Nursing Interventions and Rationales
- Assess client’s ability to perform ADLs independently with the Katz Index of Independence in Activities of Daily Living. The Katz Index is the most appropriate instrument for assessing client’s ADL abilities (Shelkey & Wallace, 1998).
- Assess self-efficacy (The Self-Efficacy for Functional Activities scale); assess outcome expectations (Outcome Expectations for Functional Activities scale). Based on assessment, promote motivation and self-efficacy for ADL functioning by role modeling via videotape or partnering; verbal encouragement; individualize care using humor, kindness, joy, and excitement with achievements; social supports; and decrease unpleasant sensations with the ADL function. EBN: Assessment and interventions for self-efficacy strengthen client efficacy expectations and improve functional performance (Resnick, 2002).
- Assess for grieving resulting from loss of function. [read more...]
Nursing Interventions and Rationales for Adult
- If in a typical bathing setting for the client, assess the client’s ability to bathe self via direct observation using physical performance tests for ADLs. Observation of bathing performed in an atypical bathing setting may result in false data for which use of a physical performance test compensates to provide more accurate ability data.
- Ask the client for input on bathing habits and cultural bathing preferences. EB: Creating opportunities for guiding personal care honors long-standing routines, increases control, and makes bath time more pleasant for caregiver (Perimutter & Camberg, 2004).
- Develop a bathing care plan based on the client’s own history of bathing practices that addresses skin needs, self-care needs, client response to bathing, and equipment needs. Bathing is a healing rite and should be a comforting experience that concentrates on the client’s needs, rather than being a routinely scheduled task (Rasin & Barrick, 2004).
- Individualize bathing by identifying function of bath (e.g., odor, urine removal), frequency required to achieve function, and best bathing form (e.g., towel bathing, tub, shower) to meet client preferences, preserve client dignity, make bathing a soothing experience, and reduce client aggression. [read more...]
Definition : Facilitation of patency of airway passages
Activities
- open the airway, using the chin lift or jaw thrust technique, as appropriate
- position patient to maximize ventilation potential
- identify patient requiring actual/potential airway insertion
- insert oral or nasopharyngeal airway, as appropriate
- perform chest physical therapy, as appropriate [read more...]
Definition: The inability to clear secretions or obstruction of the respiratory tract to maintain the cleanliness of the airway.
defining Characteristics:
- Dispneu, Decreased breath sounds
- Orthopneu
- Cyanosis
- Abnormal breath sounds (rales, wheezing)
- Difficulty speaking
- Cough, not efektif or no
- Eyes widened
- Production of sputum
- Fidget
- Changes in the frequency and rhythm of the breath
Related factors:
- Environment: smoking, inhaling cigarette smoke, passive smoking-POK, infections
- Physiological: neuromuscular dysfunction, bronchial wall hyperplasia, airway allergy, asthma.
- Obstruction of the airway: airway spasm, secretion detained, the number of mucus, the presence of artificial airway, bronchial secretions, the presence of exudate in the alveoli, the presence of foreign bodies in the airway.
Compromised Family Coping for Client/Family Teaching
- Provide truthful information and support for the family and significant people regarding the client’s specific illness or condition. EBN: The results of this study indicate that attention needs to be given to methods of providing information and support to couples coping with prostate cancer. Both patients and partners need to be included in discussions about the effect of the illness and treatments so that both can feel more prepared to manage them (Harden et al, 2002).
- Refer women with recurrent breast cancer and their family caregivers to a FOCUS Program [read more...]
Compromised Family Coping for Home Care :
- The interventions described previously may be adapted for home care use.
- Assess the reason behind the breakdown of family coping. Knowledge of the reasons behind compromised coping will assist in identification of appropriate interventions. Are family members physically able to aid client? Is there a lack of resources? Do past relationship issues interfere with motivation? Are family members feeling stressed dealing with client’s care needs? [read more...]
Compromised Family Coping for Multicultural
- Acknowledge racial/ethnic differences at the onset of care. EBN: Acknowledgment of race/ethnicity issues will enhance communication, establish rapport, and promote treatment outcomes (D’Avanzo et al, 2001; Ludwick & Silva, 2000; Vontress & Epp, 1997).
- Approach families of color with respect, warmth, and professional courtesy. EB: Instances of disrespect and lack of caring have special significance for families of color (D’Avanzo et al, 2001; Vontress & Epp, 1997). Latina mothers of developmentally disabled adults reported their relationship with the educational and service delivery systems to be characterized by poor communication, low effort in providing services, negative attitudes of professionals toward the client-children, and negative treatment of parents by professionals (Shapiro et al, 2004).
- Assess for the influence of cultural beliefs, norms, and values on the family’s perceptions of coping [read more...]
Suggested NIC Interventions Compromised Family Coping
- Caregiver Support
- Coping Enhancement
- Family Involvement Promotion
- Family Mobilization
- Family Support
- Mutual Goal Setting
- Normalization Promotion
- Sibling Support
Example NIC Activities—Family Support
Appraise family’s emotional reaction to client’s condition; promote trusting relationship with family
Nursing Interventions and Rationales
- Assess the strengths and deficiencies of the family system [read more...]
