caregivers, J Aging Health 18(5):660
685, 2006.
Cooper C, et al: Abuse of people with dementia by family carers: representative cross sectional survey, BMJ 338:b155, 2009.
Deeken J, et al: Care for the caregivers: a review of self-report instruments developed to measure the burden, needs, and quality of life
of informal caregivers, J Pain Symptom Manage 26(4):922 953,
2003.
Eldh AC, Carlsson E: Seeking a balance between employment and the
care of an ageing parent, Scand J Caring Sci 25(2):285 293, 2011.
Elliot AF, Burgio LD, Decoster J: Enhancing caregiver health, J Am
Geriatr Soc 58(1):30 37, 2010.
Gallagher S, et al: Caregiving is associated with low secretion rates of
immunoglobulin A in saliva, Brain Behav Immun 22(4):565 572,
2008.
Giger J, Davidhizar R: Transcultural nursing: assessment and intervention, St Louis, 2008, Mosby.
Giovannetti ER, et al: Dif?culty assisting with health care tasks among
caregivers of multimorbid older adults, J Gen Intern Med 27(1):37
44, 2012.
Gitlin LN, Jacobs M, Earland TV: Translation of a dementia caregiver
intervention for delivery in homecare as a reimbursable Medicare
service: outcomes and lessons learned, Gerontologist 50(6):847 854,
2010.
Given BA, Sherwood P, Given CW: Support for caregivers of cancer
patients: transition after active treatment, Cancer Epidemiol Biomarkers Prev 20(10):2015 2021, 2011.
Given CW, et al: The caregiver reaction assessment (CRA) for caregivers
to persons with chronic physical and mental impairments, Res Nurs
Health 15(4):271 383, 1992.
Goins RT, et al: Adult caregiving among American Indians: the role of
cultural factors, Gerontologist 51(3):310 320, 2011.
Gouin J, Hantsoo L, Kiecolt-Glaser JK: Immune dysregulation and
chronic stress among older adults: a review, Neuroimmunomodulation 15(4-6):251 259, 2008.
Green TL, King KM: Relationships between biophysical and psychosocial outcomes following minor stroke, Can J Neurosci Nurs
33(2):15 23, 2011.
Greene A, et al: Can assessing caregiver needs and activating community
networks improve caregiver-de?ned outcomes? Palliat Med, Sep 19
2011 [Epub ahead of print].
Gullatte M, et al: Religiosity, spirituality, and cancer fatalism beliefs on
delay in breast cancer diagnosis in African American women, J Relig
Health, 2009. [Epub ahead of print].
Hendrix CC, et al: Pilot study: individualized training for caregivers of
hospitalized older veterans, Nurs Res 60(6):436 441, 2011.
Holland JM, Currier JM, Gallagher-Thompson D: Outcomes from the
Resources for Enhancing Alzheimer s Caregiver Health (REACH)
program for bereaved caregivers, Psychol Aging 24(1):190 202, 2009.
Hricik A, et al: Changes in caregiver perceptions over time in response
to providing care for a loved one with a primary malignant brain
tumor, Oncol Nurs Forum 38(2):149 155, 2011.
Hudson PL, Hayman-White K: Measuring the psychosocial characteristics of family caregivers of palliative care patients: psychometric
properties of nine self-report instruments, J Pain Symptom Manage
31(3):215 228, 2006.
Hwang B, et al: Caregiving for patients with heart failure, Am J Crit Care
20(6):431 442, 2011.
Kong EH: The in?uence of culture on the experiences of Korean,
Korean American, and Caucasian-American family caregivers of
frail older adults: a literature review, Taehan Kanho Hakhoe Chi
37(2):213 220, 2007.
Kramer BJ, et al: Complicated grief symptoms in caregivers of persons
with lung cancer, Omega 62(3):201 220, 2011.
Kruithof WJ, Visser-Meily JM, Post MW: Positive caregiving experiences are associated with life satisfaction in spouses of stroke survivors, J Stroke Cerebrovasc Dis, 2011. Jun 1 [Epub ahead of print].
Langer SL, et al: Marital adjustment, satisfaction and dissolution
among hematopoietic stem cell transplant patients and spouses:
a prospective, ?ve-year longitudinal investigation, Psychooncology
19(2):190 200, 2010.
Lovell B, Moss M, Wetherell M: The psychosocial, endocrine and
immune consequences of caring for a child with autism or ADHD,
Psychoneuroendocrinology 37(4):534 542, 2012.
Matsuzawa T, et al: Predictive factors for hospitalized and institutionalized caregiving of the aged patients with diabetes mellitus in Japan,
Kobe J Med Sci 56(4):E173 E183, 2011.

Merluzzi TV, et al: Assessment of self-ef?cacy for caregiving: the critical
role of self-care in caregiver stress and burden, Palliat Support Care
9(1):15 24, 2011.
Molinuevo JL, Hernandez B, TRACE: Assessment of the information
provided by the medical specialist on Alzheimer s disease and that
retained by the patient caregivers, Neurologia, 2011, Sep 8 [Epub
ahead of print].
Moore CD: Enhancing health care communication skills: preliminary
evaluation of a curriculum for family caregivers, Home Health Care
Serv Q 27(1):21 35, 2008.
= Independent
B = Evidence-Based
198
? = Collaborative
Risk for caregiver role strain
Northouse LL, et al: Interventions with family caregivers of cancer

patients: meta-analysis of randomized trials, CA Cancer J Clin
60(5):317 339, 2010.
Novak M, Guest C: Application of a multidimensional caregiver burden
inventory, Gerontologist 29(6):798 803, 1989.
Sherwood PR, et al: The impact of a problem-solving intervention on
increasing caregiver assistance and improving caregiver health, Support Care Cancer 20(9):1937 1947, 2012.
Shirai Y, et al: Reaping caregiver feelings of gain: the roles of socioemotional support and mastery, Aging Ment Health 13(1):106 117,
C
Paun O, Farran CJ: Chronic grief management for dementia caregivers
in transition, J Gerontol Nurs 37(12):28 35, 2011.
Pinquart M, Sorensen S: Correlates of physical health of informal caregivers: a meta-analysis, J Gerontol B Psychol Sci Soc Sci 62(2):P126
P137, 2007.
Quinn C, Clare L, Woods B: The impact of the quality of relationship on the experiences and wellbeing of caregivers of people with
dementia: a systematic review, Aging Ment Health 13(2):143 154,
2009.
Ricci M, et al: Clinical ?ndings, functional abilities and caregiver
distress in the early stage of dementia with Lewy bodies (DLB) and
Alzheimer s disease (AD), Arch Gerontol Geriatr 49(2):e101 e104,
2009.
Robinson B: Validation of a Caregiver Strain Index, J Gerontol
38(3):344 348, 1983.
Schoenmakers B, Buntinx F, Delepeleire J: Factors determining the
impact of caregiving on caregivers of elderly patients with dementia,
Maturitas 66(2):191 200, 2010.
Schulz R, Beach SR: Caregiving as a risk factor for mortality: the Caregiver Health Effects Study, JAMA 282(23):2215 2219, 1999.
Schumacher KL, et al: Family caregiving skill: development of the concept, Res Nurs Health 23(3):191 203, 2000.
Schwartz K: Breast cancer and health care beliefs, values, and practices
of Amish women, Diss Abstr 29(1):587, 2008.
2009.
Siefert ML, et al: The caregiving experience in a racially diverse sample
of cancer family caregivers, Cancer Nurs 31(5):399 407, 2008.
Sinclair AJ, et al: Caring for older adults with diabetes mellitus, Diabet
Med 27(9):1055 1059, 2010.
Sussman T, Regehr C: The in?uence of community-based services
on the burden of spouses caring for their partners with dementia,
Health Soc Work 34(1):29 39, 2009.
Vitaliano P, et al: The screen for caregiver burden, Gerontologist
31(1):76 83, 1991.
Vroman K, Morency J: I do the best I can : caregivers perceptions of
informal caregiving for older adults in Belize, Int J Aging Hum Dev
72(1):1 25, 2011.
Williams AL, McCorkle R: Cancer family caregivers during the palliative, hospice, and bereavement phases: a review of the descriptive
psychosocial literature, Palliat Support Care 9(3):315 325, 2011.
Zahid MA, Ohaeri JU: Relationship of family caregiver burden with
quality of care and psychopathology in a sample of Arab subjects
with schizophrenia, BMC Psychiatry 10:71, 2010.
Zarit SH, et al: Relatives of the impaired elderly: correlates of feelings of
burden, Gerontologist 20(6):649 655, 1980.
Risk for Caregiver Role Strain
Betty Ackley, MSN, EdS, RN

NANDA-I
De?nition
At risk for caregiver vulnerability for felt dif?culty in performing the family
caregiver role
Risk Factors
Amount of caregiving tasks, care receiver exhibits bizarre behavior, care receiv
er exhibits deviant behavior,
caregiver health impairment, caregiver is female, caregiver is spouse, caregiver
isolation, caregiver not developmentally ready for caregiver role, caregiver s competing role commitment
s, co-dependency, cognitive
problems in care receiver, complexity of caregiving tasks, congenital defect, de
velopmental delay of caregiver, developmental delay of care receiver, discharge of family member with sig
ni?cant home care needs,
duration of caregiving required, family dysfunction before the caregiving situat
ion, family isolation, illness
severity of the care receiver, inadequate physical environment for providing car
e (e.g., housing, transportation, community services, equipment), inexperience with caregiving, instability
in the care receiver s health,
lack of recreation for caregiver, lack of respite for caregiver, marginal caregi
ver s coping patterns, marginal
family adaptation, past history of poor relationship between caregiver and care
receiver, premature birth,
presence of abuse, presence of situational stressors that normally affect famili
es (e.g., signi?cant loss, disaster
or crisis, economic vulnerability, major life events), presence of violence, psy
chological problems in caregiver, psychological problems in care receiver, substance abuse, unpredictable i
llness course
NIC, Client Outcomes, Nursing Interventions, Client/Family Teaching, Rationales,
and References
Refer to care plan for Caregiver Role Strain.
= Independent

B = Evidence-Based
? = Collaborative
Risk for ineffective cerebral tissue perfusion
199
Risk for ineffective Cerebral tissue perfusion
NANDA-I
Laura Mcilvoy, PhD, RN, CCRN, CNRN

De?nition
Risk for decrease in cerebral tissue circulation

C
Risk Factors
Abnormal partial thromboplastin time; abnormal prothrombin time; akinetic left v
entricular segment; aortic atherosclerosis; arterial dissection; atrial ?brillation; atrial myxoma; bra
in tumor; carotid stenosis; cerebral aneurysm; coagulopathy (e.g., sickle cell anemia); dilated cardiomyopathy;
disseminated intravascular
coagulation; embolism; head trauma; hypercholesterolemia; hypertension; infectiv

e endocarditis; left atrial
appendage thrombosis; mechanical prosthetic valve; mitral stenosis; recent myoca
rdial infarction; sick sinus
syndrome; substance abuse; thrombolytic therapy; treatment-related side effects
(cardiopulmonary bypass,
medications); transient ischemic attack
NOC
Acute Confusion Level, Tissue Perfusion: Cerebral, Agitation Level, Neurological
Status, Cognition, Seizure
Control, Motor Strength
Tissue Perfusion: Cerebral as evidenced by the following indicators: Headache/Re
stlessness/Listlessness/Agitation/Vomiting/
Fever/Impaired Cognition/Decreased level of consciousness/Motor weakness/Dysphag
ia/Slurred speech. (Rate the outcome and indicators of Tissue Perfusion: Cerebral: 1 = severe, 2 = substantial, 3 = moderate, 4
= mild, 5 = none [see Section I].)
Client Outcomes
State absence of headache
Demonstrate appropriate orientation to person, place, time, and situation
Demonstrate ability to follow simple commands
Demonstrate equal bilateral motor strength
Demonstrate adequate swallowing ability
NIC
Medication Management, Neurologic Monitoring, Positioning: Neurologic, Cerebral
Perfusion Promotion,
Fall Prevention, Cognitive Stimulation, Environmental Management: Safety
Example NIC Activities Neurologic Monitoring
Monitor pupillary size, shape, symmetry, and reactivity; Monitor level of consci
ousness; Monitor level of orientation; Monitor trend of
Glasgow Coma Scale; Monitor facial symmetry; Note complaint of headache
? To decrease risk of reduced cerebral perfusion r/t stroke or transient ischem
ic attack:
Obtain a family history of hypertension and stroke to identify persons who may b
e at increased risk of
stroke. EB: A positive family history of stroke increases risk of stroke by appr
oximately 30% (Goldstein et al,
2011).
= Independent
B = Evidence-Based
? = Collaborative
200
Risk for ineffective cerebral tissue perfusion
Monitor BP regularly, as hypertension is a major risk factor for both

ischemic and hemorrhagic
stroke. EB: Systolic BP should be treated to a goal of less than 140 mm Hg and d
iastolic BP to less than
90 mm Hg, while clients with diabetes or renal disease have a BP goal of less th
an 130/80 mm Hg (Goldstein et al, 2011).
C
REFERENCES
Teach hypertensive clients the importance of taking their physician-ordered ant
ihypertensive agent to
prevent stroke. EB: Meta-analysis found thiazide diuretics, ACE inhibitors (ACEI
), and calcium channel
blockers (CCB) all reduced the risk of stroke compared with no treatment or plac
ebo (Wright & Musini,
2009).
Stress smoking cessation at every encounter with clients, utilizing multimodal
techniques to aid in
quitting, such as counseling, nicotine replacement, and oral smoking cessation m
edications. EB: Epidemiological studies show a consistent and overwhelming relationship between smoki
ng and both ischemic
and hemorrhagic stroke (Goldstein et al, 2011).
Teach clients who experience a transient ischemic attack (TIA) that they are at
increased risk for a
stroke. CEB: Overall stroke risk in TIA patients is 5.2% at 7 days and 10.3% at
90 days (Giles & Rothwell,
2007; Johnson et al, 2007; Rothwell et al, 2007).
Teach clients with a history of acute coronary syndromes (unstable an
gina, non-STEMI [non-STelevation myocardial infarction], and STEMI [ST-elevation myocardial infarction]
) that they are at risk
for stroke. CEB: Cardiovascular disease and stroke have the same pathophysiology
and therefore the same
risk factors. The rate of stroke after a STEMI is markedly increased (Smith et a
l, 2006; Witt et al 2005).
Screen clients 65 years of age and older for atrial ?brillation with pulse asse
ssment. EB: Atrial ?brillation
is associated with a ?vefold increase in stroke. Systematic pulse assessment in
primary care setting resulted
in a 60% increase in the detection of atrial ?brillation (Goldstein et al, 2011)
.
Call 911 or activate the rapid response team of a hospital immediately in clien
ts displaying the symptoms
of stroke as determined by the Cincinnati Stroke Scale (F: facial drooping, A: a
rm drift on one side,
S: speech slurred), being careful to note the time of symptom appearance. Additi
onal symptoms of
stroke include sudden numbness/weakness of face, arm or leg, especially on one s
ide, sudden confusion,
trouble speaking or understanding, sudden dif?culty seeing in one or both eyes,
sudden trouble walking,
dizziness, loss of balance or coordination, or sudden severe headache (National
Stroke Association,
2012). CEB: The Cincinnati Stroke Scale (derived from the NIH Stroke Scale) is u
sed to identify patients
having a stroke who may be candidates for thrombolytic therapy (Kothari et al, 1
999). EMS activation results
in faster physician assessment, computer tomography, and neurological evaluation
, which facilitates administering thrombolytics to eligible stroke victims in the required 3-hour time pe
riod (Adams et al, 2007).
Use clinical practice guidelines for glycemic control and BP targets to guide t
he care of diabetic patients
that have had a stroke or TIA. CEB: The American Stroke Association recommends t
hat evidence-based
guidelines be used in the care of diabetic clients. Good glycemic control has be
en associated with decreased
incidence of strokes (Furie et al, 2011; Handelsman et al, 2011).
? To decrease risk of reduced cerebral perfusion pressure: Cerebral perfusion p
ressure = Mean arterial pressure - intracranial pressure (CPP = MAP - ICP): See care plan for Decreased Intr
acranial Adaptive
Capacity.
Maintain euvolemia. CEB: Infusing intravenous ?uids to sustain normal circulati
ng volume helps maintain normal cerebral blood ?ow (Bullock, Chestnut, & Clifton, 2001).
Maintain head of bed ?at or less than 30 degrees in acute stroke clients. CEB:
Both mean blood ?ow velocity in the middle cerebral artery and CPP are increased with lowering head posit
ion from 30 degrees to 0
degrees in both ischemic and hemorrhagic stroke clients (Schwarz et al, 2002; Wo
jner-Alexandrov et al, 2005).
Adams HP, et al: Guidelines for the early management of adults with
ischemic stroke, Stroke 38:1655 1711, 2007.
Bullock R, Chestnut R, Clifton G: Management and prognosis of severe
traumatic brain injury, J Neurotrauma 17(6&7):451 627, 2001.
Furie KL, et al: Guidelines for the prevention of stroke in patients with
stroke or transient ischemic attack, Stroke 42:227 276, 2011.
Giles MF, Rothwell PM: Risk of stroke early after transient ischemic
attack: a systematic review and meta-analysis, Lancet Neurol
6(12):1063 1072, 2007.
Goldstein LB, et al: Guidelines for the primary prevention of stroke,
Stroke 42:517 584, 2011.
Handelsman Y, et al: American Association of Clinical Endocrinologist
medical guidelines for clinical practice for developing a diabetes
mellitus comprehensive care plan, Endocr Pract 17(Suppl 2):1 53,
2011.
Johnson SC, et al: Validity and refinement of scores to predict early
stroke risk after transient ischemic attack, Lancet 369:283 292,
2007.
= Independent
B = Evidence-Based
? = Collaborative
Ineffective childbearing process
201
Kothari R, et al: Cincinnati prehospital stroke scale: reproducibility and
validity, Ann Emerg Med 33(4):373 378, 1999.
National Stroke Association: Warning signs of a stroke, 2012. http:/
/www.stroke.org/site/PageServer?pagename=symp. accessed August
27, 2012.
Smith SC, et al: AHA/ACC guidelines for secondary prevention for
patients with coronary and other atherosclerotic valve disease: 2006
update, Circulation 113:2326 2372, 2006.

Witt BJ, et al: A community-based study of stroke incidence after myocardial infarction, Ann Intern Med 143:785 792, 2005.
Rothwell PM, et al: Effect of urgent treatment of transient ischemic
attack and minor stroke on early recurrent stroke (EXPRESS Study):
a prospective population based sequential comparison, Lancet
370:1432 1442, 2007.
Schwarz S, et al: Effects of induced hypertension on intracranial pressure and ?ow velocities of the middle cerebral arteries in patients
with large hemispheric stroke, Stroke 33(4):998 1004, 2002.
Wojner-Alexandrov A, et al: Heads down: ?at positioning improves
blood ?ow velocity in acute ischemic stroke, Neurology 64:1354
2357, 2005.
Wright JM, Musini VM: First-line drugs for hypertension, Cochrane
Database Syst Rev(3):CD001841, 2009.
C
Ineffective Childbearing Process
Kimberly J. Johnson-Crisanti, MSN, CNM

NANDA-I
De?nition
Pregnancy and childbirth process and care of newborn that does not match the env
ironmental context,
norms, and expectations
During Pregnancy
Does not access support systems appropriately
Does not report appropriate physical preparations
Does not report appropriate prenatal lifestyle (e.g., diet, elimination, sleep,
bodily movement, exercise,
personal hygiene)
Does not report availability of support systems
Does not report managing unpleasant symptoms in pregnancy
Does not report a realistic birth plan
Does not seek necessary knowledge (e.g., of labor and delivery, newborn care)
Failure to prepare necessary newborn care items
Inconsistent prenatal health visits
Lack of prenatal visits
Lack of respect for unborn baby
During Labor and Delivery
Does not demonstrate appropriate baby feeding techniques
Does not demonstrate attachment behavior to the newborn baby
Lacks proactivity during labor and delivery
Does not report lifestyle (e.g., diet, elimination, sleep, bodily movement, per
sonal hygiene) that is appropriate for the stage of labor
Does not respond appropriately to onset of labor
After Birth
Does not demonstrate appropriate baby feeding techniques
Does not demonstrate appropriate breast care
Does not demonstrate attachment behavior to the baby
Does not demonstrate basic baby care techniques
Does not provide safe environment for the baby
Does not report appropriate postpartum lifestyle (e.g., diet, elimination, slee
p, bodily movement, personal hygiene)
= Independent
B = Evidence-Based
202
? = Collaborative

Related Factors
C
De?cient knowledge (e.g., of labor and delivery, newborn care)
Domestic violence
Inconsistent prenatal health visits
Lack of appropriate role models for parenthood
Lack of cognitive readiness for parenthood
Lack of maternal con?dence
Lack of prenatal health visits
Lack of a realistic birth plan
Lack of suf?cient support systems
Maternal powerlessness
Maternal psychological distress
Suboptimal maternal nutrition
Substance abuse
Unsafe environment
Unplanned pregnancy
Unwanted pregnancy
NOC
Nursing Outcomes Classi?cation
Fetal Status: Antepartum, Intrapartum, Maternal Status: Antepartum, Intrapartum,
Depression Level, Family Resiliency, Knowledge: Substance Use Control, Social Support, Spiritual Supp
ort
Example NOC Outcomes with Indicators
Maternal Status: Antepartum as evidenced by the following indicators: Emotional
attachment to fetus/Coping with
discomforts of pregnancy/Mood lability/Has realistic birth plan/Has support syst
em. (Rate each indicator of Maternal Status:
Antepartum: 1 = severe deviation from normal range, 2 = substantial deviation fr
om normal range, 3 = moderate deviation

from normal range, 4 = mild deviation from normal range, 5 = no deviation from n
ormal range [see Section I].)
Client Outcomes
Antepartum
Obtain early prenatal care in the ?rst trimester and maintain regular visits
Obtain knowledge level needed for appropriate care of oneself during pregnancy
including good nutrition
and psychological health
Understand the risks of substance abuse and resources available
Feel empowered to seek social and spiritual support for emotional well-being d
uring pregnancy
Utilize support systems for labor and emotional support
Develop a realistic birth plan taking into account any high risk pregnancy iss
ues
Be able to understand the labor and delivery process and comfort measures to m
anage labor pain
Postpartum
Utilize a safe environment for self and infant
Obtain knowledge to provide appropriate newborn care and postpartum care of se
lf
Obtain knowledge to develop appropriate bonding and parenting skills
NIC
High-Risk Pregnancy Care, Intrapartal Care
= Independent
B = Evidence-Based
? = Collaborative

Example NIC Activities High-Risk Pregnancy Care
Instruct patient on importance of receiving regular prenatal care and to follow
plan of care by taking prescribed medications and
following nutrition guidelines; Encourage identi?cation of psychosocial/psycholo
gical issues and substance use and appropriate treatment and referrals as needed
Encourage early prenatal care and regular prenatal visits. EBN: A study compare
d outcomes of infants born
to women who received Medicaid and prenatal care coordination (PNCC) services ve
rsus women who received
Medicaid but did not receive PNCC. Women who received PNCC services resulted in
fewer low-birth-weight
infants, fewer preterm infants, and fewer infants transferred to the neonatal in
tensive care unit. PNCC is an
effective strategy for preventing adverse birth outcomes (Van Dijk, Anderko, & S
tetzer, 2011).
? Identify any high-risk factors that may require additional surveillance such a
s preterm labor, hypertensive
disorders of pregnancy, diabetes, depression, other chronic medical conditions,
presence of fetal anomalies, or other high-risk factors. EB: A Cochrane study found that early and regu
lar prenatal care can improve
maternal and fetal outcomes by screening for risk factors and providing appropri
ate intervention and referrals
(Dowswell et al, 2010).
? Assess and screen for signs and symptoms of depression during pregna
ncy and in postpartal period
including history of depression or postpartum depression, poor prenatal care, po
or weight gain, hygiene
issues, sleep problems, substance abuse, and preterm labor. If depression is pre
sent, refer for behavioralcognitive counseling, and/or medication (postpartum period only). Both counselin
g and medication are
considered relatively equal to help with depression. EB: Research demonstrates t
hat early screening, treatment, and referral can improve pregnancy outcome by decreasing preterm labor, pr
eterm birth, and low-birthweight infants. Psychosocial support can improve bonding between mother and infa
nt and allow the mother
to appropriately care for infant (Yawn, 2011; Yonkers, Vigod & Ross, 2011).
? Observe for signs of alcohol use and counsel women to stop drinking during pre
gnancy. Give appropriate
referral for treatment if needed. EB: Alcohol is teratogenic, and prenatal expos
ure may result in growth
impairment, facial abnormalities, central nervous system and/or intellectual imp
airment, and behavioral disorders. Evidence suggests women s past pregnancy, current drinking behavior, and a
ttitude toward alcohol use
in pregnancy were the strongest predictors of alcohol consumption in pregnancy (
Barclay, 2011; Peadon et al
2011).
? Obtain a smoking history and counsel women to stop smoking for the safety of t
he baby. Give appropriate
referral to smoking cessation program if needed. EB: Tobacco smoking in pregnanc
y remains one of the few
preventable factors associated with complications in pregnancy, low birth weight
, and preterm birth and has
serious long-term health implications for women and babies. Smoking cessation tr
eatment resulted in reduced
low-birth-weight infants and decreased preterm births, and there was an increase
in mean birth weight (Lumley et al, 2009).
? Monitor for substance abuse with recreational drugs. Refer to drug treatment p
rogram as needed. Refer
opiate-dependent women to methadone clinics to improve maternal and fetal pregna
ncy outcomes. EB:
Opiate-dependent women experience a sixfold increase in maternal obstetric compl
ications and give birth to
low-weight babies (Minozzi et al, 2008). The newborn may experience narcotic wit
hdrawal (neonatal abstinence syndrome) have development problems, increased neonatal mortality, and a 7
4-fold increased risk of
sudden infant death syndrome. Maintenance treatment with methadone provides a st
eady concentration of
opiate in the pregnant woman s blood preventing the adverse effects on the fetus o
f repeated withdrawals.
Buprenorphine may also be prescribed. These treatments can reduce illicit drug u
se, improve compliance with
obstetric care, and improve birth weight but are still associated with neonatal
abstinence syndrome (Minozzi
et al, 2008).
? Monitor for psychosocial issues including lack of social support system, lonel
iness, depression, lack of
con?dence, maternal powerlessness, domestic violence, and socioeconomic problems
. EB: A study that
compared psychosocial assessment versus routine care for pregnant women conclude
d that the providers who
assessed psychosocial factors were more likely to identify psychosocial concerns
, including family violence, and
to rate the level of concern as high. In two trials, women identi?ed they did no
t want to feel so alone, be judged,
be misunderstood and they wanted to feel an increased sense of their own worth (
Austin et al, 2008; Gentry
et al, 2010; Small et al, 2011). Social support interventions can improve health
. The use of doulas can provide
assistance in addressing social-psychological issues and socioeconomic dispariti
es.
203
C
= Independent
B = Evidence-Based
204
? = Collaborative
? Monitor for signs of domestic violence. Refer to a community program for abus
ed women that provides
safe shelter as needed. EB: Fear about judgments about their capacity to provide
appropriate care for their
children often holds women back from disclosing depression and intimate partner
violence. Psychological violence during pregnancy by an intimate partner is strongly associated with postna
tal depression (Ludermir
C
REFERENCES
et al, 2010; Small et al, 2011).
Provide antenatal education to increase the woman s knowledge needed to make info
rmed choices during
pregnancy, labor, and birth and to promote a healthy lifestyle. EB: The use of d
oulas and childbirth educators has been shown to reduce medical interventions and improve maternal and inf
ant outcomes in women
(Gentry et al, 2010). CEB: A Cochrane review found a lack of quality evidence co
ncerning the effects of antenatal education (Gagnon & Sandall, 2007).
Encourage expectant parents to prepare a realistic birth plan in order to prepa
re for the physical and
emotional aspects of the birth process and to plan ahead for how they want vario
us situations handled.
CEB: A Discussion Birth Plan and a Hospital Birth Plan can be used to facilitate com
munication with the
expectant parents, their care provider and the hospital staff for events that oc
cur during labor and birth. Both
plans can assist expectant parents to make educated and informed decisions (Kauf
man, 2007).
Encourage good nutritional intake during pregnancy to facilitate proper growth
and development of the
fetus. Women should consume an additional 300 calories per day during pregnancy
and achieve a total
weight gain of 25 to 30 lb. EB: Low plasma folate concentrations in pregnancy ar
e associated with preterm
birth. Preconceptual folate supplementation is associated with a 50% to 70% redu
ction in preterm birth. Stud-
ies revealed that there was little change in dietary patterns in pregnancy, whic
h is of concern because women
were not able to improve their overall diets in pregnancy (Bukowski et al, 2009;
Crozier et al, 2009). CEB:
A study of low and middle income countries showed that supplementation with mult
i-micronutrients showed
a reduction in low birth weight and maternal anemia (Haider & Bhutta, 2006).
Multicultural
? Provide depression screening for clients of all ethnicities. EB: Race and eth
nicity are important risk factors
for antenatal depression. A study found that non-Hispanic white women, black wom
en, and Asian/Paci?c
Islander women had an increased risk for antenatal depression. The prevalence of
antenatal depression was
15.3% in black women, 6.9% in Latinas, and 3.6% in non-Hispanic white women (Gav
in et al, 2011).
Provide obstetrical care that is culturally diverse to ensure a safe and satisf
ying childbearing experience.
EBN: Nurses must acknowledge that the maternity health care system has a unique
culture that may clash
with the cultures of many of our clients. Women not accustomed to this culture o
f potential risk in prenatal
care, childbirth, and neonatal care may be frightened, overwhelmed, or made to f
eel guilty if they are not willing to undergo some of the expected interventions (Lewallen, 2011).
Austin MP, Priest SR, Sullivan EA: Antenatal psychosocial assessment
for reducing perinatal mental health morbidity, Cochrane Database
Syst Rev(4):CD005124, 2008.
Barclay L: ACOG calls for alcohol screen annually and at prenatal visit,
Obstet Gynecol 18:383 388, 2011.
Bukowski R, et al: Preconceptual folate supplementation and the risk of
spontaneous preterm birth: a cohort study, PLoS Med 6(5), 2009.
Crozier S, et al: Dietary patterns change little from before to during
pregnancy, J Nutr 139(10):1956 1963, 2009.
Dowswell T, et al: Alternative versus standard packages of antenatal care
for low-risk pregnancy, Cochrane Database Syst Rev(10):CD000934,
2010.
Gagnon AJ, Sandall J: Individual or group antenatal education
for childbirth or parenthood, or both, Cochrane Database Syst
Rev(3):CD002869, 2007.
Gavin A, et al: Racial differences in the prevalence of antenatal depression, Gen Hosp Psychiatry 33(2):87 93, 2011.
Gentry Q, et al: Going beyond the call of doula : a grounded theory
analysis for the diverse roles community-based doulas play in the
lives of pregnant and parenting adolescent mothers, J Perinat Educ
19(4):24 40, 2010.
Haider BA, Bhutta ZA: Multiple-micronutrient supplementation for women during pregnancy, Cochrane Database Syst
Rev(4):CD004905, 2006.
Kaufman T: Evolution of the birth plan, J Perinat Educ 16(3):47 52,
2007.
Lewallen LP: The importance of culture in childbearing, J Obstet Gynecol Neonat Nurs 40:4 8, 2011.
Ludermir A, et al: Violence against women by their intimate partner
during pregnancy and postnatal depression: a prospective cohort
study, Lancet 376(9744):903 910, 2010.
Lumley J, et al: Interventions for promoting smoking cessation during
pregnancy, Cochrane Database Syst Rev(3):CD001055, 2009.
Minozzi S, et al: Maintenance agonist treatments for opiate dependent

pregnant women, Cochrane Database Syst Rev(2):CD006318, 2008.
Peadon E, et al: Attitudes and behavior predict women s intention to
drink alcohol during pregnancy: the challenge for health professionals, BMC Public Health 11:584, 2011.
Small R, et al: The power of social connection and support in improving
health: lessons from social support interventions with childbearing
women, BMC Public Health 11(Suppl 5):S4, 2011.
= Independent
B = Evidence-Based
? = Collaborative
Readiness for enhanced childbearing process
205
Van Dijk JW, Anderko L, Stetzer F: The impact of prenatal care coordination on birth outcomes, J Obstet Gynecol Neonat Nurs 40:98 108,
2011.
Yawn B: Recognizing & managing postpartum depression, Am Acad
Fam Physician Sci Assemb, 2011. Retrieved May 29, 2012, from http:
Yonkers KA, Vigod S, Ross LE: Diagnosis, pathophysiology, and management of mood disorders in pregnant and postpartum women,
Obstet Gynecol 117(4):961 977, 2011.
//www.medscape.com/viewarticle/749874.
Readiness for enhanced Childbearing Process
Gail B. Ladwig, MSN, RN

C
NANDA-I
De?nition
A pattern of preparing for and maintaining a healthy pregnancy, childbirth proce
ss, and care of newborn that
is suf?cient for ensuring well-being and can be strengthened
During Pregnancy
Attends regular prenatal health visits; demonstrates respect for unborn baby; pr
epares necessary newborn
care items; reports appropriate physical preparations; reports appropriate prena
tal lifestyle (e.g., nutrition,
elimination, sleep, bodily movement, exercise, personal hygiene)
Reports availability of support systems; reports realistic birth plan; reports m
anaging unpleasant symptoms in pregnancy; seeks necessary knowledge (e.g., of labor and delivery, newbo
rn care)
Demonstrates attachment behavior to the newborn baby; is proactive during labor
and delivery; reports
lifestyle (e.g., diet, elimination, sleep, bodily movement, personal hygiene) th
at is appropriate for the stage of
labor; responds appropriately to onset of labor; uses relaxation techniques appr
opriate for the stage of labor;
utilizes support systems appropriately
After Birth
Demonstrates appropriate baby feeding techniques; demonstrates appropriate
breast care; demonstrates
attachment behavior to the baby; demonstrates basic baby care techniques; provid
es safe environment for
the baby; reports appropriate postpartum lifestyle (e.g., diet, elimination, sle
ep, bodily movement, exercise,
personal hygiene); utilizes support system appropriately
NOC
Knowledge: Pregnancy, Knowledge: Infant Care, Knowledge: Postpartum Maternal Hea
lth
Knowledge: Pregnancy as evidenced by client conveying understanding of the follo
wing indicators: Importance of frequent
prenatal care/Importance of prenatal education/Bene?ts of regular exercise/Healt
hy nutritional practices/Anatomic and physiological
changes with pregnancy/Psychological changes associated with pregnancy/Birthing
options/Effective labor techniques/Signs and symptoms of labor. (Rate the outcome and indicators of Knowledge: Pregnancy: 1 = no
knowledge, 2 = limited knowledge,
3 = moderate knowledge, 4 = substantial knowledge, 5 = extensive knowledge [see
Section I].)
Client Outcomes
During Pregnancy
State importance of frequent prenatal care/education
State knowledge of anatomic, physiological, psychological changes with pregnanc
y
= Independent
B = Evidence-Based
? = Collaborative
206
Report appropriate lifestyle choices prenatal: activity and exercise/healthy n

utritional practices
C
Report appropriate lifestyle choices during labor
State knowledge of birthing options, signs and symptoms of labor, and effectiv
e labor techniques
After Birth
Report appropriate lifestyle choices postpartum
State normal physical sensations following delivery
State knowledge of recommended nutrient intake, strategies to balance activity
and rest, appropriate exercise, time frame for resumption of sexual activity, strategies to manage stress
List strategies to bond with infant
State knowledge of proper handling and positioning of infant/infant safety
State knowledge of feeding technique and bathing of infant
NIC
Prenatal Care, Intrapartal Care, Postpartal Care, Attachment Promotion, Infant C
are: Newborn
Example NIC Activities Prenatal Care
Encourage prenatal class attendance; Discuss nutritional needs and concerns (e.g
., balanced diet, folic acid, food safety, and supplements); Discuss activity level with patient (e.g., appropriate exercise, activit
ies to avoid, and importance of rest); Discuss importance
of participating in prenatal care throughout entire pregnancy while encouraging
involvement of patient s partner or other family
member
Refer to care plans Risk for impaired Attachment; Readiness for enhanced Breastf
eeding; Readiness for
enhanced family Coping; Readiness for enhanced Family Processes; Risk for dispro
portionate Growth;
Readiness for enhanced Nutrition; Readiness for enhanced Parenting; Ineffective
Role Performance
Prenatal Care
? Ensure that pregnant clients have an adequate diet and take multimicronutrien
t supplements during
pregnancy. EB: Nutrition plays an important role in the growth and development o
f the fetus. Overall, the
diet of pregnant women has been reported to be de?cient in calories and micronut
rients. Prenatal supplementation with multimicronutrients was associated with a signi?cantly reduced risk
of low-birth-weight infants
and with improved birth weight (Shah et al, 2009).
Encourage pregnant clients to include enriched cereal grain products in their
diets. EB: The number of
pregnancies affected by neural tube defects greatly decreased in the United Stat
es after the forti?cation of cereal
grain products with folic acid was mandated (CDC, 2010).
Assess smoking status of pregnant client and offer effective smoking-cessation
interventions. EB: Smoking

during pregnancy is associated with delivery of preterm infants, low infant birt
h weight, and increased infant
mortality. After delivery, exposure to secondhand smoke can increase an infant s r
isk for respiratory tract infections and for dying of sudden infant death syndrome (Tong et al, 2009). Prenatal
smoking prevalence remains
high in the United States. To reduce prenatal smoking prevalence, efforts should
focus on delivering evidencebased cessation interventions to women who are most likely to smoke before pregn
ancy, younger non-Hispanic
white, Alaska Native, and American Indian women, who were identi?ed in this stud
y (Tong et al, 2011).
? Assess for signs of depression and make appropriate referral: inadequate weig
ht gain, underutilization of
prenatal care, increased substance use, and premature birth. Past personal or fa
mily history of depression,
single, poor health functioning, and alcohol use. EB: These signs occurring duri
ng pregnancy may be associated with depression treatment. Engagement is important, as untreated depression
during pregnancy may
have unfavorable outcomes for both women and children (Sexton et al, 2012).
Intrapartal Care
Encourage psychosocial support during labor. EB: In this study at the Universit
y College Hospital Ibadan,
Nigeria, women with anticipated vaginal delivery were recruited and randomized a
t the antenatal clinic. The
= Independent
B = Evidence-Based
? = Collaborative

experimental group had companionship in addition to routine care throughout labo
r until 2 hours after delivery, while the controls had only routine care. The primary outcome measure was c
esarean section rate. Women
with companionship had better labor outcomes compared to those without (Morhason
-Bello et al, 2009).
Consider using aromatherapy during labor. EB: Aromatherapy has been used in chi
ldbirth to reduce anxiety
and pain (Horowitz, 2011).
Offer immersion bath during labor. EBN: The present ?ndings of this study sugge
st that use of an immersion
bath is a suitable alternative form of pain relief for women during labor (da Si
lva, de Oliveira, & Nobre, 2009).
Provide massage and relaxation techniques during labor. EB: The ?ndings in this
study suggest that regular
massage with relaxation techniques from late pregnancy to birth is an acceptable
coping strategy for pain relief
(Kimber et al, 2008).
Offer the client in labor a light diet and water. EB: In this study consumption
of a light diet during labor did
not in?uence obstetric or neonatal outcomes in participants, nor did it increase
the incidence of vomiting.
Women who are allowed to eat in labor have similar lengths of labor and operativ
e delivery rates to those
allowed water only (O Sullivan et al, 2009).
Multicultural
Prenatal
Provide prenatal care for black and white clients. EB: Black-white disparities
in infant mortality persist in
the United States. In the years 2001 to 2004, Wisconsin had the highest black in
fant mortality rate (IMR) in
the 40 states reporting. IMRs have declined in Wisconsin from 2002 to 2007 despi
te national trends. Preliminary information suggests contributing factors may include improvement in adequa
te medical care and prenatal care for all (CDC, 2009).
Refer the client to a centering pregnancy group (8 to 10 women of similar gesta
tional age receive group
prenatal care after initial obstetrical visit) or group prenatal care. EBN: Afri
can-American women in group
care had signi?cantly fewer preterm births. Women in Centering Pregnancy groups
were more likely to initiate
breastfeeding, more ready for labor and birth and signi?cantly more satis?ed wit
h their prenatal care (Klima,
2009). The majority of perinatal deaths occur in developing countries. In this a
rticle we describe the implementation and evaluation of group prenatal care in Iran. Birth weight was greater f
or the infants of women in
group prenatal care compared with those in individual care. We have shown that g
roup prenatal care has
improved birth weight. Low birth weight (LBW), preterm birth, and perinatal deat
h, although not signi?cant,
were lower in the intervention group (Jafari et al, 2010).
Intrapartal
Consider the client s culture when assisting in labor and delivery. EB: This stud
y demonstrated the need for
a culturally sensitive, reliable, and valid instrument to better understand the
self-ef?cacy of childbirth as a
basis for developing effective interventions to increase normal childbirth among
Iranian pregnant women
(Khorsandi et al, 2008).
Postpartal
Provide health and nutrition education for Chinese women after childbirth. Prov
ide information and guidance on contemporary postpartum practices and take away common misconceptions ab
out traditional
dietary and health behaviors (e.g., fruit and vegetables should be restricted be
cause of cold nature). Encourage a balanced diet and discourage unhealthy hygiene taboos. EB: Sitting month is
the Chinese tradition for
postpartum customs. Available studies indicate that some of the traditional post
partum practices are potentially
harmful for women s health. Chinese women are advised to follow a speci?c set of f
ood choices and health care
practices. For example, the puerperal women should stay inside and not go outdoo
rs; all windows in the room
should be sealed well to avoid wind. Bathing and hair washing should be restrict
ed to prevent possible headache
and body pain in later years. Foods such as fruits, vegetables, soybean products
, and cold drinks that are considered cold should be avoided. In contrast, foods such as brown sugar, ?sh, chicken,
and pig s trotter, which are
considered hot, should be encouraged. It is believed that if a woman does not obse
rve these restrictions, she may
suffer from poor health later in life. Several studies indicated that the incide
nces of postpartum health problems
are high and these problems may have relation to traditional and unscienti?c die
tary and behavior practices in
the postpartum period. Available Chinese data also suggested that the incidences
of constipation and hemorrhoids were associated with lack of exercise and a decreased intake of fruit and
vegetables; the risk of oral problems was associated with no teethbrushing and excessive intake of sugar during t
he puerperium (Liu et al, 2009).
207
C
= Independent
B = Evidence-Based
208
? = Collaborative
Health and nutrition education should include the Chinese family (particularly
the relative who will be
staying with the new mother) after the woman gives birth. EB: The results of thi
s study found that increased
nutrition and health care knowledge did not lead to parallel dietary and health
behavior changes. This lack of
change is attributed to the fact that in China, the tradition to support a newly
delivered woman and her baby
C
for the ?rst month after childbirth at home is still common. Most of the women h
ad an elder female of the family such as her mother or mother-in-law as the support person. The elder female
who takes care of the women
may have hindered the changes due to traditional beliefs. The main problematic a
spect of the study was the

education intervention subjects aimed directly to the study of women, yet sitting
month was usually recognized as an important event in the family and the postpartum woman has been take
n care by her mother or
mother-in-law (Liu et al, 2009).
Home Care
Prenatal
? Involve pregnant drug users in drug treatment programs that include coordinat
ed interventions in several
areas: drug use, infectious diseases, mental health, personal and social welfare
, and gynecological/obstetric care. EB: This literature search revealed that involving pregnant drug users
in drug treatment is likely to
decrease the chances of prenatal and perinatal complications related to drug use
and to increase access to prenatal care. Timely medical intervention can effectively prevent vertical transmi
ssion of human immunode?ciency virus and hepatitis B virus, as well as certain other sexually transmitte
d diseases, and would allow
newborns infected with hepatitis C virus during birth to receive immediate treat
ment (Gyarmathy et al, 2009).
Postpartal
Provide video conferencing to support new parents. EBN: The ?ndings of this stu
dy indicate that VC equipment may be helpful for parents discharged from the hospital early after childbi
rth (Lindberg, Christensson, &
Ohrling, 2009).
Consider re?exology for postpartum women to improve sleep quality. EBN: In this
RCT an intervention
involving foot re?exology in the postnatal period signi?cantly improved the qual
ity of sleep in postpartum
women (Liet al, 2011).
Prenatal
Provide dietary and lifestyle counseling as part of prenatal care to pregnant w
omen. EB: In this study an
organized, consistent program of dietary and lifestyle counseling reduced weight
gain in pregnancy (Asbee
et al, 2009). Community-level interventions of improved perinatal care practices
can bring about a reduction
in maternal mortality (Kidney et al, 2009).
Provide the following information in parenting classes, via DVD and I
nternet: support mechanisms,
information and antenatal education, breastfeeding, practical baby care, and rel
ationship changes. Include
fathers in the parenting classes. EB: The men felt very involved with their part
ners pregnancy but excluded
from antenatal appointments and antenatal classes, and by the literature that wa
s available. Parents had been
unaware of, and surprised at, the changes in the relationship with their partner
s. They would have liked more
information on elements of parenting and baby care, relationship changes, and pa
rtners perspectives prior to
becoming parents. Parents suggested that information be provided on a DVD (Deave
, Johnson, & Ingram,
2008; St George & Fletcher, 2011).
Provide group prenatal care to families in the military. EBN: Group PNC offers
the potential for continuity
of provider, which the women were concerned was lacking. It also offers communit
y with other women. In the

process, women gain knowledge and power as health care consumers (Kennedy et al,
2009).
Postpartal
Encourage physical activity in postpartum women; provide telephone counseling,
pedometers, referral to
community PA resources, social support, email advice on PA/pedometer goals, and
newsletters. EB: In
this study these interventions were effective in increasing physical activity in
postpartum women (Albright,
Maddock, & Nigg, 2009).
Teach mothers of young children principles of a healthy lifestyle: substitute h
igh-fat foods with low-fat
foods such as fruits and vegetables, increase physical activity,
consider a community-based
= Independent
B = Evidence-Based
? = Collaborative
REFERENCES
Risk for ineffective childbearing process

self-management intervention to prevent weight gain. EBN: Preventing weight gain
rather than treating
established obesity is an important economic and public health response to the r
apidly increasing rates of obesity worldwide. In this study both a single health education session and interac
tive behavioral intervention
resulted in a similar weight loss in the short term, although more participants
in the interactive intervention
lost or maintained weight. Self-monitoring appears to enhance weight lo
ss when part of an intervention
(Lombard et al, 2009).
209
C
Albright CL, Maddock JE, Nigg CR: Increasing physical activity in postpartum multiethnic women in Hawaii: results from a pilot study,
BMC Womens Health 9:4, 2009.
Asbee SM, et al: Preventing excessive weight gain during pregnancy
through dietary and lifestyle counseling: a randomized controlled
trial, Obstet Gynecol 113(2 Pt 1):305 312, 2009.
Centers for Disease Control and Prevention (CDC): CDC grand rounds:
additional opportunities to prevent neural tube defects with folic
acid forti?cation, MMWR Morb Mortal Wkly Rep 59(31):980 984,
2010.
Centers for Disease Control and Prevention (CDC): Apparent disappearance of the black-white infant mortality gap-Dane County, Wisconsin, 1990-2007, MMWR Morb Mortal Wkly Rep 58(20):561 565,
2009.
da Silva FM, de Oliveira SM, Nobre MR: A randomised controlled trial
evaluating the effect of immersion bath on labour pain, Midwifery
25(3):286 294, 2009.
Deave T, Johnson D, Ingram J: Transition to parenthood: the needs
of parents in pregnancy and early parenthood, BMC Pregnancy
Childbirth 8:30, 2008.
Gyarmathy VA, et al: Drug use and pregnancy-challenges for public
health, Euro Surveill 4(9):33 36, 2009.
Horowitz S: Aromatherapy: current and emerging applications, Altern
Complement Ther 17(1):26 31, 2011.
Ionescu-Ittu R, et al: Prevalence of severe congenital heart disease after
folic acid forti?cation of grain products: time trend analysis in
Quebec, Canada, BMJ 338:b1673, 2009.
Jafari F, et al: Comparison of maternal and neonatal outcomes of group
versus individual prenatal care: a new experience in Iran, Health
Care Women Int 31(7):571 584, 2010.
Kennedy HP, et al: I wasn t alone a study of group prenatal care in
the military, J Midwifery Womens Health 54(3):176 183, 2009.
Khorsandi M, et al: Iranian version of childbirth self-ef?cacy inventory,
J Clin Nurs 17(21):2846 2855, 2008.
Kidney E, et al: Systematic review of effect of community-level interventions to reduce maternal mortality, BMC Pregnancy Childbirth 9:2,
2009.
Kimber L, et al: Massage or music for pain relief in labour: a pilot randomised placebo controlled trial, Eur J Pain 12(8):961 969, 2008.
Klima C, Norr K, Vonderheid S, Handler A: Introduction of CenteringPregnancy in a public health clinic, Midwifery 54(1):27 34, 2009.
Li CY, et al: Randomised controlled trial of the effectiveness of using
foot re?exology to improve quality of sleep amongst Taiwanese
postpartum women, Midwifery 27(2):181 186, 2011.
Lindberg I, Christensson K, Ohrling K: Parents experiences of using
videoconferencing as a support in early discharge after childbirth,
Midwifery 25(4):357 365, 2009.
Liu N, et al: The effect of health and nutrition education intervention
on women s postpartum beliefs and practices: a randomized controlled trial, BMC Public Health 9:45, 2009.
Lombard CB, et al: Weight, physical activity and dietary behavior
change in young mothers: short term results of the HeLP-her cluster
randomized controlled trial, Nutrition J 8:17, 2009.
Morhason-Bello IO, et al: Assessment of the effect of psychosocial support during childbirth in Ibadan, south-west Nigeria: a randomised
controlled trial, Aust N Z J Obstet Gynaecol 49(2):145 150, 2009.
O Sullivan G, et al: Effect of food intake during labour on obstetric
outcome: randomised controlled trial, BMJ 338:b784, 2009.
Sexton MB, et al: Predictors of recovery from prenatal depressive
symptoms from pregnancy through postpartum, J Womens Health
21(1):43 49, 2012.
Shah PS, Ohlsson A: Knowledge Synthesis Group on Determinants of
Low Birth Weight and Preterm Births: Effects of prenatal multimicronutrient supplementation on pregnancy outcomes: a meta-analysis, CMAJ 180(12):E99 108, 2009.
St George JM, Fletcher RJ: Fathers online: learning about fatherhood
through the Internet, J Perinat Educ 20(3):154 162, 2011.
Tong VT, et al: Trends in smoking before, during, and after pregnancy.
Pregnancy Risk Assessment Monitoring System (PRAMS), United
States, 31 sites, 2000-2005, MMWR Surveill Summ 58(4):1 29, 2009.
Tong VT, et al: Age and racial/ethnic disparities in prepregnancy
smoking among women who delivered live births, Prev Chron Dis
8(6):A121, 2011.
Risk for ineffective Childbearing Process

NANDA-I
De?nition
Risk for a pregnancy and childbirth process and care of newborn that does not ma
tch the environmental
context, norms, and expectations
Risk Factors
De?cient knowledge (e.g., of labor and delivery, newborn care), domestic violenc
e, inconsistent prenatal
health visits, lack of appropriate role models for parenthood, lack of cognitive
readiness for parenthood, lack
of maternal con?dence, lack of prenatal health visits, lack of realistic birth p
lan, lack of suf?cient support
= Independent
B = Evidence-Based
210
Impaired comfort
? = Collaborative
systems, maternal powerlessness, maternal psychological distress, suboptimal mat

ernal nutrition, substance
abuse, unplanned pregnancy, unwanted pregnancy
NIC, NOC, Client Outcomes, Nursing Interventions, Client/Family Teaching, Ration
ales,
C
and References
Refer to care plan for Ineffective Childbearing Process.
Impaired Comfort
Katharine Kolcaba, PhD, RN

NANDA-I
De?nition
Perceived lack of ease, relief, and transcendence in physical, psychospiritual,
environmental, and sociocultural dimensions
Anxiety; crying; disturbed sleep pattern; fear; illness-related symptoms;
inability to relax; insuf?cient
resources (e.g., ?nancial, social support); irritability; moaning; noxious envir
onmental stimuli; reports being
uncomfortable; reports being cold; reports being hot; reports distressing sympto
ms; reports hunger; reports
itching; reports lack of ease or contentment in situation; restlessness
NOC
Client Satisfaction, Symptom Control, Comfort Status, Coping, Hope, Pain and/or
Anxiety Management,
Personal Well-Being, Spiritual Health
Comfort Status as evidenced by the following indicators: Physical and psychologi
cal well-being/Symptom control/Enhanced
comfort. (Rate the outcome and indicators of Comfort Status: 1 = severely compro
mised, 2 = substantially compromised,
3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [see Sec
tion I].)
Client Outcomes
Provide evidence for improved comfort compared to baseline
Identify strategies, with or without signi?cant others, to improve and/or maint
ain acceptable comfort
level
Perform appropriate interventions, with or without signi?cant others, as needed
to improve and/or maintain acceptable comfort level
Evaluate the effectiveness of strategies to maintain/and or reach an acceptable
comfort level
Maintain an acceptable level of comfort when possible
NIC
Calming Techniques, Massage, Healing Touch, Heat/Cold Application, Hope Inspirat
ion, Humor, Meditation Facilitation, Music Therapy, Pain Management, Presence; Progressive
Muscle Relaxation, Spiritual
Growth Facilitation, Distraction
Example NIC Activities Hope Inspiration
Assist the client/signi?cant others to identify areas of hope in life; Help to e
xpand spiritual self; Involve the client actively in own care
= Independent
B = Evidence-Based
? = Collaborative
Impaired comfort
Nursing Interventions and Rationales*
Assess client s current level of comfort. This is the ?rst step in helping client
s achieve improved comfort.
Sources of assessment data to determine level of comfort can be subjective, obje
ctive, primary, or secondary
(Kolcaba, 2012; Wilkinson & VanLeuven, 2007).
Comfort is a holistic state under which pain management is included. Management
of discomforts, however, can be better managed, and with fewer analgesics, by also addressing other
comfort needs such as anxiety, insuf?cient information, social isolation, or ?nancial dif?culties. CEB: On
e randomized study (N = 53)
found that female breast cancer clients undergoing radiation therapy rated their
overall comfort as being greater
than the sum of the hypothesized components of comfort, which provided evidence
for the theory of the holistic
nature of comfort (Kolcaba & Steiner, 2000, in Kolcaba, 2012).
Assist clients to understand how to rate their current state of holistic comfor
t, utilizing institution s preferred method of documentation. Documentation of comfort prenursing and postnurs
ing interactions is
essential to demonstrating the ef?cacy of nursing activities (Kolcaba, 2003; Kol
caba, Tilton, & Drouin, 2006,
in Kolcaba, 2012).
Enhance feelings of trust between the client and the health care provider. To a
ttain the highest comfort
level, clients must be able to trust their nurse (Kolcaba, 2003; Kolcaba et al,
2004). CEB: This randomized
design (N = 31) demonstrated the importance of promoting open relationships with
clients, which helps to
acknowledge their individuality. Knowing the client/signi?cant others is essenti
al in the provision of optimum
palliative and terminal care (Kolcaba et al, 2004, in Kolcaba, 2012).
Manipulate the environment as necessary to improve comfort. CEB: In two experim
ental studies, the pro-
tocol included that all clients be asked about preferences for light, furnishing
s, body position, television settings,
etc. (Kolcaba et al, 2004; Dowd et al, 2007, in Kolcaba, 2012).
Encourage early mobilization and provide routine position changes to decrease p
hysical discomforts associated with bed rest. CEB: An experimental study of 420 individuals following no
nemergency cardiac catheterization found consistently lower scores for back discomfort with no increase
in bleeding in the intervention
group, when they were turned every hour (Chair et al, 2003). A review comparing
the study by Chair et al
found its results to be consistent with other studies that have found that backr
est elevation, side lying, and early
ambulation all improved comfort (Benson, 2004).
Provide simple massage. CEB: Two experiments, one with 31 and one with 60 clien
ts, demonstrated that
hand massage was helpful for reducing discomfort and anxiety and promoting relax
ation and sleep (Kolcaba
et al, 2004; Kolcaba, Schirm, & Steiner, 2006).
Provide healing touch, which is well-suited for clients who cannot tolerate mor
e stimulating interventions
such as simple massage. EBN: In an experiment (N = 58), college students experie
nced enhanced comfort
immediately after healing touch, compared to their baseline comfort level (Dowd
et al, 2007).
Inform the client of options for control of discomfort such as meditation and g
uided imagery, and provide these interventions if appropriate. CEB: A study found that female breast c
ancer clients (N = 53) treated
with guided imagery while undergoing radiation therapy had signi?cant improvemen
ts in comfort compared
with the control group (Kolcaba, 2003).
Utilize empathy as a response to a client s negative emotions. EBN: An evaluation
interaction analysis
found that an accurate empathic response to a client s expressions of negative emo
tions can contribute to comfort (Eide, Sibbern, & Johannessen, 2011).
Encourage clients to use relaxation techniques to reduce pain, anxiety, depress
ion, and fatigue. EBN: In a
systematic review of randomized controlled studies, it was found that relaxation
training was effective for
decreasing pain intensity, anxiety, depression, and fatigue in clients with chro
nic musculoskeletal pain (Persson et al, 2008).
Geriatric
Utilize hand massage for elders because most respond well to touch and the prov
ider s presence. EBN: In
an experiment (N = 60), the effects of hand massage on comfort of nursing home r
esidents was found to be
signi?cant immediately after the massage compared to residents who did not recei
ve hand massage (Kolcaba,
Schirm, & Steiner, 2006, in Kolcaba, 2012).
*In updating these comfort interventions, Dr. Kolcaba wishes to acknowledge the
invaluable assistance of Katharine K. Mayer, RN,
MSN, of University Hospitals of Cleveland and Kimberly N. Fiolliett-Vranic, MSN,
RN, Coronary Care Unit, Cleveland Clinic Foundation.
211
C
= Independent
B = Evidence-Based
212
? = Collaborative
Impaired comfort
Discomfort from cold can be treated with warmed blankets. EBN: This study (N =
126) found signi?cantly
increased comfort and decreased anxiety in clients who used self-controlled warm
ing gowns (Wagner, Byrne, &
Kolcaba, 2006).
C
Use complementary touch therapies such as re?exology on clients with dementia t
o reduce pain and
stress. EBN: In a study conducted on nursing home residents (N = 21), it was fou
nd that re?exology was an
effective treatment of stress and observed pain in residents with mild to modera
te dementia (Hodgson &
Andersen, 2008).
Acknowledge any unmet physical, psychological, emotional, spiritual, and enviro
nmental needs when
attempting to understand the behavior of an elderly client with dementia. As car
egivers, all possible causes
for demented elderly clients behavior must be considered to maximize comfort (Gal
laher & Long, 2011).
Provide simple massage. EBN: A prospective study design (N = 52) found that pro
viding massage to nursing
home residents with dementia was effective in controlling agitation (Holliday-We
lsh, Gessert, & Renier, 2009).
Multicultural
Identify and clarify cultural language used to describe pain and other discomfo
rts. CEB: Clients may
interchange words meaning discomfort and pain, may refer to minor discomforts as
pain, or may not discuss
non-painful discomforts at all (Kolcaba, 2003).
Assess skin for ashy or yellow-brown appearance. Black skin appears ashy and br
own skin appears yellow-
brown when clients have pallor sometimes associated with discomfort (Peters, 200
7).
Use soap sparingly if the skin is dry. Black skin tends to be dry, and soap wil
l exacerbate this condition.
Encourage and allow clients to practice their own cultural beliefs and recogniz
e the impact different cultures have on a client s belief about health care, suffering, and decision-making.
Hindus believe in reincarnation, which gives them comfort during the dying process. Hindus also believe t
hat physical suffering can lead
to spiritual growth (Thrane, 2010).
Assess for cultural and religious beliefs when providing care to clients. EBN:
In a hermeneutic phenomenological study conducted in six medical-surgical wards in Iran (N = 22), it was f
ound that family members play
an important role in the comfort of the patient. It was also found that caregive
rs should allow patients to follow
religious and traditional principles to facilitate comfort despite physical cons
traints (Youse? et al, 2009).
Teach techniques to use when the client is uncomfortable, including relaxation
techniques, guided imagery, hypnosis, and music therapy. EBN: Interventions such as progressive muscle
relaxation training, guided
imagery, and music therapy can effectively decrease the perception of uncomforta
ble sensations, including pain
(Kolcaba, 2003). CEB & EBN: Families want to learn how to provide comfort measur
es to their loved ones who
are uncomfortable. (Kolcaba et al, 2004, in Kolcaba, 2012).
Instruct the client and family on prescribed medications and therapies that imp
rove comfort (Kolcaba, 2003).
Teach the client to follow up with the physician or other practitioner if disco
mfort persists (Kolcaba,
2003).
Encourage clients to utilize the Internet as a means of providing education to
complement medical care
for those who may be homebound or unable to attend face-to-face education. EBN:
In a randomized trial
with intervention (N = 41), it was found that the Internet was an effective mode
for delivering self-care education to older clients with chronic pain (Berman et al, 2009).
Mental Health
Encourage clients to use guided imagery techniques. EBN: A quasi-experimental d
esign (N = 60) found that
patients who listened to a guided imagery compact disk once a day for 10 days ha
d improved comfort and
decreased depression, anxiety, and stress over time (Apstolo & Kolcaba, 2009, in
Kolcaba, 2012).
Provide psychospiritual support and a comforting environment in order to enhanc
e comfort. EBN: In a
cross-sectional descriptive study (N = 98), it was found that cancer patients ha
d lower comfort levels relating
to psychospiritual and environmental comfort than to physical and sociocultural
comfort. Improvements in
psychospiritual and environmental support will enhance overall comfort (Kim & Kw
on, 2007).
Providing music and verbal relaxation therapy can reduce anxiety. EBN: A litera
ture review found that
music and verbal relaxation therapy provided reduced chemotherapy-induced anxiet
y (Lin et al, 2011).
Caregivers should not hesitate to use humor when caring for their clients. EBN:
Analysis of two studies
found that humor can be comforting and can contribute to a positive experience f
or both patient and caregiver
(Kinsman-Dean & Major, 2008).
= Independent
B = Evidence-Based
? = Collaborative
REFERENCES
Readiness for enhanced comfort
213
Benson G: Changing patients position in bed after non-emergency
coronary angiography reduced back pain, Evid Based Nurs 7(1):19,
2004.
Kinsman-Dean RA, Major JE: From critical care to comfort care: the
sustaining value of humour, J Clin Nurs 17:1088 1095, 2008.
Kolcaba K: Comfort theory and practice: a holistic vision for health care,
Berman RLH, et al: The effectiveness of an online mind-body intervention for older adults with chronic pain, J Pain 10(1):68 79, 2009.
Chair SY, et al: Effect of positioning on back pain after coronary angiography, J Adv Nurs 42(5):470 478, 2003.
Dowd T, et al: Comparison of healing touch and coaching on stress and
comfort in young college students, Holist Nurs Pract 21(4):194 202,
2007.
Eide H, Sibbern T, Johannessen T: Empathic accuracy of nurses
immediate response to ?bromyalgia patients expressions of negative emotions: an evaluation using interaction analysis, J Adv Nurs
67(6):1242 1253, 2011.
Gallaher M, Long DO: Demystifying behaviors, addressing pain, and
maximizing comfort research and practice: partners in care, J Hospice Palliat Nurs 13(2):71 78, 2011.
Hodgson N, Andersen S: The clinical ef?cacy of re?exology in nursing
home residents with dementia, J Altern Complement Med 14(3):269
275, 2008.
Holliday-Welsh D, Gessert C, Renier C: Massage in the management
of agitation in nursing home residents with cognitive impairment,
Geriatr Nurs 30(2):108 117, 2009.
Kim KS, Kwon SH: Comfort and quality of life of cancer patients, Asian
Nurs Res 1:125 135, 2007.
Readiness for enhanced Comfort
New York, 2003, Springer.
Kolcaba K: TheComfortLine.com. Retrieved June 21, 2012, from www.
TheComfortLine.com.
Kolcaba K, et al: Ef?cacy of hand massage for enhancing comfort of
hospice patients, J Hospice Palliat Care 6(2):91 101, 2004.
Kolcaba K, Schirm V, Steiner R: Effects of hand massage on comfort of
nursing home residents, Geriatr Nurs 27(2):85 91, 2006.
Lin MF, et al: A randomized controlled trial of the effect of music
therapy and verbal relaxation on chemotherapy-induced anxiety,
J Clin Nurs 20:988 999, 2011.
Persson AL, et al: Relaxation as a treatment for chronic musculoskeletal
pain a systematic review of randomized controlled studies, Phys
Ther Rev 13(5):355 365, 2008.
Peters J: Examining and describing skin conditions, Pract Nurse
34(8):39 40, 43, 45, 2007.
Thrane S: Hindu end of life, J Hospice Palliat Nurs 12(6):337 342, 2010.
Wagner D, Byrne M, Kolcaba K: Effect of comfort warming on preoperative patients, AORN J 84(3):1 13, 2006.
Wilkinson J, VanLeuven K: Fundamentals of nursing, Philadelphia,
2007, FA Davis.
Youse? H, et al: Comfort as a basic need in hospitalized patients in Iran:
hermeneutic phenomenology study, J Clin Nurs 65(9):1891 1898, 2009.
Natalie Fischetti, PhD, RN
C
NANDA
De?nition
A pattern of ease, relief and transcendence in physical, psychospiritual, enviro
nmental, and/or social dimensions that is suf?cient for well-being and can be strengthened
Expresses desire to enhance comfort; expresses desire to enhance feelings of con
tentment; expresses desire to
enhance relaxation; expresses desire to enhance resolution of complaints
NOC
Outcomes (Nursing Outcomes Classi?cation)
Client Satisfaction: Caring, Symptom Control, Comfort Status, Coping, Hope, Moti
vation, Pain Control,
Participation in Health Care Decisions, Spiritual Health
Comfort Status as evidenced by the following indicators: Physical well-being/Sym
ptom control/Psychological well-being. (Rate
the outcome and indicators of Comfort Level: 1 = not at all satis?ed, 2 = somewh
at satis?ed, 3 = moderately satis?ed,
4 = very satis?ed, 5 = completely satis?ed.)
Client Outcomes
Assess current level of comfort as acceptable
Express the need to achieve an enhanced level of comfort
Identify strategies to enhance comfort
= Independent
B = Evidence-Based
214
? = Collaborative
Perform appropriate interventions as needed for increased comfort

Evaluate the effectiveness of interventions at regular intervals
Maintain an enhanced level of comfort when possible
C
NIC
Interventions (Nursing Interventions Classi?cation)
Calming Technique, Cutaneous Stimulation, Environmental Management, Comfort, Hea
t/Cold Application, Hope Inspiration, Humor, Meditation Facilitation, Music Therapy, Pain Mana
gement, Presence, Simple Guided Imagery, Simple Massage, Simple Relaxation Therapy, Spiritual Growth
Facilitation, Therapeutic
Play, Therapeutic Touch, Touch, Distraction
Example NIC Activities Spiritual Growth Facilitation
Assist the patient with identifying barriers and attitudes that hinder growth or
self-discovery; Assist the patient to explore beliefs as
related to healing of the body, mind, and spirit; Model healthy relating and rea
soning skills
Assess client s current level of comfort. This is the ?rst step in helping client
s to achieve enhanced comfort.
Sources of assessment data to determine level of comfort can be subjective, obje
ctive, primary, secondary, focused,
or even special needs (Wilkinson & VanLeuven, 2007). While clinicians are assess
ing pain more frequently, this
has not resulted in widespread pain reduction. A solution may be to establish co
mfort-function goals for clients,
reminding clients to tell their nurse when pain interferes with function (Pasero
& McCaffrey, 2004).
Help clients understand that enhanced comfort is a desirable, positive, and ach
ievable goal. CEB: Human
beings strive to have their basic comfort needs met, but comfort is more than ju
st the absence of pain (Kolcaba,
2003). Comfort is best recognized when a person leaves the state of discomfort a
nd nurses can enhance their

client s comfort in everyday practice (Malinowski & Stamler, 2002).
Enhance feelings of trust between the client and the health care provider. CEB:
To attain the highest comfort level a client must be able to trust the nurse (Hupcey, Penrod, & Morse, 20
00) EBN: Patients had greater
feelings of emotional comfort when they felt secure, informed and valued (Willia
ms, Dawson, & Kristjanson,
2009). EBN: Trust is an essential element in the nurse-patient relationship (Bel
l & Duffy, 2009).
Use therapeutic massage for enhancement of comfort. CEB: This study determined
the effects of hand
massage on clients near the end of life, with clients reporting feeling special
and that the massage felt good.
Also, meaningful connectedness was achieved (Kolcaba et al, 2004). Massage is he
lpful for low back pain
and other orthopedic problems (Dryden, Baskwill, & Preyde, 2004). EBN: Women who
received massage in
the latent labor period prior to delivery had less pain perception than women wh
o did not (Yildirim &
Sahin, 2004).
Teach and encourage use of guided imagery. Guided imagery can be helpful on pai
n level, physical functional status, and self-ef?cacy on persons with ?bromyalgia (Menzies, Taylor, &
Bourguignon, 2006). Visual
imagery with mind-body relaxation may be used for symptom control in Hispanic pe
rsons diagnosed with
?bromyalgia (Menzies & Kim, 2008). EBN: Guided imagery was utilized in a study o
f psychiatric patients and
was found to signi?cantly improve their comfort level (Apstolo & Kolcaba, 2009).
Guided imagery was used
to relieve postoperative pain in elderly orthopedic patients.
Use of heat application to enhance pain relief. EBN: Heat can be helpful with p
ain management of women
with perineal pain during the second stage of labor; 79.9% of women identi?ed re
lief of perineal pain with the
use of warm packs during the second stage of labor. Eighty-?ve percent of these
women found it so effective that
they would use it during subsequent births (Dahlen et al, 2009).
Foster and instill hope in clients whenever possible. EBN: This study was the ?
rst to document the effectiveness of a brief hope intervention. The intervention produced a signi?cant effect
on pain tolerance. The increase
in pain tolerance was stronger for females than males (Berg, Snyder, & Hamilton,
2008). See the care plan for
Hopelessness.
Provide opportunities for and enhance spiritual care activities. The need for c
omfort and reassurance may
be perceived as spiritual needs. To meet these needs, nurses engaged in interact
ion when they comforted and
assured clients. Participants also identi?ed absolution as a spiritual need, and
there is evidence that forgiveness
may bring one feelings of joy, peace, elation, and a sense of renewed self-worth
(Narayanasomy et al, 2004).
= Independent
? = Collaborative
B = Evidence-Based

Individuals who practiced spiritual meditation were found to have a greater incr
ease in pain tolerance (Wachholtz & Pargament, 2008).
? Enhance social support and family involvement. EBN: Methods to help terminally
ill clients and their families transition from cure to comfort care included spending an increased amount
of time with one s family,
appointing one close friend to act as a contact person for other friends, and es
tablishing an email list serve for
updates of a client s status and care (Duggleby & Berry, 2005).
? Encourage mind-body therapies such as meditation as an enhanced comfort activi
ty. EB: The most common therapies used were meditation, imagery, and yoga. Research demonstrating th
e connection between the
mind and body has therefore increased interest in the potential use of these the
rapies (Wolsko et al, 2004).
EBN: Meditation has been shown to reduce anxiety, relieve pain, decrease depress
ion, enhance mood and selfesteem, decrease stress, and generally improve clinical symptoms (Bonadonna, 200
3). A review of clinical trials
for meditation and massage used in end of life found that there was a signi?cant
relationship between meditation and pain reduction in the two studies that assessed pain (Lafferty et al, 2
006).
? Promote participation in creative arts and activity programs. EBN: A creative
arts program for caregivers of
cancer clients was shown to lower anxiety, and positive emotions were expressed
(Walsh, Martin, & Schmidt,
2004). The use of an individualized music protocol program by elderly women was
shown to promote and
maintain sleep (Johnson, 2003).
? Encourage clients to use health information technology (HIT) as needed. Client
services can now include
management of medications, symptoms, emotional support, health education, and he
alth information
(Moody, 2005). EBN: Injured car occupants experienced signi?cantly lower dimensi
ons of pain and discomfort with nursing intervention via telephone (Franzen et al, 2009).
Evaluate the effectiveness of all interventions at regular intervals and adjust
therapies as necessary. It is
important for nurses to determine comfort and pain management goals because comf
ort goals will change with
circumstances. Ask questions and ask them frequently, such as How is your comfort
? Establish guidelines for
frequency of assessment and document responses noting if goals are being met (Ko
lcaba, 2003). EB: A comprehensive palliative care project was conducted at 11 sites. The interdi
sciplinary review process built trust,
endorsed creativity, and ultimately resulted in better meeting the needs of clie
nts, families, and the community
(London et al, 2005). Evaluation must be planned for, ongoing, and systematic. E
valuation demonstrates caring and responsibility on the part of the nurse (Wilkinson & VanLeuven, 2007).
? Explain all procedures, including sensations likely to be experienced during t
he procedure. EBN: Patients
undergoing abdominal surgery in an experimental group received routine care and
a preoperative nursing
intervention which included explaining the causes of pain that would occur due t
o the operation, explaining
the in?uences of postoperative pain and the importance of early out-of-bed activ
ities, teaching how to reduce
pain using nonpharmacological methods, encouraging requesting pain medications a
fter surgery, encouraging
expression of feelings and concerns, and setting a pain control goal. This group
had a signi?cant decrease in
postoperative anxiety and a statistically signi?cantly lower postoperative pain
intensity 4 hours and 24 hours
after the surgical procedure (Lin & Wang, 2004).
Pediatric
Assess and evaluate child s level of comfort at frequent intervals. Comfort needs
should be individually
assessed and planned for. With assessment of pain in children, it is best to use
input from the parents or a
primary care provider. Use only accepted scales for standardized pain
assessment (Remke & Chrastek,
2007).
Skin-to-skin contact (SSC) and selection of most effective method improves the
comfort of newborns
during routine blood draws. EB: Premature infants who received skin-toskin contact demonstrated a
decrease in pain reaction during heel lancing (Castral et al, 2008).
Adjust the environment as needed to enhance comfort. Environmental comfort meas
ures include maintaining orderliness; quiet; minimizing furniture; special attention to temperature,
light and sound, color, and
landscape (Kolcaba & DeMarco, 2005).
Encourage parental presence whenever possible. The same basic principles for ma
naging pain in adults
and children apply to neonates. In addition to other comfort measures, parental
presence should be encouraged whenever possible (Pasero, 2004). EBN: This study reported the effects of c
o-residence and caregiving on
the parents of children dying with AIDS. Although parents who did more caregivin
g did experience anxiety,
insomnia, and fatigue, the caregiving experiences for many parents gave them an
opportunity to ful?ll their
perceived duty as parents before their child died. This in turn resulted in bett
er physical and emotional health
outcomes (Kespichayawattana & VanLandingham, 2003).
215
C
= Independent
B = Evidence-Based
216
? = Collaborative
Promote use of alternative comforting strategies such as positioning, presence,

massage, spiritual care,
music therapy, art therapy, and story-telling to enhance comfort when needed. In
addition to oral sucrose,
other comfort measures should be used to alleviate pain such as swaddling, skinto-skin contact with
mother, nursing, rocking, and holding (Pasero, 2004). EBN: Building on the belie
f that parents are the
C
primary care providers and health care resource for families, the blended infant
massage parenting program
is effective for both mother and infant (Porter & Porter, 2004). EBN: In this st
udy, focus groups were conducted with Moroccan pediatric oncology nurses and physicians to better understa
nd how pain management
was achieved in children with cancer. When no medication was available to reliev
e pain, other techniques were
used to comfort clients. These included use of cold therapy, presence, holding a
child s hand, utilizing distraction techniques, playing with them, story-telling, and encouraging parental enga
gement activities (McCarthy
et al, 2004). EB: In a study that examined the effects of music on pain in a ped
iatric burn unit during nursing
procedures, the use of music during procedures reduced pain (Whitehead-Pleaux et
al, 2007). EBN: A Talk
and Touch intervention by the mothers of PICU infants found that 62 percent of t
he mothers felt that the
intervention made a difference in the pain the infant experienced and 73 percent
felt that talk and touch
decreased their infant s distress (Rennick et al, 2011).
? Support child s spirituality. CEB: Children are born with an intrinsic spiritua
l essence that can be enhanced.
Spirituality promotes a sense of hope, comfort, and strength and creates a sense
of being loved and nurtured by
a higher power (Elkins & Cavendish, 2004).
Multicultural
Identify cultural beliefs, values, lifestyles, practices, and problem-so
lving strategies when assessing
clients. Cultural sensitivity must always be a component of pain assessment. The
nurse must remember
that pain expression will vary among clients and that variation must also be ack
nowledged within cultures
(Andrews & Boyle, 2003). EBN: In a qualitative study that identi?ed issues in pa
in management, cultural
beliefs were cited as impediments or barriers to pain management; for example, s
ome Moroccan physicians
felt illness-related pain was inevitable, that suffering was normal, and that it
had to be endured, especially
by boys (McCarthy et al, 2004). EBN: In a qualitative study, Muslim
patients, particularly Shiites,
expressed feeling more comfortable when they were allowed to practice their reli
gious beliefs (Youse? et al,
2009).
Enhance cultural knowledge by actively seeking out information regarding differ
ent cultural and ethnic
groups. Cultural knowledge is the process of actively seeking information about
different cultural and ethnic
groups such as their world views, health conditions, health practices, use of ho
me remedies or self-medication,
barriers to health care, and risk-taking or health-seeking behaviors (Institute
of Medicine, 2002).
Recognize the impact of culture on communication styles and techniques. Communi
cation and culture are
closely intertwined, and communication is the way culture is transmitted and pre
served. It in?uences how feelings are expressed, decisions are made, and what verbal and nonverbal expression
s are acceptable. By the age
of 5, cultural patterns of communication can be identi?ed in children (Giger & D
avidhizar, 2004).
Provide culturally competent care to clients from different cultural groups. Cu
ltural competency requires
health care providers to act appropriately in the context of daily interactions
with people who are different from
themselves. Providers need to honor and respect the beliefs, interpersonal style
s, attitudes, and behaviors of
others. This level of cultural awareness requires providers to refrain from form
ing stereotypes and judgments
based on one s own cultural framework (Institute of Medicine, 2002). EBN: The ?ndi
ngs from a review of two
studies of Japanese and American women suggest that although there were common e
thical concerns between
the two cultures, the cultural context of the underlying values may create very
different meanings and result in
different nursing practices (Wros, Doutrich, & Izumi, 2004).
Home Care
The nursing interventions described previously in Readiness for enhanced Comfor
t may be used with
clients in the home care setting. When needed, adaptations can be made to meet t
he needs of speci?c
clients, families, and communities.
? Make appropriate referrals to other organizations or providers as needed to e
nhance comfort. Referrals
should have merit, be practical, timely, individualized, coordinated, and mutual
ly agreed upon by all involved
(Hunt, 2005).
? Promote an interdisciplinary approach to home care. Members of the interdisci
plinary team who provide
specialized care to enhance comfort can include the physician, physical
therapist, occupational therapist,
nutritionist, music therapist, social worker, etc. (Stanhope & Lancaster, 2006).
= Independent
B = Evidence-Based
? = Collaborative
REFERENCES

Evaluate regularly if enhanced comfort is attainable in the home care setting.
Home health agencies monitor client outcomes closely. Evaluation is an ongoing process and is essential f
or the provision of quality care
(Stanhope & Lancaster, 2006).
Use music therapy at home. EBN: The use of music 30 minutes prior to peak agita
tion in dementia patients
demonstrated that their mean pain levels after listening to music were signi?can
tly lower than before the music
intervention (Park, 2010).
Teach client how to regularly assess levels of comfort.
Instruct client that a variety of interventions may be needed at any given time
to enhance comfort.
Help clients to understand that enhanced comfort is an achievable goal.
Teach techniques to enhance comfort as needed.
? When needed, empower clients to seek out other health professionals as member
s of the interdisciplinary
team to assist with comforting measures and techniques.
Encourage self-care activities and continued self-evaluation of achieved comfo
rt levels to ensure enhanced
comfort will be maintained.
217
C
Andrews M, Boyle J: Transcultural concepts in nursing, ed 4, Philadelphia, 2003, Lippincott Williams & Wilkins.
Apstolo J, Kolcaba K: The effects of guided imagery on comfort,
depression, and stress of psychiatric inpatients with depressive
disorders, Arch Psychiatr Nurs 23(6):403 411, 2009.
Bell L, Duffy A: A concept analysis of nurse-patient trust, Br J Nurs
(BJN) 18(1):46 51, 2009.
Berg C, Snyder C, Hamilton N: The effectiveness of a hope intervention in coping with cold pressor pain, J Health Psychol 13:804
809, 2008.
Bonadonna R: Meditation s impact on chronic illness, Holist Nurs Pract
17(6):309 319, 2003.
Castral T, et al: The effects of skin-to-skin contact during acute pain in
preterm newborns, Eur J Pain 12(4):464 471, 2008.
Dahlen H, et al: Soothing the ring of ?re : Australian women s and
midwives experiences of using perineal warm packs in the second
stage of labor, Midwifery 25(2):e39 e48, 2009.
Dryden T, Baskwill A, Preyde M: Massage therapy for the orthopaedic
patient: a review, Orthop Nurs 23:327 332, 2004.
Duggleby W, Berry P: Transitions and shifting goals of care for palliative
patients and their families, Clin J Oncol Nurs 9(4):425 428, 2005.
Elkins M, Cavendish R: Developing a plan for pediatric spiritual care,
Holist Nurs Pract 18(4):179 184, 2004.
Franzen C, et al: Injured road users health-related quality of life after
telephone intervention: a randomized controlled trial, J Clin Nurs
18(1):108 116, 2009.
Giger J, Davidhizar R: Transcultural nursing: assessment and intervention, ed 4, St. Louis, 2004, Mosby.
Hunt R: Introduction to community-based nursing, ed 3, Philadelphia,
2005, Lippincott.
Hupcey JE, Penrod J, Morse JM: Establishing and maintaining trust
during acute care hospitalizations, including commentary by Robinson CA, Sch Inq Nurs Pract 14(3):227 248, 2000.
Institute of Medicine: Speaking of health, Washington, DC, 2002,
National Academies Press.
Johnson J: The use of music to promote sleep in older women, J Community Health Nurs 20:27 35, 2003.
Kespichayawattana J, VanLandingham M: Effects of coresidence and
caregiving on health of Thai parents of adult children with AIDS, J
Nurs Schol 35(3):217 224, 2003.
Kolcaba K: Comfort theory and practice, New York, 2003, Springer.
Kolcaba K, DeMarco M: Comfort theory and application to pediatric
nursing, Pediatr Nurs 31(3):187 194, 2005.
Kolcaba K, et al: Ef?cacy of hand massage for enhancing the comfort of
hospice patients, Int J Palliat Nurs 6(2):91 102, 2004.
Lafferty W, et al: Evaluating CAM treatment at the end of life: a review

of clinical trials for massage and meditation, Complement Ther Med
14(2):100 112, 2006.
Lin L, Wang R: Abdominal surgery, pain and anxiety, J Adv Nurs
51(3):252 260, 2004.
London M, et al: Evaluation of a comprehensive, adaptable, lifeaf?rming, longitudinal palliative care project, J Palliat Med
8(6):1214 1225, 2005.
Malinowski A, Stamler L: Comfort: exploration of the concept in nursing, J Adv Nurs 39(6):599 606, 2002.
McCarthy P, et al: Managing children s cancer pain in Morocco, J Nurs
Scholarsh 36(1):11 15, 2004.
Menzies V, Kim S: Relaxation and guided imagery in Hispanic persons
diagnosed with ?bromyalgia: a pilot study, Fam Commun Health
31(3):204 212, 2008.
Menzies V, Taylor A, Bourguignon C: Effects of guided imagery on
outcomes of pain, functional status, and self-ef?cacy in persons
diagnosed with ?bromyalgia, J Altern Complement Med 12(1):23 30,
2006.
Moody L: E-health web portals: delivering holistic healthcare and making home the point of care, Holist Nurs Pract 19(4):156 160, 2005.
Narayanasomy A, et al: Responses to the spiritual needs of older people,
J Adv Nurs 48(1):6 16, 2004.
Park H: Effects of music on pain for home-dwelling persons with
dementia, Pain Manag Nurs 11(3):141 147, 2010.
Pasero C: Pain relief for neonates, Am J Nurs 104(5):44 47, 2004.
Pasero C, McCaffrey M: Comfort-function goals, Am J Nurs 104(9):77
81, 2004.
Porter L, Porter B: A blended infant massage parenting enhancement
program for recovering substance abusing mothers, Pediatr Nurs
30(5):363 401, 2004.
Remke S, Chrastek J: Improving care in the home for children with palliative care needs, Home Healthc Nurse 25(1):45 51, 2007.
Rennick J, et al: Mothers experiences of touch and talk nursing intervention to optimise pain management in the PICU: a qualitative
study, Intensive Crit Care Nurs 27(3):151 157, 2011.
Stanhope M, Lancaster J: Foundation of nursing in the community, ed 2,
St. Louis, 2006, Mosby.
= Independent
B = Evidence-Based
218
? = Collaborative
Readiness for enhanced communication
Wachholtz A, Pargament K: Migraines and meditation: does spirituality

matter? J Behav Med 31(4):351 366, 2008.
Walsh S, Martin S, Schmidt L: Testing the ef?cacy of a creative-arts
intervention with family caregivers of patients with cancer, J Nurs
Scholarsh 36(3):214 219, 2004.
Wolsko P, et al: Use of mind-body medical therapies, J Gen Intern Med

19:43 50, 2004.
Wros P, Doutrich D, Izumi S: Ethical concerns: comparison of values
from two cultures, Nurs Health Sci 6(2):131 140, 2004.
Yildirim G, Sahin N: The effect of breathing and skin stimulation
C
Whitehead-Pleaux AM, et al: Exploring the effects of music therapy on
pediatric pain: phase 1, J Music Ther 46(3):217 241, 2007.
Wilkinson J, VanLeuven K: Fundamentals of nursing, Philadelphia,
2007, FA Davis.
Williams A, Dawson S, Kristjanson L: Patients felt greater personal
techniques on labour pain perception of Turkish women, Pain Res
Manag 9(4):183 187, 2004.
Youse? H, et al: Comfort as a basic need in hospitalized patients in Iran:
a hermeneutic phenomenology study, J Adv Nurs 65(9):1891 1898,
2009.
control and emotional comfort in hospital when they felt secure,
informed, and valued, Evid Based Nurs 12(1):29, 2009.
Readiness for enhanced Communication
Stacey M. Carroll, PhD, ANP-BC, and Suzanne White, MSN, RN, PHCNS-BC
NANDA-I
De?nition
A pattern of exchanging information and ideas with others that is suf?cient for
meeting one s needs and life s
goals and can be strengthened
Able to speak a language; able to write a language; expresses feelings; expresse
s satisfaction with ability to
share ideas with others; expresses satisfaction with ability to share
information with others; expresses
thoughts; expresses willingness to enhance communication; forms phrases; forms s
entences; forms words;
interprets nonverbal cues appropriately; uses nonverbal cues appropriately
NOC
Communication, Communication: Expressive, Receptive
Communication as evidenced by the following indicators: Use of spoken language/U
se of written language/Acknowledgment
of messages received/Exchanges messages accurately with others. (Rate the outcom
e and indicators of Communication: 1 =
severely compromised, 2 = substantially compromised, 3 = moderately compromised,
mildly compromised, 5 = not compromised
[see Section I].)
Client Outcomes
Express willingness to enhance communication
Demonstrate ability to speak or write a language
Form words, phrases, and language
Express thoughts and feelings

Use and interpret nonverbal cues appropriately
Express satisfaction with ability to share information and ideas with others
NIC
Active Listening, Communication Enhancement: Hearing De?cit, Communication Enhan
cement: Speech
De?cit
= Independent

B = Evidence-Based
? = Collaborative
Readiness for enhanced communication

Example NIC Activity Communication Enhancement: Hearing De?cit
Listen attentively; allowing patient adequate time to process communication and
respond; Verify what was said or written using
patient s response before continuing
Establish a therapeutic nurse-client relationship: provide appropriate educatio
n for the client, demonstrate caring by being present to the client. CEB: Clients who were nonvocal and
ventilated appreciated
nursing care that was delivered in an individualized, caring manner (Carroll, 20
07).
Assess the client s readiness to communicate, using an individualized approach.
Avoid making assumptions regarding the client s preferred communication method. EBN: Using v
aried communication
approaches improved communication ef?ciency and client engagement (Radtke et al,
2011).
Assess the client s literacy level. Screening clients literacy levels upon assess
ment using REALM (Rapid Estimate of Adult Literacy in Medicine) allows providers to tailor information accor
dingly (Rajda & George, 2009).
Listen attentively and provide a comfortable environment for communicating; us
e these practical guidelines to assist in communication: Slow down and listen to the client s story; use
augmentative and alternative communication methods (such as lip-reading, communication boards, writing,
body language, and
computer/electronic communication devices) as appropriate; repeat instructions i
f necessary; limit the
amount of information given; have the client teach back to con?rm understanding; a
void asking, Do
you understand? ; be respectful, caring, and sensitive. EB: Multiple augmentative
and alternative communication methods, applied with an individualized and creative approach, aid in f
acilitating communication
(Radtke et al, 2011).
? Provide communication with specialty nurses such as clinical nurse specialist
s or nurse practitioners who
have knowledge about the client s situation. CEB: Clients report being well inform
ed and having high satisfaction with nurse practitioner communication (Hayes, 2007).
? Refer couples in maladjusted relationships for psychosocial intervention and
social support to strengthen
communication; consider nurse specialists. EB: Being part of a strong dyad may s
erve as a buffering factor
regarding post-traumatic stress related to a cancer diagnosis (Brosseau, McDonal
d, & Stephen, 2011).
Consider using music to enhance communication between client who is dying and
his/her family. EB: In
clients with communication dif?culties, music therapy resulted in improvement in
communication (Leow,
Drury, & Hong, 2010).
See care plan for Impaired verbal Communication.
Pediatric
? All individuals involved in the care and everyday life of children with learn
ing dif?culties need to have a
collaborate approach to communication. EB: Effective collaborative implementatio
n can meet a wide range
of communication and learning needs (Greenstock & Wright, 2010).
Geriatric
? Assess for hearing and vision impairments and make appropriate referrals for
hearing aids. Healthy People
2020 encourages early identi?cation of people with hearing and vision loss (Heal
thy People 2020, 2011).
Use touch if culturally acceptable when communicating with older clients and th
eir families. Touch has a calming effect on a client who may be frightened due to dif?culty with communication
(Grossbach, Stranberg, &
Chan, 2011).
Consider singing during caregiving of clients with dementia. EB: When professio
nal caregivers sang to clients with dementia during care, enhanced communication and cooperation resulted
(Hammar et al, 2011).
Multicultural
Home Care
The interventions described previously may be used in home care.
219
= Independent
B = Evidence-Based
220
? = Collaborative
Impaired verbal communication

C
REFERENCES
See Impaired verbal Communication for additional references.
Brosseau DC, McDonald MJ, Stephen JE: The moderating effect of
relationship quality in partner secondary traumatic stress among
couples coping with cancer, Fam Syst Health 29(2):114 126, 2011.
Carroll SM: Silent, slow lifeworld: the communication experiences of
nonvocal ventilated patients, Qual Health Res 17(9):1165 1177,
2007.
Greenstock L, Wright J: Collaborative implementation: working
together when using graphic symbols, Child Lang Teach Ther
27(3):331 343, 2010.
Grossbach I, Stranberg S, Chan L: Promoting effective communication for patients receiving mechanical ventilation, Crit Care Nurse
Hammar LM, et al: Communicating through caregiver singing during morning care situations in dementia care, Scand J Caring Sci
25:160 168, 2011.
Hayes E: Nurse practitioners and managed care: patient satisfaction and
intention to adhere to nurse practitioner plan of care, J Am Acad
Nurse Pract 19(8):418 426, 2007.
Leow M, Drury V, Hong P: The experience and expectations of terminally ill patients receiving music therapy in the palliative setting: a
systematic review, JBI Lib Syst Rev 8(27):1088 1111, 2010.
Rajda C, George NM: The effect of education and literacy levels on
health outcomes, JNP 5(2):115 119, 2009.
31(3):46 61, 2011.
Impaired verbal Communication
Stacey M. Carroll, PhD, ANP-BC, and Suzanne White, MSN, RN, PHCNS-BC
NANDA-I
De?nition
Decreased, delayed, or absent ability to receive, process, transmit, and/or use
a system of symbols
Absence of eye contact; cannot speak; dif?culty expressing thoughts ver
bally (e.g., aphasia, dysphasia,
apraxia, dyslexia); dif?culty forming sentences; dif?culty forming words (e.g.,
aphonia, dyslalia, dysarthria);

dif?culty in comprehending usual communication pattern; dif?culty in maintaining
usual communication
pattern; dif?culty in selective attending; dif?culty in use of body expressions;
dif?culty in use of facial expressions; disorientation to person; disorientation to space; disorientation to time
; does not speak; dyspnea;
inability to speak language of caregiver; inability to use body expressions; ina
bility to use facial expressions;
inappropriate verbalization; partial visual de?cit; slurring; speaks with dif?cu
lty; stuttering; total visual de?cit; verbalizes with dif?culty; willful refusal to speak
Absence of signi?cant others; alteration in self-concept; alteration of central
nervous system; altered perceptions; anatomic defect (e.g., cleft palate, alteration of the neuromuscular visu
al system, auditory system,
phonatory apparatus); brain tumor; chronic low self-esteem; cultural differences
; decreased circulation to
brain; differences related to developmental; emotional conditions; environmental
barriers; lack of information; physical barrier (e.g., tracheostomy, intubation); physiological condition
s; psychological barriers (e.g.,
psychosis, lack of stimuli); situational low self-esteem; stress; treatment-rela
ted side effects (e.g., pharmaceutical agents); weakened musculoskeletal system
NOC
Communication, Communication: Expressive, Receptive
Communication as evidenced by the following indicators: Use of spoken and writte
n language/Acknowledgment of messages
received/Exchanges messages accurately with others. (Rate the outcome and indica
tors of Communication: 1 = severely compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly com
promised, 5 = not compromised [see Section I].)
= Independent
B = Evidence-Based
? = Collaborative

Client Outcomes
Use effective communication techniques
Use alternative methods of communication effectively
Demonstrate congruency of verbal and nonverbal behavior
Demonstrate understanding even if not able to speak
Express desire for social interactions
NIC
Active Listening, Communication Enhancement: Hearing De?cit, Communication Enhan

cement: Speech
De?cit
Example NIC Activities Communication Enhancement: Hearing De?cit
Listen attentively; Allow client adequate time to process communication and resp
ond; Verify what was said or written using client s
response before continuing
Assess the language spoken, cultural considerations, literacy level, cognitive
level, and use of glasses and/
or hearing aids. A comprehensive nursing assessment assists in understanding any
communication dif?culties
(Patak et al, 2009).
Determine client s own perception of communication dif?culties and potential sol
utions when possible.
EB: The Communication Con?dence Rating Scale for Aphasia (CCRSA) was found to be
an effective tool for
assessment of the self-report of communication con?dence among clients with apha
sia (Babbitt et al, 2011).
Involve a familiar person when attempting to communicate with a client who has
dif?culty with communication, if accepted by the client. EBN: Family members recognized clients cue
s and had a deeper understanding of clients needs (Dreyer & Nortvedt, 2008).
Listen carefully. Validate verbal and nonverbal expressions particularly when d
ealing with pain and utilize
nonverbal scales for pain when appropriate. EBN: The revised nonverbal pain scal
e (NVPS) was found to be
superior to the original NVPS in assessing pain in sedated clients receiving mec
hanical ventilation in the ICU
(Kabes, Graves, & Norris, 2009).
Use therapeutic communication techniques: speak in a well-modulated voice, use
simple communication, maintain eye contact at the client s level, get the client s attention before
speaking, and show concern
for the client. EB: Effective communication between clients and health care prof
essionals facilitates positive
relations (Wain, Kneebone, & Billings, 2008).
Avoid ignoring the client with verbal impairment; be engaged and provide meanin
gful responses to client concerns. EBN: Meaningful responses and emotional support by nurses facilitated org
anized behavior and initiative in
adults with communication impairments as a result of intellectual disabilities a
nd autism (Bakken et al, 2008).
Use touch as appropriate. Touch has a calming effect on a client who may be fr
ightened due to dif?culty with
communication (Grossbach, Stranberg, & Chan, 2011).
Use presence. Spend time with the client, allow time for responses, and make t
he call light readily available. Relationship-centered care involves the art of nursing, presence, and cari
ng (Finfgeld-Connett, 2008).
Explain all health care procedures. CEB: Clients who were nonvocal and ventila
ted were attuned to everything occurring around them, and they appreciated explanations from the nurse (C
arroll, 2007). EB: Being
understood was described as important by those who were ventilated (Laasko, Hart
elius, & Idvall, 2009) and
those who were deaf (Andrade et al, 2010).
Be persistent in deciphering what the client is saying, and do not pretend to

understand when the message is
unclear. CEB: Persons who were nonvocal and ventilated appreciated persistence o
n the nurses part with respect
to being understood, and found it bothersome when others pretended to understand
them (Carroll, 2007).
? Utilize an individualized and creative multidisciplinary approach to augmenta
tive and alternative communication assistance and other interventions. EB: A combination of high-technol
ogy (with voice output)
and low-technology options improved communication ef?ciency (Radtke et al, 2011)
. EBN: A story-telling
221
C
= Independent
B = Evidence-Based
222
? = Collaborative
intervention with clients with dementia resulted in improved communication skill

s and social interaction
(Phillips, Reid-Arndt, & Pak, 2010).
Use consistent nursing staf?ng for those with communication impairments. CEB:
Consistent nursing care
increased client-nurse communication and decreased client powerlessness (Carroll
, 2007).
C
? Consult communication specialists as appropriate. Speech language pathologist
s, audiologists, and interpreters provide more comprehensive communication assistance for those wi
th impaired communication
(Patak et al, 2009). LRTs are pro?cient lipreaders who determine what a nonvocal
client is mouthing and then
verbalize the client s words verbatim to others, in order to facilitate communicat
ion (Carroll, 2003; Grossbach,
Stranberg, & Chan, 2011).
? When the client is having dif?culty communicating, assess and refer for audio
logy consultation for hearing loss. Suspect hearing loss when:

Client frequently complains that people mumble, claims that others speech is not
clear, or client hears
only parts of conversations.
Client often asks people to repeat what they said.
Client s friends or relatives state that client doesn t seem to hear very well, or p
lays the television or
radio too loudly.
Client does not laugh at jokes due to missing too much of the story.
Client needs to ask others about the details of a meeting that the client attend
ed.
Client cannot hear the doorbell or the telephone.
Client ?nds it easier to understand others when facing them, especially in a noi
sy environment.
People with hearing loss do not hear sounds clearly. The loss may range from hea
ring speech sounds faintly or
in a distorted way to profound deafness (American Academy of Audiology, 2011).
When communicating with a client with a hearing loss:
Obtain client s attention before speaking and face toward his or her unaffected si
de or better ear while
allowing client to see speaker s face at a reasonably close distance. Correct posi
tioning increases the client s
awareness of the interaction and enhances the client s ability to communicate (Ale
xander Graham Bell
Association for the Deaf and Hard of Hearing, 2011).
Provide suf?cient light and do not stand in front of window. Light illuminates t
he speaker s face, making
expressions and lip movements clearer. Standing in front of a window causes glar
e, which impedes the client s
ability to clearly see the speaker (Alexander Graham Bell Association for the De
af and Hard of Hearing, 2011).
Remove masks if safe to do so, or use see-through masks and reduce background no
ise whenever possible. Information on see-through masks: www.amphl.org. EB: Noise reduction redu
ced listening effort,
even in those who are hearing (Sarampalis et al, 2009).
Do not raise voice or overenunciate. This practice distorts the voice and lips,
inhibiting effective lip-reading
(Middleton et al, 2010).
Avoid making assumptions about the communication choice of those with hearing lo
ss or voice impairments. EBN: After seeking client input, communication rounds or communication ca
re plans can be completed (Happ et al, 2010).
Pediatric
Observe behavioral communication cues in infants. EB: Because they are preverba
l, infants are completely
reliant on a caregiver in their immediate environment to be sensitive and recogn
ize their distress (Riddle &
Racine, 2009).
Identify and de?ne at least two new forms of socially acceptable communication
alternatives that may be
used by children with signi?cant disabilities. EB: Children with severe intellec
tual disabilities and little or no
spoken language may bene?t from the use of augmentative and alternative communic
ation (AAC) strategies
such as the use of graphic symbols (Stephenson, 2009). EB: If distal gestures ca
n be elicited, students with limited symbolic and intentional communication may show more communication independ
ence, choice making,

and actions that affect daily routines (McLaughlin & Cascella, 2008).
Teach children with severe disabilities functional communication skills. EB: S
tudents can develop functional communication skills if they are given intensive, consistent communicatio
n interventions and a mechanism for expressing themselves (Parker, Grimmett, & Summers, 2008).
? Refer children with primary speech and language delay/disorder for speech and
language therapy interventions. EB: Speech and language therapy services often target resources toward
parents in order to address
issues of delay/dif?culty in children that could impact on school learning (Burn
s & Radford, 2008). EB: The
use of integrated treatment models that simultaneously target speech, phonologic
al awareness, and reading is
= Independent
B = Evidence-Based
? = Collaborative

critical to ensure treatment is ef?cient and effective in improving these childr
en s oral and written language
development (McNeill, Gillon, & Dodd, 2009).
Geriatric
Carefully assess all clients for hearing dif?culty using an audiometer. Healthy
People 2020 encourages early
identi?cation of people with hearing loss (Healthy People 2020, 2011).
Avoid use of elderspeak. EB: Using elderspeak, a speech style similar to baby tal
k that fails to communicate
appropriate respect, increases resistiveness to care in clients with dementia (W
illiams et al, 2009).
Initiate communication with the client with dementia, and give client time to r
espond. The responsibility
to use a creative approach and take the time to listen and understand clients wh
o have dementia lies with the
clinician (Jootun & McGhee, 2011).
Encourage the client to wear hearing aids, if appropriate. EB: Hearing aid usag
e is low among older adults
with hearing loss, despite the bene?ts of hearing aids (Golding et al, 2010; Gop
inath et al, 2011). Older women
with poor hearing acuity had poorer balance and higher risk of falls in addition
to communication dif?culties
(Viljanen et al, 2009).
Facilitate communication and reminiscing with memory boxes that contain objects
, photographs, and writings that have meaning for the client. EB: Collage creation as a means of remini
scence facilitated the conveying
of information by older adults with dementia who had dif?culty communicating ver
bally (Stallings, 2010).
Continue to ?nd means to communicate even with those who are nonverbal. EB: Com
munication between
those with advanced dementia and their caregivers was enhanced using Adaptive-In
teraction, a system that
recognizes nonverbal cues (Ellis & Astell, 2010).
Multicultural
Nurses should become more sensitive to the meaning of a culture s nonverbal commu
nication modes, such
as eye contact, facial expression, touching, and body language. EBN: All cultura
l groups have rules regarding
patterns of social interaction. Culture in?uences not only the manner in which f
eelings are expressed, but also
which verbal and nonverbal expressions of communication are considered
appropriate (Ball, Bindler, &
Cowen, 2010).
Assess for the in?uence of cultural beliefs, norms, and values on the client s co
mmunication process.
EBN: The nurse must be aware of personal beliefs about communication and control
personal reactions by a
broadened understanding of the beliefs and behaviors of others (Giger & Davidhiz
ar, 2008). EBN: Cultural
imposition may result when a health care provider is unaware of another person s b
eliefs and plans and implements care without taking into account the cultural beliefs of the client (Lewis
et al, 2011).
Assess personal space needs, acceptable communication styles, acceptable body l
anguage, interpretation
of eye contact, perception of touch, and use of paraverbal modes when communicat
ing with the client.
EBN: Nurses need to consider multiple factors when interpreting verbal and nonve
rbal messages (Giger &
Davidhizar, 2008).
Assess for how language barriers contribute to health disparities among ethnic
and racial minorities. EBN:
Attending to linguistic differences is important not only because it can enhance
the respectful treatment of typically vulnerable populations, but because it can help to prevent serious adverse
outcomes (Carnevale et al, 2009).
EBN: Communication dif?culties are a major obstacle for immigrant clients and ca
n lead to insuf?cient information and poor quality nursing care in contrast to the majority population (Jir
we, Gerrish, & Emami, 2010).
Although touch is generally bene?cial, there may be certain instances where it
may not be advisable due
to cultural considerations. CEB & EBN: Touch is largely culturally de?ned and co
nveys various meanings
depending on the client s culture (Leininger & McFarland, 2002; Lewis et al, 2011)
.
Modify and tailor the communication approach in keeping with the client s particu
lar culture. EBN:
Along with having the knowledge, consideration, understanding, and respect for a
n individual, a tailoring or
adaptation must take place in an attempt to meet one s needs and demonstrate cultu
ral sensitivity (Foronda,
2008).
Use reminiscence therapy as a language intervention. EB: Issues of culture, lan
guage, and aging are challenging. Less engaged residents and clients who are nonverbal, immobile, or who
have other occupational performance issues may become engaged in occupations of reminiscence that are rich
in personal meaning and
relevance (Hodges & Schmidt, 2009).

The Of?ce of Minority Health (OMH) of the U.S. Department of Health and Human S
ervices (DHHS)
standards on culturally and linguistically appropriate services (CLAS) in health
care should be used as
needed. EB: The recommended standards cover three broad areas of competence requ
irements for health care
223
C
= Independent
B = Evidence-Based
224
? = Collaborative
for racial or ethnic minorities: (1) culturally competent care, (2) language acc
ess services, and (3) organizational support for cultural competence (CLAS, 2011).
Home Care
C
REFERENCES
The interventions described previously may be adapted for home care use.
Teach the client and family techniques to increase communication, including the
use of communication
devices and tactile touch. Incorporate multidisciplinary recommendations. EB: Re

commendations by SLPs
were omitted from discharge summaries at a high rate, placing clients at risk fo
r lack of continuity of care
(Kind et al, 2011).
? Refer the client to a speech-language pathologist (SLP) or audiologist. Audio
logical assessment quanti?es
and quali?es hearing in terms of the degree of hearing loss, the type of hearing
loss, and the con?guration of
the hearing loss. Once a particular hearing loss has been identi?ed, a treatment
and management plan can be
put into place by an SLP (Baumgartner, Bewyer, & Bruner, 2008).
Alexander Graham Bell Association for the Deaf and Hard of Hearing:
Communicating with people who have a hearing loss. Retrieved July
13, 2011, from http://agbell.org/NetCommunity/Document.Doc
?id=343.
American Academy of Audiology: How s your hearing? Retrieved July
13, 2011, from http://www.howsyourhearing.org.
Andrade PC, et al: Communication and information barriers to health
assistance for deaf patients, Am Ann Deaf 155(1):31 37, 2010.
Babbitt EM, et al: Psychometric properties of the Communication
Con?dence Rating Scale for Aphasia (CCRSA): Phase 2, Aphasiology
25(6/7):727 735, 2011.
Bakken TL, et al: Effective communication related to psychotic disorganized behavior in adults with intellectual disability and autism, Nord
J Nurs Res Clin Stud 28(2):9 13, 2008.
Ball JW, Bindler RC, Cowen KJ: Child health nursing: parenting with
children and families, ed 2, Upper Saddle River, NJ, 2010, Pearson.
Baumgartner CA, Bewyer E, Bruner D: Management of communication
and swallowing in intensive care: the role of the speech pathologist,
AACN Adv Crit Care 19(4):433 443, 2008.
Burns A, Radford J: Parent-child interaction in Nigerian families:
conversation analysis, context and culture, Child Lang Teach Ther
24(2):193 209, 2008.
Carroll SM: Lip-reading translating for non-vocal ventilated patients,
JAMPHL Online 1(2), 2003. Retrieved November 26, 2006, from
www.amphl.org.
Carroll SM: Silent, slow lifeworld: the communication experiences of
nonvocal ventilated patients, Qual Health Res 17(9):1165 1177,
2007.
Carnevale F, et al: Ethical considerations in cross-linguistic nursing,
Nurs Ethics 16(6):813 826, 2009.
CLAS (Culturally and Linguistically Appropriate Services). Retrieved
December 2, 2011, from http://www.minorityhealth.hhs.gov/temp
lates/browse.aspx?lvl=2&lvlID=15.
Dreyer A, Nortvedt P: Sedation of ventilated patients in intensive care
units: Relatives experiences, J Adv Nurs 61(5):549 556, 2008.
Ellis M, Astell A: Communication and personhood in advanced dementia, Healthc Couns Psychother J 10(3):32 35, 2010.
Finfgeld-Connett D: Qualitative convergence of three nursing concepts: art of nursing, presence and caring, J Adv Nurs 63(5):527
534, 2008.
Foronda C: A concept analysis of cultural sensitivity, J Transcult Nurs
19(207):207 212, 2008.
Giger J, Davidhizar R: Communication. In Giger J, Davidhizar R, editors: Transcultural nursing: assessment and intervention, St Louis,
2008, Mosby.
Golding M, et al: Use of hearing aids and assistive listening devices in an
older Australian population, J Am Acad Audiol 21(10):642 653, 2010.

Gopinath B, et al: Incidence and predictors of hearing aid use and
ownership among older adults with hearing loss, Ann Epidemiol
21(7):497 506, 2011.
Grossbach I, Stranberg S, Chan L: Promoting effective communication for patients receiving mechanical ventilation, Crit Care Nurse
31(3):46 61, 2011.
Happ MB, et al: SPEACS-2: Intensive care unit communication
rounds with speech language pathology, Geriatr Nurs 31(3):170
177, 2010.
Healthy People 2020: Hearing and other sensory or communication disorders. Retrieved July 31, 2011, from www.healthypeople.gov/2020/top
icsobjectives2020/overviewaspx?topicid=20.
Hodges C, Schmidt R: An exploration of reminiscence and post-war
European immigrants living in a multicultural aged-care setting in
Australia, Occup Ther Int 16(2):154 168, 2009.
Jirwe M, Gerrish K, Emami A: Student nurses experiences of communication in cross-cultural care encounters, Scand J Caring Sci
24(3):436 444, 2010.
Jootun D, McGhee G: Effective communication with people who have
dementia, Nurs Stand 25(25):40 46, 2011.
Kabes AM, Graves JK, Norris J: Further validation of the nonverbal pain
scale in intensive care patients, Crit Care Nurse 29(1):59 66, 2009.
Kind A, et al: Omission of dysphagia therapies in hospital discharge
communications, Dysphagia 26(1):49 61, 2011.
Laasko K, Hartelius L, Idvall M: Ventilator-supported communication:
a case study of patient and staff experiences, J Med Speech Lang
Pathol 17(4):153 164, 2009.
Leininger MM, McFarland MR: Transcultural nursing: concepts, theories,
research and practices, ed 3, New York, 2002, McGraw-Hill.
Lewis SL, et al: Medical surgical nursing: assessment and management of
clinical problems, ed 8, St Louis, 2011, Elsevier.
McLaughlin K, Cascella P: Eliciting a distal gesture via dynamic assessment among students with moderate to severe intellectual disability,
Commun Disord Q 29(2):75 81, 2008.
McNeill B, Gillon G, Dodd B: Phonological awareness and early reading
development in childhood apraxia of speech (CAS), Int J Lang Commun Disord 44(2):175 192, 2009.
Middleton A, et al: Communicating in a healthcare setting with people
who have hearing loss, BMJ 341:c4672, 2010.
Parker AT, Grimmett ES, Summers S: Evidence-based communication practices for children with visual impairments and additional
disabilities: an examination of single-subject design studies, J Vis
Impair Blind 102(9):540 552, 2008.
= Independent
B = Evidence-Based
Acute confusion
? = Collaborative
225
Patak L, et al: Spotlight on improving patient-provider communication:
a call to action, J Nurs Admin 39(9):372 376, 2009.
Phillips LJ, Reid-Arndt SI, Pak Y: Effects of a creative expression intervention on emotions, communication, and quality of life in persons
with dementia, Nurs Res 59(6):417 425, 2010.
Stephenson J: Picture-book reading as an intervention to teach the use
of line drawings for communication with students with severe intellectual disabilities, AAC Augment Altern Commun 25(3):202 214,
2009.
Viljanen A, et al: Hearing acuity as a predictor of walking dif?culties in
Radtke JV, et al: Listening to the voiceless patient: case reports in
assisted communication in the intensive care unit, J Palliat Med
14(6):791 795, 2011.
Riddle RP, Racine N: Assessing pain in infancy: the caregiver context,
Pain Res Manage 14(1):27 32, 2009.
Sarampalis A, et al: Objective measures of listening effort: effects of
background noise and noise reduction, J Speech Lang Hear Res
52:1230 1240, 2009.
Stallings JW: Collage as a therapeutic modality for reminiscence in
patients with dementia, Art Ther 37(3):136 140, 2010.
Acute Confusion
Mila W. Grady, MSN, RN
older women, J Am Geriatr Soc 57(12):2282 2286, 2009.
Wain HR, Kneebone II, Billings J: Patient experience of neurologic
rehabilitation: a qualitative investigation, Arch Phys Med Rehabil
63(5):527 534, 2008.
Williams KN, et al: Elderspeak communication: Impact on dementia
care, Am J Alzheimers Dis Other Dement 24(1):11 20, 2009.
C
NANDA-I
De?nition
Abrupt onset of reversible disturbances of consciousness attention, cognition, a
nd perception that develop
over a short period of time
Fluctuation in cognition, level of consciousness, psychomotor activity; hallucin
ations; increased agitation;
increased restlessness; lack of motivation to follow through with goal-directed
behavior or purposeful behavior; lack of motivation to initiate goal-directed behavior or purposeful behavio
r; misperceptions
Alcohol abuse; delirium; dementia; drug abuse, ?uctuation in sleep-wake
cycle, over 60 years of age,
polypharmacy
NOC
Cognition, Distorted Thought Self-Control, Information Processing, Memory
Cognition as evidenced by the following indicators: Communication clear for age/
Comprehension of the meaning of situations/
Attentiveness/Concentration/Cognitive orientation. (Rate the outcome and indicat
ors of Cognition: 1 = severely compromised,
2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromise
d, 5 = not compromised [see Section I].)
Client Outcomes
Demonstrate restoration of cognitive status to baseline
Be oriented to time, place, and person
Demonstrate appropriate motor behavior
Maintain functional capacity
NIC
Delirium Management, Delusion Management
= Independent
B = Evidence-Based
226
? = Collaborative
Acute confusion
Example NIC Activities Delirium Management

Inform client of time, place, and person as needed; Provide information slowly a
nd in small doses, with frequent rest periods
C
Assess the client s behavior and cognition systematically and continually through
out the day and night, as
appropriate. Utilize a validated tool to assess presence of delirium such as the
Confusion Assessment
Method (CAM) or Delirium Observation Screening Scale. EB: The best evidence in a
review of the literature
supports the use of the CAM (Wong et al, 2010). Delirium is often underrecognize
d and underdiagnosed
(O Mahoney et al, 2011). EBN: Nurses are missing key symptoms of delirium; use of
an objective instrument
is essential in guiding assessment and documentation (Steis & Fick, 2008).
Recognize that delirium may be superimposed on dementia; the nurse must be awar
e of the client s baseline cognitive function. EB: Dementia increases the risk and severity of deliriu
m (Voyer et al, 2011b).

Recognize that there are three distinct types of delirium based on either arous
al or motor disturbances
(Breitbart & Alici, 2008):
Hyperactive: delirium characterized by restlessness, agitation, hypervigilance,
hallucinations and delusions; may be combative
Hypoactive: delirium characterized by psychomotor retardation, lethargy, sedatio
n, reduced awareness
of surroundings and confusion
Mixture of both hyper- and hypodelirium: the client ?uctuates between periods of
hyperactivity and
agitation and hypoactivity and sedation. EB: The hypoactive form of delirium was
most often unrecognized
by physicians in a study of clients in a mixed ICU (van Eijk et al, 2009). Many
older adults in the emergency
department present with the hypoactive subtype, which is missed the majority of
the time (Han et al, 2009);
these clients have worse outcomes (Flinn et al, 2009).
Identify clients who are at high risk for delirium. EB: Predisposing factors le
ading to increased vulnerability
for delirium include: cognitive impairment, severity of illness, older age, depr
ession, vision and/or hearing
impairment, and functional impairment (Sendelbach & Guthrie, 2009) and clients w
ith advanced cancer
(Bush & Bruera, et al, 2009), often due to the anticholinergic effects of opioid
s. Dementia increases the risk and
severity of delirium (Voyer et al, 2011b). EBN: There was a signi?cant reduction
in delirium in hospitalized
elders when a delirium prevention protocol was implemented (Robinson et al, 2008
).
Identify precipitating factors that may precede the development of delirium: us
e of restraints, indwelling
bladder catheter, metabolic disturbances, polypharmacy, pain, infection, dehydra
tion, constipation, electrolyte imbalances, immobility, general anesthesia, hospital admission for fract
ures or hip surgery, anticholinergic medications, anxiety, sleep deprivation, and environmental factors.
Prevention of delirium
must be a high priority in light of frequency of occurrence, high treatment cost
s, longer hospital length of stay,
higher rates of functional decline and institutional care, and higher mortality.
Delirium may persist and may
lead to long-term cognitive decline (O Mahoney et al, 2011). EB: Recognize that cl
ients who are highly vulnerable for developing delirium require relatively fewer precipitating factors to d
evelop delirium (Sendelbach &
Guthrie, 2009). Clients who might bene?t from a proactive geriatrics consultatio
n include those over 65 or 70,
with baseline cognitive dysfunction, multiple comorbidities, chronic use of psyc
hotropic medications, drug or
alcohol dependence, sensory impairment, immobility or functional decline, surger
y, prolonged hospital stay,
ICU stay, recurrent hospitalizations within the past year, and poor social suppo
rt (Flinn et al, 2009).
Perform an accurate mental status examination that includes the following:
Overall appearance, manner, and attitude
Behavior characteristics and level of psychomotor behavior (activity may be incr
eased or decreased and
may include spastic movements or tremors with delirium)
Mood and affect (may be paranoid or fearful with delirium; may have rapid mood s
wings)
Insight and judgment
Cognition as evidenced by level of consciousness, orientation to time, place, an
d person, thought process (thinking may be disorganized, distorted, fragmented, slow or accelerated w
ith delirium), and content (perceptual disturbances such as visual, auditory or tactile delusions or h
allucinations)
Level of attention (may be decreased with delirium; may be unable to focus, main
tain attention or shift
attention, or may be hypervigilant)
Memory (recent and immediate memory is impaired with delirium; unable to registe
r new information)
Arousal (may ?uctuate with delirium; sleep-wake cycle may be disturbed)
= Independent
B = Evidence-Based
? = Collaborative
Acute confusion
Language (may have rapid, rambling, slurred, incoherent speech) (Breitbart & Ali
ci, 2008; Sendelbach
& Guthrie, 2009)
? Assess for and report possible physiological alterations (e.g., sepsis, hypog
lycemia, hypoxia, hypotension,
infection, changes in temperature, ?uid and electrolyte imbalance, and use of me
dications with known
cognitive and psychotropic side effects). Delirium is often unrecognized
, inappropriately treated, or
untreated, especially in terminally ill clients (Breitbart & Alici, 2008). EB: A
void unnecessary catheterization;
utilize infection control protocols to prevent infection, and maintain usual sle
ep schedule (O Mahoney et al,
2011).
? Treat the underlying risk factors or the causes of delirium in collaboration
with the health care team:
establish/maintain normal ?uid and electrolyte balance; normal body temperature,
normal oxygenation
(if the client experiences low oxygen saturation, deliver supplemental oxygen),
normal blood glucose
levels, normal blood pressure. EB: These factors are common contributors to deli
rium in the older adult
(Flinn et al, 2009).
? Conduct a medication review and eliminate unnecessary medications. Medication
s that should be minimized or discontinued include anticholinergics, antihistamines, and benzo
diazepines; cholinesterase
inhibitors should be continued, as should carbidopa and levodopa for clients wit
h parkinsonism (Flinn
et al, 2009).
Communicate client status, cognition, and behavioral manifestations to all neces

sary providers.
Monitor for any trends occurring in these manifestations, including laboratory t
ests.
EB: Careful monitoring is needed to identify the potential etiologic factors for
delirium (Sendelbach &
Guthrie, 2009).
Identify, evaluate and treat pain quickly and adequately (see care plans for A
cute Pain or Chronic Pain).
Around the clock acetaminophen may result in less opioid use (Bourne, 2008). EB:
There was an association between low doses of analgesia and the development of delirium in hospitali
zed clients experiencing pain
(Robinson & Vollmer, 2010). Untreated pain is a potential cause of delirium, as
is excessive opioid administration (Clegg & Young, 2011). Delirium can interfere with pain recognition (Bre
itbart & Alici, 2008).
Promote regulation of bowel and bladder function. EB: Constipation may precipi
tate delirium (O Mahoney
et al, 2011). Catheters should be removed by postoperative day 2 to decrease inf
ection risk (Flinn et al, 2009);
urinary retention may precipitate delirium (Waardenburg, 2008).
Ensure adequate nutritional and ?uid intake. Dehydration often precipitates de
lirium (Thomas et al, 2008).
EB: BMI less than 20 is an important risk factor for the development of delirium
in postoperative older adult
hip fracture clients (Juliebo et al, 2009).
Promote early mobilization and rehabilitation. EB: Impaired mobility is a risk
factor for developing delirium
(Brouquet et al, 2010).
Promote continuity of care; avoid frequent changes in staff and surroundings.
EB: Changes may contribute
to feelings of disorientation and confusion (O Mahoney et al, 2011).
Plan care that allows for an appropriate sleep-wake cycle. Please refer to the
care plan for Sleep deprivation. Both delirium and sleep deprivation are associated with disrupted neurotra
nsmitters. It is sometimes
dif?cult to tell which came ?rst. It is known that benzodiazepines deplete melat
onin in the body which is
needed for normal sleep (Figueroa-Ramos et al, 2009). EB: Sleep deprivation may
potentially be a modi?able
risk factor for the development of delirium (Weinhouse et al, 2009).
Facilitate appropriate sensory input by having clients use aids (e.g., glasses
, hearing aids) as needed; check
for impacted ear wax. Sensory impairment is a predisposing factor for the develo
pment of delirium (Voyer
et al, 2009). EBN: Clients with hearing loss receive lower doses of pain medicat
ion and have a higher incidence
of delirium (Robinson et al, 2008).
Modulate sensory exposure and establish a calm environment. Environments with
too much or too little
stimulation may precipitate delirium; noise reduction, appropriate lighting base
d on time of day, reduced clutter, and quiet music are strategies that may impact delirium (Schreier, 2010).
Provide reality orientation, including identifying self by name at each contac
t with the client, calling the
client by their preferred name, using orientation techniques, providing familiar
objects from home such
as an afghan, providing clocks and calendars, and gently correcting misperceptio
ns. Facilitate regular
visits from family and friends. EB: Persons at risk for delirium should be provi
ded clocks and calendars that
are easily visible; family and friends may help with reorientation (O Mahoney et a
l, 2011).
Use gentle, caring communication; provide reassurance of safety; give simple e
xplanations of procedures
(Bourne, 2008). Clients with delirium often respond to caring even though they m
ay not understand the verbal message.
227
C
= Independent
B = Evidence-Based
228
? = Collaborative
Acute confusion
Provide supportive nursing care, including meeting basic needs such as feeding,
toileting, and hydration.
Delirious clients are unable to care for themselves due to their confusion (Rubi
n et al, 2011).
? Recognize that delirium is frequently treated with an antipsychotic medicatio
n. Administer cautiously as
ordered, if there is no other way to keep the client safe. Watch for side effect
s of the medications. Be aware of
C
paradoxical effects and side effects such as extrapyramidal symptoms, agitation,
sedation, and arrhythmias; these
may exacerbate the delirium (Bourne, 2008). EB: Haloperidol is recommended as th
e ?rst-line agent for delirium at
the end of life (NCCN Clinical Practice Guidelines in Oncology, 2011); atypical
antipsychotics such as risperidone,
olanzapine, and quetiapine have been utilized with comparable response (Fong, Tu
lebaev, & Inouye, 2009).
Critical Care
Recognize admission risk factors for delirium. EB: Risk factors related to ICU
clients include daily alcohol
use of greater than 3 units, living at home alone, smoking more than 10 cigarett
es per day, and cognitive

impairment; precipitating risk factors included more than three infusions, prese
nce of an endotracheal tube or
tracheotomy, internal medicine admission, and factors such as isolation, no visi
ble daylight, and a lack of visitors (Van Rompaey et al, 2009).
Monitor for delirium in each client in critical care daily. Utilize the Confusi
on Assessment Method for the
ICU (CAM-ICU) or the Intensive Care Delirium Screening Checklist (ICDSC). Deliri
um is extremely common in critically ill clients (Sona, 2009) but often remains undiagnosed due to
lack of assessment (Guenther
et al, 2010) or because of the presence of hypoactive delirium (Girard, Pandhari
pande, & Ely, 2008). EB: The
use of reliable, validated tools such as the CAM-ICU should be a routine part of
daily critical care due to the
underdetection of delirium and impact on morbidity (Spronk et al, 2009).
? Sedate critical care clients carefully; monitor sedation, analgesia, and deli
rium scores. EB: Sedatives and
analgesics prescribed to improve patient-ventilator dyssynchrony and treat anxie
ty and pain may precipitate
delirium (Banerjee, Girard, &Pandharipande, 2011). Individualized titratio
n of sedation, analgesia, and
delirium therapies, utilizing management protocols and initiating nonpharmacolog
ic measures are associated
with improved outcomes (Skrobik et al, 2010).
Awaken the client daily. This has been associated with decreased incidence of
ventilator-associated pneumonia; also monitoring the client for continued need for intubation is needed sinc
e intubation itself is associated
with increased incidence of delirium. NOTE: A sedation vacation may not be appro
priate for all clients, such
as those receiving neuromuscular blockade (Bourne, 2008). EB: Benzodiazepines in
crease the risk of delirium
in a dose-dependent manner (Pandharipande et al, 2008).
Bundle awakening and breathing coordination, choosing the appropriate sedative
, monitoring for delirium, and promotion of exercise and early mobility. EB: Bundling these activities
was found to improve
functional and cognitive outcomes for critically ill clients (Banerjee, Girard,
& Pandharipande, 2011).
Initiate mobilization, physical therapy, and occupational therapy early in the
ICU stay. EB: Clients who
experienced daily interruption of sedation with early mobilization had
more ventilator-free days and an
improved functional status at discharge, as well as a 50% decrease in the durati
on of delirium (Schweikert
et al, 2009).
Encourage visits from families. EB: Clients in the intensive care who did not
receive visits were at greater risk
of developing delirium (Van Rompaey et al, 2009).
Geriatric
Assess older adults upon hospital admission and routinely for risk factors, pre
cipitating factors, and the
presence of delirium. Predisposing factors include advanced age, sensory impairm
ent, functional impairment,
dementia, malnutrition, dehydration and previous history of depression. EBN: Old
er adults who undergo
cardiac surgery are at an increased risk for developing delirium (Koster et al,
2011). CEB: Delirium affects one
third of hospitalized older adults (Inouye, 2006) and is the most prevalent comp
lication in hospitalized older
adults (Young & Inouye, 2007).
Avoid the use of restraints. EBN: In a study of long-term care residents with
dementia, the use of physical
restraints was the factor most associated with delirium; initiate alter
native interventions (Voyer et al,
2011a).
? Evaluate all medications for potential to cause or exacerbate deliri
um. Review the Beers Criteria for
Potentially Inappropriate Medication Use in Elderly. Elderly are very prone to m
edication side effects that
can include confusion; drug interactions contribute to the development of deliri
um (Flinn et al, 2009). EB:
Avoid or reduce benzodiazepines; prescribe with caution opioids, dihydropyridine
s, and antihistamine H1
antagonists (Clegg & Young, 2011).
= Independent
B = Evidence-Based
? = Collaborative
REFERENCES
Acute confusion
Establish or maintain elimination patterns of urination and defecation. EB & EB
N: Urinary retention or a
urinary tract infection resulting in urosepsis, as well as constipation
, may lead to delirium in the elderly
(Faezah, Zhang, & Yin, 2008; Waardenburg, 2008).
? Determine if the client is nourished; watch for protein-calorie malnutrition.
Consult with physician or
dietitian as needed. EBN: A study found increased delirium in a group of extende
d care clients who had
decreased body weight, possibly because of protein-binding from polyphar
macy of medications (Culp &
Cacchione, 2008).
Explain hospital routines and procedures slowly and in simple terms; repeat in
formation as necessary.
Provide continuity of care when possible, avoid room changes, and encourage vi
sits from family members
or signi?cant others. EB: Frequent changes may contribute to confusion (O Mahoney
et al, 2011).
If clients know that they are not thinking clearly, acknowledge the concern. F
ear is frequently experienced
by people with delirium. EB: Confusion is frightening; the memory of the deliriu
m can be moderately to
severely distressing (Bruera et al, 2009).
Keep the client s sleep-wake cycle as normal as possible (e.g., avoid letting th
e client take daytime naps,
avoid waking the client at night, give sedatives but not diuretics at bedtime, p
rovide pain relief and back
rubs). The relationship between delirium and sleep deprivation is reciprocal (Fi
gueroa-Ramos et al, 2009).
Home Care
Some of the interventions described previously may be adapted for home care use
.
Assess and monitor for acute changes in cognition and behavior. An acute change
in cognition and behavior
is the classic presentation of delirium and should be considered a medical emerg
ency (Bond, 2009).
Delirium is reversible but can become chronic if untreated. The client may be d
ischarged from the hospital to home care in a state of undiagnosed delirium. EB: Delirium may occur in a
pproximately 20% of clients 6 months after hospital discharge (Cole et al, 2009).
Avoid preconceptions about the source of acute confusion; assess each occurren
ce on the basis of available
evidence.
? Institute case management of frail elderly clients to support continued indep

endent living if possible once
delirium has resolved.
? Teach the family to recognize signs of early confusion and seek medical help.
Counsel the client and family regarding the management of delirium and its sequ
elae. EB: Families experience a high degree of distress when observing a loved one in delirium (Arend & C
hristensen, 2009); the majority of clients with advanced cancer were able to remember their delirium episode
which caused moderate to
severe distress to themselves as well as to their family caregivers (Bruera et a
l, 2009). Families should be told
that symptoms of delirium may persist for months; clients may need ongoing assis
tance (Cole et al, 2009).
229
C
Arend E, Christensen M: Delirium in the intensive care unit: a review,
Br Assoc Crit Care Nurses 14(3):145 154, 2009.
Banerjee A, Girard TD, Pandharipande P: The complex interplay
between delirium, sedation, and early mobility during critical illness: applications in the trauma unit, Curr Opinion Anesth
24(2):195 201, 2011.
Bond SM: Delirium at home: strategies for home health clinicians,
Home Healthc Nurse 27(1):24 34, 2009.
Bourne RS: Delirium and use of sedation agents in intensive care, Crit
Care Nurs 13(4):195 202, 2008.
Breitbart W, Alici Y: Agitation and delirium at the end of life: We
couldn t manage him, JAMA 300(24):2898 2910, 2008.
Brouquet A, et al: Impaired mobility, ASA status and administration
of tramadol are risk factors for postoperative delirium in patients
aged 75 years or more after major abdominal surgery, Ann Surg
251(4):759 765, 2010.
Bruera E, et al: Impact of delirium and recall on the level of distress in
patients with advanced cancer and their family caregivers, Cancer
115(9):2004 2012, 2009.
Bush SH, Bruera E: The assessment and management of delirium in
cancer patients, Oncologist 14(10):1039 1049, 2009.
Clegg A, Young JB: Which medications to avoid in people at risk of
delirium: a systematic review, Age Ageing 41(1):23 29, 2011.
Cole MG, et al: Persistent delirium in older hospital patients: a systematic review of frequency and prognosis, Age Ageing 38(1):19 26,
2009.
Culp KR, Cacchione PZ: Nutritional status and delirium in long-term
care elderly individuals, Appl Nurs Res 21(2):66 74, 2008.
Faezah S, Zhang D, Yin LF: The prevalence and risk factors of delirium
amongst the elderly in acute hospital, Singapore Nurs J 35(1):11 14,
2008.
Figueroa-Ramos MI, et al: Sleep and delirium in ICU patients: a review
of mechanisms and manifestations, Intensive Care Med 35(5):781
795, 2009.
Flinn DR, et al: Prevention, diagnosis, and management of postoperative delirium in older adults, J Am Coll Surg 209(2):261 268, 2009.
Fong TG, Tulebaev SR, Inouye SK: Delirium in elderly adults: diagnosis,
prevention and treatment, Nat Rev Neurol 5(4):210 220, 2009.
= Independent
B = Evidence-Based
230
? = Collaborative
Chronic confusion
Girard TD, Pandharipande PP, Ely EW: Review: Delirium in the intensive care unit, Crit Care 12(Suppl 3):S3, 2008.
Guenther U, et al: Validity and reliability of the CAM-ICU ?owsheet to
diagnose delirium in surgical ICU patients, J Crit Care 25(1):144
151, 2010.
Sendelbach S, Guthrie PF: Acute confusion/delirium evidence-based
guideline, Ames, IA, 2009, John A. Hartford Foundation Center of
Geriatric Nursing Excellence, University of Iowa.
Skrobik Y, et al: Protocolized intensive care unit management of analgesia, sedation, and delirium improves analgesia and subsyndromal
C
Han JH, et al: Delirium in older emergency department patients: recognition, risk factors, and psychomotor subtypes, Acad Emerg Med
16(3):193 200, 2009.
Inouye SK: Current concepts: delirium in older persons, N Engl J Med
354(11):1157 1165, 1217 1220:2006.
Juliebo V, et al: Risk factors for preoperative and postoperative delirium
in elderly patients with hip fracture, J Am Geriatr Soc 57(8):1354
1361, 2009.
Koster S, et al: Risk factors for delirium after cardiac surgery: a systematic review, Eur J Cardiovasc Nurs 10(4):197 204, 2011.
National Comprehensive Cancer Network: Clinical practice guidelines
in oncology, version 2.2011, palliative care. Retrieved November 1,
2011, from http://www.nccn.org/professionals/physician_gls/pdf/
palliative.pdf.
O Mahoney R, et al: Synopsis of the National Institute for Health and
Clinical Excellence guideline for prevention of delirium, Ann Intern
Med 154(11):746 751, 2011.
Pandharipande P, et al: Prevalence and risk factors for development
of delirium in surgical and trauma intensive care unit patients,
J Trauma 65(1):34 41, 2008.
Robinson S, et al: Delirium prevention for cognitive, sensory and mobil-
ity impairments, Res Theory Nursing Pract 22(2):103 113, 2008.

Robinson S, Vollmer C: Undermedication for pain and precipitation of
delirium, Medsurg Nurs 19(2):79 83, 2010.
Rubin FH, et al: Sustainability and scalability of the hospital elder life
program at a community hospital, J Am Geriatr Soc 59(2):359 365,
2011.
Schreier AM: Nursing care, delirium, and pain management for the
hospitalized older adult, Pain Manage Nurs 11(3):177 185, 2010.
Schweikert W, et al: Early physical and occupational therapy in mechanically ventilated, critically ill patients: a randomized control trial,
Lancet 373(9678):1874 1882, 2009.
Chronic Confusion
Mila W. Grady, MSN, RN
delirium rates, Anesth Analg 111(2):451 463, 2010.
Sona C: Assessing delirium in the intensive care unit, Crit Care Nurs
29(2):103 104, 2009.
Spronk PE, et al: Occurrence of delirium is severely underestimated
in the ICU during daily care, Intensive Care Med 35(7):1276 1280,
2009.
Steis MR, Fick DM: Are nurses recognizing delirium? A systematic
review, J Gerontol Nurs 34(9):40 48, 2008.
Thomas DR, et al: Understanding clinical dehydration and its treatment, J Am Med Dir Assoc 9(5):292 301, 2008.
Van Eijk MM, et al: Comparison of delirium assessment tools in a
mixed intensive care unit, Crit Care Med 37(6):1881 1885, 2009.
Van Rompaey B, et al: Risk factors for delirium in intensive care
patients: a prospective cohort study, Crit Care 13(3):R77, 2009.
Voyer P, et al: Predisposing factors associated with delirium among
demented long-term care residents, Clin Nurs Res 18(2):153 171,
2009.
Voyer P, et al: Precipitating factors associated with delirium among
long-term care residents with dementia, Appl Nurs Res 24(3):171
178, 2011a.
Voyer P, et al: Factors associated with delirium severity among older
persons with dementia, J Neurosci Nurs 43(2):62 69, 2011b.
Waardenburg IE: Delirium caused by urinary retention in elderly
people: a case report and literature review on the cystocerebral
syndrome, J Am Geriatr Soc 56(12):2371 2372, 2008.
Weinhouse GL, et al: Bench-to bedside review: delirium in ICU
patients importance of sleep deprivation, Crit Care 13(6):234,
2009.
Wong C, et al: Does this patient have delirium? Value of bedside instruments, JAMA 304(7):779 786, 2010.
Young J, Inouye SK: Delirium in older people, BMJ 334(7598):842 846,
2007.
NANDA-I
De?nition
Irreversible, long-standing, and/or progressive deterioration of intellect and p
ersonality characterized by
decreased ability to interpret environmental stimuli; decreased capacity for int
ellectual thought processes;
and manifested by disturbances of memory, orientation, and behavior
Altered interpretation; altered personality; altered response to stimuli; clinic
al evidence of organic impairment; impaired long-term memory; impaired short-term memory; impaired socializat
ion; long-standing
cognitive impairment; no change in level of consciousness; progressive cognitive
impairment
Alzheimer s disease; cerebrovascular attack; head injury; Korsakoff s psychosis; mul
ti-infarct dementia
NOC
Cognition, Cognitive Orientation, Distorted Thought Self-Control
= Independent
B = Evidence-Based
? = Collaborative
Chronic confusion
Cognition as evidenced by the following indicators: Cognitive orientation/Commun
icates clearly for age/Comprehends the meaning
of situations/Attentiveness/Concentration. (Rate the outcome and indicators of C
ognition: 1 = severely compromised, 2 =
substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5
= not compromised [see Section I].)
Client Outcomes
Remain content and free from harm
Function at maximal cognitive level
Participate in activities of daily living at the maximum of functional ability
Have minimal episodes of agitation (as agitation occurs in up to 70% of clients
with dementia)
NIC
Dementia Management, Environmental Management, Surveillance: Safety
Example NIC Activities Dementia Management
Use distraction rather than confrontation to manage behavior; Give one simple di
rection at a time
Determine the client s cognitive level using a screening tool such as the Mini-Me
ntal State Exam (MMSE),
Mini-Cog (includes a three-item recall and clock drawing test), or Montreal Cogn
itive Assessment. Age,
education, and literacy must be taken into account when interpreting results of
the MMSE (Mitchell, 2009) as
well as culture and ethnicity (Struble & Sullivan, 2011); an abnormal score nece
ssitates further evaluation. For
older adults with mild cognitive impairment, the Short Test of Mental Status and
Montreal Cognitive Assessment are more sensitive diagnostic tools than the MMSE (Petersen, 2011). EB: The
clock drawing test is useful
for detecting moderate to severe dementia; its usefulness in detecting early cas
es of dementia is limited (Pinto &
Peters, 2009).
? In clients who are complaining of memory loss, assess for depression, alcohol
use, medication use, sleep,
and nutrition. These factors may be implicated in memory loss (Struble & Sulliva
n, 2011).
? Recognize that pharmacological treatment to slow the progression of Alzheimer s
disease is most effective
when used early in the course of the disease. The U.S. Food and Drug Administrat
ion has approved ?ve
drugs that slow the progression of symptoms for approximately 6 to 12 months; ov
er 75 experimental therapies
are being clinically tested in humans (Alzheimer s Association, 2011).
If hospitalized, gather information about the client s pre-admission cognitive f
unctioning, daily routines
and care, and decision-making capacity. Establishing continuity of care lessens
risk for hospitalized clients.
Informed consent may create a dilemma; decision-making capacity will vary depend
ing on the degree of cognitive impairment (Weitzel et al, 2011). EBN & EB: Individuals with a history of c
ognitive dysfunction are at
higher risk for acute confusion during acute illness (Voyer et al, 2011a). Clien
ts with mild cognitive impairment may be able to make decisions regarding their care (Okonkwo et al, 2008).
Assess the client for signs of depression: anxiety, sadness, irritability, agi
tation, somatic complaints, tension, loss of concentration, insomnia, poor appetite, apathy, ?at affect, and wi
thdrawn behavior. EB: Up
to 95% of individuals with dementia have some neuropsychiatric problems (Gauthie
r et al, 2010), with the
most common being apathy, depression, and anxiety; others include aggression, ag
itation, delusions, and hallucinations (Jalbert, Daiello, & Lapane, 2008). The Cornell Scale is a reliable
and valid tool to assess for
depression in dementia (Leontjevas, van Hooren, & Mulders, 2009). Approximately
20% of older adults may
be affected by signi?cant depressive symptoms (Thielke, Diehr, & Unutzer, 2010).
Assess the client for anxiety if he or she reports worry regarding physical or
cognitive health, reports feelings
of being anxious, shortness of breath, dizziness, or exhibit behaviors such as r
estlessness, irritability, noise
sensitivity, motor tension, fatigue, or sleep disturbances. The Rating Anxiety i
n Dementia (RAID) Scale
may be utilized; this may require caregiver input. Recognize that anxiety is com
mon in dementia, is often
231
= Independent
B = Evidence-Based
232
? = Collaborative
Chronic confusion
undiagnosed, and may signi?cantly impact quality of life. CEB: Symptoms of anxie
ty may progress to more
challenging behaviors which negatively impact function and may contribute to dis
charge from assisted living
to nursing home care (Aud, 2004). CEB: The RAID scale is a reliable and valid to
ol for identifying and measuring anxiety in dementia (Shankar et al, 1999).
C
? Recognize that clients with Alzheimer s disease may experience apathy, anxiety
and depression, psychomotor agitation, and psychotic or manic syndromes; nonpharmacological interventi
ons for management
should be attempted ?rst. EB: More than 75% of clients with Alzheimer s disease pr
esented with one or more
neuropsychiatric syndromes; therapeutic strategies must be planned accordingly (
Spaletta et al, 2010). Best
practice guidelines recommend psychological interventions as the ?rst approach t
o treatment (Ballard et al,
2009). Medication for neuropsychiatric symptoms should be prescribed after nonph
armacological interventions have been tried and should be administered at the lowest possible dose and
chosen with regard to side
effects and adverse reactions (Gauthier et al, 2010).
Determine client s normal routines and attempt to maintain them. CEB: Activities
that are designed to be
consistent with past routines were effective at providing engagement and interes
t and enhancing quality of life
(Cohen-Mans?eld & Jensen, 2006).
Obtain information about the client s life history from the family; collaborate w
ith family members to
provide optimal care. EBN: Knowing the history, interests, needs, and preference
s of the individual is essential
to person-centered care and helpful when initiating conversation, activities, an
d routines; the family s unique
knowledge should be incorporated into the plan of care (Edvardsson, Fetherstonha
ugh, & Nay, 2010).
Begin each interaction with the client by gaining and maintaining eye contact,
identifying yourself and calling the client by name. Approach the client with a caring, loving, and an accept
ing attitude, and speak calmly
and slowly. EB: Dementia causes a loss of the ability to learn new things and re
member people and places (episodic memory); clients will need reassurance and frequent reminding of the ident
ity of caregivers (Yu et al, 2009).
To enhance communication, use a calm approach, avoid distractions, show interes

t, keep communication
simple, give clear choices, give the client time with word ?nding, use repetitio
n and rephrasing, and utilize
gestures, prompts, and cues or visual aids. Listen attentively to unde
rstand nonverbal messages, and
engage in topics of interest to the client. EB: These communication techniques a
ssist in focusing attention,
incorporate nonverbal means of communication, simplify memory demands, compensat
e for cognitive slowing, and assist with retrieval and comprehension (Smith et al, 2011).
Engage the client in scheduled activities that relate to past interests, exper
iences, and hobbies and are
matched to current preferences and abilities. EB: Activities that were once mean
ingful to the client in terms
of self-identity are more likely to result in engagement, even for those with se
vere cognitive impairment. Residents with current interests in art, music, and pets were more engaged in stimul
i that re?ected those current
interests (Cohen-Mans?eld et al, 2010a).
Promote regular exercise. EB: Exercising regularly may signi?cantly slow the r
ate of functional decline in
individuals with Alzheimer s disease (Littbrand et al, 2009); a small study demons
trated that a speci?c walking program for individuals in the later stages of dementia can reduce functiona
l and cognitive decline (Venterelli, Scarsini, & Schena, 2011).
Provide opportunities for contact with nature or nature-based stimuli, such as
facilitating time spent
outdoors or indoor gardening. EB: Horticultural-based therapy programs provide p
ositive engagement and
may be bene?cial for dif?cult to engage clients with dementia (Jarrott & Gigliot
ti, 2010). EBN: Individuals
with dementia experience more barriers to experiencing nature, which may be an u
ntapped source of pleasure
for them (Bossen, 2010).
Provide animal-assisted therapy. EB: This activity can successfully engage resi
dents with dementia, promoting communication and social interaction regardless of the level of cognitive fu
nction (Marx et al, 2010). In a
study of animal-assisted therapy with a group of clients with severe Alzheimer s d
isease, animal-assisted therapy was associated with a decrease in sadness and anxiety and an increase in mot
or activity and positive emotions (Mossello et al, 2011).
Break down self-care tasks into simple steps (e.g., instead of saying, Take a s
hower, say to the client,
Please follow me. Sit down on the bed. Take off your shoes. Now take off your soc
ks. ). Utilize gestures
when giving directions; allow for adequate time and model the desired action if
needed or possible. EB:
Assistance in focusing attention, modeling behavior, and using prompts and cues
maximizes communication
with individuals with dementia (Smith et al, 2011).
Promote routines and facilitate success by keeping frequently used items in a
visible and consistent location. Consistently practicing routines in an unchanged environment will assist t
he client in successful maintenance and performance of skills (Bourgeois & Hickey, 2009).
= Independent
B = Evidence-Based
? = Collaborative
Chronic confusion
Use reminiscence and life review therapeutic interventions for clients in the e
arly to middle stages of
dementia; ask questions about the client s past activities, important events and e
xperiences from the past
while utilizing photographs, videos, artifacts, music or newspaper clippings or
multimedia technology to
stimulate memories. EB: In a small preliminary study utilizing YouTube videos, i
t was found that reminiscence and life review may improve well-being and social engagement (O Rourke et al
, 2011). Memories from
childhood or young adulthood are generally intact in the early and middle stages
of Alzheimer s (Smith et al,
2011).
For clients in the middle to late stages of dementia, engage them in creative
expression through the
use of TimeSlips story-telling groups. EB: In a study of residents in long-term
care settings who were
involved in TimeSlips groups, the residents were more alert, socially engaged, h
ad more interactions with
staff and others, and staff had more positive views of residents than
facilities without the TimeSlips
groups (Fritsch, 2009).
If the client is verbally agitated (repetitive verbalizations, complai
nts, moaning, muttering, threats,
screaming), assess for and address unsatis?ed basic needs or environmental facto
rs that may be addressed.
EB: Disruptive vocalizations may be an indication that the client with dementia
has the need for comfort,
attention, or more or less stimulation (Beedard et al, 2011). Behaviors are not
solely due to cognitive impairment and may be due to an unmet need or environmental factors that may be overwh
elming or understimulating (Gitlin et al, 2009).
Utilize music as a nonpharmacological approach to managing anxiety. Identify mu
sic preferences of the
client; interview family members if necessary. For anxious clients who
are having problems relaxing
enough to eat, try having them listen to music during meals. EBN: Preferred musi
c listening is an effective
intervention to decrease anxiety in older adults with dementia (Sung, Chang, & L
ee, 2010); utilizing percussion instruments with familiar music was found to be a cost effective
method for decreasing anxiety and
improving psychological well-being (Sung et al, 2012).
Assist clients in way?nding, monitoring them so that they do not get lost in u
nfamiliar settings. EB:
Dementia and some related disorders cause impaired spatial learning; security me
asures should be unobtrusive, personal surroundings should include familiar objects, and facilities shou
ld be designed to have a homelike appearance (Fleming & Purandare, 2010).
For clients who wander, utilize technologies that monitor but do not restrict.
Direct the client who is
wandering to a more soothing location with lower light levels and less variation
in noise if necessary. EB:
Motion detectors may improve quality of life by allowing clients to wander safel
y without restriction (Wigg,
2010). Modify the environment to reduce wandering if that is the therapeutic goa
l (Algase et al, 2010).
Promote sleep by promoting daytime activity, creating a restful sleep environm
ent, decreasing waking, and
promoting quiet. EB: Sleep disorders are very common in those with dementia; ind
ividuals with Lewy body dementia experience disturbed sleep twice as often (Bliwise et al, 2011). Promoting a
dark and quiet nighttime environment, a comfortable sleeping temperature for the client, encouraging physical ac
tivity, especially in the afternoon,
maintaining a consistent schedule of meals and activities, maintaining a bright
daytime environment, and facilitating outdoor activity are all methods of improving sleep (Neikrug & Ancoli-Israel
, 2010).
Provide structured social and physical activities that are individualized for
the client. EB: Combined weekly
live music and occupational therapy sessions resulted in an improvement in disru
ptive behavior and depressive
symptoms in adults with dementia (Han et al, 2010).
Provide activities for the client, such as folding washcloths and sorting or s
tacking activities or other hobbies the individual enjoyed prior to the onset of dementia. EB: The purposeful u
se of activities tailored to an
individual s abilities may allow the individual to maintain social roles and feeli
ngs of connectedness, express
themself in a positive way, enhance self-identity, reduce frustration, and preve
nt boredom, resulting in less
agitation (Gitlin et al, 2009).
Use cues, such as picture boards denoting day, time, and location, to help clie
nt with orientation. EBN:
Reality orientation, used not when clients are agitated, but as overall reminder
s of orientation, can help some
clients remain more oriented (Yu et al, 2009).
? If the client becomes increasingly confused and/or agitated, perform the foll
owing steps:
Assess the client for physiological causes, including acute hypoxia, pain, medic
ation effects, malnutrition, and infections such as urinary tract infection, fatigue, electrolyte distu
rbances, and constipation.
Dementia increases the risk and severity of delirium, which may be precipitated
by several factors (Voyer
et al, 2011b).
Assess for psychological causes, including changes in the environment, caregiver
, routine, demands to
perform beyond capacity, or multiple competing stimuli, including discomfort. CE
B: Agitated behaviors
233
C
= Independent
B = Evidence-Based
234
? = Collaborative
Chronic confusion
can be an expression of a need that is not being met (Kolanowski, Litaker, & Bue
ttner, 2005; Kovach et al,
2005).
In clients with agitated behaviors, rather than confronting the client, decrease
stimuli in the environment or provide diversional activities such as quiet music, looking through a ph
oto album, or providing
C
the client with textured items to handle. EB: Music may reduce aggres
sive behaviors during bathing,
reduce agitation at mealtime or in general; structured activities that include m
anipulating, nurturing, sorting or using the tactile sense may reduce agitation (Cohen-Mans?eld, Dakheel-Ali
, & Marx, 2009).
If clients with dementia become more agitated, assess for pain. EBN: Pain assess
ment should begin with
eliciting a self-report using a valid and reliable tool. For the client with cog
nitive impairment, identify potential causes of pain, physiologic indicators, and assess behaviors that might ind
icate pain, elicit information
from family or signi?cant others regarding behaviors that are a change from base
line that could indicate
pain, and initiate an analgesic trial if indicated (Pasero, 2009).
Avoid using restraints if at all possible. EB: The use of trunk restraints is
associated with higher fall risk for
clients with dementia (Luo, Lin, & Castle, 2011).
? Use PRN or low-dose regular dosing of psychotropic or antianxiety drugs only
as a last resort; start with the
lowest possible dose. They can be effective in managing symptoms of psychosis an
d aggressive behavior, but
have undesirable side effects. EB: Psychotropic medications can cause sedation,
orthostatic hypotension and dizziness; use is associated with an increased risk of hospitalization from hip fract
ure (Jalbert et al, 2010).

? Avoid the use of anticholinergic medications such as diphenhydramine. Anticho
linergic medications have
a high side-effect pro?le that includes disorientation, urinary retention, and e
xcessive drowsiness, especially in
those with decreased cognition; the anticholinergic side effects outweigh the an
tihistaminic effects (Artero et al,
2008; Uusvaara et al, 2009).
For predictable dif?cult times, such as during bathing and grooming, try the f
ollowing:
Massage the client s hands or back to relax the client. EBN: Hand and back massage
have been shown to
induce physiological and psychological relaxation (Harris & Richards, 2010).
Approach the client in a client-centered framework: utilize respectful, positive
statements, give directions one step at a time, provide short and clear cues, utilize verbal praise fo
r successful task completion.
EB: Modifying activity demands on an individual basis will result in skill reten
tion and maximum independence (Padilla, 2011).
Involve the family in care of the client. EBN: Establishing a partnership of sha
red responsibility, transparency, and trust is essential to family caregivers (Legault & Ducharme, 2009).
For care of early dementia clients with primarily symptoms of memory loss, see
the care plan for Impaired
Memory.
For clients nearing the end of life, consider a hospice referral. EB: Family m
embers of individuals with
dementia reported higher perceptions of the quality of care and quality of dying
experience with hospice care
(Teno et al, 2011).
For care of clients with self-care de?cits, see the appropriate care plan (Fee
ding Self-Care de?cit; Dressing Self-Care de?cit; and Toileting Self-Care de?cit).
Geriatric
Note: All interventions are appropriate with geriatric clients.
Multicultural
Assess for the in?uence of cultural beliefs, norms, and values on the family s or
caregiver s understanding
of chronic confusion or dementia. EBN: What the family considers normal and abno
rmal health behavior
may be based on cultural perceptions (Giger & Davidhizar, 2008). Hispanic and Ch
inese caregivers were more
likely to believe that Alzheimer s can be diagnosed with a blood test and is a nor
mal part of aging, which may
delay seeking help with management (Gray et al, 2009). Korean American immigrant
s may have a strong
stigma regarding the diagnosis of Alzheimer s disease, may consider memory loss as
part of the normal aging
process, and lack knowledge regarding cause, diagnosis, and treatment (Lee, Lee,
& Diwan, 2010).
Inform the client s family or caregiver of the meaning of and reasons for common
behavior observed in
clients with dementia. EB: An understanding of behavior will enable the client s f
amily or caregiver to provide
the client with a safe environment. Disease expression may vary in different eth
noracial groups; Latinos were
found in one study to have more depressive symptoms (Livney et al, 2011).
Assist the family or caregiver in identifying barriers that would prevent the u
se of social services or other
supportive services that could help reduce the impact of caregiving; r

efer to social services or other
= Independent
B = Evidence-Based
? = Collaborative
Chronic confusion
supportive services. EB: Knowledge about the disease, common concerns, beliefs a
bout risks and treatment
have been identi?ed as important areas to discuss in Alzheimer s outreach efforts
for racial and ethnic minorities (Connell et al, 2009). Barriers to services do exist; Hispanic individuals
reported a longer history of memory loss at the time of referral, African Americans were 30% less likely to be p
rescribed cholinesterase inhibitors,
and minority ethnic groups were less likely to receive 24-hour care or be enroll
ed in research trials (Cooper
et al, 2010). Asian cultures have a great sense of respect and responsibility fo
r older adults; interdependence is
valued; coping strategies and strength from religion and spirituality should be
supported (Lim et al, 2010).
Home Care
Note: Keeping the client as independent as possible is important. Because commun
ity-based care is usually
less structured than institutional care, in the home setting the goal of maintai
ning safety for the client takes
on primary importance.
Provide information to the family and home care client regarding adv
ance directives. This is a legal
requirement of the Consolidated Omnibus Budget Reconciliation Act (COBRA). Encou
raging advance care
planning, identifying goals for end-of-life care, and providing information to m
ake treatment decisions in
accordance with the client s wishes are important interventions for health care pr
oviders (Black et al, 2009).
Assess the client s memory and executive function de?cits before assuming the in
ability to make any
medical decisions; driving capacity and ?nancial capacity should be assessed for
clients with mild cognitive impairment. Decisional capacities for informed consent include: understandi
ng and demonstrating comprehension of diagnosis and treatment-related information, appreciation of the s
igni?cance of the information,
reasoning regarding alternatives and consequences, and expressing a choice (Weit
zel et al, 2011). EB: Clients
with mild cognitive impairment should be proactive in engaging in ?nancial and l
egal planning in light of the
risk of developing dementia (Marson et al, 2009).
Assess the home for safety features and client needs for assistive devices. Re
fer to the interventions for

Feeding Self-Care de?cit, Dressing Self-Care de?cit, Bathing Self-Care de?cit as
needed.
Promote cognitive stimulation (conversation, singing, dancing, creative activi
ties, games) and memory
training exercises for individuals in the early stages of dementia. EBN: Cogniti
ve training interventions may
improve cognition, learning, memory, problem-solving abilities as well as abilit
y to carry out ADLs; cognitive
training is most effective when combined with medication (Yu et al, 2009).
Provide education and support to the family regarding effective communication
and ways to manage
cognitive and behavioral changes; be prepared to offer support and information t
o family members who
live at a distance as well. EB: Family members desired education regarding commu
nication and management
of behavioral changes (Rosa et al, 2010). Changes in symptoms and behavioral cha
llenges were associated with
higher caregiver burden and depression; psychosocial and pharmacologic intervent
ions to manage neuropsychiatric symptoms may alleviate the suffering of the client and promot
e the well-being of the caregiver
(Mohamed et al, 2010).
Use familiar aspects of the environment (smells, music, foods, pictures) to cu
e the client, capitalizing on
habit to remind the client of activities in which the client can participate. EB
N: While clients with dementia
are probably unable to learn new activities because of deteriorated explicit mem
ory, preserved implicit memory
or habit may be useful in maximizing functional ability (Hong & Song, 2009).
Instruct the caregiver to provide a balanced activity schedule that does not s
tress the client or deprive him
or her of stimulation; avoid sustained low- or high-stimulation activity. EB: Pl
anned, individualized structured activities can prevent agitation (Gitlin et al, 2009).
Encourage the use of preferred music listening to evoke memories and promote r
elaxation. EB: In a small
study of caregiver-administered music, caregivers and care recipients reported i
ncreased relaxation, comfort
and happiness, with caregivers showing the most bene?t, citing enjoyment in remi
niscence and participation
in musical activities with their loved ones (Hanser et al, 2011).
? If the client will require extensive supervision on an ongoing basis, evaluat
e the client for day care
programs. Refer the family to medical social services to assist with this proces
s if necessary. Day care
programs provide safe, structured care for the client and respite for the family
, cost a great deal less than
nursing home care, and provide stress relief and respite for the caregiver (Alzh
eimer s Association, 2009).
CEB: Adult day care programs have been shown to reduce stress associated with wo
rk, leisure, and family
needs (Schacke & Zank, 2006). For younger individuals with early onset dementia
who are in the early
stages, assisting staff with responsibilities in adult day care centers may prom
ote self-esteem (Silverstein,
Wong, & Brueck, 2010).
235
C
= Independent
B = Evidence-Based
236
? = Collaborative
Chronic confusion
Encourage the family to include the client in family activities when possible.
Reinforce the use of therapeutic communication guidelines (see Client/Family Teaching and Discharge Planni
ng) and sensitivity to
the number of people present. These steps help the client maintain dignity and l
ead to familial socialization
of the client.
C
REFERENCES
Assess family caregivers for caregiver stress, loneliness, and depression. Car
egivers experience physical and
emotional health challenges, with $7.9 billion in additional health care costs i
n 2010 (Alzheimer s Association,
2011). Anxiety, depression, exhaustion, and grief are common in caregivers of ch
ronically ill family members
(Hanser et al, 2011).
Refer to the care plan for Caregiver Role Strain.
? Refer the client to medical social services as necessary to evaluate ?nancial
resources and initiate bene?ts
or access to providers. EBN: Limited resources serve as barriers to effective us
e of community services (Beeber,
Thorpe, & Clipp, 2008).
? Institute case management for frail elderly clients to support continued inde
pendent living.
In the early stages of dementia, provide the caregiver with information on illn
ess processes, needed care,
available services, role changes, and the importance of advance directi
ves discussion; facilitate family
cohesion. EB: Provide information to caregivers gradually, introduce change slow
ly, facilitate legal changes,
and provide continuous support to caregivers (Livingston, 2010).
Teach the family how to converse with a memory-impaired person and strategies f
or handling challenging
behaviors. EB: Educational needs of caregivers mainly relate to communication sk
ills as well as management
of dif?cult behaviors (Rosa et al, 2010).
Teach the family how to provide physical care for the client (bathing, feeding
, and ADLs) as well as coping
strategies to deal with the burden of caregiving. EB: Interventions that improve
competence in care and coping may lessen caregiver stress (Williams et al, 2010).
Discuss with the family what to expect as the dementia progresses.
? Counsel the family about resources available regarding end-of-life decisions
and legal concerns. EB: Family members report distress regarding decision making throughout the course of d
ementia, having insuf?cient
information, lack of support in having these discussions with family members in
the early stages of dementia,
role con?ict, maintaining the dignity of their family member, family con?ict; su
pporting caregivers throughout
the process and assisting them in advocacy is essential (Livingston et al, 2010)
.
? Inform the family that as dementia progresses, hospice care may be available
in the home or nursing
home in the terminal stages to help the caregiver. EB: 70% of individuals with d
ementia in the United States
die in the nursing home (Fulton et al, 2011). Clients who have hospice are more
likely to die in the location of

their choice and have improved caregiver satisfaction (Shega et al, 2008).
Note: The nursing diagnoses Impaired Environmental Interpretation Syndrome and C
hronic Confusion
are very similar in de?nition and interventions. Impaired Environmental Interpre
tation Syndrome must
be interpreted as a syndrome when other nursing diagnoses would also apply. Chro
nic Confusion may be
interpreted as the human response to a situation or situations that require a le
vel of cognition of which the
individual is no longer capable.
Algase DL, et al: Wandering and the physical environment, Am J
Alzheimers Dis Other Demen 25(4):340 346, 2010.
Alzheimer s Association: 2009 Alzheimer s disease facts and ?gures.
Retrieved October 8, 2011, from http://www.alz.org/national/
documents/report_alzfacts?gures2009.pdf.
Alzheimer s Association: Alzheimer s Association report: 2011
Alzheimer s disease facts and figures, Alzheimers Dement
7(2):208 244, 2011.
Artero S, et al: Risk pro?les for mild cognitive impairment and progression to dementia are gender speci?c, J Neurol Neurosurg Psychiatry
79(9):979 984, 2008.
Aud MA: Residents with dementia in assisted living facilities:
the role of behavior in discharge decisions, J Gerontol Nurs
30(6):16 26, 2004.
Ballard C, et al: Management of agitation and aggression associated
with Alzheimer s disease: controversies and possible solutions, Curr
Opinion Psych 22(6):532 540, 2009.
Beeber AS, Thorpe JM, Clipp EC: Community-based service use by
elders with dementia and their caregivers: a latent class analysis,
Nurs Res 57(5):312, 2008.
Beedard A, et al: Reducing verbal agitation in people with dementia:
evaluation of an intervention based on the satisfaction of basic
needs, Aging Ment Health 15(7):855 865, 2011.
Black BS, et al: Surrogate decision makers understanding of dementia
patients prior wishes for end-of-life care, J Aging Health 21(4):627
650, 2009.
Bliwise DL, et al: Sleep disturbance in dementia with Lewy bodies and
Alzheimer s disease: a multicenter analysis, Dement Geriatr Cogn
Disord 31(3):239 246, 2011.
= Independent
B = Evidence-Based
Chronic confusion
? = Collaborative
237
Bossen A: The importance of getting back to nature for people with
dementia, J Gerontol Nurs 36(2):17 22, 2010.
Bourgeois MS, Hickey EM: Dementia: from diagnosis to management: a
functional approach, New York, 2009, Psychology Press.
Cohen-Mans?eld J, Jensen B: Do interventions bringing current selfKolanowski AM, Litaker M, Buettner L: Ef?cacy of theory-based activities for behavioral symptoms of dementia, Nurs Res 54(4):219 228,
2005.
Kovach C, et al: A model of consequences of need-driven, dementiacompromised behavior, J Nurs Scholarsh 37(2):134 140, 2005.
care practices into greater correspondence with those performed
premorbidly bene?t the person with dementia? A pilot study, Am J
Cohen-Mans?eld J, Dakheel-Ali M, Marx MS: Engagement in persons
with dementia: the concept and its measurement, Am J Geriatr Psych
17(4):299 307, 2009.
Cohen-Mans?eld J, et al: The impact of past and present preferences
on stimulus engagement in nursing home residents with dementia,
Aging Ment Health 14(1):67 73, 2010a.
Cohen-Mans?eld J, et al: The underlying meaning of stimuli: impact on
engagement of persons with dementia, Psychiatry Res 177(1-2):
216 222, 2010b.
Connell CM, et al: Racial differences in knowledge and beliefs about
Alzheimer disease, Alzheimer Dis Assoc Disord 23(2):110 116, 2009.
Cooper C, et al: A systematic review and meta-analysis of ethnic differences in use of dementia treatment, care, and research, Am J Geriatr
Psychiatry 18(3):193 203, 2010.
Edvardsson D, Fetherstonhaugh D, Nay R: Promoting a continuation
of self and normality: person-centred care as described by people
with dementia, their family members and aged care staff, J Clin Nurs
19(17-18):2611 2618, 2010.
Fleming R, Purandare N: Long-term care for people with dementia:
environmental design guidelines, Int Psychogeriatr 22(7):1084 1096,
2010.
Fritsch T, et al: Impact of TimeSlips, a creative expression intervention program, on nursing home residents with dementia and their
caregivers, Gerontologist 49(1):117 127, 2009.
Fulton AT, et al: Palliative care for patients with dementia in long-term
care, Clin Geriatr Med 27(2):153 170, 2011.
Gauthier S, et al: Management of behavioral problems in Alzheimer s
disease, Int Psychogeriatr 22(3):346 372, 2010.
Giger J, Davidhizar R: Transcultural nursing: assessment and intervention, St Louis, 2008, Mosby.
Gitlin LN, et al: The tailored activity program to reduce behavioral
symptoms in individuals with dementia: feasibility, acceptability,
and replication potential, Gerontologist 49(3):428 439, 2009.
Gray HL, et al: Ethnic differences in beliefs regarding Alzheimer disease
among dementia family caregivers, Am J Geriatr Psych 17(11):925
933, 2009.
Han P, et al: A controlled naturalistic study on a weekly music therapy
and activity program on disruptive and depressive behaviors in
dementia, Dement Geriatr Cogn Disord 30(6):540 546, 2010.
Hanser SB, et al: Home-based music strategies with individuals who

have dementia and their family caregivers, J Music Ther 48(1):2 27,
2011.
Harris M, Richards KC: The physiological and psychological effects of
slow-stroke back massage and hand massage on relaxation in older
people, J Clin Nurs 19(7-8):917 926, 2010.
Hong GR, Song JA: Relationship between familiar environment and
wandering behaviour among Korean elders with dementia, J Clin
Nurs 18(9):1365 1373, 2009.
Jalbert JJ, Daiello LA, Lapane K: Dementia of the Alzheimer type, Epidemiol Rev 30:15 34, 2008.
Jalbert JJ, et al: Antipsychotic use and the risk of hip fracture among
older adults af?icted with dementia, J Am Med Dir Assoc 11(2):120
127, 2010.
Jarrott SE, Gigliotti CM: Comparing responses to horticultural-based
and traditional activities in dementia care programs, Am J Alzheimer
Dis Other Demen 25(8):657 665, 2010.
Lee SE, Lee HY, Diwan S: What do Korean American immigrants know
about Alzheimer s disease (AD)? The impact of acculturation and
exposure to the disease on AD knowledge, Int J Geriatr Psychiatry
25(1):66 73, 2010.
Legault A, Ducharme F: Advocating for a parent with dementia in a
long-term care facility: the process experienced by daughters, J Family Nurs 15(2):198 219, 2009.
Leontjevas R, van Hooren S, Mulders A: The Montgomery-Asberg
Depression Rating Scale and the Cornell Scale for Depression in
Dementia: a validation study with patients exhibiting early-onset
dementia, Am J Geriatr Psychiatry 17(1):56 64, 2009.
Lim JB, et al: Coping strategies in?uence caregiver outcomes among
Asian family caregivers of persons with dementia in Singapore,
Alzheimer Dis Assoc Disord 25(1):34 41, 2011.
Littbrand H, et al: The effect of a high-intensity functional exercise
program on activities of daily living: a randomized controlled
trial in residential care facilities, J Am Geriatr Soc 57(10):1741
1749, 2009.
Livingston G, et al: Making decisions for people with dementia who
lack capacity: qualitative study of family carers in UK, Brit Med J
341:c4184, 2010.
Livney MG, et al: Ethnoracial differences in the clinical characteristics
of Alzheimer disease at initial presentation at an urban Alzheimer s
disease center, Am J Geriatr Psychiatry 19(5):430 439, 2011.
Luo H, Lin M, Castle N: Physical restraint use and falls in nursing
homes: a comparison between residents with and without dementia,
Am J Alzheimers Dis Other Demen 26(1):44 50, 2011.
Marson DC, et al: Clinical interview assessment of ?nancial capacity
in older adults with mild cognitive impairment and Alzheimer s
disease, J Am Geriatr Soc 57(5):806 814, 2009.
Marx MS, et al: The impact of different dog-related stimuli on engagement of persons with dementia, Am J Alzheimers Dis Other Demen
25(1):37 45, 2010.
Mitchell AJ: A meta-analysis of the accuracy of the mini-mental state
examination in the detection of dementia and mild cognitive
impairment, J Psych Res 43(4):411 431, 2009.
Mohamed S, et al: Caregiver burden in Alzheimer disease: crosssectional and longitudinal correlates, Am J Geriatr Psychiatry
18(10):917 927, 2010.
Mossello E, et al: Animal-assisted activity and emotional status of
patients with Alzheimer s disease in day care, Int Psychogeriatr
23(6):899 905, 2011.
Neikrug AB, Ancoli-Israel: Sleep disturbances in nursing homes, J Nutr

Health Aging 14(3):207 211, 2010.
Okonkwo OC, et al: Medical decision-making capacity in mild cognitive
impairment: a 3-year longitudinal study, Neurology 71(19):1474
1480, 2008.
O Rourke J, et al: YouTube: a useful tool for reminiscence therapy in
dementia? Age Ageing 40(6):742 744, 2011.
Padilla R: Effectiveness of interventions designed to modify the activity demands of the occupations of self-care and leisure for people
with Alzheimer s disease and related dementia, Am J Occup Ther
65(5):523 531, 2011.
Pasero C: Challenges in pain assessment, J PeriAnesthesia Nurs
24(1):50 54, 2009.
Petersen RC: Mild cognitive impairment, N Engl J Med 364(23):2227
2234, 2011.
Pinto E, Peters R: Literature review of the clock drawing test as a tool
for cognitive screening, Dement Geriatr Cogn Disord 27(3):201 213,
2009.
C
= Independent
B = Evidence-Based
238
? = Collaborative
Constipation
Rosa E, et al: Needs of caregivers of the patients with dementia, Arch

Gerontol Geriatr 51(1):54 58, 2010.
Schacke C, Zank S: Measuring the effectiveness of adult day care as a
facility to support family caregivers of dementia patients, J Appl
Gerontol 25:65 81, 2006.
Teno JM, et al: Does hospice improve quality of care for persons dying
from dementia? J Am Geriatr Soc 58(8):1531 1536, 2011.
Thielke S, Diehr P, Unutzer J: Prevalence, incidence, and persistence
of major depressive symptoms in the cardiovascular health study,
Aging Ment Health 14(2):168 176, 2010.
C
Shankar KK, et al: The development of a valid and reliable scale for
rating anxiety in dementia (RAID), Aging Ment Health 3(1):39 49,
1999.
Shega JW, et al: Patients dying with dementia: experience at the end of
life and impact of hospice care, J Pain Symptom Manag 35(5):499
507, 2008.
Silverstein NM, Wong CM, Brueck KE: Adult day health care for
participants with Alzheimer s disease, Am J Alzheimers Dis Other
Demen 25(3):276 283, 2010.
Smith E, et al: Memory and communication support in dementia:

research-based strategies for caregivers, Int Psychogeriatr 23(2):256
263, 2011.
Spaletta G, et al: Neuropsychiatric symptoms and syndromes in a large
cohort of newly diagnosed, untreated patients with Alzheimer disease, Am J Geriatr Psychiatry 18(11):1026 1035, 2010.
Struble LM, Sullivan B-J: Cognitive health in older adults, Nurse Pract
36(4):24 34, 2011.
Sung HC, Chang AM, Lee WL: A preferred music listening intervention
to reduce anxiety in older adults with dementia in nursing homes,
J Clin Nurs 19(7-8):1056 1064, 2010.
Sung HC, et al: A group music intervention using percussion instruments with familiar music to reduce anxiety and agitation of
institutionalized older adults with dementia, Int J Geriatr Psychiatry
27(6):621 627, 2012.
Uusvaara J, et al: Association between anticholinergic drugs and apolipoprotein E epsilon4 allele and poorer cognitive function in older
cardiovascular patients: a cross-sectional study, J Am Geriatr Soc
57(3):427 431, 2009.
Venterelli M, Scarsini R, Schena F: Six-month walking program changes
cognitive and ADL performance in patients with Alzheimer, Am J
Voyer P, et al: Factors associated with delirium severity among older
persons with dementia, J Neurosci Nurs 43(2):62 69, 2011a.
Voyer P, et al: Precipitating factors associated with delirium among
long-term care residents with dementia, Appl Nurs Res 24(3):171
178, 2011b.
Weitzel T, et al: The special needs of the hospitalized patient with
dementia, MedSurg Nurs 20(1):13 18, 2011.
Wigg JM: Liberating the wanderers: using technology to unlock doors
for those living with dementia, Sociol Health Illn 32(2):288 303,
2010.
Williams VP, et al: Video-based coping skills to reduce health risk and
improve psychological and physical well-being in Alzheimer s disease family caregivers, Psychosomatic Med 72(9):897 904, 2010.
Yu F, et al: Cognitive training for early-stage Alzheimer s disease and
dementia, J Gerontol Nurs 35(3):23 29, 2009.
Risk for acute Confusion

NANDA-I
De?nition
At risk for reversible disturbances of consciousness, attention, cognition, and
perception that develop over a
short period of time
Risk Factors
Decreased mobility, decreased restraints, dementia, ?uctuation in sleep-w
ake cycle, history of stroke,
impaired cognition, infection, male gender, metabolic abnormalities: azot
emia, decreased hemoglobin,
dehydration, electrolyte imbalances, increased BUN/creatinine, malnutrition
, over 60 years of age, pain,
pharmaceutical agents: anesthesia, anticholinergics, diphenhydramine, multiple m
edications, opioids, psychoactive drugs, sensory deprivation, substance abuse, urinary retention
ales,
and References
Refer to care plan for Acute Confusion.
Constipation
Marilee Schmelzer, PhD, RN

NANDA-I
De?nition
Decrease in normal frequency of defecation, accompanied by dif?cult or incomplet
e passage of stool and/or
passage of excessively hard, dry stool
= Independent
B = Evidence-Based
? = Collaborative
Constipation
Feeling of rectal fullness; feeling of rectal pressure; straining with defecatio
n; unable to pass stool; abdominal
pain; abdominal tenderness; anorexia; atypical presentations in older adults (e.
g., change in mental status,
urinary incontinence, unexplained falls, elevated body temperature); borborygmi;
change in bowel pattern;
decreased frequency; decreased volume of stool; distended abdomen; generalized f
atigue; hard, formed stool;
headache; hyperactive bowel sounds; hypoactive bowel sounds; increased abdominal
pressure; indigestion;
nausea; oozing liquid stool; palpable abdominal or rectal mass; percussed abdomi
nal dullness; pain with
defecation; severe ?atus; vomiting
Functional
Abdominal muscle weakness; habitual denial; habitual ignoring of urge to defecat
e; inadequate toileting
(e.g., timeliness, positioning for defecation, privacy); irregular defecation ha
bits; insuf?cient physical activity; recent environmental changes
Psychological
Depression, emotional stress, mental confusion
Pharmacological
Aluminum-containing antacids; anticholinergics, anticonvulsants; antidiarrhe
al agents, antidepressants,
antilipemic agents, bismuth salts, calcium carbonate, calcium channel blockers,
diuretics, iron salts, laxative
overdose, nonsteroidal antiin?ammatory drugs (NSAIDs), opioids, phen
othiazines, sedatives, and
sympathomimetics
Mechanical
Neurological impairment, electrolyte imbalance, hemorrhoids, Hirschsprung s diseas
e, obesity, postsurgical
obstruction, pregnancy, prostate enlargement, rectal abscess, rectal anal ?ssure
s, rectal anal stricture, rectal
prolapse, rectal ulcer, rectocele, tumors
Physiological
Change in eating patterns, change in usual foods, decreased motility of gastroin
testinal tract, defecation disorder, dehydration, inadequate dentition, inadequate oral hygiene, insuf?cient ?
ber intake, insuf?cient ?uid
intake, poor eating habits
NOC
Bowel Elimination, Hydration
Bowel Elimination as evidenced by the following indicators: Elimination pattern/
Stool soft and formed/Passage of stool
without aids/Ease of stool passage. (Rate each indicator of Bowel Elimination: 1
= severely compromised, 2 = substantially
compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not comprom
ised [see Section I].)
Client Outcomes
Maintain passage of soft, formed stool every 1 to 3 days without straining
State relief from discomfort of constipation
Identify measures that prevent or treat constipation
239
= Independent
? = Collaborative
B = Evidence-Based
240
Constipation
NIC
Suggested NIC Intervention
C
Constipation/Impaction Management
Example NIC Activities Constipation/Impaction Management
Identify factors (e.g., medications, bed rest, and diet) that may cause or contr
ibute to constipation/impaction; Institute a toileting
schedule, as appropriate
Assess usual pattern of defecation, including time of day, amount and frequency
of stool, consistency of
stool; history of bowel habits or laxative use; diet, including ?ber and ?uid in
take; exercise patterns; personal remedies for constipation; obstetrical/gynecological history; surgeries; d
iseases that affect bowel
motility; alterations in perianal sensation; present bowel regimen. Individual b
owel habits vary and clients
with constipation experience a variety of symptoms (Spinzi et al, 2009).
Consider emotional in?uences (e.g., depression and anxiety) on defecation. Emot
ions in?uence gastrointestinal function, possibly because control of both emotions and gastrointestina
l function is located in the
limbic system of the brain. Dif?culties with defecation often begin in childhood
(e.g., during toilet training),
and constipation is also associated with sexual and physical abuse, depression,
and anxiety (Whitehead et al,
2009). EBN: In a study, clients with functional constipation were compared to no
rmal controls; subjects with
functional constipation had signi?cantly higher anxiety and depression scores (Z
hou et al, 2010).
Have the client or family keep a 7-day diary of bowel habits, including informa
tion such as time of day;
usual stimulus; consistency, amount, and frequency of stool; dif?culty defecatin
g; ?uid consumption; and
use of any aids to defecation. Health care providers de?ne constipation mainly i
n terms of frequency, but
those affected are more concerned about hard stool and discomfort and straining
when attempting to defecate
(Wald et al, 2008). CEB: A diary of bowel habits is valuable in treatment of con
stipation; the use of a diary has
proven to be more accurate than client recall in determining the presence of con
stipation (Andersen et al,
2006).
Use the Bristol Stool Scale to assess stool consistency. The Bristol Stool scal
e is widely used as a more objec-
tive measure to describe stool consistency (Tack et al, 2011).

? Review the client s current medications. EB: Many medications are associated wit
h chronic constipation
including opioids, anticholinergics, antidepressants, antihypertensives (e.g., c
lonidine, calcium channel blockers), antispasmodics, diuretics, anticonvulsants, and psychotropics (Eoff & Lemb
o, 2008; Spinzi et al, 2009).
? If clients are suffering from constipation and are taking constipating medicat
ions, consult with the health
care provider (with prescriptive powers) about the possibilities of decreasing t
he medication dosages or
?nding an alternative medication that is less constipating (Gallagher, O Mahony, &
Quigley, 2008).
? Recognize that opioids cause constipation. If the client is receiving temporar
y opioids (e.g., for acute
postoperative pain), request an order for routine stool softeners from the prima
ry care practitioner, monitor bowel movements, and request a laxative if the client develops constipation
. If the client is receiving
around-the-clock opiates (e.g., for palliative care), request an order for Senok
ot-S and institute a bowel
regimen. Opioids cause constipation because they decrease propulsive movement in
the colon and enhance
sphincter tone, making it dif?cult to defecate. Senokot-S is recommended to prev
ent constipation when opioids
are given around the clock (Kyle, 2007). EB: In a study of hip fracture clients
who received opioids following
surgery, clients who received prophylactic laxatives were less likely to develop
constipation than those who did
not (Davies et al, 2008).
? If the client is terminally ill and is receiving around-the-clock opioids for
palliative care, speak with the
prescribing provider about ordering methylnaltrexone, a drug that blocks opioid
effects on the gastrointestinal tract without interfering with analgesia. Methylnaltrexone is FDA appro
ved for clients in palliative
care when other laxatives are ineffective (Greenwood-Van Meerveld & Standifer, 2
008). Methylnaltrexone
does not replace, but is given in addition to, the usual laxative regimen (Kyle,
2009). EB: In an RCT with
subjects with opioid-induced constipation, a signi?cantly greater percentage of
those who received methylnaltrexone had a bowel movement within 4 hours (without other laxatives) than those
who received placebo
(Thomas et al, 2008). In a randomized study of clients who took opioids for chro
nic, nonmalignant pain, those
= Independent
B = Evidence-Based
Constipation
? = Collaborative
who received subcutaneous methylnaltrexone daily or every other day had signi?ca
ntly more bowel movements than subjects who received the placebo (Michna et al, 2011).
If new onset of constipation, determine if the client has recently stopped smo
king. Constipation is common, but usually transient, when people stop smoking (Wilcox et al, 2010). CEB:
In a survey about perceived
effects of various foods and beverages on constipation, cigarettes was the item
that was most often perceived to
have a laxative effect among smokers in all three groups (Mller-Lissner et al, 20
05).
Palpate for abdominal distention, percuss for dullness, and auscultate bowel s
ounds. In clients with constipation the abdomen is often distended and tender, and stool in the colon produce
s a dull percussion sound.
Bowel sounds will be present.
? Check for impaction; if present, perform digital removal of stool per provide
r s order. An impaction is
hard stool that is too large to move through the sphincter and must be removed m
anually. Clients with neurogenic bowel dysfunction (e.g., spinal cord injury) commonly require manual evacu
ation of stool (Coggrave &
Norton, 2009).
Encourage ?ber intake of 20 g/day (for adults) ensuring that the ?ber is palat
able to the individual and
that ?uid intake is adequate. Add ?ber gradually to decrease bloating and ?atus.
Larger stools move through
the colon faster than smaller stools, and dietary ?ber make stools bigger becaus
e it is undigested in the upper
intestinal tract. Fiber fermentation by bacteria in the colon produces gas. The
effectiveness of water-insoluble
?bers (e.g., wheat bran) on bowel function is well supported by research, and th
ere is growing evidence that
water-soluble ?bers (e.g., psyllium) also promote laxation (Vuksan et al, 2008).
CEB: The Nurses Health
Study found that women with a median ?ber intake of 20 g/day were less likely to
experience constipation than
those with a median intake of 7 g/day (Dukas, Willett, & Giovannucci, 2003). In
a study of subjects receiving
each of 5 treatments in a randomized design, the 5 treatments included: (1) bran
cereal, (2) bran with corn
cereal, (3) bran with psyllium cereal, (4) a cereal blend of 70% glucomannan and
30% xanthan, and (5) the
low-?ber control diet. All four cereals produced signi?cantly greater bowel move
ment than the low-?ber control
diet and all were well tolerated (Vuksan et al, 2008). Researchers found that ry
e bread shortened intestinal
transit time, softened the feces, and eased defecation of women with constipatio
n, and that yogurt lessened the
bloating and ?atulence resulting from rye bread (Hongisto et al, 2006).
Use a mixture of bran cereal, applesauce, and prune juice; begin administration
in small amounts and
gradually increase amount. Keep refrigerated. Always check with the primary care
provider before initiating this intervention. It is important that the client also ingest suf?cient ?ui
ds. CEB: This bran mixture has
been shown to be effective even with short-term use in elderly clients recoverin
g from acute conditions; however, it has not been tested with an RCT (Joanna Briggs Institute, 2008). NOTE:
Giving ?ber without suf?cient

?uid may result in worsening of constipation. Additional dietary ?ber and bulk-f
orming laxatives are inappropriate for those who have dif?culty ingesting adequate ?uids, such as clients
in palliative care (Kyle, 2007).
Provide prune or prune juice daily. Each 100 g of prunes contain about 6 g of
?ber, 15 g of sorbitol, and 184
mg of polyphenol; all have laxative effects (Attaluri et al, 2011). CEB: In a st
udy about the perceived effects of
various foods and beverages on stool consistency, over half of subjects surveyed
reported that prunes had a
softening effect on their stools (Mller-Lissner et al, 2005). In a randomized stu
dy, dried prunes produced
signi?cantly more complete spontaneous bowel movements (CSBMs) per week than psy
llium, and both treatments produced signi?cantly more CSBMs than at baseline (Attaluri et al, 2011).
Encourage a ?uid intake of 1.5 to 2 L/day (6 to 8 glasses of liquids per day),
unless contraindicated because
of other health concerns such as renal or heart disease. Cereal ?bers such as wh
eat bran add additional bulk
by attracting water to the ?ber, so adequate ?uid intake is essential. CEB: When
dehydrated, the body absorbs
additional water from stools, resulting in dry, hard stools that are dif?cult to
pass (Sykes, 2006). Increasing
?uid intake is not helpful if the person is already well hydrated.
? If the client is uncomfortable or in pain due to constipation or has acute or
chronic constipation that does
not respond to increased ?ber, ?uid, activity, and appropriate toileting, refer
the client to the primary care
provider for an evaluation of bowel function and health status. There can be mul
tiple causes of constipation,
such as endocrine disorders (e.g., hypothyroidism), depression, neurological con
ditions (e.g., multiple sclerosis
and Parkinson s disease), anorectal disorders, and Hirschsprung s disease (Eoff & Le
mbo, 2008).
Encourage clients to resume walking and activities of daily living as soon as
possible if their mobility has
been restricted. Encourage turning and changing positions in bed, lifting the hi
ps off the bed, performing
range-of-motion exercises, alternately lifting each knee to the chest, doing whe
elchair lifts, doing waist
twists, stretching the arms away from the body, and pulling in the abdomen while
taking deep breaths.
Bed rest and decreased mobility lead to constipation, but additional exercise do
es not help the constipated
person who is already mobile. When the client has diminished mobility,
even minimal activity increases
241
= Independent
B = Evidence-Based
242
? = Collaborative
Constipation
peristalsis, which is necessary to prevent constipation (Joanna Briggs Institute

, 2008). CEB: Twelve weeks of
physical activity signi?cantly decreased symptoms of constipation and dif?culty
defecating in sedentary clients
with chronic constipation, but transit time decreased only in subjects who had a
bnormally long transit time
before starting the exercise program (DeSchryver et al, 2005). In a study of 192
hospitalized clients which
C
included daily recording of activity levels, being bedridden for 2 to 3 weeks ac
counted for a sixfold increase in
dissatisfaction with bowel emptying (Cardin et al, 2010).
Ask clients when they normally have a bowel movement and assist them to the ba
throom at that same
time every day to establish regular elimination. An optimal time for many indivi
duals is 30 minutes after
breakfast because of the gastrocolic re?ex (Godfrey & Rose, 2007). CEB: When cli
ents followed a bowel program that included adequate hydration, dietary ?ber and regular toileting, most
resumed normal bowel elimination patterns without laxatives (Benton et al, 1997). When subjects who had su
ffered a stroke were randomly
scheduled for morning or evening defecation, those defecating in the morning aft
er breakfast returned to regular elimination patterns signi?cantly faster. Subjects whose defecation was sche
duled for the same time of day
as their normal, pre-stroke patterns also resumed normal elimination pa
tterns signi?cantly faster (Venn,
1992).
Provide privacy for defecation. If not contraindicated, help the client to the
bathroom and close the door.
Bowel elimination is a private act in Western cultures, and a lack of privacy ca
n hinder the defecation urge,
thus contributing to constipation (Kyle, 2011).
Help clients onto a bedside commode or toilet so they can either squat or lean
forward while sitting. Recognize that it is dif?cult to impossible to defecate in the lying supine positio
n. Sitting upright allows gravity
to aid defecation. CEB: A study of men found that ?exing the hip to 90 degrees o
r more straightens the angle
between the anus and the rectum and pulls the anal canal open, to decrease the r
esistance to the movement of
feces from the rectum and the amount of pressure needed to empty the rectum. Hip
?exion is greatest when

squatting or when leaning forward while sitting (Tagart, 1966). In a study invol
ving volunteers, defecation
required signi?cantly less time and was signi?cantly easier when squatting than
when sitting (Sikirov, 2003).
In another study, researchers found a signi?cant decrease in the ability of subj
ects to defecate both a water?lled balloon and a silicone device in the lying position versus the sitting pos
ition (Rao, Kavolic, & Rao, 2006).
Teach clients to respond promptly to the defecation urge. CEB: A study of male
volunteers determined that
the defecation urge can be delayed and that delaying defecation decreased bowel
movement frequency, stool
weight, and transit time (Klauser et al, 1990).
? Provide laxatives, suppositories, and enemas only as needed if other more nat
ural interventions are not
effective, and as ordered only; establish a client goal of eliminating their use
. EB & CEB: Moderate evidence
exists for the ef?cacy of lactulose, laxatives containing polyethylene glycol, a
nd bulking agents (e.g., psyllium
and bran) for the treatment of constipation in the elderly (Joanna Briggs Instit
ute, 2008). Use of stimulant
laxatives should be avoided because they result in laxative dependence and loss
of normal bowel function.
Laxatives (e.g., bisacodyl) and enemas also damage the surface epithelium of the
colon (Schmelzer et al, 2004).
? When giving large volume enema solutions (e.g., soap-suds or tap-water enemas
), measure the amount
of ?uid given and the amount expelled, especially when giving repeated enemas. U
se a low concentration
of Castile soap in the soap-suds enema. Enema ?uid can be retained, and this ret
ained ?uid can be harmful
for the client prone to ?uid overload. CEB: In studies comparing the effectivene
ss of soap-suds enemas in preoperative liver transplant clients (Schmelzer et al, 2000) and in healthy subjec
ts (Schmelzer et al, 2004), the
amount of enema solution given was often larger than the amount of returns, and
some subjects retained large
amounts of solution. Biopsies taken immediately after soap-suds and tap-water en
emas demonstrated damage
to the surface epithelium of the colon (Schmelzer et al, 2004).
Geriatric
Assess older adults for the presence of factors that contribute to constipation
, including dietary ?ber and
?uid intake (less than 1.5 L/day), physical activity, use of constipating medica
tions, and diseases that are
associated with constipation.
Explain the importance of adequate ?ber intake, ?uid intake, activity, and esta
blished toileting routines to
ensure soft, formed stool. EB: Strong evidence exists for the ef?cacy of adequat
e hydration and dietary ?ber
in the prevention of constipation in older adults; moderate evidence exists for
the effectiveness of increased
activity for those restricted to bed rest (Joanna Briggs Institute, 2008). In an
RCT of elderly nursing home residents who were chronically ill and regularly used laxatives, those who received
an additional 5.1 g of oat bran
with their usual diets had signi?cant reductions in laxative use when compared t
o those who did not (Sturtzel
& Elmadfa, 2008). CEB: A study involving institutionalized elderly men
with chronic constipation

= Independent
B = Evidence-Based
? = Collaborative
Constipation
demonstrated that, with use of a bran mixture, clients were able to discontinue
use of oral laxatives (Howard,
West, & Ossip-Klein, 2000).
Determine the client s perception of normal bowel elimination and laxative use;
promote adherence to a
regular schedule. EB: In a survey in the United States, United Kingdom, Germany,
France, Italy, Brazil, and
South Korea, elderly subjects reported more constipation and used laxatives more
often than younger subjects
(Wald et al, 2008).
Explain why straining (Valsalva maneuver) should be avoided. Excessive straini
ng can cause syncope or
cardiac dysrhythmias in susceptible people (Gallagher, O Mahony, & Quigley, 2008).
Respond quickly to the client s call for assistance with toileting.
Offer food, ?uids, activity and toileting opportunities to elderly clients who
are cognitively impaired. Even
cognitively impaired individuals who are unable to initiate a request for food,
?uids, and so forth may respond
when opportunities are offered (Gallagher, O Mahony, & Quigley, 2008). EB: In an R
CT study involving
nursing home residents, subjects who received the treatment protocol (offering o
f food, ?uid, activity, and toileting opportunities) had signi?cantly more bowel movements than the control gro
up. Both cognitively intact
and cognitively impaired subjects bene?ted from the treatment (Schnelle et al, 2
010).
Avoid regular use of enemas in the elderly. Enemas can cause ?uid and electrol
yte imbalances (Gallagher,
O Mahony, & Quigley, 2008) and damage to the colonic mucosa (Schmelzer et al, 2004
). However, judicious
enema use may help prevent impactions (Gallagher, O Mahony, & Quigley, 2008).
? Use opioids cautiously. Opioids cause constipation (Davies et al, 2008).
Position the client on the toilet or commode and place a small footstool under
the feet. Placing a small
footstool helps the client assume a squatting posture to facilitate defecation.
Home Care
Take complaints seriously and evaluate claims of constipation in a matter-of-fa
ct manner. Continued
constipation can lead to bowel obstruction, a medical emergency. Use of a matter
-of-fact manner will limit
positive reinforcement of the behavior if actual constipation does not exist. Re
fer to the care plan for Perceived Constipation.
Assess the self-care management activities the client is already using. CEB: M
any older adults seek solutions
to constipation, with laxative use a frequent remedy that creates its own proble
ms (Annells & Koch, 2002).
The following treatment recommendations have been offered):
? Acknowledge the client s life-long experience of bowel function; respect belie
fs, attitudes, and preferences, and avoid patronizing responses.
? Make available comprehensive, useful written information about
constipation and possible
solutions.
? Make available empathetic and accessible professional care to provide treatm
ent and advice; a multidisciplinary approach (including physician, nurse, and pharmacist) should be use
d.
? Institute a bowel management program.
? Consider affordability when suggesting solutions to constipation; discuss co
st-effective strategies.
? Discuss a range of solutions to constipation and allow the client to choose
the preferred options.
? Have orders in place for a suppository and enema as the need may occur. As p
art of a bowel management program, suppositories or enemas may become necessary.
Although the use of a bedside commode may be necessitated by the client s condit
ion, allow the client to
use the toilet in the bathroom when possible and provide assistance. Bowel elimi
nation is a very private act,
and a lack of privacy can contribute to constipation.
In older clients, routinely advise consumption of ?uids, fruits, and vegetable
s as part of the diet, and
ambulation if the client is able. Introduce a bowel management program at the ?r
st sign of constipation.
Constipation is a major problem for terminally ill or hospice clients, who may n
eed very high doses of opioids
for pain management (Sykes, 2006).
? Refer for consideration of the use of polyethylene glycol 3350 (PEG-3350) for
constipation. CEB: In a
study of PEG-3350 use for idiopathic constipation, researchers concluded that it
appeared to be safe and ef?cacious when dietary and lifestyle changes were ineffective. Clients reported incr
eased perceived bowel control,
with reduced complaints of straining, stool hardness, bloating, and gas (Stoltz
et al, 2001). There is good evidence to support the use of PEG for chronic constipation (Ramkumar & Rao, 2005).
Advise the client against attempting to remove impacted feces on his or her ow
n. Older or confused clients
in particular may attempt to remove feces and cause rectal damage.
243
= Independent
B = Evidence-Based
244
? = Collaborative
Constipation
When using a bowel program, establish a pattern that is very regular and allows
the client to be part of the
family unit. Regularity of the program promotes psychological and/or physiologic
al readiness to evacuate stool.
Families of home care clients often cannot proceed with normal daily activities
until bowel programs are complete.
C
REFERENCES
Instruct the client on normal bowel function and the need for adequate ?uid and
?ber intake, activity, and
a de?ned toileting pattern in a bowel program.
Encourage the client to heed defecation warning signs and develop a regular sch
edule of defecation by
using a stimulus such as a warm drink or prune juice. Most cases of constipation
are mechanical and result
from habitual neglect of impulses that signal the appropriate time for defecatio
n.
Encourage the client to avoid long-term use of laxatives and enemas and to grad
ually withdraw from their
use if they are used regularly. Use of stimulant laxatives should be avoided; lo
ng-term use can result in dependence on laxative for defecation (Roerig et al, 2010).
If not contraindicated, teach the client how to do bent-leg sit-ups to increase
abdominal tone; also encourage the client to contract the abdominal muscles frequently throughout the day.
Help the client develop a
daily exercise program to increase peristalsis.
Andersen C, et al: The effect of a multidimensional exercise programme

on symptoms and side-effects in cancer patient undergoing
chemotherapy the use of semi-structured diaries, Eur J Oncol Nurs
10:247 262, 2006.
Annells M, Koch T: Older people seeking solutions to constipation: the
laxative mire, J Clin Nurs 11:603, 2002.
Attaluri A, et al: Randomised clinical trial: dried plums (prunes) vs psyllium for constipation, Aliment Pharmacol Ther 33:822 828, 2011.
Benton JM, et al: Changing bowel hygiene practice successfully: a program to reduce laxative use in a chronic care hospital, Geriatr Nurs
18(1):12 17, 1997.
Cardin F, et al: Constipation in the acutely hospitalized older patients,
Arch Gerontol Geriatr 50:277 281, 2010.
Coggrave MJ, Norton C: The need for manual evacuation and oral
laxatives in the management of neurogenic bowel dysfunction after
spinal cord injury: a randomized controlled trial of a stepwise protocol, Spinal Cord 48:504 510, 2010.
Davies EC, et al: The use of opioids and laxatives, and incidence of
constipation, in patients requiring neck-of-femur (NOF) surgery: a
pilot study, J Clin Pharm Ther 33:561 566, 2008.
DeSchryver AM, et al: Effects of regular physical activity on defecation
pattern in middle-aged patients complaining of chronic constipation, Scand J Gastroenterol 40:422 429, 2005.
Dukas L, Willett WC, Giovannucci EL: Association between physical
activity, ?ber intake, and other lifestyle variables and constipation in
a study of women, Am J Gastroenterol 98(8):1790 1796, 2003.
Eoff JC, Lembo AG: Optimal treatment of chronic constipation in managed care: review and roundtable discussion, J Managed Care Pharm
(Suppl) 14(9-a):S1 S17, 2008.
Gallagher PF, O Mahony D, Quigley MM: Management of chronic
constipation in the elderly, Drugs Aging 25(10):807 821, 2008.
Godfrey JR, Rose S: Conversations with the experts: toward optimal
health: Suzanne Rose, MD, MSEd, discusses management of constipation in women, J Womens Health 16(9):1252 1257, 2007.
Greenwood-Van Meerveld B, Standifer KM: Methylnaltrexone in the
treatment of opioid-induced constipation, Clin Exp Gastroenterol
49-58:2008, 2008.
Hongisto S-M, et al: A combination of ?bre-rich rye bread and yoghurt
containing Lactobacillus GG improves bowel function in women
with self-reported constipation, Eur J Clin Nutr 60:319 324, 2006.
Howard LV, West D, Ossip-Klein DJ: Chronic constipation management for institutionalized older adults, Geriatr Nurs 21(2):78, 2000.
Joanna Briggs Institute: Management of constipation in older adults,
Aust Nurs J 16(5):32 35, 2008.
Jones MP, et al: Brain-gut connections in functional GI disorders:
anatomic and physiologic relationships, Neurogastrointest Motil
18:91 103, 2006.
Klauser AG, et al: Behavioral modi?cation of colonic function. Can
constipation be learned? Dig Dis Sci 35(10):1271 1275, 1990.
Kyle G: Constipation and palliative care where are we now? Int J Palliat Nurs 13(1):6 16, 2007.
Kyle G: Methylnaltrexone: a subcutaneous treatment for opioidinduced constipation in palliative care patients, Int J Palliat Nurs
15(11):533 540, 2009.
Kyle G: Risk assessment and management tools for constipation, Br J
Community Nurs 16(5):224 230, 2011.
Michna E, et al: Subcutaneous methylnaltrexone for treatment of
opioid-induced constipation in patients with chronic, nonmalignant
pain: a randomized controlled study, J Pain 12(5):554 562, 2011.

Mller-Lissner SA, et al: The perceived effect of various foods and beverages on stool consistency, Eur J Gastroenterol Hepatol 17:109 112,
2005.
Rao SSC, Kavolic R, Rao S: In?uence of body position and stool
characteristics on defecation in humans, Am J Gastroenterol
206(101):2790 2796, 2006.
Ramkumar D, Rao SS: Ef?cacy and safety of traditional medical therapies for chronic constipation: systematic review, Am J Gastroenterol
100(4):936 971, 2005.
Roerig JL, et al: Laxative abuse: epidemiology, diagnosis and management,
Drugs 70(12):1487 1503, 2010. doi; 10.2165/11898640-00000000000000.
Schmelzer M, et al: Colonic cleansing, ?uid absorption, and discomfort
following tap water and soapsuds enemas, Appl Nurs Res 13(2):83,
2000.
Schmelzer M, et al: Safety and effectiveness of large-volume enema solutions, Appl Nurs Res 17(4):265 274, 2004.
Schnelle JF, et al: A controlled trial of an intervention to improve
urinary and fecal incontinence and constipation, J Am Geriatr Soc
58(8):1504 1511, 2010.
Sikirov D: Comparison of straining during defecation in three positions:
results and implications for human health, Dig Dis Sci 48(7):1201
1205, 2003.
Spinzi G, et al: Constipation in the elderly, Drugs Aging 26(6):469 474,
2009.
= Independent
B = Evidence-Based
? = Collaborative
Perceived constipation
245
Stolz R, et al: An ef?cacy and consumer preference study of polyethylene glycol 3350 for the treatment of constipation in regular laxative
users, Home Health Consult 8(2):21, 2001.
Sturtzel B, Elmadfa I: Intervention with dietary ?ber to treat constipation and reduce laxative use in residents of nursing homes, Ann
Vuksan V, et al: Using cereal to increase dietary ?ber intake to the
recommended level and the effect of ?ber on bowel function in
healthy persons consuming North American diets, Am J Clin Nutr
88:1256 1262, 2008.
Wald A, et al: A multinational survey of prevalence and patterns of

Nutr Metab 52(suppl 1):54 56, 2008.
Sykes NP: The pathogenesis of constipation, J Support Oncol 4(5):213
218, 2006.
Tack J, et al: Diagnosis and treatment of chronic constipation a European perspective, Neurogastroenterol Motil 23:697 710, 2011.
Tagart REB: The anal canal and rectum: their varying relationship and
its effect on anal continence, Dis Colon Rectum 9(6):449 452, 1966.
Thomas J, et al: Methylnaltrexone for opioid-induced constipation in
advanced illness, N Engl J Med 358(22):2332 2343, 2008.
Venn MR: The in?uence of timing and suppository use on ef?ciency
and effectiveness of bowel training after a stroke, Rehabil Nurs
17(3):116 121, 1992.
laxative use among adults with self-de?ned constipation, Aliment
Pharmacol Ther 28:917 930, 2008.
Whitehead WE, et al: Conservative and behavioural management of
constipation, Neurogastroenterol Motil 2(21(Suppl):55 61, 2009.
Wilcox CS, et al: An open-label study of naltrexone and bupropion
combination therapy for smoking cessation in overweight and obese
subjects, Addict Behav 35(3):229 234, 2010.
Zhou L, et al: Functional constipation: implications for nursing interventions, J Clin Nurs 19:1838 1843, 2010.
C
Perceived Constipation
Betty Ackley, MSN, EdS, RN, and Marilee Schmelzer, PhD, RN

NANDA-I
De?nition
Self-diagnosis of constipation and abuse of laxatives, enemas, and suppositories
to ensure a daily bowel
movement
Expectation of a daily bowel movement that results in overuse of laxatives, enem
as, and suppositories; expectation of a passage of stool at same time every day
Cultural or family health beliefs, faulty appraisals (long-term expectat
ions/habits), impaired thought
processes
NOC
Bowel Elimination, Health Beliefs, Health Beliefs: Perceived Threat
Bowel Elimination as evidenced by the following indicators: Elimination pattern/
Stool soft and formed/ Passage of stool
without aids/Ease of stool passage. (Rate each indicator of Bowel Elimination: 1
= severely compromised, 2 = substantially
compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not comprom
ised [see Section I].)
Client Outcomes
Regularly defecate soft, formed stool without use of aids
Explain the need to decrease or eliminate the use of stimulant laxatives, suppo
sitories, and enemas
Identify alternatives to stimulant laxatives, enemas, and suppositories for ens
uring defecation
Explain that defecation does not have to occur every day
NIC
Bowel Management; Medication Management
= Independent
B = Evidence-Based
246
? = Collaborative
Example NIC Activities Bowel Management

Note preexistent bowel problems, bowel routine, and use of laxatives; Initiate a
bowel training program, as appropriate
C
Have the client keep a 7-day diary of bowel habits, including information such
as time of day; usual stimulus; consistency, amount, and frequency of stool; dif?culty defecating; ?uid con
sumption; and use of any
aids to defecation. Health care providers de?ne constipation mainly in terms of
frequency, but those affected
are more concerned about hard stool and discomfort and straining when attempting
to defecate (Wald et al,
2008). CEB & EB: A diary of bowel habits is valuable in treatment of constipatio
n; the use of a diary has proven
to be more accurate than client recall in determining the presence of constipati
on (Andersen et al, 2006). A
bowel diary was shown to be helpful for clients with opioid-induced constipation
(Camilleri et al, 2010).
Determine the client s perception of an appropriate defecation pattern. The clie
nt may need to be taught
that one bowel movement every 1 to 3 days is normal (Mayo Foundation for Medical
Education and Research,
2011a).
Recognize the emotional in?uences (e.g., depression and anxiety) on defecation
. The relationship between
emotions and bowel function can be explained as stress-mediated brain-gut dysfun
ction and can range from
altered stress-induced mucosal immune function to impaired ability of the centra
l nervous system to down-
regulate incoming gut or body afferent signals (Drossman, 2011). Dif?culties wit
h defecation often begin in
childhood (e.g. during toilet training) (van Dijk et al, 2007), and constipation
is also associated with sexual
and physical abuse, depression, and anxiety (Whitehead et al, 2009). EBN: In a s
tudy, clients with functional
constipation were compared to normal controls; subjects with functional constipa
tion had signi?cantly higher
anxiety and depression scores (Zhou et al, 2010).
Monitor the use of laxatives, suppositories, or enemas and suggest replacing t
hem with increased ?ber
intake along with increased ?uids to 2 L/day. Use of stimulant laxatives should
be avoided; long-term use can
result in dependence on laxative for defecation. In elderly clients with heart f
ailure, use of laxatives containing
magnesium can lead to hypermagnesemia and possibly result in increased mortality
(Corbi et al, 2008) An
increase in ?ber intake to 20 to 30 g/day along with an increase in ?uid intake
can help clients with chronic
constipation (Sturtzel & Elmadfa, 2008).
Encourage ?ber intake of 20 g/day (for adults) ensuring that the ?ber is palat
able to the individual and that
?uid intake is adequate. Add ?ber gradually to decrease bloating and ?atus. Some
people with eating disorders
do not eat enough ?ber to produce stools. Larger stools move through the colon f
aster than smaller stools, and dietary
?ber makes stools bigger because it is undigested in the upper intestinal tract.
Fiber fermentation by bacteria in the
colon produces gas. The effectiveness of water-insoluble ?bers (e.g., wheat bran
) on bowel function is well supported
by research, and there is growing evidence that water-soluble ?bers (e.g., gluco
mannan and psyllium) also promote
laxation (Vuksan et al., 2008). For further information on use of ?ber, please r
efer to care plan Constipation.
Use a mixture of bran cereal, applesauce, and prune juice; begin administratio
n in small amounts and
gradually increase amount. Keep refrigerated. Always check with the primary care
practitioner before
initiating this intervention. It is important that the client also ingest suf?ci
ent ?uids. EBN & CEB: This
bran mixture has been shown to be effective even with short-term use in elderly
clients recovering from acute
conditions; however, it has not been tested with an RCT (Joanna Briggs Institute
, 2008). NOTE: Giving ?ber
without suf?cient ?uid has resulted in worsening of constipation (Mller-Lissner e
t al, 2005).
Teach clients to respond promptly to the defecation urge. CEB: A study of male
volunteers determined that the
defecation urge can be delayed and that delaying defecation decreased bowel move
ment frequency, stool weight, and
transit time (Klauser et al, 1990). The re?ex that causes the urge to defecate d
iminishes after a few minutes and may
remain quiet for several hours; as a result, the stool becomes hardened and more
dif?cult to expel.
? Obtain a referral to a dietitian for analysis of the client s diet and input on
how to improve the diet to
ensure adequate ?ber intake and nutrition.
? Assess for signs of depression, other psychological disorders, and a history
of physical or sexual abuse.
Often, people with functional constipation have experienced physical or sexual a
buse, and symptoms of constipation may arise from psychological problems (O Brien et al, 2009). EB: A study
found that somatic complaints of constipation were common in people with depression (Afridi, Siddiqi,
& Ansari, 2009).
Encourage the client to increase activity, walking for at least 30 minutes at
least 5 days a week as tolerated.
Decreased mobility leads to constipation, but additional exercise does not help
the constipated person who is
already mobile. When the client has diminished mobility, even minimal activity i
ncreases peristalsis, which is
= Independent
B = Evidence-Based
? = Collaborative
necessary to prevent constipation (Joanna Briggs Institute, 2008). EB: A program
of increased toileting assistance, increased exercise, and choice of food and ?uid snacks every 2 hours for
8 hours per day over 3 months
resulted in increased number of stools for nursing home residents (Schnelle et a
l, 2010).
? Observe for the presence of an eating disorder, the use of laxatives to contr
ol or decrease weight; refer for
counseling if needed. People with eating disorders suffer from constipation and
other gastrointestinal symptoms, or use laxatives as part of inducing weight loss (Roerig et al, 2010). CEB
: Laxative abuse is found in
clients with both anorexia and bulimia nervosa and may be associated with worsen
ing of the eating disorder
as a form of self-harm (Tozzi et al, 2006).
Home Care
Take complaints seriously and evaluate claims of constipation in a matter-of-fa
ct manner. Continued
constipation can lead to bowel obstruction, a medical emergency. Presence of a p
attern of perceived constipation does not mean actual constipation cannot occur. However, use of a matter-of
-fact manner will limit positive reinforcement of the behavior.
Obtain family and client histories of bowel or other patterned behavior proble
ms. History may reveal a
psychological cause for the constipation (e.g., withholding) (van Dijk et al, 20
07).
Observe family cultural patterns related to eating and bowel habits. Cultural
patterns may control bowel
habits.
Encourage a mindset and program of self-care management. Elicit from the client
the self-talk he or she
uses to describe body perceptions; correct fatalistic interpretations.
Instruct the client in a healthy lifestyle that supports normal bowel function
(e.g., activity, ?uid intake,
diet) and encourage progressive inclusion of these elements into daily activitie
s.
Discuss the client s self-image. Help the client to reframe the self-concept as
capable. Developing the ability
to see themself as capable of self-care management may take time, as will making
lifestyle changes.
Instruct the client and family in appropriate expectations for having bowel mo
vements.
Offer instruction and reassurance regarding explanations for variation from th
e previous pattern of bowel
movements. The client may have unrealistic expectations regarding the frequency
or type of bowel movements
and may assume that constipation exists when there is a reasonable explanation f
or deviation from the past
pattern. The client may resort to the use of laxatives inappropriately.
Contract with the client and/or a responsible family member regarding the use
of laxatives. Have the client maintain a bowel pattern diary. Observe for diarrhea or frequent evacuation.
Intermittent care does not
allow for 24-hour supervision. Contracting allows guided control of care by the
client in partnership with the
nurse, and the diary promotes more accurate reporting.
? Teach the family to carry out the bowel program per the physician s orders.
? Refer for home health aide services to assist with personal care,
including the bowel program, if
appropriate.
Identify a contingency plan for bowel care if the client is dependent on outsi
de persons for such care.
Explain normal bowel function and the necessary ingredients for a regular bowel
regimen (e.g., ?uid,
?ber, activity, and regular schedule for defecation).
Work with the client and family to develop a diet that ?ts the client s lifestyle
and includes increased ?ber.
Teach the client that it is not necessary to have daily bowel movements and tha
t the passage of anywhere
from three stools each day to three stools each week is considered normal. Expla
in to the client the harmful effects of the continual use of defecation aids such laxatives and enemas. La
zy bowel syndrome may
occur if laxatives are used too frequently, causing the bowels to become depende
nt on laxatives to stimulate a
bowel movement. Overuse of laxatives can also lead to poor absorption of vitamin
s and other nutrients and
damage to the gastrointestinal tract (Mayo Foundation for Medical Education and
Research, 2011b). Frequent use of enemas can result in harm including absorption of bacteria and toxi
ns (Seow-Choen, 2009).
Encourage the client to gradually decrease the use of the usual laxatives and o
r enemas, and recognize it
may take months for the process to do it gradually.
Determine a method of increasing the client s ?uid intake and ?t this practice in
to client s lifestyle.
Explain what Valsalva maneuver is and why it should be avoided.
247
= Independent

B = Evidence-Based
248
? = Collaborative
Risk for constipation
Work with the client and family to design a bowel training routine that is base
d on previous patterns
(before laxative or enema abuse) and incorporates the consumption of warm ?uids,
increased ?ber, and
increased ?uids; privacy; and a predictable routine.
C
REFERENCES
Refer care plan for Constipation for additional Nursing Interventions, Rational
es, and Client/Family
Teaching and Discharge Planning.
Afridi MI, Siddiqui MA, Ansari A: Gastrointestinal somatization
in males and females with depressive disorder, J Pak Med Assoc
59(10):675 679, 2009.
Andersen C, et al: The effect of a multidimensional exercise programme
on symptoms and side-effects in cancer patient undergoing
chemotherapy the use of semi-structured diaries, Eur J Oncol Nurs
10:247 262, 2006.
Camilleri M, et al: Validation of a bowel function diary for assessing
opioid-induced constipation, Am J Gastroenterol 106(3):497 506, 2011.
Corbi G, et al: Hypermagnesemia predicts mortality in elderly with
congestive heart disease: relationship with laxative and antacid use,
Rejuv Res 11(1):129 138, 2008.
Drossman DA: Abuse, trauma, and GI illness: is there a link? Am J
Gastroenterol 106(1):14 25, 2011.
Eoff JC, Lembo AJ: Optimal treatment of chronic constipation in man-
aged care: review and roundtable discussion, J Manage Care Pharm

(Suppl) 14(9a):S1 S17, 2008.
Joanna Briggs Institute: Management of constipation in older adults,
Aust Nurs J 16(5):32 35, 2008.
Klauser AG, et al: Behavioral modi?cation of colonic function. Can
constipation be learned? Dig Dis Sci 35(10):1271 1275, 1990.
Mayo Foundation for Medical Education and Research: Constipation:
diseases and conditions, 2011a. Retrieved October 30, 2011, from
http://www.mayoclinic.com/health/constipation/DS00063/
DSECTION=symptoms.
Mayo Foundation for Medical Education and Research: Constipation.
Complications, diseases, and condition, 2011b. Retrieved October 30,
2011, from http://www.mayoclinic.com/health/constipation/
DS00063/DSECTION=complications.
Mller-Lissner SA, et al: Myths and misconceptions about constipation,
Am J Gastroenterol 100(1):232 242, 2005.
O Brien S, et al: Sexual abuse: a strong predictor of outcomes after
colectomy for slow-transit constipation, Dis Colon Rectum
52(11):1844 1847, 2009.
Roerig JS, et al: Laxative abuse: epidemiology, diagnosis and management, Drugs 70(12):1487 1503, 2010.
Schnelle JF, et al: A controlled trial of an intervention to improve
urinary and fecal incontinence and constipation, J Am Geriatr Soc
58(8):1504 1511, 2010.
Seow-Choen F: The physiology of colonic hydrotherapy, Colorectal Dis
11(7):686 688, 2009.
Sturtzel B, Elmadfa I: Intervention with dietary ?ber to treat constipation and reduce laxative use in residents of nursing homes, Ann
Nutr Metab 52(Suppl 1):54 56, 2008.
Tozzi F, et al: Features associated with laxative abuse in individuals with
eating disorders, Psychosomat Med 68(3):470 477, 2006.
van Dijk M, et al: Chronic childhood constipation: a review of the literature and the introduction of a protocolized behavioral intervention program, Patient Educ Couns 67:63 77, 2007.
Vuksan V, et al: Using cereal to increase dietary ?ber intake to the
recommended level and the effect of ?ber on bowel function in
healthy persons consuming North American diets, Am J Clin Nutr
88:1256 1262, 2008.
Wald A, et al: A multinational survey of prevalence and patterns of
laxative use among adults with self-de?ned constipation, Aliment
Pharmacol Ther 28:917 930, 2008.
Whitehead WE, et al: Conservative and behavioural management of
constipation, Neurogastroenterol Motil 21(Suppl 2):55 61, 2009.
Zhou L, et al: Functional constipation: implications for nursing interventions, J Clin Nurs 19:1838 1843, 2010.
Risk for Constipation

NANDA-I
De?nition
At risk for a decrease in normal frequency of defecation accompanied by dif?cult
or incomplete passage of
stool and/or passage of excessively hard, dry stool

Risk Factors
Functional
Abdominal weakness; habitual denial/ignoring of urge to defecate; recent environ
mental changes; inadequate toileting (e.g., timeliness, positioning for defecation, privacy); irregul
ar defecation habits; insuf?cient
physical activity
Psychological
Depression; emotional stress; mental confusion
= Independent
B = Evidence-Based
? = Collaborative
Contamination
Physiological
Change in usual eating patterns, change in usual foods, decreased motility of ga
strointestinal tract, dehydration, inadequate dentition, inadequate oral hygiene, insuf?cient ?ber intake, in
suf?cient ?uid intake, poor
eating habits
Pharmacological
Aluminum-containing antacids, anticholinergics, anticonvulsants, antidepressants
, antilipemic agents, bismuth salts, calcium carbonate, calcium channel blockers, diuretics, iron salts,
laxative overuse, nonsteroidal
antiin?ammatory drugs, opioids, phenothiazines, sedatives, and sympathomimetics
Mechanical
Electrolyte imbalance, hemorrhoids, Hirschsprung s disease, neurological impairmen
t, obesity, postsurgical
obstruction, pregnancy, prostate enlargement, rectal abscess, rectal anal ?ssure
s, rectal anal stricture, rectal
prolapse, rectal ulcer, rectocele, tumors
ales,
and References
Refer to care plans for Constipation.
249
Contamination
Laura V. Polk, PhD, RN, and Pauline M. Green, PhD, RN, CNE
NANDA-I
De?nition
Exposure to environmental contaminants in doses suf?cient to cause adverse healt
h effects
Pesticides
Dermatological effects of pesticide exposure; gastrointestinal effects of
pesticide exposure; neurological
effects of pesticide exposure; pulmonary effects of pesticide exposure; renal ef
fects of pesticide exposure;
major categories of pesticides: insecticides, herbicides, fungicides, antimicrob
ials, rodenticides; major pesticides: organophosphates, carbamates, organochlorines, pyrethrum, arsenic,
glycophosphates, bipyridyls,
chlorophenoxy
Chemicals
Dermatological effects of chemical exposure; gastrointestinal effects of
chemical exposure; immunologic
effects of chemical exposure; neurological effects of chemical exposure; pulmona
ry effects of chemical exposure; renal effects of chemical exposure; major chemical agents: petroleum-based
agents, anticholinesterases
type I agents act on proximal tracheobronchial portion of the respiratory tract,
type II agents act on alveoli;
type III agents produce systemic effects
Biologicals
Dermatological effects of exposure to biologics; gastrointestinal effects of exp
osure to biologics; pulmonary
effects of exposure to biologics; neurological effects of exposure to biologics;
renal effects of exposure to
biologics (toxins from organisms [bacteria, viruses, fungi])
Pollution
Neurological effects of pollution exposure; pulmonary effects of pollution expos
ure (major locations: air,
water, soil; major agents: asbestos, radon, tobacco, heavy metal, lead, noise, e
xhaust)
Waste
Dermatological effects of waste exposure; gastrointestinal effects of waste expo
sure; hepatic effects of waste
exposure; pulmonary effects of waste exposure (categories of waste: trash, raw s
ewage, industrial waste)
= Independent
B = Evidence-Based
? = Collaborative
250
Contamination
Radiation
External exposure through direct contact with radioactive material; genetic effe
cts of radiation exposure;
immunologic effects of radiation exposure; neurological effects of radiation exp
osure; oncological effects of
radiation exposure
C
External
Chemical contamination of food; chemical contamination of water; exposure to bio
terrorism; exposure to
disasters (natural or human-made); exposure to radiation (occupation in radiolog
y; employment in nuclear
industries and electrical generating plants; living near nuclear industries and/
or electrical generating plants);
exposure through ingestion of radioactive material (e.g., food/water contaminati
on); ?aking, peeling paint
in presence of young children; ?aking, peeling plaster in presence of young chil
dren; ?oor surface (carpeted
surfaces hold contaminant residue more than hard ?oor surfaces); geographic area
(living in area where high
level of contaminants exist); household hygiene practices; inadequate municipal
services (trash removal,
sewage treatment facilities); inappropriate use of protective clothing; lack of
breakdown of contaminants
once indoors (breakdown is inhibited without sun and rain exposure); lack of pro
tective clothing; lacquer in
poorly ventilated areas; lacquer without effective protection; living in poverty
(increases potential for multiple exposure, lack of access to health care, poor diet); paint in poorly venti
lated areas; paint without effective protection; personal hygiene practices; playing in outdoor areas where envi
ronmental contaminants are
used; presence of atmospheric pollutants; use of environmental contaminants in t
he home (e.g., pesticides,
chemicals, environmental tobacco smoke); unprotected contact with chemicals (e.g
., arsenic); unprotected
contact with heavy metals (e.g., chromium, lead)
Internal
Age (children <5 years, older adults); concomitant exposures; developmental char
acteristics of children;
female gender; gestational age during exposure; nutritional factors (e.g., obesi
ty, vitamin and mineral de?ciencies); preexisting disease states; pregnancy; previous exposures; smoking
NOC
Community Health Status, Family Physical Environment, Anxiety Level, Fear Level
Community Health Status as evidenced by the following indicators: Evidence of he
alth protection measures/Compliance
with environmental health standards/Health status of population. (Rate the outco
me and indicators of Community Health
Status: 1 = poor, 2 = fair, 3 = good, 4 = very good, 5 = excellent [see Section

I].)
Client Outcomes
Have minimal health effects associated with contamination
Cooperate with appropriate decontamination protocol
Participate in appropriate isolation precautions
Community Will (Specify Time Frame):
Utilize health surveillance data system to monitor for contamination incidents
Utilize disaster plan to evacuate and triage affected members
Have minimal health effects associated with contamination
NIC
Triage: Disaster, Infection Control, Anxiety Reduction, Crisis Intervention, Hea
lth Education
= Independent
B = Evidence-Based
? = Collaborative
Contamination
Example NIC Activities Triage: Disaster
Initiate appropriate emergency measures, as indicated; Monitor for and treat lif
e-threatening injuries or acute needs
? Help individuals cope with contamination incident by doing the following:
Use groups that have survived terrorist attacks as useful resource for victims
Provide accurate information on risks involved, preventive measures, use of anti
biotics, and vaccines
Assist to deal with feelings of fear, vulnerability, and grief
Encourage individuals to talk to others about their fears
Assist victims to think positively and to move toward the future
CEB: A crisis situation follows a predictable course in which individuals progre
ss in response to a precipitating
stressor and that culminate in a state of acute crisis. Interventions aimed at s
upporting an individual s coping
help the person deal with feelings of fear, helplessness, and loss of control th
at are normal reactions in a crisis
situation (Boscarino et al, 2006; Caplan, 1964).
Triage, stabilize, transport, and treat affected community members. CEB: Accur
ate triage and early treatment provide the best chance of survival to affected persons (Murdoch & Cymet, 2
006; Veenema, 2007).
Utilize approved procedures for decontamination of persons, clothing, and equip
ment. Victims may ?rst
require decontamination prior to entering health facility to receive care in ord
er to prevent the spread of contamination (U.S. Army Medical Research Institute of Infectious Diseases, 2005).
Utilize appropriate isolation precautions: universal, airborne, droplet, and c

ontact isolation. Proper use of
isolation precautions prevents cross-contamination by contaminating agents (U.S.
Army Medical Research
Institute of Infectious Diseases, 2005).
Monitor individual for therapeutic effects, side effects, and compliance with
postexposure drug therapy.
Drug therapy may extend over a long period of time and will require monitoring f
or compliance as well as
therapeutic and side effects (Veenema, 2007).
? Collaborate with other agencies (local health department, emergency medical s
ervice [EMS], state and
federal agencies). Communication among agencies increases ability to handle cris
is ef?ciently and correctly
(CDC, 2009; Veenema, 2007).
Geriatric
Help the client identify age-related factors that may affect response to contam
ination incidents.
Encourage family members to acknowledge and validate the client s concerns. Valid
ation alleviates anxiety
and increases client s ability to cope (Boscarino et al, 2006).
Advise the elderly to follow public notices related to drinking water. Contamin
ated water can harm the
health of older persons and those with chronic conditions (EPA, 2009).
Encourage older adults to receive in?uenza vaccination when it is available beg
inning as early as late
August and continuing through the end of February. This administration schedule
is cost effective, and
comorbidities increase a person s risk of in?uenza and in?uenza-related complicati
ons (Lee et al, 2009).
Pediatric
Provide environmental health hazard information. Developing children are more v
ulnerable to environmental toxicants due to greater and longer exposure and particular susceptibilit
y windows (Children s Environmental Health Network, 2006).
Caution families to avoid having children play in streams following heavy rainf
all. Exposure to microbial
water contamination after periods of heavy rainfall is linked to an increase in
acute gastrointestinal illnesses in
children (Drayna et al, 2010).
Multicultural
Ask about use of imported or culture-speci?c products. Immigrant children are a
t increased risk of contamination, particularly from lead, related to exposure to imported cul
ture-speci?c products (Lin et al,
2010).
Assess exposure to multiple pollutants, pre-existing disease, poor nutrition, s
ubstandard housing, and
limited access to health care. These factors related to lower socioeconomic stat
us increase Latino children s
susceptibility to environmental contaminants (Carter-Pokras et al, 2007).
251
C
= Independent
B = Evidence-Based
252
? = Collaborative
Risk for contamination
Nurses need to consider the cultural and social factors that impact access to a
nd understanding of the
health care system, particularly for groups such as migrant workers who do not h
ave consistent care providers EB: Subtle cultural biases in how nurses approach care can affect outcome
s (Holmes, 2006).
C
REFERENCES
Home Care
Assess current environmental stressors and identify community resources. Access
ing resources decreases
stress and increases ability to cope (Boscarino et al, 2006).
Residential settings may present household related hazards that impact health s
uch as spread of nosocomial infections and unsanitary, unsafe conditions (Gershon et al, 2008).
Provide truthful information to the person or family affected.
Discuss signs and symptoms of contamination.
Explain decontamination protocols.
Explain need for isolation procedures.
Well-managed efforts at communication of contamination information ensure that m

essages are correctly
formulated, transmitted, and received and that they result in meaningful actions
(ATSDR, 2006).
Emphasize the importance of pre- and postexposure treatment of contamination. E
arly treatment will
decrease associated complications related to contamination (ATSDR, 2010).
Agency for Toxic Substances and Disease Registry (ATSDR): A primer
on health risk communication: principles and practices. Overview of
issues and guiding principles, 2006. Retrieved April 1, 2009, from
http://www.atsdr.cdc.gov/risk/-riskprimer/vision.html.
Agency for Toxic Substances and Disease Registry (ATSDR): Medical
management guideline for parathion, 2010. Retrieved August 2, 2011,
from http://www.atsdr.cdc.gov/MMG/MMG.asp?id=1140&tid=246.
Boscarino J, et al: Fear of terrorism and preparedness in New York
City 2 years after the attacks: implications for disaster planning and
research, J Public Health Manag Pract 12(6):505 513, 2006.
Caplan G: Principles of preventive psychiatry, New York, 1964, Basic Books.
Carter-Pokras O, et al: The environmental health of Latino children,
J Pediatr Healthc 21(5):307 314, 2007.
Centers for Disease Control and Prevention (CDC): Emergency preparedness & response, 2009. Retrieved March 19, 2009, from http://
www.bt.cdc.gov.
Children s Environmental Health Network: Resource guide on children s
environmental health, 2006, Retrieved March 19, 2009, from
http://www.cehn.org/cehn/-resourceguide/rgtoc.html.
Drayna P, et al: Association between rainfall and pediatric emergency
department visits for acute gastrointestinal illness, Environ Health
Perspect 118:1439 1443, 2010.
Environmental Protection Agency (EPA): Fact sheet: Water works:
information for older adults and family caregivers (publication no.
EPA-100-F-09 044), 2009.
Gershon R, et al: Home health care patients and safety hazards in the
home: preliminary ?ndings, Rockville, MD, 2008, Agency for Healthcare Research and Quality (AHRQ).
Holmes SM: An ethnographic study of the social context of migrant
health in the United States, PLoS Med 3(10):e448, 2006.
Lee BY, et al: The timing of in?uenza vaccination for older adults
(65 years and older), Vaccine 27(50):7110 7115, 2009.
Lin CG, et al: Pediatric lead exposure from imported Indian spices and
cultural powders, Pediatrics 125(4):e828 e835, 2010.
Murdoch S, Cymet TC: Treating victims after disaster: physical and
psychological effects, Compr Ther 32(1):39 42, 2006.
U.S. Army Medical Research Institute of Infectious Diseases: USAMRIID s medical management of biological casualties handbook, ed 6,
Fort Detrick, MD, 2005, Author.
Veenema TG: Disaster nursing and emergency preparedness for chemical,
biological and radiological terrorism and other hazards, ed 2, New
York, 2007, Springer.
Risk for Contamination
Laura V. Polk, PhD, RN, and Pauline M. Green, PhD, RN, CNE
NANDA-I
De?nition
Accentuated risk of exposure to environmental contaminants in doses suf?cient to
cause adverse health
effects
Risk Factors
See Related Factors in Contamination care plan.
= Independent
B = Evidence-Based
? = Collaborative
Risk for contamination

NOC
Risk Control, Health Beliefs: Perceived Threat, Knowledge: Health Resources, Kno
wledge: Health Behavior,
Community Disaster Readiness, Community Health Status. See Contamination for oth
er possible NOC
outcomes.
Risk Control as evidenced by the following indicators: Monitors environmental ri
sk factors/Avoids exposure to health threats/Follows selected risk control strategies. (Rate the outcome and indicators of Risk
Control: 1 = never demonstrated, 2 = rarely
demonstrated, 3 = sometimes demonstrated, 4 = often demonstrated, 5 = consistent
ly demonstrated [see Section I].)
Client Outcomes
Remain free of adverse effects of contamination
Utilize health surveillance data system to monitor for contamination incidents
Participate in mass casualty and disaster readiness drills
Remain free of contamination-related health effects
Minimize exposure to contaminants
NIC
Environmental Risk Protection, Bioterrorism Preparedness, Environmental Ma
nagement: Safety, Health
Education, Health Screening, Immunization/Vaccination Management, Risk Ide
nti?cation, Surveillance:
Safety, Community, Communicable Disease Management, Community Disaster Preparedn
ess, Health Policy Monitoring
Example NIC Activities Environmental Risk Protection

Assess environment for potential and actual risk; Monitor incidents of illness a
nd injury related to environmental hazards
? Conduct surveillance for environmental contamination. Notify agencies authori
zed to protect the environment of contaminants in the area. Early surveillance and detection are critic
al components of preparation
(Murdoch & Cymet, 2006; Veenema, 2007)
Assist individuals to modify the environment to minimize risk or assist in relo
cating to safer environment.
Modi?cation of the environment will decrease the risk of actual contamination oc
curring (Veenema & Toke,
2006).
Schedule mass casualty and disaster readiness drills. Practice in handling cont
amination occurrences will
decrease the risk of exposure during actual contamination events (Chung & Shanno
n, 2005).
Provide accurate information on risks involved, preventive measures, use of ant
ibiotics, and vaccines.
Well-managed efforts at communication of contamination information ensure that m
essages are correctly
formulated, transmitted, and received, and that they result in meaningful action
s (ATSDR, 2006).
Assist to deal with feelings of fear and vulnerability. EB: Interventions aimed
at supporting an individual s
coping help the person deal with feelings of fear, helplessness, and loss of con
trol that are normal reactions in a
crisis situation (Boscarino et al, 2006).
For more interventions including Pediatric, Geriatric, Multicultural, and Home
Care, see the Contamination care plan.
253
C
= Independent
B = Evidence-Based
254
? = Collaborative
Risk for adverse reaction to iodinated contrast media
REFERENCES
Agency for Toxic Substances and Disease Registry (ATSDR): Medical
management guideline for parathion, 2012. Retrieved August 2, 2011,
from http://www.atsdr.cdc.gov/MMG/MMG.asp?id=1140&tid=246.
Murdoch S, Cymet TC: Treating victims after disaster: physical and
psychological effects, Compr Ther 32(1):39 42, 2006.
Veenema TG: Disaster nursing and emergency preparedness for chemical,
C
Boscarino J, et al: Fear of terrorism and preparedness in New York
City 2 years after the attacks: implications for disaster planning and
research, J Public Health Manag Pract 12(6):505 513, 2006.
Chung S, Shannon M: Hospital planning for acts of terrorism and
other public health emergencies involving children, Arch Dis Child
biological and radiological terrorism and other hazards, ed 2, New
York, 2007, Springer.
Veenema T, Toke J: Early detection and surveillance for biopreparedness and emerging infectious diseases, Online J Issues Nurs 11(1):3,
2006.
90(12):1300 1307, 2005.
Risk for adverse reaction to iodinated Contrast media

NANDA-I
De?nition
At risk for any noxious or unintended reaction associated with the use of iodina
ted contrast media that can
occur within 7 days after contrast agent injection
Risk Factors
Anxiety; concurrent use of medications (e.g., beta-blockers, interleukin-2, metf
ormin, nephrotoxic medications); dehydration; extremes of age; fragile veins (e.g., prior or actual chemo
therapy treatment or radiation
in the limb to be injected, multiple attempts to obtain intravenous access, indw
elling intravenous lines in
place for more than 24 hours, previous axillary lymph node dissection in the lim
b to be injected, distal intravenous access sites: hand, wrist, foot, ankle); generalized debilitation; histor
y of allergies; history of previous
adverse effect from iodinated contrast media; physical and chemical properties o
f the contrast media (e.g.,
iodine concentration, viscosity, high osmolality, ion toxicity); unconsci
ousness; underlying disease (e.g.,
heart disease, pulmonary disease, blood dyscrasias, endocrine disease, renal dis
ease, pheochromocytoma,
autoimmune disease)
NOC
Tissue Perfusion: Renal, Kidney Function

Kidney Function as evidenced by: 24-hour intake and output balance/Blood urea ni
trogen/Serum creatinine/Urine color/Serum
electrolytes. (Rate the outcome and indicators of Kidney Function: 1 = severely
compromised, 2 = substantially compromised, 3 = moderately compromised, 4 = mildly compromised, 5 = not compromised [
see section I].)
Client Outcomes
Maintain normal blood urea nitrogen and serum creatinine levels
Maintain urine output of 0.5 mL/kg/hr
Maintain serum electrolytes (K+, PO4, Na+) within normal limits
NIC
Fluid/Electrolyte Management, Laboratory Data Interpretation
= Independent
B = Evidence-Based
? = Collaborative
Risk for adverse reaction to iodinated contrast media

Example NIC Activities Fluid/Electrolyte Management
Monitor for serum electrolytes levels, as available; Weigh daily and monitor tre
nds; Monitor vital signs, as appropriate. Recognize that
iodinated contrast media can be harmful to clients in a number of ways including
onset of contrast-induced nephropathy, allergic
reactions to the dye, and damage to veins and vascular access devices.
Contrast-Induced Nephropathy (CIN)
? Protect clients from contrast media induced nephropathy by taking the following
actions:
Watching for closely spaced studies using contrast media and consulting with pro
vider for change in
scheduling of studies if needed (Cheung, Ponnusamy & Anderton, 2008). Multiple a
dministration of contrast within 72 hours is considered a risk factor for CIN (O Donovan, 2010).
Notifying the provider and the radiology staff if the client has preexisting ren
al disease. Clients with
preexisting impaired renal function are prone to develop acute contrast media in
duced nephropathy (CIN)
(Schilcher et al, 2011; Wong et al, 2011).
Ensuring that clients having diagnostic testing with contrast are well hydrated
with IV saline as ordered
before and after the examination. EB: Hydration with crystalloids has been shown
to prevent renal insuf?ciency by diluting the IV contrast. Fluids without salt have been shown to incr
ease acute kidney injury
(Rudnick, Goldfarb, & Tumlin, 2008).

Recognize that many clients with decreased renal function are not aware of their
health status, and that
a questionnaire checklist administered before testing may not be satisf
actory to ?nd clients with
impaired renal function that should receive contrast media carefully or who are
not a candidate for testing utilizing contrast media because of possible increased renal dysfunction. EB
: A study found that use
of a pre-procedure checklist was not effective in identifying all the clients wi
th a history of chronic kidney
disease to protect them from further kidney damage; instead point-of-care creati
ne testing was recommended
(Kalisz et al, 2011).
Recognizing that cancer clients are often very vulnerable to contrast induced ne
phropathy due to frequent imaging examinations. Cancer clients have frequent examinations requiring
contrast for tumor staging and assessment of treatment response. In addition the risk is com
pounded by advancing age,
co-administration of nephrotoxic chemotherapy drugs, and dehydration from gastro
intestinal complications
from drugs and radiation (Heiken, 2008).
? Monitor the client carefully for symptoms of hypovolemia following use of con
trast media including
intake and output, blood pressure measurements, and new onset of postural hypote
nsion with dizziness.
Hypovolemia can happen following contrast media administration due to the increa
sed osmolarity of the
contrast media, resulting in postprocedure diuresis (O Donovan, 2011).
? Monitor the client carefully for symptoms of acute failure following use of c
ontrast media including
decreased or normal urinary output, and increased creatinine levels. Contrast me
dia is thought to be
harmful to the kidneys in several ways, through being cytotoxic to the kidney it
self, through ischemia of
the kidneys, and renal cell necrosis. Damage to the kidney results in acute rena
l failure (O Donovan,
2010). See Risk for ineffective Renal Perfusion if CIN is present for further in
terventions regarding
kidney function.
Allergic Reaction to Contrast Media
Recognize that both allergic and anaphylactoid reactions can occur. Anaphylaxis
occurs rapidly, often
within 20 minutes of injection, versus a less serious anaphylactoid reaction, wh
ich can occur later after an
hour. Hypersensitivity reactions can be divided into immediate occurring less th
an 1 hour of administration
and less immediate occurring more than 1 hour after injection (Brockow & Ring, 2
010).
Watch carefully for symptoms of a reaction, which can be either mild, moderate,
or severe. Report all
symptoms to primary care physician because symptoms can advance from mild to sev
ere rapidly.
Mild Reactions: Urticaria, pruritus, rhinorrhea, nausea, emesis, diaphoresis,
coughing, dizziness
Moderate Reactions: Persistent emesis, widespread urticaria, headache, edema o
f the face, laryngeal
edema, mild dyspnea, palpitations, tachycardia/bradycardia, hypertension, abdomi
nal cramps
Severe Reactions: Severe bronchospasm, severe arrhythmias, severe hypotension,

pulmonary edema,
laryngeal edema, seizures, syncope, death (Wilson, 2011)
255
C
= Independent
B = Evidence-Based
256
? = Collaborative
Readiness for enhanced community coping
Vein Damage and Damage to Vascular Access Devices

After diagnostic testing using contrast media given IV, inspect the IV site use
d for administration for possible problems such as extravasation, or development of compartment syndrome wit
h excessive amounts
of contrast pushed into the tissues under pressure. The incidence of serious com
plications associated with the
C
REFERENCES
media has increased since advent of use of power or pressure mechanical injector
s. Unfortunately compartment
syndrome though rare can result in infection, loss of use of the affected extrem
ity, necrosis, skin sloughing,

amputation, need for skin grafting, paralysis, and death (Wilson, 2011).
Recognize that a vascular access device utilized for administration of
contrast media can rupture
from the high pressures utilized to administer the contrast media. The Food and
Drug Administration
(FDA) has received more than 250 adverse event reports in which vascular access
devices have ruptured
when used with power injectors. The adverse events include rupture and device fr
agmentation (Earhart &
McMahon, 2011).
Geriatric
Screen the elderly client thoroughly before diagnostic testing utilizing contra
st media. The elderly are more
likely to have pre-existing renal failure, along with other comorbidities and ar
e more vulnerable to develop
renal damage (Cheung et al, 2008; O Donovan, 2011).
Brockow K, Ring J: Anaphylaxis to radiographic contrast media, Curr
Opin Allergy Clin Immunol 11(4):326 331, 2010.
Cheung C, Ponnusamy A, Anderton J: Management of acute renal
failure in the elderly patient, Drugs Aging 25(6):455 476, 2008.
Earhart A, McMahon P: Vascular access and contrast media, J Infusion
Nurs 34(2):97 105, 2011.
Heiken JP: Contrast safety in the cancer patient: preventing contrastinduced nephropathy, Cancer Imaging 8(Suppl A):S124 S127, 2008.
Kalisz KR, et al: Detection of renal dysfunction by point-of-care creatinine testing in patients undergoing peripheral MR angiography, AJR
197(2):430 435, 2011.
O Donovan K: Preventing contrast-induced nephropathy part 1: what is
CIN? BJCN 5(12):576 581, 2010.
O Donovan K: Preventing contrast-induced nephropathy part 2: preventive strategies, BJCN 6(1):6 10, 2011.
Rudnick MR, Goldfarb S, Tumlin J: Contrast induced nephropathy: is
the picture any clearer? Clin J Am Soc Nephrol 3(1):261 262, 2008.
Schilcher G, et al: Early detection and intervention using neutrophil
gelatinase-associated lipocalin (NGAL) may improve renal outcome
of acute contrast media induced nephropathy: a randomized
controlled trial in patients undergoing intra-arterial angiography
(ANTI-CIN Study), BMC Nephrol 17:12 39, 2011.
Wilson B: Contrast media-induced compartment syndrome, Radiol
Technol 83(1):63 77, 2011.
Wong PC, et al: Pathophysiology of contrast-induced nephropathy, Int J
Cardiol 158(2):186 192, 2011.
Readiness for enhanced community Coping
Dawn Fairlie, ANP, FNP, GNP, DNS(c)

NANDA-I
De?nition
Pattern of community
is satisfactory for
demands or needs of
ement of current and
problems/stressors
activities for adaptation and problem solving that

meeting the
the community but that can be improved for manag
future
One or more characteristics that indicate effective coping:
Active planning by community for predicted stressors; active problem solving by
community when faced
with issues; agreement that community is responsible for stress managem
ent; positive communication
among community members; positive communication between community/aggregates and
larger community; programs available for recreation; programs available for relaxation; reso
urces suf?cient for managing
stressors
NOC
Community Competence, Community Health Status
= Independent
B = Evidence-Based
? = Collaborative
Readiness for enhanced community coping

Community Health Status as evidenced by the following indicators: Prevalence of
health promotion programs/Health
status of infants, children, adolescents, adults, elders/Participation rates in
community health programs. (Rate the outcome and
indicators of Community Health Status: 1 = poor, 2 = fair, 3 = good, 4 = very go
od, 5 = excellent [see Section I].)
Community Outcomes
Develop enhanced coping strategies
Maintain effective coping strategies for management of stress
NIC
Environmental Management: Community, Health Policy Monitoring: Program Developme
nt
Example NIC Activities Program Development
Assist the group or community in identifying signi?cant health needs or problems
; Identify alternative approaches to address the
need(s) or problem(s)
Note: Interventions depend on the speci?c aspects of community coping that can b
e enhanced (e.g., planning
for stress management, communication, development of community power, community
perceptions of stress,
community coping strategies). Nursing interventions are conducted in collaborati
on with key members of the
community, community/public health nurses, and members of other disciplines (And
erson & McFarlane, 2011).

Describe the roles of community/public health nurses in working with healthy c
ommunities. EBN: Nurses
at general and specialists levels (bachelor s and master s degrees) have signi?cant r
oles in helping communities
to achieve optimum health, including coping with stress (Chinn, 2012; Stanhope &
Lancaster, 2009).
Help the community to obtain funds for additional programs. EBN: Hea
lthy communities may need
additional funding sources to strengthen community resources (Anderson & McFarla
ne, 2011; Chinn, 2012).
Encourage positive attitudes toward the community through the media and other
sources. EB: Negative
attitudes or stigmas create additional stress and de?cits in social support (And
erson & McFarlane, 2011;
Chinn, 2012; Stanhope & Lancaster, 2009).
Help community members to collaborate with one another for power enhancement an
d coping skills.
EBN: Community members may not have suf?cient skills to collaborate for enhanced
coping. Health care
providers can promote effective collaboration skills (Anderson & McFarlane, 2011
; Chinn, 2012).
Assist community members with cognitive skills and habits of mind for problem
solving. EBN: The cognitive skills and habits of mind of critical thinking support problem-solving ab
ility (Rubenfeld & Scheffer,
2010).
Demonstrate optimum use of power resources. EBN: Optimum use of power resource
s and working for
community empowerment supports coping (Chinn, 2012).
Reduce poverty whenever possible. EB: Poverty is a major determinant of poor he
alth, and people living on
low income consistently have higher rates of morbidity and mortality due to chro
nic and acute illness. Therefore, primary health care providers should consider and address income
as a distinct risk to health, and
researchers should explore these issues with a broader group of primary care pro
viders and people who live in
poverty (Bloch, Rozmovits, & Giambrone, 2011).
? Collaborate with community members to improve educational levels within the c
ommunity. EB: Patient
safety, self-care behaviors, adherence to treatment plans, knowledge of one s medi
cal condition, health care
quality, and positive health outcomes are compromised by low health literacy. Th
ere is also compromised physical and mental health, as well as greater risk of hospitalization, and increased
mortality (Evangelista et al, 2010).
Multicultural
Refer to care plan Ineffective community Coping.
257
C
= Independent
B = Evidence-Based
258
? = Collaborative
Defensive coping
Client/family Teaching and Discharge Planning

Review coping skills, power for coping, and the use of power resources.
C
REFERENCES
Refer to Ineffective community Coping for additional references.
Bloch G, Rozmovits L, Giambrone B: Barriers to primary care responsiveness to poverty as a risk factor for health, BMC Fam Pract 12:62,
2011.
Evangelista LS, et al: Health literacy and the patient with heart failure
implications for patient care and research: a consensus statement of
the Heart Failure Society of America, J Card Fail 16(1):9 16, 2010.
Rubenfeld MG, Scheffer BK: Critical thinking tactics for nurses: achieving
IOM competencies, ed 2, Boston, 2010, Jones and Bartlett.
Stanhope M, Lancaster J: Foundations of nursing in the community:
community-oriented approach, ed 3, St Louis, 2009, Mosby.
Defensive Coping
Patricia Ferreira, RN, MSN, Michelangelo Juvenak, Biologist/Immunologist, MSc, P

hd,
and Gail B. Ladwig, MSN, RN
NANDA-I
De?nition
Repeated projection of falsely positive self-evaluation based on a self-protecti
ve pattern that defends against
underlying perceived threats to positive self-regard
Denial of obvious problems; denial of obvious weaknesses; dif?culty establishing
relationships; dif?culty in
perception of reality testing; dif?culty maintaining relationships; grandiosity;
hostile laughter; hypersensitivity

to criticism; hypersensitivity to slight; lack of follow-through in therapy; lac
k of follow-through in treatment;
lack of participation in therapy; lack of participation in treatment; projection
of blame; projection of responsibility; rationalization of failures; reality distortion; ridicule of others; s
uperior attitude toward others
Con?ict between self-perception and value system; de?cient support system; fear
of failure; fear of humiliation; fear of repercussions; lack of resilience; low level of con?dence in other
s; low level of self-con?dence;
uncertainty; unrealistic expectations of self
NOC
Coping, Decision Making, Impulse Self-Control, Information Processing
Coping as evidenced by the following indicators: Identi?es effective and ineffec
tive coping patterns/Modi?es lifestyle to reduce
stress. (Rate the outcome and indicators of Coping: 1 = never demonstrated, 2 =
rarely demonstrated, 3 = sometimes
demonstrated, 4 = often demonstrated, 5 = consistently demonstrated [see Section
I].)
Client Outcomes
Acknowledge need for change in coping style
Accept responsibility for own behavior
Establish realistic goals with validation from caregivers
Solicit caregiver validation in decision-making
= Independent
B = Evidence-Based
? = Collaborative
Defensive coping
NIC
Suggested Nursing Interventions
Body Image Enhancement, Complex Relationship Building, Coping Enhancement
, Patient Contracting,
Self-Awareness Enhancement, Self-Esteem Enhancement, Socialization Enhancement,
Surveillance
Example NIC Activities Self-Awareness Enhancement
Encourage patient to recognize and discuss thoughts and feelings; Assist patient
in identifying behaviors that are self-destructive
Assess for possible symptoms associated with defensive coping: depressi
ve symptoms, excessive selffocused attention, negativism and anxiety, hypertension, post-traumatic s

tress disorder (PTSD) (e.g.,
exposure to terrorism), unjust world beliefs. Depression is often associated wit
h use of defensive coping
(Hobfoll, Canetti-Nisim, & Johnson, 2006). CEB: The heightened self-focused atte
ntion might result from automatically instigated states of self-focused attention and paradoxical effects of
defensive efforts to avoid selffocus. This study demonstrated, in group comparisons, that negative affect group
obtained higher scores on the
Self-re?ectiveness scale
than the control group (p < 0.03) (Hping, de Jo
ng-Meyer, & Abrams, 2006).
Repressive (or defensive) coping has been associated with elevated blood pressur
e levels, essential hypertension,
and paroxysmal hypertension. Cardiovascular clients who use a repressive style h
ave shown mixed results during recuperation (Gleiberman, 2007). In this study, authors related that exposur
e to terrorism was signi?cantly related to greater loss and gain of psychosocial resources and to greater
posttraumatic stress disorder
(PTSD) and depressive symptoms (Hobfoll, Canetti-Nisim, & Johnson, 2006). In two
studies, the Unjust
World Views Scale (UJWVS) was developed. Belief in an unjust world was related t
o defensive coping, anger,
and perceived future risk. These ?ndings contribute to theory development and su
ggest that a belief in an
unjust world may serve a self-protective function. Clinical implications are dis
cussed as unjust world views also
were found to be potentially maladaptive (Lench & Chang, 2007).
Stimulate cognitive behavioral stress management (CBSM). CEB: Although denial m
ay be an effective means
of distress reduction in the short term, reliance on this coping strategy may re
sult in a decreased capacity to
effectively manage a variety of disease-related stressors in the long term. CBSM
addresses this potentially detrimental pattern by teaching stress reduction skills that may decrease depressed
mood via reduced reliance on
denial coping (Carrico et al, 2006).
Ask appropriate questions to assess whether denial (defensive coping) is being
used in association with
alcoholism. CEB: Alcohol abuse is a major problem in the United States, but indi
viduals are not getting treatment. In this survey, denial or refusal to admit severity and fear of social emb
arrassment were the top two
reasons for not seeking help (To & Vega, 2006).
Promote interventions with multisensory stimulation environments. EB: Multisens
ory stimulation environments (MSEs) are a popular space for intervention in the numerous forms of di
sability, with occupational,
therapeutic, or educational objectives (Castelhano & Roque, 2009).
Empower the client/caregiver s self-knowledge. EB: Theory of therapist resilience
: the theory that was constructed
included a central category (Integration of Self with Practice), a paradigm (Tru
st in Self), and two main categories
(Career Development and Practice of Therapy). The process involved an initial ca
lling, a positive agency experience, career corrections, the in?uence of relationships, and a move to a more ?e
xible environment (Clark, 2009).
Geriatric
? Identify problems with alcohol in the elderly with the appropriate tools and
make suitable referrals. Tools
such as the Alcohol Use Disorders Identi?cation Test (AUDIT), Michigan Alcohol S
creening Test-Geriatric
Version (MAST-G), and the Alcohol-Related Problems Survey (ARPS) may have additi
onal use in this population. Brief interventions have been shown to be effective in producing sustain
ed abstinence or reducing levels
of consumption, thereby decreasing hazardous and harmful drinking (Culberson, 20
06).
Encourage exercise for positive coping. CEB: After a 10-week period, the elderl
y participants in this exercise
group reported signi?cant improvements in stress, mood, and several quality-of-l
ife indices (Starkweather,
2007).
259
C
= Independent
B = Evidence-Based
260
? = Collaborative
Defensive coping
Stimulate individual reminiscence therapy. EB: After eight sessions, an elderly

woman had a happier expression on her face, was willing to express herself more verbally, had more interac
tion with others, and required
medication less frequently to help her sleep (Chou, Lan, & Chao, 2008).
C
Stimulate group reminiscence therapy. CEB: Participation in reminiscence activi
ties can be a positive and
valuable experience for demented older persons. Consequently, the development of
a structured care program
for elderly persons with cognitive impairment and the need for long-term care is
essential. Thus, health providers in long-term care facilities should be trained in reminiscence group therapy
and to be able to deliver such a
program to the targeted group (Wang, 2007).

Multicultural
Acknowledge racial/ethnic differences at the onset of care. CEB: Acknowledgment
of race/ethnicity issues
will enhance communication, establish rapport, and promote treatment outcomes (D A
vanzo et al, 2001).
African American parents who denied experiences of racism reported higher rates
of behavior problems in their
children, in contrast to African American parents who actively coped with racism
and reported lower levels of
behavior problems in their children (Caughy, O Campo, & Muntaner, 2004).
Assess an individual s sociocultural backgrounds in teaching self-management and
self-regulation as a
means of supporting hope and coping with a diagnosis of type 2 diabetes. EBN: Fi
ndings obtained from the
themes of this study illustrated that self-management of clients with diabetes i
s highly related to their own
sociocultural environment and experiences (Lin et al, 2008).
Encourage the client to use spiritual coping mechanisms such as faith and praye
r. CEB & EBN: Prayer is a
powerful way of coping and is practiced by all Western religions and several Eas
tern traditions (Mohr, 2006).
Spirituality inspired hope among caregivers of stroke clients (Pierce et al, 200
8). This study indicates that black
American young adult college students may utilize religious coping methods for p
sychological stress (KohnWood et al, 2012)
Encourage spirituality as a source of support for coping. EB: The association a
mong spirituality/religiosity,
positive appraisals, and internal adaptive coping strategies indicates that the
utilization of spirituality/religiosity goes far beyond fatalistic acceptance, but can be regarded as an active copi
ng process (Bssing et al, 2009).
Home Care
? Refer the client for a behavioral program that teaches coping skills via Lifes
kills workshop and/or video.
CEB: Commercially available, facilitator- or self-administered behavioral traini
ng products can have signi?cant bene?cial effects on psychosocial well-being in a healthy community sample
(Kirby et al, 2006).
Teach coping skills to family caregivers of cancer clients. CEB: A coping skill
s intervention was effective in
improving caregiver quality of life, reducing burden related to client s symptoms,
and caregiving tasks compared with hospice care alone or hospice plus emotional support (McMillan et al,
2006).
Teach caregivers the COPE intervention (creativity, optimism, planning, expert
information) to assist
with symptom management. CEB: Symptom distress, a measure that encompasses clien
t suffering along with
intensity, was signi?cantly decreased in the group in which caregivers were trai
ned to better manage client
symptoms (McMillan & Small, 2007).
Family-based intervention may prevent anxiety disorders in the offspring of par
ents with anxiety disorders.
EB: Parental satisfaction with the intervention was high. Findings suggest that
a family-based intervention may
prevent the onset of anxiety disorders in the offspring of parents with anxiety
disorders (Ginsburg, 2009).
REFERENCES
Refer to Ineffective Coping for additional references.
Bssing A, et al: Are spirituality and religiosity resources for patients
with chronic pain conditions? Pain Med 10(2):327 339, 2009.
Carrico AW, et al: Reductions in depressed mood and denial coping
during cognitive behavioral stress management with HIV-positive
gay men treated with HAART, Ann Behav Med 31(2):155 164, 2006.
Castelhano, N, Roque L: The integration of the Computer-mediated Ludic
Experience in Multisensory Environments, in Proc. of the DiGRA
(Digital Conference on Information Systems) 2009-Breaking New
Ground: Innovation in Games, Play, Practice and Theory, Newport,
UK, September 2009
Caughy MO, O Campo PJ, Muntaner C: Experiences of racism
among African American parents and the mental health of their
preschool-aged children, Am J Public Health 94(12):2118 2124,
2004.
Chou YC, Lan YH, Chao SY: Application of individual reminiscence
therapy to decrease anxiety in an elderly woman with dementia,
Hu Li Za Zhi 55(4):105 110, 2008.
Clark P: Resiliency in the practicing marriage and family therapist,
J Marital Fam Ther 35(2):231 247, 2009.
= Independent
B = Evidence-Based
? = Collaborative
Ineffective coping
261
Culberson JW: Alcohol use in the elderly: beyond the CAGE. Part 2:
Screening instruments and treatment strategies, Geriatrics
61(11):20 26, 2006.
D Avanzo CE, et al: Developing culturally informed strategies for
substance-related interventions. In Naegle MA, D Avanzo CE, ediLench HC, Chang ES: Belief in an unjust world: when beliefs in a just
world fail, J Pers Assess 89(2):126 135, 2007.
Lin CC, et al: Diabetes self-management experience: a focus group study
of Taiwanese patients with type 2 diabetes, J Clin Nurs 17(5a):34 42,
2008.
tors: Addictions and substance abuse: strategies for advanced practice

nursing, St Louis, 2001, Mosby.
Ginsburg GS: The Child Anxiety Prevention Study: intervention model
and primary outcomes, J Consult Clin Psychol 77(3):580 587, 2009.
Gleiberman L: Repressive/defensive coping, blood pressure, and cardiovascular rehabilitation, Curr Hypertens Rep 9(1):7 12, 2007.
Hobfoll SE, Canetti-Nisim D, Johnson RJ: Exposure to terrorism, stressrelated mental health symptoms, and defensive coping among Jews
and Arabs in Israel, J Consult Clin Psychol 74(2):207 218, 2006.
Hping W, de Jong-Meyer R, Abrams D: Excessive self-focused attention and defensiveness among psychiatric patients: a vicious cycle?
Psychol Rep 98(2):307 317, 2006.
Kirby ED, et al: Psychosocial bene?ts of three formats of a standardized
behavioral stress management program, Psychosom Med 68(6):
816 823, 2006.
Kohn-Wood L, et al: Coping styles, depressive symptoms and race during the transition to adulthood, Ment Health Relig Cult 15(4):
363 372, 2012.
McMillan SC, et al: Impact of coping skills intervention with family
caregivers of hospice patients with cancer: a randomized clinical
trial, Cancer 106(1):214 222, 2006.
McMillan SC, Small BJ: Using the COPE intervention for family caregivers to improve symptoms of hospice homecare patients: a clinical
trial, Oncol Nurs Forum 34(2):313 321, 2007.
Mohr WK: Spiritual issues in psychiatric care, Perspect Psychiatr Care
42(3):174 183, 2006.
Pierce LL, et al: Spirituality expressed by caregivers of stroke survivors,
West J Nurs Res 30(5):606 619, 2008.
Starkweather AR: The effects of exercise on perceived stress and IL-6
levels among older adults, Biol Res Nurs 8(3):186 194, 2007.
To SE, Vega CP: Alcoholism and pathways to recovery: new survey
results on views and treatment options, MedGenMed 8(1):2, 2006.
Wang JJ: Group reminiscence therapy for cognitive and affective
function of demented elderly in Taiwan, Int J Geriatr Psychiatry
22(12):1235 1240, 2007.
C
Ineffective Coping
Arlene T. Farren, RN, PhD, AOCN, CTN-A

NANDA-I
De?nition
Inability to form a valid appraisal of the stressors, inadequate choices of prac
ticed responses, and/or inability
to use available resources
Change in usual communication patterns; decreased use of social support
; destructive behavior toward
others; destructive behavior toward self; dif?culty organizing information; fati
gue; high illness rate; inability
to attend to information; inability to meet basic needs; inability to
meet role expectations; inadequate
problem solving; lack of goal-directed behavior; lack of resolution of problem;
poor concentration; reports

inability to ask for help; reports inability to cope; risk taking; sleep pattern
disturbance; substance abuse; use
of forms of coping that impede adaptive behavior
Disturbance in pattern of appraisal of threat; disturbance in pattern of tension
release; gender differences in
coping strategies; high degree of threat; inability to conserve adaptive energie
s; inadequate level of con?dence
in ability to cope; inadequate level of perception of control; inadequate opport
unity to prepare for stressor;
inadequate resources available; inadequate social support created by characteris
tics of relationships; maturational crisis; situational crisis; uncertainty
NOC
Coping, Decision-Making, Impulse Self-Control, Information Processing
Coping as evidenced by the following indicators: Identi?es effective and ineffec
tive coping patterns/Modi?es lifestyle to reduce
stress. (Rate the outcome and indicators of Coping: 1 = never demonstrated, 2 =
rarely demonstrated, 3 = sometimes demonstrated, 4 = often demonstrated, 5 = consistently demonstrated [see Section I].)
= Independent
B = Evidence-Based
262
? = Collaborative
Ineffective coping
Client Outcomes
C
Use effective coping strategies
Use behaviors to decrease stress
Remain free of destructive behavior toward self or others
Report decrease in physical symptoms of stress
Report increase in psychological comfort
Seek help from a health care professional as appropriate
NIC
Coping Enhancement, Decision-Making Support
Example NIC Activities Coping Enhancement
Assist the patient in developing an objective appraisal of the event; Explore wi
th the client previous methods of dealing with life
problems

Observe for contributing factors of ineffective coping such as poor self-concep
t, grief, lack of problemsolving skills, lack of support, recent change in life situation, maturational o
r situational crises. EB: In a
large sample (n =758) of people living with HIV, the top three life stressors id
enti?ed were taking on too many
things at once, not having enough money for what is needed, and having a scary e
xperience in childhood that
one continues to think about (Gibson et al, 2011).
Use verbal and nonverbal therapeutic communication approaches including empathy
, active listening,
and confrontation to encourage the client and family to express emotions such as
sadness, guilt, and
anger (within appropriate limits); verbalize fears and concerns; and set goals.
EBN: Clinicians communication skills contribute to the well-being of clients and minimize psychosocia
l problems (Duff et al, 2009).
EB: Solution-focused communication with clients helps to focus on goals and help
s ?nd solutions (Ruddick,
2011).
Collaborate with the client to identify strengths such as the ability to relate
the facts and to recognize the
source of stressors. EBN: Hart and Grindel (2010) examined coping and self-care
behavior in individuals
with type 2 diabetes and found that coping ef?cacy was associated with self-care
behaviors. The researchers
recommended that nurses collaborate with patients to identify successful
coping strategies. EB: Ruddick
(2011) describes solution-focused communications as enhancing the identi?cation
of strengths and resources
for coping.
Encourage the client to describe previous stressors and the coping mechanisms u
sed. EBN: A psychoeducation intervention that included clients identi?cation of symptoms, types of cop
ing strategies used before and
after the event, and ways to select alternative strategies was accompanied by me
dication intervention for participants with post-traumatic stress disorder (PTSD) and statistically s
igni?cantly improved PTSD and
depression were found (O?az, Haitpoglu, & Ayan, 2008).
Be supportive of coping behaviors; allow the client time to relax. EBN: SolariTwadell (2010) found a selection of nursing interventions used by parish nurses (n = 1,161) to provide copin
g assistance to women including presence, touch, emotional support, and coping enhancement.
Provide opportunities for the client to discuss the meaning the situation might
have for the client. EBN: Parish
nurses (n = 1,161) identi?ed frequent use of values clari?cation, spiritual grow
th facilitation, and hope instillation in their work with women (Solari-Twadell PA, 2010). In a systematic revie
w examining the characteristics of coping in adults with advanced cancer, seven factors were identi?ed, w
hich included creating meaning
(Thomsen, Rydahl-Hansen, & Wagner, 2010).
Assist the client to set realistic goals and identify personal skills and knowl
edge. EBN: Researchers found
that participants who were 4 months after myocardial infarction experiencing fat
igue described fumbling cop-
ing strategies. The researchers concluded that nursing interventions to assist c

lients to identify and reduce
stressors and increase clients ability to cope with stressors would be useful (Al
sen, Brink, & Persson, 2008). EB:
= Independent
B = Evidence-Based
? = Collaborative
Ineffective coping
In one correlational study, adjusting goals was found to be an effective coping
strategy in childless people
(Kraaij, Garnefski, & Schroevers, 2009).
Provide information regarding care before care is given. EBN: One systematic r
eview examining coping
interventions for parents included the importance of informing parents of what t
o expect in their children and
in relation to their own responses (Peek & Melnyk, 2010). EB: In a clinical tria
l of families responsible for taking care of a relative with mental illness, a family-led education intervention
resulted in signi?cant differences
in coping and decreased information needs between the intervention and control g
roup (Pickett-Schenk et al,
2008).
Discuss changes with the client before making them. EBN: When dealing with adul
ts with cancer, the
authors assert the importance of informing patients of treatment relate
d symptoms and toxicities to help
patients prepare for the treatment course; furthermore, nurses should discuss ad
ditional coping strategies to
help with managing treatment-related problems (Boucher, Olson, & Piperdi, 2011).
Provide mental and physical activities within the client s ability (e.g., reading
, television, radio, crafts, outings, movies, dinners out, social gatherings, exercise, sports, games). EBN: In
a pilot study of a nurse-based,
in-home transitional care intervention for seriously mentally ill persons, resea
rchers found that one of the factors of importance to community transition was involvement in daily activities (
Rose, Gerson, & Carbo, 2007).
Discuss the client s and family s power to change a situation or the need to accept
a situation. EBN:
Researchers conducted a controlled trial of a nursing intervention to facilitate
older adults (n = 89) access to
community resources to assist them to remain at home. Researchers found the olde
r adults accepted the intervention and had improved health empowerment, purposeful participation in goal at
tainment, and well-being
(Shearer, Fleury, & Belyea, 2010). EB: Acceptance of illness and acceptance thro
ugh coping strategies have
been found to be associated with subjective health in a sample (n = 106) of card
iac patients (Karademas &
Hondronikola, 2010).
Offer instruction regarding alternative coping strategies. EBN: Mindfulness me
ditation intervention assisted
coping with unpleasant symptoms for hospitalized clients receiving hematopoietic
stem cell transplantation
(Bauer-Wu, Sullivan, & Rosenbaum, 2008).
Encourage use of spiritual resources as desired. EBN: Spiritual activities suc
h as prayer, meditation, and
doing good deeds played a major role in coping with living with HIV in a sample
of Thai women practicing
Buddhism (Ross, Sawatphanit, & Suwansujarid, 2007). In a small qualitative study
of Mexican American
cancer survivors (n = 5), three themes were uncovered, one of which was the use
of spiritual resources to cope
with cancer (Campesino, 2009).
Encourage use of social support resources. EB: Authors of a systematic review
of interventions for supporting
informal caregivers of terminal patients concluded the ?ndings suggest practitio
ners should consider that informal caregivers may need additional support (Candy et al, 2011). Low social suppo
rt predicted maladaptive
coping in cancer survivors (Zucca et al, 2010).
? Refer for additional or more intensive therapies as needed. EBN: More complex
interventions are available to assist with coping, for example, a nurse-delivered intervention for depr
ession in clients with cancer
(Forchuk, 2009). Victims of crime need the assistance of a multidisciplinary tea
m to cope and achieve a positive recovery (Green, Choi, & Kane, 2010).
Pediatric
Monitor the client s risk of harming self or others and intervene appropriately.
See care plan for Risk for
Suicide. CEB: Adolescents may use self-harming behaviors as a means of communica
tion or way of coping
(Murray & Wright, 2006).
Support adolescent and children s individual coping styles. EBN: Researchers foun
d that a connection to
school could be protective against ineffective coping patterns in a sample of 16
6 fourth graders (Rice et al,
2008). In a study of coping of 4- to 6-year-olds who were hospitalized, research
ers concluded that it was essential to support children s individual coping strategies with information, guidance
, and participation in decisions (Salmela, Salanter, & Aronen, 2010). EB: In one study of youth with type 1
diabetes, the following
coping skills were observed: Younger children used more coping that involved cho
osing an alternate activity,
helping others, and an emotional response (taking personal responsibility), wher
eas adolescents used more
coping that involved persistence, alternate thinking, and talking things over (t
aking personal responsibility)
(Hema, Roper, & Nehring, 2009).
Encourage moderate aerobic exercise (as appropriate). CEB: Exercise was found t
o decrease the likelihood of
depressive feelings when used as a positive coping strategy for school-age child
ren with angry feelings (Goodwin, 2006).
263
C
= Independent
B = Evidence-Based
264
? = Collaborative
Ineffective coping
Geriatric
? Assess and report possible physiological alterations (e.g., sepsis, hypoglyce
mia, hypotension, infection,
changes in temperature, ?uid and electrolyte imbalances, and use of medications
with known cognitive
C
and psychotropic side effects). EB: A reversible pathophysiological process may
be causing symptoms (Rocchiccioli & Sanford, 2009).
Screen for elder neglect or other forms of elder mistreatment. CEB & EB: Abuse
of older people is a serious
and growing social problem (Wang, Tseng, & Chen, 2007). In one study of 86 perso
ns with Alzheimer s disease
and their caregivers, researchers found predictors of caregiver abuse behaviors
included caregivers who were
male, had greater burden, and whose care recipient had greater irritability and
cognitive impairment (with less
functional impairment)(Cooper et al, 2008).
Encourage the client to make choices (as appropriate) and participate in planni
ng care and scheduled activities. CEB & EBN: Older persons with heart failure transitioning to home from the
hospital made choices about
participation in the therapeutic regimen based on their individual goals for com
munity living during a nursing
intervention study, which resulted in positive client outcomes and cost savings
(McCauley, Bixby, & Naylor, 2006).
In a pilot study examining depression care preferences of older home care client
s, researchers concluded client preferences during care planning may improve participation in geriatric depression car
e management (Fyffe et al, 2008).
Target selected coping mechanisms for older persons based on client features, u
se, and preferences. CEB:
Elders with arthritis reported cognitive efforts, diversional activities, and as
sertive actions were useful in deal-
ing with daily stress (Tak, 2006). EB: Data from 37 interviews in one study of A
frican American older adults
with mild symptoms of depression revealed culturally based coping strategies, wh
ich included self-reliance
strategies, keeping depressive symptoms from family and friends, denial, use of
less stigmatizing emotional
expressions, and prayer and relationship with God (Conner et al, 2010).
Increase and mobilize support available to older persons by encouraging a varie
ty of mechanisms involving family, friends, peers, and health care providers. EBN: Researchers conducte
d a controlled trial of a
nursing intervention to facilitate older adults (n = 89) access to community reso
urces to assist them to remain
at home. Researchers found the older adults accepted the intervention and had im
proved health empowerment, purposeful participation in goal attainment, and well-being (Shearer, Fleu
ry, & Belyea, 2010).
Actively listen to complaints and concerns. EBN: One of the most frequently use
d strategies by nurses in
end-of-life care and communication was active and passive listening (Boyd et al,
2011).
Engage the client in reminiscence. EBN: In a review of the literature, one auth
or found that while more
research is needed, reminiscence was a promising intervention for older adults a
nd proposes a protocol for a
structured group reminiscence intervention (Stinson, 2009).
Multicultural
Assess for the in?uence of cultural beliefs, norms, and values on the client s pe
rceptions of effective coping. EBN: The representation of strength in?uences African American women s conceptu
alization of depression and coping strategies (Porter & Pacquiao, 2011).
Assess the in?uence of fatalism on the client s coping behavior. EB: While fatali
sm has been a culturally
associated concept, recent studies of Latinos experiencing post-traumatic sympto
ms and African American
women diagnosed with cancer have found no signi?cant ?ndings related to fatalism
and traumatic symptoms
or fatalism and delay in seeking treatment for breast cancer (Gullatte et al, 20
10). More research is needed.
Assess the in?uence of cultural con?icts that may affect coping abilities. EBN:
In one ethnographic study,
the researcher concluded that in the United States, there are differences betwee
n nurses cultures and those of
Syrian Muslims and suggested that improved cultural knowledge can lesse
n cultural pain and con?icts
(Wehbe-Alamah, 2011).
Assess for intergenerational family problems that can overwhelm coping abilitie
s. EB: While generalization
is not possible, in one qualitative case study of intergenerational dynamics in
a Euro-American family experiencing the suicide of a father and daughter, areas for assessment were illuminat
ed and included the role of
ways of dealing with the initial death, presence of incarceration of family memb
ers, and the perceptions of
family survivors of suicide (Sandage, 2010).
Encourage spirituality as a source of support for coping. EBN: In a small quali
tative study of Mexican
American cancer survivors (n = 5), three themes were uncovered, one of which was
the use of spiritual resources
to cope with cancer (Campesino, 2009).

Negotiate with the client with regard to the aspects of coping behavior that wi
ll need to be modi?ed. EBN:
The use of self-mutilation as a coping behavior or communication of strength has
been found in many cultures.
= Independent
B = Evidence-Based
? = Collaborative
Ineffective coping
One case study reports the care of a Pakistani woman who began self-cutting when
she ?rst arrived in the
United States. The author identi?es the importance of open communication with in
dividualized care, referrals, and support for more effective coping patterns (Williams & Hamilton, 2009)
.
Encourage moderate aerobic exercise (as appropriate). CEB: In a group of Africa
n American elders with
chronic health conditions, exercise was used as a coping strategy for effectivel
y managing chronic health conditions (Loeb, 2006).
Identify which family members the client can count on for support. EBN: In a st
udy of sources of social
support for adults living with HIV (n = 150), researchers found that spouses, fr
iends, siblings, and mothers
provided appraisal, belonging, and tangible support (Grant et al, 2009).
Support the inner resources that clients use for coping. EB: In a qualitative s
tudy of 23 Sudanese refugees,
participants used a number of coping strategies to deal with pre-immigration, tr
ansition, and post-immigration
dif?culties including reliance on religious beliefs, relying on inner resources,
and focus on the future (Khawaja
et al, 2008).
Use an empowerment framework to rede?ne coping strategies. EBN: In an
intervention study of an
empowerment intervention in a group (n = 18) of Norwegian women undergoing or re
covering from treatment for breast cancer, researchers used empowerment strategies such as re?ectio
n on strengths and resources
and af?rmation of strengths and abilities contributing to the empowerment of the
participants (Stang & Mittelmark, 2010). EB: In a qualitative study of deaf people in the United States,
researchers found that many
participants self-identi?ed as members of an ethno-linguistic minority.
Both individual and community
empowerment strategies were uncovered in the Internet weblog format, such as the
value of using American
Sign Language, use of humor, and advocating for social justice (Hamill & Stein,
2011).
Home Care
? Assess for suicidal tendencies. Refer for mental health care immediately if i
ndicated.
Identify an emergency plan should the client become suicidal. Ineffective copin
g can occur in a crisis situation and can lead to suicidal ideation if the client sees no hope for a solution
. A suicidal client is not safe in the
home environment unless supported by professional help. Refer to the care plan f
or Risk for Suicide.
Observe the family for coping behavior patterns. Obtain family and client histo
ry as possible. CEB: Family
assessment is necessary to guide interventions and activate appropriate resource
s (Ellenwood & Jenkins, 2007).
? Assess for effective symptoms after cerebrovascular accident (CVA) in the elde
rly, particularly emotional
lability and depression. Refer for evaluation and treatment as indicated. CEB: I
n a study of older persons
poststroke, researchers found a range of physical and psychological concerns, wi
th some clients expressing fears
of getting worse while others expressed hope for recovery. In either case, nurse
s can assist with the needs and
promote the use of effective coping (Popovich, Fox, & Bandagi, 2007).
Encourage the client to use self-care management to increase the experience of
personal control. Identify
with the client all available supports and sense of attachment to oth
ers. Refer to the care plan for
Powerlessness. EBN: In a study of coping strategies of Latino women spouses of s
troke survivors, women
maintained a sense of spousal obligation to care and used emotion-focu
sed coping to preserve their own
physical and psychological health (Arabit, 2008). In a qualitative study of Afri
can American women (n = 46)
with low incomes trying to lose weight, the women, who were generally had low we
ight loss self-ef?cacy, did not
set goals regarding weight loss and exercise, and did not have suf?cient support
from family and friends to
make the necessary changes (Mastin, Campo, & Askelson, 2012).
? Refer the client and family to support groups. CEB: Predictors of participatio
n in support groups by cancer
clients include trusted others views of support groups, support received from spe
cial others, and the person s
own beliefs about support groups (Grande, Myers, & Sutton, 2006).
? If monitoring medication use, contract with the client or solicit assistance f
rom a responsible caregiver.
Elders with arthritis identi?ed taking medications as an assertive action coping
strategy (Tak, 2006).
? Institute case management for frail elderly clients to support continued indep
endent living. EBN: Case
management provides home-based care of frail elderly using a process of assessme
nt and medication review
leading to new diagnoses, coordination of care, and tailoring of servi
ces that match individual needs
(Elwyn et al, 2008).
? If the client is homebound, refer for psychiatric home health care services fo
r client reassurance and
implementation of a therapeutic regimen. CEB: Researchers found a therapeutic li
fe review intervention
delivered by home care workers enhanced mood in women participants (Symes et al,
2007). CEB: An intervention study of a peer-based and regular case management for community-dwelling ad
ults with severe mental
265
C
= Independent
B = Evidence-Based
266
? = Collaborative
Ineffective coping
illness demonstrated that improved positive regard at 6 months predicted and sus
tained treatment motivation
for psychiatric, alcohol, and drug use problems and attendance at Alco
holics and Narcotics Anonymous
meetings (Sells et al, 2006).
C
REFERENCES
Teach the client to problem solve. Have the client de?ne the problem and cause,
and list the advantages
and disadvantages of the options. CEB: A systematic review regarding healthy cop
ing in diabetes management suggested there is evidence from well-controlled intervention studies about
coping/problem solving interventions, which support their use (Fisher et al, 2007).
Provide the seriously ill client and his or her family with needed information
regarding the condition and
treatment. CEB: Researchers concluded that seriously ill hospitalized clients ha
ve poor knowledge of CPR and
would bene?t from improved understanding of CPR and their role (clients and fami
ly) in the decision-making
process (Heyland et al, 2006).
Teach relaxation techniques. EBN: Mindfulness meditation (MBSR) was taught to
community-dwelling
adults who found the intervention promoted health awareness, personal s
elf-care, and overall well-being
(Matchim, Armer, & Stewart, 2008).
Work closely with the client to develop appropriate educational tools that add
ress individualized needs.
EB: Researchers developed a purpose-based information assessment (PIA) tool to e
valuate how effective the
information met the clients individual needs; ?ndings included estimates supporti
ng the validity, reliability,
and sensitivity of the PIA. Researchers concluded that the PIA can be used to id
entify strengths and limitations
in meeting an individual s information needs (Feldman-Stewart, Brennestuhl, & Brun
dage, 2007).
? Teach the client about available community resources (e.g., therapists, minis
ters, counselors, self-help groups).
EBN: Researchers concluded from a review of the literature regarding couples sur
viving prostate cancer that in
addition to meeting educational needs, nurses must assess for potential concerns
and make recommendations and
referrals to assist couples with ?nding appropriate resources for coping with is
sues related to their relationship
(Galbraith, Fink, & Wilkins, 2011). EB: While research suggests that persons nee
ding community services are interested in using them, not all who need services use them, due in part to the need
for more information about resources,
how to use them more effectively, or availability of services (Janda et al, 2008
).
Alsen P, Brink E, Persson L: Living with incomprehensible fatigue after
recent myocardial infarction, J Adv Nurs 64(5):459 468, 2008.
Arabit LD: Coping strategies of Latino women caring for a spouse
recovering from stroke: a grounded theory, J Theory Construct
12(2):42 49, 2008.
Bauer-Wu S, Sullivan AM, Rosenbaum E: Facing the challenges of
hematopoietic stem cell transplantation with mindfulness meditation: a pilot study, Integr Cancer Ther 7(2):62 69, 2008.
Boucher J, Olson L, Piperdi B: Preemptive management of dermatologic
toxicities associated with epidermal growth factor receptor inhibitors, Clin J Oncol Nurs 15(5):501 508, 2011.
Boyd D, et al: Nurses perceptions and experiences with end-of-life

communication and care, Oncol Nurs Forum 38(3):E229 E239,
2011.
Campesino M: Exploring perceptions of cancer care delivery among
older Mexican American adults, Oncol Nurs Forum 36(4):413 420,
2009.
Candy B, et al: Interventions for supporting informal caregivers of
patients in the terminal phase of a disease, Cochrane Database Syst
Rev(6), CD007617:2011.
Conner KO, et al: Barriers to treatment and culturally endorsed coping
strategies among depressed African American older adults, Aging
Ment Health 14(8):971 983, 2010.
Cooper C, et al: Screening for elder abuse in dementia in the LASER-AD
study: prevalence, correlates, and validation of instruments, Int J
Geriatr Psychiatry 23(3):283 288, 2008.
Duff E, et al: A follow-up study of oncology nurses after communication skills training, Cancer Nurs Pract 8(1):27 31, 2009.
Ellenwood AE, Jenkins JE: Unbalancing the effects of chronic illness: non-traditional family therapy assessment and intervention
approach, Am J Fam Ther 35(3):265 277, 2007.
Elwyn G, et al: Case management by nurses in primary care: analysis of
73 success stories, Qual Prim Care 16(2):75 82, 2008.
Feldman-Stewart D, Brennestuhl S, Brundage MD: A purpose-based
evaluation of information for patients: an approach to measuring
effectiveness, Patient Educ Couns 65(3):311 319, 2007.
Fisher EB, et al: Healthy coping, negative emotions, and diabetes management: a systematic review, Diabetes Educ 33(6):1080 1103, 2007.
Forchuk C: A nurse-delivered intervention was effective for depression
in patients with cancer, Evid Based Nurs 12(1):17, 2009.
Fyffe DC, et al: Older home care patients preferred approaches to
depression care: a pilot study, J Gerontol Nurs 34(8):17 22, 2008.
Galbraith ME, Fink R, Wilkins GG: Couples surviving prostate cancer:
challenges in their lives and relationships, Semin Oncol Nurs
27(4):300 308, 2011.
Gibson K, et al: Mastery and coping moderate the negative effect of
acute and chronic stressors on mental health-related quality of life
in HIV, AIDS Patient Care STDs 25(6):371 381, 2011.
Goodwin RD: Association between coping with anger and feelings of
depression among youths, AM J Publ Health 96(4):664 669, 2006.
Grande GE, Myers LB, Sutton SR: How do patients who participate in
cancer support groups differ from those who do not? Psychol Oncol
15(4):321 334, 2006.
Grant JS, et al: Sources of social support provided to people living with
HIV, J Nurs Healthc Chronic Illn 1(4):331 338, 2009.
= Independent
B = Evidence-Based
Ineffective coping
? = Collaborative
267
Green DL, Choi JJ, Kane MN: Coping strategies for victims of crime:
effects of the use of emotion-focused, problem-focused, and
avoidance-oriented coping, J Hum Behav Soc Environ 20(6):732
743, 2010.
Gullatte MM, et al: Religiosity, spirituality, and cancer fatalism on delay
Popovich JM, Fox PG, Bandagi R: Coping with stroke: psychological and social dimensions in U.S. patients, Int J Psychiatr Nurs Res
12(3):1474 1487, 2007.
Porter SN, Pacquiao DF: Social and cultural construction of depression among African American women, UPNAAI Nurs J 7(1):13 15,
in breast cancer diagnosis in African American women, J Religion
Health 49(1):62 72, 2010.
Hamill AC, Stein CH: Culture and empowerment in the deaf community: an analysis of internet weblogs, J Community Appl Soc Psychol
21(5):388 406, 2011.
Hart PL, Grindel CG: Illness representations, emotional distress, coping
strategies, and coping ef?cacy as predictors of patient outcomes in
type 2 diabetes, J Nurs Healthc Chronic Illn 2(3):225 240, 2010.
Hema DA, Roper SO, Nehring JW, et al: Daily stressors and coping
responses of children and adolescents with type 1 diabetes, Child
Care Health Dev 35(3):330 339, 2009.
Heyland DK, et al: Understanding cardiopulmonary resuscitation decision making: perspectives of seriously ill hospitalized patients and
family members, Chest 130(2):419 428, 2006.
Janda M, et al: Unmet supportive care needs and interest in services
among patients with a brain tumor and their carers, Patient Educ
Couns 71(2):251 258, 2008.
Karademas EC, Hondronikola I: The impact of illness acceptance and
helplessness to subjective health and their stability over time: a prospective study in a sample of cardiac patients, Psychol Health Med
15(3):336 346, 2010.
Khawaja NG, et al: Dif?culties and coping strategies of Sudanese
refugees: a qualitative approach, Transcult Psychiatry 45(3):489 512,
2008.
Kraaij V, Garnefski N, Schroevers MJ: Coping, goal adjustment, and
positive and negative effect in de?nitive infertility, J Health Psychol
14(1):18 26, 2009.
Loeb SJ: African American older adults coping with chronic health
conditions, J Transcult Nurs 17(2):139 147, 2006.
Mastin T, Campo S, Askelson NM: African American women and
weight loss: disregarding environmental challenges, J Transcult Nurs
23(1):38 45, 2012.
Matchim Y, Armer JM, Stewart BR: IOS new scholar paper: a qualitative
study of participants perceptions of the effect of mindfulness meditation practice on self care and overall well-being, Self Care Depend
Care Nurs 16(2):46 53, 2008.
McCauley KM, Bixby MB, Naylor MD: Advanced practice nurses
strategies to improve outcomes and reduce costs in elders with heart
failure, Dis Manag 9(5):302 310, 2006.
Murray BL, Wright K: Integration of a suicide risk assessment and intervention approach: the perspective of youth, J Psychiatr Ment Health
Nurs 13(2):157 164, 2006.
O?az F, Haitpoglu S, Ayan H: Effectiveness of psychoeducation
intervention on post-traumatic stress disorder and coping styles of
earthquake survivors, J Clin Nurs 17(5):677 687, 2008.
Peek G, Melnyk BM: Coping interventions for parents of children newly
diagnosed with cancer: an evidence review with implications for
clinical practice and future research, Pediatr Nurs 36(6):306 313,
2010.
Pickett-Schenk SA, et al: Improving knowledge about mental illness
through family-led education: the journey of hope, Psychiatr Serv
59(1):49 56, 2008.
17 19, 2011.
Rice M, et al: Relationship of anger, stress and coping with school connectedness in fourth-grade children, J Sch Health 78:149 156, 2008.
Rocchiccioli JT, Sanford JT: Revisiting geriatric failure to thrive: a complex and compelling clinical condition, J Gerontol Nurs 35(1):18 24,
2009.
Rose LE, Gerson L, Carbo C: Transitional care for seriously mentally ill
persons: a pilot study, Arch Psychiatr Nurs 21(6):297 308, 2007.
Ross R, Sawatphanit W, Suwansujarid T: Finding peace (Kwam Sangob): a Buddhist way to live with HIV, J Holistic Nurs 25(4):228
235, 2007.
Ruddick F: Coping with problems by focusing on solutions, Ment
Health Pract 14(8):28 30, 2011.
Salmela M, Salanter S, Aronen ET: Coping with hospital related fears:
experiences of pre-school-aged children, J Adv Nurs 66(6):1222
1231, 2010.
Sandage SJ: Intergenerational suicide and family dynamics: a hermeneutic phenomenological case study, Contemp Fam Ther 32(2):209 227,
2010.
Sells D, et al: The treatment relationship in peer-based and regular case
management for clients with severe mental illness, Psychiatr Serv
57(8):1179 1184, 2006.
Shearer BC, Fleury JD, Belyea M: Randomized control trial of the
health empowerment intervention: feasibility and impact, Nurs Res
59(3):203 211, 2010.
Solari-Twadell PA: Providing coping assistance for women with behavioral interventions, JOGNN 39(2):205 211, 2010.
Stang J, Mittelmark MB: Intervention to enhance empowerment in a
breast cancer self-help group, Nurs Inquiry 17(1):46 56, 2010.
Stinson CK: Structured group reminiscence: an intervention for older
adults, J Contin Educ Nurs 40(1):521 528, 2009.
Symes L, et al: The feasibility of home care workers delivering an intervention to decrease depression among home-dwelling older women,
Issues Ment Health Nurs 28(7):799 810, 2007.
Tak SH: An insider perspective of daily stress and coping in elders with
arthritis, Orthop Nurs 25(2):27 32, 2006.
Thomsen TG, Rydahl-Hansen S, Wagner L: A review of potential factors relevant to coping in patients with advanced cancer, J Clin Nurs
19(23/24):3410 3426, 2010.
Wang J, Tseng H, Chen K: Development and testing of screening indicators for psychological abuse of older people, Arch Psychiatr Nurs
21(1):40 47, 2007.
Wehbe-Alamah H: The use of Culture Care Theory with Syrian Muslims in the mid-western United States, Online J Cult Competence
Nurs Healthc 1(3):1 12, 2011.
Williams KA, Hamilton K: Culturally competent assessment of care of
self-mutilation in urologic nursing, Urol Nurs 29(3):191 194, 2009.

Zucca AC, et al: Life is precious and I m making the best of it: coping
strategies of long-term cancer survivors, Psycho Oncol 19(12):1268
1276, 2010.
C
= Independent

B = Evidence-Based
? = Collaborative

Ineffective Breathing Pattern

Uploaded by

Document Information

Original Description:

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Ineffective Breathing Pattern

Uploaded by

Copyright:

Available Formats

Ineffective breathing pattern

CEB = Classic Research

EBN = Evidence-Based Nursing