risk for impaired parent/infant/ child Attachment
Taxonomy II: Role Relationships—Class 2 Family Relationships (00058)
[Diagnostic Division: Social Interaction] Submitted 1994
[Diagnostic Division: Social Interaction] Submitted 1994
Definition: Disruption of the interactive process between parent/SO and infant that fosters the development of a protective and nurturing reciprocal relationship
Risk Factors
Inability of parents to meet personal needs
Anxiety associated with the parent role
Substance abuse
Premature infant; ill infant/child who is unable to effectively initiate parental contact due to altered behavioral organization
Separation; physical barriers
Lack of privacy
[Parents who themselves experienced altered attachment]
[Uncertainty of paternity; conception as a result of rape/sexual abuse]
[Difficult pregnancy and/or birth (actual or perceived)]
Inability of parents to meet personal needs
Anxiety associated with the parent role
Substance abuse
Premature infant; ill infant/child who is unable to effectively initiate parental contact due to altered behavioral organization
Separation; physical barriers
Lack of privacy
[Parents who themselves experienced altered attachment]
[Uncertainty of paternity; conception as a result of rape/sexual abuse]
[Difficult pregnancy and/or birth (actual or perceived)]
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes/Evaluation
Criteria—Parent Will:
• Identify and prioritize family strengths and needs.
• Exhibit nurturant and protective behaviors toward child.
• Identify and use resources to meet needs of family members.
• Demonstrate techniques to enhance behavioral organization of the infant/child.
• Engage in mutually satisfying interactions with child.
Criteria—Parent Will:
• Identify and prioritize family strengths and needs.
• Exhibit nurturant and protective behaviors toward child.
• Identify and use resources to meet needs of family members.
• Demonstrate techniques to enhance behavioral organization of the infant/child.
• Engage in mutually satisfying interactions with child.
Actions/Interventions
NURSING PRIORITY NO.1. To identify causative/contributing factors:
• Interview parents, noting their perception of situation, individual concerns.
• Assess parent/child interactions.
• Ascertain availability/use of resources to include extended family, support groups, and financial.
• Evaluate parents’ ability to provide protective environment, participate in reciprocal relationship.
NURSING PRIORITY NO.1. To identify causative/contributing factors:
• Interview parents, noting their perception of situation, individual concerns.
• Assess parent/child interactions.
• Ascertain availability/use of resources to include extended family, support groups, and financial.
• Evaluate parents’ ability to provide protective environment, participate in reciprocal relationship.
NURSING PRIORITY NO.2. To enhance behavioral organization of infant/child:
• Identify infant’s strengths and vulnerabilities. Each child is born with his or her own temperament that affects interactions with caregivers.
• Educate parents regarding child growth and development, addressing parental perceptions. Helps clarify realistic expectations.
• Identify infant’s strengths and vulnerabilities. Each child is born with his or her own temperament that affects interactions with caregivers.
• Educate parents regarding child growth and development, addressing parental perceptions. Helps clarify realistic expectations.
• Assist parents in modifying the environment to provide appropriate stimulation.
• Model caregiving techniques that best support behavioral organization.
• Respond consistently with nurturance to infant/child.
• Model caregiving techniques that best support behavioral organization.
• Respond consistently with nurturance to infant/child.
NURSING PRIORITY NO.3. To enhance best functioning of parents:
• Develop therapeutic nurse-client relationship. Provide a consistently warm, nurturant, and nonjudgmental environment.
• 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.
• Support and guide parents in process of assessing resources.
• Involve parents in activities with the infant/child that they can accomplish successfully. Enhances self-concept.
• Recognize and provide positive feedback for nurturant and protective parenting behaviors. Reinforces continuation of desired behaviors.
• Minimize number of professionals on team with whom parents must have contact to foster trust in relationships.
• Develop therapeutic nurse-client relationship. Provide a consistently warm, nurturant, and nonjudgmental environment.
• 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.
• Support and guide parents in process of assessing resources.
• Involve parents in activities with the infant/child that they can accomplish successfully. Enhances self-concept.
• Recognize and provide positive feedback for nurturant and protective parenting behaviors. Reinforces continuation of desired behaviors.
• Minimize number of professionals on team with whom parents must have contact to foster trust in relationships.
NURSING PRIORITY NO.4. To support parent/child attachment during separation:
• Provide parents with telephone contact as appropriate.
• Establish a routine time for daily phone calls/initiate calls as indicated. Provides sense of consistency and control; allows for planning of other activities.
• Invite parents to use Ronald McDonald House or provide them with a listing of a variety of local accommodations, restaurants when child is hospitalized out of town.
• Arrange for parents to receive photos, progress reports from the child.
• Suggest parents provide a photo and/or audiotape of themselves for the child.
• Consider use of contract with parents to clearly communicate expectations of both family and staff.
• Suggest parents keep a journal of infant/child progress.
• Provide “homelike” environment for situations requiring supervision of visits.
• Provide parents with telephone contact as appropriate.
• Establish a routine time for daily phone calls/initiate calls as indicated. Provides sense of consistency and control; allows for planning of other activities.
• Invite parents to use Ronald McDonald House or provide them with a listing of a variety of local accommodations, restaurants when child is hospitalized out of town.
• Arrange for parents to receive photos, progress reports from the child.
• Suggest parents provide a photo and/or audiotape of themselves for the child.
• Consider use of contract with parents to clearly communicate expectations of both family and staff.
• Suggest parents keep a journal of infant/child progress.
• Provide “homelike” environment for situations requiring supervision of visits.
NURSING PRIORITY NO.5. To promote wellness (Teaching/ Discharge Considerations):
• Refer to addiction counseling/treatment, individual counseling, or family therapies as indicated.
• Identify services for transportation, financial resources, housing, and so forth.
• Develop support systems appropriate to situation (e.g., extended family, friends, social worker).
• Refer to addiction counseling/treatment, individual counseling, or family therapies as indicated.
• Identify services for transportation, financial resources, housing, and so forth.
• Develop support systems appropriate to situation (e.g., extended family, friends, social worker).
• Explore community resources (e.g., church affiliations, volunteer groups, day/respite care).
Documentation Focus
ASSESSMENT/REASSESSMENT
• Identified behaviors of both parents and child.
• Specific risk factors, individual perceptions/concerns.
• Interactions between parent and child.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Parents’/child’s responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible.
• Plan for home visits to support parents and to ensure infant/ child safety and well-being.
• Specific referrals made.
ASSESSMENT/REASSESSMENT
• Identified behaviors of both parents and child.
• Specific risk factors, individual perceptions/concerns.
• Interactions between parent and child.
PLANNING
• Plan of care and who is involved in planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Parents’/child’s responses to interventions/teaching and actions performed.
• Attainment/progress toward desired outcomes.
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible.
• Plan for home visits to support parents and to ensure infant/ child safety and well-being.
• Specific referrals made.
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risk for Aspiration
Taxonomy II: Safety/Protection—Class 2 Physical Injury (00039)
[Diagnostic Division: Respiration]
Submitted 1988
read more : http://nursingscript.blogspot.com/2012/01/risk-for-aspiration.html
[Diagnostic Division: Respiration]
Submitted 1988
read more : http://nursingscript.blogspot.com/2012/01/risk-for-aspiration.html
risk for Aspiration
Definition: At risk for entry of gastrointestinal secretions, oropharyngeal secretions, or [exogenous food] solids or fluids into tracheobronchial passages [due to dysfunction or absence of normal protective mechanisms]
Risk Factors
Reduced level of consciousness
Depressed cough and gag reflexes
Depressed cough and gag reflexes
Impaired swallowing [owing to inability of the epiglottis and true vocal cords to move to close off trachea]
Facial/oral/neck surgery or trauma; wired jaws Situation hindering elevation of upper body [weakness, paralysis]
Incomplete lower esophageal sphincter [hiatal hernia or other esophageal disease affecting stomach valve function], delayed gastric emptying, decreased gastrointestinal motility, increased intragastric pressure, increased gastric residual
Presence of tracheostomy or endotracheal (ET) tube; [inadequate or overinflation of tracheostomy/ET tube cuff]
[Presence of] gastrointestinal tubes; tube feedings/medication administration
Facial/oral/neck surgery or trauma; wired jaws Situation hindering elevation of upper body [weakness, paralysis]
Incomplete lower esophageal sphincter [hiatal hernia or other esophageal disease affecting stomach valve function], delayed gastric emptying, decreased gastrointestinal motility, increased intragastric pressure, increased gastric residual
Presence of tracheostomy or endotracheal (ET) tube; [inadequate or overinflation of tracheostomy/ET tube cuff]
[Presence of] gastrointestinal tubes; tube feedings/medication administration
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Desired Outcomes/Evaluation
Criteria—Client Will:
• Experience no aspiration as evidenced by noiseless respirations, clear breath sounds; clear, odorless secretions.
• Identify causative/risk factors.
• Demonstrate techniques to prevent and/or correct aspiration.
Actions/Interventions
NURSING PRIORITY NO.1. To assess causative/contributing factors:
• Note level of consciousness/awareness of surroundings,cognitive impairment.
• Evaluate presence of neuromuscular weakness, noting muscle groups involved, degree of impairment, and whether they are of an acute or progressive nature (e.g., Guillain-Barré,amyotrophic lateral sclerosis—ALS).
• Assess amount and consistency of respiratory secretions and strength of gag/cough reflex.
• Observe for neck and facial edema, for example, client with head/neck surgery, tracheal/bronchial injury (upper torso burns, inhalation/chemical injury).
• Note administration of enteral feedings, being aware of potential for regurgitation and/or misplacement of tube.
• Ascertain lifestyle habits, for instance, use of alcohol, tobacco, and other CNS-suppressant drugs; can affect awareness and muscles of gag/swallow.
NURSING PRIORITY NO.2. To assist in correcting factors that can lead to aspiration:
• Monitor use of oxygen masks in clients at risk for vomiting. Refrain from using oxygen masks for comatose individuals.
• Keep wire cutters/scissors with client at all times when jaws are wired/banded to facilitate clearing airway in emergency situations.
• Maintain operational suction equipment at bedside/chairside.
• Suction (oral cavity, nose, and ET/tracheostomy tube) as needed to clear secretions. Avoid triggering gag mechanism when performing suction or mouth care.
• Assist with postural drainage to mobilize thickened secretions that may interfere with swallowing.
• Auscultate lung sounds frequently (especially in client who is coughing frequently or not coughing at all; ventilator client being tube-fed) to determine presence of secretions/silent aspiration.
• Elevate client to highest or best possible position for eating and drinking and during tube feedings.
• Feed slowly, instruct client to chew slowly and thoroughly.
• Give semisolid foods; avoid pureed foods (increased risk of aspiration) and mucus-producing foods (milk). Use soft foods that stick together/form a bolus (e.g., casseroles, puddings, stews) to aid swallowing effort.
• Provide very warm or very cold liquids (activates temperature receptors in the mouth that help to stimulate swallowing). Add thickening agent to liquids as appropriate.
• Avoid washing solids down with liquids.
• Ascertain that feeding tube is in correct position. Measure residuals when appropriate to prevent overfeeding. Add food coloring to feeding to identify regurgitation.
• Determine best position for infant/child (e.g., with the head of bed elevated 30 degrees and infant propped on right side after feeding because 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 crush, if appropriate.
• Refer to speech therapist for exercises to strengthen muscles and techniques to enhance swallowing.
NURSING PRIORITY NO.3. To promote wellness (Teaching/ Discharge Considerations):
• Review individual risk/potentiating factors.
• Provide information about the effects of aspiration on the lungs.
• Instruct in safety concerns when feeding oral or tube feeding. Refer to ND impaired Swallowing.
• Train client to suction self or train family members in suction techniques (especially if client has constant or copious oral secretions) to enhance safety/self-sufficiency.
• Instruct individual/family member to avoid/limit activities that increase intra-abdominal pressure (straining, strenuous exercise, tight/constrictive clothing), which may slow digestion/increase risk of regurgitation.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings/conditions that could lead to problems of aspiration.
• Verification of tube placement, observations of physical findings.
PLANNING
• Interventions to prevent aspiration or reduce risk factors and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s responses to interventions/teaching and actions performed.
• Foods/fluids client handles with ease/difficulty.
• Amount/frequency of intake.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions to be taken.
Desired Outcomes/Evaluation
Criteria—Client Will:
• Experience no aspiration as evidenced by noiseless respirations, clear breath sounds; clear, odorless secretions.
• Identify causative/risk factors.
• Demonstrate techniques to prevent and/or correct aspiration.
Actions/Interventions
NURSING PRIORITY NO.1. To assess causative/contributing factors:
• Note level of consciousness/awareness of surroundings,cognitive impairment.
• Evaluate presence of neuromuscular weakness, noting muscle groups involved, degree of impairment, and whether they are of an acute or progressive nature (e.g., Guillain-Barré,amyotrophic lateral sclerosis—ALS).
• Assess amount and consistency of respiratory secretions and strength of gag/cough reflex.
• Observe for neck and facial edema, for example, client with head/neck surgery, tracheal/bronchial injury (upper torso burns, inhalation/chemical injury).
• Note administration of enteral feedings, being aware of potential for regurgitation and/or misplacement of tube.
• Ascertain lifestyle habits, for instance, use of alcohol, tobacco, and other CNS-suppressant drugs; can affect awareness and muscles of gag/swallow.
NURSING PRIORITY NO.2. To assist in correcting factors that can lead to aspiration:
• Monitor use of oxygen masks in clients at risk for vomiting. Refrain from using oxygen masks for comatose individuals.
• Keep wire cutters/scissors with client at all times when jaws are wired/banded to facilitate clearing airway in emergency situations.
• Maintain operational suction equipment at bedside/chairside.
• Suction (oral cavity, nose, and ET/tracheostomy tube) as needed to clear secretions. Avoid triggering gag mechanism when performing suction or mouth care.
• Assist with postural drainage to mobilize thickened secretions that may interfere with swallowing.
• Auscultate lung sounds frequently (especially in client who is coughing frequently or not coughing at all; ventilator client being tube-fed) to determine presence of secretions/silent aspiration.
• Elevate client to highest or best possible position for eating and drinking and during tube feedings.
• Feed slowly, instruct client to chew slowly and thoroughly.
• Give semisolid foods; avoid pureed foods (increased risk of aspiration) and mucus-producing foods (milk). Use soft foods that stick together/form a bolus (e.g., casseroles, puddings, stews) to aid swallowing effort.
• Provide very warm or very cold liquids (activates temperature receptors in the mouth that help to stimulate swallowing). Add thickening agent to liquids as appropriate.
• Avoid washing solids down with liquids.
• Ascertain that feeding tube is in correct position. Measure residuals when appropriate to prevent overfeeding. Add food coloring to feeding to identify regurgitation.
• Determine best position for infant/child (e.g., with the head of bed elevated 30 degrees and infant propped on right side after feeding because 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 crush, if appropriate.
• Refer to speech therapist for exercises to strengthen muscles and techniques to enhance swallowing.
NURSING PRIORITY NO.3. To promote wellness (Teaching/ Discharge Considerations):
• Review individual risk/potentiating factors.
• Provide information about the effects of aspiration on the lungs.
• Instruct in safety concerns when feeding oral or tube feeding. Refer to ND impaired Swallowing.
• Train client to suction self or train family members in suction techniques (especially if client has constant or copious oral secretions) to enhance safety/self-sufficiency.
• Instruct individual/family member to avoid/limit activities that increase intra-abdominal pressure (straining, strenuous exercise, tight/constrictive clothing), which may slow digestion/increase risk of regurgitation.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings/conditions that could lead to problems of aspiration.
• Verification of tube placement, observations of physical findings.
PLANNING
• Interventions to prevent aspiration or reduce risk factors and who is involved in the planning.
• Teaching plan.
IMPLEMENTATION/EVALUATION
• Client’s responses to interventions/teaching and actions performed.
• Foods/fluids client handles with ease/difficulty.
• Amount/frequency of intake.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Long-term needs and who is responsible for actions to be taken.
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death Anxiety
Taxonomy II: Coping/Stress Tolerance—Class 2 Coping Response (00147)
[Diagnostic Division: Ego Integrity]
Submitted 1998
[Diagnostic Division: Ego Integrity]
Submitted 1998
Definition: Apprehension, worry, or fear related to death or dying
Related Factors
To be developed
To be developed
Defining Characteristics
SUBJECTIVE
SUBJECTIVE
Fear of: developing a terminal illness; the process of dying; loss of physical and/or mental abilities when dying; premature death because it prevents the accomplishment of important life goals; leaving family alone after death; delayed demise
Negative death images or unpleasant thoughts about any event related to death or dying; anticipated pain related to dying
Powerlessness over issues related to dying; total loss of control over any aspect of one’s own death
Worrying about: the impact of one’s own death on SOs; being the cause of other’s grief and suffering
Concerns of overworking the caregiver as terminal illness incapacitates self; about meeting one’s creator or feeling doubtful about the existence of God or higher being
Denial of one’s own mortality or impending death
OBJECTIVE
Deep sadness
(Refer to ND anticipatory Grieving.)
Desired Outcomes/Evaluation
Criteria—Client Will:
• Identify and express feelings (e.g., sadness, guilt, fear) freely/effectively.
• Look toward/plan for the future one day at a time.
• Formulate a plan dealing with individual concerns and eventualities of dying.
OBJECTIVE
Deep sadness
(Refer to ND anticipatory Grieving.)
Desired Outcomes/Evaluation
Criteria—Client Will:
• Identify and express feelings (e.g., sadness, guilt, fear) freely/effectively.
• Look toward/plan for the future one day at a time.
• Formulate a plan dealing with individual concerns and eventualities of dying.
Actions/Interventions
NURSING PRIORITY NO.1. To assess causative/contributing factors:
• Determine how client sees self in usual lifestyle role functioning and perception and meaning of anticipated loss to him or her and SO(s).
• Ascertain current knowledge of situation to identify misconceptions, lack of information, other pertinent issues.
• Determine client’s role in family constellation. Observe patterns of communication in family and response of family/ SO to client’s situation and concerns. In addition to identifying areas of need/concern, also reveals strengths useful in addressing the concerns.
• Assess impact of client reports of subjective experiences and past experience with death (or exposure to death); for example, witnessed violent death or as a child viewed body in casket, and so on.
• Identify cultural factors/expectations and impact on current situation/feelings.
• Note physical/mental condition, complexity of therapeutic regimen.
• Determine ability to manage own self-care, end-of-life and other affairs, awareness/use of available resources.
• Observe behavior indicative of the level of anxiety present (mild to panic) as it affects client’s/SO’s ability to process information/participate in activities.
• Identify coping skills currently used and how effective they are. Be aware of defense mechanisms being used by the client.
• Note use of drugs (including alcohol), presence of insomnia, excessive sleeping, avoidance of interactions with others.
• Note client’s religious/spiritual orientation, involvement in religious/church activities, presence of conflicts regarding spiritual beliefs.
• Listen to client/SO reports/expressions of anger/concern, alienation from God, belief that impending death is a punishment for wrongdoing, and so on.
• Determine sense of futility, feelings of hopelessness, helplessness, lack of motivation to help self.May indicate presence of depression and need for intervention.
• Active-listen comments regarding sense of isolation.
• Listen for expressions of inability to find meaning in life or suicidal ideation.
NURSING PRIORITY NO.2. To assist client to deal with situation:
• Provide open and trusting relationship.
• Use therapeutic communication skills of Active-listening, silence, acknowledgment. Respect client desire/request not to talk. Provide hope within parameters of the individual situation.
• Encourage expressions of feelings (anger, fear, sadness, etc.). Acknowledge anxiety/fear. Do not deny or reassure client that everything will be all right. Be honest when answering questions/providing information. Enhances trust and therapeutic relationship.
• Provide information about normalcy of feelings and individual grief reaction.
• Make time for nonjudgmental discussion of philosophic issues/questions about spiritual impact of illness/situation.
• Review life experiences of loss and use of coping skills, noting client strengths and successes.
• Provide calm, peaceful setting and privacy as appropriate. Promotes relaxation and ability to deal with situation.
• Assist client to engage in spiritual growth activities, experience prayer/meditation and forgiveness to heal past hurts. Provide information that anger with God is a normal part of the grieving process. Reduces feelings of guilt/conflict, allowing client to move forward toward resolution.
• Refer to therapists, spiritual advisors, counselors to facilitate grief work.
• Refer to community agencies/resources to assist client/SO for planning for eventualities (legal issues, funeral plans, etc.).
NURSING PRIORITY NO.3. To promote independence:
• Support client’s efforts to develop realistic steps to put plans into action.
• Direct client’s thoughts beyond present state to enjoyment of each day and the future when appropriate.
• Provide opportunities for client to make simple decisions. Enhances sense of control.
• Develop individual plan using client’s locus of control to assist client/family through the process.
• Treat expressed decisions and desires with respect and convey to others as appropriate.
• Assist with completion of Advance Directives and cardiopulmonary resuscitation (CPR) instructions.
Documentation Focus
ASSESSMENT/REASSESSMENT
• Assessment findings, including client’s fears and signs/symptoms being exhibited.
• Responses/actions of family/SO(s).
• Availability/use of resources.
PLANNING
• Plan of care and who is involved in planning.
IMPLEMENTATION/EVALUATION
• Client’s response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
DISCHARGE PLANNING
• Identified needs and who is responsible for actions to be taken.
• Specific referrals made.
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Anxiety [specify level:mild,moderate, severe, panic]
Definition:Vague uneasy feeling of discomfort or dread accompanied by an autonomic response (the source often nonspecific or unknown to the individual); a feeling of apprehension caused by anticipation of danger. It is an alerting signal that warns of impending danger and enables the individual to take measures to deal with threat.
RELATED FACTORS
Unconscious conflict about essential [beliefs]/goals and values of life
Situational/maturational crises
Stress
Familial association/heredity
Interpersonal transmission/contagion
Threat to self-concept [perceived or actual]; [unconscious conflict]
Threat of death [perceived or actual]
Threat to or change in health status [progressive/debilitating disease, terminal illness], interaction patterns, role function/status, environment [safety], economic status
Unmet needs
Exposure to toxins
Substance abuse
[Positive or negative self-talk]
[Physiological factors, such as hyperthyroidism, pulmonary embolism, dysrhythmias, pheochromocytoma, drug therapy including steroids]
Unconscious conflict about essential [beliefs]/goals and values of life
Situational/maturational crises
Stress
Familial association/heredity
Interpersonal transmission/contagion
Threat to self-concept [perceived or actual]; [unconscious conflict]
Threat of death [perceived or actual]
Threat to or change in health status [progressive/debilitating disease, terminal illness], interaction patterns, role function/status, environment [safety], economic status
Unmet needs
Exposure to toxins
Substance abuse
[Positive or negative self-talk]
[Physiological factors, such as hyperthyroidism, pulmonary embolism, dysrhythmias, pheochromocytoma, drug therapy including steroids]
DEFINING CHARACTERISTICS
Subjective
Behavioral
Expressed concerns due to change in life events; insomnia
Affective
Regretful; scared; rattled; distressed; apprehensive; uncertainty; fearful; feelings of inadequacy; jittery;
worried; painful/persistent increased helplessness; [sense of impending doom]; [hopelessness]
Cognitive
Fear of unspecific consequences; awareness of physiological symptoms
Physiological
Shakiness
Sympathetic
Dry mouth, heart pounding; weakness; respiratory difficulties; anorexia; diarrhea
Parasympathetic
Tingling in extremeties; nausea; abdominal pain; diarrhea; urinary frequency/hesitancy; faintness; fatigue; sleep disturbance; [chest, back, neck pain]
Subjective
Behavioral
Expressed concerns due to change in life events; insomnia
Affective
Regretful; scared; rattled; distressed; apprehensive; uncertainty; fearful; feelings of inadequacy; jittery;
worried; painful/persistent increased helplessness; [sense of impending doom]; [hopelessness]
Cognitive
Fear of unspecific consequences; awareness of physiological symptoms
Physiological
Shakiness
Sympathetic
Dry mouth, heart pounding; weakness; respiratory difficulties; anorexia; diarrhea
Parasympathetic
Tingling in extremeties; nausea; abdominal pain; diarrhea; urinary frequency/hesitancy; faintness; fatigue; sleep disturbance; [chest, back, neck pain]
Objective
Behavioral
Poor eye contact, glancing about, scanning and vigilance, extraneous movement [e.g., foot shuffling, hand/arm movements, rocking motion]; fidgeting; restlessness; diminished productivity; [crying/tearfulness]; [pacing/purposeless activity], [immobility]
Behavioral
Poor eye contact, glancing about, scanning and vigilance, extraneous movement [e.g., foot shuffling, hand/arm movements, rocking motion]; fidgeting; restlessness; diminished productivity; [crying/tearfulness]; [pacing/purposeless activity], [immobility]
Affective
Increased wariness; focus on self; irritability; overexcited; anguish
Cognitive
Preoccupation; impaired attention; difficulty concentrating; forgetfulness; diminished ability to problem-solve; diminished learning ability; rumination; tendency to blame others; blocking of thought; confusion; decreased perceptual field
Physiological
Voice quivering; trembling/hand tremors; increased tension, facial tension, increased perspiration
Sympathetic
Cardiovascular excitation; facial flushing; superficial vasoconstriction; increased pulse/respiration; increased blood pressure; pupil dilation; twitching, increased reflexes
Parasympathetic
Urinary urgency; decreased blood pressure/pulse
Increased wariness; focus on self; irritability; overexcited; anguish
Cognitive
Preoccupation; impaired attention; difficulty concentrating; forgetfulness; diminished ability to problem-solve; diminished learning ability; rumination; tendency to blame others; blocking of thought; confusion; decreased perceptual field
Physiological
Voice quivering; trembling/hand tremors; increased tension, facial tension, increased perspiration
Sympathetic
Cardiovascular excitation; facial flushing; superficial vasoconstriction; increased pulse/respiration; increased blood pressure; pupil dilation; twitching, increased reflexes
Parasympathetic
Urinary urgency; decreased blood pressure/pulse
Sample Clinical Applications:Major life changes/events, hospital admissions/surgery, cancer, hyperthyroidism, drug intoxication/abuse, mental health disorders
DESIRED OUTCOMES/EVALUATION CRITERIA
Client Will (Include Specific Time Frame)
• Appear relaxed and report anxiety is reduced to a manageable level.
• Verbalize awareness of feelings of anxiety.
• Identify healthy ways to deal with and express anxiety.
• Demonstrate problem-solving skills.
• Use resources/support systems effectively.
• Appear relaxed and report anxiety is reduced to a manageable level.
• Verbalize awareness of feelings of anxiety.
• Identify healthy ways to deal with and express anxiety.
• Demonstrate problem-solving skills.
• Use resources/support systems effectively.
ACTIONS/INTERVENTIONS
NURSING PRIORITY NO.1. To assess level of anxiety:
• Review familial/physiological factors, such as genetic depressive factors, psychiatric illness; active medical conditions (e.g., thyroid problems, metabolic imbalances, cardiopulmonary disease, anemia, dysrhythmias); recent/ongoing stressors (e.g., family member illness/death, spousal conflict/abuse, loss of job). These factors can cause/exacerbate anxiety/anxiety disorders.
• Review familial/physiological factors, such as genetic depressive factors, psychiatric illness; active medical conditions (e.g., thyroid problems, metabolic imbalances, cardiopulmonary disease, anemia, dysrhythmias); recent/ongoing stressors (e.g., family member illness/death, spousal conflict/abuse, loss of job). These factors can cause/exacerbate anxiety/anxiety disorders.
• Determine current prescribed medication regimen and recent drug history of prescribed or OTC medications (e.g., steroids, thyroid preparations, weight-loss pills, caffiene. Can heighten feelings/sense of anxiety.
• Identify client’s perception of the threat represented by the situation. Distorted perceptions of the situation may magnify feelings. Understanding client’s point of view promotes a more accurate plan of care.
• Note cultural factors that may influence anxiety. Individual responses are influenced by the cultural values/beliefs and culturally learned patterns of family of origin. (For example, ArabAmericans are very expressive about feelings, whereas Chinese are more reticent). Biological factors may also be involved.
• Monitor physical responses; for example, palpitations/rapid pulse, repetitive movements, pacing. Changes in vital signs may suggest degree of anxiety client is experiencing or reflect the impact of physiological factors such as endocrine imbalances, medication effect.
• Observe behavior indicative of anxiety, which can be a clue to the client’s level of anxiety:
Mild
Alert, more aware of environment, attention focused on environment and immediate events.
Restless, irritable, wakeful, reports of insomnia.
Motivated to deal with existing problems in this state.
Moderate
Perception narrower, concentration increased and able to ignore distractions in dealing with problem(s).
Voice quivers or changes pitch.
Trembling, increased pulse/respirations.
Severe
Range of perception is reduced; anxiety interferes with effective functioning.
Preoccupied with feelings of discomfort/sense of impending doom.
Increased pulse/respirations with reports of dizziness, tingling sensations, headache, and so forth.
Panic
Ability to concentrate is disrupted; behavior is disintegrated; client distorts the situation and does not have realistic perceptions of what is happening. May be experiencing terror or confusion or be unable to speak or move (paralyzed with fear).
• Note own feelings of anxiety or uneasiness. Feelings of anxiety are circular, and those in contact with the client may find themselves feeling more anxious.
• Note use of drugs (including alcohol), insomnia, or excessive sleeping, and limited/avoidance of interactions with others, which may be behavioral indicators of use of drugs/withdrawal to deal with problems.
• Review results of diagnostic tests (e.g., drug screens, cardiac testing, complete blood count, chemistry panel), which can point to physiological sources of anxiety.
• Review coping skills used in past. Can determine those that might be helpful in currentcircumstances.
• Identify client’s perception of the threat represented by the situation. Distorted perceptions of the situation may magnify feelings. Understanding client’s point of view promotes a more accurate plan of care.
• Note cultural factors that may influence anxiety. Individual responses are influenced by the cultural values/beliefs and culturally learned patterns of family of origin. (For example, ArabAmericans are very expressive about feelings, whereas Chinese are more reticent). Biological factors may also be involved.
• Monitor physical responses; for example, palpitations/rapid pulse, repetitive movements, pacing. Changes in vital signs may suggest degree of anxiety client is experiencing or reflect the impact of physiological factors such as endocrine imbalances, medication effect.
• Observe behavior indicative of anxiety, which can be a clue to the client’s level of anxiety:
Mild
Alert, more aware of environment, attention focused on environment and immediate events.
Restless, irritable, wakeful, reports of insomnia.
Motivated to deal with existing problems in this state.
Moderate
Perception narrower, concentration increased and able to ignore distractions in dealing with problem(s).
Voice quivers or changes pitch.
Trembling, increased pulse/respirations.
Severe
Range of perception is reduced; anxiety interferes with effective functioning.
Preoccupied with feelings of discomfort/sense of impending doom.
Increased pulse/respirations with reports of dizziness, tingling sensations, headache, and so forth.
Panic
Ability to concentrate is disrupted; behavior is disintegrated; client distorts the situation and does not have realistic perceptions of what is happening. May be experiencing terror or confusion or be unable to speak or move (paralyzed with fear).
• Note own feelings of anxiety or uneasiness. Feelings of anxiety are circular, and those in contact with the client may find themselves feeling more anxious.
• Note use of drugs (including alcohol), insomnia, or excessive sleeping, and limited/avoidance of interactions with others, which may be behavioral indicators of use of drugs/withdrawal to deal with problems.
• Review results of diagnostic tests (e.g., drug screens, cardiac testing, complete blood count, chemistry panel), which can point to physiological sources of anxiety.
• Review coping skills used in past. Can determine those that might be helpful in currentcircumstances.
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.
• Be available to client for listening and talking. Establishes rapport, promotes expression of feelings, and helps client/SO look at realities of the illness/treatment without confronting issues they are not ready to deal with.
• 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.
• Be available to client for listening and talking. Establishes rapport, promotes expression of feelings, and helps client/SO look at realities of the illness/treatment without confronting issues they are not ready to deal with.
• Encourage client to acknowledge and to express feelings—for example, crying (sadness), laughing (fear, denial), swearing (fear, anger), and using Active-listening, reflection. Often acknowledging feelings enables client to accept and deal more appropriately with situation, thus relieving anxiety.
• 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.
• Clarify meaning of feelings/actions by providing feedback and checking meaning with the client. Validates meaning and ensures accuracy of communication.
• Acknowledge anxiety/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 honesty, further isolating client.
• Be aware of defense mechanisms being used (e.g., denial, regression, and so forth). Use of defense mechanisms may be helpful coping mechanisms 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 his actual problems.
• 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.
• Provide accurate information about the situation. Helps client to identify what is reality based and provides opportunity for client to feel reassured.
• If the client is a child, be truthful, avoid bribing, and provide physical contact (e.g., hugging, rocking). Soothes fears and provides assurance. Children need to recognize that their feelings are not different from others.
• 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.
• Clarify meaning of feelings/actions by providing feedback and checking meaning with the client. Validates meaning and ensures accuracy of communication.
• Acknowledge anxiety/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 honesty, further isolating client.
• Be aware of defense mechanisms being used (e.g., denial, regression, and so forth). Use of defense mechanisms may be helpful coping mechanisms 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 his actual problems.
• 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.
• Provide accurate information about the situation. Helps client to identify what is reality based and provides opportunity for client to feel reassured.
• If the client is a child, be truthful, avoid bribing, and provide physical contact (e.g., hugging, rocking). Soothes fears and provides assurance. Children need to recognize that their feelings are not different from others.
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risk for latex Allergy Response
Definition: Risk of hypersenitivity to natural latex rubber products
RISK FACTORS
History of reactions to latex
Allergies to bananas, avocados, tropical fruits, kiwi, chestnuts, poinsettia plants
History of allergies and asthma
Professions with daily exposure to latex
Multiple surgical procedures, especially from infancy
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
History of reactions to latex
Allergies to bananas, avocados, tropical fruits, kiwi, chestnuts, poinsettia plants
History of allergies and asthma
Professions with daily exposure to latex
Multiple surgical procedures, especially from infancy
NOTE: A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred and nursing interventions are directed at prevention.
Sample Clinical Applications:Multiple allergies, neural tube defects (e.g., spina bifida, myelomeningoceles), multiple surgeries at early age, chronic urological conditions (e.g., neurogenic bladder, exstrophy of bladder), spinal cord trauma
DESIRED OUTCOMES/EVALUATION CRITERIA
Client Will (Include Specific Time Frame)
• Identify and correct potential risk factors in the environment.
• Demonstrate appropriate lifestyle changes to reduce risk of exposure.
• Identify resources to assist in promoting a safe environment.
• Recognize need for/seek assistance to limit response/complications.
• Identify and correct potential risk factors in the environment.
• Demonstrate appropriate lifestyle changes to reduce risk of exposure.
• Identify resources to assist in promoting a safe environment.
• Recognize need for/seek assistance to limit response/complications.
ACTIONS/INTERVENTIONS
NURSING PRIORITY NO.1 To assess causative/contributing factors:
• Identify persons in high-risk categories such as those with history of certain food allergies (e.g., banana, avocado, chestnut, kiwi, papya, peach, nectarine); asthma; skin conditions (e.g., eczema); those occupationally exposed to latex products (e.g., healthcare workers, police/firefighters, emergency medical technicians [EMTs], food handlers, hairdressers, cleaning staff, factory workers in plants that manufacture latex-containing products); those with neural tube defects (e.g., spina bifida) or congenital urological conditions requiring frequent surgeries and/or catheterizations (e.g., extrophy of the bladder). Note: The most
severe reactions tend to occur with latex proteins contacting internal tissues during invasive procedures and when they touch mucous membranes of the mouth, vagina, urethra, or rectum.
• Question client regarding latex allergy upon admission to healthcare facility, especially when procedures are anticipated (e.g., laboratory, emergency department, operating room, wound care management, one-day surgery, dentist). Current information indicates that natural latex is found in thousands of medical supplies; however, many manufacturers are now using synthetic SB latex. These products have not been associated with allergic reactions, even among individuals that are sensitive to natural latex.
• Identify persons in high-risk categories such as those with history of certain food allergies (e.g., banana, avocado, chestnut, kiwi, papya, peach, nectarine); asthma; skin conditions (e.g., eczema); those occupationally exposed to latex products (e.g., healthcare workers, police/firefighters, emergency medical technicians [EMTs], food handlers, hairdressers, cleaning staff, factory workers in plants that manufacture latex-containing products); those with neural tube defects (e.g., spina bifida) or congenital urological conditions requiring frequent surgeries and/or catheterizations (e.g., extrophy of the bladder). Note: The most
severe reactions tend to occur with latex proteins contacting internal tissues during invasive procedures and when they touch mucous membranes of the mouth, vagina, urethra, or rectum.
• Question client regarding latex allergy upon admission to healthcare facility, especially when procedures are anticipated (e.g., laboratory, emergency department, operating room, wound care management, one-day surgery, dentist). Current information indicates that natural latex is found in thousands of medical supplies; however, many manufacturers are now using synthetic SB latex. These products have not been associated with allergic reactions, even among individuals that are sensitive to natural latex.
NURSING PRIORITY NO.2 To assist in correcting factors that could lead to latex allergy:
• Ascertain that facilities have established policies and procedures. Promotes awareness in the workplace to address safety and reduce risk to workers and client.
• Create latex-safe environments in care setting (e.g., substitute nonlatex products, such as natural rubber gloves, PCV IV tubing, latex-free tape, thermometers, electrodes, oxygen cannulas, etc.). Reduces risk of exposure.
• Promote good skin care when latex gloves may be preferred/required for barrier protection (e.g., in specific disease conditions such as HIV or during surgery). Use powder-free gloves, wash hands immediately after glove removal; refrain from use of oil-based hand cream. Reduces dermal and respiratory exposure to latex proteins that bind to the powder in gloves.
• Discuss necessity of avoiding latex exposure. Recommend/assist client/family to survey environment and remove any medical or household products containing latex. Avoidance of latex is the only way to prevent the allergy.
• Provide worksite review/recommendations to prevent exposure. Latex allergy can be a disabling occupational disease. Education about the problem promotes prevention of allergic reaction, facilitates timely intervention, and helps nurse to protect clients, latex-sensitive colleagues, and themselves.
• Ascertain that facilities have established policies and procedures. Promotes awareness in the workplace to address safety and reduce risk to workers and client.
• Create latex-safe environments in care setting (e.g., substitute nonlatex products, such as natural rubber gloves, PCV IV tubing, latex-free tape, thermometers, electrodes, oxygen cannulas, etc.). Reduces risk of exposure.
• Promote good skin care when latex gloves may be preferred/required for barrier protection (e.g., in specific disease conditions such as HIV or during surgery). Use powder-free gloves, wash hands immediately after glove removal; refrain from use of oil-based hand cream. Reduces dermal and respiratory exposure to latex proteins that bind to the powder in gloves.
• Discuss necessity of avoiding latex exposure. Recommend/assist client/family to survey environment and remove any medical or household products containing latex. Avoidance of latex is the only way to prevent the allergy.
• Provide worksite review/recommendations to prevent exposure. Latex allergy can be a disabling occupational disease. Education about the problem promotes prevention of allergic reaction, facilitates timely intervention, and helps nurse to protect clients, latex-sensitive colleagues, and themselves.
NURSING PRIORITY NO.3 To promote wellness (Teaching/Discharge Considerations):
• Instruct client/care providers about types of potential reactions. Reaction may be gradual and progressive (e.g., irritant contact rash with gloves); can be progressive, affecting multiple body systems; or may be sudden and anaphylactic requiring lifesaving treatment.
• Identify measures to take if reactions occur and ways to avoid exposure to latex products to reduce risk of injury. (Refer to ND latex Allergy Response.)
• Refer to allergist for testing as appropriate. Testing may include challenge test with latex gloves, skin patch test, or blood test for IgE.
• Encourage client to wear medical ID bracelet and emphasize importance of informing all new care providers of hypersensitivity to reduce preventable exposures.
• Refer to resources (e.g., Latex Allergy News, National Institute for Occupational Safety and Health [NIOSH], Kendall’s Healthcare Products [Web site], Hudson RCI [Web site]) for further information about common latex products in the home, latex-free products, and assistance.
• Instruct client/care providers about types of potential reactions. Reaction may be gradual and progressive (e.g., irritant contact rash with gloves); can be progressive, affecting multiple body systems; or may be sudden and anaphylactic requiring lifesaving treatment.
• Identify measures to take if reactions occur and ways to avoid exposure to latex products to reduce risk of injury. (Refer to ND latex Allergy Response.)
• Refer to allergist for testing as appropriate. Testing may include challenge test with latex gloves, skin patch test, or blood test for IgE.
• Encourage client to wear medical ID bracelet and emphasize importance of informing all new care providers of hypersensitivity to reduce preventable exposures.
• Refer to resources (e.g., Latex Allergy News, National Institute for Occupational Safety and Health [NIOSH], Kendall’s Healthcare Products [Web site], Hudson RCI [Web site]) for further information about common latex products in the home, latex-free products, and assistance.
DOCUMENTATION FOCUS
Assessment/Reassessment
• Assessment findings, pertinent history of contact with latex products, and frequency of exposure.
• Assessment findings, pertinent history of contact with latex products, and frequency of exposure.
Planning
• Plan of care and who is involved in planning.
• Teaching plan.
• Plan of care and who is involved in planning.
• Teaching plan.
Implementation/Evaluation
• Response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
• Response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
Discharge Planning
• Long-term needs and who is responsible for actions to be taken.
• Specific referrals made.
• Long-term needs and who is responsible for actions to be taken.
• Specific referrals made.
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The Nursing Process
Over time, the nursing process expanded to five steps and has gained widespread acceptance as the basis for providing effective nursing care. Nursing process is now included in the conceptual framework of all nursing curricula, is accepted in the legal definition of nursing in the Nurse Practice Acts of most states, and is included in the ANA Standards of Clinical Nursing Practice.
The five steps of the nursing process consist of the following:
The five steps of the nursing process consist of the following:
- Assessment is an organized dynamic process involving three basic activities: a) systematically gathering data, b) sorting and organizing the collected data, and c) documenting the data in a retrievable fashion. Subjective and objective data are collected from various sources, such as the client interview and physical assessment. Subjective data are what the client or significant others report, believe, or feel, andobjective data are what can be observed or obtained fromother sources, such as laboratory and diagnostic studies,old medical records, or other healthcare providers. Usinga number of techniques, the nurse focuses on eliciting aprofile of the client that supplies a sense of the client’s overall health status, providing a picture of the client’s physical,psychological, sociocultural, spiritual, cognitive, and developmental levels; economic status; functional abilities; and lifestyle. The profile is known as the client database.
- Diagnosis/need identification involves the analysis of collected data to identify the client’s needs or problems, also known as the nursing diagnosis. The purpose of this step is to draw conclusions regarding the client’s specific needs or human responses of concern so that effective care can be planned and delivered. This process of data analysis uses diagnostic reasoning (a form of clinical judgment) in which conclusions are reached about the meaning of the collected data to determine whether or not nursing intervention is indicated. The end product is the client diagnostic statement that combines the specific client need with the related factors or risk factors (etiology), and defining charac-
teristics (or cues) as appropriate. The status of the client’s needs are categorized as actual or currently existing diagnoses and potential or risk diagnoses that could develop due to specific vulnerabilities of the client. Ongoing changes in healthcare delivery and computerization of the client record require a commonality of communication to ensure continuity of care for the client moving from one setting/level of healthcare to another. The use of standardized terminology or NANDA International nursing diagnosis labels provides nurses with a common language for identifying client needs. Furthermore, the use of standardized nursing diagnosis labels also promotes identification of appropriate goals, provides acuity information, is useful in creating standards for nursing practice, provides a base for quality improvement, and facilitates research supporting evidence-based nursing practices. - Planning includes setting priorities, establishing goals, identifying desired client outcomes, and determining specific nursing interventions. These actions are documented as the plan of care. This process requires input from the client/ significant others to reach agreement regarding the plan to facilitate the client taking responsibility for his or her own care and the achievement of the desired outcomes and goals. Setting priorities for client care is a complex and dynamic challenge that helps ensure that the nurse’s attention and subsequent actions are properly focused. What is perceived today to be the number one client care need or appropriate nursing intervention could change tomorrow, or, for that matter, within minutes, based on changes in the client’s condition or situation. Once client needs are prioritized, goals for treatment and discharge are established that indicate the general direction in which the client is expected to progress in response to treatment. The goals may be shortterm—those that usually must be met before the client is discharged or moved to a lesser level of care—and/or long-
term, which may continue even after discharge. From these goals, desired outcomes are determined to measure the client’s progress toward achieving the goals of treatment or the discharge criteria. To be more specific, outcomes are client responses that are achievable and desired by the client that can be attained within a defined period, given the situation and resources. Next, nursing interventions are chosen that are based on the client’s nursing diagnosis, the established goals and desired outcomes, the ability of the nurse to successfully implement the intervention, and the ability and the willingness of the client to undergo or participate in the intervention, and they reflect the client’s age/situation and individual strengths, when possible. Nursing interventions are direct-care activities or prescriptions for behaviors, treatments, activities, or actions that assist the client in achieving the measurable outcomes. Nursing interventions, like nursing diagnoses, are key elements of the knowledge of nursing and continue to grow as research supports the connection between actions and outcomes (McCloskey & Bulechek, 2000). Recording the planning step in a written or computerized plan of care provides for continuity of care, enhances communication, assists with determining agency or unit staffing needs, documents the nursing process, serves as a teaching tool, and coordinates provision of care among disciplines. A valid plan of care demonstrates individualized client care by reflecting the concerns of the client and significant others, as well as the client’s physical, psychosocial, and cultural needs and capabilities. - Implementation occurs when the plan of care is put into action, and the nurse performs the planned interventions. Regardless of how well a plan of care has been constructed, it cannot predict everything that will occur with a particular client on a daily basis. Individual knowledge and expertise and agency routines allow the flexibility that is necessary to adapt to the changing needs of the client. Legal and ethical concerns related to interventions also must be considered. For example, the wishes of the client and family/significant others regarding interventions and treatments must be discussed and respected. Before implementing the interventions in the plan of care, the nurse needs to understand the reason for doing each intervention, its expected effect, and any potential hazards that can occur. The nurse must also be sure that the interventions are a) consistent with the established plan of care, b) implemented in a safe and appropriate manner, c) evaluated for effectiveness, and d) documented in a timely manner.
- Evaluation is accomplished by determining the client’s progress toward attaining the identified outcomes and by monitoring the client’s response to/effectiveness of the selected nursing interventions for the purpose of altering the plan as indicated. This is done by direct observation of the client, interviewing the client/significant other, and/or reviewing the client’s healthcare record. Although the process of evaluation seems similar to the activity of assessment, there are important differences. Evaluation is an ongoing process, a constant measuring and monitoring of the client status to determine: a) appropriateness of nursing actions, b) the need to revise interventions, c) development of new client needs, d) the need for referral to other resources, and e) the need to rearrange priorities to meet changing demands of care. Comparing overall outcomes and noting the effectiveness of specific interventions are the clinical components of evaluation that can become the basis for research for validating the nursing process and supporting evidenced-based practice. The external evaluation process is the key for refining standards of care and determining the protocols, policies, and procedures necessary for the provision of quality nursing care for a specific situation or setting.
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latex Allergy Response
Definition: A hypersensitive reaction to natural latex rubber products
RELATED FACTORS
Hypersensitivity to natural latex rubber protein
Hypersensitivity to natural latex rubber protein
DEFINING CHARACTERISTICS
Subjective
Life-threatening reactions occurring <1 hour after exposure to latex proteins:
Tightness in chest; [feeling breathless]
Gastrointestinal characteristics: Abdominal pain; nausea
Orofacial characteristics: Itching of the eyes; nasal/facial/oral itching; nasal congestion
Generalized characteristics: Generalized discomfort; increasing complaints of total body warmth
Type IV reactions occurring >1 hour after exposure to latex protein:
Discomfort reaction to additives such as thiurams and carbamates
Objective
Life-threatening reactions occurring <1 hour after exposure to latex proteins:
Contact urticaria progressing to generalized symptoms
Edema of the lips/tongue/uvula/throat
Dyspnea; wheezing; bronchospasm; respiratory arrest
Hypotension; syncope; cardiac arrest
Orofacial characteristics: Edema of sclera/eyelids; erythema/tearing of the eyes; nasal facial/erythema; rhinorrhea
Generalized characteristics: Flushing; generalized edema; restlessness
Type IV reactions occurring >1 hour after exposure to latex protein:
Eczema; irritation; redness
Subjective
Life-threatening reactions occurring <1 hour after exposure to latex proteins:
Tightness in chest; [feeling breathless]
Gastrointestinal characteristics: Abdominal pain; nausea
Orofacial characteristics: Itching of the eyes; nasal/facial/oral itching; nasal congestion
Generalized characteristics: Generalized discomfort; increasing complaints of total body warmth
Type IV reactions occurring >1 hour after exposure to latex protein:
Discomfort reaction to additives such as thiurams and carbamates
Objective
Life-threatening reactions occurring <1 hour after exposure to latex proteins:
Contact urticaria progressing to generalized symptoms
Edema of the lips/tongue/uvula/throat
Dyspnea; wheezing; bronchospasm; respiratory arrest
Hypotension; syncope; cardiac arrest
Orofacial characteristics: Edema of sclera/eyelids; erythema/tearing of the eyes; nasal facial/erythema; rhinorrhea
Generalized characteristics: Flushing; generalized edema; restlessness
Type IV reactions occurring >1 hour after exposure to latex protein:
Eczema; irritation; redness
Sample Clinical Applications:Multiple allergies, neural tube defects (e.g., spina bifida,
myelomeningoceles), multiple surgeries at early age, chronic urological conditions (e.g.,
neurogenic bladder, exstrophy of bladder), spinal cord trauma
myelomeningoceles), multiple surgeries at early age, chronic urological conditions (e.g.,
neurogenic bladder, exstrophy of bladder), spinal cord trauma
Client Will (Include Specific Time Frame)
• Be free of signs of hypersensitive response.
• Verbalize understanding of individual risks/responsibilities in avoiding exposure.
• Identify signs/symptoms requiring prompt intervention.
• Be free of signs of hypersensitive response.
• Verbalize understanding of individual risks/responsibilities in avoiding exposure.
• Identify signs/symptoms requiring prompt intervention.
NURSING PRIORITY NO.1 To assess contributing factors:
• Identify persons in high-risk categories such as those with history of certain food allergies (e.g., banana, avocado, chestnut, kiwi, papaya, peach, nectarine), prior allergies, asthma, and skin conditions (e.g., eczema and other dermatitis), those occupationally exposed to latex products (e.g., healthcare workers, police/firefighters, emergency medical technicians [EMTs], food handlers, hairdressers, cleaning staff, factory workers in plants that manufacture latex-containing products), those with neural tube defects (e.g., spina bifida) or congenital urological conditions requiring frequent surgeries and/or catheterizations (e.g., extrophy of the bladder). Note: The most severe reactions tend to occur with latex proteins contacting internal tissues during invasive procedures and when they touch mucous membranes of the mouth, vagina, urethra, or rectum.
• Question new client regarding latex allergy upon admission to healthcare facility, especially when procedures are anticipated (e.g., laboratory, emergency department, operating room, wound care management, one-day surgery, dentist). Basic safety information to help healthcare providers prevent/prepare for safe environment for client and themselves while providing care.
• Discuss history of exposure: client works in environment where latex is manufactured or latex gloves are used frequently; child was blowing up balloons (may be an acute reaction to the powder); use of condoms (may affect either partner); individual requires frequent catheterizations. Finding cause of reaction may be simple or complex but often requires diligent investigation and history-taking from multiple sources.
• Administer or note presence of positive skin-prick test (SPT), when performed. Sensitive, specific, and rapid test but should be used with caution in persons with suspected sensitivity, as it carries risk of anaphylaxis.
• Perform challenge/patch test, if appropriate, to identify specific allergens in client with known type IV hypersensitivity.
• Note response to radioallergosorbent test (RAST) or enzyme-linked latex-specific IgE (ELISA). Performed to measure the quantity of IgE antibodies in serum after exposure to specific antigens and has generally replaced skin tests and provocation tests, which are inconvenient, often painful, and/or hazardous to the client.
• Identify persons in high-risk categories such as those with history of certain food allergies (e.g., banana, avocado, chestnut, kiwi, papaya, peach, nectarine), prior allergies, asthma, and skin conditions (e.g., eczema and other dermatitis), those occupationally exposed to latex products (e.g., healthcare workers, police/firefighters, emergency medical technicians [EMTs], food handlers, hairdressers, cleaning staff, factory workers in plants that manufacture latex-containing products), those with neural tube defects (e.g., spina bifida) or congenital urological conditions requiring frequent surgeries and/or catheterizations (e.g., extrophy of the bladder). Note: The most severe reactions tend to occur with latex proteins contacting internal tissues during invasive procedures and when they touch mucous membranes of the mouth, vagina, urethra, or rectum.
• Question new client regarding latex allergy upon admission to healthcare facility, especially when procedures are anticipated (e.g., laboratory, emergency department, operating room, wound care management, one-day surgery, dentist). Basic safety information to help healthcare providers prevent/prepare for safe environment for client and themselves while providing care.
• Discuss history of exposure: client works in environment where latex is manufactured or latex gloves are used frequently; child was blowing up balloons (may be an acute reaction to the powder); use of condoms (may affect either partner); individual requires frequent catheterizations. Finding cause of reaction may be simple or complex but often requires diligent investigation and history-taking from multiple sources.
• Administer or note presence of positive skin-prick test (SPT), when performed. Sensitive, specific, and rapid test but should be used with caution in persons with suspected sensitivity, as it carries risk of anaphylaxis.
• Perform challenge/patch test, if appropriate, to identify specific allergens in client with known type IV hypersensitivity.
• Note response to radioallergosorbent test (RAST) or enzyme-linked latex-specific IgE (ELISA). Performed to measure the quantity of IgE antibodies in serum after exposure to specific antigens and has generally replaced skin tests and provocation tests, which are inconvenient, often painful, and/or hazardous to the client.
NURSING PRIORITY NO.2 To take measures to reduce/limit allergic response/avoid exposure to allergens:
• Ascertain client’s current symptoms, noting rash, hives, itching, eye symptoms, edema, diarrhea, nausea, and feeling of faintness. Baseline for determining where the client is along a continuum of symptoms so that appropriate treatments can be initiated.
• Determine time since exposure (e.g., immediate or delayed onset such as 24 to 48 hours).
• Assess skin (usually hands but may be anywhere) for dry, crusty, hard bumps, horizontal cracks caused by irritation from chemicals used in/on the latex item (e.g., latex or powder used in latex gloves, condoms, etc.). Dry itchy rash (contact irritation) is the most common response and is not a true allergic reaction but can progress to a delayed type of allergic contact dermatitis with oozing blisters and spread in a way similar to poison ivy.
• Assist with treatment of contact dermatitis/type IV reaction:
Wash affected skin with mild soap and water.
Wash hands between glove changes and after each glove removal.
Avoid oil-based salves or lotions when using latex gloves.
Consider application of topical steroid ointment.
Inform client that the most common cause is latex gloves but that many other products contain latex and could aggravate condition.
• Monitor closely for signs of systemic reactions (e.g., difficulty breathing or swallowing; wheezing; hoarseness; stridor; hypotension; tremors; chest pain; tachycardia; dysrhythmias; edema of face, eyelids, lips, tongue, and mucous membranes). Type IV response can progress to type I anaphylaxis.
• Note behavior such as agitation, restlessness, and expressions of fearfulness, in the presence of above listed symptoms. Indicative of severe allergic response that can result in anaphylactic reaction and lead to respiratory/cardiac arrest.
• Administer treatment, as appropriate, if severe/life-threatening reaction occurs:
Stop treatment or procedure, if needed.
Support airway and administer 100% oxygen or mechanical ventilation, if needed.
Administer emergency medications and treatments per protocol (e.g., antihistamines, epinephrine, corticosteroids, and IV fluids).
• Educate care providers in ways to prevent inadvertent exposure (e.g., post latex precaution signs in client’s room, document allergy to latex in chart, routinely monitor client’s environment for latex-containing products and remove them promptly) and in emergency treatment measures should they be needed.
• Ascertain that latex-safe environment (e.g., surgery/hospital room) and products are available according to recommended facility guidelines and standards, including equipment and supplies, (e.g., powder-free, low-protein latex products) and latex-free items (e.g., gloves, syringes, catheters, tubings, tape, thermometers, electrodes, oxygen cannulas, underpads, storage bags, diapers, feeding nipples, etc.), as appropriate.
• Notify physicians, colleagues, and medical products suppliers of condition (e.g., pharmacy so that medications can be prepared in latex-free environment, home-care oxygen company to provide latex-free cannulas).
• Encourage client to wear medical ID bracelet to alert providers to condition if client is unresponsive.
• Ascertain client’s current symptoms, noting rash, hives, itching, eye symptoms, edema, diarrhea, nausea, and feeling of faintness. Baseline for determining where the client is along a continuum of symptoms so that appropriate treatments can be initiated.
• Determine time since exposure (e.g., immediate or delayed onset such as 24 to 48 hours).
• Assess skin (usually hands but may be anywhere) for dry, crusty, hard bumps, horizontal cracks caused by irritation from chemicals used in/on the latex item (e.g., latex or powder used in latex gloves, condoms, etc.). Dry itchy rash (contact irritation) is the most common response and is not a true allergic reaction but can progress to a delayed type of allergic contact dermatitis with oozing blisters and spread in a way similar to poison ivy.
• Assist with treatment of contact dermatitis/type IV reaction:
Wash affected skin with mild soap and water.
Wash hands between glove changes and after each glove removal.
Avoid oil-based salves or lotions when using latex gloves.
Consider application of topical steroid ointment.
Inform client that the most common cause is latex gloves but that many other products contain latex and could aggravate condition.
• Monitor closely for signs of systemic reactions (e.g., difficulty breathing or swallowing; wheezing; hoarseness; stridor; hypotension; tremors; chest pain; tachycardia; dysrhythmias; edema of face, eyelids, lips, tongue, and mucous membranes). Type IV response can progress to type I anaphylaxis.
• Note behavior such as agitation, restlessness, and expressions of fearfulness, in the presence of above listed symptoms. Indicative of severe allergic response that can result in anaphylactic reaction and lead to respiratory/cardiac arrest.
• Administer treatment, as appropriate, if severe/life-threatening reaction occurs:
Stop treatment or procedure, if needed.
Support airway and administer 100% oxygen or mechanical ventilation, if needed.
Administer emergency medications and treatments per protocol (e.g., antihistamines, epinephrine, corticosteroids, and IV fluids).
• Educate care providers in ways to prevent inadvertent exposure (e.g., post latex precaution signs in client’s room, document allergy to latex in chart, routinely monitor client’s environment for latex-containing products and remove them promptly) and in emergency treatment measures should they be needed.
• Ascertain that latex-safe environment (e.g., surgery/hospital room) and products are available according to recommended facility guidelines and standards, including equipment and supplies, (e.g., powder-free, low-protein latex products) and latex-free items (e.g., gloves, syringes, catheters, tubings, tape, thermometers, electrodes, oxygen cannulas, underpads, storage bags, diapers, feeding nipples, etc.), as appropriate.
• Notify physicians, colleagues, and medical products suppliers of condition (e.g., pharmacy so that medications can be prepared in latex-free environment, home-care oxygen company to provide latex-free cannulas).
• Encourage client to wear medical ID bracelet to alert providers to condition if client is unresponsive.
NURSING PRIORITY NO.3 To promote wellness (Teaching/Learning):
• Instruct in signs of reaction and emergency treatment needs. Reactions range from skin irritation to anaphylaxis. Reaction may be gradual but progressive, affecting multiple body systems, or may be sudden, requiring lifesaving treatment. Allergy can result in chronic illness, disability, career loss, hardship, and death. There is no cure except complete avoidance of latex
• Emphasize the critical importance of taking immediate action for type I reaction to limit life-threatening symptoms.
• Demonstrate procedure and recommend client carry auto-injectable epinephrine to provide timely emergency treatment, as needed.
• Emphasize necessity of informing all new care providers of hypersensitivity to reduce preventable exposures.
• Instruct in signs of reaction and emergency treatment needs. Reactions range from skin irritation to anaphylaxis. Reaction may be gradual but progressive, affecting multiple body systems, or may be sudden, requiring lifesaving treatment. Allergy can result in chronic illness, disability, career loss, hardship, and death. There is no cure except complete avoidance of latex
• Emphasize the critical importance of taking immediate action for type I reaction to limit life-threatening symptoms.
• Demonstrate procedure and recommend client carry auto-injectable epinephrine to provide timely emergency treatment, as needed.
• Emphasize necessity of informing all new care providers of hypersensitivity to reduce preventable exposures.
• Instruct client/family/SO that latex exposure occurs through contact with skin or mucous membrane, by inhalation, parenteral injection, or wound inoculation.
• Instuct client/SO(s) to survey and routinely monitor environment for latex-containing products, and replace as needed.
• Provide printed lists or Web sites for identifying common household products that may contain latex (e.g, carpet backing, hoses, rubber grip utensils, diapers, undergarments, shoes, toys, pacifiers, computer mouse pad, erasers, rubber bands, and much more) and where to obtain latex-free products and supplies.
• Provide resource and assistance numbers for emergencies. When allergy is suspected or the potential for allergy exists, protection must begin with identification and removal of possible sources of latex.
• Provide worksite review/recommendations to prevent exposure. Latex allergy can be a disabling occupational disease. Education about the problem promotes prevention of allergic reaction, facilitates timely intervention, and helps nurse to protect clients, latex-sensitive colleagues, and themselves.
• Recommend full medical workup for client presenting with hand dermatitis, especially if job tasks include use of latex.
• Contact suppliers to verify that latex-free equipment, products, and supplies are available, including (but not limited to) low-allergen/powder-free synthetic gloves, airways, masks, stethoscope tubings, IV tubing, tape, thermometers, urinary catheters, stomach and intestinal tubes, electrodes, oxygen cannulas, pencil erasers, wrist name bands, and rubber bands.
• Ascertain that procedures are in place to identify and resolve problems with medical devices relevant to allergic reactions or glove performance.
• Refer to resources, including but not limited to ALERT (Allergy to Latex Education & Resource Team, Inc.), Latex Allergy News, Spina Bifida Association, National Institute for Occupational Safety and Health (NIOSH), Kendall’s Healthcare Products [Web site], Hudson RCI [Web site]), for further information about common latex products in the home, latex-free products, and assistance.
• Instuct client/SO(s) to survey and routinely monitor environment for latex-containing products, and replace as needed.
• Provide printed lists or Web sites for identifying common household products that may contain latex (e.g, carpet backing, hoses, rubber grip utensils, diapers, undergarments, shoes, toys, pacifiers, computer mouse pad, erasers, rubber bands, and much more) and where to obtain latex-free products and supplies.
• Provide resource and assistance numbers for emergencies. When allergy is suspected or the potential for allergy exists, protection must begin with identification and removal of possible sources of latex.
• Provide worksite review/recommendations to prevent exposure. Latex allergy can be a disabling occupational disease. Education about the problem promotes prevention of allergic reaction, facilitates timely intervention, and helps nurse to protect clients, latex-sensitive colleagues, and themselves.
• Recommend full medical workup for client presenting with hand dermatitis, especially if job tasks include use of latex.
• Contact suppliers to verify that latex-free equipment, products, and supplies are available, including (but not limited to) low-allergen/powder-free synthetic gloves, airways, masks, stethoscope tubings, IV tubing, tape, thermometers, urinary catheters, stomach and intestinal tubes, electrodes, oxygen cannulas, pencil erasers, wrist name bands, and rubber bands.
• Ascertain that procedures are in place to identify and resolve problems with medical devices relevant to allergic reactions or glove performance.
• Refer to resources, including but not limited to ALERT (Allergy to Latex Education & Resource Team, Inc.), Latex Allergy News, Spina Bifida Association, National Institute for Occupational Safety and Health (NIOSH), Kendall’s Healthcare Products [Web site], Hudson RCI [Web site]), for further information about common latex products in the home, latex-free products, and assistance.
DOCUMENTATION FOCUS
Assessment/Reassessment
• Assessment findings/pertinent history of contact with latex products/frequency of exposure.
• Type/extent of symptoms.
Planning
• Plan of care and interventions and who is involved in planning.
• Teaching plan.
Implementation/Evaluation
• Response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
Discharge Planning
• Discharge needs/referrals made, additional resources available.
Assessment/Reassessment
• Assessment findings/pertinent history of contact with latex products/frequency of exposure.
• Type/extent of symptoms.
Planning
• Plan of care and interventions and who is involved in planning.
• Teaching plan.
Implementation/Evaluation
• Response to interventions/teaching and actions performed.
• Attainment/progress toward desired outcome(s).
• Modifications to plan of care.
Discharge Planning
• Discharge needs/referrals made, additional resources available.
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