Extended Care

EXTENDED CARE Patients in the acute care setting may be discharged to an extended-care facility. Patients requiring relatively shortterm rehabilitation and those needing long-term care/permanent nursing care are included in this group. The level of care and needs of the patient (e.g., physical, occupational, rehabilitation therapy; IV and respiratory support) are frequently the deciding factors in the choice of placement. Additionally, visual impairments, memory/mental impairment, and physical immobility lead to a loss of independence for many individuals. Although elderly people are the primary population in extended-care facilities, increasing numbers of younger individuals are requiring care for debilitating conditions when they cannot be managed in the home setting.

RELATED CONCERNS AIDS Cancer Cerebrovascular accident (CVA)/ stroke Craniocerebral trauma (acute rehabilitative phase) End of life/hospice care Multiple sclerosis Psychosocial aspects of care Spinal cord injury (acute rehabilitative phase) Surgical intervention Ventilatory assistance (mechanical)

Patient Assessment Database Data depend on underlying physical/psychosocial conditions necessitating continuation of structured care.

TEACHING/LEARNING Discharge plan considerations:

Projected mean length of stay:Depends on underlying disease/condition and individual care needs. Therefore, this may be a temporary or permanent placement. May require assistance with treatments, self-care activities, homemaker/maintenance tasks, or alternative living arrangements (e.g., group home) Refer to section at end of plan for postdischarge considerations.

DIAGNOSTIC STUDIES (DEPENDENT ON AGE, GENERAL HEALTH, AND MEDICAL CONDITION) CBC: Reveals problems such as infection, anemia, other abnormalities. Chemistry profile: Evaluates general organ function/imbalances. Age-related changes include decreased serum albumin, up to 20% increase in alkaline phosphatase, decreased urine creatinine clearance. Urinalysis: Provides information about kidney function; determines presence of UTI or DM. Note: Bacteria is common in some populations, especially the elderly and bedridden, reflecting urinary stasis. Pulse oximetry: Determines oxygenation, respiratory function. Communicable disease screens: To rule out tuberculosis (TB), HIV, venereal disease, hepatitis. Drug screen: As indicated by usage to identify therapeutic or toxic levels. Visual acuity testing: Identifies cataracts/other vision problems. Tonometer test: Measures intraocular pressure. Chest x-ray: Reveals size of heart, lung abnormalities/disease conditions, changes of the large blood vessels and bony structure of the chest. ECG: Provides baseline data; detects abnormalities, e.g., ST-segment and T-wave changes, atrial and ventricular dysrhythmias, and various heart blocks are common in the elderly.

NURSING PRIORITIES 1. 2. 3. 4.

Promote physiological and psychological well-being. Provide for security and safety. Prevent complications of disease and/or aging process. Promote effective coping skills and independence.

5. Encourage continuation of healthy habits, participation in plan of care to meet individual needs and wishes.

DISCHARGE GOALS 1. 2. 3. 4. 5. 6.

Patient dealing realistically with current situation. Homeostasis maintained. Injury prevented. Complications prevented/minimized. Patient meeting ADLs by self/with assistance as necessary. Plan in place to meet needs after discharge as appropriate.

NURSING DIAGNOSIS: Anxiety [specify level]/Fear May be related to Change in health status, role functioning, interaction patterns, socioeconomic status, environment Unmet needs; recent life changes, loss of friends/SO Possibly evidenced by Apprehension, restlessness, repetitive questioning; pacing, purposeless activity; insomnia Various behaviors (appears overexcited, withdrawn, worried, fearful); presence of facial tension, trembling, hand tremors Expressed concern regarding changes in life events Focus on self; lack of interest in activity DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Anxiety [or] Fear Control (NOC) Verbalize understanding of reasons for change, as able. Demonstrate appropriate range of feelings and lessened fear. Participate in routine and special/social events as capable. Verbalize acceptance of situation.

ACTIONS/INTERVENTIONS

RATIONALE

Anxiety Reduction (NIC)

Independent Provide patient/SO with a copy of A Patient’s Bill of Rights and review it with them. Discuss facility’s rules, e.g., visitors, off-grounds visits, personal property.

Provides information that can foster confidence that individual rights do continue in this setting and patient is still “his or her own person” and has some control over what happens.

Ascertain whether patient has completed Advance Directives. Provide information as appropriate.

Ensures patient/family wishes will be known to provide direction to caregivers.

Determine patient/SO attitude toward admission to facility and expectations for the future.

If this is expected to be a temporary placement, patient/SO concerns will be different than if placement is permanent. When patient is giving up own home and way of life, feelings of helplessness, loss, and grief are to be expected.

ACTIONS/INTERVENTIONS

RATIONALE

Anxiety Reduction (NIC)

Independent Help family/SO to be honest with patient regarding admission. Be clear about actions/events.

Family may have difficulty dealing with decision/reality of permanent placement and may avoid discussing situation with patient. Honesty decreases “surprises,” assists in maintaining trust, and may enhance coping.

Identify support person(s) important to patient and include in care activities, mealtime, and so on, as appropriate.

During adjustment period/times of stress, patient may benefit from presence of trusted individual who can provide reassurance and reduce sense of isolation.

Assess level of anxiety and discuss reasons when possible.

Identifying specific problems enables individual to deal more realistically with them and care provider to intervene as necessary, e.g., patient who is being neglected or abused or has unrelieved pain may be very anxious and afraid or unable to verbalize.

Develop nurse-patient relationship.

Trusting relationships among patient/SO/staff promote optimal care and support.

Make time to listen to patient about concerns, and encourage free expression of feelings, e.g., anger, hostility, fear, and loneliness.

Being available in this way allows patient to feel accepted, begin to acknowledge and deal with feelings related to circumstances of admission.

Acknowledge reality of situation and feelings of patient. Accept expressions of anger while limiting aggressive, acting-out behavior.

Permission to express feelings allows for beginning resolution. Acceptance promotes sense of self-worth. Note: Psychosocial and/or physiological disturbances can occur as a result of transfer from one environment to another (i.e., relocation stress syndrome).

Identify strengths and successful coping behaviors and incorporate into problem solving.

Building on past successes increases likelihood of positive outcome in present situation. Enhances sense of control and management of current deficits.

Orient to physical aspects of facility, schedules, and activities. Introduce to roommate(s) and staff. Give explanation of roles.

Getting acquainted is an important part of admission. Knowledge of where things are and who patient can expect assistance from can be helpful in reducing anxiety.

Determine patient’s usual schedule and incorporate into facility routine as much as possible.

Consistency provides reassurance and may lessen confusion and enhance cooperation.

Provide information in written or taped form as well.

Overload of information is difficult to process. Patient can refer to written or taped material as needed to refresh memory/learn new information.

Give careful thought to room placement. Provide help and encouragement in placing patient’s own belongings around room. Do not transfer from one room to another without patient approval/documentable need.

Location, roommate compatibility, and place for personal belongings are important considerations for helping patient feel “at home.” Changes are often met with resistance and can result in emotional upset and decline in physical condition. Note: Persons with severe behavioral problems/cognitive dysfunctions may require a private room.

ACTIONS/INTERVENTIONS

RATIONALE

Anxiety Reduction (NIC)

Independent Note behavior, presence of suspiciousness/paranoia, irritability, defensiveness. Compare with SO’s description of customary responses.

Increased stress, physical discomfort, and fatigue may temporarily exacerbate mental deterioration (cognitive inaccessibility) and further impair communication (social inaccessibility). This represents a catastrophic episode that can escalate into a panic state and violence.

Be aware of escalating anxiety, presence of delirium. Look for possible causes.

Common causes of delirium include drug toxicity, electrolyte imbalances, withdrawal states (alcohol, other drugs), pain/trauma (especially hip fractures), and advanced disease resulting in organ failure.

Collaborative Refer to social service or other appropriate agency for assistance. Have case manager/social worker discuss ramifications of Medicare/Medicaid if patient is eligible for these resources.

Often patient is not aware of the resources available, and providing current information about individual coverage/limitations and other possible sources of support will assist with adjustment to new situation.

NURSING DIAGNOSIS: Grieving, anticipatory May be related to Perceived, actual, or potential loss of physiopsychosocial well-being, personal possessions, or SO; cultural beliefs about aging/debilitation Possibly evidenced by Denial of feelings, depression, sorrow, guilt Alterations in the activity level, sleep patterns, eating habits, libido DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Grief Resolution (NOC) Identify and express feelings appropriately. Progress through the grieving process. Enjoy the present and plan for the future, one day at a time.

ACTIONS/INTERVENTIONS

RATIONALE

Grief Work Facilitation (NIC)

Independent Assess emotional state. Note cultural beliefs, expectations.

Anxiety and depression are common reactions to changes/losses associated with long-term illness or debilitating condition. In addition, changes in neurotransmitter levels (e.g., increased monoamine oxidase [MAO] and serotonin levels with decreased norepinephrine) may potentiate depression in elderly patients. Personal expectations may affect response to change.

Make time to listen to patient. Encourage free expression of hopeless feelings and desire to die.

It is more helpful to allow these feelings to be expressed and dealt with than to deny or ignore them.

Assess suicidal potential.

May be related to physical disease, social isolation, and grief. Note: Studies indicate women are three times as likely to attempt suicide; however, men are three times as likely to succeed.

Involve SO in discussions and activities to the level of their willingness.

When SOs are involved, there is more potential for successful problem solving. Note: SO may not be available or may not choose to be involved.

Provide liberal touching/hugs as individually accepted.

Conveys sense of concern/closeness to reduce feelings of isolation and enhance sense of self-worth. Note: Touch may be viewed as a threat by some patients and escalate feelings of agitation/anger.

Identify spiritual concerns. Discuss available resources and encourage participation in religious activities as appropriate.

Search for meaning is common to those facing changes in life. Participation in religious/spiritual activities can provide sense of direction and peace of mind.

Assist with/plan for specifics as necessary (e.g., Advance Directives to determine code status/Living Will wishes, making of will, funeral arrangements if appropriate).

Having these issues resolved can help patient/SO deal with the grieving process and may provide peace of mind.

Collaborative Refer to other resources as indicated, e.g., psychiatric clinical nurse specialist, case manager/social worker, spiritual advisor.

May need further assistance to resolve some problems.

NURSING DIAGNOSIS: Thought Processes, disturbed May be related to Physiological changes of aging, loss of cells/brain atrophy, decreased blood supply, altered sensory input Pain; effects of medications Psychological conflicts: disrupted life pattern Possibly evidenced by Slower reaction times, gradual memory loss, altered attention span; disorientation; inability to follow Altered sleep patterns Personality changes DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Cognitive Ability (NOC) Maintain usual reality orientation. Risk Control (NOC) Recognize changes in thinking and behavior. Identify interventions to deal effectively with situation/deficits.

ACTIONS/INTERVENTIONS

RATIONALE

Cognitive Stimulation (NIC)

Independent Allow adequate time for patient to respond to questions/ comments and to make decisions.

Reaction time may be slowed with aging (changes in metabolism/cerebral blood flow) or with brain injuries and some neuromuscular conditions.

Discuss happenings of the past. Place familiar objects in room. Encourage the display of photographs/photo albums, frequent visits from SO/friends.

Events of the past may be more readily recalled by the elderly patient, because long-term memory usually remains intact. Reminiscence/life review and companionship are beneficial to patients.

Note presence of short-term memory loss, and provide with aids (e.g., calendars, clocks, room signs, pictures) to assist in continual reorientation.

Short-term memory loss presents a challenge for nursing care, especially if patient cannot remember such things as how to use the call bell or how to get to the bathroom. This problem is not in patient’s control but may be less frustrating if simple reminders are used. It may be helpful for older person (and family) to know that short-term memory loss is common and is not necessarily a sign of “senility.”

Evaluate individual stress level and deal with it appropriately.

Stress level may be greatly increased because of recent losses, e.g., poor health, death of spouse/companion, loss of home. In addition, some conflicts that occur with age come from previously unresolved problems that may need to be dealt with now.

ACTIONS/INTERVENTIONS

RATIONALE

Cognitive Stimulation (NIC)

Independent Assess physical status/psychiatric symptoms. Institute interventions appropriate to findings.

Not all mental changes are the result of aging, and it is important to rule out physical causes before accepting these as unchangeable. May be pain (often unreported/underestimated), metabolic, toxic, druginduced (e.g., antiparkinson agents, tricyclic antidepressants), or the result of infectious, cardiac, or respiratory disorders.

Reorient to person/place and time as appropriate.

Helps patient maintain focus.

Have patient repeat verbal/written instructions.

Verifies hearing/ability to read and comprehend.

Note cyclic changes in mentation/behavior, e.g., evening confusion, picking at bedclothes, banging on side rails, pacing, shouting, wandering aimlessly.

“Sundowner syndrome” may occur in response to visual/hearing deficits enhanced by declining light, fatigue, inflexible institution schedules, peak/trough drug levels, dehydration, and electrolyte imbalances.

Involve in regular exercise, activity, and diversional programs.

Promotes release of endorphins, enhancing sense of wellbeing, and can improve thinking abilities. Note: Studies suggest withdrawn and inactive patients are at greater risk of evening confusion.

Schedule at least one rest period per day.

Prevents fatigue; enhances general well-being.

Provide brighter lighting in room/area by midafternoon (e.g., 3 PM) or earlier on cloudy/winter days.

Maximizes visual perception; may limit evening confusion.

Turn off lights at bedtime. Provide night-lights where appropriate.

Reinforces “sleep time” while meeting safety needs.

Support patient’s involvement in own care. Provide opportunity for choices on a daily basis.

Choice is a necessary component in everyday life. Cognitively impaired patients may respond with aggressive behavior as they lose control in their lives.

Collaborative Review results of laboratory/diagnostic tests, e.g., electrolytes, thyroid studies, rapid plasma reagin (RPR), full drug screen, computed tomography (CT) scan.

Aids in establishing cause of changes in mentation and determining treatment options. Note: The latter four tests can identify the causes of dementia in 90% of cases.

Administer medications as indicated, e.g., tacrine (Cognex), donepezil (Aricept).

These drugs may fight dementia by blocking chemical breakdown of acetylcholine and improving cholinergic function. Aricept has been shown to improve intellectual ability and daily functioning in mild to moderate Alzheimer’s disease (as assessed by Alzheimer’s Disease Assessment Scale [ADAS-Cog]).

NURSING DIAGNOSIS: Family Coping, ineffective: compromised May be related to Placement of family member in extended-care facility Temporary family disorganization and role changes Situational/transitional crises SO may be facing Patient providing little support for SO Prolonged disease or disability progression that exhausts the supportive capacity of SOs Possibly evidenced by SO describes significant preoccupation with personal reactions, e.g., fear, anticipatory grief, guilt, anxiety SO attempts assistive/supportive behaviors with unsatisfactory results SO withdraws from patient SO displays protective behavior disproportionate (too little or too much) to patient’s abilities/need for autonomy DESIRED OUTCOMES/EVALUATION CRITERIA—FAMILY WILL: Family Coping (NOC) Identify/verbalize resources within themselves to deal with the situation. Interact appropriately with patient and staff, providing support and assistance as indicated. Verbalize knowledge and understanding of situation.

ACTIONS/INTERVENTIONS

RATIONALE

Family Support (NIC)

Independent Introduce staff and provide SO with information about facility and care. Be available for questions. Provide tour of facility.

Helpful to establish beginning relationships. Offers opportunities for enhancing feelings of involvement.

Determine involvement and availability of family/SO.

Clarifies expectations and abilities, identifies needs.

Encourage SO participation in care at level of desire and capability and within limits of safety. Include in social events/celebrations.

Helps family to feel at ease and allows them to feel supportive and a part of patient’s life.

Accept choices of SO regarding level of involvement in care.

Families may choose to ignore patient or may project feelings of guilt regarding placing patient in facility by criticizing staff. Note: Feelings of dissatisfaction with the staff may be transferred back to patient.

Evaluate SO’s/caregiver’s level of stress/coping abilities, especially before planning for discharge.

Caring for/about patients with chronic/debilitating conditions places a heavy strain on SO. Although support groups may be very helpful, learning stress management techniques may be more effective in strengthening individual coping as the focus is on the SO rather than the SO-patient relationship.

Support the caregiver with attention, compassion, time, respect, honesty, advocacy, and understanding.

Nursing interventions need to prepare the caregivers for the challenges they face and meet their needs for compassion and caring.

ACTIONS/INTERVENTIONS

RATIONALE

Family Support (NIC)

Independent Identify availability and use of community support systems.

Helps determine areas of need, and provides information regarding additional resources to enhance coping.

Be aware of caregivers’ own feelings of disapprovaland frustration about patient’s/SO’s choices and goals that differ from those of staff, and deal with appropriately.

Group care conferences or individual counseling may be helpful in problem solving.

Collaborative Inform SO of services available to them (meal tickets, family cooking time, group care conference, visiting nurse, caseworker, social services).

Promotes feeling of involvement; eases transition in adjustment to patient’s admission to home care or facility care.

Advise caregivers of resources available, such as Eldercare Locator, SeniorNet, Today’s Caregiver, Caregiver Network, Inc.

Helps nurses, patients, and caregivers feel supported and able to provide more skillful care.

NURSING DIAGNOSIS: Poisoning, risk for [drug toxicity] Risk factors may include Reduced metabolism; impaired circulation; precarious physiological balance, presence of multiple diseases/organ involvement Use of multiple prescribed/OTC drugs Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Medication Response (NOC) Maintain prescribed drug regimen free of untoward side effects.

ACTIONS/INTERVENTIONS

RATIONALE

Medication Management (NIC)

Independent Determine allergies, medication, and other drug use history.

Helps avoid repetition/creation of problems.

Review resources (e.g., drug manuals, pharmacist) for information about toxic symptoms and side effects. List drug actions and interactions and idiosyncracies, e.g., medications that are given with or without foods, as well as those that should not be crushed.

Provides information about drugs being taken and identifies possible interactions. Toxicity can be increased in the debilitated and older patient with symptoms not as apparent.

ACTIONS/INTERVENTIONS

RATIONALE

Medication Management (NIC)

Independent Discuss self-administration of/access to OTC products.

Limits interference with prescribed regimen/desired drug action and organ function. May prevent inadvertent overdosing/toxic reactions. Note: Appropriate use of OTC products kept at bedside or via free access at nurses’ station fosters independence and enhances sense of control and self-esteem.

Identify swallowing problems or reluctance to take tablets or capsules.

May not be able to or want to take medication.

Give pills in a spoonful of soft foods, e.g., applesauce, ice cream; or use liquid form of medication if available.

Ensures proper dosage if patient is unable to/does not like to swallow pills.

Open capsules or crush tablets only when appropriate.

Should not be done unless absolutely necessary because this may alter absorption of medications; e.g., entericcoated tablets, when crushed, may be absorbed in stomach instead of the intestines.

Make sure medication has been swallowed.

Ensures effective therapeutic use of medication and prevents pill hoarding.

Observe for changes in condition/behavior.

Behavior may be only indication of drug toxicity, and early identification of problems provides for appropriate intervention. Note: Elderly individuals have increased sensitivity to anticholinergic effects of medications; therefore, use of anticholinergics, antiparkinson agents, benzodiazepines, CNS depressants, and tricyclic antidepressants may cause delirium/confusion.

Use discretion in the administration of sedatives.

A quiet place where patient can pace, or seclusion, may be more helpful. If patient is destructive or excessively disruptive, pharmacological or mechanical control measures may be required. Convenience of the staff is never a reason for sedating patient; however, patient safety and rights of other patients need to be taken into consideration.

Collaborative Review drug regimen routinely with physician and pharmacist.

Provides opportunity to alter therapy (e.g., reduce dosage, discontinue medications) as patient’s needs and organ functions change.

Obtain serum drug levels as indicated.

Determines therapeutic/toxicity levels.

NURSING DIAGNOSIS: Communication, impaired verbal May be related to Degenerative changes (e.g., reduced cerebral circulation, hearing loss); progressive neurological disease (e.g., Parkinson’s disease, Alzheimer’s disease) Laryngectomy/tracheostomy; stroke, traumatic brain injury Possibly evidenced by Impaired articulation; difficulty with phonation; inability to modulate speech, find words, name, or identify objects (aphasia, dysarthria) Diminished hearing ability DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Communication Ability (NOC) Establish method of communication by which needs can be expressed. Demonstrate congruent verbal and nonverbal communication.

ACTIONS/INTERVENTIONS

RATIONALE

Communication Enhancement: Speech Deficit (NIC)

Independent Assess reason for lack of communication, including CNS and neuromuscular functioning, gag/swallow reflexes, hearing, teeth/mouth problems.

Identification of the problem is essential to appropriate intervention. Sometimes patients do not want to talk, may think they talk when they do not, may expect others to know what they want, may not be able to comprehend or be understood.

Determine whether patient is bilingual or whether English is primary language.

With declining cerebral function/diminished thought processes, increased level of stress, patient may mix languages/revert to original language.

Investigate how SO communicates with patient.

Provide opportunity to develop/continue effective communication patterns, which have already been established.

Assess patient knowledge base and level of comprehension. Treat patient as an adult, avoiding pity and impatience.

Knowing how much to expect of patient can help to avoid frustration and unreasonable demands for performance. However, having an expectation that patient will understand may help raise level of performance.

Establish therapeutic nurse-patient relationship through Active-Listening, being available for problem solving.

Aids in dealing with communication problems.

Make patient aware of presence when entering the room by speaking, turning a light off and on/touching patient or mattress as appropriate.

Getting attention is the first step in communication.

Make eye contact, place self at or below patient’s level, and speak face to face.

Conveys interest and promotes contact.

ACTIONS/INTERVENTIONS

RATIONALE

Communication Enhancement: Speech Deficit (NIC)

Independent Speak slowly and distinctly, using simple sentences, yes/no questions. Avoid speaking loudly or shouting. Supplement with written communication when possible/needed. Allow sufficient time for reply; remain relaxed with patient.

Assists in comprehension and overall communication. Patient may respond poorly to high-pitched sounds; shouting also obscures consonants and amplifies vowels.

Use other creative measures to assist in communication, e.g., picture chart/alphabet board, sign language, lip reading when appropriate.

Many options are available, depending on individual situation. Note: Sign language also may be used effectively with other than hearing-impaired individuals.

Communication Enhancement: Hearing Deficit (NIC) Check ears for excess cerumen.

Hardened earwax may decrease hearing acuity and causes tinnitus.

Ascertain whether patient has/uses hearing aid.

Patient may have, but not use, hearing aid (e.g., may not fit well, may need batteries).

Be aware that behavioral problems may be associated with hearing loss.

Anger, explosive temper outbursts, frustration, embarrassment, depression, withdrawal, and paranoia may be attempts to deal with communication problems.

Collaborative Refer to speech therapists; ear, nose, and throat physician; or for audiometry as needed.

May be helpful to patient and staff in improving communication. Determines extent of hearing loss and whether a hearing aid is appropriate. Note: Some sources believe 90% of patients in extended-care facilities have some degree of hearing loss (presbycusis) because this is a common age change. Hearing aids are most effective with conductive losses and may help with sensorineural losses.

NURSING DIAGNOSIS: Sleep Pattern, disturbed May be related to Internal factors: illness, psychological stress, inactivity External factors: environmental changes, facility routines Possibly evidenced by Reports of difficulty in falling asleep/not feeling well-rested Interrupted sleep, awakening earlier than desired Change in behavior/performance, increasing irritability, listlessness DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Sleep (NOC) Report improvement in sleep/rest pattern. Verbalize increased sense of well-being and feeling rested.

ACTIONS/INTERVENTIONS

RATIONALE

Sleep Enhancement (NIC)

Independent Ascertain usual sleep habits and changes that are occurring.

Determines need for action and helps identify appropriate interventions.

Provide comfortable bedding and some of own possessions, e.g., pillow, afghan.

Increases comfort for sleep and physiological/psychological support.

Establish new sleep routine incorporating old pattern and new environment.

When new routine contains as many aspects of old habits as possible, stress and related anxiety may be reduced, enhancing sleep.

Match with roommate who has similar sleep patterns and nocturnal needs.

Decreases likelihood that “night owl” roommate may delay patient’s falling asleep or create interruptions that cause awakening.

Encourage some light physical activity during the day. Make sure patient stops activity several hours before bedtime as individually appropriate.

Daytime activity can help patient expand energy and be ready for nighttime sleep; however, continuation of activity close to bedtime may act as a stimulant, delaying sleep.

Promote bedtime comfort regimens, e.g., warm bath and massage, a glass of warm milk, wine, or brandy at bedtime.

Promotes a relaxing, soothing effect. Note: Milk has soporific qualities, enhancing synthesis of serotonin, a neurotransmitter that helps patient fall asleep faster and sleep longer.

Instruct in relaxation measures.

Helps induce sleep.

Reduce noise and light.

Provides atmosphere conducive to sleep.

Encourage position of comfort, assist in turning as needed.

Repositioning alters areas of pressure and promotes rest.

Place bed in low position, against wall as indicated. Avoid use of side rails. Place mat on floor if appropriate.

Presense of confusion/nighttime disorientation places patient at risk for falls. Side rails pose a safety risk for falls (as when trying to climb out of bed to void) or for entrapment/death. Note: Small grab bar properly installed may facilitate patient getting out of bed.

Avoid interruptions when possible (e.g., awakening for medications or therapies).

Uninterrupted sleep is more restful, and patient may be unable to return to sleep when wakened.

Collaborative Administer sedatives, hypnotics, as indicated.

May be given to help patient sleep/rest during transition period from home to new setting. Note: Avoid habitual use, because these drugs decrease REM (rapid eye movement) sleep time.

NURSING DIAGNOSIS: Nutrition: imbalanced, less/more than body requirements May be related to Impaired dentition; dulling of senses of smell and taste Cognitive limitations, depression Inability to feed self effectively Sedentary activity level Possibly evidenced by Reported/observed dysfunctional eating patterns Weight under/over ideal for height and frame Poor muscle tone, pale conjunctivae/mucous membranes Signs/symptoms of vitamin/protein deficits, electrolyte imbalances DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Nutritional Status (NOC) Maintain normal weight or progress toward weight goal with normalization of laboratory values and be free of signs of malnutrition/obesity. Demonstrate eating patterns/behaviors to maintain appropriate weight.

ACTIONS/INTERVENTIONS

RATIONALE

Nutrition Management (NIC)

Independent Assess causes of weight loss/gain, e.g., dysphagia due to decreased saliva production, neurogenic/psychogenic disturbances, tumors, muscular dysfunction, altered senses of smell and taste, or dysfunctional eating patterns related to depression.

Aids in creating plan of care/choice of interventions. Note: In elderly patients, saliva secretion may be decreased by as much as 66%, taste buds atrophy with reduced sensitivity to sweet and salt.

Check state of patient’s dental health periodically, including fit and condition of dentures, if present.

Oral infections/dental problems, shrinking gums, and loose-fitting dentures decrease patient’s ability to chew.

Weigh on admission and on a regular basis.

Monitors nutritional state and effectiveness of interventions.

Monitor total caloric intake as indicated.

If dietary plan is ineffective in meeting individual goals, calorie count/food diary may help identify problem areas.

Observe condition of skin; note muscle wasting, brittle nails; dry, lifeless hair, and signs of poor healing.

Reflects lack of adequate nutrition.

Evaluate activity pattern.

Extremes of exercise (e.g., sedentary life, continuous pacing) affect caloric needs.

Incorporate favorite foods and maintain as near-normal food consistency as possible, e.g., soft or finely ground food with gravy or liquid added. Avoid baby food whenever possible.

Aids in maintaining intake, especially when mouth and dental problems exist. Baby food is often unpalatable and can decrease appetite and lower self-esteem.

ACTIONS/INTERVENTIONS

RATIONALE

Nutrition Management (NIC)

Independent Encourage the use of spices (other than sodium) to patient’s personal taste.

Reduction in number and acuity of taste buds results in food tasting bland and decreases enjoyment of food and desire to eat.

Provide small, frequent feedings as indicated.

Decreased gastric motility causes patient to feel full and reduces intake.

Serve hot foods hot and cold foods cold.

Foods served at the proper temperature are more palatable, and enjoyment may increase appetite.

Promote a pleasant environment for eating, with company if possible.

Eating is in part a social event, and appetite can improve with increased socialization.

Have healthy snack foods (e.g., cheese, crackers, soup, fruit) available on a 24-hr basis.

Helps meet individual needs and enhances intake within caloric recommendations.

Plan for social events; provide for snacks, even when working to reduce total calories.

Eating is part of socialization, and being able to respond to body’s needs enhances sense of control and willingness to participate in dietary program.

Encourage exercise and activity program within individual ability.

Promotes sense of well-being and may improve appetite.

Collaborative Consult with dietitian.

Aids in establishing specific nutritional program to meet individual patient needs.

Provide balanced diet with individually appropriate protein, complex carbohydrates, and calories. Include supplements between meals as indicated.

Adjustments may be needed to deal with the body’s decreased ability to process protein, as well as decreased metabolic rate and levels of activity. Note: Reduced production of salivary ptyalin inhibits digestion of complex carbohydrates in elderly individuals, affecting dietary plan. In addition, delayed insulin release by the pancreas and reduced peripheral sensitivity to insulin can decrease glucose tolerance.

Administer vitamin/mineral supplements as appropriate.

With age, renal and other regulatory systems cannot compensate as well for errors in intake. Mineral requirements change as hormone levels, metabolism, and GI function change. In addition, absorption can be impaired by medication use and chronic illness.

Refer for dental care routinely and as needed.

Maintenance of oral/dental health and good dentition can enhance intake.

NURSING DIAGNOSIS: Self-Care deficit: (specify) May be related to Depression, discouragement, loss of mobility, general debilitation; perceptual/cognitive impairment Possibly evidenced by Inability to manage ADLs; unkempt appearance DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Self-Care: Activities of Daily Living (ADL) (NOC) Peform self-care activities within level of own ability. Demonstrate techniques/lifestyle changes to meet own needs. Use resources effectively.

ACTIONS/INTERVENTIONS

RATIONALE

Self-Care Assistance (NIC)

Independent Determine current capabilities (0–4 scale) and barriers to participation in care.

Identifies need for/level of interventions required.

Involve patient in formulation of plan of care at level of ability.

Enhances sense of control and aids in cooperation and maintenance of independence.

Encourage self-care. Work with present abilities; do not pressure patient beyond capabilities. Provide adequate time for patient to complete tasks. Have expectation of improvement and assist as needed.

Doing for oneself enhances feeling of self-worth. Failure can produce discouragement and depression.

Provide and promote privacy, including during bathing/ showering.

Modesty may lead to reluctance to participate in care or perform activities in the presence of others.

Use specialized equipment as needed, e.g., tub transfer seat, grab bars, raised toilet seat.

Enhances ability to move/perform activities safely.

Give tub bath, using a two-person or mechanical lift if necessary. Use shower chair and spray attachment, as appropriate. Avoid chilling.

Provides safety for those who cannot get into the tub alone. Shower may be more feasible for some patients, although it may be less beneficial/desirable to patient. Elderly/debilitated patients are more prone to chilling.

Shampoo/style hair as needed. Provide/assist with manicure.

Aids in maintaining appearance. Shampooing may be required more/less frequently than bathing schedule.

Encourage use of barber/beauty salon if patient is able.

Enhances self-image and self-esteem, preserving dignity of patient.

Acquire clothing with modified fasteners as indicated.

Use of Velcro instead of buttons/shoelaces can facilitate process of dressing/undressing.

Encourage/assist with routine mouth/teeth care daily.

Reduces risk of gum disease/tooth loss; promotes proper fitting of dentures.

ACTIONS/INTERVENTIONS

RATIONALE

Self-Care Assistance (NIC)

Collaborative Consult with physical/occupational therapists and rehabilitation specialist.

Useful in establishing exercise/activity program and in identifying assistive devices to meet individual needs/facilitate independence.

NURSING DIAGNOSIS: Skin Integrity, risk for impaired Risk factors may include General debilitation; reduced mobility; changes in skin and muscle mass associated with aging, sensory/motor deficits Altered circulation; edema; poor nutrition Excretions/secretions (bladder and bowel incontinence) Problems with self-care Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Risk Control (NOC) Maintain intact skin. Identify individual risk factors. Demonstrate behaviors/techniques to prevent skin breakdown/facilitate healing.

ACTIONS/INTERVENTIONS

RATIONALE

Skin Surveillance (NIC)

Independent Inspect skin, tissues, and mucous membranes routinely.

Provides opportunity for early intervention in potential high-risk population, who may have thin, less elastic, and more fragile skin and tissues.

Anticipate and use preventive measures in patients who are at risk for skin breakdown, such as anyone who is thin, obese, aging, or debilitated.

Decubitus ulcers are difficult to heal, and prevention is the best treatment.

Assess nutritional status and initiate corrective measures as indicated. Provide balanced diet, e.g., adequate protein, vitamins, and minerals.

A positive nitrogen balance and improved nutritional state can help prevent skin breakdown and promote ulcer healing. Note: May need additional calories and protein if draining ulcer present.

Maintain strict skin hygiene, using mild, nondetergent soap (if any), drying gently and thoroughly, and lubricating with lotion or emollient.

A daily bath is usually not necessary in elderly patients because there is atrophy of sebaceous and sweat glands, and bathing may create dry-skin problems. However, as epidermis thins with age, cleansing and use of lubricants is needed to keep skin soft/pliable and protect susceptible skin from breakdown.

ACTIONS/INTERVENTIONS

RATIONALE

Skin Surveillance (NIC)

Independent Change position frequently in bed and chair. Recommend 10 min of exercise each hr and/or perform passive ROM.

Improves circulation, muscle tone, and joint motion and promotes patient participation.

Use a rotation schedule in turning patient. Use draw/turn sheet. Pay close attention to patient’s comfort level.

Allows for longer periods free of pressure; prevents shearing or tearing motions that can damage fragile tissues. Note: Use of prone position depends on patient tolerance and should be maintained for only a short time.

Massage bony prominences gently with lotion or cream.

Enhances circulation to tissues, increases vascular tone, and reduces tissue edema. Note: Contraindicated if area is pink/red because cellular damage may occur. Gentle massage around area may stimulate circulation to impaired tissues.

Keep sheets and bedclothes clean, dry, and free from wrinkles, crumbs, and other irritating material.

Avoids friction/abrasions of skin.

Use elbow/heel protectors, foam/water or gel pads, sheepskin for positioning in bed and when up in chair.

Reduces risk of tissue abrasions and decreases pressure that can impair cellular blood flow. Promotes circulation of air along skin surface to dissipate heat/moisture.

Provide for safety during ambulation, using appropriate adaptive devices, e.g., walker, cane.

Loss of muscle strength and flexibility and physical disease process/debilitation may result in impaired coordination.

Limit exposure to temperature extremes/use of heating pad or ice pack.

Decreased sensitivity to pain/heat/cold increases risk of tissue trauma.

Examine feet and nails routinely and provide foot and nail care as indicated:

Foot problems are common among patients who are elderly, diabetic, bedfast, and/or debilitated.

Keep nails cut short and smooth;

Jagged, rough nails can cause tissue damage/infection.

Use lotion, softening cream on feet;

Prevents drying/cracking of skin; promotes maintenance of healthy skin.

Check for fissures between toes, swab with hydrogen peroxide or dust with antiseptic powder, and place a wisp of cotton between the toes;

Prevents spread of infection and/or tissue injury.

Rub feet with witch hazel or a mentholated preparation and have patient wear lightweight cotton stockings.

Even though rash may not be present, burning and itching may be a problem. Note: Witch hazel may be contraindicated if skin is dry.

Inspect skin surface/folds (especially when incontinence pad/pants are used) and bony prominences routinely. Increase preventive measures when reddened areas are noticed.

Skin breakdown can occur quickly with potential for infection and necrosis, possibly involving muscle and bone. There is increased risk of redness/irritation around legs as a result of elastic bands in adult diapers/incontinence pads.

ACTIONS/INTERVENTIONS

RATIONALE

Skin Surveillance (NIC)

Independent Continue regimen for redness and irritation when break in skin occurs.

Aggressive measures are important because decubitus ulcers can develop in a matter of a few hours.

Collaborative Observe for decubitus ulcer development, and treat immediately according to protocol.

Timely intervention may prevent extensive damage.

Provide waterbed, alternating pressure/egg-crate or gel mattress, and pad for chair.

Provides protection and improved circulation by decreasing amount of pressure on tissues.

Monitor Hb/Hct and blood glucose levels.

Anemia, dehydration, and elevated glucose levels are factors in skin breakdown and can impair healing.

Refer to podiatrist as indicated.

May need professional care for such problems as ingrown toenails, corns, bony changes, skin/tissue ulceration.

Provide whirlpool treatments as appropriate.

Increases circulation and has a debriding action.

Assist with topical applications; hydrogel dressings; skin barrier dressings (DuoDerm, Opsite); collagenase therapy; absorbable gelatin sponges (Gelfoam); aerosol sprays.

Although there are differing opinions about the efficacy of these agents, individual or combination use may enhance healing. Aids in healing/cellular regeneration.

Administer nutritional supplements and vitamins as indicated. May be needed to close large ulcers. Prepare for/assist with skin grafting. (Refer to CP: Burns, ND: Skin Integrity, impaired.)

NURSING DIAGNOSIS: Urinary Elimination, risk for impaired Rick factors may include Changes in fluid/nutritional pattern Neuromuscular changes Perceptual/cognitive impairment Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Urinary Elimination (NOC) Maintain/regain effective pattern of elimination. Initiate necessary lifestyle changes. Participate in treatment regimen to correct/control situation, e.g., bladder training program or use of indwelling catheter.

ACTIONS/INTERVENTIONS

RATIONALE

Urinary Elimination Management (NIC)

Independent Monitor voiding pattern. Identify possible reasons for changes, e.g., disorientation, neuromuscular impairment, psychotropic medications.

This information is essential to plan for care and influences choice of individual interventions. Nocturia, frequency, and urgency are common because bladder capacity and/or tone is affected. Bladder pelvic muscles and sphincter tone may be affected.

Palpate bladder. Observe for “overflow” voiding; determine frequency and timing of dribbling/voiding.

Bladder distension indicates urinary retention, which may cause incontinence and infection.

Promote fluid intake of 2000–3000 mL/day within cardiac tolerance; include fruit juices, especially cranberry juice. Schedule fluid intake times appropriately.

Maintains adequate hydration and promotes kidney function. Acid-ash juices act as an internal pH acidifier, retarding bacterial growth. Note: Patient may decrease fluid intake in an attempt to control incontinence and become dehydrated. Instead, fluids may be scheduled to decrease frequency of incontinence (e.g., limit fluids after 6 PM to reduce need to void during the night).

Institute bladder program (including scheduled voiding times, Kegel exercise) involving patient and staff in a positive manner.

Regular toileting times may help control incontinence. Program is more apt to be successful when positive attitudes and cooperation are present.

Assist patient to sit upright on bedpan/commode.

Provides functional position for voiding.

Provide/encourage perineal care daily and as needed.

Reduces risk of contamination/ascending infection.

Use adult incontinence pads/pants during day if needed. Keep patient clean and dry. Provide frequent skin care.

When training is unsuccessful, this is the preferred method of management. Note: Using incontinence pads during night allows exposure of skin to air, reducing risk of irritation.

Avoid verbal or nonverbal signs of rejection, disgust, or disapproval over failures.

Expressions of disapproval lower self-esteem and are not helpful to a successful program.

Provide regular catheter care and maintain patency if indwelling catheter is present.

Prevents infection and/or minimizes reflux.

Collaborative Administer medications as indicated, e.g.: Oxybutynin chloride (Ditropan); tolterodine tartrate(Detrol); Vitamin C, methenamine mandelate (Mandelamine).

Promotes bladder sphincter control.

Bladder pH acidifiers retard bacterial growth.

Maintain indwelling catheter/provide intermittent catheterization.

May be used if continence cannot be maintained to prevent skin breakdown and resultant problems.

Irrigate catheter with acetic acid solution, if indicated.

May be done to maintain acid pH and retard bacterial growth.

NURSING DIAGNOSIS: Constipation/Diarrhea, risk for Risk factors may include Changes in/inadequate nutrition or fluid intake; poor muscle tone, change in level of activity Medication side effects Perceptual/cognitive impairment, depression Lack of privacy Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Bowel Elimination (NOC) Establish/maintain normal patterns of bowel functioning. Demonstrate changes in lifestyle as necessitated by risk or contributing factors. Participate in bowel program, as indicated.

ACTIONS/INTERVENTIONS

RATIONALE

Bowel Management (NIC)

Independent Ascertain usual bowel pattern and aids used (e.g., previous long-term laxative use). Compare with current routine.

Determines extent of problem and indicates need for/type of interventions appropriate. Many patients may already be laxative-dependent, and it is important to reestablish as near-normal functioning as possible.

Assess reasons for problems; rule out medical causes, e.g., bowel obstruction, cancer, hemorrhoids, drugs, impaction.

Identification/treatment of underlying medical condition is necessary to achieve optimal bowel function.

Determine presence of food/drug sensitivities.

May contribute to diarrhea.

Institute individualized program of exercise, rest, diet, and bowel retraining.

Depends on the needs of patient. Loss of muscular tone reduces peristalsis or may impair control of rectal sphincter.

Provide diet high in bulk in the form of whole-grain cereals, breads, fresh fruits (especially prunes, plums).

Improves stool consistency, promotes evacuation.

Decrease or eliminate foods such as dairy products.

These foods are known to be constipating.

Encourage increased fluid intake.

Promotes normal stool consistency.

Use adult incontinence pads/pants, if needed. Keep patient clean and dry. Provide frequent perineal care. Apply skin protective ointment to anal area.

Prevents skin breakdown.

Keep air freshener in room/at bedside or in bathroom.

Limits noxious odors and may help reduce patient embarrassment/concern.

ACTIONS/INTERVENTIONS

RATIONALE

Bowel Management (NIC)

Independent Give emotional support to patient. Avoid “blaming” (talk/actions) if incontinence occurs.

Decreases feelings of frustration and embarrassment.

Collaborative Administer medications as indicated: Bulk-providers/stool softeners, e.g., Metamucil;

Camphorated tincture of opium (Paregoric), diphenoxylate with atropine (Lomotil).

Promotes regularity by increasing bulk and/or improving stool consistency. May be needed on a short-term basis when diarrhea persists.

NURSING DIAGNOSIS: Falls, risk for Risk factors may include Presence of arthritis, decreased ROM, difficulty with mobility Use of assistive devices (e.g., walker, cane)/wheelchair Perceptual/cognitive impairments Problems with continence Medication use (e.g., antihypertensives, angiotensin-converting enzyme [ACE] inhibitors, diuretics) Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Safety Behavior: Fall Prevention (NOC) Verbalize understanding of indvidual factors that contribute to possibility of injury. Demonstrate techniques/behaviors to enhance safety and reduce individual risks. Be free of falls/associated injury.

ACTIONS/INTERVENTIONS

RATIONALE

Fall Prevention (NIC)

Independent Determine functional ability (0–4 Functional Level scale), nature of any impairment (physical, cognitive), and perform fall risk screen.

Identifies need for/degree of intervention required.

Plan activities/visits with adequate rest periods as necessary.

Prevents fatigue.

Supervise participation in/assist with self-care, occupational/recreational activities as appropriate. Encourage patient to call for assistance as needed.

Promotes independence and self-esteem, while meeting safety needs.

ACTIONS/INTERVENTIONS Fall Prevention (NIC)

RATIONALE

Independent Provide chairs with firm, high seats and lifting mechanisms when indicated.

Facilitates rising from seated position.

Assist with transfers and ambulation if indicated; show patient/SO ways to move safely.

Prevents accidental falls/injury, especially in patient with altered gait, generalized weakness, orthostatic hypotension, fatigue, and vision disturbances.

Obtain supportive shoes and well-fitting, nonskid slippers.

Assists patient to walk with a firm step/maintain sense of balance, and prevents slipping.

Remove extraneous furniture/scatter rugs from pathways. Avoid clutter on floors.

Prevents patient from bumping into furniture and reduces risk of falling/injuring self.

Encourage use of hand rails in hallway, stairwells, and bathrooms. Keep bed height in low position.

Promotes independence in mobility; reduces risk of falls.

Review safe use of mobility aids/adjunctive devices, e.g., walker, braces, prosthetics.

Facilitates activity, reduces risk of injury.

Provide for environmental changes to meet visual deficiencies.

Prevents accidents and reduces sense of sensory deprivation. If patient is visually impaired, will need assistance and ongoing orientation to surroundings.

Speak to patient when entering the room, and let patient know when leaving.

Special actions help patient who cannot see to know when someone is there.

Encourage patient with eyeglasses/contact lenses to wear them. Be sure eyeglasses are kept clean. Determine reason if eyeglasses are not being worn.

Optimal visual acuity facilitates participation in activities and reduces risk of falls/injury. Patient may not be wearing eyeglasses because they need adjustment or change in correction.

Collaborative Arrange for regular eye examinations.

Identifies development/progression of vision problem (e.g., myopia, hyperopia, presbyopia, astigmatism, cataract and glaucoma, tunnel vision, loss of peripheral fields, blindness) and specific options for care.

Consult with physical/occupational therapists, rehabilitation specialist.

Useful in creating individual exercise/activity program and identifying adjunctive aids. Note: Even in the elderly population, inclusion of moderate weight-lifting in the exercise program can improve bone density and help maintain muscle tone/strength.

NURSING DIAGNOSIS: Diversional Activity, deficient May be related to Environmental lack of diversional activity; long-term care requirements Physical limitations; psychological condition, e.g., depression Possibly evidenced by Statements of boredom, depression, lack of energy Disinterest, lethargy, withdrawn behavior, hostility DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Leisure Participation (NOC) Recognize own response and initiate appropriate coping actions. Engage in satisfying activities within personal limitations.

ACTIONS/INTERVENTIONS

RATIONALE

Activity Therapy (NIC)

Independent Determine avocation/hobbies patient previously pursued. Incorporate activities, if appropriate, into present program.

Encourages involvement and helps stimulate patient mentally/physically to improve overall condition and sense of well-being.

Encourage participation in mix of activities/stimuli, e.g., music, news program, educational presentations, crafts, social interactions, as appropriate.

Offering different activities helps patient try out new ideas and develop new interests. Activities need to be personally meaningful for patient to derive the most enjoyment from them (e.g., talking or Braille books for the blind, closed-caption TV broadcasts for the deaf/hearing impaired).

Provide change of scenery when possible; alter personal environment; encourage trips to shop/participate in local/family events.

Stimulates energy and provides new outlook for patient.

Collaborative Refer to occupational therapist, activity director.

Can introduce and design new programs to provide positive stimuli for patient.

NURSING DIAGNOSIS: Sexuality Patterns, risk for ineffective Risk factors may include Biopsychosocial alteration of sexuality Interference in psychological/physical well-being; self-image Lack of privacy/SO Possibly evidenced by [Not applicable; presence of signs and symptoms establishes an actual diagnosis.] DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT WILL: Sexual Functioning (NOC) Verbalize knowledge and understanding of sexual limitations, difficulties, or changes that have occurred. Demonstrate improved communication and relationship skills. Identify appropriate options to meet needs.

ACTIONS/INTERVENTIONS

RATIONALE

Sexual Counseling (NIC)

Independent Note patient/SO cues regarding sexuality.

May be concerned that condition/environmental restrictions may interfere with sexual function or ability, but is afraid to ask directly.

Determine cultural and religious/value factors and conflicts that may be present.

Affects patient’s perception of existing problems and response of others (e.g., family, staff, other residents). Provides starting point for discussion and problem solving.

Assess developmental and lifestyle issues.

Factors such as menopause and aging, adolescence, and young adulthood need to be taken into consideration with regard to sexual concerns about illness and long-term care.

Provide atmosphere in which discussion of sexuality is encouraged/permitted.

When concerns are identified and discussed, problem solving can occur.

Provide privacy for patient/SO.

Demonstrates acceptance of need for intimacy, and provides opportunity to continue previous patterns of interaction as much as possible.

Collaborative Refer to sex counselor/therapist, family therapy when needed.

May require additional assistance for resolution of problems.

NURSING DIAGNOSIS: Health Maintenance, impaired May be related to Lack of, or significant alteration in, communication skills Complete or partial lack of gross and/or fine motor skills Perceptual/cognitive impairment, lack of ability to make deliberate/thoughtful judgments Lack of material resources Possibly evidenced by Demonstrated lack of knowledge regarding basic health practices Reported/observed inability to take responsibility for meeting basic health needs; impairment of personal support system Demonstrated lack of behaviors adaptive to internal or external environmental changes DESIRED OUTCOMES/EVALUATION CRITERIA—PATIENT/CAREGIVER WILL: Participation: Health Care Decisions (NOC) Verbalize understanding of factors contributing to current situation. Adopt lifestyle changes supporting individual healthcare goals. Assume responsibility for own healthcare needs when possible.

ACTIONS/INTERVENTIONS

RATIONALE

Health Education (NIC)

Independent Assess level of adaptive behavior; knowledge and skills about health maintenance, environment, and safety.

Identifies areas of concern/need and aids in choice of interventions.

Provide information about individual healthcare needs.

Provides knowledge base and encourages participation in decision making.

Develop plan with patient/SO for self-care incorporating existing disabilities adapting and organizing care.

Assists patient/caregiver to maintain and manage desired level of independence when possible.

Maintain adequate hydration and balanced diet with sufficient protein intake.

Promotes general well-being and aids in disease prevention.

Schedule adequate rest with progressive activity program.

Prevents fatigue and enhances general well-being.

Promote good handwashing and personal hygiene. Use aseptic techniques as necessary.

Prevents contamination/cross-contamination, reducing risk of illness/infection.

Protect from exposure to infections; avoid extremes of temperature. Recommend the wearing of masks/other interventions as indicated.

With age, immune protective responses slow down and physiological reactions to temperature extremes may be impaired. As organ function decreases (especially thymus gland) and natural antibodies decline, patients are at increased risk for infection. Staff and/or visitors with colds or other infections may expose patient to these illnesses.

Encourage cessation of smoking.

Smokers are prone to bronchitis and ineffective clearing of secretions.

Encourage reporting of signs/symptoms as they occur.

Provides opportunity for early recognition of developing complications and timely intervention to prevent serious illness.

ACTIONS/INTERVENTIONS

RATIONALE

Health System Guidance (NIC)

Independent Note patient’s previous use of professional services, and continue as appropriate. Include in choice of new healthcare providers as able.

Preserves continuity and promotes independence in meeting own healthcare needs.

Observe for/monitor changes in vital signs, e.g., temperature elevation.

Early identification of onset of illness allows for timely intervention and may prevent serious complications. Note: Elderly persons often display subnormal temperatures, so presence of a low-grade fever may be of serious concern.

Collaborative Identify resources for/administer medications as indicated: Immunizations, e.g., Haemophilus influenzae (flu), pneumonia; Antibiotics.

Reduces risk of acquiring contagious/potentially lifethreatening diseases. May be used prophylactically, depending on individual disease process/risk factors and to treat infections.

Schedule preventive/routine healthcare appointments based on individual needs, e.g., with cardiologist, podiatrist, ophthalmologist, dentist.

Promotes optimal recovery/maintenance of health.

Refer to support services as indicated, e.g., home health agency, durable medical equipment company, Senior Resources, social services, national hospice organization, Alzheimer’s Disease and Related Disorders Association, American Association of Retired Persons [AARP], Center for Health Care Ethics, Choice in Dying, American Bar Association, Commission on Legal Problems of the Elderly, Adult Protective Services; Internet resources

Many community resources are available, and often untapped, to make life and care of the individual easier.

POTENTIAL CONSIDERATIONS following discharge from care facility Refer to plan of care for diagnosis that required admission.