General Care Plans
PART I: Medical-Surgical Nursing
ADDITIONAL NURSING DIAGNOSES/PROBLEMS:
“Palliative and End-of-Life Care,” as appropriate for issues facing patients who are dying p. 103
“Anxiety Disorders” for Ineffective Coping p. 704
“Bipolar Disorder” for Risk for Other-Directed Violence p. 710
“Major Depression” for Hopelessness p. 727
Risk for Suicide p. 727
Grieving p. 729
for the Patient’s Family
and Significant Others 6
Note: The Health Insurance Portability and Accountability Act of 1996 (HIPAA) restricts who may request and receive health care–related information about a patient in order to protect confidentiality. Health care providers must be sensitive to and aware of expressed patient prefer- ences before discussing the patient with others, including family. This includes divulging informa- tion regarding a patient’s presence in the hospital.
Nursing Diagnosis:
Fear
related to the patient’s life-threatening condition and knowledge deficit
Desired Outcome:
Following intervention, significant others/family members report that fear has lessened.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the family’s fears and their understanding of the patient’s clinical situation.
Some fears may be realistic; others may not be and need clarification.
Evaluate verbal and nonverbal responses. Some family members may not readily verbalize their fears but may give nonverbal cues such as withdrawing emotionally (evidenced by body position, facial expression, attitude of disinterest), refusing to be present during discussion, or disrupting discussion.
Acknowledge the family’s fear. Simple acknowledgment and giving more information can go a long
way toward decreasing fear. For example, “I understand these tubes must frighten you, but they are necessary to help nourish your son.”
Assess the family’s history of coping behavior. How a family has coped with fear in the past often is a reliable predictor of how they will cope in the current situation. For example, “How does your family react to difficult situations?”
Awareness of maladaptive responses may assist the nurse in fostering more productive methods of coping.
Provide opportunities for family members to express fears and concerns. Verbalizing feelings in a nonthreatening environment can help them deal with unresolved/unrecognized issues that may be
contributing to the current stressor. Anger, denial, withdrawal, and demanding behavior may be adaptive coping responses during the initial period of crisis.
Identifying fears also enables the nurse to dispel inaccuracies, which
Interrupted Family Processes
Psychosocial Support for the Patient’s Family and Significant Others85
General Care Plans
PART I: Medical-Surgical Nursing
ASSESSMENT/INTERVENTIONS RATIONALES
Provide information at frequent intervals about the patient’s status, treatments, and equipment used.
This information increases the family’s knowledge of the patient’s health status, helping alleviate fear of the unknown.
Explain implications of HIPAA to the family and how this affects the type of information that can be given and how it can be given (e.g., no specific information can be given by phone or email).
Protection of patient privacy is critical. Helping families to understand what information can be provided and why will help alleviate anxiety.
Encourage the family to use positive coping behaviors by identifying fears, developing goals, identifying supportive resources, facilitating realistic perceptions, and promoting problem solving.
When under stress, the family may not recall sources of support without being reminded. For example, “Who usually helps your family during stressful times?”
Recognize anxiety, and encourage family members to describe their feelings.
Before family members can learn coping strategies, they must first clarify their feelings. For example, “You seem very uncomfortable tonight. Can you describe your feelings?”
Be alert to maladaptive responses to fear. Provide referrals to a psychiatric clinical nurse specialist or other staff member as appropriate.
Violence, withdrawal, severe depression, hostility, and unrealistic expectations for the staff or of the patient’s recovery are maladaptive responses to fear, and they require expert guidance.
Offer realistic hope, even if it is hope for the patient’s peaceful death. Even though family members may have feelings of hopelessness, it sometimes helps to hear realistic expressions of hope.
Explore the family’s desire for spiritual or other counseling. People often derive hope and experience a decrease in fear and dread from spiritual counseling.
Assess your own feelings about the patient’s life-threatening illness. Without personal awareness of one’s beliefs, a health care provider’s attitude and fears may be reflected inadvertently to the family.
For other interventions, see Interrupted Family Processes and Disabled Family Coping listed later in this care plan.
Nursing Diagnosis:
Interrupted Family Processes
related to the situational crisis (the patient’s illness)
Desired Outcome:
Following intervention, family members demonstrate effective adaptation to change/traumatic situation as evidenced by seeking external support when necessary and sharing concerns within the family unit.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the family’s character: social, environmental, ethnic, and cultural factors; relationships; and role patterns.
Having this detailed information will help the nurse develop an individualized care plan.
Identify the family’s developmental stage. The family may be dealing with other situational or maturational crises, such as managing an elderly parent or a teenager with a learning disability.
Assess previous adaptive behaviors. How the family has dealt with problems in the past may be a reliable predictor of how they will adapt to current issues. For example, “How does your family react in stressful situations?”
Discuss observed conflicts and communications. Awareness of this information will assist with development of an individualized plan of care, including referral for specialized care if appropriate. For example, “I noticed that your brother would not visit your mother today. Has there been a problem we should be aware of? Knowing about it may help us better care for your mother.”
Acknowledge the family’s involvement in patient care and promote strengths. Encourage the family to participate in patient care conferences. Promote frequent, regular patient visits by family members.
This reinforces positive ways of dealing with the crisis and promotes a sense of involvement and control for the family. For example, “You were able to encourage your wife to turn and cough. That is very important to her recovery.”
continued
PART I: Medical-Surgical Nursing
Provide the family with information and guidance related to the patient. Discuss the stresses of hospitalization, and encourage the family to discuss feelings of anger, guilt, hostility, depression, fear, or sorrow. Refer to clergy, clinical nurse specialist, or social services as appropriate.
Encouraging expressions of emotion helps family members begin the process of grieving. For example, “You seem to be upset since being told that your husband is not leaving the hospital today.” Acknowledging their feelings promotes acceptance and facilitates therapeutic communication.
Evaluate patient and family responses to one another. Encourage the family to reorganize roles and establish priorities as appropriate.
These actions will help facilitate the family’s adaptation to the situation regarding the patient and prevent unnecessary conflict. Helping family members redefine their roles may reduce confusion and provide direction.
For example, “I know your husband is concerned about his insurance policy and seems to expect you to investigate it. I’ll ask the financial counselor to talk with you.”
Encourage the family to schedule periods of rest and activity outside the hospital and to seek support when necessary.
Persons undergoing stress sometimes require guidance of others to promote their own self-care. For example, “Your neighbor volunteered to stay in the waiting room this afternoon. Would you like to rest at home? I’ll call you if anything changes.”
Nursing Diagnoses:
Compromised Family Coping/
Caregiver Role Strain
related to inadequate or incorrect information or misunderstanding, temporary family disorganization and role change, exhausted support persons or systems, unrealistic expectations, fear, anxiety, or financial burden
Desired Outcome:
Following intervention, family members begin to verbalize feelings, iden- tify ineffective coping patterns, identify strengths and positive coping behaviors, and seek information and support from the nurse or other support persons or systems outside the family.
ASSESSMENT/INTERVENTIONS RATIONALES
Establish open, honest communication within the family. Help family members identify strengths, stressors, inappropriate behaviors, and personal needs.
These actions will help promote positive, effective communication among family members while enabling them to examine areas that contribute both to effective and ineffective coping in a nonthreatening environment. For example, “I understand your mother was very ill last year. How did you manage the situation?”
“I know your loved one is very ill. How can I help you?”
Assess family members for ineffective coping and identify factors that inhibit effective coping.
Ineffective methods of coping (e.g., depression, chemical dependency, violence, withdrawal) can interfere with ability to deal with the current situation. Awareness of barriers to effective coping (e.g., inadequate support system, grief, fear of disapproval by others, and deficient knowledge) is the first step toward promoting changes and healthy adaptation. For example, “You seem to be unable to talk about your husband’s illness. Is there anyone with whom you can talk about it?”
Assess the family’s knowledge about the patient’s current health status and treatment. Provide information often, and allow sufficient time for questions. Reassess the family’s understanding at frequent intervals.
By providing information frequently and answering questions, stress, fear, and anxiety can be attenuated.
Provide opportunities in a private setting for family members to talk and share concerns with nurses. If appropriate, refer the family to a psychiatric clinical nurse specialist for therapy.
The family may need additional assistance in working through their issues.
PART I
MEDICAL-SURGICAL NURSING: General Care Plans Disabled Family Coping
Psychosocial Support for the Patient’s Family and Significant Others87
General Care Plans
PART I: Medical-Surgical Nursing
ASSESSMENT/INTERVENTIONS RATIONALES
Offer realistic hope. Help the family to develop realistic expectations for the future and to identify support persons or systems that will assist them.
These actions will foster realistic expectations about the patient’s future health status and promote adaptation to impending changes.
Help the family to reduce anxiety and caregiver strain by encouraging diversional activities (e.g., time spent outside the hospital) and interaction with support persons or systems outside the family.
Promoting respites enhances coping and helps family members remain focused and supportive of the patient. For example, “I know you want to be near your son, but if you would like to go home to rest, I will call you if any changes occur.”
For more information, see Chapter 8, “Palliative and End-of-Life Care,”
p. 104, for Caregiver Role Strain.
Nursing Diagnosis:
Disabled Family Coping
related to unexpressed feelings, ambivalent family relationships, or disharmo- nious coping styles among family members
Desired Outcome:
Within the 24-hr period before hospital discharge, family members begin to verbalize feelings; identify sources of support, as well as ineffective coping behaviors that create ambivalence and disharmony; and do not demonstrate destructive behaviors.
ASSESSMENT/INTERVENTIONS RATIONALES
Establish open, honest communication and rapport with family members. An atmosphere in which the family can express honest feelings and needs will help move them toward healthy coping and adaptation.
For example, “I am here to care for your mother and to help your family as well.”
Identify ineffective coping behaviors. Refer to a psychiatric clinical nurse specialist, case manager, clergy, or support group as appropriate.
Ineffective coping behaviors (e.g., violence, depression, substance misuse, withdrawal) can interfere with learning effective strategies. Awareness of ineffective or destructive coping behaviors is the first step toward promoting change. For example,
“You seem to be angry. Would you like to talk to me about your feelings?”
Identify perceived or actual conflicts. This information enables the family to examine areas that require change in a nonthreatening environment and identify potential sources of support. For example, “Are you able to talk freely with your family members?” “Are your brothers and sisters able to help and support you during this time?”
Assist in the quest for healthy functioning and adaptations within the family unit (e.g., facilitate open communication among family members and encourage behaviors that support family cohesiveness).
Facilitating open communication among family members and encouraging behaviors that support family cohesiveness promote skill acquisition in a nonthreatening environment and identify existing coping strengths. For example, “Your mother enjoyed your last visit. Would you like to see her now?”
Help family members develop realistic goals, plans, and actions. Refer them to clergy, psychiatric nurse, social services, financial counseling, and family therapy as appropriate.
These actions help provide direction in making necessary changes and adaptations.
Encourage family members to spend time outside the hospital and to interact with support individuals. Respect their need for occasional withdrawal.
A life out of balance adds to stress and promotes maladaptive coping.
Include family members in the patient’s plan of care. Offer them opportunities to become involved in patient care.
Becoming involved in the patient’s care (e.g., range-of-motion exercises, patient hygiene, and comfort measures such as back rubs) may decrease feelings of powerlessness, thereby increasing coping ability.
PART I: Medical-Surgical Nursing
Readiness for Enhanced Family Coping
related to use of support persons or systems, referrals, and choosing experiences that optimize wellness
Desired Outcomes:
Family members express intent to use support persons, systems, and resources, and identify alternative behaviors that promote communication and strengths.
Family members express realistic expectations and do not demonstrate ineffective coping behaviors.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess family relationships, interactions, support persons or systems, and individual coping behaviors.
This assessment facilitates development of an individualized care plan using existing family structure.
Permit movement through stages of adaptation. Encourage further positive coping.
Such an environment allows family members to process events surrounding the patient’s illness in a healthy manner.
Acknowledge expressions of hope, plans, and growth among family members.
A sense of hopefulness is essential to process painful events in a healthy manner.
Provide opportunities in a private setting for family interactions, discussions, and questions.
Discussions and sharing of emotions in a nonpublic forum encourages development of open, honest communication within the family. For example, “I know the waiting room is very crowded. Would your family like some private time together?”
Refer the family to community or support groups (e.g., ostomy support group, head injury rehabilitation group).
Many people benefit from support of other people who have had similar experiences in learning new coping strategies.
Encourage the family to explore outlets that foster positive feelings. Examples of outlets that foster positive feelings and thus promote effective coping include periods of time outside the hospital area, meaningful communication with the patient or support individuals, and relaxing activities such as showering, eating, exercising.
Nursing Diagnosis:
Deficient Knowledge
related to unfamiliarity with the patient’s current health status or therapies
Desired Outcome:
Following intervention, family members/significant others begin to verbal- ize knowledge and understanding about the patient’s current health status and treatment.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the family’s health and digital literacy (language, reading, comprehension, ability to navigate and use computers/Internet for information seeking). Assess culture and culturally specific education needs.
This assessment helps ensure that information is selected and presented in a manner that is culturally and educationally appropriate.
At frequent intervals, inform the family about the patient’s current health status, therapies, and prognosis. Use individualized verbal, written, and audiovisual strategies to promote their understanding.
Being informed frequently promotes accurate understanding of the patient’s health status and allays unnecessary anxiety. In turn, this enables family members to process and plan.
At frequent intervals, evaluate the family’s comprehension of information provided. Assess factors for misunderstanding, and adjust teaching as appropriate.
Some individuals in crisis need repeated explanations before comprehension can be ensured. For example, “I have explained many things to you today. Would you mind summarizing what I’ve told you so that I can be sure you understand your husband’s status and what we are doing to care for him?”
PART I
MEDICAL-SURGICAL NURSING: General Care Plans Deficient Knowledge
Psychosocial Support for the Patient’s Family and Significant Others89
General Care Plans
PART I: Medical-Surgical Nursing
ASSESSMENT/INTERVENTIONS RATIONALES
Encourage the family to relay correct information to the patient. This will reinforce comprehension for both the family and patient and promote open communication.
Inquire of family members if their information needs are being met. This action reinforces understanding by family members and assures them that the information/support they desire will be met. For example, “Do you have any questions about the care your mother is receiving or about her condition?”
Help family members use the information they receive to make health care decisions about the patient.
Family members may require assistance in processing information and applying it appropriately (e.g., regarding surgery, resuscitation, organ donation).
7
Nursing Diagnoses:
Acute Confusion/
Risk for Injury
related to age-related decreased physiologic reserve, renal function, or cardiac function; altered sensory/perceptual reception occurring with poor vision or hearing; or decreased brain oxygenation occurring with illness state and decreased functional lung tissue
Desired Outcomes:
The patient’s mental status returns to normal for the patient within 3 days of treatment. The patient sustains no evidence of injury or harm as a result of mental status.
ASSESSMENT/INTERVENTIONS RATIONALES
Assess the patient’s baseline level of consciousness (LOC) and mental status on admission. Obtain preconfusion functional and mental status abilities from significant other or clinical caregiver. Ask the patient to perform a three-step task. For example, “Raise your right hand, place it on your left shoulder, and then place the right hand by your right side.”
A component of the Mini-Mental Status Examination, this assessment of a three-step task provides a baseline for subsequent assessments of a patient’s confusion. A three-step task is complex and is a gross indicator of brain function.
Because it requires attention, it can also test for delirium.
Use the confusion assessment method (CAM) to help identify the presence or absence of confusion/delirium.
Delirium is a serious problem for hospitalized older adults and often goes unrecognized. The CAM tool (Waszynski, 2007) can be administered in a short period of time. CAM is a simple, standardized tool that can be used by bedside clinicians and has been validated in settings from medical-surgical areas to intensive care units. If your agency does not already employ this tool, there are several on-line sources that describe it in detail.
Test short-term memory by showing the patient how to use the call light, having the patient return the demonstration, and then waiting at least 5 min before having the patient demonstrate use of the call light again.
Document the patient’s actions in behavioral terms. Describe the
“confused” behavior.
Inability to remember beyond 5 min indicates poor short-term memory.
Identify the cause of acute confusion. Acute confusion is caused by physical and psychosocial conditions and not by age alone. For example, oximetry or arterial blood gas (ABG) values may reveal low oxygenation levels, serum glucose or fingerstick glucose may reveal high or low glucose level, and electrolytes and complete blood count (CBC) will ascertain imbalances and/or presence of elevated white blood cell (WBC) count as a determinant of infection. Hydration status may be determined by pinching skin over the sternum or forehead for turgor (tenting occurs with fluid volume deficit) and