Interventions

Intervention for ND of ineffective coping

NURSING PRIORITY NO. 2 To assess coping abilities and skills: • Ascertain client's understanding of current situation and its impact on life and work. Client may not understand situation, and being aware of these factors is necessary to planning care and identifying appropriate interventions.8 • Active-listen and identify client's perceptions of what is happening and effectiveness of coping techniques. Reflecting client's thoughts can provide a forum for understanding perceptions in relation to reality for planning care and determining accuracy of interventions needed.2,3 • Discuss cultural background and whether some beliefs from family may contribute to difficulties coping with situation. Family of origin can have a positive or negative effect on individual's ability to deal with stressful situations.5 • Evaluate client's decision-making ability. When ability to make decisions is impaired by illness or treatment regimen, it is important to take this into consideration when planning care to maximize participation and positive outcomes.9 • Determine previous methods of dealing with life problems. Identifies successful techniques that can be used in current situation. Often client is preoccupied by current concerns and does not think about previous successful skills.8 NURSING PRIORITY NO. 3 To assist client to deal with current situation: • Call client by name. Ascertain how client prefers to be addressed. Using client's name enhances sense of self and promotes individuality and self-esteem.2 • Encourage communication with staff/significant others (SOs). Developing positive interactions between staff, SO(s), and client ensures that everyone has the same understanding.8 • Use reality orientation (e.g., clocks, calendars, bulletin boards) and make frequent references to time and place as indicated. Place needed and familiar objects within sight for visual cues. Often client can be disoriented by changes in routine and anxiety about illness and treatment regimens, and these measures help the client maintain orientation and a sense of reality.9 • Provide for continuity of care with same personnel taking care of the client as often as possible. Developing relationships with same caregivers promotes trust and enables client to discuss concerns and fears freely.9 • Explain disease process, procedures, or events in a simple, concise manner. Devote time for listening. May help client to express emotions, grasp situation, and feel more in control. • Discuss use of medications as needed. Short-term use of anti-anxiety medication or antidepressants may be helpful for lifting mood and encouraging individual to develop new coping skills.6 • Provide for a quiet environment and position equipment out of view as much as possible. Anxiety is increased by noisy surroundings. • Schedule activities so periods of rest alternate with nursing care. Increase activity slowly. Client is weakened by illness and failure to cope with situation. Ensuring rest can promote ability to cope.8 • Assist client in use of diversion, recreation, and relaxation techniques. Learning new skills can be helpful for reducing stress and will be useful in the future as the client learns to cope more successfully. • Emphasize positive body responses to medical conditions, but do not negate the seriousness of the situation (e.g., stable blood pressure during gastric bleed or improved body posture in depressed client). Acknowledging the reality of the illness while accurately stating the facts can provide hope and encouragement.8 • Encourage client to try new coping behaviors and gradually master situation. Practicing new ways of dealing with what is happening leads to being more comfortable and can promote a positive outcome as client relaxes and handles illness and treatment regimen more successfully.9 • Confront client when behavior is inappropriate, pointing out difference between words and actions. Provides external locus of control, enhancing safety while client learns self-control.2 • Assist in dealing with change in concept of body image as appropriate. (Refer to ND disturbed Body Image.) New view of self may be negative, and client needs to incorporate change in a positive manner to enhance self-image.10 NURSING PRIORITY NO. 4 To provide for meeting psychological needs: • Treat the client with courtesy and respect. Converse at client's level, providing meaningful conversation while performing care. Enhances therapeutic relationship.2 • Take advantage of teachable moments. Individuals learn best and are open to new information when they feel accepted and are in a comfortable environment.10 • Allow client to react in own way without judgment by staff/caregivers. Provide support and diversion as indicated. Unconditional positive regard and support promote acceptance, enabling client to deal with difficult situation in a positive way.8 • Encourage verbalization of fears and anxieties and expression of feelings of denial, depression, and anger. Free expression allows for dealing with these feelings, and when the client knows that these are normal reactions, he or she can deal with them better.10 • Help client to learn how to substitute positive thoughts for negative ones (i.e., "I can do this; I am in charge of myself"). The mind plays a significant role in one's response to stressors, and negative thoughts can actually increase the impact of the stressor.13 • Provide opportunity for expression of sexual concerns. Important aspect of person that may be difficult to express. Providing an opening for discussion by asking sensitive questions allows client to talk about concerns.10 • Help client to set limits on acting-out behaviors and learn ways to express emotions in an acceptable manner. Enables client to gain sense of self-esteem, promoting internal locus of control.2

Intervention for ND of ineffective breastfeeding

NURSING PRIORITY NO. 2 To assess infant causative/contributing factors: • Determine suckling problems or infant anomaly (e.g., cleft lip/palate). These factors indicate need for interventions directed at correcting individual situation. Conditions such as cleft palate need evaluation for correction and individualized instruction in holding infant upright and using special nipple or feeding device, such as a Haberman feeder.1,2 Note: One study indicated that about one-half of mothers in the study were unable to breastfeed infants with cleft lip and/or palate.14 • Note prematurity. Degree of prematurity will dictate type of interventions needed to deal with situation. Infant may be put to breast if sufficiently developed or mother may pump breast and the breast milk given via gavage. If infant breastfeeds, mother should pump afterward because the premature infant's suck cannot empty breast.2 • Encourage mother to keep a log of intake and output. Review feeding schedule to note increased demand for feeding (at least eight times/day, taking both breasts at each feeding for more than 15 min on each side) or use of supplements with artificial nipple. Provides opportunity to evaluate infant's growth, determine whether sufficient nourishment is provided, and make adjustments as needed.2 • Evaluate baby latching and note observable signs of inadequate infant intake. Inadequate latching, baby latching onto mother's nipples with sustained suckling but minimal audible swallowing noted, infant arching and crying at the breasts with resistance to latching on, decreased urinary output/frequency of stools, and inadequate weight gain all indicate need for evaluation and intervention.1,7 • Determine whether baby is content after feeding or exhibits fussiness and crying within the first hour after breastfeeding. Suggests unsatisfactory breastfeeding process.1 • Note any correlation between maternal ingestion of certain foods and "colicky" response of infant. Some foods may seem to result in reaction by the infant, and identification and elimination may correct the problem.2 NURSING PRIORITY NO. 3 To assist mother to develop skills of successful breastfeeding: • Provide emotional support to mother. Use one-to-one instruction with each feeding during hospital stay/clinic visit. New mothers say they would like more support, encouragement, and practical information, especially when they are discharged early. Contact during each feeding provides the opportunity to develop nurse-client relationship in which these goals can be attained.1 Note: Adoptive mothers choosing to breastfeed will require more supportive instruction from a lactation consultant to assist with induced lactation techniques.8 • Encourage skin-to-skin or kangaroo care, especially for the premature infant. Studies show that early skin-to-skin mother-infant contact is correlated with exclusive breastfeeding while in the hospital.16,21 • Inform mother how to assess and correct a latch if needed. Demonstrate asymmetric latch by aiming infant's lower lip as far from base of the nipple as possible and then bringing infant's chin and lower jaw in contact with breast while mouth is wide open and before upper lip touches breast. This position allows infant to use both tongue and jaw more effectively to obtain milk from the breast.17,21 • Discuss early infant feeding cues (e.g., rooting, lip smacking, sucking fingers or hand) versus the late cue of crying. New mothers may not be aware that these behaviors indicate hunger and may not respond appropriately. Early recognition of infant hunger promotes timely and more rewarding feeding experience for infant and mother.1,8 • Recommend avoidance or overuse of supplemental bottle feedings and pacifiers (unless specifically indicated). These can lessen infant's desire to breastfeed. The shape of the mouth and lips and the sucking mechanism are different for breast and bottle, and the infant may be confused by the difference, causing interference in the breastfeeding process and increasing risk of early weaning. Note: Adoptive mothers may not develop a full breast milk supply, necessitating supplemental feedings.1,8 • Restrict use of nipple shields (i.e., only temporarily to help draw the nipple out) and then place baby directly on nipple. These have been found to contribute to lactation failures. Shields prevent the infant's mouth from coming into contact with the mother's nipple, which is necessary for continued release of prolactin (promoting milk production) and can interfere with or prevent establishment of adequate milk supply. However, temporary use of shield may be beneficial in the presence of severe nipple cracking. Hand pumps can also help draw a flat nipple out before latching.6 • Discuss and demonstrate breastfeeding aids (e.g., infant sling, nursing footstool, or pillows) and suggest using a variety of nursing positions to find the most comfortable ones for mother and infant. Positions particularly helpful for "plus-sized" women or those with large breasts include the "football" hold, with infant's head to mother's breast and body curved around behind her, or lying down to nurse.10 • Encourage frequent rest periods, sharing household and childcare duties. The new mother may feel overwhelmed with taking care of infant and carrying out other household duties; having assistance can limit fatigue and facilitate relaxation at feeding times.6 Note: Research suggests a correlation between psychological stress and development of breast disease (e.g., breast pain, milk stasis, mastitis) leading to early weaning.19 • Suggest abstinence or restriction of tobacco, caffeine, alcohol, drugs, and excess sugar, as appropriate. May affect milk production/letdown reflex and can be passed on to the infant.1 • Promote early management of breastfeeding problems. Dealing with problems in a timely manner will promote successful breastfeeding.1,7 For example: Engorgement: Wear supportive bra; apply heat or cool applications to the breasts and massage from chest wall down to nipple; soothe "fussy baby" before latching on the breast and properly position baby on breast/nipple; alternate the side on which baby starts nursing; nurse round the clock or pump with piston-type electric breast pump with bilateral collection chambers at least 8 to 12 times/day; and avoid using bottle, pacifier, or supplements.13 Sore nipples: Wear 100% cotton fabrics, do not use soap/alcohol/drying agents on nipples, and avoid use of nipple shields or nursing pads that contain plastic; cleanse and pat dry with a clean cloth; apply thin layer of highly purified anhydrous (HPA) lanolin on nipple. Note: This cream is edible and does not need to be removed before breastfeeding.12,18 Administer a mild pain reliever as appropriate. Infant should latch on least sore side or begin with hand expression to establish letdown reflex, properly position infant on breast and nipple, and use a variety of nursing positions. Break suction after breastfeeding is complete. Clogged ducts: Use larger bra or extender to avoid pressure on site; use moist or dry heat and gently massage from above plug down to nipple; nurse infant, hand express, or pump after massage; and nurse more often on affected side. Inhibited letdown: Use relaxation techniques before nursing (e.g., maintain quiet atmosphere, massage, apply heat to breasts, have beverage available, assume position of comfort, place infant on mother's chest, skin-to skin). Encourage mother to relax and enjoy her baby. Mastitis: Promote bedrest (with infant) for several days; administer antibiotics; provide warm, moist heat before and during nursing; and empty breasts completely, continuing to nurse baby at least 8 to 12 times/day, or pumping breasts for 24 hours, and then resuming breastfeeding as appropriate. • Demonstrate use of hand expression, hand pump, and electric piston-type breast pump with bilateral collection chamber when necessary to maintain or increase milk supply. Note: Studies indicate that mothers taught hands-on pumping increased the mean daily volume of milk by 48%.20 The need to use a pump to store milk for feedings while the mother is away (i.e., going back to work or simply to allow time away from the infant) demands some degree of proficiency in the use of the pump.1 NURSING PRIORITY NO. 4 To condition infant to breastfeed: • Scent breast pad with breast milk and leave in bed with infant along with mother's photograph when separated from mother for medical purposes (e.g., prematurity). • Increase skin-to-skin contact (kangaroo care). • Provide practice times at breast for infant to "lick and learn." • Express small amounts of milk into baby's mouth. • Have mother pump breast after feeding to enhance milk production. • Use supplemental nutrition system cautiously when necessary. • Identify special interventions for feeding in presence of cleft lip/palate. These measures promote optimal interaction between mother and infant and provide adequate nourishment for the infant, enhancing successful breastfeeding.1,21

Intervention for ND of readiness for enhanced comfort

NURSING PRIORITY NO. 2 To assist client in developing plan to improve comfort: • Review knowledge base and note coping skills that have been used previously to change behavior and promote well-being. Brings these to client's awareness and promotes use in current situation.8 • Acknowledge client's strengths in present situation that can be used to build on in planning for future. Physical • Collaborate in treating or managing medical conditions involving oxygenation, elimination, mobility, cognitive abilities, electrolyte balance, thermoregulation, and hydration to promote physical stability.2,5,6 • Work with client to prevent pain, nausea, itching, thirst, and other physical discomforts. • Suggest parent be present during procedures to comfort child. • Suggest age-appropriate comfort measures (e.g., back rub, change of position, cuddling, use of heat or cold) to provide nonpharmacological pain management. • Participate in interventions and age-appropriate activities, such as Therapeutic Touch, biofeedback, self-hypnosis, guided imagery, breathing exercises, play therapy, and humor, that promote ease and relaxation and can refocus attention. • Assist client to use or modify medication regimen to make best use of pharmacological pain management. • Assist client/SO(s) to develop or modify plan for activity and exercise within individual ability, emphasizing necessity of allowing sufficient time to finish activities. • Maintain open and flexible visitation with client's desired persons. • Encourage and plan care to allow individually adequate rest periods to prevent fatigue. Encourage client to schedule activities for periods when he/she has the most energy to maximize effectiveness. • Discuss routines to promote restful sleep. Psychospiritual • Interact with client in therapeutic manner. The nurse could be the most important comfort intervention for meeting client's needs. For example, assuring client that nausea can be treated successfully with both pharmacological and nonpharmacological methods may be more effective than simply administering an antiemetic without reassurance and comforting presence.7 • Encourage verbalization of feelings and make time for active-listening and interacting. • Identify ways (e.g., meditation, sharing oneself with others, being out in nature or garden, other spiritual activities) to achieve connectedness or harmony with self, others, nature, or a higher power. • Establish realistic activity goals with client. Enhances commitment to promoting optimal outcomes. • Involve client/SO(s) in schedule planning and decisions about timing and spacing of treatments to promote relaxation and desire for involvement in plan. • Encourage client to do whatever possible (e.g., self-care, sit up in chair, walk). Enhances self-esteem and independence. • Use age-appropriate distraction with music, chatting or texting with family/friends, watching TV, and playing video or computer games to limit dwelling on negatives and to transcend unpleasant sensations and situations. • Encourage client to make use of beneficial coping behaviors and assertiveness skills, prioritizing goals and activities. Promotes sense of control and improves self-esteem. • Offer and identify opportunities for client to participate in experiences that enhance control and independence. Environmental • Provide quiet environment and calm activities. • Provide for periodic changes in the personal surroundings when client is confined. Use the individual's input in creating the changes (e.g., seasonal bulletin boards, color changes, rearranging furniture, pictures). • Suggest activities, such as bird-watching, planting a garden in a window box or terrarium, or populating a fishbowl or aquarium, to stimulate observation as well as involvement and participation in activity. Sociocultural • Encourage age-appropriate diversional activities (e.g., TV, radio, playtime, socialization or outings with others). • Avoid overstimulation or understimulation (cognitive and sensory). • Make appropriate referrals to available support groups, hobby clubs, or service organizations.

Intervention for ND of impaired comfort

NURSING PRIORITY NO. 2 To assist client to alleviate discomfort: • Review knowledge base and note coping skills that have been used previously to change behavior and promote well-being. Brings these to client's awareness and promotes use in current situation.8 • Acknowledge client's strengths in present situation and build on those strengths in planning for future. Physical • Collaborate in treating and managing medical conditions involving oxygenation, elimination, mobility, cognitive abilities, electrolyte balance, thermoregulation, and hydration, to promote physical stability.2,5,6 • Work with client to prevent pain, nausea, itching, thirst, and other physical discomforts. • Review medications or treatment regimen to determine possible changes or options to reduce side effects. • Suggest parent be present during procedures to comfort child. • Provide age-appropriate comfort measures (e.g., back rub, change of position, cuddling, use of heat or cold) to provide nonpharmacological pain management. • Discuss interventions and activities to promote ease, such as Therapeutic Touch, massage, healing touch, biofeedback, self-hypnosis, guided imagery, breathing exercises, play therapy, and humor, to promote relaxation and refocus attention. Note: In recent years, a number of studies have documented emotional and physical health benefits that come from touch. This research is suggesting that touch is truly fundamental to human communication, bonding, and health.9,11 • Assist client to use and modify medication regimen to make best use of pharmacological pain or symptom management. • Assist client/SO(s) to develop plan for activity and exercise within individual ability emphasizing necessity of allowing sufficient time to finish activities. • Maintain open and flexible visitation with client's desired persons. • Encourage and plan care to allow individually adequate rest periods to prevent fatigue. Schedule activities for periods when client has the most energy to maximize participation. • Discuss routines to promote restful sleep. Psychospiritual • Interact with client in therapeutic manner. The nurse could be the most important comfort intervention for meeting client's needs. For example, assuring client that nausea can be treated successfully with both pharmacological and nonpharmacological methods may be more effective than simply administering antiemetic without reassurance and comforting presence.7 • Encourage verbalization of feelings and make time for listening and interacting. • Identify ways (e.g., meditation, sharing oneself with others, being out in nature or garden, other spiritual activities) to achieve connectedness or harmony with self, others, nature, and/or a higher power. • Establish realistic activity goals with client. Enhances commitment to promoting optimal outcomes. • Involve client/SO(s) in schedule planning and decisions about timing and spacing of treatments to promote relaxation and reduce sense of boredom. • Encourage client to do whatever possible (e.g., self-care, sit up in chair, walk). Enhances self-esteem and independence. • Use distraction with music, chatting, texting with family/friends, watching TV or videos, or playing computer games to limit dwelling on negatives and to transcend unpleasant sensations and situations. • Encourage client to make use of beneficial coping behaviors and develop assertiveness skills, prioritizing goals and activities. Promotes sense of control and improves self-esteem. • Offer or identify opportunities for client to participate in experiences that enhance control and independence. Environmental • Provide quiet environment and calm activities. • Provide for periodic changes in the personal surroundings when client is confined. Use the individual's input in creating the changes (e.g., seasonal bulletin boards, color changes, rearranging furniture, pictures). • Suggest activities, such as bird feeders or baths for bird-watching, a garden in a window box or terrarium, or a fishbowl or aquarium, to stimulate observation as well as involvement and participation in an activity. Sociocultural • Encourage age-appropriate diversional activities (e.g., TV, radio, computer games, playtime, socialization or outings with others). • Avoid overstimulation or understimulation (cognitive and sensory). • Make appropriate referrals to available support groups, hobby clubs, and service organizations.

Intervention for ND of decisional conflict

NURSING PRIORITY NO. 2 To assist client to develop/effectively use problem-solving skills: • Promote safe and hopeful environment, as needed. Client needs to be protected and supported while he or she regains inner control.7 • Encourage verbalization of conflicts and concerns. Helps client to clarify these issues so he or she can come to a resolution of the situation.7,8 • Accept verbal expressions of anger or guilt. Set limits on maladaptive behavior. Verbalization of feelings enables client to sift through feelings and begin to deal with situation. Behavior that is inappropriate is not helpful for dealing with the situation and will lead to feelings of guilt and low self-worth.2 • Clarify and prioritize individual goals, noting where the subject of the "conflict" falls on this scale. Helps to identify importance of problems client is addressing, enabling realistic problem-solving.2 • Identify strengths and use of positive coping skills (e.g., use of relaxation techniques, willingness to express feelings). Helpful for developing solutions to current situation.1 • Identify positive aspects of this experience and assist client to view it as a learning opportunity. Reframing the situation can help the client see things in a different light, enabling client to develop new and creative solutions.1 • Correct misperceptions client may have and provide factual information, as needed. Promotes understanding and enables client to make better decisions for own situation.1,6 • Provide opportunities for client to make simple decisions regarding self-care and other daily activities. Accept choice not to do so. Advance complexity of choices, as tolerated. Acceptance of what client wants to do, with gentle encouragement to progress, enhances self-esteem and ability to try more. Providing individualized decision support can help the client move to more difficult decisions.1,6 • Encourage child to make developmentally appropriate decisions concerning own care. Fosters child's sense of self-worth and enhances ability to learn and exercise coping skills.4 • Discuss time considerations, setting time line for small steps and considering consequences related to not making or postponing specific decisions to facilitate resolution of conflict. When time is a factor in making a decision, these strategies can promote movement toward solution.4 • Have client list some alternatives to present situation or decisions, using a brainstorming process. Include family in this activity, as indicated (e.g., placement of parent in long-term care facility, use of intervention process with addicted member). Involving family and looking at different options can promote successful resolution of decision to be made. Refer to NDs interrupted Family Processes, dysfunctional Family Processes, compromised family Coping, Moral Distress.7,8 • Practice use of problem-solving process with current situation and decision. Promotes identification of different possibilities that may not have been thought of otherwise.1 • Discuss and clarify spiritual concerns, accepting client's values in a nonjudgmental manner. Client will be willing to consider own situation when accepted as an individual of worth.5

Intervention for ND of impaired verbal communication

NURSING PRIORITY NO. 2 To assist client to establish a means of communication to express needs, wants, ideas, and questions: • Ascertain that you have client's attention before communicating. • Establish rapport with client, initiate eye contact, shake hands, address by preferred name, meet family members present, ask simple questions, smile, and engage in brief social conversation if appropriate. Helps establish a trusting relationship with client/family, demonstrating caring about the client as a person.2-4,18 • Advise other care providers of client's communication deficits (e.g., deafness, aphasia, mechanical ventilation strategies) and needed means of communication (e.g., writing pad, signing, yes/no responses, gestures, picture board) to minimize client's frustration and promote understanding.19 • Provide and encourage use of glasses, hearing aids, dentures, and electronic speech devices as needed to maximize sensory perception and improve speech patterns.2,4 • Maintain a calm, unhurried manner and sit at client's eye level if possible. Provide sufficient time for client to respond. Sitting down conveys that nurse has time and interest in communicating. • Pay attention to speaker. Be an active listener. • Begin conversation with elderly individual with casual and familiar topics (e.g., weather, happenings with family members) to convey interest and stimulate conversation and reminiscence.2,14 • Reduce environmental distractions and background noise (e.g., close the door, turn down the radio or television).14,20,21 • Refrain from shouting when directing speech to a confused, deaf, or hearing-impaired client. Speak slowly and clearly, pitching voice low to increase likelihood of being understood.2,15,20,21 • Be honest and let the speaker know when you have difficulty understanding. Repeat part of message that you do understand so speaker does not have to repeat entire message.11 • Clarify type and special features of aphasia, when present. Aphasia is a temporary, permanent, or progressive impairment of language affecting production or comprehension of speech and the ability to read or write. Some people with aphasia have problems primarily with expressive language (what is said), while others have problems with receptive language (what is understood). Aphasia can also be global (person understands almost nothing that is said and says little or nothing).4,11 • Note diagnosis of apraxia (impairment in carrying out purposeful movements affecting rhythm and timing of speech), dysarthria (language code can be correct but the right body parts do not move at the right time to produce the right message), or dementia (defect is in decline in mental functions, including memory, attention, intellect, and personality) to help clarify individual needs, appropriate interventions.11,12 • Determine meaning of words used by the client and congruency of communication and nonverbal messages. • Evaluate the meaning of words that are used/needed to describe aspects of healthcare (e.g., pain) and ascertain how to communicate important concepts.5 • Observe body language, eye movements, and behavioral clues. For example, client may react with tears, grimacing, stiff posture, turning away, or angry outbursts when pain present.13 • Use confrontation skills, when appropriate, within an established nurse-client relationship to clarify discrepancies between verbal and nonverbal cues.4,15 • Point to objects or demonstrate desired actions when client has difficulty with language. Speaker's own body language and gestures can be used to assist client's understanding. • Validate meaning of nonverbal communication; do not make assumptions because they may be wrong. Be honest; if you do not understand, seek assistance from others.18 • Work with confused, brain-injured, mentally disabled, or sensory-deprived client to correctly interpret his or her environment. Establish understanding and convey to others meaning of symbolic speech to reduce frustration. Teach basic signs such as "eat," "toilet," "more," and "finished" to communicate basic needs.4,15 • Provide reality orientation by responding with simple, straightforward, honest statements. Associate words with objects using repetition and redundancy to improve communication patterns.2,4,15 • Assess psychological response to communication impairment and willingness to find alternative means of communication. • Identify family member who can speak for client and who is the family decision maker regarding healthcare decisions.5,16 • Note significant other's (SO's)/parents'/caregiver's speech patterns and interactive manner of communicating with client, including gestures.20 • Obtain interpreter with language or signing abilities and preferably with medical knowledge when needed. Federal law mandates that interpretation services be made available. A trained, professional interpreter who translates precisely and possesses a basic understanding of medical terminology and healthcare ethics is preferred (over a family member) to enhance client and provider interactions.6 • Evaluate ability to read and write, as well as musculoskeletal status, including manual dexterity (e.g., ability to hold a pen and write), and the need or desire for pictures or written communications and instructions as part of treatment plan. • Plan for and provide alternative methods of communication:2-4,17,22 Provide pad and pencil or a slate board when client is able to write but cannot speak. Use letter or picture board when client can't write and picture concepts are understandable to both parties. Note: Studies show that visual aids may improve the accuracy of medication assessment and may be especially beneficial for clients with communication barriers.22 Establish hand or eye signals when client can understand language but cannot speak or has physical barrier to writing. Remove isolation mask when client is deaf and reads lips. Obtain or provide access to typewriter or computer if communication impairment is long-standing or client is used to this method. • Consider form of communication when placing IV. IV positioned in hand or wrist may limit ability to write or sign. • Answer call bell promptly. Anticipate needs and avoid leaving client alone with no way to summon assistance. Reduces fear, conveys caring to client, and protects nurse from problems associated with failure to provide due care.4 • Refer for appropriate therapies and support services. Client and family may have multiple needs (e.g., sources for further examinations and rehabilitation services, local community or national support groups and services for disabled, financial assistance with obtaining necessary aids for improving communication).4

Intervention for ND of disorganized infant behavior

NURSING PRIORITY NO. 2 To assist parents in providing coregulation to the infant: • Provide a calm, nurturant, physical, and emotional environment. Provides optimal infant comfort. Models behavior for parent(s) and optimizes learning.2,3 • Encourage parents to hold infant, including skin-to-skin contact as appropriate. Touch enhances parent-infant bonding and provides means of calming.3 Research suggests skin-to-skin contact or kangaroo care may have a positive effect on infant development by enhancing neurophysiological organization and an indirect effect by improving parental mood, perceptions, and interactive behavior.6 • Model gentle handling of baby and appropriate responses to infant behavior. Provides cues to parent.3 • Support and encourage parents to be with infant and participate actively in all aspects of care. Situation may seem overwhelming to new parents. Emotional and physical support enhances coping. Parents who are able to help in the care of their infant express lower levels of helplessness and powerlessness.1,2 • Encourage parents to refrain from social interaction during feedings as appropriate. Infant may have difficulty/lack necessary energy to manage feeding and social stimulation simultaneously.5 • Provide positive feedback for progressive parental involvement in caregiving process. Transfer of care from staff to parents progresses along a continuum as parents' confidence level increases and they are able to take on more complex care activities.7 • Discuss infant growth and development, pointing out current status and progressive expectations as appropriate. Augments parent knowledge of coregulation.2 • Incorporate the parents' observations and suggestions into plan of care. Demonstrates valuing of parents' input and encourages continued involvement.2,4 NURSING PRIORITY NO. 3 To deliver care within the infant's stress threshold: • Provide a consistent caregiver. Facilitates recognition of infant cues or changes in behavior. Communication is optimized if family is familiar with caregiver.2 • Support hands to mouth and face; offer pacifier or nonnutritive sucking at the breast with gavage feedings. Provides opportunities for infant to self-regulate.2,5 • Avoid aversive oral stimulation, such as routine oral suctioning; suction endotracheal tube only when clinically indicated. Maximizes infant comfort, preventing undue/noxious stimulation.1,2 • Use Oxyhood large enough to cover the infant's chest so arms will be inside the hood. Allows for hand-to-mouth self-calming activities during this therapy.2 • Provide opportunities for infant to grasp. Helps with development of motor function skills and can have a calming effect.2,5 • Provide boundaries or containment during all activities. Use swaddling, nesting, bunting, and caregiver's hands as indicated. Enhances infant's feelings of security and safeness. Avoids startle reflex and accompanying distress.2,3 • Allow adequate time and opportunities to hold infant. Handle infant very gently; move infant smoothly, slowly, and keep contained, avoiding sudden or abrupt movements. Provides comfort to infant and models behavior to parent(s).3 • Maintain normal alignment, position infant with limbs softly flexed and shoulders and hips adducted slightly. Use appropriate-sized diapers. Avoids unnecessary discomfort.2 • Evaluate chest for adequate expansion, placing rolls under trunk if prone position is indicated. Provides for ease of respirations.2 • Avoid restraints, including at IV sites. If an IV board is necessary, secure to limb positioned in normal alignment. Optimizes comfort and movement.1,2 • Provide a pressure-eliminating mattress, water bed, or gel pillow for infant who does not tolerate frequent position changes. Minimizes tissue pressure and risk of tissue injury.2 • Visually assess color, respirations, activity, and invasive lines without disturbing infant. Assess with "hands on" every 4 hr as indicated and prn. Allows for undisturbed rest and quiet periods.2,3 • Group care activities, schedule time for rest, and organize sleep and wake states to maximize tolerance of infant. Defer routine care when infant is in quiet sleep. Gives infant a sense of routine and also provides for undisturbed rest and longer periods of quiet.2,3,5 • Provide care with baby in side-lying position. Begin by talking softly to the baby and then placing hands in a containing hold on baby, allowing baby to prepare. Proceed with least invasive manipulations first. Gradual build from comforting touch, to nursing care, to invasive interventions decreases overall stress of infant. Shortens perception of "being bothered" time and facilitates a more rapid calming phase.3 • Respond promptly to infant's agitation or restlessness. Provide "time-out" when infant shows early cues of overstimulation. Comfort and support the infant after stressful interventions. Decreases stress for both infant and family. Facilitates calming phase.3 • Remain at infant's bedside for several minutes after procedures and caregiving to monitor infant's response and provide necessary support. Allows for more rapid intervention(s) if infant becomes overstressed.3 • Administer analgesics as individually appropriate. Maintains optimal comfort.1-4 NURSING PRIORITY NO. 4 To modify the environment to provide appropriate stimulation: • Introduce stimulation as a single mode and assess individual tolerance. Light/Vision • Reduce lighting perceived by infant; introduce diurnal lighting (and activity) when infant achieves physiological stability. (Daylight levels of 20 to 30 candles and night-light levels of less than 10 candles are suggested.) Change light levels gradually to allow infant time to adjust. Lowering light levels reduces visual stimulation and provides a comforting environment. Diurnal lighting allows the stable infant to begin perception of day and night cycles and to establish circadian rhythms.1 • Protect the infant's eyes from bright illumination during examinations and procedures, as well as from indirect sources, such as neighboring phototherapy treatments. Prevents retinal damage and reduces visual stressors.2 • Deliver phototherapy (when required) with Biliblanket devices if available. Alleviates need for eye patches to protect vision.2 • Provide a caregiver's face (preferably a parent's) as visual stimulus when infant shows readiness (awake, attentive). Begins process of visual recognition.1 • Evaluate/readjust placement of pictures, stuffed animal, etc., within infant's immediate environment. Promotes state maintenance and smooth transition, allowing infant to look away easily when visual stimuli become stressful.5 Sound • Identify sources of noise in environment and eliminate/reduce to minimize auditory stimulus, reduce startle response in infant, and provide a comforting environment:2 Speak in a low voice. Reduce volume on alarms and telephones to safe but not excessive volume. Pad metal trash can lids. Open paper packages such as IV tubing and suction catheters slowly and at a distance from bedside. Conduct rounds or report away from bedside. Place soft, thick fabric such as blanket rolls and toys near infant's head to absorb sound. Keep all incubator portholes closed, closing with two hands to avoid loud snap with closure and associated startle response. • Refrain from playing musical toys or tape players inside incubator. Even very soft sounds echo in an enclosed space. What an adult may find soothing is likely to overstimulate an infant.2,3 • Avoid placing items on top of incubator; if necessary to do so, pad surface well. Contact with the external parts of the incubator causes reverberation inside the chamber. • Conduct regular decibel (dB) checks of interior noise level in incubator (recommended not to exceed 60 dB). Verifies that decibel levels are within acceptable range.2 • Provide auditory stimulation to console and support infant before and through handling or to reinforce restfulness. Provides modeling of behavior for family and increased comfort for infant.3 Olfactory • Be cautious in exposing infant to strong odors (e.g., alcohol, Betadine, perfumes). Olfactory capability of the infant is very sensitive.1 • Place a cloth or gauze pad scented with milk near the infant's face during gavage feeding. Enhances association of milk with act of feeding and gastric fullness.2 • Invite parents to leave near infant a handkerchief that they have scented by wearing close to their body. Strengthens infant recognition of parents.2 Vestibular • Move and handle the infant slowly and gently. Do not restrict spontaneous movement. Maintains comfort while encouraging motor function skill.2 • Provide vestibular stimulation to console, stabilize breathing/heart rate, or enhance growth. Use a water bed (with or without oscillation); a motorized, moving bed or cradle; or rocking in the arms of a caregiver. Gustatory • Dip pacifier in milk and offer to infant for sucking and tasting during gavage feeding. Further enhances feeding recognition with touch and taste cues.2 Tactile • Maintain skin integrity and monitor closely. Limit frequency of invasive procedures. Decreases chance of infections. Decreases infant discomfort.1 • Minimize use of chemicals on skin (e.g., alcohol, povidone-iodine, solvents) and remove afterward with warm water. Chemical compounds remove the natural protective mechanisms of skin, and infants are often very sensitive to integumentary injury.1 • Limit use of tape and adhesives directly on skin. Use DuoDerm under tape. Helps prevent dermal injury and allergic reactions.1 • Touch infant with a firm, containing touch; avoid light stroking. Provide a sheepskin or soft linen. Note: Tactile experience is the primary sensory mode of the infant. Light stroking can cause tickle sensations that are irritating rather than pleasurable. Firm touch is reassuring.2 • Encourage frequent parental holding of infant (including skin-to-skin). Supplement activity with extended family, staff, volunteers. For family members, touch enhances bonding. If family is not readily available, infant needs regular skin-to-skin contact from caregivers for comfort and reassurance.3

Intervention for ND of readiness for enhanced communication

NURSING PRIORITY NO. 2 To improve client's ability to communicate thoughts, needs, and ideas: • Maintain a calm, unhurried manner. Provide sufficient time for client to respond. An atmosphere in which client is free to speak without fear of criticism provides the opportunity to explore all the issues involved in making decisions to improve communication skills.10 • Pay attention to speaker. Be an active listener. The use of active-listening communicates acceptance and respect for the client, establishing trust, and promoting openness and honest expression. It communicates a belief that the client is a capable and competent person. • Sit down and maintain eye contact, preferably at the client's level, and spend time with the client. Conveys message that the nurse has time and interest in communicating.10 • Encourage client to express feelings and clarify meaning of nonverbal clues. Client may be reluctant to share dissatisfaction with events. • Help client identify and learn to avoid use of nontherapeutic communication. These barriers are recognized as detriments to open communication, and learning to avoid them maximizes the effectiveness of communication between client and others. • Obtain interpreter with language or signing abilities as needed. May be needed to enhance understanding of words and language concepts to ascertain that interpretation of communication is accurate.6,10 • Encourage use of computer/tablet, pad and pencil, slate board, or letter or picture board when interacting or to interface in new situations, as indicated. When client has physical impairments that interfere with spoken communication, alternative means can provide concepts that are understandable to both parties.4,10 • Obtain or provide access to voice-enabled computer. Use of these devices may be more helpful when communication challenges are long-standing or when client is used to using them.1 • Respect client's cultural communication needs. Different cultures can dictate beliefs of what is normal or abnormal (i.e., in some cultures, eye-to-eye contact is considered disrespectful, impolite, or an invasion of privacy; silence and tone of voice have various meanings, and slang words can cause confusion).4 • Provide or encourage use of glasses, hearing aids, dentures, or electronic speech devices, as needed. These devices maximize sensory perception and can improve understanding and enhance speech patterns.7 • Reduce distractions and background noises (e.g., close the door, turn down the radio or television). A distracting environment can interfere with communication, limiting attention to tasks, and makes speech and communication more difficult. Reducing noise can help both parties hear clearly, improving understanding.8 • Associate words with objects using gestures, repetition and redundancy, point to objects, or demonstrate desired actions. Speaker's own body language can be used to enhance client's understanding when neurological conditions result in difficulty understanding language.9 • Use confrontation skills carefully, when appropriate, and within an established nurse-client relationship. Can be used to clarify discrepancies between verbal and nonverbal cues, enabling client to look at areas that may require change.10

Interventions for ND of readiness for enhanced childbearing process

NURSING PRIORITY NO. 2 To promote maximum participation in childbearing process: During Pregnancy • Maintain open attitude toward beliefs of client/couple. Acceptance is important to developing and maintaining relationship and supporting independence.2 • Explain office visit routine and rationale for ongoing screening and close monitoring (e.g., urine testing, blood pressure monitoring, weight, fetal growth). Emphasize importance of keeping regular appointments. Reinforces relationship between health assessment and positive outcome for mother/baby.12 • Suggest father/siblings attend prenatal office visits and listen to fetal heart tones as appropriate. Promotes a sense of involvement and helps make baby a reality for family members. • Provide information about need for additional laboratory studies and diagnostic tests or procedure(s). Review risks and potential side effects. Aids in making informed decisions.8,12 • Discuss any medications that may be needed to control or treat medical conditions. Helpful in choosing treatment options because need must be weighed against possible harmful effects on the fetus.12 • Provide anticipatory guidance, including discussion of nutrition, regular moderate exercise, comfort measures, rest, employment, breast care, sexual activity, and health habits and lifestyle. Information encourages acceptance of responsibility and promotes self-care: Review nutrition requirements and optimal prenatal weight gain to support maternal-fetal needs. Dietary focus should be on balanced nutrients and calories to produce appropriate weight gain and to supply adequate vitamins and minerals for healthy fetus. Inadequate prenatal weight gain and/or below normal prepregnancy weight increases the risk of intrauterine growth restriction in the fetus and delivery of a low-birth-weight infant.8,12 Encourage moderate exercise such as walking or non-weight-bearing activities (e.g., swimming, bicycling) in accordance with client's physical condition and cultural beliefs. Nonendurance, antepartal exercise regimens tend to shorten labor, increase likelihood of a spontaneous vaginal delivery, and decrease need for oxytocin augmentation.4,5 In some cultures, inactivity may be viewed as a protection for mother/child.1,6 Recommend a consistent sleep and rest schedule (e.g., 1- to 2-hour daytime nap and 8 hours of sleep each night) in a dark, cool room. Provides rest to meet metabolic needs associated with growth of maternal/fetal tissues.12 Identify anticipatory adaptations for significant other (SO)/family necessitated by pregnancy. Family members will need to be flexible in adjusting own roles and responsibilities in order to assist client to meet her needs related to the demands of pregnancy, both expected and unplanned, such as prolonged nausea, fatigue, and emotional lability.12 Provide or reinforce information about potential teratogens, such as alcohol, nicotine, illicit drugs, the STORCH group of viruses (syphilis, toxoplasmosis, other, rubella, cytomegalovirus, herpes simplex), and HIV. Helps client make informed decisions and choices about behaviors and environment that can promote healthy offspring. Note: Research supports the fact that alcohol and recreational drug use can lead to a wide range of negative effects in the neonate. Smoking negatively affects placental circulation; even smoking fewer than 10 cigarettes per day is associated with an increased risk of fetal death, damage in utero, abruptio placentae, placenta previa, and low birth weight.4,8,13-15 • Use various methods for learning, including pictures, to discuss fetal development. Visualization enhances reality of child and strengthens learning process.4 • Discuss signs of labor onset; how to distinguish between false and true labor, when to notify healthcare provider, and when to leave for hospital or birth center; and stages of labor and delivery. Helps client to recognize onset of labor, to ensure timely arrival, and to cope with labor and delivery process.12 During Labor and Delivery • Demonstrate or review behaviors and techniques (e.g., breathing, focused imagery, music, other distraction; aromatherapy; abdominal effleurage, back and leg rubs, sacral pressure, repositioning, back rest; oral and perineal care, linen changes; shower or hot tub use) partner can use to assist with pain control and relaxation. Enhances feeling of well-being. May block pain impulses within the cerebral cortex through conditioned responses and cutaneous stimulation, facilitating progression of normal labor.4 • Discuss available analgesics, usual responses and side effects (client and fetal), and duration of analgesic effect in light of current situation. Allows client to make informed choice about means of pain control and can allay client's fears or anxieties about medication use. Note: If conservative measures are not effective and increasing muscle tension impedes progress of labor, judicious use of medication can enhance relaxation, shorten labor, limit fatigue, and prevent complications.4 • Support client's decision about the use or nonuse of medication in a nonjudgmental manner. Continue encouragement for efforts and use of relaxation techniques. Enhances client sense of control and may prevent or decrease need for medication. Note: Continued support may be needed to help reduce feelings of failure in the client/couple who may have anticipated an unmedicated birth and did not follow through with that plan.12 After Birth • Initiate early breastfeeding or oral feeding according to hospital protocol. Initial feeding for breastfed infants usually occurs in the delivery room. Otherwise, 5 to 15 mL of sterile water may be offered in the nursery to assess effectiveness of sucking, swallowing, gag reflexes, and patency of esophagus. If aspirated, sterile water is easily absorbed by pulmonary tissues.7,9 • Note frequency and amount and length of feedings. Encourage demand feedings instead of "scheduled" feedings. Hunger and length of time between feedings vary from feeding to feeding.7,9 Note frequency, amount, and appearance of regurgitation. Excessive regurgitation increases feeding needs. • Evaluate neonate/maternal satisfaction following feedings. Provides opportunity to answer client questions, offer encouragement for efforts, identify needs, and problem-solve solutions.7,9 • Demonstrate and supervise infant care activities related to feeding and holding; bathing, diapering, and clothing; care of circumcised male infant; and care of umbilical cord stump. Provide written and pictorial information for parents to refer to after discharge. Promotes understanding of principles and techniques of newborn care and fosters parents' skills as caregivers.3,12 • Provide information about newborn interactional capabilities, states of consciousness, and means of stimulating cognitive development. Helps parents recognize and respond to infant cues during interactional process and fosters optimal interaction, attachment behaviors, and cognitive development in infant. The state of consciousness can be divided into the sleep and the wake states, involving separate and predictable behavioral characteristics.12 • Promote sleep and rest. Reduces metabolic rate and allows nutrition and oxygen to be used for healing process rather than for energy needs.12 • Provide for unlimited participation for father and siblings. Ascertain whether siblings attended an orientation program. Facilitates family development and ongoing process of acquaintance and attachment. Helps family members feel comfortable caring for newborn. • Monitor and document the client's/couple's interactions with infant. Note presence of bonding (acquaintance) behaviors (e.g., making eye contact, using high-pitched voice and en face [face-to-face] position as culturally appropriate, calling infant by name, holding infant closely).2,12

Intervention for ND of ineffective childbearing process

NURSING PRIORITY NO. 2 To promote optimal maternal well-being: During Pregnancy • Emphasize importance of maternal well-being including discussion of nutrition, regular moderate exercise, comfort measures, rest, and sexual activity. Fetal well-being is directly related to maternal health, especially during the first trimester, when developing organ systems are most vulnerable to injury from environmental or hereditary factors: Review nutrition requirements and optimal prenatal weight gain to support maternal-fetal needs. Dietary focus should be on balanced nutrients and calories to produce appropriate weight gain and to supply vitamins and minerals for healthy fetus. Inadequate prenatal weight gain and/or below normal prepregnancy weight increases the risk of intrauterine growth retardation in the fetus and delivery of a low-birth-weight infant.8,12 Encourage moderate exercise such as walking, or non-weight-bearing activities (e.g., swimming, bicycling) in accordance with client's physical condition and cultural beliefs. Nonendurance antepartal exercise tends to shorten labor, increases likelihood of a spontaneous vaginal delivery, and decreases need for oxytocin augmentation.4,5 In some cultures, inactivity may be viewed as a protection for the mother.1,6 Recommend a consistent sleep and rest schedule (e.g., 1- to 2-hour daytime nap and 8 hours of sleep each night) in a dark, comfortable room. Provides rest to meet metabolic needs associated with growth of maternal and fetal tissues.12 • Provide necessary referrals (e.g., dietitian, social services, supplemental nutrition assistance programs including the Women, Infants, and Children [WIC] program) as indicated. May need additional assistance with nutritional choices and may have budget or financial constraints. Supplemental federal/state food programs help promote optimal maternal, fetal, and infant nutrition.12 • Encourage participation in a smoking-cessation program and alcohol/drug abstinence as appropriate. Reduces risk of premature birth, stillbirth, low birth weight, congenital defects, drug withdrawal of newborn, and fetal alcohol syndrome.14 • Explain psychological reactions, including ambivalence, introspection, stress reactions, and emotional lability, as being characteristic of pregnancy. Helps client/couple understand mood swings and may provide opportunity for partner to offer support and affection at these times.4 Note: However, the stressors associated with pregnancy may lead to abuse/exacerbate existing abusive behavior.18,19 • Discuss personal situation and options, providing information about resources available to client. Partner may be upset about an unplanned pregnancy, financial concern regarding supporting the child, or even jealousy that attention is shifting to the unborn child, creating safety issues for client/family.19 After Birth • Promote sleep and rest. Reduces metabolic rate and allows energy and oxygen to be used for healing process.12 • Provide information about self-care, including perineal care and hygiene; physiological changes, including normal progression of lochial flow; need for sleep and rest; importance of progressive postpartum exercise program; and role changes. Helps prevent infection, fosters healing and recuperation, and contributes to positive adaptation to physical and emotional changes, enhancing feelings of general well-being.12 • Review nipple and breast care, special dietary needs for lactating mother, factors that facilitate or interfere with successful breastfeeding, use of breast pump and appropriate suppliers, and proper storage of expressed milk. Prevents nipple cracking and soreness, enhancing comfort, facilitates role of breastfeeding mother, and helps ensure adequate milk supply.8 • Discuss normal psychological changes and needs associated with the postpartal period. Client's emotional state may be somewhat labile at this time and often is influenced by physical well-being. Anticipating such changes may reduce the stress associated with this transition period that necessitates learning new roles and taking on new responsibilities.4,8,12 • Discuss sexuality needs and plans for contraception. Provide information about available methods, including advantages/disadvantages. Client/couple may need clarification regarding available contraception methods and the fact that pregnancy could occur even prior to the 4- to 6-week postpartum visit.8 • Reinforce importance of postpartum examination by healthcare provider and interim follow-up as appropriate. Follow-up visit is necessary to evaluate recovery of reproductive organs, healing of episiotomy/laceration repair, general well-being, and adaptation to life changes.12 NURSING PRIORITY NO. 3 To promote appropriate participation in childbearing process: During Pregnancy • Develop nurse-client relationship, maintaining an open attitude toward beliefs of client/couple. Acceptance is important to developing and maintaining relationship and supporting independence.2 • Explain office visit routine and rationale for ongoing screening and close monitoring (e.g., urine testing, blood pressure monitoring, weight, fetal growth). Emphasize importance of keeping regular appointments. Reinforces relationship between health assessment and positive outcomes for mother and baby.12 • Suggest father/siblings attend office visits and listen to fetal heart tones as appropriate. Promotes a sense of involvement and helps make baby a reality for family members. • Provide anticipatory guidance regarding health habits/lifestyle and employment concerns: Review physical changes to be expected during each trimester. Questions will continue to arise as new changes occur, regardless of whether changes are anticipated or unexpected, and knowledge of normal variations can be reassuring. Also prepares client/couple for managing common discomforts associated with pregnancy.4,12 Discuss signs/symptoms requiring evaluation by primary provider during prenatal period (e.g., excessive vomiting, fever, unresolved illness of any kind, decreased fetal movement). Allows for timely intervention.12 Identify anticipatory adaptations for SO/family necessitated by pregnancy. Family members will need to be flexible in adjusting own roles and responsibilities in order to assist client to meet her needs related to the demands of pregnancy, both expected and unplanned, such as prolonged nausea, fatigue, and emotional lability.12 Provide information about potential teratogens, such as alcohol, nicotine, illicit drugs, the STORCH group of viruses (syphilis, toxoplasmosis, other, rubella, cytomegalovirus, herpes simplex), and HIV. Helps client make informed decisions/choices about behaviors/environment that can promote healthy offspring. Note: Research supports the attribution of a wide range of negative effects in the neonate from alcohol and recreational drug use and smoking.4,8,13-15 • Provide information about need for additional laboratory studies and diagnostic tests or procedure(s). Review risks and potential side effects. Aids in making informed decisions and choosing treatment options.8,12 • Discuss signs of labor onset; how to distinguish between false and true labor, when to notify healthcare provider, and when to leave for birth center/hospital as appropriate; and stages of labor and delivery. Helps ensure timely arrival and enhances coping with labor/delivery process.12 • Determine anticipated infant feeding plan. Discuss physiology and benefits of breastfeeding. Breastfeeding provides a protective effect against respiratory illnesses, ear infections, gastrointestinal diseases, and allergies, including asthma, eczema, and atopic dermatitis.9 • Encourage attendance at prenatal and childbirth classes. Provide information about father/sibling or grandparent participation in classes and delivery if client desires. Knowledge gained helps reduce fear of unknown and increases confidence that client/couple can manage the preparation for the birth of their child. Helps family members to realize they are an integral part of the pregnancy and delivery.11,12 During Labor and Delivery • Support use of positive coping mechanisms. Enhances feelings of competence and fosters self-esteem.12 • Demonstrate behaviors and techniques (e.g., breathing, focused imagery, music, other distractions; aromatherapy; abdominal effleurage, back or leg rubs, sacral pressure, repositioning, back rest; oral care, linen changes, shower/tub use) that partner can use to assist with pain control and relaxation. Enhances feeling of well-being. May block pain impulses within the cerebral cortex through conditioned responses and cutaneous stimulation, facilitating progression of normal labor.4 • Discuss available analgesics, appropriate timing, usual responses and side effects (client and fetal), and duration of analgesia effect in light of current situation. Allows client to make informed choices about means of pain control and can allay client's fears and anxieties about medication use. Note: If conservative measures are not effective and increasing muscle tension impedes progress of labor, judicious use of medication can enhance relaxation, shorten labor, limit fatigue, and prevent complications.4 • Honor client's decision about the use or nonuse of medication in a nonjudgmental manner. Continue encouragement for efforts and use of relaxation techniques. Enhances client's sense of control and may prevent or reduce need for medication. Note: Continued support may be needed to help reduce feelings of failure in the client/couple who may have anticipated an unmedicated birth and did not follow through with that plan.12 After Birth • Monitor and document the client's/couple's interactions with infant. Presence of bonding acquaintance behaviors (e.g., making eye contact, using high-pitched voice and en face [face-to-face] position as culturally appropriate, calling infant by name, holding infant closely) are indicators of beginning the attachment process.2,12 • Initiate early breast or oral feeding according to facility protocol and client preference. Initiating feeding for breastfed infants usually occurs in the delivery room; otherwise, 5 to 15 mL of sterile water may be offered in the nursery to assess effectiveness of sucking, swallowing, gag reflexes, and patency of esophagus. If aspirated, sterile water is easily absorbed by pulmonary tissues.7,9 • Provide for unlimited participation of father and siblings. Ascertain whether siblings attended orientation program. Facilitates family development and ongoing process of acquaintance/attachment and helps family members feel more comfortable caring for newborn.

Intervention for ND of disturbed body image

NURSING PRIORITY NO. 3 To assist client and SO(s) to deal with/accept issues of self-concept related to body image: • Establish a therapeutic nurse-client relationship. Conveys an attitude of caring and develops a sense of trust in which client can discuss concerns and find answers to issues confronting him or her in new situation.4,8 • Visit client frequently and acknowledge the individual as someone who is worthwhile. Provides opportunities for listening to concerns and questions to promote dealing positively with individual situation and change in body image.1 • Assist in correcting underlying problems when possible. Promotes optimal healing and adaptation to individual situation (i.e., amputation, presence of colostomy, mastectomy, impotence).1 • Provide assistance with self-care needs or measures, as necessary, while promoting individual abilities and independence. Client may need support to achieve the goal of independence and positive return to managing own life. • Work with client's self-concept without moral judgments regarding client's efforts or progress (e.g., "You should be progressing faster; you're weak, lazy, not trying hard enough"). Such statements diminish self-esteem and are counterproductive to progress. Positive reinforcement encourages client to continue efforts and strive for improvement.2,8 • Discuss concerns about fear of mutilation, prognosis, and rejection when client is facing surgery or potentially poor outcome of procedure or illness. Addresses realities and provides emotional support to enable client to be ready to deal with whatever the outcome may be.1 • Acknowledge and accept feelings of dependency, grief, and hostility. Conveys a message of understanding.1 • Encourage verbalization of and role-play anticipated conflicts to enhance handling of potential situations. Provides an opportunity to imagine and practice how different situations can be dealt with, thus promoting confidence.4 • Encourage client and SO(s) to communicate feelings to each other and discuss situation openly. Enhances relationship, improving sense of self-worth and sense of support.2 • Alert staff to be cognizant of own facial expressions and other nonverbal behaviors. Important to convey acceptance and not revulsion, especially when the client's appearance is affected. Clients are very sensitive to reactions of those around them, and negative reactions will affect self-esteem and may retard adaptation to situation.1 • Encourage family members to treat client normally and not as an invalid. Helps client return to own routine and begin to gain confidence in ability to manage own life.1 • Encourage client to look at and touch affected body part to begin to incorporate changes into body image. Acceptance will enhance self-esteem and enable client to move forward in a positive manner.1,7 • Allow client to use denial without participating (e.g., client may at first refuse to look at a colostomy; the nurse says, "I am going to change your colostomy now" and proceeds with the task). Provides individual time to adapt to situation.4 • Set limits on maladaptive behavior; assist client to identify positive behaviors. Self-esteem will be damaged if client is allowed to continue behaviors that are destructive or not helpful, and adaptation to new image will be delayed.4,10 • Provide accurate information, as desired or requested. Reinforce previously given information. Accurate knowledge helps client make better decisions for the future.4 • Discuss the availability of prosthetics, reconstructive surgery, and physical and occupational therapy or other referrals, as dictated by individual situation. Provides hope that situation is not impossible and the future does not look so bleak.1,7,8 • Help client to select and creatively use clothing or makeup to minimize body changes and enhance appearance.1 • Discuss reasons for infectious isolation and procedures when used, and make time to sit down and talk or listen to client while in the room. Promotes understanding and decreases sense of isolation and loneliness.1

Intervention for ND of insufficient breast milk production

NURSING PRIORITY NO. 3 To increase mother's milk supply: • Instruct on how to differentiate between perceived and actual insufficient milk supply. Normal breastfeeding frequencies, suckling times, and amounts vary not only between mothers, but also based on infant's needs/moods. Milk production is likely to be a reflection of the infant's appetite rather than the mother's ability to produce milk.4,5 • Provide emotional support to mother. Use one-to-one instruction with each feeding during hospital stay, clinic, or home visit. Increases likelihood of continuation of breastfeeding efforts and achievement of goals.11,14 • Refer adoptive mothers choosing to breastfeed to a lactation consultant. Adoptive mothers choosing to breastfeed will require more supportive instruction from a professional consultant to assist with induced lactation techniques.14 • Inform mother how to assess and correct a latch if needed. Demonstrate asymmetric latch, aiming infant's lower lip as far from base of the nipple as possible and then bringing infant's chin and lower jaw in contact with breast while mouth is wide open and before upper lip touches breast. Correct latching-on is the most effective way to stimulate milk supply.2,9 • Encourage unrestricted frequency and duration of breastfeeding. Provides stimulation of breast tissue and may increase milk supply naturally.9 • Recommend reducing or stopping supplemental feedings if used. Gradual tapering off of supplementation can increase frequency/duration of infant's breastfeeding stimulating maternal milk production.9,14 • Demonstrate breast massage technique. Improves oxytocin release and milk removal to increase milk supply naturally.9,14 Also, gently massaging breast while infant feeds from it can improve the release of higher-calorie hindmilk from the milk glands.1,9 • Use breast pump 8 to 12 times a day. Expressing with a hospital-grade, double (automatic) pump is ideal for stimulation/reestablishing milk supply.1,9 • Recommend mother adjust the electric pump to her maximum comfortable vacuum. Enhances milk flow rate and milk yield and minimizes occurrence of tissue damage.9 • Suggest using a breast pump or hand expression after infant finishes breastfeeding. Continued breast stimulation cues the mother's body that more milk is needed, increasing supply.7 • Encourage use of relaxation techniques during hand or mechanical expression. Facilitates oxytocin release to improve milk removal.9 • Monitor increased filling of breasts in response to nursing and/or pumping to help evaluate effectiveness of interventions. • Discuss appropriate/safe use of herbal supplements. Herbs such as sage, parsley, oregano, peppermint, jasmine, and yarrow may have a negative effect on milk supply if taken in large quantities. A number of herbs have been used for centuries to stimulate milk production, with fenugreek (Trigonella foenum-graecum) being the most commonly recommended herbal galactogogue to facilitate lactation.4,9 • Discuss possible use of prescribed medications (galactogogues) to increase milk production. Domperidone (Motilium) is approved by the American Academy of Pediatrics for use in breastfeeding mothers and has fewer side effects. Metoclopramide (Reglan) has been shown to increase milk supply anywhere from 72% to 110% depending on how many weeks the mother is postpartum.1,6,9

Intervention for ND of acute confusion

NURSING PRIORITY NO. 3 To maximize level of function, prevent further deterioration: • Assist with treatment of underlying problem. Interventions to establish and maintain normal fluid and electrolyte balance and oxygenation, treat infectious process or pain, detoxify from alcohol and other drugs, and provide psychological interventions can resolve or diminish confusion.1-7,9,11,12,14 • Monitor and adjust medication regimen and note response. Determine which medications can be changed or eliminated when polypharmacy, side effects, or adverse reactions are determined to be associated with current condition. • Implement helpful communication measures:1-7,9,11,14 Use short, simple sentences. Speak slowly and clearly. Call client by name and identify yourself at each contact. Tell client what you want done, not what to do. Orient client to surroundings, staff, and necessary activities as often as needed. Acknowledge client's fears and feelings. Confusion can be very frightening, especially when client knows thinking is not normal. Listen to what client says and try to identify message and emotion or need being communicated. Limit choices and decisions until client is able to make them. Give simple directions. Allow sufficient time for client to respond, communicate, and make decisions. Present reality concisely and briefly and avoid challenging illogical thinking. Defensive reactions may result. Refer to ND impaired verbal Communication for additional interventions. • Manage environment, using the following measures:1-7,9-11,14,15 Provide undisturbed rest periods. Eliminate extraneous noise and stimuli. Preventing overstimulation can help client relax and can result in reduced level of confusion. Provide calm and comfortable environment with good lighting. Encourage client to use vision or hearing aids, when needed, to reduce disorientation and discomfort from sensory overload or deprivation. Observe client on regular basis, informing client of this schedule. Provide adequate supervision (may need one-to-one during severe episode), remove harmful objects from environment, provide siderails and seizure precautions, place call bell and position needed items within reach, clear traffic paths, and ambulate with devices to meet client's safety needs and reduce risk of falls. Provide clear feedback on appropriate and inappropriate behavior. Remove client from situation; provide time-out or seclusion, as indicated, for protection of client/others. Encourage family/SO(s) to participate in reorientation and provide ongoing normal life input (e.g., current news and family happenings). Provide normal levels of essential sensory and tactile stimulation—include personal items and pictures. Client may respond positively to well-known person and familiar items. • Note behavior that may be indicative of potential for violence and take appropriate actions to prevent injury to client/caregiver. (Refer to ND risk for other-directed Violence.) • Administer medication cautiously to control restlessness, agitation, and hallucinations. Depending on the cause of acute delirium, medications could include sedatives, neuroleptics, and antidotes. Sedation with conventional antipsychotic agents (e.g., haloperidol, lorazepam, droperidol) may be used, although many other agents may be tried, including electrolytes, glucose, vitamins, antibiotics, etc. (Note: Sedation should be avoided if it will interfere with, or cloud the results of, serial neurological examinations.)2,5-7,11 • Assist with treatment of alcohol or drug intoxication and/or withdrawal, as indicated.11,12,14 • Avoid or limit use of restraints. May worsen agitation and increase likelihood of untoward complications including injury or death.5,12,15 • Mobilize elderly client (especially after orthopedic injury) as soon as possible. Older person with low level of activity prior to crisis is at particular risk for acute confusion and may fare better when out of bed.4,14,15 • Establish and maintain elimination patterns. Disruption of elimination may be a cause for confusion, or changes in elimination may also be a symptom of acute confusion.5 • Consult with psychiatric clinical nurse specialist or psychiatrist for additional interventions related to disruptive behaviors, psychosis, and unresolved symptoms. • Refer to ND [disturbed Sensory Perception (Specify)] for additional interventions.

Intervention for ND of decreased Cardiac output

NURSING PRIORITY NO. 3 To minimize/correct causative factors, maximize cardiac output: Acute/severe phase7-10,12,15 • Keep client on bedrest or chairrest in position of comfort. Decreases oxygen consumption and demand, reducing myocardial workload and risk of decomposition. Note: In congestive state, client may be placed in semi-Fowler's or high Fowler's position to reduce preload and ventricular filling. A supine position may be needed to increase venous return and promote diuresis. May raise legs 20 to 30 degrees in shock situation (Trendelenburg position); however, current studies to support the use of the Trendelenburg position during shock do not reveal any beneficial or sustained changes in systolic blood pressure or cardiac output.18 • Administer supplemental oxygen, as indicated (by cannula, mask, endotracheal or tracheostomy tube with mechanical ventilation), to improve cardiac function by increasing available oxygen and reducing oxygen consumption. Note: A critically ill client may be on ventilator to support cardiopulmonary function.12 • Monitor vital signs frequently to evaluate response to treatments and activities. Perform periodic hemodynamic measurements, as indicated (e.g., arterial, CVP, PAWP, left atrial pressure; cardiac output and cardiac index, oxygen saturation). These measurements (via central line monitoring) are commonly used in the critically ill to provide continuous, accurate assessment of cardiac function and response to inotropic and vasoactive medications that affect cardiac contractility and systemic circulation (preload and afterload). Note: A multicenter research study evaluating the clinical effectiveness of clinical management guided by a pulmonary artery catheter in adult intensive care patients (N = 1,041) found no clear evidence that management guided by a pulmonary catheter was either beneficial or harmful.15,17 • Monitor cardiac rhythm continuously to note changes and evaluate effectiveness of medications and devices (e.g., implanted pacemaker/defibrillator). • Administer or restrict fluids, as indicated. Replacement of blood and large amounts of IV fluids may be needed if low output state is due to hypovolemia. Use infusion pumps for IVs to monitor IV rates closely to prevent bolus or exacerbation of fluid overload. • Assess hourly or periodic urinary output and daily weight, noting 24-hour total fluid balance to evaluate kidney function and effects of interventions, as well as to allow for timely alterations in therapeutic regimen. • Administer medications as indicated (e.g., inotropic drugs to maintain systemic perfusion and preserve end-organ performance, antiarrhythmics to improve cardiac output; diuretics to reduce congestion by improving urinary output; vasopressors and/or dilators as indicated to manage systemic effects of vasoconstriction and low cardiac output; pain medications and anti-anxiety agents to reduce oxygen demand and myocardial workload; anticoagulants to improve blood flow and prevent thromboemboli). Note: Randomized clinical trials demonstrate consistent mortality benefit from angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs); direct-acting vasodilators, beta blockers, and aldosterone antagonists. Additionally, some data show benefits from two new classes of drugs: ARB/neprilysin inhibitor and sinus node modulator.7 • Note reports of anorexia or nausea and limit or withhold oral intake as indicated. Symptoms may be systemic reaction to low cardiac output, visceral congestion, or reaction to medications or pain. • Assist with preparations for and monitor response to support procedures or devices as indicated (e.g., cardioversion, pacemaker, angioplasty and stent placement, coronary artery bypass graft or valve replacement, intra-aortic balloon pump, left ventricular assist device [LVAD]; total artificial heart [TAH], transplantation). Any number of interventions may be required to correct a condition causing heart failure or to support a failing heart during recovery from myocardial infarction, while awaiting transplantation, or for long-term management of chronic heart failure. Note: The application of LVAD during reperfusion procedures causes reduction of the left ventricular preload, increases regional myocardial blood flow and lactate extraction, and improves general cardiac function.6,7 • Promote rest periods in bed or chair with upper body elevated, as indicated, to reduce catecholamine-induced stress response and cardiac workload:11,15 Decrease stimuli, providing quiet environment. Schedule activities and assessments to maximize sleep periods. Assist with or perform self-care activities for client. Avoid the use of restraints whenever possible, especially if client is confused. • Use sedation and analgesics, as indicated, with caution to achieve desired rest state without compromising hemodynamic responses. Postacute/Chronic Phase6,7,11 • Provide for adequate rest, positioning client for maximum comfort. • Encourage changing positions slowly, dangling legs before standing to reduce risk of orthostatic hypotension. • Increase activity levels gradually as permitted by individual condition, noting vital sign response to activity. • Administer medications, as appropriate, and monitor cardiac responses. • Encourage relaxation techniques to reduce anxiety and muscle tension. • Refer for nutritional needs assessment and management to provide for supportive nutrition while meeting diet restrictions (e.g., IV nutrition or total parenteral nutrition, sodium-restricted or other type of diet with frequent small feedings). • Monitor intake/output and calculate 24-hour fluid balance. Provide or restrict fluids, as indicated, to maximize cardiac output and improve tissue perfusion.15 NURSING PRIORITY NO. 4 To enhance safety/prevent complications:2,14,15 • Wash hands before and after client contact, maintain aseptic technique during invasive procedures, and provide site care, as indicated, to prevent hospital-acquired infection. (Refer to ND risk for Infection for additional interventions.) • Provide antipyretics and fever control actions as indicated. Adjust ambient environmental temperature to maintain body temperature in near-normal range. • Maintain patency of invasive intravascular monitoring and infusion lines and tape connections to prevent exsanguination or air embolus. • Minimize activities that can elicit Valsalva response (e.g., rectal straining, vomiting, spasmodic coughing with suctioning, prolonged breath-holding during pushing stage of labor) and encourage client to breathe deeply in and out during activities that increase risk of Valsalva effect. Valsalva response to breath-holding causes increased intrathoracic pressure, reducing cardiac output and blood pressure.14 • Avoid prolonged sitting position for all clients and supine position for sleep or exercise for gravid clients (second and third trimesters) to maximize vascular return.2,15 • Elevate legs when in sitting position and edematous extremities when at rest. Apply antiembolic hose or sequential compression devices when indicated, being sure they are individually fitted and appropriately applied. Limits venous stasis, improves venous return, and reduces risk of thrombophlebitis. (Refer to ND ineffective peripheral Tissue Perfusion for additional interventions.) • Provide skin care, a special bed or mattress (e.g., air, water, gel, foam), and assist with frequent position changes to prevent the development of pressure ulcers. • Provide psychological support to reduce anxiety and its adverse effects on cardiac function: Maintain calm attitude and limit stressful stimuli. Provide and encourage use of relaxation techniques, such as massage therapy, soothing music, or quiet activities. Promote visits from family/significant others to provide positive social interaction. Provide information about testing procedures and client participation. Explain limitations imposed by condition and dietary and fluid restrictions. Share information about positive signs of improvement.

Intervention for ND of risk for unstable blood glucose level

• Ascertain whether client and SO(s) are certain they are obtaining accurate readings on glucose-monitoring device and are adept at using device. In addition to checking blood glucose more frequently when it is unstable, it is wise to ascertain that equipment is functioning properly and being used correctly. All available devices will provide accurate readings if properly used and maintained and routinely calibrated. However, there are many other factors that may affect the accuracy of numbers, such as size of blood drop with fingersticking, forgetting a bolus from insulin pump, and injecting insulin into lumpy subcutaneous site. Note: Although expensive and not yet widely used because of lagging FDA approval (as of 2015), technology advances include a real-time continuous blood glucose monitoring system for detecting blood glucose trends, as well as a warning system for extreme highs and lows.1,13,14 • Provide information on balancing food intake, antidiabetic agents, and energy expenditure. • Review medical necessity for regularly scheduled lab screening and monitoring tests for diabetes. Screening tests may include fasting plasma glucose or oral glucose tolerance tests. In the known or sick diabetic, tests can include fasting, daily (or numerous times in a day) finger-stick glucose levels. Also, in diabetics, regular testing of hemoglobin (Hgb)A1C and the estimated average glucose help determine glucose control over time (few months). At present, there is no consensus for a hard and fast number; some guidelines state that "HgbA1C level of 6.5%" is diagnostic for a diabetes diagnosis, while others indicate that a level of "less than 7%" is a reasonable goal for many, but not all patients and should be based on individualized assessment of risk for complications.12,13 • Discuss home glucose monitoring according to individual parameters (e.g., six times per day for normal day and more frequently during times of stress) to identify and manage glucose fluctuations. • Identify common situations that could contribute to client's glucose instability on daily, occasional, or crisis basis. Multiple factors can be in play at any time, such as missing meals, an adolescent growth spurt, or infection or other illness. • Review client's diet, especially carbohydrate intake. Glucose balance is determined by the amount of carbohydrates consumed, which should be determined in needed grams/day.2 • Encourage client to read labels and choose carbohydrates described as having a low glycemic index (GI) and foods with adequate protein, higher fiber, and low fat content. These foods produce a slower rise in blood glucose and more stable release of insulin. Note: For most people with diabetes, the first tool for managing blood glucose is some form of carbohydrate counting. Because the type of carbohydrate also affects glucose, using the GI may be helpful in "fine-tuning" blood glucose management.3 • Discuss how client's antidiabetic medication(s) work. Drugs and combinations of drugs work in varying ways with different blood glucose control and side effects. Understanding drug actions can help client avoid or reduce risk of potential for hypoglycemic reactions.4 For client receiving insulin: • Emphasize importance of checking expiration dates of medication, inspecting insulin for cloudiness if it is normally clear, and monitoring proper storage and preparation (when mixing is required). Affects insulin absorbability and effectiveness.1 • Review type(s) of insulin used (e.g., rapid, short, intermediate, long-acting, combinations, premixed) and delivery method (e.g., subcutaneous, intramuscular injection; prefilled pen; pump). Note time when short-acting and long-acting insulins are administered. Remind client that only short-acting insulin is used in pump. Affects timing of effects and provides clues to potential timing of glucose instability.1,5 • Check injection sites periodically. Insulin absorption can vary from day to day in healthy sites and is less absorbable in lumpy sites. • Ascertain that all injections are being given. Children, teenagers, and elderly clients may forget injections or be unable to self-inject; they may need reminders and supervision.1

Intervention for ND of acute substance withdrawal syndrome

• Consult with medical toxicologist or regional poison control center as needed. Useful resources for diagnosis and management of acute/critically ill clients, especially those with multi-substance use.3 • Provide environmental safety as indicated, e.g., bed in low position, call device within reach, doors full open or closed position, padded side rails, family member or sitter at bedside as appropriate. Reduces risk of injury in presence of distorted sense of reality. • Monitor vital signs (VS) and level of consciousness (LOC) frequently during acute withdrawal. VS and LOC can be labile based on specific substance(s) and length of time since last used. For example, hypertension frequently occurs in acute withdrawal phase but may quickly progress to hypotension. • Elevate head of bed. Decreases potential for aspiration and lowers diaphragm, enhancing lung expansion. • Monitor respiratory rate, depth, and pattern. Note periods of apnea or Cheyne-Stokes respirations. Toxicity levels may change rapidly, e.g., hyperventilation common during acute alcohol withdrawal phase, or marked respiratory depression can occur because of central nervous system depressant effects of substance used. • Administer supplemental oxygen, as needed. Hypoxia may occur with respiratory depression and chronic anemia. • Monitor body temperature. Elevation may occur because of sympathetic stimulation, dehydration, and/or infection, causing vasodilation and compromising venous return and cardiac output. • Record intake/output, 24-hour fluid balance; skin turgor, status of mucous membranes. Preexisting dehydration, nausea/vomiting, diuresis, and diaphoresis may compromise cardiovascular function as well as renal perfusion, impacting drug clearance. • Administer fluid/electrolytes as indicated. Depending on substances used, client is susceptible to excessive fluid losses and electrolyte imbalances, especially potassium and magnesium that can result in life-threatening dysrhythmias. Magnesium sulfate also beneficial in reducing tremors and seizure activity.3,5 • Reorient frequently to person, place, time, and surrounding environment. May have calming effect and limit misinterpretation of external stimuli. • Encourage client to verbalize anxiety. Explain substance withdrawal increases anxiety and uneasiness. Anxiety may be physiologically or environmentally caused, and client may be unable to identify and/or accept what is happening. Note: Individuals with alcohol use disorders often also have posttraumatic stress disorder (PTSD).6 • Monitor for suicidal tendencies. May need to use emergency commitments or legal hold for client's safety once medically stable. • Provide symptom management as indicated. Medications for nausea/vomiting, anxiety, trembling/"shakes," insomnia, seizure activity promote comfort and facilitate recovery.3 • Administer medications treating specific substance(s) used. For example, beta-adrenergic blockers may speed up the alcohol withdrawal process but are not useful in preventing seizures or DTs,3,4 and methadone is used to assist opioid withdrawal.7 Note: There are no Food and Drug Administration (FDA)-approved medications for treating cannabis, cocaine, or methamphetamine substance use disorders (SUDs), and medication-assisted treatments (MATs) are rarely used to treat adolescent alcohol use.9 • Administer thiamine, vitamins C and B complex as indicated. Vitamin deficiency, especially thiamine, is associated with ataxia, loss of eye movement and pupillary response, palpitations, postural hypotension, and exertional dyspnea.3 • Develop trusting relationship, project an accepting attitude about substance use. Provides client a sense of humanness, helping to decrease paranoia and distrust. (Client will be able to detect biased or condescending attitude of caregivers, negatively impacting relationship.) • Determine understanding of current situation. Provides information about degree of denial, acceptance of personal responsibility, and commitment to change. • Arrange "intervention" or confrontation in controlled setting when client sufficiently recovered from withdrawal to address addiction issues. Client more likely to contract for treatment while still hurting and experiencing fear and anxiety from last substance use episode. • Confront use of defensive behaviors—denial, projection, and rationalization. Helps client accept the reality of the problems as they exist. • Identify individual triggers for substance use (e.g., exhaustion, loneliness/isolation, depression) and client's plans for living without drugs/alcohol. Provides opportunity to discuss substance tension-reducing strategies and to develop and refine plan. • Use crisis intervention techniques to initiate behavior changes. Calming effect enables client to be receptive to care and therapeutic interventions. • Instruct in use of relaxation skills, guided imagery, and visualization techniques. Helps client relax and develop new ways to deal with stress and to problem-solve. • Facilitate visit by a group member/possible sponsor as appropriate, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Crystal Methamphetamine Anonymous (CMA), Smart Recovery. Puts client in direct contact with support system necessary for managing sobriety and drug-free life. • Administer antipsychotic medications as necessary. May be indicated for prolonged or profound psychosis following lysergic acid diethylamide (LSD) or phencyclidine (PCP) intoxication. • Engage entire family in multidimensional family therapy as indicated. Program developed for adolescents with SUDs and their families to address the various influences on client's substance use by improving family functioning and collaboration with other systems, such as school and juvenile justice.8

Intervention for ND of autonomic dysreflexia

• Investigate associated complaints/syndrome of symptoms (e.g., severe pounding headache, [blood pressure may be >200/100 mmHg], chest pain, irregular heart rate or dysrhythmias, blurred vision, nausea, facial flushing, metallic taste, severe anxiety; minimal symptoms or expressed complaints in presence of significantly elevated blood pressure—silent AD]). Body's reaction to misinterpreted sensations from below the injury site, resulting in an autonomic reflex, can cause blood vessels to constrict and increase blood pressure. This is a potentially life-threatening condition, requiring immediate and correct action.1-3,5 • Note onset of crying, irritability, or somnolence in infant or child who may present with nonspecific symptoms and may not be able to verbalize discomfort.1,6 • Locate and attempt to eliminate causative stimulus, moving in a stepwise fashion: Cause can be anything that would normally cause pain or discomfort below level of injury.1-5 Assess for bladder distention: Note: The two most common inciting stimuli are bladder and bowel distention, respectively, commonly a blocked urinary catheter.3 Empty bladder by voiding or catheterization, applying local anesthetic ointment (if indicated/per facility procedure to prevent exacerbation of AD by procedure). Ascertain that urine is free-flowing if Foley or suprapubic catheter is in place, empty drainage bag, straighten tubing if kinked, and lower drainage bag if it is higher than bladder. Irrigate gently or change catheter, if it is not draining freely. • Note color, character, and odor of urine; obtain specimen for culture as indicated (acute urinary infection can cause AD).3 • Check for distended bowel (if urinary problem is not causing AD). Note: Fecal impaction is the second most common cause of AD.3 Perform digital stimulation, checking for constipation or impacted stool. (If symptoms first appear while performing digital stimulation, stop procedure.) Apply local anesthetic ointment to rectum; remove impaction after symptoms subside to remove causative problem without causing additional symptoms. • Check for skin pressure or irritation (if bowel problem is not causing AD): Perform a pressure release if sitting. Check for tight clothing, straps, and belts. Note whether pressure sore has developed or changed. Observe for bruising and signs of infection. Check for ingrown toenail, other injury to skin or tissue (e.g., burns, sunburn), or fractured bones. • Check for other possible causes (if skin pressure is not causing AD): Menstrual cramps, sexual activity, or labor and delivery. Abdominal conditions (e.g., colitis, ulcer). Environmental temperature extremes. • Take steps to reduce blood pressure, thereby reducing potential for stroke (primary concern):1-6 Elevate head of bed immediately or place in sitting position with legs hanging down. Lowers blood pressure by pooling of blood in legs and decreases intracranial pressure caused by vasodilation in the brain, thus reducing headache.3 Loosen any clothing or restrictive devices. Lowers blood pressure by pooling of blood in abdomen and lower extremities. Monitor vital signs frequently during acute episode. Blood pressure may fluctuate quickly due to impaired autonomic regulation. Continue to monitor blood pressure at intervals during procedures to remove cause of AD and after acute episodic symptoms subside to evaluate effectiveness of interventions and antihypertensives. • Administer medications, as indicated. If an episode is particularly severe, or persists after removal of suspected cause, antihypertensive medications with rapid onset and short duration (e.g., nifedipine, nitrates, mecamylamine diazoxide, phenoxybenzamine) may be used to block excessive autonomic nerve transmission, normalize heart rate, and reduce hypertension.1,4 • Know contraindications and cautions associated with antihypertensive medications; adjust dosage of antihypertensive medications carefully for child, elderly person, individual with known heart disease, male client using sildenafil for sexual activity, and pregnant woman. Prevents complications, including unknown reactions in a child or systemic hypotension or seizure activity.4 Note: Use of nitrate-containing medications is an absolute contraindication to sildenafil use because of the possibility of a fatal response.1,3

Intervention for ND of Activity Intolerance

• Monitor vital signs before and during activity, watching for changes in blood pressure, heart and respiratory rate, and post-activity vital sign response. Vital signs may change during activity (including higher or lower pulse or blood pressure) and should return to baseline within 5 to 7 min after activity if response to activity is normal.1 • Observe respiratory rate, noting breathing pattern, breath sounds, skin color, and mental status. Pallor and/or cyanosis, presence of respiratory distress, or confusion may be indicative of need for oxygen during activities, especially if respiratory infection or compromise is present. • Plan care with rest periods between activities to reduce fatigue. • Assist with self-care activities. Adjust activities or reduce intensity level, or discontinue activities that cause undesired physiological changes. Prevents overexertion. • Increase exercise/activity levels gradually; encourage stopping to rest for 3 minutes during a 10-minute walk, or sitting down instead of standing to brush hair. Methods of conserving energy. • Encourage expression of feelings contributing to or resulting from condition. Provide positive atmosphere while acknowledging difficulty of the situation for the client. Helps to minimize frustration, rechannel energy. • Involve client/significant others (SOs) in planning of activities as much as possible. May give client opportunity to perform desired or essential activities during periods of peak energy. • Assist with activities and provide and monitor client's use of assistive devices. Enables client to maintain mobility while protecting from injury. • Promote comfort measures and provide for relief of pain to enhance client's ability and desire to participate in activities.9,11 (Refer to NDs acute Pain, chronic Pain.) • Provide referral to collaborative disciplines, such as an exercise physiologist, psychological counseling/therapy, occupational/physical therapy, and recreation/leisure specialists. May be needed to develop individually appropriate therapeutic regimens. • Prepare for/assist with and monitor effects of exercise-capacity testing. May be performed to determine degree of oxygen desaturation and/or hypoxemia that occurs with exertion or to optimize titration of supplemental oxygen when used.5,8 • Implement graded exercise or rehabilitation program under direct medical supervision. Gradual increase in activity avoids excessive myocardial workload and associated oxygen demand and has been shown to exert positive health benefits, even in those with chronic diseases. One intervention review found that for people with mild to moderate systolic heart failure, there was neither a reduction nor an increase in the risk of death with exercise. However, following exercise training, there was a reduction in hospital admissions due to systolic heart failure.4 • Administer supplemental oxygen, medications, prepare for surgery, and other treatments, as indicated. Type of therapy or medication is dependent on the underlying condition and might include medications (e.g., antiarryhthmics, bronchodilators) or surgery (e.g., stents or coronary artery bypass graft) to improve myocardial perfusion and systemic circulation. Other treatments might include iron preparations or blood transfusion to treat severe anemia or use of oxygen and bronchodilators to improve respiratory function.6,7,12,14

Intervention for ND of decreased intracranial adaptive capacity

• Perform periodic assessments of the client's level of consciousness and/or neurological status, blood pressure, breath sounds, temperature, amount of respiratory secretions, central venous pressure, heart rate and rhythm, fluid balance, nutritional status, and serial laboratory values, as with any critically ill client. • Perform interventions specific to client with increased ICP: Elevate head of bed as individually appropriate. Optimal head of bed position is determined by both ICP and coronary perfusion pressure measurements—that is, which degree of elevation lowers ICP while maintaining adequate cerebral blood flow. Studies show that in most cases, an elevation of 30 degrees significantly decreases ICP while maintaining cerebral blood flow.6,7 Maintain head and neck in neutral position, supporting with small towel rolls or pillows to maximize venous return. Note: Lateral and rotational neck flexion has been shown to be the most consistent trigger of sustained increases in ICP.3,4 Avoid causing hip flexion of 90 degrees or more. Hip flexion may trap venous blood in the intra-abdominal space, increasing abdominal and intrathoracic pressure and reducing venous outflow from the head, increasing cerebral pressure.5 Limit or prevent activities such as coughing, vomiting, and straining at stool and avoid or restrict use of restraints. These factors often increase intrathoracic/abdominal pressures or agitation and markedly increase ICP.1 Suction with caution and only when needed. Pass catheter just beyond end of endotracheal tube without touching tracheal wall or carina. Administer lidocaine intratracheally if indicated to reduce cough reflex. Note: Studies have reported significant increase in ICP and decrease in CCP during suctioning in ventilated clients with brain injury, especially if they are not well sedated.3,15 Hyperoxygenate before suctioning as appropriate to minimize hypoxia. Note: Studies show that in most clients, hyperventilation is not necessary; however, therapeutic hyperventilation (Paco2 of 30 to 35 mm) may be used for a short period of time in acute neurological deterioration to reduce intracranial hypertension while other methods of ICP control are initiated.3,7,8,11 • Investigate increased restlessness to determine causative factors and initiate corrective measures as indicated: Decrease extraneous stimuli and provide comfort measures (e.g., quiet environment, soft voice, tapes of familiar voices played through earphones, back massage, gentle touch as tolerated) to reduce central nervous system stimulation and promote relaxation.4 Limit painful procedures (e.g., venipunctures, redundant neurological evaluations) to those that are absolutely necessary in order to minimize preventable elevations in ICP.3 Provide rest periods between care activities and limit duration of procedures. Lower lighting and noise levels and schedule and limit activities to provide a restful environment and limit spikes in ICP associated with noxious stimuli.3 Encourage family/significant others to talk to client. Familiar voices appear to have a relaxing effect on many comatose individuals (thereby reducing ICP).1 • Administer and restrict fluid intake as necessary, and administer IV fluids via pump or control device to maintain intravascular volume sufficient to maintain cerebral perfusion while preventing inadvertent vascular overload, cerebral edema, and increased ICP.6 • Weigh as indicated. Calculate fluid balance every shift/daily to determine fluid needs, maintain hydration, and prevent fluid overload.1 • Monitor and manage body temperature. Regulate environmental temperature and bed linens and use cooling blanket as indicated to decrease metabolic and oxygen needs when fever is present or when therapeutic hypothermia therapy is used. Lowering the body temperature has been shown to lower ICP and improve outcomes for recovery.3,6,13 • Provide appropriate safety measures/initiate treatment for seizures to prevent injury and increase of ICP or hypoxia. • Administer supplemental oxygen as indicated to prevent cerebral ischemia. • Administer medications (e.g., antihypertensives, diuretics, analgesics, sedatives, antipyretics, vasopressors, antiseizure drugs, neuromuscular blocking agents, corticosteroids) as appropriate to maintain cerebral homeostasis and manage symptoms associated with neurological injury. Note: Controversy continues concerning the use of steroids in the setting of TBI as a neuroprotective strategy. Review of five key randomized control trials (RCTs) consistently showed that corticosteroids do not confer significant benefit in the TBI population.12 • Administer enteral or parenteral nutrition to achieve positive nitrogen balance, reducing effects of post-brain injury metabolic and catabolic states, which can lead to complications such as immunosuppression, infection, poor wound healing, loss of body mass, and multiple organ dysfunction. Studies have shown that parenteral nutritional support can be given to these clients without worsening cerebral edema.10 • Prepare client for surgery as indicated (e.g., evacuation of hematoma or space-occupying lesion) to reduce ICP and enhance circulation.

Intervention for ND of risk for acute substance withdrawal syndrome

• Provide environmental safety as indicated, e.g., bed in low position, call device within reach, doors full open or closed position, situated close to nursing station as appropriate. Reduces risk of injury in presence of distorted sense of reality. • Monitor vital signs (VS) and level of consciousness (LOC) frequently during acute withdrawal. VS and LOC can be labile based on specific substance(s) and length of time since last used. For example, hypertension frequently occurs in acute withdrawal phase but may quickly progress to hypotension. • Monitor respiratory rate, depth, and pattern. Toxicity levels may change rapidly, e.g., hyperventilation common during acute alcohol withdrawal phase or marked respiratory depression can occur because of central nervous system depressant effects of substance used. • Encouraging client to verbalize anxiety. Anxiety may be physiologically or environmentally caused, and client may be unable to identify and/or accept what is happening. Note: Individuals with alcohol use disorders often also have posttraumatic stress disorder (PTSD).3 • Provide symptom management as indicated. Medications for nausea/vomiting, anxiety, trembling/"shakes," insomnia, seizure activity promote comfort and facilitate recovery.1 • Administer medications treating specific substance(s) used. For example, beta-adrenergic blockers may speed up the alcohol withdrawal process but are not useful in preventing seizures or DTs,1,2 and methadone is used to assist opioid withdrawal.4 Note: There are no FDA-approved medications for treating cannabis, cocaine, or methamphetamine SUDs, and medication-assisted treatments (MAT) are rarely used to treat adolescent alcohol use.6 • Administer thiamine, vitamins C and B complex as indicated. Vitamin deficiency, especially thiamine, is associated with ataxia, loss of eye movement and pupillary response, palpitations, postural hypotension, and exertional dyspnea.1 NURSING PRIORITY NO. 3 To promote long-term sobriety: • Develop trusting relationship, project an accepting attitude about substance use. Provides client a sense of humanness, helping to decrease paranoia and distrust. • Arrange "intervention" or confrontation in controlled setting when client sufficiently recovered from withdrawal to address addiction issues. Client more likely to contract for treatment while still hurting and experiencing fear and anxiety from last substance use episode. • Confront use of defensive behaviors—denial, projection, and rationalization. Helps client accept the reality of the problems as they exist. • Identify individual triggers for substance use (e.g., loneliness/isolation, depression) and client's plans for living without drugs/alcohol. Provides opportunity to discuss substance tension-reducing strategies and to develop and refine plan. • Instruct in use of relaxation skills, guided imagery, and visualization techniques. Helps client relax and develop new ways to deal with stress and to problem-solve. • Facilitate visit by a group member/possible sponsor as appropriate, such as Alcoholics Anonymous (AA), Narcotics Anonymous (NA), Crystal Methamphetamine Anonymous (CMA), Smart Recovery. Puts client in direct contact with support system necessary for managing sobriety and drug-free life. • Administer antipsychotic medications as necessary. May be indicated for prolonged or profound psychosis following lysergic acid diethylamide (LSD) or phencyclidine (PCP) intoxication. • Engage entire family in multidimensional family therapy as indicated. Program developed for adolescents with SUDs and their families to address the various influences on client's substance use by improving family functioning and collaboration with other systems, such as school and juvenile justice.5

Interventions for nursing dx of risk for adverse reaction to iodinated contrast media

- Administer infusions using the "6 rights" - Perform imaging tests that do not require contrast media when possible. - Administer IV fluids as appropriate to reduce incidence of contrast- induced nephropathy - Administer medications (steroid + antihistamine) before, during, and after injection or procedures to reduce risk or severity of reaction. - Observe IV site frequently - Halt infusion immediately to prevent tissue damage from contrast agent if client reports site discomfort or if redness or swelling is noted. - Monitor results of lab studies (creatinine clearance)

Interventions for nursing dx of risk for acute substance withdrawal syndrome

- Provide environmental safety as indicated (bed in lowest position, call device within reach, doors full open or closed position, situated close to nursing station as appropriate). - Monitor VS and LOC frequently during acute withdrawal. - Monitor RR, depth, and pattern. - Encourage client to verbalize anxiety. - Provide symptom management as indicated. - Administer medications treating specific substances used. - Administer thiamine, vitamins C and B complex as indicated.

Interventions for nursing dx of risk for activity intolerance

- Implement physical therapy or exercise program in conjunction with the client and other team members, such as PT/OT. - Implement progressive conditioning program and support inclusion of exercise or activity in groups - Instruct client in proper performance of unfamiliar activities and/or alternative ways of doing familiar activities.

Interventions for nursing dx of risk for allergy reaction

- Perform challenge or patch test to identify specific allergens. - Provide allergen-free environment (clean, dust-free room, use of air filters to reduce mold and pollens in air) to reduce exposure to allergens. - Collaborate with all healthcare providers to administer medications and perform procedures with client's allergies in mind. - Encourage client to wear medical ID bracelet - refer to allergy specialist.

Interventions for nursing dx of ineffective airway clearance

- Position head as appropriate for condition/disorder - Insert oral airway, using correct size for adult. Have emergency equipment at bedside (such as tacheostomy equipment, ambu-bag, suction apparatus) - Suction (nasal, tracheal, oral) when indicated using correct size catheter and suction timing - Assist with pr prepare for appropriate testing (pulmonary function test or sleep studies) - Assist with procedures (bronchoscopy or tracheostomy) to clear or maintain open airway - Keep environment free of smoke, dust, and feather pillows according to situation. Remove precipitators of allergic types of respiratory reactions that can trigger/exacerbate acute episode. - Elevate HOB or change position - this facilitates respiratory function by use of gravity. - Position appropriately and discourage use of oil-based products around nose to prevent vomiting with aspiration into lungs. - Exercise diligence in providing oral hygiene, removing substances, and keeping oral mucosa hydrated. Airways can be obstructed by substances such as thickened secretions. - Encourage and instruct deep breathing and directed coughing exercises. - Mobilize client to reduce risk of atelectasis, enhance lung expansion, and move drainage within the lungs. - Administer analgesics to improve cough effort when pain is inhibiting. - Administer expectorants, anti-inflammatory agents, bronchodilators, and mucolytic agents as indicated to relax smooth respiratory musculature, reduce airway edema, and mobilize secretions. - Increase fluid intake and encourage warm versus cold liquids as appropriate. Warm hydration can help liquefy viscous secretions and improve secretion clearance. - Provide nebulizer or room humidifier to deliver supplemental humidification to reduce viscosity of secretions. - Assist with use of respiratory devices and treatments (incentive spirometer, mechanical ventilation, flutter, cough assist) - Perform or assist client in learning airway clearance techniques - postural drainage, percussion, flutter devices, breathing techniques.

Intervention for ND of defensive coping

NURSING PRIORITY NO. 2 To assist client to deal with current situation: • Provide explanation of rules of the treatment program and discuss consequences of lack of cooperation. Encourage client participation in setting of consequences and agreement to them. Promotes understanding and possibility of cooperation on the part of the client, especially when client has been involved in the decisions.2 • Set limits on manipulative behavior; be consistent in enforcing consequences when rules are broken and limits tested. Providing clear information and following through on identified consequences reduces the ability to manipulate staff or therapist and environment.3 • Develop therapeutic relationship to enable client to test new behaviors in a safe environment. Use positive, nonjudgmental approach and "I" messages. Promotes sense of self-esteem and enhances sense of control. • Encourage control in all situations possible; include client in decisions and planning. Preserves autonomy, enabling realization of sense of self-worth. • Acknowledge individual strengths and incorporate awareness of personal assets and strengths in plan. Promotes use of positive coping behaviors and progress toward effective solutions.4 • Convey attitude of acceptance and respect (unconditional positive regard). Avoids threatening client's self-concept, preserving existing self-esteem.2 • Encourage identification and expression of feelings. Provides opportunity for client to learn about and accept self and feelings as normal.2 • Provide or encourage use of healthy outlets for release of hostile feelings (e.g., punching bags, pounding boards). Involve in outdoor recreation program when available. Promotes acceptable expression of these feelings, which, when unexpressed, can lead to development of undesirable behaviors and make situation worse.4 • Provide opportunities for client to interact with others in a positive manner. Promotes self-esteem and encourages client to learn how to develop and enhance relationships.4 • Assist client with problem-solving process. Identify and discuss responses to situation, maladaptive coping skills. Suggest alternative responses to situation. Helps client select more adaptive strategies for coping.2 • Use confrontation judiciously to help client begin to identify defense mechanisms (e.g., denial, projection) that are hindering development of satisfying relationships.2 • Assist with treatments for physical illnesses as appropriate. Taking care of physical self will enable client to deal with emotional and psychological issues more effectively.4

Intervention for ND of anxiety (specify level)

NURSING PRIORITY NO. 2 To assist client to identify feelings and begin to deal with problems: • Establish a therapeutic relationship, conveying empathy and unconditional positive regard. Enables client to become comfortable and to begin looking at feelings and dealing with situation.2 • Be available to client for listening and talking. Establishes rapport, promotes expression of feelings, and helps client/significant other look at realities of the illness or treatment without confronting issues they are not ready to deal with.2 • Encourage client to acknowledge and to express feelings—for example, crying (sadness), laughing (fear, denial), or swearing (fear, anger)—using active-listening, reflection techniques. Often, acknowledging feelings enables client to accept and deal more appropriately with situation, thus relieving anxiety.7 • Assist client to develop self-awareness of verbal and nonverbal behaviors. Becoming aware helps client to control these behaviors and begin to deal with issues that are causing anxiety.8 • Clarify meaning of feelings or actions by providing feedback and checking meaning with the client. Validates meaning and ensures accuracy of communication.9 • Acknowledge anxiety or fear. Do not deny or reassure client that everything will be all right. Validates reality of feelings. False reassurances may be interpreted as lack of understanding or dishonesty, further isolating client.2 • Be aware of defense mechanisms being used (e.g., denial, regression). Use of defense mechanisms may be a helpful coping mechanism initially. However, continued use of such mechanisms diverts the energy that the client needs for healing, thus delaying the client from focusing and dealing with the actual problem.5 • Identify coping skills the individual is using currently, such as anger, daydreaming, forgetfulness, eating, smoking, or lack of problem solving. These may be useful for the moment but may eventually interfere with resolution of current situation.5 • Provide accurate information about the situation. Helps client to identify what is reality based and provides opportunity for client to feel reassured.13 • Respond truthfully, avoid bribing, and provide physical contact (e.g., hugging, rocking) when client is a child. Soothes fears and provides assurance. Children need to recognize that their feelings are not different from those of others.4 NURSING PRIORITY NO. 3 To provide measures to comfort and aid client to handle problematic situations: • Provide comfort measures (e.g., calm or quiet environment, soft music, warm bath, back rub, Therapeutic Touch). Aids in meeting basic human need, decreasing sense of isolation, and assisting client to feel less anxious. Therapeutic Touch requires the nurse to have specific knowledge and experience to use the hands to correct energy field disturbances by redirecting human energies to help or heal.2,10 • Modify procedures as necessary (e.g., substitute oral for intramuscular medications, combine blood draws or use finger-stick method). Limits degree of stress and avoids overwhelming child or anxious adult.1 • Manage environmental factors, such as harsh lighting, high traffic flow, excessive noise. May be confusing or stressful to older individuals. Managing these factors can lessen anxiety, especially when client is in strange and unusual circumstances.1 • Discuss the use of music and accommodate client's preferences. Promotes calming atmosphere, helping to alleviate anxiety.2 • Accept client as is. The client may need to be where he or she is at this point in time, such as in denial after receiving the diagnosis of a terminal illness.2 • Allow the behavior to belong to the client; do not respond personally. Reacting personally can escalate the situation, promoting a nontherapeutic situation and increasing anxiety. • Assist client to use anxiety for coping with the situation if helpful. Moderate anxiety heightens awareness and can help client to focus on dealing with problems.8 • Encourage awareness of negative self-talk and discuss replacing with positive statements, such as using "can" instead of "can't," etc. Negative self-talk promotes feelings of anxiety and self-doubt. Becoming aware and replacing these thoughts can enhance sense of self-worth and reduce anxiety.8 PANIC STATE • Stay with client, maintaining a calm, confident manner. Presence communicates caring and helps client to regain control and sense of calm. • Speak in brief statements using simple words. Client is not able to comprehend complex information at this time. • Provide for nonthreatening, consistent environment or atmosphere. Minimize stimuli and monitor visitors and interactions with others. Lessens effect of transmission of anxious feelings. • Set limits on inappropriate behavior and help client to develop acceptable ways of dealing with anxiety. • Provide safe controls and environment until client regains control. Behavior may result in damage or injury that client will regret when control is regained, diminishing sense of self-worth. • Gradually increase activities and involvement with others as anxiety is decreased. Promotes sense of normalcy, helps control feelings of anxiety. • Use cognitive therapy to focus on and correct faulty catastrophic interpretations of physical symptoms. For example, thoughts of dying increase anxiety and feelings of panic. Controlling these thoughts allows client to look at situation more realistically and begin to deal appropriately with what is happening. • Administer anti-anxiety agents or sedatives, as ordered. Appropriate medication can be helpful in enabling the client to regain control.13

Intervention for ND of compromised family coping

NURSING PRIORITY NO. 2 To assist family to reactivate/develop skills to deal with current situation: • Encourage family members to verbalize feelings openly and clearly. Promotes understanding of feelings in relationship to current events and helps them to hear what other person is saying, leading to more appropriate interactions.5 • Discuss underlying reasons for client's behavior. Helps family/SO understand and accept or deal with client behaviors that may be triggered by emotional or physical effects of illness.4 • Assist the family and client to understand "who owns the problem" and who is responsible for resolution. Avoid placing blame or guilt. When these boundaries are defined, each individual can begin to take care of own self and stop taking care of others in inappropriate ways.3,4 • Encourage client and family to develop problem-solving skills to deal with the situation. Use of these skills enables each member of the family to identify what he or she sees as the problem to be dealt with and contribute ideas for solutions that are acceptable to him or her, promoting more effective interactions among the family members.4

Intervention for ND of risk for allergy reaction

NURSING PRIORITY NO. 2 To take measures to avoid exposure and reduce/limit allergic response: • Discuss client's current symptoms, noting reports of rash, hives, itching; teary eyes, localized swelling (e.g., of lips) or diarrhea, nausea, and feeling of faintness. Try to ascertain if client/care provider associates these symptoms with certain food, substances, or environmental factors (triggers). May help isolate cause for a reaction. Baseline for determining where the client is along a continuum of symptoms, so that appropriate treatments can be initiated.5 • Provide allergen-free environment (e.g., clean, dust-free room, use of air filters to reduce mold and pollens in air, etc.) to reduce client exposure to allergens. • Collaborate with all healthcare providers to administer medications and perform procedures with client's allergies in mind. Perform challenge or patch test, if appropriate. • Encourage client to wear medical ID bracelet/necklace to alert providers to condition if client is unresponsive or unable to relay information for any reason. • Refer to physician/allergy specialists as indicated for interventions related to specific allergy conditions.

Intervention for ND of chronic functional constipation

NURSING PRIORITY NO. 3 To reduce unacceptable pattern of elimination: • Collaborate in treatment of underlying medical cause where appropriate (e.g., surgery to repair rectal prolapse, biofeedback to retrain anorectal or pelvic floor dysfunction, medications, and combinations of therapies as indicated) to improve body and bowel function. Note: Treatment is highly individual. For example, clients with slow-transit constipation tend to benefit from fiber, osmotic laxatives, and stimulant laxatives (e.g., bisacodyl), whereas those with evacuation disorders usually do not need medication other than fiber supplementation following pelvic floor retraining.4,12 • Review client's current medication regimen with physician to determine if drugs contributing to constipation can be discontinued or changed. • Administer medications, as indicated, such as stool softeners (e.g., docusate sodium [Colase, Surfak]) to provide moisture to stool, mild stimulants (e.g., bisacodyl [Dulcolax, Bisco-Lax]) to cause rhythmic muscle contractions and improve transit time, osmotic agents (e.g., polyethylene glycol [PEG, Miralax]) to absorb water in intestine, and opoid antagonist (e.g., methylanaltrexone [Relistor]) to treat constipation in client with advanced/terminal illness necessitating long-term opioid analgesia and/or client who is unresponsive to laxatives. • Remove impacted stool digitally, when necessary, after applying lubricant and anesthetic ointment to anus to soften impaction and decrease rectal pain. • Administer enemas (e.g., hyperosmolar agents [e.g., Fleet enema] to draw water into colon) or suppositories, as indicated.4,6 • Promote lifestyle changes:1-11 Instruct in and encourage a personalized dietary program that involves adjustment of dietary fiber and bulk in diet (e.g., fruits, vegetables, whole grains) and fiber supplements (e.g., wheat bran, psyllium) to improve consistency of stool and increase transit time through colon if slow transit through colon is causing symptoms. Promote adequate fluid intake, including water, high-fiber fruit and vegetable juices, fruit/vegetable smoothies, and popsicles. Suggest drinking warm, stimulating fluids (e.g., decaffeinated coffee, hot water, tea) to avoid dehydration; promote moist, soft feces; and facilitate passage of stool. • Instruct in/assist with other means of triggering defecation (e.g., abdominal massage, digital stimulation, placement of rectal stimulant suppositories) to provide predictable and effective elimination and reduce evacuation problems when long-term or permanent bowel dysfunction is present. Refer for physical therapy or other medical/surgical practitioners for additional interventions as indicated. Physical therapy may be useful in improving mobility, pelvic floor retraining, and activity levels. Biofeedback treatment with muscle relaxation of anal sphincters and the puborectalis can result in a cure for constipation associated with certain evacuation disorders. Surgical interventions may be used in some instances (e.g., Malone antegrade continence enema procedure, sacral anterior root stimulation) to treat long-term, intractable constipation due to neurogenic bowel.5,12

Intervention for ND of risk for adverse reaction to iodinated contrast media

• Administer infusions using the "6 rights" system (right client, right medication, right route, right dose, right time, right documentation) to prevent client from receiving improper contrast agent or dosage. Note: Clients undergoing more than one procedure at a time (such as cardiac angiography and angioplasty) receive a higher dose and are at greater risk for renal insufficiency reactions. • Perform imaging tests that do not require contrast media where possible when client is at high risk for reaction. • Administer intravenous fluids as appropriate to reduce incidence of contrast-induced nephropathy by supporting intravascular volume, diluting contrast media, and promoting its elimination.4,5 • Administer medications (e.g., methylprednisilone [Deltasone], Benadryl) before, during, and after injection or procedures to reduce risk or severity of reaction.3 • Observe intravenous injection site frequently to ascertain that no extravasation of contrast solution is occurring. • Halt infusion immediately to prevent tissue damage from contrast agent if client reports site discomfort or redness or swelling is noted. • Monitor results of lab studies (e.g., creatinine clearance) to ascertain status of kidney function.

Intervention for ND of readiness for enhanced coping

• Discuss desire to improve ability to manage stressors of life. Understanding client's decision to seek new information to enhance life will help client determine what is needed to learn new coping skills.2 • Discuss client's understanding of concept of knowing what can and cannot be changed. Acceptance of reality that some things cannot be changed allows client to focus energies on dealing with things that can be changed.6 • Help client strengthen problem-solving skills. Learning the process for problem solving will promote successful resolution of potentially stressful situations that arise.4,6

Intervention for ND of risk for impaired attachment

• Educate parents regarding child growth and development, where indicated, addressing parental perceptions. Parents often have misconceptions about the abilities of their children, and providing correct information clarifies expectations and is more realistic.6 • Assist parents in modifying the environment. The environment can be changed to provide appropriate stimulation (e.g., to diminish stimulation before bedtime, to simplify when the environment is too complex to handle, to provide life space where the child can play unrestricted, resulting in freedom for the child to meet his or her needs).2,7 (Refer to ND readiness for enhanced organized Infant Behavior.) • Model caregiving techniques that best support behavioral organization, such as attachment parenting. Recognizing that the child deserves to have his or her needs taken seriously and responding to those needs in a loving fashion promotes trust, and children learn to model their behavior after what they have seen the parents do.9,11 • Respond consistently with nurturance to infant/child. Babies come wired with an ability to signal their needs by crying, and when parents respond to these signals, they develop a sensitivity that in turn develops parental intuition, providing infants with gratification of their needs and trust in their environment.10 NURSING PRIORITY NO. 3 To enhance best functioning of parents: • Develop a therapeutic nurse-client relationship. Provide a consistently warm, nurturant, and nonjudgmental environment. Parents are often surprised to find that a tiny infant can cause so many changes in their lives and need help to adjust to this new experience. The warm, caring relationship of the nurse can help with this adjustment and provide the information and empathy they need at this time.1 • Assist parents in identifying and prioritizing family strengths and needs. Promotes positive attitude by looking at what they already do well and using those skills to address needs.2 • Support and guide parents in process of assessing resources. Outside support is important at this time, and making sure that parents receive the help they need will help them in this adjustment period.12 • Involve parents in activities with the infant/child that they can accomplish successfully. Parent participation (mentoring and modeling) in activities such as those recommended in Baby Gymboree Play and Music® creative play, and baby yoga can enable the parents to get to know their child and themselves, enhancing their confidence and self-concept.12 • Recognize and provide positive feedback for nurturant and protective parenting behaviors. Using "I" messages to let parents know their behaviors are effective reinforces continuation of desired behaviors and promotes feelings of confidence in their abilities.2,12 NURSING PRIORITY NO. 4 To support parent/child attachment during separation: • Provide parents with telephone contact as appropriate. Knowing there is someone they can call if they have problems provides a sense of security.3 • Establish a routine time for daily phone calls or initiate calls as indicated when child is hospitalized. Provides sense of consistency and control; allows for planning of other activities so parents can maintain contact and get information on a regular basis.1 • Minimize number of professionals on team with whom parents must have contact. Parents begin to know the individuals they are dealing with on a regular basis, fostering trust in these relationships and providing opportunities for modeling and learning.3 • Invite parents to use resources, such as the Ronald McDonald House, or provide a listing of a variety of local accommodations and restaurants. When child is hospitalized out of town, parents need to have a place to stay so they can have ready access to the hospital and be able to rest and refresh from time to time.3 • Arrange for parents to receive photos and progress reports from the child. Provides information and comfort as the child progresses, allowing the parents to continue to have hope for a positive resolution.3 • Suggest parents use cell phone with FaceTime, if available, or provide a photo and/or audiotape of themselves when separated for the child. Provides a connection during the separation, sustaining attachment between parent and child.1 • Consider use of a contract with parents. Clearly communicating expectations of both family and staff serves as a reminder of what each person has committed to and serves as a tool to evaluate whether expectations are being maintained.3 • Suggest parents keep a journal of infant/child progress. Serves as a reminder of the progress that is being made, especially when they become discouraged and believe infant/child is "never" going to be better.3 • Provide "homelike" environment for situations requiring supervision of visits. An environment that is comfortable supports the family as they work toward resolving conflicts and promotes a sense of hopefulness, enabling them to experience success when family is involved with a legal situation.12

Intervention for ND of ineffective airway clearance

• Elevate head of the bed or change position, as needed. Elevation or upright position facilitates respiratory function by use of gravity; however, the client in severe distress will seek position of comfort.3 • Position appropriately (e.g., head of bed elevated, client on side, rather than supine) and discourage use of oil-based products around nose to prevent vomiting with aspiration into lungs. (Refer to NDs risk for Aspiration, impaired Swallowing.) • Exercise diligence in providing oral hygiene, removing substances, and keeping oral mucosa hydrated. Airways can be obstructed by substances such as blood or thickened secretions. These can be managed by strict attention to good oral hygiene, especially in the client who is unable to provide that for self. Note: Instances of inspissated (thickened, dense, dehydrated) secretions as the cause of death have been reported.2 • Encourage and instruct in deep-breathing and directed-coughing exercises; teach (presurgically) and reinforce (postsurgically) breathing and coughing while splinting incision to maximize cough effort, lung expansion, and drainage and to reduce impairment associated with pain. • Mobilize client as soon as possible. Reduces risk or effects of atelectasis, enhancing lung expansion and drainage of different lung segments.5 • Administer analgesics, as indicated. Analgesics may be needed to improve cough effort when pain is inhibiting. Note: Overmedication, especially with opioids, can depress respirations and cough effort. • Administer medications (e.g., expectorants, anti-inflammatory agents, bronchodilators, mucolytic agents), as indicated, to relax smooth respiratory musculature, reduce airway edema, and mobilize secretions.8 • Increase fluid intake to at least 2,000 mL/day within cardiac tolerance (may require IV in acutely ill, hospitalized client). Encourage or provide warm versus cold liquids, as appropriate. Warm hydration can help liquefy viscous secretions and improve secretion clearance. Note: Individuals with compromised cardiac function may develop symptoms of CHF (crackles, edema, weight gain).4,5 • Provide ultrasonic nebulizer or room humidifier, as needed, to deliver supplemental humidification, helping to reduce viscosity of secretions. • Assist with use of respiratory devices and treatments (e.g., intermittent positive-pressure breathing [IPPB], incentive spirometer [IS], positive expiratory pressure mask, mechanical ventilation, airway clearance vest/oscillatory airway device [flutter], assisted and directed cough techniques). Various therapies/modalities may be required to maintain adequate airways and improve respiratory function and gas exchange depending on the cause for airway impairment. For example, an evidence-based review supports the notion that in individuals with neuromuscular conditions, cough may be made more effective by using manual assistance or positive-pressure insufflation devices. However, in clients with COPD, these same devices can be detrimental, causing decreased peak expiratory flow. (Refer to NDs ineffective Breathing Pattern, impaired Gas Exchange, impaired spontaneous Ventilation.)3,12 • Assist with use of respiratory devices and treatments (e.g., intermittent positive-pressure breathing [IPPB], incentive spirometer [IS], positive expiratory pressure mask, mechanical ventilation, airway clearance vest/oscillatory airway device [flutter], assisted and directed cough techniques). Various therapies/modalities may be required to maintain adequate airways and improve respiratory function and gas exchange depending on the cause for airway impairment. For example, an evidence-based review supports the notion that in individuals with neuromuscular conditions, cough may be made more effective by using manual assistance or positive-pressure insufflation devices. However, in clients with COPD, these same devices can be detrimental, causing decreased peak expiratory flow. (Refer to NDs ineffective Breathing Pattern, impaired Gas Exchange, impaired spontaneous Ventilation.)3,12 NURSING PRIORITY NO. 3 To assess changes, note complications: • Auscultate breath sounds, noting changes in air movement to ascertain current status and effects of treatments to clear airways. • Monitor vital signs, noting blood pressure or pulse changes. Observe for increased respiratory rate, restlessness or anxiety, and use of accessory muscles for breathing, suggesting advancing respiratory distress. • Monitor and document serial chest radiographs, ABGs, pulse oximetry readings. Identifies baseline status, influences interventions, and monitors progress of condition and/or treatment response. • Evaluate changes in sleep pattern, noting insomnia or daytime somnolence. May be evidence of nighttime airway incompetence or sleep apnea. (Refer to NDs Insomnia, Sleep Deprivation) • Document response to drug therapy and/or development of adverse reactions or side effects with antimicrobial agents, steroids, expectorants, and bronchodilators. Pharmacological therapy is used to prevent and control symptoms, reduce severity of exacerbations, and improve health status. The choice of medications depends on availability of the medication, the client's decision making about medication regimen, and response to any given medication.10 • Observe for signs/symptoms of infection (e.g., increased dyspnea, onset of fever, increase in sputum volume, change in color or character) to identify infectious process and promote timely intervention.10 • Obtain sputum specimen, preferably before antimicrobial therapy is initiated, to point to effective antimicrobial agent. Note: The presence of purulent sputum during an exacerbation of symptoms is a sufficient indication for starting antibiotic therapy, but a sputum culture and antibiogram (antibiotic sensitivity) may be done if the illness is not responding to the initial antibiotic.10

Intervention for ND of ineffective community coping

• Encourage community members/groups to engage in problem-solving activities. Individuals who are involved in the problem-solving process and make a commitment to the solutions have an investment and are more apt to follow through on their commitments.3,5 • Develop a plan jointly with community to deal with deficits in support. Working together will enhance efforts and help to meet identified goals.3,5

Intervention for ND of risk for unstable blood pressure

• Refer for and collaborate in treatment/management of underlying condition(s) that can restore hemodynamic stability or reduce risk of blood pressure fluctuations. • Monitor blood pressure as indicated and evaluate trends. Correlate client's symptoms with potential or identified cause for blood pressure instability. • Address personal factors (e.g., age and developmental level, social and cultural influences, life experiences, cognitive/emotional/psychological impairment that require modifications in healthcare management, teaching, and follow-up. • Discuss with client/SO those risk factors that are modifiable (e.g., taking medications as prescribed, avoiding substance misuse/[abuse]). • Recommend changing position from supine to standing slowly and in stages, avoiding standing motionless or for long periods of time, or sitting with legs crossed to enhance safety and reduce gravitational blood pooling in the lower extremities. • Identify available support systems, as needed. Client or caregiver may need community resources (e.g., home healthcare services, assistance with medication setup/administration, supervision or day care for frail elderly or child). • Emphasize importance of regular and long-term medical follow-up appointments for monitoring blood pressure and disease/condition trends and to provide for early intervention to reduce risk of complications. • Refer to appropriate NDs (as listed above) for related interventions.

Intervention for ND of risk for bleeding

• Prepare client for, or assist with, diagnostic studies, such as x-rays, computed tomography or magnetic resonance imaging scans, ultrasound, or colonoscopy, to determine presence of injuries or disorders that could cause internal bleeding (e.g., ectopic pregnancy, damaged spleen following vehicle crash, epidural hemorrhage 2 days after a fall, reports of rectal bleeding). NURSING PRIORITY NO. 3 To prevent bleeding/correct potential causes of excessive blood loss: • Apply direct pressure and ice to bleeding site, insert nasal packing, or perform fundal massage as appropriate. • Restrict activity and encourage bedrest or chairrest until bleeding abates. • Maintain patency of vascular access for fluid administration or blood replacement as indicated. • Assist with treatment of underlying conditions causing or contributing to blood loss, such as medical treatment of systemic infections or balloon tamponade of esophageal varices prior to sclerotherapy; proton pump inhibitor medications or antibiotics for gastric ulcer; and surgery for internal abdominal trauma or retained placenta. Treatment of underlying conditions may prevent or halt bleeding complications. • Provide special intervention for an at-risk client (e.g., individual with bone marrow suppression, chemotherapy, uremia) to prevent bleeding associated with tissue injury: Monitor closely for overt bleeding. Maintain pressure or pressure dressings as indicated for a longer period of time. May be required to stop bleeding, such as pressure dressings over arterial puncture site or surgical dressings. Hematest secretions and excretions for occult blood for early identification of internal bleeding. Protect client from trauma such as falls, accidental or intentional blows, or lacerations that could cause bleeding. Use soft toothbrush or toothettes for oral care to reduce risk of injury to oral mucosa. • Collaborate in evaluating need for replacing blood loss or specific components and be prepared for emergency interventions. Institution or physician may have specific guidelines for transfusion, such as platelet count less than 20,000/mcL or Hg less than 7 g/dL, in addition to the client's clinical status. • Be prepared to administer hemostatic agents, such as desmopressin, which promotes clotting and may stop bleeding by increasing coagulation factor VIII and the von Willebrand factor, or medications to prevent bleeding, such as proton pump inhibitors to reduce the risk of gastrointestinal bleeding and need for replacement transfusion.

Interventions for nursing dx of risk for unstable blood glucose level

- Ascertain whether client and SOs are certain they are obtaining accurate readings on glucose-monitoring device and are adept at using device. In addition to checking BS more frequently when it is unstable, it is wise to ascertain that equipment is functioning properly and being used correctly. There are many factors that may affect the accuracy of numbers, such as sie of blood drop with fingerstick, forgetting a bolus from insulin pump, and injecting insulin into lumpy subQ site. - Provide information on balancing food intake, antidiabetic agents, and energy expenditure. - Review medical necessity for regularly scheduled lab screening and monitoring tests for diabetes. - Discuss home glucose monitoring according to individual parameters (ex: six times per day for normal day and more frequently during times of stress). - Review common situations that could contribute to client's glucose instability on daily, occasional, or crisis basis. - Review client's diet, especially carbohydrate intake. - Encourage client to read labels and choose carbohydrates described as having low glycemic index and foods with adequate protein, higher fiber, and low fat content. These foods produce a slower rise in BS and more stable release of insulin. - Discuss how clients antidiabetic medications work. - Emphasize importance of checking expiration dates of medication, inspecting insulin for cloudiness if it is normally clear, and monitoring proper storage and preparation (when mixing is required. This affects insulin absorbability and effectiveness. - Review types of insulin used and delivery method. Only short-acting insulin is used in pump. - Check injection sites periodically. Insulin absorption can vary from day to day in healthy sites and is less absorbable in lumpy sites. - Ascertain that all injections are being given.

Interventions for nursing dx of acute substance withdrawal syndrome

- Consult with medical toxicologist or regional poison control center as needed - Provide environmental safety as indicated (bed in lowest position, call device within reach, doors full open or closed, padded side rails, family member or sitter at bedside as appropriate). - Monitor VS and LOC frequently during withdrawal. - Elevate HOB to decrease potential for aspiration and enhance lung expansion. - Monitor RR, depth, and pattern. Note periods of apnea or cheyne-stokes respirations. - Administer supplemental oxygen as needed. - Monitor temp, elevation of temp may occur d/t several reasons - Record intake/output, 24 hour fluid balance, skin turgor, status of mucous membranes - Reorient frequently to person, place, time, and surrounding environment. - Administer fluid/electrolytes as indicated. - Encourage client to verbalize anxiety. Explain substance withdrawal increases anxiety and uneasiness. - Monitor for SI - Provide symptom management - Administer medications treating specific substances used. - Administer thiamine, vitamin C, and vitamin B complex as indicated.

Interventions for nursing dx of ineffective activity planning

- Encourage expression of feelings contributing to or resulting from situation. Maintain a positive atmosphere without seeming overly cheerful. - Discuss client's perception of self as worthless and not deserving of success and happiness. - Gently confront ambivalent, angry, or depressed feelings. - Help client learn how to reframe negative thoughts about self into a positive view of what's happening. - Involve client/SOs in planning an activity. - Direct client to start with one desired or needed activity and to break it down into specific steps. - Encourage client to recognize procrastinating behaviors and make decision to change. - Assist client to develop skills of relaxation, imagery, or visualization, and mindfulness. - Assist client to investigate the idea that seeking pleasure (hedonism) is interfering with motivation to accomplish goals.

Interventions for nursing dx of risk for ineffective activity planning

- Encourage recognition of feelings associated with issues that prevent client from planning desired activities. - Help client to reframe negative thoughts about self into a positive view of what he/she is able to achieve. - Encourage client to recognize procrastinating behaviors and make a decision to change. - Develop a plan with the client to deal with activities in small steps. - Encourage client to engage in activity of choice with a friend or family member. - Investigate with the client the possibility that seeking pleasure (hedonism) may interfere with achieving life goals.

Interventions for nursing dx of anxiety (mild, moderate, severe, panic)

- Establish therapeutic relationship, conveying empathy and unconditional positive regard. - Be available to client for listening and talking. - Encourage client to acknowledge and to express feelings. Ex: crying (sadness), laughing (fear, denial), or swearing (fear, anger) - using active listening and reflection techniques. - Assist client to develop self-awareness of verbal and nonverbal behaviors. - Clarify meaning of feelings or actions by providing feedback and checking meaning with the client. - Acknowledge anxiety or fear. Do not deny or reassure client that everything will be alright. - Be aware of defense mechanisms being used (denial/regression). - Identify coping skills the individual is using currently, such as anger, daydreaming, forgetfulness, eating, smoking, or lack of problem solving. - Provide accurate information about the situation. - Provide comfort measures (calm/quiet environment, soft music, warm bath, back rub, therapeutic touch). This aids in meeting basic human need, decreasing sense of isolation and assisting client to feel less anxious. - Modify procedures as necessary (substitute oral or IM injections, combine blood draws, ect.) to limit the degree of stress and avoid overwhelming client. - Manage environmental factors such as harsh lighting, high traffic flow, and excessive noise. Discuss the use of music and accommodate the client's preferences. - Accept client as is. This may be where they need to be at this point in time (ex: denial). - Allow the behavior to belong to the client and do not respond personally. - Assist the client to use anxiety for coping with the situation if helpful. - Encourage awareness of negative self-talk and discuss replacing with positive statements such as using "can" instead of "can't", ect. Negative self talk promotes feelings of anxiety and self-talk. Panic state: - stay with the client, maintaining a calm, confident manner. - Speak in brief statements using simple words. - Provide for nonthreatening, consistent environment or atmosphere. - Set limits on inappropriate behavior and help client to develop acceptable ways of dealing with anxiety. - Provide safe controls and environment until client regains control. - Gradually increase activities and involvement with others as anxiety decreases. - Use cognitive therapy to focus on and correct faulty catastrophic interpretations of physical symptoms. - Administer anti-anxiety agents or sedatives, as ordered.

Interventions for nursing dx of Autonomic dysreflexia

- Investigate associated complaints/syndrome of symptoms (e.g., severe pounding HA, BP may be greater than 200/100, chest pain, irregular heart rate or dysrhythmias, blurred vision, nausea, facial flushing, metallic taste, severe anxiety, minimal symptoms or expressed complaints in the presence of significantly elevated BP - locate and attempt to eliminate causative stimulus, moving in a stepwise fashion: the cause can be anything that would normally cause pain or discomfort below level of injury. - Assess for bladder distention and bowel distention, as well as for a blocked urinary catheter. Bladder distention is the first most common cause of AD, and fecal impaction is the second most common cause. - Empty bladder by voiding or catheterization, applying local anesthetic ointment if indicated - Ascertain that urine is free flowing if foley or SP catheter is in place, empty drainage bag, straighten tubing if kinked, and lower drainage bag if it is higher than bladder. - Note color, character, and odor of urine and obtain specimen for culture as indicated (acute urinary infection can cause AD) - Perform digital stimulation, checking for constipation or impacted stool. If symptoms appear or worsen with digital stimulation, stop the procedure. - Apply local anesthetic ointment to rectum, remove impaction after symptoms subside. - Check for skin pressure or irritation - Perform a pressure release if sitting - Check for tight clothing, straps, belts - Note whether pressure sore has developed or changed - Observe for bruising or signs of infection - check for ingrown toenail or other injury to skin or tissue (burn, sunburn, fracture) - Check for other possible causes (menstrual cramps) - Abdominal conditions (colitis, ulcer) - Environmental temperature extremes (hot/cold) - Take steps to reduce BP (thereby reducing potential for stroke which is the primary concern with AD) - Elevate HOB immediately or place in sitting position with legs hanging down to lower intracranial pressure - Loosen any clothing or restrictive devices (lowers BP by pooling of blood in abdomen and lower extremities) - Monitor BS frequently during acute episode. - Administer medications as indicated (antihypertensives)

Interventions for nursing dx of risk for autonomic dysreflexia

- Monitor VS routinely, noting changes in BP, HR, and temp especially during times of physical stress to identify trends and intervene in a timely manner. BP elevation of 20-40mmHg above baseline may be indicative of AD. - Instruct all caregivers in regularly times elimination and safe bowel and bladder or catheter care, as well as in interventions for long-term prevention of skin stress or breakdown (e.g., appropriate padding for skin and tissues, proper positioning with frequent pressure-relief actions, routine foot and toenail care) to reduce risk of AD. - Instruct client/caregiver in additional preventive interventions (e.g., temperature control, preventing pressure ulcers, blisters, ingrown toenails, checking frequently for tight clothes or leg straps, sunburn and other burn prevention.) - Administer antihypertensive medications as indicated.

Interventions for nursing dx of decreased intracranial adaptive capacity

- Perform periodic assessments of the client's LOC and/or neurological status, BP, breath sounds, temp, amount of secretions, central venous pressure, HR, and heart rhythm, fluid balance, nutritional status, and lab values. - Perform interventions specific to clieant with increased ICP: elevate HOB - maintain head and neck in neutral position , supporting with small towel rolls or pillows to maximize venous return. - Avoid causing hip flexion of 90 degrees or more - limit or prevent activities such as coughing, vomiting, and straining at stool and avoid or restrict use of restraints. - Suction with caution and only when needed. Pass catheter just beyond end of endotracheal tube without touching the tracheal wall or carina. Administer lidocaine intratracheally if indicated. - Hyperoxygenate before suctioning. - Investigate increased restlessness. - Decrease extraneous stumuli and provide comfort measures (quiet environment, soft voice, tapes of familiar voices played through earphones, back massage, gentle touch as tolerated) - Limit painful procedures to those that are absolutely necessary - provide rest periods between care activities and limit duration of procedures. - Lower lighting and noise levels and schedule and limit activities to provide a restful environment. - Encourage family/significant others to talk to client. - Administer and restrict fluid intake as necessary and administer IV fluids via pump. - Weigh as indicated. - Monitor and manage body temp. Regulate environmental temp and bed linens and use cooling blanket as indicated. - Provide approprate safety measures - initiate treatment for seizures - administer supplemental oxygen as indicated - Administer medications as appropriate - Administer enteral or parenteral nutrition

Interventions for nursing dx of risk for aspiration

- Place client in proper position for age and condition of disease affecting airways, such as being upright for meals to decrease likelihood of drainage into trachea, and reduce reflux and improve gastric emptying. - Encourage client to cough, as able, to clear secretions. - Provide close monitoring for use of oxygen masks in clients at risk for vomiting. Refrain form using oxygen mask for comatose individuals. - Keep wire cutters or scissors with client at all times when jaws are wired or banded to assist with clearing airway in emergency. - Assist with oral care, postural drainage, and other respiratory therapies to remove or mobilize thickened secretions that may interfere with swallowing and block airway. - In client requiring suctioning to manage secretions - maintain operational suction equipment at bedside. Suction as needed. - Avoid triggering gag mechanism when performing suction or mouth care. - Avoid keeping client supine or flat when on mechanical ventilation. - Keep HOB elevated during enteral feedings for at least 30 minutes. - Provide a rest period prior to feeding time - rested individuals may have less difficulty with swallowing. - Feed slowly and instruct client to take small bites and to chew thoroughly. - Vary placement of food in client's mouth according to type of deficit (right side of mouth for those weak on left side). - Avoid pureed foods and mucus-producing foods (milk) - Use semisolid or soft foods that stick together and form a bolus (casseroles, puddings, stews) which aids swallowing effort by improving client's ability to manipulate food with the tongue. - Determine food and liquid viscosity best tolerated by client. Add thickening agents as appropriate. - Offer very warm or very cold liquids to activate temperature receptors in the mouth that help stimulate swallowing. - Avoid washing solids down with liquids to prevent bolus of food pushing down too rapidly, increasing risk of aspiration. - Provide oral medications in elixir form or crushed. - Time medications to coincide with meals when possible. - Refer to physician or speech language pathologist. - Ask client about fullness to prevent overfeeding. - Minimize use of sedatives/hypnotics when possible, these can impair coughing and swallowing.

Interventions for nursing dx of activity intolerance

- Plan care with rest periods - Assist with self-care activities - Increase exercise/activity levels gradually - Encourage expression of feelings regarding condition - Involve patient/SOs in helping plan activities as much as possible. - Assist with activities and provide and monitor client's use of assistive devices. - Promote comfort measures and provide relief of pain - Implement rehab program - Administer supplemental oxygen, medications, and other tx's

Interventions for nursing dx of risk for unstable BP

- refer for and collabolrate in treatment/management of underlying conditions - Monitor BP as indicated and evaluate trends. Correlate client's symptoms with potential or identified cause for BP instability. - Address personal factors (age, developmental level, social and cultural influences, life experiences, cognitive/emotional/psychological impairment) that require modifications in healthcare management, teaching, and follow-up. - Discuss with client/SO those risk factors that are modifiable (taking medications as prescribed, avoiding substance misuse) - Recommend changing position from supine to standing slowly and in stages, avoiding standing motionless or for long periods of time or sitting with legs crossed to enhance safety and reduce gravitational blood pooling in LE. - Identify available support systems as needed (home healthcare) - Emphasize importance of regular and long term medical follow up appointments for monitoring BP and disease/condition.

Intervention for ND of death anxiety

NURSING PRIORITY NO. 2 To assist client to deal with situation: • Provide open and trusting relationship. Promotes opportunity to explore feelings about impending death.2 • Make time for nonjudgmental discussion of philosophical issues or questions about spiritual impact of illness or situation. Can help client clarify own position on these issues.3 • Respect client's desire or request not to talk. Provide hope within parameters of the individual situation. Promotes open environment that encourages client to talk freely about thoughts and feelings. Client may not be ready to talk about situation or concerns about death, or he or she may be denying the reality of what is happening.1,8 • Encourage expressions of feelings (e.g., anger, fear, sadness, etc.). Acknowledge anxiety or fear. Do not deny or reassure client that everything will be all right. Be honest when answering questions and providing information. Enhances trust and a therapeutic relationship.2 • Use therapeutic communication skills of active-listening. Technique acknowledges reality of feelings and encourages client to find own solutions.2 • Provide information about normalcy of feelings and individual grief reaction. Most individuals question their reactions and whether they are normal, and information can provide reassurance.3 (Refer to ND Grieving.) • Identify coping skills currently used and how effective they are. Be aware of defense mechanisms being used by the client. Provides a starting point to plan care and assists client to acknowledge reality and deal more effectively with what is happening.3 • Review life experiences of loss, noting client strengths and successes. Provides opportunity to identify and use previously successful skills.2 • Provide a calm, peaceful setting and privacy, as appropriate. Promotes relaxation and enhances ability to deal with situation.8 • Include family in discussions and decision making, as appropriate. Involved family members can provide support and ideas for problem-solving.7 • Note client's religious or spiritual orientation, involvement in religious or church activities, and presence of conflicts regarding spiritual beliefs. May benefit by referral to appropriate resource to help client resolve issues, if desired.7 • Assist client to engage in spiritual growth activities, experience prayer or meditation, and practice forgiveness to heal past hurts. Provide information that anger with God is a normal part of the grief process. May reduce feelings of guilt or conflict, allowing client to move forward toward resolution.1 • Refer to therapists, spiritual advisors, or counselors, as appropriate. Promotes facilitation of grief work. • Refer to community agencies and resources. Assists client/SO in planning for eventualities (legal issues, hospice home care, funeral plans, etc.).

Intervention for ND of risk for contamination

NURSING PRIORITY NO. 2 To assist client to reduce or correct individual risk factors: • Assist client to develop plan to address individual safety needs and injury or illness prevention in home, community, and work setting. • Repair, replace, or correct unsafe household items or situations (e.g., flaking or peeling paint or plaster, filtering unsafe tap water). • Review effects of secondhand smoke and importance of refraining from smoking in home or car where others are likely to be exposed. • Encourage removal or proper cleaning of carpeted floors, especially for small children and persons with respiratory conditions. Carpets hold up to 100 times as much fine-particle material as a bare floor and can contain metals and pesticides.1 • Encourage timely cleaning or replacement of air filters on furnace and air-conditioning unit. Good ventilation cuts down on indoor air pollution from carpets, machines, paints, solvents, cleaning materials, and pesticides. • Recommend periodic inspection of well water and tap water to identify possible contaminants. • Encourage client to install carbon monoxide monitors and other air pollutant detectors in home as appropriate. • Recommend placing dehumidifier in damp areas to retard growth of molds. • Review proper handling of household chemicals:4,5,9 Read chemical labels to be aware of primary hazards (especially in commonly used household cleaning and gardening products). Follow directions printed on product label (e.g., avoid use of certain chemicals on food preparation surfaces, refrain from spraying garden chemicals on windy days). Choose least hazardous products for the job, preferably multiuse products to reduce number of different chemicals used and stored. Use products labeled "nontoxic" wherever possible. Use form of chemical that most reduces risk of exposure (e.g., cream instead of liquid or aerosol). Wear protective clothing, gloves, and safety glasses when using chemicals. Avoid mixing chemicals at all times and use in well-ventilated areas. Store chemicals in locked cabinets. Keep chemicals in original labeled containers and do not pour into other containers. • Place safety stickers on chemicals to warn of harmful contents. • Review proper food-handling, storage, and cooking techniques. • Stress importance of pregnant or lactating women following fish or wildlife consumption guidelines provided by state, U.S. territorial, or Native American tribes. Ingestion of noncommercial fish or wildlife can be a significant source of pollutants.8

Interventions for ND of readiness for enhanced family coping

NURSING PRIORITY NO. 2 To assist family to develop/strengthen potential for growth: • Provide time to talk with family to discuss their views of the situation. Provides an opportunity to hear family's understanding and determine how realistic their ideas are for planning how they are going to deal with situation in the most positive manner.3 • Establish a relationship with family/client. Therapeutic relationships foster growth and enable family to identify skills needed for coping with difficult situation or illness.3 • Provide a role model with whom the family may identify. Setting a positive example can be a powerful influence in changing behavior, and as family members learn more effective communication skills, consideration for others, warmth, and understanding, family relationships will be enhanced.2 • Discuss importance of open communication and of not having secrets. Functional communication is clear, direct, open, and honest, with congruence between verbal and nonverbal. Dysfunctional communication is indirect, vague, and controlled, with many double-bind messages. Awareness of this information can enhance relationships among family members.3 • Demonstrate techniques such as active-listening, "I" messages, and problem solving. Learning these skills can facilitate effective communication and improve interactions within the family.2 • Establish social goals of achieving and maintaining harmony with oneself, family, and community. Enables client to interact with others in positive ways.3

Intervention for ND of risk for aspiration

NURSING PRIORITY NO. 2 To assist in correcting factors that can lead to aspiration: • Place client in proper position for age and condition or disease affecting airways. Adult and child should be upright for meals to decrease likelihood of drainage into trachea and to reduce reflux and improve gastric emptying.2,4 Prone position may provide shorter gastric emptying time and decreased incidence of regurgitation and subsequent aspiration in premature infants.8 • Encourage client to cough, as able, to clear secretions. May simply need to be reminded or encouraged to cough (such as might occur in elderly person with delayed gag reflex or in postoperative, sedated client).2 • Provide close monitoring for use of oxygen masks in clients at risk for vomiting. Refrain from using oxygen mask for comatose individuals. • Keep wire cutters or scissors with client at all times when jaws are wired or banded to facilitate clearing airway in emergencies. • Assist with oral care, postural drainage, and other respiratory therapies to remove or mobilize thickened secretions that may interfere with swallowing and block airway.6 • In client requiring suctioning to manage secretions:6,9,10 Maintain operational suction equipment at bedside or chairside. Suction (oral cavity, nose, and endotracheal/tracheostomy tube) as needed, using correct size of catheter and timing for adult or child to clear secretions in client with more frequent or congested-sounding cough; presence of coarse rhonchi and expiratory wheezing (audible with or without auscultation); visible secretions; increased peak pressures during volume-cycled ventilation; indication from client that suctioning is necessary; suspected aspiration of gastric or upper airway secretions; or otherwise unexplained increases in shortness of breath, respiratory rate, or heart rate. Avoid triggering gag mechanism when performing suction or mouth care. Avoid keeping client supine or flat when on mechanical ventilation (especially when also receiving enteral feedings). Supine positioning and enteral feeding have been shown to be independent risk factors for the development of aspiration pneumonia. • For a verified swallowing problem:3-5,11 Provide a rest period prior to feeding time. Rested person may have less difficulty with swallowing. Elevate client to highest or best possible position for eating and drinking. Feed slowly and instruct client to take small bites and to chew thoroughly. Vary placement of food in client's mouth according to type of deficit (e.g., place food in right side of mouth if facial weakness present on left side). Use semisolid or soft foods that stick together and form a bolus (e.g., casseroles, puddings, stews), which aids swallowing effort by improving client's ability to manipulate food with the tongue. Avoid pureed foods and mucus-producing foods (milk). Determine food and liquid viscosity best tolerated by client. Add thickening agent to liquids, as appropriate. Some individuals may swallow thickened liquids better than thin liquids. Offer very warm or very cold liquids to activate temperature receptors in the mouth that help to stimulate swallowing. Avoid washing solids down with liquids to prevent bolus of food pushing down too rapidly, increasing risk of aspiration. • Provide oral medications in elixir form or crushed, if appropriate. Have client self-medicate when possible. Time medications to coincide with meals when possible. • Refer to physician and/or speech language pathologist, as appropriate, for medical and surgical interventions or for specific exercises to strengthen muscles and techniques to enhance swallowing. • When feeding tube is in place:4,12,13 Note radiograph and/or measurement of aspirate pH following placement of feeding tube to verify correct position. Ask client about feeling of fullness and/or measure residuals just prior to feeding and several hours after feeding, when appropriate, to prevent overfeeding. Elevate head of bed 30 degrees during and for at least 30 minutes after bolus feedings. • Determine best position for infant/child (e.g., with the head of bed elevated 30 degrees and infant propped on right side after feeding). Upper airway patency is facilitated by upright position, and turning to right side decreases likelihood of drainage into trachea. • Provide oral medications in elixir form or crushed, if appropriate. • Minimize use of sedatives/hypnotics when possible. Agents can impair coughing and swallowing.

Intervention for ND of contamination

NURSING PRIORITY NO. 2 To assist in treating effects of exposure: • Implement a coordinated decontamination plan (e.g., removal of clothing, showering with soap and water, other initial decontamination procedures) following consultation with medical toxicologist, hazardous materials team, industrial hygiene, and safety officer to prevent further harm to client and to protect healthcare providers.8,9 • Ensure availability and proper use of personal protective equipment (PPE) (e.g., high-efficiency particulate air [HEPA] filter masks, special garments, barrier materials, including gloves and face shield) to protect from exposure to biological, chemical, and radioactive hazards.8-10 • Provide for isolation or group/cohort individuals with same diagnosis or exposure, as resources require. Limited resources may dictate open wardlike environment; however, the need to control spread of infection still exists. Only plague, smallpox, and viral hemorrhagic fevers require more than standard infection control precautions. • Provide therapeutic interventions, as individually appropriate. Specific needs of the client and the level of care available at a given time and location determine response. • Refer pregnant client for individually appropriate diagnostic procedures or screenings. Helpful in determining effects of teratogenic exposure on fetus allowing for informed choices and preparations. Chemical toxins can include (and are not limited to) lead, arsenic, chlorine, mercury, pesticides.16 • Screen breast milk in lactating client following radiation exposure. Depending on type and amount of exposure, breastfeeding may need to be briefly interrupted or occasionally terminated.12-14 • Cooperate with and refer to appropriate agencies (e.g., CDC, U.S. Army Medical Research Institute of Infectious Diseases, Federal Emergency Management Agency, Department of Health and Human Services, Office of Emergency Preparedness, EPA) to prepare for and manage mass casualty incidents.9,10

Intervention for ND of interrupted breastfeeding

NURSING PRIORITY NO. 2 To assist mother to maintain breastfeeding, as desired: • Provide information, as needed, regarding need or decision to interrupt breastfeeding. • Give emotional support to mother and support her decision regarding cessation or continuation of breastfeeding. Many women are ambivalent about breastfeeding, and providing information about the pros and cons of both breastfeeding and bottle-feeding, along with support for the mother's/couple's decision, will promote a positive experience.1,8 • Promote peer counseling for teen mothers. Provides positive role model teen can relate to and feel comfortable with discussing concerns and feelings.9 • Educate father/significant other (SO) about the benefits of breastfeeding and how to manage common lactation challenges. Enlisting support of father/SO is associated with higher ratio of successful breastfeeding at 6 months.12 • Discuss and demonstrate use of breastfeeding aids (e.g., infant sling, nursing footstool or pillows, hand expression, manual and/or electric piston-type breast pump). Enhances comfort and relaxation for breastfeeding. When circumstances dictate that mother and infant are separated for a time, whether due to illness, prematurity, or returning to work or school, the milk supply can be maintained by use of the pump. Storing the milk for future use enables the infant to continue to receive the value of breast milk. Learning the correct technique is important for successful use of the pump.1,4,13,15 • Review techniques for storage and use of expressed breast milk. Provides safety and optimal nutrition, promoting continuation of the breastfeeding process.1 • Determine if a routine visiting schedule or advance warning can be provided. When infant remains in the hospital or when working mother continues to nurse, it helps to make preparations so that infant will be hungry and ready to feed when the mother arrives. A sleepy baby can be gently played with to arouse him or her; clothing can be loosened or diaper changed, exposing infant to room air; or if infant is hungry and upset, a calm voice and gentle rocking can calm the infant and prepare him or her to nurse.1 • Provide privacy and calm surroundings when mother breastfeeds in hospital or work setting. Note: Federal law 2010 requires an employer to provide a place and reasonable break time for an employee to express her breast milk for her baby for 1 year after birth.20 • Problem-solve return-to-work or school issues or periodic infant care requiring bottle or supplemental feeding.14,15 • Recommend using expressed breast milk instead of formula or at least partial breastfeeding for as long as mother and child are satisfied. Prevents temporary interruption in breastfeeding, decreasing the risk of premature weaning.13,15 NURSING PRIORITY NO. 3 To promote successful infant feeding: • Recommend or provide for infant sucking on a regular basis, especially if gavage feedings are part of the therapeutic regimen. Reinforces that feeding time is pleasurable and enhances digestion.1 • Explain anticipated changes in feeding needs and frequency. Growth spurts require increased intake or more feedings by infant.13 • Discuss proper use and choice of supplemental nutrition and alternate feeding methods (e.g., bottle or syringe, finger feeding, cup feeding, or supplemental nursing system feeding). If infant is not receiving sufficient nourishment, whether by mother's choice to reduce number of feedings (e.g., returning to work) or necessity (e.g., specific maternal illness, medication use), other means for supplementing intake must be taken, and mother needs to be given information regarding method chosen.1 • Review safety precautions when bottle-feeding is necessary/chosen. Identifying importance of proper flow of formula from nipple, frequency of burping, holding bottle instead of propping, techniques of formula preparation, and sterilization techniques are necessary for successful bottle-feeding.1 NURSING PRIORITY NO. 5 To assist mother in weaning process, when desired: • Discuss reducing frequency of daily feedings or breast pumping by once every 2 to 3 days. Preferred method of weaning, if circumstance permits, to reduce problems associated with engorgement.16,17 • Encourage wearing a snug, well-fitting bra, but refrain from binding breasts because of increased risk of clogged milk ducts and inflammation.15,16 • Recommend expressing some milk from breasts regularly each day over a 1- to 3-week period, if necessary, to reduce discomfort associated with engorgement until milk production decreases.16,17 • Suggest holding infant differently during bottle-feeding or interactions or having another family member give infant's bottle feeding to prevent infant rooting for mother's breast and limit stimulation of her nipples. • Discuss use of ibuprofen or acetaminophen for discomfort during weaning process.8 • Suggest use of ice packs to breast tissue (not nipples) for 15 to 20 min at least four times a day to help reduce swelling during sudden weaning.17

Intervention for ND of readiness for enhanced organized infant behavior

NURSING PRIORITY NO. 2 To assist parents to enhance infant's integration: • Provide positive feedback for parental involvement in caregiving process. Transfer of care from staff to parents progresses along a continuum as parents' confidence level increases and they are able to take on more responsibility.7 • Discuss use of skin-to-skin contact (kangaroo care [KC]) as appropriate. Research suggests KC may have a positive effect on infant development by enhancing neurophysiological organization and an indirect effect by improving parental mood, perceptions, and interactive behavior.6 • Review infant growth and development, pointing out current status and progressive expectations. Increases parental knowledge base and level of confidence.2-4 • Identify cues reflecting infant stress. Attention to cues allows for early intervention in case of problem development.2-4 • Discuss possible modifications of environmental stimuli, handling, activity schedule, sleep, and pain control needs based on infant's behavioral cues. Stimulation that is properly timed and appropriate in complexity and intensity allows the infant to maintain a stable balance of his/her subsystems and enhances development.5 • Discuss parents' perceptions of needs and provide recommendations for modifications of environmental stimuli, activity schedule, sleep, and pain control needs. While care provided is satisfactory, some modifications may enhance infant's integration and development.1,4 • Incorporate parents' observations and suggestions into plan of care. Demonstrates value of and regard for parents' input and enhances sense of ability to deal with situation.2,4

Intervention for ND of readiness for enhanced community coping

NURSING PRIORITY NO. 2 To assist the community in adaptation and problem-solving for management of current and future needs/stressors: • Define and discuss current needs and anticipated or projected concerns. Agreement on scope and parameters of needs is essential for effective planning. • Determine community's strengths. Plan can build on strengths to address areas of weakness. • Identify and prioritize goals to facilitate accomplishment. Helps to bring the community together to meet a common concern or threat, maintain focus, and facilitate accomplishment.4 • Identify and interact with available resources (e.g., persons, groups, financial, governmental, as well as other communities). Promotes cooperation. Major catastrophes, such as earthquakes, floods, and terrorist activity, affect more than the local community, and communities need to work together to deal with and accomplish reconstruction and future growth.5 • Make a joint plan with the community and the larger community to deal with adaptation and problem-solving. Promotes management of problems and stressors to enable most effective solution for identified concern.2 • Seek out and involve underserved and at-risk groups within the community, including the homeless. Supports communication and commitment of community as a whole.2

Intervention for ND of risk for constipation

NURSING PRIORITY NO. 2 To facilitate an acceptable pattern of elimination: • Promote healthy lifestyle for elimination:1-8 Instruct in and encourage balanced fiber and bulk (e.g., fruits, vegetables, whole grains) in diet and fiber supplements (e.g., wheat bran, psyllium) to improve consistency of stool and facilitate passage through colon. Limit foods with little or no fiber or diet high in fats (e.g., ice cream, cheese, meats, fast food, processed foods). Promote adequate fluid intake, including water, high-fiber fruit and vegetable juices, fruit/vegetable smoothies, and popsicles. Suggest drinking warm, stimulating fluids (e.g., decaffeinated coffee, hot water, tea) to avoid dehydration; promote moist, soft feces; and facilitate passage of stool. Encourage daily activity and exercise within limits of individual ability to stimulate contractions of the intestines. Encourage client to not ignore urge. Provide privacy and routinely scheduled time for defecation (bathroom or commode preferable to bedpan) to promote psychological readiness and comfort. • Recommend use of medications (stool softeners, mild stimulants, or bulk-forming agents) as needed and/or routinely when appropriate to prevent constipation (e.g., client taking pain medications, especially opiates, or who is inactive or immobile).8

Intervention for ND of chronic confusion

NURSING PRIORITY NO. 2 To limit effects of deterioration/maximize level of function: • Assist in treating conditions (e.g., depression, infections, malnutrition, electrolyte imbalances, and adverse medication reactions) that may contribute to or exacerbate distress, discomfort, and agitation.1-6 • Implement behavioral and environmental management interventions to promote orientation, provide opportunity for client interaction using current cognitive skills, and preserve client's dignity and safety:6,9,11,12 Ascertain interventions previously used or tried and evaluate effectiveness. Provide calm environment and minimize relocations; eliminate extraneous noise and stimuli that may increase client's level of agitation or confusion. Introduce yourself at each contact, if needed. Call client by preferred name. Use touch judiciously. Tell client what is being done before touching to reduce sense of surprise or negative reaction. Be supportive and sensitive to fears, misperceived threats, and frustration with expressing what is wanted. Be open and honest when discussing client's disease, abilities, and prognosis. and prognosis. Maintain continuity of caregivers and care routines as much as possible. Use positive statements, offer guided choices between two options. Avoid speaking in loud voice, crowding, restraining, shaming, demanding, or condescending actions toward client. Set limits on acting-out behavior for safety of client/others. Remove from stressors and agitation triggers or danger, move client to quieter place, and offer privacy. Simplify client's tasks and routines to accommodate fluctuating abilities and to reduce agitation associated with multiple options or demands. Provide for or assist with daily care activities, including bathing, dressing, grooming, toileting, and exercise. Client may "forget" how to perform activities of daily living. Monitor and assist with meeting nutritional needs and feeding and fluid intake and monitor weight. Provide finger food if client has problems with eating utensils or is unable to sit to eat. Assist with toileting and perineal care, as needed. Provide incontinence supplies. Allow adequate rest between stimulating events. Use lighting and visual aids to reduce confusion. Encourage family/SO(s) to provide ongoing orientation/input to include current news and family happenings. Maintain continuity of caregivers and care routines as much as possible. Use positive statements, offer guided choices between two options. Avoid speaking in loud voice, crowding, restraining, shaming, demanding, or condescending actions toward client. Set limits on acting-out behavior for safety of client/others. Remove from stressors and agitation triggers or danger, move client to quieter place, and offer privacy. Simplify client's tasks and routines to accommodate fluctuating abilities and to reduce agitation associated with multiple options or demands. Provide for or assist with daily care activities, including bathing, dressing, grooming, toileting, and exercise. Client may "forget" how to perform activities of daily living. Monitor and assist with meeting nutritional needs and feeding and fluid intake and monitor weight. Provide finger food if client has problems with eating utensils or is unable to sit to eat. Assist with toileting and perineal care, as needed. Provide incontinence supplies. Allow adequate rest between stimulating events. Use lighting and visual aids to reduce confusion. Encourage family/SO(s) to provide ongoing orientation/input to include current news and family happenings. Maintain reality-oriented relationship and environment (e.g., clocks, calendars, personal items, seasonal decorations). Encourage participation in resocialization groups to help restore or maintain client's independence and dignity. Allow client to reminisce or exist in own reality if not detrimental to well-being. Avoid challenging illogical thinking because defensive reactions may result. Provide appropriate safety measures. Client who is confused needs close supervision. Safety measures (such as use of identification bracelet and alarms on unlocked exits, lockup of toxic substances and medication, supervision of outdoor activities and wandering, removal of car or car keys, lowered temperature on hot water tank) can prevent injuries.4 • Avoid use of restraints as much as possible. Investigate use of alternatives (such as bed nets, electronic bed pads, chair alarms, laptop trays), when required. Although restraints can prevent falls, they can increase client's agitation and distress, resulting in injury or even death.7,9,10 • Administer medications (e.g., antidepressants, anxiolytics, antipsychotics), as ordered, at lowest possible therapeutic dose. Monitor for expected and/or adverse responses, side effects, and interactions. May be used to manage symptoms of psychosis and aggressive behaviors but need to be used cautiously.5,13 • Implement complementary therapies (e.g., music or dance therapy; animal-assisted therapy; massage, Therapeutic Touch [if touch is tolerated], aromatherapy, bright light treatment) as ordered or desired. Monitor client's response to each modality and modify as indicated. Use of alternative therapies tailored to the client's preferences, skills, and abilities can be calming and provide relaxation and can be carried out by a wide range of health and social care providers and volunteers.11 • Refer to NDs acute Confusion, impaired Memory, impaired verbal Communication for additional interventions. • Discuss caregiver burden when appropriate. Provide educational materials and list of available resources, help lines, Web sites, and so forth, as desired, to assist SO(s) in dealing and coping with long-term care issues.5,7,9 (Refer to NDs caregiver Role Strain, risk for caregiver Role Strain.) • Involve SO(s) in care and discharge planning. Maintain frequent interactions with SOs in order to relay information, to change care strategies, try different responses, or implement other problem-solving solutions.6 • Identify appropriate community resources (e.g., Alzheimer's Disease and Related Disorders Association, stroke or other brain injury support groups, senior support groups, specialist day services, home care, respite care; adult placement and short-term residential care; clergy, social services, occupational and physical therapists; assistive technology and telecare; attorney services for advance directives, durable power of attorney) to provide support for client and SOs and assist with problem solving.5,11

Intervention for ND of risk for acute confusion

NURSING PRIORITY NO. 2 To maximize level of function, prevent further deterioration, correct existing risk factors: • Assist with treatment of underlying problem (e.g., drug intoxication or substance abuse, infectious processes, hypoxemia, biochemical imbalances, nutritional deficits, pain management) to reduce potential for confusion.1,2,5,8 • Monitor and adjust medication regimen and note response. May identify medications that can be changed or eliminated in client prone to adverse or exaggerated responses to medications (including confusion).1,2,5 • Provide normal levels of essential sensory and tactile stimulation—include personal items and pictures, desired music, activities, and contacts. Encourage family/SO(s) to participate in orientation by providing ongoing input (e.g., current news and family happenings).1,2 • Maintain calm environment and eliminate extraneous noise and stimuli to prevent overstimulation. • Provide adequate supervision: remove harmful objects from environment, provide siderails and seizure precautions, place call bell and position needed items within reach, clear traffic paths, and ambulate with devices to meet client's safety needs and reduce risk of falls. Encourage client to use vision or hearing aids and other adaptive equipment when needed to assist client in interpretation of environment and communication. • Avoid or limit use of restraints. Can cause agitation and increase likelihood of untoward complications.4,7 • Promote early ambulation and recreational activities to enhance well-being and reduce effects of prolonged bedrest or inactivity.1 • Establish and maintain elimination patterns. Disruption of elimination may be a cause for confusion or precipitate delerium.7

Intervention for ND of risk for decreased cardiac output

NURSING PRIORITY NO. 2 To minimize risk factors, maximize cardiac output:6-8,10 • Provide for adequate rest. • Increase activity levels gradually as permitted by individual condition, noting vital sign response to activity. • Administer medications, as appropriate, and monitor cardiac responses. • Encourage relaxation techniques to reduce anxiety and muscle tension. • Elevate legs when in sitting position and edematous extremities when at rest. Apply antiembolic hose or sequential compression devices when indicated, ensuring they are individually fitted and appropriately applied. Limits venous stasis, improves venous return, and reduces risk of thrombophlebitis. • Avoid prolonged sitting position for all clients and supine position for sleep or exercise for gravid clients (second and third trimesters) to maximize vascular return.2,3

Intervention for ND of readiness for enhanced breastfeeding

NURSING PRIORITY NO. 2 To promote effective breastfeeding behaviors: • Initiate breastfeeding within first hour after birth. The time of the first feeding is determined by the infant's physiological and behavioral cues. Throughout the first 2 hours after birth, the infant is usually alert and ready to nurse. Early feedings are of great benefit to mother and infant because oxytocin release is stimulated, helping to expel the placenta and prevent excessive maternal blood loss; the infant receives the immunological protection of colostrum; peristalsis is stimulated; lactation is accelerated; and maternal-infant bonding is enhanced.2 • Encourage skin-to-skin contact. Place infant on mother's stomach, skin-to-skin after delivery. Many full-term infants are alert and capable of latching onto mother's breast without assistance.9 Studies show that early skin-to-skin mother-infant contact is correlated with exclusive breastfeeding while in the hospital.10 • Demonstrate asymmetric latch aiming infant's lower lip as far from base of the nipple as possible, then bringing infant's chin and lower jaw in contact with breast while mouth is wide open and before upper lip touches breast. This position allows infant to use both tongue and jaw more effectively to obtain milk from the breast.9 • Demonstrate how to support and position infant and use of aids (e.g., infant sling, nursing footstool, or pillows). The mother should be made as comfortable as possible and given specific instructions for positioning self and baby depending on the type of birth (e.g., cesarean section or vaginal).1,5 • Observe mother's return demonstration/teach back. Provides practice and the opportunity to correct misunderstandings and add additional information to promote optimal experience for breastfeeding.1 • Keep infant with mother for unrestricted breastfeeding duration and frequency. Rooming-in offers opportunity for spontaneous encounters for the family to practice handling skills and increase confidence in own ability. It also encourages feeding in response to cues from the baby and increases bonding.1 • Discuss early infant feeding cues (e.g., rooting, lip smacking, sucking fingers or hand) versus the late cue of crying. Early recognition of infant hunger promotes timely and more rewarding feeding experience for infant and mother. NOTE: For healthy infants, discourage use of pacifiers and artificial nipples in first month of life to avoid "nipple confusion" and to establish mother's milk supply.6 • Encourage mother to follow a well-balanced diet containing an extra 500 calories/day, continue her prenatal vitamins, and drink at least 2,000 to 3,000 mL of fluid/day. There is an increased need for maternal energy, protein, minerals, and vitamins, as well as increased fluid intake, during lactation to restore what the mother loses in secreting milk to provide adequate nutrients for the nourishment of the infant and to protect the mother's own stores.4 • Provide information, as needed, in support of breastfeeding. Having adequate information about the nutritional, psychological, immunological advantages, contraindications, and disadvantages of breastfeeding helps the parents to make a decision that is best for the family. Many mothers indicate that if they had had adequate information, they would have chosen to breastfeed.1 • Promote peer counseling for teen mothers. Provides positive role model teen can relate to and feel comfortable with discussing concerns and feelings.6

Intervention for ND of disabled family coping

NURSING PRIORITY NO. 2 To provide assistance to enable family to deal with the current situation: • Establish rapport with family members who are available. Promotes therapeutic relationship and support for problem-solving solutions.1 • Acknowledge difficulty of the situation for the family. Communicates understanding of family's feelings and can reduce blaming and guilt feelings.2 • Active-listen to concerns, note both overconcern and lack of concern. Identifies accuracy of client's information and measure of concern, which may interfere with ability to resolve situation.2 • Allow free expression of feelings, including frustration, anger, hostility, and hopelessness, while placing limits on acting out or inappropriate behaviors. Provides opportunity to identify accuracy and validate appropriateness of feelings. Limits or minimizes risk of violent behavior.4 • Give accurate information to SO(s) from the beginning. Establishes trust and promotes opportunity for clarification and correction of misunderstandings.4 • Act as liaison between family and healthcare providers. Establishes single contact to provide explanations and clarify treatment plan, enhancing reliability of information.4 Provide brief, simple explanations about use and alarms when equipment (such as a ventilator) is required. Identify appropriate professional(s) for continued support and problem solving. Having information and ready access to appropriate resources can reduce feelings of helplessness and promote sense of control.1 • Provide time for private interaction between client and family/SO(s). Individuals need to talk about what is happening and process new and frightening information to learn to deal with situation or diagnosis within family relationships.3 • Accompany family when they visit client. Being available for questions, concerns, and support promotes trusting relationship in which family feels free to learn all they can about situation or diagnosis.3 • Assist SO(s) to initiate therapeutic communication with client. Learning to use new methods of communication (active-listening and "I" messages) can enhance relationships and promote effective problem solving for the family.3 • Include SO(s) in the plan of care. Provide instruction and demonstrate necessary skills. Promotes family's ability to provide care and develop a sense of control over difficult situation.4,5 • Refer client to protective services as necessitated by risk of physical harm or neglect. Removing client from home is sometimes necessary to individual safety. May reduce stress on family to allow opportunity for therapeutic intervention.4

Intervention for ND of ineffective breathing pattern

NURSING PRIORITY NO. 2 To provide for relief of causative factors, promoting ease of breathing:6-11 • Assist in treatment of underlying conditions, administering medications and therapies as ordered. • Suction airway to clear secretions as needed. (Refer to ND ineffective Airway Clearance for additional interventions.) • Maintain emergency equipment in readily accessible location and include age- and size-appropriate airway, ET, and tracheostomy tubes (e.g., infant, child, adolescent, adult). • Administer oxygen (by cannula, mask, mechanical ventilation) at lowest concentration needed (per ABGs, pulse oximetry) for underlying pulmonary condition and current respiratory problem.11-13 (Refer to ND impaired Gas Exchange for additional interventions.) • Elevate head of bed or have client sit up in chair; support with pillows to prevent slumping and promote rest, or place in position of comfort, as appropriate, to promote maximal inspiration. • Reposition client frequently to enhance respiratory effort and ventilation of all lung segments, especially if immobility is a factor. • Encourage early ambulation using assistive devices, as individually indicated. Involve client in program of exercise training to prevent onset or reduce severity of respiratory complications and to improve respiratory muscle strength.11 • Direct client in breathing efforts as needed. Encourage slower and deeper respirations and use of the pursed-lip technique, to assist client in "taking control" of the situation, especially when condition is associated with anxiety and air hunger. • Coach client in effective coughing techniques. Place in appropriate position for clearing airways. Splint rib cage and surgical incisions as appropriate. Medicate for pain, as indicated. Promotes more effective breathing and airway management, especially when client is guarding, as might occur with chest, rib cage, or abdominal injuries or surgeries. (Refer to NDs acute Pain; chronic Pain for additional interventions.) • Provide and assist with use of respiratory therapy adjuncts. • Maintain calm attitude while working with client/significant others (SOs). Provide quiet environment, instruct and reinforce client in the use of relaxation techniques, and administer anti-anxiety medications as indicated to reduce intensity of anxiety and deal with fear that may be present. (Refer to NDs Fear; Anxiety for additional interventions.) • Avoid overfeeding, such as might occur with young infant or client on tube feedings. Abdominal distention can interfere with breathing as well as increase the risk of aspiration. • Ascertain that client possesses and properly operates continuous positive airway pressure machine when obstructive sleep apnea is causing breathing problems. • Maintain emergency equipment in readily accessible location and include age/size-appropriate ET/tracheostomy tubes (e.g., infant, child, adolescent, adult) when ventilatory support might be needed. • Assist with bronchoscopy or chest tube insertion as indicated.

Interventions for risk for chronic functional constipation

NURSING PRIORITY NO. 3 To facilitate normal bowel function: • Promote healthy lifestyle for elimination:1-10 Encourage balanced fiber and bulk (e.g., fruits, vegetables, whole grains) in diet and fiber supplements (e.g., wheat bran, psyllium) to promote soft consistency of stool and facilitate passage through colon. Promote adequate fluid intake, including water, high-fiber fruit and vegetable juices, fruit/vegetable smoothies, and popsicles. Suggest drinking warm, stimulating fluids (e.g., decaffeinated coffee, hot water, tea) to avoid dehydration; promote moist, soft feces; and facilitate passage of stool. Encourage daily activity and exercise within limits of individual ability to stimulate contractions of the intestines. Encourage client to not ignore urge. Provide privacy and routinely scheduled time for defecation (bathroom or commode preferable to bedpan) to promote psychological readiness and comfort.

Intervention for ND of constipation

NURSING PRIORITY NO. 4 To facilitate return to usual/acceptable pattern of elimination: • Promote lifestyle changes.1-8 Limit foods with little or no fiber or diet high in fats (e.g., ice cream, cheese, meats, fast foods, processed foods). Note: Clients with descending or sigmoid colostomy must avoid constipation. Some may find it helpful to create their own dietary bulk laxative by combining unprocessed millers bran, applesauce, and prune juice. Promote adequate fluid intake, including water, high-fiber fruit and vegetable juices, fruit/vegetable smoothies, and popsicles. Suggest drinking warm, stimulating fluids (e.g., decaffeinated coffee, hot water, tea) to avoid dehydration; promote moist, soft feces; and facilitate passage of stool. Encourage daily activity and exercise within limits of individual ability to stimulate contractions of the intestines. Encourage client to not ignore urge. Provide privacy and routinely scheduled time for defecation (bathroom or commode preferable to bedpan) to promote psychological readiness and comfort. • Provide sitz bath before stools to relax sphincter and after stools for cleansing and soothing effect to rectal area.4 • Review client's current medication regime with physician to determine if drugs contributing to constipation can be discontinued or changed. • Administer stool softeners (to provide moisture to stool), mild stimulants (to cause rhythmic contractions of the bowel), lubricants (to enable stool to more easily pass), saline or hyperosmolar laxatives, or bulk-forming agents (to draw water into colon) as ordered or routinely, when appropriate (e.g., for client receiving opiates, decreased level of activity/immobility).1-3,5-8 • Apply lubricant/anesthetic ointment to anus, if needed. • Establish bowel program to include predictable interval timing for colostomy irrigation or toileting, use of particular position for defecation, abdominal massage, colostomy irrigation, biofeedback for pelvic floor dysfunction, and medications as indicated to provide predictable and effective elimination and reduce evacuation problems when long-term or permanent bowel dysfunction is present.

Intervention for ND of Ineffective activity planning

• Encourage expression of feelings contributing to or resulting from situation. Maintain a positive atmosphere without seeming overly cheerful. Helps client to begin to be aware of frustration and redirect energy into productive actions.5 • Discuss client's perception of self as worthless and not deserving of success and happiness. This belief is common among individuals who struggle with feelings of low self-esteem/self-confidence. They believe that anything they do is bound to fail, and feelings of anxiety and worry contribute to failure. Procrastinating and postponing the task results in failure. Sometimes the underlying feelings are those of wanting to be perfect, and the task may not be perfect if it is finished.4,8 • Gently confront ambivalent, angry, or depressed feelings. Client may react negatively and withdraw if these feelings are not dealt with in a sensitive manner.1 • Help client learn how to reframe negative thoughts about self into a positive view of what is happening. Reframing turns a negative thought into something positive to change how it affects the individual.1 • Involve client/significant others (SOs) in planning an activity. Having the support of the family and nurse will help promote success.1 • Direct client to start with one desired or needed activity and to break it down into specific steps. Makes activity more manageable, and as each step is accomplished, individual feels more confident about ability to finish the task.1 • Encourage client to recognize procrastinating behaviors and make a decision to change. Procrastination is a learned behavior, possibly in the family of origin, and serves many purposes for the individual. It can be changed but requires motivation and strong desire.3,8,9 • Accompany client to activity of own choosing, encouraging participation together, if appropriate. Support from caregiver may enable client to begin participating and gain confidence.1,9 • Assist client to develop skills of relaxation, imagery or visualization, and mindfulness. Using these techniques can help the client learn to overcome stress and be able to manage life's difficulties more effectively.2,6 • Assist client to investigate the idea that seeking pleasure (hedonism) is interfering with motivation to accomplish goals. Some philosophers believe that pleasure is the only good for a person, and the individual does not see other aspects of life, interfering with accomplishments.7

Intervention for ND of risk for ineffective activity planning

• Encourage recognition of feelings associated with issues that prevent client from planning desired activities. Awareness of frustration and/or anxiety will help client redirect energy into productive activities.5,10 • Help client to reframe negative thoughts about self into a positive view of what he/she is able to achieve. The belief that individuals are worthless and not deserving of success and happiness is prevalent among many people who are anxious, leading to the belief that anything tried is doomed to failure.2,5,6,14 • Encourage client to recognize procrastinating behaviors and make a decision to change. Often this learned behavior comes from the family of origin. A decision to change may require therapy to change the ingrained habit.5,11,13 • Develop a plan with the client to deal with activities in small steps. Learning to do this will help client to feel more organized and successful in completing the desired task.4,5,12 • Encourage client to engage in activity of choice with a friend, family member. Support may encourage client to pursue activity and be successful at completion.1 • Investigate with the client the possibility that seeking pleasure (hedonism) may interfere with achieving life goals. Individual may believe that pleasure is the only good and avoid tasks or activities viewed as not fun or pleasurable, thereby interfering with accomplishments.7

Intervention for ND of Risk for activity intolerance

• Implement physical therapy or exercise program in conjunction with the client and other team members, such as a physical and/or occupational therapist, exercise or rehabilitation physiologist. Collaborative program with short- and long-term achievable goals enhances likelihood of success and may motivate client to adopt a lifestyle of physical exercise for enhancement of health.2 • Promote or implement progressive conditioning program and support inclusion in exercise or activity groups to prevent or limit effects of deconditioning. Instruct client in energy-conserving activities and benefits of alternating activity and rest periods while continuing activities. Note: studies continue to support the positive effects of exercise training on exercise [activity] tolerance.6,7 • Instruct client in proper performance of unfamiliar activities and/or alternate ways of doing familiar activities to learn methods of conserving energy and promote safety in performing activities.

Intervention for ND of risk for autonomic dysreflexia

• Monitor vital signs routinely, noting changes in blood pressure, heart rate, and temperature, especially during times of physical stress to identify trends and intervene in a timely manner.1,2 Note: The baseline blood pressure in spinal cord-injured clients (adult and child) is lower than in the general population; therefore, an elevation of 20 to 40 mmHg above baseline may be indicative of autonomic dysreflexia (AD).5,6 • Instruct all caregivers in regularly timed elimination and safe bowel and bladder or catheter care, as well as in interventions for long-term prevention of skin stress or breakdown (e.g., appropriate padding for skin and tissues, proper positioning with frequent pressure-relief actions, routine foot and toenail care) to reduce risk of AD episode. Note: The two most common inciting stimuli are bladder and bowel distention, respectively; commonly a blocked urinary catheter.1,3,4,6 • Instruct client/caregivers in additional preventive interventions (e.g., temperature control; preventing pressure ulcers, blisters, ingrown toenails; checking frequently for tight clothes or leg straps; sunburn and other burn prevention).1,4-6 • Administer antihypertensive medications, as indicated. At-risk client may be placed on routine "maintenance dose," such as when noxious stimuli cannot be removed (e.g., presence of chronic sacral pressure ulcer, fracture, acute postoperative pain).1 • Refer to ND Autonomic Dysreflexia.